Publications by authors named "Nancy E Adler"

163 Publications

Salivary cytokine cluster moderates the association between caregivers perceived stress and emotional functioning in youth.

Brain Behav Immun 2021 05 2;94:125-137. Epub 2021 Mar 2.

Douglas Mental Health University Institute, Douglas Research Center, McGill University, Montreal, QC, Canada; Ludmer Centre for Neuroinformatics and Mental Health and Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, QC, Canada. Electronic address:

Some individuals exposed to early life stress show evidence of enhanced systemic inflammation and are at greater risk for psychopathology. In the current study, caregivers and their offspring (0-17 years) were recruited at a pediatric clinic visit at the University of California, San Francisco (UCSF). Mothers and seven-year-old children from the Growing Up inSingaporeTowards healthy Outcomes (GUSTO) prospective birth cohort were used as a replication cohort. Caregivers perceived stress was measured to determine potential intergenerational effects on the children's functioning and inflammation levels. Children's emotional functioning in the UCSF cohort was evaluated using the Pediatric Quality of Life (PedsQL) inventory. Child emotional and behavioral functioning was measured using the Child Behavior Checklist (CBCL) in GUSTO. Saliva was collected from the children and salivary levels of IL-6, IL-1β, IL-8 and TNF-α were measured using an electrochemiluminescent cytokine multiplex panel. Child IL-6, IL-1β, IL-8 cytokine levels were clustered into low, average, and high cytokine cluster groups using hierarchical cluster analysis. We did not find that salivary cytokine clusters were significantly associated with children's emotional or behavioral function. However, cytokine clusters did significantly moderate the association between increased caregiver perceived stress and reduced child emotional functioning (UCSF cohort) and increased Attention-Deficit-Hyperactivity (ADH) problems (GUSTO cohort, uncorrected Cohen's F2 = 0.02). Using a cytokine clustering technique may be useful in identifying those children exposed to increased caregiver perceived stress that are at risk of emotional and attention deficit hyperactivity problems.
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http://dx.doi.org/10.1016/j.bbi.2021.02.025DOI Listing
May 2021

A reply to Shachak.

J Am Med Inform Assoc 2021 06;28(6):1358-1359

Center for Health and Community, University of California, San Francisco, California, USA.

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http://dx.doi.org/10.1093/jamia/ocab022DOI Listing
June 2021

A call for social informatics.

J Am Med Inform Assoc 2020 11;27(11):1798-1801

Center for Health and Community, University of California, San Francisco, California, USA.

As evidence of the associations between social factors and health outcomes continues to mount, capturing and acting on social determinants of health (SDOH) in clinical settings has never been more relevant. Many professional medical organizations have endorsed screening for SDOH, and the U.S. Office of the National Coordinator for Health Information Technology has recommended increased capacity of health information technology to integrate and support use of SDOH data in clinical settings. As these efforts begin their translation to practice, a new subfield of health informatics is emerging, focused on the application of information technologies to capture and apply social data in conjunction with health data to advance individual and population health. Developing this dedicated subfield of informatics-which we term social informatics-is important to drive research that informs how to approach the unique data, interoperability, execution, and ethical challenges involved in integrating social and medical care.
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http://dx.doi.org/10.1093/jamia/ocaa175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671633PMC
November 2020

Social Determinants of Health and Diabetes: A Scientific Review.

Diabetes Care 2020 Nov 2. Epub 2020 Nov 2.

The Brown School and The School of Medicine, Washington University in St. Louis, St. Louis, MO.

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http://dx.doi.org/10.2337/dci20-0053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783927PMC
November 2020

The association between objective and subjective socioeconomic status and subjective well-being: A meta-analytic review.

Psychol Bull 2020 11;146(11):970-1020

Department of Psychiatry.

This meta-analysis tested if the links between socioeconomic status (SES) and subjective well-being (SWB) differ by whether SES is assessed objectively or subjectively. The associations between measures of objective SES (i.e., income and educational attainment), subjective SES (i.e., the MacArthur ladder SES and perceived SES), and SWB (i.e., happiness and life satisfaction) were synthesized across 357 studies, totaling 2,352,095 participants. Overall, the objective SES and subjective SES measures were moderately associated (r = .32). The subjective SES-SWB association (r = .22) was larger than the objective SES-SWB association (r = .16). The income-SWB association (r = .23) was comparable with the ladder SES-SWB association (r = .22) but larger than the perceived SES-SWB association (r = .196). The education-SWB association (r = .12) was smaller than the associations with both measures of subjective SES. The subjective SES-SWB association was partially explained by common method variance. The subjective SES-SWB association, particularly with the ladder SES measure, also mediated the objective SES-SWB association. In moderation analyses, the objective SES-SWB associations strengthened as samples increased in wealth and population density. The subjective SES-SWB associations strengthened as samples increased in population density, decreased in income inequality, and decreased in relative social mobility. The role of common method variance, social comparisons, and other processes in explaining the SES-SWB links are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/bul0000258DOI Listing
November 2020

Effects of In-Person Navigation to Address Family Social Needs on Child Health Care Utilization: A Randomized Clinical Trial.

JAMA Netw Open 2020 06 1;3(6):e206445. Epub 2020 Jun 1.

Center for Health and Community, University of California, San Francisco.

Importance: While many organizations endorse screening for social risk factors in clinical settings, few studies have examined the health and utilization effects of interventions to address social needs.

Objective: To compare the acute care utilization effects of a written resources handout vs an in-person navigation service intervention to address social needs.

Design, Settings, And Participants: In this secondary analysis of a randomized clinical trial, 1809 adult caregivers of pediatric patients seen in primary and urgent care clinics of 2 safety-net hospitals in northern California were recruited between October 13, 2013, and August 27, 2015. Each participating family was randomly assigned to an in-person navigator intervention vs active control to address the family's social needs. Analyses were conducted between February 28, 2018, and September 25, 2019.

Interventions: Caregivers either received written information about relevant local resources related to social needs (active control) or met with a patient navigator focused on helping them resolve social needs (navigator intervention). After an initial in-person visit, navigation services included telephone, email, and/or in-person follow-up for up to 3 months.

Main Outcome And Measures: Child emergency department visit or hospitalization within 12 months of study enrollment.

Results: Among the 1300 caregivers enrolled in the study without missing follow-up data, most spoke English (878 [67.5%]) and were women (1127 [86.7%]), with a mean (SD) age of 33.0 (9.33) years. Most children were aged 0 to 5 years (779 of 1300 [59.9%]), 723 children (55.6%) had Hispanic ethnicity, and 462 children (35.5%) were in excellent health; 840 families (64.6%) were recruited from urgent care. In total, 637 families (49.0%) were randomized to the in-person navigator group and 663 (51.0%) to the active control group. There was no difference in risk of an emergency department visit between the 2 groups. Children enrolled in the in-person navigator group had a decreased risk of hospitalization within 12 months (hazard ratio, 0.59; 05% CI, 0.38-0.94; P = .03), making them 69% less likely to be hospitalized.

Conclusions And Relevance: In this randomized clinical trial evaluating heath care utilization effects of programs designed to address social needs among families, children enrolled in the navigation group were significantly less likely to be hospitalized after the intervention but equally likely to have an emergency department visit. These findings strengthen our understanding of the effects of addressing social needs in clinical settings as part of a comprehensive strategy to improve health and reduce health care utilization.

Trial Registration: ClinicalTrials.gov Identifier: NCT01939704.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.6445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265099PMC
June 2020

Effects of In-Person Assistance vs Personalized Written Resources About Social Services on Household Social Risks and Child and Caregiver Health: A Randomized Clinical Trial.

JAMA Netw Open 2020 03 2;3(3):e200701. Epub 2020 Mar 2.

Department of Family and Community Medicine, University of California, San Francisco.

Importance: Social and economic contexts shape children's short- and long-term health. Efforts to address contextual risk factors are increasingly incorporated into pediatric health care.

Objective: To compare the effectiveness of 2 social risk-related interventions.

Design, Setting, And Participants: This randomized clinical trial included English- and/or Spanish-speaking caregiver-child dyads recruited from a pediatric urgent care clinic nested in a large, urban, safety-net hospital. Study recruitment, enrollment, and follow-up were conducted from July 18, 2016, to March 8, 2019. Data analysis was conducted from January 1, 2019, to January 20, 2020.

Interventions: Following standardized social risk assessment, caregivers were randomly assigned to receive either written information regarding relevant government and community social services resources or comparable written information plus in-person assistance and follow-up focused on service access.

Main Outcomes And Measures: Caregiver-reported number of social risk factors and child health 6 months after enrollment.

Results: Among 611 caregiver-child dyads enrolled in the study, 302 dyads were randomized to the written resources group and 309 dyads were randomized to the written resources plus in-person assistance group. The mean (SD) age of children was 6.1 (5.0) years; 483 children (79.1%) were Hispanic; and 315 children (51.6%) were girls. There were no significant differences between groups in the effects of the interventions. In post hoc secondary analyses, the number of reported social risks decreased from baseline to 6-month follow-up in both groups: caregivers who received written resources alone reported a mean (SE) of 1.28 (0.19) fewer risks at follow-up, while those receiving written resources plus in-person assistance reported 1.74 (0.21) fewer risks at follow-up (both P < .001). In both groups, there were small but statistically significant improvements from baseline to follow-up in child health (mean [SE] change: written resources, 0.37 [0.07]; written resources plus in-person assistance, 0.24 [0.07]; both P < .001).

Conclusions And Relevance: This randomized clinical trial compared 2 approaches to addressing social risks in a pediatric urgent care setting and found no statistically significant differences in the social risk and child and caregiver health effects of providing written resources at the point of care with vs without in-person longitudinal navigation services. Caregivers in both groups reported fewer social risks and improved child and caregiver health 6 months after the intervention. These findings deepen understanding of effective doses of social risk-related interventions.

Trial Registration: ClinicalTrials.gov Identifier: NCT02746393.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.0701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064877PMC
March 2020

Effects of In-Person Assistance vs Personalized Written Resources About Social Services on Household Social Risks and Child and Caregiver Health: A Randomized Clinical Trial.

JAMA Netw Open 2020 03 2;3(3):e200701. Epub 2020 Mar 2.

Department of Family and Community Medicine, University of California, San Francisco.

Importance: Social and economic contexts shape children's short- and long-term health. Efforts to address contextual risk factors are increasingly incorporated into pediatric health care.

Objective: To compare the effectiveness of 2 social risk-related interventions.

Design, Setting, And Participants: This randomized clinical trial included English- and/or Spanish-speaking caregiver-child dyads recruited from a pediatric urgent care clinic nested in a large, urban, safety-net hospital. Study recruitment, enrollment, and follow-up were conducted from July 18, 2016, to March 8, 2019. Data analysis was conducted from January 1, 2019, to January 20, 2020.

Interventions: Following standardized social risk assessment, caregivers were randomly assigned to receive either written information regarding relevant government and community social services resources or comparable written information plus in-person assistance and follow-up focused on service access.

Main Outcomes And Measures: Caregiver-reported number of social risk factors and child health 6 months after enrollment.

Results: Among 611 caregiver-child dyads enrolled in the study, 302 dyads were randomized to the written resources group and 309 dyads were randomized to the written resources plus in-person assistance group. The mean (SD) age of children was 6.1 (5.0) years; 483 children (79.1%) were Hispanic; and 315 children (51.6%) were girls. There were no significant differences between groups in the effects of the interventions. In post hoc secondary analyses, the number of reported social risks decreased from baseline to 6-month follow-up in both groups: caregivers who received written resources alone reported a mean (SE) of 1.28 (0.19) fewer risks at follow-up, while those receiving written resources plus in-person assistance reported 1.74 (0.21) fewer risks at follow-up (both P < .001). In both groups, there were small but statistically significant improvements from baseline to follow-up in child health (mean [SE] change: written resources, 0.37 [0.07]; written resources plus in-person assistance, 0.24 [0.07]; both P < .001).

Conclusions And Relevance: This randomized clinical trial compared 2 approaches to addressing social risks in a pediatric urgent care setting and found no statistically significant differences in the social risk and child and caregiver health effects of providing written resources at the point of care with vs without in-person longitudinal navigation services. Caregivers in both groups reported fewer social risks and improved child and caregiver health 6 months after the intervention. These findings deepen understanding of effective doses of social risk-related interventions.

Trial Registration: ClinicalTrials.gov Identifier: NCT02746393.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.0701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064877PMC
March 2020

Understanding the Psychological Distress of Food Insecurity: A Qualitative Study of Children's Experiences and Related Coping Strategies.

J Acad Nutr Diet 2020 03 17;120(3):395-403. Epub 2020 Jan 17.

Background: Food insecurity, a condition of inadequate household food availability, affects 15.7% of US households with children. Food insecurity is generally believed to affect the quantity and quality of food consumed. However, an understudied but important aspect of the experience of food insecurity is psychological distress.

Objective: To critically explore the psychological distress associated with children's food insecurity using children's own reports of their experiences.

Design: In-depth qualitative interviews conducted with children to better understand the psychological distress associated with food insecurity.

Participants/setting: Sixty children (aged 7 to 14 years) were recruited from the San Francisco Bay Area. Children were eligible in the case that they spoke English fluently and their parent reported any experience of household food insecurity during the past year.

Results: Children discussed six themes related to the psychological distress associated with food insecurity: worrying about not having enough food, worrying about their parents' well-being, anger and frustration about not having enough food, embarrassment about their family's food situation, strain on the family's dynamics due to food insecurity, and sadness over not having enough food. After describing their experiences, children described strategies they employed to tolerate or cope with food insecurity, including distracting from or using their imagination to cope with food insecurity, increasing tolerance of their family's food situation, and appreciating their parents for providing food and resources.

Conclusions: Food insecurity contributes to children's psychological distress. Given the known effects of chronic stress in childhood, the psychological distress of food insecurity may represent an important mechanism by which food insecurity adversely influences children's growth and development and deserves investigation in future studies.
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http://dx.doi.org/10.1016/j.jand.2019.10.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047973PMC
March 2020

Racial discrimination and telomere shortening among African Americans: The Coronary Artery Risk Development in Young Adults (CARDIA) Study.

Health Psychol 2020 Mar 13;39(3):209-219. Epub 2020 Jan 13.

Department of Psychiatry, University of California, San Francisco.

Objective: Telomeres are protective sequences of DNA capping the ends of chromosomes that shorten over time. Leukocyte telomere length (LTL) is posited to reflect the replicative history of cells and general systemic aging of the organism. Chronic stress exposure leads to accelerated LTL shortening, which has been linked to increased susceptibility to and faster progression of aging-related diseases. This study examined longitudinal associations between LTL and experiences of racial discrimination, a qualitatively unique source of minority psychosocial stress, among African Americans.

Method: Data are from 391 African Americans in the Coronary Artery Risk Development in Young Adults (CARDIA) Telomere Ancillary Study. We examined the number of domains in which racial discrimination was experienced in relation to LTL collected in Years 15 and 25 (Y15: 2000/2001; Y25: 2010/2011). Multivariable linear regression examined if racial discrimination was associated with LTL. Latent change score analysis (LCS) examined changes in racial discrimination and LTL in relation to one another.

Results: Controlling for racial discrimination at Y15, multivariable linear regression analyses indicated that racial discrimination at Y25 was significantly associated with LTL at Y25. This relationship remained robust after adjusting for LTL at Y15 (b = -.019, = .015). Consistent with this finding, LCS revealed that increases in experiences of racial discrimination were associated with faster 10-year LTL shortening (b = -.019, = .015).

Conclusions: This study adds to evidence that racial discrimination contributes to accelerated physiologic weathering and health declines among African Americans through its impact on biological systems, including via its effects on telomere attrition. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/hea0000832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373166PMC
March 2020

Alternative causal inference methods in population health research: Evaluating tradeoffs and triangulating evidence.

SSM Popul Health 2020 Apr 9;10:100526. Epub 2019 Dec 9.

Center for Health and Community, University of California, San Francisco, 3333, California St, Suite, 465, Campus Box 0844, San Francisco, CA, 94143-0844, USA.

Population health researchers from different fields often address similar substantive questions but rely on different study designs, reflecting their home disciplines. This is especially true in studies involving causal inference, for which semantic and substantive differences inhibit interdisciplinary dialogue and collaboration. In this paper, we group nonrandomized study designs into two categories: those that use confounder-control (such as regression adjustment or propensity score matching) and those that rely on an instrument (such as instrumental variables, regression discontinuity, or differences-in-differences approaches). Using the Shadish, Cook, and Campbell framework for evaluating threats to validity, we contrast the assumptions, strengths, and limitations of these two approaches and illustrate differences with examples from the literature on education and health. Across disciplines, all methods to test a hypothesized causal relationship involve unverifiable assumptions, and rarely is there clear justification for exclusive reliance on one method. Each method entails trade-offs between statistical power, internal validity, measurement quality, and generalizability. The choice between confounder-control and instrument-based methods should be guided by these tradeoffs and consideration of the most important limitations of previous work in the area. Our goals are to foster common understanding of the methods available for causal inference in population health research and the tradeoffs between them; to encourage researchers to objectively evaluate what can be learned from methods outside one's home discipline; and to facilitate the selection of methods that best answer the investigator's scientific questions.
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http://dx.doi.org/10.1016/j.ssmph.2019.100526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926350PMC
April 2020

Associations Between Social Factor Documentation and Hospital Length of Stay and Readmission Among Children.

Hosp Pediatr 2020 01;10(1):12-19

Psychiatry, and.

Background And Objectives: Social risk factors are linked to children's health, but little is known about how frequently these factors are documented using the (ICD) or whether documentation is associated with health care use outcomes. Using a large administrative database of pediatric hospitalizations, we examined the prevalence of ICD social risk code documentation and hypothesized that social code documentation would be associated with longer length of stay (LOS) and readmission.

Methods: We analyzed hospitalizations of children ages ≤18 using the 2012 Nationwide Readmissions Database. The following ICD social codes were used as predictors: family member with alcohol and/or drug problem, history of abuse, parental separation, foster care, educational circumstance, housing instability, other economic strain, and legal circumstance. Outcomes included long LOS (top quintile) and readmission within 30 days after discharge. Covariates included individual, hospital, and season variables.

Results: Of 926 073 index hospitalizations, 7432 (0.8%) had social codes. Social code documentation was significantly associated with long LOS. Adjusting for covariates, family alcohol and/or drug problem (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.16-2.35), foster care (OR 2.37, 95% CI 1.53-3.65), other economic strain (OR 2.12, 95% CI 1.38-3.26), and legal circumstances (OR 1.66; 95% CI 1.02-2.71) remained significant predictors of long LOS. Social code documentation was not associated with readmission after adjusting for covariates.

Conclusions: Social ICD codes are associated with prolonged LOS and readmission in pediatric hospitalizations, but they are infrequently documented. Future work exploring these associations could help to determine if addressing social risk factors in inpatient settings might improve child health outcomes.
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http://dx.doi.org/10.1542/hpeds.2019-0123DOI Listing
January 2020

Associations Between Social Factor Documentation and Hospital Length of Stay and Readmission Among Children.

Hosp Pediatr 2020 01;10(1):12-19

Psychiatry, and.

Background And Objectives: Social risk factors are linked to children's health, but little is known about how frequently these factors are documented using the (ICD) or whether documentation is associated with health care use outcomes. Using a large administrative database of pediatric hospitalizations, we examined the prevalence of ICD social risk code documentation and hypothesized that social code documentation would be associated with longer length of stay (LOS) and readmission.

Methods: We analyzed hospitalizations of children ages ≤18 using the 2012 Nationwide Readmissions Database. The following ICD social codes were used as predictors: family member with alcohol and/or drug problem, history of abuse, parental separation, foster care, educational circumstance, housing instability, other economic strain, and legal circumstance. Outcomes included long LOS (top quintile) and readmission within 30 days after discharge. Covariates included individual, hospital, and season variables.

Results: Of 926 073 index hospitalizations, 7432 (0.8%) had social codes. Social code documentation was significantly associated with long LOS. Adjusting for covariates, family alcohol and/or drug problem (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.16-2.35), foster care (OR 2.37, 95% CI 1.53-3.65), other economic strain (OR 2.12, 95% CI 1.38-3.26), and legal circumstances (OR 1.66; 95% CI 1.02-2.71) remained significant predictors of long LOS. Social code documentation was not associated with readmission after adjusting for covariates.

Conclusions: Social ICD codes are associated with prolonged LOS and readmission in pediatric hospitalizations, but they are infrequently documented. Future work exploring these associations could help to determine if addressing social risk factors in inpatient settings might improve child health outcomes.
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http://dx.doi.org/10.1542/hpeds.2019-0123DOI Listing
January 2020

Healthcare Sector Activities to Identify and Intervene on Social Risk: An Introduction to the American Journal of Preventive Medicine Supplement.

Am J Prev Med 2019 12;57(6 Suppl 1):S1-S5

Center for Health and Community, University of California, San Francisco, San Francisco, California.

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http://dx.doi.org/10.1016/j.amepre.2019.07.009DOI Listing
December 2019

The PedBE clock accurately estimates DNA methylation age in pediatric buccal cells.

Proc Natl Acad Sci U S A 2020 09 14;117(38):23329-23335. Epub 2019 Oct 14.

Department of Psychiatry, Harvard Medical School-McLean Hospital, Belmont, MA 02478.

The development of biological markers of aging has primarily focused on adult samples. Epigenetic clocks are a promising tool for measuring biological age that show impressive accuracy across most tissues and age ranges. In adults, deviations from the DNA methylation (DNAm) age prediction are correlated with several age-related phenotypes, such as mortality and frailty. In children, however, fewer such associations have been made, possibly because DNAm changes are more dynamic in pediatric populations as compared to adults. To address this gap, we aimed to develop a highly accurate, noninvasive, biological measure of age specific to pediatric samples using buccal epithelial cell DNAm. We gathered 1,721 genome-wide DNAm profiles from 11 different cohorts of typically developing individuals aged 0 to 20 y old. Elastic net penalized regression was used to select 94 CpG sites from a training dataset ( = 1,032), with performance assessed in a separate test dataset ( = 689). DNAm at these 94 CpG sites was highly predictive of age in the test cohort (median absolute error = 0.35 y). The Pediatric-Buccal-Epigenetic (PedBE) clock was characterized in additional cohorts, showcasing the accuracy in longitudinal data, the performance in nonbuccal tissues and adult age ranges, and the association with obstetric outcomes. The PedBE tool for measuring biological age in children might help in understanding the environmental and contextual factors that shape the DNA methylome during child development, and how it, in turn, might relate to child health and disease.
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http://dx.doi.org/10.1073/pnas.1820843116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519312PMC
September 2020

Building the evidence on Making Health a Shared Value: Insights and considerations for research.

SSM Popul Health 2019 Dec 22;9:100474. Epub 2019 Aug 22.

Center for Health and Community at the University of California San Francisco, San Francisco, CA, USA.

The Robert Wood Johnson Foundation (RWJF)'s Culture of Health Action Framework guides a movement to improve health and advance health equity across the nation. Action Area One of the Framework, Making Health a Shared Value, highlights the role of individual and community factors in achieving a societal commitment to health and health equity, centered around three drivers: Mindset and Expectations, Sense of Community, and Civic Engagement. To stimulate research about how Action Area One and its drivers may impact health, Evidence for Action (E4A), a signature research funding program of RWJF, developed and released a national Call for Proposals (CFP). The process of formulating the CFP and reviewing proposals surfaced important challenges for research on creating and sustaining shared values to foster and maintain a Culture of Health. In this essay, we describe these considerations and provide examples from funded projects regarding how challenges can be addressed.
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http://dx.doi.org/10.1016/j.ssmph.2019.100474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715953PMC
December 2019

Transactions between Maternal and Child Depressive Symptoms Emerge Early in Life.

J Clin Child Adolesc Psychol 2019 Aug 27:1-11. Epub 2019 Aug 27.

Department of Psychiatry, University of California.

Maternal depression is a robust risk factor for children's internalizing symptoms; however, the intergenerational transmission of mood disorders is likely more complex than unidirectional parent-directed effects. Theoretical models support transactional associations between maternal and child symptomatology over time but have not been well examined, especially in younger high-risk samples. The present investigation examined predictive transactional relations between maternal depression and children's internalizing in toddlerhood and early childhood using a cross-lagged panel model. Participants were 162 low-income, largely racial/ethnic minority mothers and their offspring (32% African American, 16% White, 52% Other/Multiethnic; 53% female) who were assessed when children were 18 months and 4 years old. There were significant cross-sectional relations between maternal depressive and child internalizing symptoms when children were 18 months but not 4 years of age. Cross-lagged associations were evident such that maternal depression symptoms at 18 months were positively associated with internalizing symptoms among children at 4 years, adjusting for prior maternal symptom levels and the cross-sectional correlations between maternal-child symptoms at 18 months. Within the same model, children's internalizing symptoms at 18 months were also positively associated with maternal depressive symptoms at 4 years, adjusting for prior child symptom levels and cross-sectional correlations. This study is among the first to demonstrate that transactional relations between maternal and child mood symptoms occur as early as toddlerhood/early childhood. Findings highlight the potential utility of inclusive, family-focused interventions that support both parents and children in the treatment of early emotional problems.
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http://dx.doi.org/10.1080/15374416.2019.1644649DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044043PMC
August 2019

Association of Social and Behavioral Risk Factors With Earlier Onset of Adult Hypertension and Diabetes.

JAMA Netw Open 2019 05 3;2(5):e193933. Epub 2019 May 3.

Department of Pediatrics, University of California, San Francisco.

Importance: The National Academy of Medicine has recommended incorporating information on social and behavioral factors associated with health, such as educational level and exercise, into electronic health records, but questions remain about the clinical value of doing so.

Objective: To examine whether National Academy of Medicine-recommended social and behavioral risk factor domains are associated with earlier onset of hypertension and/or diabetes in a clinical population.

Design, Setting, And Participants: This prospective cohort study used data collected from April 1, 2005, to December 31, 2016, from a population-based sample of 41 745 patients from 4 cycles of Kaiser Permanente Northern California's Adult Member Health Survey, administered to members at 19 Kaiser Permanente Northern California medical center service populations. The study used Kaplan-Meier survival tables and Cox proportional hazards regression analysis to estimate the onset of hypertension and diabetes among patients with no indication of disease at baseline. Data analysis was performed from June 2, 2017, to March 26, 2019.

Exposures: Race/ethnicity, educational level, financial worry, partnership status, stress, intimate partner violence, concentrated neighborhood poverty, depressive symptoms, infrequent exercise, smoking, heavy alcohol consumption, and cumulative social and behavioral risk.

Main Outcomes And Measures: Onset of hypertension and diabetes during the 3.5 years after survey administration.

Results: The study included 18 133 people without baseline hypertension (mean [SD] age, 48.1 [15.3] years; 10 997 [60.7%] female; and 11 503 [63.4%] white) and 35 788 people without baseline diabetes (mean [SD] age, 56.2 [16.9] years; 20 191 [56.4%] female; and 24 351 [68.0%] white). There was a dose-response association between the number of social and behavioral risk factors and likelihood of onset of each condition. Controlling for age, sex, race/ethnicity, body mass index, and survey year, hazard ratios (HRs) comparing those with 3 or more risk factors with those with 0 risk factor were 1.41 (95% CI, 1.17-1.71) for developing hypertension and 1.53 (95% CI, 1.29-1.82) for developing diabetes. When the same covariates were adjusted for, having less than a high school educational level (hazard ratio [HR], 1.84; 95% CI, 1.40-2.43), being widowed (HR, 1.38; 95% CI, 1.11-1.71), concentrated neighborhood poverty (HR, 1.26; 95% CI, 1.00-1.59), infrequent exercise (HR, 1.22; 95% CI, 1.08-1.38), and smoking (HR, 1.35; 95% CI, 1.10-1.67) were significantly associated with hypertension onset. Having less than a high school educational level (HR, 1.58; 95% CI, 1.26-1.97), financial worry (HR, 1.29; 95% CI, 1.13-1.46), being single or separated (HR, 1.24; 95% CI, 1.08-1.42), high stress (HR, 1.28; 95% CI, 1.09-1.51), intimate partner violence (HR, 1.68; 95% CI, 1.14-2.48), concentrated neighborhood poverty (HR, 1.31; 95% CI, 1.07-1.60), depressive symptoms (HR, 1.28; 95% CI, 1.10-1.50), and smoking (HR, 1.53; 95% CI, 1.27-1.86) were significantly associated with diabetes onset, although heavy alcohol consumption was associated with protection (HR, 0.75; 95% CI, 0.66-0.85) rather than risk.

Conclusions And Relevance: Independent of traditional risk factors, individual and cumulative social and behavioral risk factor exposures were associated with onset of hypertension and diabetes within 3.5 years in a clinical setting. The findings support the value of assessing social and behavioral risk factors to help identify high-risk patients and of providing targets for intervention.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.3933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537925PMC
May 2019

Stress Disorders and Dementia in the Danish Population.

Am J Epidemiol 2019 03;188(3):493-499

Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark.

There is an association between stress and dementia. However, less is known about dementia among persons with varied stress responses and sex differences in these associations. We used this population-based cohort study to examine dementia among persons with a range of clinician-diagnosed stress disorders, as well as the interaction between stress disorders and sex in predicting dementia, in Denmark from 1995 to 2011. This study included Danes aged 40 years or older with a stress disorder diagnosis (n = 47,047) and a matched comparison cohort (n = 232,141) without a stress disorder diagnosis with data from 1995 through 2011. Diagnoses were culled from national registries. We used Cox proportional hazards regression to estimate associations between stress disorders and dementia. Risk of dementia was higher for persons with stress disorders than for persons without such diagnosis; adjusted hazard ratios ranged from 1.6 to 2.8. There was evidence of an interaction between sex and stress disorders in predicting dementia, with a higher rate of dementia among men with stress disorders except posttraumatic stress disorder, for which women had a higher rate. Results support existing evidence of an association between stress and dementia. This study contributes novel information regarding dementia risk across a range of stress responses, and interactions between stress disorders and sex.
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http://dx.doi.org/10.1093/aje/kwy269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6395166PMC
March 2019

Danish-like Regulations May Improve Postabortion Mental Health Risk-Reply.

JAMA Psychiatry 2019 01;76(1):100

Centre for Integrated Register-Based Research (CIRRAU), National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark.

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http://dx.doi.org/10.1001/jamapsychiatry.2018.2605DOI Listing
January 2019

The biological embedding of early-life socioeconomic status and family adversity in children's genome-wide DNA methylation.

Epigenomics 2018 11 23;10(11):1445-1461. Epub 2018 Oct 23.

Department of Psychiatry, Center for Health & Community, Weill Neuroscience Institute, University of California, San Francisco, 3333 California Street, Suite 465, San Francisco, CA 94118, USA.

Aim: To examine variation in child DNA methylation to assess its potential as a pathway for effects of childhood social adversity on health across the life course.

Materials & Methods: In a diverse, prospective community sample of 178 kindergarten children, associations between three types of social experience and DNA methylation within buccal epithelial cells later in childhood were examined.

Results: Family income, parental education and family psychosocial adversity each associated with increased or decreased DNA methylation (488, 354 and 102 sites, respectively) within a unique set of genomic CpG sites. Gene ontology analyses pointed to genes serving immune and developmental regulation functions.

Conclusion: Findings provided support for DNA methylation as a biomarker linking early-life social experiences with later life health in humans.
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http://dx.doi.org/10.2217/epi-2018-0042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462839PMC
November 2018

Differences in Febrile and Respiratory Illnesses in Minority Children: The Sociodemographic Context of Restrictive Parenting.

Acad Pediatr 2019 07 27;19(5):534-541. Epub 2018 Sep 27.

Department of Psychiatry (DS Roubinov, NR Bush, N Adler, and WT Boyce), Weill Institute for Neurosciences, University of California, San Francisco; Department of Pediatrics (NR Bush, N Adler, and WT Boyce), University of California, San Francisco.

Objective: To examine the moderating role of restrictive parenting on the relation of socioeconomic status (SES) to febrile illnesses (FIs) and upper respiratory illnesses (URIs) among ethnic minority and non-minority children.

Methods: Children from diverse ethnic backgrounds (Caucasian, African American, Asian, Latino, other, or multiethnic) were followed across the course of the kindergarten year. Parents reported on SES and parenting. A nurse completed 13 physical exams per child over the year to assess FIs and URIs.

Results: During the school year, 28% of children (n = 199, 56% ethnic minority) exhibited one or more FIs (range, 0-6) and 90% exhibited one or more URIs (range, 0-10). No main or moderating effects of SES or restrictive parenting on FIs or URIs were found among Caucasian children; however, among ethnic minority children, the relation of SES to FIs was conditional upon restrictive parenting (β = .66; P = .02), as the fewest FIs were found for lower SES minority children whose parents reported more restrictive practices. Additionally, among minority children, more restrictive parenting was marginally associated with fewer URIs (β = -.21; P = .05).

Conclusions: Unexpectedly, among minority children the fewest illnesses occurred among lower SES children whose parents endorsed more restrictive parenting. This may be due to unique appraisals of this rearing style among minority children in lower SES environments and its potential to influence immune functioning. Results suggest variability in the effects of parenting on offspring health and support context-specific evaluations of parenting in efforts to ameliorate early health disparities.
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http://dx.doi.org/10.1016/j.acap.2018.09.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437018PMC
July 2019

Current and past depressive symptoms and contraceptive effectiveness level method selected among women seeking reproductive health services.

Soc Sci Med 2018 Oct 13;214:20-25. Epub 2018 Aug 13.

Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, United States.

Rationale: More thoroughly understanding the association between elevated depressive symptoms and effectiveness level of contraceptive method selected at a reproductive health visit could help women prevent unintended pregnancy.

Objective: This study examined how the association between both current and past depressive symptoms and effectiveness level of contraceptive method selected at a clinic visit varies by type of reproductive health visit.

Methods: Current and past depressive symptoms and contraceptive method selected were assessed among 1215 women aged 18-25 years seeking general reproductive health or abortion services at 40 community clinics throughout the United States. Using standard categories of effectiveness based on pregnancy rates during typical use, women's contraceptive method selected was coded as a low (e.g., no method, withdrawal, condoms), moderately (pill, patch, ring, or shot), or highly effective method (IUD, sterilization, implant). Depression status was divided into four categories: 1) no elevated depressive symptoms ever, 2) current elevated depressive symptoms only, 3) past elevated depressive symptoms only, and 4) past and current elevated depressive symptoms. Visit type, general reproductive health versus abortion care, was a moderator. The interaction effect between depressive symptoms and visit type on contraceptive method effectiveness level chosen was estimated with multinomial logistic regression analyses.

Results: In general reproductive health visits, having both elevated current and past depressive symptoms increased women's likelihood of choosing low versus moderately effective methods (RRR = 5.63, 95% CI = 2.31 to 13.71, p < .0005). In contrast, among abortion patients, only current elevated depressive symptoms were associated with choosing high versus moderate effectiveness methods (RRR = 1.74, 95% CI = 1.06 to 2.86, p = .029).

Conclusion: Results suggest that considering both women's current and past elevated depressive symptoms and the type of reproductive health visit may assist providers in helping women prevent unintended pregnancy.
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http://dx.doi.org/10.1016/j.socscimed.2018.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6245651PMC
October 2018

Lack of partner impacts newborn health through maternal depression: A pilot study of low-income immigrant Latina women.

Midwifery 2018 Sep 7;64:63-68. Epub 2018 Jun 7.

Center for Health and Community, Department of Psychiatry, University of California, San Francisco, USA.

Introduction: Latina women have a high burden of depression and other mental health issues, particularly in the perinatal period. Suboptimal maternal mental health can have adverse developmental and physiological impacts on child growth. The present study examines the impact of unplanned pregnancy and pregnancy relationship status on prenatal maternal depression in a sample of low-income Latina women. We hypothesized that the association between these prenatal stressors and newborn health would be mediated through prenatal depression.

Method: The present study included a sample 201 Latina mothers and their children recruited from prenatal clinics during their second or third trimesters. Depression symptomology, relationship status were collected prenatally. At birth, several indices of newborn health were examined, including head circumference percentile and birthweight. Finally, planned pregnancy status was retrospectively collected when the child was between 1 and 2 years old.

Results: Structural equation modelling revealed that single women, compared to partnered women, had higher levels of depression. Higher levels of depression, in turn, predicted poorer newborn health. Unplanned pregnancy was not significantly associated with newborn health.

Discussion: These results suggest that relationship status may be an important screening question for medical examiners to ask to pregnant Latina women during prenatal visits. These results are consistent with past research investigating the effects of maternal mental health on adverse birth outcomes that propose that stressful early environments shape developmental trajectories.
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http://dx.doi.org/10.1016/j.midw.2018.05.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6084475PMC
September 2018

Examining the Association of Antidepressant Prescriptions With First Abortion and First Childbirth.

JAMA Psychiatry 2018 08;75(8):828-834

Centre for Integrated Register-Based Research (CIRRAU), National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark.

Importance: The repercussions of abortion for mental health have been used to justify state policies that limit access to abortion in the United States. Much earlier research has relied on self-report of abortion or mental health conditions or on convenience samples. This study uses data that rely on neither.

Objective: To examine whether first-trimester first abortion or first childbirth is associated with an increase in women's initiation of a first-time prescription for an antidepressant.

Design, Setting, And Participants: This study linked data and identified a cohort of women from Danish population registries who were born in Denmark between January 1, 1980, and December 30, 1994. Overall, 396 397 women were included in this study; of these women, 30 834 had a first-trimester first abortion and 85 592 had a first childbirth.

Main Outcomes And Measure: First-time antidepressant prescription redemptions were determined and used as indication of an episode of depression or anxiety, and incident rate ratios (IRRs) were calculated comparing women who had an abortion vs women who did not have an abortion and women who had a childbirth vs women who did not have a childbirth.

Results: Of 396 397 women whose data were analyzed, 17 294 (4.4%) had a record of at least 1 first-trimester abortion and no children, 72 052 (18.2%) had at least 1 childbirth and no abortions, 13 540 (3.4%) had at least 1 abortion and 1 childbirth, and 293 511 (74.1%) had neither an abortion nor a childbirth. A total of 59 465 (15.0%) had a record of first antidepressant use. In the basic and fully adjusted models, relative to women who had not had an abortion, women who had a first abortion had a higher risk of first-time antidepressant use. However, the fully adjusted IRRs that compared women who had an abortion with women who did not have an abortion were not statistically different in the year before the abortion (IRR, 1.46; 95% CI, 1.38-1.54) and the year after the abortion (IRR, 1.54; 95% CI, 1.45-1.62) (P = .10) and decreased as time from the abortion increased (1-5 years: IRR, 1.24; 95% CI, 1.19-1.29; >5 years: IRR, 1.12; 95% CI, 1.05-1.18). The fully adjusted IRRs that compared women who gave birth with women who did not give birth were lower in the year before childbirth (IRR, 0.47; 95% CI, 0.43-0.50) compared with the year after childbirth (IRR, 0.93; 95% CI, 0.88-0.98) (P < .001) and increased as time from the childbirth increased (1-5 years: IRR, 1.52; 95% CI, 1.47-1.56; >5 years: IRR, 1.99; 95% CI, 1.91-2.09). Across all women in the sample, the strongest risk factors associated with antidepressant use in the fully adjusted model were having a previous psychiatric contact (IRR, 3.70; 95% CI, 3.62-3.78), having previously obtained an antianxiety medication (IRR, 3.03; 95% CI, 2.99-3.10), and having previously obtained antipsychotic medication (IRR, 1.88; 95% CI, 1.81-1.96).

Conclusions And Relevance: Women who have abortions are more likely to use antidepressants compared with women who do not have abortions. However, additional aforementioned findings from this study support the conclusion that increased use of antidepressants is not attributable to having had an abortion but to differences in risk factors for depression. Thus, policies based on the notion that abortion harms women's mental health may be misinformed.
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http://dx.doi.org/10.1001/jamapsychiatry.2018.0849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143090PMC
August 2018

Family Socioeconomic Status, Cortisol, and Physical Health in Early Childhood: The Role of Advantageous Neighborhood Characteristics.

Psychosom Med 2018 06;80(5):492-501

From the Department of Psychiatry (Roubinov, Hagan, Boyce, Adler, Bush), Weill Institute for Neurosciences, University of California, San Francisco; Department of Psychology (Hagan), San Francisco State University; and Department of Pediatrics (Boyce, Adler, Bush), University of California, San Francisco.

Objective: Children from families with lower socioeconomic status (SES) evidence greater physiological dysregulation and poorer health. Despite recognition of environmental contributors, little is known about the influence of neighborhood characteristics. The present study examined the moderating role of community-level risks and resources on the relation of family SES to children's daily cortisol output and physical health during the kindergarten year.

Methods: In fall and spring of kindergarten, children's (N = 338) daily total cortisol was measured and parents and teachers rated children's global physical health. Parents reported family SES. Neighborhood characteristics were assessed using the Child Opportunity Index, a population-level tool that evaluates the quality of multiple domains of neighborhood attributes.

Results: In fall, children reared in lower SES family environments had higher cortisol when residing in lower quality (lower opportunity) neighborhoods (b = -.097, p < .001), but there was no relation between family SES and children's cortisol in more advantaged (higher opportunity) neighborhoods (b = -.023, p = .36). Lower family SES was prospectively associated with poorer physical health in spring (controlling for fall health) only among children living in lower opportunity neighborhoods (b = -.250, p = .018) and was unrelated to physical health among children residing in higher opportunity neighborhoods (b = .042, p = .70).

Conclusions: Higher opportunity neighborhoods may protect against the negative consequences of low family SES on children's stress physiology and physical health. Public health interventions that bolster neighborhood opportunities may benefit young children reared in socioeconomically disadvantaged family environments.
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http://dx.doi.org/10.1097/PSY.0000000000000585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5976531PMC
June 2018

Neighborhood Child Opportunity and Individual-Level Pediatric Acute Care Use and Diagnoses.

Pediatrics 2018 05 6;141(5). Epub 2018 Apr 6.

Departments of Psychiatry.

: media-1vid110.1542/5751513300001PEDS-VA_2017-2309 OBJECTIVES: Although health care providers and systems are increasingly interested in patients' nonmedical needs as a means to improve health, little is known about neighborhood conditions that contribute to child health problems. We sought to determine if a novel, publicly available measure of neighborhood context, the Child Opportunity Index, was associated with pediatric acute care visit frequency and diagnoses.

Methods: This cross-sectional study included San Francisco residents <18 years of age with an emergency department and/or urgent care visit to any of 3 medical systems ( = 47 175) between 2007 and 2011. Hot-spot analysis was used to compare the spatial distribution of neighborhood child opportunity and income. Generalized estimating equation logistic regression models were used to examine independent associations between neighborhood child opportunity and frequent acute care use (≥4 visits per year) and diagnosis group after adjusting for neighborhood income and patient age, sex, race and/or ethnicity, payer, and health system.

Results: Neighborhood child opportunity and income had distinct spatial distributions, and we identified different clusters of high- and low-risk neighborhoods. Children living in the lowest opportunity neighborhoods had significantly greater odds of ≥4 acute care visits per year (odds ratio 1.33; 95% confidence interval 1.03-1.73) compared with those in the highest opportunity neighborhoods. Neighborhood child opportunity was negatively associated with visits for respiratory conditions, asthma, assault, and ambulatory care-sensitive conditions but positively associated with injury-related visits.

Conclusions: The Child Opportunity Index could be an effective tool for identifying neighborhood factors beyond income related to child health.
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http://dx.doi.org/10.1542/peds.2017-2309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991499PMC
May 2018

Eating with others and meal location are differentially associated with nutrient intake by sex: The Diabetes Study of Northern California (DISTANCE).

Appetite 2018 08 27;127:203-213. Epub 2018 Mar 27.

School of Public Health, University of California, Berkeley, 207-B University Hall, Berkeley, CA 94720-97360, United States.

Though eating with others is often a social behavior, relationships between social contexts of eating and nutrient intake have been underexplored. This study evaluates how social aspects of eating - frequencies of eating meals with others, meals prepared at home, and meals outside the home - are associated with nutrient intake. Because diet improvement can reduce complications of diabetes mellitus, we surveyed a multi-ethnic cohort of persons with type 2 diabetes (n = 770) about social aspects of diet (based on 24-hour recalls). Sex-stratified multiple regression analyses adjusted for confounders assessed the relationship between frequency of eating with others and nutrient intake (total energy, energy from fat, energy from carbohydrates, Healthy Eating Index/HEI, Dietary Approaches to Stop Hypertension/DASH score). Although there was slight variation in men's versus women's propensity to share meals, after adjustment for confounders, there was no consistently significant association between meals with others and the 5 nutrient intake measures for either men or women. The directions of association between categories of eating with others and diet quality (HEI and DASH scores) - albeit not significant - were different for men (positive) and women (mostly negative), which warrants further investigation. The next analyses estimated nutrient intake associated with meals prepared at home, and meals consumed outside the home. Analyses indicated that greater meal frequency at home was associated with significantly better scores on diet quality indices for men (but not women), while meal frequency outside the home was associated with poorer diet quality and energy intake for women (but not men). Better measurement of social dimensions of eating may inform ways to improve nutrition, especially for persons with diabetes for whom diet improvement can result in better disease outcomes.
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http://dx.doi.org/10.1016/j.appet.2018.03.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994367PMC
August 2018

Social Prescribing in the U.S. and England: Emerging Interventions to Address Patients' Social Needs.

Am J Prev Med 2018 05 15;54(5):715-718. Epub 2018 Mar 15.

Center for Health and Community, University of California, San Francisco, San Francisco, California.

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http://dx.doi.org/10.1016/j.amepre.2018.01.039DOI Listing
May 2018

Social isolation and all-cause mortality: a population-based cohort study in Denmark.

Sci Rep 2018 03 16;8(1):4731. Epub 2018 Mar 16.

Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, 8200, Denmark.

Social isolation is associated with increased mortality. Meta-analytic results, however, indicate heterogeneity in effect sizes. We aimed to provide new evidence to the association between social isolation and mortality by conducting a population-based cohort study. We reconstructed the Berkman and Syme's social network index (SNI), which combines four components of social networks (partnership, interaction with family/friends, religious activities, and membership in organizations/clubs) into an index, ranging from 0/1 (most socially isolated) to 4 (least socially isolated). We estimated cumulative mortality and adjusted mortality rate ratios (MRR) associated with SNI. We adjusted for potential important confounders, including psychiatric and somatic status, lifestyle, and socioeconomic status. Cumulative 7-year mortality in men was 11% for SNI 0/1 and 5.4% for SNI 4 and in women 9.6% for SNI 0/1 and 3.9% for SNI 4. Adjusted MRRs comparing SNI 0/1 with SNI 4 were 1.7 (95% CI: 1.1-2.6) among men and 1.6 (95% CI: 0.83-2.9) among women. Having no partner was associated with an adjusted MRR of 1.5 (95% CI: 1.2-2.1) for men and 1.7 (95% CI: 1.2-2.4) for women. In conclusion, social isolation was associated with 60-70% increased mortality. Having no partner was associated with highest MRR.
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http://dx.doi.org/10.1038/s41598-018-22963-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5856842PMC
March 2018
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