Background: Inequities in cancer morbidity and mortality have been well reported; however, the extent to which these inequities are mediated by modifiable risk factors is unclear. This study aimed to quantify the mediating effects of modifiable risk factors including smoking, excess alcohol consumption, low fruit and vegetable intake, physical inactivity and obesity in associations between socioeconomic position (SEP) and cancer morbidity and mortality. Methods: We used eight cycles of the nationally representative cross-sectional Canadian Community Health Survey (2000-2011) to identify a cohort of adults (≥35 years) without cancer at the time of study administration (n = 400,250) and followed until March 31, 2012. SEP was measured by creating a latent variable consisting of self-reported education and household income. Self-reported modifiable risk factors including smoking, excess alcohol consumption, low fruit and vegetable intake, physical inactivity and obesity were considered as potential mediators. The outcome was cancer morbidity and mortality and for its ascertainment, the cohort was linked to administrative health data in the Discharge Abstract Database and the Canadian Mortality Database. We used generalized structural equation modeling to estimate mediating effects of modifiable risk factors in associations between low SEP and cancer morbidity and mortality in the total population and stratified by sex. Results: There was a clear socioeconomic gradient in cancer morbidity and mortality. Modifiable risk factors mediated 45.6% of associations between low SEP and cancer morbidity and mortality. Smoking was the most important mediator in the total population and in males, which respectively explained 15.5% and 42.2% of associations between low SEP and cancer morbidity and mortality. For females, obesity was the most important mediator. Conclusions: Modifiable risk factors are important mediators of inequities in cancer morbidity and mortality. Nevertheless, over half of these associations remained unexplained. While midstream interventions that target modifiable risk factors may help to alleviate inequities in cancer risk in the short-term, ultimately upstream interventions are needed to reduce and prevent inequities in cancer morbidity and mortality.

 

Purpose: There is a need for evidence on what strategies - or combination of strategies - work best in increasing healthy food purchases and consumption, while not enhancing socio-economic inequalities in dietary intake. This study is the first to examine the efficacy of combined nudging and pricing strategies on increasing healthy food purchases and possible differences by socioeconomic position (SEP).

Methods: A randomized study design was used within a virtual supermarket (SN VirtuMart). Participants were exposed to five within-subject conditions (control, nudging, pricing, price salience and price salience with nudging) and randomized to one of three between-subject arms (25% price increase on unhealthy products, 25% price discount on healthy products, or 25% price increases and discounts). 455 participants of low and high SEP (using either education or income as proxy) conducted their weekly shopping in the supermarket for five consecutive weeks. Data were analyzed using linear mixed models.

Results: In total, 346 (76%) adults completed all five shops within the SN VirtuMart. Median age was 32.5, 49.2% had high education and 32.8% had high income. Nudging and pricing strategies alone did not significantly increase healthy food purchase (e.g., in the price increase and discount arm B_nudging = 1.8, 95%CI = -0.1; 3.7 and B_pricing= 0.7, 95%CI = -1.2; 2.6), whereas combined salient price increases with discounts led to an absolute increase in the percentage of healthy food purchases (B_{price salience} = 4.5, 95%CI = 2.6; 6.4). Combining salient pricing and nudging strategies led to significant increases in the percentage of healthy products in all three pricing arms, with the largest effect found in the combined price increase and discount arm (B_{price salience and nudging} = 4.0, 95%CI = 2.0; 6.0). These effects were not modified by SEP.

Conclusions: Combining price increases of unhealthy foods with price discounts on healthy foods and advertising these price changes (salience), and combining the salient price strategies with nudges increases healthy food purchases. These effects were similar across socioeconomic subgroups. Further research is needed to estimate the effect of combined nudging and salient pricing strategies in real world settings.

 

Purpose: Food-away-from-home (FAFH, a meal or food item prepared for consumption by a commercial or non-commercial institution) continues to make up a large proportion of the American diet. Over 50% of U.S. adults consume at least three FAFH meals per week. This statistic is concerning because FAFH meals are often higher in calories, saturated fat, sodium, and added sugars compared to home-prepared meals. Several studies have reported racial/ethnic and socioeconomic differences in FAFH purchasing, respectively. There is limited understanding of the how the intersection of these two factors influences FAFH purchasing. Thus, the objective of this research is to evaluate the intersection of race/ethnicity and socioeconomic status (SES) in regards to FAFH purchasing among U.S. households.

 

Methods: We obtained and analyzed cross-sectional data from the United States Department of Agriculture’s (USDA) National Household Food Acquisition and Purchase Survey (FoodAPS). This program collected detailed information on food purchases over a 7-day period for 4,826 households between April 2012 and January 2013. The FAFH data contained information on 116,074 food and beverage items purchased by members of these households. We assessed the relationship between race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and other) and SES (<100%, 100-185%, >185% of the federal poverty line) in regards to several FAFH measures including total money spent ($), total pounds of food acquired, and sources of FAFH (i.e., grocery store, fast food, etc.).

 

Results: Preliminary analyses revealed racial/ethnic and SES differences in total money spent and total pounds of FAFH acquired over the 7-day period. Non-Hispanic black and Hispanic households spent less money on FAFH compared to non-Hispanic white households. On average, the amount of money spent on FAFH increased across levels of SES with >185% households spending the most on FAFH. We observed this trend among all households except non-Hispanic black households. Low-income non-Hispanic black households (i.e., <100%) spent more money on FAFH compared to low-income households of other races.

 

Conclusions: Regression models with interaction terms will assess the intersection of race/ethnicity and SES in regards to FAFH purchasing after adjusting for important covariates such as education level and geographic location.

Purpose:  Tax credits are suggested as one type of economic instrument to alleviate financial barriers to physical activity (PA). We examined potential income disparities in the (1) awareness and uptake of the Child Fitness Tax Credit (CFTC) in Alberta, Canada in 2012 and 2014, and (2) differences in PA and sport participation of children from families who did and did not claim the credit.

Methods: Secondary analyses of three cross-sectional datasets of grade five students (10-11 years) were used, including APPLE Schools in 2012 (N=1037), and Real Kids in 2012 (N=2676) and 2014 (N=3125). For all datasets, parents reported whether they claimed the CFTC in the previous year, their education and household income, and their child’s gender and organized PA from the previous year. Children self-reported their PA from the last 7-days. In APPLE Schools the children also wore time-stamped Omron pedometers for 8 consecutive days. Analyses included chi-square difference tests, and linear and logistic regressions controlling for clustering within schools, child gender, parent education, and household income.

Results: Between 57-70% of parents reported claiming the CFTC in the previous year, and 87-91% were aware of the credit. However, higher income families were more likely to be aware of and to have claimed the credit compared to low income families. A logistic regression analysis showed that children whose parents claimed the credit were more likely to engage in organized PA at least once per week (main effect; OR=3.27-4.25, ps<.01). However, this varied by household income (interaction effect), with the difference in organized PA participation between those who did and did not claim the credit being lower for families who made <$50,000/year (OR=3.27-4.25, ps<.01) compared to families who made >$50,000/year (OR=8.73-9.45, ps<.001). No other effects were observed.

Conclusions: Though the CFTC had some impact on organized PA, it had no impact on overall PA or steps. Furthermore, a clear income disparity exists in the awareness and uptake of the CFTC. Due to the income disparities evident with the CFTC, and the lack of impact on overall PA, this policy is not recommended as an economic instrument to facilitate PA.

Several studies have described the impact that Food Insecurity (FIS) has on different factors at a physical, mental and social level, which is also observed in young adults and adolescents. The aim of the study was to describe the association of food insecurity in undergraduate Mexican students with the presence of anemia, and depression and anxiety predisposition.

An online survey was applied to 1329 young students. FIS was assessed by the Latin American and Caribbean Food Security Scale (ELCSA). To asses depression predisposition, the Patient Health Questionnaire (PHQ-9) was used. And for Anxiety the Generalized Anxiety Disorder Scale (GAD-7) was applied. In a subsample of 286 female students, hemoglobin (Hb) was measured by capillary blood with an HemoCue Hb201+.

A food insecurity (FIS) rate of 58.2% was observed, of which 29.4% was low, 19.9% moderate, and 8.9% severe FIS. The prevalence of low Hb was 14.3%. Regarding depression and anxiety predisposition, it was observed in 58.5% and 67.2% of the subjects respectively. 52.1% of the students presented simultaneously depression and anxiety predisposition. That variable was contrasted with FIS, obtaining an OR of 2.642 (95% CI, 2.110 - 3.306).

This study indicates that the predisposition of depression and anxiety among undergraduate Mexican students is highly related to living with food insecurity. It also indicates a relatively high prevalence of low hemoglobin values (anemia). Food insecurity is a matter of great concern for national and international health agencies since it not only has implications on nutritional, but also mental health.

Purpose: Dietary intake is a key determinant of chronic disease and shares a similar socioeconomic patterning.  Inequities in diet quality may be widening in the US, however recent analyses have not been conducted in other nations. Moreover, prior US studies have only examined change in absolute dietary gaps between more and less advantaged groups. Quantifying change in absolute and relative dietary gaps and gradients according to multiple indicators of socioeconomic position (SEP) can provide a more comprehensive perspective of change, but has not yet been performed. The purpose of this study was, for the first time, to quantify change in absolute and relative gaps and gradients in diet quality between 2004 and 2015 according to three indicators of SEP (household income, household educational attainment and area-level disadvantage) among adults in Canada. Methods: Adults who participated in the nationally representative, cross-sectional 2004 (n=21,200) or 2015 (n=14,300) Canadian Community Health Survey - Nutrition were included. In each year, participants were classified as low-, mid-, or high-SEP based on self-reported equivalized household income, highest household-level educational attainment and residential address (i.e. area-level disadvantage).  Self-reported dietary intake in the previous 24 hours was used to derive a Healthy Eating Index-2015 score from 0-100 representing diet quality at each time point. Bootstrap survey-weighted t-tests and multivariate linear regression models, adjusted for age, sex, race/ethnicity, urban/rural residence and day of data collection, examined change in diet quality over time. Results:  Between 2004 and 2015, diet quality improved in all SEP groups. Absolute and relative dietary inequities according to education and area-level disadvantage remained stable over time. Diet quality improved more in lower compared to higher income groups, leading to a slight narrowing of income-related absolute and relative inequities. Conclusions: This study was the first to quantify change in absolute and relative dietary gaps and gradients internationally. Absolute and relative inequities in diet quality remained stable or narrowed slightly in Canada between 2004 and 2015. Proportionate universalism may help to simultaneously address absolute and relative inequities in diet quality by providing universal access to resources with a scale and intensity proportionate to need.

Purpose:

In 2014, as the Flint, MI lead water crisis began in the USA, the nearby city of Toledo, OH faced a water crisis of its own. A cyanobacteria bloom in Lake Erie (city water supply) caused a neurotoxin called microcystin to contaminate the drinking water. Considering this backdrop and historical racial disproportionality in experiencing environmental contamination, we sought to investigate racial differences in city water avoidance, water intake, and healthfulness of beverage alternatives. 

 

Methods:

We collected survey data in 2017 from residents (n=264) in the UpTown neighborhood of Toledo as part of a larger longitudinal impact assessment study. The survey included a brief food-frequency questionnaire/screener, items about city water avoidance, sociodemographics, and other nutritional/health/economic variables. Data were analyzed cross-sectionally using two sample t-tests and chi-squared tests. 

 

Results:

Mean age was 44.9±13.8 years, 66.8% were women, and median annual household income was very low-income ($7,500). Participants were non-Hispanic black (50.4%), non-Hispanic white (36.7%), mixed race/ethnicity (6.1%), Hispanic/Latino(a) (3.4%), or other races/ethnicities (3.4%). Nearly half (47.0%; n=124) reported avoiding city water; with one-quarter (25.8%; n=68) avoiding due to health/safety concerns, rather than taste/preference (21.2%; n=56). Compared to those not avoiding city water, those avoiding due to health/safety concerns consumed total water significantly less frequently (2.22±1.06 times/day vs. 1.89±1.15; p<0.05; Cohen’s d=0.303). Compared to non-Hispanic white participants, non-Hispanic black participants were significantly more likely to avoid city water due to health/safety concerns (X²(1, N=184)=10.95, p<0.01). Further, of the sub-sample that avoided city water due to health/safety concerns, non-Hispanic black participants consumed sugar-sweetened beverages significantly more frequently than non-Hispanic white participants (1.57±1.72 times/day vs. 0.85±0.90; p<0.05; Cohen’s d=0.466).

 

Conclusions:

This study indicates that within in a low-income area in OH, racial differences may contribute to the level of trust about the health/safety of city water. Non-Hispanic black residents avoiding city water due to health/safety concerns were more likely to consume sugar-sweetened beverages; although, it is unclear how generalizable these findings are. As environmental contamination events become more frequent, likely in relation to global climate change, more research is needed to investigate how these events impact dietary behaviors in the short and long term.