Delaying high school start times prolongs weekday sleep. However, it is not clear if longer sleep reduces depression symptoms and if the impact of such policy change is the same across groups of adolescents. We examined how gains in weekday sleep impact depression symptoms in 2,134 high school students (mean age 15.16 ± 0.35 years) from the Minneapolis metropolitan area. Leveraging a natural experiment design, we used the policy change to delay school start times as an instrument to estimate the effect of a sustained gain in weekday sleep on repeatedly measured Kandel-Davies depression symptoms. We also evaluated whether allocating the policy change to subgroups with expected benefit could improve the impact of the policy. Over 2 years, a sustained half-hour gain in weekday sleep expected as a result of the policy change to delay start times decreased depression symptoms by 0.78 points, 95%CI (-1.32,-0.28), or 15.6% of a standard deviation. The benefit was driven by a decrease in fatigue and sleep-related symptoms. While symptoms of low mood, hopelessness, and worry were not affected by the policy on average, older students with greater daily screen use and higher BMI experienced greater improvements in mood symptoms than would be expected on average, signaling heterogeneity. Nevertheless, universal implementation outperformed prescriptive strategies. High school start time delays are likely to universally decrease fatigue and overall depression symptoms in adolescents. Students who benefit most with respect to mood are older, spend more time on screens and have higher BMI.

Introduction: Innovative smoking cessation approaches that overcome barriers such as traveling

Surveillance data indicate that food security rates increased among Supplemental Nutrition Assistance Program (SNAP) participants during the COVID-19 pandemic (2020 and 2021) compared with pre-pandemic (2019), but this could have been due to increased participation from better resourced households. Our objective was to examine if demographic differences between SNAP-participating households in each year were responsible for the increased prevalence of food secure households. We calculated the observed 30-d food security prevalence among SNAP-participating households for each year. We used indirect standardisation to produce expected 2020 and 2021 prevalences with 2019 as the standard population using household size, income, age, sex, race, Hispanic ethnicity, presence of children, single parent household, metropolitan status and census region. We calculated standardised prevalence ratios (SPRs) to understand if the observed prevalence was higher than expected given any changes in the demographic profile compared to 2019. The Current Population Survey data were collected by the United States Census Bureau and Department of Agriculture. Our sample included 5,245 SNAP-participating households. The observed prevalence of food secure households increased by 3⋅6 percentage points comparing 2019 to 2020 (SPR = 1⋅06, 95 % confidence interval = 1⋅00, 1⋅11) and by 8⋅6 percentage comparing 2019 to 2021 (SPR = 1⋅13, 95 % confidence interval = 1⋅07, 1⋅18). The greater prevalence of food secure SNAP households during the pandemic did not appear to be attributable to socio-demographic differences compared to pre-pandemic. Despite hesitance among policymakers to expand or enhance social safety net programmes, permanently incorporating COVID-19-related policy interventions could lessen food insecurity in years to come.

Purpose: Smokers can spend a substantial amount on cigarettes, potentially constraining their ability to purchase food. We tested the association of smoking cessation and household food security. Methods: Using the Current Population Survey (2001–2019), we longitudinally linked the Tobacco Use Supplement and the Food Security Supplement (n = 71,278). Among adult smokers (n = 13,144), we used modified Poisson regression to model household food insecurity as a function of quit status (continuing smokers vs. recent quitters), adjusting for sex, age, household size, children in the household, and other household smokers. We also used multinomial logistic regression to examine more detailed food security status (high, marginal, low, very low). Results: The adjusted probability of household food insecurity at follow-up was 11% (95% CI: 8.7%–13%) for recent quitters and 20% (95% CI: 19%–21%) for continuing smokers. Continuing smokers had a lower adjusted probability of high food security (69% vs. 80%) and a higher adjusted probability of marginal (11% vs. 9.8%), low (12% vs. 7%), and very low food security (7.8% vs. 3.6%) compared to recent quitters. Conclusions: Cigarette cessation is associated with a lower risk of household food insecurity. Therefore, promoting tobacco cessation alongside food assistance and poverty reduction policies may help alleviate food insecurity.

The emergency food system (EFS) is a critical part of the United States’ social safety net. Using 2015–2020 Current Population Survey Food Security Supplement data, we identified trends in EFS use among food insecure, low-income households by estimating the probability of EFS use adjusting for demographics using multivariable logistic regression. From 2015 to 2019, between 31.0% and 34.4% of households received emergency food, while 42.4% did in 2020. EFS use did not increase in 2020 compared to prior years for older adults and non-metropolitan households. Targeted outreach should be used to expand the reach of this resource to underserved and marginalized populations.”.

<p>Despite a dramatic reduction in commercial cigarette smoking prevalence in the US, children are still commonly exposed to secondhand smoke (SHS), which is a cause of various pediatric health problems. Further, SHS exposure is patterned by race and class, exacting an inequitable toll on children from families with lesser social and economic advantage. In this issue, Titus and colleagues’ (Am J Epidemiol. XXXX;XXX(XX):XXXX–XXXX) used natural experiment evaluation methods (difference-in-difference) to test whether the recently implemented HUD policy which forbade smoking in and around New York City Housing Authority (NYCHA) buildings impacted child respiratory health. The results from their work remind us that policies do not always impact outcomes as we might expect. Given that policy is one of the most potent tools for population health promotion, this work underlines the need for epidemiology to engage in policy evaluation at all stages of the policy lifecycle, in order to discover comprehensive approaches to policy development and implementation that prioritize equity and address structural racism.</p>

<p>Racism is embedded in society, and higher education is an important structure for patterning economic and health outcomes. Historically Black Colleges and Universities (HBCUs) were founded on anti-racism while predominantly white institutions (PWIs) were often founded on white supremacy. This contrast provides an opportunity to study the association between structural racism and health among Black Americans. We used the National Longitudinal Study of Adolescent to Adult Health (Add Health) to estimate the long-term causal effect of attending an HBCU (vs. PWI) on depressive symptoms among Black students in the United States from 1994-2018. While we found no overall association with attending an HBCU (vs. PWI) on depressive symptoms, we found that this association varied by baseline mental health and region, and across time. For example, among those who attended high school outside of the South, HBCU attendance was protective against depressive symptoms 7 years later, and the association was strongest for those with higher baseline depressive symptoms. We recommend equitable state and federal funding for HBCUs, and that PWIs implement and evaluate antiracist policies to improve mental health of Black students.</p>

BACKGROUND Cancer survivors are at increased risk of pain due to their either cancer and/or treatments. Substances like alcohol may be used to self-medicate cancer pain; however, these substances pose their own health risks that may be more pronounced for cancer survivors. METHODS We used cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS) 2012-2019 to quantify the association between cancer pain and alcohol use. We used negative binomial regression, with interaction terms added to examine variations across age, sex, and race. We also examined whether alcohol use relates to cancer pain control status. RESULTS Cancer survivors with cancer pain were more likely to be younger, female, Black, and to have been diagnosed with breast cancer. Cancer pain was associated with lower alcohol consumption (incidence rate ratio (IRR): 0.88, confidence interval (CI): 0.77, 0.99). This association was primarily among people 65 and older, women, and white and Hispanic people. Cancer pain control status was not related to alcohol use. CONCLUSIONS Lower alcohol use among cancer survivors with pain has many possible explanations, including several alternative pain management strategies or a decrease in social engagement. Our findings of racial and gender disparities in cancer pain are consistent with the broader evidence on disparities in pain. IMPLICATIONS FOR CANCER SURVIVORS Cancer pain management for marginalized groups should be improved. Healthcare providers should screen cancer survivors for both pain and substance use, to prevent unhealthy self-medication behaviors.

Background: Sleep duration, quality, and timing may influence dietary quality. In adults, poor dietary quality is a risk factor for numerous chronic diseases. It is unclear how these various sleep domains influence adolescents' diets because prior population-based studies have not effectively manipulated sleep, did not include objective sleep measures, and had short follow-up times. Objectives: The objectives of this study were to examine 1) how adolescent sleep characteristics relate to dietary quality; and 2) how delay in high school start times (which lengthened sleep duration) affects dietary quality over 2 y. Methods: In the START study, adolescents (grades 9-11, n = 423) attending 5 high schools in the Minneapolis, Minnesota metropolitan area were annually assessed in 3 waves (2016-2018). At Baseline, all schools started "early"(07:30 or 07:45). From Follow-up 1 through Follow-up 2, 2 "policy change schools"shifted to later start times (to 08:20 and 08:50). Three "comparison schools"maintained their early start throughout. Sleep characteristics were measured with actigraphy. Mixed-effect regression models were used to examine cross-sectional and longitudinal associations of sleep characteristics with dietary quality, and school start time policy change with dietary quality change. Results: Cross-sectionally, later sleep midpoint and onset were associated with dietary quality scores 1.6-1.7 lower (both P < 0.05). However, no prospective associations were observed between sleep characteristics and dietary quality in longitudinal models. Shifting to later school start time tended to be associated with a 2.4-point increase in dietary quality score (P = 0.09) at Follow-up 1, but was not associated with change in dietary quality scores at Follow-up 2 (P = 0.35). Conclusions: High school students attending delayed-start schools maintained better dietary quality than students in comparison schools; however, differences were not statistically significant. Overall study findings highlight the complexity of the relation between sleep behavior and diet in adolescence.

Purpose: Few adolescents spend enough time asleep on school nights. This problem could be addressed by delaying high school start times, but does this translate to reduced prevalence of sleep–wake problems like awakening too early or feeling sleepy during the day? Methods: The START study (n = 2,414) followed a cohort of students from five Minnesota high schools to evaluate impacts of school start time delays. Participants were enrolled in ninth grade (Baseline) when all schools started early (7:30 or 7:45 A.M.). At Follow-Up 1 (10th grade) and Follow-Up 2 (11th grade), two schools had delayed their start times by 50 and 65 minutes while three comparison schools started at 7:30 A.M. Six sleep–wake behaviors were assessed at all three time points via survey. Generalized estimating equation models were used to investigate changes in sleep–wake problems between policy change and comparison schools. Results: The prevalence of sleep–wake problems at Baseline ranged from 11% for being late to class due to oversleeping to 48% for needing to be told to wake multiple times in the morning. Compared to students from comparison schools, students at policy change schools reported smaller increases in the prevalence of feeling sleepy daily and oversleeping and being late to class between 9th and 11th grade. After implementation of the delayed start, awakening too early was more common among students at policy change schools compared to the comparison schools. Conclusions: This longitudinal study provides evidence that delaying high school start times reduces daytime sleepiness and school tardiness.

Background: A steep rise in food insecurity is among the most pressing US public health problems that has resulted from the COVID-19 pandemic. Objective: This study aimed to (1) describe how food-insecure emerging adults are adapting their eating and child-feeding behaviors during COVID-19 and (2) identify barriers and opportunities to improve local food access and access to food assistance. Design: The COVID-19 Eating and Activity Over Time study collected survey data from emerging adults during April to October 2020 and completed interviews with a diverse subset of food-insecure respondents. Participants/setting: A total of 720 emerging adults (mean age: 24.7 ± 2.0 years; 62% female; 90% living in Minnesota) completed an online survey, and a predominately female subsample (n = 33) completed an interview by telephone or videoconference. Main outcome measures: Survey measures included the short-form of the US Household Food Security Survey Module and 2 items to assess food insufficiency. Interviews assessed eating and feeding behaviors along with barriers to healthy food access. Analyses performed: Descriptive statistics and a hybrid deductive and inductive content analysis. Results: Nearly one-third of survey respondents had experienced food insecurity in the past year. Interviews with food-insecure participants identified 6 themes with regard to changes in eating and feeding behavior (eg, more processed food, sporadic eating), 5 themes regarding local food access barriers (eg, limited enforcement of COVID-19 safety practices, experiencing discrimination), and 4 themes regarding barriers to accessing food assistance (eg, lack of eligibility, difficulty in locating pantries). Identified recommendations include (1) expanding the distribution of information about food pantries and meal distribution sites, and (2) increasing fresh fruit and vegetable offerings at these sites. Conclusions: Interventions of specific relevance to COVID-19 (eg, stronger implementation of safety practices) and expanded food assistance services are needed to improve the accessibility of healthy food for emerging adults.

Background Research has shown that early high school start times, which are asynchronous with adolescent biology, are one of the most significant obstacles to youth being able to net sufficient sleep. Given that adolescence is a critical period that sets the stage for long-term obesity risk behavior patterns, there is an need to understand the obesity-related implications of increased sleep as a result of intervention and policy changes. Methods We evaluated a community-based natural experiment in school start time policy modification when several Minneapolis-St. Paul, MN metro area school districts shifted to later school start times in Fall 2016. We collected data on student weight and related risks (via paper survey, objective weight and height measurement, dietary recall, and sleep actigraphy) before and after two districts (two high schools) shifted their start times later and in a comparison district (three high schools) which kept their start times early (7:30am) through the course of the study. Our specific aims were: 1) Determine how a shift to a later high school start time relates to objectively measured weight change over time. 2) Identify the relationship between school start times and obesity-related behaviors over time.At baseline we had 2,133 returned surveys (93% participation) and 2,037 (86% participation) objective height/weight measurements from 9th grade students (class of 2019) in the five schools. The sample was 87.7% white, 12.8% reported qualifying for free/reduced price lunch (a measure of lower socio-economic status), and the mean age was 15.2 (SD=0.35) years. Discussion The products of this research will clarify causal connections between sleep and obesity among adolescents as well as provide evidence for whether a school start time policy can minimize unhealthy weight gain.

<h3>Importance</h3><p>Sleep is a resource that has been associated with health and well-being; however, sleep insufficiency is common among adolescents.</p><h3>Objective</h3><p>To examine how delaying school start time is associated with objectively assessed sleep duration, timing, and quality in a cohort of adolescents.</p><h3>Design, Setting, and Participants</h3><p>This observational cohort study took advantage of district-initiated modifications in the starting times of 5 public high schools in the metropolitan area of Minneapolis and St Paul, Minnesota. A total of 455 students were followed up from grade 9 (May 3 to June 3, 2016) through grade 11 (March 15 to May 21, 2018). Data were analyzed from February 1 to July 24, 2019.</p><h3>Exposures</h3><p>All 5 participating schools started early (7:30amor 7:45am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), 2 schools delayed their start times by 50 and 65 minutes, whereas 3 comparison schools started at 7:30amthroughout the observation period.</p><h3>Main Outcomes and Measures</h3><p>Wrist actigraphy was used to derive indices of sleep duration, timing, and quality. With a difference-in-difference design, linear mixed-effects models were used to estimate differences in changes in sleep time between delayed-start and comparison schools.</p><h3>Results</h3><p>A total of 455 students were included in the analysis (among those identifying sex, 225 girls [49.5%] and 219 boys [48.1%]; mean [SD] age at baseline, 15.2 [0.3] years). Relative to the change observed in the comparison schools, students who attended delayed-start schools had an additional mean 41 (95% CI, 25-57) objectively measured minutes of night sleep at follow-up 1 and 43 (95% CI, 25-61) at follow-up 2. Delayed start times were not associated with falling asleep later on school nights at follow-ups, and students attending these schools had a mean difference-in-differences change in weekend night sleep of −24 (95% CI, −51 to 2) minutes from baseline to follow-up 1 and −34 (95% CI, −65 to −3) minutes from baseline to follow-up 2, relative to comparison school participants. Differences in differences for school night sleep onset, weekend sleep onset latency, sleep midpoints, sleep efficiency, and the sleep fragmentation index between the 2 conditions were minimal.</p><h3>Conclusions and Relevance</h3><p>This study found that delaying high school start times could extend adolescent school night sleep duration and lessen their need for catch-up sleep on weekends. These findings suggest that later start times could be a durable strategy for addressing population-wide adolescent sleep deficits.</p>

Purpose. To estimate the effect of Healthy, Hunger-Free Kids Act of 2010 (HHFKA) implementation on dietary quality of all US school-aged children and adolescents, and examine whether those effects differed by demographic group. Methods. We used survey regression on 2007-2016 National Health and Nutrition Examination Survey (NHANES) data to estimate the proportion of energy intake from school foods and the association between school food intake and dietary quality, before and after HHFKA passage/implementation. To account for demographic changes in the US population over time, inverse probability weighting was employed. The product of the proportion of energy from school foods and the association between school food intake and dietary quality estimated the effect of HHFKA implementation on dietary quality. Results. School food intake quantity remained stable during the study period. HHFKA implementation improved students' dietary quality by 4.3 Healthy Eating Index-2010 (HEI) points (95% CI: 2.5, 6.1) on days when school foods were eaten, and by 1.3 HEI points (95% CI: 0.73, 1.8) averaged over all days annually. Conclusions. HHFKA implementation improved the total dietary quality of US school students. US students would benefit from eating school meals in the post-HHFKA era, and HHFKA regulations should not be relaxed.