title: Perception of neighborhood problems, health behaviors, and diabetes outcomes among adults with diabetes in managed care: the Translating Research Into Action for Diabetes (TRIAD) study.
abstract: OBJECTIVE
  Recent data suggest that residential environment may influence health behaviors and outcomes. We assessed whether perception of neighborhood problems was associated with diabetes behaviors and outcomes.
  
  
  METHODS
  This cross-sectional analysis included 7,830 diabetic adults enrolled in Translating Research Into Action for Diabetes, a study of diabetes care and outcomes in managed care settings. Perception of neighborhood problems was measured using a summary score of participants' ratings of crime, trash, litter, lighting at night, and access to exercise facilities, transportation, and supermarkets. Outcomes included health behaviors and clinical outcomes. Hierarchical regression models were used to account for clustering of patients within neighborhoods and to adjust for objective neighborhood socioeconomic status (percentage living in poverty) and potential individual-level confounders (age, sex, race/ethnicity, education, income, comorbidity index, and duration of diabetes).
  
  
  RESULTS
  After adjustment, residents of neighborhoods in the lowest tertile (most perceived problems) reported higher rates of current smoking (15 vs. 11%) than those in the highest tertile and had slightly lower participation in any weekly physical activity (95 vs. 96%). In addition, their blood pressure control was worse (25 vs. 31% <130/80 mmHg), and their Short Form 12 scores were slightly lower (44 vs. 46 units for emotional well-being and 43 vs. 44 units for physical well-being); all P < 0.01.
  
  
  CONCLUSIONS
  Neighborhood problems were most strongly associated with more smoking and higher blood pressure, both of which have significant implications for cardiovascular risk. Potential mechanisms that explain these associations should be further explored in longitudinal studies.
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. tgary@jhsph.edu
authors.forename: Tiffany L
authors.initials: TL
authors.lastname: Gary
authors.forename: Monika M
authors.initials: MM
authors.lastname: Safford
authors.forename: Robert B
authors.initials: RB
authors.lastname: Gerzoff
authors.forename: Susan L
authors.initials: SL
authors.lastname: Ettner
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Karter
authors.forename: Gloria L
authors.initials: GL
authors.lastname: Beckles
authors.forename: Arleen F
authors.initials: AF
authors.lastname: Brown
mesh_terms: D000328:Adult; D003415:Crime; D003430:Cross-Sectional Studies; D003710:Demography; D003920:Diabetes Mellitus / Q000453:epidemiology / Q000523:psychology*; D004522:Educational Status; D004777:Environment; D005006:Ethnicity; D005260:Female; D015438:Health Behavior; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010465:Perception; D012907:Smoking / Q000453:epidemiology; D012940:Social Problems / Q000523:psychology*; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology