Friday, July 16, 2021

Trends in Diversity and Representativeness of Health Care Workers in the United States, 2000 to 2019

Introduction

Despite evidence that greater diversity among health care workers may allow them to better care for patients with diverse cultural, social, economic, and clinical needs,¹^-3 data are limited on trends in diversity and representativeness of US health care workers by occupation. Using US Census data from 2000 to 2019, we examined national trends in representativeness in select health care occupations by race/ethnicity and sex.

Methods

In this cross-sectional study, we used 2 data sources: (1) the Decennial Census long form, a nationally representative, US Census–administered survey, from 2000, and (2) the American Community Survey, a nationally representative Census-administered survey, from 2001 to 2019. Response rates for both exceeded 90%.⁴^,5 This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The University of California Los Angeles institutional review board determined that the study was not human subjects research and therefore exempt from review and the requirement for informed consent.

Occupation, race, (White, Black, American Indian or Alaska Native, Chinese, Japanese, other Asian or Pacific Islander, other race, 2 major races, or ≥3 major races) and ethnicity (not Hispanic, Mexican, Puerto Rican, Cuban, and other Hispanic origin) were self-reported. Participants who selected Chinese, Japanese, or other Asian or Pacific Islander were included into the category Asian. Participants who selected Mexican, Puerto Rican, Cuban, and other were included in the Hispanic category. Participants who selected other race, 2 major races, or 3 or more major races were excluded, leaving 4 groups: non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic. We estimated the composition of select health care occupations (Table 1) by race/ethnicity and sex in 2000 to 2004 and 2015 to 2019. For each occupation, we calculated the change in percentage in each race/ethnicity and sex subgroup between these 2 periods using linear regression. In addition, in each occupation, we assessed the population representativeness of each race/ethnicity and sex subgroup by calculating the ratio of the percentage of a specific subgroup in an occupation (eg, Black male physicians) to the percentage of the US population in that subgroup (eg, Black men).⁶ We used Census-provided sampling weights to make nationally representative estimates. P values were from 2-sided tests, and results were deemed statistically significant at P < .05. Analyses were conducted in Stata version 16.1 (StataCorp).

Results

Our study included 1 648 924 individuals (1 303 496 [79.1%] women; 345 428 [20.9%] men) across 6 health care occupations (Table 1). The percentage of White men in relatively more remunerative occupations (ie, physicians and surgeons, pharmacists, and dentists) decreased between 2000 to 2004 and 2015 to 2019. For example, the percentage of physicians and surgeons who were White men decreased from 54.1% (95% CI, 53.3% to 54.9%) to 43.8% (95% CI, 43.3% to 44.3%) (difference, −10.3 [95% CI, −11.2 to −9.3] percentage points), while the percentage of dentists who were White men decreased 15.6 (95% CI, 13.5 to 17.6) percentage points. Little to no change was observed in the percentage of men from underrepresented minorities in these occupations. For example, no change was observed in the percentage of physicians and surgeons who were Hispanic men (difference, 0.2 [95% CI, −0.2 to 0.6] percentage points) or in the percentage of pharmacists who were Black men (difference, −0.06 [95% CI, −0.8 to 0.6] percentage points). Statistically significant increases were observed in the percentage of both Black and Hispanic women in these 3 occupations. For example, the percentage of pharmacists who were Black women increased 1.3 (95% CI, 0.6 to 2.0) percentage points, and the percentage of dentists who were Hispanic women increased 1.0 (95% CI, 0.4 to 1.7) percentage points. Increases for White and Asian women in these occupations were larger than for Black and Hispanic women.

Significant increases were observed among most minority race/ethnicity and sex subgroups in less remunerative occupations (ie, nurses, therapists, and health care aides). In an analysis of population representativeness in 2015 to 2019, Black and Hispanic men and women remained considerably underrepresented relative to the US population in more remunerative occupations (Table 2).

Discussion

In a nationally representative sample, little to no increase in Black or Hispanic men was observed among physicians and surgeons, pharmacists, and dentists between 2000 and 2019. While there were increases in Black and Hispanic women in these occupations, increases among White and Asian women were larger. Altogether, increases in representation of these 4 subgroups of women were accompanied by large declines in the proportion of White men. Other health care occupations, such as nurses, therapists, and health care aides, had increases across most minority subgroups during the examined period. These results quantify the current representativeness of the US health care workforce and changes in its composition during the past 2 decades. Study limitations include the use of self-reported survey data.

Article Information

Accepted for Publication: May 12, 2021.

Published: July 15, 2021. doi:10.1001/jamanetworkopen.2021.17086

Corresponding Author: Anupam B. Jena, MD, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (jena@hcp.med.harvard.edu).

Author Contributions: Dr Ly had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Both authors.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Both authors.

Supervision: Jena.

Conflict of Interest Disclosures: Dr Jena reported receiving consulting fees from Pfizer; Bioverativ; Bristol Myers Squibb; Merck, Sharp, and Dohme; Janssen Pharmaceuticals; Edwards Life Sciences; Novartis; Amgen; Eli Lilly and Co; Vertex Pharmaceuticals; AstraZeneca; Celgene; Tesaro; Sanofi Aventis; Precision Health Economics; and Analysis Group outside the submitted work. No other disclosures were reported.

Disclaimer: The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs or the US government.

References

Alsan M, Garrick O, Graziani G. Does diversity matter for health? experimental evidence from Oakland. Am Econ Rev 2019; 109: 4071-4111. doi:10.1257/aer.20181446 Google Scholar Crossref

Mertz EA, Wides CD, Kottek AM, Calvo JM, Gates PE. Underrepresented minority dentists: quantifying their numbers and characterizing the communities they serve. Health Aff (Millwood). 2016;35(12):2190-2199. doi:10.1377/hlthaff.2016.1122 PubMed Google Scholar Crossref

Institute of Medicine. In the nation’s compelling interest: ensuring diversity in the health-care workforce. Accessed May 4, 2021. https://www.nap.edu/catalog/10885/in-the-nations-compelling-interest-ensuring-diversity-in-the-health

Griffin DH, Love SP, Obenski SM. Can the American Community Survey replace the Census long form? Accessed May 4, 2021. http://www.asasrms.org/Proceedings/y2003/Files/JSM2003-000596.pdf

IPUMS USA. Select samples. Accessed May 4, 2021. https://usa.ipums.org/usa-action/samples

Lett LA, Murdock HM, Orji WU, Aysola J, Sebro R. Trends in racial/ethnic representation among US medical students. JAMA Netw Open. 2019;2(9):e1910490. doi:10.1001/jamanetworkopen.2019.10490
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Key Points

Question What are the experiences of Black and Latinx communities during the COVID-19 pandemic, and how are these experiences associated with their perspectives on COVID-19 mitigation behaviors, testing, and vaccines?

Findings This community-engaged qualitative study found that fear, illness, and loss experienced during the pandemic motivated information seeking and mitigation behaviors; vaccine skepticism was high, as was demand for clearer information. Among Black participants, racism and medical experimentation were associated with distrust.

Meaning These findings suggest that perspectives on COVID-19 mitigation behaviors, testing, and vaccines among Black and Latinx communities are informed by devastating experiences, and transparent information from public officials is needed to eliminate vaccine skepticism.

Abstract

Importance Black and Latinx communities have been disproportionately affected by the COVID-19 pandemic, yet little work has sought to understand their perspectives.

Objective To explore the experiences of Black and Latinx communities during the pandemic to better understand their perspectives on COVID-19 mitigation behaviors (eg, mask wearing), testing, and vaccines.

Design, Setting, and Participants In this community-engaged qualitative study conducted with 18 community-based organizations and 4 health care organizations between November 19, 2020, and February 5, 2021, in New Jersey counties severely affected by the pandemic, group and individual interviews were used to purposively sample 111 Black and Latinx individuals. A total of 13 group interviews were organized by race/ethnicity and language: 4 English-speaking groups with Black participants (n = 34), 3 Spanish-speaking groups with Latinx participants (n = 24), and 4 English-speaking groups with Black and Latinx participants (n = 36). To understand the views of health care workers from these communities, 2 additional groups (n = 9) were convened and supplemented with individual interviews.

Main Outcomes and Measures Description of Black and Latinx participants’ experiences during the COVID-19 pandemic and their perspectives on mitigation behaviors, testing, and vaccines.

Results The study included 111 participants (87 women [78.4%]; median age, 43 years [range, 18-93 years]). Participants described the devastating effects of the pandemic on themselves, loved ones, and their community. Their experiences were marked by fear, illness, loss, and separation. These experiences motivated intense information seeking, mitigation behaviors, and testing. Nevertheless, vaccine skepticism was high across all groups. Participants did not trust the vaccine development process and wanted clearer information. Black participants expressed that they did not want to be subjects of experiments.

Conclusions and Relevance The remaining unknowns about new vaccines need to be acknowledged and described for Black and Latinx communities to make informed decisions. Ultimately, scientists and public officials need to work transparently to address unanswered questions and work collaboratively with trusted community leaders and health professionals to foster partnered approaches, rather than focusing on marketing campaigns, to eliminate vaccine skepticism.

Introduction

As of May 2021, the US has the highest number of cases and deaths in the world. Within the US, the pandemic is disproportionately affecting Black and Latinx groups.¹^,2 For example, age-adjusted mortality rates for Black and Latinx Americans far exceed those for White Americans.³ Multiple factors are associated with this inequality, including comorbid conditions that increase susceptibility and disease severity.⁴^,5 Disparities in COVID-19 outcomes are also a function of structural and institutional racism.⁶ Factors such as residential segregation, wealth inequality, and mass incarceration impact the ability of members from different racial/ethnic and socioeconomic groups to avoid infection and seek care.⁷^-11 These factors are the legacy of slavery, Jim Crow laws (state and local laws enacted in the late 19th and early 20th centuries that enforced racial segregation in the southern United States), and discriminatory public health interventions that together are associated with a pervasive sense of distrust of public health authorities.¹²^,13

Black and Latinx groups have been the target of multiple discriminatory health interventions.¹⁴ Experiences including experimentation during slavery, the Tuskegee Syphilis Study, and the contraception trials in Puerto Rican women, predispose Black and Latinx communities to skepticism about public health interventions.¹²^,15 Today, this history provides critical context for the strategies needed to fight the COVID-19 pandemic, including Centers for Disease Control and Prevention–recommended mitigation behaviors (eg, mask wearing, handwashing, and physical distancing), testing, and vaccines.¹⁶ In recent surveys, Black, Latinx, and low-income respondents were much less likely to report trust in public health officials in association with COVID-19, compared with White respondents.¹⁷ Black and Latinx adults are also more likely to “wait and see” before receiving the COVID-19 vaccination.¹⁸

Surveys, news reports, and anecdotes have brought attention to the inequities experienced by Black and Latinx communities during the COVID-19 pandemic.¹⁷^,19 To date, little work has delved deeply into the experiences of these communities to better understand their perspectives on COVID-19 mitigation behaviors, testing, and vaccines. Such information is critical to develop appropriate public health messages and strategies. Therefore, this study explores the experiences of Black and Latinx adults during the pandemic to understand how these experiences are associated with their perspectives on COVID-19 public health strategies.

Methods

We conducted online group and individual interviews as part of NJ HEROES TOO (New Jersey Healthcare Essential Worker Outreach and Education Study–Testing Overlooked Occupations),²⁰^,21 funded by the National Institutes of Health Rapid Acceleration of Diagnostics–Underserved Populations (RADx-UP) Initiative.²² The RADx-UP Initiative seeks to better understand disparities among underserved populations, including access to testing. We purposively sampled Black and Latinx individuals from New Jersey counties (ie, Essex, Middlesex, Passaic, and Union) with high rates of COVID-19 infections and deaths during the initial surge in 2020, high levels of poverty, and large concentrations of Black and Latinx populations. Adults older than 18 years of age who identified as Black or Latinx with English or Spanish as their primary language were eligible. We partnered with 18 community-based organizations and 4 health care organizations in these counties. Through biweekly online meetings, representatives helped with development of the research protocol, recruitment, and debriefing sessions to help interpret findings.²³ This study was approved by the Rutgers Biomedical Health Sciences institutional review board and follows the Standards for Reporting Qualitative Research (SRQR) reporting guideline.²⁴ All participants provided verbal consent prior to participation.

Data Collection

We organized 13 group interviews and 8 individual interviews between November 19, 2020, and February 5, 2021, using a secure Zoom platform. Group interviews had a primary and secondary facilitator (M.E.J., D.H., D.L., and/or S.V.H.) with 2 study team members (Z.R.-N., M.B.P., M.M., and/or E.M.A.) for notetaking and technical assistance. Facilitators followed the interview guide, which we developed through literature review, the team’s experience, and partner feedback (eMethods in the Supplement). We adapted and added questions to explore emerging themes. Group interviews were organized by race/ethnicity and language: 4 English-speaking groups with Black participants, 3 Spanish-speaking groups with Latinx participants, and 4 English-speaking groups that included Black and Latinx participants (Figure). We also conducted 2 group interviews with Black and Latinx participants who worked in health care settings as ancillary or support staff, given their unique perspective as health care workers and community members. We supplemented health care worker group interviews with 8 individual interviews to accommodate their schedules. Group interviews lasted approximately 90 minutes, and individual interviews lasted 20 to 30 minutes. All interviews were recorded and transcribed. We used ATLAS.ti 8 software (ATLAS.ti) to facilitate data management.

Data Analysis

We used an “editing” approach to analyze the data.²⁵ Transcripts were first read openly to gain an initial sense of the group conversation. On a second reading, meaningful segments of text were highlighted, then cut, pasted, and rearranged to create 4- to 5-page summaries organized around emerging themes. We then analyzed the summaries together of groups with only Black participants to identify themes that were common to those groups; subsequently, we identified themes in summaries of groups with only Latinx participants in the same manner. Looking across both sets, we then identified the themes common to both groups. At that point, we analyzed the groups with Black and Latinx participants to confirm or disconfirm the existing findings and found that we had achieved data saturation—no new themes emerged from this analysis. Finally, we analyzed health care worker data, using the same process, which yielded similar findings; therefore, we include health care worker perspectives under our key themes.

Results

We recruited 200 individuals, 64 of whom were not eligible and 25 did not attend, for a final sample of 111 individuals (87 women [78.4%]; 68 Black participants [61.3%] and 43 Latinx participants [38.7%]; median age, 43 years [range, 18-93 years]). The Table summarizes sample demographic characteristics, and the eTable in the Supplement summarizes demographic characteristics by group. We identified 2 key themes from the data: (1) the devastating effects of the pandemic motivated intense information seeking and mitigation behaviors and testing and (2) even within that context, vaccine skepticism was high (Box).

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Black and Latinx Community Perspectives on COVID-19 Mitigation Behaviors, Testing, and Vaccines | Vaccination | JAMA Network Open | JAMA Network

Black, Latinx people confident in COVID-19 safety precautions but skeptical about vaccines

A Rutgers study finds vaccine campaigns in Black and Latinx communities depend on transparent information and building on trusted relationships

RUTGERS UNIVERSITY

Research News

Black and Latinx people intensely sought information on COVID-19 and engaged in public health measures such as mask-wearing and testing due to devastating experiences during the pandemic but are still skeptical about vaccines, according to a Rutgers study.

The findings, which appear in JAMA Network Open, offer insight into what motivates people in Black and Latinx communities - which have been disproportionately affected by the pandemic - to embrace COVID-19 safety precautions but to hesitate about vaccines. The findings may also help to develop appropriate public health messages and strategies.

Researchers interviewed 111 Black and Latinx people from New Jersey low-income counties with high rates of COVID-19 infections and deaths during the initial surge in 2020. They also interviewed health care workers in these communities to understand their views.

"Fear, illness and loss experienced during the pandemic motivated them to intensely seek information and take safety precautions like wearing a mask, social distancing and washing hands to protect themselves and loved ones," said co-author Manuel Jimenez, an assistant professor of pediatrics, family medicine and community health at Rutgers Robert Wood Johnson Medical School. "However, participants did not trust the vaccine development process and wanted clearer information."

The study found that:

Latinx participants, in particular, reported difficulty finding testing sites, transportation issues and language barriers. This was more pronounced for undocumented people who were told to pay for testing if they are ineligible for unemployment benefits and other assistance programs.
Some participants did not feel safe inside or outside their homes, and described uncertainty about who among them had the virus. Crowded living conditions resulted in contact with neighbors and housemates who had COVID-19.
Participants questioned how a vaccine for a new virus could be developed so rapidly when other diseases have been around for decades without successful vaccines. They also expressed concerns that the vaccine development process, including that clinical trials had been "rushed," and worried about the short- and long-term side effects.
They questioned whether vaccines would work against variants and wanted clear and transparent information on vaccine effectiveness. Many wanted to see how others would respond to vaccination first.
Black participants mentioned distrust of health care systems and government, citing experience of racism, discriminatory interventions and medical experimentation.

"We need to reduce logistical barriers and improve access to testing within underserved communities, regardless of documentation status," said co-principal investigator Shawna Hudson, professor and research division chief in the Department of Family Medicine and Community Health at Rutgers Robert Wood Johnson Medical School. "Health care providers should offer convenient testing options, accessible sites within walking distance, translated information and transparency about free testing to address these barriers."

Logistical barriers to testing must be addressed and vaccine skepticism needs to be taken seriously, the report concluded, the researchers said.

"The remaining unknowns about new vaccines need to be acknowledged and described for these communities to make informed decisions," Jimenez said. "Scientists and public officials need to work collaboratively with trusted community leaders and health professionals to provide transparent information, including remaining unknowns, so that these communities can make informed decisions rather than focusing on marketing campaigns to eliminate vaccine hesitancy."

###

The study was conducted as part of NJ HEROES TOO (New Jersey Healthcare Essential Worker OutReach and Education Study - Testing Overlooked Occupations) in collaboration with 18 community-based organizations and four health care organizations, funded by the NIH Rapid Acceleration of Diagnostics Underserved Populations (RADx-UP) Initiative.

Other Rutgers authors include Zorimar Rivera-Núñez, Benjamin F. Crabtree, Diane Hill, Maria B. Pellerano, Donita Devance, Myneka Macenat, Daniel Lima, Emmanuel Martinez Alcaraz, Jeanne M. Ferrante, Emily S. Barrett, Martin J. Blaser and Reynold A. Panettieri Jr.

Body mass index as a risk factor for diabetes varies throughout the world

A new study provides the first empirical evidence for tailoring BMI thresholds for diabetes screening in low- and middle-income countries.

MASSACHUSETTS GENERAL HOSPITAL

Research News

BOSTON - The unprecedented increase in overweight and obesity in low- and middle-income countries (LMICs) has led to an alarming rise in diabetes in these regions. Of the estimated 463 million people with diabetes worldwide, 79% live in LMICs.

Until now, however, there were scant empirical data to guide clinicians and health systems in determining which individuals should be screened for diabetes based on body mass index (BMI). "There are guidelines from the World Health Organization that recommend screening individuals age 40 and older with a BMI of 25 kg/m2 and above for diabetes," says Jennifer Manne-Goehler, MD, ScD, faculty member at the Medical Practice Evaluation Center at Massachusetts General Hospital (MGH). "But it's long been suspected that these BMI and age thresholds may not be optimal for diabetes screening in all regions of the world. Our goal was to estimate the relationship between BMI and diabetes risk across many low- and middle-income countries to help resource-strapped health systems devise the most effective screening programs for their populations," says Manne-Goehler, senior author of a new study published in The Lancet.

Manne-Goehler and investigators from 57 countries spent five years compiling and leveraging existing datasets of more than 680,000 people in LMICs that included every individual's weight, height and a diabetes biomarker--either a blood glucose measurement or hemoglobin A1c.

The study, the first of its kind, found substantial regional differences in the association between BMI and diabetes risk. Across all LMICs, people with a BMI of 23 kg/m2 or greater had an increased risk of diabetes. There was, however, variability in the optimal BMI to choose for diabetes screening among regions and genders, ranging from 23.8 kg/m2 among men in East/Southeast Asia to 28.3 kg/m2 among women in the Middle East, North Africa, Latin America and the Caribbean. The investigators also found differences in the risk of diabetes across BMI categories in several regions. For example, men and women in sub-Saharan Africa and East/Southeast Asia had more than a 100% increase in the risk of diabetes between being overweight and obese. These findings, in part, reinforced a growing literature from Asian and South Asian countries that recommends using lower BMI thresholds to better characterize metabolic risk in these populations.

And while diabetes increased in middle age and beyond, the proportion of individuals with diabetes rose steeply across all regions in the 35-to-44 age group, and among men 25 to 34 years old in sub-Saharan Africa. "Diagnosing diabetes in younger adults can prevent long-term complications of the disease," says Manne-Goehler.

"Although the data aren't prescriptive, our hope is that policymakers in LMICs will find this evidence useful as they try to decide how they will spend limited resources to optimize diabetes screening for their particular populations," she adds.

The research also demonstrates the power of collaborations among countries to create important evidence to inform public health guidelines. "It's difficult to draw meaningful high-level global conclusions when individual countries are examining diabetes risk in only one country's survey," says Manne-Goehler. The World Health Organization is creating a global strategy called the Global Diabetes Compact to scale up care for people with diabetes, for example. "We believe that our collaboration of many investigators across these 57 countries can help inform best diabetes screening practices throughout the world," she says.

"LMICs now have evidence-based specific answers to the 'Who? When? and How much?' regarding diabetes prevention and screening in relation with BMI," writes Siméon Pierre Choukem, MD, dean of the faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Cameroon, in a related commentary in The Lancet. "These results have major public health implications as the actual burden of diabetes in LMICs is probably underestimated because of the current screening guidelines, and it is unclear to what extent."

The global team of investigators are now studying how waist circumference might increase the accuracy of diabetes risk assessment when used with BMI, and they are also examining the relationship between behavioral factors--alcohol, smoking, physical activity and diet--and risk of diabetes across these 57 countries. In the future, the researchers also hope to create collaborations that include surveys from high-income countries to facilitate direct comparisons across a wider spectrum of global health settings. "Health systems in every country in the world have to make the best use of their resources to improve the health of their populations," says Manne-Goehler.

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Manne-Goehler is an attending physician in the Division of Infectious Diseases at Brigham and Women's Hospital. First author Felix Teufel is a medical student and research assistant at the Heidelberg Institute of Global Health, Heidelberg University Hospital, Germany. Second author Jacqueline Seiglie, MD, MSc, is an endocrinologist and global health fellow at MGH and an instructor in Medicine at Harvard Medical School (HMS). The other MGH co-authors are James Meigs, MD, MPH, co-director of the MGH Clinical Research Program's Clinical Effectiveness Research Group and professor of Medicine at HMS, and Deborah Wexler, MD, MSc, associate clinical chief of the MGH Diabetes Unit, clinical director of the MGH Diabetes Center and associate professor of Medicine at HMS.

About the Massachusetts General Hospital
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In August 2020, Mass General was named #6 in the U.S. News & World Report list of "America's Best Hospitals."

Study shows diet causes 84% drop in troublesome menopausal symptoms--without drugs

PHYSICIANS COMMITTEE FOR RESPONSIBLE MEDICINE

Research News

WASHINGTON--A new study, published by the North American Menopause Society in the journal Menopause, found a plant-based diet rich in soy reduces moderate-to-severe hot flashes by 84%, from nearly five per day to fewer than one per day. During the 12-week study, nearly 60% of women became totally free of moderate-to-severe hot flashes. Overall hot flashes (including mild ones) decreased by 79%.

The study, called the WAVS trial--the Women's Study for the Alleviation of Vasomotor Symptoms-shows that diet changes can be much more powerful for treating hot flashes than scientists had thought. Vasomotor symptoms refer to night sweats, hot flashes, and flushes.

The study used no hormone medications or extracts. Instead, the research team tested a combination of a low-fat plant-based diet plus 1/2 cup of ordinary soybeans added to a salad or soup each day.

"This is a game changer for women aged 45 and over, most of whom we now know can get prompt relief from the most severe and troubling menopause symptoms without drugs," says lead researcher Neal Barnard, MD, president of the Physicians Committee and adjunct professor at the George Washington University School of Medicine.

As many as 80% of postmenopausal women suffer from hot flashes. Heat wells up from the chest, causing flushing, sweating, and chills. At night, hot flashes interfere with sleep. Estrogen-based medications were once routinely used to treat hot flashes but have been shown to increase the risk of breast cancer and other serious problems. Isoflavone extracts from soybeans work only modestly, leaving women and their doctors with few effective options.

Study Details

Postmenopausal women reporting two or more hot flashes per day were randomly assigned to either an intervention group--consisting of a low-fat, vegan diet, including half a cup of cooked soybeans daily--or to a control group that made no diet changes for 12 weeks. Frequency and severity of hot flashes were recorded using a mobile application, and vasomotor, psychosocial, physical, and sexual symptoms were assessed using the Menopause Specific Quality of Life Questionnaire (MENQOL).

Each participant was given a digital self-calibrating scale to track body weight day by day, a mobile app to track hot flashes in real time, and an Instant Pot to prepare soybeans at home. Each week, the group got together with the research team via Zoom.

"Previous studies have shown that soy could be beneficial, so we decided to put a diet change to the test," says study author Hana Kahleova, MD, PhD, director of clinical research for the Physicians Committee. "We believe that the combination is what is important. By the end of the study, the majority of women on a plant-based diet rich in soy reported that they no longer experienced moderate-to-extreme hot flashes at all and that they experienced significant improvements in their quality of life."

Key Findings

Total hot flashes decreased by 79% and moderate-to-severe hot flashes decreased by 84% in the intervention group. At the study's conclusion, 59% of intervention-group participants reported becoming free of moderate and severe hot flashes. There was no change in this variable in the control group.

In previous randomized trials, soy products have been shown to modestly reduce the frequency of hot flashes. The researchers theorize that the effect may be a result of soy products containing isoflavones, which can be metabolized by gut bacteria into equol--a nonsteroidal compound that has been shown in some studies to reduce the incidence and severity of hot flashes. Previous studies have also shown that those following vegetarian or vegan diets produce higher levels of equol. The new study showed a more robust response, using the combination of a plant-based diet plus soy.

Many study participants also reported improvements in sexual symptoms, mood, and overall energy.

"This was basically a lifesaver for me," said one study participant. "I've got my quality of life back." Another said, "I am sleeping better, and my hot flashes diminished tremendously." Several participants also noticed significant weight loss and better digestion.
"Before you jump to any kind of medication, I would try this route, because it's easy," a study participant said. "Anybody can do it."

The study was based on the new approach to menopausal symptoms described by Dr. Barnard in his book Your Body in Balance. After the book was released in 2020, a reader contacted Dr. Barnard to let him know that his method eliminated her hot flashes within five days. Rather than using isoflavone extracts or soy foods such as soy milk or tofu, she used whole soybeans.

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Founded in 1985, the Physicians Committee for Responsible Medicine is a nonprofit organization that promotes preventive medicine, conducts clinical research, and encourages higher standards for ethics and effectiveness in education and research.

Measuring nitrogen to improve its management

New study measures how nitrogen is managed in agriculture around the world

UNIVERSITY OF MARYLAND CENTER FOR ENVIRONMENTAL SCIENCE

Research News

The business world is familiar with Peter Drucker's assertion that "If you can't measure it, you can't improve it." For the sake of environmental sustainability and food security, there is an urgent need for agriculture to improve its use of nitrogen fertilizers, but can we properly measure it?

A new paper* published in Nature Food offers the first comprehensive comparison of the most advanced international efforts to measure how nitrogen is managed in agriculture. Zhang et al synthesize results from nearly thirty researchers from ten different research groups across the world, including universities, private sector fertilizer associations, and the United Nations Food and Agriculture Organization (FAO). They each estimated how much nitrogen is added to croplands as fertilizer and manure, how much of the added nitrogen is harvested in crops, and how much is left over as potential environmental pollution.

"This intercomparison project enables researchers, agronomists, and policy makers to identify where we can improve nitrogen budget estimates," said lead author, Associate Professor Xin Zhang of the University of Maryland Center for Environmental Science. "This knowledge is the basis for improving sustainable nitrogen management and for addressing food security and environmental pollution challenges."

Nitrogen matters because it is essential for farmers to obtain good crop yields, but when a large fraction of it is not taken up by the intended crops, it leaks into the environment as nitrate in groundwater, rivers, lakes, and estuaries, where it contributes to noxious and harmful algal blooms and can pose human health risks. Excess nitrogen can also be lost from croplands as gaseous pollutants that pose respiratory human health risks and contribute to climate change and stratospheric ozone destruction. Hence, nitrogen needs to be managed carefully to maximize food production but minimize environmental pollution.

''Learning how to monitor nitrogen use in agriculture is a fundamental component of the 2030 Sustainable Development Agenda," said coauthor Dr. Francesco Tubiello of the FAO in Italy. "This study supports the development of improved national statistics that can be used to this end.''

"At first blush, this new study demonstrated some surprising and troubling differences among the ten research groups, suggesting that our ability to measure, and thus manage this essential nutrient and potent pollutant is not as good as it needs to be," said Eric Davidson, Professor at the University of Maryland Center for Environmental Science. "Digging into the data more deeply, however, many of these differences were explained by varying definitions and methods used by the different groups."

There is widespread agreement among these experts that use of nitrogen fertilizers in still growing, the average global efficiency of their use is stagnant, and so the surplus nitrogen that is not taken up by crops is also growing at a troubling rate. The types of crops and the geographic regions where improvements in measurement were also identified, thus facilitating needed improvements in both measurements and management.

"The United Nations Environment Programme adopted a resolution in 2019 calling for a global action to promote sustainable nitrogen management," noted contributing author Dr. Luis Lassaletta of Universidad Politécnica de Madrid. "Cutting nitrogen waste in half by 2030 would be an ambitious goal that would significantly improve environmental quality," he added.

The first step to action, however, is to obtain good estimates of nitrogen budgets in agricultural systems, as demonstrated in this study, so that we can better manage what we are able to measure with greater confidence.

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*"Quantification of global and national nitrogen budgets for crop production" was published in Nature Food on July 15.

DOI: 10.1038/s43016-021-00318-5. Once the paper is published online, it will be available at the following URL: https://www.nature.com/articles/s43016-021-00318-5

UNIVERSITY OF MARYLAND CENTER FOR ENVIRONMENTAL SCIENCE

The University of Maryland Center for Environmental Science leads the way toward better management of Maryland's natural resources and the protection and restoration of the Chesapeake Bay. From a network of laboratories located across the state, UMCES scientists provide sound evidence and advice to help state and national leaders manage the environment, and prepare future scientists to meet the global challenges of the 21st century.

http://www.umces.edu

Report outlines how public transit agencies can advance equity

SAGE

Research News

Austin, Texas (July 15, 2021)

Access to high-quality public transportation can make communities more equitable by increasing access to critical opportunities such as employment, health care and healthy food, particularly for low-income individuals and people of color. A new paper published today in the Transportation Research Record identifies six broad categories of equity-advancing practices that reach beyond existing guidelines and could be widely employed by public transit agencies nationwide.

"Many of the established practices for understanding and advancing public transit equity focus on precise quantitative measurements that are disconnected from riders' day-to-day experiences," said Alex Karner, an assistant professor of community and regional planning at The University of Texas at Austin and the study's lead author. "In transit, equity goes far beyond simply assessing how service is distributed. We wanted to lift up practices that agencies were using to create fairer and more just public transit systems."

The report studied eight public transit providers in various cities across the country and identified six practices that can help ensure that public transit works well for those who need it the most. These are:

Establishing advisory committees to provide more formal, regular and specialized channels for public input than can be achieved through traditional meetings;
Partnering with advocacy organizations, which can overcome barriers to public involvement and include hard-to-reach populations;
Incorporating equity into capital planning to ensure that transit vehicles, maintenance and system expansions equitably benefit population groups;
Planning with other regional transportation agencies that are often a critical venue for equity-related conversations that cross regional boundaries, covering issues such as gentrification, housing affordability, commuter-oriented public transit and other issues;
Using ride-hailing and microtransit solutions, where appropriate, to facilitate public transit use and reduce gaps in service; and
Creating an equity culture by altering hiring, contracting and organizational practices to better weave equity principles throughout an entire agency.

In addition to establishing these broad categories, the paper assesses each method, offering insight into its limitations and opportunities by assessing real-world implementation as employed by the eight public transit organizations included in the report. Some of the highlights include the convening of a "Transit Equity Advisory Committee" by the Tri-County Metropolitan District of Oregon (TriMet) that successfully advocated for a reduced-fare program and decriminalized fare evasion; and TriMet's subsequent creation of a dedicated Department of Equity, Inclusion and Community Affairs to assist with their equity-related goals.

"At the end of the day, transportation equity is about fairness," Karner said. "There are many ways that public transit agencies can pursue this goal. Our key result is that the agencies doing the most in this space have made it their mission to incorporate equity into all aspects of their day-to-day operations. And they are the most likely to succeed."

The transit organizations included in the study are Capital Metro in Austin; the Champaign-Urbana Mass Transit District; LINK Houston, an equity-oriented nonprofit organization in Houston; the Metropolitan Transit Authority of Harris County in the Houston Metro; the Massachusetts Bay Transportation Authority; the Massachusetts Department of Transportation; TriMet; and rabbittransit, a rural transit provider in southeast Pennsylvania.

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The paper, co-authored by community and regional planning graduate student Kaylyn Levine, was completed in collaboration with Federal Transit Administration partners and a community advisory group assembled to provide input on the broader research effort.

This article, "Equity-Advancing Practices at Public Transit Agencies in the United States", by Alex Karner and Kaylyn Levin and published in Transportation Research Record, will be free to access for a limited time and can be read here https://journals.sagepub.com/doi/full/10.1177/03611981211016861

About The University of Texas at Austin School of Architecture:

A top-tier school of design and planning, The School of Architecture offers degrees in architecture, architectural history, community and regional planning, historic preservation, interior design, landscape architecture, sustainable design, and urban design. Its faculty comprises many accomplished and award-winning professionals with a broad range of expertise in architectural history, design, building systems, technology, sustainability, transportation, Latin American architecture and urbanism, and the social effects of the built environment. The school also advances scholarship through three dedicated research units: the Center for American Architecture and Design, the Center for Sustainable Development, and the Lady Bird Johnson Wildflower Center.

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