Background: Extreme heat is a leading weather-related cause of illness and death in many locations across the globe, including subtropical Australia. The possibility of increasingly frequent and severe heat waves warrants continued efforts to reduce this health burden, which could be accomplished by targeting intervention measures toward the most vulnerable communities.

Objectives: We sought to quantify spatial variability in heat-related morbidity in Brisbane, Australia, to highlight regions of the city with the greatest risk. We also aimed to find area-level social and environmental determinants of high risk within Brisbane.

Methods: We used a series of hierarchical Bayesian models to examine city-wide and intracity associations between temperature and morbidity using a 2007–2011 time series of geographically referenced hospital admissions data. The models accounted for long-term time trends, seasonality, and day of week and holiday effects.

Results: On average, a 10°C increase in daily maximum temperature during the summer was associated with a 7.2% increase in hospital admissions (95% CI: 4.7, 9.8%) on the following day. Positive statistically significant relationships between admissions and temperature were found for 16 of the city’s 158 areas; negative relationships were found for 5 areas. High-risk areas were associated with a lack of high income earners and higher population density.

Conclusions: Geographically targeted public health strategies for extreme heat may be effective in Brisbane, because morbidity risk was found to be spatially variable. Emergency responders, health officials, and city planners could focus on short- and long-term intervention measures that reach communities in the city with lower incomes and higher population densities, including reduction of urban heat island effects.

Background: While there is ample evidence for health risks associated with heat and other extreme weather events today, little is known about the impact of weather patterns on population health in preindustrial societies.

Objective: To investigate the impact of weather patterns on population health in Sweden before and during industrialization.

Methods: We obtained records of monthly mortality and of monthly mean temperatures and precipitation for Skellefteå parish, northern Sweden, for the period 1800-1950. The associations between monthly total mortality, as well as monthly mortality due to infectious and cardiovascular diseases, and monthly mean temperature and cumulative precipitation were modelled using a time series approach for three separate periods, 1800−1859, 1860-1909, and 1910-1950.

Results: We found higher temperatures and higher amounts of precipitation to be associated with lower mortality both in the medium term (same month and two-months lag) and in the long run (lag of six months up to a year). Similar patterns were found for mortality due to infectious and cardiovascular diseases. Furthermore, the effect of temperature and precipitation decreased over time.

Conclusions: Higher temperature and precipitation amounts were associated with reduced death counts with a lag of up to 12 months. The decreased effect over time may be due to improvements in nutritional status, decreased infant deaths, and other changes in society that occurred in the course of the demographic and epidemiological transition.

Contribution: The study contributes to a better understanding of the complex relationship between weather and mortality and, in particular, historical weather-related mortality.

Type 2 diabetes (T2D) is a complex metabolic disease that is more prevalent in ethnic groups such as Mexican Americans, and is strongly associated with the risk factors obesity and insulin resistance. The goal of this study was to perform whole genome gene expression profiling in adipose tissue to detect common patterns of gene regulation associated with obesity and insulin resistance. We used phenotypic and genotypic data from 308 Mexican American participants from the Veterans Administration Genetic Epidemiology Study (VAGES). Basal fasting RNA was extracted from adipose tissue biopsies from a subset of 75 unrelated individuals, and gene expression data generated on the Illumina BeadArray platform. The number of gene probes with significant expression above baseline was approximately 31,000. We performed multiple regression analysis of all probes with 15 metabolic traits. Adipose tissue had 3,012 genes significantly associated with the traits of interest (false discovery rate, FDR ≤ 0.05). The significance of gene expression changes was used to select 52 genes with significant (FDR ≤ 10^-4) gene expression changes across multiple traits. Gene sets/Pathways analysis identified one gene, alcohol dehydrogenase 1B (ADH1B) that was significantly enriched (P < 10^-60) as a prime candidate for involvement in multiple relevant metabolic pathways. Illumina BeadChip derived ADH1B expression data was consistent with quantitative real time PCR data. We observed significant inverse correlations with waist circumference (2.8 x 10[superscript -9]), BMI (5.4 x 10^-6), and fasting plasma insulin (P < 0.001). These findings are consistent with a central role for ADH1B in obesity and insulin resistance and provide evidence for a novel genetic regulatory mechanism for human metabolic diseases related to these traits.

Background: To examine the influence of ethnicity on liver transaminases among adolescents with type 2 diabetes mellitus (T2DM).

Methods: A retrospective medical chart review of 57 (30 males and 27 females) newly diagnosed patients with T2DM. Ethnicity was determined by self-report and height, weight, body mass index (BMI) and glycosylated hemoglobin (HbA1c) were obtained using standard clinical procedures. Fasting levels of alanine aminotransaminase (ALT) and aspartate aminotransferase (AST) were collected prior to the initiation of any therapy.

Results: Age, gender, height, weight, BMI, and HbA1c did not differ between ethnic groups. Compared to African-Americans, Hispanics had significantly higher ALT (23.9 ± 3.4 vs. 107.8 ± 20.3, p=0.002) and AST (17.7 ± 2.5 vs. 71.1 ± 15.7, p<0.001) and were significantly more likely to have ALT values above the upper limit of normal (20% vs. 71%, p=0.005) and twice the upper limit of normal (0% vs. 39%, p=0.05) as well as AST values above the upper limit of normal (0% vs. 53%, p=0.002). No differences in ALT or AST were found between Hispanics and non-Hispanic whites or between African-Americans and non-Hispanic whites.

Conclusions: These preliminary findings suggest that Hispanic children with T2DM may be at higher risk for developing non-alcoholic fatty liver disease and indicate that a comprehensive hepatic evaluation is warranted in this population. Future studies that incorporate more precise and proximal measures of liver health are warranted in this population.

Society is heavily dependent on a reliable electric supply; all infrastructure systems depend on electricity to operate. When the electric system fails, the impacts can be catastrophic (food spoilage, inoperable medical devices, lack of access to water, etc.). The social impacts, defined as the direct and indirect impacts on people, of power outages must be explored as the likelihood of power outages and blackouts are increasing. However, compared to other hazards, such as heat and flooding, the knowledge base on the impacts of power outages is relatively small. The purpose of this thesis is to identify what is currently known about the social impacts of power outages, identify where gaps in the literature exist, and deploy a survey to explore power outage experiences at the household level. This thesis is comprised of two chapters, a systematic literature review on the current knowledge of the social impacts of power outages and a multi-city survey focused on power outage experiences.

The first chapter comprised of a systematic literature review using a combined search of in Scopus which returned 762 candidate articles were identified that potentially explored the social impacts of power outages. However, after multiple filtering criteria were applied, only 45 articles met all criteria. Four themes were used to classify the literature, not exclusively, including modeling, social, technical, and other. Only papers that were classified as “social” - meaning they observed how people were affected by a power outage - or in combination with other categories were used within the review.

From the literature, populations of concern were identified, including minority demographics - specifically Blacks or African Americans, children, elderly, and rural populations. The most commonly reported health concerns were from those that rely on medical devices for chronic conditions and unsafe generator practices. Criminal activity was also reported to increase during prolonged power outages and can be mitigated by consistent messaging on where to receive assistance and when power will be restored. Providing financial assistance and resources such as food and water can reduce the crime rate temporarily, but the crime rate can be expected to increase once the relief expires. Authorities should expect looting to occur, especially in poorer areas, during prolonged power outages. Gaps in the literature were identified and future directions for research were provided.

The second chapter consists of a multi-city survey that targeted three major cities across the United States (Detroit, MI; Miami, FL; and Phoenix, AZ). The survey was disseminated through Amazon’s Mechanical Turk and hosted by Qualtrics. 896 participants from the three cities qualified to complete the full version of the survey. Three criteria had to be met for participants to complete the full survey including residing in one of the three target cities, living at their primary address for a majority of the year, and indicate they had experienced a power outage within the last five years.

Participants were asked questions regarding the number of outages experienced in the last five years, the length of their most recent and longest outage experienced, if they owned a generator, how they managed their longest power outage, if participants or anyone in their household relies on a medical device, the financial burden their power outage caused, and standard demographic- and income-related questions. Race was a significant variable that influenced the outage duration length but not frequency in Phoenix and Detroit. Income was not a significant variable associated with experiencing greater economic impacts, such as having thrown food away because of an outage and not receiving help during the longest outage. Additional assessments similar to this survey are needed to better understand household power outage experiences.

Findings from this thesis demonstrate traditional metrics used in vulnerability indices were not indicative of who experienced the greatest effects of power outages. Additionally, other factors that are not included in these indices, such as owning adaptive resources including medical devices and generators in Phoenix and Detroit, are factors in reducing negative outcomes. More research is needed on this topic to indicate which populations are more likely to experience factors that can influence positive or negative outage outcomes.

Access to air conditioned space is critical for protecting urban populations from the adverse effects of heat exposure. Yet there remains fairly limited knowledge of penetration of private (home air conditioning) and distribution of public (cooling centers and commercial space) cooled space across cities. Furthermore, the deployment of government-sponsored cooling centers is not based on the location of existing cooling resources (residential air conditioning and air conditioned public space), raising questions of the equitability of access to heat refuges.

Using Los Angeles County, California and Maricopa County, Arizona (whose county seat is Phoenix) we explore the distribution of private and public cooling resources and access inequities at the household level. We do this by evaluating the presence of in-home air conditioning and developing a walking-based accessibility measure to air conditioned public space using a combined cumulative opportunities-gravity approach. We find significant inequities in the distribution of residential air conditioning across both regions which are largely attributable to building age and inter/intra-regional climate differences. There are also regional disparities in walkable access to public cooled space.

At average walking speeds, we find that official cooling centers are only accessible to a small fraction of households (3% in Los Angeles, 2% in Maricopa) while a significantly higher number of households (80% in Los Angeles, 39% in Maricopa) have access to at least one other type of public cooling resource which includes libraries and commercial establishments. Aggregated to a neighborhood level, we find that there are areas within each region where access to cooled space (either public or private) is limited which may increase the health risks associated with heat.

Our previous studies show reduced abundance of the β-subunit of mitochondrial H+-ATP synthase (β-F1-ATPase) in skeletal muscle of obese individuals. The β-F1-ATPase forms the catalytic core of the ATP synthase, and it is critical for ATP production in muscle. The mechanism(s) impairing β-F1-ATPase metabolism in obesity, however, are not completely understood. First, we studied total muscle protein synthesis and the translation efficiency of β-F1-ATPase in obese (BMI, 36±1 kg/m²) and lean (BMI, 22±1 kg/m²) subjects. Both total protein synthesis (0.044±0.006 vs 0.066±0.006%·h^-1) and translation efficiency of β-F1-ATPase (0.0031±0.0007 vs 0.0073±0.0004) were lower in muscle from the obese subjects when compared to the lean controls (P<0.05). We then evaluated these same responses in a primary cell culture model, and tested the specific hypothesis that circulating non-esterified fatty acids (NEFA) in obesity play a role in the responses observed in humans. The findings on total protein synthesis and translation efficiency of β-F1-ATPase in primary myotubes cultured from a lean subject, and after exposure to NEFA extracted from serum of an obese subject, were similar to those obtained in humans. Among candidate microRNAs (i.e., non-coding RNAs regulating gene expression), we identified miR-127-5p in preventing the production of β-F1-ATPase. Muscle expression of miR-127-5p negatively correlated with β-F1-ATPase protein translation efficiency in humans (r = – 0.6744; P<0.01), and could be modeled in vitro by prolonged exposure of primary myotubes derived from the lean subject to NEFA extracted from the obese subject. On the other hand, locked nucleic acid inhibitor synthesized to target miR-127-5p significantly increased β-F1-ATPase translation efficiency in myotubes (0.6±0.1 vs 1.3±0.3, in control vs exposure to 50 nM inhibitor; P<0.05). Our experiments implicate circulating NEFA in obesity in suppressing muscle protein metabolism, and establish impaired β-F1-ATPase translation as an important consequence of obesity.

Maricopa County is the home of the Phoenix metropolitan area, an expansive city with serious air quality concerns. To ameliorate air quality in the county, the Maricopa County Air Quality Department developed a website and mobile application called "Clean Air Make More" as a means of outreach and engagement. In doing this, the county has found a way to engender a bilateral relationship between individuals and their government agency. This study analyzes the effectiveness of Clean Air Make More in establishing this relationship and engaging the community in efforts to improve air quality. It concludes that the design of the application effectively meets user needs, but marketing efforts should target populations disposed to taking action regarding air quality.

Background:
Environmental heat exposure is a public health concern. The impacts of environmental heat on mortality and morbidity at the population scale are well documented, but little is known about specific exposures that individuals experience.

Objectives:
The first objective of this work was to catalyze discussion of the role of personal heat exposure information in research and risk assessment. The second objective was to provide guidance regarding the operationalization of personal heat exposure research methods.

Discussion:
We define personal heat exposure as realized contact between a person and an indoor or outdoor environment that poses a risk of increases in body core temperature and/or perceived discomfort. Personal heat exposure can be measured directly with wearable monitors or estimated indirectly through the combination of time–activity and meteorological data sets. Complementary information to understand individual-scale drivers of behavior, susceptibility, and health and comfort outcomes can be collected from additional monitors, surveys, interviews, ethnographic approaches, and additional social and health data sets. Personal exposure research can help reveal the extent of exposure misclassification that occurs when individual exposure to heat is estimated using ambient temperature measured at fixed sites and can provide insights for epidemiological risk assessment concerning extreme heat.

Conclusions:
Personal heat exposure research provides more valid and precise insights into how often people encounter heat conditions and when, where, to whom, and why these encounters occur. Published literature on personal heat exposure is limited to date, but existing studies point to opportunities to inform public health practice regarding extreme heat, particularly where fine-scale precision is needed to reduce health consequences of heat exposure.