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1.  Correlates of Medical Nutrition Therapy and Cardiovascular Outcomes in Youth with Type 1 Diabetes 
Journal of nutrition education and behavior  2013;45(6):10.1016/j.jneb.2013.06.003.
To examine whether the types of medical nutrition therapies (MNTs) taught to and used by youth with type 1 diabetes (T1D) varies by socio-demographic characteristics and cardiovascular (CVD) risk factors
Cross-sectional study
The SEARCH for Diabetes in Youth study is a population-based cohort of individuals with clinical diagnosed diabetes
1,191 individuals with T1D
Main Outcome Measures
Types of MNTs and frequency of use
Bivariate analysis and multivariate linear regression (P<0.05)
More race/ethnic minorities (vs. whites), individuals with parents
Conclusions and Implications
In individuals with T1D, race/ethnic minorities, individuals with parents
PMCID: PMC3825757  PMID: 23891147
medical nutrition therapy; type 1 diabetes; cardiovascular risk
Diabetes Care  2013;36(7):1842-1850.
To test the novel hypothesis that nutritional factors previously associated with type 1 diabetes etiology or with insulin secretion are prospectively associated with fasting C-peptide (FCP) concentration among youth recently diagnosed with type 1 diabetes.
Included were 1,316 youth with autoantibody-positive type 1 diabetes who participated in the SEARCH for Diabetes in Youth study (baseline disease duration, 9.9 months; SD, 6.3). Nutritional exposures included breastfeeding and age at introduction of complementary foods, baseline plasma long-chain omega-3 fatty acids including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), vitamin D, vitamin E, and, from a baseline food frequency questionnaire, estimated intake of the branched-chain amino acid leucine and total carbohydrate. Multiple linear regression models were conducted to relate each nutritional factor to baseline FCP adjusted for demographics, disease-related factors, and other confounders. Prospective analyses included the subset of participants with preserved β-cell function at baseline (baseline FCP ≥0.23 ng/mL) with additional adjustment for baseline FCP and time (mean follow-up, 24.3 months; SD, 8.2; n = 656). FCP concentration was analyzed as log(FCP).
In adjusted prospective analyses, baseline EPA (P = 0.02), EPA plus DHA (P = 0.03), and leucine (P = 0.03) were each associated positively and significantly with FCP at follow-up. Vitamin D was unexpectedly inversely associated with FCP (P = 0.002).
Increased intake of branched-chain amino acids and long-chain omega-3 fatty acids may support preservation of β-cell function. This represents a new direction for research to improve prognosis for type 1 diabetes.
PMCID: PMC3687285  PMID: 23801797
Journal of advanced nursing  2012;69(6):1428-1437.
Our purpose in this paper is to propose a new method for extracting findings from research reports included in mixed-methods mixed research synthesis studies.
International initiatives in the domains of systematic review and evidence synthesis have been focused on broadening the conceptualization of evidence, increased methodological inclusiveness and the production of evidence syntheses that will be accessible to and usable by a wider range of consumers. Initiatives in the general mixed-methods research field have been focused on developing truly integrative approaches to data analysis and interpretation.
Data source
The data extraction challenges described here were encountered and the method proposed for addressing these challenges was developed, in the first year of the ongoing (2011–2016) study: Mixed-Methods Synthesis of Research on Childhood Chronic Conditions and Family.
To preserve the text-in-context of findings in research reports, we describe a method whereby findings are transformed into portable statements that anchor results to relevant information about sample, source of information, time, comparative reference point, magnitude and significance and study-specific conceptions of phenomena.
Implications for nursing
The data extraction method featured here was developed specifically to accommodate mixed-methods mixed research synthesis studies conducted in nursing and other health sciences, but reviewers might find it useful in other kinds of research synthesis studies.
This data extraction method itself constitutes a type of integration to preserve the methodological context of findings when statements are read individually and in comparison to each other.
PMCID: PMC3535067  PMID: 22924808
data extraction; mixed research synthesis; nurses; nursing; qualitative research; quantitative research; research methodology
High consumption of dietary fructose has been shown to contribute to dyslipidemia and elevated blood pressure in adults, but there are few data in youth, particularly those at greater risk of cardiovascular disease (CVD). The aim of this study was to examine the association between fructose intake and CVD risk factors in a diverse population of youth with type 1diabetes (T1D).
This was a cross-sectional analysis of data from the SEARCH for Diabetes in Youth study, including 2085 youth ages 10–22 years with T1D, of which 22% were racial/ethnic minority and 50% were female. A semi-quantitative food frequency questionnaire was used to assess intake.
Median daily fructose consumption was 7.9% of total calories. Fructose intake was positively associated with triglycerides (p<.01), but not with total cholesterol, LDL-cholesterol, HDL-cholesterol, or blood pressure after adjustment for physical activity and socio-demographic, clinical, and dietary covariates. An increase in fructose intake of 22 grams (equivalent to a 12 oz. can of soda) was associated with a 23% higher odds of borderline/ high versus low triglycerides (p<.005).
These data suggest that children with T1D should moderate their intake of fructose, particularly those with borderline or high triglycerides.
PMCID: PMC3764988  PMID: 23540682
Fructose; cardiovascular risk factors; triglycerides; adolescents; type 1 diabetes
Greater understanding of the mechanisms (mediators) by which behavioral change interventions work is critical to developing theory and refining interventions. Although systematic reviews have been advocated as a method for exploring mediators, this is rarely done. One challenge is that intervention researchers typically test only two paths of the mediational model: the effect of the intervention on mediators and on outcomes. We addressed this challenge by drawing information not only from intervention studies but also from observational studies, which provide data on associations between potential mediators and outcomes. We also reviewed qualitative studies of participants’ perceptions of why and how interventions worked. Using data from intervention (n= 37) and quantitative observational studies (n=55), we conducted a meta-analysis of the mediation effects of eight variables. Qualitative findings (n=6) contributed to more in-depth explanations for findings. The methods used have potential to contribute to understanding of core mechanisms of behavioral change interventions.
PMCID: PMC3155731  PMID: 21415244
systematic review; mediation analysis; meta-analysis; antiretroviral therapy; treatment adherence
Mixed methods–mixed research synthesis is a form of systematic review in which the findings of qualitative and quantitative studies are integrated via qualitative and/or quantitative methods. Although methodological advances have been made, efforts to differentiate research synthesis methods have been too focused on methods and not focused enough on the defining logics of research synthesis—each of which may be operationalized in different ways—or on the research findings themselves that are targeted for synthesis. The conduct of mixed methods–mixed research synthesis studies may more usefully be understood in terms of the logics of aggregation and configuration. Neither logic is preferable to the other nor tied exclusively to any one method or to any one side of the qualitative/quantitative binary.
PMCID: PMC3467952  PMID: 23066379
mixed research synthesis; systematic review; aggregation; configuration
Rationale, aims and objectives
Finding ways to incorporate disparate types of evidence into research syntheses has the potential to build a better evidence base for clinical practice and policy. Yet conducting such mixed research synthesis studies is challenging. Researchers have to determine whether and how to use adjusted and unadjusted quantitative findings in combination with each other and with qualitative findings.
Among quantitative findings, adjustment for confounding, either via study design or statistical analysis, can be a considerable source of heterogeneity. Yet there is no consensus about the best way to synthesize findings resulting from different methods for addressing confounding. When synthesizing qualitative and quantitative findings, additional considerations include determining whether findings are amenable to synthesis by aggregation or configuration, which, in turn, depends on the degree of interpretive transformation of findings.
Qualitative survey findings appear similar in form to unadjusted or minimally adjusted quantitative findings and, when addressing the same relationship, can be summed. More interpreted qualitative findings appear similar in form to adjusted findings found in, for example, structural equation models specifying the relationship among a host of latent variables. An option for synthesis of conceptually similar models is reciprocal translation.
These decisions will ultimately be judged on the meaningfulness of their results to practice or policy.
PMCID: PMC3063329  PMID: 21040243
adjustment; confounding; meta-analysis; qualitative research; quantitative research; research synthesis
Journal of pain and symptom management  2010;10.1016/j.jpainsymman.2010.04.013.
Cancer survivors employ distinct sets of coping behaviors that vary in their associations with psychological health and quality of life. However, existing research has largely focused on white and middle class subjects.
This study explores whether clusters with differing coping profiles could be identified among older African American cancer survivors and whether these profiles varied on cultural factors and physical, psychological, and relationship well-being.
Four hundred forty-nine older African American cancer survivors recruited from outpatient oncology clinics completed a questionnaire booklet containing the Ways of Helping Questionnaire (WHQ), the Brief Index of Race-Related Stress (IRRS), the Religious Involvement Scale, Mutuality Scale, and the Short Form 12 Health Survey Questionnaire (SF-12). A k-means cluster analysis was conducted using the WHQ.
Four distinct coping profiles were identified and labeled High Coping, Low Encouraging Healthy Behaviors, Low Coping and Strong/Distracting Behaviors. Coping profiles were associated with participant’s gender, age, and living alone. Controlling for these demographic differences, coping profiles were associated with religiosity, experiences with racism, and physical, psychological and relationship well-being.
The findings from this study lend support for examining coping profiles and health outcomes among African American cancer survivors. This research also suggests that these profiles vary on cultural factors. This information should prove useful to researchers as they develop culturally appropriate interventions for this underserved population.
PMCID: PMC3029503  PMID: 20832984
cancer; African Americans; coping profiles; cluster analysis; religious involvement; experienced racism; quality of life
Quality & quantity  2011;45(3):653-669.
The possible utility of Bayesian methods for the synthesis of qualitative and quantitative research has been repeatedly suggested but insufficiently investigated. In this project, we developed and used a Bayesian method for synthesis, with the goal of identifying factors that influence adherence to HIV medication regimens. We investigated the effect of 10 factors on adherence. Recognizing that not all factors were examined in all studies, we considered standard methods for dealing with missing data and chose a Bayesian data augmentation method. We were able to summarize, rank, and compare the effects of each of the 10 factors on medication adherence. This is a promising methodological development in the synthesis of qualitative and quantitative research.
PMCID: PMC3092168  PMID: 21572970
Meta-analysis; Meta-synthesis; Synthesis; Cross-design synthesis; Bayesian data augmentation; Missing data; Gibbs sampling
Research in nursing & health  2010;33(4):316-328.
The purpose of the current study was to examine patterns of state anxiety and pregnancy-specific distress across pregnancy in a diverse sample of women with (n = 113) and without (n = 250) prior miscarriage. For both groups, state anxiety and pregnancy-specific distress were highest in the first trimester and decreased significantly over the course of pregnancy. Compared to women without prior miscarriage, women with prior miscarriage experienced greater state anxiety in the second and third trimesters. Having a living child did not buffer state anxiety in women with a prior miscarriage. Attention to patterns of distress can contribute to delivery of appropriate support resources to women experiencing pregnancy after miscarriage and may help reduce risk for stress-related outcomes.
PMCID: PMC3070408  PMID: 20544819
miscarriage; pregnancy; anxiety; prenatal stress; perinatal loss
Nursing research  2010;59(2):102-109.
Existing spiritual support scales for use with cancer survivors focus on the support believed to come from a religious community, clergy, or health care providers.
The objective of this study was to evaluate the reliability and validity of a new measure of spiritual support believed to come from God in older Christian African American cancer survivors.
The Perceived Support From God Scale was administered to 317 African American cancer survivors aged 55–89 years. Psychometric evaluation involved identifying underlying factors, conducting item analysis and estimating reliability, and obtaining evidence on the relationship to other variables or the extent to which the Perceived Support From God Scale correlates with religious involvement and depression.
The Perceived Support From God Scale consists of 15 items in two subscales (Support From God and God’s Purpose for Me). The two subscales explained 59% of the variance. Cronbach’s α coefficients were .94 and .86 for the Support From God and God’s Purpose for Me subscales, respectively. Test–retest correlations were strong, supporting the temporal stability of the instrument. Pearson’s correlations to an existing religious involvement and beliefs scale were moderate to strong. Subscale scores on Support From God were negatively correlated to depression.
Initial support for reliability and validity was demonstrated for the Perceived Support From God Scale. The scale captures a facet of spirituality not emphasized in other measures. Further research is needed to evaluate the scale with persons of other racial/ethnic groups and to explore the relationship of spirituality to other outcome measures.
PMCID: PMC2867661  PMID: 20216012
African Americans; cancer; spiritual support
Cancer nursing  2010;33(2):156-163.
Depression is becoming an increasing concern in cancer patients because of its impact on quality of life. Although risk factors of having depression have been examined in the literature, there has been no research examining these factors in older African American cancer patients.
This study explores the demographic and illness-related risk factors in older African American cancer patients.
Two hundred eighty-three patients were recruited from outpatient oncology clinics. These older African American patients completed a questionnaire that included the Geriatric Depression Scale as well as sociodemographic characteristics and medical information. χ2 Tests, trend tests, and logistic regression were used to identify the demographic and illness-related factors that predict depression in the sample.
The overall prevalence of depression in the sample was 27.2%. Younger age (<65 years), employment status, proximity to family, and multiple symptoms due to cancer or treatment were independent predictors of depression.
This study represents the first attempt to describe the risk factors of depression within older African American cancer patients. Findings indicate a high prevalence of depression in African American cancer patients which can be attributed to identifiable risk factors.
Implications for Practice
An understanding of the risk factors associated with depression can be used to identify those cancer patients at risk for depression and initiate early interventions to improve psychological outcomes and lessen the potential burden of cancer on these patients.
PMCID: PMC2844350  PMID: 20142741
African Americans; Cancer; Depression
Reports of qualitative studies typically do not offer much information on the numbers of respondents linked to any one finding. This information may be especially useful in reports of basic, or minimally interpretive, qualitative descriptive studies focused on surveying a range of experiences in a target domain, and its lack may limit the ability to synthesize the results of such studies with quantitative results in systematic reviews. Accordingly, the authors illustrate strategies for deriving plausible ranges of respondents expressing a finding in a set of reports of basic qualitative descriptive studies on antiretroviral adherence and suggest how the results might be used. These strategies have limitations and are never appropriate for use with findings from interpretive qualitative studies. Yet they offer a temporary workaround for preserving and maximizing the value of information from basic qualitative descriptive studies for systematic reviews. They show also why quantitizing is never simply quantitative.
PMCID: PMC2784172  PMID: 19448052
mixed-methods research; qualitative; quantitizing; research synthesis
Bayesian meta-analysis is a frequently cited but very little-used method for synthesizing qualitative and quantitative research findings. The only example published to date used qualitative data to generate an informative prior probability and quantitative data to generate the likelihood. We developed a method to incorporate both qualitative and quantitative evidence in the likelihood in a Bayesian synthesis of evidence about the relationship between regimen complexity and medication adherence.
Data were from 11 qualitative and six quantitative studies. We updated two different non-informative prior distributions with qualitative and quantitative findings to find the posterior distribution for the probabilities that a more complex regimen was associated with lower adherence and that a less complex regimen was associated with greater adherence.
The posterior mode for the qualitative findings regarding more complex regimen and lesser adherence (using the uniform prior with Jeffreys' prior yielding highly similar estimates) was 0.588 (95% credible set limits 0.519, 0.663) and for the quantitative findings was 0.224 (0.203, 0.245); due to non-overlapping credible sets, we did not combine them. The posterior mode for the qualitative findings regarding less complex regimen and greater adherence was 0.288 (0.214, 0.441) and for the quantitative findings was 0.272 (0.118, 0.437); the combined estimate was 0.299 (0.267, 0.334).
The utility of Bayesian methods for synthesizing qualitative and quantitative research findings at the participant level may depend on the nature of the relationship being synthesized and on how well the findings are represented in the individual reports.
PMCID: PMC2764871  PMID: 19770121
Research in nursing & health  2009;32(3):243-259.
Although researchers have identified beneficial coping strategies for cancer patients, existing coping measures do not capture the preferred coping strategies of older African American cancer survivors. A new measure, the Ways of Helping Questionnaire (WHQ), was evaluated with 385 African American cancer survivors. Validity evidence from factor analysis resulted in 10 WHQ subscales (Others There for Me, Physical and Treatment Care Needs, Help from God, Church Family Support, Helping Others, Being Strong for Others, Encouraging My Healthy Behaviors, Others Distract Me, Learning about Cancer, and Distracting Myself). Reliability evidence was generally strong. Evidence regarding hypothesized relationships with measures of well-being and another coping measure was mixed. The WHQ’s content coverage makes it especially relevant for older African American cancer survivors.
PMCID: PMC2752043  PMID: 19259991
coping; social support; African Americans; cancer; instrument development

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