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author:("subab, Amy F")
1.  Simulated Adaptations to an Adult Dietary Self-report Tool to Accommodate Children: Impact on Nutrient Estimates 
Objective
To simulate the effect of child-friendly adaptations of the National Cancer Institute's Automated Self-administered 24-hour dietary recall (ASA24) on estimates of nutrient intake.
Method
One hundred twenty children, 8-13 years old entered their previous day's intake using the ASA24 and completed an interviewer-administered recall using the Nutrition Data System for Research (NDSR). Based on a hypothesis that proposed adaptations to the ASA24 will not significantly affect mean nutrient estimates, ASA24 data were manipulated post-administration to simulate a child-friendly version in which two categories of data collection were removed: 1) foods not likely to be consumed by children (45%) based on previous analyses of national dietary data and, 2) food detail questions (probes) to which children are unlikely to know the answers (46%), based on our experience.
Results
Mean estimates of select nutrients between the beta version of ASA24 and the simulated child-friendly recall showed no significant differences, indicating that the food and probe elimination did not significantly affect results. However, a comparison of total sugar and Vitamin C assessments between the original ASA24, the child-friendly version and NDSR showed that the daily nutrient totals for both nutrients were significantly higher in the self-administered methods (both ASA24 and child-friendly version) than in NDSR (interviewer-administered) which warrants a review of different methods for obtaining information about foods that are sources of these nutrients.
Conclusion
The simulation of child-friendly adaptations showed that it is feasible to implement thereby reducing child-friendly response burden without significantly affecting the results.
doi:10.1080/07315724.2013.789339
PMCID: PMC3771395  PMID: 24015716
ASA24; children; dietary recall; self-administered; Automated Multiple Pass Method (AMPM); Automated Self-Administered 24 Hour Recall (ASA24); ASA24-Kids; Food and Nutrient Database for Dietary Studies (FNDDS)
2.  Index-based Dietary Patterns and the Risk of Prostate Cancer in the NIH-AARP Diet and Health Study 
American Journal of Epidemiology  2013;177(6):504-513.
Few studies have investigated the relationship between overall diet and the risk of prostate cancer. We examined the association between 3 diet quality indices—the Healthy Eating Index-2005 (HEI-2005), Alternate Healthy Eating Index-2010 (AHEI-2010), and alternate Mediterranean diet score (aMED)—and prostate cancer risk. At baseline, dietary intake was assessed in a cohort of 293,464 US men in the National Institutes of Health (NIH)-AARP Diet and Health Study. Cox proportional hazards regression was used to estimate hazard ratios. Between 1995 and 2006, we ascertained 23,453 incident cases of prostate cancer, including 2,251 advanced cases and 428 fatal cases. Among men who reported a history of prostate-specific antigen testing, high HEI-2005 and AHEI-2010 scores were associated with lower risk of total prostate cancer (for the highest quintile compared with the lowest, hazard ratio (HR) = 0.92, 95% confidence interval (CI): 0.86, 0.98, P for trend = 0.01; and HR = 0.93, 95% CI: 0.88, 0.99, P for trend = 0.05, respectively). No significant association was observed between aMED score and total prostate cancer or between any of the indices and advanced or fatal prostate cancer, regardless of prostate-specific antigen testing status. In individual component analyses, the fish component of aMED and ω-3 fatty acids component of AHEI-2010 were inversely associated with fatal prostate cancer (HR = 0.79, 95% CI: 0.65, 0.96, and HR = 0.94, 95% CI: 0.90, 0.98, respectively).
doi:10.1093/aje/kws261
PMCID: PMC3657529  PMID: 23408548
diet; food habits; prostatic neoplasms
3.  A mixed-effects model approach for estimating the distribution of usual intake of nutrients: The NCI method 
Statistics in medicine  2010;29(27):10.1002/sim.4063.
It is of interest to estimate the distribution of usual nutrient intake for a population from repeat 24-h dietary recall assessments. A mixed effects model and quantile estimation procedure, developed at the National Cancer Institute (NCI), may be used for this purpose. The model incorporates a Box–Cox parameter and covariates to estimate usual daily intake of nutrients; model parameters are estimated via quasi-Newton optimization of a likelihood approximated by the adaptive Gaussian quadrature. The parameter estimates are used in a Monte Carlo approach to generate empirical quantiles; standard errors are estimated by bootstrap. The NCI method is illustrated and compared with current estimation methods, including the individual mean and the semi-parametric method developed at the Iowa State University (ISU), using data from a random sample and computer simulations. Both the NCI and ISU methods for nutrients are superior to the distribution of individual means. For simple (no covariate) models, quantile estimates are similar between the NCI and ISU methods. The bootstrap approach used by the NCI method to estimate standard errors of quantiles appears preferable to Taylor linearization. One major advantage of the NCI method is its ability to provide estimates for subpopulations through the incorporation of covariates into the model. The NCI method may be used for estimating the distribution of usual nutrient intake for populations and subpopulations as part of a unified framework of estimation of usual intake of dietary constituents.
doi:10.1002/sim.4063
PMCID: PMC3865776  PMID: 20862656
statistical distributions; diet surveys; nutrition assessment; mixed-effects model; nutrients; percentiles
4.  Dietary Glycemic Index, Glycemic Load, and Risk of Cancer: A Prospective Cohort Study 
American Journal of Epidemiology  2008;169(4):462-472.
Previous studies have provided limited evidence for a harmful effect of high glycemic index and dietary glycemic load on cancer. The authors analyzed associations among glycemic index, glycemic load, and risk of cancer in women and men in the National Institutes of Health–AARP Diet and Health Study. Published glycemic index values were assigned to 225 foods/food groups. Glycemic load was calculated by multiplying the glycemic index, carbohydrate content, and intake frequency of individual foods reported on a food frequency questionnaire. From 1995 through 2003, the authors identified 15,215 and 33,203 cancer cases in women and men, respectively. Cox proportional hazards models were used to estimate multivariate relative risks and 95% confidence intervals. For women and men, respectively, the relative risks for total cancer for high versus low glycemic index were 1.03 (Ptrend = 0.217) and 1.04 (Ptrend = 0.012) and, for glycemic load, were 0.90 (Ptrend = 0.024) and 0.93 (Ptrend = 0.01). Associations with total cancer held only among the overweight for glycemic index and among those of healthy weight for glycemic load. These findings suggest that glycemic index and glycemic load are not strong predictors of cancer incidence. The direction and small magnitude of associations might be explained by the manner in which high glycemic index and glycemic load track with overall diet and lifestyle patterns.
doi:10.1093/aje/kwn347
PMCID: PMC2726642  PMID: 19095757
diet; glycemic index; neoplasms; prospective studies
5.  Assessment of the Accuracy of Portion Size Reports Using Computer-Based Food Photographs Aids in the Development of an Automated Self-Administered 24-Hour Recall 
Objective
To assess the accuracy of portion-size estimates and participant preferences using various presentations of digital images.
Design
Two observational feeding studies were conducted. In both, each participant selected and consumed foods for breakfast and lunch, buffet style, serving themselves portions of nine foods representing five forms (eg, amorphous, pieces). Serving containers were weighed unobtrusively before and after selection as was plate waste. The next day, participants used a computer software program to select photographs representing portion sizes of foods consumed the previous day. Preference information was also collected. In Study 1 (n=29), participants were presented with four different types of images (aerial photographs, angled photographs, images of mounds, and household measures) and two types of screen presentations (simultaneous images vs an empty plate that filled with images of food portions when clicked). In Study 2 (n=20), images were presented in two ways that varied by size (large vs small) and number (4 vs 8).
Subjects/setting
Convenience sample of volunteers of varying background in an office setting.
Statistical analyses performed
Repeated-measures analysis of variance of absolute differences between actual and reported portions sizes by presentation methods.
Results
Accuracy results were largely not statistically significant, indicating that no one image type was most accurate. Accuracy results indicated the use of eight vs four images was more accurate. Strong participant preferences supported presenting simultaneous vs sequential images.
Conclusions
These findings support the use of aerial photographs in the automated self-administered 24-hour recall. For some food forms, images of mounds or household measures are as accurate as images of food and, therefore, are a cost-effective alternative to photographs of foods.
doi:10.1016/j.jada.2009.10.007
PMCID: PMC3773715  PMID: 20102828
7.  Differences between food group reports of low energy reporters and non-low energy reporters on a food frequency questionnaire 
Background
Low-energy reporters (LERs) and non-LERs differ with respect to a number of characteristics, including self-reported intake of foods. Limited data exists investigating food intake differences with LERs identified using doubly labeled water (DLW).
Objective
In the Observing Protein and Energy Nutrition Study (September, 1999-March, 2000), differences were examined between food group reports of LERs and non-LERs on a food frequency questionnaire (FFQ) (n=440).
Design
LERs were identified using DLW. LERs' (n=220) and non-LERs' (n=220) reports of 43 food groups on the FFQ were examined in three ways: whether they reported consuming a food group (yes/no), how frequently they reported consuming it (times/day), and the reported portion size (small, medium, or large). Analyses were adjusted for total energy expenditure from DLW.
Results
LERs compared to non-LERs were less likely to report consumption for one food group among women (soft drinks/regular) and no food groups among men. Reported mean daily frequency of consumption was lower in LERs compared to non-LERs for 23 food groups among women and 24 food groups among men (18 food groups were similar in men and women). Additionally, reported mean portion sizes were smaller for LERs compared to non-LERs for 6 food groups among women and 5 food groups among men (3 food groups were similar in men and women). Results varied minimally by sex and body mass index (BMI).
Conclusions
LERs as compared to non-LERs were more likely to differ regarding their reported frequency of consumption of food groups than their reported consumption (yes/no) of the food groups or the food groups' reported portion sizes. Results did not vary greatly by sex or BMI. It still remains to be known whether improvement in questionnaire design or additional tools or methods would lead to a decrease in differential reporting due to LER status on an FFQ.
doi:10.1016/j.jada.2009.04.004
PMCID: PMC3721508  PMID: 19559136
energy underreporting; dietary assessment; food frequency questionnaire; foods
8.  Taking Advantage of the Strengths of 2 Different Dietary Assessment Instruments to Improve Intake Estimates for Nutritional Epidemiology 
American Journal of Epidemiology  2012;175(4):340-347.
With the advent of Internet-based 24-hour recall (24HR) instruments, it is now possible to envision their use in cohort studies investigating the relation between nutrition and disease. Understanding that all dietary assessment instruments are subject to measurement errors and correcting for them under the assumption that the 24HR is unbiased for usual intake, here the authors simultaneously address precision, power, and sample size under the following 3 conditions: 1) 1–12 24HRs; 2) a single calibrated food frequency questionnaire (FFQ); and 3) a combination of 24HR and FFQ data. Using data from the Eating at America’s Table Study (1997–1998), the authors found that 4–6 administrations of the 24HR is optimal for most nutrients and food groups and that combined use of multiple 24HR and FFQ data sometimes provides data superior to use of either method alone, especially for foods that are not regularly consumed. For all food groups but the most rarely consumed, use of 2–4 recalls alone, with or without additional FFQ data, was superior to use of FFQ data alone. Thus, if self-administered automated 24HRs are to be used in cohort studies, 4–6 administrations of the 24HR should be considered along with administration of an FFQ.
doi:10.1093/aje/kwr317
PMCID: PMC3271815  PMID: 22273536
combining dietary instruments; data collection; dietary assessment; energy adjustment; epidemiologic methods; measurement error; nutrient density; nutrient intake
9.  Dietary fiber intake and mortality in the NIH-AARP Diet and Health Study 
Archives of internal medicine  2011;171(12):1061-1068.
Background
Dietary fiber has been hypothesized to lower risk of coronary heart disease, diabetes, and some cancers. However, little is known of the effect of dietary fiber on total death and cause-specific deaths.
Methods
We examined dietary fiber intake in relation to total mortality and death from specific causes in the NIH-AARP Diet and Health Study, a prospective cohort study. Diet was assessed using a food frequency questionnaire at baseline. Cause of death was identified using the National Death Index Plus. Cox proportional hazard models were used to estimate relative risks (RRs) and two-sided 95% confidence intervals (CI).
Results
During an average of 9 years of follow-up, we identified 20,126 deaths in men and 11,330 deaths in women. Dietary fiber intake was associated with significantly lowered risk of total death in both men and women (multivariate RR comparing the highest vs. the lowest quintile =0.78, 95% CI:0.73–0.82, p-trend, <0.001 in men; 0.78. 95% CI:0.73–0.85, p-trend, <0.001 in women). Dietary fiber intake also lowered risk of death from cardiovascular, infectious, and respiratory diseases by 24%–56% in men and 34%–59% in women. Inverse association between dietary fiber intake and cancer death was observed in men, but not in women. Dietary fiber from grains, but not from other sources, was significantly inversely related to total and cause-specific death in both men and women.
Conclusions
Dietary fiber may reduce the risk of death from cardiovascular, infectious and respiratory diseases. Making fiber-rich food choices more often may provide significant health benefits.
doi:10.1001/archinternmed.2011.18
PMCID: PMC3513325  PMID: 21321288
10.  Associations between food patterns defined by cluster analysis and colorectal cancer incidence in the NIH-AARP Diet and Health Study 
Objectives
To examine associations between food patterns, constructed with cluster analysis, and colorectal cancer incidence within the National Institutes of Health (NIH)–AARP Diet and Health Study.
Design
A prospective cohort, aged 50–71 years at baseline in 1995–96, followed until the end of 2000.
Subjects and Method
Food patterns were constructed, separately in men (n=293 576) and women (n=198 730), with 181 food variables (daily intake frequency per 1 000 kilocalories) from a food frequency questionnaire. Four large clusters were identified in men and three in women. Cox proportional hazards regression examined associations between patterns and cancer incidence.
Result
In men, a Vegetable and Fruit Pattern was associated with reduced colorectal cancer incidence (multivariate HR: 0.85 95%CI: 0.76, 0.94), when compared to less salutary food choices. Both the Vegetable and Fruit pattern and a Fat-Reduced Foods pattern were associated with reduced rectal cancer incidence in men. In women, a similar Vegetable and Fruit pattern was associated with colorectal cancer protection (age-adjusted HR: 0.82 95%CI: 0.70, 0.95), but the association was not statistically significant in multivariate analysis.
Conclusion
These results, together with findings from previous studies support the hypothesis that micronutrient dense, low-fat, high-fiber food patterns protect against colorectal cancer.
doi:10.1038/ejcn.2008.40
PMCID: PMC3500882  PMID: 18685556
food patterns; cluster analysis; colorectal cancer; prospective cohort
11.  Added sugar, sugar-sweetened foods and beverages and risk of pancreatic cancer in the NIH-AARP Diet and Health Study 
Background
Although hyperglycemia, hyperinsulinemia and insulin resistance have been hypothesized to be involved in the development of pancreatic cancer, results from epidemiologic studies on added sugar intake are inconclusive.
Objective
Our objective was to investigate whether the consumption of total added sugar, sugar-sweetened foods and beverages is associated with pancreatic cancer risk.
Design
We prospectively examined 487922 men and women aged 50–71 years and free of cancer and diabetes in 1995–96. Total added dietary sugar intake in teaspoons per day (based on USDA’s Pyramid Servings Database) was assessed with a food frequency questionnaire. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated with adjustment for total energy and potential confounding factors.
Results
During an average 7.2 years of follow-up, 1258 incident pancreatic cancer cases were ascertained. The median intakes for the lowest and highest quintiles of total added sugar intake were 12.6 g/day and 96.2 g/day. No overall increased risk of pancreatic cancer was observed in men or women with high intake of total added sugar or sugar-sweetened foods and beverages. For men and women combined, the multivariate RRs of the highest versus lowest intake categories were 0.85 (95% CI: 0.68, 1.06; P trend= 0.07) for total added sugar, 1.01 (95% CI: 0.82,1.23; P trend= 0.58) for sweets, 0.98 (95% CI: 0.82,1.18; P trend= 0.49) for dairy desserts, 1.12 (95% CI: 0.91,1.39; P trend= 0.35) for sugar added to coffee and tea, and 1.01 (95% CI: 0.77,1.31; P trend= 0.76) for sugar-sweetened soft drinks.
Conclusion
Our results do not support the hypothesis that consumption of added sugar, or sugar-sweetened foods and beverages is associated with overall risk of pancreatic cancer.
PMCID: PMC3500146  PMID: 18689380
12.  Sugars in diet and risk of cancer in the NIH-AARP Diet and Health Study 
Prospective epidemiologic data on the effects of different types of dietary sugars on cancer incidence have been limited. In this report, we investigated the association of total sugars, sucrose, fructose, added sugars, added sucrose and added fructose in the diet with risk of 24 malignancies. Participants (n = 435,674) aged 50–71 years from the NIH-AARP Diet and Health Study were followed for 7.2 years. The intake of individual sugars was assessed using a 124-item food frequency questionnaire (FFQ). Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) in multivariable models adjusted for confounding factors pertinent to individual cancers. We identified 29,099 cancer cases in men and 13,355 cases in women. In gender-combined analyses, added sugars were positively associated with risk of esophageal adenocarcinoma (HRQ5 vs. Q1: 1.62, 95% CI: 1.07–2.45; Ptrend = 0.01); added fructose was associated with risk of small intestine cancer (HRQ5 vs. Q1: 2.20, 95% CI: 1.16–4.16; Ptrend = 0.009); and all investigated sugars were associated with increased risk of pleural cancer. In women, all investigated sugars were inversely associated with ovarian cancer. We found no association between dietary sugars and risk of colorectal or any other major cancer. Measurement error in FFQ-reported dietary sugars may have limited our ability to obtain more conclusive findings. Statistically significant associations observed for the rare cancers are of interest and warrant further investigation.
doi:10.1002/ijc.25990
PMCID: PMC3494407  PMID: 21328345
Sugars; added sugars; diet; cancer; AARP Study
13.  The accuracy of the Goldberg method for classifying misreporters of energy intake on a food frequency questionnaire and 24-hour recalls: Comparison with doubly labeled water 
Background/Objectives
Adults often misreport dietary intake; the magnitude varies by the methods used to assess diet and classify participants. The objective was to quantify the accuracy of the Goldberg method for categorizing misreporters on a food frequency questionnaire (FFQ) and two 24-hour recalls (24HR).
Subjects/Methods
We compared the Goldberg method, which uses an equation to predict total energy expenditure (TEE), to a criterion method that uses doubly labeled water (DLW), in a study of 451 men and women. Underreporting was classified using recommended cutpoints and calculated values. Sensitivity and specificity, positive and negative predictive value (PPV and NPV), and the area under the receiver operating characteristic curve (AUC) were calculated. Predictive models of underreporting were contrasted for the Goldberg and DLW methods.
Results
AUC were 0.974 and 0.972 on the FFQ, and 0.961 and 0.938 on the 24HR for men and women, respectively. The sensitivity of the Goldberg method was higher for the FFQ (92%) than the 24HR (50%); specificity was higher for the 24HR (99%) than the FFQ (88%); PPV was high for the 24HR (92%) and FFQ (88%). Simulation studies indicate attenuation in odds ratio estimates and reduction of power in predictive models.
Conclusions
Although use of the Goldberg method may lead to bias and reduction in power in predictive models of underreporting, the method has high predictive value for both the FFQ and the 24HR. Thus, in the absence of objective measures of TEE or physical activity, the Goldberg method is a reasonable approach to characterizing underreporting.
doi:10.1038/ejcn.2011.198
PMCID: PMC3319469  PMID: 22127332
Diet; Diet Surveys; Energy Intake; Statistical Bias; Questionnaires/standards; Research Design
14.  Validating an FFQ for intake of episodically consumed foods: application to the National Institutes of Health–AARP Diet and Health Study 
Public Health Nutrition  2011;14(7):1212-1221.
Objective
To develop a method to validate an FFQ for reported intake of episodically consumed foods when the reference instrument measures short-term intake, and to apply the method in a large prospective cohort.
Design
The FFQ was evaluated in a sub-study of cohort participants who, in addition to the questionnaire, were asked to complete two non-consecutive 24 h dietary recalls (24HR). FFQ-reported intakes of twenty-nine food groups were analysed using a two-part measurement error model that allows for nonconsumption on a given day, using 24HR as a reference instrument under the assumption that 24HR is unbiased for true intake at the individual level.
Setting
The National Institutes of Health–AARP Diet and Health Study, a cohort of 567 169 participants living in the USA and aged 50–71 years at baseline in 1995.
Subjects
A sub-study of the cohort consisting of 2055 participants.
Results
Estimated correlations of true and FFQ-reported energy-adjusted intakes were 0·5 or greater for most of the twenty-nine food groups evaluated, and estimated attenuation factors (a measure of bias in estimated diet–disease associations) were 0·4 or greater for most food groups.
Conclusions
The proposed methodology extends the class of foods and nutrients for which an FFQ can be evaluated in studies with short-term reference instruments. Although violations of the assumption that the 24HR is unbiased could be inflating some of the observed correlations and attenuation factors, results suggest that the FFQ is suitable for testing many, but not all, diet–disease hypotheses in a cohort of this size.
doi:10.1017/S1368980011000632
PMCID: PMC3190597  PMID: 21486523
Diet; Food; Epidemiological methods; Questionnaires; Validation studies
15.  Dietary quercetin, quercetin-gene interaction, metabolic gene expression in lung tissue and lung cancer risk 
Carcinogenesis  2009;31(4):634-642.
Epidemiological and mechanistic evidence on the association of quercetin-rich food intake with lung cancer risk and carcinogenesis are inconclusive. We investigated the role of dietary quercetin and the interaction between quercetin and P450 and glutathione S-transferase (GST) polymorphisms on lung cancer risk in 1822 incident lung cancer cases and 1991 frequency-matched controls from the Environment And Genetics in Lung cancer Etiology study. In non-tumor lung tissue from 38 adenocarcinoma patients, we assessed the correlation between quercetin intake and messenger RNA expression of the same P450 and GST metabolic genes. Multivariate odds ratios (ORs) and 95% confidence intervals (CIs) for sex-specific quintiles of intake were calculated using unconditional logistic regression adjusting for putative risk factors. Frequent intake of quercetin-rich foods was inversely associated with lung cancer risk (OR = 0.49; 95% CI: 0.37–0.67; P-trend < 0.001) and did not differ by P450 or GST genotypes, gender or histological subtypes. The association was stronger in subjects who smoked >20 cigarettes per day (OR = 0.35; 95% CI: 0.19–0.66; P-trend = 0.003). Based on a two-sample t-test, we compared gene expression and high versus low consumption of quercetin-rich foods and observed an overall upregulation of GSTM1, GSTM2, GSTT2, and GSTP1 as well as a downregulation of specific P450 genes (P-values < 0.05, adjusted for age and smoking status). In conclusion, we observed an inverse association of quercetin-rich food with lung cancer risk and identified a possible mechanism of quercetin-related changes in the expression of genes involved in the metabolism of tobacco carcinogens in humans. Our findings suggest an interplay between quercetin intake, tobacco smoking, and lung cancer risk. Further research on this relationship is warranted.
doi:10.1093/carcin/bgp334
PMCID: PMC2847089  PMID: 20044584
16.  Comparing 3 Dietary Pattern Methods—Cluster Analysis, Factor Analysis, and Index Analysis—With Colorectal Cancer Risk 
American Journal of Epidemiology  2009;171(4):479-487.
The authors compared dietary pattern methods—cluster analysis, factor analysis, and index analysis—with colorectal cancer risk in the National Institutes of Health (NIH)–AARP Diet and Health Study (n = 492,306). Data from a 124-item food frequency questionnaire (1995–1996) were used to identify 4 clusters for men (3 clusters for women), 3 factors, and 4 indexes. Comparisons were made with adjusted relative risks and 95% confidence intervals, distributions of individuals in clusters by quintile of factor and index scores, and health behavior characteristics. During 5 years of follow-up through 2000, 3,110 colorectal cancer cases were ascertained. In men, the vegetables and fruits cluster, the fruits and vegetables factor, the fat-reduced/diet foods factor, and all indexes were associated with reduced risk; the meat and potatoes factor was associated with increased risk. In women, reduced risk was found with the Healthy Eating Index-2005 and increased risk with the meat and potatoes factor. For men, beneficial health characteristics were seen with all fruit/vegetable patterns, diet foods patterns, and indexes, while poorer health characteristics were found with meat patterns. For women, findings were similar except that poorer health characteristics were seen with diet foods patterns. Similarities were found across methods, suggesting basic qualities of healthy diets. Nonetheless, findings vary because each method answers a different question.
doi:10.1093/aje/kwp393
PMCID: PMC2842201  PMID: 20026579
colorectal neoplasms; food habits; risk
17.  Alcohol Consumption and Lung Cancer Risk in the Environment and Genetics in Lung Cancer Etiology (EAGLE) Study 
American Journal of Epidemiology  2009;171(1):36-44.
The authors investigated the relation between alcohol consumption and lung cancer risk in the Environment and Genetics in Lung Cancer Etiology (EAGLE) Study, a population-based case-control study. Between 2002 and 2005, 2,100 patients with primary lung cancer were recruited from 13 hospitals within the Lombardy region of Italy and were frequency-matched on sex, area of residence, and age to 2,120 randomly selected controls. Alcohol consumption during adulthood was assessed in 1,855 cases and 2,065 controls. Data on lifetime tobacco smoking, diet, education, and anthropometric measures were collected. Adjusted odds ratios and 95% confidence intervals for categories of mean daily ethanol intake were calculated using unconditional logistic regression. Overall, both nondrinkers (odds ratio = 1.42, 95% confidence interval: 1.03, 2.01) and very heavy drinkers (≥60 g/day; odds ratio = 1.44, 95% confidence interval: 1.01, 2.07) were at significantly greater risk than very light drinkers (0.1–4.9 g/day). The alcohol effect was modified by smoking behavior, with no excess risk being observed in never smokers. In summary, heavy alcohol consumption was a risk factor for lung cancer among smokers in this study. Although residual confounding by tobacco smoking cannot be ruled out, this finding may reflect interplay between alcohol and smoking, emphasizing the need for preventive measures.
doi:10.1093/aje/kwp332
PMCID: PMC2800301  PMID: 19933698
alcohol drinking; case-control studies; ethanol; lung neoplasms; risk factors; smoking
18.  Need for Technological Innovation in Dietary Assessment 
doi:10.1016/j.jada.2009.10.008
PMCID: PMC2823476  PMID: 20102826
Dietary assessment; dietary studies
19.  Challenges in converting an interviewer-administered food probe database to self-administration in the National Cancer Institute Automated Self-administered 24-Hour Recall (ASA24) 
The National Cancer Institute (NCI) is developing an automated, self-administered 24-hour dietary recall (ASA24) application to collect and code dietary intake data. The goal of the ASA24 development is to create a web-based dietary interview based on the US Department of Agriculture (USDA) Automated Multiple Pass Method (AMPM) instrument currently used in the National Health and Nutrition Examination Survey (NHANES). The ASA24 food list, detail probes, and portion probes were drawn from the AMPM instrument; portion-size pictures from Baylor College of Medicine’s Food Intake Recording Software System (FIRSSt) were added; and the food code/portion code assignments were linked to the USDA Food and Nutrient Database for Dietary Studies (FNDDS). The requirements that the interview be self-administered and fully auto-coded presented several challenges as the AMPM probes and responses were linked with the FNDDS food codes and portion pictures. This linking was accomplished through a “food pathway,” or the sequence of steps that leads from a respondent’s initial food selection, through the AMPM probes and portion pictures, to the point at which a food code and gram weight portion size are assigned. The ASA24 interview database that accomplishes this contains more than 1,100 food probes and more than 2 million food pathways and will include about 10,000 pictures of individual foods depicting up to 8 portion sizes per food. The ASA24 will make the administration of multiple days of recalls in large-scale studies economical and feasible.
doi:10.1016/j.jfca.2009.02.003
PMCID: PMC2786178  PMID: 20161418
National Health and Nutrition Examination Survey; NHANES; 24-hour recall; Self-administered 24-hour dietary recall; ASA24; Food portion photograph; AMPM interview; Food data management
20.  Effect of smoking status on total energy expenditure 
Individuals who smoke generally have a lower body mass index (BMI) than nonsmokers. The relative roles of energy expenditure and energy intake in maintaining the lower BMI, however, remain controversial. We tested the hypothesis that current smokers have higher total energy expenditure than never smokers in 308 adults aged 40-69 years old of which 47 were current smokers. Energy expenditure was measured by doubly labeled water during a two week period in which the subjects lived at home and performed their normal activities. Smoking status was determined by questionnaire. There were no significant differences in mean BMI (mean ± SD) between smokers and never smokers for either males (27.8+5.1 kg/m2 vs. 27.5+4.0 kg/m2) or females (26.5+5.3 kg/m2 vs. 28.1+6.6 kg/m2), although the difference in females was of similar magnitude to previous reports. Similarly, total energy expenditure of male smokers (3069+764 kcal/d) was not significantly different from that of never smokers (2854+468 kcal/d), and that of female smokers (2266+387 kcal/d) was not different from that of never smokers (2330+415 kcal/d). These findings did not change after adjustment for age, fat-free mass and self-reported physical activity. Using doubly labeled water, we found no evidence of increased energy expenditure among smokers, however, it should be noted that BMI differences in this cohort also did not differ by smoking status.
doi:10.1186/1743-7075-7-81
PMCID: PMC2989978  PMID: 21040542
21.  Dietary Fatty Acids and Pancreatic Cancer in the NIH-AARP Diet and Health Study 
Background
Previous research relating dietary fat, a modifiable risk factor, to pancreatic cancer has been inconclusive.
Methods
We prospectively analyzed the association between intakes of fat, fat subtypes, and fat food sources and exocrine pancreatic cancer in the National Institutes of Health–AARP Diet and Health Study, a US cohort of 308 736 men and 216 737 women who completed a 124-item food frequency questionnaire in 1995–1996. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models, with adjustment for energy intake, smoking history, body mass index, and diabetes. Statistical tests were two-sided.
Results
Over an average follow-up of 6.3 years, 865 men and 472 women were diagnosed with exocrine pancreatic cancer (45.0 and 34.5 cases per 100 000 person-years, respectively). After multivariable adjustment and combination of data for men and women, pancreatic cancer risk was directly related to the intakes of total fat (highest vs lowest quintile, 46.8 vs 33.2 cases per 100 000 person-years, HR = 1.23, 95% CI = 1.03 to 1.46; Ptrend  = .03), saturated fat (51.5 vs 33.1 cases per 100 000 person-years, HR = 1.36, 95% CI = 1.14 to 1.62; Ptrend < .001), and monounsaturated fat (46.2 vs 32.9 cases per 100 000 person-years, HR = 1.22, 95% CI = 1.02 to 1.46; Ptrend = .05) but not polyunsaturated fat. The associations were strongest for saturated fat from animal food sources (52.0 vs 32.2 cases per 100 000 person-years, HR = 1.43, 95% CI = 1.20 to 1.70; Ptrend < .001); specifically, intakes from red meat and dairy products were both statistically significantly associated with increased pancreatic cancer risk (HR = 1.27 and 1.19, respectively).
Conclusion
In this large prospective cohort with a wide range of intakes, dietary fat of animal origin was associated with increased pancreatic cancer risk.
doi:10.1093/jnci/djp168
PMCID: PMC2724851  PMID: 19561318
22.  Modeling Data with Excess Zeros and Measurement Error: Application to Evaluating Relationships between Episodically Consumed Foods and Health Outcomes 
Biometrics  2009;65(4):1003-1010.
Summary
Dietary assessment of episodically consumed foods gives rise to nonnegative data that have excess zeros and measurement error. Tooze et al. (2006, Journal of the American Dietetic Association 106, 1575–1587) describe a general statistical approach (National Cancer Institute method) for modeling such food intakes reported on two or more 24-hour recalls (24HRs) and demonstrate its use to estimate the distribution of the food’s usual intake in the general population. In this article, we propose an extension of this method to predict individual usual intake of such foods and to evaluate the relationships of usual intakes with health outcomes. Following the regression calibration approach for measurement error correction, individual usual intake is generally predicted as the conditional mean intake given 24HR-reported intake and other covariates in the health model. One feature of the proposed method is that additional covariates potentially related to usual intake may be used to increase the precision of estimates of usual intake and of diet-health outcome associations. Applying the method to data from the Eating at America’s Table Study, we quantify the increased precision obtained from including reported frequency of intake on a food frequency questionnaire (FFQ) as a covariate in the calibration model. We then demonstrate the method in evaluating the linear relationship between log blood mercury levels and fish intake in women by using data from the National Health and Nutrition Examination Survey, and show increased precision when including the FFQ information. Finally, we present simulation results evaluating the performance of the proposed method in this context.
doi:10.1111/j.1541-0420.2009.01223.x
PMCID: PMC2881223  PMID: 19302405
Dietary measurement error; Dietary survey; Episodically consumed foods; Excess zero models; Food frequency questionnaire; Fish; Individual usual intake; Mercury; Nonlinear mixed models; Regression calibration; 24-hour recall
23.  Observational Epidemiologic Studies of Nutrition and Cancer: The Next Generation (with Better Observation) 
It would be of enormous public health importance if diet and physical activity—both modifiable behavioral factors--were causally related to cancer. Nevertheless, the nutritional epidemiology of cancer remains problematic, in part because of persistent concerns that standard questionnaires measure diet and physical activity with too much error. We present a new strategy for addressing this measurement error problem. First, as background, we note that food frequency and physical activity questionnaires require respondents to report ‘typical’ diet or activity over the previous year or longer. Multiple 24-hour recalls (24HR), based on reporting only the previous day’s behavior, offer potential cognitive advantages over the questionnaires, and biomarker evidence suggests the 24HR is more accurate than the food frequency questionnaire. The expense involved in administering multiple 24HRs in large epidemiologic studies, however, has up to now been prohibitive. In that context, we suggest that internet-based 24HRs, for both diet and physical activity, represent a practical and cost-effective approach for incorporating multiple recalls in large epidemiologic studies. We discuss 1) recent efforts to develop such internet-based instruments and their accompanying software support systems; 2) ongoing studies to evaluate the feasibility of using these new instruments in cohort studies; 3) additional investigations to gauge the accuracy of the internet-based recalls vis-à-vis standard instruments and biomarkers; and 4) new statistical approaches for combining the new instruments with standard assessment tools and biomarkers The incorporation of internet-based 24HRs into large epidemiologic studies may help advance our understanding of the nutritional determinants of cancer.
doi:10.1158/1055-9965.EPI-08-1129
PMCID: PMC2688809  PMID: 19336550
Nutrition; Diet; Physical Activity; Cancer; Measurement error
24.  Glycemic Index, Carbohydrates, Glycemic Load, and the Risk of Pancreatic Cancer in a Prospective Cohort Study 
Diets with high glycemic index and glycemic load have been associated with insulin resistance. Insulin resistance has been implicated in the etiology of pancreatic cancer. We prospectively investigated the associations between glycemic index, carbohydrates, glycemic load, and available carbohydrates dietary constituents (starch and simple sugar) intake and the risk of pancreatic cancer. We followed the participants in the NIH-AARP Diet and Health Study from 1995/1996 through December 2003. A baseline self-administered food frequency questionnaire was used to assess the dietary intake and exposure information. A total of 1,151 exocrine pancreatic cancer cases were identified from 482,362 participants after excluding first-year of follow-up. We used multivariate Cox proportional hazards regression models to calculate relative risks (RR) and 95% confidence intervals (95% CI) for pancreatic cancer. There were no associations between glycemic index, total or available carbohydrates, gycemic load, and pancreatic cancer risk. Participants with high free fructose and glucose intake were at a greater risk of developing pancreatic cancer (highest compared with lowest quintile, RR, 1.29; 95% CI, 1.04–1.59; P trend = 0.004 and RR, 1.35; 95% CI, 1.10–1.67; P trend = 0.005, respectively). There were no statistically significant interactions by body mass index, physical activity, or smoking status. Our results do not support an association between glycemic index, total or available carbohydrate intake, and glycemic load and pancreatic cancer risk. The higher risk associated with high free fructose intake needs further confirmation and elucidation.
doi:10.1158/1055-9965.EPI-08-1135
PMCID: PMC2687095  PMID: 19336549
25.  Dairy food, Calcium, and Risk of Cancer in the NIH-AARP Diet and Health Study 
Archives of internal medicine  2009;169(4):391-401.
Background
Dairy food and calcium have been hypothesized to play roles that differ among individual cancer sites, but the evidence has been limited and inconsistent. Moreover, the effect of dairy food and calcium on cancer in total is unclear.
Methods
Dairy food and calcium in relation to total cancer as well as cancer at individual sites were examined in the NIH-AARP Diet and Health Study. Intakes of dairy food and calcium from foods and supplements were assessed with a food frequency questionnaire. Incident cancer cases were identified through linkage with state cancer registries. Cox proportional hazard model was used to estimate relative risks (RRs) and tow-sided 95% confidence intervals (CI).
Results
During average of 7 years of follow-up, we identified 36,965 and 16,605 cancer cases in men and women, respectively. Calcium intake was not related to total cancer in men, but was non-linearly associated with total cancer in women: risk decreased up to approximately 1,300 mg/day, above which no further risk reduction was observed. In both men and women, dairy food and calcium were inversely associated with cancers of the digestive system (multivariate RR for the highest quintile of total calcium vs. the lowest = 0.84, 95% CI: 0.77–0.92 in men and 0.77, 95% CI: 0.69–0.91 in women). Decreased risk was particularly pronounced with colorectal cancer. Supplemental calcium was also inversely associated with colorectal cancer risk.
Conclusions
Our study suggests that calcium intake is associated with lower risk of total cancer and cancers of the digestive system, especially colorectal cancer.
doi:10.1001/archinternmed.2008.578
PMCID: PMC2796799  PMID: 19237724

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