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1.  Proportion of Gestational Diabetes Mellitus Attributable to Overweight and Obesity Among Non-Hispanic Black, Non-Hispanic White, and Hispanic Women in South Carolina 
Maternal and child health journal  2014;18(8):1919-1926.
Objective was to estimate race-specific proportions of gestational diabetes mellitus (GDM) attributable to overweight and obesity in South Carolina. South Carolina birth certificate and hospital discharge data were obtained from 2004 to 2006. Women who did not have type 2 diabetes mellitus before pregnancy were classified with GDM if a diagnosis was reported in at least one data source. Relative risks (RR) and 95 % confidence intervals were calculated using the log-binomial model. The modified Mokdad equation was used to calculate population attributable fractions for overweight body mass index (BMI: 25.0–29.9 kg/m2), obese (30.0–34.9 kg/m2), and extremely obese (≥ 35 kg/m2) women after adjusting for age, gestational weight gain, education, marital status, parity, tobacco use, pre-pregnancy hypertension, and pregnancy hypertension. Overall, the adjusted RR of GDM was 1.6, 2.3, and 2.9 times higher among the overweight, obese, and extremely obese women compared to normal-weight women in South Carolina. RR of GDM for extremely obese women was higher among White (3.1) and Hispanic (3.4) women than that for Black women (2.6). The fraction of GDM cases attributable to extreme obesity was 14.0 % among White, 18.1 % among Black, and 9.6 % among Hispanic women. The fraction of GDM cases attributable to obesity was about 12 % for all racial groups. Being overweight (BMI: 25.0–29.9) explained 8.8, 7.8, and 14.4 % of GDM cases among White, Black, and Hispanic women, respectively. Results indicate a significantly increased risk of GDM among overweight, obese, and extremely obese women. The strength of the association and the proportion of GDM cases explained by excessive weight categories vary by racial/ethnic group.
PMCID: PMC4181606  PMID: 24531925
Health disparity; Racial difference; Population attributable fraction; Epidemiology
Cancer causes & control : CCC  2012;24(2):277-285.
Type 2 diabetes mellitus (T2DM) prevalence has increased dramatically in the United States since the early 1970s. Though T2DM is known to be associated with colorectal cancer (CRC), information on racial differences in the relationship between T2DM and CRC is limited.
Using a retrospective cohort design we compared the association between T2DM and CRC, including subsites of the colon, in African Americans (AAs) and European Americans (EAs) in South Carolina, a region with large racial disparities in rates of both diseases. A total of 91,836 individuals who were ≥30 years old on January 1, 1990 and had ≥12 months of South Carolina Medicaid eligibility between January 1, 1990 and December 31, 1995 were included in the analyses. Cancer data from 1996 to 2007, included information on anatomic subsite.
Subjects who had T2DM (n=6,006) were >50% more likely to be diagnosed with colon cancer compared to those without T2DM (n=85,681). The association between T2DM and colon cancer was higher in AAs [odds ratio (OR) = 1.72 (95% Confidence Interval:1.21,2.46); n=47,984] than among EAs (OR = 1.24; 0.73,2.11; n=43,703). Overall, individuals with T2DM were over twice as likely to be diagnosed with in situ or local colon cancer (OR = 2.12; 1.40,3.22; n=191) compared to those without T2DM, with a higher likelihood among AAs (OR = 2.49;1.52,4.09; n=113).
Results from a Medicaid population in a high-risk region of the country, showed an increased likelihood of CRC with T2DM and suggest a racial disparity that disfavors AAs and provides further impetus for efforts aimed at diabetes prevention in this group.
PMCID: PMC3557726  PMID: 23197224
cohort study design; colorectal cancer; diabetes mellitus type II; health status disparities; incidence; South Carolina
3.  Scientific Decision Making, Policy Decisions, and the Obesity Pandemic 
Rising and epidemic rates of obesity in many parts of the world are leading to increased suffering and economic stress from diverting health care resources to treating a variety of serious, but preventable, chronic diseases etiologically linked to obesity, particularly type 2 diabetes mellitus and cardiovascular diseases. Despite decades of research into the causes of the obesity pandemic, we seem to be no nearer to a solution now than when the rise in body weights was first chronicled decades ago. The case is made that impediments to a clear understanding of the nature of the problem occur at many levels. These obstacles begin with defining obesity and include lax application of scientific standards of review, tenuous assumption making, flawed measurement and other methods, constrained discourse limiting examination of alternative explanations of cause, and policies that determine funding priorities. These issues constrain creativity and stifle expansive thinking that could otherwise advance the field in preventing and treating obesity and its complications. Suggestions are made to create a climate of open exchange of ideas and redirection of policies that can remove the barriers that prevent us from making material progress in solving a pressing major public health problem of the early 21st century.
PMCID: PMC3759398  PMID: 23726399
4.  Association of coffee consumption with all-cause and cardiovascular disease mortality 
Mayo Clinic proceedings. Mayo Clinic  2013;88(10):10.1016/j.mayocp.2013.06.020.
To evaluate the association between coffee consumption and mortality from all causes and cardiovascular disease (CVD).
Patients and Methods
Data from the Aerobics Center Longitudinal Study (ACLS) representing a total of 43,727 participants contributing to 699,632 person-years of follow-up time, were included. Baseline data were collected by an in-person interview based on standardized questionnaires and a medical examination, including fasting blood chemistry analysis, anthropometry, blood pressure, electrocardiography, and a maximal graded exercise test, between February 3, 1971 and December 30, 2002. Cox regression analysis was used to quantify the association between coffee consumption and all-cause and cause-specific mortality.
During the 17-year median follow-up period, 2512 deaths occurred (32% due to CVD). In multivariate analyses, coffee intake was positively associated with all-cause mortality in men. Men who drank >28 cups coffee per week had higher all-cause mortality (hazard ratio (HR): 1.21; 95% confidence interval (CI): 1.04–1.40). However, after stratification based on age, both younger (<55 years) men and women showed a statistically significant association between high coffee consumption (>28 cups/week) and all-cause mortality, after adjusting for potential confounders and fitness level (HR: 1.56; 95% CI: 1.30–1.87 for men and HR: 2.13; 95% CI: 1.26–3.59 for women, respectively).
In this large cohort, a positive association between coffee consumption and all-cause mortality was observed among men and both men and women <55 years of age. Based on our findings, it seems appropriate to suggest that younger people avoid heavy coffee consumption (ie, averaging >4 cups/day). However, this finding should be assessed in future studies from other populations.
PMCID: PMC3835155  PMID: 23953850
5.  Diet and proinflammatory cytokine levels in head and neck squamous cell carcinoma 
Cancer  2014;120(17):2704-2712.
Proinflammatory cytokine levels may be associated with cancer stage, recurrence, and survival. A study was undertaken to determine if cytokine levels were associated with dietary patterns and fat-soluble micronutrients in previously untreated head and neck squamous cell carcinoma (HNSCC) patients.
This was a cross-sectional study of 160 newly diagnosed HNSCC patients who completed pretreatment food frequency questionnaires (FFQ) and health surveys. Dietary patterns were derived from FFQs using principal component analysis. Pretreatment serum levels of the proinflammatory cytokines IL-6, TNF-α, and IFN-γ were measured by ELISA and serum carotenoid and tocopherol levels by HPLC. Multivariable ordinal logistic regression models examined associations between cytokines and quartiles of reported and serum dietary variables.
Three dietary patterns emerged: whole foods, Western, and convenience foods. In multivariable analyses, higher whole foods pattern scores were significantly associated with lower levels of IL-6, TNF-α, and IFN-γ (P = <0.001, P = 0.008, and P = 0.03, respectively). Significant inverse associations were reported between IL-6, TNF-α, and IFN-γ levels and quartiles of total reported carotenoid intake (P = 0.006, P = 0.04, and P = 0.04, respectively). There was an inverse association between IFN-γ levels and serum α-tocopherol levels (P = 0.03).
Consuming a pretreatment diet rich in vegetables, fruit, fish, poultry and whole grains may be associated with lower proinflammatory cytokine levels in patients with HNSCC.
PMCID: PMC4141000  PMID: 24830761
dietary patterns; carotenoids; cytokines; head and neck cancer
6.  Angiotensin receptor blockers: are they related to lung cancer? 
Journal of hypertension  2013;31(8):10.1097/HJH.0b013e3283621ea3.
Angiotensin receptor blockers (ARBs) are commonly used antihypertensive medication with several other additional proven benefits. Recent controversy on association of lung cancer and other solid malignancy with the use of ARBs is concerning, although the follow-up studies have shown no such association.
We used data from the Department of Veterans Affairs electronic medical record system and registries to conduct a retrospective cohort study that compared first-time ARB users with nonusers in 1:15 ratio, after balancing for many baseline differences using inverse probability of treatment weights. We conducted time-to-event survival analyses on the weighted cohort.
Of the 1 229 902 patients in the analytic cohort, 346 (0.44%) of the 78 075 treated individuals had a newly incident lung cancer and 6577 (0.57%) of 1 151 826 nontreated individuals were diagnosed with lung cancer. On double robust regression, the weighted hazard ratio was 0.74 (0.67–0.83, P<0.0001), suggesting a lung cancer reduction effect with ARB use. There was no difference in rates by ARB subtype.
In this large nationwide cohort of United States Veterans, we found no evidence to support any concern of increased risk of lung cancer among new users of ARBs compared with nonusers. Our findings were consistent with a protective effect of ARBs.
PMCID: PMC3879726  PMID: 23822929
angiotensin receptor blockers; cancer registry; Department of Veterans Affairs; drug safety; inverse probability of treatment weight; lung cancer; propensity score; survival analysis
7.  Underreporting of energy intake and associated factors in a Latino population at risk of developing type 2 diabetes 
The objective of this study is to examine the extent of underreporting of total caloric intake and associated factors in a low-income, low-literacy, predominantly Caribbean Latino community in Lawrence, Massachusetts. Two hundred fifteen Latinos participated in a diabetes prevention study, with eligibility included a ≥30% risk of developing diabetes in 7.5 years. Dietary self-reported energy intake (EI) was assessed using three randomly selected days of 24-hour diet recalls. Basal metabolic rate (BMRest) was estimated using the Mifflin-St Jeor equation. Underreporting was determined by computing a ratio of EI to BMRest, with a ratio of 1.55 expected for sedentary populations. Linear regression analyses were used to identify factors associated with underreporting (EI:BMRest ratio). The population was predominately female (77%), middle-aged [mean =52 years; standard deviation (SD)=11], obese (78% had a BMI≥30 kg/m2); low-literate (62% < high school education), unemployed (57% reported no job), married or living with partner (52%), and some had a family history of diabetes (37% had siblings with diabetes). Reported total daily EI was 1540 kcal (SD=599), whereas estimated BMR was 1495.7 kcal/day (SD=245.1). When multiplied by an activity factor (1.20 for sedentariness), expected caloric intake was 1794 (SD=294.0), indicating underreporting by an average of 254 Kcal/day. Mean EI/BMRest was 1.03 (SD=0.37), and was lower for participants with higher BMI, siblings with diabetes, sedentary lifestyle, and the unemployed. EI underreporting is prevalent in this low-income, low- literacy Caribbean Latino population. Future studies are needed to develop dietary assessment measures that minimize underreporting in this population.
PMCID: PMC4017735  PMID: 18502234
8.  A Farmers’ Market at a Federally Qualified Health Center Improves Fruit and Vegetable Intake among Low-income Diabetics 
Preventive medicine  2013;56(5):288-292.
A 22-week federally qualified health center (FQHC)-based farmers’ market (FM) and personal financial incentive intervention designed to improve access to and consumption of fruits and vegetables (FV) among low-income diabetics in rural South Carolina was evaluated.
A mixed methods, one-group, repeated-measures design was used. Data were collected in 2011 before (May/June), during (August), and after (November) the intervention with 41 diabetes patients from the FQHC. FV consumption was assessed using a validated National Cancer Institute FV screener modified to include FV sold at the FM. Sales receipts were recorded for all FM transactions. A mixed-model, repeated measures analysis of variance was used to assess intervention effects on FV consumption. Predictors of changes in FV consumption were examined using logistic regression.
A marginally significant (p=0.07) average increase of 1.6 servings of total FV consumption per day occurred. The odds of achieving significant improvements in FV consumption increased for diabetics using financial incentives for payment at the FM (OR: 38.8, 95% CI: 3.4–449.6) and for those frequenting the FM more often (OR: 2.1, 95% CI: 1.1–4.0).
Results reveal a dose-response relationship between the intervention and FV improvements and emphasize the importance of addressing economic barriers to food access.
PMCID: PMC3633661  PMID: 23384473
Prevention & control; Community health centers; Health promotion; Diabetes Mellitus; Type 2; Obesity; Poverty
9.  Provider Communication and Role Modeling Related to Patients' Perceptions and Use of a Federally Qualified Health Center-based Farmers' Market 
Health promotion practice  2013;15(2):288-297.
Farmers’ markets have the potential to improve the health of underserved communities, shape people’s perceptions, values, and behaviors about healthy eating, and serve as a social space for both community members and vendors. This study explored the influence of health care provider communication and role modeling for diabetic patients within the context of a farmers’ market located at a federally qualified health center (FQHC). Although provider communication about diet decreased over time, communication strategies included: providing patients with “prescriptions” and vouchers for market purchases; educating patients about diet; and modeling healthy purchases. Data from patient interviews and provider surveys revealed that patients enjoyed social aspects of the market including interactions with their health care provider, and providers distributed prescriptions and vouchers to patients, shopped at the market, and believed the market had potential to improve the health of FHQC staff and patients. Provider modeling of healthy behaviors may influence patients’ food-related perceptions and dietary behaviors.
PMCID: PMC3871943  PMID: 23986503
federally qualified health center; farmers’ market; diabetes; obesity prevention; patient-provider communication; communication intervention
10.  Interdisciplinary, Translational, and Community-Based Participatory Research 
Preventing cancer, downstaging disease at diagnosis, and reducing mortality require that relevant research findings be translated across scientific disciplines and into clinical and public health practice. Interdisciplinary research focuses on using the languages of different scientific disciplines to share techniques and philosophical perspectives to enhance discovery and development of innovations; (i.e., from the “left end” of the research continuum). Community-based participatory research (CBPR), whose relevance often is relegated to the “right end” (i.e., delivery and dissemination) of the research continuum, represents an important means for understanding how many cancers are caused as well as for ensuring that basic science research findings affect cancer outcomes in materially important ways. Effective interdisciplinary research and CBPR both require an ability to communicate effectively across groups that often start out neither understanding each other’s worldviews nor even speaking the same language. Both demand an ability and willingness to treat individuals from other communities with respect and understanding. We describe the similarities between CBPR and both translational and interdisciplinary research, and then illustrate our points using squamous cell carcinoma of the esophagus as an example of how to deepen understanding and increase relevance by applying techniques of CBPR and interdisciplinary engagement.
PMCID: PMC2679168  PMID: 19336548
11.  Findings from the Community Health Intervention Program in South Carolina: Implications for Reducing Cancer-Related Health Disparities 
The South Carolina Cancer Prevention and Control Research Network (SC-CPCRN) implemented the Community Health Intervention Program (CHIP) mini-grants initiative to address cancer-related health disparities and reduce the cancer burden among high-risk populations across the state. The mini-grants project implemented evidence-based health interventions tailored to the specific needs of each community.
To support the SC-CPCRN’s goals of moving toward greater dissemination and implementation of evidence-based programs in the community to improve public health, prevent disease, and reduce the cancer burden.
Three community-based organizations were awarded $10,000 each to implement one of the National Cancer Institute’s evidence-based interventions. Each group had 12 months to complete their project. SC-CPCRN investigators and staff provided guidance, oversight, and technical assistance for each project. Grantees provided regular updates and reports to their SC-CPCRN liaisons to capture vital evaluation information.
The intended CHIP mini-grant target population reach was projected to be up to 880 participants combined. Actual combined reach of the three projects reported upon completion totaled 1,072 individuals. The majority of CHIP participants were African-American females. Participants ranged in age from 19 to 81 years. Evaluation results showed an increase in physical activity, dietary improvements, and screening participation.
The success of the initiative was the result of a strong community-university partnership built on trust. Active two-way communication and an honest open dialogue created an atmosphere for collaboration. Communities were highly motivated. All team members shared a common goal of reducing cancer-related health disparities and building greater public health capacity across the state.
PMCID: PMC3755099  PMID: 23645547
12.  Racial Disparities in Breast Cancer Mortality in a Multi-Ethnic Cohort in the Southeast 
Cancer  2011;118(10):2693-2699.
Although much has been done to examine those factors associated with higher mortality among African American women, there is a paucity of literature which examines disparities among rural African Americans in South Carolina. The purpose of this investigation was to examine the association of race and mortality among BrCA patients in a large cohort residing in South Carolina for which treatment regimens are standardized for all patients.
Subjects included 1209 women diagnosed with BrCA between 2000–2002 at a large, local hospital containing a comprehensive breast center. Kaplan Meier survival curves were calculated to determine survival rates among AA and EA women, stratified by disease stage or other prognostic characteristics. Adjusting for various characteristics, Cox multivariable survival models were used to estimate the hazard ratio (HR)
The 5-year overall all-cause mortality survival proportion was ~78% for AA women and ~89% for EA women, p<0.01. In analyses of sub-populations of women with identical disease characteristics, AA women had significantly higher mortality than EA women for the same type of breast cancer disease. In multivariable models, AA women had significantly higher mortality than EA women for both BrCA specific death (HR = 2.41; 1.21–4.79) and all-cause mortality (HR = 1.42; 1.06–1.89).
AA women residing in rural South Carolina had lower survival for breast cancer even after adjustment for disease-related prognostic characteristics.
These findings support health interventions among AA BrCA patients aimed at tertiary prevention strategies or further down-staging of disease at diagnosis.
PMCID: PMC3269560  PMID: 21953316
Breast Neoplasms; Mortality; African Americans; Health Status Disparities; Tertiary Prevention
13.  Colonoscopy Screening Rates Among Patients of Colonoscopy-trained African-American Primary Care Physicians 
Cancer  2011;117(22):5151-5160.
When performed competently, colonoscopy screening can reduce colorectal cancer rates, especially in high-risk groups such as African Americans (AAs). Training primary care physicians (PCPs) to perform colonoscopy may improve screening rates among underserved high-risk populations.
We compared colonoscopy screening rates and computed adjusted odds ratios for colonoscopy-eligible patients of trained AA PCPs (study group) vs. untrained PCPs (comparison group), before and since initiating colonoscopy training. All colonoscopies were performed at a licensed ambulatory surgery center with specialist standby support. Retrospective chart review was conducted on 200 consecutive, established outpatients aged ≥50 years at each of 12 PCP offices (7 trained AA PCPs and 5 untrained PCPs, practicing in the same geographic region), total 1,244 study group and 923 comparison group patients.
Post-training colonoscopy rates in both groups were higher than pre-training rates: 48.3% vs. 9.3% in the study group, 29.6% vs. 9.8% in the comparison group (both p<0.001). AA patients in the study group showed over 5-fold increase (8.9% pre-training vs. 52.8% post training), with no change among Whites (18.2% vs. 25.0%). Corresponding pre- and post-training rates among comparison patients were 10.4% and 38.7% respectively among AAs (p<0.001), and 13.3% vs. 13.2% respectively among Whites. After adjusting for demographics, duration since becoming the PCP’s patient, and health insurance, the study group had a 66% higher likelihood of colonoscopy in the post-training period (OR=1.66; CI, 1.30, 2.13), and AAs had a five-fold increased likelihood of colonoscopy relative to Whites.
Colonoscopy-trained PCPs may help reduce colorectal cancer disparities.
PMCID: PMC3145827  PMID: 21523762
Screening colonoscopy; Colorectal cancer screening; African American screening rate; Colonoscopy-trained primary care physicians
14.  Intake of Grains and Dietary Fiber and Prostate Cancer Aggressiveness by Race 
Prostate Cancer  2012;2012:323296.
Purpose. To examine the associations among intake of refined grains, whole grains and dietary fiber and aggressiveness of prostate cancer in African Americans (AA, n = 930) and European Americans (EA, n = 993) in a population-based, case-only study (The North Carolina-Louisiana Prostate Cancer Project, PCaP). Methods. Prostate cancer aggressiveness was categorized as high, intermediate or low based on Gleason grade, PSA level and clinical stage. Dietary intake was assessed utilizing the NCI Diet History Questionnaire. Logistic regression (comparing high to intermediate/low aggressive cancers) and polytomous regression with adjustment for potential confounders were used to determine odds of high prostate cancer aggressiveness with intake of refined grains, whole grains and dietary fiber from all sources. Results. An inverse association with aggressive prostate cancer was observed in the 2nd and 3rd tertiles of total fiber intake (OR = 0.70; 95% CI, 0.50–0.97 and OR = 0.61; 95% CI, 0.40–0.93, resp.) as compared to the lowest tertile of intake. In the race-stratified analyses, inverse associations were observed in the 3rd tertile of total fiber intake for EA (OR = 0.44; 95% CI, 0.23–0.87) and the 2nd tertile of intake for AA (OR = 0.57; 95% CI, 0.35–0.95). Conclusions. Dietary fiber intake was inversely associated with aggressive prostate cancer among both AA and EA men.
PMCID: PMC3503404  PMID: 23213538
15.  Genetic polymorphisms in the cyclooxygenase-1 and cyclooxygenase-2 genes and risk of colorectal adenoma 
Cyclooxygenase (COX) enzymes, COX1 and COX2, are key in converting arachidonic acid (AA) into prostaglandins that have been associated with colorectal carcinogenesis. The aim of our study was to investigate associations of polymorphisms in COX genes, alone and in interaction with exposures known to be related to inflammation and AA metabolism, with risk of colorectal adenomas.
Materials and methods
In a community-, colonoscopy-based case–control study with 162 incident, sporadic colorectal adenoma cases and 211 controls, we investigated associations of two promoter polymorphisms (−842 A >G in COX1 and −765 G>C in COX2) and two polymorphisms in the 3′-UTR of COX2 (8473 T>C and 9850 A>G) with risk of adenomas. Multiple logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) of colorectal adenoma after adjusting for potential confounders.
Overall, there was no evidence for an association between any of the four polymorphisms and colorectal adenomas. However, we found a statistically significant interaction between the COX2 8473 T>C polymorphism and nonsteroidal anti-inflammatory drug (NSAIDs) use (Pinteraction =0.03): The greatest reduced risk was observed for individuals with the 8473 C variant allele who also regularly used NSAIDs (OR=0.35, 95% CI 0.16–0.75).
These results suggest that the C allele of COX2 8473 T>C polymorphism may interact with NSAIDs to reduce risk for colorectal adenoma.
PMCID: PMC3461962  PMID: 19205707
COX1; COX2; Polymorphisms; Inflammation; Colorectal adenoma
16.  Joint spatial survival modeling for the age at diagnosis and the vital outcome of prostate cancer 
Statistics in medicine  2008;27(18):3612-3628.
Prostate cancer is the most common malignancy in men and a leading cause of cancer mortality among males in the United States. Large geographical variation and racial disparities exist in both the incidence of prostate cancer and in the survival rate after diagnosis. In this population-based study, a joint spatial survival model is constructed to investigate factors that affect the age at diagnosis of prostate cancer and the subsequent survival. The joint model for these two time-to-event outcomes is specified through parametric models for age at diagnosis and survival time conditional on diagnosis age. To account for possible correlation in these outcomes among men from the same geographical region, frailty terms are included in the survival model. Both spatially correlated and uncorrelated frailties are incorporated in each model considered. The deviance information criterion (DIC) is used to select a best-fitting model within the Bayesian framework. The results from our final best-fitting model indicate that race, marital status at diagnosis, and cancer stage are significantly associated with both of the two time-to-event outcomes. No pattern emerged in the geographical distribution of age at prostate cancer diagnosis. In contrast, a spatially clustered pattern was observed in the geographic distribution of survival experience post diagnosis.
PMCID: PMC3417137  PMID: 18416442
Prostate cancer; joint spatial survival model; spatial clustering; deviance information criterion (DIC)
17.  Higher Micronutrient Intake Is Associated With Human Papillomavirus-Positive Head and Neck Cancer: A Case-Only Analysis 
Nutrition and Cancer  2011;63(5):734-742.
No studies have investigated dietary differences between head and neck squamous cell carcinoma (HNSCC) patients with human papillomavirus (HPV)-positive tumors and patients with HPV-negative tumors. This study was designed to investigate the relationship between diet and HPV status in HNSCC patients. Cases of HNSCC were recruited from 2 clinical centers participating in the University of Michigan Head and Neck Specialized Program of Research Excellence (SPORE). HPV tissue genotyping was performed, and epidemiological and dietary data collected. Multivariable logistic regression tested whether pretreatment consumption of 12 selected micronutrients was significantly associated with HPV-positive status in 143 patients newly diagnosed with cancer of the oral cavity or pharynx. After controlling for age, sex, body mass index, tumor site, cancer stage, problem drinking, smoking, and energy intake, significant and positive associations were observed between vitamin A, vitamin E, iron, β-carotene, and folate intake and HPV-positive status (Ptrend < 0.05), suggesting that diet may be a factor in the improved prognosis documented in those with HPV-positive HNSCC. Dietary differences by HPV status should be considered in prognostic studies to better understand the influence of diet on HNSCC survival.
PMCID: PMC3391594  PMID: 21667401
18.  Developing Partnerships and Recruiting Dyads for a Prostate Cancer Informed Decision Making Program: Lessons Learned From a Community-Academic-Clinical Team 
Journal of Cancer Education  2012;27(2):243-249.
Prostate cancer (PrCA) is the most commonly diagnosed non-skin cancer among men. PrCA mortality in African-American (AA) men in South Carolina is ~50% higher than for AAs in the U.S as a whole. AA men also have low rates of participation in cancer research. This paper describes partnership development and recruitment efforts of a Community-Academic-Clinical research team for a PrCA education intervention with AA men and women that was designed to address the discordance between high rates of PrCA mortality and limited participation in cancer research. Guided by Vesey's framework on recruitment and retention of minority groups in research, recruitment strategies were selected and implemented following multiple brainstorming sessions with partners having established community relationships. Based on findings from these sessions culturally appropriate strategies are recommended for recruiting AA men and women for PrCA education research. Community-based research recruitment challenges and lessons learned are presented.
PMCID: PMC3352970  PMID: 22528633
African-American men and women; Community-based participatory research; Research partnerships; Recruitment; Cancer communication; Multi-media
19.  Forced expiratory volume predicts all-cause and cancer mortality in Mumbai, India: results from a population-based cohort study 
Background Reduction in pulmonary function, as estimated by forced expiratory volume in 1 s (FEV1), has been found to predict all-cause mortality in developed-country populations. This study was designed to examine the association between FEV1 and mortality in an urban developing-country population.
Methods Data from the large, well-characterized Mumbai Cohort Study (Maharashtra, India) were used to compute hazard ratios (HRs; deaths/100-ml FEV1) and 95% confidence intervals (CIs) from Cox proportional hazards regression models in which age, tobacco use, education, height and relative body weight were controlled.
Results A total of 13 261 deaths occurred in this cohort of 148 173 individuals. After controlling for important covariates, there was a 1.7% reduction in risk of overall death in women for each 100-ml increment in FEV1 (HR = 0.983; 95% CI = 0.980–0.986) and a 1.5% reduction in men (HR = 0.985; 95% CI = 0.984–0.986). There was a 1.6% reduction in cancer deaths in women (HR = 0.984; 95% CI = 0.973–0.996) and a 0.8% reduction in men (HR = 0.992; 95% CI = 0.987–0.997). The largest reductions in women were observed in tuberculosis deaths (3.7%/100-ml increment in FEV1), and in men in respiratory system deaths (3.2%).
Conclusions In a densely populated urban Indian population, FEV1 predicted overall and cancer mortality. Effects were larger in women and were not attenuated by exclusion of smokers or restricting analyses to subjects dying >2 years from recruitment. Because FEV1 may be affected by air pollution, which is worsening in urban areas of most developing countries, further research is recommended to deepen understanding of these factors in relation to mortality.
PMCID: PMC3031342  PMID: 20846948
Mortality; FEV1; neoplasms; tobacco; cohort study; respiratory function tests; air pollution
20.  Clustering of Unhealthy Behaviors in the Aerobics Center Longitudinal Study 
Prevention Science  2011;13(2):183-195.
Clustering of unhealthy behaviors has been reported in previous studies; however the link with all-cause mortality and differences between those with and without chronic disease requires further investigation.
To observe the clustering effects of unhealthy diet, fitness, smoking, and excessive alcohol consumption in adults with and without chronic disease and to assess all-cause mortality risk according to the clustering of unhealthy behaviors.
Participants were 13,621 adults (aged 20–84) from the Aerobics Center Longitudinal Study. Four health behaviors were observed (diet, fitness, smoking, and drinking). Baseline characteristics of the study population and bivariate relations between pairs of the health behaviors were evaluated separately for those with and without chronic disease using cross-tabulation and a chi-square test. The odds of partaking in unhealthy behaviors were also calculated. Latent class analysis (LCA) was used to assess clustering. Cox regression was used to assess the relationship between the behaviors and mortality.
The four health behaviors were related to each other. LCA results suggested that two classes existed. Participants in class 1 had a higher probability of partaking in each of the four unhealthy behaviors than participants in class 2. No differences in health behavior clustering were found between participants with and without chronic disease. Mortality risk increased relative to the number of unhealthy behaviors participants engaged in.
Unhealthy behaviors cluster together irrespective of chronic disease status. Such findings suggest that multi-behavioral intervention strategies can be similar in those with and without chronic disease.
PMCID: PMC3304050  PMID: 22006293
Health behaviors; Clustering; Chronic disease; All-cause mortality
21.  Quality and Safety of Screening Colonoscopies Performed by Primary Care Physicians With Standby Specialist Support 
Medical care  2010;48(8):703-709.
Expanding the population’s access to colonoscopy screening can reduce colorectal cancer disparities. Innovative strategies are needed to address the prevailing 50% colonoscopy screening gap, partly attributable to inadequate specialist workforce. This study examined the quality of colonoscopies by primary care physicians (PCPs) with standby specialist support at a licensed ambulatory surgery center.
Retrospective data on 10,958 consecutive colonoscopies performed by 51 PCPs on 9815 patients from October 2002 to November 2007 were used to calculate the rates of cecal intubation, detection of polyps, adenomas, advanced neoplasia and cancer, adverse events, and time taken for endoscope insertion and withdrawal. The center’s protocol requires a 2-person technique (using a trained technician), polyp search and removal during both scope insertion and withdrawal, and onsite expert always available for rescue assistance (either navigational or therapeutic).
Mean patient age was 58.3 (±10.9) years, 48.0% were male, and 48.1% African-American. The cecal intubation rate was 98.1%, polyp detection rate 63.1%, hyperplastic polyp 27.5%, adenoma 29.9%, advanced neoplasia 5.7%, cancer 0.63%, major adverse events 0.06% (including 2 perforations; no death). Mean insertion and withdrawal times were 14.4 (±9.3) and 10.9 (±6.8) minutes, respectively; 13.2 (±8.6) and 8.0 (±4.5) minutes without polyps found, and 15.1 (±9.6) and 12.5 (±7.3) minutes when ≥1 polyp was found.
In the largest published study of PCP-performed colonoscopies with standby specialist support, we observed performance quality indicators and lesion detection rates that are comparable to documented rates for experienced gastroenterologists. Systems that use PCPs with specialist backup support enable high-quality colonoscopy performance by PCPs.
PMCID: PMC2959169  PMID: 20613663
screening colonoscopy; primary care physicians; colorectal neoplasms; colonic polyps; adenomatous polyps; patient safety; performance quality; procedure time
22.  Dietary patterns and the risk of mortality: impact of cardiorespiratory fitness 
Background While dietary patterns that are both predictive of chronic disease and mortality have been identified, the confounding effects of cardiorespiratory fitness have not been properly addressed. The primary objective was to assess the relation between dietary patterns with all-cause mortality, while controlling for the potentially confounding effects of fitness.
Methods This was a prospective cohort study. Participants consisted of 13 621 men and women from the Aerobics Center Longitudinal Study (ACLS). Participants completed a clinical exam and 3-day diet record between 1987 and 1999. Participants were followed for mortality until 2003. Reduced rank regression (RRR) was used to identify dietary patterns that predicted unfavourable total and high-density lipoprotein-cholesterol, triglyceride, glucose, blood pressure, uric acid, white blood cell and body mass index values.
Results One primary dietary pattern emerged and was labelled the Unhealthy Eating Index. This pattern was characterized by elevated consumption of processed and red meat, white potato products, non-whole grains, added fat and reduced consumption of non-citrus fruits. The hazard ratio for all-cause mortality in the fifth vs the first quintile of the Unhealthy Eating Index was 1.40 (1.02–1.91). This risk estimate was reduced by 13.5 and 55.0% after controlling for self-reported physical activity and fitness, respectively.
Conclusion In this study the association between diet and overall mortality was, in large part, confounded by fitness.
PMCID: PMC2912488  PMID: 19380370
All-cause mortality; cardiorespiratory fitness; reduced rank regression
23.  Successful subject recruitment for a prostate cancer behavioral intervention trial 
Inadequate participant recruitment, which may lead to unrepresentative study samples that threaten a study’s validity, is often a major challenge in the conduct of research studies.
The purpose of this article is to describe the development and implementation of a recruitment plan and evaluate the different recruitment strategies for a prostate cancer behavioral intervention trial.
Our recruitment plan was based on a framework (The Heiney–Adams Recruitment Model) that we developed, which combines relationship building and social marketing. We evaluated the success of our model using several different recruitment sources including: mailed letters, physician referral, and self-referral.
Recruitment rates ranged from 67% for a support services department mailing to 100% for physician referral. While our original list of contacted patients was comprised of only 13% African American (AA) men, 22% of our recruited participants were AA.
One of the strongest barriers to recruitment was strict patient eligibility. Another significant barrier was the lack of electronic records systems to allow for the identification of large numbers of potential participants.
In conclusion, our model incorporating social marketing and relationship building was quite successful in recruiting for a prostate cancer behavioral study, particularly AA participants. In developing strategies, future researchers should attend to issues of staffing, financial resources, physician support, and eligibility criteria in the light of study accrual.
PMCID: PMC2959175  PMID: 20571136
24.  Racial Differences in Follow-up of Abnormal Mammography Findings Among Economically Disadvantaged Women 
Cancer  2009;115(24):5788-5797.
In the United States and particularly South Carolina, African-American women suffer disproportionately higher mortality rates than do European-American women. The timeliness of patient adherence to the follow-up of mammographic abnormalities may influence prognosis and survival. Consequently, the purpose of the present investigation was to examine racial differences in the completion and completion time of a diagnostic work-up following a finding of a suspicious breast abnormality.
Study participants of the Best Chance Network, a state-wide service program that provides free mammography screenings to economically disadvantaged and medically underserved women, were included in the study. Racial differences in tumor characteristics and adherence to recommended work-up were tested using Chi-square and t-tests. Logistic and Cox regression modeling was used to assess the relationship between work-up completion and other factors among African-American and European-American women.
Completion of the work-up was associated with the number of previous procedures and income, with no significant differences noted by race. The amount of time to completion of the work-up was influenced by previous procedures, income, and race. After accounting for completion time, African-American women were 12% less likely than European-American women to complete the recommended work-up (HR=0.88, p-value=0.01).
This study established a racial disparity in the time to completion of a diagnostic work-up among Best Chance Network participants. These findings highlight the importance of understanding factors associated with delays and adherence in completion of recommended work-up when breast abnormalities are detected in mammograms.
PMCID: PMC2959171  PMID: 19859902
Mammography; health status disparities; African Americans; medically uninsured; breast neoplasms
25.  Circadian Disruption, Per3, and Human Cytokine Secretion 
Integrative cancer therapies  2009;8(4):329-336.
Circadian disruption has been linked with inflammation, an established cancer risk factor. Per3 clock gene polymorphisms have also been associated with circadian disruption and with increased cancer risk. Patients completed a questionnaire and provided a blood sample prior to undergoing a colonoscopy (n = 70). Adjusted mean serum cytokine concentrations (IL-6, TNF-alpha, gamma-INF, IL-I ra, IL-I-beta, VEGF) were compared among patients with high and low scores for fatigue (Multidimensional Fatigue Inventory), depressive symptoms (Beck Depression Inventory II), or sleep disruption (Pittsburgh Sleep Quality Index), or among patients with different Per3 clock gene variants. Poor sleep was associated with elevated VEGF, and fatigue-related reduced activity was associated with elevated TNF-alpha concentrations. Participants with the 4/5 or 5/5 Per3 variable tandem repeat sequence had elevated IL-6 concentrations compared to those with the 4/4 genotype. Biological processes linking circadian disruption with cancer remain to be elucidated. Increased inflammatory cytokine secretion may playa role.
PMCID: PMC2959170  PMID: 19926609
circadian rhythm; clock gene; cytokine; inflammation

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