Validation of a self-administered diet history questionnaire using multiple diet records

Assessment of the Efficacy, Safety, and Effectiveness of Weight Control and Obesity Management Mobile Health Interventions: Systematic Review

BACKGROUND

The use of apps to tackle overweight and obesity by tracking physical and dietary patterns and providing recommendations and motivation strategies to achieve personalized goals has increased over recent years. However, evidence of the efficacy, effectiveness, and safety of these apps is severely lacking.

OBJECTIVE

The aim of this study was to identify efficacy, safety, and effectiveness criteria used to assess weight control, overweight, and obesity management in mobile health (mHealth) interventions through a systematic review.

METHODS

PubMed, PsycINFO, Scopus, UK Trial Database, ClinicalTrials.gov, and the Cochrane Library were surveyed up to May 2018. All types of clinical studies were considered. A total of 2 independent reviewers assessed quality using Scottish Intercollegiate Guidelines Network (SIGN) criteria. Ratings were used to provide an overall score for each study (low, moderate, or high). Data were synthesized in evidence tables.

RESULTS

From 233 potentially relevant publications, only 28 studies were included. Of these, 13 (46%) were randomized control trials, 11 were single-arm studies (39%), 3 were nonrandomized controlled trials (11%), and 1 study was a cluster randomized trial (4%). The studies were classified as low (15), high (7), and moderate (6) quality according to SIGN criteria. All studies focused on efficacy, with only 1 trial mentioning safety and another 1 effectiveness. In 11 studies, the apps were used as stand-alone interventions, the others were multicomponent studies that included other tools for support such as sensors or websites. The main management tool included in the apps was feedback messaging (24), followed by goal-setting mechanisms (20) and self-monitoring (19). The majority of studies took weight or body mass index loss as the main outcome (22) followed by changes in physical activity (14) and diet (12). Regarding outputs, usability, adherence, and engagement (17) were the most reported, followed by satisfaction (7) and acceptability (4).

CONCLUSIONS

There is a remarkable heterogeneity among these studies and the majority have methodological limitations that leave considerable room for improvement. Further research is required to identify all relevant criteria for assessing the efficacy of mHealth interventions in the management of overweight and obesity.

TRIAL REGISTRATION

PROSPERO CRD42017056761; https://tinyurl.com/y2zhxtjx.

Folic acid supplementation and risk of colorectal neoplasia during long-term follow-up of a randomized clinical trial

BACKGROUND

The Aspirin/Folate Polyp Prevention Study previously found folic acid increased risk of advanced and multiple colorectal adenomas during a surveillance colonoscopy interval starting about 3 y after randomization.

OBJECTIVE

We conducted secondary analyses to evaluate folic acid effects with additional follow-up after treatment was stopped.

METHODS

In total, 1021 participants recently diagnosed with colorectal adenomas were randomly assigned to 1 mg/d of folic acid (n = 516) or placebo (n = 505), with or without aspirin, beginning 6 July 1994. The original 3-y treatment period was extended into a subsequent colonoscopy interval, but eventually stopped prematurely on 1 October 2004. With additional post-treatment follow-up, a total of 663 participants who extended treatment completed a second colonoscopic surveillance interval after the initial 3-y follow-up. In addition, 490 participants provided information regarding a subsequent surveillance colonoscopy occurring before completion of follow-up on 31 May 2012, including 325 who had agreed to extended treatment. Study endpoints included conventional adenomas, sessile serrated adenomas/polyps (SSA/Ps), or colorectal cancer, and RRs with 95% CIs were adjusted for baseline characteristics associated with availability of follow-up.

RESULTS

Among those who extended treatment, any colorectal neoplasia was found in 118 (36%) participants assigned to placebo and 146 (43%) assigned to folic acid during the second surveillance interval (RR: 1.21; 95% CI: 0.99, 1.47; P = 0.06). Increased risk of SSA/P with extended folic acid supplementation was statistically significant during the second surveillance interval (RR: 1.94; 95% CI: 1.02, 3.68; P = 0.04). There was no evidence of post-treatment effects for any colorectal neoplasia (RR: 1.01; 95% CI: 0.80, 1.28; P = 0.94), and the post-treatment effect for SSA/P was no longer statistically significant (RR: 1.38; 95% CI: 0.59, 3.19; P = 0.46).

CONCLUSIONS

Delayed treatment effects were not observed, but folic acid may increase SSA/P risk. This trial was registered at clinicaltrials.gov as NCT00272324.

Lifetime Drinking Trajectories and Nonfatal Acute Myocardial Infarction

BACKGROUND

The relation of lifetime drinking trajectories to coronary heart disease is not well understood.

METHODS

Cases hospitalized for a nonfatal acute myocardial infarction (AMI) and healthy population-based controls matched on age and sex completed a physical examination and an interview covering known AMI risk factors and a detailed lifetime drinking history. Distinct lifetime drinking trajectories based on ounces of ethanol consumed per decade between ages 10 and 59 years were derived and characterized according to lifetime drinking patterns associated with each. Sex-specific multiple logistic regression analyses were conducted to estimate AMI risk among participants who never drank regularly compared to lifetime drinking trajectories and risk associated with distinct trajectories among former and current drinkers.

RESULTS

Two lifetime drinking trajectories were derived, early peak and stable. Early peak trajectories were characterized by earlier onset of regular drinking, less frequent drinking, more drinks per drinking day, fewer total drinks, more frequent drunkenness per drinking year, and reduced alcohol intake or abstention by middle age. Never drinking regularly, reported by significantly more women than men, was associated with significantly higher AMI risk than stable lifetime drinking trajectories among men and in the sex-combined analysis of former drinkers only. Compared to stable lifetime drinking trajectories, early peak trajectories were associated with significantly higher AMI risk among male former drinkers, among sex-combined former drinkers, and among female current drinkers.

CONCLUSIONS

Epidemiological studies of alcohol and health in populations over age 35 may have underestimated the impact of heavy episodic drinking during adolescence and emerging adulthood on the cardiovascular system.

Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial

BACKGROUND

Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo.

METHODS

In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, number NCT02008565.

FINDINGS

Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change -1·5 points, 95% CI -3·4 to 0·4, p=0·12), biofeedback versus education (-0·7 points, -2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (-1·9 points, -4·1 to 0·3, p=0·092) or versus loperamide plus education (-1·1 points, -3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group).

INTERPRETATION

In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health.

Investigating Gains in Neurocognition in an Intervention Trial of Exercise (IGNITE): Protocol

Despite the ubiquity of normal age-related cognitive decline there is an absence of effective approaches for improving neurocognitive health. Fortunately, moderate intensity exercise is a promising method for improving brain and cognitive health in late life, but its effectiveness remains a matter of skepticism and debate because of the absence of large, comprehensive, Phase III clinical trials. Here we describe the protocol for such a randomized clinical trial called IGNITE (Investigating Gains in Neurocognition in an Intervention Trial of Exercise), a study capable of more definitively addressing whether exercise influences cognitive and brain health in cognitively normal older adults. We are conducting a 12-month, multi-site, randomized dose-response exercise trial in 639 cognitively normal adults between 65 and 80 years of age. Participants are randomized to (1) a moderate intensity aerobic exercise condition of 150 min/week (N = 213), (2) a moderate intensity aerobic exercise condition at 225 min/week (N = 213), or (3) a light intensity stretching-and-toning control condition for 150 min/week (N = 213). Participants are engaging in 3 days/week of supervised exercise and two more days per week of unsupervised exercise for 12 months. A comprehensive cognitive battery, blood biomarkers and battery of psychosocial questionnaires is assessed at baseline, 6 and 12-months. In addition, brain magnetic resonance imaging, physiological biomarkers, cardiorespiratory fitness, physical function, and positron emission tomography of amyloid deposition are assessed at baseline and at the 12-month follow-up. The results from this trial could transform scientific-based policy and health care recommendations for approaches to improve cognitive function in cognitively normal older adults.

Bone mineral density, energy availability, and dietary restraint in collegiate cross-country runners and non-running controls

PURPOSE

Weight-bearing activities such as running have been shown to be osteogenic. However, investigations have also shown that running may lead to site-specific deficiencies in bone mineral density (BMD) as well as overall low BMD. The purpose of this investigation was to evaluate and compare the BMD of female and male collegiate cross-country runners with non-running controls. In addition, energy availability and disordered eating attitudes and behaviors were assessed.

METHODS

BMD of 60 collegiate cross-country runners and 47 BMI and age-matched non-running controls were measured via DXA scans. Participants completed a Block 2014 Food Frequency Questionnaire and Eating Disorder Examination Questionnaire.

RESULTS

Controlling for fat-free mass (FFM), male runners showed greater BMD at the femoral neck (0.934 ± 0.029 vs. 0.866 ± 0.028 g cm2, p < 0.05), total hip (1.119 ± 0.023 vs. 1.038 ± 0.021 g cm2, p < 0.05), and whole body (1.119 ± 0.023 vs. 1.038 ± 0.021 g cm2, p < 0.05) than male controls. The female runners had greater whole-body BMD than female controls (1.143 ± 0.018 vs. 1.087 ± 0.022 g cm2, p < 0.05). Runners scored significantly higher than controls in dietary restraint (1.134 ± 1.24 vs. 0.451 ± 0.75, p < 0.05), male runners were significantly higher than male controls in eating concern (1.344 ± 1.08 vs. 0.113 ± 0.27, p < 0.05) and female runners were significantly higher than male runners in shape concern (1.056 ± 1.27 vs. 0.242 ± 0.31, p < 0.05). Forty-two percent of the male runners and 29% of female runners had an energy availability of less than 30 kcals kg-1FFM.

CONCLUSION

It appears that distance running has beneficial effects on whole-body BMD and site-specific areas. Further research is warranted to further clarify the health effects of eating behaviors and EA of distance runners.

The Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial

OBJECTIVE

To assess the feasibility and initial efficacy of a structured parent training program for children with autism spectrum disorder and moderate food selectivity.

STUDY DESIGN

This 16-week randomized trial compared the Managing Eating Aversions and Limited variety (MEAL) Plan with parent education. MEAL Plan (10 core and 3 booster sessions) provided parents with nutrition education and strategies to structure meals and expand the child's diet. Parent education (10 sessions) provided information about autism without guidance on nutrition, meal structure, or diet. In addition to feasibility outcomes, primary efficacy outcomes included the Clinical Global Impression - Improvement scale and the Brief Autism Mealtime Behaviors Inventory. Grams consumed during a meal observation served as a secondary outcome.

RESULTS

There were 38 eligible children (19 per group, 32 males). For MEAL Plan, attrition was <10% and attendance >80%. Therapists achieved >90% fidelity. At week 16, positive response rates on the Clinical Global Impression - Improvement scale were 47.4% for the MEAL Plan and 5.3% for parent education (P < .05). The adjusted mean difference (SE) on Brief Autism Mealtime Behaviors Inventory at week 16 was 7.04 (2.71) points (P = .01) in favor of MEAL Plan. For grams consumed, the adjusted standard mean difference (SE) was 30.76 (6.75), also in favor of MEAL Plan (P = .001).

CONCLUSIONS

The MEAL Plan seems to be feasible, and preliminary efficacy results are encouraging. If further study replicates these results, the MEAL Plan could expand treatment options for children with autism spectrum disorder and moderate food selectivity.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02712281.

Hypoglycaemic treatment adherence and the association with psychological, self-management and glycaemic characteristics in adults with type 1 diabetes

AIM

The purpose of this study was to examine adherence to hypoglycaemia treatment guidelines in adults with type 1 diabetes (T1DM). The American Diabetes Association recommends consumption of 15-20 g of glucose to treat hypoglycaemia. Overtreatment may result in poor glycaemic control and greater glycaemic variability. It is not fully understood how well T1DM adults comply with hypoglycaemia treatment recommendations.

DESIGN

A secondary analysis using a descriptive comparative design.

METHODS

Using real-time measures over six consecutive days, we examined (a) adherence to hypoglycaemia treatment guidelines and (b) comparisons of demographic self-management behaviour, psychological characteristics and glycaemia between adherent and non-adherent groups.

RESULTS

Findings revealed those who overtreated consumed more daily grain servings and reported higher stress and depressed mood compared with those who followed treatment recommendations. Findings suggest that hypoglycaemia treatment practices and psychological factors influencing self-management should be assessed.

Differences In Nutritional And Physical Health Indicators Among Older African Americans, European Americans, And Hispanic Americans

Inadequate protein intake contributes to poor nutritional status, reduced muscle mass, strength and function, and increased mortality. Evaluating differences in protein intake and related health indicators among racial/ethnic groups enables the development of targeted interventions. This study's purpose was to determine differences in protein intake, nutritional status, and muscle strength/function among 273 older African, European, and Hispanic Americans. Protein intake, nutritional status, grip strength, timed-up-and-go (TUG), and chair stand assessments were conducted. Protein intake was significantly greater among Hispanic Americans (0.96 g/kg body weight) followed by European Americans (0.83 g/kg body weight), and African Americans (0.64 g/kg body weight). Intakes by all groups were below recommendations. Low nutritional status, grip strength, chair rise, and TUG scores were observed in African Americans and European American females and were consistent with lower protein intakes. Results show significant differences among the groups and the need for interventions to improve diet and physical health.

Association of Sugary Beverage Consumption With Mortality Risk in US Adults: A Secondary Analysis of Data From the REGARDS Study

Importance

Research has linked sugar-sweetened beverage (SSB) consumption to coronary heart disease (CHD) risk, but the role of nutritionally similar fruit juice and the association of these beverages with mortality risk is unknown.

Objective

To assess the association of SSBs and 100% fruit juices, alone and in combination (sugary beverages), with mortality.

Design, Setting, and Participants

This cohort study is a secondary analysis of data obtained from 30 183 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. The REGARDS study was designed to examine modifiers of stroke risk. Enrollment took place from February 2003 to October 2007, with follow-up every 6 months through 2013. Overall, 30 183 non-Hispanic black and white adults 45 years and older were enrolled in the REGARDS study. Those with known CHD, stroke, or diabetes at baseline (12 253 [40.6%]) and those lacking dietary data (4490 [14.9%]) were excluded from the current study, resulting in a sample size of 13 440. Data were analyzed from November 2017 to December 2018.

Exposures

Sugar-sweetened beverage and 100% fruit juice consumption was estimated using a validated food frequency questionnaire and examined using categories of consumption that align with recommended limits for added sugar intake as a percentage of total energy (TE; <5%, 5%-<10%, and ≥10%) and 12-oz serving increments.

Main Outcomes and Measures

All-cause and CHD-specific mortality were determined from cause of death records and family interviews and adjudicated by a trained team. Multivariable adjusted hazard ratios (HRs) were estimated using regression models.

Results

Overall, 13 440 participants had a mean (SD) age of 63.6 (9.1) years at baseline, 7972 (59.3%) were men, 9266 (68.9%) were non-Hispanic white, and 9482 (70.8%) had overweight or obesity. There were 1000 all-cause and 168 CHD-related deaths during follow-up (mean [SD] follow-up, 6.0 [1.8] years). Mean (SD) sugary beverage consumption was 8.4% (8.3%) of TE/d (4.4% [6.8%] TE/d from SSBs; 4.0% [6.8%] TE/d from 100% fruit juice). Among high (≥10% of TE) vs low (<5% of TE) sugary beverage consumers, risk-adjusted HRs were 1.44 (95% CI, 0.97-2.15) for CHD mortality and 1.14 (95% CI, 0.97-1.33) for all-cause mortality. Risk-adjusted all-cause mortality HRs were 1.11 (95% CI, 1.03-1.19) for each additional 12 oz of sugary beverage consumed and 1.24 (95% CI, 1.09-1.42) for each additional 12 oz of fruit juice consumed. In risk-adjusted models, there was no significant association of sugary beverage consumption with CHD mortality.

Conclusions and Relevance

These findings suggest that consumption of sugary beverages, including fruit juices, is associated with all-cause mortality. Well-powered and longer-term studies are needed to inform their association with CHD mortality risk.

Dietary index scores and invasive breast cancer risk among women with a family history of breast cancer

BACKGROUND

Many epidemiologic studies have analyzed the relations of individual foods and nutrients and breast cancer risk with inconsistent results. Few studies have examined recommendation-based dietary indices and breast cancer risk.

OBJECTIVE

The aim of this study was to determine associations between recommendation-based dietary index scores and incident invasive breast cancer.

METHODS

The Sister Study is a prospective cohort of 50,884 US women (baseline: 2003-2009) who had a sister with breast cancer but no prior breast cancer themselves. We created scores for the Dietary Approaches to Stop Hypertension (DASH) diet, Alternative Mediterranean Diet (AMED), and Alternative Healthy Eating Index-2010 (AHEI-2010) from dietary intakes estimated by a baseline-validated Block food-frequency questionnaire (FFQ). We used Cox regression to estimate multivariable-adjusted HRs and 95% CIs for total invasive breast cancer risk and by estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) status.

RESULTS

We documented 1,700 invasive breast cancer cases through 2015 (mean follow-up, 7.6 y). Individuals in the highest quartile of DASH scores had a lower risk of invasive breast cancer compared with those in the lowest quartile (HR: 0.78; 95% CI: 0.67, 0.90; P-trend = 0.001), with stronger associations for ER- (HR: 0.61; 95% CI: 0.40, 0.94; P-trend = 0.006) as well as ER-/PR- and ER-/PR-/HER2- subtypes. AHEI-2010 (HR for highest compared with lowest quartile: 0.90; 95% CI: 0.78, 1.03; P-trend = 0.15) and AMED (HR for highest compared with lowest quartile: 0.90; 95% CI: 0.77, 1.06; P-trend = 0.07) were weakly and nonsignificantly associated with breast cancer risk, but after excluding alcohol, AHEI-2010 was inversely associated with risk of ER-/PR- (HR: 0.64; 95% CI: 0.42, 0.98; P-trend = 0.04) and ER-/PR-/HER2- subtypes. We did not observe any significant interactions by menopausal status or other participant characteristics.

CONCLUSIONS

DASH scores were inversely associated with breast cancer risk; DASH and AHEI-2010 scores excluding alcohol were particularly inversely associated with risk of ER-/PR- and ER-/PR-/HER2- breast cancers. This trial was registered at clinicaltrials.gov as NCT00047970.

A multivariate discrete failure time model for the analysis of infant motor development

We develop a multivariate discrete failure time model for the analysis of infant motor development. We use the model to jointly evaluate the time (in months) to achievement of three well-established motor milestones: sitting up, crawling, and walking. The model includes a subject-specific latent factor that reflects underlying heterogeneity in the population and accounts for within-subject dependence across the milestones. The factor loadings and covariate effects are allowed to vary flexibly across milestones, and the milestones are permitted to have unique at-risk intervals corresponding to different developmental windows. We adopt a Bayesian inferential approach and develop a convenient data-augmented Gibbs sampler for posterior computation. We conduct simulation studies to illustrate key features of the model and use the model to analyze data from the Nurture study, a birth cohort examining infant health and development during the first year of life.

Ethnic, geographic and dietary differences in arsenic exposure in the multi-ethnic study of atherosclerosis (MESA)

Differences in residential location as well as race/ethnicity and dietary habits may result in differences in inorganic arsenic (iAs) exposure. We investigated the association of exposure to iAs with race/ethnicity, geography, and dietary intake in a random sample of 310 White, Black, Hispanic, and Chinese adults in the Multi-Ethnic Study of Atherosclerosis from 6 US cities with inorganic and methylated arsenic (ΣAs) measured in urine. Dietary intake was assessed by food-frequency questionnaire. Chinese and Hispanic race/ethnicity was associated with 82% (95% CI: 46%, 126%) and 37% (95% CI: 10%, 70%) higher urine arsenic concentrations, respectively, compared to White participants. No differences were observed for Black participants compared to Whites. Urine arsenic concentrations were higher for participants in Los Angeles, Chicago, and New York compared to other sites. Participants that ate rice ≥2 times/week had 31% higher urine arsenic compared to those that rarely/never consumed rice. Participants that drank wine ≥2 times/week had 23% higher urine arsenic compared to rare/never wine drinkers. Intake of poultry or non-rice grains was not associated with urinary arsenic concentrations. At the low-moderate levels typical of the US population, exposure to iAs differed by race/ethnicity, geographic location, and frequency of rice and wine intake.

Adherence to American Cancer Society and American Institute of Cancer Research dietary guidelines in overweight African American breast cancer survivors

PURPOSE

The American Cancer Society (ACS) and the American Institute for Cancer Research (AICR) each created dietary and physical activity guidelines to improve cancer survivorship. Despite African American breast cancer survivors (AABCS) having the lowest survival rates of any racial or ethnic group, limited information exists on their adherence to cancer-specific lifestyle recommendations. The study's purpose was to measure adherence to ACS/AICR dietary recommendations in AABCS.

METHODS

Two hundred ten AABCS enrolled in the Moving Forward intervention trial, a randomized, community-based, 6-month weight loss study, were assessed for socio-demographics, dietary intake (via food frequency questionnaire), and related health factors at baseline. We operationalized the dietary recommendations put forth by ACS/AICR and created component and total adherence index scores. Descriptive statistics were used to calculate the proportion of women who met recommendations. Student's t test and χ2 tests were used to compare participant characteristics by median adherence scores.

RESULTS

The mean total ACS/AICR score was 12.7 ± 2.5 out of 21 points (median, 13; range, 5 to 21). Over 90% were moderately or completely adherent to limiting alcohol and red & processed meat consumption, but the majority failed to meet the other recommendations to eat whole grains, legumes, fruits, vegetables, and avoid added sugars. Women with total scores below the median were younger, with higher BMI, had fewer years of education, and lower income levels.

IMPLICATIONS FOR CANCER SURVIVORS

The present study extends the literature on AABCS adherence to cancer survivor-specific dietary guidelines. Findings will inform future dietary lifestyle interventions in this population.

Prevalence of Thiamin Deficiency in Ambulatory Patients with Heart Failure

BACKGROUND

Thiamin is a required coenzyme in energy production reactions that fuel myocardial contraction. Therefore, thiamin deficiency (TD) may aggravate cardiac dysfunction in patients with systolic heart failure (HF).

OBJECTIVE

To determine the prevalence of TD in ambulatory participants with HF as well as the relationships between thiamin status and HF severity, dietary thiamin intake, diuretic use, and circulating neurohormones.

DESIGN

A cross-sectional study comparing the prevalence of TD in ambulatory patients with HF with that of controls. Demographic, anthropometric, nutrition, medication use, and heart function data were collected from direct interviewing, questionnaires, and medical records. Blood samples were obtained to measure levels of neurohormones and assess TD.

PARTICIPANTS/SETTING

Fifty age-matched control participants without HF and 100 outpatients with HF and reduced left ventricular function were recruited from clinics at St Michael's Hospital, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada, between September 2009 and February 2011.

MAIN OUTCOME MEASURES

To assess TD, erythrocyte thiamin pyrophosphate (TPP) was measured using high-performance liquid chromatography. TD was defined as TPP<6.07 μg/dL (180 nmol/L).

STATISTICAL ANALYSES PERFORMED

Prevalence rates were analyzed using χ² test. Nonparametric statistics (Jonckheere-Terpstra, Kruskal-Wallis, Spearman's correlation) were used to assess TPP levels in relation to HF severity, medication use and plasma concentrations of F2-isoprostanes, norepinephrine, and N-terminal pro-brain natriuretic peptide (NT-proBNP).

RESULTS

There was no significant difference in the prevalence of TD in outpatients with HF (6%) and controls (6%) (P=0.99). No relationship was found between heart function, thiamin intake, use or dose of diuretics, and TD. A positive relationship was observed between erythrocyte TPP and F2-isoprostane levels (r_s=0.22, P=0.03) but not between erythrocyte TPP and norepinephrine (P=0.45) and NT-proBNP (P=0.58).

CONCLUSION

The prevalence of TD was low in ambulatory HF participants suggesting that, unlike hospitalized patients, ambulatory patients may be at a low risk for TD.

Exercise Training in "At-Risk" Black and White Women: A Comparative Cohort Analyses

PURPOSE

Few data on the effect of exercise interventions in black women at risk for cardiovascular disease are available.

METHODS

Women ≥18 yr of age without known cardiovascular disease with ≥1 coronary risk factor were enrolled in a community-based exercise program ≥3 d·wk for ≥30 min per session for 6 months. Exercise training intensity ~50% to 80% of functional capacity, using heart rate (HR) and/or rating of perceived exertion (RPE) as the primary intensity modulators. Preconditioning versus postconditioning quality of life assessments (depression and level of daytime sleepiness), dietary fat intake, Duke Activity Status Index score, changes in cardiovascular efficiency (systolic/diastolic blood pressure (SBP/DBP), HR, RPE during a standardized submaximal workload), and anthropometric measures, including body weight, body mass index, and waist circumference, were evaluated.

RESULTS

Of 556 volunteers, 143 were excluded, leaving 413 women (222 white, 191 black; mean ± SD age, 61 ± 9 yr) who met compliance criteria. Both groups demonstrated significant (P < 0.05) postconditioning decreases in body mass index, waist circumference, resting SBP/DBP, and total and LDL cholesterol, and reductions in HR, SBP/DBP, and RPE at a fixed submaximal workload, and in fat screener, depression, and sleep scores. Duke Activity Status Index scores increased significantly (P < 0.0001) for both groups, signifying increases in self-reported functional capacity. Although 87 women (21%) experienced a musculoskeletal injury/discomfort during the program, there were no exercise-related cardiovascular events.

CONCLUSIONS

A progressive moderate-to-vigorous exercise intervention without preliminary exercise testing elicited comparable improvements in coronary risk factors, anthropometric and quality of life measures, and cardiovascular efficiency in "at-risk" black and white women. These adaptations were achieved at exercise levels below those recommended in contemporary physical activity guidelines.

Changes in Lean Mass, Absolute and Relative Muscle Strength, and Physical Performance After Gastric Bypass Surgery

CONTEXT

Bariatric surgery results in reduced muscle mass as weight is lost, but postoperative changes in muscle strength and performance are incompletely understood.

OBJECTIVE

To examine changes in body composition, strength, physical activity, and physical performance following Roux-en-Y gastric bypass (RYGB).

DESIGN, PARTICIPANTS, OUTCOMES

In a prospective cohort of 47 adults (37 women, 10 men) aged 45 ± 12 years (mean ± SD) with body mass index (BMI) 44 ± 8 kg/m2, we measured body composition by dual-energy X-ray absorptiometry, handgrip strength, physical activity, and physical performance (chair stand time, gait speed, 400-m walk time) before and 6 and 12 months after RYGB. Relative strength was calculated as absolute handgrip strength/BMI and as absolute strength/appendicular lean mass (ALM).

RESULTS

Participants experienced substantial 12-month decreases in weight (-37 ± 10 kg or 30% ± 7%), fat mass (-48% ± 12%), and total lean mass (-13% ± 6%). Mean absolute strength declined by 9% ± 17% (P < 0.01). In contrast, relative strength increased by 32% ± 25% (strength/BMI) and 9% ± 20% (strength/ALM) (P < 0.01 for both). There were clinically significant postoperative improvements in all physical performance measures, including mean improvement in gait speed of >0.1 m/s (P < 0.01) and decrease in 400-m walk time of nearly a full minute.

CONCLUSIONS

In the setting of dramatic weight loss, lean mass and absolute grip strength declined after RYGB. However, relative muscle strength and physical function improved meaningfully and are thus noteworthy positive outcomes of gastric bypass.

The STRONG Kids 2 Birth Cohort Study: A Cell-to-Society Approach to Dietary Habits and Weight Trajectories across the First 5 Years of Life

BACKGROUND

Dietary habits formed during the first 5 y of life portend lifelong eating patterns.

OBJECTIVE

The Synergistic Theory Research Obesity and Nutrition Group (STRONG) Kids 2 birth cohort study aimed to examine multilevel predictors of weight trajectories and dietary habits including individual biology, child socioemotional and behavioral characteristics, family environment, and child care environment over the first 5 y of life. This report describes recruitment strategies, an overview of survey measures, and basic descriptive statistics of the cohort.

METHODS

The cohort includes 468 mothers and their offspring. A brief survey was completed at a 1-wk home visit including child's birth weight, intent to breastfeed, collection of an infant stool sample, and additional contact information should the family move. Mothers completed surveys including diet, child temperament, family environment, and child care when their child was 6 wk, 3, 12, 18, 24, 36, 48, and 60 mo of age. Height and weight of the mother and child were collected at each visit. Stool samples of the child were collected at each visit as well as saliva at 1 visit.

RESULTS

Close to half of the mothers were either overweight (24.2%) or obese (25.2%) prepregnancy. At 6 wk of age, 32.9% of the children were overweight and 31.4% were obese based on direct measurement.

CONCLUSIONS

The STRONG Kids 2 research team has adopted a socioecological model that accounts for multiple influences on children's health including biological, child social and behavioral, family household organization, and community factors. The study is limited by a relatively educated and nondiverse sample. However, variations in maternal and child weight may inform future prevention programs and policy aimed at improving the diet and health of children under the age of 5 y.This trial was registered at clinicaltrials.gov as NCT03341858.

Ideal cardiovascular health, glycaemic status and incident type 2 diabetes mellitus: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

AIMS/HYPOTHESIS

Ideal cardiovascular health (CVH) is associated with lower diabetes risk. However, it is unclear whether this association is similar across glycaemic levels (normal [<5.6 mmol/l] vs impaired fasting glucose [IFG] [5.6-6.9 mmol/l]).

METHODS

A secondary data analysis was performed in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Incident diabetes was assessed among 7758 participants without diabetes at baseline (2003-2007) followed over 9.5 years. Baseline cholesterol, blood pressure, diet, smoking, physical activity and BMI were used to categorise participants based on the number (0-1, 2-3 and ≥4) of ideal CVH components. Risk ratios (RRs) were calculated using modified Poisson regression, adjusting for cardiovascular risk factors.

RESULTS

Among participants (mean age 63.0 [SD 8.4] years, 56% female, 73% white, 27% African-American), there were 891 incident diabetes cases. Participants with ≥4 vs 0-1 ideal CVH components with normal fasting glucose (n = 6004) had 80% lower risk (RR 0.20; 95% CI 0.10, 0.37), while participants with baseline IFG (n = 1754) had 13% lower risk (RR 0.87; 95% CI 0.58, 1.30) (p for interaction by baseline glucose status <0.0001). Additionally, the magnitude of the association of ideal CVH components with lower diabetes risk was stronger among white than African-American participants (p for interaction = 0.0338).

CONCLUSIONS/INTERPRETATION

A higher number of ideal CVH components was associated with a dose-dependent lower risk of diabetes for participants with normal fasting glucose but not IFG. Tailored efforts that take into account observed differences by race and glycaemic level are needed for the primordial prevention of diabetes.

An Examination of Demographic and Psychosocial Factors, Barriers to Healthy Eating, and Diet Quality Among African American Adults

A healthy diet is associated with lower risk of chronic disease. African Americans generally have poor diet quality and experience a higher burden of many chronic diseases. We examined the associations of demographic and psychosocial factors and barriers to diet quality among African American adults. This cross-sectional study included 100 African American adults in a southeastern metropolitan area. Psychosocial factors (social support, self-efficacy), and barriers to healthy eating were assessed with validated measures. Diet quality was assessed using the Healthy Eating Index (HEI-2010). Nested linear regressions were used to examine the association between the variables of interest and HEI scores. Participants reported having social support (M (mean) = 2.0, SD (standard deviation) = 0.6, range 0⁻3), high levels of self-efficacy (M = 3.1, SD = 0.7, range 1⁻4), and low barriers (M = 1.4, SD = 0.6, range 0⁻4) to engage in healthy eating but total mean HEI scores needed improvement (M = 54.8, SD = 10.9, range 27.1⁻70.0). Participants consumed significantly higher empty calories and lower whole fruits, dairy, and total protein foods than the national average. Barriers to healthy eating (b = -12.13, p = 0.01) and the interaction between age and barriers (b = 0.25, p = 0.02) were most strongly associated with lower HEI scores. Younger African Americans with the highest barriers to healthy eating had the lowest HEI scores. Culturally appropriate interventions targeting empty calories, barriers to healthy eating, and knowledge of the Dietary Guidelines for Americans are needed for African Americans.

Low-carbohydrate diets and prevalence, incidence and progression of coronary artery calcium in the Multi-Ethnic Study of Atherosclerosis (MESA)

The evidence linking low-carbohydrate diets (LCD) to CVD is controversial, and results from epidemiological studies are inconsistent. We aimed to assess the relationship between LCD patterns and coronary artery Ca (CAC) scores from computed tomography in the Multi-Ethnic Study of Atherosclerosis cohort. Our sample included 5614 men and women free of clinical CVD at baseline (2000-2002), who had a FFQ, a baseline measure and ≥1 measure of CAC during follow-up. We excluded those with implausible energy intake or daily physical activity. The overall, animal-based and plant-based LCD scores were calculated based on intakes of macronutrients. Relative risk regression and robust regression models were used to examine the cross-sectional and longitudinal relationship between LCD score quintile and CAC outcomes, after adjustment for multiple cardiovascular risk factors. The mean age of participants was 63 years. The median intakes of total carbohydrate, fat and protein were 53·7, 30·5 and 15·6 % energy/d, respectively. Among 2892 participants with zero CAC scores at baseline, 264 developed positive scores during 2·4-year follow-up (11-59 months). Among those with positive scores at baseline, the median increase in CAC was 47 units over the course of follow-up. The overall, the animal-based and the plant-based LCD scores were not associated with CAC prevalence, incidence and progression. In conclusion, diets low in carbohydrate and high in fat and/or protein, regardless of the sources of protein and fat, were not associated with higher levels of CAC, a validated predictor of cardiovascular events, in this large multi-ethnic cohort.

Vitamin A and β-carotene in pregnant and breastfeeding post-bariatric women in an urban population

Background As breastfeeding awareness and social acceptance are increased, maternal nutritional deficiency requires more investigation. Methods A prospective cohort study was conducted to determine if vitamin A deficiency is more common in pregnant, lactating post-bariatric surgery women in an inner city population. Antepartum, women after bariatric surgery and controls with no history of malabsorption were recruited. Third trimester, postpartum maternal blood and cord blood were collected as well as three breast milk samples: colostrum, transitional and mature milk. A nutritional survey of diet was completed. Each serum sample was analyzed for total retinol and β-carotene; breast milk samples were analyzed for retinol and retinyl esters, total retinol and β-carotene. Results Fifty-three women after bariatric surgery and 66 controls were recruited. Postpartum serum retinol was significantly higher in women after bariatric surgery in the univariate analysis (P<0.0001) and confirmed in the multiple linear mixed model (P=0.0001). Breast milk colostrum retinol and transitional milk total retinol were significantly greater in the bariatric surgery group in the univariate analysis (P=0.03 and P=0.02, respectively), but not after adjusting for confounders. Serum β-carotene in the third trimester and postpartum were lower (P<0.0001 and P=0.003, respectively) in the bariatric surgery group but not after adjusting for confounders. Vitamin A deficiency was high in both groups in serum and breast milk samples. Conclusion Nutritional deficiencies in breastfeeding women after bariatric surgeries may in fact be less common than in control women in an inner city.

Life's Simple 7 and Peripheral Artery Disease: The Multi-Ethnic Study of Atherosclerosis

INTRODUCTION

In 2010, the American Heart Association initiated Life's Simple 7 with the goal of significantly improving cardiovascular health by the year 2020. The association of Life's Simple 7 with risk of peripheral artery disease has not been thoroughly explored.

METHODS

Racially diverse individuals from the Multi-Ethnic Study of Atherosclerosis (2000-2012) were followed for incident peripheral artery disease (ankle brachial index ≤0.90) and decline in ankle brachial index (≥0.15) over approximately 10 years of follow-up. Cox and logistic regression were used to assess associations of individual Life's Simple 7 components (score 0-2) and overall Life's Simple 7 score (score 0-14) with incident peripheral artery disease and ankle brachial index decline, respectively, adjusted for age, sex, race/ethnicity, education, and income. Analyses were performed in 2016-2018.

RESULTS

Of 5,529 participants, 251 (4.5%) developed incident peripheral artery disease; 419 (9.8%) of 4,267 participants experienced a decline in ankle brachial index. Each point higher for the overall Life's Simple 7 score was associated with a 17% lower rate of incident peripheral artery disease (hazard ratio=0.83, 95% CI=0.78, 0.88, p<0.001). Additionally, each point higher in overall Life's Simple 7 was associated with a 0.94-fold lower odds of decline in ankle brachial index (OR=0.94, 95% CI=0.87, 0.97, p=0.003). Four components (smoking, physical activity, glucose, and blood pressure) were associated with incident peripheral artery disease and two (smoking and glucose) with decline in ankle brachial index.

CONCLUSIONS

Better cardiovascular health as measured by Life's Simple 7 is associated with lower incidence of peripheral artery disease and less decline in ankle brachial index. Use of the Life's Simple 7 to target modifiable health behaviors may aid in decreasing the population burden of peripheral artery disease-related morbidity and mortality.

Associations of the Mediterranean diet with cognitive and neuroimaging phenotypes of dementia in healthy older adults

Background

Accumulating evidence suggests that higher Mediterranean diet (MedDiet) adherence is associated with higher global cognitive performance and brain structural integrity as well as decreased risk of Alzheimer disease (AD) and vascular dementia (VaD).

Objectives

We directly examined cross-sectional associations between the MedDiet and cognitive and neuroimaging phenotypes associated with AD and VaD (separately) in a cohort of nondemented, nondepressed older adults.

Methods

Community-dwelling older adults (n = 82; aged ∼68.8 y; 50% female, 50% minority) underwent dietary (Block Food Frequency Questionnaire 2005) and neuropsychological assessments and neuroimaging. MedDiet scores were quantified with the use of published criteria, and participants were divided into High and Low (median split) adherence groups. We focused our neuropsychological investigation on cognitive phenotypes primarily associated with AD [i.e., learning and memory (L&M)] and VaD (i.e., information processing and executive functioning). AD neuroimaging phenotypes consisted of hippocampal and dentate gyrus volumes quantified using T1-weighted images and the FreeSurfer 6.0 segmentation pipeline (http://surfer.nmr.mgh.harvard.edu). The VaD neuroimaging phenotype consisted of total white matter hyperintensity (WMH) volumes quantified using combined T1-weighted and T2-fluid-attenuated inversion recovery images. Neuroimaging metrics were adjusted for total intracranial volume. Separate multivariable linear regression models controlling for age, sex, education, body mass index, and caloric intake examined the associations between MedDiet groups (High compared with Low) and cognitive and neuroimaging outcomes.

Results

When compared with the Low MedDiet group, the High MedDiet group was associated with better L&M performance and larger dentate gyri. MedDiet adherence was not associated with information processing, executive functioning, or WMH.

Conclusion

Results highlight the association between increasing MedDiet adherence and specific cognitive and neuroimaging phenotypes that, when altered, are associated with AD.

Comparison of food consumption and nutrient intake assessed with three dietary assessment methods: results of the German National Nutrition Survey II

PURPOSE

Comparison of food consumption, nutrient intake and underreporting of diet history interviews, 24-h recalls and weighed food records to gain further insight into specific strength and limitations of each method and to support the choice of the adequate dietary assessment method.

METHODS

For 677 participants (14-80 years) of the German National Nutrition Survey II confidence intervals for food consumption and nutrient intake were calculated on basis of bootstrapping samples, Cohen's d for the relevance of differences, and intraclass correlation coefficients for the degree of agreement of dietary assessment methods. Low energy reporters were identified with Goldberg cut-offs.

RESULTS

In 7 of 18 food groups diet history interviews showed higher consumption means than 24-h recalls and weighed food records. Especially mean values of food groups perceived as socially desirable, such as fruit and vegetables, were highest for diet history interviews. For "raw" and "cooked vegetables", the diet history interviews showed a mean consumption of 144 and 109 g/day in comparison with 68 and 70 g/day in 24-h recalls and 76 and 75 g/day in weighed food records, respectively. For "fruit", diet history interviews showed a mean consumption of 256 g/day in comparison with 164 g/day in 24-h recalls and 147 g/day in weighed food records. No major differences regarding underreporting of energy intake were found between dietary assessment methods.

CONCLUSIONS

With regard to estimating food consumption and nutrient intake, 24-h recalls and weighed food records showed smaller differences and better agreement than pairwise comparisons with diet history interviews.

Dietary outcomes within the study of novel approaches to weight gain prevention (SNAP) randomized controlled trial

BACKGROUND

Young adults (YA) are at high-risk for unhealthy dietary behaviors and weight gain. The Study of Novel Approaches to Weight Gain Prevention (SNAP) Trial demonstrated that two self-regulation approaches were effective in reducing weight gain over 2 years compared with control. The goal of this analysis was to examine effects of intervention on dietary outcomes and the association of diet changes with weight change.

METHODS

Participants were 599 YA, age 18-35 years, BMI 21.0-30.0 kg/m² (27.4 ± 4.4 years; 25.4 ± 2.6 kg/m²; 22% men; 73% non-Hispanic White), who were recruited in Providence, RI and Chapel Hill, NC and randomized to self-regulation with Small Changes (SC), self-regulation with Large Changes (LC) or Control (C). SC and LC emphasized frequent self-weighing to cue behavior changes (small daily changes vs. periodic large changes) and targeted high-risk dietary behaviors. Diet and weight were assessed at baseline, 4 months and 2 years.

RESULTS

LC and SC had greater decreases in energy intake than C at 4 months but not 2 years. LC had the greatest changes in percent calories from fat at 4 months, but differences were attenuated at 2 years. No differences in diet quality were observed. Across conditions, increased total energy consumption, fast food, meals away from home, and binge drinking, and decreased dietary quality and breakfast consumption were all associated with weight gain at 2 years.

CONCLUSIONS

This study suggests the need to strengthen interventions to produce longer term changes in dietary intake and helps to identify specific behaviors associated with weight gain over time in young adults.

TRIAL REGISTRATION

Clinicaltrials.gov # NCT01183689 , registered August 18, 2010.

Impact of Nutritional Intake on Function in People with Mild-to-Moderate Multiple Sclerosis

Background

We sought to assess the associations between nutrition and ambulation, daily activity, quality of life (QOL), and fatigue in individuals with mild-to-moderate disability with multiple sclerosis (MS).

Methods

This cross-sectional pilot study included 20 ambulatory adult volunteers with MS (14 women and 6 men; mean ± SD age, 57.9 ± 10.2 years; mean ± SD Expanded Disability Status Scale score = 4.1 ± 1.8). Primary outcome variables included dietary assessment and the 6-Minute Walk Test (6MWT). Secondary measures included the Timed 25-Foot Walk test, Timed Up and Go test, daily activity, and three self-report questionnaires: the 12-item Multiple Sclerosis Walking Scale, the 36-item Short Form Health Survey (SF-36), and the Modified Fatigue Impact Scale.

Results

Significant correlations were seen between the percentage of diet comprising fats and the 6MWT (r = 0.51, P = .02) and the physical functioning component of the SF-36 (r = 0.47, P = .03). The percentage of carbohydrates was significantly correlated with the 6MWT (r = -0.43, P = .05), daily activity (r = -0.59, P = .005), and the physical functioning component of the SF-36 (r = -0.47, P = .03). Cholesterol, folate, iron, and magnesium were significantly positively correlated with the physical functioning component of the SF-36 and the 6MWT.

Conclusions

These findings indicate better ambulation, daily function, and QOL with increased fat intake, decreased carbohydrate intake, and increased intake of the micronutrients cholesterol, folate, iron, and magnesium in people with mild-to-moderate MS. This pilot study highlights the potential impact of diet on function and QOL in MS.

Higher diet-dependent acid load is associated with risk of breast cancer: Findings from the sister study

Dietary factors that contribute to chronic low-grade metabolic acidosis have been linked to breast cancer risk, but to date no epidemiologic study has examined diet-dependent acid load and breast cancer. We used data from 43,570 Sister Study participants who completed a validated food frequency questionnaire at enrollment (2003-2009) and satisfied eligibility criteria. The Potential Renal Acid Load (PRAL) score was used to estimate diet-dependent acid load. Higher scores reflect greater consumption of protein and phosphorus, and lower consumption of potassium, calcium and magnesium. The association between PRAL and breast cancer was evaluated using multivariable Cox proportional hazards regression. We identified 1,614 invasive breast cancers diagnosed at least 1 year after enrollment (mean follow-up, 7.6 years). The highest PRAL quartile, reflecting greater acid-forming potential, was associated with increased risk of breast cancer (HR_{highest vs. lowest quartile} : 1.21 [95% CI, 1.04-1.41], p_trend = 0.04). The association was more pronounced for estrogen receptor (ER)-negative (HR_{highest vs. lowest quartile} : 1.67 [95% CI, 1.07-2.61], p_trend = 0.03) and triple-negative breast cancer (HR_{highest vs. lowest quartile} : 2.20 [95% CI, 1.23-3.95], p_trend = 0.02). Negative PRAL scores, representing consumption of alkaline diets, were associated with decreased risk of ER-negative and triple-negative breast cancer, compared to a PRAL score of 0 representing neutral pH. Higher diet-dependent acid load may be a risk factor for breast cancer while alkaline diets may be protective. Since PRAL scores are positively correlated with meat consumption and negatively correlated with fruit and vegetable intake, results also suggest that diets high in fruits and vegetables and low in meat may be protective against hormone receptor negative breast cancer.

Associations of ideal cardiovascular health with GlycA, a novel inflammatory marker: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Unhealthy lifestyles and inflammation contribute to cardiovascular disease (CVD). GlycA is a novel biomarker of systemic inflammation representing post-translational glycosylation of acute phase reactants and associated with increased clinical CVD risk.

HYPOTHESIS

We hypothesized that ideal cardiovascular health (CVH), as assessed by (higher) Life's Simple 7 (LS7) scores, would be associated with lower GlycA levels among individuals free of CVD in a multiethnic community-based population.

METHODS

This was a cross-sectional study of 6479 Multi-Ethnic Study of Atherosclerosis participants [53% women; mean age 62 ± 10 years] with GlycA levels measured at baseline by nuclear magnetic resonance spectroscopy. The LS7 metrics (smoking, physical activity, diet, body mass index, blood pressure, cholesterol, and glucose) were each scored as ideal (2), moderate (1), or poor (0). Total scores were summed and categorized as optimal (12-14), average (8-11), and inadequate (0-7). Linear regression assessed percent difference in GlycA by LS7 scores, after adjusting for age, sex, ethnicity, education, income, family history of CVD, and other inflammatory biomarkers.

RESULTS

GlycA levels were 403.4 ± 63.1, 374.4 ± 59.2, and 350.3 ± 56.2 micromoles per liter (μmol/L) for inadequate, average, and optimal CVH, respectively (P-trend <0.001). After multivariable adjustment, GlycA remained independently and inversely associated with CVH categories, with a lower mean GlycA level of 5 μmol/L (95% confidence interval 4.5-5.8) for each one unit increment in LS7 score.

CONCLUSIONS

Among this group of ethnically diverse individuals without CVD, suboptimal CVH is associated with higher GlycA levels, independent of traditional inflammatory biomarkers. Strategies aimed at improving CVH might reduce GlycA, which could be a marker of reduced risk of future CVD events.

Serum and Erythrocyte Biomarkers of Nutrient Status Correlate with Short-Term Α-Carotene, Β-Carotene, Folate, and Vegetable Intakes Estimated by Food Frequency Questionnaire in Military Recruits

OBJECTIVE

Food frequency questionnaires (FFQs) estimate habitual dietary intake and require evaluation in populations of interest in order to determine accuracy. Thus, the purpose of this study was to determine agreement between circulating biomarkers and FFQ estimated dietary intake in a military population consuming all meals in a dining facility over 12 weeks.

METHODS

2014 Block FFQs were administered and fasted blood samples were drawn to assess nutritional biomarkers at the end of a 12-week training period in male (n = 141) and female (n = 125) Marine recruits undergoing initial military training. FFQ estimates of alpha- and beta-carotene, folate, and fruit and vegetable intake and circulating concentrations of serum alpha- and beta-carotene and serum and erythrocyte folate were measured. Partial correlations were used in the full model, and weighted kappa coefficients were used to determine agreement between ranking quartiles of dietary intake estimates with corresponding biomarker status quartiles.

RESULTS

Serum and dietary intake of alpha-carotene were positively associated in males (p = 0.009) and females (p < 0.001), as was serum and intake of beta-carotene (males, p = 0.002; females, p < 0.001). Alpha-carotene was positively associated with vegetable intake in males (p = 0.02) and beta-carotene with vegetable intake in females (p = 0.003). Serum folate in males (p = 0.002) and erythrocyte folate in females (p = 0.02) were associated with dietary folate intake. In females, the relationships between biomarker and dietary estimates yielded significant kappa coefficients. In males, a significant kappa coefficient was observed for erythrocyte folate and dietary intake of folate only. The kappa coefficient for serum and estimated intake of beta-carotene was not significant in males.

CONCLUSION

Twelve-week habitual intake of alpha-and beta-carotene and folate were correlated with circulating biomarkers in a military training population. The 2014 Block FFQ was able to accurately rank females into quartiles of nutrient status based on intake, while males were ranked less accurately than females.

Women with Preterm Birth Have Evidence of Subclinical Atherosclerosis a Decade After Delivery

Background: Women with preterm birth (PTB) have excess risk of cardiovascular disease (CVD) and metabolic dysregulation after delivery, but vascular mechanisms are poorly understood. We considered that women with PTB may have evidence of subclinical atherosclerosis after delivery, perhaps related to cardiometabolic risk factors. Materials and Methods: The Pregnancy Outcomes and Community Health Moms (POUCHmoms) study followed women from pregnancy through 7 to 15 years after delivery (n = 678). Women underwent B-mode ultrasound to measure the average intima-media thickness (IMT) across the common carotid, bulb, and internal carotid artery segments at follow-up (n = 605). Linear regression estimated the overall and segment-specific difference in IMT between women with preterm and term births. Results: Women were, on average, 38 years old (SD 5.7) at the follow-up visit. Those with a prior preterm versus term birth had thicker mean IMT (average of eight segments, 0.592 mm vs. 0.575, p = 0.04). Differences persisted after accounting for age, race, smoking, and body mass index (difference = +0.018 mm, p = 0.019) and were attenuated after adjustment for blood pressure, medication use, and total cholesterol (difference = +0.014, p = 0.052). Thicker mean bulb IMT in women with PTB was robust to cardiovascular risk factor adjustments (fully adjusted difference = +0.033, p = 0.029). Excluding cases of prepregnancy hypertension or preeclampsia did not change results. Conclusions: Mechanisms leading to subclinical atherosclerosis may link PTB with future CVD. PTB differences in maternal vessel remodeling in the carotid bulb, an arterial segment more prone to early development of atherosclerosis, were independent of traditional risk factors suggesting that novel processes may be involved.

A Prospective Study of Environmental Exposures and Early Biomarkers in Autism Spectrum Disorder: Design, Protocols, and Preliminary Data from the MARBLES Study

BACKGROUND

Until recently, environmental factors in autism spectrum disorder (ASD) were largely ignored. Over the last decade, altered risks from lifestyle, medical, chemical, and other factors have emerged through various study designs: whole population cohorts linked to diagnostic and/or exposure-related databases, large case-control studies, and smaller cohorts of children at elevated risk for ASD.

OBJECTIVES

This study aimed to introduce the MARBLES (Markers of Autism Risk in Babies-Learning Early Signs) prospective study and its goals, motivate the enhanced-risk cohort design, describe protocols and main exposures of interest, and present initial descriptive results for the study population.

METHODS

Families having one or more previous child with ASD were contacted before or during a pregnancy, and once the woman became pregnant, were invited to enroll. Data and biological samples were collected throughout pregnancy, at birth, and until the child's third birthday. Neurodevelopment was assessed longitudinally. The study began enrolling in 2006 and is ongoing.

RESULTS

As of 30 June 2018, 463 pregnant mothers have enrolled. Most mothers ([Formula: see text]) were thirty years of age or over, including 7.9% who are fourty years of age or over. The sample includes 22% Hispanic and another 25% nonHispanic Black, Asian, or multiracial participants; 24% were born outside the United States. Retention is high: 84% of participants whose pregnancies did not end in miscarriage completed the study or are still currently active. Among children evaluated at 36 months of age, 24% met criteria for ASD, and another 25% were assessed as nonASD nontypical development.

CONCLUSION

Few environmental studies of ASD prospectively obtain early-life exposure measurements. The MARBLES study fills this gap with extensive data and specimen collection beginning in pregnancy and has achieved excellent retention in an ethnically diverse study population. The 24% familial recurrence risk is consistent with recent reported risks observed in large samples of siblings of children diagnosed with ASD. https://doi.org/10.1289/EHP535.

Pharmaceutical use according to participation in worksite wellness screening and health campaigns

This study evaluated whether participation in worksite wellness screening and health campaigns influences the number and cost (USD) of pharmacy medication claims. Analyses are based on 2531 workers employed all four academic years in a large school district in the western United States, 2010–11 through 2013–14. Mean and ratio comparisons were adjusted by age, sex, year, and baseline health. Approximately 84.2% of employees participated in wellness screening and 60.1% completed one or more health campaigns. Those completing wellness screening were 1.09 (95% CI 1.06–1.13) times more likely to file a claim. Mean total cost remained near $934 (SD = $3695) over the academic years, positively associated with years of wellness screening, suggesting increased awareness of the need for medication through screening. Women were 1.02 (95% CI 1.00–1.05) times more likely than men to participate in wellness screening and had greater total pharmacy cost ($990.6 [SD = $4023.7] vs. $777.9 [SD = $2580.5], p = 0.0104). Women were 1.38 (95% CI 1.32–1.44) times more likely to complete a health campaign. Mean number of pharmacy claims was lower (9.8 vs. 10.6, p = 0.0069) in those completing at least one health campaign, suggesting greater health orientation in women. Those completing at least one health campaign were 0.96 (95% CI 0.92–0.99) times as likely to have a total cost of medication above the median, 0.94 (95% CI 0.88–1.01) as likely to have a total cost of medication above the 75th percentile, and 0.84 (0.75–0.96) times as likely to have a total cost above the 90th percentile.

Is self-rated health associated with ideal cardiovascular health? The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Self-rated health (SRH) is an indicator of health status-a determinant of health-promoting behaviors and a predictor of morbidity/mortality. Little is known about the association between SRH and ideal cardiovascular health (CVH), as measured by the AHA Life's Simple 7 (LS7) metrics, or whether the relationship between SRH and CVH differs by race/ethnicity.

HYPOTHESIS

Favorable SRH is associated with better CVH.

METHODS

We conducted a cross-sectional analysis of 6457 men and women (4 race/ethnicities) who participated in the Multi-Ethnic Study of Atherosclerosis. SRH was measured on a 5-point Likert scale (excellent, very good, good, fair, and poor). CVH was assessed using the LS7 metrics, each scored from 0 to 2, with a total score of 0 to 14. Scores of 0 to 8 indicate inadequate, 9 to 10, average, and 11 to 14, optimal CVH. ORs and 95% CIs were calculated for associations between SRH and CVH scores using multinomial logistic regression, adjusted for age, sex, race/ethnicity, education, income, marital status, health insurance, and chronic diseases.

RESULTS

Mean age of participants was 62 ± 10 years; 53% were female. Odds of ideal CVH increased as SRH improved. Compared with poor-fair SRH, adjusted ORs and 95% CIs for optimal CVH by SRH status were excellent, 4.9 (3.4-7.0); very good, 2.2 (1.6-3.1); and good, 1.5 (1.1-2.1). Results were similar by race/ethnicity, sex, and age groups.

CONCLUSIONS

More favorable SRH was associated with better CVH, irrespective of sex, race/ethnicity, or age. Further research could explore whether optimization of SRH predicts CVH.

An Evaluation of Factors Predicting Diet Quality among Cancer Patients

A high diet quality is associated with a lower risk of cancer mortality. However, the predictive factors of diet quality among cancer patients are not well understood. This study determines the socio-demographic and disease-related factors that affect diet quality among cancer patients. Two hundred and forty-two cancer patients completed questionnaires assessing sociodemographic and disease-related characteristics. Diet quality was measured using the Healthy Eating Index 2010 (HEI). Independent sample t-tests and one-way ANOVA with post-hoc analysis using the Tukey HSD test were used to compare mean HEI scores across these characteristics. A regression model was used to determine factors that predicted diet quality. The overall HEI score among cancer patients was 61.59 (SD = 11.67). Patients with a high school degree or General Education Diploma (GED) or less had lower HEI scores (β = -4.03, p = 0.04; β = -7.77, p = 0.001, respectively) compared to those with college degrees. Additionally, homemakers had significantly higher HEI scores (β = 7.95, p = 0.008) compared to those who worked at least 40 hours per week. Also, individuals with some types of cancers (e.g., endometrial or uterine) had significantly higher HEI scores (β = 12.56, p = 0.002) than those with other cancers (e.g., head and neck). Our findings will help oncology healthcare providers identify and target cancer patients with specific demographic characteristics who are at increased risk for consuming poor-quality diets with much needed food resource interventions.

Body composition and physical function in the Women's Health Initiative Observational Study

Physical function is critical for mobility and quality of life. We hypothesized that higher total lean mass is associated with higher physical function, and body fat inversely associated, among postmenopausal women. Women's Health Initiative Observational Study participants at Pittsburgh, PA; Birmingham, AL; and Tucson-Phoenix, AZ (1993–1998) completed dual-energy X-ray absorptiometry scans and the Rand SF-36 questionnaire at baseline and 3 y (N = 4526). Associations between quartiles (Q1–4) of lean or fat mass and physical function were tested using linear regression, adjusted for demographics, lifestyle factors, medical history, and scanner serial number. At baseline, participants had a mean ± SD age of 63.4 ± 7.4 y and BMI of 27.4 ± 5.8 kg/m². Higher percent lean mass was positively associated with physical function at baseline (Q4, 83.6 ± 0.6 versus Q1, 74.6 ± 0.7; p < 0.001), while fat mass (kg and %) was inversely associated (e.g., Q4, 73.7 ± 0.7 versus Q1, 84.2 ± 0.7 kg; p_trend < 0.001). Physical function had declined across the cohort at 3 y; the highest relative lean mass quartile at baseline conferred a lesser decline in physical function than the lowest (Q4, −3.3 ± 0.6 versus Q1–7.0 ± 0.6; p_trend < 0.001), while the highest fat mass quartile (% and kg) conferred greater decline (ex. Kg Q4, −6.7 ± 0.7 versus Q1–2.8 ± 0.6; p_trend < 0.001). Increased fat mass (≥5%), but not lean mass, was associated with lower physical function at 3 y (p < 0.001). Adiposity, as well as lean mass, requires consideration in the prediction of physical function among postmenopausal women over time.

•

Lean mass (%) is positively associated with physical function in menopause.

•

Body fat is negatively associated with physical function in menopause.

•

Decline in physical function is more rapid with gains in fat during menopause.

•

Body composition influence on functional decline is more evident among women <65 y.

Effect of exercise on metabolic syndrome in black women by family history and predicted risk of breast cancer: The FIERCE Study

BACKGROUND

This study examined the effects of supervised and home-based exercise interventions on changes in metabolic syndrome (MetS) according to breast cancer risk (high vs low) in black women enrolled in the Focused Intervention on Exercise to Reduce Cancer (FIERCE) trial.

METHODS

Postmenopausal, obese, metabolically unhealthy black women, 45 to 65 years old, were randomized to supervised aerobic exercise (73 women), home-based walking-based exercise (69 women), or a control arm (71 women). Participants in the exercise arms underwent a 6-month intervention with study assessments conducted at the baseline and 6 months. The primary outcome measure was MetS (fasting glucose, waist circumference, blood pressure, serum triglycerides, and high-density lipoprotein [HDL]). The intervention effects on MetS, stratified by breast cancer risk as measured by the family history of breast cancer and model-based projected breast cancer risk, were examined with intent-to-treat analyses using generalized estimating equation models.

RESULTS

Among women with a family history of breast cancer, the exercise arms had lower mean MetS z scores, which suggested an improvement in the metabolic profile, than controls at 6 months (controls, + 0.55; home-based arm, -0.97, P < .01; supervised arm, -0.89, P < .01). Stratified analyses by projected breast cancer risk suggested similar but statistically nonsignificant findings, with those at high risk having more favorable changes in the MetS z score in the exercise arms versus the control arm. These changes were primarily attributable to changes in blood pressure, triglycerides, and HDL.

CONCLUSIONS

Short-term aerobic activity regimens may improve the metabolic profile and thereby reduce breast cancer risk in obese, metabolically unhealthy black women at high risk for cancer. © 2018 American Cancer Society.

Dietary Patterns and Mediterranean Diet Score and Hazard of Recurrent Coronary Heart Disease Events and All-Cause Mortality in the REGARDS Study

BACKGROUND

Previously, we reported on associations between dietary patterns and incident acute coronary heart disease (CHD) in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Here, we investigated the associations of dietary patterns and a dietary index with recurrent CHD events and all-cause mortality in REGARDS participants with existing CHD.

METHODS AND RESULTS

We included data from 3562 participants with existing CHD in REGARDS. We used Cox proportional hazards regression to examine the hazard of first recurrence of CHD events-definite or probable MI or acute CHD death-and all-cause mortality associated with quartiles of empirically derived dietary patterns (convenience, plant-based, sweets, Southern, and alcohol and salads) and the Mediterranean diet score. Over a median 7.1 years (interquartile range, 4.4, 8.9 years) follow-up, there were 581 recurrent CHD events and 1098 deaths. In multivariable-adjusted models, the Mediterranean diet score was inversely associated with the hazard of recurrent CHD events (hazard ratio for highest score versus lowest score, 0.78; 95% confidence interval, 0.62-0.98; PTrend=0.036). The Southern dietary pattern was adversely associated with the hazard of all-cause mortality (hazard ratio for Q4 versus Q1, 1.57; 95% confidence interval, 1.28-1.91; PTrend<0.001). The Mediterranean diet score was inversely associated with the hazard of all-cause mortality (hazard ratio for highest score versus lowest score, 0.80; 95% confidence interval, 0.67-0.95; PTrend=0.014).

CONCLUSIONS

The Southern dietary pattern was associated with a greater hazard of all-cause mortality in REGARDS participants. Greater adherence to the Mediterranean diet was associated with both a lower hazard of recurrent CHD events and all-cause mortality.

Health of Philippine Emigrants Study (HoPES): study design and rationale

BACKGROUND

Immigrants to the United States are usually healthier than their U.S.-born counterparts, yet the health of immigrants declines with duration of stay in the U.S. This pattern is often seen for numerous health problems such as obesity, and is usually attributed to acculturation (the adoption of "American" behaviors and norms). However, an alternative explanation is secular trends, given that rates of obesity have been rising globally. Few studies of immigrants are designed to distinguish the effects of acculturation versus secular trends, in part because most studies of immigrants are cross-sectional, lack baseline data prior to migration, and do not have a comparison group of non-migrants in the country of origin. This paper describes the Health of Philippine Emigrants Study (HoPES), a study designed to address many of these limitations.

METHODS

HoPES is a dual-cohort, longitudinal, transnational study. The first cohort consisted of Filipinos migrating to the United States (n = 832). The second cohort consisted of non-migrant Filipinos who planned to remain in the Philippines (n = 805). Baseline data were collected from both cohorts in 2017 in the Philippines, with follow-up data collection planned over 3 years in either the U.S. for the migrant cohort or the Philippines for the non-migrant cohort. At baseline, interviewers administered semi-structured questionnaires that assessed demographic characteristics, diet, physical activity, stress, and immigration experiences. Interviewers also measured weight, height, waist and hip circumferences, blood pressure, and collected dried blood spot samples.

DISCUSSION

Migrants enrolled in the study appear to be representative of recent Filipino migrants to the U.S. Additionally, migrant and non-migrant study participants are comparable on several characteristics that we attempted to balance at baseline, including age, gender, and education. HoPES is a unique study that approximates a natural experiment from which to study the effects of immigration on obesity and other health problems. A number of innovative methodological strategies were pursued to expand the boundaries of current immigrant health research. Key to accomplishing this research was investment in building collaborative relationships with stakeholders across the U.S. and the Philippines with shared interest in the health of migrants.

Ethnic, Geographic, and Genetic Differences in Arsenic Metabolism at Low Arsenic Exposure: A Preliminary Analysis in the Multi-Ethnic Study of Atherosclerosis (MESA)

We investigated the effect of candidate variants in AS3MT (arsenic (III) methyltransferase) with urinary arsenic metabolites and their principal components in a subset of 264 participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Urinary arsenic species, including inorganic arsenic (iAs), monomethylarsonate (MMA), dimethylarsinate (DMA), and arsenobetaine (Ab), were measured using high performance liquid chromatography-inductively coupled plasma mass spectrometry (HPLC-ICPMS) and corrected for organic sources from seafood consumption by regressing Ab on arsenic species using a validated method. Principal components of arsenic metabolism were also used as independent phenotypes. We conducted linear regression of arsenic traits with allelic dosage of candidate single nucleotide polymorphisms (SNPs) rs12768205 (G > A), rs3740394 (A > G), and rs3740393 (G > C) measured using Illumina MetaboChip. Models were stratified by non-Hispanic white vs. all other race/ethnicity and adjusted for age, sex, arsenic exposure, study site, and population stratification. Consistent with previous studies, rs12768205 showed evidence for strongest association (non-Hispanic white: iAs% -0.14 (P 0.83), MMA% -0.66 (0.49), DMA% 0.81(0.49); other race/ethnicity: 0.13 (0.71), -1.21 (0.09), 1.08 (0.20)). No association, however, passed the strict Bonferroni p-value. This was a novel study among an ethnically diverse population exposed to low arsenic levels.

Relationship between dietary carbohydrates intake and circulating sex hormone-binding globulin levels in postmenopausal women

BACKGROUND

Low circulating levels of sex hormone-binding globulin (SHBG) have been shown to be a direct and strong risk factor for type 2 diabetes, cardiovascular diseases, and hormone-dependent cancers, although the relationship between various aspects of dietary carbohydrates and SHBG levels remains unexplored in population studies.

METHODS

Among postmenopausal women with available SHBG measurements at baseline (n = 11 159) in the Women's Health Initiative, a comprehensive assessment was conducted of total dietary carbohydrates, glycemic load (GL), glycemic index (GI), fiber, sugar, and various carbohydrate-abundant foods in relation to circulating SHBG levels using multiple linear regressions adjusting for potential covariates. Linear trend was tested across quartiles of dietary variables. Benjamini and Hochberg's procedure was used to calculate the false discovery rate for multiple comparisons.

RESULTS

Higher dietary GL and GI (both based on total and available carbohydrates) and a higher intake of sugar and sugar-sweetened beverages were associated with lower circulating SHBG concentrations (all P trend  < 0.05; Q -values = 0.04,0.01, 0.07, 0.10, 0.01, and <0.0001, respectively). In contrast, women with a greater intake of dietary fiber tended to have elevated SHBG levels (P trend  = 0.01, Q -value = 0.04). There was no significant association between total carbohydrates or other carbohydrate-abundant foods and SHBG concentrations.

CONCLUSIONS

The findings suggest that low GL or GI diets with low sugar and high fiber content may be associated with higher serum SHBG concentrations among postmenopausal women. Future studies investigating whether lower GL or GI diets increase SHBG concentrations are warranted.

Effects of Gastric Bypass Surgery on Bone Mass and Microarchitecture Occur Early and Particularly Impact Postmenopausal Women

Roux-en-Y gastric bypass (RYGB) surgery is a highly effective treatment for obesity but negatively affects the skeleton. Studies of skeletal effects have generally examined areal bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), but DXA may be inaccurate in the setting of marked weight loss. Further, as a result of modestly sized samples of mostly premenopausal women and very few men, effects of RYGB by sex and menopausal status are unknown. We prospectively studied the effects of RYGB on skeletal health, including axial and appendicular volumetric BMD and appendicular bone microarchitecture and estimated strength. Obese adults (N = 48; 27 premenopausal and 11 postmenopausal women, 10 men) with mean ± SD body mass index (BMI) 44 ± 7 kg/m² were assessed before and 6 and 12 months after RYGB. Participants underwent spine and hip DXA, spine QCT, radius and tibia HR-pQCT, and laboratory evaluation. Mean 12-month weight loss was 37 kg (30% of preoperative weight). Overall median 12-month increase in serum collagen type I C-telopeptide (CTx) was 278% (p < 0.0001), with greater increases in postmenopausal than premenopausal women (p = 0.049). Femoral neck BMD by DXA decreased by mean 5.0% and 8.0% over 6 and 12 months (p < 0.0001). Spinal BMD by QCT decreased by mean 6.6% and 8.1% (p < 0.0001); declines were larger among postmenopausal than premenopausal women (11.6% versus 6.0% at 12 months, p = 0.02). Radial and tibial BMD and estimated strength by HR-pQCT declined. At the tibia, detrimental changes in trabecular microarchitecture were apparent at 6 and 12 months. Cortical porosity increased at the radius and tibia, with more dramatic 12-month increases among postmenopausal than premenopausal women or men at the tibia (51.4% versus 18.3% versus 3.0%, p < 0.01 between groups). In conclusion, detrimental effects of RYGB on axial and appendicular bone mass and microarchitecture are detectable as early as 6 months postoperatively. Postmenopausal women are at highest risk for skeletal consequences and may warrant targeted screening or interventions. © 2017 American Society for Bone and Mineral Research.

Relationships of sex hormone levels with leukocyte telomere length in Black, Hispanic, and Asian/Pacific Islander postmenopausal women

BACKGROUND

Sex hormones may play important roles in sex-specific biological aging. In the study, we specifically examined associations between circulating sex hormone concentrations and leukocyte telomere length (TL).

METHODS

A cross-sectional study was conducted among 1124 Black, 444 Hispanic, and 289 Asian/Pacific Islander women in the Women's Health Initiative Observational Cohort. Estradiol and testosterone concentrations were measured using electrochemiluminescence immunoassays; TL was measured using quantitative polymerase chain reaction.

RESULTS

Women in the study were aged 50-79 years. Estradiol concentrations were not significantly associated with TL in this sample. The associations between total and free testosterone and TL differed by race/ethnicity (P_interaction  = 0.03 and 0.05 for total and free testosterone, respectively). Total and free testosterone concentrations were not associated with TL in Black and Hispanic women, whereas in Asian/Pacific Islander women their concentrations were inversely associated with TL (P_trend  = 0.003 for both). These associations appeared robust in multiple subgroup analyses and multivariable models adjusted for potential confounding factors. In Asian/Pacific Islander women, a doubling of serum free and total testosterone concentrations was associated with a 202-bp shorter TL (95% confidence interval [CI] 51-353 bp) and 203-bp shorter TL (95% CI 50-355 bp), respectively.

CONCLUSIONS

Serum estradiol concentrations were not associated with leukocyte TL in this large sample of postmenopausal women. Total and free testosterone concentrations were inversely associated with TL in Asian/Pacific Islander women, but not in Black and Hispanic women, although future studies to replicate our observations are warranted particularly to address potential ethnicity-specific relationships.