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Buawangpong N, Pinyopornpanish K, Phinyo P, Jiraporncharoen W, Angkurawaranon C, Soontornpun A. Effect of Comorbidities on Ten-Year Survival in Patients with Dementia. J Alzheimers Dis 2023; 94:163-175. [PMID: 37212105 DOI: 10.3233/jad-221259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND There is a verified association between comorbidity and survival in patients with dementia. OBJECTIVE To describe the ten-year survival probability of patients with dementia and to identify the impact of comorbidity. METHODS The prognostic retrospective cohort study was conducted using data from adults with dementia who had visited the outpatient departments at Maharaj Nakorn Chiang Mai hospital between 2006 and 2012. Dementia was verified in accordance with standard practice guidelines. Secondary data detailing about patient age, gender, date of dementia diagnosis and death, types of dementia, and comorbidities at the time of dementia diagnosis was obtained from electronic medical records. The association between comorbidity, patients' underlying disease at dementia diagnosis, and overall survival were analyzed using a multivariable Cox proportional hazard model adjusted for age, gender, types of dementia, and other comorbidities. RESULTS Of the 702 patients, 56.9% were female. Alzheimer's disease (39.6%) was the most prevalent type of dementia. Median overall survival was 6.0 years (95% CI 5.5- 6.7). The comorbidities associated with a high risk of mortality included liver disease (aHR 2.70, 95% CI 1.46- 5.00), atrial fibrillation (aHR 2.15, 95% CI 1.29- 3.58), myocardial infarction (aHR 1.55, 95% CI 1.07- 2.26), and type 2 diabetes mellitus (aHR 1.40, 95% CI 1.13- 1.74). CONCLUSION Overall survival rate of patients with dementia in Thailand was comparable to previous studies. Several comorbidities were associated with a ten-year survival. The prognosis of patients with dementia may be improved by appropriate care of comorbidities.
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Affiliation(s)
- Nida Buawangpong
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Kanokporn Pinyopornpanish
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Wichuda Jiraporncharoen
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Chaisiri Angkurawaranon
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Global Health and Chronic Conditions Research Group, Chiang Mai University, Chiang Mai, Thailand
| | - Atiwat Soontornpun
- Department of Internal Medicine, Division of Neurology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Lehmann DJ, Elshorbagy A, Hurley MJ. Many Paths to Alzheimer's Disease: A Unifying Hypothesis Integrating Biological, Chemical, and Physical Risk Factors. J Alzheimers Dis 2023; 95:1371-1382. [PMID: 37694367 DOI: 10.3233/jad-230295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Sporadic Alzheimer's disease (AD) is a complex, multifactorial disease. We should therefore expect to find many factors involved in its causation. The known neuropathology seen at autopsy in patients dying with AD is not consistently seen in all patients with AD and is sometimes seen in patients without dementia. This suggests that patients follow different paths to AD, with different people having slightly different combinations of predisposing physical, chemical and biologic risk factors, and varying neuropathology. This review summarizes what is known of the biologic and chemical predisposing factors and features in AD. We postulate that, underlying the neuropathology of AD is a progressive failure of neurons, with advancing age or other morbidity, to rid themselves of entropy, i.e., the disordered state resulting from brain metabolism. Understanding the diverse causes of AD may allow the development of new therapies targeted at blocking the paths that lead to dementia in each subset of patients.
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Affiliation(s)
- Donald J Lehmann
- Oxford Project to Investigate Memory and Ageing (OPTIMA), Department of Pharmacology, University of Oxford, Oxford, UK
| | - Amany Elshorbagy
- Department of Pharmacology, University of Oxford, Oxford, UK
- Department of Physiology, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Michael J Hurley
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
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Valentine D, Teerlink CC, Farnham JM, Rowe K, Kaddas H, Tschanz J, Kauwe JSK, Cannon-Albright LA. Comorbidity and Cancer Disease Rates among Those at High-Risk for Alzheimer's Disease: A Population Database Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192416419. [PMID: 36554301 PMCID: PMC9778263 DOI: 10.3390/ijerph192416419] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 06/10/2023]
Abstract
(1) Importance: Alzheimer's disease (AD) is complex and only partially understood. Analyzing the relationship between other more treatable or preventable diseases and AD may help in the prevention and the eventual development of treatments for AD. Risk estimation in a high-risk population, rather than a population already affected with AD, may reduce some bias in risk estimates. (2) Objective: To examine the rates of various comorbidities and cancers in individuals at high-risk for AD, but without a clinical diagnosis, relative to individuals from the same population with normal AD risk. (3) Design, Setting, and Participants: We conducted a study using data from the Utah Population Database (UPDB). The UPDB contains linked data from the Utah Cancer Registry, Utah death certificates, the Intermountain Health patient population, and the University of Utah Health patient population. Subjects were selected based on the availability of ancestral data, linked health information, and self-reported biometrics. (4) Results: In total, 75,877 participants who were estimated to be at high risk for AD based on family history, but who did not have an active AD diagnosis, were analyzed. A lower incidence of diabetes (RR = 0.95, 95% CI [0.92,0.97], p < 0.001), hypertension (RR = 0.97, 95% CI [0.95,0.99], p < 0.001), and heart disease (RR = 0.95, 95% CI [0.93,0.98], p < 0.001) was found. There was no difference in rates of cerebrovascular disease or other forms of dementia. Of the 15 types of cancer analyzed: breast (RR = 1.23, 95% CI [1.16, 1.30], p < 0.001); colorectal (RR = 1.30, 95% CI [1.21, 1.39], p < 0.001); kidney (RR = 1.49, 95% CI (1.29, 1.72), p < 0.001); lung (RR = 1.25, 95% CI [1.13, 1.37], p < 0.001); non-Hodgkin's Lymphoma (RR = 1.29, 95% CI [1.15, 1.44], p < 0.001); pancreas (RR = 1.34, 95% CI [1.16, 1.55], p < 0.001); stomach (RR = 1.59, 95% CI [1.36, 1.86], p < 0.001); and bladder (RR = 1.40, 95% CI [1.25, 1.56], p < 0.001), cancers were observed in significant excess among individuals at high-risk for AD after correction for multiple testing. (5) Conclusions and Relevance: Since age is the greatest risk factor for the development of AD, individuals who reach more advanced ages are at increased risk of developing AD. Consistent with this, people with fewer comorbidities earlier in life are more likely to reach an age where AD becomes a larger risk. Our findings show that individuals at high risk for AD have a decreased incidence of various other diseases. This is further supported by our finding that our high-risk group was also found to have an increased incidence of various cancers, which also increase in risk with age. There is the possibility that a more meaningful or etiological relationship exists among these various comorbidities. Further research into the etiological relationship between AD and these comorbidities may elucidate these possible interactions.
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Affiliation(s)
- David Valentine
- Department of Biology, Brigham Young University, Provo, UT 84602, USA
| | - Craig C. Teerlink
- Genetic Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - James M. Farnham
- Genetic Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Kerry Rowe
- National Oncology Program, Veterans Administration, Durham, NC 27705, USA
| | - Heydon Kaddas
- Genetic Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - JoAnn Tschanz
- Department of Psychology, Utah State University, Logan, UT 84322, USA
| | - John S. K. Kauwe
- Department of Biology, Brigham Young University, Provo, UT 84602, USA
| | - Lisa A. Cannon-Albright
- Genetic Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA
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Rocaspana-García M, Blanco-Blanco J, Arias-Pastor A, Gea-Sánchez M, Piñol-Ripoll G. Study of community-living Alzheimer's patients' adherence to the Mediterranean diet and risks of malnutrition at different disease stages. PeerJ 2018; 6:e5150. [PMID: 30002978 PMCID: PMC6037138 DOI: 10.7717/peerj.5150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/12/2018] [Indexed: 01/09/2023] Open
Abstract
Background Alzheimer’s disease (AD) is a neurodegenerative disease that is characterized by deficits in episodic memory. It is the most common form of dementia and affects 50–70% of patients with cognitive impairments over the age of 65. Elderly people are particularly susceptible to malnutrition and that risk is even higher in patients with AD. This study assessed the nutritional status of patients with AD at different stages of AD and explored how that status correlated with cognitive, functional and behavioural variables and caregiver overburden. The characteristics of the diet and the degree of adherence to the Mediterranean diet were also analysed. Methods This was a cross-sectional study that was representative of the general population and it was carried out in the Unit of Cognitive Disorders, Lleida, Spain. The participants were 111 subjects with AD who were aged 65 and over and still living at home. The subjects’ nutritional status was assessed using the Mini Nutritional Assessment (MNA) and Controlling Nutritional Status system. The monthly food intake was estimated using the short Food Frequency Questionnaire and adherence to the Mediterranean diet was evaluated using the Mediterranean Diet Score. The Mini Mental State Examination (MMSE), Global Deterioration Scale, Neuropsychiatric Inventory (NPI) and Zarit Burden Interview (ZBI) were also used. Results We found that 68% of the subjects presented with a risk of malnutrition and 19% were malnourished according to the MNA scale. Patients ate a higher quantity of meat and dairy products than recommended and fewer products from the remaining healthier food groups. Of the 111 subjects, 73% showed low adherence to the Mediterranean diet and 27% showed moderate adherence. There was a partial correlation between nutritional status and the MMSE when the data were adjusted for age and sex (r = 0, 318; p = 0.001) and inverse correlations were found for functional status (r = − 0.283; p = 0.004) and the NPI (r = − 0.409; p = 0.000) and ZBI scales (r = − 0.433; p = 0.000) when they were adjusted using the same variables. The ZBI scale (OR 1.08, 95% CI [1.01–1.15]) showed an increase in the risk of malnutrition in the multivariate analysis. Discussion Alterations in nutritional status were more common during the advanced stages of AD and were also associated with behavioural changes and caregiver overburden. Low adherence to traditional healthy diets in Mediterranean countries and food intake profiles should be considered when managing patients with AD. Other countries can use the results to examine diets in people with AD that are high in meat and dairy and low in healthy food groups like fruit and vegetables.
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Affiliation(s)
| | - Joan Blanco-Blanco
- GESEC Research Group, Faculty of Nursing and Physiotherapy, University of Lleida, Health Care Research Group (GRECS), Biomedical Research Institute of Lleida (IRBLleida), Lleida, Spain
| | - Alfonso Arias-Pastor
- Unit of Cognitive Disorders, Santa Maria University Hospital, Clinical Neuroscience Research, Biomedical Research Institute of Lleida (IRBLleida), Lleida, Spain
| | - Montserrat Gea-Sánchez
- GESEC Research Group, Faculty of Nursing and Physiotherapy, University of Lleida, Health Care Research Group (GRECS), Biomedical Research Institute of Lleida (IRBLleida), Lleida, Spain
| | - Gerard Piñol-Ripoll
- Unit of Cognitive Disorders, Santa Maria University Hospital, Clinical Neuroscience Research, Biomedical Research Institute of Lleida (IRBLleida), Lleida, Spain
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Haspula D, Clark MA. Molecular Basis of the Brain Renin Angiotensin System in Cardiovascular and Neurologic Disorders: Uncovering a Key Role for the Astroglial Angiotensin Type 1 Receptor AT1R. J Pharmacol Exp Ther 2018; 366:251-264. [PMID: 29752427 DOI: 10.1124/jpet.118.248831] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/08/2018] [Indexed: 12/13/2022] Open
Abstract
The central renin angiotensin system (RAS) is one of the most widely investigated cardiovascular systems in the brain. It is implicated in a myriad of cardiovascular diseases. However, studies from the last decade have identified its involvement in several neurologic abnormalities. Understanding the molecular functionality of the various RAS components can thus provide considerable insight into the phenotypic differences and mechanistic drivers of not just cardiovascular but also neurologic disorders. Since activation of one of its primary receptors, the angiotensin type 1 receptor (AT1R), results in an augmentation of oxidative stress and inflammatory cytokines, it becomes essential to investigate not just neuronal RAS but glial RAS as well. Glial cells are key homeostatic regulators in the brain and are critical players in the resolution of overt oxidative stress and neuroinflammation. Designing better and effective therapeutic strategies that target the brain RAS could well hinge on understanding the molecular basis of both neuronal and glial RAS. This review provides a comprehensive overview of the major studies that have investigated the mechanisms and regulation of the brain RAS, and it also provides insight into the potential role of glial AT1Rs in the pathophysiology of cardiovascular and neurologic disorders.
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Affiliation(s)
- Dhanush Haspula
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, Wisconsin (D.H.); and College of Pharmacy, Department of Pharmaceutical Sciences, Nova Southeastern University, Ft. Lauderdale, Florida (M.A.C.)
| | - Michelle A Clark
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, Wisconsin (D.H.); and College of Pharmacy, Department of Pharmaceutical Sciences, Nova Southeastern University, Ft. Lauderdale, Florida (M.A.C.)
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Socio-demographic and cardiovascular disease risk factors associated with dementia: Results of a cross-sectional study from Lebanon. Prev Med Rep 2017; 9:1-5. [PMID: 29255666 PMCID: PMC5723378 DOI: 10.1016/j.pmedr.2017.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/07/2017] [Accepted: 11/12/2017] [Indexed: 11/22/2022] Open
Abstract
Little evidence from the Arab region is available on dementia and its associated risk factors. This study is the first in Lebanon to examine the association between community older adults' socio-demographics and cardiovascular disease risk factors (CVDRF) and dementia in the aim of closing the knowledge gap. A cross-sectional household survey was conducted in 2013 in Beirut and two districts of Mount Lebanon with 502 older adults (65 years and above) and their informants. Data was collected on CVDRF and socio-demographics using structured questionnaires and dementia was assessed using the 10/66 Dementia Research Group validated tools. Multivariable analysis was done using a generalized estimating equation to account for cluster effect. Being older and perceiving personal income as insufficient significantly increased the odds of dementia [OR75–84 years = 4.00 (95%CI = 1.46, 10.95); OR85 + years = 7.07 (1.84, 27.03); ORinsufficient income = 3.90 (1.58, 9.60)]. Having uncontrolled hypertension (versus no hypertension) was the only significant CVDRF that increased the odds of dementia [OR = 6.35 (1.60, 25.10)]. Interventions targeting uncontrolled hypertension that aim to increase awareness about proper management of this chronic condition would contribute to the needed preventive efforts against CVDRFs in response to dementia risk. Further research on the association between income sufficiency – one indicator of low socio-economic status – and dementia is warranted. This is the first community-based dementia prevalence study conducted in Lebanon. Monitoring adherence to hypertension medication is a needed dementia intervention. The association between dementia and socio-economic status warrants more research.
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Promyo K, Cho JY, Park KH, Jaiswal L, Park SY, Ham KS. Artemisia scoparia attenuates amyloid β accumulation and tau hyperphosphorylation in spontaneously hypertensive rats. Food Sci Biotechnol 2017; 26:775-782. [PMID: 30263603 PMCID: PMC6049576 DOI: 10.1007/s10068-017-0077-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/11/2016] [Accepted: 02/17/2017] [Indexed: 12/27/2022] Open
Abstract
The preventive effects of Artemisia scoparia extract (AS) and AS + garlic extract (ASG) on the risk of Alzheimer's disease (AD) were evaluated in spontaneously hypertensive rats. Rats were supplemented with diets containing 2% (w/w) of AS or ASG for 6 weeks. The AS group showed lower levels of amyloid β and beta-site amyloid precursor protein cleaving enzyme 1 expressions and higher expression levels of low-density lipoprotein receptor-related protein 1 than did the control group (p < 0.05). In addition, the AS showed remarkably reduced levels of phosphorylated tau proteins and suppressed expression of phosphorylated glycogen synthase kinase 3β at tyrosine 216 (active form) (p < 0.05). The ASG group also suppressed amyloid β accumulation and tau hyperphosphorylation. However, there was no synergistic effect of garlic with AS in lowering the risk of AD. These results indicate that AS could be a potential candidate to ameliorate the risk of AD.
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Affiliation(s)
- Kitipong Promyo
- Department of Food Engineering and Solar Salt Research Center, Mokpo National University, Muan, Jeonnam 58554 Republic of Korea
| | - Jeong-Yong Cho
- Department of Food Engineering and Solar Salt Research Center, Mokpo National University, Muan, Jeonnam 58554 Republic of Korea
| | - Kyung-Hee Park
- Department of Food Engineering and Solar Salt Research Center, Mokpo National University, Muan, Jeonnam 58554 Republic of Korea
| | - Lily Jaiswal
- Department of Food Engineering and Solar Salt Research Center, Mokpo National University, Muan, Jeonnam 58554 Republic of Korea
| | - Sun-Young Park
- Department of Food Engineering and Solar Salt Research Center, Mokpo National University, Muan, Jeonnam 58554 Republic of Korea
| | - Kyung-Sik Ham
- Department of Food Engineering and Solar Salt Research Center, Mokpo National University, Muan, Jeonnam 58554 Republic of Korea
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Snowden MB, Steinman LE, Bryant LL, Cherrier MM, Greenlund KJ, Leith KH, Levy C, Logsdon RG, Copeland C, Vogel M, Anderson LA, Atkins DC, Bell JF, Fitzpatrick AL. Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence? Int J Geriatr Psychiatry 2017; 32:357-371. [PMID: 28146334 PMCID: PMC5962963 DOI: 10.1002/gps.4652] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 11/30/2016] [Accepted: 12/02/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality. METHODS This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study. RESULTS Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions. CONCLUSIONS This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Mark B. Snowden
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Lesley E. Steinman
- Health Promotion Research Center, University of Washington, Seattle, WA, USA
| | - Lucinda L. Bryant
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Monique M. Cherrier
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Kurt J. Greenlund
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Katherine H. Leith
- College of Social Work, Hamilton College, University of South Carolina, Columbia, SC, USA
| | - Cari Levy
- Division of Health Care Policy and Research, School of Medicine, University of Colorado and the Denver Veterans Affairs Medical Center, Denver, CO, USA
| | - Rebecca G. Logsdon
- UW School of Nursing, Northwest Research Group on Aging, Seattle, WA, USA
| | - Catherine Copeland
- Health Promotion Research Center, University of Washington, Seattle, WA, USA
| | - Mia Vogel
- Health Promotion Research Center, University of Washington, Seattle, WA, USA
| | - Lynda A. Anderson
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, and Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - David C. Atkins
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Janice F. Bell
- Betty Irene Moore School of Nursing, University of California, Davis, CA, USA
| | - Annette L. Fitzpatrick
- Departments of Family Medicine, Epidemiology, and Global Health, School of Medicine and School of Public Health, University of Washington, Seattle, WA, USA
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