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Huang JF, Tan QC, Bai H, Wang J, Bergman M, Wu Z. Bone mineral density, osteopenia and osteoporosis among US adults with cancer. QJM 2022; 115:653-660. [PMID: 35092293 DOI: 10.1093/qjmed/hcac015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 01/13/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Bone mineral deficits are one of the most common complications in cancer survivors. However, there are no studies evaluating bone mineral density (BMD) and the prevalence of osteopenia and osteoporosis among patients with different types of cancers. AIM The objective was to assess BMD and evaluate the prevalence of osteopenia and osteoporosis among US adults with cancer. DESIGN A cross-section propensity score matching study. METHODS We extracted data from National Health and Nutrition Examination Survey database from 2005 to 2018. We compared BMD in participants with and without cancer which was further analyzed according to cancer type. We conducted logistic regression to evaluate adjusted odds ratios of osteopenia and osteoporosis and determine risk factors for their development. RESULTS We found that BMD was significantly higher in participants without cancer than cancer patients. Furthermore, the median BMD of patients with breast cancer or skin cancer (including melanoma) was significantly lower than participants without cancer. People with breast, lung, genitourinary and skin cancers were more likely to incur osteopenia/osteoporosis than those without cancer. CONCLUSIONS BMD differs depending upon type in survivors. Individuals with a history of cancer have a poor understanding of osteoporosis and its risk factors. Understanding risk factors in patients with cancers identified in our study may be helpful for preventing osteoporosis and fractures and the development of screening guidelines.
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Affiliation(s)
- J-F Huang
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, No. 17 Changle Xi Road, Xi'an, Shaanxi Province 710032, China
| | - Q-C Tan
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, No. 17 Changle Xi Road, Xi'an, Shaanxi Province 710032, China
| | - H Bai
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, No. 17 Changle Xi Road, Xi'an, Shaanxi Province 710032, China
| | - J Wang
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, No. 17 Changle Xi Road, Xi'an, Shaanxi Province 710032, China
| | - M Bergman
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, VA New York Harbor Healthcare System, NYU Grossman School of Medicine, 423 East 23rd Street, New York, NY 10010, USA
| | - Z Wu
- Department of Orthopaedics, Xijing Hospital, The Air Force Medical University, No. 17 Changle Xi Road, Xi'an, Shaanxi Province 710032, China
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Bailey S, Lin J. The association of osteoporosis knowledge and beliefs with preventive behaviors in postmenopausal breast cancer survivors. BMC Womens Health 2021; 21:297. [PMID: 34380488 PMCID: PMC8359538 DOI: 10.1186/s12905-021-01430-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 07/22/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Postmenopausal breast cancer survivors (PBCS) are at increased risk of bone loss and fractures due to age-related decline of estrogen, and this risk is compounded by aromatase inhibitor cancer therapy. Several patient-level targetable risk factors can mitigate osteoporosis risk; however, adequate health behavior and risk perception in this population are underreported. The goal of this study was to evaluate osteoporosis knowledge and beliefs and assess their association with engagement in osteoporosis preventive behaviors among PBCS. METHODS In this cross-sectional descriptive study, early stage I-IIIA PBCS (ages 55-86 years) completed the Facts on Osteoporosis Quiz, Osteoporosis Health Beliefs Scale, and Osteoporosis Preventive Behaviors questionnaires. Participants who were non-English speaking or declined to participate were excluded. Clinical and sociodemographic information were obtained from chart review and baseline questionnaire, respectively. Fisher's exact test, Student t-test, and Wilcoxon Mann-Whitney tests were used where appropriate to assess the association between knowledge and beliefs with engagement in osteoporosis preventive behaviors. RESULTS The mean participant age was 66.1 years with 20% self-reporting as non-Hispanic White, 40% non-Hispanic Black, 27% Hispanic, and 13% other. Approximately 83% of the cohort had estrogen receptor positive breast cancer and received a bone density scan within the last six years. Osteoporosis knowledge (10.5 ± 3.4), seriousness (14.9 ± 3.8), and susceptibility (14.0 ± 3.5) mean scores were low among PBCS. Most PBCS (75%) were adherent to calcium and vitamin D supplements, but only 47% reported engagement in strength-training exercises. Married/partnered, higher osteoporosis knowledge and health motivation scores were associated with strength-training exercise. After adjustment for marital status and osteoporosis knowledge, only health motivation score remained significantly associated with strength-training exercise (OR 5.56, 95% CI 1.35-22.93). CONCLUSIONS PBCS are highly motivated to keep a healthy lifestyle despite limited osteoporosis knowledge, perceived risk, and susceptibility. However, < 50% participated in strength-training exercise. Our findings suggest that oncologic care should include osteoporosis and fracture prevention strategies, directed at encouraging cancer survivors to increase their engagement in osteoporosis preventive behaviors, particularly strength-training exercises.
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Affiliation(s)
- Stacyann Bailey
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, NY, New York, USA.
| | - Jenny Lin
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, NY, New York, USA
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Formenti AM, Dalla Volta A, di Filippo L, Berruti A, Giustina A. Effects of Medical Treatment of Prostate Cancer on Bone Health. Trends Endocrinol Metab 2021; 32:135-158. [PMID: 33509658 DOI: 10.1016/j.tem.2020.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 01/13/2023]
Abstract
Medical treatment of prostate cancer (PC) is multidisciplinary, resulting in prolonged survival. Androgen-deprivation therapy (ADT) can have negative effects on skeletal metabolism, particularly if combined with glucocorticoids. We discuss the pathophysiology and effects of ADT and glucocorticoids on skeletal endpoints, as well as the awareness and management of bone fragility. Coadministration of glucocorticoids is necessary with abiraterone because this causes a novel acquired form of 17-hydroxylase deficiency and synergistically increases the risk of fracture by affecting bone quality. Bone antiresorptive agents [selective estrogen receptor modulators (SERMS), bisphosphonates, and denosumab] increase bone mineral density (BMD) and in some instances reduce fracture risk in PC patients on ADT. Awareness and management of bone health in PC can be improved by integrating endocrinologists into the multidisciplinary PC team.
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Affiliation(s)
- Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita Salute University, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Hospital, Milan, Italy
| | - Alberto Dalla Volta
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili, Brescia, Italy
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita Salute University, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Hospital, Milan, Italy
| | - Alfredo Berruti
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili, Brescia, Italy
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita Salute University, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Hospital, Milan, Italy.
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Kim TJ, Koo KC. Pathophysiology of Bone Loss in Patients with Prostate Cancer Receiving Androgen-Deprivation Therapy and Lifestyle Modifications for the Management of Bone Health: A Comprehensive Review. Cancers (Basel) 2020; 12:cancers12061529. [PMID: 32532121 PMCID: PMC7352908 DOI: 10.3390/cancers12061529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 12/24/2022] Open
Abstract
Androgen-deprivation therapy (ADT) is a systemic therapy administered for the management of advanced prostate cancer (PCa). Although ADT may improve survival, long-term use reduces bone mass density (BMD), posing an increased risk of fracture. Considering the long natural history of PCa, it is essential to preserve bone health and quality-of-life in patients on long-term ADT. As an alternative to pharmacological interventions targeted at preserving BMD, current evidence recommends lifestyle modifications, including individualized exercise and nutritional interventions. Exercise interventions include resistance training, aerobic exercise, and weight-bearing impact exercise, and have shown efficacy in preserving BMD. At the same time, it is important to take into account that PCa is a progressive and debilitating disease in which a substantial proportion of patients on long-term ADT are older individuals who harbor axial bone metastases. Smoking cessation and limited alcohol consumption are commonly recommended lifestyle measures in patients receiving ADT. Contemporary guidelines regarding lifestyle modifications vary by country, organization, and expert opinion. This comprehensive review will provide an evidence-based, updated summary of lifestyle interventions that could be implemented to preserve bone health and maintain quality-of-life throughout the disease course of PCa.
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Affiliation(s)
- Tae Jin Kim
- Department of Urology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam 13496, Korea
| | - Kyo Chul Koo
- Department of Urology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Korea
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Abstract
PURPOSE OF REVIEW The improvement in prostate cancer survival over time, even in those with advanced disease, has led to an increasing recognition of the impact of prostate cancer and its treatment on bone health. Cancer treatment-induced bone loss (CTIBL) is a well-recognized entity but greater awareness of the risks associated with CTIBL and its treatment is required. RECENT FINDINGS The principal culprit in causing CTIBL is hormonal ablation induced by prostate cancer treatment, including several new agents which have been developed in recent years which significantly improve survival, but may cause CTIBL. This review discusses the impact of prostate cancer and its treatment on bone health, including published evidence on the underlying pathophysiology, assessment of bone health, and strategies for prevention and treatment. It is important to recognize the potential cumulative impact of systemic prostate cancer treatments on bone health.
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Affiliation(s)
| | - Abdulazeez Salawu
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Janet E Brown
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
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Assessing information needs on bone health in cancer survivors. J Cancer Surviv 2015; 10:480-8. [DOI: 10.1007/s11764-015-0491-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/10/2015] [Indexed: 12/13/2022]
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Mind the gaps: missed opportunities to promote bone health among cancer survivors. Support Care Cancer 2014; 23:611-4. [PMID: 25370892 DOI: 10.1007/s00520-014-2497-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/24/2014] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Many cancer treatments have a negative effect on bone health and can lead to osteoporosis. Additionally, the risk of osteoporosis during cancer survivorship may differ by racial and ethnic group. Overall, cancer survivors may be poorly informed about the risk of bone loss due to treatment. EXERCISE PRESCRIPTION Exercise can be prescribed to improve bone health and reduce risk of fracture. Women participating in the Improving Physical Activity After Cancer Treatment pilot study (IMPAACT) experienced significant improvements in bone health. The pilot work also suggests that cancer survivors of diverse racial/ethnic profiles may not fit the normal risk profile for osteoporosis and could be overlooked during screening. IN SUMMARY The lack of awareness of poor bone health in cancer survivors needs to be addressed, especially for those who do not fit the normal osteoporosis risk profile. Exercise is a safe and effective part of a cancer survivorship plan and is useful in promoting bone health.
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Choi KH, Park SM, Park JS, Park JH, Kim KH, Kim MJ. Prevalence of and factors associated with osteoporosis among Korean cancer survivors: a cross-sectional analysis of the Fourth and Fifth Korea National Health and Nutrition Examination Surveys. Asian Pac J Cancer Prev 2014; 14:4743-50. [PMID: 24083737 DOI: 10.7314/apjcp.2013.14.8.4743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Identifying and managing osteoporosis among cancer survivors is an important issue, yet little is known about the bone health of cancer survivors in Korea. This study was designed to measure the prevalence of osteoporosis and to assess related factors among Korean cancer survivors. MATERIALS AND METHODS This study was designed as a cross-sectional analysis. Data were obtained from dual energy X-ray absorptiometry measurement of the lumbar vertebrae and femoral neck, and from standardized questionnaires among 556 cancer survivors and 17,623 non-cancer controls who participated in the Fourth and Fifth Korea National Health and Nutrition Examination Surveys (2008-2011). We calculated adjusted proportions of osteoporosis in non-cancer controls vs. cancer survivors, and we performed multivariate logistic regression analysis. RESULTS The prevalence of osteoporosis among cancer survivors was significant higher than that of the non-cancer controls after adjusting for related factors. Furthermore, osteoporosis among cancer survivors was higher in elderly subjects (60-69 years : adjusted odds ratio (aOR) 3.04, 95% CI : 1.16-8.00, ≥70 years : aOR 6.60, 95% CI 2.20-19.79), in female cancer survivors (aOR: 7.03, 95% CI: 1.88-26.28), and in a group with lower monthly income (aOR: 3.38, 95% CI: 1.31-8.71). In male cancer survivors, underweight and lower calcium intake were risk factors. CONCLUSIONS These data suggest that the osteoporosis among cancer survivors varies according to non-oncologic and oncologic factors. Effective screening should be applied, and a sufficient and comprehensive management should be matched to individual cancer survivors early after cancer treatment.
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Affiliation(s)
- Kyung-Hyun Choi
- Department of Family Medicine, Dong-A University College of Medicine, Busan, Korea E-mail : ,
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Limburg C, Maxwell C, Mautner B. Prevention and Treatment of Bone Loss in Patients With Nonmetastatic Breast or Prostate Cancer Who Receive Hormonal Ablation Therapy. Clin J Oncol Nurs 2014; 18:223-30. [DOI: 10.1188/14.cjon.223-230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tripathy D, Durie BGM, Mautner B, Ferenz KS, Moul JW. Awareness, concern, and communication between physicians and patients on bone health in cancer. Support Care Cancer 2014; 22:1601-10. [PMID: 24477326 DOI: 10.1007/s00520-014-2127-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 01/08/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE This study aims to explore physician-patient communications about bone metastases and cancer treatment-induced bone loss (CTIBL). METHODS The study utilizes online survey of patients with breast cancer, prostate cancer, and multiple myeloma, and the physicians who treat them. RESULTS Even though 69 and 48 % of patients with nonmetastatic breast and prostate cancer aware of treatment-induced bone loss, only 39 and 23 %, respectively, were concerned about bone loss. Yet, 62 and 71 % of oncologists treating breast and prostate cancer felt that their patients were concerned. Among patients with metastatic breast and prostate cancer, two thirds had not discussed treatment for bone metastases with their doctor; when discussed, 88 and 91 % of discussions were initiated by the doctor, usually prior to initiating treatment. Most myeloma patients (77 %) had discussed treatment options with their physicians; 99 % of hematologists reported discussing treatment of bone disease with patients. CONCLUSIONS Physicians are primary sources of information to patients regarding bone health. There is a gap between what physicians assume their patients know about bone health and the patients' perceptions, presenting a need for systematic awareness and education.
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Affiliation(s)
- Debu Tripathy
- USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave., #3447, Los Angeles, CA, 90033, USA,
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Mays D, Gerfen E, Mosher RB, Shad AT, Tercyak KP. Validation of a milk consumption stage of change algorithm among adolescent survivors of childhood cancer. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2012; 44:464-468. [PMID: 22770832 PMCID: PMC3509362 DOI: 10.1016/j.jneb.2012.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 04/04/2012] [Accepted: 04/16/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To assess the construct validity of a milk consumption Stages of Change (SOC) algorithm among adolescent survivors of childhood cancer ages 11 to 21 years (n = 75). METHODS Baseline data from a randomized controlled trial designed to evaluate a health behavior intervention were analyzed. Assessments included a milk consumption SOC algorithm and hypothesized theoretical and behavioral predictors of SOC. RESULTS Compared with survivors who expressed no readiness to change, those expressing readiness to change behavior for both 2 and 4 daily servings of milk reported more frequent milk consumption (P < .001), greater dietary calcium intake (P = .006), and were more likely to meet age-specific recommendations for daily calcium intake (P = .01). CONCLUSIONS AND IMPLICATIONS Results provide support for the construct validity of the milk consumption SOC algorithm relative to behavioral criteria. Research is needed to further examine algorithm validity with respect to theoretical predictors of SOC.
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Affiliation(s)
- Darren Mays
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20007, USA.
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12
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Abstract
Osteoporosis is a major public health issue in the general population, particularly in postmenopausal women. Patients with cancer may not only be at risk for primary osteoporosis, but for secondary osteoporosis related to cancer therapies-particularly therapies that impair gonadal function, lead to loss of serum estrogen, and negatively affect bone turnover. Normal bone remodeling is influenced by the receptor activator for nuclear kappa-B ligand pathway, calcium, vitamin D, and other nutrition factors, as well as modifiable and nonmodifiable factors. Identifying which patients with cancer are at risk for bone mineral density loss is important and may include patients with breast or prostate cancer, some survivors of pediatric malignancies, and adults with other tumors. Nurses play a major role in identifying those patients and their risk for low-impact fractures, which can have a significant effect on patient morbidity and mortality. Counseling and teaching are central nursing functions, as well as safely administering therapies, particularly bisphosphonates and denosumab.
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Affiliation(s)
- Rita Wickham
- School of Nursing, Northern Michigan University, Marquette, MI, USA.
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Abstract
As people with cancer survive longer, and as the US population ages, skeletal effects of cancer treatment are becoming more pronounced. This is particularly true for breast and prostate cancer survivors because of the high average age of patients with these malignancies, the propensity of older adults in general toward the development of osteoporosis, and the wide use of therapeutic agents in these cancers that negatively impact bone health. Various therapies used in the treatment and prevention of cancer may cause decreases in bone mineral density and an increased risk of debilitating fracture, even in the absence of bone metastases. Aging is both a baseline risk factor in the development of osteoporosis and bony fracture, as well as a predictor of poor outcome after fracture. A variety of mechanisms may be responsible for the development of bone loss in patients with breast or prostate cancer. Cytotoxic chemotherapy may directly exert long-term toxic effects on bone. Chemotherapy and endocrine therapy can induce hypogonadism, leading to an increased rate of bone loss. The risk of skeletal events in older adults due to cancer therapy should be appreciated by all oncologists, geriatricians, and internists. The following review may serve as a guide to the skeletal side effects of cancer therapy in older adults with breast or prostate cancer, how to screen for treatment-related bone loss, and how to best prevent and/or treat skeletal events.
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Affiliation(s)
- Ari VanderWalde
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA.
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Gaines JM, Marx KA. Older men's knowledge about osteoporosis and educational interventions to increase osteoporosis knowledge in older men: A systematic review. Maturitas 2011; 68:5-12. [DOI: 10.1016/j.maturitas.2010.08.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 08/30/2010] [Accepted: 08/31/2010] [Indexed: 10/18/2022]
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Larson BR, Looker S, Herrera DM, Creagan ET, Hayman SR, Kaur JS, Jatoi A. Cancer patients and their companion animals: results from a 309-patient survey on pet-related concerns and anxieties during chemotherapy. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2010; 25:396-400. [PMID: 20180089 PMCID: PMC6014965 DOI: 10.1007/s13187-010-0062-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 01/22/2010] [Indexed: 05/10/2023]
Abstract
The purpose of this study was to explore whether cancer patients, who are actively receiving cancer therapy and who sometimes have only a few months to live, have anxieties or concerns that arise as a result of not being able to care for their pets during their illness or after their demise. A survey was developed and utilized among such patients to assess whether they had pet-related concerns and anxieties and to determine whether they desired more information on available pet-related resources. Three hundred nine patients completed the survey, and 170 (55%) had a pet(s). The majority described that their pets helped them during their cancer. Only 4% of all patients and 7% of the pet owners desired more information on community resources for pet care, and 80% of pet owners had family members who were already helping them with pet care. Cancer patients appear to benefit from their pets and report few pet-related concerns. Healthcare providers at other medical centers should consider determining whether their patients have needs and anxieties related to caring for their pets and whether educational efforts should be put forth to focus on such issues.
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Affiliation(s)
- Brenda R Larson
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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An assessment of the level of osteoporosis knowledge in postmenopausal breast cancer patients. Int J Orthop Trauma Nurs 2010. [DOI: 10.1016/j.ijotn.2010.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Lohse B. QALYs, concept maps, Robinson matrices, and visual information processing enrich nutrition education evaluation. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2008; 40:198. [PMID: 18457792 DOI: 10.1016/j.jneb.2008.03.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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