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Socio-economic status (SES) has been associated with measures of diet quality; however, such measures have not directly captured overall eating practices in individuals. Based on the factor analysis of fifty-six food groups from FFQ, associations between patterns of food consumption and SES were examined in a nationwide sample of 17 062 black (34·6 %) and white participants (age >45 years) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Logistic regression models adjusted for age, sex, racial group and geographic region were used to examine adherence to five emergent dietary patterns (convenience, plant-based, sweets/fats, southern and alcohol/salads) according to four levels each of individual education, household income and community-level SES. Further models assessed adherence to these dietary patterns by racial group, and an overall model including both racial groups examined whether the relationships between SES and adherence to these dietary patterns differed among black and white participants. For all the three measures of SES, higher SES had been associated with greater adherence to plant-based and alcohol/salads patterns, but lower adherence to sweets/fats and southern patterns. Statistically significant differences between black and white participants were observed in the associations between household income and adherence to alcohol/salads, individual education and adherence to plant-based and sweets/fats, and community SES and adherence to convenience patterns. As adherence to dietary patterns has been shown to be associated with health outcomes in this population (e.g. stroke), the present study offers valuable insight into behavioural and environmental factors that may contribute to health disparities in the diverse US population.

The relationship between folate and colorectal cancer (CRC) risk is unclear. We investigated the association of two biomarkers of folate status, plasma folate and red blood cell (RBC) folate, with CRC risk using a nested case-control design in the Women's Health Initiative Observational Study. Postmenopausal women (n = 93,676) aged 50-79 years were enrolled in the Women's Health Initiative Observational Study (1993-1998). A fasting blood draw and extensive health, dietary and lifestyle data were collected upon enrollment. Through 2008, 988 incident CRC cases were reported and confirmed with medical records adjudication. Cases and controls were matched on age (± 3 years), enrollment date (± 1 year), race/ethnicity, blood draw date (± 6 months) and hysterectomy status. Plasma and RBC folate were determined by radio assay. Folate biomarker values were divided into quartiles, and conditional logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CI) for the associations of folate with total CRC, by tumor site and by stage at diagnosis. Additional analyses examined whether risks varied across time periods corresponding to the United States folic acid fortification policy: prefortification (1994-1995), perifortification (1996-1997) and postfortification (1998). ORs for overall CRC risk comparing Q4 vs. Q1 were 0.91 (95% CI 0.67-1.24) and 0.91 (95% CI 0.67-1.23) for RBC and plasma folate, respectively. There were no changes in risk attributable to food supply fortification. These results do not support an overall association of folate with CRC risk and suggest that folic acid fortification of the US food supply did not alter the associations in these postmenopausal women.

Introduction Few large studies describe quality control procedures and reproducibility findings in cardiovascular ultrasound, particularly in novel techniques such as speckle tracking echocardiography (STE). We evaluate the echocardiography assessment performance in the Coronary Artery Risk Development in Young Adults (CARDIA) study Year 25 (Y25) examination (2010–2011) and report findings from a quality control and reproducibility program conducted to assess Field Center image acquisition and reading center (RC) accuracy. Methods The CARDIA Y25 examination had 3475 echocardiograms performed in 4 US Field Centers and analyzed in a RC, assessing standard echocardiography (LA dimension, aortic root, LV mass, LV end-diastolic volume [LVEDV], ejection fraction [LVEF]), and STE (two- and four-chamber longitudinal, circumferential, and radial strains). Reproducibility was assessed using intraclass correlation coefficients (ICC), coefficients of variation (CV), and Bland–Altman plots. Results For standard echocardiography reproducibility, LV mass and LVEDV consistently had CV above 10% and aortic root below 6%. Intra-sonographer aortic root and LV mass had the most robust values of ICC in standard echocardiography. For STE, the number of properly tracking segments was above 80% in short-axis and four-chamber and 58% in two-chamber views. Longitudinal strain parameters were the most robust and radial strain showed the highest variation. Comparing Field Centers with echocardiography RC STE readings, mean differences ranged from 0.4% to 4.1% and ICC from 0.37 to 0.66, with robust results for longitudinal strains. Conclusion Echocardiography image acquisition and reading processes in the CARDIA study were highly reproducible, including robust results for STE analysis. Consistent quality control may increase the reliability of echocardiography measurements in large cohort studies.

Objectives: To examine associations between objective measures of activity level and mortality risk in older men. Design: Prospective cohort study. Setting: Six U.S. sites. Participants: Men aged 71 and older followed an average of 4.5 years (N = 2,918). Measurements: Time awake spent in sedentary behavior (metabolic equivalent (MET) level ≤1.50), light activity (MET level 1.51–2.99), and at least moderate activity (MET level ≥3.00) measured using an activity monitor worn for 5 days or longer and expressed as quartiles. Deaths were confirmed with death certificates; cause of death was adjudicated by review of certificates and records. Results: During follow-up, 409 (14%) men died. After multivariable adjustment, comparing Q4 with Q1, more time spent in sedentary behavior (Q4 vs Q1, hazard ratio (HR) = 1.51, 95% confidence interval (CI) = 1.10–2.08), less time spent in light activity (Q1 vs Q4, HR = 1.54, 95% CI = 1.06–2.24), and less time spent in at least moderate activity (Q1 vs Q4, HR = 1.56, 95% CI = 1.09–2.25) were similarly associated with greater mortality risk primarily due to higher risks of cardiovascular and noncardiovascular, noncancer death. The association between time spent in sedentary behavior and mortality varied according to time spent at higher activity level. More time spent in sedentary behavior was associated with greater risk of death in men spending 1.2 (median) h/d or more in at least moderate activity (Q4 vs Q1, HR = 2.09, 95% CI = 1.26–3.49) but not in those spending less time (Q4 vs Q1, HR = 1.02, 95% CI = 0.62–1.66) (P = .005 for interaction). Conclusion: In older men exceeding current guidelines on physical activity, more time spent in sedentary behavior is associated with greater mortality risk.

BACKGROUND Renal cell carcinoma (RCC) is the eighth leading cancer among women in incidence and commonly is diagnosed at a more advanced stage. Oxidative stress has been considered to play an important role in the pathogenesis of RCC. Various dietary micronutrients have antioxidant properties, including carotenoids and vitamins C and E; thus, diets rich in these nutrients have been evaluated in relation to RCC prevention. The objective of this study was to explore the correlation between antioxidant micronutrients and the risk of RCC. METHODS In total, 96,196 postmenopausal women who enrolled in the Women's Health Initiative (WHI) between 1993 and 1998 and were followed through July 2013 were included in this analysis. Dietary micronutrient intake was estimated from the baseline WHI food frequency questionnaire, and data on supplement use were collected using an interview-based inventory procedure. RCC cases were ascertained from follow-up surveys and were centrally adjudicated. The risks for RCC associated with intake of α-carotene, β-carotene, β-cryptoxanthin, lutein plus zeaxanthin, lycopene, vitamin C, and vitamin E were analyzed using Cox proportional hazards regression adjusted for confounders. RESULTS Two hundred forty women with RCC were identified during follow-up. Lycopene intake was inversely associated with RCC risk (P = .015); compared with the lowest quartile of lycopene intake, the highest quartile of intake was associated with a 39% lower risk of RCC (hazard ratio, 0.61; 95% confidence interval, 0.39-0.97). No other micronutrient was significantly associated with RCC risk. CONCLUSIONS The current results suggest that further investigation into the correlation between lycopene intake and the risk of RCC is warranted. Cancer 2015;121:580–588. © 2014 American Cancer Society.

Introduction: Healthy behaviors lower blood pressure (BP) in short-term randomized trials. Hypothesis: Maintaining healthy behaviors for 25 years will be associated with low cumulative BP burden. Methods: In 1985-86, the Coronary Artery Risk Development in Young Adults (CARDIA) study enrolled 5115 adults 18-30 years old. BP and health behaviors were measured at 8 exams over 25 years. Optimal health behaviors were body mass index (BMI) < 25 kg/m 2 , never smoking, moderate / vigorous physical activity ≥ 150 minutes weekly, no / moderate alcohol intake (women / men: 0-7 / 0-14 drinks weekly) and Dietary Approaches to Stop Hypertension (DASH) adherence score ≥ 15. Also, maintaining ≥ 4 optimal behaviors was assessed. Using Proc Traj in SAS, 4630 adults who had ≥ 1 optimal behavior at baseline and attended ≥ 3 exams were grouped by change in mid-BP with age. Odds ratios (OR) were calculated for each higher level of BP burden associated with maintaining versus not maintaining optimal behaviors at all exams. Results: Those who did versus did not maintain optimal BMI were less likely to have moderate-stable, elevated-stable or moderate / elevated-increasing versus low-stable BP burden ( Figure, Panel A ). There was a non-statistically significant lower OR for the highest versus low-stable BP burden in adults who maintained optimal smoking and alcohol intake ( Figure, Panels B-C ). Optimal physical activity and DASH diet were not associated with mid-BP burden ( Figure, Panels D-E ). The OR (95% CI) for moderate / elevated-increasing versus low-stable BP burden in those maintaining ≥ 4 optimal behaviors was 0.73 (0.39 - 1.38). Conclusion: Maintaining optimal BMI into middle age preserves low BP burden.

Risk factors for nocturnal hypertension are more common among blacks compared with whites. We hypothesized nocturnal hypertension and nocturnal non-dipping BP are more common among blacks compared with whites. We analyzed data for 781 participants of the population-based Coronary Artery Risk Development in Young Adults (CARDIA) study who completed ambulatory blood pressure (BP) monitoring (ABPM) in 2015-2016. Awake and sleep periods were defined using actigraphy and self-report. Nocturnal hypertension was defined as mean sleep systolic BP (SBP)/diastolic BP (DBP) ≥ 120/70 mm Hg. Non-dipping SBP and DBP, separately, were defined as a decline in mean sleep BP, relative to mean awake BP < 10%. The mean age of participants was 54.7 years, 21.1% were white women, 38.5% were black women, 16.8% were white men and 23.6% were black men. The prevalence of nocturnal hypertension was 18.2% and 44.5% among white and black women, respectively, and 35.9% and 59.8% among white and black men, respectively. After multivariable adjustment, the prevalence of nocturnal hypertension was higher among black women, white men and black men, each compared with white women (Table). The prevalence of non-dipping SBP was 21.2% and 40.9% among white and black women, respectively, and 19.8% and 37.5% among white and black men, respectively. After multivariable adjustment, non-dipping SBP was more common among black women and black men compared with white women. There were no statistically significant differences in non-dipping DBP across race-gender after multivariable adjustment. Nocturnal hypertension and non-dipping SBP are more common among blacks compared with whites even after adjustment for mean BP.

Background Obesity is highly prevalent in African American women, especially those in the rural southern USA, resulting in persistent health disparities. Objective To test the effectiveness of an evidence-based behavioural weight loss intervention delivered by community health advisors to African American women in the rural south. Design and Methods Overweight or obese African American women (30–70 years) from eight counties in Mississippi and Alabama participated in a 24-month randomized controlled trial of an evidence-based behavioural weight loss programme augmented with community strategies to support healthy lifestyles (Weight Loss Plus, N = 154) compared to the weight loss programme alone (Weight Loss Only, N = 255). This study reports on 6-month outcomes on primary (weight change) and secondary (waist circumference, blood pressure, lipids, fasting blood glucose) outcomes, coinciding with the completion of the intensive weight loss phase. Results Weight Loss Only participants lost an average of 2.2 kg (P < 0.001). Weight Loss Plus participants lost an average of 3.2 kg (P < 0.001). The proportion of the total sample that lost at least 5% of their body weight was 27.1% with no difference between treatment groups. Similarly, we observed statistically significant reductions in blood pressure, waist circumference and triglycerides in each treatment group, with no statistical differences between groups. Conclusion Trained lay health staff and volunteers from the rural southern USA were able to deliver a translation of a high-intensity behavioural intervention targeted to African American women, resulting in clinically meaningful weight loss and improvement in other metabolic outcomes in a significant proportion of participants.

Subjective social status (SSS), or perceived social status, may explain, in part, the relationship between socioeconomic status (SES) and obesity. The objective of this study was to test whether SSS mediates the relationship between two indicators of SES (income and education) and body mass index (BMI).A cross-sectional, structural equation path analysis was applied to the Coronary Artery Risk Development in Young Adults (CARDIA) study (n = 2,624). The analysis tested whether SSS (MacArthur scale), education, and income were associated with BMI at the year 20 examination (adjusting for sex, age, and race), and it was hypothesized that the associations of education and income with BMI would be at least partly mediated by SSS.SSS had a significant direct effect on BMI (-0.21, P = 0.018). Education had a significant direct relationship with SSS (0.11, P 0.001) and a small but significant indirect relationship with BMI through SSS (-0.02, P = 0.022). Although income did not have a significant direct relationship with BMI, it did have a significant indirect relationship through SSS (b = -0.05, P = 0.019).Results are consistent with the hypothesized model in which SSS partially mediates the relationship between SES indicators and BMI.

Objectives. To investigate the effects of marijuana in the development of incident cardiovascular and cerebrovascular outcomes. Methods. Participants were 5113 adults aged 18 to 30 years at baseline (1985–1986) from the Coronary Artery Risk Development in Young Adults study, who were followed for more than 25 years. We estimated cumulative lifetime exposure to marijuana using repeated assessments collected at examinations every 2 to 5 years. The primary outcome was incident cardiovascular disease (CVD) through 2013. Results. A total of 84% (n = 4286) reported a history of marijuana use. During a median 26.9 years (131 990 person-years), we identified 215 CVD events, including 62 strokes or transient ischemic attacks, 104 cases of coronary heart disease, and 50 CVD deaths. Compared with no marijuana use, cumulative lifetime and recent marijuana use showed no association with incident CVD, stroke or transient ischemic attacks, coronary heart disease, or CVD mortality. Marijuana use was not associated with CVD when stratified by age, gender, race, or family history of CVD. Conclusions. Neither cumulative lifetime nor recent use of marijuana is associated with the incidence of CVD in middle age.

African Americans (AA), both men (M) and women (W), have higher CVD mortality rates than European Americans (E), but AAM have lower prevalence of coronary calcified plaque than WM. AAs also have higher blood pressure (BP) and HDL-C than W; HDL-C is lower in M than W. We tested the hypotheses that AA race is related to higher risk of hypertension (HTN)-related events, and being male is related to higher risk of atherothrombotic (ATH)-related events, placing AAM at particularly high risk for CVD. Methods: We used baseline risk factor data, and adjudicated events through 28 years of follow-up from the CARDIA study which recruited 5,115 participants aged 18-30 years at baseline (1985-6). ATH-related events included acute coronary syndrome with or without MI, coronary revascularization, and CHD and other atherosclerosis death. HTN-related events included heart failure, end-stage renal disease (ESRD), stroke, and death due to cardiomyopathy. CVD events excluded ESRD and included peripheral artery disease procedures. We analyzed time to first event censoring at death without incident CVD and at follow-up end. We built adjusted Cox models with forward selection including race, sex, age, education, and smoking status as forced predictors and selecting among physical activity, anthropometry, glycemia, lipid, and blood pressure risk factors. Results: In unadjusted analyses, risk of HTN-related events was related to race (p Conclusion: Race and sex are differentially associated with early HTN- vs ATH-related events, and AAM were at increased risk for both.

Introduction: Circulating plasminogen activator inhibitor-1 (PAI-1) levels are elevated in obesity and diabetes mellitus (DM) in cross-sectional studies. Preclinical studies support a role for PAI-1 in obesity development and insulin signaling. To date, no studies have investigated the prospective association of PAI-1 in young adults with incident obesity and DM. Hypothesis: Higher PAI-1 concentrations and greater increases in PAI-1 during young adulthood are associated with higher incidence of obesity and diabetes. Methods: We performed an ancillary study in CARDIA measuring PAI-1 in plasma at exam year (Y) 7 and Y20 in a subset of 1200 participants (ppts) free of obesity and DM at Y7. Multivariable logistic regression was used to examine the association between PAI-1 at Y7 and change from Y7 to Y20 with incident obesity and diabetes by Y30. Covariates for adjustment included demographics (age, race, sex, center, education), lifestyle risk factors (physical activity, energy intake, smoking), metabolic traits (BMI, fasting glucose [for DM]), and Y7 PAI-1 level. Results: At Y7, ppts (32±4 years, 54% female, 37% black) had mean BMI 24.5±3 kg/m 2 , fasting glucose 89±8 mg/dL, and median PAI-1 14 (IQR: 8-24) ng/mL. Median change in PAI-1 from Y7 to Y20 was +10.0 ng/mL (IQR: +1.0-28.0 ng/dL). Each 1 standard deviation higher ln(PAI-1) at Y7 was associated with an adjusted hazards ratio for incident DM of 1.35 (95% CI: 1.09-1.67). Each 1 standard deviation greater increase in PAI-1 from Y7 to Y20 was associated with an adjusted odds ratio (OR) for incident obesity and DM of 1.21 (1.02-1.43) and 1.36 (1.10-1.68), respectively. When examined by quartiles, the highest (vs. lowest) quartile of Y7 to Y20 PAI-1 change was associated with an adjusted OR of 2.37 (1.33-4.21) for incident obesity and 3.11 (1.45-6.68) for incident DM by Y30, independent of Y7 BMI and PAI-1 (FIGURE) . Conclusions: Higher plasma PAI-1 levels and greater increases in PAI-1 during young adulthood are positively associated with incident obesity and DM by middle age.

Background: We have shown that the Southern dietary pattern, characterized by added fats, fried foods, organ and processed meats, and sugar-sweetened beverages, is associated with a greater risk of incident CHD in REGARDS, a national, population-based, longitudinal cohort. We sought to determine if the Southern pattern, other dietary patterns, and the Mediterranean diet score were associated with CHD events and mortality in REGARDS participants who previously reported CHD. Methods: REGARDS enrolled white and black adults aged ≥45 years between 2003-2007. Data were analyzed from 3,562 participants with CHD at baseline. Participants completed an FFQ at baseline, from which 5 dietary patterns were derived through factor analysis (Table). The Mediterranean diet score was calculated for each participant. Expert-adjudicated CHD events included myocardial infarction and CHD death. Cox proportional hazards regression was used to model the association of the dietary patterns and score with CHD events and death, adjusting for sociodemographics, lifestyle factors, energy intake, anthropometrics, and medical conditions. Results: Over 7 years of follow-up, there were 581 recurrent CHD events and 1,098 deaths. In fully-adjusted analyses, the highest quartile of adherence to the alcohol/salads pattern and highest group of the Mediterranean diet score were associated with lower risk of recurrent CHD compared to the lowest quartile/group (HR: 0.76; 95% CI: 0.59 – 0.98, HR: 0.78; 95% CI: 0.62 – 0.98, respectively). The highest quartile of adherence to the Southern pattern was associated with higher mortality (HR: 1.57; 95% CI: 1.28 – 1.91), while the highest group of the Mediterranean diet score was associated with lower mortality (HR: 0.80; 95% CI: 0.68 – 0.95). Conclusions: While the Southern dietary pattern was not related to risk of recurrent CHD, it was associated with higher mortality in REGARDS participants with existing CHD. Greater adherence to a Mediterranean diet was associated with lower risk of recurrent CHD and mortality.

Introduction: Racial disparities in healthy lifestyles may begin in youth and increase over the lifespan. Hypothesis: Maintaining healthy lifestyles until 50 years of age will be lower in blacks compared with whites. Methods: The population-based Coronary Artery Risk Development in Young Adults (CARDIA) study enrolled 5115 blacks and whites aged 18-30 years in 1985-1986. Eight exams were completed over 25 years of follow-up. At each exam, optimal lifestyles were defined as body mass index (BMI) < 25 kg/m 2 , never smoking status, moderate or vigorous physical activity ≥ 150 minutes per week, no or moderate alcohol intake (drinks per week [women / men]: 0-7 / 0-14) and Dietary Approaches to Stop Hypertension (DASH) adherence score ≥ 15. Optimal cardiovascular health (CVH) was defined as having ≥ 4 optimal lifestyles. The age-specific percentage of blacks and whites maintaining optimal lifestyles was calculated using a modified Kaplan Meier method. Hazard ratios (HR) were calculated for maintaining optimal lifestyles over 25 years in blacks compared with whites. Results: At the baseline exam, 4900 participants (mean age: 26 years; black: 51%) had ≥ 1 optimal lifestyle. By 50 years of age, maintaining BMI < 25 kg/m 2 , never smoking status, moderate or vigorous physical activity ≥ 150 minutes per week, DASH diet adherence and optimal CVH were lower in blacks versus whites while maintaining no or moderate alcohol intake was higher ( Table ). The multivariable adjusted HR (95% confidence interval) comparing blacks to whites for maintaining BMI < 25 kg/m 2 was 0.57 (0.52-0.63), never smoking status was 0.82 (0.66-1.01), moderate or vigorous physical activity ≥ 150 minutes per week was 0.83 (0.76-0.91), no or moderate alcohol intake was 1.19 (1.03-1.37), DASH diet adherence was 0.71 (0.61-0.82) and optimal CVH was 0.63 (0.56-0.72). Conclusion: Blacks were less likely to maintain optimal lifestyles until 50 years of age. Reducing racial differences in the maintenance of optimal CVH may help prevent racial disparities in cardiovascular disease.

Background: Cardiovascular health (CVH) is worse among African Americans than whites, yet it is unclear whether differences in health behaviors fully account for these racial disparities. We investigated whether racial differences in CVH factors (blood pressure, glucose, and cholesterol) were explained by body mass index (BMI) and CVH behaviors (smoking and physical activity) in CARDIA. Methods: This cross-sectional analysis included 2,866 African-American and white CARDIA participants from four field centers (Birmingham, AL; Chicago, IL; Minneapolis, MN; and Oakland, CA) who completed the year 30 examination (2015-2016; 71% retention). We created a summary CVH factor score (range 0-6) using poor, intermediate, and ideal levels of blood pressure, glucose, and cholesterol, with higher scores indicative of better CVH. Linear regression was used to evaluate the association of race with the summary score in unadjusted and adjusted models. Results: Mean age (SD) was 55 (3.6) years, 57% were women, and 47% were African-American. The mean CVH factor score (SD) was 4.4 (1.2) for whites and 3.9 (1.3) for African Americans (p Conclusion: The racial disparity in CVH factor score persisted after accounting for BMI and CVH behaviors. Thus, roles of other factors, such as social determinants of health and diet, warrant further investigation.

Background: Trajectory of AHA’s cardiovascular health (CVH) through young adulthood are associated with subclinical CVD. The human epigenome is modifiable by lifestyle and environmental factors and may be an important mechanism of CVH outcomes. We sought to determine associations of epigenetic markers with CVH trajectories and with coronary artery calcification (CAC) through young adulthood. Methods: Among CARDIA ppts, we performed methylome analysis at follow up year (Y) 15 and Y20 using Illumina Methylation EPIC array (~850K CpG loci). We compared methylome between those with optimal CVH at baseline and remained stable (optimal-stable, n=645) and individuals with baseline optimal but declining CVH during follow up (n=100) to identify methylomic biomarkers of CVH trajectories. Differentially methylated CpGs were further examined in association with incident CAC risk at Y25 (n=745), and for their potential mediating role in CVH-associated CAC risk. Results: In 1,087 CARDIA ppts (mean age=25 at baseline), we identified 25 hypermethylated CpGs (18 at Y15, 13 at Y20, including 6 seen at both Y15 and Y20) significantly associated with optimal-stable CVH trajectories. The 6 common CpGs were stable (mean ICC = 0.66) whereas the remaining 19 CpGs were dynamic (mean ICC = 0.39) over a 5-year interval. Hypermethylation of 6 stable CpGs was associated with a decreased risk of having future CAC incidence ( Table 1 ). Hypermethylation of 10 (out of 19) dynamic CpGs at Y20 was associated with a decreased risk for incident CAC while the associations was less pronounced at Y15. Mediation analyses showed that hypermethylation of these 16 CpGs at Y15 and Y20 contributed 15% and 23% reduction in the CVH-associated relative risks (RRs) of CAC incidence at Y25. Conclusion: We observed distinct methylomic patterns in young adulthood with stable optimal CVH trajectories relative to those with declining CVH. CVH associated methylomic marks may predict CAC incidence and potentially mediate the associations of CVH trajectories with incident CAC risk.

Importance Coronary artery calcium (CAC) is associated with coronary heart disease (CHD) and cardiovascular disease (CVD); however, prognostic data on CAC are limited in younger adults. Objective To determine if CAC in adults aged 32 to 46 years is associated with incident clinical CHD, CVD, and all-cause mortality during 12.5 years of follow-up. Design, Setting, and Participants The Coronary Artery Risk Development in Young Adults (CARDIA) Study is a prospective community-based study that recruited 5115 black and white participants aged 18 to 30 years from March 25, 1985, to June 7, 1986. The cohort has been under surveillance for 30 years, with CAC measured 15 (n = 3043), 20 (n = 3141), and 25 (n = 3189) years after recruitment. The mean follow-up period for incident events was 12.5 years, from the year 15 computed tomographic scan through August 31, 2014. Main Outcomes and Measures Incident CHD included fatal or nonfatal myocardial infarction, acute coronary syndrome without myocardial infarction, coronary revascularization, or CHD death. Incident CVD included CHD, stroke, heart failure, and peripheral arterial disease. Death included all causes. The probability of developing CAC by age 32 to 56 years was estimated using clinical risk factors measured 7 years apart between ages 18 and 38 years. Results At year 15 of the study among 3043 participants (mean [SD] age, 40.3 [3.6] years; 1383 men and 1660 women), 309 individuals (10.2%) had CAC, with a geometric mean Agatston score of 21.6 (interquartile range, 17.3-26.8). Participants were followed up for 12.5 years, with 57 incident CHD events and 108 incident CVD events observed. After adjusting for demographics, risk factors, and treatments, those with any CAC experienced a 5-fold increase in CHD events (hazard ratio [HR], 5.0; 95% CI, 2.8-8.7) and 3-fold increase in CVD events (HR, 3.0; 95% CI, 1.9-4.7). Within CAC score strata of 1-19, 20-99, and 100 or more, the HRs for CHD were 2.6 (95% CI, 1.0-5.7), 5.8 (95% CI, 2.6-12.1), and 9.8 (95% CI, 4.5-20.5), respectively. A CAC score of 100 or more had an incidence of 22.4 deaths per 100 participants (HR, 3.7; 95% CI, 1.5-10.0); of the 13 deaths in participants with a CAC score of 100 or more, 10 were adjudicated as CHD events. Risk factors for CVD in early adult life identified those above the median risk for developing CAC and, if applied, in a selective CAC screening strategy could reduce the number of people screened for CAC by 50% and the number imaged needed to find 1 person with CAC from 3.5 to 2.2. Conclusions and Relevance The presence of CAC among individuals aged between 32 and 46 years was associated with increased risk of fatal and nonfatal CHD during 12.5 years of follow-up. A CAC score of 100 or more was associated with early death. Adults younger than 50 years with any CAC, even with very low scores, identified on a computed tomographic scan are at elevated risk of clinical CHD, CVD, and death. Selective use of screening for CAC might be considered in individuals with risk factors in early adulthood to inform discussions about primary prevention.

Introduction This study examines the health lifestyles of a cohort of blacks and whites in relation to cardiovascular disease (CVD). The link between health lifestyles and CVD is well established, but most of the focus has been on SES and more research is needed on racial differences. Methods Data were from the Coronary Artery Risk Development in Young Adults study of black ( n =2,451) and white ( n =2,351) men and women. Data were analyzed from baseline examinations in 1985–1986 when the participants were aged 18–30 years and any fatal or nonfatal CVD event that occurred over approximately the next 28 years (until August 2013). The first stage of the analysis used latent class models to identify distinct health lifestyles on the basis of race. The second stage used multinomial logit regression models to analyze specific characteristics in relation to the health lifestyles classes, followed by the third stage in which Cox proportional hazards models analyzed associations of the lifestyle classes with CVD risk. Results Four separate health lifestyle patterns for blacks and four for whites were identified, with the “unhealthy” lifestyle among blacks (hazard ratio, 1.60) and “most unhealthy” lifestyle among whites (hazard ratio, 3.12) showing an elevated risk of CVD. An important difference is that, in every lifestyle class, blacks showed a higher probability of excessive energy intake than whites—indicative of the potential for obesity. Conclusions Health lifestyles differ by race and support the exploratory hypothesis that distinct classes of healthy–unhealthy lifestyles exist within each racial group.

ObjectiveThe objective of this study was to evaluate whether increased serum 25-hydroxyvitamin D3 (25OHD3) concentrations, in response to calcium/vitamin D (CaD) supplementation, are associated with improved lipids in postmenopausal women.MethodsThe parent trial was a double-blind, randomize

Background: Breakfast is associated with lower body weight in observational studies. Public health authorities commonly recommend breakfast consumption to reduce obesity, but the effectiveness of adopting these recommendations for reducing body weight is unknown. Objective: We tested the relative effectiveness of a recommendation to eat or skip breakfast on weight loss in adults trying to lose weight in a free-living setting. Design: We conducted a multisite, 16-wk, 3-parallel-arm randomized controlled trial in otherwise healthy overweight and obese adults [body mass index (in kg/m2) between 25 and 40] aged 20–65 y. Our primary outcome was weight change. We compared weight change in a control group with weight loss in experimental groups told to eat breakfast or to skip breakfast [no breakfast (NB)]. Randomization was stratified by prerandomization breakfast eating habits. A total of 309 participants were randomly assigned. Results: A total of 283 of the 309 participants who were randomly assigned completed the intervention. Treatment assignment did not have a significant effect on weight loss, and there was no interaction between initial breakfast eating status and treatment. Among skippers, mean (±SD) baseline weight-, age-, sex-, site-, and race-adjusted weight changes were −0.71 ± 1.16, −0.76 ± 1.26, and −0.61 ± 1.18 kg for the control, breakfast, and NB groups, respectively. Among breakfast consumers, mean (±SD) baseline weight-, age-, sex-, site-, and race-adjusted weight changes were −0.53 ± 1.16, −0.59 ± 1.06, and −0.71 ± 1.17 kg for the control, breakfast, and NB groups, respectively. Self-reported compliance with the recommendation was 93.6% for the breakfast group and 92.4% for the NB group. Conclusions: A recommendation to eat or skip breakfast for weight loss was effective at changing self-reported breakfast eating habits, but contrary to widely espoused views this had no discernable effect on weight loss in free-living adults who were attempting to lose weight. This trial was registered at clinicaltrails.gov as {"type":"clinical-trial","attrs":{"text":"NCT01781780","term_id":"NCT01781780"}}NCT01781780.

Poor diet quality is thought to be a leading risk factor for years of life lost. We examined how scores on 4 commonly used diet quality indices—the Healthy Eating Index 2010 (HEI), the Alternative Healthy Eating Index 2010 (AHEI), the Alternate Mediterranean Diet (aMED), and the Dietary Approaches to Stop Hypertension (DASH)—are related to the risks of death from all causes, cardiovascular disease (CVD), and cancer among postmenopausal women. Our prospective cohort study included 63,805 participants in the Women's Health Initiative Observational Study (from 1993–2010) who completed a food frequency questionnaire at enrollment. Cox proportional hazards models were fit using person-years as the underlying time metric. We estimated multivariate hazard ratios and 95% confidence intervals for death associated with increasing quintiles of diet quality index scores. During 12.9 years of follow-up, 5,692 deaths occurred, including 1,483 from CVD and 2,384 from cancer. Across indices and after adjustment for multiple covariates, having better diet quality (as assessed by HEI, AHEI, aMED, and DASH scores) was associated with statistically significant 18%–26% lower all-cause and CVD mortality risk. Higher HEI, aMED, and DASH (but not AHEI) scores were associated with a statistically significant 20%–23% lower risk of cancer death. These results suggest that postmenopausal women consuming a diet in line with a priori diet quality indices have a lower risk of death from chronic disease.

Background and aim: Dietary patterns are associated cross-sectionally with cellular adhesion molecules (CAMs). We studied prospective associations of three dietary patterns with CAMs. Methods and results: In the Coronary Artery Risk Development in Young Adults (CARDIA) study, diet was assessed at years 0 (1985-86) and 7 (1992-93) examinations. Four circulating CAMs (E-selectin, P-selectin, soluble intercellular adhesion molecule 1 (sICAM-1), and vascular cellular adhesion molecule (VCAM)) were assayed at years 7 and 15 (2000-01). We created one index score "A Priori Diet Quality Score" and derived dietary patterns using principal components analysis (PCA). Multivariable linear regression models predicted year 15 CAMs from averaged (year 0/7) dietary patterns. The A Priori Diet Quality Score rated 46 food groups beneficial, neutral or adverse based on hypothesized health effects. We derived two PCA dietary patterns: "fruit and vegetables (FV)" (high intakes of fruit, vegetables, and whole grains) and "meat" (high intakes of red meat, refined grain, and butter). All dietary patterns were related to E-selectin and sICAM-1. P-selectin was not related to the FV dietary pattern. VCAM was only related to the A Priori Diet Quality Score. Strongest associations were for the meat dietary pattern with E-selectin (effect size 28% of an SD (+3.9/13.7 ng/mL)) and P-selectin (effect size 37% of an SD (+4.1/11.2 ng/mL)) and the A Priori Diet Quality Score with sICAM-1 (effect size 34% of an SD (-15.1/44.7 ng/mL)) and VCAM (effect size of 26% of an SD (-45.1/170.3 ng/mL)). Conclusion: This prospective analysis suggests that dietary patterns are associated with CAMs. (C) 2014 Elsevier B. V. All rights reserved.

Background: Few studies have evaluated whether adherence to dietary recommendations is associated with mortality among cancer survivors. In breast cancer survivors, we examined how postdiagnosis Healthy Eating Index (HEI)-2005 scores were associated with all-cause and cause-specific mortality. Methods: Our prospective cohort study included 2,317 postmenopausal women, ages 50 to 79 years, in the Women's Health Initiative's Dietary Modification Trial (n = 1,205) and Observational Study (n = 1,112), who were diagnosed with invasive breast cancer and completed a food frequency questionnaire after being diagnosed. We followed women from this assessment forward. We used Cox proportional hazards models to estimate multivariate-adjusted HRs and 95% confidence intervals (CI) for death from any cause, breast cancer, and causes other than breast cancer, according to HEI-2005 quintiles. Results: Over 9.6 years, 415 deaths occurred. After adjustment for key covariates, women consuming better quality diets had a 26% lower risk of death from any cause (HRQ4:Q1, 0.74; 95% CI, 0.55–0.99; Ptrend = 0.043) and a 42% lower risk of death from non–breast cancer causes (HRQ4:Q1, 0.58; 95% CI, 0.38–0.87; Ptrend = 0.011). HEI-2005 score was not associated with breast cancer death (HRQ4:Q1, 0.91; 95% CI, 0.60–1.40; Ptrend = 0.627). In analyses stratified by tumor estrogen receptor (ER) status, better diet quality was associated with a reduced risk of all-cause mortality among women with ER+ tumors (n = 1,758; HRQ4:Q1, 0.55; 95% CI, 0.38–0.79; Ptrend = 0.0009). Conclusion: Better postdiagnosis diet quality was associated with reduced risk of death, particularly from non–breast cancer causes. Impact: Breast cancer survivors may experience improved survival by adhering to U.S. dietary guidelines. Cancer Epidemiol Biomarkers Prev; 23(4); 575–83. ©2014 AACR.

Background: The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets are characterized by higher intake of fruit, vegetables, whole grains, and unsaturated fatty acids. All of these foods and nutrients may affect cholesterol, inflammation, the development of atherosclerosis, and, therefore, risk of cardiac death. Objective: Our objective was to examine the association between the Mediterranean and DASH dietary patterns and risk of sudden cardiac death (SCD) in women. Design: We used a prospective cohort of 93,122 postmenopausal women enrolled in the Women's Health Initiative study between 1993 and 1998 and followed for an average of 10.5 y. Women completed a food-frequency questionnaire (FFQ) twice during follow-up. We scored their diets according to how closely the reported diet resembled each dietary pattern. SCD was defined as death that occurred within 1 h of symptom onset. Results: A higher Mediterranean diet score was associated with lower risk of SCD (HR: 0.64; 95% CI: 0.43, 0.94) when women in the highest quintile were compared with women in the lowest quintile after adjustment for age, total energy, race, income, smoking, and physical activity. After adjustment for potential mediators, the association was similar (HR: 0.67; 95% CI: 0.46, 0.99). A higher DASH diet score was not associated with risk of SCD. However, sodium intake, which is a crucial component of the DASH dietary pattern, was not well characterized by the FFQ. Conclusion: The Mediterranean dietary pattern may be associated with lower risk of SCD in women. This trial was registered at clinicaltrials.gov as {"type":"clinical-trial","attrs":{"text":"NCT00000611","term_id":"NCT00000611"}}NCT00000611.

OBJECTIVES: The objective was to examine the prospective association of major dietary protein sources with all-cause and cause-specific mortality in U.S. women. METHODS: We included 127,495 postmenopausal women aged 50 to 79 years old at study entry who were enrolled between 1993 and 1998 in the Women's Health Initiative from September 1993, and followed through February 2017. Prospective cohort study. We used multivariable Cox proportional hazards models to estimate adjusted HRs of all cause, cardiovascular, cancer and dementia mortality in relation to major protein sources. RESULTS: During 2,302,230 person-years of follow-up, 35,043 deaths occurred. Total protein or animal protein intake was not significantly associated with all-cause or cause-specific mortality. Plant protein intake was inversely associated with all-cause, CVD and dementia mortality, with multivariable-adjusted HRs (95% CIs), comparing the higher with the lowest quintile, as 0.91 (0.86, 0.95), 0.87 (0.79, 0.95), and 0.81 (0.70, 0.94), respectively. Substituting 5% energy from animal protein with plant protein was associated with a 13% lower risk of all-cause mortality. For major protein sources, consumption of unprocessed red meat, processed red meat, and eggs, was associated with higher risk of all-cause mortality, with multivariable-adjusted HRs (95% CIs), comparing the higher with the lowest quintile, as 1.07 (1.03, 1.11), 1.07 (1.03, 1.11), and 1.14 (1.10, 1.18), respectively, while nut consumption was associated with a slightly lower risk of all-cause mortality, with multivariable-adjusted HRs (95% CIs), comparing the higher with the lowest quintile, as 0.97 (0.93, 0.99). Substituting 4 ounce equivalent/day of total red meat with poultry, fish/shellfish, or nuts, was associated with a 8%, a 12%, and a 12% lower risk of all-cause mortality, respectively. CONCLUSIONS: Different dietary protein sources have varying associations with lower all-cause, CVD and dementia mortality. Substituting total red meat with poultry, fish/shellfish, or nuts was associated with lower risk of all-cause mortality. FUNDING SOURCES: NIH.

Cost-effective strategies to maintain healthy active lifestyle in aging populations are required to address the global burden of age-related diseases. ASPREE will examine whether the potential primary prevention benefits of low dose aspirin outweigh the risks in older healthy individuals. Our primary hypothesis is that daily oral 100. mg enteric-coated aspirin will extend a composite primary endpoint termed 'disability-free life' including onset of dementia, total mortality, or persistent disability in at least one of the Katz Activities of Daily Living in 19,000 healthy participants aged 65. years and above ('US minorities') and 70. years and above (non-'US minorities'). ASPREE is a double-blind, randomized, placebo-controlled trial of oral 100. mg enteric-coated acetyl salicylic acid (ASA) or matching placebo being conducted in Australian and US community settings on individuals free of dementia, disability and cardiovascular disease (CVD) events. Secondary endpoints are all-cause and cause specific mortality, fatal and non-fatal cardiovascular events, fatal and non-fatal cancer (excluding non-melanoma skin cancer), dementia, mild cognitive impairment, depression, physical disability, and clinically significant bleeding. To 20 September 2013 14,383 participants have been recruited. Recruitment and study completion are anticipated in July 2014 and December 2018 respectively. In contrast to other aspirin trials that have largely focused on cardiovascular endpoints, ASPREE has a unique composite primary endpoint to better capture the overall risk and benefit of aspirin to extend healthy independent lifespan in older adults in the US and Australia.

Sarcopenia is defined as age-related decrease in muscle mass and performance. Several consensus definitions of sarcopenia exist, each providing different cut points and methodologies for assessing muscle mass and muscle strength. Thus, wide variation in the prevalence of sarcopenia has been reported, generally ranging up to 45% for men and 26% for women. Risk factors for sarcopenia include age, malnutrition, and physical inactivity. Additional evidence suggests a protective role for protein supplementation in older adults in order to preserve lean body mass and prevent frailty, accepted intervention targets for reducing the risk of sarcopenia. Protein supplements vary widely in their composition, and small trials of heterogeneous study designs have made it difficult to extrapolate findings to develop data-driven, evidence-based recommendations for protein supplementation in sarcopenia prevention. Short-term randomized, controlled trials of muscle protein synthesis have demonstrated that whey protein increases synthesis more so than casein or soy isolates. Studies also suggest that essential amino acids stimulate muscle protein synthesis to a greater extent than non-essential amino acids. This review summarizes the epidemiological and clinical trial evidence establishing the current definitions for sarcopenia and provides an overview of the state of the evidence for protein supplementation to prevent and/or mitigate sarcopenia.

Study objectives To determine whether the duration of sleep, sleep quality, insomnia, or sleep disturbance was associated with incident breast cancer in the Women's Health Initiative (WHI). Design Prospective cohort study. Setting Women enrolled in one of the Clinical Trial (CT) arms or the Observational Study (OS) from the WHI conducted in the United States. Participants This study included 110,011 women age 50 to 79 years with no history of cancer. Measurements and results Typical sleep duration, sleep quality, and other self-reported sleep measures over the past 4 weeks were assessed during the screening visits for both the CT and OS participants. The presence of insomnia and level of sleep disturbance was calculated from an index of the WHI Insomnia Rating Scale. The outcome for this study was primary, invasive breast cancer. A total of 5,149 incident cases of breast cancer were identified in this study. No statistically significant associations were found between sleep duration, sleep quality, insomnia, or level of sleep disturbance with the risk of breast cancer after multivariable adjustment. A positive trend was observed for increasing sleeping duration with the risk of estrogen receptor positive breast cancer, but the association estimates for each sleep duration category were weak and nonsignificant. Conclusions This study does not provide strong support for an association between self-reported sleep duration, sleep quality, insomnia, or sleep disturbance with the risk of breast cancer.

Regression calibration using biomarkers provides an attractive approach to strengthening nutritional epidemiology. We consider this approach to assessing the relationship of fat and total energy consumption with postmenopausal breast cancer. In analyses that included fat density data, biomarker-calibrated total energy was positively associated with postmenopausal breast cancer incidence in cohorts of the US Women's Health Initiative from 1994-2010. The estimated hazard ratio for a 20% increment in calibrated food frequency questionnaire (FFQ) energy was 1.22 (95% confidence interval (CI): 1.15, 1.30). This association was not evident without biomarker calibration, and it ceased to be apparent following control for body mass index (weight (kg)/height (m)(2)), suggesting that the association is mediated by body fat deposition over time. The hazard ratio for a corresponding 40% increment in FFQ fat density was 1.05 (95% CI: 1.00, 1.09). A stronger fat density association, with a hazard ratio of 1.19 (95% CI: 1.00, 1.41), emerged from analyses that used 4-day food records for dietary assessment. FFQ-based analyses were also carried out by using a second dietary assessment in place of the biomarker for calibration. This type of calibration did not correct for systematic bias in energy assessment, but may be able to accommodate the "noise" component of dietary measurement error. Implications for epidemiologic applications more generally are described.

Background: Large cohort studies have reported no relationship between dietary fat and nonmelanoma skin cancer (NMSC), although a low-fat diet intervention reduced NMSC risk in a small clinical trial. In animal studies, skin tumor development has been reduced by low-fat diet. We evaluated the effect of a low-fat dietary pattern on NMSC and melanoma in the Women's Health Initiative Dietary Modification trial. Methods: Postmenopausal women aged 50 to 79 years (n = 48,835) were randomly assigned to the low-fat dietary pattern intervention (n = 19,541) or comparison group (n = 29,294). The intervention goals included decreasing fat intake to 20% or less of calories, increasing vegetable and fruit intake, and increasing grain intake. Self-reported incident NMSC (n = 4,907) and physician-adjudicated incident melanoma (n = 279) were ascertained every 6 months. Results: Over 8.1 years of follow-up, the low-fat diet intervention did not affect overall incidence of NMSC [HR 0.98; 95% confidence interval (CI), 0.92–1.04] or melanoma (HR, 1.04; 95% CI, 0.82–1.32). In subgroup analyses of melanoma risk, baseline fat intake interacted significantly with group assignment (Pinteraction = 0.006). Among women with higher baseline fat intake, the dietary intervention significantly increased risk (HR, 1.48; 95% CI, 1.06–2.07), whereas, among women with lower baseline fat intake, the intervention tended to reduce melanoma risk (HR, 0.72; 95% CI, 0.50–1.02). Conclusions: In this large randomized trial, a low-fat dietary pattern did not affect overall incidence of NMSC or melanoma. Impact: A low-fat diet does not reduce incidence of NMSC, but an interaction between baseline fat intake and dietary intervention on melanoma risk warrants further investigation. Cancer Epidemiol Biomarkers Prev; 22(9); 1509–19. ©2013 AACR.

Summary We provide arguments to the debate question and update a previous meta-analysis with recently published studies on effects of sugar-sweetened beverages (SSBs) on body weight/composition indices (BWIs). We abstracted data from randomized controlled trials examining effects of consumption of SSBs on BWIs. Six new studies met these criteria: (i) human trials, (ii) 3 weeks duration, (iii) random assignment to conditions differing only in consumption of SSBs and (iv) including a BWI outcome. Updated meta-analysis of a total of seven studies that added SSBs to persons’ diets showed dose-dependent increases in weight. Updated metaanalysis of eight studies attempting to reduce SSB consumption showed an equivocal effect on BWIs in all randomized subjects. When limited to subjects overweight at baseline, meta-analysis showed a significant effect of roughly 0.25 standard deviations (more weight loss/less weight gain) relative to controls. Evidence to date is equivocal in showing that decreasing SSB consumption will reduce the prevalence of obesity. Although new evidence suggests that an effect may yet be demonstrable in some populations, the integrated effect size estimate remains very small and of equivocal statistical significance. Problems in this research area and suggestions for future research are highlighted.

Objective The Medifast 5 & 1 Plan (MD) is a portion-controlled, nutritionally-balanced, low-fat weight-loss plan. We studied the effects of MD compared with a reduced-energy, food-based diet (FB) on body weight, waist circumference, fat mass, and other measures in adults. Design We conducted a 2 parallel-arm, randomized, controlled trial comparing MD to FB over 52 weeks. A total of 120 men and women aged 19-65 years with BMI ≥35 and ≤50 kg/m2 were randomized to MD (n = 60) or FB (n = 60). Follow-up included a 26-week weight-loss phase and 26-week weight-maintenance phase. Anthropometric, body composition, biochemical, and appetite/satiety measures were performed at baseline, 26 and 52 weeks. An intention-to-treat, linear mixed models analysis was the primary analysis. Results Fifty MD subjects (83.3%) and 45 FB subjects (75.0%) completed the study on assigned treatment. At 26 weeks, race-adjusted mean weight loss was 7.5 kg in MD subjects vs. 3.8 kg in FB subjects (P = 0.0002 for difference); reduction in waist circumference was 5.7 cm in MD vs. 3.7 cm in FB (P = 0.0064); and fat mass loss was 6.4 kg in MD vs. 3.7 kg in FB (P = 0.0011). At 52 weeks, the corresponding reductions were 4.7 vs. 1.9 kg (P = 0.0004); 5.0 vs. 3.6 cm (P = 0.0082); and 4.1 vs. 1.9 kg (P = 0.0019) in MD and FB subjects, respectively. Conclusion In obese adults, MD resulted in significantly greater reductions in body weight and fat compared with an FB diet for one year after randomization.

Background: The role of one-carbon metabolism nutrients in colorectal carcinogenesis is not fully understood. Associations might be modified by mandated folic acid (FA) fortification or alcohol intake. Objective: We investigated associations between intakes of folate, riboflavin, vitamin B-6, and vitamin B-12 and colorectal cancer (CRC) in the Women's Health Initiative Observational Study, stratified by time exposed to FA fortification and alcohol intake. Design: A total of 88,045 postmenopausal women were recruited during 1993–1998; 1003 incident CRC cases were ascertained as of 2009. Quartiles of dietary intakes were compared; HRs and 95% CIs were estimated by Cox proportional hazards models. Results: Dietary and total intakes of vitamin B-6 in quartile 4 compared with quartile 1 (HR: 0.80; 95% CI: 0.66, 0.97 and HR: 0.80; 95% CI: 0.66, 0.99, respectively) and total intakes of riboflavin (HR: 0.81; 95% CI: 0.66, 0.99) were associated with reduced risk of CRC overall and of regionally spread disease. In current drinkers who consumed

Estrogen receptor-negative (ER(-)) breast cancer has few known or modifiable risk factors. Because ER(-) tumors account for only 15% to 20% of breast cancers, large pooled analyses are necessary to evaluate precisely the suspected inverse association between fruit and vegetable intake and risk of ER(-) breast cancer.Among 993 466 women followed for 11 to 20 years in 20 cohort studies, we documented 19 869 estrogen receptor positive (ER(+)) and 4821 ER(-) breast cancers. We calculated study-specific multivariable relative risks (RRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression analyses and then combined them using a random-effects model. All statistical tests were two-sided.Total fruit and vegetable intake was statistically significantly inversely associated with risk of ER(-) breast cancer but not with risk of breast cancer overall or of ER(+) tumors. The inverse association for ER(-) tumors was observed primarily for vegetable consumption. The pooled relative risks comparing the highest vs lowest quintile of total vegetable consumption were 0.82 (95% CI = 0.74 to 0.90) for ER(-) breast cancer and 1.04 (95% CI = 0.97 to 1.11) for ER(+) breast cancer (P (common-effects) by ER status.001). Total fruit consumption was non-statistically significantly associated with risk of ER(-) breast cancer (pooled multivariable RR comparing the highest vs lowest quintile = 0.94, 95% CI = 0.85 to 1.04).We observed no association between total fruit and vegetable intake and risk of overall breast cancer. However, vegetable consumption was inversely associated with risk of ER(-) breast cancer in our large pooled analyses.

Background: Although long-chain ω-3 (n−3) PUFAs (LCω3PUFAs) have been linked to the prevention of some inflammatory disorders, little is known about the association between these fatty acids and incidence of asthma. Objective: The objective was to prospectively investigate the association between LCω3PUFAs and fish intake and incidence of asthma among American young adults. Design: A 20-y follow-up longitudinal analysis was conducted in a biracial cohort of 4162 Americans, aged 18–30 y, with a history of asthma at baseline in 1985. Diet was assessed by a validated interviewer-administered quantitative food-frequency questionnaire at the examinations in 1985, 1992, and 2005. Incident self-reported asthma was defined as having a physician diagnosis of asthma and/or the use of asthma medications between 1985 and 2005. Results: During the 20-y follow-up, 446 incident cases of asthma were identified. LCω3PUFA intake was significantly inversely associated with incidence of asthma after adjustment for sociodemographic, major lifestyle, and dietary confounders. The multivariable-adjusted HR for the highest quintile of LCω3PUFA intake as compared with the lowest quintile was 0.46 (95% CI: 0.33, 0.64; P-trend < 0.01). However, a higher frequency of nonfried fish consumption was not significantly associated with the risk of asthma. DHA showed a greater inverse association than did EPA. The association between LCω3PUFAs and incident asthma was not appreciably modified by sex, race, BMI, smoking status, or atopic status. Conclusion: This study showed that intakes of LCω3PUFAs are inversely longitudinally associated with the incidence of asthma in American young adults.

Although diet is thought to affect the natural history of heart failure (HF), nutrient intake in HF patients has not been well studied. Based on prior research linking high intake of Ca, Mg and K to improved cardiovascular health, we hypothesised that these nutrients would be inversely associated with mortality in people with HF. Of the 161 808 participants in the Women's Health Initiative (WHI), we studied 3340 who experienced a HF hospitalisation. These participants were followed for post-hospitalisation all-cause mortality. Intake was assessed using questionnaires on food and supplement intake. Hazard ratios (HR) and 95 % CI were calculated using Cox proportional hazards models adjusted for demographics, physical function, co-morbidities and dietary covariates. Over a median of 4·6 years of follow-up, 1433 (42·9 %) of the women died. HR across quartiles of dietary Ca intake were 1·00 (referent), 0·86 (95 % CI 0·73, 1·00), 0·88 (95 % CI 0·75, 1·04) and 0·92 (95 % CI 0·76, 1·11) (P for trend = 0·63). Corresponding HR were 1·00 (referent), 0·86 (95 % CI 0·71, 1·04), 0·88 (95 % CI 0·69, 1·11) and 0·84 (95 % CI 0·63, 1·12) (P for trend = 0·29), across quartiles of dietary Mg intake, and 1·00 (referent), 1·20 (95 % CI 1·01, 1·43), 1·06 (95 % CI 0·86, 1·32) and 1·16 (95 % CI 0·90, 1·51) (P for trend = 0·35), across quartiles of dietary K intake. Results were similar when total (dietary plus supplemental) nutrient intakes were examined. In summary, among WHI participants with incident HF hospitalisation, intakes of Ca, Mg and K were not significantly associated with subsequent mortality.

This study examined differences in socio-demographic characteristics and health behaviors relevant to chronic medical conditions (CMCs) in the Mid-South region (Alabama, Mississippi, Louisiana, Kentucky, Tennessee, and Arkansas), and identified subpopulations with increased burden of chronic disease.Data were obtained from the 2013 Behavioral Risk Factor Surveillance System. The top five most prevalent CMCs in the Mid-South were analyzed: asthma, high blood pressure (HBP), obesity, arthritis, and depression. Adjusted odds ratios (AOR) and confidence intervals (CI) of race-gender combinations were estimated using logistic regression. Differences in associations between socio-demographic characteristics and CMCs according to income were also examined.The weighted prevalence estimates of the top five CMCs ranged from 66% (asthma) to 20% (depression). Higher income and employment were associated with better outcomes in all five CMCs. Higher educational attainment and physical activity were associated with better HBP, obesity, and arthritis status. Black and white females had higher odds of asthma compared to white males (black AOR = 1.7, CI: 1.1-2.6, white AOR = 1.7, CI: 1.3-2.2). Black males had lower odds of arthritis (AOR = 0.8, CI: 0.6-0.9), while white females had higher odds (AOR = 1.3, CI: 1.2-1.4). Similarly, the odds of depression were lower among black males (AOR = 0.5, CI: 0.4-0.6) and higher among white females (AOR = 2.2, CI: 2.0-2.5). Income-related differences by race were observed for HBP and obesity.Disparities in CMCs are associated with income and disproportionately affect the black population. In the Mid-South, race and gender disparities in the top five chronic conditions are more prominent among higher-income rather than lower-income individuals.

Identifying factors that contribute to the preservation of cognitive function is imperative to maintaining quality of life in advanced years. Of modifiable risk factors, diet quality has emerged as a promising candidate to make an impact on cognition. The objective of this study was to evaluate associations between empirically derived dietary patterns and cognitive function. This study included 18 080 black and white participants aged 45 years and older from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Principal component analysis on data from the Block98 FFQ yielded five dietary patterns: convenience, plant-based, sweets/fats, Southern, and alcohol/salads. Incident cognitive impairment was defined as shifting from intact cognitive status (score >4) at first assessment to impaired cognitive status (score ≤4) at latest assessment, measured by the Six-Item Screener. Learning, memory and executive function were evaluated with the Word List Learning, Word List Delayed Recall, and animal fluency assessments. In fully adjusted models, greater consumption of the alcohol/salads pattern was associated with lower odds of incident cognitive impairment (highest quintile (Q5)v. lowest quintile (Q1): OR 0·68; 95 % CI 0·56, 0·84;Pfor trend 0·0005). Greater consumption of the alcohol/salads pattern was associated with higher scores on all domain-specific assessments and greater consumption of the plant-based pattern was associated with higher scores in learning and memory. Greater consumption of the Southern pattern was associated with lower scores on each domain-specific assessment (allP

Telephone-based interactive voice response (IVR) systems could be an effective tool for promotion of physical activity among older women. To test IVR feasibility, we enrolled 30 older women in a 10-week physical activity intervention designed around National Institute on Aging (NIA) Go4Life® educational materials with IVR coaching. Participants (mean age = 76 years) significantly increased physical activity by a mean 79 ± 116 (SD) minutes/week (p

Background Glycemic index (GI) and glycemic load (GL) may be implicated in acne pathogenesis. Objective This cross-sectional study examined differences between GI/GL and biological factors associated with acne among adults with and without moderate/severe acne. Secondary objectives included examining differences between food-aggravated acne beliefs and acne-specific quality of life among adults with and without moderate/severe acne. Design As part of a cross-sectional study, participants completed a 5-day food record; blood draw to measure biological factors associated with acne (ie, glucose, insulin, insulin-like growth factor-1, insulin-like growth factor binding protein-3, and sex hormone-binding globulin concentrations); body composition assessment; and questionnaire to evaluate food-aggravated acne beliefs and acne-specific quality of life. Food records were analyzed using Nutrition Data Services for Research. Participants Sixty-four participants (no acne, n=32; moderate/severe acne, n=32) from New York City, NY, were included in this study. Statistical analysis Independent sample t tests and Mann-Whitney tests examined differences in anthropometric measurements, dietary intakes, biological factors associated with acne, insulin resistance, and acne-specific quality of life between acne groups. A χ 2 test for independence assessed differences in food-aggravated acne beliefs between acne groups. Results Participants with moderate/severe acne consumed greater total carbohydrate ( P =0.003), available carbohydrate ( P P P P =0.002) and insulin-like growth factor-1 ( P =0.009) concentrations, greater insulin resistance ( P =0.001), and lower sex hormone–binding globulin ( P =0.015) concentrations compared to participants without acne. Although there were no differences between groups, 61% of participants reported food-influenced acne. Participants with moderate/severe acne reported a lower quality of life compared to participants without acne ( P Conclusions The results from this cross-sectional study suggest a relationship between dietary carbohydrate, including GL, and acne. Future research is necessary to determine the effect of medical nutrition therapy on biological factors associated with acne and acne severity.

Marked racial differences exist in dietary patterns and obesity, as well as cancer mortality. This study aims to assess whether dietary patterns are associated with cancer mortality overall and by race. We identified 22,041 participants from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Dietary patterns were categorized into: Convenience (Chinese and Mexican foods, pasta, pizza), Plant-based (fruits, vegetables), Southern (added fats, fried foods, sugar-sweetened beverages), Sweets/Fats (sugary foods) and Alcohol/Salads (alcohol, green-leafy vegetables, salad dressing). Using Cox regression, we examined the association between quartiles of dietary patterns and cancer mortality, adjusted for potential confounders, overall among all participants and stratified by race. A total of 873 cancer deaths were observed over the 10-year observation period: 582 (66.7%) in Whites and 291 (33.3%) in Blacks. Greater adherence to the Southern dietary pattern was associated with an increased risk of cancer mortality (4th vs. 1st quartile HR: 1.67; 95% CI: 1.32-2.10) overall, especially among Whites (4th vs. 1st quartile HR: 1.59; 95% CI: 1.22-2.08). The convenience (HR: 0.73; 95% CI: 0.56-0.94) and Plant-based (HR: 0.72; 95% CI: 0.55-0.93) dietary patterns were associated with up to a 28% reduced risk of cancer mortality, but only among Whites. Greater adherence to the Southern dietary pattern increased the risk of cancer mortality, while greater adherence to the convenience and Plant-based diets reduced the risk of cancer mortality among Whites. Racial differences were observed in the association between dietary patterns and cancer mortality, but warrant further study.

Objective We describe the formulation and implementation of a participatory evaluation plan for three Transdisciplinary Collaborative Centers for Health Disparities Research funded by the National Institute of Minority Health and Health Disparities. Methods Although different in scope of work, all three centers share a common goal of establishing sustainable centers in health disparities science in three priority areas – social determinants of health, men’s health research, and health policy research. Results The logic model guides the process, impact, and outcome evaluation. Emphasis is placed on process evaluation in order to establish a “blue print” that can guide other efforts as well as assure that activities are being implemented as planned. Conclusion We have learned three major lessons in this process: (1) Significant engagement, participation, and commitment of all involved is critical for the evaluation process; (2) Having a “roadmap” (logic model) and “directions” (evaluation worksheets) are instrumental in getting members from different backgrounds to follow the same path; and (3) Participation of the evaluator in the leadership and core meetings facilitates continuous feedback.

Introduction: Carbohydrate quality and quantity have been associated with several chronic diseases, but few studies have investigated associations with cognitive impairment. The objective of this study was to test the hypothesis that higher glycemic load (GL), glycemic index (GI), and available carbohydrate intakes are associated with higher odds of incident cognitive impairment in a large, prospective cohort. Methods: This analysis utilized the REGARDS study, a national cohort of 30,239 black and white participants (age > 45 yr). Dietary intake was assessed by the Block98 food frequency questionnaire, from which values for GL, GI, and available carbohydrate (total carbohydrate minus dietary fiber) were estimated. Incident cognitive impairment was defined as shifting from an intact cognitive status (a score >4) at the first cognitive assessment to an impaired cognitive status (a score ≤4) at the most recent cognitive assessment, measured by the Six-Item Screener. Logistic regression was used to evaluate the odds of incident cognitive impairment by quintile of GL, GI, and available carbohydrate. Results: This analysis included 16,755 participants free of stroke and cognitive impairment at baseline. A total of 1,513 cases of incident cognitive impairment were observed over a mean follow-up of 7.5 years. After adjustment for sociodemographic variables and cognitive risk factors, participants in the highest quintile of glycemic load had 42% higher odds of incident cognitive impairment compared to those in the lowest quintile (Q5 vs Q1: OR=1.42; 95% CI: 1.06, 1.89; p for trend: 0.02). Similarly, participants in the highest quintile of available carbohydrate had 42% higher odds of incident cognitive impairment (Q5 vs Q1: OR=1.42; 95% CI: 1.05, 1.91; p for trend: 0.04). No significant associations were observed with glycemic index (See Table 1). Conclusion: Consuming a dietary pattern lower in available carbohydrate and glycemic load may aid in the preservation of cognitive function in older ages.

Introduction: Although observational evidence suggests that the food environment is associated with diet behaviors, the literature is inconsistent. Most studies ignore potential bias due to healthier people selecting healthier residential neighborhoods and healthier food outlets locating in areas where there is demand. Hypotheses: Greater availability of fast food restaurants (vs. full-service restaurants) and convenience stores and grocery stores (vs. supermarkets) is associated with lower diet quality, accounting for potential bias. Methods: We used 20 years (1985-6; 1992-3; 2005-6) of data from CARDIA study (n=26,203 observations) with geographically-linked, time-varying neighborhood-level data. Using instrumental-variables regression with a generalized method of moments estimator, we estimated the longitudinal association between the percent of neighborhood fast food restaurants, full-service restaurants, convenience stores, grocery stores, and supermarkets (per total food outlets within 1-km network distance of respondents’ residences at each exam) and an a priori diet quality score, with higher scores indicating higher diet quality. We adjusted for individual-level sociodemographics, health behaviors, baseline study center, exam year, and total other food outlets. We included theoretically-justified instrumental variables related to neighborhood-level sociodemographics, road connectivity, physical activity facilities, and housing prices. Results: Across exam years the mean diet quality score was 64.3 (SD=12.8; range: 24-107). Relative to the percent of neighborhood full-service restaurants, a 10% increase in the density of fast food restaurants (mean=12.3; SD=13.0) was associated with a lower a priori diet quality score over time (β=-3.5; 95% CI=-6.0, -0.90; p=0.01), after adjusting for potential residential selection and purposeful store placement. However, relative to the percent of supermarkets, neither the percent of convenience stores (β=-0.85; 95% CI=0.12, -1.93; p=0.12), nor grocery stores (β=-0.72; 95% CI=-1.70, -0.26; p=0.15), was associated with diet quality. Conclusions: Compared to standard regression models, our findings suggest that efforts to reduce the availability of neighborhood fast food restaurants, but not other types of food outlets, may be associated with minor improvements to diet behaviors. This suggests that the selective nature of where people and stores locate may influence associations of the food environment with diet quality.

We appreciate the comments from Dr Archer regarding our recent report in Circulation on dietary patterns and hazard of incident acute coronary heart disease in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.1 However, we respectfully disagree with his characterization of the data in our report as “uncorroborated anecdotes” that are without scientific validity. Dr Archer has argued for some time that memory-based dietary assessment methods, including the food frequency questionnaire used in REGARDS and countless other highly regarded cohort studies, result in implausible dietary data because of an unknown percentage …

The possible effects on body weight of chewing gum on a regular schedule have not been tested in a randomized controlled trial (RCT). We conducted an 8-week RCT in 201 overweight and obese adults to test the hypothesis that receiving printed material on good nutrition and chewing gum for a minimum of 90 min/day (n = 102) would lead to greater weight loss than receiving printed nutrition information only (n = 99). Changes in BMI, waist circumference, and blood pressure were secondary outcomes. Adherence to the gum-chewing protocol in the intervention group was >95%. In the intention-to-treat analysis, there were virtually no changes in weight or BMI in either group between baseline and the end of the intervention at 8 weeks. Waist circumference decreased significantly in the intervention group between baseline and 8 weeks (mean ± SD change = -1.4 ± 5.3 cm; P = 0.0128); however, there was no significant difference in change in waist circumference comparing the groups. Similarly, systolic and diastolic blood pressure decreased significantly in the intervention group between baseline and 8 weeks (-3.0 ± 9.9 mm Hg; P = 0.0032 and -3.2 ± 7.3 mm Hg; P = 0.0001, respectively); however, there were no significant differences in the changes in systolic or diastolic blood pressure between the groups. Analyses including completers only produced essentially the same results. We conclude that chewing gum on a regular schedule for 8 weeks did not facilitate weight loss in these overweight and obese adults.

Background: The food supply and dietary preferences have changed in recent decades. Objective: We studied time- and age-related individual and population-wide changes in a dietary quality score and food groups during 1985–2006. Design: The Coronary Artery Risk Development in Young Adults (CARDIA) study of 5115 black and white men and women [aged 18–30 y at year 0 (1985–1986)] assessed diet at examinations at study years 0, 7 (1992–1993), and 20 (2005–2006). The dietary quality score, which was validated by its inverse association with cardiovascular disease risk, summed 46 food groups rated by investigators as positive or negative on the basis of hypothesized health effects. We used repeated-measures regression to estimate time-specific mean diet scores and servings per day of food groups. Results: In 2652 participants with all 3 diet assessments, the mean (±SD) dietary quality score increased from 64.1 ± 13.0 at year 0 to 71.1 ± 12.6 at year 20, which was mostly attributable to increased age. However, the secular trend, which was estimated from differences of dietary quality scores across time at a fixed age (age-matched time trend) decreased. The diet score was higher in whites than in blacks and in women than in men and increased with education, but demographic gaps in the score narrowed over 20 y. There tended to be increases in positively rated food groups and decreases in negatively rated food groups, which were generally similar in direction across demographic groups. Conclusions: The CARDIA study showed many age-related, desirable changes in food intake over 20 y of observation, despite a secular trend toward a lower diet quality. Nevertheless, demographic disparities in diet persist.

Background: Epidemiologic studies examining associations between carotenoid intakes and risk of breast cancer by estrogen receptor (ER) and progesterone receptor (PR) status are limited. Objective: We investigated these associations in a pooled analysis of 18 cohort studies. Design: Of 1,028,438 participants followed for a maximum follow-up of 26 y across studies, 33,380 incident invasive breast cancers were identified. Study-specific RRs and 95% CIs were estimated by using Cox proportional hazards regression and then pooled by using a random-effects model. Results: α-Carotene, β-carotene, and lutein/zeaxanthin intakes were inversely associated with the risk of ER-negative (ER−) breast cancer (pooled multivariable RRs of the comparison between the highest and lowest quintiles): α-carotene (0.87; 95% CI: 0.78, 0.97), β-carotene (0.84; 95% CI: 0.77, 0.93), and lutein/zeaxanthin (0.87; 95% CI: 0.79, 0.95). These variables were not inversely associated with the risk of ER-positive (ER+) breast cancer (pooled multivariable RRs for the same comparison): α-carotene (1.04; 95% CI: 0.99, 1.09), β-carotene (1.04; 95% CI: 0.98, 1.10), and lutein/zeaxanthin (1.00; 95% CI: 0.93, 1.07). Although the pooled RRs for quintile 5 for β-cryptoxanthin were not significant, inverse trends were observed for ER− and ER+ breast cancer (P-trend ≤ 0.05). Nonsignificant associations were observed for lycopene intake. The associations were largely not appreciably modified by several breast cancer risk factors. Nonsignificant associations were observed for PR-positive and PR-negative breast cancer. Conclusions: Intakes of α-carotene, β-carotene, and lutein/zeaxanthin were inversely associated with risk of ER−, but not ER+, breast cancer. However, the results need to be interpreted with caution because it is unclear whether the observed association is real or due to other constituents in the same food sources.

Background: It is unclear whether circulating insulin or glucose levels are associated with increased risk of colorectal cancer. Few prospective studies have examined this question, and only one study had repeated measurements. Methods: We conducted a prospective study of colorectal cancer risk using the subsample of women in the Women's Health Initiative study whose fasting blood samples, collected at baseline and during follow-up, were analysed for insulin and glucose. Cox proportional hazards models were used to assess associations with colorectal cancer risk in both baseline and time-dependent covariates analyses. Results: Among 4902 non-diabetic women with baseline fasting serum insulin and glucose values, 81 incident cases of colorectal cancer were identified over 12 years of follow-up. Baseline glucose levels were positively associated with colorectal cancer and colon cancer risk: multivariable-adjusted hazard ratio (HR) comparing the highest (⩾99.5 mg dl−1) with the lowest tertile (

Some previous studies have suggested that consuming dairy products, particularly the low-fat variety, lowers the incidence of type 2 diabetes. However, no study to our knowledge has focused on an ethnically diverse group of postmenopausal women, a population with a high risk of this disease. We conducted a prospective cohort study of 82,076 postmenopausal women enrolled in the Women’s Health Initiative Observational Study who did not report diabetes at enrollment. Total, low-fat, and high-fat dairy product and yogurt intakes were estimated from FFQ at baseline and 3 y of follow-up. Treated diabetes incidence was ascertained from annual follow-up questionnaires. During 8 y of follow-up, 3946 cases of incident treated diabetes were reported (annual incidence, 0.73%; cumulative incidence, 4.8%). After multivariable adjustment, low-fat dairy product consumption was inversely associated with the risk of type 2 diabetes. RR was roughly 0.5–0.6 in the upper quintiles compared with the lowest quintile (median servings/d, 2.8 in the 5th quintile and 1.5 in the 4th quintile vs. 0.05 in the first quintile; P-trend , 0.001). The inverse relationship was more pronounced in women with a higher BMI. High yogurt consumption was associated with a significant decrease in diabetes risk, whereas there was no relationship between high-fat dairy product consumption and diabetes risk. A diet high in low-fat dairy products is associated with lower diabetes risk in postmenopausal women, particularly those who are obese. J. Nutr. 141: 1969–1974, 2011.