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Background - With a maternal mortality ratio of 692 per 100,000 live births and modern contraception prevalence of 1%, understanding factors hindering Somali women from using modern contraception is key to developing and implementing locally adopted public health responses. The purpose of this qualitative study is to explore barriers and facilitators to the use of modern contraception among married women in Mogadishu. Methods - We conducted a qualitative study using semi-structured, in-depth interviews with 21 married women aged >18 years, living in different neighborhoods in Mogadishu between July—December 2018. We recruited the participants using a convenience sampling method. We used thematic analysis and adapted ecological model as a framework for the synthesis.Results – The findings show that systemic, individual and socio-cultural barriers hinder women’s ability to access modern contraception. Barriers identified by this study include: Health communication messages and contraceptive information provided by health providers, prevalent religious fallacies among women and fear of permanent infertility upon modern contraception. Conclusion - Training health providers in the principles of modern contraception, in addition to the medical ethics that govern their responsibility to provide correct and relevant information to their patients, is vital for increasing modern contraception use among Somali women. The findings of this study may be used for designing public health interventions that promote acceptance and the use of modern contraception among both women and men in Somalia.

Background: A growing proportion of children born in Europe are born to immigrant parents. Knowledge about their health is essential for preventive and curative medicine and health services planning. Objective: To investigate differences in diagnoses given in secondary and tertiary healthcare between Norwegian-born children to immigrant and non-immigrant parents. Methods: Data from the Medical Birth Registry of Norway, the Norwegian Patient Registry and Statistics Norway were linked by the national personal identification number. The study population included children born in Norway aged 0–10 years between 2008 and 2018 ( N=1,015,267). Diagnostic categories from three main domains of physical health, given in secondary or tertiary care; infections, non-infectious medical conditions and non-infectious neurological conditions were included from 2008 onwards. Hazards of diagnoses by immigrant background were assessed by Cox regressions adjusted for sex and birth year. Results: Children of immigrants generally had higher hazards than children with Norwegian background of some types of infections, obesity, nutrition-related disorders, skin diseases, blood disease and genital disease. Children of immigrants from Africa also had higher hazards of cerebral palsy, cerebrovascular diseases and epilepsy. Conversely, most groups of children of immigrants had lower hazards of acute lower respiratory tract infections, infections of the musculoskeletal system, infections of the central nervous system, diseases of the circulatory system, hearing impairment, immune system disorders, chronic lower respiratory disease and headache conditions. Conclusions: Children of immigrants did not present with overall worse health than children without immigrant background, but the distribution of health problems varied between groups.

Background Norway implemented a regular cervical cancer screening program based on triennial screening in 1995, recommending participation of all women between 25 and 69 years of age. Somali and Pakistani women have the lowest participation in cervical cancer screening in Norway. This study evaluates the effect of a community-based intervention aimed at increasing participation in the screening program among women from these two groups. Methods The intervention consisted of an oral 20–25 min presentation in Urdu and Somali on cervical cancer and screening and practical information on how to make an appointment and payment for the test. The participants were invited to pose questions related to the topic after the presentation. This study was carried out in four geographical areas surrounding the capital Oslo between February and October 2017, among women aged 25–69 years from Pakistan and Somalia. We recruited women in the intervention group directly from different community institutions, households, and religious sites. Women from Pakistan and Somalia residing in Oslo were the controls. The absolute intervention effect was measured as difference in absolute proportion of women screened and estimated as the interaction between time and group allocation in a generalized estimation equation model with binomial distribution and identity link function. Results The percentage of women screened in the intervention group increased, from 46 to 51%. The corresponding increase in proportion in the control group was from 44 to 45.5%. After adjustment for potential confounders the intervention group showed a significant larger increase in participation in the screening program as compared to the control group with an absolute difference in change in proportion screened of 0.03 (95% CI; 0.02- 0.06). Conclusions Our findings suggest that theory-based, culturally and linguistically sensitive educational interventions can raise awareness and motivate immigrant women to participate in cervical cancer screening program. In addition, approaching health professionals as well as immigrant women, might improve participation even more. Trial registration NCT03155581. Retrospectively registered, on 16 May 2017.

Background The European Action Plan for Sexual and Reproductive Health emphasizes the importance of improving access to contraceptive services for disadvantaged groups. However, a prior study showed that the prevalence of abortion is two times higher among refugees compared to non-immigrants in Norway. Similarly, a recent study reported that 50% of Somali women in Oslo had unintended childbirth on one occasion or more. These findings are supported by several studies in Europe that showed immigrant and refugee women have higher rates of unintended pregnancy and abortion than Non-immigrant women, and more than half of immigrants, who seek abortion are not using any form of contraception, raising concerns about their access to utilization of modern contraception. However, none of these studies have explored reasons underlying immigrant women's underutilization of modern contraception. The present study aimed to explore the barriers and facilitators to contraceptive usage among Somali immigrant women in Oslo area. Methods A qualitative study using unstructured in-depth interviews with twenty one Somali women of reproductive age, >18 years, was conducted in Oslo from May-August 2018. The participants were recruited using purposive sampling method. Interviews began with a general question and were followed with some probing questions, and were continued until data saturation was reached. Data were analyzed using thematic analysis. Results Although the majority of the participants were educated, aware of the importance of contraceptive methods and interested in child spacing, systemic and socio-cultural barriers were found to be hindering their access to contraception. Several barriers were identified, including: language problems, lack of adequate information, religious beliefs, gender roles and social pressure. Conclusion Eliminating the barriers which prevent women from receiving their desired form of contraception will have important public health implications, including lengthening inter-pregnancy intervals, and fewer unplanned pregnancies and abortions. These findings can support policy makers, civil society organizations and health providers to develop cultural sensitive programmes and educational interventions, which help Somali immigrant women overcome the identified barriers to contraception.

Background Obesity is becoming an important public health challenge, especially among immigrants coming from low and middle income to high-income countries. In this study we examined the relationship between overweight/obesity and various socio-demographic indicators among different immigrant groups in Norway. Methods We used data from the Living Conditions Survey among Immigrants 2016, conducted by Statistics Norway. Our study sample included 4194 immigrants from 12 different countries. Participants were asked about a number of topics including health, weight, height, demographic factors, length of residence and employment. We ran logistic regression analysis to determine the odds ratio (OR) of the associations between socio-demographic factors with adiposity among immigrants. Results Approximately 53% of the sample was overweight/obese. There was a significant difference in overweight/obesity by gender, age, country of origin and marital status. Overall immigrant men were almost 52% more likely to be overweight/obese than women. Women from Somalia had the highest odds (13.1; CI: 7.4–23.1) of being overweight/obese, followed by Iraq (8.6; CI: 4.9–14.9), Pakistan (7.5; CI: 4.2–13.4), Kosovo (7.0; CI: 4.1–12.1), and Turkey (6.8; CI: 4.0–11.6) as compared to the women from Vietnam (reference). Whereas men from Turkey had the highest odds (5.2; CI: (3.2–8.3)) of being overweight/obese, followed by Poland (4.2; CI: 2.7–6.1), Bosnia (4.1; CI: (2.6–6.5) and Kosovo (3.9; CI: 2.5–6.1). The odds for obesity increased with age and odds were highest in the eldest group 45–66 years (4.3; CI: 3.2–5.8) as compared to reference group16–24 years. The odds of being overweight/obese was higher among married (1.6; CI: 1.3–1.9) and divorced/separated/widowed (1.5; CI: 1.1–2.0) as compared to singles. Education, employment status, physical activity and length of residence were not associated with the odds of being overweight/obese. Conclusion The findings of this study call attention to the importance of a greater understanding of the processes leading to obesity among certain immigrant groups in Norway. Moreover, there is a need for culturally adapted prevention strategies targeting immigrant men and women with high rates of overweight/obesity.

Background Groups of immigrant and minority women are more often diagnosed with advanced stage breast cancer than other women. Mammographic screening aims to reduce mortality from breast cancer through early detection in asymptomatic women. Purpose To compare mammographic screening attendance among immigrant and minority women to that of other women. Material and Methods A literature search of PubMed, Embase, Google Scholar, and Cochrane identified 1369 papers published between January 1995 and March 2016. In the review, we included 33 studies investigating mammographic screening attendance among immigrant and/or minority women. In a meta-analysis, we included 19 of the studies that compared attendance among immigrant and/or minority women with that among other women, using a random effects model. Results The review included studies from Europe, North America, and Oceania, with 42,666,093 observations of opportunities for mammographic screening. Attendance was generally lower among immigrant and minority women compared to other women (46.2% vs. 55.0%; odds ratio = 0.64, 95% confidence interval = 0.56–0.73; P 2 = 99.9%). Non-Western immigrants had lower attendance rates than other immigrants. Conclusion Immigrant and minority women had lower mammographic screening attendance than other women, which could potentially put them at increased risk for more advanced breast cancer. This review emphasizes the importance of continued efforts to engage with the preventative health needs of diverse populations in attempts to achieve equality in access to, and use of, care.

Background The attendance to cervical cancer screening is low among immigrants in many high-income countries. Although several interventions have been experimentally tested,implementation remains a challenge. Several factors are an impediment, including the lack of methodological descriptions of the development and implementation of such interventions. In this paper,we present in detail the development, methodological challenges and practical implementation of a community based intervention aimed to increase the participation of immigrant women in cervical cancer screening in Norway. Methods This study was initially designed as a cluster randomized trial to be carried out in four geographical areas near Oslo between Feb-October 2017. Participants were immigrant women aged 25–69 years from Pakistan and Somalia. This paper describes the theoretical background for the development of the intervention,followed by challenges,the changes in the original design and solutions adopted related to the study design,recruitment and implementation of the intervention. The intervention was developed based on two theoretical frameworks, the Ecological and the Heron’s six categories intervention framework. An oral 20–25 min presentation in the language of participants encompassing topics of cervical cancer and screening was given according to the needs detected in focus groups conducted at the beginning of the study,followed by an opportunity to raise questions and answering a short questionnaire. Results Contrary to the initial study design, this had to be converted into a non-randomised trial due to the difficulties associated with randomization of immigrant families who are finely scattered in heavily populated towns and a high risk of contamination. We therefore adopted a pragmatic approach and recruited women in the intervention areas through a variety of channels and institutions. Neighboring areas were considered to be non-randomised controls. Female researchers with Pakistani and Somali background invited as many women as possible in the intervention areas. Among the women who were invited to participate,42% of the Pakistani and 78% of Somali attended the meetings. Conclusion Despite the careful development of a culturally adapted health intervention in collaboration with the community; randomization and recruitment of immigrants for community trials remains challenging. Nevertheless, sharing strategies to overcome specific challenges related to promoting health interventions for immigrants, can be of potential help to scale-up interventions and for building new research projects. Trial registration NCT03155581. Retrospectively registered, on 16 May 2017. Electronic supplementary material The online version of this article (10.1186/s12874-019-0795-8) contains supplementary material, which is available to authorized users.

Intervention trials and guidelines for the prevention of type 2 diabetes (T2D) in populations of South Asian origin often include strategies to improve diet and physical activity that are based on those developed for other populations. These may be suboptimal for the South Asian target populations. We aimed to provide an overview of included recommended dietary and physical activity components, and to identify whether these were supported by evidence of their effectiveness. Databases were searched until September 2017 for intervention studies and guidelines with an adult South Asian population without T2D. The protocol was registered in PROSPERO, registration number: CRD42015207067. The quality of included studies and guidelines was assessed. Dietary and physical activity components, and effects on T2D incidence, glycemic status and adiposity measures, were summarized in tabular format and evaluated narratively. Eighteen intervention studies and four guidelines were identified. Dietary and physical activity components were similar to recommendations for the general population. Intervention studies and guidelines did not reference evidence to support the effectiveness of components included in the intervention for South Asian populations in particular. Moreover, we were unable to assess patterns of components to determine the effects of specific components. Evaluation of current and emerging components among South Asian populations and subgroups seems necessary to formulate more specific recommendations in future intervention studies and guidelines.

Abdi A Gele,1,2 Samera A Qureshi,1 Prabhjot Kour,1 Bernadette Kumar,1 Esperanza Diaz1,3 1Norwegian Center for Minority Health Research, 2Department of Health, Institute of Nursing and Health Promotion, Oslo and Akershus University College, Oslo; 3Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Abstract: Norway has a low incidence and mortality rate of cervical cancer, which is mainly due to the high participation rate of women in cervical cancer screening. However, the attendance of cervical cancer screening was reported to be low among immigrant women. For this reason, we conducted a qualitative study to obtain better insight into perceived barriers and challenges to cervical cancer screening among Somali and Pakistani women in the Oslo region. A convenient sample of 35 (18 Pakistani, 17 Somali) women were recruited for the study in collaboration with Somali and Pakistani community partners. Focus group discussions were used to explore barriers and facilitators to cervical cancer screening, whereas the Ecological Model was used as the framework for the study. The study found three levels of barriers to cervical cancer screening. The individual level included a lack of understanding of the benefits of the screening. The sociocultural level included the stigma attached to the disease and the belief that women who are unmarried are sexually inactive. The system-related level included a lack of trust toward the health care system. Based on the study results, and using a common denominator approach for the immigrant groups included, the study recommends three communication strategies with the potential to improve women’s participation in cervical cancer screening: 1) in-person communication and information material at health centers; 2) verbal communication with women through seminars and workshops to educate them about their risk of cancer and the importance of screening and 3) the initiation of better recall through SMS and letters written in native languages. Finally, an intervention study that compares the aforementioned strategies and proves their effectiveness in increasing immigrant women’s participation in cervical cancer screening is recommended. Keywords: cervical cancer, immigrant women, Somali and Pakistani women, preventive health

Background Mammographic density (MD) is one of the strongest breast cancer risk factors. Its age-related characteristics have been studied in women in western countries, but whether these associations apply to women worldwide is not known. Methods and findings We examined cross-sectional differences in MD by age and menopausal status in over 11,000 breast-cancer-free women aged 35–85 years, from 40 ethnicity- and location-specific population groups across 22 countries in the International Consortium on Mammographic Density (ICMD). MD was read centrally using a quantitative method (Cumulus) and its square-root metrics were analysed using meta-analysis of group-level estimates and linear regression models of pooled data, adjusted for body mass index, reproductive factors, mammogram view, image type, and reader. In all, 4,534 women were premenopausal, and 6,481 postmenopausal, at the time of mammography. A large age-adjusted difference in percent MD (PD) between post- and premenopausal women was apparent (–0.46 cm [95% CI: −0.53, −0.39]) and appeared greater in women with lower breast cancer risk profiles; variation across population groups due to heterogeneity (I2) was 16.5%. Among premenopausal women, the √PD difference per 10-year increase in age was −0.24 cm (95% CI: −0.34, −0.14; I2 = 30%), reflecting a compositional change (lower dense area and higher non-dense area, with no difference in breast area). In postmenopausal women, the corresponding difference in √PD (−0.38 cm [95% CI: −0.44, −0.33]; I2 = 30%) was additionally driven by increasing breast area. The study is limited by different mammography systems and its cross-sectional rather than longitudinal nature. Conclusions Declines in MD with increasing age are present premenopausally, continue postmenopausally, and are most pronounced over the menopausal transition. These effects were highly consistent across diverse groups of women worldwide, suggesting that they result from an intrinsic biological, likely hormonal, mechanism common to women. If cumulative breast density is a key determinant of breast cancer risk, younger ages may be the more critical periods for lifestyle modifications aimed at breast density and breast cancer risk reduction., Valerie McCormack and colleagues reveal reduced breast density with increased age in women from different ethnic groups; however increased breast density in young women is a cancer risk., Author summary Why was this study done? Breast density, a measure of the amount of dense to fatty tissue in the breast, is a strong marker of breast cancer risk. Breast density determinants have been studied in high-income countries, but not in women worldwide. What did the researchers do and find? We studied how breast density differed by age and menopausal status in diverse groups of women from 22 countries worldwide. For over 11,000 women, mammograms were read centrally and risk factor data harmonised. We found that, regardless of the country and ethnic group of women, breast density was much lower in postmenopausal than in premenopausal women of the same age. Additionally, as a relative proportion of breast area, breast density was lower in older women both among premenopausal and postmenopausal women. Among premenopausal women, breast density changed with age without an increase in breast area, but among postmenopausal women, the latter also increased. What do these findings mean? That this change in breast density with age is seen internationally suggests that the change is due to a universal biological mechanism inherent to all women. If cumulative breast density is a key determinant of breast cancer risk, younger ages may be the more critical periods for lifestyle modifications aimed at breast density and breast cancer risk reduction.

Accepted manuscript version. Published version available in International Journal of Cancer, 140, 1770–1780 (2017) Traditionally there have been differences in cancer incidence across geographic regions. When immigrants have moved from low-income to high-income countries, their incidence have changed as they have adapted to the lifestyle in the new host country. Given worldwide changes in lifestyle factors over time, we decided to examine cancer incidence in immigrant groups in Norway, a country with a recent immigration history, complete cancer registration and universal public health care. We linked immigration history for the complete population to information on cancer diagnosis from the Cancer Registry of Norway for the period 1990–2012. Age-standardized (world) overall and site-specific cancer incidence were estimated for different immigrant groups and compared to incidence among individuals born in Norway. Among 850,008 immigrants, 9,158 men and 10,334 women developed cancer, and among 5,508,429 Norwegian-born, 263,316 men and 235,020 women developed cancer. While incidence of breast and colorectal cancer were highest among individuals born in Norway and other high-income countries, other cancer types were higher in immigrants from low-income countries. Lung cancer incidence was highest in Eastern European men, and men and women from Eastern Europe had high incidence of stomach cancer. Incidence of liver cancer was substantially higher in immigrants from low-income countries than in individuals born in Norway and other high-income countries. Our results mirror known cancer challenges across the world. Although cancer incidence overall is lower in immigrants from low-income countries, certain cancers, such as lung, liver and stomach cancer, represent major challenges in specific immigrant groups.

Supplemental Digital Content is available in the text., The prevalence of cervical cancer is high among some groups of immigrants. Although there is evidence of low participation in cervical cancer screening programs among immigrants, studies have been subject to selection bias and accounted for few immigrant groups. The aim of this study was to compare the proportion of several groups of immigrants versus nonimmigrants attending the cervical cancer-screening program in Norway. In addition, we aimed to study predictors for attendance to the screening program. Register-based study using merged data from four national registries. All Norwegian-born women (1 168 832) and immigrant women (152 800) of screening age for cervical cancer (25–69 years) registered in Norway in 2008 were included. We grouped the immigrants by world’s geographic region and carried out descriptive analyses and constructed several logistic regression models. The main outcome variable was whether the woman was registered with a Pap smear in 2008 or not. Immigrants had lower rates of participation compared with Norwegian-born women; Western Europe [adjusted odds ratio (OR), 95% confidence interval (CI): 0.84, 0.81–0.88], Eastern Europe (OR 0.64, 95% CI: 0.60–0.67), Asia (OR 0.74, 95% CI: 0.71–0.77), Africa (OR 0.61, 95% CI: 0.56–0.67) and South America (OR 0.87, 95% CI: 0.79–0.96). Younger age, higher income, residence in rural areas, and having a female general practitioner (GP) were associated with Pap smear. Longer residential time in Norway and having a nonimmigrant GP were associated with screening for some immigrant groups. Appropriate interventions targeting both immigrants and GPs need to be developed and evaluated.

IntroductionUnmet need for contraception is defined as the proportion of fertile individuals who do not use contraceptives despite wanting to space or limit their childbearing. Studies show that immigrant women in Europe, have higher rates of unintended pregnancies and abortion than native born women. Somali women, have the highest fertility rate in Norway which is much higher than the total fertility rate in Norway (4.0 vs. 1.7). This study investigates the unmet need for contraception among Somali immigrant women in Oslo, Norway, compared to their original population in Mogadishu, Somalia.MethodsA community based, cross sectional study was carried out among Somali women in Oslo (N = 228) and Mogadishu (N = 229) from May to December 2018. Pre-structured questionnaires were given to women who were recruited through snow-ball sampling. Data was analyzed using SPSS version 25. We performed a chi-square test for the analyses of categorical variables, a t-test for continuous variables and multivariate logistic analysis to determine the association between exposure and outcome variable.ResultsThe unmet needs for contraception among Somali women in Oslo was 20.2%, which is similar to unmet needs for contraception of women in many sub-Saharan African countries. The unmet needs for Somali immigrant women in Oslo (20.2) is two times lower than that of their original population in Somalia (48.5). The odds of having unmet needs for contraception was nearly, three times higher among Somali women in Mogadishu compared to those in Oslo (OR: 2.6, CI: 2.56-7.68). The mean intended fertility was 4 among the women in Oslo and 10.8 in Mogadishu. About 13.4% of study participants in Oslo and 86.6% of those in Mogadishu consider modern contraception irrelevant for women's health. Nearly 50% of women in both places had unintended childbirth on one or more occasion.ConclusionThe study results show the prevalence of unmet needs for contraception among Somali immigrant women Oslo, is 4 fold higher than that of Norway (20.2 vs 5.5). Information Education Communication to both men and women, may reduce the high unmet need for contraception and also improve partner communication on family planning among Somali immigrants in Oslo. Training primary health providers for provision of tailored information about the modern contraception to immigrant women, which includes an individualized counselling may improve partners' knowledge, demand and uptake of modern contraception.

BACKGROUND: Inter-women and intra-women comparisons of mammographic density (MD) are needed in research, clinical and screening applications; however, MD measurements are influenced by mammography modality (screen film/digital) and digital image format (raw/processed). We aimed to examine differences in MD assessed on these image types. METHODS: We obtained 1294 pairs of images saved in both raw and processed formats from Hologic and General Electric (GE) direct digital systems and a Fuji computed radiography (CR) system, and 128 screen-film and processed CR-digital pairs from consecutive screening rounds. Four readers performed Cumulus-based MD measurements (n = 3441), with each image pair read by the same reader. Multi-level models of square-root percent MD were fitted, with a random intercept for woman, to estimate processed-raw MD differences. RESULTS: Breast area did not differ in processed images compared with that in raw images, but the percent MD was higher, due to a larger dense area (median 28.5 and 25.4 cm2 respectively, mean √dense area difference 0.44 cm (95% CI: 0.36, 0.52)). This difference in √dense area was significant for direct digital systems (Hologic 0.50 cm (95% CI: 0.39, 0.61), GE 0.56 cm (95% CI: 0.42, 0.69)) but not for Fuji CR (0.06 cm (95% CI: -0.10, 0.23)). Additionally, within each system, reader-specific differences varied in magnitude and direction (p, published_or_final_version

Mammographic density (MD) is a quantitative trait, measurable in all women, and is among the strongest markers of breast cancer risk. The population-based epidemiology of MD has revealed genetic, lifestyle and societal/environmental determinants, but studies have largely been conducted in women with similar westernized lifestyles living in countries with high breast cancer incidence rates. To benefit from the heterogeneity in risk factors and their combinations worldwide, we created an International Consortium on Mammographic Density (ICMD) to pool individual-level epidemiological and MD data from general population studies worldwide. ICMD aims to characterize determinants of MD more precisely, and to evaluate whether they are consistent across populations worldwide. We included 11755 women, from 27 studies in 22 countries, on whom individual-level risk factor data were pooled and original mammographic images were re-read for ICMD by a core team to obtain standardized comparable MD data. In the present article, we present (i) the rationale for this consortium; (ii) characteristics of the studies and women included; and (iii) study methodology to obtain comparable MD data from original re-read films. We also highlight the risk factor heterogeneity captured by such an effort and, thus, the unique insight the pooled study promises to offer through wider exposure ranges, different confounding structures and enhanced power for sub-group analyses.

Investigating the association between dietary factors and mammographic density (MD) could shed light on the relationship between diet and breast cancer risk. We took advantage of a national mammographic screening program to study the association between intake of nutrients and MD. In this study, we analyzed data of 2,252 postmenopausal women aged 50-69 yr who participated in the Norwegian Breast Cancer Screening Program in 2004. MD was assessed on digitized mammograms using a computer-assisted method. We used multivariate linear regression models to determine least square means of percent and absolute MD. Overall, we observed no associations between MD and intake of total calories, protein, carbohydrates, cholesterol, and dietary fiber. There was a positive borderline statistically significant association between absolute MD and total fat intake (P = 0.10) and between percent MD and intake of saturated fat (P = 0.06). There was no association between MD and intake of calcium, retinol, vitamins A, B12, C, or D, or combined intake of vitamin D and calcium. This study provides some evidence of an association between MD and dietary intake. Our study highlights the importance of adequate adjustments for BMI in studies of diet and MD.

BACKGROUND: The role of vitamin D in breast cancer etiology is unclear. There is some, but inconsistent, evidence that vitamin D is associated with both breast cancer risk and mammographic density (MD). We evaluated the associations of MD with month the mammogram was taken, and with vitamin D intake, in a population of women from Norway--a country with limited sunlight exposure for a large part of the year. METHODS: 3114 women aged 50-69, who participated in the Norwegian Breast Cancer Screening Program (NBCSP) in 2004 or 2006/07, completed risk factor and food frequency (FFQ) questionnaires. Dietary and total (dietary plus supplements) vitamin D, calcium and energy intakes were estimated by the FFQ. Month when the mammogram was taken was recorded on the mammogram. Percent MD was assessed using a computer assisted method (Madena, University of Southern California) after digitization of the films. Linear regression models were used to investigate percent MD associations with month the mammogram was taken, and vitamin D and calcium intakes, adjusting for age, body mass index (BMI), study year, estrogen and progestin therapy (EPT), education, parity, calcium intakes and energy intakes. RESULTS: There was no statistical significant association between the month the mammogram was taken and percent MD. Overall, there was no association between percent MD and quartiles of total or dietary vitamin D intakes, or of calcium intake. However, analysis restricted to women aged

INTRODUCTION: Type 2 diabetes (T2D) is a major health concern among populations of South Asian ethnicity. Although dietary and physical activity interventions may reduce the risk of T2D, the effectiveness has been moderate among South Asians. This might (in part) be because this subgroup follows strategies that were originally developed for interventions among other populations. Therefore, this review aims to assess the evidence for the current dietary and physical activity strategies recommended in T2D prevention intervention studies and guidelines for South Asians.METHODS AND ANALYSIS: Included will be all studies and guidelines on dietary and/or physical activity strategies to prevent T2D in adult South Asians. Two reviewers will search online databases from their start until the present date for published and unpublished experimental/quasiexperimental studies, with at least an abstract in English. References of identified articles and key reviews will be screened for additional studies. Guidelines will be identified by searches in online databases and websites of public organisations. Finally, expert consultations will be held to supplement any missing information. Trial quality will be assessed with the Quality Assessment Tool for Quantitative Studies Data, and guidelines with the Appraisal of Guidelines for Research & Evaluation II. Data on the strategies recommended, targeting and evidence on effectiveness will be extracted by two reviewers and presented in tabular and narrative forms. Recommendations will be compared with the National Institute for Health and Care Excellence guidelines [PH35]. Overall findings on dietary and physical activity recommendations, as well as findings for specific subgroups (eg, by sex), will be discussed.ETHICS AND DISSEMINATION: Ethics assessment is not required. Start date: 1 January 2016, finishing and reporting date 31 July 2016. Results will be published in a peer-reviewed scientific journal, the project report of EuroDHYAN (www.eurodhyan.eu) and in a PhD dissertation.TRIAL REGISTRATION NUMBER: The protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO) registration number CRD42015027067.

Mammographic density (MD) is a strong risk factor for breast cancer and may represent a useful intermediate marker for breast cancer risk. Physical activity (PA) is known to be associated with a reduced risk of breast cancer. If PA is associated with MD then this would be useful for breast cancer prevention studies. MD was assessed on digitized mammograms using a computer assisted method (Madena) in 2218 postmenopausal women. A questionnaire assessed PA, by asking about the duration and intensity of light, moderate, strenuous PA/week. We used multivariate linear regression models to estimate least square means of percent MD by total and intensity of PA with adjustment for confounders. The mean age (± s.d) was 58.4 (±5.3) and mean BMI was 24.6 (±4.6). We observed a statistically significant inverse association between total PA and MD in the over-weight (BMI = 25.0-29.9) women, where mean MD among women with highest activity (>360 mins/week) was 12.6% (95%CI; 11.2%-14.0%), while among women with no activity it was 15.9% (95 CI; 13.6%-18.2%, p for trend = 0.04). There was no association in the other BMI strata. MD was 12.1% (11.2%-13.0%) in the highest group (> 180 mins/week) of moderate/strenuous activity and in the no activity group 14.8% (14.2%-15.5%, p for trend = 0.001) in the over-weight women. There was no association between light PA and MD in all women combined or in any other BMI strata. We found some evidence of an inverse association between PA and MD among overweight women.

Introduction Mammographic density (MD) is one of the strongest known breast cancer risk factors. Estrogen and progestin therapy (EPT) has been associated with increases in MD. Dense breast tissue is characterized by increased stromal tissue and (to a lesser degree) increased numbers of breast epithelial cells. It is possible that genetic factors modify the association between EPT and MD, and that certain genetic variants are particularly important in determining MD in hormone users. We evaluated the association between MD and 340 tagging single nucleotide polymorphisms (SNPs) from about 30 candidate genes in hormone metabolism/growth factor pathways among women who participated in the Norwegian Breast Cancer Screening Program (NBCSP) in 2004. Methods We assessed MD on 2,036 postmenopausal women aged 50 to 69 years using a computer-assisted method (Madena, University of Southern California) in a cross-sectional study. We used linear regression to determine the association between each SNP and MD, adjusting for potential confounders. The postmenopausal women were stratified into HT users (EPT and estrogen-only) and non-users (never HT). Results For current EPT users, there was an association between a variant in the prolactin gene (PRL; rs10946545) and MD (dominant model, Bonferroni-adjusted P (Pb) = 0.0144). This association remained statistically significant among current users of norethisterone acetate (NETA)-based EPT, a regimen common in Nordic countries. Among current estrogen-only users (ET), there was an association between rs4670813 in the cytochrome P450 gene (CYP1B1) and MD (dominant model, Pb = 0.0396). In never HT users, rs769177 in the tumor necrosis factor (TNF) gene and rs1968752 in the region of the sulfotransferase gene (SULT1A1/SULT1A2), were significantly associated with MD (Pb = 0.0202; Pb = 0.0349). Conclusions We found some evidence that variants in the PRL gene were associated with MD in current EPT and NETA users. In never HT users, variants in the TNF and SULT1A1/SULT1A2 genes were significantly associated with MD. These findings may suggest that several genes in the hormone metabolism and growth factor pathways are implicated in determining MD.

While studies have shown that use of postmenopausal hormone therapy with estrogen and progestogen (EPT) increases mammographic density, aspects of this association remain unclear. We examined whether mammographic density differed by type of hormone therapy (HT) used, dose, duration of use, time since last use, and whether the effects are modified by age and body mass index (BMI). Using a cross-sectional design, we recruited 2,424 postmenopausal women aged 50–69 years participating in the Norwegian Breast Cancer Screening Program. Mammographic density was assessed with a computer-assisted method, and we estimated mean absolute and percent mammographic density through multiple linear regression, and adjusting for possible confounders. Mammographic density was higher among current HT users (percent density: 22.6%; 95% CI: 22.1–23.2%) than among former (17.7%; 17.2–18.2%) or never users (16.3%; 15.7–16.8%). The highest density was seen in current EPT users of high-dose norethisterone acetate (NETA) regimens who had a percent density of 26.2% (24.3–28.1%). Results differed when considering the combined effect of age and BMI. The effect of EPT on mammographic density was modified by age and BMI, with no apparent association among the youngest women (aged 50–55) with the highest BMI (BMI ≥ 26). A higher mammographic density was found in EPT users compared to never HT users, particularly in women using high-dose NETA regimens. Age and BMI modified the association between EPT use and mammographic density.

Mammographic density is a strong risk factor for breast cancer. While alcohol intake has been associated with increased breast cancer risk, the association between alcohol consumption and mammographic density is not clear. We assessed the association between alcohol consumption and mammographic density among women who participated in the Norwegian Breast Cancer Screening Program in 2004. Mammographic density was assessed on digitized mammograms from 2,251 postmenopausal women aged 50–69 years, using a computer assisted method. Current intake of beer, wine (red and white), and liquor was assessed using a validated food frequency questionnaire. Non-drinkers were defined as complete abstainers (i.e., those who reported no intake of any type of alcohol). We used multivariate linear regression models to estimate least square means of percent mammographic density by categories of alcohol intake with adjustment for potential confounders. We also checked for possible effect modification by stratifying the analyses by age, body mass index, and hormone therapy. The mean percent mammographic density was almost similar for drinkers 18.3% (95% CI: 17.6–18.9%) and non-drinkers 17.8% (95% CI: 16.1–19.4%) (P = 0.59). There was no indication that amount of alcohol consumed was associated with percent mammographic density, with a mean percent density among women with the highest intake (>90 g of alcohol per week) of 18.2% (95% CI: 16.9–19.0%), only slightly different from that of non-drinkers 18.3% (17.3–19.6%) (P for trend = 0.99). There was no association between any type of alcohol consumed and mammographic density.There was no effect modification by body mass index, age, or hormone therapy use. We found no evidence of an association between alcohol intake and percent mammographic density.

We describe mammographic density and how it is associated with breast cancer risk, what mammographic density represents biologically, as well as evidence that it is associated with breast cancer risk factors and is modifiable. Mammographic density has a large unused potential in mammographic screening programs. Currently mammographic density is being used as a biomarker or surrogate endpoint for breast cancer risk in a number of studies, and we discuss the rationale for doing this, as well as the challenges involved. A major challenge is the need for an automated method that can yield an even more precise estimate of the dense areas in the breast. Currently the most widely used methods are various computer-assisted methods. These are reader intensive, but so far the methods that yield the highest estimates for breast cancer risk. Once a robust automated method for assessing mammographic density or breast density is developed, this measure will probably become even more widely used, not just in epidemiology, but also in screening programs and in clinical practice.

Mammographic density (MD) is one of the strongest known breast cancer risk factors. Estrogen and progestin therapy (EPT) has been associated with increases in MD, and is known to increase breast cancer risk possibly through increased proliferation of breast epithelial cells. It is possible that genetic factors modify the association between EPT and MD, and that certain genetic variants are particularly important in determining MD in hormone users. We evaluated the association between mammographic density and 340 SNPs (singular nucleotide polymorphisms) from about 30 putative genes in hormone metabolism / growth factor pathways among women who participated in the Norwegian Breast Cancer Screening Program (NBCSP) in 2004. We assessed mammographic density on 2040 postmenopausal women aged 50–69 years using a computer assisted method (Madena, University of Southern California). We ran multiple regressions models (dominant and additive), adjusting for age, body mass index (BMI) with and without adjustments for multiple comparisons (the number of SNPs per gene). We stratified the postmenopausal women into current, past and never EPT users. For postmenopausal current EPT users there was an association between a variant in the prolactin gene (rs10946545) and MD (dominant model p=0.0002). This association was also present in women who were currently using norethisterone acetate (NETA) based EPT, a regimen common in Nordic countries. In past EPT users, we found that two variants in the catechol-O-methyltransferase gene (COMT; rs2239395 and rs5992500) were associated with MD (dominant model p=0.0112), but the association was no longer significant when we adjusted for multiple tests. Among current estrogen only users, there was an association between a variant in the cytochrome P450 gene (CYP1B1; rs4670813) and MD in current estrogen only users (dominant model p=0.0028). We also found an association between a variant in the vascular endothelial growth factor gene (VEGF; rs833052) and MD for current users of high dose NETA EPT (dominant model p=0.0021), while in low dose NETA EPT users a variant in the tumor necrosis factor gene (TNF; rs4947324) was associated with MD (dominant model p=0.0007). We found some evidence that variants in the prolactin and COMT genes were associated with MD in current or past EPT users. We also found associations between genetic variants in TNF and MD in low dose NETA users, and between variants in VEGF and MD in high dose NETA users. Citation Information: Cancer Prev Res 2011;4(10 Suppl):A87.

While studies have shown that the use of post-menopausal hormone therapy increases mammographic density, certain aspects of this association remain unclear. We examined whether mammographic density differs according to the type of hormone therapy used, dose, duration of use, time since last use, as well as whether the effects are modified by age and body mass index (BMI). We used a cross-sectional design and recruited 2265 post-menopausal women, aged 50-69 who participated in the Norwegian Breast Cancer Screening Program in 2004. Mammographic density was assessed with the computer-assisted method (Madena), and we estimated mean percent mammographic density, controlling for possible confounding factors. Statistical analyzes were performed for all women combined and by age and BMI. Mammographic density was higher among current hormone therapy users (percent density: 20.8%; 95% CI: 19.6-21.9%), than among former (18.7%; 18.1-19.3%) or never HT users (16.7%; 15.8-17.6%). Ever users of combined estrogen-progestogen therapy (EPT) had higher percent density (20.0%; 19.1-20.9%) than estrogen-only (ET) users (18.3%, 17.7-18.9%) and never users (16.7%, 15.8-17.6%), and the highest density was seen in current EPT users (21.4%; 20.1-22.6%). Time since last use was significantly associated with density, with women who quit more than 3 years ago having density similar to never users. Mammographic density declined with increasing age and BMI. In analyses stratified by BMI, we found higher densities with EPT use in all categories, with somewhat smaller differences between ever and never EPT users in women with BMI of 26 and higher. When stratifying analyses by age, mammographic density was similar in EPT users and never users in women aged 55 and below. However, this was not true in leaner women (BMI of 23 or less). Among these young women (55 or less) with low BMI (23 or less), EPT users had higher percent density than never users. The percent density was 26.8% (23.7-29.8%) in never users, and 31.7% (28.0-35.4%) in ever users. No statistically significant difference in density was found in women older than 62 years old with a BMI of 26 and above, with percent density of 6.8% (5.3-8.3%), and 9.3% (6.9-11.6%) in never and ever users, respectively. Higher mammographic density was seen in ever users of estradiol and norethisterone acetate regimens (Activelle and Kliogest) compared to other EPT. Mammographic density was higher in women using high rather than low doses of estradiol and progestogen. In conclusion, the highest mammographic density was found in EPT users compared to ET and never users, particularly in users of the norethisterone acetate regimens. This increase was bigger in women taking high rather than low EPT doses. The association between EPT use and mammographic density was modified by age and BMI. These results have important implications and should be considered when, for example, deciding on which type and dose of hormones to prescribe. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3726. doi:10.1158/1538-7445.AM2011-3726

Background Urinary incontinence (UI) is a prevalent symptom in middle-aged women, but data on incidence is limited and rarely reported. In order to analyze incidence, remission, or development patterns of severity and types of UI, we have established a 15-year prospective cohort (1997–2012). Methods The Cohort is based on the national collection of health data gathered from county studies (CONOR). Hordaland Health Study (HUSK) is one of them from Hordaland County. Each of the county studies may have local sub-studies and our Cohort is one of them. The Cohort included women aged 40–45 in order to have a broad approach to women's health including UI and other lower urinary tract symptoms (LUTS). A onefifth random sampling from HUSK was used to create the Cohort in 1997–1999. For the necessary sample size a preliminary power calculation, based on a 70% response rate at inclusion and 5% annual attrition rates was used. The Cohort is planned to collect data through questionnaires every second year for the 15-year period from 1997–2012. Discussion The Cohort represents a relatively large random sample (N = 2,230) of about 15% of the total population of women born between 1953–57 in the county of Hordaland. Our data shows that the cohort population is very similar to the source population. The baseline demographic, social and medical characteristics of the Cohort are compared with the rest of women in HUSK (N = 7,746) and there were no significant differences between them except for the level of education (P = 0.001) and yearly income (P = 0.018), which were higher in the Cohort population. Urological characteristics of participants from the Cohort (N = 1,920) were also compared with the other participants (N = 3,400). There were no significant statistical differences except for somewhat more urinary continence (P = 0.04), more stress incontinence (P = 0.048) and smaller amount of leakage (P = 0.015) in the Cohort. In conclusion, the Cohort ispopulation-based, with little selection bias, and thus is a rather unique study forinvestigating UI and LUTS in comparison with many other projects with similar purposes.