Abstract P1-02-07: Adherence to breast cancer screening recommendations among underserved participants in an urban safety net mammography clinic

Background: The Georgetown Lombardi Comprehensive Cancer Center's Capital Breast Care Center (CBCC) is a safety net mammography screening center that uses a community-based patient navigation program to provide underserved minority women guidelines-concordant mammography screening. Given that screening navigation is designed to eliminate some established barriers such as, access, transportation, and cost, we retrospectively examined patient adherence rates to regular (annual/biennial) mammography screening. We also investigated whether patient demographics are associated with adherence to breast cancer screening.

Methods: Data were derived from medical records of patients that received a baseline mammogram at CBCC in 2011 (n = 1,637) and were followed up for 4 years. Within the study time period of 2011-2015, patients were of age 40-74 and had not received a prior breast cancer diagnosis. 10 definitive cases of breast cancer were newly diagnosed in this population during the follow-up period and were excluded from the analysis. Adherence was then calculated based on the American College of Radiology (annual screening starting at 40) and the United States Preventive Services Task Force guidelines (biennial screening starting at 50).

Results: In 2011, the mean age of women screened at CBCC was 51.25 years with 45% being 40-50 years of age. CBCC has a predominantly minority population with 48% of the women identifying as Black/African American (AA) and 41% identifying as Hispanic in 2011. Over the 4 year follow up period, 41.11% of the patients screened in 2011 did not return for another screen. The adherence rate for annual screening in the 40-74 age group was 3.3% (3.0% in Black/AA; 4.2% in Hispanic) over the 4-year follow-up. The adherence rate for biennial screening among the 50-74-year-old age group was 21% overall (20% among Black/AA; 26% among Hispanics). Approximately 40% of the participants with baseline screenings in 2011 received at least one additional screening over the 4 year follow up but their mammography schedules were not guidelines concordant and they were labeled as “partially adherent” for this analysis.

Conclusion: While the number of partially adherent patients was consistent with previous population-based adherence studies, the proportion of non-adherent patients was higher compared with other population-based studies in primarily Non-Hispanic White populations. Our analysis highlights the importance of focusing on adherence to guidelines and not just mammography initiation in underserved minority populations through educational interventions targeted to patients and providers.

Citation Format: McClenathan MM, Lu J, Oppong BA, Adams-Campbell LL, Dash C. Adherence to breast cancer screening recommendations among underserved participants in an urban safety net mammography clinic [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-02-07.

A Community-Based Outreach Navigator Approach to Establishing Partnerships for a Safety Net Mammography Screening Center

Washington, DC, has one of the highest incidence and mortality rates for breast cancer in the USA. Patient navigation coupled with informational and community resources are important strategies that assist patients' access and help them understand the complex world of cancer care. The Georgetown Lombardi Comprehensive Cancer Center's Capital Breast Care Center (CBCC) is a safety net mammography screening center that utilizes a community-based navigation program. In addition to providing assistance with coordination of clinical services, navigators at CBCC are integral in establishing intra-community partnerships to educate members of the community about breast cancer screening. The aim of this study was to detail the role of patient navigation at the CBCC, with an emphasis on community engagement and community-based partnerships. We describe the process by which CBCC established partnerships with multiple community organizations between 2004 and 2015 and analyzed data of women screened in relationship to the evolution of the patient navigation services. Application of the CBCC navigation model that integrates individual patient outreach with community engagement has yielded viable and lasting community partnerships that have resulted in an increase in mammography uptake, especially among medically underserved minority women.

Cardiorespiratory Fitness and Metabolic Syndrome in Postmenopausal African-American Women

We examined the association of cardiorespiratory fitness with metabolic syndrome in overweight/obese postmenopausal African-American women. Pooled baseline data on 170 African-American women from 2 exercise trials were examined. Metabolic syndrome was defined as at least 3 of the following: abdominal obesity, glucose intolerance, hypertension, low high-density lipoprotein cholesterol (HDL-C), and high triglycerides. Cardiorespiratory fitness (VO2peak) was determined using the Bruce treadmill protocol and categorized as: Very Low (VLCRF<18 mL·kg(-1) min(-1)), Low (LCRF=18.0-220-22-22.0 mL·kg(-1) min(-1)), and Moderate (MCRF>22.0 mL·kg(-1) min(-1)). Associations of metabolic syndrome with cardiorespiratory fitness were analyzed using one-way ANOVA and linear regression. VO2peak was significantly lower in the VLCRF compared to the MCRF group. Lower cardiorespiratory fitness was associated with higher prevalence of metabolic syndrome, abdominal obesity, hypertriglyceridemia, and low HDL among overweight/obese postmenopausal African-American women. In fully adjusted models, higher waist circumference and triglycerides were associated with lower VO2peak levels (P<0.01) and higher HDL-C was associated with higher VO2peak levels (P=0.03). Overweight/obese postmenopausal African-American women with very low cardiorespiratory fitness are more likely to have metabolic syndrome, higher body mass index, and unhealthier levels of certain metabolic syndrome components than women with moderate cardiorespiratory fitness.

Longitudinal association of measures of adiposity with serum antioxidant concentrations in postmenopausal women

BACKGROUND/OBJECTIVES

The relationship between obesity and circulating levels of antioxidants is poorly understood. Most studies that have examined the association of adiposity with blood or tissue concentrations of antioxidant micronutrients have been cross-sectional, and few have compared the associations for indices of overall obesity and central obesity. Our aim was to prospectively examine the longitudinal association of body mass index (BMI), waist circumference (WC), waist circumference-height ratio (WCHtR) and waist-hip ratio (WHR) with major serum antioxidants in a population of postmenopausal women.

SUBJECTS/METHODS

We used a subsample of participants in the Women's Health Initiative aged 50-79 years at entry with available fasting blood samples and anthropometric measurements obtained at multiple time points over 12.8 years of follow-up (N=2672). Blood samples were used to measure α-carotene, β-carotene, β-cryptoxanthin, lutein+zeaxanthin, α-tocopherol, γ-tocopherol and retinol at baseline, and at years 1, 3 and 6. We used mixed-effects linear regression analyses to examine associations between anthropometric measures and serum antioxidants at baseline and over time, controlling for covariates.

RESULTS

In longitudinal analyses, carotenoids, and particularly β-carotene, were strongly and inversely associated with BMI, WC and WCHtR and less so with WHR. α-Tocopherol showed a strong positive association with WHR but not with other anthropometric measures, whereas γ-tocopherol was positively and strongly associated with BMI, WC, WCHtR and less so with WHR. Retinol was positively associated with WHR. The inverse association of several carotenoids with anthropometric measures was stronger in never and former smokers compared with current smokers and in women without the metabolic syndrome. The inverse association of carotenoids with obesity measures may reflect reduced micronutrient concentrations owing to inflammation associated with obesity.

CONCLUSIONS

In the present study, the strongest observed associations between anthropometric variables and micronutrients were an inverse association of WC with serum β-carotene and a positive association of WC with γ-tocopherol.

Abstract PD2-7: Vigorous exercise across the lifespan and reduced risk of estrogen receptor negative breast cancer in African American women

Background. Recreational exercise has been associated with a reduced risk of breast cancer, but evidence regarding breast cancer among African American women and about breast cancer subtypes is sparse.

Methods. We assessed lifetime vigorous exercise (average of high school, age 21, age 30, and baseline) in the Black Women's Health Study in relation to the incidence of invasive breast cancer overall (n = 1,377), estrogen receptor-positive (ER+) breast cancer (n = 556), estrogen receptor-negative (ER-) breast cancer (n = 327), and triple negative breast cancer (TN) (n = 103); analyses were based on 275,188 person years of follow-up of 44,704 African American women who were aged 30 or more at entry to the study. Cox proportional hazards models estimated incidence rate ratios (IRR) and 95% confidence intervals (CI), controlling for breast cancer risk factors.

Results. For ER- breast cancer, the IRRs for 1-2.2 hours/week, 2.3-2.9 hours/week, and 3+ hours/week relative to &lt;1 hour/week were 0.76 (95% CI 0.52-1.11), 0.78 (95% CI 0.52-1.17) and 0.53 (95% CI 0.31-0.90), respectively; the p value for trend was 0.058. The inverse association was apparent only among postmenopausal women. There was also an inverse association, although nonsignificant, of exercise with the incidence of TN breast cancer. Vigorous exercise was not associated with a reduction in ER+ breast cancer risk.

Conclusion. These results indicate that physical activity may protect against the development of ER- breast cancer in African American women. The association, if confirmed, is of great public health importance given the high mortality associated with this subtype and its higher incidence in African American women.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD2-7.

Effect of Ethnicity and Geographical Location on Body Weight, Dietary Restraint, and Abnormal Eating Attitudes

Previous studies have examined the effect of ethnicity on obesity, concerns about shape and weight, and attitudes about eating. We hypothesized that geographical location would also influence these variables, and that students growing up in the northern part of the United States and attending northern colleges would differ from students from the South. To examine this, we studied a random sample of 275 African-Americans (AA) and 224 white college students in the entering class of two northern colleges (University of Pittsburgh or University of Massachusetts) or two southern colleges (Augusta or Paine College). All subjects were weighed and completed the Revised Restraint Scale and the EAT-26. AA women were heavier than white women, with no differences due to geographical location. Despite being thinner, white women reported more dietary restraint than AA women. This difference between AA and white women was apparent in both northern and southern college students. In contrast, geographical location was the strongest determinant of bulimic attitudes; both men and women at northern colleges reported higher bulimia scores than those at southern schools. Thus ethnicity appears to be a major determinant of body weight and attitudes about shape and dieting, whereas geographical location appears to exert greater influence on bulimic attitudes.

Anthropometric predictors of elevated prostate specific antigen among rural and urban Nigerians: a population-based study

BACKGROUND

Obesity has been associated with incidence and mortality of carcinoma of the prostate (CaP), but the relationship of BMI to CaP risk remains controversial across populations.

OBJECTIVE

To describe the anthropometric correlates of elevated prostate specific antigen in Nigeria, a low-incidence region for CaP that currently reports rising incidence.

SUBJECTS AND METHODS

Weight, height and skin fold thickness were measured for men, aged 40 years and older. Waist-to-hip ratio (WHR) and body mass index (BMI) were computed. Prostate specific antigen (PSA) status and prostate size were determined. Mean anthropometric indices were compared across groups using Student's t-test, association between anthropometry and PSA was by Spearman's correlation, and mean PSA was tested for linearity across tertiles of anthropometry. Prediction of elevated PSA was determined by multivariate logistic regression controlling for age and prostate size.

RESULTS

Of 350 consecutive men contacted, 281(80.3%) completed the survey, mean age 56.9(13.5) years, and elevated PSA prevalence 31(11.0 %). WHR was 0.92 for rural and urban men, BMI (22.9 vs 24.7, p<0.002, and skin fold thickness was lower for rural men. PSA correlated directly with age, r=0.360, p<0.0001 and negatively with height, r=-0.136, p<0.023. WHR remained a significant predictor of elevated PSA,[OR 3.04 (95% CI 1.13 - 8.15)], after adjusting for age and enlarged prostate.

CONCLUSION

Central adiposity may be a more important predictor of elevated PSA than BMI in this population. There is need to investigate the role of hormonal, metabolic, and genetic correlates of central adiposity in carcinoma of the prostate risk in this population.

Recent mammography use among African-American women

OBJECTIVE

The incidence of breast cancer in Black women is lower, but their mortality rate is higher, compared to White women. Lower rates of mammography use among Black women in the past may have resulted in later diagnosis of breast cancer, leading to shorter survival periods and higher mortality rates. We assessed recent mammography use in a large national study, the Black Women's Health Study.

DESIGN

In 1995, 27,632 US Black women aged 40-69 years completed mailed questionnaires, which included questions on mammography use.

RESULTS

Seventy-three percent of women aged 40-49, and 82% of those aged 50-69, reported having had a mammogram within the previous three years. Use was greater among women with higher levels of education, and among those who had cystic breast disease or a mother or sister with breast cancer.

CONCLUSIONS

The high rate of recent mammography use among participants in the Black Women's Health Study agrees with national data. If breast cancer mortality rates in Black women continue to exceed those in White women, despite the lower incidence among Black women, reasons other than differential mammography use must be sought.

Follow-up of a large cohort of Black women

High retention rates in follow-up studies reduce the potential for biased data due to selective losses. The Black Women's Health Study began in 1995 when 64,500 participants aged 21-69 years enrolled by completing postal health questionnaires. Follow-up is carried out biennially. On the basis of data collected between enrollment and completion of the first follow-up, the authors assessed the usefulness of various follow-up methods and compared the characteristics of respondents, nonrespondents, and women lost to follow-up because of an unknown address. The 1997 questionnaire was completed by 82.8% of the participants. The study population was highly mobile: 56.5% moved at least once, and 1.5% moved at least four times. Moving was associated with younger age: A total of 71.7% of participants aged 21-29 years moved at least once compared with 43.2% of women aged 50-69. The most successful and cost-effective method for eliciting completed questionnaires from participants was sending multiple waves of questionnaires. Telephone calls to nonrespondents were successful but were highly labor intensive. Demographic and health characteristics of the women were similar regardless of which mailing was completed, except that early respondents had higher levels of education. Respondents were more highly educated and older than were nonrespondents and lost subjects but were quite similar in all other characteristics. These data suggest that follow-up of a mobile population of African-American women can be successful.

Height and breast cancer risk: results from the Black Women's Health Study (United States)

OBJECTIVES

Numerous studies, but not all, have yielded positive associations between adult height and risk of breast cancer. There are few data on black women. We evaluated adult height in relation to breast cancer in data from the Black Women's Health Study, a prospective cohort study of 64,530 African-American women aged 18-69 years at baseline in 1995.

METHODS

A total of 910 cases of breast cancer were analyzed: 700 prevalent cases reported at baseline and 210 incident cases that occurred during the first 2 years of follow-up. A comparison group of controls frequency-matched on 5-year category of birth year was chosen from among participants who had not developed breast cancer. Odds ratios (OR) were calculated for various categories of adult height compared to a reference category of height less than or equal to 61 inches (155 cm), with control for current age, age at menarche, and years of education.

RESULTS

Increased height was associated with an increased risk of breast cancer overall (p trend = 0.001); the OR for the highest category of height, > 69 inches (175 cm), was 1.6 (95% confidence interval 1.1-2.3). The association was stronger among premenopausal women and women who had less than 16 years of education. Results were similar for prevalent and incident cases.

CONCLUSION

The present findings indicate that height is associated with breast cancer risk in African-American women.

Insulin-like growth factor-1 and breast cancer risk in postmenopausal African-American women

We explored the relationship between insulin-like growth factor-1 (IGF-1) concentrations and breast cancer risk. Also, we examined whether obesity, sex hormone-binding globulin (SHBG), and estradiol influenced IGF-1 concentrations. A pilot study of 60 postmenopausal African-American women (30 cases and 30 controls) was used. Plasma concentrations of IGF-1 were higher among the cases, as compared to the controls. A negative trend was seen for plasma concentrations of IGF-1 and TNM (tumor-node-metastasis) stage and IGF-1 and body mass index. IGF-1 was found to be associated negatively with SHBG. After adjustment, plasma concentrations of IGF-1 remained significantly and positively associated with breast cancer risk (odds ratio, 1.183; 95% confidence interval, 1.167-1.201). No significant associations for breast cancer risk were observed for estradiol, SHBG, and body mass index. Further research with a larger sample is needed to clarify the relationships between obesity and IGF-1 concentrations to breast cancer risk in this population.

Strenuous physical activity and breast cancer risk in African-American women

OBJECTIVES

Some studies of white women suggest that exercise reduces the incidence of breast cancer. There are no data on black women. We assessed the relationship between strenuous physical activity and prevalent breast cancer among participants in the Black Women's Health Study.

METHODS

Data on strenuous recreational physical activity at various ages and other factors were collected in 1995 by mail questionnaire from 64,524 United States black women aged 21 to 69 years. The 704 women who reported breast cancer (cases) were matched on age and on menopausal status at the time of the breast cancer diagnosis with 1408 women who did not report breast cancer (controls). Odds ratios for levels of physical activity at various ages were derived from conditional logistic regression with control for potential confounding factors.

RESULTS

Odds ratios for > or =7 h per week relative to < 1 were significantly reduced for strenuous activity at age 21 for breast cancer overall and premenopausal breast cancer, at age 30 for breast cancer overall, and at age 40 for postmenopausal breast cancer. There was no evidence of a reduction associated with exercise in high school.

CONCLUSIONS

The findings of the present study suggest that strenuous physical activity in early adulthood is associated with a reduced risk of breast cancer in African-American women.

A comparison between BMI and Conicity index on predicting coronary heart disease: the Framingham Heart Study

PURPOSE

This study examined the relationship of mortality and morbidity of coronary heart disease with body mass index (BMI) and Conicity index (CI).

METHODS

Among 5209 Framingham Heart Study participants, 1882 men and 2373 women had waist and weight measurement at the 4th examination period and height measured on the 5th visit. These were used for BMI and CI.

RESULTS

During a 24-year follow-up, 597 men and 468 women developed CHD and 248 men and 150 women died from CHD associated causes. In men the relative risks (RR) (95% confidence interval) adjusted for age, hypertension, diabetes, smoking status, and total cholesterol for CHD incidence in 2nd, 3rd, and 4th quartiles of BMI were 1.28 (1.0, 1.65), 1.45 (1.13, 1.86), and 1.53 (1.19, 1.96). The RR for CHD incidence in the 4th quartile of BMI in women was 1.56 (1.16, 2.08). No CI quartiles were risk factors for CHD incidence. There was 86% higher risk of CHD related death in the 4th quartile of BMI than the 1st quartile of BMI in women. In men no significantly higher risks of death were found across the quartiles of BMI. No associations were found between CI quartiles and CHD mortality.

CONCLUSIONS

Obesity as measured by BMI is an important risk factor for CHD incidence in men and women and for CHD mortality in women. CI was not associated with an increase in CHD incidence or mortality. Thus, BMI is a better marker than CI for predicting CHD incidence and mortality.

Descriptive epidemiology of physical activity in African-American women

OBJECTIVES

We assessed walking for exercise and moderate and strenuous physical activity in relation to both demographic and health-related characteristics among African-American women from various parts of the United States who participate in the Black Women's Health Study.

METHODS

The data were collected in 1995 by mail questionnaire from 64,524 U.S. black women aged 21 to 69 years. The 64,101 women who provided data on physical activity are the subjects of the present report.

RESULTS

The present study revealed low levels of physical activity among the African-American women: 57% reported an hour or less per week walking for exercise, 18% reported moderate activity, and 61% reported strenuous physical activity. Strenuous physical activity increased with education. Higher levels of walking for exercise and moderate and strenuous activity were associated with higher levels of participation in strenuous exercise in high school.

CONCLUSION

Physical activity levels are low in African-American women. Based on the findings of the present study it may be suggested that educational efforts to increase levels of physical activity should start at an early age.

Addictive behaviors and depression among African Americans residing in a public housing community

Numerous studies have indicated that there is an association between cigarette smoking, alcohol use, and depression. However, little attention has been devoted to understanding how demographic factors, such as socioeconomic status and ethnicity, influence these relationships. To address this gap in the literature, cigarette and alcohol use were examined in a sample of African Americans from an urban area. A single public-housing community in Washington, DC was selected for complete ascertainment of the adult population. A total of 126 African American subjects were recruited. Semi-structured interviews were conducted to assess depressive symptoms and to characterize cigarette and alcohol use patterns. Cigarette smoking was not related to the severity of depressive symptoms. By contrast, increased symptoms of depression were related to alcohol use patterns. Light drinkers had a mean score of 5.77 on the Centers for Epidemiologic Studies Depression Scale, compared to a mean of 8.30 for abstainers and 10.07 for heavy drinkers (F = 4.968, p < .003). An analysis of patterns of substance use revealed that subjects were more likely to either abstain from both substances (30.2%) or to use both substances (32.5%) (chi2 = 8.516, df = 1. p < .004). It is unclear which specific processes work to link alcohol use and depressive symptoms in this group of urban African Americans from a low-income community. What is clear is that alcohol use is clearly related to depressive symptoms in the sample. It is hypothesized that both self-medicating processes and substance-induced depressive symptoms may be responsible for these findings. Important factors to consider in developing effective intervention programs that target this specific population are discussed.

Correlates of hysterectomy among African-American women

Hysterectomy is the second most common surgery performed on US women. Baseline data from a large study of African-American women were used to examine correlates of premenopausal hysterectomy. Analyses were conducted on participants aged 30-49 years; 5,163 had had a hysterectomy and 29,787 were still menstruating. Multiple logistic regression was used to compute prevalence odds ratios for the association of hysterectomy with various factors. Hysterectomy was associated with region of residence: Odds ratios for living in the South, Midwest, and West relative to the Northeast were 2.63 (95% confidence interval (CI): 2.38, 2.91), 2.02 (95% CI: 1.81, 2.25), and 1.89 (95% CI: 1.68, 2.12), respectively. Hysterectomy was inversely associated with years of education and age at first birth: Odds ratios were 1.96 (95% CI: 1.74, 2.21) for < or =12 years of education relative to >16 years and 4.33 (95% CI: 3.60, 5.22) for first birth before age 20 relative to age 30 or older. Differences in the prevalence of major indications for hysterectomy did not explain the associations. This study indicates that the correlates of hysterectomy among African-American women are similar to those for White US women. The associations with geographic region and educational attainment suggest that there may be modifiable factors which could lead to reduced hysterectomy rates.

Risk factors for coronary heart disease in African American women

There have been few studies of risk factors for coronary heart disease in African American women. The authors investigated factors associated with prevalent coronary heart disease in data provided by participants in the Black Women's Health Study. In 1995, 64,530 US Black women aged 21-69 years completed postal health questionnaires. The 352 women who reported having had a heart attack (cases) were frequency matched 5:1 on age with 1,760 women who had not (controls); medical record review for 35 cases indicated that two-thirds had had a heart attack and the remainder had other coronary heart disease. Odds ratios, obtained from multiple logistic regression analyses, were significantly elevated for cigarette smoking, drug-treated hypertension, drug-treated diabetes mellitus, elevated cholesterol level, and history of heart attack in a parent. High body mass index (kg/m2) was associated with coronary heart disease in the absence of control for hypertension, diabetes mellitus, and elevated cholesterol but not when they were controlled, suggesting that obesity may influence risk as a result of its effects on blood pressure, glucose tolerance, and cholesterol levels. Odds ratios increased with increasing parity and with decreasing age at first birth. These data suggest that important risk factors for coronary heart disease are similar in Black women and White women.

Cardiovascular reactivity in Zimbabwe

OBJECTIVE

In this study, we examined the effects of residency and gender on cardiovascular reactivity to a speech stressor in 50 rural Zimbabweans (24 males, 26 females) and 47 urban Zimbabweans (25 males and 22 females).

METHODS

Participants were engaged in 4 periods: pre-task rest period, speech preparatory period, speaking task period, and the final recovery period. During each period, systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were assessed.

RESULTS

There was a significant interaction between area of residence and period for SBP and HR. Urban residents exhibited greater SBP and HR during the speaking phase of the speech task than did rural residents. However, rural residents displayed more exaggerated HR reactivity during the speech preparatory phase as compared to the urban residents. No gender differences were observed on blood pressure or heart rate reactivity.

CONCLUSION

In conclusion, the more exaggerated SBP and HR reactivity to the speaking phase among urban residents as compared to rural residents may be influenced by factors associated with urbanization.

Perceptions and knowledge of breast cancer among African-American women residing in public housing

OBJECTIVE

The purpose of this study, theoretically based on the Health Belief Model, was to assess breast cancer perceptions, knowledge, and screening behavior of low-income, African-American women residing in public housing.

METHODS

One hundred twenty (120) randomly selected women were interviewed to determine their perceived susceptibility to breast cancer, perceived severity of the disease, perceived barriers to breast cancer screening, and perceived benefits of mammography. Knowledge about breast cancer causes, risk factors, symptoms, and screening was also assessed. Contingency tables and Student's t test were used to analyze the data.

RESULTS

The results demonstrated that 80.7% of women aged 40 and older had a previous mammogram. Approximately 92% of women reported having a clinical breast examination, and 75.8% performed breast self-examination. Knowledge of breast cancer was poor among the women in this study. Most women did not perceive themselves or a particular racial or economic group to be more susceptible to breast cancer. Moreover, the women in the sample did not perceive breast cancer as a fatal disease. Overall, women in the sample endorsed the benefits of mammography and denied the relevance of commonly cited barriers to breast cancer screening. The constructs of the Health Belief Model were not significantly related to mammography or breast self-examination. However, perceived severity and perceived barriers were found to be significantly related to clinical breast examination.

CONCLUSIONS

Rates of early detection behaviors in this sample are commendable. Future research should focus on actual determinants and facilitators of regular screening behavior within a theoretical framework that incorporates cultural, ethnic, and socioeconomic diversity.

Obesity and hypertension among college-educated black women in the United States

It is established that obesity is an important risk factor for hypertension, but there is little information on this relationship among highly educated black women. We assessed the relationship of body mass index (weight (kg)/height2 (m)) to prevalent hypertension among US black women who had completed college, and among less educated women as well. The data were collected in 1995 in the Black Women's Health Study: 64530 African-American women aged 21 to 69 years enrolled by completing mailed health questionnaires; 44% of the participants had completed college. We compared the 9394 participants who reported a diagnosis of hypertension treated with a diuretic or antihypertensive drug (cases) with 9259 participants of similar ages who did not have hypertension (controls). Multivariate odds ratios were estimated by logistic regression. The odds ratio for treated hypertension increased with increasing body mass index at every educational level. Among college-educated women, the odds ratio for hypertension was 2.7 for overweight women (index 27.3-32.3) and 4.9 for severely overweight women (index > or =32.3), relative to women with a body mass index <22.8. The prevalences of obesity and hypertension were high among the college-educated women, although not as high as among women with fewer years of education. About a quarter of the difference in the prevalence of hypertension across educational levels was explained by the difference in the proportions who were overweight or severely overweight. These results document a high prevalence of obesity and hypertension, and a strong association of obesity with hypertension, among highly educated US black women.

Plasma lipid alterations in African-American women with breast cancer

The purpose of this study was to examine the relationship between plasma lipid and lipoprotein levels, stage of disease and breast cancer risk in African-American women. The study population comprised 163 African-American women: patients (n = 58) and controls (n = 105), with mean ages of 57.2 years and 47.7 years respectively. Approximately 71% and 56% of the women with breast cancer and the control population, respectively, were postmenopausal. Those with cancer had significantly higher education levels, P < or = 0.01, and higher triglyceride levels compared to the controls, P < or = 0.001, but lower body mass index (BMI) levels, P < or = 0.01. There were no statistically significant differences observed in total cholesterol, high-density-lipoprotein-containing cholesterol and low-density-lipoprotein-containing cholesterol between the patients and controls. After adjustments for age, education, BMI, and menopausal status, triglycerides remained significantly and positively associated with breast cancer risk. The significant correlation between the high levels of triglycerides and breast cancer risk (odds ratio = 5.12) may be attributed to differences in lipid metabolism between the women with breast cancer and controls, or to the consequences of breast cancer.

Correlates of postmenopausal female hormone use among black women in the United States

OBJECTIVE

To assess correlates of the use of postmenopausal female hormone supplements among black women.

METHODS

We assessed information obtained from 64,564 U.S. black women 21-69 years of age who enrolled in the Black Women's Health Study in 1995 by completing postal questionnaires. Included in the present analyses were 13,352 women 40-69 years of age who had ceased menstruating. Most resided in ten states, with 66% from California, New York, Illinois, Michigan, Georgia, and New Jersey; 41.0% had completed college.

RESULTS

Among the 13,352 women 40 years of age or older who had ceased menstruating, 49.2% reported ever use of female hormone supplements and 33.3% were using them currently. Unopposed oral estrogens accounted for 63.4% of the medications being used currently. The use of supplements was highest in the western U.S. and lowest in the Northeast. The strongest correlate of use was menopause due to bilateral oophorectomy. Use peaked at 50-54 years of age and then declined, and also was associated positively with lower body mass index, greater years of education, participation in vigorous exercise, and past oral contraceptive use. Use was associated inversely with having a positive history of diabetes, heart attack, or breast cancer. Some of the drug use reported was at variance with suggested guidelines: unopposed estrogen was taken by some women who had a uterus, and estrogen together with a progestin was taken by some women who had had a hysterectomy.

CONCLUSION

These data indicate that patterns of use of postmenopausal female hormone supplements among black women who participated in the present study are similar to those documented in white women. Women with risk factors for coronary artery disease were not more likely to use supplements than women at lower risk, a pattern that is not in accordance with suggestions that the greatest benefit of supplements may accrue to high-risk women. Because users differ from nonusers in important characteristics that may affect the incidence of coronary heart disease, breast cancer, and other illnesses, observational studies of the health effects of these medications must control carefully for correlates of use.

A randomized controlled trial of weight reduction and exercise for diabetes management in older African-American subjects

OBJECTIVE

To evaluate a weight loss and exercise program designed to improve diabetes management in older African-Americans.

RESEARCH DESIGN AND METHODS

Overweight African-Americans (n = 64) ages 55-79 years with NIDDM were randomized to either an intervention (12 weekly group sessions, 1 individual session, and 6 biweekly group sessions) or usual care (1 individual session, and 6 biweekly group sessions) or usual care (1 class and 2 informational mailings). Clinical and behavioral variables were assessed at 0, 3, and 6 months of treatment.

RESULTS

Significant net differences in the intervention versus usual care were observed for weight (-2.0 kg, P = 0.006), physical activity, and dietary intake of fat, saturated fat, cholesterol, and nutrition knowledge at 3 months (all P < 0.05) and for weight at 6 months (-2.4 kg; P = 0.006) and mean HbA1c values at 3 and 6 months (respectively, -1.6 and -2.4%, both P < 0.01). After the adjustment for changes in weight and activity, the intervention participants were approximately twice as likely to have a one unit decrease in HbA1c value as those in usual care. Blood pressure increase sin usual care participants resulted in net differences (intervention minus control) at 3 and 6 months of -3.3 (P = 0.09) and -4.0 (P = 0.05) mmHg diastolic, respectively, and -8.4 (P = 0.06) and -5.9 (P > 0.10) mmHg systolic, respectively. Blood lipid profiles improved more in intervention than usual care participants, but not significantly.

CONCLUSIONS

The intervention program was effective in improving glycemic and blood pressure control. The decrease in HbA1c values was generally independent of the relatively modest changes in dietary intake, weight, and activity and may reflect indirect program effects on other aspects of self-care.

Literacy assessment in a cardiovascular nutrition education setting

We assessed functional literacy of hypercholesterolemic or hypertensive African Americans (n = 339) prior to their participation in a nutrition education program. A word pronunciation and recognition test using 20 common cardiovascular or nutrition terms was first developed based on correlations with standardized reading achievement test scores, then administered to program participants. Nearly half (48%) had word recognition scores equivalent to a < or = 8th grade reading level. Lower scores were associated with less education, lower income, unemployment, heavier work activity if employed, less healthy diets, history of heart disease or diabetes, and higher depression scores (all P < 0.01); several of these associations were independent of education. The educational materials were geared to a 5th to 8th grade reading level. However, when both audiotaped and printed instruction were provided, individuals with reading scores < or = 8th grade preferentially used the tapes. This brief and relatively unobtrusive literacy assessment may help to identify persons who can benefit most from audiovisual approaches to cardiovascular nutrition education.

Recruitment strategies for black women at risk for noninsulin-dependent diabetes mellitus into exercise protocols: a qualitative assessment

The literature is devoid of any specific data describing exercise therapy in blacks at risk for diabetes. The increasing and striking prevalence of obesity and diabetes among several indigenous populations demonstrates the unfortunate interplay between genetic predisposition and a "modern" sedentary lifestyle. Any successful intervention to reduce the risk of acquiring or attenuating the severity of diabetes must focus on behavioral, cultural, psychosocial, and social factors that are amenable to change. Thus, the objective of this study is to present qualitative data that can be useful in the recruitment of blacks into exercise protocols that could prove to be beneficial in preventing diabetes. Focus groups were conducted on 57 black women residing in Washington, DC, Columbia, Maryland, and Hartford, Connecticut. Barriers to exercising included lack of child care, lack of transportation, neighborhood constraints, and family. Incentives that would increase black women's ability to participate in an exercise protocols include transportation, child care, and an exercise environment that includes blacks.

The relationship of body mass index to reproductive factors in pre- and postmenopausal African-American women with and without breast cancer

To date, there are virtually no existing data on the relationship between obesity, menopausal status, and breast cancer in African-Americans. Therefore, the present study was designed to test the following hypotheses in an African-American population: (1) there exists a positive association between BMI and breast cancer among postmenopausal women; (2) there exists an inverse association between BMI and breast cancer among premenopausal women; and (3) similar associations between BMI and reproductive factors exist for both pre- and postmenopausal breast cancer cases. The study population comprised 357 African-American women (n = 193 breast cancer cases; n = 164 controls). No significant differences were observed between premenopausal cases and controls for BMI, obesity categories, and reproductive factors. Among the postmenopausal women, the cases had significantly lower weight and BMI levels than the controls. Age at first pregnancy and parity were significantly lower among postmenopausal cases than their controls. No significant associations were revealed between body mass index and breast cancer for pre- and postmenopausal women. In the present study, early age at menarche was the only reproductive factor that was an independent predictor of BMI for both pre- and postmenopausal women, irrespective of breast cancer status. Also, these findings strongly suggest the need to consider reproductive factors, particularly age at menarche, as a covariate of BMI and other obesity-related diseases.

Circadian rhythm of hypertensives in a Cameroon population: a pilot study

The present study was designed to determine diurnal blood pressure (BP) variations in black hypertensive Africans in Cameroon. Also the study assessed sex differences associated with ambulatory BP measurements in this black population. A total of 69 adult Cameroonians aged 25-55 years, who attended a hypertensive clinic in Yaounde, Cameroon, were recruited on a voluntary basis. The mean ages of the males and females were 48.9 and 45.8 years, respectively. Ambulatory BP monitoring was recorded with Spacelabs ICR Model 5300 ambulatory BP monitoring systems. SBP, DBP and heart rate were measured every 30 min over a 24 h period. There were no significant mean differences observed between males and females on 24 h, daytime or night-time BPs. Among the Cameroonians, 31.7% (20 of 63) of the study population were 'non-dippers'. There were no sex difference for dippers compared with non-dippers. Significant nocturnal declines were noted for SBP, DBP, heart rate and mean arterial pressure. The results of the present study reveal that in this select Cameroonian population, there exists a nocturnal decline in BP.

Body mass index and coronary artery disease in African-Americans

There are limited data available concerning the influence of obesity, a major cardiovascular disease risk factor, in relationship to coronary artery disease (CAD). This is of considerable importance to African-Americans since African-Americans have one of the world's highest CAD mortality rates coupled with the fact that obesity is extremely prevalent in this population. The present study assessed the relationship between body mass index and CAD in African-Americans undergoing coronary angiography. Eight hundred sixty-six available cardiac catheterization reports between the years 1983 through 1990 were retrospectively reviewed at Howard University Hospital in Washington, D.C. CAD was prevalent in 59.6% and 41.2%, males and females, respectively. Among the males overweight and obesity were found in 22.4% and 20.9%, respectively, compared to 39.6% and 30.6% for females. An upside-down U-shaped relationship between BMI and CAD was found. The interpretation of this finding is that being overweight is associated with increased risk of CAD compared to the lean and obese.

John Henryism and blood pressure in black college students

Previous research on John Henryism, a coping mechanism linked to hypertension in blacks, has focused almost exclusively on rural, low-socioeconomic status (SES), adult populations. Furthermore, these studies have not evaluated mediating influences of John Henryism except in terms of SES. The primary focus of the current investigation was to examine the influence of John Henryism on cardiovascular disease risk factors among a relatively healthy sample of 421 urban, black college students. A second component of the study was to determine the role of social support as a mediating influence on those with limited coping resources and high John Henryism scores. Approximately 30% of males and 9% of females had systolic blood pressures > or = 140 mm Hg or diastolic blood pressures > or = 90. Females had higher John Henryism scores than males. John Henryism was also correlated with social support in females. Gender-specific regression models revealed that John Henryism was not an independent predictor of blood pressure in black college students. The results are discussed in terms of apparent gender differences with regard to overall coping mechanisms in black students and possible explanations for the lack of a John Henryism-blood pressure relationship in this population.

Obesity, body fat distribution, and blood pressure in Nigerian and African-American men and women

This article describes a study that assesses body fat distribution patterns in Nigerian and African-American males and females and determines the association between body fat distribution patterns and blood pressure in young adults of differing geographical and ethnic backgrounds. The study population was comprised of 275 African Americans (92 males and 183 females) and 282 Nigerians (219 males and 63 females). The mean ages for the African-American males and females were 18.7 and 18.9 years, respectively, compared with 21 and 19.2 years for the Nigerian males and females. African Americans were more likely to be obese and overweight compared with their Nigerian counterparts. However, there were no significant differences between the two ethnic groups within gender for body fat distribution patterns based on waist-to-hip ratio. Despite being leaner, the Nigerians had higher diastolic blood pressures than the African Americans. There were no significant associations observed between blood pressure and waist-to-hip ratio for either the Nigerian or the African-American males or females, and body mass index was associated consistently with blood pressure only among the African Americans. These findings suggest that body mass index, a general indicator of obesity, is a better correlate of blood pressure than the waist-to-hip ratio among African Americans.

Sex and ethnic differences associated with urinary sodium and potassium in African-American US white and Nigerian college students

BP and urinary sodium and potassium were assessed in 183 African-American, 113 US white and 72 Nigerian college students. SBP was higher in African-American males compared with Nigerian and US white males (123.1, 117.6 and 115.7 mmHg, respectively, P < 0.05). There were no significant differences observed between African-American and white male students in overnight urinary excretion rates of sodium and potassium. In contrast, African-American females excreted more sodium (41.0 vs. 31.3 mEq per 8 hours, P < 0.01) and potassium (12.0 vs. 8.9 mEq per 8 hours, P < 0.05) compared with white females. Only among the white students was a significant sex difference observed in urinary electrolyte excretion rates, where males excreted at higher rates than females. Multiple regression models for the African-Americans revealed that potassium explained only 4% of the SBP variance. Among the US whites and Nigerians, sodium explained 4.9% and 6.8%, respectively, of the DBP variance.

Nutritional status of urban Nigerian school children relative to the NCHS reference population

The present study assessed the growth problems in an indigenous African population of Nigerian urban public school children. The study population consisted of 1390 Nigerian children (predominantly Igbo), 718 boys and 672 girls, ages 4-10 years. Compared to the National Center for Health Statistics (NCHS) reference population, the Nigerian children had an excess prevalence of both short stature and underweight. The prevalence of short stature was 14.2% for the boys and 17.4% for the girls. Approximately 20% of the children were underweight whereas less than 1% were considered overweight. These data demonstrate an excess of both acute and chronic malnutrition relative to the NCHS reference population.

The sickle gene: a marker for blood pressure?

Blood pressure patterns were studied in 224 Nigerians comprising 22 families with at least one child with sickle cell anemia (SS) and 18 families without sickle cell anemia (AA) in a community with a high frequency of the sickle trait (AS). Among the offspring (n = 162; mean age: 10.1 years), systolic blood pressure did not differ between the SS, AS, or AA groups. However, the SS group had significantly lower diastolic blood pressure than the AS or AA groups (60.6 versus 66.5 and 65.4 mm Hg, respectively; P < .01). After controlling for genotype, age, body mass index, and sex, regression analysis revealed that age was the only independent correlate of blood pressure.

Are race differences in the prevalence of hypertension explained by body mass and fat distribution? A survey in a biracial population

Body mass and body fat distribution are important considerations in the study of hypertension. However, few studies have investigated the relationships with regards to race differences in elevated arterial pressure. A population-based sample of black and white adults was assessed by interview and physical measurement. The prevalence of hypertension (defined as 140/90 mmHg and/or medically treated) was disproportionately higher among blacks than whites. In addition, blacks had a higher prevalence of the more severe hypertension (160/95 mmHg) and hypertension with higher prevalence at earlier ages than whites. Black females had a significantly higher distribution of body mass index (BMI) than white females, while no difference was found in the distributions of males. White males had a higher distribution of waist to hip ratio (WHR) than black males, while black females had the higher values compared to white females. The prevalence of hypertension increased with BMI and WHR. Blacks maintained higher rates of hypertension after controlling for BMI and WHR, however, the margin of difference diminished when BMI and WHR was considered together. The black-white difference in hypertension was not completely explained by BMI and WHR. In addition, the strength of the association of hypertension and body size was different for blacks and whites which suggests possible differences in the mechanisms regulating blood pressure.

Tracking of blood pressure and anthropometric measures in Nigerian children

Persistence in ranks (tracking) for blood pressure and anthropometric measures over a one year period was examined in 208 Nigerian children (age 6-17 years). Systolic blood pressure tracked better than diastolic blood pressure (r = 0.52 to 0.72) and r = 0.25 to 0.55, respectively). For systolic blood pressure, 56.5%-70.6% of the Nigerian children remained in the top tertile after one year compared with 45.5%-69.2% for diastolic blood pressure. Weight showed the strongest correlation over the one year period (r = 0.88 to 0.97), whereas skinfolds demonstrated the weakest association (r = 0.54 to 0.82). The association between anthropometric measures at baseline and blood pressure one year later revealed for both males and females that height and weight were positively and significantly correlated with blood pressure.

Physical activity, stress, and type A behavior in blacks

We assessed the relationship between potential risk factors for coronary heart disease, including type A behavior, leisure time physical activity, and stress in a young black adult population. The study population consisted of 192 black college freshmen at the University of Pittsburgh. The mean age of male subjects was 18.4; the mean age of female subjects was 18.5 years. No significant sex differences were noted for body mass index, type A behavior, stress, or physical activity levels. For both men and women, type A (Framingham) was positively correlated with stress. Only among women was there a positive association between type A (Bortner) and physical activity.

Atypical myocardial infarction and hypertension: an inner city experience

The clinical features of 304 patients with acute myocardial infarction with and without hypertension were studied retrospectively. This inner city population consisted of 172 (57%) males and 132 (43%) females; 155 (51%) patients were black, 88 (29%) Hispanic, and 61 (20%) white by self-identification. Hypertension (greater than or equal to 160/95 mmHg) was present on admission in 46% (139) of patients. Typical ischaemic chest pain was the most common presenting symptom and occurred with a similar frequency in patients with and without hypertension. However, the group with hypertension consisted of proportionately more females than males, more frequently had previously diagnosed hypertension and congestive heart failure, and more often presented with shortness of breath and pulmonary oedema. The racial distribution, mean ages, prevalence of angina, previous myocardial infarction, diabetes, smoking, family history of cardiovascular disease, type of myocardial infarction, peak creatinine phosphokinase, plasma cholesterol, and mortality rates were similar in both groups. Thus, female sex, history of hypertension, history of congestive heart failure, and pulmonary oedema characterised patients with compared to those without hypertension. These findings suggest that the higher mortality rate observed in hypertensives during follow-up after myocardial infarction may be due, at least in part, to more severe underlying left ventricular dysfunction.

Blood pressure in Nigerian college males

Hypertension is a major cause of morbidity and mortality in US black populations. There are however limited data available on college educated blacks in either the United States or Africa. The purpose of the present study was to examine blood pressure and its correlates in a Nigerian college population in comparison with US data. The study population comprised 211 Nigerian male college students (mean age, 20.9 years). The means and standard deviations for systolic and diastolic blood pressures among the Nigerians were 119.9 (12.6) and 73.3 (10.0) mm Hg, respectively. Weight, height, and body mass index means for the Nigerians were 133.6 pounds, 68.5 inches, and 20.1 kg/m2, respectively. Compared with US college-educated blacks, the Nigerians had higher systolic blood pressures but were leaner than their US counterparts. There was however a significant positive correlation between weight and systolic blood pressure for the Nigerians, which was similar to that observed among US college students. These data suggest that in a lean population, the Nigerian males' weight is still an important correlate of blood pressure as is seen in the US.

Genetic studies of human apolipoproteins. X. The effect of the apolipoprotein E polymorphism on quantitative levels of lipoproteins in Nigerian blacks

Human apolipoprotein E exhibits genetic polymorphism in all populations examined to date. By isoelectric focusing and immunoblotting, three common alleles have been demonstrated in 365 unrelated Nigerian blacks. Furthermore, the APO E genetic polymorphism's effect on quantitative levels of lipids and lipoproteins has been determined. The respective frequencies of the APO E*2, APO E*3, and APO E*4 alleles are .027, .677, and .296. The effect of APO E polymorphism is significant only on total cholesterol and low-density lipoprotein cholesterol. The average excesses of the APO E*2 allele are to lower total cholesterol and low-density lipoprotein cholesterol by 9.19 mg/dl and 11.11 mg/dl, respectively. The average excesses of the APO E*4 allele are to increase total cholesterol and low-density lipoprotein cholesterol by 5.64 mg/dl and 6.18 mg/dl, respectively. On the basis of the differences in (a) the distribution of APO E allele frequencies between the Nigerians and other populations and (b) dietary lipids, we propose a model that shows that lipid metabolism is influenced by the combined effects of the APO E polymorphism and environmental factors.

Genetic studies of human apolipoproteins. XI. The effect of the apolipoprotein C-II polymorphism on lipoprotein levels in Nigerian blacks

The human apolipoprotein C-II locus exhibits genetically determined structural polymorphism in United States and African blacks. In the present study, we have investigated the effect of the apoC-II polymorphism on quantitative serum levels of total cholesterol, total high density lipoprotein (HDL) cholesterol, cholesterol in high density lipoprotein subfractions, low density lipoprotein (LDL) cholesterol, and triglycerides (TG) in a sample of 368 unrelated Nigerian blacks. The frequencies of the APOC-II*1 and APOC-II*2 alleles in the samples were 0.947 and 0.053, respectively. In males, the effect of the APOC-II*2 allele was to lower the total serum cholesterol and LDL-cholesterol levels by 13.28 mg/dl and 10.55 mg/dl, respectively, relative to the common allele, APOC-II*1. In females, the effect was to lower total plasma cholesterol by 4.49 mg/dl and LDL-cholesterol by 3.21 mg/dl. The effect of apoC-II on quantitative lipoprotein levels is shown to be independent of variation at the linked apoE locus, but the products of the two loci interact in determining overall quantitative phenotypes.

Genetic studies of human apolipoproteins. VIII. Role of the apolipoprotein H polymorphism in relation to serum lipoprotein concentrations

Apolipoprotein H (APO H) has recently been identified as a structural component of chylomicrons, very low-density lipoproteins (VLDL), low-density lipoproteins (LDL), and high-density lipoproteins (HDL). Although the precise metabolic function of APO H in lipid metabolism is not certain, it has been suggested that APO H may be involved in triglyceride (TG) metabolism. In addition to the previously described quantitative polymorphism, we have recently detected a common qualitative polymorphism at the APO H structural locus. To test the role of APO H genetic variation in determining lipoprotein and lipid levels, we have estimated the allelic effects of APO H variation on TG, VLDL, LDL, HDL, HDL3, and total cholesterol on 356 Nigerian blacks (189 males, 167 females). While no significant effect of phenotype was observed on lipoprotein levels, the effect of interaction between phenotype and gender was significant. Therefore, data on males and females were analyzed separately using analysis of variance after adjusting for age and body mass index. Logarithmic transformation of pertinent variables was done to bring the distribution of the variables closer to normality. A statistically significant effect of phenotype was observed on triglyceride levels in females only (P less than 0.05). Further analysis of this phenotypic effect revealed that it is due to the impact of the APO H*3 allele, which raises triglycerides by 9.92 mg/dl as compared to the common allele, APO H*2. These findings are in accordance with the postulated role of APO H in triglyceride metabolism. On the basis of its sex-specific effect, we propose a hypothesis that may explain the combined influence of the quantitative and qualitative polymorphisms at the APO H locus on triglyceride levels in females.