Margaret K. Hargreaves

The Association between Perceived Discrimination and Underutilization of Needed Medical and Mental Health Care in a Multi-Ethnic Community Sample

This study examines the association between perceived discrimination and underutilization of needed medical and mental health care, in a representative, multi-ethnic community sample. Data were derived from a cross sectional survey of 10,098 White, U.S.-born Black, African-born Black, American Indian, Hispanic, and Southeast Asian adults in Hennepin County, Minnesota. Even after controlling for socio-demographic characteristics, health care access, and physical and mental health, perceived discrimination was associated with underutilization of medical care among Whites, U.S.-born Blacks, and American Indians and was associated with underutilization of mental health care among Whites, U.S.-born Blacks, Southeast Asians, and American Indians. Correlates of different types of discrimination (major, everyday, health care) on underutilization of care varied among ethnic groups. The higher prevalence of discrimination among racial and ethnic minorities may contribute to their underutilization of health care services. Future research is needed to understand the impacts of different types of discrimination on different groups.

Comparing Diabetes Prevalence Between African Americans and Whites of Similar Socioeconomic Status

OBJECTIVES We investigated whether racial disparities in the prevalence of type 2 diabetes exist beyond what may be attributable to differences in socioeconomic status (SES) and other modifiable risk factors. METHODS We analyzed data from 34331 African American and 9491 White adults aged 40 to 79 years recruited into the ongoing Southern Community Cohort Study. Participants were enrolled at community health centers and had similar socioeconomic circumstances and risk factor profiles. We used logistic regression to estimate the association between race and prevalence of self-reported diabetes after taking into account age, SES, health insurance coverage, body mass index, physical activity, and hypertension. RESULTS Multivariate analyses accounting for several diabetes risk factors did not provide strong support for higher diabetes prevalence rates among African Americans than among Whites (men: odds ratio [OR]=1.07; 95% confidence interval [CI]=0.95, 1.20); women: OR=1.13, 95% CI=1.04, 1.22). CONCLUSIONS Our findings suggest that major differences in diabetes prevalence between African Americans and Whites may simply reflect differences in established risk factors for the disease, such as SES, that typically vary according to race.

The Southern Community Cohort Study: Investigating Health Disparities

Summary: Over 73,700 adults age 40–79, nearly 70% African American, were recruited at community health centers across 12 southeastern states; individual characteristics were recorded and biologic specimens collected at baseline for later follow-up. The Southern Community Cohort Study is a unique national resource for assessing determinants of racial/ethnic differentials in diseases.

Evaluation of 11 breast cancer susceptibility loci in African-American women.

Recent genome-wide association studies (GWAS) have identified multiple common genetic risk variants for breast cancer among women of Asian and European ancestry. Investigating these genetic susceptibility loci in other populations would be helpful to evaluate the generalizability of the findings and identify the causal variants for breast cancer. We evaluated 11 GWAS-identified genetic susceptibility loci for breast cancer in a study including 2,594 African-American women (810 cases and 1,784 controls). Two single-nucleotide polymorphisms, rs13387042 (2q35) and rs1219648 (FGFR2 gene), were found to be associated with breast cancer risk. Risk increased nearly linearly with the number of affected risk alleles, with a 2-fold elevated risk for women homozygous for the risk alleles in both single-nucleotide polymorphisms. No additional significant associations, however, were identified for the other nine loci evaluated in the study. The results from this study extend some of the recent GWAS findings to African-Americans and may guide future efforts to identify the causal variants for breast cancer. (Cancer Epidemiol Biomarkers Prev 2009;18(10):2761–4)

Lung Cancer Risk Among Smokers of Menthol Cigarettes

BACKGROUND Menthol cigarettes, preferred by African American smokers, have been conjectured to be harder to quit and to contribute to the excess lung cancer burden among black men in the Unites States. However, data showing an association between smoking menthol cigarettes and increased lung cancer risk compared with smoking nonmenthol cigarettes are limited. The Food and Drug Administration is currently considering whether to ban the sale of menthol cigarettes in the United States. METHODS We conducted a prospective study among 85,806 racially diverse adults enrolled in the Southern Community Cohort Study during March 2002 to September 2009 according to cigarette smoking status, with smokers classified by preference for menthol vs nonmenthol cigarettes. Among 12,373 smokers who responded to a follow-up questionnaire, we compared rates of quitting between menthol and nonmenthol smokers. In a nested case-control analysis of 440 incident lung cancer case patients and 2213 matched control subjects, using logistic regression modeling we computed odds ratios (ORs) and accompanying 95% confidence intervals (CIs) of lung cancer incidence, and applied Cox proportional hazards modeling to estimate hazard ratios (HRs) of lung cancer mortality, according to menthol preference. RESULTS Among both blacks and whites, menthol smokers reported smoking fewer cigarettes per day; an average of 1.6 (95% CI = 1.3 to 2.0) fewer for blacks and 1.8 (95% CI = 1.3 to 2.3) fewer for whites, compared with nonmenthol smokers. During an average of 4.3 years of follow-up, 21% of participants smoking at baseline had quit, with menthol and nonmenthol smokers having equal odds of quitting (OR = 1.02, 95% CI = 0.89 to 1.16). A lower lung cancer incidence was noted in menthol vs nonmenthol smokers (for smokers of <10, 10-19, and ≥ 20 cigarettes per day, compared with never smokers, OR = 5.0 vs 10.3, 8.7 vs 12.9, and 12.2 vs 21.1, respectively). These trends were mirrored for lung cancer mortality. In multivariable analyses adjusted for pack-years of smoking, menthol cigarettes were associated with a lower lung cancer incidence (OR = 0.65, 95% CI = 0.47 to 0.90) and mortality (hazard ratio of mortality = 0.69, 95% CI = 0.49 to 0.95) than nonmenthol cigarettes. CONCLUSIONS The findings suggest that menthol cigarettes are no more, and perhaps less, harmful than nonmenthol cigarettes.

Diet, nutritional status, and cancer risk in american blacks

About 35% (10-70%) of all cancers may be associated with nutritional causes (1). However, while natural or added substances in foods may be carcinogenic, nutritional deficiencies or excesses may promote carcinogenesis. We compared data from blacks and whites using dietary and nutritional status surveys in the United States to determine whether the poorer dietary patterns and nutritional status of American blacks may be associated with their higher incidence and mortality from certain cancers (compared with whites). Our review indicates that blacks eat more nitrate and animal foods and not enough fiber in relation to protein, fat, and carbohydrate. Blacks also have poorer nutritional status with respect to getting enough thiamine, riboflavin, vitamins A and C, and iron, to being obese (females), and to being underweight (males). This is in agreement with hypotheses regarding the interactions between diet and cancer (associations found in whites) and dose-response relationships reported for some cancers for which blacks have a higher incidence and mortality than whites. More large-scale prospective case-control and cohort studies are needed in both blacks and whites to elucidate the contribution of specific dietary and nutritional factors to the risk of specific cancers in these population groups. However, such studies must be preceded by methodological research to obtain more valid measures of dietary and nutritional status.

Operationalization of community-based participatory research principles: Assessment of the National Cancer Institute's Community Network Programs

OBJECTIVES We examined how National Cancer Institute-funded Community Network Programs (CNPs) operationalized principles of community-based participatory research (CBPR). METHODS We reviewed the literature and extant CBPR measurement tools. On the basis of that review, we developed a 27-item questionnaire for CNPs to self-assess their operationalization of 9 CBPR principles. Our team comprised representatives of 9 of the National Cancer Institutes 25 CNPs. RESULTS Of the 25 CNPs, 22 (88%) completed the questionnaire. Most scored well on CBPR principles of recognizing community as a unit of identity, building on community strengths, facilitating colearning, embracing iterative processes in developing community capacity, and achieving a balance between data generation and intervention. CNPs varied in the extent to which they employed CBPR principles of addressing determinants of health, sharing power among partners, engaging the community in research dissemination, and striving for sustainability. CONCLUSIONS Although the development of assessment tools in this field is in its infancy, our findings suggest that fidelity to CBPR processes can be assessed in a variety of settings.

Stages of change and the intake of dietary fat in African-American women: improving stage assignment using the Eating Styles Questionnaire.

OBJECTIVE To develop an algorithm for determining the stage of change for dietary fat intake in African-American women. DESIGN We examined the relationships between stage of change, dietary fat intake, and associated eating behaviors and developed an assessment tool for placing subjects in their appropriate stage of change. SUBJECTS Working class and middle-income African-American women in Nashville, Tenn; 174 in study 1 and 208 in study 2. STATISTICAL ANALYSES Fat and fiber intake by stage of change was examined using multivariate analysis of variance. Hierarchical cluster analysis was performed using Wards method. RESULTS A significant difference in fat intake was noted between women trying to change their intake and those not trying to change in study 1 (P < .001) and study 2 (P < .03). Of those trying to change, only 34% (study 1) and 9% (study 2) of subjects reported fat intakes below the Healthy People 2000 goal of 30% of energy from fat. In study 1, cluster analysis identified 14 groups of foods that significantly separated subjects into not trying, noncompliant, and compliant categories. Compliant subjects ate out less; ate fewer snack foods and less chicken, meat, and fat; and ate more fruits, vegetables, breakfast foods, and low-fat products. These results led to development of the Eating Styles Questionnaire (study 2), which facilitated more appropriate placement of the noncompliant group in stages of change for dietary fat intake. APPLICATIONS/CONCLUSIONS These data support the stage construct of the Transtheoretical Model for dietary fat reduction in African-American women. Moreover, the Eating Styles Questionnaire (ESQ) can improve determination of stage of change for this group of women. The ESQ can be used to diagnose the eating styles that contribute to a high-fat intake and help in the design of interventions to lower fat intakes.

Blood vitamin D levels in relation to genetic estimation of African ancestry.

Background: African-Americans generally have lower circulating levels of 25 hydroxyvitamin D [25(OH)D] than Whites, attributed to skin pigmentation and dietary habits. Little is known about the genetic determinants of 25(OH)D levels nor whether the degree of African ancestry associates with circulating 25(OH)D. Methods: With the use of a panel of 276 ancestry informative genetic markers, we estimated African and European admixture for a sample of 758 African-American and non-Hispanic White Southern Community Cohort Study participants. For African-Americans, cut points of <85%, 85% to 95%, and ≥95% defined low, medium, and high African ancestry, respectively. We estimated the association between African ancestry and 25(OH)D and also explored whether vitamin D exposure (sunlight, diet) had varying effects on 25(OH)D levels dependent on ancestry level. Results: The mean serum 25(OH)D levels among Whites and among African-Americans of low, medium, and high African ancestry were 27.2, 19.5, 18.3, and 16.5 ng/mL, respectively. Serum 25(OH)D was estimated to decrease by 1.0 to 1.1 ng/mL per 10% increase in African ancestry. The effect of high vitamin D exposure from sunlight and diet was 46% lower among African-Americans with high African ancestry than among those with low/medium ancestry. Conclusions: We found novel evidence that the level of African ancestry may play a role in clinical vitamin D status. Impact: This is the first study to describe how 25(OH)D levels vary in relation to genetic estimation of African ancestry. Further study is warranted to replicate these findings and uncover the potential pathways involved. Cancer Epidemiol Biomarkers Prev; 19(9); 2325–31. ©2010 AACR.

Obesity and All-Cause Mortality Among Black Adults and White Adults

In recent pooled analyses among whites and Asians, mortality was shown to rise markedly with increasing body mass index (BMI; weight (kg)/height (m)(2)), but much less is known about this association among blacks. This study prospectively examined all-cause mortality in relation to BMI among 22,014 black males, 9,343 white males, 30,810 black females, and 14,447 white females, aged 40-79 years, from the Southern Community Cohort Study, an epidemiologic cohort of largely low-income participants in 12 southeastern US states. Participants enrolled in the cohort from 2002 to 2009 and were followed up to 8.9 years. Hazard ratios and 95% confidence intervals for mortality were obtained from sex- and race-stratified Cox proportional hazards models in association with BMI at cohort entry, adjusting for age, education, income, cigarette smoking, and alcohol consumption. Elevated BMI was associated with increased mortality among whites (hazard ratios for BMI >40 vs. 20-24.9 = 1.37 (95% confidence interval (CI): 1.02, 1.84) and 1.47 (95% CI: 1.15, 1.89) for white males and white females, respectively) but not significantly among blacks (hazard ratios = 1.13 (95% CI: 0.89, 1.43) and 0.87 (95% CI: 0.72, 1.04) for black males and black females, respectively). In this large cohort, obesity in mid-to-late adulthood among blacks was not associated with the same excess mortality risk seen among whites.