Stephen J. Mooney

Epidemiology in the Era of Big Data

Big Data has increasingly been promoted as a revolutionary development in the future of science, including epidemiology. However, the definition and implications of Big Data for epidemiology remain unclear. We here provide a working definition of Big Data predicated on the so-called “three V’s”: variety, volume, and velocity. From this definition, we argue that Big Data has evolutionary and revolutionary implications for identifying and intervening on the determinants of population health. We suggest that as more sources of diverse data become publicly available, the ability to combine and refine these data to yield valid answers to epidemiologic questions will be invaluable. We conclude that while epidemiology as practiced today will continue to be practiced in the Big Data future, a component of our field’s future value lies in integrating subject matter knowledge with increased technical savvy. Our training programs and our visions for future public health interventions should reflect this future.

Validity of an Ecometric Neighborhood Physical Disorder Measure Constructed by Virtual Street Audit

Neighborhood physical disorder is thought to affect mental and physical health, but it has been difficult to measure objectively and reliably across large geographical areas or multiple locales. Virtual street audits are a novel method for assessing neighborhood characteristics. We evaluated the ecometric properties of a neighborhood physical disorder measure constructed from virtual street audit data. Eleven trained auditors assessed 9 previously validated items developed to capture physical disorder (e.g., litter, graffiti, and abandoned buildings) on 1,826 block faces using Google Street View imagery (Google, Inc., Mountain View, California) dating from 2007-2011 in 4 US cities (San Jose, California; Detroit, Michigan; New York, New York; and Philadelphia, Pennsylvania). We constructed a 2-parameter item response theory scale to estimate latent levels of disorder on each block face and defined a function using kriging to estimate physical disorder levels, with confidence estimates, for any point in each city. The internal consistency reliability of the resulting scale was 0.93. The final measure of disorder was positively correlated with US Census data on unemployment and housing vacancy and negatively correlated with data on owner-occupied housing. These results suggest that neighborhood physical disorder can be measured reliably and validly using virtual audits, facilitating research on possible associations between physical disorder and health.

Development and deployment of the Computer Assisted Neighborhood Visual Assessment System (CANVAS) to measure health-related neighborhood conditions.

Public health research has shown that neighborhood conditions are associated with health behaviors and outcomes. Systematic neighborhood audits have helped researchers measure neighborhood conditions that they deem theoretically relevant but not available in existing administrative data. Systematic audits, however, are expensive to conduct and rarely comparable across geographic regions. We describe the development of an online application, the Computer Assisted Neighborhood Visual Assessment System (CANVAS), that uses Google Street View to conduct virtual audits of neighborhood environments. We use this system to assess the inter-rater reliability of 187 items related to walkability and physical disorder on a national sample of 150 street segments in the United States. We find that many items are reliably measured across auditors using CANVAS and that agreement between auditors appears to be uncorrelated with neighborhood demographic characteristics. Based on our results we conclude that Google Street View and CANVAS offer opportunities to develop greater comparability across neighborhood audit studies.

Prenatal Exposure to Phthalates and Childhood Body Size in an Urban Cohort

Background: Phthalate exposures are hypothesized to increase obesity; however, prior research has been largely cross-sectional. Objective: We evaluated associations between prenatal phthalate exposures and body mass index (BMI) at child ages 5 and 7 years. Methods: Nine metabolites of six phthalates—di(2-ethylhexyl) phthalate (DEHP), di-n-octyl-, di-iso-butyl-, di-n-butyl-, butylbenzyl-, and diethyl phthalates—were measured in spot urine samples collected from pregnant African-American and Dominican women during their third trimester, and from their children at ages 3 and 5 years. To reduce multiple comparison issues, we initially used principal component analysis (PCA) to identify major patterns of natural log (ln)-transformed metabolite concentrations. Height and weight were assessed at ages 5 and 7 years, and fat mass and waist circumference at age 7. Linearized generalized estimating equation analyses related maternal component scores to child anthropometric outcomes at ages 5 (n = 326) and 7 (n = 330) years. Results: PCA identified a DEHP component and a non-DEHP component. In boys, higher maternal non-DEHP, but not DEHP, component scores were associated with lower BMI z-score (β = –0.30; 95% CI: –0.50, –0.10, n = 156), lower fat percentage (β = –1.62; 95% CI: –2.91, –0.34, n = 142), and smaller waist circumference (β = –2.02; 95% CI: –3.71, –0.32, n = 124). No significant associations with anthropometric outcomes were seen in girls (for BMI z-score, β = 0.07; 95% CI: –0.18, 0.31, n = 181). Interactions between sex and non-DEHP component association with outcomes were statistically significant (p < 0.01). Conclusions: Contrary to hypotheses, prenatal non-DEHP phthalate exposures were associated with lower BMI z-score, waist circumference, and fat mass in boys during early childhood. Citation: Maresca MM, Hoepner LA, Hassoun A, Oberfield SE, Mooney SJ, Calafat AM, Ramirez J, Freyer G, Perera FP, Whyatt RM, Rundle AG. 2016. Prenatal exposure to phthalates and childhood body size in an urban cohort. Environ Health Perspect 124:514–520; http://dx.doi.org/10.1289/ehp.1408750

Incidence and Predictors of Bowel Obstruction in Elderly Patients With Stage IV Colon Cancer: A Population-Based Cohort Study

IMPORTANCE Research has been limited on the incidence, mechanisms, etiology, and treatment of symptoms that require palliation in patients with terminal cancer. Bowel obstruction (BO) is a common complication of advanced abdominal cancer, including colon cancer, for which small, single-institution studies have suggested an incidence rate of 15% to 29%. Large population-based studies examining the incidence or risk factors associated with BO in cancer are lacking. OBJECTIVE To investigate the incidence and risk factors associated with BO in patients with stage IV colon cancer. DESIGN AND SETTING Retrospective cohort, population-based study of patients in the Surveillance, Epidemiology, and End Results and Medicare claims linked databases who were diagnosed as having stage IV colon cancer from January 1, 1991, through December 31, 2005. PATIENTS Patients 65 years or older with stage IV colon cancer (n = 12 553). MAIN OUTCOMES AND MEASURES Time to BO, defined by inpatient hospitalization for BO. We used Cox proportional hazards regression models to determine associations between BO and patient, prior treatment, and tumor features. RESULTS We identified 1004 patients with stage IV colon cancer subsequently hospitalized with BO (8.0%). In multivariable analysis, proximal tumor site (hazard ratio, 1.22 [95% CI, 1.07-1.40]), high tumor grade (1.34 [1.16-1.55]), mucinous histological type (1.27 [1.08-1.50]), and nodal stage N2 (1.52 [1.26-1.84]) were associated with increased risk of BO, as was the presence of obstruction at cancer diagnosis (1.75 [1.47-2.04]). A more recent diagnosis was associated with decreased risk of subsequent obstruction (hazard ratio, 0.84 [95% CI, 0.72-0.98]). CONCLUSIONS AND RELEVANCE In this large population of patients with stage IV colon cancer, BO after diagnosis was less common (8.0%) than previously reported. Risk was associated with site and histological type of the primary tumor. Future studies will explore management and outcomes in this serious, common complication.

Comparison of anthropometric and body composition measures as predictors of components of the metabolic syndrome in a clinical setting

PROBLEM The use of body mass index (BMI) to assess obesity and health risks has been criticized in scientific and lay publications because of its failure to account for body shape and inability to distinguish fat mass from lean mass. We sought to determine whether other anthropometric measures (waist circumference (WC), waist-to-height ratio (WtH), percent body fat (%BF), fat mass index (FMI), or fat-free mass index (FFMI)) were consistently better predictors of components of the metabolic syndrome than BMI is. METHODS Cross-sectional measurements of height, weight, waist circumference and percent body fat were obtained from 12,294 adults who took part in annual physical exams provided by EHE International, Inc. Blood pressure was measured during the exam and HDL, LDL, and fasting glucose were measured from blood samples. Pearson correlations, linear regression, and adjusted Receiver Operator Characteristic (ROC) curves were used to relate each anthropometric measure to each metabolic risk factor. RESULTS None of the measures was consistently the strongest predictor. BMI was the strongest predictor of blood pressure, measures related to central adiposity (WC and WtH) performed better at predicting fasting glucose, and all measures were roughly comparable at predicting cholesterol levels. In all, differences in areas under ROC curves were 0.03 or less for all measure/outcome pairs that performed better than BMI. CONCLUSION Body mass index is an adequate measure of adiposity for clinical purposes. In the context of lay press critiques of BMI and recommendations for alternative body-size measures, these data support clinicians making recommendations to patients based on BMI measurements.

Bowel obstruction in elderly ovarian cancer patients: A population-based study

PURPOSE Bowel obstruction is a common pre-terminal event in abdominal/pelvic cancer that has mainly been described in small single-institution studies. We used a large, population-based database to investigate the incidence, management, and outcomes of obstruction in ovarian cancer patients. PATIENTS AND METHODS We identified patients with stages IC-IV ovarian cancer, aged 65 years or older, in the Surveillance, Epidemiology and End Results (SEER)-Medicare database diagnosed between January 1, 1991 and December 31, 2005. We modeled predictors of inpatient hospitalization for bowel obstruction after cancer diagnosis, categorized management of obstruction, and analyzed the associations between treatment for obstruction and outcomes. RESULTS Of 8607 women with ovarian cancer, 1518 (17.6%) were hospitalized for obstruction subsequent to cancer diagnosis. Obstruction at cancer diagnosis (HR=2.17, 95%CI: 1.86-2.52) and mucinous tumor histology (HR=1.45, 95%CI: 1.15-1.83) were associated with increased risk of subsequent obstruction. Surgical management of obstruction was associated with lower 30-day mortality (13.4% in women managed surgically vs. 20.2% in women managed non-surgically), but equivalent survival after 30 days and equivalent rates of post-obstruction chemotherapy. Median post-obstruction survival was 382 days in women with obstructions of adhesive origin and 93 days in others. CONCLUSION In this large-scale, population-based assessment of patients with advanced ovarian cancer, nearly 20% of women developed bowel obstruction after cancer diagnosis. While obstruction due to adhesions did not signal the end of life, all other obstructions were pre-terminal events for the majority of patients regardless of treatment.

Stigma and the etiology of depression among the obese: An agent-based exploration

BACKGROUND Obesity and depression are comorbid more often than chance predicts. However, depression among the obese is more common in settings where obesity is less common. This suggests that body habitus norms and social stigmatization may play a role in the etiology of depression among the obese. METHODS We developed an agent-based social network model to explore mechanisms by which deviance from normative body habitus may contribute to social isolation in the obese. At each of 240 simulated months (20 years), each agent updated its body mass index based on environmental, peer influence, and stochastic factors. At each month, each agent was subject to social ostracization and consequent depression if its body mass index deviated from that of its peers and the network-wide mean. We compared risk of depression as a function of obesity and obesity norms through simulations of a high-obesity context simulating the US state of Mississippi and a low-obesity context simulating the US state of Colorado, then explored the relationship between global obesogenic forces and agent-specific resistance to the forces. RESULTS Over 1000 simulations in each context, 25 percent of obese agents in simulated Colorado were ever-depressed as compared to 21 percent in simulated Mississippi, although 10 percent overall were ever-depressed in both settings. High and low levels of resistance to obesogeneity prevented the most depression, whereas medium resistance levels were more depressogenic. CONCLUSIONS Social stigma and ostracization that occur as a consequence of deviance from body habitus norms may be a plausible mechanism by which weight stigma may influence depression in the obese. Public health interventions targeting individuals rather than obesogenic environments may modify body habitus norms with the unintended consequence of increasing stigma-based social isolation among those who remain obese.

Management and Outcomes of Bowel Obstruction in Patients with Stage IV Colon Cancer: A Population-Based Cohort Study

BACKGROUND: Bowel obstruction is a common complication of late-stage abdominal cancer, especially colon cancer, which has been investigated predominantly in small, single-institution studies. OBJECTIVE: We used a large, population-based data set to explore the surgical treatment of bowel obstruction and its outcomes after hospitalization for obstruction among patients with stage IV colon cancer. DESIGN: This was a retrospective cohort study. SETTING AND PATIENTS: We identified 1004 patients aged 65 years or older in the Surveillance, Epidemiology and End Results-Medicare database diagnosed with stage IV colon cancer January 1, 1991 to December 31, 2005, who were later hospitalized for bowel obstruction. MAIN OUTCOME MEASURES: We describe outcomes after hospitalization and analyzed the associations between surgical treatment of obstruction and outcomes. RESULTS: Hospitalization for bowel obstruction occurred a median of 7.4 months after colon cancer diagnosis, and median survival after obstruction was approximately 2.5 months. Median hospitalization for obstruction was about 1 week and in-hospital mortality was 12.7%. Between discharge and death, 25% of patients were readmitted to the hospital at least once for obstruction, and, on average, patients lived 5 days out of the hospital for every day in the hospital between obstruction diagnosis and death. Survival was 3 times longer in those whose obstruction claims suggested an adhesive obstruction origin. In multivariable models, surgical compared with nonsurgical management was not associated with prolonged survival (p = 0.134). LIMITATIONS: Use of an administrative database did not allow determination of quality of life or relief of obstruction as an outcome, nor could nonsurgical interventions, eg, endoscopic stenting or octreotide, be assessed. CONCLUSIONS: In this population-based study of patients with stage IV colon cancer who had bowel obstruction, overall survival following obstruction was poor irrespective of treatment. Universally poor outcomes suggest that a diagnosis of obstruction in the setting of advanced colon cancer should be considered a preterminal event.

Beyond METs: types of physical activity and depression among older adults.

BACKGROUND/OBJECTIVES physical activity may be beneficial in reducing depression incidence among the elderly. A key unanswered question is whether certain types of physical activity are particularly associated with decreased depression incidence. We examined the relationship between quantity and type of physical activity and subsequent depression using longitudinal data from elderly adults in New York City (NYC). METHODS we followed 3,497 adults aged 65-75 living in NYC for three years. Total physical activity was measured using the Physical Activity Scale for the Elderly (PASE) and type of physical activity was measured using a latent class analysis of PASE item responses. We used generalised estimating equations to measure the relationship between quantity and latent class of physical activity at waves 1-2 and depression at waves 2-3, controlling for wave-1 depression. RESULTS individuals in the second highest quartile (50-75%) (odds ratio (OR) = 0.45; 95% confidence interval (CI) = 0.23, 0.88) and highest quartile of activity (OR = 0.31; 95% CI = 0.16, 0.63) had lower odds of depression. Among all subjects, athletic types (OR = 0.25; 95% CI = 0.12, 0.51) and walker types (OR = 0.58; 95% CI = 0.34, 0.99) had lower odds of depression. Among non-disabled participants, walkers (OR = 0.36; 95% CI = 0.18, 0.73), athletic types (OR = 0.14; 95% CI = 0.06, 0.32), domestic/gardening types (OR = 0.29; 95% CI = 0.12, 0.73) and domestic/gardening athletic types (OR = 0.13; 95% CI = 0.02, 0.75) had lower odds of depression. CONCLUSION respondents who practised the highest levels of physical activity and who performed athletic activities were at lower risk for depression. Interventions aimed at promoting athletic physical activity among older adults may generate benefits for mental health.