Representative Public Health Surveys Pose Several Challenges: Lessons Learned Across 9 Communities During the COVID-19 Pandemic.

Community surveillance surveys offer an opportunity to obtain important and timely public health information that may help local municipalities guide their response to public health threats. The objective of this paper is to present approaches, challenges, and solutions from SARS-CoV-2 surveillance surveys conducted in different settings by 2 research teams. For rapid assessment of a representative sample, a 2-stage cluster sampling design was developed by an interdisciplinary team of researchers at Oregon State University between April 2020 and June 2021 across 6 Oregon communities. In 2022, these methods were adapted for New York communities by a team of veterinary, medical, and public health practitioners. Partnerships were established with local medical facilities, health departments, COVID-19 testing sites, and health and public safety staff. Field staff were trained using online modules, field manuals describing survey methods and safety protocols, and in-person meetings with hands-on practice. Private and secure data integration systems and public awareness campaigns were implemented. Pilot surveys and field previews revealed challenges in survey processes that could be addressed before surveys proceeded. Strong leadership, robust trainings, and university-community partnerships proved critical to successful outcomes. Cultivating mutual trust and cooperation among stakeholders is essential to prepare for the next pandemic.

Evaluation of a Wastewater-Based Epidemiological Approach to Estimate the Prevalence of SARS-CoV-2 Infections and the Detection of Viral Variants in Disparate Oregon Communities at City and Neighborhood Scales.

BACKGROUND: Positive correlations have been reported between wastewater SARS-CoV-2 concentrations and a community's burden of infection, disease or both. However, previous studies mostly compared wastewater to clinical case counts or nonrepresentative convenience samples, limiting their quantitative potential. OBJECTIVES: This study examined whether wastewater SARS-CoV-2 concentrations could provide better estimations for SARS-CoV-2 community prevalence than reported cases of COVID-19. In addition, this study tested whether wastewater-based epidemiology methods could identify neighborhood-level COVID-19 hotspots and SARS-CoV-2 variants. METHODS: Community SARS-CoV-2 prevalence was estimated from eight randomized door-to-door nasal swab sampling events in six Oregon communities of disparate size, location, and demography over a 10-month period. Simultaneously, wastewater SARS-CoV-2 concentrations were quantified at each community's wastewater treatment plant and from 22 Newport, Oregon, neighborhoods. SARS-CoV-2 RNA was sequenced from all positive wastewater and nasal swab samples. Clinically reported case counts were obtained from the Oregon Health Authority. RESULTS: Estimated community SARS-CoV-2 prevalence ranged from 8 to 1,687/10,000 persons. Community wastewater SARS-CoV-2 concentrations ranged from 2.9 to 5.1 log10 gene copies per liter. Wastewater SARS-CoV-2 concentrations were more highly correlated (Pearson's r=0.96; R2=0.91) with community prevalence than were clinically reported cases of COVID-19 (Pearson's r=0.85; R2=0.73). Monte Carlo simulations indicated that wastewater SARS-CoV-2 concentrations were significantly better than clinically reported cases at estimating prevalence (p<0.05). In addition, wastewater analyses determined neighborhood-level COVID-19 hot spots and identified SARS-CoV-2 variants (B.1 and B.1.399) at the neighborhood and city scales. DISCUSSION: The greater reliability of wastewater SARS-CoV-2 concentrations over clinically reported case counts was likely due to systematic biases that affect reported case counts, including variations in access to testing and underreporting of asymptomatic cases. With these advantages, combined with scalability and low costs, wastewater-based epidemiology can be a key component in public health surveillance of COVID-19 and other communicable infections. https://doi.org/10.1289/EHP10289.

The Survey of the Health of Wisconsin (SHOW) Program: An Infrastructure for Advancing Population Health.

Introduction: The Survey of the Health of Wisconsin (SHOW) was established in 2008 by the University of Wisconsin (UW) School of Medicine and Public Health (SMPH) with the goals of (1) providing a timely and accurate picture of the health of the state residents; and (2) serving as an agile resource infrastructure for ancillary studies. Today, the SHOW program continues to serve as a unique and vital population health research infrastructure for advancing public health. Methods: SHOW currently includes 5,846 adult and 980 minor participants recruited between 2008 and 2019 in four primary waves. WAVE I (2008-2013) includes annual statewide representative samples of 3,380 adults ages 21 to 74 years. WAVE II (2014-2016) is a triannual statewide sample of 1,957 adults (age ≥18 years) and 645 children (age 0-17). WAVE III (2017) consists of follow-up of 725 adults from the WAVE I and baseline surveys of 222 children in selected households. WAVEs II and III include stool samples collected as part of an ancillary study in a subset of 784 individuals. WAVE IV consists of 517 adults and 113 children recruited from traditionally under-represented populations in biomedical research including African Americans and Hispanics in Milwaukee, Wisconsin. Findings to Date: The SHOW resource provides unique spatially granular and timely data to examine the intersectionality of multiple social determinants and population health. SHOW includes a large biorepository and extensive health data collected in a geographically diverse urban and rural population. Over 60 studies have been published covering a broad range of topics including, urban and rural disparities in cardio-metabolic disease and cancer, objective physical activity, sleep, green-space and mental health, transcriptomics, the gut microbiome, antibiotic resistance, air pollution, concentrated animal feeding operations and heavy metal exposures. Discussion: The SHOW cohort and resource is available for continued follow-up and ancillary studies including longitudinal public health monitoring, translational biomedical research, environmental health, aging, microbiome and COVID-19 research.

Sleep problems and risk of cancer incidence and mortality in an older cohort: The Cardiovascular Health Study (CHS).

BACKGROUND: Sleep problems (SP) can indicate underlying sleep disorders, such as obstructive sleep apnea, which may adversely impact cancer risk and mortality. METHODS: We assessed the association of baseline and longitudinal sleep apnea and insomnia symptoms with incident cancer (N = 3930) and cancer mortality (N = 4580) in the Cardiovascular Health Study. We used Cox proportional hazards regression to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) to evaluate the associations. RESULTS: Overall, 885 incident cancers and 804 cancer deaths were identified over a median follow-up of 12 and 14 years, respectively. Compared to participants who reported no sleep apnea symptoms, the risk of incident cancer was inversely associated [(HR (95%CI)] with snoring [0.84 (0.71, 0.99)]. We noted an elevated prostate cancer incidence for apnea [2.34 (1.32, 4.15)] and snoring [1.69 (1.11, 2.57)]. We also noted an elevated HR for lymphatic or hematopoietic cancers [daytime sleepiness: 1.81 (1.06, 3.08)]. We found an inverse relationship for cancer mortality with respect to snoring [0.73 (0.62, 0.8)] and apnea [(0.69 (0.51, 0.94))]. We noted a significant inverse relationship between difficulty falling asleep and colorectal cancer death [0.32 (0.15, 0.69)] and snoring with lung cancer death [0.56 (0.35, 0.89)]. CONCLUSIONS: The relationship between SP and cancer risk and mortality was heterogeneous. Larger prospective studies addressing more cancer sites, molecular type-specific associations, and better longitudinal SP assessments are needed for improved delineation of SP-cancer risk dyad.

The Survey of the Health of Wisconsin (SHOW) Program: An infrastructure for Advancing Population Health Sciences.

PURPOSE: The Survey of the Health of Wisconsin (SHOW) was established in 2008 by the University of Wisconsin (UW) School of Medicine and Public Health (SMPH) with the goals of 1) providing a timely and accurate picture of the health of the state residents; and 2) serving as an agile resource infrastructure for ancillary studies. Today SHOW continues to serve as a vital population health research infrastructure. PARTICIPANTS: SHOW currently includes 5,846 adult and 980 minor participants recruited between 2008-2019 in four primary waves. WAVE I (2008-2013) includes annual statewide representative samples of 3,380 adults ages 21 to 74 years. WAVE II (2014-2016) is a triannual statewide sample of 1957 adults (age ≥18 years) and 645 children. WAVE III (2017) consists of follow-up of 725 adults from the WAVE I and baseline surveys of 222 children in selected households. WAVEs II and III include stool samples collected as part of an ancillary study in a subset of 784 individuals. WAVE IV consist of 517 adults and 113 children recruited from traditionally under-represented populations in biomedical research including African Americans and Hispanics in Milwaukee county, WI. FINDINGS TO DATE: The SHOW provides extensive data to examine the intersectionality of multiple social determinants and population health. SHOW includes a large biorepository and extensive health data collected in a geographically diverse urban and rural population. Over 60 studies have been published covering a broad range of topics including, urban and rural disparities in cardio-metabolic disease and cancer, objective physical activity, sleep, green-space and mental health, transcriptomics, the gut microbiome, antibiotic resistance, air pollution, concentrated animal feeding operations and heavy metal exposures. FUTURE PLANS: The SHOW cohort is available for continued longitudinal follow-up and ancillary studies including genetic, multi-omic and translational environmental health, aging, microbiome and COVID-19 research. ARTICLE SUMMARY: Strengths and limitations: The Survey of the Health of Wisconsin (SHOW) is an infrastructure to advance population health sciences including biological sample collection and broader data on individual and neighborhood social and environmental determinants of health.The extensive data from diverse urban and rural populations offers a unique study sample to compare how socio-economic gradients shape health outcomes in different contexts.The objective health data supports novel interdisciplinary research initiatives and is especially suited for research in causes and consequences of environmental exposures (physical, chemical, social) across the life course on cardiometabolic health, immunity, and aging related conditions.The extensive biorepository supports novel omics research into common biological mechanisms underlying numerous complex chronic conditions including inflammation, oxidative stress, metabolomics, and epigenetic modulation.Ancillary studies, such as the Wisconsin Microbiome Study, have expanded the utility of the study to examine human susceptibility to environmental exposures and opportunities for investigations of the role of microbiome in health and disease.Long-standing partnerships and recent participation among traditionally under-represented populations in biomedical research offer numerous opportunities to support community-driven health equity work.No biological samples were collected among children.The statewide sampling frame may limit generalizability to other regions in the United States.

Reasons Behind Preferences for Community-Based Continence Promotion.

OBJECTIVES: This study aimed to understand the potential reach of continence promotion intervention formats among incontinent women. METHODS: The Survey of the Health of Wisconsin conducts household interviews on a population-based sample. In 2016, 399 adult women were asked about incontinence and likelihood of participation in continence promotion via 3 formats: single lecture, interactive 3-session workshop, or online. Descriptive analyses compared women likely versus unlikely to participate in continence promotion. To understand format preferences, modified grounded theory was used to conduct and analyze telephone interviews. RESULTS: One hundred eighty-seven (76%) of 246 incontinent women reported being likely to attend continence promotion: 111 (45%) for a single lecture, 43 (17%) for an interactive 3-session workshop, and 156 (64%) for an online program. Obesity, older age, nonwhite race, prior health program participation, and Internet use for health information were associated with reported continence promotion participation. Cited advantages of a single lecture included convenience and ability to ask questions. A workshop offered accountability, hands-on learning, and opportunity to learn from others; online format offered privacy, convenience, and self-directed learning. CONCLUSIONS: Most incontinent women are willing to participate in continence promotion, especially online.

Perspectives on the Future of Epidemiology: A Framework for Training.

Over the past century, the field of epidemiology has evolved and adapted to changing public health needs. Challenges include newly emerging public health concerns across broad and diverse content areas, new methods, and vast data sources. We recognize the need to engage and educate the next generation of epidemiologists and prepare them to tackle these issues of the 21st century. In this commentary, we suggest a skeleton framework upon which departments of epidemiology should build their curriculum. We propose domains that include applied epidemiology, biological and social determinants of health, communication, creativity and ability to collaborate and lead, statistical methods, and study design. We believe all students should gain skills across these domains to tackle the challenges posed to us. The aim is to train smart thinkers, not technicians, to embrace challenges and move the expanding field of epidemiology forward.

Individuals' perceptions of social support from family and friends are associated with lower risk of sleep complaints and short sleep duration.

OBJECTIVE: To examine whether individuals' perceptions of social support (SS) from partners, other family members, and friends are associated with risk of sleep complaints and short sleep duration. METHODS: A cross-sectional and prospective study with 1,688 community dwelling adults from the Retirement and Sleep Trajectories study. Four annual, self-administered questionnaires were mailed to participants in the year 2010-2014. Self-reports of individuals' perceptions of SS were obtained at the baseline survey. Sleep quality and duration were self-reported on each of the four surveys over the follow-up. Associations were examined with mixed-effect models, controlling for confounders. RESULTS: In fully adjusted analyses, compared with those reporting low SS from their partner, the risk of reporting more than 1 sleep symptom was significantly lower among those with intermediate (relative risk, RR = 0.68; 95% confidence interval, CI = 0.53-0.87) and high SS (RR = 0.61; 95% CI=0.48-0.77). Similarly, relative to those with low SS, those reporting high SS from family (RR = 0.74; 95% CI = 0.57-0.94) and friends (RR = 0.73; 95% CI = 0.58-0.92) had lower risk of having more than 1 sleep symptom. Compared with those with low, intermediate (RR = 0.70; 95% CI = 0.52-0.96), and high SS (RR = 0.63; 95% CI = 0.48-0.84) from partners, intermediate (RR = 0.76; 95% CI = 0.59-0.97) and high SS (RR = 0.69; 95% CI = 0.51-0.92) from family and high SS (RR = 0.74; 95% CI = 0.56-0.99) from friends were associated with lower risk of short sleep (≤6 h). CONCLUSION: The perception of higher SS from relatives and friends is independently associated with lower risk of poor sleep quality and short sleep duration. Future research and intervention studies should test whether strengthening social relationships can positively effect sleep health.

One-year changes in self-reported napping behaviors across the retirement transition.

OBJECTIVE: To estimate associations of retirement with self-reported frequency and duration of naps. DESIGN: Prospective cohort study. SETTING: Population-based. PARTICIPANTS: 1359 current and former Wisconsin state employees, aged 54-69. MEASUREMENTS: Four annual surveys mailed between 2010 and 2014 elicited employment status and nap characteristics. Changes in employment status and nap characteristics were identified from survey pairs measured 1 year apart (up to 3 survey pairs per subject). General linear mixed models with repeated measures were used to estimate changes in minutes napped per week (MNPW), weekly nap frequency, and individual nap duration as predicted by retirement transitions vs stable employment status. All models were adjusted for demographic characteristics, self-rated health, medical diagnoses, sleep problems, circadian preference, and change in nocturnal sleep duration. RESULTS: There were 3101 survey pairs in the analytic sample. Full retirement (transition from working ≥35 h/wk to not working for pay) over a 1-year period predicted a statistically significantly larger mean change in MNPW than stable employment status: mean (95% confidence interval) = +48 (+16, +80) MNPW. Associations between staged retirement transitions (from full-time to part-time work, or from part-time work to full retirement) and 1-year changes in MNPW were not statistically significant. The MNPW changes associated with full retirement were attributable to nap frequency increase of +0.4 (+0.1, +0.8) d/wk; nap duration did not change significantly. CONCLUSIONS: Compared with stable employment status, full retirement is associated with an average 1-year increase of +48 MNPW. This change is attributable to a frequency gain of 0.4 d/wk napped. Changes in nap duration were negligible.

Actigraphic Sleep and Dietary Macronutrient Intake in Children Aged 6-9 Years Old: A Pilot Study.

The objective of this study was to examine the relationship between different sleep parameters and energy and macronutrient intake in school-aged children. A total of 203 children 6 to 9 years of age participated in this cross-sectional study. Anthropometric measurements were taken first. Diet was assessed with 3-day food logs and sleep was measured with a questionnaire on sleep quality and a wrist actigraph worn for at least 7 days. A decrease of 165.45 kcal was observed per each additional hour of sleep during the week (ß (95% CI) = -165.45 (-274.01, -56.88); p = 0.003). This relationship was also observed for fat (ß (95% CI) = -11.14 (-18.44, -3.84); p = 0.003) and protein (ß (95% CI) = -13.27 (-22.52, -4.02); p = 0.005). An increase in weekend sleep efficiencies for those under the recommended threshold of 85% also had a similar association with energy (ß (95% CI) = -847.43 (-1566.77, 128.09); p = 0.021) and carbohydrate (ß (95% CI) = -83.96 (-161.76, -6.15); p = 0.035)) intake. An increase in habitual sleep variability was related with a slight increase in protein intake (ß (95% CI) = 0.32 (0.031, 0.62); p = 0.031). Children who slept less had a higher energy intake, especially from fat and protein and those who presented inefficient sleep had a higher carbohydrate intake. Strategies to enhance sleep quality and quantity combined with dietary recommendations could help to improve energy and macronutrient intake levels in children.

Predictors of discordance in self-report versus device-measured physical activity measurement.

PURPOSE: Accurate measurement of free-living physical activity is challenging in population-based research, whether using device-based or reported methods. Our purpose was to identify demographic predictors of discordance between physical activity assessment methods and to determine how these predictors modify the discordance between device-based and reported physical activity measurement methods. METHODS: Three hundred forty-seven adults from the Survey of the Health of Wisconsin wore the ActiGraph accelerometer for 7 days and completed the Global Physical Activity Questionnaire. Multivariate linear regression was conducted to assess predictors of discordance including gender, education, body mass index, marital status, and other individual level characteristics in physical activity reporting. RESULTS: Seventy-seven percent of men and 72% of women self-reported meeting the U.S. Centers for Disease Control and Prevention guidelines for aerobic activity but when measured by accelerometer, only 21% of men and 17% of women met guidelines. Demographic characteristics that predicted discordance between methods in multivariate regression included greater educational attainment (P < .001) and partnered status (P = .003). CONCLUSIONS: These varying levels of discordance imply that comparisons of self-reported activity among groups defined by (or substantially varying by) educational attainment or marital status should be done with considerable caution as observed differences may be due, in part, to systematic, differential measurement biases among groups.

Chronic kidney disease mortality trends in selected Central America countries, 1997-2013: clues to an epidemic of chronic interstitial nephritis of agricultural communities.

BACKGROUND: In Central America, chronic interstitial nephritis of agricultural communities (CINAC) has reached epidemic proportions. Clusters of cases have been described in several farming communities. Its aetiology remains uncertain and a controversy exists on its key triggers, among them the heat stress-dehydration mechanism and the toxic exposure to agrochemicals. METHODS: This study analysed the mortality pattern and trend of chronic kidney disease code N18 (CKD-N18) according to the International Statistical Classification of Diseases and Related Health Problems-10th Revision, the proxy and the underlying cause of death, in four selected Central American countries from 1997 to 2013. In addition, we used exponential regression to retrospectively model the likely onset and prior trajectory of the epidemic. RESULTS: Between 1997 and 2013, CKD-N18 mortality accounting 47 885 deaths (31% were female), 19 533 of which occurred below 60 years of age (26% female). The excess of mortality starts as early as 10-14 years of age for both boys and girls. El Salvador and Nicaragua, with mortality rates between 9-fold and 12-fold higher than reference countries, were the most affected. Statistical modelling suggests that the epidemic commenced around the mid-1970s, coinciding with important changes in modes of agricultural production. CONCLUSIONS: This study provides the most comprehensive mortality analysis of this epidemic published to date and confirms an excess of CKD-N18 mortality and its relation with the epidemic of CINAC. The overall trends and the mortality pattern among women, children and adolescents suggest that the heat stress-dehydration hypothesis cannot fully explain this epidemic and that other environmental factors, more likely agricultural practices and agrochemicals, may be causally involved.

Food insecurity and cardiovascular health: Findings from a statewide population health survey in Wisconsin.

BACKGROUND: The social and economic environment has become a major area of interest regarding the determinants of cardiovascular health. Among markers of economic distress, food insecurity has been found associated with metabolic disorders, dyslipidemia, and obesity, but no previous studies have examined its association with overall cardiovascular health. METHODS AND RESULTS: We conducted a cross-sectional analysis among 2935 participants in the Survey of the Health of Wisconsin (SHOW), a statewide population-based representative sample. The presence of food insecurity was determined by an affirmative answer to the question "In the last 12months, have you been concerned about having enough food for you or your family?" Cardiovascular health (CVH) was defined based on the American Heart Association Life's Simple 7 criteria and classified as "poor," "intermediate," or "ideal" using previously published criteria. "Good" CVH was defined as having no poor in any of the seven criteria (any amount of intermediate or ideal). Crude and adjusted odds ratios (OR) of good CVH according to presence of food insecurity were calculated using logistic regression models. Overall, food insecurity was associated with a decreased likelihood of good CVH (OR 0.53; 95% Confidence Interval 0.31 to 0.92; p=0.02). This association persisted in models controlling for age, gender, race, and urbanization. CONCLUSIONS: Participants who were food insecure were significantly less likely to have good CVH compared to participants who were food secure. Even though this study cannot confirm causality, these results suggest that food insecurity might be one of several socio-economic barriers contributing to poor CVH.

Developing and Implementing "Waupaca Eating Smart": A Restaurant and Supermarket Intervention to Promote Healthy Eating Through Changes in the Food Environment.

PURPOSE: Restaurants and food stores are suitable settings for healthy eating interventions. A community-academic partnership developed and implemented "Waupaca Eating Smart" (WES), a healthy eating program in restaurants and supermarkets of a rural, Midwest community. Previous interventions targeted either restaurants or small food stores nearly all in urban areas. Intervention design and implementation is rarely documented, making replication difficult for interested researchers and communities. In this article, we report the activities we undertook to develop and implement WES. METHODS: Working with a local nutrition and activity coalition, we used evidence-based strategies guided by the social ecological model and social marketing principles to inform the content of WES. Formative assessment included a review of the literature, statewide key informant interviews and focus groups with restaurant and food store operators and patrons, a local community survey, and interviews with prospective WES businesses. WES was implemented in seven restaurants and two supermarkets and evaluated for feasibility and acceptance using surveys and direct observation of WES implementation. FINDINGS: Prior to this intervention, only one of seven restaurants had three or more meals that met WES nutrition criteria. By the end of the program, 38 meals were labeled and promoted to restaurant customers, and the team had staffed four side salad taste tests for supermarket customers. Four and 10 months after intervention launch, the majority of the program's strategies were observed in participating outlets, suggesting that these program's strategies are feasible and can be sustained. Operators reported strong satisfaction overall. CONCLUSIONS: A combined restaurant- and supermarket-based healthy eating intervention is feasible and positively valued in rural communities. Further research is needed to better understand how to foster sustainability of these interventions and their impact on customer food choices.

Obstructive sleep apnea and cancer: Epidemiologic links and theoretical biological constructs.

Sleep disorders have emerged as highly prevalent conditions in the last 50-75 y. Along with improved understanding of such disorders, the realization that perturbations in sleep architecture and continuity may initiate, exacerbate or modulate the phenotypic expression of multiple diseases including cancer has gained increased attention. Furthermore, the intermittent hypoxia that is attendant to sleep disordered breathing, has recently been implicated in increased incidence and more adverse prognosis of cancer. The unifying conceptual framework linking these associations proposes that increased sympathetic activity and/or alterations in immune function, particularly affecting innate immune cellular populations, underlie the deleterious effects of sleep disorders on tumor biology. In this review, the epidemiological evidence linking disrupted sleep and intermittent hypoxia to oncological outcomes, and the potential biological underpinnings of such associations as illustrated by experimental murine models will be critically appraised. The overarching conclusion appears supportive in the formulation of an hypothetical framework, in which fragmented sleep and intermittent hypoxia may promote changes in multiple signalosomes and transcription factors that can not only initiate malignant transformation, but will also alter the tumor microenvironment, disrupt immunosurveillance, and thus hasten tumor proliferation and increase local and metastatic invasion. Future bench-based experimental studies as well as carefully conducted and controlled clinical epidemiological studies appear justified for further exploration of these hypotheses.

Smoking, central adiposity, and poor glycemic control increase risk of hearing impairment.

OBJECTIVES: To determine associations between smoking, adiposity, diabetes mellitus, and other risk factors for cardiovascular disease (CVD) and the 15-year incidence of hearing impairment (HI). DESIGN: A longitudinal population-based cohort study (1993-95 to 2009-10), the Epidemiology of Hearing Loss Study (EHLS). SETTING: Beaver Dam, Wisconsin. PARTICIPANTS: Participants in the Beaver Dam Eye Study (1988-90; residents of Beaver Dam, WI, aged 43-84 in 1987-88) were eligible for the EHLS. There were 1,925 participants with normal hearing at baseline. MEASUREMENTS: Fifteen-year cumulative incidence of HI (pure-tone average of hearing thresholds at 0.5, 1, 2, and 4 kHz greater than 25 decibels hearing level in either ear). Cigarette smoking, exercise, and other factors were ascertained according to questionnaire. Blood pressure, waist circumference, body mass index, and glycosylated hemoglobin were measured. RESULTS: Follow-up examinations (≥1) were obtained from 87.2% (n=1,678; mean baseline age 61). The 15-year cumulative incidence of HI was 56.8%. Adjusting for age and sex, current smoking (hazard ratio (HR)=1.31, P=.048), education (<16 years; HR=1.35, P=.01), waist circumference (HR=1.08 per 10 cm, P=.02), and poorly controlled diabetes mellitus (HR=2.03, P=.048) were associated with greater risk of HI. Former smokers and people with better-controlled diabetes mellitus were not at greater risk. CONCLUSION: Smoking, central adiposity, and poorly controlled diabetes mellitus predicted incident HI. These well-known risk factors for CVD suggest that vascular changes may contribute to HI in aging. Interventions targeting reductions in smoking and adiposity and better glycemic control in people with diabetes mellitus may help prevent or delay the onset of HI.

Putative Links Between Sleep Apnea and Cancer: From Hypotheses to Evolving Evidence.

In recent years, the potentially adverse role of sleep-disordered breathing in cancer incidence and outcomes has emerged. In parallel, animal models of intermittent hypoxia (IH) and sleep fragmentation (SF) emulating the two major components of OSA have lent support to the notion that OSA may enhance the proliferative and invasive properties of solid tumors. Based on several lines of evidence, we propose that OSA-induced increases in sympathetic outflow and alterations in immune function are critically involved in modifying oncologic processes including angiogenesis. In this context, we suggest that OSA, via IH (and potentially SF), promotes changes in several signaling pathways and transcription factors that coordinate malignant transformation and expansion, disrupts host immunologic surveillance, and consequently leads to increased probability of oncogenesis, accelerated tumor proliferation, and invasion, ultimately resulting in adverse outcomes.

Community-based restaurant interventions to promote healthy eating: a systematic review.

INTRODUCTION: Eating in restaurants is associated with high caloric intake. This review summarizes and evaluates the evidence supporting community-based restaurant interventions. METHODS: We searched all years of PubMed and Web of Knowledge through January 2014 for original articles describing or evaluating community-based restaurant interventions to promote healthy eating. We extracted summary information and classified the interventions into 9 categories according to the strategies implemented. A scoring system was adapted to evaluate the evidence, assigning 0 to 3 points to each intervention for study design, public awareness, and effectiveness. The average values were summed and then multiplied by 1 to 3 points, according to the volume of research available for each category. These summary scores were used to determine the level of evidence (insufficient, sufficient, or strong) supporting the effectiveness of each category. RESULTS: This review included 27 interventions described in 25 studies published since 1979. Most interventions took place in exclusively urban areas of the United States, either in the West or the South. The most common intervention categories were the use of point-of-purchase information with promotion and communication (n = 6), and point-of-purchase information with increased availability of healthy choices (n = 6). Only the latter category had sufficient evidence. The remaining 8 categories had insufficient evidence because of interventions showing no, minimal, or mixed findings; limited reporting of awareness and effectiveness; low volume of research; or weak study designs. No intervention reported an average negative impact on outcomes. CONCLUSION: Evidence about effective community-based strategies to promote healthy eating in restaurants is limited, especially for interventions in rural areas. To expand the evidence base, more studies should be conducted using robust study designs, standardized evaluation methods, and measures of sales, behavior, and health outcomes.

Food insecurity and dyslipidemia in a representative population-based sample in the US.

OBJECTIVE: The association of food insecurity with dyslipidemia has not been firmly established. The main objective of this study was to assess whether food insecurity was associated with dyslipidemia. METHOD: A population-based sample of 1,663 adults from the 2008-2011 Survey of the Health of Wisconsin was used. Food insecurity was defined as an affirmative response to either of the questions: (1) "In the last 12months, have you been concerned about having enough food for you or your family?" (2) "In the last 12months, have your food choices been limited because there wasn't enough money?" High total cholesterol was defined as total cholesterol (TC) >240mg/dL or taking prescribed lipid-lowering medication. Low high-density lipoprotein cholesterol (HDL-C) was defined as <40mg/dL in men and <50mg/dL in women. RESULTS: Food insecurity was not associated with high TC either among men or women. Food insecurity was associated with a higher likelihood of low HDL-C among women (adjusted odds ratio [AOR]: 2.31 {95% confidence interval [CI]: 1.42, 3.76}), but not among men. Obesity appears to be a partial mediator of the association among women (P from the Sobel test=0.01). CONCLUSION: These findings suggest that food insecurity may contribute to an increased risk of low HDL-C in women.