Building Climate Change into Medical Education: A Society of General Internal Medicine Position Statement.

Building expertise in climate and planetary health among healthcare professionals cannot come with greater urgency as the threats from climate change become increasingly apparent. Current and future healthcare professionals-particularly internists-will increasingly need to understand the interconnectedness of natural systems and human health to better serve their patients longitudinally. Despite this, few national medical societies and accreditation bodies espouse frameworks for climate change and planetary health-related education at the undergraduate (UME), graduate (GME), and continuing (CME) medical education level. As a community of medical educators with an enduring interest in climate change and planetary health, the Society of General Internal Medicine (SGIM) recognizes the need to explicitly define structured educational opportunities and core competencies in both UME and GME as well as pathways for faculty development. In this position statement, we build from the related SGIM Climate and Health position statement, and review and synthesize existing position statements made by US-based medical societies and accreditation bodies that focus on climate change and planetary health-related medical education, identify gaps using Bloom's Hierarchy, and provide recommendations on behalf of SGIM regarding the development of climate and planetary health curricula development. Identified gaps include (1) limited systematic approach to climate and planetary health medical education at all levels; (2) minimal emphasis on learner-driven approaches; (3) limited focus on physician and learner well-being; and (4) limited role for health equity and climate justice. Recommendations include a call to relevant accreditation bodies to explicitly include climate change and planetary health as a competency, extend the structural competency framework to climate change and planetary health to build climate justice, proactively include learners in curricular development and teaching, and ensure resources and support to design and implement climate and planetary health-focused education that includes well-being and resiliency.

The effect of different methods to identify, and scenarios used to address energy intake misestimation on dietary patterns derived by cluster analysis.

BACKGROUND: All self-reported dietary intake data are characterized by measurement error, and validation studies indicate that the estimation of energy intake (EI) is particularly affected. METHODS: Using self-reported food frequency and physical activity data from Alberta's Tomorrow Project participants (n = 9847 men 16,241 women), we compared the revised-Goldberg and the predicted total energy expenditure methods in their ability to identify misreporters of EI. We also compared dietary patterns derived by k-means clustering under different scenarios where misreporters are included in the cluster analysis (Inclusion); excluded prior to completing the cluster analysis (ExBefore); excluded after completing the cluster analysis (ExAfter); and finally, excluded before the cluster analysis but added to the ExBefore cluster solution using the nearest neighbor method (InclusionNN). RESULTS: The predicted total energy expenditure method identified a significantly higher proportion of participants as EI misreporters compared to the revised-Goldberg method (50% vs. 47%, p < 0.0001). k-means cluster analysis identified 3 dietary patterns: Healthy, Meats/Pizza and Sweets/Dairy. Among both men and women, participants assigned to dietary patterns changed substantially between ExBefore and ExAfter and also between the Inclusion and InclusionNN scenarios (Hubert and Arabie's adjusted Rand Index, Kappa and Cramer's V statistics < 0.8). CONCLUSIONS: Different scenarios used to account for EI misreporters influenced cluster analysis and hence the composition of the dietary patterns. Continued efforts are needed to explore and validate methods and their ability to identify and mitigate the impact of EI misestimation in nutritional epidemiology.

Impact of adherence to cancer-specific prevention recommendations on subsequent risk of cancer in participants in Alberta's Tomorrow Project.

OBJECTIVE: The World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) publish recommendations for cancer prevention. The present study aimed to estimate the association between adherence to these cancer-specific prevention recommendations and subsequent development of cancer in a prospective cohort. DESIGN: A composite adherence score was constructed based on questionnaire data to reflect overall adherence to WCRF/AICR lifestyle-related recommendations on body fatness, physical activity, diet and alcoholic drinks. Multivariable Cox proportional hazard regression models were used to assess the association (hazard ratio; 95 % CI) between the adherence score and risk of developing cancer. SETTING: Alberta's Tomorrow Project, a prospective cohort study.ParticipantsMen and women (n 25 100, mean age at enrolment 50·5 years) recruited between 2001 and 2009 with no previous cancer diagnosis were included in analyses. RESULTS: Cancer cases (n 2066) were identified during a mean follow-up of 11·7 years. Participants who were most adherent to the selected WCRF/AICR recommendations (composite score: 4-6) were 13 % (0·87; 0·78, 0·98) less likely to develop cancer compared with those who were least adherent (composite score: 0-2). Each additional recommendation met corresponded to a 5 % (0·95; 0·91, 0·99) reduction in risk of developing cancer. When stratified by sex, the associations remained significant for women, but not for men. CONCLUSIONS: Adherence to lifestyle-related cancer prevention recommendations was associated with reduced risk of developing cancer over the follow-up term in this Canadian cohort.

Patterns and predictors of adherence to colorectal cancer screening recommendations in Alberta's Tomorrow Project participants stratified by risk.

BACKGROUND: Colorectal cancer (CRC) screening is an important modifiable behaviour for cancer control. Regular screening, following recommendations for the type, timing and frequency based on personal CRC risk, contributes to earlier detection and increases likelihood of successful treatment. METHODS: To determine adherence to screening recommendations in a large provincial cohort of adults, participants in Alberta's Tomorrow Project (n = 9641) were stratified based on increasing level of CRC risk: age (Age-only), family history of CRC (FamilyHx), personal history of bowel conditions (PersonalHx), or both (Family/PersonalHx) using self-reported information from questionnaires. Provincial and national guidelines for timing and frequency of screening tests were used to determine if participants were up-to-date based on their CRC risk. Screening status was compared between enrollment (2000-2006) and follow-up (2008) to determine screening pattern over time. RESULTS: The majority of participants (77%) fell into the average risk Age-only strata. Only a third of this strata were up-to-date for screening at baseline, but the proportion increased across the higher risk strata, with > 90% of the highest risk Family/PersonalHx strata up-to-date at baseline. There was also a lower proportion (< 25%) of the Age-only group who were regular screeners over time compared to the higher risk strata, though age, higher income and uptake of other screening tests (e.g. mammography) were associated with a greater likelihood of regular screening in multinomial logistic regression. CONCLUSIONS: The low (< 50%) adherence to regular CRC screening in average and moderate risk strata highlights the need to further explore barriers to uptake of screening across different risk profiles.

Diet quality is associated with reduced incidence of cancer and self-reported chronic disease: Observations from Alberta's Tomorrow Project.

The objective of this study was to assess diet quality using the Healthy Eating Index-2005 Canada (HEI-2005-Canada) and its association with risk of cancer and chronic disease in a sample of Alberta's Tomorrow Project (ATP) participants. Food frequency questionnaires completed by 25,169 participants (38% men; mean age 50.3 (9.2)) enrolled between 2000 and 2008 were used to calculate HEI-2005-Canada scores. Data from a subset of participants (n=10,735) who reported no chronic disease at enrollment were used to investigate the association between HEI-2005-Canada score and development of self-reported chronic disease at follow-up (2008). Participants were divided into HEI-2005-Canada score quartiles. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for cancer and chronic disease incidence. In this cohort, mean HEI-2005-Canada scores for men and women were 50.9 and 55.5 (maximum range 0-100), respectively. In men, higher HEI-2005-Canada score (Q4 vs. Q1) was associated with lower cancer risk (HR (95% CI) 0.63 (0.49-0.83)) over the course of follow-up (mean (SD)=10.4 (2.3) years); the same was not observed in women. In contrast, higher overall HEI-2005-Canada score (Q4 vs. Q1) was associated with lower risk of self-reported chronic disease (0.85 (0.75-0.97)) in both men and women over follow-up (4.2 (2.3) years). In conclusion, in this cohort better diet quality was associated with a lower risk of cancer in men and lower risk of chronic disease in both sexes. Future studies with longer follow-up and repeated measures of diet may be helpful to elucidate sex-specific associations between dietary quality and disease outcomes.

Lessons from Studies to Evaluate an Online 24-Hour Recall for Use with Children and Adults in Canada.

With technological innovation, comprehensive dietary intake data can be collected in a wide range of studies and settings. The Automated Self-Administered 24-hour (ASA24) Dietary Assessment Tool is a web-based system that guides respondents through 24-h recalls. The purpose of this paper is to describe lessons learned from five studies that assessed the feasibility and validity of ASA24 for capturing recall data among several population subgroups in Canada. These studies were conducted within a childcare setting (preschool children with reporting by parents), in public schools (children in grades 5-8; aged 10-13 years), and with community-based samples drawn from existing cohorts of adults and older adults. Themes emerged across studies regarding receptivity to completing ASA24, user experiences with the interface, and practical considerations for different populations. Overall, we found high acceptance of ASA24 among these diverse samples. However, the ASA24 interface was not intuitive for some participants, particularly young children and older adults. As well, technological challenges were encountered. These observations underscore the importance of piloting protocols using online tools, as well as consideration of the potential need for tailored resources to support study participants. Lessons gleaned can inform the effective use of technology-enabled dietary assessment tools in research.

The Comparative Reliability and Feasibility of the Past-Year Canadian Diet History Questionnaire II: Comparison of the Paper and Web Versions.

Advances in technology-enabled dietary assessment include the advent of web-based food frequency questionnaires, which may reduce costs and researcher burden but may introduce new challenges related to internet connectivity and computer literacy. The purpose of this study was to evaluate the intra- and inter-version reliability, feasibility and acceptability of the paper and web Canadian Diet History Questionnaire II (CDHQ-II) in a sub-sample of 648 adults (aged 39-81 years) recruited from Alberta's Tomorrow Project. Participants were randomly assigned to one of two groups: (1) paper, web, paper; or (2) web, paper, web over a six-week period. With few exceptions, no statistically significant differences in mean nutrient intake were found in the intra- and inter-version reliability analyses. The majority of participants indicated future willingness to complete the CDHQ-II online, and 59% indicated a preference for the web over the paper version. Findings indicate that, in this population of adults drawn from an existing cohort, the CDHQ-II may be administered in paper or web modalities (increasing flexibility for questionnaire delivery), and the nutrient estimates obtained with either version are comparable. We recommend that other studies explore the feasibility and reliability of different modes of administration of dietary assessment instruments prior to widespread implementation.

Alberta's Tomorrow Project: adherence to cancer prevention recommendations pertaining to diet, physical activity and body size.

OBJECTIVE: To explore cross-sectional adherence to cancer prevention recommendations by adults enrolled in a prospective cohort in Alberta, Canada. DESIGN: Questionnaire data were used to construct a composite cancer prevention adherence score for each participant, based on selected personal recommendations published by the World Cancer Research Fund/American Institute for Cancer Research (2007). Data were self-reported on health and lifestyle, past-year physical activity and past-year FFQ. The scores accounted for physical activity, dietary supplement use, body size, and intakes of alcohol, fruit, vegetables and red meat. Tobacco exposure was also included. Scores ranged from 0 (least adherent) to 7 (most adherent). SETTING: Alberta's Tomorrow Project; a research platform based on a prospective cohort. SUBJECTS: Adult men and women (n 24 988) aged 35-69 years recruited by random digit dialling and enrolled in Alberta's Tomorrow Project between 2001 and 2009. RESULTS: Of the cohort, 14 % achieved adherence scores ≥5 and 60 % had scores ≤3. Overall adherence scores were higher in women (mean (sd): 3·4 (1·1)) than in men (3·0 (1·2)). The extent of overall adherence was also associated with level of education, employment status, annual household income, personal history of chronic disease, family history of chronic disease and age. CONCLUSIONS: Reported adherence to selected personal recommendations for cancer prevention was low in this cohort of adults. In the short to medium term, these results suggest that more work is required to identify behaviours to target with cancer prevention strategies at a population level. Future work will explore the associations between adherence scores and cancer risk in this cohort.

Design, methods and demographics from phase I of Alberta's Tomorrow Project cohort: a prospective cohort profile.

BACKGROUND: Prospective cohorts have the potential to support multifactorial, health-related research, particularly if they are drawn from the general population, incorporate active and passive follow-up and permission is obtained to allow access by researchers to data repositories. This paper describes Phase I of the Alberta's Tomorrow Project cohort, a broad-based research platform designed to support investigations into factors that influence cancer and chronic disease risk. METHODS: Adults aged 35-69 years living in Alberta, Canada, with no previous cancer diagnosis other than nonmelanoma skin cancer were recruited to the project by telephone-based random digit dialling. Participants were enrolled if they returned a Health and Lifestyle Questionnaire. Past year diet and physical activity questionnaires were mailed 3 months after enrolment. Consent was sought for active follow-up and linkage with administrative databases. Depending on enrolment date, participants were invited to complete up to 2 follow-up questionnaires (2004 and 2008). RESULTS: Between 2001 and 2009, 31 072 (39% men) participants (mean age 50.2 [± 9.2] yr) were enrolled and 99% consented to linkage with administrative databases. Participants reported a wide range of educational attainment and household income. Compared with provincial surveillance data from the Canadian Community Health Survey, Alberta's Tomorrow Project participants had higher body mass index, lower prevalence of smoking and similar distribution of chronic health conditions. Follow-up questionnaires were completed by 83% and 72% of participants in 2004 and 2008, respectively. Robust quality control measures resulted in low frequencies of missing data. INTERPRETATION: Alberta's Tomorrow Project provides a robust platform, based on a prospective cohort design, to support research into risk factors for cancer and chronic disease.

A realist study of the mechanisms of cardiac rehabilitation.

AIM: The aim of this paper is to report patients' experiences of cardiac rehabilitation and perceptions of the mechanisms and contexts influencing its long-term effectiveness. BACKGROUND: Cardiac rehabilitation programmes for the secondary prevention of coronary heart disease are common. The effects of these programmes, however, can be inconsistent and little is known of the personal and contextual factors that influence service effectiveness. METHOD: Forty-seven participants with a formal diagnosis of coronary heart disease who had attended a programme of cardiac rehabilitation in Scotland 3 years previously were included in focus groups to discuss their perceptions and experiences (30 males and 17 females). The data were generated in 2002 and analysed using the realist approach of Pawson and Tilley (1997). RESULTS: Participants' accounts indicated that the didactic content of cardiac rehabilitation was not strongly linked to longer-term health behaviour change. The main positive effects of cardiac rehabilitation were related to the effect of participation on mediating social and body-focused mechanisms that were triggered when the rehabilitation setting was perceived to be safe. Social mechanisms identified included social comparisons, camaraderie, and social capital. Body-focused mechanisms included greater knowledge of personal physical boundaries and a greater trust in the heart-diseased body. Collectively, these mechanisms had a positive effect on confidence that was perceived as being imperative to maintain health behaviour change. CONCLUSIONS: More support is required to promote health behaviour change after the completion of cardiac rehabilitation. Use of community-based exercise services and conventional or web-based support groups for coronary heart disease patients should be encouraged, as these appear to extend the positive health effects of the mechanisms that promote behaviour change. At the completion of cardiac rehabilitation programmes, patients should be referred to safe and appropriate community-based exercise services. Further research is needed to examine the effects on health outcomes of mechanisms and contexts related to cardiac rehabilitation.