Effectiveness of diabetes education interventions in rural America: a systematic review.

The purpose of this systematic review is to summarize the characteristics of recent studies on diabetes education interventions in rural areas and identify the relative proportion of studies with characteristics of interest that showed a reduction in glycated hemoglobin (A1C). A systematic literature search was performed in Web of Science, PubMed and PsychInfo, using keywords and Medical Subject Heading terms. Articles conducted in rural areas of the United States tested an educational intervention for people with type 2 diabetes, and reported outcomes were identified. A total of 2762 articles were identified, of which 27 were included. Of the 27 articles, most were implemented in the Southeast (n = 13). Of the 21 interventions that measured A1C, 10 reported a statistically significant decrease in A1C. The proportion of studies with a significant A1C reduction was higher for the studies that used telehealth/online, delivered by a collaboration between health-care professionals and lay educators or included family or group components. Only three studies included their criteria in determining rurality. Future diabetes education interventions may consider including family members or group sessions, holding online sessions and partnering with local resources. Additionally, stronger research methods are needed to test practical and effective interventions to improve diabetes education in rural areas.

Working With Rural Producers to Expand EBT in Farmers' Markets: A Case Study in Hardeman County, Tennessee.

Rural residents tend to eat less fruits and vegetables, placing them at higher risk of chronic diseases compared with urban residents. Farmers' markets can provide increased access to fresh produce for rural communities. Encouraging markets to accept Supplemental Nutrition Assistance Program (SNAP) benefits through Electronic Benefit Transfer (EBT) can expand access to healthy foods to low-income residents. Rural markets are less likely to accept SNAP compared with urban markets. Rural producers have identified lack of knowledge and limited support about the application process as barriers for accepting SNAP. This case study details how our Extension program helped a rural producer through the SNAP application process. We started with a workshop to inform rural producers about the benefits of accepting SNAP. After the workshop, we provided hands-on support and assistance to help one producer navigate the EBT application process as well as how to implement and advertise SNAP at the market. Implications for practitioners about tips to help producers overcome challenges and barriers for EBT acceptance are discussed.

A Community Profile of Walking and Cycling for Exercise or Transportation in a Rural County in the Southeastern United States.

People living in rural areas of the United States, especially in the southern region, are much less likely to walk or cycle for leisure time or transportation. The purpose of this study is to provide a more detailed community-level estimate of walking and cycling behaviors and attitudes among adults living in a rural county (Hardeman County, TN) participating in a High Obesity Program (HOP) from the Centers for Disease Control and Prevention. Telephone interviews and online surveys regarding walking and cycling behaviors, attitudes, and perceptions of the built environment were completed by 634 adults. Questions originated from the 2002 National Survey of Bicyclist and Pedestrian Attitudes and Behavior. Respondents were classified as walkers, cyclists, or both. Chi-square and logistic regression were used for data analysis. Of adults in this county, 67.2% were walkers and 16.2% cyclists. Both forms of active living tended to decrease with age, especially after 50 years. Walking was associated with younger ages, 2-person households, positive perceived health, and a feeling that walking was good for them. Cycling was only associated with age. Most people felt that their communities were safe places to walk or bike. Walking was most often done on roads or road shoulder. Social support and intrinsic motivators may also play a role in walking and bicycling in rural areas. Interventions that promote walking and cycling in rural areas should provide a means for social support, creating activity-friendly routes perceived to be safe, and enhanced destinations for places to be physically active.

Improving Lifestyle Behaviors After Breast Cancer Treatment Among African American Women With and Without Diabetes: Role of Health Care Professionals.

BACKGROUND: Little is known about the effect of health professionals' advice on promoting healthy lifestyle behaviors (diet and exercise) among breast cancer patients. PURPOSE: To identify predictors of receiving lifestyle advice from health professionals and its impact on healthy lifestyle behaviors. METHODS: We used data from a randomized controlled trial of an interactive, cancer-communication video program using African American breast cancer survivor stories for newly diagnosed African American breast cancer patients (Stages 0-III). Participants completed five interviews over 2 years. This intervention did not significantly affect changes in quality-of-life outcomes. In secondary analysis, we examined differences in baseline variables between women with and without diabetes. Logistic regression models identified independent predictors of receiving advice from "a doctor or other health professional" to improve diet and exercise and of self-reported change in diet and exercise habits at 2 year follow-up. RESULTS: Of 193 patients included (85% of 228 enrolled), 53 (28%) had diabetes. At 2 year follow-up, a greater proportion of women with (vs. without) diabetes reported receiving advice by a doctor/health professional to improve their diet (73% vs. 57%, p = .04,). Predictors of receiving dietary advice were obesity, diabetes, and breast-conserving surgery (each p < .05). Women receiving dietary advice were 2.75 times more likely to report improving their diet (95% confidence interval: 1.17, 6.46) at follow-up, but receiving physical activity advice was not significantly associated with patients reporting an increase in exercise. CONCLUSIONS: Although receiving dietary advice predicted dietary improvements, receiving exercise advice did not lead to an increase in physical activity. CLINICAL TRIAL REGISTRATION: Trial Number NCT00929084.

Pre-Existing Diabetes in Early Stage Breast Cancer Patients is Associated with Lack of Improvement in Quality of Life 2 Years After Diagnosis.

PURPOSE: Type 2 diabetes is a common comorbidity among breast cancer survivors. Our aim was to assess the association between diabetes and quality of life (QOL) in newly diagnosed early stage (0-IIA) breast cancer patients over a 2-year follow-up. METHODS: We used data from a longitudinal study of 549 breast cancer patients, aged ≥40 years. During four telephone interviews administered 4-6 weeks and 6, 12, and 24 months after definitive surgical treatment, we measured QOL using the Functional Assessment of Cancer Therapy-Breast (FACT-B) scale; higher scores indicate better QOL. Repeated measures analysis of variance was used to test the change over time in total FACT-B and each of the five subscales (physical, social, emotional and functional well-being, and breast cancer concerns), comparing patients with and without diabetes at baseline. RESULTS: After adjusting for covariates (age, race, body mass index, education, marital status, cancer staging, and surgical side effects), patients with (vs. without) diabetes reported lower QOL over time on the total FACT-B (least-squares mean [standard error] 106.2 [2.1] vs. 112.0 [1.1]; p = 0.0038) and on physical, social, emotional, and functional well-being subscales (each p < 0.05). Over the 2-year follow-up, QOL improved significantly for the emotional well-being (p < 0.0001) and breast cancer concern subscales (p = 0.0282) among patients without diabetes, but not among patients with diabetes. CONCLUSION: Early stage breast cancer patients with diabetes may need additional care considerations to improve QOL.

Breakfast intake among adults with type 2 diabetes: influence on daily energy intake.

OBJECTIVE: To assess the association between breakfast energy and total daily energy intake among individuals with type 2 diabetes. DESIGN: Cross-sectional study. Daily energy intake was computed from a 24 h dietary recall. Multiple regression models were used to estimate the association between daily energy intake (dependent variable) and quartiles of energy intake at breakfast (independent variable), expressed in either absolute or relative (percentage of total daily energy intake) terms. Orthogonal polynomial contrasts were used to test for linear and quadratic trends. Models were controlled for sex, age, race/ethnicity, BMI, physical activity and smoking. In addition, we used separate multiple regression models to test the effect of quartiles of absolute and relative breakfast energy on energy intake at lunch, dinner and snacks. SETTING: The 1999-2004 National Health and Nutrition Examination Survey (NHANES). SUBJECTS: Participants aged ≥30 years with self-reported history of diabetes (n 1146). RESULTS: Daily energy intake increased as absolute breakfast energy intake increased (linear trend, P<0·0001; quadratic trend, P=0·02), but decreased as relative breakfast energy intake increased (linear trend, P<0·0001). In addition, while higher quartiles of absolute breakfast intake had no associations with energy intake at subsequent meals, higher quartiles of relative breakfast intake were associated with lower energy intake during all subsequent meals and snacks (P<0·05). CONCLUSIONS: Consuming a breakfast that provided less energy or comprised a greater proportion of daily energy intake was associated with lower total daily energy intake in adults with type 2 diabetes.

Influence of lifestyle factors on inflammation in men and women with type 2 diabetes: results from the National Health and Nutrition Examination Survey, 1999-2004.

BACKGROUND: Type 2 diabetes is associated with low-grade systemic inflammation, increasing the risk for various adverse health outcomes. PURPOSE: Our objective was to investigate the association between C-reactive protein (CRP), a marker for systemic inflammation, and lifestyle factors in a national sample of people with type 2 diabetes. METHODS: This study analyzed data from 1,086 men and women with diabetes, who completed the 1999-2004 NHANES. Lifestyle factors included diet quality, body mass index (BMI), smoking, and physical activity. RESULTS: Stratified logistic regression showed that for both men and women, BMI was a strong predictor of elevated CRP after adjusting for age, energy intake, race/ethnicity, medications, diabetes duration, and glycosylated hemoglobin. However, among men, but not among women, the likelihood of elevated CRP increased with lower diet quality and physical inactivity. CONCLUSIONS: Among people with type 2 diabetes, higher levels of CRP were associated with lower diet quality and physical inactivity among men, and with obesity among both men and women.

Food after deprivation rewards the earlier eating.

Food intake can be increased by learning to anticipate the omission of subsequent meals. We present here a new theory that such anticipatory eating depends on an associative process of instrumental reinforcement by the nutritional repletion that occurs when access to food is restored. Our evidence over the last decade from a smooth-brained omnivore has been that food after deprivation rewards intake even when those reinforced ingestive responses occur long before the physiological signals from renewed assimilation. Effects of food consumed after self-deprivation might therefore reward extra eating in human beings, through brain mechanisms that could operate outside awareness. That would have implications for efforts to reduce body weight. This food reward mechanism could be contributing to the failure of the dietary component of interventions on obesity within controlled trials of the management or prevention of disorders such as hypertension, atherosclerosis and type 2 diabetes.

Reinforcement of anticipatory eating by short as well as long fasts.

Rats can learn to anticipate the omission of subsequent meals by increasing food intake. Our previous reports have analysed group means at each trial but that does not allow for rats learning at different speeds. This paper presents instead a rat-by-rat analysis of all the raw data from previous experiments. The re-analysis supports the published evidence that the capacity for reinforcement generated by withholding of food is greater after a longer fast than after a shorter fast, but that the learning is quicker after the shorter fast. The individualised analyses also extend the evidence that the pattern of learning, extinction and re-learning with shorter fasts is similar to that with longer fasts. These findings indicate that, contrary to our previous interpretation, a single learning mechanism can explain the effects of both durations of food deprivation.

Exploring Extension Agent Capacity and Readiness to Adopt Policy, Systems and Environmental Change Approaches.

Introduction: Enhanced Extension outreach strategies combine traditional direct education programs with public health approaches like policy, systems, and environmental (PSE) change. However, the Cooperative Extension system and county-based Family and Consumer Sciences (FCS) Extension agents have historically prioritized direct education programming and diffusion of enhanced outreach strategies has varied. Extension personnel may lack capacity and readiness for successful PSE change implementation. This study explored perceived acceptability, capacity, and readiness for PSE change work among FCS Extension agents in two states. Method: A survey was developed framed by selected domains from the Consolidated Framework for Implementation Research: Intervention Characteristics, Inner Setting, Characteristics of Individuals, and Process. All questions utilized a 5-point Likert scale, except for an item examining respondents' stage of change regarding PSE change strategies. Descriptive statistics and response frequencies for all variables were calculated. Results: Survey responses (n = 116) indicated PSE change work was perceived as valuable. Potential barriers included perceived complexity, organizational readiness issues (e.g., reporting and evaluation structures; performance incentives), and worries about stakeholder responses in shifting away from direct education. Responses indicated self-efficacy for skills important in implementing PSE change. Most respondents (53%) indicated being at the pre-contemplation or contemplation stage of change in pursuing PSE change work. Discussion: Combining PSE change strategies and direct education programming allows Extension to do what it does best - provide effective programs to improve and sustain health and wellbeing of individuals and families. Findings are informative for others aiming to build capacity within community educators, Extension and public health professionals to implement PSE change.

Differences in food intake among obese and nonobese women and men with type 2 diabetes.

OBJECTIVE: Weight reduction is a key goal for the prevention of vascular complications in obese individuals with type 2 diabetes, but a nutritionally balanced intake is also important in this regard. We compared dietary intakes and vitamin supplement use between obese and nonobese women and men with type 2 diabetes to identify gaps in adherence to nutritional management guidelines. METHODS: We analyzed data from a longitudinal study of adults with type 2 diabetes, wherein participants were assessed once per season over 1 year. Dietary data were collected using a validated semiquantitative, self-administered food-frequency questionnaire. Given the absence of seasonal variations in anthropometric variables and dietary intake, data from multiple visits were averaged for each individual. Associations of both intake of fruit and vegetables and nutrients related to cardiovascular disease risk were compared between obese (body mass index ≥ 30 kg/m²) and nonobese individuals through multivariable linear regression with adjustments for age, education, and energy intake. RESULTS: Among the 200 participants (93 women and 107 men), 53% of women and 43% of men were obese. Compared with nonobese women, obese women consumed more saturated fat (mean difference, 1.2% of total energy intake; 95% confidence interval [CI], 3% to 2.2%) and sodium (mean difference, 0.3 g; 95% CI, 0.04 to 0.5 g), and they had a lower intake of fiber (mean difference, -2.7 g; 95% CI, -4.4 to -0.9 g) and magnesium (mean difference, -33.6 mg; 95% CI, -55.2 to -12.0 g). No differences in dietary intake were observed between obese and nonobese men, but the intakes of men overall were similar to those of obese women. Compared with nonobese participants, fewer obese individuals used vitamin/mineral supplements (women: 37% vs 48%, men: 26% vs 38%). CONCLUSIONS: Obese women and both obese and nonobese men appeared to have poorer dietary quality compared with nonobese women. Our findings support the need to emphasize dietary composition in addition to weight control in diabetes.

Quality of life in patients with breast cancer before and after diagnosis: an eighteen months follow-up study.

BACKGROUND: Measuring quality of life in breast cancer patients is of importance in assessing treatment outcomes. This study examined the impact of breast cancer diagnosis and its treatment on quality of life of women with breast cancer. METHODS: This was a prospective study of quality of life in breast cancer patients. Quality of life was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its breast cancer supplementary measure (QLQ-BR23) at three points in time: baseline (pre diagnosis), three months after initial treatment and one year after completion of treatment (in all 18 months follow-up). At baseline the questionnaires were administered to all suspected identified patients while both patients and the interviewer were blind to the final diagnosis. Socio-demographic and clinical data included: age, education, marital status, disease stage and initial treatment. Repeated measure analysis was performed to compare quality of life differences over the time. RESULTS: In all, 167 patients diagnosed with breast cancer. The mean age of breast cancer patients was 47.2 (SD = 13.5) years and the vast majority (82.6%) underwent mastectomy. At eighteen months follow-up data for 99 patients were available for analysis. The results showed there were significant differences in patients' functioning and global quality of life at three points in time (P < 0.001). Although there were deteriorations in patients' scores for body image and sexual functioning, there were significant improvements for breast symptoms, systematic therapy side effects and patients' future perspective (P < 0.05). CONCLUSION: The findings suggest that overall breast cancer patients perceived benefit from their cancer treatment in long-term. However, patients reported problems with global quality of life, pain, arm symptoms and body image even after 18 months following their treatments. In addition, most of the functional scores did not improve.

Hyper-homeostatic learning of anticipatory hunger in rats.

Anticipatory hunger is a learnt increase in intake of food having a flavour or texture that predicts a long fast. This learning was studied in rats trained on a single food or a choice between protein-rich and carbohydrate-rich foods, presented for 1.5 h after 3 h without maintenance food at the start of the dark phase. Eight training cycles provided a pseudo-random sequence of 3 h and 10 h post-prandial fasts with a day on maintenance food between each training fast. The measure of anticipatory hunger is the difference over one 4-day cycle between the intake of test food having an odour predictive of the longer fast (TL) and intake of food with an odour cuing to the shorter fast (TS). Previous experiments showed that conditioning of preference for the odour before the shorter fast competes with learning to avoid hunger during the longer fast (anticipatory hunger), generating a cubic or quartic contrast. TL minus TS showed a strong cubic trend over 8 training cycles with both single and choice meals. There was a switch from preference for the short-fast odour at cycle 2 (TL-TS=-0.86 g) to a peak of anticipatory hunger at cycle 6 (TL-TS=1.57 g). We conclude that anticipatory hunger is learnt when a choice is given between protein-rich and carbohydrate-rich foods as well as on a single food. In addition, since anticipatory hunger extinguishes itself, such learning improves on negative-feedback homeostasis with a feed-forward "hyper-homeostatic" mechanism.

Comparison of Lavandula angustifolia Mill. tincture and imipramine in the treatment of mild to moderate depression: a double-blind, randomized trial.

Depression is a major health problem and is not only underrecognized and undertreated but is associated with significant morbidity and mortality. Lavandula angustifolia Mill. (Lamiacae) is used to treat depression. Many medicinal plant textbooks refer to this indication, whereas there is no evidence-based document. Our objective was to compare the efficacy of tincture of L. angustifolia with imipramine in the treatment of mild to moderate depression and to evaluate the possible adjuvant effect of this tincture in a 4 week double-blind, randomized trial. Forty-five adult outpatients who met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, for major depression based on the structured clinical interview for DSM IV participated in the trial. Patients have a baseline Hamilton Rating Scale for Depression score of at least 18. In this double-blind, single-center trial, patients were randomly assigned to receive lavandula tincture (1:5 in 50% alcohol ) 60 drops/day plus placebo tablet (Group A), tablet imipramine 100 mg/day plus placebo drop (Group B) and tablet imipramine 100 mg/day plus lavandula tincture 60 drops/day (Group C) for a 4-week study. In this small preliminary double-blind and randomized trial, lavandula tincture at this concentration was found to be less effective than imipramine in the treatment of mild to moderate depression (F=13.16, df=1, P=.001). In the imipramine group, anticholinergic effects such as dry mouth and urinary retention were observed more often that was predictable, whereas headache was observed more in the lavandula tincture group. A combination of imipramine and lavandula tincture was more effective than imipramine alone (F=20.83, df=1, P<.0001). As this study indicates, one of the advantages of this combination is a better and earlier improvement. The main overall finding from this study is that lavandula tincture may be of therapeutic benefit in the management of mild to moderate depression as adjuvant therapy. A large-scale trial is justified.

The Hospital Anxiety and Depression Scale (HADS): translation and validation study of the Iranian version.

BACKGROUND: The Hospital Anxiety and Depression Scale (HADS) is a widely used instrument to measure psychological morbidity in cancer patients. This study aimed to translate and test the reliability and validity of the Iranian version of the HADS. METHODS: The English language version of the HADS was translated into Persian (Iranian language) and was used in this study. The questionnaire was administered to a consecutive sample of 167 breast cancer patients and statistical analysis was performed to test the reliability and validity of the HADS. RESULTS: In general the Iranian version of the HADS was found to be acceptable to almost all patients (99%). Cronbach's alpha coefficient (to test reliability) has been found to be 0.78 for the HADS anxiety sub-scale and 0.86 for the HADS depression sub-scale. Validity as performed using known groups comparison analysis showed satisfactory results. Both anxiety and depression sub-scales discriminated well between sub-groups of patients differing in clinical status as defined by their disease stage. CONCLUSION: This preliminary validation study of the Iranian version of the HADS proved that it is an acceptable, a reliable and valid measure of psychological distress among cancer patients.

The role of depression in the development of breast cancer: analysis of registry data from a single institute.

Although controversial, the belief that developing breast cancer may be associated with psychological distress is not uncommon. The present study examined the role of psychological variables in the development of breast cancer in women attending a breast clinic for medical examination in Tehran, Iran. During a three-year period (1997-1999) a trained female nurse interviewed all women attending the Iranian Center for Breast Cancer (ICBC) before a confirmed diagnosis was made (N = 3000). Data were collected on demographic variables (age, education and marital status), known risk factors (age at menarche, age at first time full term pregnancy, family history of breast cancer, menopausal status, and oral contraceptive use), psychological variables, including history of psychiatric medications, depression (depressed mood, hopelessness, and loss of interests and pleasures), anxiety (mental and somatic signs) and two single measures of overall health and quality of life. In all, 243 patients were diagnosed as having breast cancer. A total of 486 patients with benign disease were randomly selected from the original cohort as controls. Univariate and multivariate logistic regression analyses were performed to determine the predictive effect of each factor on the risk of breast cancer. There were no significant differences between cases and controls except for age at menarche (P = 0.007) and family history of breast cancer (P<0.001). With regard to psychological variables studied, the results showed that there were significant differences between cases and controls regarding depression (depressed mood P<0.0001, hopelessness P = 0.001, and loss of interest and pleasures P = 0.001), and anxiety (mental signs P = 0.006). Finally, after performing multiple logistic regression analysis in addition to family history and age at menarche, depressed mood and hopelessness showed significant results (odds ratios of 1.90, and 1.63 respectively). The findings of the present study suggest that in addition to the known risk factors, psychological determinants such as depressed mood may play an important role in etiology of breast cancer and deserve further investigation, especially in different populations.

Participants' perceptions of a group based program incorporating hands-on meal preparation and pedometer-based self-monitoring in type 2 diabetes.

BACKGROUND: Nutrition education (portion sizes, balanced meals) is a cornerstone of diabetes management; however, moving from information to behavior change is challenging. Through a single arm intervention study, we recently demonstrated that combining education with group-based meal preparation training has measureable effects on weight, eating behaviour, and glycemic control in adults with type 2 diabetes. In the present study, we conducted an in-depth examination of participants' perceptions of this strategy, through focus group discussion, to delineate effective elements of the strategy from participants' perspectives. METHODS: Participants who had completed the nutrition education/meal preparation training program were invited to attend one of four focus group discussions. These were led by experienced facilitators and guided by questions addressing experiences during the intervention and their perceived impact. Audiotapes were transcribed and qualitative content analysis of transcripts was performed. We report herein themes that achieved saturation across the four discussions. RESULTS: Twenty-nine (80.6%, 29/36) attended a focus group discussion. The program elements perceived as effective by participants included the hands-on interactive learning approach to meal preparation, the grocery store tour, pedometer-based self-monitoring, experiencing the link between food consumption/physical activity and glucose changes during the program, and peer support. Discussants reported changes in eating and walking behaviour, greater confidence in ability to self-manage diabetes, reductions in glucose levels and/or need for glucose-lowering medications, and, in some cases, weight loss. Family members and friends were facilitators for some and barriers for others in terms of achieving health behavior changes. CONCLUSIONS: Among adults with type 2 diabetes, a group based program that included hands-on meal preparation and pedometer-based self-monitoring was perceived as effective in conveying information, developing skills, building confidence, and changing health behaviors.

Increased risk of colorectal cancer in type 2 diabetes is independent of diet quality.

BACKGROUND: Poor diet increases the risk of both colorectal cancer and type 2 diabetes. We investigated the role of diet in the association between diabetes and colorectal cancer. METHODS: We analyzed data from 484,020 individuals, aged 50-71 years who participated in the prospective National Institutes of Health-AARP Diet and Health Study and were cancer free at baseline (1995-1996). History of diabetes was self-reported. Diet quality was measured with the Healthy Eating Index-2005 (HEI-2005), using a self-administered food-frequency questionnaire. Cox regression models were constructed to estimate the hazard ratios (HR) and 95% confidence intervals (CI) of first primary incident colorectal cancer, overall and by anatomical location. RESULTS: During an average follow-up of 9.2 years, we identified 7,598 new cases of colorectal cancer. After controlling for non-dietary confounders, diabetes was associated with increased risk of colorectal cancer (HR 1.27, 95% CI: 1.18, 1.36). Further adjustment for diet quality did not attenuate this association. Diabetes was associated with a HR of 1.23 (95% CI: 1.07, 1.40) in individuals with good diet (quartile 4 of HEI-2005) and 1.58 (95% CI: 1.34, 1.86) in those with poor diet (quartile 1 of HEI-2005), compared to those with no diabetes and good diet. Moreover, diabetes was associated with a stronger risk of proximal than distal colon cancer (HR: 1.33 vs. HR: 1.20), while poor diet was associated with a weaker risk of proximal colon cancer (HR: 1.18 vs. HR: 1.46). CONCLUSION: Diabetes and poor diet, independently and additively are associated with the increased risk of colorectal cancer.

Income disparity and risk of death: the importance of health behaviors and other mediating factors.

BACKGROUND: Income disparities in mortality are profound in the United States, but reasons for this remain largely unexplained. The objective of this study was to assess the effects of health behaviors, and other mediating pathways, separately and simultaneously, including health insurance, health status, and inflammation, in the association between income and mortality. METHODS: This study used data from 9925 individuals aged 20 years or older who participated in the 1999-2004 National Health and Nutrition Examination Survey (NHANES) and were followed up through December 31, 2006 for mortality. The outcome measures were all-cause and CVD/diabetes mortality. During follow-up 505 persons died, including 196 deaths due to CVD or diabetes. RESULTS: After adjusting for age, sex, education, and race/ethnicity, risk of death was higher in low-income than high-income group for both all-cause mortality (Hazard ratio [HR], 1.98; 95% confidence interval [CI]: 1.37, 2.85) and cardiovascular disease (CVD)/diabetes mortality (HR, 3.68; 95% CI: 1.64, 8.27). The combination of the four pathways attenuated 58% of the association between income and all-cause mortality and 35% of that of CVD/diabetes mortality. Health behaviors attenuated the risk of all-cause and CVD/diabetes mortality by 30% and 21%, respectively, in the low-income group. Health status attenuated 39% of all-cause mortality and 18% of CVD/diabetes mortality, whereas, health insurance and inflammation accounted for only a small portion of the income-associated mortality (≤6%). CONCLUSION: Excess mortality associated with lower income can be largely accounted for by poor health status and unhealthy behaviors. Future studies should address behavioral modification, as well as possible strategies to improve health status in low-income people.

Decreasing trend of tumor size and downstaging in breast cancer in Iran: results of a 15-year study.

The aim of this cross-sectional study was to show the characteristics of breast cancer across a period of 15 years according to pathological records in Tehran, Iran. In the year 1985, a 20-year study was designed and developed in five major hospitals in Tehran to study the burden and characteristics of breast cancer in Iran. This study is based on the data collected from 1986 through 2000. SPSS version 13 was used for statistical analysis. In this study, 1612 female breast cancer records were reviewed. The mean age of patients was 47.95+/-12.42 years with a median of 47 years. Over the study period, the proportion of tumors diagnosed at T2 increased with a decline in the proportion of T3 cases. Similarly, the percentage of stage II cases at diagnosis increased, whereas stage III decreased. We detected a decrease in tumor size and downstaging of female breast cancer in Tehran, Iran. This can be attributed to the overall improvement in the level of health in Iran and also educational activities that teach women how to perform breast self-exam and when and why to ask for breast examination.