A systems thinking framework for understanding rising childhood obesity in the Caribbean.

OBJECTIVE: The aim of this study is to develop a systems thinking framework to describe the common complexities of childhood obesity in the Caribbean region and identify potential areas of intervention. METHODS: Group model building (GMB) is a form of systems science. Trained GMB facilitators in Puerto Rico, the US Virgin Islands, Barbados, and Trinidad and Tobago convened a group of multi-disciplinary stakeholders in a series of virtual meetings in 2021 to elaborate a hypothesis of the system driving childhood obesity represented by causal loop diagrams (CLD). Commonalities and differences between the CLDs from each island were identified and reconciled to create a synthesized CLD. RESULTS: A single explanatory CLD across the islands was developed and includes nine reinforcing loops. These loops addressed the interconnected role of schools, policy, commercial determinants, community and the personal experience of the child in rising childhood obesity rates. CONCLUSIONS: Despite differences across settings, there is a core system driving childhood obesity in the Caribbean, as described by stakeholders in GMB workshops. Policy solutions to the problem must be multi-faceted and multi-level to address the interlinked reinforcing loops of the complex system and reduce rates of childhood obesity.

Perinatal factors, female breast cancer, and associated risk factors in Puerto Rico: evidence from the Atabey epidemiology of breast cancer study.

PURPOSE: There is increasing evidence that exposures in utero and in infancy impact breast cancer risk. No previous studies have evaluated these associations among women in Puerto Rico. METHODS: In a population-based case-control study of breast cancer epidemiology in the San Juan metropolitan area in Puerto Rico, we examined the association of early life factors with breast cancer risk and breast cancer risk factors. Both cases (n = 315) and controls (n = 348) completed interviewer-administered questionnaires, including self-reported birth country, birthweight, and history of having been breastfed. Comparisons of characteristics of those with and without the early life factors were made with t-tests or chi-squared tests; associations between early life factors and breast cancer risk were estimated with unconditional logistic regression adjusting for age, education, body mass index (BMI), age at menarche, parity, and menopausal status. RESULTS: Women who had been breastfed tended to have higher adult body mass index (BMI), higher education, and lower parity (p < 0.05). Higher birthweight was associated with higher adult BMI and lower educational attainment (p < 0.05). Those born outside of Puerto Rico or the US were more likely to have higher educational attainment and earlier age at menarche than those born within Puerto Rico or the US (p < 0.05). We found no significant associations between any of the early life factors and breast cancer risk. CONCLUSION: We did not find evidence of an association of early life factors with breast cancer risk among women in Puerto Rico.

Onion and Garlic Intake and Breast Cancer, a Case-Control Study in Puerto Rico.

Studies show an inverse association between onion and garlic intake and risk of cancers of the lung, prostate, and stomach. There is limited evidence on the association between onion and garlic intake and breast cancer. We assessed this association in a population-based, case-control study in Puerto Rico. Incident, primary breast cancer cases (n = 314) were identified among women aged 30-79 from hospital and clinic records. Controls (n = 346) were women with no history of cancer other than nonmelanoma skin cancer, residents of the same area. Dietary intake was estimated using a food frequency questionnaire. Total onion and garlic intake included sofrito (a popular garlic- and onion-based condiment) intake frequency. Unconditional logistic regression assessed the association between onion and garlic consumption and breast cancer adjusting for age, education, parity, family history, body mass index, age at menarche, total energy, and smoking. Inverse associations with breast cancer were observed for moderate (OR (odds ratio) = 0.59, 95% CI (confidence interval): 0.35, 1.01) and high consumption (OR = 0.51, 95% CI: 0.30, 0.87) compared to low consumption of onion and garlic (Ptrend = 0.02). Results were similar when stratified by menopausal status. Study results suggest that high onion and garlic consumption is protective against breast cancer in this population.

Sun Exposure Is Associated with Reduced Breast Cancer Risk among Women Living in the Caribbean: The Atabey Study in Puerto Rico.

BACKGROUND: Though inconsistent, there is evidence that sun exposure is associated with reduced breast cancer risk. Previous studies have been conducted in geographical regions with seasonal variation in UV radiation, including periods of low to no exposure, and among participants mostly of European descent. Puerto Rico has no significant seasonal fluctuation, with continuous exposure to very high UV radiation. METHODS: We conducted a population-based case-control study of breast cancer among women in metropolitan San Juan, Puerto Rico, examining a cumulative sun exposure index (SEI) based on a comparison of reflectance of sun-exposed and non-exposed skin. A chromameter was used to measure skin reflectance and estimate the difference between constitutive (unexposed) and facultative (exposed) skin pigmentation in 307 cases and 328 controls. Breast cancer risk factors were ascertained with interviewer-administered questionnaires. OR and 95% confidence intervals (CI) were estimated with unconditional logistic regression. RESULTS: Adjusted breast cancer odds were lower for the highest tertile of the SEI (ORadj = 0.47; 95% CI, 0.29-0.74). Results were similar within strata of estrogen receptor status. In analyses stratified by constitutive skin pigmentation, among participants with darker skin color, breast cancer risk was lower with more sun exposure (ORadj = 0.33; 95% CI, 0.16-0.70). CONCLUSIONS: We found lower risk of breast cancer associated with greater sun exposure in a population living with high, continuous sun exposure. This beneficial finding should be placed in the context of other effects of sun exposure. IMPACT: Sun exposure is a modifiable factor that may contribute, directly or indirectly, to lower breast cancer risk.

Development of the Anthropometric Grouping Index for the Eastern Caribbean Population Using the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study Data.

Improving public health initiative requires an accurate anthropometric index that is better suited to a specific community. In this study, the anthropometric grouping index is proposed as a more efficient and discriminatory alternative to the popular BMI for the Eastern Caribbean population. A completely distribution-free cluster analysis was performed to obtain the 11 categories, leading to AGI-11. Further, we studied these groups using novel non-parametric clustering summaries. Finally, two generalized linear mixed models were fitted to assess the association between elevated blood sugar, AGI-11 and BMI. Our results showed that AGI-11 tends to be more sensitive in predicting levels of elevated blood sugar compared to BMI. For instance, individuals identified as obese III according to BMI are (POR: 2.57; 95% CI: (1.68, 3.74)) more likely to have elevated blood sugar levels, while, according to AGI, individuals with similar characteristics are (POR: 3.73; 95% CI: (2.02, 6.86)) more likely to have elevated blood sugar levels. In conclusion, the findings of the current study suggest that AGI-11 could be used as a predictor of high blood sugar levels in this population group. Overall, higher values of anthropometric measures correlated with a higher likelihood of high blood sugar levels after adjusting by sex, age, and family history of diabetes.

Breast Cancer in a Caribbean Population in Transition: Design and Implementation of the Atabey Population-Based Case-Control Study of Women in the San Juan Metropolitan Area in Puerto Rico.

Global breast cancer incidence varies considerably, particularly in comparisons of low- and high-income countries; rates may vary even within regions. Breast cancer rates for Caribbean countries are generally lower than for North America and Europe. Rates in Puerto Rico are in the middle of the range between the highest and the lowest Caribbean countries. Populations in transition, with greater variability in risk factor exposures, provide an important opportunity to better understand breast cancer etiology and as potential sources of variation in rates. Understanding of exposures across the life span can potentially contribute to understanding regional differences in rates. We describe here the design and implementation of a population-based, case-control study in the San Juan Metropolitan Area (SJMA) of Puerto Rico, the Atabey Epidemiology of Breast Cancer Study. We describe steps taken to ensure that the study was culturally appropriate, leveraging the Atabey researchers' understanding of the culture, local health system, and other required resources to effectively recruit participants. A standardized, in-person interview was developed, with attention to life course events customized to the study population. In order to understand variation in global breast cancer rates, studies customized to the populations outside of North America and Europe are required.

Foods Contributing to Macronutrient Intake of Women Living in Puerto Rico Reflect Both Traditional Puerto Rican and Western-Type Diets.

Lack of variability in dietary intake within a population makes identification of relationships between diet and disease difficult. Studies in populations with greater interindividual variation can provide important insights. The Puerto Rican diet is in transition from a traditional to a more Western-type diet, resulting in greater interindividual variability. We identified foods contributing to absolute intake and variability in the intake of macronutrients among Puerto Rican women. One hundred women, aged 30⁻79, residents of San Juan, Puerto Rico, completed three, interviewer-administered, 24-h dietary recalls from which foods contributing to absolute intake and intake variability in intake of energy, fat, protein, carbohydrate and dietary fiber were determined. The overall prevalence of intake of foods was also calculated. Traditional Puerto Rican foods such as legumes, rice, and plantains were important contributors to the intake of calories and macronutrients as were foods more typical of Western diets including white bread and sweetened carbonated beverages. Identification of food sources of nutrients for this population with a diet in transition can contribute to the development of instruments to measure dietary intake and to understand the contribution of diet to the etiology of chronic disease among Puerto Rican women.

Descriptive analysis of patients with community-onset and hospital-onset methicillin-resistant Staphylococcus aureus infections.

Three hundred sixty-seven hospital- and community-onset methicillin-resistant Staphylococcus aureus (MRSA) infections diagnosed in a Dallas-Fort Worth Metroplex community hospital are described. Differences in age, gender, ethnicity, and susceptibility to four antibiotics between the two groups of patients are explored.