Health-Related and Behavioral Factors Associated With Lung Cancer Stage at Diagnosis: Observations From Alberta's Tomorrow Project.

BACKGROUND: Lung cancer is the leading cause of cancer death in Canada, with stage at diagnosis among the top predictors of lung cancer survival. Identifying factors associated with stage at diagnosis can help reduce lung cancer morbidity and mortality. This study used data from a prospective cohort study of adults living in Alberta, Canada to examine factors associated with lung cancer stage at diagnosis. METHODS: This cohort study used data from adults aged 35-69 years enrolled in Alberta's Tomorrow Project. Partial Proportional Odds models were used to examine associations between sociodemographic characteristics and health-related factors and subsequent lung cancer stage at diagnosis. RESULTS: A total of 221 participants (88 males and 133 females) developed lung cancer over the study period. Nearly half (48.0%) of lung cancers were diagnosed at a late stage (stage IV), whereas 30.8 % and 21.3% were diagnosed at stage I/II and III, respectively. History of sunburn in the past year was protective against late-stage lung cancer diagnosis (odds ratio (OR) .40, P=.005). In males, a higher number of lifetime prostate specific antigen tests was associated with reduced odds of late-stage lung cancer diagnosis (odds ratio .66, P=.02). Total recreational physical activity was associated with increased odds of late-stage lung cancer diagnosis (OR 1.08, P=.01). DISCUSSION: Lung cancer stage at diagnosis remains a crucial determinant of prognosis. This study identified important factors associated with lung cancer stage at diagnosis. Study findings can inform targeted cancer prevention initiatives towards improving early detection of lung cancer and lung cancer survival.

Towards refining World Cancer Research Fund/American Institute for Cancer Research cancer prevention recommendations for red and processed meat intake: insights from Alberta's Tomorrow Project cohort.

Current cancer prevention recommendations advise limiting red meat intake to <500 g/week and avoiding consumption of processed meat, but do not differentiate the source of processed meat. We examined the associations of processed meat derived from red v. non-red meats with cancer risk in a prospective cohort of 26 218 adults who reported dietary intake using the Canadian Diet History Questionnaire. Incidence of cancer was obtained through data linkage with Alberta Cancer Registry with median follow-up of 13·3 (interquartile range (IQR) 5·1) years. Multivariable Cox proportional hazards regression models were adjusted for covariates and stratified by age and sex. The median consumption (g/week) of red meat, processed meat from red meat and processed meat from non-red meat was 267·9 (IQR 269·9), 53·6 (IQR 83·3) and 11·9 (IQR 31·8), respectively. High intakes (4th Quartile) of processed meat from red meat were associated with increased risk of gastrointestinal cancer adjusted hazard ratio (AHR): 1·68 (95 % CI 1·09, 2·57) and colorectal cancers AHR: 1·90 (95 % CI 1·12, 3·22), respectively, in women. No statistically significant associations were observed for intakes of red meat or processed meat from non-red meat. Results suggest that the carcinogenic effect associated with processed meat intake may be limited to processed meat derived from red meats. The findings provide preliminary evidence towards refining cancer prevention recommendations for red and processed meat intake.

High-sensitivity C-reactive protein, hemoglobin A1c and breast cancer risk: a nested case-control study from Alberta's Tomorrow Project cohort.

PURPOSE: Our aim is to examine the associations between high-sensitivity C-reactive protein (hsCRP) and hemoglobin A1c (HbA1c), common biomarkers of inflammation and insulin resistance, respectively, with breast cancer risk, while adjusting for measures of excess body size. METHODS: We conducted a nested case-control study within the Alberta's Tomorrow Project cohort (Alberta, Canada) including 197 incident breast cancer cases and 394 matched controls. The sample population included both pre- and postmenopausal women. Serum concentrations of hsCRP and HbA1c were measured from blood samples collected at baseline, along with anthropometric measurements, general health and lifestyle data. Conditional logistic regression was used to evaluate associations between hsCRP, HbA1c, and breast cancer risk adjusted for excess body size (body fat percentage) and other risk factors for breast cancer. RESULTS: Higher concentrations of hsCRP were associated with elevated breast cancer risk (odds ratio [OR] 1.27; 95% confidence interval [95% CI] 1.03-1.55). The observed associations were unchanged with adjustment for body fat percentage. Higher HbA1c concentrations were not significantly associated with an increased breast cancer risk (OR 1.22; 95% CI 0.17-8.75). CONCLUSION: These data suggest that hsCRP may be associated with elevated breast cancer risk, independent of excess body size. However, elevated concentrations of HbA1c did not appear to increase breast cancer risk in apparently healthy women.

School-Age Children Can Recall Some Foods and Beverages Consumed the Prior Day Using the Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) without Assistance.

BACKGROUND: Technological innovations allow for collection of 24-h recalls (24HRs) in a broader range of studies than previously possible. The web-based Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) has been shown to be feasible and to perform well in capturing true intake among adults. However, data to inform use with children are limited. OBJECTIVE: This observational feeding study was conducted to evaluate children's ability to accurately report a lunchtime meal using ASA24 without assistance. METHODS: The study was conducted among children (n = 100) aged 10-13 y within a school setting. Students were served an individual cheese pizza, baby carrots, ranch dip, yogurt, a cookie, and 1 choice of water, juice, or milk. Plate waste was collected and weighed. The next day, participants completed ASA24 and a sociodemographic questionnaire. Descriptive statistics were generated to determine match rates by food item and age, and linear regression analyses were conducted to examine associations between sociodemographic characteristics and accuracy of reported energy and nutrient intake. Associations between true and reported energy and nutrient intakes and portion sizes were assessed with use of t tests. RESULTS: Just under half (49%) of children fully completed ASA24 (median time, 41 min). Children reported an exact, close, or far match for 58% of all foods and beverages consumed, ranging from 29% for dip to 76% for pizza, but also reported some items not consumed as part of the study meal. Older children completed the recall in a shorter time than younger children (mean 31 among 13 y compared with 52 min among 10 y). Intakes of energy (39%), protein (33%), and sodium (78%) were significantly overestimated, whereas portion sizes for cookies (53%) and juice (69%) were underestimated. CONCLUSIONS: Children can report some foods and drinks consumed using ASA24, but our findings suggest challenges with independent completion, necessitating research to examine strategies, such as training and resources, to support data quality.

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.

Systemic use of antibiotics and risk of diabetes in adults: A nested case-control study of Alberta's Tomorrow Project.

AIMS: Previous observational studies using administrative health records have suggested an increased risk of diabetes with use of antibiotics. However, unmeasured confounding factors may explain these results. This study characterized the association between systemic use of antibiotics and risk of diabetes in a cohort of adults in Canada, accounting for both clinical and self-reported disease risk factors. MATERIALS AND METHODS: In this nested case-control study, we used data from Alberta's Tomorrow Project (ATP), a longitudinal cohort study in Canada, and the linked administrative health records (2000-2015). Incident cases of diabetes were matched with up to 8 age and sex-matched controls per case. Conditional logistic regression was used to examine the association between antibiotic exposures and incident diabetes after sequentially adjusting for important clinical and lifestyle factors. RESULTS: This study included 1676 cases of diabetes and 13 401 controls. Although 17.9% of cases received more than 5 courses of antibiotics, compared to 13.8% of controls (P < .0001), the association between antibiotic use and risk of diabetes was progressively reduced as important clinical and lifestyle factors were accounted for. In fully adjusted models, compared to participants with 0 to 1 courses of antibiotics, participants receiving more antibiotics had no increased risk of diabetes [Odds Ratio, 0.97 (0.83-1.13) for 2 to 4 courses and 0.98 (0.82-1.18) for ≥5 courses]. CONCLUSIONS: After adjustment for clinical and difficult-to-capture lifestyle data, we found no association between systemic use of antibiotics and risk of diabetes. Our results suggest that those positive associations observed in previous studies using only administrative records might have been confounded.

Changes in body mass index and incidence of diabetes: A longitudinal study of Alberta's Tomorrow Project Cohort.

Although obesity is a known risk factor for diabetes, the impact of body mass index (BMI) changes over time, especially BMI reduction, on diabetes development is less than clear. The objective of this study is to characterize the association between BMI changes over time and incidence of diabetes in a cohort of adults in Alberta. From 2000 to 2008, Alberta's Tomorrow Project (ATP) enrolled participants aged 35-69 to a population-based prospective cohort study. BMI was calculated from self-reported height and weight; change in BMI (∆BMI) was calculated as the difference between baseline and follow-up measurements. Diabetes cases were identified using the Canadian National Diabetes Surveillance System algorithm applied to linked administrative data (2000-2015). Multivariable Cox regression was used to examine the association between ∆BMI and incidence of diabetes. In a subset of the ATP cohort (n=19,164), 1168 incident cases of diabetes were identified during 198,853person-years of follow-up. Overall, BMI increase was associated with increased risk and BMI reduction was associated with reduced risk of diabetes. Particularly, compared to minimal BMI change (±5%), moderate (5%-10%) reduction in BMI was associated with 34% (95% CI: 12%-51%) reduction in risk of diabetes in participants with obesity; whereas 10% or greater increase in BMI was associated with an increased risk of diabetes of 64% or more in participants with overweight and obesity; in participants with normal and underweight, BMI changes was not apparently associated with risk of diabetes. Public health programs promoting weight loss, even at a moderate extent, would reduce risk of diabetes.

The Canadian Partnership for Tomorrow Project: a pan-Canadian platform for research on chronic disease prevention.

BACKGROUND: Understanding the complex interaction of risk factors that increase the likelihood of developing common diseases is challenging. The Canadian Partnership for Tomorrow Project (CPTP) is a prospective cohort study created as a population-health research platform for assessing the effect of genetics, behaviour, family health history and environment (among other factors) on chronic diseases. METHODS: Volunteer participants were recruited from the general Canadian population for a confederation of 5 regional cohorts. Participants were enrolled in the study and core information obtained using 2 approaches: attendance at a study assessment centre for all study measures (questionnaire, venous blood sample and physical measurements) or completion of the core questionnaire (online or paper), with later collection of other study measures where possible. Physical measurements included height, weight, percentage body fat and blood pressure. Participants consented to passive follow-up through linkage with administrative health databases and active follow-up through recontact. All participant data across the 5 regional cohorts were harmonized. RESULTS: A total of 307 017 participants aged 30-74 from 8 provinces were recruited. More than half provided a venous blood sample and/or other biological sample, and 33% completed physical measurements. A total of 709 harmonized variables were created; almost 25% are available for all participants and 60% for at least 220 000 participants. INTERPRETATION: Primary recruitment for the CPTP is complete, and data and biosamples are available to Canadian and international researchers through a data-access process. The CPTP will support research into how modifiable risk factors, genetics and the environment interact to affect the development of cancer and other chronic diseases, ultimately contributing evidence to reduce the global burden of chronic disease.

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.

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.

Measures of excess body weight and anthropometry among adult Albertans: cross-sectional results from Alberta's tomorrow project cohort.

BACKGROUND: Excess body weight during adulthood has been consistently associated with all-cause mortality, cardiovascular disease, and cancer at multiple sites among other chronic diseases. We describe the prevalence of excess body weight and abdominal obesity reported by participants enrolled in Alberta's Tomorrow Project (ATP). METHODS: ATP is a geographically-based cohort study conducted among adults aged 35-69 years from across the province of Alberta. Participants completed anthropometric measures and health and lifestyle questionnaires at enrolment. Overweight and obese were categorized as a body mass index (BMI) of 25.0-29.9 kg/m2 and ≥30 kg/m2, respectively. Abdominal obesity was categorized using cut-offs of waist circumference of >94 cm for men and >80 cm for women and waist-tp-hip ratio cut-offs of >0.90 for men and >0.85 for women. RESULTS: BMI and hip and waist circumference data were obtained from 12,062 men and 18,853 women enrolled between 2001 and 2009. Overall, 76.8% of men and 59.5% of women reported a BMI ≥25 kg/m2. The proportions of overweight and obese were significantly higher in older age groups (p < 0.001). In addition, the proportion of participants reporting being overweight and obese was higher among lower education (p < 0.001) and lower income groups (p < 0.001). Overall, approximately two thirds of men and women in ATP cohort reported abdominal obesity. Overweight, obesity and abdominal obesity were all associated with a history of several cardiometabolic chronic conditions including hypertension, heart attack, angina, high cholesterol, stroke and diabetes. CONCLUSION: A large majority of ATP participants were overweight and carried excess abdominal fat. Strategies to improve energy balance among Albertans are encouraged and may have a notable impact on future chronic disease burden.

Rationale, design, and methods for Canadian alliance for healthy hearts and minds cohort study (CAHHM) - a Pan Canadian cohort study.

BACKGROUND: The Canadian Alliance for Healthy Hearts and Minds (CAHHM) is a pan-Canadian, prospective, multi-ethnic cohort study being conducted in Canada. The overarching objective of the CAHHM is to understand the association of socio-environmental and contextual factors (such as societal structure, activity, nutrition, social and tobacco environments, and access to health services) with cardiovascular risk factors, subclinical vascular disease, and cardiovascular and other chronic disease outcomes. METHODS/DESIGN: Participants between 35 and 69 years of age are being recruited from existing cohorts and a new First Nations Cohort to undergo a detailed assessment of health behaviours (including diet and physical activity), cognitive function, assessment of their local home and workplace environments, and their health services access and utilization. Physical measures including weight, height, waist/hip circumference, body fat percentage, and blood pressure are collected. In addition, eligible participants undergo magnetic resonance imaging (MRI) of the brain, heart, carotid artery and abdomen to detect early subclinical vascular disease and ectopic fat deposition. DISCUSSION: CAHHM is a prospective cohort study designed to investigate the impact of community level factors, individual health behaviours, and access to health services, on cognitive function, subclinical vascular disease, fat distribution, and the development of chronic diseases among adults living in Canada.

Biobanking in the Twenty-First Century: Driving Population Metrics into Biobanking Quality.

Biospecimens are the essential substrates for human biomarker research. Across the globe, biobanks have developed the facilities and mechanisms to collect, process, store and distribute those substrates to researchers. However, despite some notable successes, less than one hundred of the tens of thousands of purported biomarkers have been independently validated. We propose the need for a new paradigm in biobanking; simply pursuing larger numbers of participants, larger networks of biobanks and higher sample integrity will not, in itself, transform the success rate or efficiency of biomarker research. We propose that biobanks must embrace the intrinsic observational nature of biospecimens and furnish the recipients of biospecimens with the population metrics (descriptive statistics) that can facilitate the scientific rigor that is mandated in other areas of observational research. In addition, we discuss the value of population-based ascertainment and recruitment and the importance of the timing of biospecimen collections. Any assessment of biospecimen quality must go beyond the sample itself and consider both the patient/participant selection and the most appropriate and informative timing for specimen collection, particularly prior to any treatment intervention in diseased populations. The examples and rationales that we present are based largely on cancer-related collections because the feasibility of population metrics is greatly assisted by the comprehensive registries that are more common for cancer than other chronic diseases. Changing the biobanking paradigm from tacitly 'experimental' to explicitly 'observational' represents a profound but urgent methodological shift that will influence the establishment, management, reporting and impact of biobanks in the twenty-first century.

The Sedentary Time and Activity Reporting Questionnaire (STAR-Q): reliability and validity against doubly labeled water and 7-day activity diaries.

We determined measurement properties of the Sedentary Time and Activity Reporting Questionnaire (STAR-Q), which was designed to estimate past-month activity energy expenditure (AEE). STAR-Q validity and reliability were assessed in 102 adults in Alberta, Canada (2009-2011), who completed 14-day doubly labeled water (DLW) protocols, 7-day activity diaries on day 15, and the STAR-Q on day 14 and again at 3 and 6 months. Three-month reliability was substantial for total energy expenditure (TEE) and AEE (intraclass correlation coefficients of 0.84 and 0.73, respectively), while 6-month reliability was moderate. STAR-Q-derived TEE and AEE were moderately correlated with DLW estimates (Spearman's ρs of 0.53 and 0.40, respectively; P < 0.001), and on average, the STAR-Q overestimated TEE and AEE (median differences were 367 kcal/day and 293 kcal/day, respectively). Body mass index-, age-, sex-, and season-adjusted concordance correlation coefficients (CCCs) were 0.24 (95% confidence interval (CI): 0.07, 0.36) and 0.21 (95% CI: 0.11, 0.32) for STAR-Q-derived versus DLW-derived TEE and AEE, respectively. Agreement between the diaries and STAR-Q (metabolic equivalent-hours/day) was strongest for occupational sedentary time (adjusted CCC = 0.76, 95% CI: 0.64, 0.85) and overall strenuous activity (adjusted CCC = 0.64, 95% CI: 0.49, 0.76). The STAR-Q demonstrated substantial validity for estimating occupational sedentary time and strenuous activity and fair validity for ranking individuals by AEE.

Are physical activity levels linked to nutrient adequacy? Implications for cancer risk.

Cancer prevention guidelines recommend a healthy body mass index, physical activity, and nutrient intake from food rather than supplements. Sedentary individuals may restrict energy intake to prevent weight gain and in so doing may compromise nutritional intake. We conducted a cross-sectional analysis to determine if adequacy of micronutrients is linked to physical activity levels (PALs) in healthy-weight adults. Tomorrow Project participants in Alberta, Canada (n = 5333), completed past-year diet and physical activity questionnaires. The percent meeting Dietary Reference Intakes (DRIs) was reported across low and high PAL groups, and the relation between PAL and percent achieved DRI was determined using multiple linear regression analyses. Overall, <50% of healthy-weight participants met DRIs for folate, calcium, and vitamin D. Percent achieved DRI increased linearly with increasing PAL in both genders (P < 0.01). A hypothetical increase in PAL from 1.4 to 1.9 was associated with a DRI that was 8%-13% higher for folate and vitamin C (men) and 5%-15% higher for calcium and iron (women). Healthy-weight adults at higher PALs appear more likely to meet DRIs for potential cancer-preventing nutrients. The benefits of higher PALs may extend beyond the usual benefits attributed to physical activity to include having a more favorable impact on nutrient adequacy.

Stage Shifting by Modifying the Determinants of Breast Cancer Stage at Diagnosis: A Simulation Study.

BACKGROUND: Breast cancer is the most common cancer in Canadian women; nearly 25% of women diagnosed with cancer have breast cancer. The early detection of breast cancer is a major challenge because tumours often grow without causing symptom. The diagnosis of breast cancer at an early stage (stages I and II) improves survival outcomes because treatments are more effective and better tolerated. To better inform the prevention of and screening for breast cancer, simulations using modifiable rather than non-modifiable risk factors may be helpful in shifting the stage at diagnosis downward. METHODS: Breast cancer stages were simulated using the data distributions from Alberta's Tomorrow Project participants who developed breast cancer. Using multivariable partial proportional odds regression models, modifiable lifestyle factors associated with the stage of cancer at diagnosis were evaluated. The proportions or mean levels of these lifestyle factors in the simulated population were systematically changed, then multiplied by their corresponding estimated odds ratios from the real data example. The effects of these changes were evaluated singly as well as cumulatively. RESULTS: Increasing total dietary protein (g/day) intake was the single most important lifestyle factor in shifting the breast cancer stage downwards followed by decreasing total dietary energy intake (kcal/day). Increasing the proportion of women who spend time in the sun between 11 am and 4 pm in the summer months, who have had a mammogram, who have been pregnant or reducing the proportion who are in stressful situations had much smaller effects. The percentage of Stage I diagnoses could be increased by approximately 12% with small modifications of these lifestyle factors. CONCLUSION: Shifting the breast cancer stage at diagnosis of a population may be achieved through changes to lifestyle factors. This proof of principle study that evaluated multiple factors associated with the stage at diagnosis in a population can be expanded to other cancers as well, providing opportunities for cancer prevention programs to target specific factors and identify populations at higher risk.

Overview of the Engagement Process to Develop the Future of Cancer Impact (FOCI) Report in Alberta: The Power of Collective Action.

This commentary provides a detailed overview of the extensive stakeholder engagement efforts critical to the development of the Future of Cancer Impact (FOCI) in Alberta report. The overarching aim of the FOCI report was to support informed and strategic discussions and actions that will help key stakeholders in the province prepare for a future with increasing cancer incidence and survival. Employing a comprehensive approach and a diverse range of engagement activities, insights from a wide spectrum of stakeholders were gathered and subsequently used to shape the content of the report. This inclusive process ensured broad representation of perspectives, contributing to a deeper understanding of the complexities in cancer care. The outcome is a robust, consensus-driven report with recommendations set to drive significant transformations within the healthcare system. These efforts highlight the critical role of extensive, inclusive, and collaborative engagement in shaping healthcare initiatives and advancing discussions crucial for the future of cancer care in Alberta.

Influence of nutrition labelling on food portion size consumption.

Nutrition labelling is an important strategic approach for encouraging consumers to make healthier food choices. The availability of highly palatable foods labelled as 'low fat or reduced calorie' may encourage the over-consumption of these products. This study aimed to determine whether the manipulation of nutrition labelling information can influence food portion size consumption. Normal and overweight men (n=24) and women (n=23) were served an identical lunch meal on three separate days, but the information they received prior to consuming the lunch meal was manipulated as follows: "baseline", "high fat/energy" and "low fat/energy". Food and energy intake was significantly increased in the low fat/energy condition compared with both baseline and the high fat/energy condition. An additional 3% (162 kJ) energy was consumed by subjects under the low fat/energy condition compared to baseline. No differences were observed between the baseline and high fat/energy condition. Subjects who consumed most in the low fat/energy condition were found to be mostly men, to have a higher BMI and to be overweight. Low fat/energy information can positively influence food and energy intake, suggesting that foods labelled as 'low fat' or 'low calorie' may be one factor promoting the consumption of large food portions.

Applying suggested new terminology and definitions for human milk feeding in the Alberta Pregnancy Outcomes and Nutrition (APrON) longitudinal pregnancy cohort.

The complexity of human milk-feeding behaviours may not be captured using simpler definitions of "exclusive" and "non-exclusive" breastfeeding. New definitions have been suggested to describe variation in these behaviours more fully but have not been widely applied. We applied the new definitions to data derived from 3-day human milk-feeding diaries. Participants (n = 1091) recorded the number, beginning/end time, and modes of feeding of infants aged 3 months. Data were used to create six exclusive groups according to feeding mode(s): (1) human milk at-breast only; (2) human milk at-breast and human milk in a bottle; (3) human milk at-breast and infant formula in a bottle; (4) human milk at-breast and human milk and infant formula mixed in the same bottle; (5) human milk at-breast, human milk in a bottle, and infant formula in a bottle (not mixed); and (6) a bottle that sometimes contained human milk and sometimes infant formula (not mixed), never at-breast. Differences in maternal and infant characteristics were examined among groups. Fifty-seven percent fed at-breast only (Group 1). Those in Group 1 spent a similar amount of time feeding directly at-breast (median 132 (IQR 98-172) min/day) as those in Groups 2 (124 (95-158)), 3 (143 (100-190)), and 5 (114 (84-142)) (p > 0.05), indicating that adding bottle feeding did not always reduce the time infants were fed at-breast. Applying new suggested definitions to describe human milk-feeding behaviours from the mothers' perspective highlights the complexity of patterns used and warrants further application and research to explore impacts on health outcomes.

Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians' mental models.

BACKGROUND: Care pathways are tools that can help family physicians navigate the complexities of the cancer diagnostic process. Our objective was to examine the mental models associated with using care pathways for cancer diagnosis of a group of family physicians in Alberta. METHODS: We conducted a qualitative study using cognitive task analysis, with interviews in the primary care setting between February and March 2021. Family physicians whose practices were not heavily oriented toward patients with cancer and who did not work closely with specialized cancer clinics were recruited with the support of the Alberta Medical Association and leveraging our familiarity with Alberta's Primary Care Networks. We conducted simulation exercise interviews with 3 pathway examples over Zoom, and we analyzed data using both macrocognition theory and thematic analysis. RESULTS: Eight family physicians participated. Macrocognitive functions (and subthemes) related to mental models were sense-making and learning (confirmation and validation, guidance and support, and sense-giving to patients), care coordination and diagnostic decision-making (shared understanding). Themes related to the use of the pathways were limited use in diagnosis decisions, use in guiding and supporting referral, only relevant and easy-to-process information, and easily accessible. INTERPRETATION: Our findings suggest the importance of designing pathways intentionally for streamlined integration into family physicians' practices, highlighting the need for co-design approaches. Pathways were identified as a tool that, used in combination with other tools, may help gather information and support cancer diagnosis decisions, with the goals of improving patient outcomes and care experience.