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Physical activity and adenomatous polyps: Measures of association and impact
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Physical activity and adenomatous polyps: Measures of association and impact
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NOTE TO USERS Copyrighted materials in this document have not been scanned at the request of the author. They are available for consultation in the author's university library. pg 256 This reproduction is the best copy available. UMI Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PHYSICAL ACTIVITY AND ADENOM ATOUS POLYPS: M EASURES OF ASSO CIATIO N AND IM PACT by Carolyn M. Ervin A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (EPIDEMIOLOGY) August 2003 Copyright 2003 Carolyn M. Ervin Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI Number: 3116693 INFORMATION TO USERS The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleed-through, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. UMI UMI Microform 3116693 Copyright 2004 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UNIVERSITY OF SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES, CALIFORNIA 90007 This dissertation, w ritten by under the direction of h ^ lL ... Dissertation Committee, and approved by all its members, has been presented to and accepted by The Graduate School, in partial fulfillment of re quirements for the degree of DOCTOR OF PHILOSOPHY a ____ y / CZfT Dean of Graduate Studies Da te .... St..12, .2003 DISSERTATION COMMITTEE Chairperson Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS LIST OF TABLES vii ABSTRACT ix 1. COLORECTAL CANCER: A REVIEW OF THE EPIDEMIOLOGY 1.1 INTRODUCTION: 1 1.1.1 C olorectal C a n c e r - U n ited S tates 1 1.1.1.1 Incidence 1 1.1.1.2 M ortality 1 1.1.1.3 Survival 2 1.1.1.4 Trends by Race and Ethnicity 2 1.1.2 C olorectal C a n c e r - W orldw ide 3 1.1.2.1 Incidence 3 1.1.2.2 M ortality 4 1.1.2.3 Survival 4 1.1.2.4 Trends by Race and Ethnicity 5 1.1.2.5 Geography 5 1.2 RISK FACTORS - ENVIRONMENTAL 6 1.2.1 D iet 6 1.2.1.1 Nutrients and Foods 6 1.2.1.2 Calcium and V itam in D 7 1.2.1.3 A lcoh ol 7 1.2.1.4 Sm oking 8 1.2.1.5 Occupational Exposures 8 1.2.1.6 Nonsteroidal A nti-inflam m atory Drugs 9 1.3 RISK FACTORS - HOST 9 1.3.1 A ge 9 1.3.2 G en d er 10 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.3.3 B o d y Size 10 1.3.4 Fam ilial a n d H er edita ry Fac to r s 10 1.3.4.1 Familial Adenomatous Polyposis - FA? 1 1 1.3.4.2 Gardner’s Syndrome 11 1.3.4.3 Hereditary Nonpolyposis Colon Cancer - FINPCC 12 1.3.4.4 Familial Colorectal Cancer - Ashkenazi Jews 12 L4 ETIOLOGY AND HISTOPATHOLOGY____________________________ 13 1.4.1 N o r m a l Cr y pt C ell Proliferation 13 1.4.2 P olyps - A b n o r m a l Cr y pt Cell Proliferation 14 1.4.2.1 Polyp Histopathology 14 1.4.2.2 Adenomatous Polyps 15 1.4.3 C olorectal C a n c e r 16 L5 GENETICS_____________________________________________________ 17 1.5.1 C lassic P a t h w a y - The “S u ppr e sso r” P a t h w a y 17 1.5.1.1 APC gene - Chromosome 5q: 18 1.5.1.2 Méthylation Status: 19 1.5.1.3 Activation of Ras Oncogenes: 19 1.5.1.4 DCC gene-Chromosome 18q 20 1.5.1.5 P53 gene - Chromosome 17p 21 1.5.2 The R o a d Less Follow ed - The “M u ta to r” Pa th w a y 21 1.5.2.1 Mismatch Repair (MMR) Genes 21 1.5.2.2 Microsatellite Instability 22 1.5.2.3 Associated Genes 23 L6 PHYSICAL ACTIVITY___________________________________________24 1.6.1 A n O verview of the S tu d ies 24 1.6.2 E a r ly S tudies OF P h y sic a l A ctivity a n d D ea th s Fr o m N eo pla sm s 24 1.6.3 Ph y sic a l A ctivity Stu d ies of C olorectal C a n c er 45 1.6.4 S tu d ies Co v er in g Site-S pecific A ssociations 69 1.6.5 Stu d ies S u m m a r y 70 L7 BIOLOGICAL MECHANISMS____________________________________ 73 1.7.1 D ec r ea sed Gastro in testin a l Tr a n sit Tim e 73 1.7.1.1 Vagal Innervation 74 1.7.2 Pr o sta g la n d in Secretion 74 ill Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.7.3 Im m u n e F u n ctio n 75 1.7.4 S ecretion of G a st r o-entero-pancreatic H orm o nes 76 1.7.5 In su l in Lev el AND G lu c o se To ler a nc e 76 L8 METHODOLOGY_______________________________________________ 76 1.8.1 Ph y sic a l A ctivity 76 1.8.1.1 Physical Activity Assessment 76 1.8.1.2 Limitations of Assessment 77 1.8.2 Ca n c e r 80 1.8.2.1 Incident versus Prevalent Cases 80 1.8.2.2 Case-Control versus Cohort Studies 80 1.8.2.3 Sample Size 81 1.8.3 Tem poral Relationships 81 1.8.4 C o n fo u n d in g 81 1.9 HETEROGENEITY BY RACE & RACIAL DIFFERENCES 82 1.10 DISCUSSION 83 2. ANALYSIS OF DATA 84 2.1 BACKGROUND 84 2.2 METHODS 84 2.2.1 S u bject R ecruitm ent a n d D a t a C ollection 84 2.2.1.1 Sigmoid I 85 2.2.1.2 Sigmoid II 88 2.3 DATA CODING AND ANALYSIS 89 2.3.1 M ea su r e m en t of Ph y sic a l A ctivity 89 2 .3.2 C o m pen dium OF Ph y sica l A ctivities 89 2.3.3 The Ph y sic a l A ctivity V a r iables 91 2.3.3.1 Frequency of Vigorous Recreational Activity 91 iv Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2.3.3.2 Weekly Vigorous Recreational Activity 92 2.3.3.3 Weekly Occupational Activity 93 2.3.3.4 Weekly Combined Occupational and Recreational Activity 94 2.3.3.5 Daily Physical Activity 94 2.3.3.6 Merged Data for Analysis 95 2.3.4 D a t a A n a l y sis 96 2A r e s u l t s _______________________________________________________ 98 2.4.1 U n c o n d itio n a l Logistic R eg ressio n 98 2.4.1.1 Total Subjects 98 2.4.1.2 White Subjects 104 2.4.1.3 African American Subjects 107 2.4.1.4 Latino Subjects 107 2.4.1.5 Asian Subjects 116 2.4 .1 .6 Male and Female Subjects 116 2.4 .2 H eterogeneity of O th er V a r iables 116 2.4.2.1 Summary of Interaction: 135 2.4.3 C orrelation - O c cupatio nal a n d Rec r ea tio n al Ph y sic a l A ctivity 136 2.4.3.1 Total Subjects 136 2.4.3.2 Stratified by Ethnicity 144 2.4.3.3 Stratified by Gender 144 2 .4 .4 M ea su r e s OF Im pa c t 145 2.4.4.1 Total Subjects 151 2.4 .4 .2 White Subjects 151 2.4.4.3 African American Subjects 152 2.4 .4 .4 Latino Subjects 152 2.4.4.5 Asian Subjects 153 2.4 .4 .6 Male Subjects 153 2.4 .4 .7 Female Subjects 154 2.4.4.8 Summary of Measures of Impact 154 2.5 DISCUSSION IM REFERENCES 162 BIBLIOGRAPHY 173 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDICES_______________________________________________________ 184 A ppen d ix A l. S igm oid I - In -p er so n Interview 185 A ppen d ix A 2. S igm oid II - S em i-qua n tita tiv e Fo o d Fr eq u enc y Q uestio n n a ir e 227 A ppen d ix A3. The C o m pen dium of Ph y sic a l A ctivities 256 A ppen d ix A 4. Gr a n t Pr o po sal 267 VI Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF TABLES Table 1 : Early Studies of Physical Activity and Deaths From Neoplasms 25 Table 2: Physical Activity Studies of Colorectal Cancer 27 Table 3: Characteristics of the study population for unmatched subjects. 99 Table 4: Odds ratios of colorectal adenomatous polyps for several physical activity measures, unmatched subjects. 102 Table 5 : Characteristics of the study population for Ethnicity - ’White”. 105 Table 6: Odds ratios of colorectal adenomatous polyps for several physical activity measures for Ethnicity =”White”. 108 Table 7: Characteristics of the study population for Ethnicity = ’’ African American”. 110 Table 8: Odds ratios of colorectal adenomatous polyps for several physical activity measures for Ethnicity =”African American”. 112 Table 9: Characteristics of the study population for Ethnicity - ’ Latino”. 113 Table 10: Odds ratios of colorectal adenomatous polyps for several physical activity measures for Ethnicity =”Latino”. 115 Table 11 : Characteristics of the study population for Ethnicity - ’ Asian”. 117 Table 12: Odds ratios of colorectal adenomatous polyps for several physical activity measures for Ethnicity - ’ Asian”. 119 Table 13: Odds ratios of colorectal adenomatous polyps for several physical activity measures, Gender = Male. 120 Table 14: Odds ratios of colorectal adenomatous polyps for several physical activity measures. Gender = Female. 121 Table 15: Interaction for vigorous physical activity measures, unmatched subjects. 122 V ll Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 16; The Correlation Matrix Table Between Recreational and Occupational Variables for all Unmatched Data, In Average MET Hours Per Week. 137 Table 17; The Correlation Matrix Table Between Recreational and Occupational Variables, In Average MET Hours Per Week, Ethnicity = White. 138 Table 18; The Correlation Matrix Table Between Recreational and Occupational Variables, In Average MET Hours Per Week, Ethnicity = African American. 139 Table 19; The Correlation Matrix Table Between Recreational and Occupational Variables, In Average MET Hours Per Week, Ethnicity = Latino. 140 Table 20; The Correlation Matrix Table Between Recreational and Occupational Variables, In Average MET Hours Per Week, Ethnicity - Asian. 141 Table 21 ; The Correlation Matrix Table Between Recreational and Occupational Variables, In Average MET Hours Per Week, Gender = Male. 142 Table 22; The Correlation Matrix Table Between Recreational and Occupational Variables, In Average MET Hours Per Week, Gender=Female. 143 Table 23; Preventable Fractions and Numbers for All Subjects 146 Table 24; Preventable Fractions and Numbers for Ethnicity = "White" 147 Table 25 ; Preventable Fractions and Numbers for Ethnicity = "Latino" 148 Table 26; Preventable Fractions and Numbers for Gender = "Male" 149 Table 27; Preventable Fractions and Numbers for Gender = "Female" 150 via Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ABSTRACT During the past decade, epidemiological evidence has generally supported an inverse association between physical activity and colorectal cancer. Most studies have measured physical activity by using either occupational activity, leisure-time activity, or a combined measure of both. The objectives of this study are to: investigate the relationship between measurements of physical activity and colorectal adenomas, and to assess whether measures correlation and impact differ by race. The subjects for this study were ascertained from two existing case-control studies of risk factors for adenomatous polyps of the large bowel at the University of Southern California, in Los Angeles. Subjects are asymptomatic persons who attended a sigmoidoscopy screening at two clinical centers. Preliminary results have shown that after the adjustment for nutritional and lifestyle covariates, frequency of vigorous recreational activity was associated with a decreased risk (Odds ratio (OR) =0.7, 95% Confidence interval (C.I.)=0.6-0.8). Occupational activity in the second quartile of physical activity was associated with a reduced prevalence of polyps (OR=0.7, 95% C.I.=0.6-0.9). Combined occupational and recreational activity in the third quartile of physical activity was also associated with a reduced prevalence of polyps (OR-0.8, 95% C.I.=0.7-0.9). Additional results will be available at the time of the presentation. The results of this research will assist in determining what amount, intensity and type of physical activity is most protective, as well as whether racial differences exist with respect to physical activity. IX Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1. Colorectal Cancer; A Review of the Epidemiology 1.1 Introduction: 1.1.1 Colorectal Cancer - United States 1.1.1.1 Incidence An estimated 135,400 new cases of colorectal cancer will be diagnosed in the United States in 2001; of these, 98,200 will be diagnosed as colon cancer and 37,200 as cancer of the rectum. 1 Colorectal cancer ranks second in cancer incidence for the combined U.S. population. Amiong males, it is the third most commonly occurring cancer, after prostate and lung cancer. Among females, it is the third most commonly diagnosed cancer, after cancers of the breast and lung. * Colorectal cancer will account for approximately 10% of all new cancer cases among males in 2001, and 11% of all new cancer cases among females. ^ A decrease in the number of incident cases began in the mid-1980’s, and continues to decline, at an average of 1.6% per year. 2 1.1.1.2 Mortality In 2001, an estimated 56,700 Americans are expected to die from colorectal cancer, or approximately 155 people a day. l Among these, 48,100 will be caused by colon cancer and 8,600 by cancer of the rectum. Colon and rectum cancer rank as the second leading cause of cancer deaths in the U.S., next to lung cancer. Among women, colorectal cancer is the third most common cause of cancer death, outranked by lung and breast cancer. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Among men it is the third most frequent cause of cancer death, preceded only by lung and prostate cancer. * Colorectal cancer will account for approximately 10% of all cancer deaths among males in 2001, and 11% of all cancer deaths among females. ' Colorectal cancer mortality rates have leveled off in recent years and are beginning to decline. Mortality rates for colorectal cancer have decreased from 1985 to 1997, on the average of 1.8% per year. 2 1.1.1.3 Survival The 1-year and 5-year survival rates for colon and rectum cancer patients in the United States are 83% and 61%, respectively, f 3 Patients with early detected colon cancer in a localized stage have a 5-year relative survival rate of 91%. However, only 37% of colorectal cancer is found at that early stage. In those patients where the cancer has spread regionally to adjacent organs or lymph nodes, the rate drops to 63%. Patients with distant métastasés have a 5-year survival rate of less than 7%. 3 1.1.1.4 Trends bv Race and Ethnicitv Cancer incidence rates vary by race and ethnic group. African Americans have the highest incidence and mortality rates for colorectal cancer. 1 African American females are more likely to develop cancers of the colon and rectum than women of other ethnic groups. They are 68% more likely to develop colorectal cancer than Asian/Pacific Islanders and 52% more likely than Hispanics. Among males, African Americans have the highest incidence rate of colorectal cancer. They are more than two times as likely to Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. develop colorectal cancer than males of other ethnic groups. Overall, from 1990 to 1997, combined cancer incidence rates decreased among whites and Hispanics (about 1% per year). During the same period, they remained stable for African Americans and Asian/Pacific Islanders, and increased slightly for American Indians, f 4 African American females are at least 38% more likely to die from colorectal cancer than females of any other ethnic group, while African American males are 28% more likely. During 1990 to 1995, overall cancer mortality rates decreased among African Americans, Hispanics, and whites. During that period, mortality rates for Asian/Pacific Islanders remained stable and increased slightly for American Indians. ^ Higher death rates among African American males and females may be attributable to a poorer probability of survival once diagnosed with cancer, l African Americans are more likely to be diagnosed with cancer at a regional or distant stage of disease, versus a localized stage when the disease is more successfully treated. In addition, African Americans have lower five-year relative survival rates than whites at each stage of diagnosis, which may suggest differences in treatment, tumor pathology, and comorbid conditions. 1 1.1.2 Colorectal Cancer - Worldwide 1.1.2.1 Incidence An estimated 783,000 new cases of colorectal cancer were diagnosed worldwide in 1990 (9.7% of all new cancer cases).^’ ^ Colorectal cancer ranks third in cancer incidence internationally.^ Among males, it is the third most commonly occurring cancer, after 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. lung and stomach cancer. Among females, it is the second most commonly diagnosed cancer, following breast cancer. Colorectal cancer accounted for approximately 9.4% of all new cancer cases among males worldwide in 1990, and 10.1% of all new cancer cases among females.^’ ^ 1.1.2.2 Mortality In 1990, worldwide, colorectal cancer accounted for 437,000 deaths or 8.4% of total cancer deaths.^ Colon and rectum cancer is the fourth leading cause of cancer deaths in the world, following lung and stomach cancer.^ Among females, colorectal cancer is the fourth most common cause of cancer death, outranked by breast, stomach and lung cancer. Among males it is the fourth most frequent cause of cancer death, preceded by lung, stomach, and liver cancer. Internationally, colorectal cancer caused approximately 9.7% of all cancer deaths among females in 1990, and 7.5% of all cancer deaths among males.6 1.1.2.3 Survival Worldwide, the estimated 5-year survival rates for colon and rectum cancer cases combined is 44%.^ The lowest estimated rate of survival is in eastern Europe, with a 5- year survival rate of 30%. The SEER program reports average 5-year survival at 60%; the European and Indian cancer registries reported 41% and 42% respectively. China and developing countries report a slightly lower survival rate of 32% and 38%. North Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. America has the highest 5-year survival rate, with a rate of 61%. Worldwide, colorectal cancer survival is on the average better than that of cancer at other less common sites. ^ 1.12.4 Trends bv Race and Ethnicitv Colon cancer rates vary by race and ethnic status. 7, 8 The highest rates are among Caucasians of northern Europe. This is consistent in both native countries and in areas of migration, such as Australasia and North America. Caucasians of southern European origin have lower rates, which tend to rise with migration. Lower colon cancer rates occur in Asia and Africa, but tend to rise with migration and westernization. There is a 20-fold international difference in rates across countries. Migrant data suggest that this can be explained by dietary and environmental differences. Exceptions include; the Maoris (Polynesians) who show a low incidence rate in New Zealand, and female Polynesians of Hawaii who have a low risk comparable to that seen in New Zealand. Male Polynesians now experience a risk similar to that seen for U.S. white populations.^’ ^ 1.1.2.5 Geography Colon cancer occurs more frequently in industrialized, western societies.^ Rates in western European countries, although still lower than those in North America, are consistently higher than rates in eastern European countries. The highest incidence rates are reported in North America, Australia, and New Zealand. The lowest rates of colon cancer are reported in Africa, Asia, and Latin America. In general, economically Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. advantaged populations exhibiting westernized lifestyle practices have higher rates of colon cancer.9 However, global differences in the incidence of preventable cancers (i.e., cervical cancer) and survival from those that are treatable (i.e., testicular cancer), show a disparity in detection and reporting. 6 1.2 Risk Factors - Environmental 1.2.1 Diet 1.2.1.1 Nutrients and Foods Diet is an important risk factor in the etiology of colorectal cancer. Diets low in fiber, high in protein, and high in fat, similar to those consumed by industrialized societies, increase the risk of colorectal cancer.^» * In the United States, as well as other industrialized countries, meat is a main source of dietary fat and present in most high fat diets. Cooked meats contain potent mutagens that are produced during high-temperature cooking, such as grilling or frying.^ These include a class of heterocyclic amines (HCA), the major ones being: IQ, methyl IQ, dimethyl IQ % , and PhlP. Heteroeyclie amines have been shown to be carcinogenic in animal models, which has heightened interest in examining cooked meat products. The degree of cooking, particularly frying and darkly browning the surface of red meat, has been reported to have a positive association with colorectal adenomas. Some studies have shown a decreased risk with consumption o f fish and s e a f o o d . * 2-14 Considering fiber, countries with the highest per capita fiber consumption tend to have lower colorectal cancer rates.^ Several case-control studies of colorectal cancer Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. have shown vegetable intake to be protective. Although an inverse association exists for fruit intake, the results are not as consistent as that for vegetables.^’ I '* ’ Diets high in fruits, vegetables and grains provide insoluble fiber, micronutrient antioxidants and phytochemicals with anticarcinogenic properties, thereby reducing the risk o f colon cancer.9 In southern Europe and Asia, where cereal consumption is high, risk of colorectal cancer is associated with consumption o f rice (Japan) or pasta and rice (southern Europe).^ 1.2.1.2 Calcium and Vitamin D Intake o f calcium, with its potential for binding with fatty acids and bile acids, is associated with a reduced colorectal cancer r i s k . 1 6 - 1 9 calcium hypothesis suggests that calcium binds with fatty and bile acids in the bowel lumen, preventing mucosal damage.^’ ^ Animal studies, as well as studies on the reduction o f rectal mucousal proliferation after supplementation with calcium carbonate, have lent credibility to this hypothesis. Similar studies have shown an inverse association between colorectal cancer and vitamin D. 20-23 1.2.1.3 Alcohol A number o f studies have examined the association between alcohol and colorectal cancer, in particular beer. Studies have found minimal or no association between alcohol use and the risk o f adenomatous polyps.^’ 2, 24 ^ recent meta-analysis o f 27 studies reported that the positive association between alcohol consumption and colorectal cancer Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. was small and not indicative of a causal role.^ Inconsistencies in alcohol studies may result from the small sample sizes, difference in the types of control groups used and methods of assessing consumption.^» 25 1.2.1.4 Smoking Although tobacco has been shown to be an epithelial carcinogen and mutagenic tobacco metabolites have been found in cervical mucus, there appears to be little or no relation between smoking and colorectal cancer.3 A greater risk has been shown to be associated with smoking cigars and pipes. 25,26 Several studies have shown an increased risk of adenomatous polyps among cigarette smokers.^» 24, 26 addition studies have linked long-standing or early onset of smoking cigarettes with colon cancer. 27-30 More recent studies have focused on the possibility that risk associated with smoking may be modified by polymorphisms in metabolized enzymes, NATl, NAT2, and CYPjai- ^ h 32 12.1.5 Occupational Exposures In the United States, colorectal cancer mortality tends to be clustered in regions with a past of intense industrial activity, such as: the North Atlantic Coast, Massachusetts, New York, and the urban Great Lakes Area.3 Painters, printers, woodworkers, automotive industry workers, and metal workers, have been shown to be among those workers at increased risk.5, 7 An association has been shown in studies of pattern and model makers in the automobile industry. Increased risk of colorectal incidence and mortality among skilled workers who are exposed to woods, plastics, fumes and solvents, 8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. suggests that there is an association between these exposures and colon cancer.^ Recent research has suggested that the link between asbestos exposure and colon cancer may be confounded by non-occupational factors and warrants further investigation.^^, 34 Studies conducted on occupational physical activity have shown that males with sedentary jobs are at least 1.6 times more likely to develop colon cancer than males whose jobs require a high level of physical activity. 35, 36 However, statistically significant relationships with occupational groups may be confounded by socio-economic status and lifestyle, as well as risk due to environmental exposure in the workplace.^ 12.1.6 Nonsteroidal Anti-inflammatorv Drugs Recent studies have suggested that nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, may reduce the risk of colorectal cancer. 37-39 NSAIDs have been shown to inhibit the synthesis of prostaglandin in humans, thereby suppressing epithelial cell proliferation and colorectal tumor formation.3 The protective effects of NSAIDs on colorectal cancer is an ongoing area of research. 1.3 Risk Factors - Host 1.3.1 Age The strongest risk factor for colorectal cancer is age. The incidence of colorectal cancer is very low at childhood and increases dramatically with age.3 Age-incidence curves gradually escalate in persons older than 40 years, increasing more swiftly among Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. those 60 to 79 years of age."*’ ^ Incidence rates rise from 10 per 100,000 at age 40-45 to 300 per 100,000 at age 75-80.^ 1.3.2 Gender Colorectal cancer occurs with approximately equal frequency among men and women.40 The incidence of colon versus rectal cancer in males is approximately 2 to 1. In females it is slightly higher, with a ratio of approximately 3 to 1.^ In the United States, the median age for diagnosis is 70 for men and 73 for women. ^ 1.3.3 Body Size Obesity, height, and abdominal adiposity among males are predictors of elevated risk of colorectal cancer.^» There is a two-fold increase in colon cancer risk among men and women in the highest body size quantile. Other studies have reported no association. Some evidence indicates that obesity in early life is related to increased risk of subsequent colorectal cancer. Two cohort studies have shown an association between height and bowel cancer.^ Weight should be ascertained several years prior to diagnosis, since colorectal cancer can cause weight loss.^> 9 1.3.4 Familial and Hereditary Factors A family history of colorectal cancer increases the risk of the disease two to three fold.^’ 42 The following conditions increase a family member’s risk for colorectal 10 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. cancer: familial adenomatous polyposis (FAP), Gardner’s syndrome, hereditary nonpolyposis colon cancer (HNPCC), and familial colorectal cancer among Ashkenazi Jews. 13.4.1 Familial Adenomatous Polyposis - FAP Familial adenomatous polyposis (FAP) is a rare autosomal dominantly by inherited disease in which an affected individual develops hundreds to thousands of adenomatous polyps in the colon and rectum. Although an individual FAP polyp is no more likely to advance to a cancerous stage than a sporadic polyp in the general population, the large number of FAP polyps guarantees that some will progress to cancer. FAP accounts for about one percent of all cases of colorectal cancer. Half of all patients with FAP develop colorectal cancer by age 40, with almost 100% developing cancer by age 50 if left untreated. FAP is caused by mutations in the APC gene, a tumor-suppressor gene on chromosome 5q21.^> 42 1.3.4.2 Gardner’s Syndrome Gardner’s syndrome is characterized by colorectal adenomas, as well as extracolonic manifestations.40> 43 These include: soft-tissue tumors, osteomas, dental abnormalities, and congenital hypertrophy of the pigmented retinal epithelium (CHPRE). Upper gastrointestinal polyps are common among patients with FAP and Gardner’s syndrome. Gastric polyps, which are mainly hyperplastic and benign, occur in roughly 50% of patients. However, duodenal adenomas, which occur in about 80% of patients, have a 11 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. greater malignant potential. Gardner’s syndrome has also been linked to the 5q chromosome, suggesting the same genetic locus is involved with both FAP and Gardner’s syndrome.^’ 40,43 1.3.4.3 Hereditary Nonpolyposis Colon Cancer - HNPCC Hereditary nonpolyposis colon cancer (HNPCC), referred to as Lynch Syndrome I and If is a relatively common autosomal dominant disorder in which affected individuals do not develop large numbers of premalignant lesions of the colon. HNPCC accounts for about two to four percent of the colorectal cancers in the western world.40 Since affected patients do not express a unique phenotype, diagnosis must be made by family history and genetic testing. Defective mismatch repair genes cause HNPCC. Germline mutations in any of the mismatch repair genes: most commonly hMSH2, hMLHl, hPMS2, and hPMSl, appear to produce the same disease.40 1.3.4.4 Familial Colorectal Cancer - Ashkenazi Jews Recent research suggests an inherited predisposition for developing colorectal cancer among Ashkenazi Jews (Jews of Eastern European descent).44 Ashkenazi Jews with transversion from T to A at APC nucleotide 3920 have approximately a two-fold increased risk of developing colorectal cancer.44 12 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.4 Etiology and Histopathology 1.4.1 Normal Crypt Cell Proliferation The normal colon and rectum lining is composed of a single layer of epithelial cells, which line the crypts or invaginations of the colon and rectum.'^® Similar to the digestive tract, these crypts serve to increase epithelial siirface area. At the base of each crypt, there are four to six stem cells, which give rise to three epithelial cell types. They are: the absorptive cells, the mucus-secreting goblet cells, and the neuroepithelial cells. With normal cell development: the cells multiply in the lower third of the crypt, differentiate in the upper two-thirds of the crypt, and are extruded at the crypt apex. Normal crypt base to apex progression occurs in a 3- to 6-day cycle. During normal cell proliferation, the birth rate of colonic epithelial cells will precisely equal the rate of colonic epithelial cell loss from the crypt apex to the lumen of the bowel.^O A rapid rate of cell proliferation, matched by a commensurate rate of cell loss is normal and essential to maintaining the epithelial covering of the bowel lumen.^ Differences in cell proliferation exist at different sites within the colon, which may explain variations in cancer incidence by colonic site. These differences in colonic cell proliferation have been examined in studies performed on mice or rats.^^» ^6 the descending colon, cell crypts have been shown to be longer and contain more cells than the ascending colon. Cell cycle times are also shorter in the descending, and the number of proliferating cells is greater. Although the percentage of cells proliferating (growth fraction) is similar for both the descending and ascending colon, there is a lower absolute number of proliferating cells in the ascending 13 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. colon crypt at a given time Sinee this may reduce the likelihood of mutation, this may also partially explain the lower risk of colon cancer in the ascending colon.3 1.4.2 Polyps - Abnormal CrvDt Cell Proliferation When the rate of cell proliferation is not matched by the rate of cell loss, adverse outcomes may result.^» If the cell loss exceeds the cell proliferation, ulcerative colitis can occur. However, when cell proliferation exceeds the rate of cell loss at the crypt apex, cells pile up on the surface of the bowel mucosa. This resulting mass of cells protruding from the colon wall is often first observed clinically as a polyp or tumor.^’ 1.4.2.1 Polyp Histopathology Histologically, polyps can be classified as two types: hyperplastic or adenomatous.^® A hyperplastic or nondysplastic polyp will consist of a large number of cells with normal morphology. In a hyperplastic polyp, the cells line up in a single row along the basement membrane and have no neoplastic tendencies. An adenomatous or dysplastic polyp consists of a large number of cells with abnormal morphology. These cells lie in several layers on the basement membrane, their nuclei are larger than normal and positioned within the cell further from the basement membrane. The abnormal intracellular and intercellular organization of these dysplastic polyps causes the ciypts to appear crowded together in a kaleidoscope pattern. As the adenomatous polyps increase in size, they become more dysplastic and are more likely to contain “villous” fingerlike projections of the dysplastic crypts.^O 14 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.4.2.2 Adenomatous Polyps 1.4.2.2.1 Glandular Morphology In terms of appearance, adenomas and adenocarcinomas are neoplastic lesions which vary in shape and architectural composition.'^^ They are attached to the bowel wall by either a stalk (called “pedunculated”) or by a broad base (called “sessile”). Using glandular morphology, adenomas can be classified into three categories: tubular (80% - 86%), tubulovillous (8% - 16%) and villous (3% - 16%). Tubular adenomas are usually the smallest and are less than 1 cm in diameter. Villous adenomas are usually the largest, and can be more than 1 cm in diameter. The severity of adenoma dysplasia is related to increasing polyp size and villous history. However, high-grade dysplasia can also occur in small tubular adenomas. Malignancy occurs in 1% of all adenomatous polyps smaller than 1 cm diameter, and 10% or more in those polyps larger than 2 cm.^^ 1.4.2.2.2 Progression As adenomatous polyps progress, they are more likely to become malignant and have the ability to invade surrounding tissue.^® Polyps usually grow into the lumen of the colon or rectum before invading deep into the mucosal epithelium, the lamina propria mucosal layer, the submucosa, the muscular layer of the intestine, and then through the surrounding serosa, where they can spread contiguously to other organs.^^ An untreated cancerous polyps or adenocarcinoma can go through a process called metastasis. During 15 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. this process, cells from the tumor break away and spread through the bloodstream or lymph system to other parts of the body where they can form “colony” tumors.^® 1.4.3 Colorectal Cancer Ninety-five percent o f colorectal cancers are adenocarcinomas. Other types o f less common cancers arising from non-epithelial cells occasionally occur, such as lymphomas and s a r c o m a s . ^ 0 , 48 Although a polyp is the earliest clinical manifestation o f colorectal neoplasia, single crypt lesions (aberrant crypt foci) can also be detected through methylene blue staining or microscopic examination o f the colonic mucosa. Similar to polyp classification, aberrant ciypt foci can be classified as nondysplastic or dysplastic (called microadenomas).40 Adenomatous polyps occur in about 5% of individuals less than 50 years old and in 50% of those over 70 years old. Benign tumors can be easily removed through colonoscopy or surgery. Malignant tumors will require additional therapy if they have already metastisized. The development of colorectal cancer is a complex and dynamic process that occurs over many years at multiple biological levels within the human body.^ Colorectal carcinogenesis requires that certain environmental and host factors combine to influence events in the intestine that will eventually result in the formation of a malignant tumor. Two intraintestinal events must occur which involve changes in the internal milieu of the gut, as well as specific anatomic or physiologic alterations in the colon/rectal epithelium. These events can be defined as “intermediate endpoints” in the causal pathway of 16 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. colorectal cancer. Other environmental (exogenous) and host (endogenous) factors; such as dietary intake, metabolic characteristics, and prior exposure to environmental factors, are interconnected in this process and play an important role in colorectal carcinogensis.^ 1.5 Genetics Various genes are considered to play a role in colorectal carcinogenesis. These include: oncogenes, tumor suppressor genes, and mismatch repair genes. In recent years, two distinct molecular pathways have evolved leading to colorectal carcinogenesis: the “suppressor” pathway and the “mutator” pathway. "^9,50 Although the molecular events in these pathways involve different combinations of mutations, there are areas of possible overlap. The evidence suggests that not all colorectal cancers follow the same genetic pathway. However, all pathways are the result of an accumulation of genetic mutations that consequently lead to colorectal cancer. ^9,50 1.5.1 Classic Pathway - The “Suppressor” Pathway The classic pathway for colorectal carcinomas, the suppressor pathway, was proposed for sporadic colorectal carcinomas by Fearon and Vogelstein. It is identified by the inactivation of tumor supressor genes, activation of oncogenes, and the loss of heterozygosity (LOH). ^0, 49, 50 the suppressor pathway, the accumulation of mutations is the most important factor. 17 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Mutations which occur during this pathway lead to both loss of tumor suppressor genes and activation of oncogenes. 49, 50 When an oncogene becomes abnormally activated, it may facilitate cell proliferation. 49 The loss of tumor suppressor genes promotes cancer when both alleles have been inactivated. 49 Colorectal tumors acquired through this pathway exhibit aneuploidy (abnormal chromosome number), with gains or losses in excess of 10"^ per chromosome per generation. Tumors developed via this pathway do not usually show microsatellite instability. 1.5.1.1 APC gene - Chromosome 5g; An early mutation APC appears to be an early event in the suppressor pathway. The APC gene is associated with a complex of proteins that comprise the adherens junctions in the plasma membrane. The adherens junctions assist in maintenance of the epithelial cell layers, cell adhesion, and cell-to-cell communication. Deletion or mutational inactivation of the APC gene is thought to lead to loss of normal cell-cell or cell-matrix communication, which ensures correct cell adhesion and intracellular signaling. ^0, 51 Inactivation of APC causes familial adenomatous polyps (FAP) and Gardner’s syndrome through germ line mutations. 40, 47 Patients with APC gene mutations develop not only early colonic adenomas, but also adenomas of the small intestine, intra-abdominal desmoid tumours, congenital hypertrophy of the retinal pigment epithelium, osteomas and bone cysts. Mutations of the APC gene occur in over 80% of sporadic colorectal tumors, both benign or malignant.49,47 18 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.5.1.2 Méthylation Status: Another early step is méthylation. A substantial loss of methyl groups in DNA, hypomethylation, has been found to occur early in colorectal tumorigenesis. In normal mammalian cells, the only known covalent modification of DNA occurs at the fifth position of cytosine at 5’-CG-3’ dinucleotides. Eighty percent of these dinucleotides are methylated, and have been implicated in the control of gene expression and chromosome condensation. In cancer cells, a generalized hypomethylation of the genome occurs relatively early during colorectal carcinogenesis. ^0 Although the role of hypomethylation is unclear, it may contribute to genome instability and aneuploidy, by inhibiting chromosome condensation at mitosis, causing problems with chromosome pairing and disjimction. 51, 53 jjj addition, focal hypomethylation can also occur, possibly the result of an increase in DNA methyltransferase, which may silence the transcription of important tumor suppressor genes. 1.5.13 Activation of Ras Oncogenes; In the normal cellular pathway, oncogenes fimction in a positive manner with cell growth and differentiation by encoding growth factors, growth factor receptors, signal transducers, and nuclear p r o t e in s .5 4 When these genes become mutated or activated they can disrupt normal cell behavior and growth. Activated oncogenes function to move the cell toward malignancy. 54 The identification of the ras gene mutations, K-ras, H-ras, and N-ras, was one of the first major breakthroughs in the molecular genetics of colorectal cancer.^® Although all 19 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. three ras genes are expressed in colonic mucosa, mutations have only been detected in K- ras and N-ras genes in colorectal tumors. Point mutations of K-ras and N-ras occur in approximately 50% of colorectal cancers and in 50% of adenomas larger than 1 cm in diameter, they are also present in less than 10% of adenomas smaller than 1 cm in size. Ras mutations are rarely seen in these smaller adenomas (less than 1 cm), which may suggest that they are acquired during adenoma development. Most of the mutations affect the c-Ki-ras gene, with the remainder affecting the N-ras gene.^® > 1.5.1.4 PCC gene- Chromosome 18q The DCC gene (for Deleted in Colon Cancer) was one of the earliest genes found to be associated with colorectal cancer. Deletion of the DCC tumor suppressor gene, on chromosome 18q, is the second most common region of allelic loss in colorectal tumors. The DCC gene codes for a cellular adhesion molecule belonging to the immunoglobin gene super-family. Cellular adhesion molecules have been implicated in tumor invasion, as well as cell growth maintenance, differentiation, and apoptosis. Loss of heterozygosity and mutation at the DCC locus appear to occur prior to invasion, which suggests that the DCC gene may be involved in receiving extra-cellular signals for growth control. In 70% of colorectal cancers , 50% of late-stage adenomas, and 10% of early-stage adenoma, at least one copy of this gene is lost.^0,47,56 2 0 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.5.1.5 P53 gene - Chromosome 17p The p53 gene on chromosome 17p was the first tumor suppressor gene to be implicated in colorectal carcinogenisis. The normal function of p53 in the cell cycle is as a checkpoint protein involved with binding DNA in a sequence-specific manner and activating transcription of adjacent genes.^®’ If the normal function of p53 is disrupted, sufficient time will not be allotted for DNA repair to be completed. As a result, DNA containing errors is replicated and DNA mutations accumulate. The p53 gene is inactivated (i.e., loss of 17p sequence) in at least 85% of colorectal cancers, but rarely in colorectal adenomas. ^ This implies that the inactivation of the 17p tumor-suppressor gene is a late, rather than initiating event, which occurs in progression from adenoma to carcinoma. 1.5.2 The Road Less Followed — The “Mutator” Pathway The second pathway leading to colorectal cancer is the “mutator” pathway, characterized by tumor microsatellite instability (MSI) and defective DNA mismatch repair. 49 This newer category of genes, called mismatch repair (MMR) genes, was found to be associated with human cancers and discovered through the investigation of HNPCC families. 57 1.5.2.1 Mismatch Repair (MMR) Genes Cancer developing along the “mutator” pathway is instigated by an inherited or somatic mutation in one of the DNA MMR genes. 49 The most thoroughly mapped 21 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. MMR pathway is the Escherichia coli méthylation pathway that depends on mut S, mut L, mut H, and dam genes. The normal fimction of the MMR gene is to identify mismatches in DNA. When an error is detected, a repair protein removes the error and reinserts the correct nucleotide. The MMR genes work jointly with other genes to perform this process known as mismatch repair. Mismatch repair is essential in stabilizing the genome, as it involves removing mismatches, stabilizing the DNA strand, and resynthesizing the new DNA strand. Without the MMR pathway, cells have a 1000-fold increase in mutations. Repetitive sequences have the highest rate of mutation. DNA replication errors (RER+ phenotype) occur during somatic slippage of the DNA polymerase and accumulate in the absence of the MMR pathway. Overall, inactivation of the MMR pathway can cause accumulation of increased mutations in oncogenes and tumor suppressor genes such as: APC, ras, DCC, and p53. 15.2.2 Microsatellite Instability A particular form of genetic instability is characteristic of the MMR defect. This is known as the replication error phenotype (RER+) or microsatellite instability (MSI). The microsatellite instability (MSI) phenotype is manifested in 90% of tumors of the HNPCC syndrome, 15-30% of all colorectal cancers, and to a varying degree in tumors of other organs. In particular, patients with HNPCC will inherit a defective allele of a DNA mismatch repair gene, and subsequently acquire a somatic mutation to inactivate this gene. The resulting inactivation of the mismatch repair genes causes MSI or replication error (RER) and ubiquitous somatic mutations (USM). Tumors with the MSI 22 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. phenotype are usually diploid with no gross genomic instability, in comparison to those generated through the classic “tumor suppressor” pathway, which display gross genomic lesions prior to aneuploidy. MSI phenotype tumors also have little loss of heterozygosity, compared to those generated through the “classic” pathway which suggests that risk factors may differ. Tumors can be classified into three categories: MSS (microsatellite stable or lacking MSI), MSI-L (low frequency of microsatellite instability), and MSI-H (high frequency of microsatellite instability). 1.5.2.3 Associated Genes The following genes have been identified as the human counterparts of E.coli and yeast MMR genes: hMSH2, hMLHl, hPMSl, hPMS2, hMSH6, and the hMSH3 genes. ^7 These genes act in the pathway which repairs mismatched DNA base pairs, so that mutations are not introduced. The most prevalent association has been shown to be between microsatellite instability and hMSH2 and hMSLHl mutations, with other genetic associations less clearly defined. ^2 Most mutations at the MSH2 locus result in truncation of the protein product and are dispersed along the entire coding region. Mutations of the MLHl gene are more heterogeneous, as they include frame shifts, missense mutations, and deletion of entire exons due to spliced substitutions. Germline mutations that have been identified in the PMSl and PMS2 genes are limited. 23 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.6 Physical Activity 1.6.1 An Overview of the Studies Several epidemiological studies indicate that physical activity plays a role in the etiology of colon cancer. These studies are summarized in Tables 1 and 2. Table 1 covers early physical activity studies, where death from neoplasms is used as a measure of outcome and occupation or athletic participation were used as a crude measure of exposure.^^ Those listed in Table 2 include studies where death or diagnosis of colorectal cancers are used as a measure of outcome and physical activity exposure is frirther categorized. A variety of measures have been used to assess physical activity. The categories include: occupational activity, leisure-time and total activity levels, and/or participation in college athletics. The assessment tools that have been utilized to estimate physical activity involve: questionnaires, interviews, and occupation. In many cases additional resources, such as The Department of Labor estimates of worker trait requirements or an index of expenditure, have been used to further code activity levels for occupational or leisure-time activity. 64, 65 i%e evidence presented in each of these studies has been derived from human populations. 1.6.2 Early Studies of Physical Activity and Deaths From Neoplasms Various preliminary occupational or athletic participation studies have laid the foundation for investigation of the association between physical activity and colorectal 24 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CD ■D O Q . C g Q . ■ D CD C/) C/) Table 1; Earlv Studies of Physical Activity and Deaths From Neoplasms o 3 CD 8 Study - Primary Author Colon Cancer Doth. Ref. Year Study Population Study Design/ Study Period Sample Size Physical Acllvlly Assessment (Exposure Variable(s)) Outcome Varlable(s) /Measures) Controlled V ariabla Statistical Mefrrods Results Comments Silvertsen, L Cause of 1921 Male subjects ■Case Series: 3135 deaths from General Occunafional Death Rates: None 1) Death rate: per I) Working Death rate in males “ 5. Dahlstrom A, W. Death deaths from the Cases; Deaths from carcinoma among Classification: 1) By age category 100,000 Based on Hypothesis: Human carcinoma may be actively engaged in a CQ from Bureau of Vital carcinoma for the years males Muscular Activitv: Average age at Census, 1920 gainful occupation is; i 3 CD "n c 3 . 3" CD "Relation o f muscular actMty to carcinoma" Death Cert. - Deaths from Car cinoma Statistics, Minnesota Board of Health for 1918- 1920 1918,1919,1920 Excluded: Women - difficulty in estimating amount of muscular activity relative to occupations of this sex Group I - Great Group 1 1 - Moderate Group III - Medium Group IV - Small Group V - Farmers Group VI - Those not engaged in gainful occupation death the reaction to and the result of chronic irritation of adult epithelial tissue bathed in body fluids altered by certain metabolic products as a result of deficient muscular activity. 1) Less than frte death rate in those not actively engaged in any gainful occupation 2) Inversely pro portional to the degree of muscular activity necessary for that occunation. CD Rook, A. Cause of 1954 Male subjects - Retrosoeetive cohort: 1595 White Males: Mortality 1) Survival rates of; None 1) Survival rates: Overall percentage of Neoplasms made up Death Cambridge Outcorne: Aueof Activity - College Intellectual and deaths in 3 a higher percentage Q. "An investigation from sportsmen, college Outcome: Survival - death and cause Afliletics: a) Men bom in different decades b) Sportsmen random group are controls 2) Average age at categories: of cause of death in C a into the longevity of Cambridge Death Cert. - alumni. In attendance from age of death & cause of death obtained from Excluded subiecis: 1) Sportsmen - Former university athletes 1) 13.6% - Sportsmen - Former athletm than in the other 2 control 3 ■D O 3" CT 1 — H CD Q. sportsmen" Neo plasms used for cancer 1860-1900, data taken from Alumni Cantabriglenses (detailed biographical list of all students) death certifrcate. Young or middle age alurrmus outside of chosen range (1860 - 1900) 2) "intellectuals" controls 3) "other" random students controls and controls c) Light and heavy sportsmen (physique) death 3) Variance of est. of ave. age at death university athletes 2) 12.3% - "Intellectuals" controls 3) 12.8%-"Other" random students groups, $ Taylor, H. L. Cause of 1962 White male clerks, switchmen, and section men widi 10 years of service in the U.S. railway industry, who had Retrosoeetive cohoru 26,219 White Males; General Occupational Age Adiirsted None 11 Age Bdiusted 1) Declining gradient 1) Demonstrated 1 — H Klepetar, E, Death Follow-up; Excluded tratients; Classification: Death Rates: rate: Based on age in overall (all-cause) association bet. O T3 CD 3 (/) Keys, A. Parian, W .. Blackburn, H. et. al "Death rates among physically active from Death Cert - Deaths due to Neo clerks: 85,112 man- years switchmen: 61,630 man-years section men: 44,867 man-years Men who acquired ten years of service between 195 land 1954 Clerks - Low (ICC* # 6 10) Switchmen - Med (ICC* #119, 120) Section men - High (ICC* #42) 1) All cause 2) Death due to neoplasms 3) Arteriosclerotic Heart Disease dist. of total pop. at risk 21 Chi-souare age-adjusted death rates and death due to neoplasms across 3 physical activity groups; All-cancer mortalitv malignancy and sedentary onployment on U.S. railways 2) Evidence of decline with (/) o ' o and sedentary employees o f the railroad industry. " plasms acquired 114 mos. serve by Dec. 31, 1951, worked in 1954, and 40 to 64 years of aue. Cases: Deaths of subjects in 1955 and 1956 in active service or retirement identified by death certificate where ICC = Interstate Commerce Commission rglssi clerks - 2.23/1000 switchmen - 2.19/1000 section men - 1.47/1000 increasing levels of occupational physical activity N J CD ■D O Q . C g Q . ■ D CD C/) C/) Table 1; Earlv Studies of Physical Activitv and Deaths From Neoplasms 8 C Q ' 3 3 " CD CD T3 O Q . C a o 3 T3 O CD Q . T3 CD (/) (/) Study - Primary Aodior Polednak, A. P. "College athletics, body she, and cancer mortality” Colon Cancer D tA i. Cause of Death &cm Death Cert. & coded by 7th ICD: neoplasm s malig nant aCD 140 205), benign (ICD 210. 229), imspeo- ified (ICD 230- 239) Ref. Year 1976 Study Population White Male subjects ■ Havard college aluttmi from 3 birth cohorts (1860-69, 1870-79, and 1880. 89), All subjects had some interest in athletics - gymnasium locker records Study Design/ Study Period Retrosoeetive cohort: Outcomei Mortality, cause of death obtained from death certificate. Sample Size 8,400 White Males; Outcome: Deaths from neoplasms Excluded subjects: Dropouts, graduate students, instructors, males bom after 1889, Those deceased w/o death certificate (n=289) Physical Aedvity Assessment (Exposure Vaidablefs)) Outcome Variable(s) /Measnre(s) Activitv - College Adiletics: 1) Major athlete 2) Minor athlete 3) Non-athletes M b ita litY 1) Mortality Rates and Mean Age at Death from Neoplasms; a) By athletic category and birth decade b) At specific sites by athletic category c) In major athletes and non athletes matched for body size 2) Correlation of height & w ei^t ControQed Variables Age and body size Matched major athletes with non-athletes by body size (height and weight) Statistical Mediods 1) Death rates and RR: Non athletes are referent group 2 )£ £ m sa . Correlation Results 1) For colon; RR = 1.6, stat. sig. difference, Athlete:Non-athlete 2) Positive association o f cancer mortality with increasing athletic 3) Major athletes had lower mean age at death from cancer than non-athletes Comments 1) Positive association of cancer mortality with increasing athletic status. 2) Former major athletes had a sig. hiÿteriate of death due to neoplasma than former non athletes. 3) Major athletes had lower mean age at deadi from cancer than non-athletes. CD ■D O Q . C g Q . ■ D CD C/) C/) Table 2; Physical Activitv and Colorectal Cancer Studies 8 C Q ' 3 3" CD CD ■ D O Q . C a O 3 " O O CD Q . ■ D CD C/) C/) Study- Primary Autiior B erg,J.W . Howell, M. A. "Occupation and bowel Persky, V. Dyer, A. R. Leonas, J. Stamler, J. Bericson D. M. et. al, SiBâxJ- Chioago People'i Gas Co. "Heart rate: a riskfaclorfor cancer?" Colon Cancer Pefa. Death from Death Cert, • Colon or Rectal Cancer Death from DeafiiCert, - Colon Cancer Ref. Year 1975 Study Population Male subjects (20.64 years of age), in the U.S. and Great Britian, selected from the 19S0 coisus Case Series Cases: U.S. - certificates of death in 1950 English - certificates of death, 1949-1953 and 1959-1963 19S1 I) Chicago Peonle's I Gas Company! I White males in I Chicago, aged 40-59 |yis., 1958 - 1976 - Free of definite coronaiy heart disease upon initial examination at baseline Study Design/ Study Period Sample Size Cases! 2709 colon + 2519 tectum cancer Physical Activity Assessment (Exposure Variabie(s)) Occupational Physical Actiyjtv- Classified by; a) Occupation b) bidustrial Group c) Industry 1) Cohort - Follow- 1) 1233 white up ISyrs males Outcome Variablc(s) /Measure(s) 1) Standardized MortaUlv Ratios ISMRl, 2) Proportionate Mortality Ratios IPMRl 1) Resting heart rate - used as a baseline exposure variable fte p rtB a te Ouintiles! < 60 61-67 68-74 75-79 >80 1) All Causes of Death/Specific Cancers a)CVD b) Cancer deaths c) Other deaths Controlled Variables None Statistical Methods 1) Standardized Mortality Ratios fSMRl! Ratio of observed to expected deaths multiplied by 100 2) Proportionate Mortality Ratios IPMRl! Ratio of observed deaths to an expected number, multiplied by 100 Results 1) High Incidence of colonic cancer m men employed in sedentary white-collar occupations. 1) Adjusted for age, systolic blood pressure, relative weight, serum cholesterol, and number of cigarettes smoked per day. 1) Higher risk athigha- occupational levels (sedentary white collar workers) 2) Manufacturing industry has an elevated PMR Multivariate analysis! a) Multiple regression b) Two-sample t-test of differences in mean heart rates, adjusted for age between those surviving and those dying from each cause of death. a) Heart rate for a) The persons with differential bet. colon and all colon cancer cancers combined decedents and were statistically nondecedents is higher in the only effect decedents. dial remains sig. after multivatiate statistical adjustments (age, SBP, etc) b) A significant association of resting heart rate and cancer mortality Comments N ) CD ■ D O Q . C g Q . ■ D CD C/) C/) Table 2; Physical Activitv and Colorectal Cancer Studies 8 C Q ' 3 3" CD CD ■ D O Q . C a O 3 " O O CD Q . ■ D CD C/) C/) Study- Primary Auâior Coloa Cancer D c ù i, Persky, V. Dyer, A. R. Leonas, J. Stamler, J. Berkson D. M. et. al. stttd v n - Chicago Western Electric Co. "Heart rate: a risk factor for cancer?" Penky, V. Dyer, A. R. Leonas, J. Stamler, J. Berkson D. M. et. al. Study in - Chicago Heart Association Detection Project "Heart rale: a riskfactorfor cancer?" Deadiftom Death Cert. ■ Colon Cancer Death from Death Cert. ■ Colon Cancer Ref. Year 1981 Study Population Study Design/ Study Period 1 1 1 Chicago Western Electric Comuanv; White males in Chicago, aged 40-55 yrs., 1957- 1974 -Free of definite coronaiy heart disease upon initial examination at baseline Cohort Followup 17 years Sample Ske 1981 im Chicago H eart I) 1899 white males Detection Prolect In Industry; White males in Chicago, aged 45-64 yrs.,1967 -1979. - Free of definite coronary heart disease upon initial examination U Cohort Followup 5 years 1) 5784 white males Physical Actlylty Assessment (Exposure Variahle(a)) 1) Resting heart rate - used as a baseline exposure variable Heart Rate Ouintiles; < 70 71-75 76-80 81-87 >88 Outcome Variablc(s} /Measurefs) 1) All Causes of Death/Specific Cancers a)CVD b) Cancer deaths c) Other deaths 1) Resting heart rate- used as a baseline exposure variable Heart Rate OulntUes; < 66 67-72 73-78 79-86 >87 Controlled Variables 1) Adjusted for age, systolic blood pressure, I relative weight, serum cholesterol, and number of cigarettes smoked per day. 1) All Causes of Death/Specific Cancers a)CVD b) Cancer deadis c) Other deaths Statistical Methods Multivariate analysis; 1) Multiple regression 2) Two-sample t-test of diilbrences in mean heart rates, acyusted for age between those surviving and those dying from each cause of death. 1) Adjusted for age, systolic blood pressure, relative weight, serum cholesterol, and number of cigarettes smoked per day. Results 1) None of the site-specific cancer victims had a statistically dlHbrent heart rate from friose subjects remaining alive. Multivariate analysis; 1) Multiple regression 2) Two-sample t-test of differences in mean heart rates, aigusted for age between those surviving and those dying from each cause of death. 1) Multivariate analysis resulted statistically difference in resting heart rates in decedents compared to survivors, for site- specific cancer. Comments l)N o association between heart rate and cancer moitality 1) Association between heart rate and cancer mortality 2) No association for cancer mortality, after breakdown by site 3) No association with colon cancer K ) 03 C D ■D O Q. C g Q. § 1 — H 3" "O C D 3 C /) C /) o ' Table 2; Physical Activitv and Colorectal Cancer Studies Phj^lcal Activity — h Study- Colon Assessment Outcorne 3 Primary Cancer Ref. Study Design/ (Exposure Vatiablefs) Controlled Statistical C D Author Defn. Year Study Population Study Period Sample Size Variable(s)) /Measure(s) Variables Methods Results Comments 8 Hoar, S, K. Death from 1984 Male and female Case-control ■ For colon Coded Occunation Colon cancer 1) Matched by: 1) Maximum likehood 1) Black males Risk of colon Blair, A. Death Cert. - colon cancer cases Death certificate m s s B and Industrv - Used 1) Odds ratios, by race. year of death, estimates of tiie odds showed an excess cancer higher in = . Colon and their matched study 820 matched Standard Occupation sex and age (<65, ^ 5 ). race, sex. ratios risk of colon managers, CQ 'Death- Cancer controls, who died Cases: Prostate or pairs Classification System 2) Colon cancer risk country of usual 2) Mantel-Haenszel chi- cancer among administrators. certificate case during 1970-1978 in colon cancer cases and the Standard associated with residence, and square employees of tire and executives i control study o f South Carolina of selected counties Industrial Classification employment in the textile age at death textile industry. than in any < 3 cancers o f the in South Carolina System industry. 2) Overall, no other categoiy C D prostate and Controls: From state strong evidence o f worker colon and mortality tigres. indicating a " n employment in other deatiis relationship bet. c the textile matched on year oi the textile 3 " industry" death, race, sex. industry and C D county of usual colon cancer. residence, and age oi O ■D O Q. C dentil a Garabrant, D. Diagnosed 1984 Male subjects (20-64 PoDUlation-based 2,950 Male Coded Full-time 1) g -A n n u a l Age- i) J S i 1) g i Age adjusted: lllR tR a te n e r 1) Risk increase o H. with primary years of age), cases btddent ease- cases; 31,294 Occupation - Arjjusted Incidence Rates Subcategorized using 1970 U.S. Census- 100.0001: stepwise w/ 3 Peters, J. M, malignancy fiom the U.S.C. Los control! controls Occupation at time of 2) PIR - Proportional by age, sex. L.A. as denom. Sedentary=24.6 decrease " § Mac*, T. M. of the colon Angeles County Cases: Cancer cases Excluded! D „ Incidence Ratios race. Adjusted 2) PIR: # cases expected. Moderate=2l.6 activity. 3 " Bernstein, L. ICDO 153 Cancer Surveillance of primary 10 patients - Codlnu! Bureau of the -1) & 2) By cancw sites for undercount. given occup. distof all High=13.4 relation obs. CT Pro^am (population malignancy of the reported Census 1970 Index on (colon, rectum. intercensus other 2)RR=1.6 across ses, race. 1 — H "Job activity based cancer registry). colon (ICDO occupa. Physical Activity nonbowel) and race. change Both 1) & 2) - Colon (Sedentary :High) colon Q. and colon diagnosed between 153)/diagnosed unclassifiable. required: -2) By SES and 2 ) ] ^ Calc, rates adj. for unreported subsection. $ cancer risk" 1972-1981 1972-1981 Women- (> 80% - Highly anatomic subsite (Ohs,/Expected occupation 2) Trend in risk 1 — H Controls: Other occupa, activity Active, 20-80% - Mod. 31 Risk Ratios & Tests (all cancer)) by 3) Risk Ratios - RR; sig. O cancers inaccurate Active, > 20% - for Trend: O f ratios of occupation x Poisson Approx., 3) No measure (ie., Sedentary) 1) and 2) and C.I.'s 100, also by Tests for Trend: relationship bet. T3 nonoccupa. and assigned rating for race* Method of Mantel physical C D activity occupa, activity level. 3) Trend! activity and 3 constitutes a Across activity rectal cancer (/) greater part of levels. 5' physical • (Black, Q activity.) Hispanic: Amer. Immigrant, white) t o CD ■D O Q . C g Q . ■ D C D C /) C /) Table 2; Physical Activitv and Colorectal Cancer Studies 8 CQ' 3 3 " (D (D T3 O Q . C a o 3 T3 O (D Q . T3 (D (/) (/) S(udy- Primary Author Vena, J. E. Graham, S. Zielezny, M. Swanson, M, K. Bames, R, E. Nolan, J. "Lifellme occupational exercise and colon cancer" Gerfaardsson, M. Norell, S, E, Kiviranta, H. Pedersen, N. L, Ahlbom, A. "Sedentary Jobs and colon Colon Cancer Défit. Hospital records- patients with cancer of the colon or rectum Case with malignant tinnorsofthe colon - coded by 7th lCD: colon 153 or rectum 154 Réf. Year 1985 1986 Study Population White male subjects (30-79 years of age), patients admitted to Roswell Park Memorial Institute in Buffelo, New York, 1957-1965. Male subjects (20-64 years of age), working men bom in Sweden, selected fiom the 1960 Swedish census. Study Design/ Study Period Case-control; Cases: Patients with cancer of the colon and cancer of the rectum. Controls: Patients w/ nonneoplastic nondigestive Retrosoeetive cohort; Follow-un 19 yrs. Cases: Patients wifli colorectal cancer (ICD 153/154), diagnosed 1961- 1979 Identified by record linkage between 1960 census and 1961-1979 cancer registry Sample Sire 1917 White Males; Ca.m- 486 210 colon + 276 rectum cancer Controls; 1431 patients w/ nonneoplastic diseases Excluded patients; Missing occupation, hist. (60 colon, 85 rectum, 362 controls), Never employed (1 rectum, 19 controls) 1.1 million Swedish males; Cases; 7115 colon + 5290 rectum cancer Physical Activity Assessment (Exposure Variable(s)) Coded Lifetime . Q S C T f f t H j a i t O l Physical Acttvitv- Occup. histoiy: 6 longest held jobs. Coding: Job Title- U.S. Dept, of Commerce-Index of Occup. for 1960 Census & Rating: one of 5 categ, of physical activity using Dept, of Labor Est. of Worker Trait Req. Occupational Physical Activitv- Classified by sitting time; Sitting <20% Sitting 20-49% Sitting 50-79% Sitting > 80% (Used Method of Garabrant) Outcome Variable(s) /Measure(a) Cancer Incidence 1) OR - Colon & Rectum Cancer by Occup. Phys. Activity (by Age) 2) QR - Colon Cancer at anatomic subsites for Occup. Phys. Activity l)Mj££É9£S. Q S l Age- standardized Z lLoeistics Regression Q £i Age- adjusted 1) RR - C.l. of cancer in exposed (sedentary) compared to ref. group (physically active). Controlled Variables Statistical Medsods 1) Miettinen OR: Age- standardized (common weighting fhotor=# unexposed controls at age level) 21 Logistics Regression OR; Age-adjusted (response var.=D status, reg. var. = age, occup. activity (dummy)) (see method of Lemeshow and Hosmer) D EE l controlled for 5 year age group, pop. density, social class, marital status, and geographical region. Results RR - est. using equiv. to Mantel-Haenzel, modified for cohort, also 90% C.l. used. 1) Trend of inc. 1) Corroborates risk w/ inc. # yrs. findings of in jobs w/ Garabrant - Inc. sedentary/light risk of colon woik, a twofold cancer assoc. risk for those w/ emp. > 20 sedentary/light yrs.(sedentary:act work. ive, 2) Inc. risk for OR=1.97,P<.001 colon cancer ) w/: increased 2) Dose-response woric years, relationship, inc. proportion risk assoc, w/ inc. woik years, and proportion of yrs. proportion of in sedentary job. life in sedentary/light jobs. 3) No assoc, w/ rectal cancer 1)RR=1.3 1) Stronger (sedentary:active. assoc, for 1.2-1.5,90% cecum, C.l.) ascending and 2) Highest risk transverse for transverse colon than for colon including descending and flexures sigmoid. (RR=1.6) 2) Cases ficm 3) Lowest risk for national cancer sigmoid registry. (RR=1.2) 3) No assoc. w/ rectal cancer Comments o C D ■D O Q. C g Q. g 1 — H 3" "O C D 3 c/) c/) o" Table 2: Physical Activitv and Colorectal Cancer Studies 3 Physical Activity — h S W y . Colon Assessment Outcome PrimBiy Cancer Ref. Study Design/ (Exposure Variable(s) Controlled Statisficai C D Auâior Delhi Year study Population Study Period Sample Size Variable(s)) Measurefs) Variables Methods Results Conunents 8 Paffenbarger, Cause of 1987 1 1 San Francisco 11 Cohort - Follow- 1) 3686 11 Occuuadonal 1) Causes of 1) Differences 1) Mantel-Haentzel - RR 1) Significant 1) Cancers of R.S. Death fiom Loneshoremen: up (22 yrs- 1951- Dockworkers actiylty: Death/Specific Cancers in age, cigarette Results - Cause primary sites = . Hyde, R. T. Death Cert. - Longshoremen in San 1972 Work energy smoking. of Death: not sig. related CQ Wing, A.L, Inc. Francisco, aged 35-74 55,635 man-yr of expenditure; systolic blood All causes: to EE. Study I- Colorectum yrs. EE* obs.) High energy; >. pressure R R = 1.46(p< 2) Tendency i Longshoremen Cancels - Offered advantages 8500 kcal/wk 0.001) firr more active < 3 and opportunities for Low energy: < 2) Coronary men to die C D "Physical study of role of 8500 kcal/wk H.D.: RR=1.97 fiom pancreatic activity and energy expenditure (p< 0.001) or colorectal " n incidence o f (EE) in health N.S. - Activity cancer. c cancer in and cancer 3) 3" diverse mortality (0.85 Longshoremen C D populations: a Li#t:Heavy) may have been 3 preiiminary reclassified: ■D report" cancer victims O could have Q. shifted down to Q. less active jobs ô (selection 3 bias)....unlikely "O Paffenbarger, Cause of 1987 n i + Additional 11 Cohort - + Add. 1) Add. 2665 11 Occuuational 1) Death fiom Selected 1) Differences 1) RR. for selected 1) Suggests 1) Found most O 3" R.S. Death fiom Loneshoremen: Longshoremen (last Longshoremen adttyltv: Cancer: in age only (age- cancers. Heavy Workers; active cargo CT Hyde, R. T. Death Cert. - Longshoremen in San 12 of (+ Study A; 3 levels of job EE: Colorectal, Pancreas, adjusted by Lower risk handlers 1 — H Wing, A.L. Inc. Francisco, aged 35-74 22 years obs. - 3686 Lung, Prostate indirect method/ colorectal cancer smoked less Q. Study n - Coloisctum yis. 1961-1972) Dockwotkersl Light,Mod.,Light/Mod. total Higher risk: while working. $ Additional Cancers - Submitted to 1961 (a+b= 95,705 Total=6351 , Heavy pop.=siand.) lung & prostate 2) Results 1 — H Longshoremen Health Exam man-yr obs. ) Longshoremen include rectal O (21 colon and cancer. "Physical rectum) T3 activity and (D incidence o f 3 cancer in (/)' diverse w populations: a o Q preliminary report" CD ■ D O Q . C g Q . ■ D C D C /) C /) Table 2; Physical Activity and Colorectal Cancer Studies 8 CQ' 3 3 " C D C D T3 O Q . C a o 3 T3 O C D Q . T3 C D (/) (/) Study- P rta s iy Author Pafknburger, as. Hyde, R. T. Wing, A.L. Study m • Harvard Alumni 'Physical activity and incidence o f cancer in diverse populations: a preliminary report" FafAnbarger, as. Hyde, R. T. Wing, A.L. Study IV ■ Harvard Alumni 'Physical activity and incidence o f cancer in diverse populations: a preliminary report" Colon Cancer Defti. Cause of Death firom Death Cert. • Inc. Colorechum Cancers Cause of Death from Death Cert. - Ine. Colorectum Cancers Ret Year 1987 Study Population Study Design/ Study Period im Harvard & Univ. of Penn. Alumni; Students from Harvard & Univ. of Penn, using records from 1916-1950. Questioimaire:1960's 1970’s Death Cert.: 1916 - 1978 JUjEsbSB- Harvard/Penn. (35- 70 yrs-1916-1978, 1.8 million person- y r ) 1987 IVl Harvard Aluwnit Men (35-74 years of age) who entered Harvard between 1 1916 and 1950. i Classified by exercise I habits as reported I through retum-mail ! questionnaires in : 1962 and 1966. Sample Size 1) 56,683 Harvard/Penn Alumni; 51,977 male + 4706 females Physical Activity Assessment (Exposure Variable(8)) 11 Leisure-time Physical Activitv - College Sports Play: > 5 hr./wk., < 5 hr./wk, Outcome Variable/s) /Measure(s) 1) Cancer Development (Nonfatal & fail) ILSsbad- Harvard; (35-74 yrs 1916-1950) 213,716 man-yr of follow-up, ending in 1978. 1) Harvard; 16,936 males 1413 (8%) aiiunni died I fiom some cause bet. ages of 35 and 80 yrs. 2) Cause of death: 45% cardiovasc.dis., 32% cancer, 13% not. causes and 10% trauma Physical Activitv 11 Leisure-time a) (< 500 kcal/wk., 500-999 kcal/wk, 1000. 1499kcal/wk,... 3500+kcal/wk.) or b) (<500, 500-1999, >2000) (ie; walk 1 tnile=100 kcal, play 1 hr light sport=350 kcal) total physical activity index in kcal/wk. 1) a) Rates (deaflis per 10,000 man-yr) and relative risk of death from all causes. b) All-cause and cause- specific mortality rates for Harvard alumni from cardiovascular, respiratory,and others. Controlled Variables 1) Matched by: age, sex, birth yr. classmates (1:4 ratio) Statistical Methods 1) Proportional Hazards Model - RR Less likely to develop rectal cancer (RR=0.5, p=0.04) For colon: (RR=0,9,p=0.6) colon + rectum: RR=0.8 More likely to develop prostate cancer (RR-1.66) l)a ) Age- adjusted by the indirect method (total pop. = standard). b) Rates adjusted for differences in age, cigarette smoking, and body mass index. l)a ) All cause death rate & relative risk of death b) Cause-specific mortality rates Results Comments 1) More active 1) Death cert, source of cancer D„ (rectal cancer D, - unreliable) 2) Non sig. relationship for colon cancer and colorectal cancer, diiection toward protective effect. 3) Non. sig relationship for breast cancer. 1)M enw/ weekly output >. 2000 kcal/wk, had a 28% lower all-cause death rate than less active men 2) Decline in death rate w/ inc. physical activity; sig. for cardiovasc. & respira 3) Colon/rectum rates trend; direct relationship w/ phys. activity. 1) Death rate steady for > 500 kcal/wk suggesting selective effect restriction of lower levels of EE as the result o f illness 2) Suggest add. research on type, timing, frequency, duration, intensity, intermittence, and seasonality of phys. activitv. tsJ C D ■D O Q. C g Q. § 1 — H 3" "O C D 3 C /) C /) o ' Table 2: Physical Activitv and Colorectal Cancer Studies 3 Physical Activity 2^ Study- Colon Assessment Outcome 3 Primary Cancer Ref. Study Design/ (Exposure Variable(s} Controlled Statistical C D Author Qefo. Year Study Population Study Period Sample Size Varinble(s)) /Measureisj Vaiiables Mefiiods Results Comments g Vena, J. E Cause of 1987 Milham's published Case<ontrol studv Males! Five Occunational PMR - Stand, Proo, 1) A4justedfor 1) PMR 11 PM R -M ale 1) No "O Graham, S, Death Bom data on male and Study to examine 64,589 cases, Categories - Based on Mortalitv Ratio age 2) Deaths from colon and Low= 1.2 association 3 . Zielezny. M. Death Cert. - female subjects ftom occupational 430,000 Dept, of Labor est. I) For specific cause of rectal cancer (observed 2 -1 .1 among women CQ Brasure, J. colon and Washington State mortality by level of controls woriter trait death and expected) High = 0.9 2) Weaker < — H Swanson, M. K. tectum from 1950 and 1979 job activity for Females! requirements 2) By occupational PMR - Female association bet. g cancers of the colon. 604 cases. (Low - 1,2,3, High: 4- cat^ory Low - 1.1 activity and "Occupational rectum, prostate, and 25,000 controls 5) 2 = 1.1 rectal cancer o exercise and risk breast High = 0.8 for men p n f cnnnp.r'' W u,A .H. Padiological 1987 White male and Retrosoeetive n ,S 8 8 Leisure-time Phvsical I) RR - C.L of cancer in 1) Adjusted for: 1) Age adjusted incidence Phvsical 1) Colorectal c Paganini-Hill, A, diag. From 5 female subjects, uppet cohort! Follow-up residents! Activitv- eiqjosed (sedentary) smoking, &RR activity! cancer 3 - Ross, R. K. hospitals - middle class residents 4.5 yrs. 58 male and 68 Classified by hours per compared to ref. group alcohol, BMI 2)RR & p-value: using 1) Females: positively o Henderson, B. E. Colorectal of a retirement female incident day (physically active). regression method, RR-0.89, (95% associated with Cancer community, 50 miles colorectal < 1 hr day' assumes disease ~ C .I.:0.5-1,6) avocadonal o "Alcohol, south of Los Angeles cancer cases. 1-2 hr day ' Poisson dist. >2 hr/day physical 3 physical acllvlly pathological > 2 hr day ' 2) Males: activity. Q. and other risk diagnosis at 5 RR-0.40, (95% 2) Results stat. C faclorsfor local hospitals C.I.:0.2 • 0.8) sig. for males. 2 colorectal >2 hr/day 3) Non sig. o ' cancer: a trend for prospective RR-0.89 (95% women due to o study" C.l.:0.5 -1.6) L small numbers 3" 2 hr/day and/or CT variation. 1 — H Albanes, D. Cause of 1989 Males and females Cohort-NHANES 12545 Recreational nbvslcal 11 RR of Cancer and all 1) Adjusted for RR - est. from Nonrecreational 1) Non Q. Blair, A. Death from from the NHANESI (10 yr. fbllow-up), snbiects! activitv sites age, smoking, proportional hazards activitv: recreational $ Taylor, P. R. Death cohort, aged 25 - 74 conducted 1971-75, 5138 males and (Questionnairel a) by level and categoiy SES, BMI, diet regression model. Active =1.0 activity • 1 — H Cert./Hospit yrs followed 7407 females Very active of physical activity includes age as an Moderate=0.9 increased risk O "Physical al Rec., Path prospectively 128 cases Moderately active 1) by sex independent variable (95%C.I.=0.6- of cancer for activity and risk Reports- through NHEFS, colorectal Quite Inactive 2) by age, race. Test for trend: 1.3) inactive T3 o f cancer In the colon and 1982-84 cancer Nonrecreational BMI, sex based on sig. of a model Inactive =1.3 individuals C D 3 NHANESI rectum Incidence Physical activitv trend variable for activity (95%C.I.=0.7- compared to 3 population" combined cancer cases Much exercise 2.4) active. w confirmed by Moderate exercise Recreational 2) Stronger 5 pathology Little or no exercise activitv! inactivity - 3 rqmrts Active = 1.0 cancer Moderate=1.2 association for (95%C.I.=0.6- colorectum. 2.2) 3) Recreational Inactive =1.8 exercise - little (95%C.1.=1.0- relation to _____ cancer. C D ■D O Q. C g Q. § 1 — H 3" "O C D 3 C/) C/) o ' Table 2; Phvsical Activitv and Colorectal Cancer Studies 3 Physical Activity Study- Colon Assessment Outcome 3 Primary Cancer Ref. Study Design/ (Exposure Variable(s) Controlled Statistical C D Audior Defta, Year Study Population Study Period Sample Size Variabiefs)) /Measnre(s) Variables Methods Results Comments § Bromuon, R. Cases 1989 White male colon PoDUlation-based 11968 Coded Full-time Cancer Incidence 1) Adjusted for 1) Odds Ratio, 95% C L - I)OR=1.4,for I) Associations ■D C. diagnosed cancer cases and other Incident case- snbiects: Occunation - Medical 1) O S - Colon cancer at age using Gart's method: used Low:High present for all 3 . Zahm, S. H, with cancer controls fiom ISBtoik 1993 cases. chart abstract. Method anatomic subsites for to calculate the MLE activity colon except CQ Chang, J, C. histologicall the Missouri Cancer Study to investigate 9965 Conçois of Garabrant (Low, Occup. estimates of OR and C l, 2) Significant sigmoid < — ► Blair, A. y confirmed Registry, diagnosed: occup. risk from Excluded; Moderate., High) 2) QR - Colon cancer at 2) Linearity of Trends Test for Trend 2) Excess risk 9 colon cancer 1984 -1987. colon cancer Control group 1 anatomic subsites for (Mantel's one tailed test) (P=0,002) for an occup. < "Occupational ICDO 153 Cases: White males - subjects wifli Occup. Phys, Activity group confined o risk o f colon diagnosed widi cancer at Level to a subsite cancer. An histologically sitesfor which 3) An inverse "n analysis by confiimed colon occupational linear trend in c anatomic cancer (ICD 153), hazards are risk, according 3" subsite" diagnosed: 1/84 - fiiought to to level of C D 6/87. contribute to >. occup. physical Controls: 1:5 match 10% cancer activity C D "O within 7 age strata deaths O Frcdriksson, M. Cases of 1989 Males and females PODUladon-based 329 cases; Coded Full-time Cancer Incidence 1) Adjusted for I) Odds ratio - from 1) Employ vrs. 1) Decreased Q. Bengfsson, N, 0. large bowel (30-75 years of age). incident case- (165 male+ Occunation - 1) Q g - Employment yrs, age,sex Mantel-Haenzel methods by physical risk for persons a Harden, L, adenoicarcin fiom the Swedish controii 164 female) Employment history by physical activity 2) 95% C i: astiïiiïi in physically o' Axelson, 0, oma-coded Cancer Registry, who Cases: Cancer cases 658 controls: Index for physical category Approximate procedure Physically active active 3 by 8th ICD: were residents of the histologically (306 male + activity: 2) S g-E xposed male described by Miettinen jobs: occupations. ■ o "Colon cancer (153.01- admission region of confirmed incident 317 female) (Sedentary,lntermed., and female(case/control) Males: OR=0,8 2) Inverse O physical 153.89) the Dept, of Oncology cases of Excluded; High) by occupation e x '-27.3) association bet. activity, anti in Umea, diagnosed adenocarcinoma of Cases: 58 Further analysis: 3) QR - Localization of Females: physioal 1 — H occupational between 1980-1983 the colon or rectum. died,l-ethical Accounts for cancer by physical OR=0,7 (X2 = activity and C D Q. exposures" diagnosed 1980- reasons, 8 - employment years activity category 141,4) colon cancer < 1983 inadequate Occupational 4) gag-Cancer risk by 21 Cancer site by risk, stronger < 1 — H Controls: Drawn histological exposures also exposure to agents Physical for left-sided 3" fiom National data or data classified activity; cancers (OR for C Population Register, miscoded, 6 Descend& sigmoid 0.5 1:2 match on unable to sigmoid/intermed (0,25,0.93) C D country, sex, age participate ,:OR=0.73 3 Controls: 35 (0,48,1,2) w ' unable to Descend& (/) answer sigmoid/high: o ' questionnaire. OR=0,49 24 controls (0,25,0,93) died CD ■D O Q. C g Q. ■ D C D C /) C /) Table 2: Phvsical Aetivitv and Colorectal Cancer Studies 8 CQ' 3 3 " (D (D T3 O Q . C a o 3 T3 O (D Q . T3 (D (/) (/) Peters, H. K Garabrant, D. H. Yu. M, C. "A cttse-control study o f occupational and dietray factors in colorectal cancer in young men by subsite" Study ■ Primary Author Colon Cancer Defii. Histologicall yconiirmed new cases of adenocarcino ma of the colon and rectum Severson, R. K Nomura, A, M, Grove, J. S. Stemmermatm, G .R ’A prospective analysis o f physical activity and cancer" Histologicall y confirmed new cases of colon and retal cancer Ref. Year 1989 1989 Study Population Male subjects (25-44 years of age), cases fi-ora the U.S.C. Los Angeles County Cancer Surveillance Program (population based cancer registry), diagnosed between 1974-1982 Incident case- control! Cases: Cancer cases histologically confirmed incident cases of adenocarcinoma of the colon or rectum, diagnosed 1974- 1982 Controls: 1:1 match on race, sex, DOB within 5 yrs., neighborhood of residence Japanese Hawaiian males (25-44 years of age),living on Oahu in 1965, bom during 1900-1919, interviewed fi'ora 1965-1968. Study Design/ Study Period PoDulation-based 147 case- control pairs: (106 colon+ 41 rectum) Excluded; Cases: refused permission by physician,unabl e to locate, no english/translat Cohort! Follow-up 18-21 yrs. Cases: Patients with newly diagnosed histologically confirmed cancer of the stomach, colon, rectum, lung, urinary bladder, or prostate. Sample Size 8006 men: (Incident cases: 192 colon, 95 rectum,172 stomach, 194 lung, 206 prostate, 70 bladder) Excluded: 81 prevalent cases of cancer at fire time of exanrination. Physical Activity Assessment (Exposure Variable(s)) Coded Full-time Occupation - Medical chart abstract, Method of Garabrant All subsites: (Sedentaiy, Moderate, Very Active) S 8 lW 8 .esK d .% W Activitv - Physical Activity Index, Method used in Framingham Study. Resting heart rate fiom EKG Outcome Variablcfs) /Measure(s) Colon cancer Incidence 1) Q g - Anatomic subsites by consump. of foods 2) Q g - Anatomic subsites for cig. smoke. & alcohol inteke 3) Q g - by subsite for job activity 4) OR - Anatomic subsites by job exposure 1) Adjusted for age, race, BMI, dietary fhctors, occupational exposures Cancer Incidence 1) Eg-C ancer by physical activity index (tertiles) 2) gg-C ancer by anatomic site and physical activity index (tertiles) 3) g g - Cancer by resting heart rate 4) g g - Cancer by physical activity work/home/recreation Controlled Variables Statistical Methods 1) Adjusted fbr age at exam., BMI,cig, smoked: for stomach, lung, and bladder cancer 1) Odds Ratio, 95% C.I. 2) Exact binomial test, for individual diohotomous varioles 3) Multivariate logistic regression analysis, for variables wifli > two levels 4) Cross classification & uncond. logistic regression 1) Relative Risk, 95% C.l. - fl'om proportional hazards regression models 2) Test for trend: Physical activity index, resting heart rate (Continuous) 3) Tertiie measures: physical activity index and resting heart rate (Ist,2nd,3rd) Results 11 All subsites: 1) Colon cancer High: 0R=1.7 risk highest in (0.9,3.4) sedentaiy job Mod: OR=1.0 categories Low: 0R=1.1 2) Cases=43 (0.8,2.3) for 21Transverse/de transverse/desc scendine: ending: men High: OR=0.8 with sedentary (02,2.7) jobs were Mod: OR=1.0 shown to have Low: OR=3.0 an increased (1.2,7,2) risk of colon cancer in the transverse or descending colon 1) Inverse High: RR=0.71 association bet. (0.51,0.99) physical Mod: RR=0.56 activity and (0.39,0.80) colon cancer Low: RR=1.00 risk, consistent 2)Reetum: across all colon High:RR-1.41 subsites. (0.84,2.36) 2) No Mod:RR=1.31 association for (0.78,2,20) rectal cancer. Low: RR=1,00 310ccupations: RR=0.72 (0,84,2,36) Leisure: RR=0,66 Comments w ( V I CD ■ D O Q . C g Q . ■ D C D C /) C /) Table 2; Phvsical Activitv and Colorectal Cancer Studies 8 CQ' 3 3 " (D (D T3 O Q . C a o 3 T3 O (D Q . T3 (D (/) (/) Ballard- Barbash, R. Sohatekin, A, Albanes. D. SchifBnan, M. H. Kieger, B. E. Kannel, W. B. Anderson, K. M. Helsel, W. E, "Physical activity and risk o f large bowel cancer in the Framingham Study" Study- Primary Author Colon Cancer Defii, Gerbardsson Verdler, M. Steineok, G. Hagman, U. Rieger, A, Norell, S. E. "Physical activity and colon cancer: , case-referent study in Stockholm" de Cohort records wifli malignancy and incident cases of large bowel cancer ICDO codes 153 154 Histologicall y confirmed • coded by 7th ICD; caecam/asce nding colon (ICD 153.0), transverse colon/flexure S(1CD 153.1), descending colon (ICD 153.2), sigmoid colon (ICD 153.3) Ref. Year 1990 1990 Study Population Framingham Studv! Males and females original cohort, aged 30 to 62 yr at 1st exam. Physical activily data avail, in 4th biennial examination (1954) Cohort initiated in 1948. prospective cohort studv of risk factors forCVD, Cohort followed w/ biennial examinrtions for a 34-yr period. Cases: 152 incident cases, patients with colorectal cancer (ICD 153/153), occurring after exam 4. Male and female colorectal cancer cases, subjects bom in Sweden 1907-1946 and had lived more than 50% of life in Sweden Study Design/ Study Period Population-based 4214 subjects; 1906 males and 2308 fbmales. 152 Incident cases: 121 cases(code 153)and 31 cases (code 154). Excluded; 427 males and 562 females of the original cohort, missing exam 4. infomtation. Populatlon-based case-control Cases; Patients with colorectal cancer (ICD 153/154), diagnosed 1986- 1988 Sample Size 1081 subjects: Cases: 452 colon + 268 rectum cancer 624 referents - selected every four months Physical Activity Assessment (Exposure Variable(s)) Self-assessed Physical Activitv - Index measure based on reported activity; basal (sleep), sedentary (sitting), slight (walking), moderate (gardening), heavy (shoveling). Physical activitv in d e x ; Low, medium, and high tertiles Total Phvsical Activitv» Occunational + leisure activitv Very active Fairly active Sedentary Outcome Varia ble(s) /Measurcfs) RR-Association bet Colon Cancer and EhMWHflMtYWfX a) Tertiles - age adjusted incidence and P- value (test for trend) b) Stratified by age and BMI 1) OR of Colon cancer subaites associated with: a) Physical activity 21 OR of left colon subsite associated with; b) Physical activity by year c) Physical activity, BMI, dietary factors Controlled Variables Statistical Methods 1) Atjjusted for; age, education, smoking, serum cholesterol, alcohol, and BMI. 1) Relative Risk, 95% C.l. - from Cox's proportional hazards regression technique 2) Linear test for trend; Physical activity index is a tertiie trend variable. 3) Tertiie measures; physical activity index I) Adjusted for; age, sex, BMI, dietary factors Results 11 Males: Medium activity: RR=1.4*,(C1; 0.8 - 2 .6) Low activity; RR=1.8*, (Cl; 1.0-3.2) 21 Females; Medium activity: RR=1.2*,(CI; 0.7-2.1) Low activity; RR=1.1»,(CI; 0 .6 - 1.8) * Compared with highest tertiie. OR - calculated using logistic regression analysis method of Breslow and Day Relative excess risk; due to interaction calculated using the method of Rothman. 11 Colon; Very active: OR=1.0 Fairly active; 0R=1.4, 95%C.l.=0.9-2.2 Sedentary; 0R=1.8, 95%C.l.=1.0-3.4 aiRectum; Very active; OR=1.0 Fairly active; OR=0.;8, 95%C.I.=0.5-1.2 sedentary; OR=0.9, 95%C.1.=0.4-1.8 Comments 1) Inactivity was associated with increased risk o f large bowel cancer among men, but not for women. 2) For women - Narrow range of physical activily and minimal reporting of heavy activity may limit ability to detect association between physical activity and large bowel cancer. 1)Low physical activity assoc, w/ excess risk of colon (not rectum) 2) Dose- response relationship w/ decreasing levels of physical activity 3) Effect seen in left colon (OR=3.2,95%C .l.=I.5-7.0) L - J 0\ CD ■ D O Q . C g Q . ■ D C D C /) C /) Table 2; Phvsical Activitv and Colorectal Cancer Studies 8 CQ' 3 3 " (D (D T3 O Q . C a o 3 T3 O (D Q . T3 (D (/) (/) Study- Prinûiry Audior Colon Cancer O e f i i . Kune, G. A. Kune,S, Watson, L, F. "Body veighl and /diyslcal aclivily as predictors o f colorectal cancer risk" Histologicall yconfimed new cases of colorectal adenocarcino Slattery, M. L. Abd-Elghany, N. Kerber, R. Schumacher, M. C. "Physical activity and colon cancer: a comparison o f various indicators o f physical acitviiy to evaluate the association" Histologicall y confiimed ■ coded by ICDO (1st ed.): codes 153.0 to 153.4 and 153.6 to 153.9 and 154.0 Ref. Year 1990 Studv Male and female residents of Melbourne. Median age - 65 years. 1990 Study Population Melbourne Colorectal Cancer Ponulation-based case-control studv. C a s m i: Histologically confirmed new cases of colorectal adenocarcinoma, diagnosed bet. April 1980 and April 1981 in Melbourne E a n m M Community controls matched to cases by age and sex. Subjects (40-79 years of age) fiom study of dietaiy intake and colon cancer, cases fl'om Utah Cancer Registry, diagnosed: July, 1979 - June, 1981 Study Design/ Study Period Populatton-baaed incident case- control! Study of dietaiy intake & colon Cases: Cancer cases w/ histolog. confirm. 1st primaiy colon cancer (ICDO 153- 153.4,153.6-153.9, 154) Controls! Pop. based/random digit dialing w/ 5 yr. age- gip. 7/79-6/81 Sample Size 1442 sublects! 786 males and 656 females. 715 Incident cases! 388 males, 327 females 221 community controls: 398 males, 329 females Excluded! cases widi a history of ulcerative colitis and familial polyposis coli (10 cases). S W L m W e o i! 231 cases, 391 controls Completion rates: 71% for cases, 74% for controls 9 excluded - completed interview, but did not complete phys. activity questionnaire. Physical Activity Assessment (Exposure Varlafale(s)) SîlfcaassM riJM sal Activitv - Total physical activity: occupational, home activities, recreational/ sporting activities combined. Physical activitv yste. lA - Totally inactive IB -N ot very active 1 - Active retired 2 - Moderate active 3 - Strenuous active Coded Full-time Occupation - Past 15 years, coding: Dictionary of Occupational Titles (Sedentary, Lt,, Med., Heavy, Veiy Heavy) Self-Assess. Activitv - Occup./Leisure, 2-3 yrs.(light, mod., intense) Total activity=leisure+occup, (calories expended) Outcome Varlable(s) /Measure(s) Controlled Variables RR.95%C.l..P-value: Assoc, b et BMI and: a) Colorectal cancer* b) Colon Cancer* c) Rectal Cancer* - adj. for age & diet Assoc, bet, nbvslcal activitv grade and: a) Colorectal cancer** b) Rectal Cancer** ** - adj. fbr age, BMI, diet 1) Adjusted for: age, BMI, diet (unspecified) 1) Correlation bet. self- reported activity & coded occupational activity, by sex and age (<65, >65). 2) Colon cancer risk associated with physical activity, by sex. Statistical Methods 1) Relative Risk, 95% C.I., P-value 2) Data analyzed using unconditional logistic regression and GUM statistical package. 1) None 2) Adjusted for age, BMI, and crude fiber consumption. 1) Speaiman Correlation Coefficient 2) Odds Ratio, C.I. Results For Assoc, bet. Phvs. Activitv and Colorectal Cancer 1) Males: ModerWe/Strenuo us activity: RR=1.5*,(C1: 0.8-2.7) 21 Females: Moderate/Strenuo us activity: RR=0.89*, (Cl: 0.3-2.8) Compared with not very active, not statsig. 1) No relation bet. activity and colorectal cancer risk among males and females 2) For women - Aninveise relation suggested. 3) 88% of men and women not very active (few Involved in strenuous activity) 1) (< 65 yrs) had greater agreement bet. self-report, and coded occup. activity. Self- rqiort. and coded occup. activity highly assoc, in younger men (r=.32) 2) Coded:OR=0.6,S elf. report.:OR“0.7,f or High;Low activity Comments 1) Lower risk of colon cancer w/ inc. activity by each of three measures: total self-report, self- report occup., and coded occup. acti-vity. 2) Despite low correlation among measures of activity, t=0.3, each measure related to colon cancer. '-J C D ■D O Q. C g Q. § 1 — H 3" "O C D 3 C /) C /) o ' Table 2: Physical Activity and Colorectal Cancer Studies o Physical Activity stu d y - Colon Assessment Outcome 3" Priinaiy Cancer Ref. Study Design/ (Exposure Varlablc(s) Controlled Statistical C D Author Defh. Year Study Population Study Period Sample Size Variable(s)) /Measure(s) Variables Methods Results Comments O Whiftemore, A. Diagnosis of 1990 Chinese men and PoDUlation-based North Self Assessed Physical Colorectal Cancer 1) Adjusted for 1) Odds ratio - from Norfli America: 1 )Increased S. adenocarcino women In North incident case- America: 473 Activitv - Physical Incidence age Mantel-Haenzel methods Chinas 432 risk of both the CQ - Wu-Williams, A, ma of colon - America (> 20 yrs) eontrol! cases Activity Index assessed 1) ID - Age and sex 2) 95% C.I.: cases colon and rectal 3" H. coded by and People's Rep. of Cases: Patients Colon; (179 by 3 measures: specific Incidence rates Approximate procedure Colon: (95 male cancer with Lee, M. ICDO(lst China (20-79 yrs) diagnosed with male+ 114 1) 4 activities (In 24 O R -C ancer Risk bv: described by Miettlnen + 78 female). increasing time i Zheng, S. ed.); codes adenocarcinoma of female). hr): a) energy source Rectum: (131 spent sitting 3 Gallagher, R. P, 153.1 to Cases ftora; British the colon (ICDO Rectum: (105 sleeping, sittlng,modera b) sat. fats and itale+ 128 2) Increased C D Jiao, D. A, 153.9 or Columbia Cancer 153.1-153.9) and male + 75 te and vigorous activity duration o f residence female) risk of Zhou. L, rectum Registry, LA. Cancer rectum (ICDO 154.0 female) 2) Job c) physical activity 1296 controls colorectal "n Wang, X. H. 154.0 to Snrv. Program, and 154.1), Jan 1,1981- 1192conttols 3) Ave. dally distance d) Quetelefs Index (678 m ale+ 618 cancer w/ 3 - Chen,K, 154.1 San Dec. 31,1986. (698 male + walked, stairs climbed (Wt. In kg/helght in m') female) duration o f 3" Jung, D. et al.. Frandsco/Oakland Controls; 1:3 match 494 female) (North America), exposure to a ? "Diet, physical Surv., Epl. and End on residence, sex. China: 432 distance cycled (China) sedentary life C D activity, and Results Program and age cases style & diet rich "O colorectal 10 hospitals In China Colon: (95 In saturated fat. O cancer among m ale+ 78 Q. Chinese In female). §. North America Rectum: (131 o' and China’ ’ male +128 3 female) ■ o 1296 controls O (678 male + — ■ 618 female) 1 — H Lee, I. M. Diagnosis of 1991 Harvard Alumni Cohort - Harvard Harvard: Physical activitv: Mortality - over 23-vr 1) Adjusted for: Multivariate Analyses - 11 Hiablv active 1 )Increased C D Q. Paifenbarger, R. colon or Health Study: males (35-79 yrs. 17,148 male Stair climbing. follow-up. age and BMI RR - Using the Poisson (>2500 kcal/wk) activity alone S., Jr. rectal cancer Males entering followed from 1965 alumni. walking, sports play: Colon and rectal cancer Regression Model at(1962 &77): (at 1962/66 or 1 —H Hsleh, C. contiitned Harvard College, to 1988). 269 cases:225 assessed In 1962/1966, 90% Cl. RR=0.50, (Cl: 1977) was not 3" by subjects between 1916-1950. colon, 44 and In 1977. 0.27-0.93) associated with C "Physical physician Questiormalre: 1962 or rectum. Of Compare 2500 21 Moderate risk of cancer. activity and risk 1966,1977,1988. 20775 eUglble, kcal/wk and <1000 active f<lQOO 2) Consistently C D o f developing vital and cancer kcal/wk. kcal/wk) at (1962 high activity i colorectal status available &77); levels are i cancer among on 17,148 - RR=0.52, (Cl: necessary to ( / ) college alumni’’ 83% foUowup 0.28-0.94) protect or two o' rate. measures Increase precision. 3) No protective association for colon cancer. L k ) O O CD ■ D O Q . C g Q . ■ D C D C /) C /) Table 2; Physical Activitv and Colorectal Cancer Studies 8 ci' 3 3 " (D (D T3 O Q . C a o 3 T3 O (D Q . T3 (D (/) (/) Study- Primary Author Giovannucci, E. Asoherio, A. Rimm, E. B. Colditz, G. A. Stampfer, M. J, WUlett, W. C. "Physical actMty, obesity, and risk for coton cancer and adenoma in men" Longnecker, M, P. Cethardsson le Verdier, M. Frumkin, H, Carpenter, C. "A case-conirol study o f physical acUvity in relation to risk o f cancer o f the right colon and rectum in men" Colon Cancer Defi). New cases of colorectal adenocarcino ma (excluding carcinoma in sim)- hospital records/path ology reports Adenocarcin omaofthe right colon (caecum, ascending colon, and flexure), and rectum (rectum and rectosigmoid junction Ref. Year 1995 Male health professionals, 40 to 75 years of age, responding to a mailed questionnaire in 1986, reassessed bet. 1986 and 1992. 1995 Male residents of Connecticut, Massassachusetts, New Hampshire, Rhode Island, and Vermont during study period - January 1, 1986 to April 6,1988 Study Design/ Study Period U s â x .Males followed for diagnosis of cancer ofthe colon or rectum. 6 yrs follow-up, reassessed every 2 years. Population-based case-con trol study. Cases! Males diagnosed with adenocarcinoma of A re right coion (caecum, ascending colon, and hepatic flexure), at one of 68 hospitals, Jan 1986-April 1988. Id'ed by hospital records or Mass. Cancw R^istry Comm unity controls: matched to cases by zip code, 5-yrage Sample Size A 7W ml*. subjects. 203 new incidence cases of colon cancer 586 diagnosed with adenomas focluded! carcmoma m situ, hyperplastic and adenomatous polyps 1108 male s a M e c ts ! 405 cases: 163 colon, 242 rectal 703 community controls Excluded! cases <3lyrs, with chronic inflammatory disease of bowel, Gardners syndrome, or familial polyposis. Physical Activity Assessment (Exposure Variablefs)) activity fouesrtonaairel 11 Median MET- Hours/Wh! (0.9,4.8,11,3,22.6, 46.8) ■MET-hrs (for activ.) =sumof(ave. time/wks) X MET value 21 Body Mass Index: (<23, 23-24.9,25- 26.9, 27-28.9, >=29) Three Measures m f Coded Occupational A £ i M .t y i 1) 5 years ago 2) 20 years ago 3) Lifetime Occup. Activity Leisure-Time in 6 activities: Jogging/running, bicycling, swimming laps, tennis, box court games, calisthenics or rowing. Outcome Variabie(s) /Measure(s) 11 RR of Colon Cancer a) by level physical activity b) by BMI 21 RR for Adenoma ^Catic^r a) by waist circum. b) by waist-hip ratio O R .95% C.l..TrendP. value: Assoc, bet cancer of right colon or rectum for: a) Coded lifetime occupational activity b) Self-reported lifetime occupational activity c) Level of leisure time physical activity d) Leisure time vs. self reported occupational ControUed Variables Statistical Methods Age, h/o polyps, family hist., diet, alcohol, aspirin use, anoking, BMI Adjusted for: smoking, SES, race, BMI, ftmily history, diet, alcohol intake RR - used Mantel- Haenszel estimates and logistic regression, a4j for age and other confounders Multivariate RR: based on proportional hazards model 1) Odds Ratios, 95% C.I., P-value 2) Data analyzed using conditional logistic r^ession and SAS and EGRET statistical packages. 3) Spearman Correlation for leisure time vs. self- reported occup. Results ForHinhvs. Low activitv: RR =0.53 (95%C.1.=0.32- 0.88) after a4j.for potential confounders For Right Colon Cancer: a) Self-Rqxrrted Lifetime Occupational "More than Light Woflt": OR=0.7, (Cl: 0.31 -1.52) b) Leisure Time Vigorous Activity "2 + hours": OR=0.60, (Cl; 0.35- 1.00) No protection against rectal cance Comments 1) Results support an inverse assoc, bet. phys. activity and risk for colon cancer 2) Height & Obesity are associated with elevated risk 1) Protective relationship for colon cancer 2) No protective relationship for rectal cancer 3) Leisure-time activity protectant for each level of occupational activity CD ■ D O Q . C g Q . ■ D C D C /) C /) Table 2; Physical Activitv and Colorectal Cancer Studies 8 ci' 3 3 " (D (D T3 O Q . C a o 3 T3 O (D Q . T3 (D (/) (/) Study- Primuty Author Thune, I. Lund, E. "Physical aciM ^ and risk o f colorectal cancer in men and women" Martinez, M. £. Cjiovoinucci, E. Spiegelman, D. Hunter, D. J. Willett, W, C, Colditz, G. A. "Lelsure-time physical actMty, body size, and colon cancer in women. Nurses' Health Study Research Group" Cobn Cancer Defii. New cases oi colorectal cancers coded according to ICD7 New cases of colorectal cancer diagnosed by hospital records or path reports Ref. Year 1996 Males and female participants in health survey fiom five geographical areas in NorwayOslo, Oppland, Sogn, Fjordane, Demso and Finiunark during 1972 1978 1997 Study Population Participants were enrolled in the Niuses' Health Study, which began in 1976. Every 2 years, subjects surveyed for update on risk factors and major medical events. Study Design/ Study Period Pnpulation-based Cases! Id'ed fi-om Cancer Registry of Norway until 12/31/91 16.3 yrs & 15.5 yrs ■ follow-up males & females S tu d y Females followed cancer of die colon, during 1986-1992 6 yrs follow-up, reassessed eveiy 2 years. Sample Size 81.516 w b iw ts ! 53,242 males and 28,274 females 335 colon cancer cases: 236 males, 99 females 228 rectal cancer cases: 170 males, 58 females Excluded: cases id'ed at autopsy,emigrat es, pre-existing malignancy 67.802 eligible 212 cases of colon cancer (97 distal, 88 proximal, 27 unknown site) 385819 person- years of follow- up Excluded! cancers ofher thanadeno- Physical Activity Assessment (Exposure Variable(s)) Occun. & Recreation.phvsical activitv bv questionnaire! Rl-Read, watch TV R2-Walk,bicycle 4h/wk R3-Fit exercise - 4h/wk R4-Reg hard train, several times per wk 01-Most sedentary 02-Work w/ walk 03-Work w/ lift 04-Heavy work activitv (questionnairel Average MET- Hours/Wk: (<2,2-4, 5-10,11-21, >21) Outcome Variable(s) /Measure(s) Controlled Variables RR.9S%C.l..P-valué! Assoc, betcoion or rectal cancer and a) Possible risk factors b) Total physical activity ■stratified by age c) Occup & Recreation, activity stratified by colon region, BMI Adjusted for: age, BMI, cholesterol, geographic region a) by Leisure-time activity -includes distal and proximal b) by BMI -includes distal and proximal c) by waist-to-hip ratio -includes distal and proximal 1) Relative Risk, 95% C.I. 2) Test for Trend using Cox's proportional hazards model- Age, family hist, smoking, aspirin use, red- meat consumption, alcohol intake, hormonal replacement Sbitisticgl Methods Results 1) R R - used Mantel- Haatszel estimates and logistic regression, adj for age and ofiier confounders 2) Tests for Trend O c c u p - & Recreation activitv combined! showed dose response: 11 Males: Moderate, RR=1.2, (01:0.8- 1-8) Active, RR=1.0, (01:0.6-1.5) 21 Females! Moderate, RR=1.0, (01:0.3- 2.8) Active, RR=0.6, (01:0.4-1.0) Sedentary = ref 11 For most active vs. least active: RR = ■ 0.54 (sig) (959iO.l.=0.33- 0.90, P for trend .03) Comments 1)0ose response for total activity with women (P for trend=0.04) 2) For males > 45, sig. trend for lower risk, higher activity (RR=0.66) 3) Males - occupational activity related to reduced risk of proximal colon cancer. 4) No relationship for rectal cancer 1) Sig. inverse assoc, bet. leisure activity and risk for colon cancer 2) High BMI/inc, hip-to waist ratio assoc, with incrisk 3) Women in highest activity categ. 70% less likely to develop distal colon cancer than least active 4) Sig. inverse assoc, bet. leisure activity and colon ê CD ■ D O Q . C g Q . ■ D C D C /) C /) Table 2; Physical Activitv and Colorectal Cancer Studies 8 ci' 3 3 " (D (D T3 O Q . C a o 3 T3 O (D Q . T3 (D (/) (/) Slatteiy, M. L. Potter, J. Cam, B. Edwards, S. Coates, A. Ma, K. N. Betiy, T. D. "Energy balance and colon cancer— beyond physical actMty" Study- Primary Auflior Diagnosis of primary colon cmcer coded by ICDO (2nd ed.); codes 18.0 and 18.2-18.9 Slattery, M. L, Edwards, E. L. Boucher, K. M. Anderson, K. Caan, B. J. "Lifestyle and colon cancer: an asessment o f factors associated vtth risk " Colon Cancer Defli. Diagnosis of primary colon cmcer coded by ICDO (2nd ed.): codes 18.0 md 18.2-18.9 Ref. Year 1997 1999 Study Population Subjects fiom 8 counties in Utah, Northern Calif. Kaiser Permmente, md Twin Cities, Mtnn., 30-79 years of age. Oct. 1,1991 md Sept. 30,1994. Population based case-control study; Cases: Patients diagnosed with first prirhary colon cmcer (ICDO 18.0 md 18.2-18.9),Oct. 1,1991 md Sept. 30.1994. Controls: 1:1 match on sex, 5-year age group Subjects fiom 8 counties in Utah, Northern Calif. Kaiser Permmente, md Twin Cities, Minn., 30-79 years of age, diagnosed between Oct. 1,1991 md Sept, 30, 1994. Study Design/ Study Period 1993 cases: 1099 male + 894 fanale 2410 controls: Population based case-control study: Cases: Patients primary colon cmcer (ICDO 18.0 and 18.2-18.9),Oct. 1,1991 m dSqjt. 30,1994. Controls: 1:1 match on sex, 5-year age group Sample Size 1290 male + 1120 female Study non: 91.3% white, 4.2% black, 4.4% Hispartic Excluded! cases widi tumors in rectosigmoid junction or rectum, PAP, ulcerative colitis, or Chron's disease 1993 cases: 2410 controls: Excluded: cases with tumors in rectosigmoid junction or rectum, FAP, ulcerative colitis, or Chron's disease Physical Activity Assessment (Exposure Vatiable(s)) Physical Activity - Interview (Other; Dietary Intake - Questionnaire, BMI - measured height & reported weight) Physical Activitv! 1 : No vigorous activi^ 2:1 to 250 kcal/wk 3:250 - 1000 kcal/wk 4; > 1000 kcal/wk for ref. year, 10 md 20 yrs ago Outcome Variabie(8) /Measure/s) OR-Association het. Colon Cancer and: a) Lifetime vigorous activity b) Energy intake c) BMI Other, a) Assoc bet. Physical activity, BMI, Energy Intake b) Interaction bet, Lifetime vigorous physical activity, BMI, Energy Intake Physical Activitv - Interview (Other: Dietaiy Intake - Questionnaire, BMI - measured height & reported weight) Physical Activitv: 1 - Low, 2,3,4, 5 - High Controlled Variables 1) Adjusted for age, BML family history, use of aspirin, dietaiy fiber md calcium For males and females: OR-Association bet. Colon Cancer and: a) Physical Activity b) Energy intake c) BMI ater: a) Best fit model of assoc, bet. lifestyle factors md colon cmcer risk b) Assessment fo factor loading matrix of lifestyle Actors Statisfical Methods 1 ) P d d ; m f » 9 ■ Unconditional logistic regression models 21 Interactions • assessed using categorical variables 3) Multiplicative Interaction - (-2x) the différence in the log likelihood of die model w/ and w/o the categorical interaction term. 1) Adjusted for age Results 11 Lifetime time activitv and increased risk of 1) Odds ratio - Unconditional logistic regression models 21 Multiple Loefatic Regressions Models - include all lifestyle factors 3) Factor analyses - used to describe aspects of lifestyle patterns A * W la # d with increased risk of colon Men(OR=1.63, 95%C.l. 1.26- 2 . 12) Women (OR=1.59,95% C.l. 1.21-2.10) (comparing lowest to highest); 2) High BML low Physical activitv, h ig h energy intake: OR=3.35 (sig) (Cl;2.09-S.351 1)-Hfe»y|e char, bv h ig h levels of Phvs. colon cancer: Men (OR=0.42, 95%C.!, 0.32- 0.55) Women (OR=0,52,95% C.l. 0,39-0.69) 2 ) mb. Medication and S m iB lm if n lf iijp m Men (OR=1.68, 95%C.l. 1.29- 2.18) Women (OR=l,63, 95% C.l. 1.23-2.16) Comments 1) Lack of lifetime vigorous leisure time activity 2) High levels of energy intake 3) A large BMI in males Results support findings; physical inactivity, high energy intake, large BMI assoc, w/ inc. 11 Liflatvles characterized bEL. high level of phys activity, most marked lifestyle assoc, w/ colon cmcer 21 Associated w d d t-W m e d , risk of colon cancer: a) Medication md supplementatio n b) Western lifestyle c) A large BMI cancer. The following is an overview of selected early physical activity studies, where the outcome variable is deaths from neoplasms (also listed in Table 1). In 1921, Silvertsen and Dahlstrom examined the relation of occupational muscular activity to carcinomas (See Table 1).G 6 The male subjects in this case series were deaths from the Bureau of Vital Statistics at the Minnesota Board of Health. Occupations were classified by amount of muscular activity involved: group I (great amount), group 1 1 (moderate amount), group 1 1 1 (small amount), group IV (farmers/seasonal work), group V (no occupation). Among their conclusions, they suggested that, “the death rate among males actively engaged in a gainful occupation is inversely proportional to the degree of muscular activity necessary for that occupation.” Although the study design was weak, the results suggested that men who worked in physically demanding occupations had a lower incidence of malignant tumors.^^ One of the first epidemiological studies of athletes was published by Rook in 1954 (see Table 1).6? Rook studied the longevity of Cambridge University sportsmen who had participated in athletic competitions by comparing their mortality with the experience of a control group composed of two sources: a convenience sample of university ‘intellectuals’ and a random selection of concurrent university attendees. The mortality of the athletes was compared to the experience of the two control groups. The overall percentages of deaths from neoplasia were higher among the athlete group than in the two control subgroups (13.6% in athletes versus 12.8% in the random controls and 12.3% in the intellectual controls).^^ 42 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. Taylor et al., conducted one of the first epidemiological studies on oceupational physical activity in 1962.^ The investigators examined cause-specific mortality rates for men employed by the U.S. railway. Data were gathered on 26,219 male subjects, employed in three different job categories within the railroad industry. The three groups were comprised of: railway office clerks, switchmen in the marshalling yard, and track section men. The corresponding levels of physical activity assigned to each job were: low, moderate, and heavy physical activity. The authors observed a declining gradient in all-cause age-adjusted death rates among the three physical activity levels, as well as a similar deelining pattern for deaths due to neoplasms. The all-caneer mortality rates for office clerks and switchmen were 2.23/1,000 and 2.19/1,000. The rate of the track section men, 1.47/1,000, was significantly lower. The overall results of the study suggested a protective effect of heavy physical activity upon cancer mortality, as well as a decline in cancer mortality with increasing levels of physical activity. When annual changes in jobs were ignored, the results were similar, reducing the probability that the association between a sedentary job and cancer had occurred after the onset of disease. In 1976, Polednak examined death certificates from a cohort of 8400 Harvard alumni males to determine mortality from neoplasms. Subjects were divided into three birth- decade cohorts (1860-69, 1870-79, and 1880-89). Athletic exposure was classified by amount of college athletic activity as major, minor, or non-athletes. Major athletes were men who had received letters for major sports such as baseball, football, rowing, and tennis. Minor athletes were those who participated in major sports, but were not awarded an athletic letter or participants in intramural sports. Non-athletes were those with no 43 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. record of athletic participation or those who only participated as freshmen. The overall results suggested a positive association of cancer mortality with increased athletic status, with former major athletes having a higher rate of death due to neoplasms than non former athletes (15.2 per 100 versus 12.3 per 100). The relative risk of death due to neoplasms among athletes compared to non-athletes was 1.24. Previous studies conducted by Polednak had indicated that Harvard major athletes of that era were considerably taller and heavier than non-athletes.69, 70 To control for confounding from these two variables, the author matched major athletes with non athletes by body size (height and weight). After matching, both the proportion of deaths due to neoplasms and mean age of death due to neoplasms were still higher in major athletes than in non-athletes, although not statistically significant.^!). However, there were still some additional issues with non-comparability of groups, as well as self selection that may have still existed. Many university athletes have a substantial socioeconomic advantage over the average adult. To control for socioeconomic differences, all subjects in Polednak’s 1976 study had an interest in athletics, and had rented lockers in a university facility. Although this may have reduced socioeconomic differences, it introduced another possible complication; that is that non-athletes may have done more athletic activity than the athletes.^^ In general, it is difficult to be assured of the comparability of athletes and non-athletes. 44 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. 1.6.3 Physical Activitv Studies of Colorectal Cancer For the purposes of this review, physical activity studies covered in this section will include those where death or diagnosis of colorectal cancer is used as a measure of outcome. The studies summarized in this section are listed in Table 2. In 1975, Berg and Howell conducted a study that analyzed mortality rates for colon and rectal cancer by occupational group in the United States and Great Britain (see Table 2).72 Death certificates in both countries were used to obtain colorectal cancer deaths. Occupations were ranked by English social class and U.S. occupational levels I - V, with farmers in a 6 * * * class. The range for the 5 levels corresponds to: level I - the professional level thru level V - U.S. laborer except farm and English unskilled professionals. Their results demonstrated that sedentary white collar professionals were at a higher risk of large bowel cancer, which was not likely the result of occupational exposure. This study led to other subsequent studies that further investigated the hypothesis that a sedentary lifestyle is associated with an increased risk of colorectal c a n c e r . 23 In 1981, Persky et al., conducted an analysis of 3 employee cohorts in 3 studies; to examine the relationship between heart rate and cancer mortality. 24 Resting heart rate was the baseline exposure variable utilized, with the assumption that adults with lower resting heart rates had higher levels of physical activity. 25 In Persky's first study, 1233 white male employees of the Chicago People’s Gas Company, aged 40 to 59 years, were followed for 18 y e a r s . 2 4 Baseline resting heart rates of subjects who were alive at the end of follow-up were compared with those who had died, for various cancers. For all cancers studied, decedents had a higher resting heart 45 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. rate than non-decedents. Among subjects with lung, colon, and all cancers, heart rates were higher for decedents. The heart rate differences between colon cancer decedents and non-decedents was the only effect that remained significant after adjustment for any effects of age, serum cholesterol, relative weight, systolic blood pressure, and cigarette smoking habits. The results of this study suggested that there was an effect of resting heart rate on colon cancer, which was independent of competing risk f a c t o r s . Persky et al., used a similar approach in a second cohort study of employees at the Chicago Western Electric C o m p a n y . this second study, 1899 white male employees, aged 40 to 55 years and free of heart disease at baseline were followed for 17 years. Cause of death analyses, comparing decedents and non-decedents, were conducted with a method similar to that used in the first study. None of the site-specific decedents had a statistically different heart rate from the non-decedents. The results suggested that after multivariate statistical adjustment there was an effect of resting heart rate on colon cancer only, which was in the anticipated direction and approached statistical significance. However, there was no significant association between resting heart rate and cancer mortality. 74 In his third study, Persky et.al. analyzed employees at the Chicago Heart Association Detection Project in Industry.74 In this study, 5784 white males of a similar age as the previous studies, were followed for 5 years. These results show a significant association of resting heart rate with all-cause and all-cancer mortality. Although site-specific cancer analyses demonstrated higher resting heart rates in cancer victims compared with survivors, these results were significant for all cancers only. Overall, the results of two of 46 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. the three studies conducted by Persky et.al., indicated that resting heart rate at baseline is an independent risk factor for cancer mortality7'^ Persky’s results showed elevated risk and approached statistical significance. However, self-selection bias must be considered since these cohorts may represent males who are inclined to be sedentary and attracted to less physically demanding jobs. However, utilizing resting heart rate as an objective measure of activity and analyzing cancer outcomes within each cohort would minimize any bias.76 Hoar and Blair conducted a case-control study to investigate the possible relationship between employment in the textile industiy and cancers of the prostate and colon in 1984.77 Death certificate information was obtained from 820 male and female colon cancer cases and their matched controls, who died during 1970-1978 in South Carolina. Subjects were residents of the seven carpetmaking counties: Dillon, Dorchester, Greenville, Laurens, Pickens, Spartanburg, and York. Although the results provided little support to their hypothesis, they did find that people in higher socioeconomic status occupations, such as managers, administrators, and executives, were at higher risk of colon cancer.77 In 1984, Garabrant et al., conducted a study of occupational physical activity and colon cancer, based on 2,950 population-based incident male cancer cases, diagnosed between 1972-1981 from the U.S.C. Los Angeles County Cancer Surveillance Program, a population based cancer registry. 36 From occupational data recorded on hospital charts at the time of diagnosis, occupation and industry were coded according to the U.S. Bureau of the Census 1970 index. All occupations were rated according to the percentage 47 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. of time each job required physical activity, as judged by experts in occupational medicine. Three categories were defined for occupational activity; sedentaiy jobs, those requiring less than 20 percent physical activity; moderately active jobs, those requiring physical activity 20 to 80 percent of the time; and highly active jobs, requiring physical activity more than 80 percent of the time. Colon cancer had a risk ratio of 1.8 (C.l. = 1.6-2.2), for the sedentary group compared with those classified as highly active. There was also a statistically significant decreasing trend for the age-adjusted incidence rates for colon cancer across sedentary to high activity level groups. Proportional incidence ratios displayed a similar statistically significant decreasing trend, as well as a risk ratio of 1.6 (C.I. = 1.3-1.8) for sedentaiy compared to highly active levels. The authors were able to control for socioeconomic status by stratifying by social class and ethnic group. An inverse relationship between level of job activity and both the annual incidence rate and proportional incidence rate was evident across all ethnic groups, socioeconomic strata, and for each subsection of the colon, from the hepatic flexure to the sigmoid. In contrast, occupational physical activity was not associated with the risk of rectal cancer.36 In a similar case-control study done in 1985, Vena et al., evaluated the association between lifetime occupational physical activity and colon cancer.35 Occupational history was obtained from 486 cases of colorectal cancer and 1431 control patients with non neoplastic digestive disease, upon hospital admission to a medical treatment center. The assessment of lifetime occupational physical activity included multiple jobs for each subject. Occupations were categorized into one of five levels of physical activity, based on the U.S. Department of Labor Dictionaiy of Occupational Titles. The five level index 48 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. of physical activity reflects the frequeney and magnitude of lifting, as well as the proportion of time standing and walking in a specific job. A life exposure index was estimated based on the amount of time a patient spent in sedentary or light work during lifetime occupational physical activity. Three physical activity exposure categories were defined by: number of work years with sedentary or light work (none, 1-20, >20); proportion of work years in jobs with sedentary or light work (none, 0.01-0.50, 0.51-0.99, 1.00); and proportion of life in jobs with sedentary or light work (none, 0.01-0.40, 0.41-1.00). All three exposure eategories were related to an increased risk of colon cancer, with inereasing sedentariness. The age- adjusted odds ratios ranged fi-om 1.8 to 2.1 (p < 0.001), comparing those never employed in a sedentary occupation with those of the hipest exposure (i.e., 100% sedentary). In each of the three exposure categories there was a clear dose-response relationship of increasing risk, going fiom no to high exposure. No relationship was observed between lifetime occupational physical activity and incidence of cancer of the rectum. The findings of this study eorroborated those of Garabrant, in that increased risk of colon cancer is associated with sedentaiy or light w o r k . 3 5 Presumably, focusing on a lifetime measure of occupational physical activity gave a more complete assessment of exposure assessment than in previous studies. This composite measurement may give a more integrated or robust measure of activity than solely utilizing the longest-held job or the one held prior to diagnosis. Incorporating jobs held during and prior to the second decade provided additional information during a critical time frame which may be useful in determining colon cancer r i s k . ^ 4 49 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. In 1986, Gerhardsson, et al., also evaluated the association between occupational activity and colorectal cancer in a 19 year follow-up study of Swedish men, aged 20 to 64 years.^^ During the follow-up period, 7,115 cases of colon cancer and 5,290 cases of rectal cancer were ascertained from the Swedish Cancer Registry. Utilizing the 1960 census to record occupation and using a method similar to that of Garabrant, occupations were classified according to time spent sitting during work hours (physically active: 0 to 49%, sedentary: 50% to 100%). The results showed that men employed in sedentary occupations had an increased risk of colon cancer (RR=1.3, 90% C.l.=1.2-1.5), with highest risk in the transverse colon including flexures (RR=1.6, 90% C.I.=1.2-2.1), and lowest risk was for sigmoid (RR=1.2). The authors also examined a separate sample of 8000 males in the same occupations from the Swedish twin regishy, to further consider confounding by leisure activity and diet. Subjects had answered a 1973 questionnaire which included information on occupation, physical activity during work hours and leisure time, and food habits. The authors found that in the same time period of interest, men in sedentary jobs showed no differences in the amount of exercise performed during leisure time than men in physically active jobs. Moreover, there was little correlation between sedentary jobs and dietaiy intake and no association was shown with rectal cancer. These results demonstrated that it was unlikely that the confounding effects of food habits and physical activity during leisure time could explain the association.^^ In 1987, Paifenbarger et al. investigated physical activity and the risk of cancer in two cohort studies of San Francisco longshoremen. The first study included 3,686 50 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. dockworkers, aged 35 to 74 years, who were followed for 22 years from 1951 through 1972. Physical activity was measured in terms of kilocalories of energy expenditure (EE) per week in various jobs performed by the longshoremen. In the second cohort study conducted by Paffenbarger et al., an additional 2,665 longshoremen were followed for the last 12 years of the 22 years of the first study. Combined with the original study, 6,351 longshoremen, aged 35 to 74 years, participated in the second study. Cancer mortality was examined at the four major cancer sites: lung, colorectum, pancreas, and prostate. Level of work activity was quantified by energy expenditure (kcal/week) and categorized into four levels of EE: light, moderate, light or moderate, and heavy. The results were not statistically significant, and showed little or no association with work activity and site-specific cancer mortality. After adjustment for age, the relative risk of death from colorectal cancer was 0.78 in men with lower energy expenditure. 79 In another 1987 study, Paffenbarger et al. followed Harvard and University of Pennsylvania alumni for 12 and 16 years, respectively. This third study included 56,683 former Harvard and Penn State students who were classified by the amount of sports played during college. The dichotomous categories for physical activity were, < 5 hours per week, and > 5 hours per week. Cases were matched to classmate controls by age, sex, and year of birth.. Risk of cancer incidence was examined at 15 separate sites. In the first analysis, the active group showed a risk ratio of 0.91 for colon cancer, and 0.46 for rectal cancer. 51 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. In a fourth study conducted in 1987, Paffenbarger examined the relationship between post-college physical activity and cancer mortality in the Harvard alumni cohort. Participants were followed for 12 to 16 years and categorized according to energy expenditure during leisure-time. A three eategory physieal activity index was used where energy expenditure was calculated in kcal per week (< 500 (2092kJ), 500 to 1999 (2092 - 8364U), and > 2000 (8368kJ). Cause-specific mortality rates across energy expenditure levels were calculated and confounders were controlled. The results showed a statistically significant inverse association of decreasing cancer mortality with increasing energy expenditure (RR=1.47). Site-specifie results showed no association with energy expenditure. Many occupational studies have only examined men. A second case-control study conducted by Vena et al. in 1987, examined the “usual occupation during most of working life” and its relationship to mortality from cancers of the colon, rectum, and breast, for men and women.*® Using Washington State mortality data from 1950 and 1979, occupational information and cause of death were obtained on 430,000 male subjects and 25,000 females. Occupational activity was again categorized into one of five levels of physical activity, based on the U.S. Department of Labor Dictionary of Occupational Titles (1-low, 2, 3, 4, and 5-high). To account for temporal changes in job titles, data were analyzed in three ten-year intervals (decade), and then re-evaluated overall for a 30-year range. For each decade and overall, the data showed a statistically significant slightly decreased risk for the two highest job-activity levels and a slightly increased risk for the sedentary job-activity levels. Colon cancer deaths 52 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. (observed/expected) showed a clear declining trend across increasing physical activity categories, for each decade-specific analysis as well as the overall range. This study was noteworthy in that it analyzed the occupational physical activity and cancer mortality in women. A statistically significant reduced risk of mortality from colon cancer was seen for women in the highest activity level, compared with the rest of the women in Washington State. In subsequent years, additional studies done by Slattery et al., Gerhardsson et al., Albanes et al., and Whittemore et al., and others have examined occupational activity and cancer in women. In another 1987 study, Wu et al., examined the relationship between long term health issues and colorectal cancer.This retrospective cohort study assessed upper-middle class white male and female residents of a retirement community. Of 11,888 residents, 58 male and 68 female incident cases of colorectal cancer were identified. Participants were surveyed concerning various long term health issues such as: diet, vitamin use, alcohol consumption, and physical activity. Subjects were categorized into 3 levels of avocational activity, < 1 hour per day, 1-2 hours per day, > 2 hours per day. The results showed that exercising for > 2 hours per day relative to < 2 hours per day reduced the risk of colon cancer for males and females (0.40 and 0.89, respectively). For males, the adjusted RR was 0.6 per hour increase across all categories. (95% C.l. 0.5 - 0.9).*^ In 1989, Albanes et al., conducted a major cohort analysis on self-reported physical activity and cancer using subjects who had participated in the first National Health and Nutrition Examination Survey (NHANES I) study.*^ The NHANES cohort was originally examined between 1971-75, and followed prospectively for 10 years and re-interviewed 5 3 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. through the Epidemiologic Follow-up Study (NHEFS). Of 12,545 subjects, aged 25-74 years old, 128 incident cases of colorectal cancer were confirmed through pathology reports. Participants were asked questions regarding recreational and non-recreational physical activity levels, information was also obtained on height, weight, BMI, and potential confounding risk factors. Self-reported non-recreational activity was classified by subject response to how active they were in a usual day as: very active, moderately active, or quite inactive. Similarly recreational activity was classified by subject response to how much exercise they got in recreation as: much exercise, moderate exercise, little or no exercise. Examining non-recreational activity, the authors observed a non-significant increased risk of colorectal cancer among males when inactive subjects were compared to very active subjects (RR=1.6, 90% C.I.= 0.7-3.5). For recreational activity, females who received moderate or less exercise had a small non-significant increase in risk of colorectal cancer. Overall, the relative risk of all-site cancer among males was 80% higher in those who were inactive than in those who were veiy active, with the effect being larger for non-recreational than recreational activity. Among females, the relative risk of all-site cancer was 30% higher, comparing inactive to very active. These results suggest a protective effect between physical activity and all-cancer mortality.* 1 Brownson et al., conducted a case-control study of white males to examine occupational risks for colon cancer.*^ Utilizing hospital records to ascertain occupational activity, 1,993 males enrolled in the Missouri Cancer registry were compared with 9,965 age-matched controls. Occupational activity was classified according to whether physical activity was required: more than 80% of the time (high activity), 20-80% of the time 5 4 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. (moderate activity), or less than 20% of the time (low activity). Excess risk was shown among males in the low activity group (OR=1.4, 95% C.I.=1.0 - 1.9, p<0.02), as well as an inverse linear trend in risk with intensity of occupational activity. Risk associated with sedentaiy occupation and anatomic subsite was highest for cancer of the caecum (OR=2.1, 95% C.I.=1.1 - 4.0).*^ In a later analysis of this dataset, Brownson found that the odds ratio for the low activity group was lower than previously reported (OR=1.2, 95% C.I.=1.0 - 1.5), and slightly elevated for the moderate activity group (0R=1.1, 95% C.I.=1.0- 1.3).87 Fredriksson et al. examined the relationship between colon cancer, physical activity and occupational exposure in a ease-control study in 1989.** Using the Swedish Cancer Registry, 165 male cases and 164 female cases were identified and compared to 658 population controls matched for age, sex, and country. Occupational history and other exposures such as food, alcohol habits, previous disease, and drug intake were ascertained via a mailed questionnaire. The authors found that persons with physically active occupations had a decreased risk. This effect was most apparent in the descending colon and sigmoid (OR=0.49), for sedentary jobs compared to active. No reduced risk was found for right-sided colon cancer.** Peters et al., found similar results in a case-control study of 147 white male colorectal cases, under the age of 45, compared with matched neighborhood controls in L.A. County. *9 Job activity was categorized into one of three levels of physical activity, based on the 1970 U.S. Bureau of Census Index of Industries and Occupations, similar to the method of Vena. Three levels of physical activity exposure were defined: physical 55 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. activity required less than 20% of the time on the job (mainly sedentaiy); physical activity required between 20% and 80% of the time on the job (moderately active); and physical activity required more than 80% of the time on the job (very active). Men with sedentary jobs had an increased risk of colon cancer, as well as tumors in the transverse or descending colon (OR=1.7 95%C.I. = 0.9 - 3.4, OR=3.0, 95%C.I. = 1.2 - 7.2). These results remained unchanged when activity levels were based on: most recent job, the number of years in a sedentary job, and the proportion of job history spent in a sedentary job.*^ In 1989, Severson et al. carried out a prospective cohort study for the analysis of physical activity and colon cancer, among 8006 Japanese men living in Oahu, Hawaii.^® Previous studies had used an indirect measurement of physical activity, like occupation, to assess physical activity. Severson used a combination of self reports to calculate a summary physical activity index, and resting heart rate EGG monitoring (a direct measurement). Physical activity index was based on the weighted sum of the amount of time the subject spent per 24 hours in the following types of activities: basal, as in sleeping or lying down; sedentary, as in sitting or standing; slight, as in walking on a level surface; moderate, as in gardening or carpentry; and heavy, as in shoveling or digging. The physical activity index and resting heart rate were divided into tertiles based on the distribution in the entire cohort, with the 1 ® * tertile used as the reference group. Using this index, increased activity was consistently associated with a decreased relative risk of colon cancer. No association was observed for rectal cancer. 56 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. In 1990, Ballard-Barbash et al., investigated the relationship between large bowel cancer and self-reported physical activity in a prospective cohort study of males and females who participated in the Framingham Study, initiated in 1948.^^ Self-assessed physical activity data were available on 1,906 males and 2,308 females, aged 30 to 62 years in 1954. After 28 years of follow-up, the cohort had 152 cases of large bowel cancer. A physical activity summary was based on a weighted sum of self-reported activities during a 24 hour period which included: basal (sleep), sedentary (sitting), slight (walking), moderate (gardening), and heavy (shoveling). Physical activity totals were categorized into low, medium, and high tertiles. They observed that inactivity was associated with an increased risk of large bowel cancer among men. For the middle and lowest tertile compared to the highest tertile the relative risk estimates for males were 1.4 ( 95%C.I. = 0.8 - 2.6) and 1.8 (95%C.I. = 1.0 - 3.2), respectively. The results were not similar for women. This may be due to the fact that women had a narrower range of physical activity. The minimal reporting of heavy activity may limit the ability to detect an association.91 Gerhardsson et al., conducted a population-based case control study in Stockholm to assess the relationship between physical activity and colorectal c a n c e r . ^ 2 The study involved 1,081 subjects, which included 452 cases of colon cancer and 268 cases of rectum cancer. Controls were randomly selected from the population and stratified by year of birth. Physical activity and dietary information were obtained via a mailed questionnaire, where respondents were asked to indicate whether they were sedentary, fairly active, or very active during work and recreational hours. The results showed that 57 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. low physical activity (sedentary at work and recreation) was associated with an increased risk of left colon cancer for men and women ( RR= 3.3, 95%C.I. = 1.0 - 10.9; RR= 4.2, 95%C.I. = 1.2 - 14.0), respectively. No association was seen for either the right colon or rectal cancer. A dose-response relationship was indicated with decreasing levels of physical activity. Kune et al., examined the association between colorectal cancer and physical activity in a case-control study conducted in Melbourne Australia.^^ Data obtained from the Melbourne Colorectal Cancer Study included 715 cases of colorectal carcinoma and 727 community controls. Physical activity data were obtained via an in-person questionnaire, by University-qualified dietitians who obtained information on physical activity including: occupational, home, and recreational activity . Height, weight and physical activity levels were ascertained for the period covered by the diet history; a period deemed most representative of the respondent’s diet in the previous 20 years. Periods included in the dietary assessment were: the previous 17-20 years (62% of cases, 57% of controls), the previous 10-16 years (22% of cases, 18% of controls), and the previous 2-9 years (16% of cases, 25% of controls). The Physical activity levels for respondents were categorized into five levels, based on the 1971 National Health and Medical Research Council of Australia and the 1974 World Health Organization ^3 The categories were defined as follows: Grade 1A - totally inactive. Grade IB — not veiy active retired. Grade 1 - active retired. Grade 2 — moderate activity, and Grade 3 — strenuous activity. The results indicated no relation between various levels of physical activity and colorectal cancer risk among males and females. Among women, an inverse association was 58 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. suggested, which disappeared after adjustment for dietary risk factors. However there were limitations in their ability to assess an association, as 88% of the subjects were not involved in strenuous activity (Grades lA, 2, and 3) and physical activity was measured only for the period of diet history. 93 Slattery et al. evaluated the association between physical activity and colon cancer by using several indicators of physical a c t i v i t y .94 Study subjects were obtained from a population-based incident case-control study of dietary intake and colon cancer in Utah. Two htmdred thirty-one first primary colon cancer cases and 391 controls, aged 40 through 79 were interviewed. Measures of physical activity were based upon self- reported activity, which included occupational and leisure-time activity, and coded occupational activity. Self-reported occupational and leisure-time activity two to three years prior to the interview were assessed. Levels of intensity of self-reported activity were classified as light, moderate, and intense. Coded occupational activity was ascertained by using the most frequent full-time occupation for the past 15 years. These were coded using the Department of Labor Dictionary of Job Titles and Estimates of Worker Trait Requirements. The occupational physical activity codes were: 1-sedentary, 2-light, 3-medium, 4-heavy, and 5-very heavy. For male subjects under 65 years of age, self-reported total activity, total non-intense activity, and occupational activity were not strongly associated with coded occupational activity (Spearman r = 0.36, 0.27, and 0.32, respectively). An even weaker association was noted among women (r = 0.23, 0.27, and 0.10). In general, associations between total activity and coded occupational activity were weaker for all subjects 65 or older. However, all indicators of physical activity were 59 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. associated with a decreased risk for colon cancer among men. Comparing the highest category of activity with those in the lowest, for total self-reported activity, self-reported occupational activity and coded occupational activity, the odds ratio were O.7., 0.7, and 0.6, respectively. For women, only self-reported total activity was associated with a decreased risk of colon cancer (OR= 0.5; 95%C.I. = 0.3 — 0.9). The researchers indicate that the coded occupational activity measure (past 15 years) may be a better indicator of lifelong activity and colon cancer than the self-reported activity which reflects more recent activity. They also suggest that coded occupational activity in women is difficult to assess and less accurate.94 In 1990, Whittemore et al., conducted a population-based case-eontrol study of colorectal cancer among Chinese men and women in western North America and the People's Republic of China.*4 The study included 905 cases, diagnosed 1981-1986, and 2,488 controls. Life-style and dietary charaeteristics were assessed via an in-person interview and diet history questionnaire. Physical energy expenditure was assessed by measures during two time periods: the reference year and during 1985. The first measure accounted for the amount of time during a 24 hour day spent in four activity categories: sleeping/reclining, sitting, light/moderate activity, and vigorous activity. If a participant reported two different activity patterns for weekday and weekend, a weighted average was used to estimate the amount of time per day spent in the aetivity. Caloric expenditure rates were estimated (specific to body weight) and assigned to each categoiy. Total calories expended on an aetivity were ealculated by multiplying the activity-specific expenditure rates by the amount of time spent in the activity. For this first measure, 60 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. expenditures over the four activities were summed to obtain a single estimate of average daily energy expenditure in calories. For the second activity measure, reported occupation was classified by physical activity on the job as: sedentaiy, active, very active, or unclassifiable. North American occupations were classified using the scheme of Garabrant; occupations in China were classified by the authors. The analysis showed an elevated colon cancer risk among men employed in sedentary occupations. For both continents and both sexes, an increased risk of both colon and rectal cancer was demonstrated with increasing time spent sitting. For physical activity, a comparison of sedentary subjects (< 5 hr/day moderate activity and < 1 hr/day vigorous activity) to active subjects (> 5 hr/day moderate activity and > 1 hr/day vigorous activity), showed the association between colorectal cancer risk and saturated fat was stronger among sedentaiy subjects. Sedentary Chinese Americans appeared to have an increased risk (more than four-fold) from the lowest to the highest categoiy of saturated fat intake. Among North American migrants, an increasing risk was shown with increasing years of residence in North America. The results suggest an increased colorectal cancer risk with duration of exposure to a sedentary life-style and a diet rich in saturated fat. The researchers state that early colorectal cancer symptoms may have influenced the activity levels of the participants during the year before diagnosis. This bias is consistent with the lack of specific association of colorectal cancer risk with reported activity among Chinese Americans.*^ In 1991, Lee et al., studied 17,148 males from the Harvard Alumni Health Study, an on-going cohort study of the predictors of chronic disease.95 In this prospective study 61 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. they investigated the effect of physical activity on the risk of developing colon or rectal cancer. After 23 years of follow-up, the cohort had 225 cases of colon cancer and 44 cases of rectal cancer. Physical activity data were self-assessed via a mailed questionnaire which asked alumni about: the number of flights of stairs climbed, city blocks walked, sports played in the past week or year, and time spent in active sports play. An index of physical activity expenditure per week was estimated by summing the kilocalories per week fi*om these activities. Alumni were categorized into the following activity levels: inactive (<1000 kilocalories/wk), moderate active (1000-2500 kilocalories/wk), highly active (>2500 kilocalories/wk). Physical activity was assessed in either 1962 or 1966 (1962/1966) and again in 1977. The researchers observed that increased activity was not associated with an increased risk of colon cancer when either assessment was used alone. However, they noted that subjects who were moderately active at both assessments, 1962/1966 and 1977, had a risk ratio for colon cancer of 0.52 (90%C.I. = 0.28 — 0.94). These results suggested that consistent high levels of activity are needed to protect against colon cancer or the double assessment of physical activity increased the precision of the physical activity measurement. No evidence showed that increased physical activity was protective against rectal cancer.^^ In 1995, Giovannucci et al. examined whether physical inactivity and obesity increased risk for colon cancer and adenomas, the precursors of cancer.^* They also examined abdominal distribution of obesity as an independent risk factor for these events. Study subjects were from The National Professionals Follow-up Study, a prospective cohort study of 47,723 U.S. male health professionals, 40 to 75 years of age. Data were 62 Reproduced with permission ofth e copyright owner. Further reproduction prohibited without permission. obtained by mailed questionnaire. In the questionnaire, participants reported average time per week spent doing specific recreational or leisure-time activities, such as walking, jogging, running, bicycling, lap swimming, tennis, squash, racquetball, and calisthenics or rowing. Subjects also reported the number of flights of stairs climbed daily and usual walking pace. The time spent at each activity per week was multiplied by its typical energy expenditure requirements expressed in metabolic equivalents (METs). For the data analysis, physical activity was divided into quintiles ( 0.9, 4.8, 11.3, 22.6, and 46.8). The results support an inverse association between physical activity and risk for colon cancer. Leisure-time physical activity was inversely associated with risk for colon cancer (high compared with low quintiles), with a relative risk, 0.53 (90%C.l. = 0.32 - 0.88; P for trend = 0.03). Body mass index was independently associated with risk for colon cancer. An association was also seen between obesity and physical inactivity and adenomas of 1 cm or more. Height, obesity, and abdominal adiposity were associated with an elevated risk. The investigators suggest that their results were informative on the low range of physical activity, as these men were employed in professions which require lower physical activity or they may be retired. In addition, the association between physical inactivity and large adenomas may reflect some influence of this variable at later stages of disease."^ I Longnecker et al., examined the association between occupational and vigorous leisure-time physical activity and risk of cancer of the right colon and rectum using data from a case-control study conducted in New England fi-om 1986 to 1988.^^ Subjects consisted of 163 cases with cancer of the right colon, 242 cases with cancer of the 63 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. rectum, and 703 community controls. Three measures of physical activity were assessed by an in-person interview and self-coding. In the first measure, occupational physical activity was ascertained for 5 years ago, 20 years ago, and lifetime occupation. Occupational activity was coded by job title, based on the U.S. Department of Labor tables, into the categories: sedentary, light work, moderate work, heavy work, and very heavy work. In a seeond occupational activity measure, subjects were asked to categorize their occupation as involving: sedentary activity, light work, or more than light work. In the third activity measure, leisure-time activities were assessed by the amount of time spent per week in the past 5 years doing six spécifié vigorous activities; jogging and running, bicycling, swimming laps, tennis, box court games, and ealisthenics or rowing. Subjects were categorized into four groups (0, <%, 1, >2 hours per week) contingent on how much time they spent at vigorous leisure-time activities. In the results, vigorous leisure-time physical activity showed an assoeiation with decreased risk of cancer of the right colon, comparing men exercising > or = 2 hours per week with those who did not exercise, (0R= 0.60; 95%C.I. = 0.35 - 1.00). Self-reported occupational activity for heavy work was less strongly related to risk of right colon cancer (OR= 0.70; 95%C.I. = 0.32 - 1.51). Occupational activity coded according to job title showed no relation to risk of right colon cancer. Overall, an association was not seen between physical activity and decreased risk of rectal cancer. The researchers state that their findings may be affected by the potential for recall bias and non-response bias, as well as error in measurement of physical activity.96 64 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In 1996, Thune et al. examined the association between self-reported occupational and recreational physical activity and the risk of colorectal cancer.^^ Subjects were from a population-based cohort study in Norway. Among 81,516 subjects, a total of 236 colon and 58 rectal cancers were observed among males, while 99 colon cancers and 58 rectal cancers were observed in females. Physical activity during recreational and occupational hours was assessed via a mailed questionnaire. Recreational activity hours were graded from 1 to 4, according to the following usual levels of physical activity: Rl= reading, watching TV or other sedentary activity, R2 = walking, bicycling or physical activity for at least four hours a week, R3 = exercise to keep fit, participation in recreational activities for at least four hours per week, and R4 = regular hard training, several times per week. Occupational activity hours were categorized into four categories: G1 = mostly sedentary, 02 = work with much walking, 03 = work with much lifting and walking, and 04 = heavy manual work. Recreational physical activity at the R3 level (> four hours recreational activity) compared to the R1 level (sedentary) was associated with decreased risk of colon cancer among females (RR = 0.62; 95% Cl 0.40- 0.97). A reduced risk of colon cancer for the proximal colon was also shown for females who were recreationally active (R2-4) compared to those who were sedentary (Rl) (RR = 0.51; 95% Cl 0.28-0.93). A narrow range of self-reported occupational activity among females may explain why this effect was not observed for occupational physical activity alone. An inverse dose-response effect was shown with total physical activity, occupational (O) and recreational (R) combined, as increasing total activity significantly reduced colon cancer risk (P for trend = 0.04). A similar inverse dose-response effect 65 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. between total physical activity and colon cancer risk was observed among males 45 years or older at entry to the study, (P for trend = 0.04), as well as a borderline significant decrease in colon cancer risk for occupational physical activity when compared to the sedentary group (RR = 0.74; 95% Cl 0.53-1.04). Males also experienced a stronger preventive effect for physical activity in the proximal as compared to distal colon. Overall, no association between physical activity and rectal cancer was observed. The study had some limitations vdth regard to the brief physical activity questionnaire, with four choices only for both recreational and occupational activity. Ability to detect an effect of occupational activity on colon cancer risk among females may have been limited by the large proportion of housewives in the cohort. In addition, statistical power among male subjects was limited, as males had a young age at entry and the number of colon cancer cases among young males was relatively small. This may have hampered the ability to find an overall protective effect of total physical activity on colon cancer in males. 97 In 1997, Martinez et al., conducted a prospective study to examine whether leisure time physical activity, body mass index, or body fat distribution could significantly influence the risk of colon cancer in women.9* The 67,802 study subjects were ascertained from the Nurses' Health Study, which began in 1976, and reassessed participants every 2 years for updates on personal information, risk factors and major medical events. During 1986 to 1992, 212 cases of colon cancer were identified (97 distal, 88 proximal, and 27 unknown). Both recreational or leisure-time physical activity were assessed via a supplement to the 1986 questionnaire. Participants self-reported the 66 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. average time per week spent in each of the following activities: walking or hiking outdoors (including golf); jogging (<10 min./mile); running (>10 min./mile); bicycling (including use of a stationary machine); lap swimming; playing tennis; playing squash or racquetball; and calisthenics, aerobics, aerobic dance, or use of a rowing machine. Women also reported the number of flights of stairs climbed daily, as well as usual walking pace. The time spent at each activity per week was multiplied by its typical energy expenditure, expressed in terms of metabolic equivalents (METs), and added together to yield a MET-hours-per-week score. For the data analysis, physical activity was divided into quintiles ( <2, 2-4, 5-10, 11-21, and >21). In the multivariate analysis, leisure-time physical activity was inversely related to risk of colon cancer. Highly active women (>21 MET-hours per week) compared to inactive women (<2 MET-hours per week), had a relative risk of colon cancer of 0.54 (95% Cl 0.33-0.90; P for trend = .03). The inverse association was more evident for cancer of the distal colon. Women in the highest activity category (>21 MET-hours per week) were 70% less likely to develop cancer in the distal colon (RR = 0.31; 95% Cl 0.12-0.77; P for trend = .01), than women in the lowest active category (<2 MET-hours per week). The study also showed a significant inverse association between leisure-time physical activity and incidence of colon cancer in women, consistent with what has been found in men. 98 In 1997 and 1999, Slattery et al. conducted two population based case control studies on subjects from 8 counties in Utah, the Northern California Kaiser Permanente Medical Care Program, and the Twin Cities metropolitan area in Minnesota.99, 100 xhe 1997 study was conducted to determine how physical inactivity interacts with other 67 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. components of energy balance, such as energy intake and body mass, in determining colon cancer nsk.^^O % e second study, done in 1999, was to determine lifestyle patterns and their association with colon cancer. For Slatteiy’s 1997 study, 1,993 cases and 2,410 age and sex-matched controls were identified. Recent and lifetime physical activity was assessed via an in-person interview regarding the intensity of activities performed at home, leisure, and at work. Body mass index (BMI) was calculated using height measured at the time of interview and reported weight for the referent year. An extensive diet questionnaire was also used to estimate energy intake. The total amount of time spent in physical activities was converted to a measurement of caloric expenditure. Lifetime activity variables were created for three time periods: the referent year, 10 years ago, and 20 years ago. Participants were ranked as follows for each time period: 1 - no vigorous activity, 2 - 1 to 250 kcal/week, 3 - 250 to 1000 kcal/week, and 4 for > 1000 kcal/week. The results demonstrated that lack of lifetime vigorous leisure-time activity was associated with increased risk of colon cancer (OR — 1.63 and 95% Cl = 1.26-2.12 and OR — 1.59 and 95% Cl = 1.21-2.10) for men and women respectively. No differences in risk were associated with physical activity by tumor site within the colon or by age at diagnosis. Subjects who were physically inactive, had high energy intakes, and had a large BMI showed the greatest risk of colon cancer (OR, 3.35 and 95% Cl, 2.09-5.35). However, high physical activity, high energy intake and large BMI resulted in a non-significant increase in colon cancer risk (OR, 1.28 and 95% Cl, 0.81-2.03). The pattern was consistent for both sexes, with some evidence that men may be at higher risk than older 68 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. women, as a result of unfavorable energy balance. These results were consistent with previous findings, which indicate that physical inactivity, high energy intake, and large body mass are associated with an increased risk of colon cancer. Moreover, energy balance seems to be associated with risk of colon cancer, which may suggest systemic metabolic influences on carcinogenesis.*®® In Slattery’s 1999 study, the authors used data from the same population-based case- control study to determine lifestyle patterns and their association with colon cancer. 99 Data were obtained from 1,993 cases and 2,410 age and sex-matched controls. Factor analyses were used to describe lifestyle patterns and group subjects. Nine lifestyle factors were used to assess men and women, which included: 1-"Western", 2-"moderation", 3- "calcium/low-fat dairy", 4-"meat and mutagens", 5-"nibblers, smoking, and coffee", 6- "alcohol", 7-"physical activity", 8-"medication and supplementation," and 9-“body size.” Overall, the lifestyle factor of 7 was most associated with colon cancer (OR = 0.42, 95% Cl = 0.32 - 0.55 and OR = 0.52, 95% Cl = 0.39 - 0.69, for both men and women, respectively). Additional lifestyle factors associated with colon cancer were: 8- “medication and supplementation”, 1-“Western”, 9-“body size”, and 3-“calcium/low-fat dairy.” Age- and tumor site-specific associations also varied for different lifestyles.99 1.6.4 Studies Covering Site-Specific Associations Several epidemiological studies have examined the role physical activity plays in relation to site of colon cancer.36,41, 80,86,88, 89,92,96-98,100-102 these studies, right sided cancers can be distinguished as those occurring in the cecum, ascending colon, and 69 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. hepatic flexure. Evidence irom some studies suggests that higher physical activity lowers the risk o f cancer in the right c o l o n . ^0, 86, 96, 97, 100 other studies have indicated that higher activity may lower the risk o f cancer in the lefl; colon.^^’ 88,89,92,98,101 One study has shown no differences in risk associated with physical activity by colon tumor site.l®2 For many studies, the association between colon cancer and physical activity has been stronger than that for rectal cancer. 78, 79,82, 84,90,92, 95, 96 xhe results often show little or no association for rectal cancer. An overview o f both occupational and leisure activity studies suggests that the relationship between high levels o f physical activity and reduced risk o f colon cancer is stronger for the left colon, and weaker or absent for the r e c t u m . 65 1.6.5 Studies Summary Overall, these studies support the hypothesis that physical inactivity is associated with an increased rate of colon cancer. On the other hand, physical activity showed no association with rectal cancer risk. In early physical activity studies (Table 1.) death from neoplasms was used as a measure of outcome. Physical activity exposure was classified using lifetime occupation or college athletic participation. Later physical activity studies (Table 2.) used death or diagnosis of colorectal cancers as a measure of outcome. For these studies, measures of physical activity exposure such as lifetime occupational activity, leisure-time physical activity, or total physical activity, were further categorized for analysis. 70 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. V2.4) was used as a nutrient database for foods. Information on the nutrient content of supplements was obtained from the Harvard School of Public Health. 2.2.1.1.4 Tissue Sample A fasting blood sample for serum lipids and other blood indicators was drawn on subjects in the morning, on the average 6 months after the sigmoidoscopy. Tumor blocks and pathology reports were also available for the cases. 2.2.1.2 Sigmoid II Study subjects were persons from either of two Southern California Kaiser Permanente Medical Centers: Bellflower or Sunset, who had a sigmoidoscopy during the period January 1, 1996 through August 25, 1998. Sigmoid II has the same study protocol as Sigmoid I in terms of : eligibility of subjects, excluded subjects, case and control selection, and matching criteria. Sigmoid II also has similar dietary and lifestyle questionnaire data available for analysis. The Sigmoid II study has 691 subjects who have been interviewed. During the accrual period, 532 potentially eligible cases and 540 potentially eligible controls were identified. Of these, 64 cases and 55 controls refused to participate, 66 cases and 67 controls refused interviews, 49 cases and 46 controls dropped out for other reasons, and they were unable to contact 7 cases and 14 controls. Interview data were obtained on the remaining 336 cases and 355 controls (63% of the eligible cases, and 66% of the eligible controls). 71 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. assessing activity over a long period of time is more significant. However, studies using activity at a point in time during adulthood showed similarly consistent associations compared to those using lifetime activity, which may indicate that both measures were highly correlated. Similar results were not seen for those studies utilizing participation in college athletics as a predictor of adult activity, as these studies showed no significant association. Historically, data have suggested that the association between physical activity and decreased colorectal cancer risk is stronger for men. However, this may be due to the smaller number of women in studies, inaccurate assessment of female occupational physical activity (possible underestimate), and small numbers of women in high-activity categories. Overall, associations did not appear to be gender-specific. A significant dose response relationship was apparent among several studies showing an inverse relationship between physical activity and colon cancer. This suggested that higher levels of physical activity are associated with a reduced risk of colon cancer. Some other studies suggested a dose response relationship or evidence of a linear trend. Studies examining site specific associations have been inconsistent. The current evidence suggests that the relationship between higher physical activity and lower risk of colon cancer is stronger for left colon. No association was seen for rectal cancer. There is still much to be learned about the effect of exercise on colon cancer. In addition, there is a need for studies that have the appropriate study subjects to allow for stratification by race, and examination of racial differences. The intensity, duration, and frequency of exercise that is beneficial also needs to be examined and clarified. As well as the correlation 72 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. between occupational and leisure-time time physical activity, and measures of impact. If physical activity reduces the risk of developing colon cancer, it should be effective in postponing mortality and enhancing longevity, in particular among those under-served minority groups who are more likely to have later stages of disease and higher mortality rates. Although the protective effect of physical activity may be small, the attributable risk of colon cancer associated with inactivity may be quite high given the prevalence of inactivity in society. 1.7 Biological Mechanisms Several biological mechanisms have been proposed by which increased physical activity can lead to a decreased risk of colon cancer.^A 103. These mechanisms are summarized below: 1.7.1 Decreased Gastrointestinal Transit Time Moderate physical activity has been shown to increase gut motility, which leads to decreased gastrointestinal transit time. 1 0 4 , 1 0 5 Decreased transit time shortens the contact time between fecal matter and the colonic mucosa. Theoretically, this may decrease colon cancer risk by reducing exposure time to carcinogens.^» ^ 3 , 7 6 , 1 0 3 , 1 0 6 Conversely, a sedentary lifestyle may lead to increased intestinal transit time; which may increase large-bowel cancer incidence by prolonging contact between colonic mucosa and fecal c a r c i n o g e n s . ^ 3 ,106 73 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.7.1.1 Vagal Innervation Moderate somatic activity, such as exercise, has been shown to increase the propulsion o f colonic contents, thereby decreasing gastrointestinal transit tim e.^® ^ Propulsive peristalsis is stimulated by the vagus nerve. In particular, increased short and long-term aerobic exercises o f varying intensity have been observed to increase vagal t o n e . * 0 3 The vagal innervation o f the colon may justify why studies have shown a greater protective effect o f physical activity for the right-sided colon. More specifically, only the right-sided colon, proximal to Caimon’s Point: a narrow area at the mid-third of the transverse colon, is irmervated parasympathetically by the vagal nerve. Therefore, gut motility in the right colon should be impacted more extensively by exercise. 103,107 Conversely, a sedentary lifestyle should have largest impact in the left colon, due to it’s storing function for fecal material. The smallest impact should be observed on the rectum, since it only intermittently filled with f e c e s . 106 However, other studies have questioned this relationship between gastrointestinal transit time and colon cancer.41,63 1.7.2 Prostaglandin Secretion A second possible biological mechanism is the effect o f prostaglandins on colon cell proliferation. Physical activity increases the F-series prostaglandins (PGF2 ) and decreases the prostaglandin PGE2.04, 65, 73, 1 0 3 The F-seiies prostaglandins (PGF2 ), have been shown to decrease the rate o f colonic cell division and increase gut motility. The prostaglandin PGE2 increases colonic cell proliferation, decreases gut 74 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. motility, and is released in greater amounts from colonic tum ors.^^> Strenuous aerobic exercise increases the levels o f PGF2 , and 6-keto PGFi . The relationship between physical activity and PGE2 is less clear; although light physical activity has led to a non-significant decline o f PGE2 73,103 Additional support for the effect o f prostaglandins comes from laboratory studies on rats and evidence in humans, where prostaglandin synthesis inhibitors, such as aspirin and nonsteroidal anti-inflammatoiy drugs, have been associated with a reduced risk o f colon cancer.^*’ 39,64 1.7.3 Immune Function Vigorous levels o f exercise influence some hnmune f i m c t i o n s .* ® ^ i n a study of the relationship between interleukin production and DMH (1,2-dimethylhydrazine) induced colon cancer performed on laboratory rats, interluekin-1 production was inversely correlated with the development o f metastasis. ^ 0 8 Ting suggests that exercise- induced increase o f interleukin-1 levels may be protective against colon c a n c e r . ^ ^ 3 Leukotienes, the lipooxygenase product o f the metabolism o f arachidonic acid, affects the production o f tumor necrosis factor by human monocytes. It has been postulated that exercise modifies the host immune response to cancer through leukotriene production. 75 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.7.4 Secretion of Gastro-entero-pancreatic Hormones Another possible biological mechanism is the secretion o f gastro-entero- pancreatic hormones, such as: motilin, vasoactive intestinal polypeptide (VIP) and pancreatic polypeptide (PP), following aerobic activity o f various intensities. Motilin and VIP influence the motility o f the large intestine, while PP affects the gallbladder. These hormones may reduce colon cancer risk by decreasing gastrointestinal transit time and bile acid excretion. 1.7.5 Insulin Level and Glucose Tolerance Insulin is a growth factor for colonic mucosal cells. It has been suggested that elevated insulin levels account for an increased risk o f colon cancer.^h 65, 109 Physical inactivity, diets high in refined sugar and fat, and abdominal obesity, are all independent determinants o f hyperinsulinemia. 1 ^ 9 Previous studies have suggested that physical activity may decrease colon cancer risk through its impact on insulin levels.^h > 10 1.8 M ethodology 1.8.1 Physical Activity 1.8.1.1 Physical Activity Assessment In recent decades, studies have shown that physical activity is consistently associated with a reduced risk o f colon cancer.^’ ^6, 36, 94, 96 Previous epidemiologic studies have 76 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. assessed physical activity by measuring two aspects o f activity: occupational and/or leisure-time activities. These two aspects o f activity, however, may reflect different patterns o f energy expenditure. Historically, occupational activity was assumed to provide a more accurate assessment o f lifetime physical activity, provided that the activity demanded by the employment remained constant from year to year.^4, 65, ill However, when job skills entail little physical activity, leisure-time activity may reflect a better measurement o f physical activity.^^ The pattern o f leisure-time activity is difficult to assess, as it is much more labile; changing from week to week, season to season, and year to year.^3’ 64,111 Studies that take into account occupational physical activity may lack measurement of leisure-time activity. Assessment o f occupational activity alone may cause underestimation o f total activity, in particular if leisure-time activity is the predominant activity for the subject.65, 94, 112 Since there is little correlation between occupational and leisure-time activity, studies that use only one measure of physical activity should be interpreted cautiously.^^’ When a less than accurate measure o f physical activity is used, the observed benefit from physical activity is smaller than its probable true benefit.64 1.8.1.2 Limitations of Assessment Epidemiologic studies o f physical activity and cancer have had difficulty in precisely assessing physical a c t i v i t y . 1 ^ 3 Although it is ideal to quantify the intensity, duration, and frequency o f the occupational and leisure-time physical activity for a specific time frame. 77 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. it is often not feasible J * 4 Moreover, even if a precise measure were attainable, it may not reflect the individual’s lifetime physical activity pattern. An optimal solution is to make multiple assessments over time, which would be both time-consuming and costly.) 1 3 Researchers have attempted to assess physical activity using: occupation, leisure-time and total activity, participation in college athletics, and fitness levels, all of which have inherent limitations, which are discussed below.^3,1 1 3 1.8.1.2.1 Occupational Assessment Studies assessing occupational activity rely on coded job titles or self report information, which is ranked by level o f physical activity.) )3,115 classification, used for many years because o f minimal cost and ease o f use in large populations, assumes that all persons in a particular job category expend similar levels o f energy.) ) ) Limitations of job classification include: possible selection bias, job intensity misclassification, secular changes in job requirements, seasonal changes in job requirements, within-job classification variability, and exclusion o f leisure-time or non-occupational physical activity. The exclusion o f leisure-time physical activity was not an issue in earlier epidemiologic studies, where work weeks were long and leisure-time activity was not as vigorous. In recent times, there has been an interest in measuring leisure-time activity. This is because o f the decrease in occupational physical activity in our technological society and the increase o f leisure-time physical activity. 65,111 78 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.8.1.2.2 College Athletic Participation Studies assessing participation o f college athletics as a measure o f physical activity ascertain college records to assess activity level during college and after. ^ College athletic participation may have been measured too long ago, and may not reflect lifetime (post-college) activity levels that may be relevant to the etiology o f colon cancer. In addition, former athletic participation may not be representative o f long-term physical activity, following the college experience. 1.8.1.2.3 Leisnre-time and Total Activity Assessment Leisure-time activity has been used as a separate index o f physical activity or it can be combined with a measure o f occupational a c t i v i t y . 113 Leisure-time activity is commonly assessed by utilizing a questionnaire regarding structured and unstructured exercise. Generally, a physical activity index will be created that quantifies the daily total amount o f physical activity for a subject. Even though many studies may give a reasonable measure o f physical activity, misclassification may occur when subjects have difficulty recalling exercise patterns. 1.8.1.2.4 Fitness Level Assessment Assessment o f physical fimess level is considered to reflect physical activity. Assessment o f physical fitness is relatively more precise. It does, however, have a strong genetic component.65 Physical fitness can be assessed by various methods such as estimation o f cardiorespiratory fitness by exercise testing or resting heart rate. 1 1 3 7 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Although cardiorespiratory fitness is considered one o f the more valid methods of measuring fitness, the validity o f resting heart rate is not as apparent. When fitness level is assessed, it is assumed that a person with a high fitness level has achieved this through an active lifestyle. 1.8.2 Cancer 1.8.2.1 Incident versus Prevalent Cases In studies on exercise and cancer, ascertainment o f incident cases is essential to study the etiologic relationship between exposure and o u t c o m e . * ^ 3, 1 1 5 Studying prevalent cases is problematic because prevalent disease is in part a function o f survival. Including these cases in the analysis introduces factors that may determine the prognosis o f the cancer cases, but be unrelated to etiology. 1.8.2.2 Case-Control versus Cohort Studies Most o f the studies examining the relationship between physical activity and colon cancer have used the case-control study design. An inherent limitation o f this type of study design is the potential for bias in the recall o f physical activity.**^» **5 Although this is not a limitation with the cohort study design, the cohort design is expensive, as well as requiring lengthy follow-up to ascertain an adequate number o f cancer cases for study power. 80 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.8.2.3 Sample Size Studies that examined site-specific cancer risk and physical activity have utilized smaller sample size s.' M ore recently, an adequate number of cases with subsite specific information has been available and allowed for research focusing on cancer subsite. In the future, there will be a need for more site-specific cases, to observe the effect of physical activity through biological mechanisms which could be specific to certain colon sites. 1.8.3 Temporal Relationships Ideally, physical activity exposure is assessed during the etiologic window of time when cancer risk is influenced. ' However, this time period of exposure that affects cancer risk is not known. Nonetheless, assessment of activity level before the subject has developed cancer or lifetime activity would be a more meaningful measurement than current activity. In addition, measurement of activity near or after the time of diagnosis is invalid, because pre-diagnostic symptoms and the diagnosis itself may cause the subject to change their behavior. 1.8.4 Confonnding Confounders pose potential limitations that must be addressed when examining the relationship between physical activity and colon cancer. ^ 5 , 76, 113 Individuals who are physically active may tend to practice positive health behaviors that are related to colon cancer risk, such as: a low fat diet.^^» "3 Potential confounders to consider include: 81 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 alcohol, diet, body mass index (wt/ht ) BMI, use of non-steroidal anti-inflammatory agents, and caloric intake ^5, 73, 113 Overall, the general consensus of the literature is that magnitude of risk associated with physical activity is at least as great as that which is reported.^'*' 65,73,113 1.9 Heterogeneity by Race & Racial Differences Current incidence and mortality rates for colon and rectum cancer still vary considerably among ethnic g r o u p s . 1^6 Overall, African Americans have the highest incidence and mortality rates of colon and rectum cancer, as they are 70% more likely to develop colon and rectum cancer than Hispanics, 30% more likely than Asian/Pacific Islanders, and nearly three times more likely than American Indians. They are also at least 33% more likely to die from colorectal cancer than whites, and more than twice as likely as Hispanics, American Indians, and Asian/Pacific Islanders. ^^6 in addition, African Americans are significantly more likely to have late-stage colorectal cancer than Whites, a similar trend in late-stage diagnosis has been seen among individuals of low socioeconomic status (SES) compared to those of higher SES.^^^ Despite promising downward trends, colorectal cancer incidence and mortality remain unequally distributed among ethnic groups. ^^6 Jq addition, descriptive studies that focus on racial differences are limited. ^6 There is a need for more studies that examine ethnic minorities, as well as those who are medically under-served. Further understanding of the role of physical 82 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. activity in colorectal cancer etiology can lead to recommendations for prevention and decreased rates of severe disease, through utilization of a modifiable risk factor. 1.10 Discussion There are many important unanswered questions regarding the effect of physical activity on colon cancer. These include: what amount, intensity, duration, and type of activity is most protective; are there gender and racial differences with respect to physical activity; does increasing or decreasing activity over a lifetime change effect; when during the carcinogenic process does exposure to activity have the most effect and at what levels? Despite the variability in measurement of physical activity, the evidence for the protective effect of physical activity against colon cancer is strong. Future studies should work toward resolving some of the major limitations; for example misclassification of exposure when categorizing physical activity levels. Further research should focus on populations at increased risk for colon cancer, such as minority populations. With the prevalence of inactivity in industrialized Western societies broadening, the attributable risk associated with inactivity may be high. Increasing physical activity in populations at risk for colon cancer could have not only significant implications for colon cancer prevention, but broader public health impact as well. 83 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2. Analysis of Data 2.1 Background During the past decade, epidemiological evidence has generally supported an inverse association between physical activity and colorectal cancer7> 24, 95, 102, 118, 119 Most epidemiologic studies have measured physical activity either by using occupational activity or leisure-time activity.25-37, 83, 90-94 Several studies have combined both measures o f activity into a single measurement, but the categories have been broad, where time frame o f activity is not well defined.22, 90, 9 1 The objective o f this study is to investigate the relationship between physical activity and colorectal adenomas, as well as estimate measures o f impact. In this study, extensive data on lifestyle factors have been collected and controlled in the analyses o f several measures o f physical activity, among men and women who underwent a screening sigmoidoscopy in Los Angeles. I will also investigate whether measures of effect and impact differ by race. To my knowledge, this has not been reported in previous studies. 2.2 Methods 2.2.1 Subject Recruitment and Data Collection Subjects were ascertained from two case-control studies of nutritional and other risk factors for adenomatous polyps of the large bowel conducted at the University of Southern California, in Los Angeles, under the direction of Dr. Robert W. Haile. Data 84 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. were obtained from the merge of these two case-control studies. The two studies are: The Sigmoidoscopy Based Case-Controi Study of Polyps I (Sigmoid I) and The Sigmoidoscopy Based Case-Controi Study of Polyps II (Sigmoid II). Subjects in both studies were asymptomatic persons who attended a sigmoidoscopy screening clinic at one of two Kaiser Permanente-Southem California clinical centers. Cases are persons with a first-time diagnosis of at least one adenomatous polyp confirmed by biopsy. Controls are subjects found to have no adenomatous polyp at sigmoidoscopy and with no history of large bowel neoplasia. Data were obtained from a food frequency questionnaire, in-person interview, fasting blood sample, and pathology material (including tumor blocks). Occupational and physical activity data are available in both datasets, as well as data on potential confounders. 2.2.1.1 Sigmoid I Study subjects were persons from either of two Southern California Kaiser Permanente Medical Centers: Bellflower or Sunset, who had a sigmoidoscopy in January 1, 1991 through August 25, 1993. Eligible men and women were fluent in English, 50 - 74 years old, and residents of Los Angeles County. Subjects were ineligible if they had a history of invasive cancer or polyps, inflammatory bowel disease, familial polyposis syndrome, severe gastrointestinal symptoms, previous bowel surgery, or physical or mental disability that would preclude an interview. Cases were subjects diagnosed for the first time with one or more histologically confirmed adenomatous polyps. Controls were subjects found to have no adenomatous polyp at sigmoidoscopy and were individually 85 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. matched to cases (1 control per case) by gender, age (by 5-year age category), calendar date of sigmoidoscopy (by 3-month category), and Kaiser center. During the accrual period, 628 potentially eligible case and 689 potentially eligible controls were identified. Of these, 70 cases and 94 controls refused interviews, and we were unable to contact 29 cases and 32 controls. Interview data were obtained on the remaining 529 cases and 563 controls. The response rate (number interviewed/number eligible) was 84% among the cases and 82% among the controls. When a control subject originally matched to a case could not be interviewed, a replacement was identified. Controls were individually matched to cases by gender, age (by 5-year age category), calendar date of sigmoidoscopy (by 3-month category), and Kaiser center. Unmatched controls occurred when the case for whom the control was matched was found not to speak English (n = 41) or was found to have invasive bowel cancer at the follow-up colonoscopy (n = 16). Unmatched cases occurred when an eligible control subject was unable to be interviewed (n = 17). 2.2.1.1.1 Sigmoidoscopy The indications for sigmoidoscopy for the interviewed subjects were: routine for 45% of cases and 44% of controls; referred due to specific minor symptoms for 16% of cases and 13% of controls; and were not given for 39% of eases and 43% of controls. The average depth of the flexible sigmoidoscope examination was 55 + 11 cm (SD) for cases and 59 + 5 cm (SD) for controls. Fifteen cases had carcinoma in situ in addition to 86 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. adenomas and were excluded. The size and number of the polyps was recorded on a study form by the sigmoidoscopist at the time of sigmoidoscopy. 2.2.1.1.2 In-Person Interview Study participants provided data on smoking, therapeutic drug use, physical activity, height, weight, family history of cancer, and other factors during a 45 minute in-person interview (see Appendix A.I.). The interview was administered in the subjects’ homes, on the average 5 months after the sigmoidoscopy. Study subjects who had adenomas were sent for a follow-up colonoscopy for adenoma removal, no additional treatment was administered. Exposure data referred to the time period up to the sigmoidoscopy. Interviewers reported remaining unaware of the case and control status for participants for 70% of the cases and 87% of the controls. 2.2.1.1.3 Food Frequency Questionnaire A 126-item semi-quantitative food Jfrequency questionnaire regarding diet in the year before the sigmoidoscopy was completed by 519 cases and 556 controls (see Appendix A.2.).120 Participants received the questionnaire via mail and completed it prior to the interview. During the in-home interview, the food frequency questionnaire was reviewed and collected by the interviewer. To compute nutrient intake, standard methods were u s e d . 1 2 1 Specific foods corresponding to items on the questionnaire were selected based on their relative fi-equency of consumption among participants in the 1988-1989 Nationwide Food Consumption Survey (U.S. Department of Agriculture Nutrition 87 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Monitoring Division, 378, 1991), southwest region. The Nutrient Data System (NDB V2.4) was used as a nutrient database for foods. Information on the nutrient content of supplements was obtained from the Harvard School of Public Health. 2.2.1.1.4 Tissue Sample A fasting blood sample for serum lipids and other blood indicators was drawn on subjects in the morning, on the average 6 months after the sigmoidoscopy. Tumor blocks and pathology reports were also available for the cases. 2.2.1.2 Sigmoid II Study subjects were persons from either of two Southern California Kaiser Permanente Medical Centers: Bellflower or Sunset, who had a sigmoidoscopy during the period January 1,1996 through August 25, 1998. Sigmoid II has the same study protocol as Sigmoid I in terms of : eligibility of subjects, excluded subjects, case and control selection, and matching criteria. Sigmoid II also has similar dietary and lifestyle questionnaire data available for analysis. The Sigmoid II study has 691 subjects who have been interviewed. During the accrual period, 532 potentially eligible cases and 540 potentially eligible controls were identified. Of these, 64 cases and 55 controls refused to participate, 66 cases and 67 controls refused interviews, 49 cases and 46 controls dropped out for other reasons, and they were unable to contact 7 cases and 14 controls. Interview data were obtained on the remaining 336 88 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. cases and 355 controls (63% of the eligible cases, and 66% of the eligible controls). Similar to Sigmoid I, when a control subject originally matched to a case could not be interviewed, a replacement was identified. 2.3 Data Coding and Analysis 23.1 Measurement of Physical Activity Measures of physical activity exposure were calculated using information from the In- Person Interview questionnaire regarding total daily activity, occupational activity, and recreational activity (see Appendix A.I.). A metabolic equivalent value (MET) was assigned for each subject’s occupational and recreational physical activity measure within the Sigmoid I and Sigmoid II datasets, utilizing the Compendium o f Physical Activities (see Appendix A.3.). A MET value is the ratio of: the metabolic rate for the specific activity divided by the resting metabolic rate (RMR) (where 1 MET=3.5 mL O^/kg body weight/min). ^ 2 2 , 1 2 3 The measures of physical activity exposure were used in conjunction with the assigned MET values for individual activities, for the calculation of the four measures of physical activity. 23.2 Compendium of Physical Activities A MET value was assigned to each subject’s physical activity measure using the Compendium o f Physical Activities (Appendix A.3.). The Compendium o f Physical Activities is a classification system which allows physical activities to be grouped by purpose, while providing flexibility in determining energy costs. 1 2 2 , 1 2 3 The 89 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Compendium has been used in various studies and was developed to facilitate the coding of physical activities, while promoting comparability of coding across studies 1 2 4 - 1 2 9 The coding scheme used in the Compendium is useful for quantifying physical activity data collected by diary, recall or direct observation methods. Based on previously published data, the Compendium provides a coding system which groups activities by purpose and intensity expressed as MET’s, allowing the energy cost of physical activities to be classified. 1 ^ 2 , 1 2 3 Energy costs represented in the Compendium were established by a review of published and unpublished data. Coded data can then be utilized to describe activity patterns of populations, to study determinants of physical activity, or to investigate the relationship between physical activity and disease. 1 2 2 , 1 2 3 The Compendium has been widely utilized by various physical activity specialists to classify physical activities by rate of energy expenditure in terms of MET intensities. Studies which have utilized the Compendium coding scheme include: the third National Health and Nutrition Examination Survey, the 1991 National Health Interview Survey, the Paffenbarger College Alumni Study, the Miimesota Leisure Time Physical Activity Questiormaire (MN-LTPA), and the MONICA Optional Survey of Physical Activity (MOSPA). 1 3 0 - 1 3 4 In addition, the Compendium coding scheme and MET intensities for activities have been referenced in various publications. 1 3 5 - 1 3 8 The coding scheme in the Compendium utilizes a five digit number to classify an activity by purpose and type of activity (ie., sports, occupation, self-care). The intensity of the coded activity is then represented as the ratio of work metabolic rate to resting metabolic rate (METs). This allows for further estimation of energy expenditure in 90 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. kilocalories or kilocalories per kilogram of body weight for various physical activities. It is suggested that utilization of a common source, such as this coding system would enhance the comparabilily of results across studies using self-reports of physical activity. 122,123 2.3.3 The Physical Activity Variables Overall, five measures of physical activity were included in this analysis. Four of these measures of physical activity, recorded in MET hours per week, were as follows: average hours of daily physical activity, average weekly hours of recreational activity, average weekly hours of occupational activity, and average weekly hours of combined occupational and recreational physical activity. In addition, frequency of vigorous weekly recreational activity was also recorded as a dichotomous variable; as less than three times per week, and greater than or equal to 3 times per week. 2.3.3.1 Frequency of Vigorous Recreational Activity To assess frequency of vigorous recreational activity, subjects were asked if they engaged in vigorous activity at least 3 times per week. “Vigorous activity” was defined as an activity that was vigorous enough to work up a sweat or get out of breath. Subjects who did engage in vigorous activity reported a detailed participation in six listed vigorous activities. This detailed description was used to calculate total weekly vigorous recreational activity. These included: walking briskly, running/jogging, swimming, bicycling, aerobic dance, and racquet sports. In addition, subjects wrote in any other unlisted vigorous activities. Some unlisted activities included square dancing, yoga, and 91 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. stationary bike. Each vigorous activity was assigned a MET value utilizing the Compendium o f Physical Activities. Subjects who participated in vigorous activities with MET values of at least four, three times per week were categorized as regularly vigorously active. Subjects who did not participate in vigorous activities, or participated in activities with MET values less than four, or participated in vigorous activities less than three times per week were considered to be not vigorously active. 2.3.3.2 Weekly Vigorous Recreational Activity Vigorous recreational activity was ranked by both duration and intensity of activity. The weekly vigorous recreational activity for subjects was calculated utilizing MET hours per week as the combined sum of the products of; total hours per week for each vigorous activity times the corresponding MET value for that activity. An individual vigorous recreational activity (VRT) for a subject in hours per week was calculated as follows: VRT = MET X (Months/Year) X (Times/Week) X (Hours) For example, a subject who had walked briskly for a total of 3 months out of the year, 5 times per week, for one hour periods was assigned a code of 11720 and MET = 4.0. This subject would have the 60 MET hours/week contributed to their weekly VRT for that particular vigorous recreational activity: VRT = 4.0 X (3 Mon/Yr.) X ( 5 Times/Wk.) X (1 Mrs.) = 60 MET hours/week. 92 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Subjects who reported they did not engage in vigorous physical activity at least three times per week were assigned a value of zero. To distinguish the intensity of vigorous recreational activity, subjects were categorized based on the MET value of vigorous activity and amount of participation per week. Subjects who participated in vigorous recreational activities with MET values of six or more, at least one hour per week were assigned the highest level of intensity. Subjects who participated in vigorous recreational activities with MET values of four or more, at least three times per week, but who engaged in activity less than the highest level of intensity were assigned to the moderate level of intensity. Those subjects who did not participate in vigorous recreational activities, or participated less than three times per week, or participated in recreational activities with MET values less than four were assigned to the lowest level of intensity (referent group). 2.3.33 Weekly Occupational Activity An occupational activity variable was created by assigning a MET hour value to the subject’s occupation, using the Compendium o f Physical Activities tables. 1 23 The corresponding occupational MET hour variable was coded for all existing occupations that matched the Compendium. For example, a respiratory therapist was assigned a code of 11610 and MET = 3.0, corresponding to an occupation which includes light/moderate workload and patient care. In some cases, occupations had several codes indicating traditional job duties performing during the work day. For example; a police officer was assigned the average of codes 11525-11528 and MET =3.45, corresponding to the 93 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. average of five occupation codes which specify daily police occupational activity. Any non-coded occupation (i.e., job description not listed in the Compendium) was indicated as a missing value. At the completion of coding records were sorted by both the occupational field and the occupational MET variable, the two printouts were checked to confirm accuracy of coding. A measure of average weekly occupational activity was estimated assuming a 40 hour work week. Thirty eight subjects with a non-coded occupation, which resulted in a missing occupational MET value, were excluded from the study. 2.33.4 Weekly Combined Occupational and Recreational Activity An average MET hour per week score was estimated for combined occupational and recreational activity. Average MET hours of weekly recreational activity and weekly occupational activity were combined for each subject, with estimates of occupational activity assuming a 40 hour work week. 23.3.5 Daily Physical Activitv Data for daily physical activity were also coded utilizing the Compendium o f Physical Activities. Average MET hours of daily activity were determined from questions that established the proportion of the day spent: sleeping or reclining, doing vigorous activity, doing light or moderate activity, and doing sitting activity in the year before the sigmoidoscopy. MET values were assigned as follows: 0.9 for sleeping and reclining, 1.0 for sitting, 2.5 for light activity (e.g. cooking, laundiy), 4.5 for moderate activity (e.g. 94 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. golf, gardening, painting), and 6.5 for vigorous activity (e.g. canying heavy objects), as used in previous research. ^ The number of hours spent in each activity category was multiplied by the MET value assigned to that category to obtain a MET-hour score in each category for a subject. To calculate a total daily MET score, all MET-hour scores were summed to give a total MET-hour score for the day. The total daily MET score (TDM) for a subject in MET hours per day was calculated as follows: TDM = 0.9 X (Hours/Day) + 1.0 X (Hours/Day) + 2.5 X (Hours/Day) + 4.5 X (Hours/Day) + 6.5 X (Hours/Day) For example, a subject who on the average in a 24 hour time period: slept 6 hours, sat for 5 hours, performed 3 hours of light activity, 2 hours of moderate activity, and 1 hour of vigorous activity, would have the 33.4 MET hours/day for their total daily MET score: TDM = 0.9 X (6 Hrs./Day) + 1.0 X (5 HrsVDay) + 2.5 X (3 Hrs./Day) + 4.5 X (2 Kh-s./Day) + 6.5 X (1 Hrs./Day) = 33.4 MET hours/day Since the questionnaire assessed weekdays and weekends separately, the average MET-hour score per day was determined from a weighted average of the weekday and weekend score (eg., 5/7 X Weekday + 2/7 X Weekend). 2.3.3 6 Merged Data for Analysis For subject data obtained from the merge of the two existing case-control studies, a total of 884 cases and 832 controls had both physical activity information available, as 95 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. well as case/control status. A total of 1,716 subjects were available for use in the unconditional analysis. A conditional logistic regression analysis was performed and restricted to those matched pairs with complete physical activity data. For the matched pairs, a total of 758 pairs had complete physical activity data. Unmatched cases occurred when an eligible control subject had not been interviewed. Unmatched controls occurred when the matching case was not able to speak English, or found to have invasive large- bowel cancer. Datasets from the two existing case-control studies were merged, which included measures developed for physical activity exposure for; total daily caloric expenditure, occupational activity and recreational activity. Various analyses were conducted on the association between physical activity and adenomatous polyps for the combined datasets. Associations were examined for total daily activity, weekly recreational activity, frequency of vigorous recreational activity, weekly occupational activity, and weekly combined occupational and recreational activity. 2.3.4 Data Analysis Descriptive statistics were performed in SAS, version 8.0. Univariate analyses and subgroup analyses were also conducted in SAS to investigate the relationship between physical activity and the prevalence of adenomatous polyps for recent physical activity. Odds ratios, 95% confidence intervals, and tests of trend are presented. Multivariate analyses, with additional trend values were performed using conditional logistic regression models in SAS, version 8.0. The results of the multivariate analysis were used 96 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to calculate approximate odds ratios while controlling for potential confoxmders, such as: smoking status, body mass index, educational status, alcohol, and medication use. Logistic regression done in SAS was also used to assess interactions. Measures of impact were estimated for corresponding significant results of the univariate and multivariate analyses and calculated in EXCEL, version 7.0. The SAS program was also used to examine measures of correlation. The data have also been stratified by race, controlling for potential confounders, to examine any racial differences. Measures of correlation, to determine whether there is a linear relationship between recreational and occupational physical activity, have been assessed. Measures of impact have also been investigated for any significant results. Both measures of correlation and impact have been examined for any differences by race. It is important to look at this relationship in various population subgroups who may be at higher risk for colorectal cancer. a meaningful question to ask is: are there racial differences with respect to the effect of physical activity? it is of interest to examine population subgroups who are at increased risk for colon cancer, and examine the attributable risk associated with physical inactivity. Increasing physical activity in populations at risk for colon cancer could have significant implications for future cancer prevention. Both unconditional and conditional logistic regression were used to estimate odds ratios. Covariates included in the multivariate model were: recent smoking status (three categories: non-smoker, current smoker, ex-smoker), body mass index (two categories: <27 kg m"^, >27 kg m'^), educational status (four categories: less than high school, high 97 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. school, technical school or some college, college or graduate school), alcohol intake (three categories: O g day'*, 1 - 13 g day'*, > 14 g day'*), aspirin use, other pain relief medication use, antacid use, and laxative use (two categories: recent user, recent non user). In the conditional logistic regression, matching factors were gender, age (by 5-year age category), calendar date of sigmoidoscopy (by 3-month category), and Kaiser center. In the unconditional logistic regression, these factors were included as covariates in the multivariate analysis. As a test for trend in effect across categories, a two-sided p-value was used, associated with a coefficient fit to the corresponding ordinal value of the category. Since body mass index could be a potential confounder or intermediate, the multivariate analyses for the relation of physical activity with adenomas were conducted with and without body mass index in the models, and the results were the same. 2.4 Results 2.4.1 Unconditional Logistic Regression 2.4.1.1 Total Subjects In the unmatched analysis, the study participants were on the average 62 years of age, predominantly male and white (Table 3). Overall, control subjects had attained a higher educational level than cases. More case than controls were current smokers; more controls were ex-smokers or non-smokers. Controls were heavier than cases (BMI>27 kg m'^), but cases consumed more alcohol, used more other pain relief medication and laxatives. Controls used more aspirin and antacid. 98 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 3: Characteristics o f the study population (unmatched n=1716). Variable Cases fn=832) Mean (SD) Controls (n=884) Mean (SD) Age (years) 61.4 (6.7) 61.8 (6.8) Females (%) 36.3 33.9 Males (%) 63.7 66.1 Studv: Sigmoid Study 1 (%) 63.5 63.6 Sigmoid Study II (%) 36.5 36.4 Location: Bellflower (%) 63.0 62.9 Sunset (%) 37.0 37.1 Ethnicity: White (%) 4 7 3 47.3 African American (%) 17.8 16.0 Latino/Hispanic (%) 16.8 18.8 Asian (%) 10.8 11.2 Other (%) 7.4 6.7 Highest level of education attained: Less than high school 4.5 4.0 High school 3 7 3 31.9 Technical school or some college 27.4 28.0 College or graduate school 30.8 36.0 Refused to answer 0 0.1 Smoking: Non-smokers (%) 36.4 44.3 Ex-smokers (%) 44.2 45.0 Current smokers (%) 19.4 10.6 Body mass index (kg m^l: < 2 7 (%) 51.0 55.5 49.0 44.5 Ave. Alcohol (g day"'): 10.3 (28.1) 7.4 (21.8) 0 g/day 45.7 47.4 1-13 g/day 34.5 36.8 > 14 g/day 19.5 15.8 99 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 3; Characteristics o f the studv population (cont.) Variable Case Controls subiects Mean (SD) Mean (SD) Medication History: Aspirin use {%) 38.7 39.9 Other pain relief medication use (%) 21.1 19.4 Antacid use (%) 28.6 29.1 Laxative use (%) 17.9 16.0 PHYSICAL ACTIVITY VARIABLES Frequency of vigorous recreational activity: < Three times per week {%) 72.4 61.7 > Three times per week (%) 27.6 38.3 Average MET hours per week of recreational activitv: 7.4 (19.8) 9.4 (21.7) 0 - < 1 M ET hrs/wk 70.0 60.9 1 - < 1 4 MET hrs/wk 13.8 16.2 > 14 MET hrs/wk 16.2 23.0 Average MET hours per week o f occuoational activitv 118.5 (52.6) 115.8 (51.2) Ouartiles Within Ouartile Means < 100 MET hrs/wk 71.1 (153) 100 MET hrs/wk 100.0 (0.0) 101 - < 140 MET hrs/wk 114.7 (12.4) > 140 MET hrs/wk 182.4 (60.9) Average MET hours per week of combined occupational activitv + recreational activitv: 125.9 (55.4) 125.2 (56.1) Quartiies : Within Ouartile Means <100 MET hrs/wk 77.4 (16.4) 100-<112 M ET hrs/wk 101.7 (3.4) 112-<140 METhns/wk 126.8 (9.4) > 140 MET hrs/wk 196.1 (64.7) Average MET hours of daily physical activity*^: 42.8 (13.6) 42.7(13.4) Quartiles: Within Ouartiles Means: < 31 MET hrs/wk 26.7 (2.5) 31 - <41 MET hrs/wk 36.7 (2.8) 41 - < 52 MET hrs/wk 46.6 (2.9) > 52 MET hrs/wk 61.0 (7.7) Physical activity variables refer to time I year before the sigmoidoscopy. A vera^ occupational activity per week assumes an average 40 hour work week. Q uartile values w ere obtained using Proc R ank in SAS. Average daily physical activity includes time spent: sleeping, sitting, or doing light, moderate or vigorous activity. 100 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Regarding recent physical activity, average weekly occupational activity was higher among cases, while controls had higher average weekly recreational activity. Frequency of vigorous recreational activity was higher among controls. Average weekly combined occupational and physical activity was similar for both cases and controls. Average daily physical activity was nearly the same for both the case and control groups. The results of the univariate analysis of physical activity showed that vigorous recreational physical activity was associated with a reduced prevalence of adenomatous polyps (Table 4). The overall association for vigorous recreational activity measures included: frequency of activity, average MET hours per week, and intensity of activity. Frequency of vigorous recreational activity (> 3 times per week), was associated with a decreased odds ratio (OR=0.6, 95% C.I.= 0.5-0.8). Average MET hours per week of vigorous recreational activity showed a decreased association across increasing categories of activity. Comparing the middle categoiy of activity (1-13 MET hours per week) and highest category (14 or more MET hours per week) to the referent categoiy (0 MET hours recreation), yielded odds ratios of 0.7 and 0.6, respectively (95% C.I.=0.6-1.0, and 95% C.I.=0.5-0.8, trend F=0.0002). Intensity of vigorous recreational activity also showed a decreased association across increasing categories of activity. Comparison of the middle and highest categories of intensity to the referent category showed a protective effect (OR=0.7, 95% C.I.=0.5-0.8, and OR=0.5,95% C.I.-0.3-0.7, trend P<0.0001). After adjustment for smoking, body mass index, educational status, alcohol, aspirin use, other pain relief medication use, antacid use, and laxative use, the inverse association for the measures of vigorous recreational physical activity was similar to those for the 101 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 4: Odds ratios o f colorectal adenomatous polyps for several physical activitv m easures, unmatched subiects Physical Activity Measure Univariate OR (Cl) Multivariate” OR (Cl) Vigorous recreational activity — three or more times per week 0.6 (0.5 - 0.8) 0.7 (0.6 - 0.9) Vigorous recreational activiCv - Average MET hours per week 0 1-13 14 or more Test for Trend P 1 0.7 0.6 0.0002 (0.6 - 1.0) (0.5-0.8) 1 0.9 0.7 0.04 (0.7-1.1) (0.5-0.9) Intensity of vigorous recreational activity‘ s : Low intensity - less than three times per week 1 Moderate intensity - > 4 METS and at least 3 times per wk. 0.7 High intensity - > 6 METS and at least I hr. per wk. 0.5 Test for Trend P <0.0001 (0.5-0.8) (O J-0.7) 1 0.8 0,5 0.007 (0.6 (0.4 1.0) 0.9) Occupational activity'Average MET hours tier week * Ouartiles: <100 100 101 - < 140 > 140 MET hr^/wk MET hrs/wk MET hrs/wk MET hrs/wk Test for Trend P 1 0.7 (0.6-0.9) 1.0 (0.8 - 1.3) 1.0 (0.8-1.4) 0.01 I 0,7 (0.5-0,9) 1.0 (0 ,7 -1 3 ) 1.0 (0,8-1.4) 0.09 Average MET hours per week of combined occupational activity + recreational activity: Ouartiles: <100 100 - < 1 1 2 112 - <140 >140 MET hrs/wk MET hrs/wk MET hrs/wk MET hrs/wk Test for Trend P 1 1.0 (0.8 - 1.3) 0.8 (0,6 - 1. 1) 1.0 (0.8-1.4) 0.25 1 1.0 (0.8-1.4) 0.8 (0.6 - 1. 1) 1.1 (0.8-1,5) 0.16 102 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 4: Odds ratios o f colorectal adenomatous potvps for several physical activitv measures, unmatched subiects fcont.) Physical Activity Measure Univariate OR (Cl) Multivariate OR (Cl) Average MET hours of daily ohvsical activity': Q.uartiies : < 31 MET hrs/day 1 1 31 - <41 MET hrs/day 0.9 (0.8- 13) 1.0 (0.7-1.4) 41 - < 5 2 MET hrs/day 0.9 (0.7- 1.3) 0.9 (0 .7 -1 3 ) > 52 MET hrs/day 0.9 (0.7- 13) 1.0 (0.7-1.3) Test for Trend P 0.99 0.97 Using an unconditional logistic regression model which included: age, sex, location, ethnicity, education level, smoking status, body mass index, intake o f alcohol, and use o f aspirin, antacid, laxative, and other pain relief medication. Reference group is subjects who reported not en^ging in vigorous physical activity three or more times per week. “Low intensity” level represents sutyects who reported not engaging in vigorous physical activity three or more times per week: “moderate intensity” level represents subjects who engaged in vigorous activities of four METs or more at least three times per week, and did not engage in high-intensity activities o f six METs or more at least I hour per week: “higji intensity” level represents subjects who engaged in vigorous activities o f six METs or more, for at least 1 hour per week, OR, odds ratio; Cl, 95% confidence intervals. Average occupational activity per week assumes an average 40 hour work week. Average daily physical activity includes time spent: sleeping, sitting, or doing light, moderate or vigorous activity. 103 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. univariate model, except the effect was weakened slightly. Frequency of vigorous recreational activity was associated with a decreased odds ratio (OR=0.7, 95% C.I.= 0.6- 0.9). Average MET hours per week of vigorous recreational activity showed a decreased association across increasing categories of activity, odds ratios of 0.9 and 0.7, respectively (95% C.I.=0.7-1.2, and 95% C.I.=0.5-0.9, trend P=0.04). Intensity of vigorous recreational activity still showed a decreased odds across increasing categories of activity (OR=0.8, 95% C.I.=0.6-1.0, and OR=0.5, 95% C.I.=0.4-0.9, trend P=0.007). Tests for trend across categories for these measures were significant for the univariate, as well as the multivariate analysis. Overall, an increase m vigorous recreational physical activity level was associated with a decreased odds of adenomatous polyps. Occupational activity, combined occupational and recreational activity, and daily physical activity showed no consistent association with the prevalence of adenomatous polyps. The association appears to be related to vigorous recreational activity. Therefore, all subsequent analysis will be restricted to vigorous physical activity. Heterogeneity of effects of vigorous physical activity will be presented next, followed by a consideration of heterogeneity by other variables. 2.4.1.2 White Subiects The 806 white study subjects had similar characteristics, compared to the overall participants in the study, with one exception: controls used more other pain relief medication, and antacids than cases (Table 5). For vigorous recreational physical activity variables, the univariate analysis for white subjects showed an association with a reduced 104 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 5: Characteristics o f the study population for Ethnicity =” W hite” fn=8061 Variable Cases tn=3911 Mean (SD) Controls tn=4151 Mean (SD) Age (years) 62.5 (6.8) 62.2 (6.7) Females (%) 33.8 34.0 Males (%) 66.2 66.0 Studv: Sigmoid Study I (%) 67.5 65.1 Sigmoid Study II (%) 32.5 34.9 Location: Bellflower (%) 69.8 713 Sunset (%) 30.2 28.7 Highest level of education attained: Less than high school 2.6 1.9 High school 37.4 31.5 Technical school or some college 29.2 27.6 College or graduate school 30.8 38.7 Refused to answer 0 0.2 Smoking: Non-smokers (%) 35.6 39.8 Ex-smokers (%) 46.6 50.0 Current smokers (%) 17.9 10.4 Bodv mass index tkg m'^): < 27(% ) 48.7 54.7 >27C%) 51.3 45.3 Ave. Alcohol fg dav ): 12.1 (24.0) 9.1 (27.6) 0 g/day 39.8 44.6 1 - 1 3 g/day 34.9 34.9 > 14 g/day 25.3 20.6 105 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Case Controls subiects Variable Mean (SD) Mean (SD) Medication History: Aspirin use (%) 44.9 44.8 Other pain relief medication use (%) 19.5 21.0 Antacid use (%) 30.6 32.7 Laxative use (%) 18.3 14.7 PHYSICAL ACTIVITY VARIABLES Frequency of vigorous recreational activitv: < Three times per week {%) 70.5 58.0 > Three times per week (%) 29.5 42.0 Average MET hours ner week o f recreational activitv: 10.2 (18.2) 7.7 (19.0) 0 - < 1 MET hrs/wk 683 56.6 1 - < 1 4 MET hrs/wk 14.8 16.9 > 14 MET hrs/wk 16.9 26.5 Average MET hours per week o f occuoational activitv 117.9 (54.8) 114.1 (48.7) Ouartiles Within Ouartile Means < 100 MET hrs/wk 70.5 (14.5) 100 MET hrs/wk 100.0 (0.0) 101 - < 120 MET hrs/wk 110.6 (9.9) > 120 MET hrs/wk 1823 (60.5) Average MET hours per week of combined occuoational activitv + recreational activitv: 125.6 (57.0) 124.3 (52.4) Ouartiles: Within Ouartiles Means: < 100 MET hrs/wk 77.4 (16.0) 1 0 0 -< 1 1 0 MET hrs/wk 101.2 (2.5) 110 <140 MET hrs/wk 124.7 (9.5) > 140 M EThiVwk 196.0 (61.0) Average MET hours o f daily ohvsical activitv"': 42.5 (13.3) 41.7 (12.8) Ouartiles: Within Ouartiles Means: < 3 2 MET hrs/wk 26.6 (23) 33 - < 41 METhrsAvk 36.4 (2.8) 41 - < 52 MET hrs/wk 4 5 3 (2.6) > 52 MET hrs/wk 59.8 (7.9) Physical activily variables refer to time 1 year before the sigmoidoscopy. Average occupational activity per week assumes an average 40 hour work week. Quartile values were obtained using Proc Rank in SAS. Average daily physical activity includes time spent: sleeping, sitting, or doing light, moderate or vigorous activity. 106 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. prevalence of adenomatous polyps (Table 6). Compared to the referent category, the middle and highest levels of vigorous recreational activity (average MET hours per week) showed significant results for both the univariate analysis and multivariate analysis for 14 hours or more. For the highest category, the univariate odds ratio (OR) was 0.5 (95% C.I. 0.4-0.8), after adjustment for the covariates, the multivariate OR was 0.6 (95% C.I. 0.4- 0.9). Similarly, tests for trend across categories for the univariate and multivariate measures were significant (P=0.001, P=0.03, respectively). 2.4.1.3 African American Subiects The characteristics of the African American subjects were similar to the overall participants, except with regard to body mass index (Table 7). No associations were seen for the univariate or multivariate results for the any of the measures of physical activity among African American subjects (Table 8). 2.4.1.4 Latino Subiects Latino subjects were also very similar to the overall participants, an exception included a lower educational level (Table 9). In the univariate analysis of vigorous physical activity, among Latinos, vigorous recreational physical activity was associated with a reduced prevalence of adenomatous polyps for frequency of vigorous activity only (OR=0.6, 95% C.I.= 0.4-0.9) (Table 10). This association was not consistent for average MET hours per week or intensity of vigorous activity. After adjustment for covariates, 107 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6: O dds ratios o f colorectal adenom atous polyps for several physical activitv m easures for Etfanicity =” W hite” . Physical Activity Measure Univariate Multivariate” OR (Cl) OR (Cl) Vigorous recreational activitv — three or more times ner week**; 0.6 (0.4 - 0.8) 0.6 (0.5 - 0.9) Vigorous recreational activity - Average MET hours per week: 0 1 1 - 13 0.7 14 or more 0.5 Test for Trend P 0.001 (0.5- (0.4 II) 0.8) 1 0.8 0.6 0.03 (0 .6- 0 ) (0.4-0.9) intensity of vigorous recreational ' : Low intensity - less than three times per week I Moderate intensity - > 4 METS and at least 3 times per wk. 0.6 High intensity - > 6 METS and at least I hr. per wk. 0.6 Test for Trend P 0.002 (0.4-0.8) (0 3 -1 .1 ) I 0.7 0.6 0.05 (0.5-1.0) (0.3 -1.1) Occupational activity'Average MET hours ner week ' Ouartiles: <100 100 101 - <120 > 120 MET hrs/wk MET hrs/wk MET hrs/wk MET hrs/wk Test for Trend P 1 0.8 (0.5-1.2) 0.9 (0 .6 -1 3 ) 1.0 (0 .7 -1 3 ) 0.60 1 0.8 (0.5-1.3) 0.8 (0 .6 -1 3 ) 0.9 (0 .6 -1 3 ) 0.81 Average MET hours per week of combined occupational activitv -t recreational activitv: Ouartiles: <100 100 - <110 11 0 - <140 > 140 MET hrs/wk MET hrs/wk MET hrs/wk MET hrs/wk Test for Trend P 1 1.0 (0 .7 -1 3 ) 0.7 (0.5-1.0) 1.1 (0.7-1.6) 0.15 1 1.0 (0.7-1.6) 0.6 (0.4-1.0) 1.0 (0 .6 -1 3 ) 0.08 108 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6: Odds ratios o f colorectal adenomatous polyps for several physical activitv measures for Ethnicity =”White” fcont.) Physical Activity Measure Univariate OR (Cl) Multivariate OR (Cl) Average MET hours of dailv ohvsical activitv ' : Quarfiles : < 32 MET hrs/day 1 1 33 - < 41 MET hrs/day 13 (0.8-1.9) 13 (0 3 -2 .1 ) 41 - < 5 2 MET hrs/day 1.0 (0 .7 -1 3 ) 0.9 (0.6-1.4) > 52 MET hrs/day 1.1 (0.8-1.7) 1.1 (0.8-1.9) Test for Trend P 0.60 036 Using an unconditional logistic regression model which included: age, sex, location, ethnicity, education level, smoking status, body mass index, intake o f alcohol, and use of aspirin, antacid, laxative, and other pain relief medication. Reference group is subjects who reported not engaging in vigorous physical activity three or more times per week. “Low intensity” level represents sulqects who reported not engaging in vigorous physical activity three or more times per week: “moderate intensity” level represents subjects who engaged in vigorous activities o f four METs or more at least three times per week, and did not engage in high-intensity activities of six METs or more at least 1 hour per week; “high intensity” level represents subjects who engaged in vigorous activities o f six METs or more, for at least 1 hour per week. OR, odds ratio; Cl, 95% confidence intervals. Average occupational activity per week assumes an average 40 hour work week. Average daily physical activity includes time spent: sleeping, sitting, or doing light, moderate or vigorous activity. 109 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 7: C haracteristics o f the studv population for Ethnicity =”African A m erican” (n=28T). Variable Cases (n=147) Mean (SD) Controls (n=140) Mean (SD) Age (years) 61.5 (7.1) 61.3 (6.5) Females (%) 4 6 3 43.6 Males (%) 53.7 56.4 Studv: Sigmoid Study 1 (%) 59.2 67.9 Sigmoid Study II (%) 40.8 32.1 Location: Bellflower (%) 49.7 48.6 Sunset (%) 50.3 51.4 Highest level of education attained: Less than high school 2.7 1.4 High school 42.5 34.3 Technical school or some college 32.2 35.0 College or graduate school 22.6 293 Refused to answer 0 0.0 Smoking: Non-smokers (%) 26.5 41.4 Ex-smokers (%) 46.3 39.3 Current smokers (%) 27.2 19.3 Bodv mass index (kg m^): < 27 (%) 39.5 40.3 > 27 (%) 60.5 59.7 Ave. Alcohol (g day''): 11.0 (38.8) 5.9 (16.2) 0 g/day 55.2 49.3 1 — 13 g/day 27.6 39.1 > 14 g/day 17.2 11.6 110 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 7: Characteristics of the studv uoDulation for E th n id tv = ’’African American” tcontl Case Controls subiects Variable Mean (SD) Mean (SD) Medication History: Aspirin use (%) 32.0 31.7 Other pain relief medication use (%) 26.9 16.4 Antacid use (%) 33.6 29.1 Laxative use {%) 19.7 25.7 PHYSICAL ACTIVITY VARIABLES Frequency of vigorous recreational activitv: < Three times per week (%) 76.9 69.3 > Three times per week (%) 23.1 30.7 Average MET hours per week o f recreational activitv: 4.8 (13.2) 7.9 (34.2) 0 - < 1 MET hrs/wk 76.2 70.7 1 - < 1 4 MET hrs/wk 10.9 1 4 j > 14 MET hrs/wk 12.9 15.0 Physical activity variables refer to time I year before the sigmoidoscopy. I l l Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 8: Odds ratios of colorectal adenomatous polyps for several physical activitv measures for Ethnicity =”African American”. Univariate Multivariate ” Physical Activity Measure OR (Cl) OR (Cl) Vigorous recreational activitv - three or more times per week*’ : 0.7 (0.4—1.1) 1.1 (0.6 — 2.0) Vigorous recreational activity - Average MET hours per week: 0 I I 1 -1 3 0.7 (03 -1.4) 1.2 (0.5-2.7) 14 or more 0.8 (0.4—1.6) 1.2 (0.6 — 2.7) Test for Trend P 0.56 0.83 Inlensitv of vigorous recreational activitv ' : Low intensity - less than three times per week 1 1 Moderate intensity-> 4 METS and at least 3 times per wk. 0.8 (0.5—1.4) 1.2 (0.7 — 2.4) High intensity- > 6 METS and at least 1 hr. per wk. 03 (0.1 - 1.2) 0.7 (0.2-3.1) Test for Trend P 0.16 0.67 ' Using an unconditional logistic regression model which included: age, sex, location, ethnicity, education level, smoking status, body mass index, intake o f alcohol, and use o f aspirin, antacid, laxative, and other pain relief medication. Reference g o u p is subjects who reported not engaging in vigorous physical activity three or more times per week. “Low intensif” level represents subjects who reported not engaging in vigorous physical activity three or more times per week: “moderate intensity” level represents subjects who engaged in vigorous activities o f four METs or more at least three times per week, and did not engage in high-intensity activities o f six METs or more at least 1 hour per week: “high intensity” level represents subjects who engaged in vigorous activities o f six METs or more, for at least I hour per week. OR, odds ratio; Cl, 95% confidence intervals. b 112 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 9: Characteristics of the study population for Ethnicity =”Lafino’' rn=304). Variable Cases (n=139) Mean (SD) Controls (n=165) Mean (SD) Age (years) 61.3 (6.3) 60.2 (6.7) Females (%) 36.7 31.5 Males (%) 63.3 68.5 Study: Sigmoid Study I (%) 61.2 56.4 Sigmoid Study II (%) 38.9 43.6 Location: Bellflower (%) 64.8 67.9 Sunset (%) 35.3 32.1 Highest level o f education attained: Less than high school 123 13.3 High school 50.7 41.2 Technical school or some college 24.6 2 7 3 College or graduate school 12.3 18.2 Refused to answer 0.0 0.0 Smoking: Non-smokers (%) 36.0 49.1 Ex-smokers (%) 2 2 3 43.6 Current smokers (%) 41.7 7 3 Body mass index (kg m'h: < 27(% ) 47.5 47.9 > 2 1 {Vo) 52.6 52.1 Ave. Alcohol (g day *): II.O (36.9) 6.9 (14.7) Og/day 43.0 41.7 1 - 1 3 g/day 40.0 44.8 > 14 g/day 17.0 13.5 113 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 9; Characteristics o f the study population for Ethnicity =”Latino” (coat.) Case Controls subiects Variable Mean (SD) Mean (SD) Medication History: Aspirin use {%) 31.7 37.2 Other pain relief medication use (%) 25.2 20.6 Antacid use (%) 29.4 29.5 Laxative use (%) 20.1 16.4 PHYSICAL ACTIVITY VARIABLES *: Freaucncv o f vigorous recreational activity: < Three times per week (%) 72.7 60.4 > Three times per week (%) 27.3 40.0 Average MET hours ner week of recreational activity: 8.9 (27.7) 9.0 (18.0) 0 - < I MET hrs/wk 70.5 60.0 1 < 1 4 MET hrs/wk 13.7 17.0 > 14 MET hrs/wk 15.8 23.0 Physical activity variables refer to time I year before the sigmoidoscopy. 114 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 10: Odds ratios of colorectal adenomatous polyps for several physical activity measures for Ethnicity =”Latino”. Univariate Multivariate ‘ Physical Activity Measure OR (Cl) OR (Cl) Vigorous recreational activity — three or more times ner week : 0.6 (0.4-0.9) 0.8 (0.4-1.3) Vigorous recreational activity - Average MET hours ner week: 0 1 1 1 -1 3 0.7 (0.4-1.3) 1.0 (0.5-2.0) 14 or more - 0.6 (0 3 -1 .1 ) 0.8 (0 .4 -1 3 ) Test for Trend P 0.15 0.78 Intensity of vigorous recreational activity : Low intensity - less than three times per week 1 1 Moderate intensity > 4 METS and at least 3 tiroes per wk. 0.7 (0.4-1.1) 0.8 (0 .5 -1 3 ) High intensity — > 6 METS and at least 1 hr. per wk. 0.4 (0.1 - 1.1) 0.7 (0.2-2.1) Test for Trend P 0.07 0.71 Using an unconditional logistic regression model which included; age, sex, location, ethnicity, education level, smoking status, body mass index, intake o f alcohol, and use o f aspirin, antacid, laxative, and other pain relief medication. Reference group is subjects who reported not engaging in vigorous physical activity three or more times per week. “Low intensity” level represents subjects who reported not engaging in vigorous, physical activity three or more times per week: “moderate intensity” level represents subjects who engaged in vigorous activities o f four METs or more at least three times per week, and did not engige in high-intensity activities o f six METs or more at least 1 hour per week: “high intensity” level represents subjects who engaged in vigorous activities o f six METs or more, for at least I hour per week. OR, odds ratio; Cl, 95% confidence intervals. 115 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the inverse association of frequency of vigorous recreational physical activity with adenomatous polyps diminished. 2.4.1.5 Asian Subiects Demographics for the 187 Asian subjects were very similar to those shown for the total study subjects (Table 11). Some exceptions included: cases having the highest educational level and higher average weekly hours of combined occupational and recreational activity. Among Asian subjects, no significant results were seen for any of the measures of vigorous physical activity (Table 12). 2.4.1.6 Male and Female Subiects Overall, there were no significant differences between males and females with respect to the effects of vigorous recreational activity (Table 13 and Table 14). 2.4.2 Heterogeneity of Other Variables The association of polyps with the various measures of vigorous physical activity did vary by educational level (high school education), age, and antacid use as described below (Table 15). Using a multivariate model, among high school educated, the OR for polyps comparing frequently vigorously active subjects with non-firequently vigorously active subjects was 1.1 (95% C.I.=0.7-1.6); and among those with higher educational levels, the OR was 0.6 (95% C.I.=0.5-0.8, Interaction P=0.002). 116 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. T able 11: Characteristics o f the study population for Ethnicity = ” A sian” n=187f. Variable Cases fn=891 Mean (SD) Controls tn=981 Mean (SD) Age (yeais) 60.1 (6.4) 61.1 (6.6) Females (%) 34.8 27.6 Males {%) 65.1 72.5 Study: Sigmoid Study I (%) 58.4 62.2 Sigmoid Study 1 1 (%) 41.6 37.8 Location: Bellflower (%) 47.2 37.8 Sunset (%) 52.8 62.2 Highest level of education attained: Less than high school 2 3 0.0 High school 13.5 16.3 Technical school or some college 16.9 23.5 College or graduate school 67.4 60.2 Refused to answer 0.0 0.0 Smoking: Non-smokers (%) 50.6 54.0 Ex-smokers (%) 14.6 8.0 Current smokers (%) 34.8 37.8 Body mass index fkg m^l: <27 (%) 84.8 85.7 >27(% ) 15.7 14.3 Ave. Alcohol tg day '): 2.7 (7.2) 3.3 (8.9) 0 g/day 55.7 63.5 1-13 g/day 36.4 30.2 > 14 g/day 8.0 6.3 117 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 11; Characteristics o f the study population for Ethnicity =”Asian’* (cont.) Case Controls subiects Variable Mean (SD) Mean (SD) Medication History: Aspirin use {%) 26.1 30.6 Other pain relief medication use (%) 14.9 11.2 Antacid use (%) 11.2 14.3 Laxative use (%) 11.2 8.2 PHYSICAL ACTIVITY VARIABLES Freouencv of vigorous recreational activité : < Three times per week (%) 70.1 74.2 > Three times per week (%) 29.9 25.8 Average MET hours ner week of recreational activity: 6.9 (14.6) 8.0 (18.7) 0 - < 1 MET hrs/wk 62.9 71.4 1 < 1 4 MET hrs/wk 20.2 10.2 > 14 MET hrs/wk 16.9 18.4 Physical activity variables refer to time I year before the sigmoidoscopy. 118 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 12: Odds ratios of colorectal adenomatous polyps for several physical activity measures for Ethnicity =”Asian”. Physical Activity Measure Univariate OR (Cl) Multivariate OR (Cl) Vigorous recreational activity — three or more times per week * * : 1.2 (0.6 — 2.2) 1.2 (0.6 — 2.6) Vigorous recreational activity ■ 0 1-13 14 or more Test for Trend P Average MET hours ner week: 1 2J 1.0 0.17 (1.0- 5 J ) (0.5 - 2 J ) 1 2.0 (0.8-5.2) 1.1 (0.5-2.7) 037 Intensity of vigorous recreational activity ^ : Low intensity - less than three times per week 1 1 Moderate intensity > 4 METS and at least 3 times per wk. 1.6 (0 .8 -3 3 ) 1.8 (0.8 — 4.2) High intensity — > 6 METS and at least 1 hr. per wk- 0.8 (03 — 2.4) 0.6 (0.2 — 1.9) Test for Trend P 0.41 0.21 “ Using an unconditional logistic regression model which included; age. sex, location, ethnicity, education level, smoking status, body mass index, intake o f alcohol, and use of aspirin, antacid, laxative, and other pain relief medication. Reference group is subjects who reported not engaging in vigorous physical activity three or more times per week. ' “Low intensity” level represents subjects who reported not engaging in vigorous physical activity three or more times per week: “moderate intensity” level represents subjects who engaged in vigorous activities o f four METs or more at least three times per week, and did not engage in high-intensity activities o f six METs or more at least I hour per week: “high intensity” level represents subjects who engaged in vigorous activities of six METs or more, for at least I hour per week. OR, odds ratio; Cl, 95% confidence intervals. 119 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 13: Odds ratios of colorectal adenomatous polyps for several physical activity measures. Gender = Male. Univariate Multivariate ' Physical Activity Measure OR (Cl) OR (Cl) Vigorous recreational activity - three or more times per week": 0.6 (0.5 — 0.8) 0.7 (0.5 — 0.9) Vigorous recreational activitv - Average MET hours per week 0 I 1 1-13 0.8 (0.6-1.2) 1.0 (0.7-1.4) 14 or more 0.6 (0.4-0.8) 0.7 (0.5-0.9) Test for Trend P 0.0004 0.06 Intensity of vigorous recreational activity^ : Low intensity - less than three times per week 1 I Moderate intensity-> 4 METS and at least 3 times per wk. 0.7 (0.5 — 0.9) 0.8 (0.6—1.0) High intensity — > 6 METS and at least 1 hr. per wk. 0.6 (0.4 — 0.9) 0.7 (0.4—1.1) Test for Trend P 0.003 0.08 * Using an unconditional logistic regression model which included; age, sex, location, ethnicity, education level, smoking status, body mass index, intake o f alcohol, and use of aspirin, antacid, laxative, and other pain relief medication. Reference group is subjects who reported not engaging in vigorous physical activity three or more times per week. ‘ “Low intensity” level represents subjects who reported not engaging in vigorous physical activity three or more times per week: “moderate intensity” level represents subjects who engaged in vigorous activities of four METs or more at least three times per week, and did not engage in high-intensity activities of six METs or more at least I hour per week: “higli intensity” level represents subjects who engaged in vigorous activities of six METs or more, for at least I hour per week. OR, odds ratio; Cl, 95% confidence intervals. b 120 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 14: Odds ratios of colorectal adenomatous polyps for several physical activitv measures. Gender = Female. Univariate Multivariate' Physical Activity Measure OR (Cl) OR (Cl) Vigorous recreational activitv — three or more times ner week 0.6 (0.5-0.9) 0.7 (0.5-1.0) Vigorous recreational activitv - Average MET hours ner week 0 1-13 14 or more Test for Trend P 1 0.6 0.7 0.04 (0.4-1.0) (0.4-1.0) 1 0.7 0.7 030 (0.4-1.2) (0.5-1.2) Intensity of vigorous recreational activity"^ : Low intensity - less than three times per week Moderate intensity - > 4 METS and at least 3 times per wk. High intensity — > 6 METS and at least 1 hr. per wk. Test for Trend P 1 0.7 0.4 0.02 (0.5-1.0) (0.2-0.9) 1 0.8 0.5 0.16 (0.5-1.2) (0.2 -1.1) “ Using an unconditional logistic regression model which included: age, sex, location, ethnicity, education level, smoking status, body mass index, intake of alcohol, and use of aspirin, antacid, laxative, and other pain relief medication. Reference group is subjects who reported not engaging in vigorous physical activity three or more times per week. “Low intensity” level represents subjects who reported not engaging in vigorous physical activity three or more times per week; “moderate intensity” level represents subjects who engaged in vigorous activities of four METs or more at least three times per week, and did not engage in high-intensity activities of six METs or more at least I hour per week: “high intensity” level represents subjects who engaged in vigorous activities of six METs or more, for at least I hour per week. OR, odds ratio; Cl, 95% confidence intervals. 1 2 1 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activitv measures, unmatched subiects. Model 1 - Includes Product Term: Frequency of Vigorous Recreational Activity X Ethnicity=Asian Covariates = FREQ VA ETH CAT2 AGE SEX LOC ALC_CAT2 ALC_CAT3 ASPRCAT OTPRCAT ANTA_CAT LAX CAT EDUCAT2 EDUCAT3 EDUCAT4 BMI_CAT SMK_CAT2 SMK CAT3 FREQ_VA*ETH_CAT2 - Frequency of Vigorous Activity (> 3 times/wk, <3 times/wk) Asian ( Asian, Non-Asian) Age of subject Sex (Male, Female) Kaiser location (Sunset, Bellflower) Ave. Alcohol (g day '), (1-13 g/day, not 1-13 g/day) Ave. Alcohol (g day"’), ^ 14 g/day, < 14 g/day) Aspirin Use (Yes, No) Other Pain Relief Medication Use (Yes, No) Antacid Use (Yes, No) Laxative Use (Yes, No) High School (Yes, No) Technical School/Some College (Yes, No) College/Graduate School (Yes, No) Body Mass Index (kg m ), (> 14 g/day, < 14 g/day) Ex-smoker (Yes, No) Current Smoker (Yes, No) Freq. of Vig. Activity ^ 3 times/wk, < 3 times/wk) X Asian ( Asian, Non-Asian) For Model 1 logit|pr(Y=I)| Bo + B ,(F R E Q _ V A ) + B ,(S E X ) + B ,(A L C _ C A T 3 ) + B ,o (A N T A _ C A T ) + B „ (E D U C A T 3 ) + B ,« (S M K _ C A T 2 ) + B i(E T H _ C A T 2 ) + B s(L O C ) + B g(A S P R _C A T ) + B „ (L A X _ C A T ) + B „ (E D U C A T 4 ) + B ,t(S M K _ C A T 3 ) + B j(A G E ) + B *(A L C _C A T 2) + B ,(O T P R _ C A T ) + B „ (E D U C A T 2 ) + B ,5(B M I_C A T ) + B ,* (F R E Q _ V A * E T H _ C A T 2 ) Fitted Model 1: Interaction P — 0.0008 logit[pr(Y=l)| =-0.8983 - 03947(FREQ_VA) 0.0314(ETH_CAT2) - 0.2G46(SEX) - 0.010l(LOC) + 0.2459(ALC_CAT3) - 0.0204(ASPR_CAT) - 0.0399(ANTA_CAT) + 0.1665(LAX_CAT) + 0.1086(EDUCAT3) + 0.1067(EDUCAT4) + 0 .0 1 1 6 (A G E ) + 0 .0 4 4 7 (A L C _ C A T 2 ) + 0 .0 8 3 5 (O T P R C A T ) - 0 .0 I7 6 (E D U C A T 2 ) + 0 .1 8 0 5 (B M I_ C A T ) + 0.1812(SMK_CAT2) + 0.7915(SMK_CAT3) + 0.6983(FREQ_VA*ETH_CAT2) After stratification by Ethnicitv=Asian Non-Asian Asian OR 0.7 1.2 95% C.l. (0.5 - 0.9) (0.6 - 2.6) P Value 0.0013 0.5888 1 2 2 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activitv measures, unmatched subiects (cont.) Model 2 - Includes Product Term: Frequency of Vigorous Recreational Activity X High School Education Covariates = FREQ VA - Frequency of Vigorous Activity (> 3 times/wk, < 3 times/wk) ETH CAT2 - Asian ( Asian, Non-Asian) ETH CAT3 - Latino/Hispanic (Latino, Non-Latino) ETH CAT4 - African American ( African American, Non-African American) ETH CATS - Other ( Other Ethnicity, Non- Other Ethnicity) AGE - Age of subject SEX - Sex (Male, Female) LOC - Kaiser Location (Sunset, Bellflower) ALC CAT2 - Ave. Alcohol (g day'*), (1-13 g/day, not 1-13 g/day) ALC CAT3 - Ave. Alcohol (g day '), (> 14 g/day, < 14 g/day) ASPR CAT - Aspirin Use (Yes, No) OTPR CAT - Other Pain Relief Medication Use (Yes, No) ANTA CAT - Antacid Use (Yes, No) LAX CAT - Laxative Use (Yes, No) EDUCAT2 - High School (Yes, No) BMI CAT - Body Mass Index (kg m \ (> 14 g/day, < 14 g/day) SMK CAT2 - Ex-smoker (Yes, No) SMK CAT3 - Current Smoker (Yes, No) FREQ_VA*EDU2 - Freq. of Vig. Activity (> 3 times/wk, < 3 times/wk) X High School (Yes, No) For Model 2: logit[pr(V=l)I = Bo + B,(FREQ_VA) + B4(ETH_CAT4) + B,(SEX) + B,o(ALC_CAT3) + B„(ANTA CAT) + B,«(BMI_CAT) + B„(FREQ_VA*EDU2) + Bz(ETH_CAT2) + Bs(ETH_CAT5) + B»(LOC) + B„(ASPR_CAT) + Bm (LAX_CAT) B„(SMK_CAT2) + B,(ETH_CAT3) + B«(AGE) + B»(ALC_CAT2) + B,2(0TPR CAT) + B,*(EDÜCÂT2) + B,8(SMK_CAT3) Fitted Model 2: logit[pr(Y=l)| Interaction P — 0.002 = -0.8981 - 0.4823(FREQ_VA) + 0.0444(ETH_CAT4) - 0.2031(SEX) + 0.2596(ALC_CAT3) + 0.1590(ETH_CAT2) + 0.1856(ETH_CAT5) + 0.0103(LOC) 0.0334(ASPR_CAT) - 0.0433(ANTA_CAT) + 0.1703(LAX_CAT) + 0.1870(BMI_CAT) + 0.1947(SMK_CAT2) + 03347(FREQ_VA*EDU2) • After stratification by “High School” Education: - 0.0650(ETH_CAT3) + 0.0124(AGE) + 0.05I2(ALC_CAT2) + 0.0804(OTPR_CAT) - 0.2591(EDUCAT2) + 0.8399(SIVfK_CAT3) Non-High School High School OR 0.6 1.1 95% C.l. (0.5 - 0.8) (0.7 - 1.6) P-Value 0.0002 0.7101 123 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activitv measures, unmatched subjects Iconl) Model 3 - Includes Product Term: Frequency of Vigorous Recreational Activity X Age of Subject Covariates = FREQ VA - Frequency of Vigorous Activity (> 3 fimcs/wk, < 3 times/wk) ETH CAT2 - Asian ( Asian, Non-Asian) ETH CAT3 - Latino/Hispanic (Latino, Non-Latino) ETH CAT4 - African American ( African American, Non-African American) ETH CAT5 - Other ( Other Ethnicity, Non- Other Ethnicity) AGE - Age of subject SEX - Sex (Male, Female) LOC - Kaiser Location (Sunset, Bellflower) ALC CAT2 - Ave. Alcohol (g day*'), (1-13 g/day, not 1-13 g/day) ALC CAT3 - Ave. Alcohol (g day '), (> 14 g/day, < 14 g/day) ASPR CAT - Aspirin Use (Yes, No) OTPR CAT - Other Pain Relief Medication Use (Yes, No) ANTA CAT - Antacid Use (Yes. No) LAX CAT - Laxative Use (Yes, No) EDUCATZ - High School Q/es, No) EDUCAT3 - Technical School/Some College (Yes, No) EDÜCAT4 - College/Graduate School (Yes, No) BMI CAT - Body Mass Index (kg m \ (> 14 g/day, < 14 g/day) SMK CAT2 - Ex-smoker (Yes, No) SMK CAT3 - Current Smoker (Yes, No) FREQ_VA*AGE - Freq. of Vig. Activity (> 3 times/wk, < 3 times/wk) X Age of Subject For Model 3: IogitJpr{Y=l)| = Fitted Model 3: logit(pr{V=l)l + B,(FREQ_VA) + Bj(ETH_CAT4) + BrfSEX) + B ,o(A L C _ C A T 3 ) + Bb(ANTA_CAT) + B ,i(E D U C A T 3 ) + B„(SMK_CAT2) Interaction P = 0.009 = -0.1600 - 2.6567(FREQ_VA) + 0.0348(ETH_CAT4) - O.I936{SEX) + 0.2488(ALC_CAT3) - 0.0368(ANTA_CAT) + 0.1419(EDUCAT3) + Bz(ETH_CAT2) + Bs(ETH_CAT5) + B a(L O C ) + B„(ASPR_CAT) + B„(LAX_CAT) + B„(EDUCAT4) + Bm(SMK_CAT3) + 0.I946(ETH_CAT2) + O.I963(ETH_CAT5) - 0.0102(LOC) - 0.0383(ASPR_CAT) + 0.1771(LAX_CAT) + 0.I771(EDUCAT4) + 0.1985(SMK_CAT2) + 0.7986(SMK_CAT3) After stratification by Age Category OR 95% C.I. + B3(ETH_CAT3) + Bs(AGE) + B,(ALC_CAT2) + B,2(0TPR_CAT) + B,5(EDUCAT2) + B,g(BMI_CAT) + B2,(FREQ_VA*AGE) - 0.0987(ETH_CAT3) - 0.00I7(AGE) + 0.0585(ALC_CAT2) + 0.0933(OTPR_CAT) + 0.00I6(EDUCAT2) + 0.1995(BMI_CAT) + 0.0380(FREQ_VA*AGE) P-Value ■AGE: 45 TO 59' 0.6 ■AGE: 60 AND OLDER’ 0.9 (0.4-0.8) (0.7-1.2) 0.0007 0.4976 124 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction fo r vigorous physical activitv measures. unmatehft«t subiects rcont> Model 4 - Includes Product Term: Average M ET hrs/wk. of Vigorous Recreational Activity X Age of Subject MET - Vigorous recreational activity - Average MET hours per week (0 - < 1 MET hrs/wk, 1 - 0 4 MET hrs/wk, > 14 MET hrs/wk) ETH CAT2 - Asian ( Asian, Non-Asian) ETH CAT3 - Latino/Hispanic (Latino, Non-Latino) ETH CAT4 - African American ( African American, Non-African American) ETH CATS - Other ( Other Ethnicity, Non- Other Ethnicity) AGE - Age of subject SEX - Sex (Male, Female) LOC - Kaiser Location (Sunset, Bellflower) ALC_CAT2 - Ave. Alcohol (g day"'), (1-13 g/day, not 1-13 g/day) - Ave. Alcohol (g day"'), (> 14 g/day, <14 g/day) ALC CAT3 ASPR CAT - Aspirin Use (Yes, No) OTPR CAT - Other Pain Relief Medication Use (Yes, No) ANTA CAT - Antacid Use (Yes. No) LAX CAT - Laxative Use (Yes, No) EDUCAT2 - High School (Yes, No) EDÜCAT3 - Technical School/Some College (Yes, No) EDUCAT4 - College/Graduate School (Yes, No) BMI CAT - Body Mass Index (kg m '\ (> 14 g/day, < 14 g/day) SMK CAT2 - Ex-smoker (Yes, No) SMK CAT3 - Current Smoker (Yes, No) MET*AGE - Vigorous recreational activity - Average MET hours per week (0 - < 1 MET hrs/wk, 1 - < 14 MET hrs/wk, > 14 MET hrs/wk) X Age of Subject For Model 4: iogitIpr(Y=l)| = Bo + B ,(M E T ) + B4(ETH_CAT4) + Bt {SEX) + B ,o (A L C _ C A T 3 ) + B ,3 (A N T A _ C A T ) + B ,((E D U C A T 3 ) + B ,,(S M K _ C A T 2 ) + Bz(ETH_CAT2) + Bs{ETH_CAT5) + BrfLOC) + B„(ASPR_CAT) + B,4(LAX_CAT) + B.XEDUCAT4) + Bjo(SMK_CAT3) + B j(E T H _ C A T 3 ) + B «(A G E ) + Bg(ALC_CAT2) + B,2(0TPR_CAT) + B,5(EDUCAT2) + B ,g (B M I_ C A T ) + B j,(M E T * A G E ) jetted Model 4: Interaction P = 0.0347 logitlpr(Y=l)I = 0.9135 - I.2589{MET) + 0.0260(ETH_CAT4) - O.I848(SEX) + 0.2479(ALC_CAT3) - 0.0363(ANTA_CAT) + 0.1660(LAX_CAT) + 0.1430(EDUCAT3) + O.I655(EDUCAT4) + 0J!040(ETH_CAT2) + O.I865(ETH_CAT5) - 0.0167(LOC) - 0.0357(ASPR_CAT) - 0 .I0 4 4 { E T H _ C A T 3 ) - 0 .0 1 6 6 (A G E ) + 0 .0 5 3 8 {A IX :_ C A T 2 ) + 0 .0 8 4 6 (O T P R _ C A T ) + 0 .0 0 0 3 (E D U C A T 2 ) + 0 .2 1 0 I(B M I_ C A T ) + 0.I923(SMK_CAT2) + 0.8035(SMK_CAT3) + 0.0178(MET* AGE) 125 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activity measures, unmatched suhi<»rt«, Model 4(cont.) After stratification bv Age Category OR 95% C.l. P-Value ‘AGE: 50 TO 59' 1-13 MET hrs/wk 0.7 (0.4-1.0) 0.0554 14 or more MET hrs/wk 0.6 (0.4 - 0.9) 0.0075 Test for Trend P 0.0119 AGE: 60 AND OLDER' 1-13 MET hrs/wk 1.2 (0.8-1.7) 0.1423 14 or more MET hrs/wk 0.8 (0.6 — 1.2) 0.2816 Test for Trend P 0.3480 1 2 6 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activitv measures, unmatched subiects (cont.) Model 5 - Includes Product Term: Intensity of Vigorous Recreational Activity X Age of Subject C o v a ria tes = A V I E T H _ C A T 2 E T H _ C A T 3 E T H _ C A T 4 E T H C A T S A G E S E X L O C A L C _ C A T 2 A L C J C A T 3 A S P R C A T O T P R C A T A N T A C A T L A X _ C A T E D U C A T Z E D U C A T 3 E D U C A T 4 B M I C A T S M K _ C A T 2 S M K C A T 3 A V I* A G E - intensity of vigorous recreational activity; (Low intensity - < 3 times/wk. Moderate intensity - > 4 METS and > 3 times /wk. High intensity — > 6 METS and ^1 hr. /wk) - Asian ( Asian, Non-Asian) - Latino/Hispanic (Latino, Non-Latino) - African American ( African American, Non-African American) - Other ( Other Ethnicity, Non- Other Ethnicity) - Age of subject - Sex (Male, Female) - Kaiser Location (Sunset, Bellflower) - Ave. Alcohol (g day '), (113 g/day, not 1-13 g/day) - Ave. Alcohol (g day '), ^ 14 g/day, <14 g/day) - Aspirin Use (Yes, No) - Other Pain Relief Medication Use (Yes, No) - Antacid Use (Yes, No) - Laxative Use (Yes, No) - High School (Yes, No) - Technical School/Some College (Yes, No) - College/Graduate School (Yes, No) - Body Mass Index (kg m^), (> 14 g/day, < 14 g/day) - Ex-smoker (Yes, No) - Current Smoker (Yes, No) - Intensity of vigorous recreational activity; (Low intensity - < 3 times/wk. Moderate intensity - > 4 METS and > 3 times /wk. High intensity — > 6 METS and >_1 hr. /wk) X Age of Subject For Model 5: logit(pr(Y=l)| = Bo + B ,(A V I) + B ^ (E T H _C A T 4) + B ,(S E X ) + B ,o (A L C _ C A T 3 ) + B „ (A N T A _ C A T ) + B ,« (E D U C A T 3 ) + B „ (S M K _ C A T 2 ) + B z (E T H _ C A T 2 ) + B ;(E T H _ C A T 5 ) + B «(L O C ) + B „ (A S P R _ C A T ) + B ,4 (L A X _ C A T ) + B,t (EDUCAT4) + B z ,(S M K _ C A T 3 ) + B j(E T H _ C A T 3 ) + B *(A G E ) + B ,(A L C _ C A T 2 ) + B ,j(O T P R _ C A T ) + B ,s(E D U C A T 2 ) + B „ (B M I_ C A T ) + B î,(A V I* A G E ) Fitted Model 5: Interaction P = 0.0079 logitlpr(Y=l)| = 1.9699 - 2.1468(AVI) + 0.0318(ETH_CAT4) - 0.1921(SEX) + 0.2480(ALC_CAT3) + 0 .I9 8 7 (E T H _ C A T 2 ) + 0 a 0 1 3 (E T H _ C A T 5 ) - 0 .0 1 4 2 (L O C ) - 0 .0 4 4 7 (A S P R _ C A T ) - 0 .0 4 3 4 (A N T A _ C A T ) + 0 .1 7 4 8 (L A X _ C A T ) + 0 .1 3 8 8 (E D U C A T 3 ) + 0 .1 5 4 5 (E D U C A T 4 ) + O .I9 6 6 (S M K _ C A T 2 ) + 0 .8 0 2 8 (S M K _ C A T 3 ) + 0 .0 3 0 6 (A V I* A G E ) - 0 .0 9 7 0 (E T H _ C A T 3 ) - 0 .0 3 19(A G E ) + 0 .0 6 6 9 (A L C _ C A T 2 ) + 0 .0 9 5 2 (O T P R _ C A T ) + 0 .0 0 0 1 (E D U C A T 2 ) + O .I988(B M I_C A T ) 127 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activitv measures, unmatched subiects. Model Slcont.) After stratification bv Age Category: OR 95% C I. P-Value ‘AGE: 45 TO 59’ Moderate intensity - > 4 METS and > 3 times /wk 0.6 (0.4 — 0.9) 0.009 High intensify - > 6 METS and hr. /wk 0.4 (0.2 — 0.7) 0.002 Test for Trend P 0.0009 'AGE: 60 AND OLDER’ Moderate intensity - > 4 METS and > 3 times/wk 0.9 (0.7—1.2) 0.4627 High intensity - > 6 METS and ^1 hr./wk 0.9 (0.5—1.6) 0.6601 Test for Trend P 0.73 128 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 ; Interaction for vigorous physical activity measures, unmatched subiects (cont) Model 6 - Includes Product Term: Frequency of Vigorous Recreational Activity X Antacid Use Covariates = FREQ VA - Frequency of Vigorous Acttvity (> 3 times/wk, < 3 times/wk) ETH CAT2 - Asian ( Asian, Non-Asian) ETH CAT3 - Latino/Hispanic (Latino, Non-Latino) ETH CAT4 - African American ( African American, Non-African American) ETH CAT5 - Other ( Other Ethnicity, Non- Other Ethnicity) AGE - Age of subject SEX - Sex (Male, Female) LOC - Kaiser Location (Sunset, Bellflower) ALC CAT2 - Ave. Alcohol (g day"'), (1-13 g/day, not 1-13 g/day) ALC CAT3 - Ave. Alcohol (g day '), ^ 14 g/day, < 14 g/day) ASPR CAT - Aspirin Use (Yes, No) OTPR CAT - Other Pain Relief Medication Use (Yes, No) ANTA CAT - Antacid Use (Yes, No) LAX CAT - Laxative Use (Yes, No) EDUCAT2 - High School (Yes, No) EDUCAT3 - Technical School/Some College (Yes, No) EDUCAT4 - College/Graduate School (Yes, No) BMI CAT - Body Mass index (kg m *\ (>14 g/day, < 14 g/day) SMK CAT2 - Ex-smoker (Yes, No) SMK CAT3 - Current Smoker (Yes, No) For Model 6: logit(pr(Y=l)J = X Antacid Use (Yes, No) Bo + B,(FREQ_VA) + B 4 (E T H _ C A T 4 ) + Bt CSEX) + B ,o (A L C _ C A T 3 ) + B ,3 (A N T A _ C A T ) + B ,s(E D U C A T 3 ) + B „ (S M K _ C A T 2 ) Fitted Model 6: Interaction P — 0.006 logitlpr(V=l)| =-0.8714 - 0.4552(FREQ_VA> + B i(E T H _ C A T 2 ) + B s(E T H _ C A T 5 ) + B *(L O C ) + B „ (A S P R _ C A T ) + B m(L A X _C A T > + B , t (E D U C A T 4> + B jo (S M K _ C A T 3 ) + B3(ETH_CAT3) + B s(A G E ) + B ,(A L C _ C A T 2 ) + B ,2 (0 T P R _ C A T ) + B ,s(E D U C A T 2 ) + B „ (B M I_ C A T ) + B i ,(F R E Q _ V A * A N T A _ C A T ) + 0 .1 7 1 2 (E T H _ C A T 2 ) + 0 .1 8 1 8 (E T H _ C A T 5 ) - 0 .0 0 5 5 (L O C ) 0 .0 3 5 8 (A S P R C A T ) + 0 .0 2 2 9 (E T H _ C A T 4 ) - 0 .1 9 3 9 (S E X ) + 0 .2 5 3 6 (A L C _ C A T 3 ) - 0 .1 8 9 4 (A N T A _ C A T ) + O .I7IO (L A X _C A T ) + 0 .1 2 1 1 (E D U C A T 3 ) + 0 .1 4 1 0 (E D U C A T 4 ) + 0 .2 0 0 2 (S M K C A T 2 ) + 0 .8 0 2 0 (S M K _ C A T 3 ) + 0 .4 5 7 7 (F R E Q _ V A * A N T A _ C A T ) - 0 .0 9 7 5 (E T H _ C A T 3 ) + 0 .0 1 I1 (A G E ) + 0 .0 4 9 6 (A L C _ C A T 2 ) + 0 .0 7 7 4 (O T P R _ C A T ) - 0 .0 1 7 2 (E D U C A T 2 ) + 0 .1 7 9 7 (B M I_ C A T ) After stratification bv Antacid Use Non Antacid Users Antacid Users OR 0.6 0 .9 9 5 % C .I. ( 0 .5 - 0 .8 ) (0.6-1.4) P-Value 0.0009 0.7891 129 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activitv measures, unmatched subiects (cont.) Model 7 - Includes Product Term: Average M ET hrs/wk. of Vigorous Recreational Activity X Antacid Use MET - Vigorous recreational activity - Average MET hours per week (0 - < 1 MET hrs/wk, 1 - < 14 MET hrs/wk, > 14 MET hrs/wk) ETH CAT2 - Asian ( Asian, Non-Asian) ETH CAT3 - Latino/Hispanic (Latino, Non-Latino) ETH CAT4 - African American ( African American, Non-African American) ETH CATS - Other ( Other Ethnicity, Non- Other Ethnicity) AGE - Age of subject SEX - Sex (Male, Female) LOC - Kaiser Location (Sunset, Bellflower) ALC CAT2 - Ave. Alcohol (g day '), (1-13 g/day, not 1-13 g/day) ALC CAT3 - Ave. Alcohol (g day"'), (> 14 g/day, < 14 g/day) ASPR CAT - Aspirin Use (Yes, No) OTPR CAT - Other Pain Relief Medication Use (Yes, No) ANTA_CAT - Antacid Use (Yes, No) LAX CAT - Laxative Use (Yes, No) EDUCAT2 - High School (Yes, No) EDUCAT3 - Technical School/Some College (Yes, No) EDUCAT4 - College/Graduate School (Yes, No) BMI CAT - Body Mass index (kg m \ (> 14 g/day, < 14 g/day) SMK CAT2 - Ex-smoker (Yes, No) SMK CAT3 - Current Smoker (Yes, No) MET* ANTA CAT - Vigorous recreational activity - Average MET hours per week (0 - < 1 MET hrs/wk, 1 - < 14 MET hrs/wk, > 14 MET hrs/wk) X Antacid Use (Yes, No) For Model 7: logitIpr(Y=t)| + B ,(M E T ) + B ^ (E T H _C A T 4) + Bt(S E X ) + B ,o (A L C _ C A T 3 ) + B ,3 (A N T A _ C A T ) + B ,« (E D U C A T 3 ) + B „ (S M K _ C A T 2 ) + B j(E T H _ C A T 2 ) + B s(E T H _ C A T 5 ) + B g(L O C ) + B „ (A S P R _ C A T ) + B ,4 (L A X _ C A T ) + B ,7 (E D U C A T 4 ) + Bm(SMK_CAT3) + Bj(ETH_CAT3) + B c(A G E ) + B ,(A L C _ C A T 2 ) + B ,2 (0 T P R _ C A T ) + B ,s(E D U C A T 2 ) + B ,» (B M I_ C A T ) + B i,(M E T * A N T A _ C A T ) Fitted Model 7: Interaction P = 0.0336 logit|pr(V=l)| = -0.6249 - 0.2522(MET) + 0.0I90(ETH_CAT4) - 0.1930(SEX) + 0 J527(ALC_CAT3) + 0 .I9 0 1 (E T H _ C A T 2 ) + 0 .1 7 8 4 (E T H _ C A T 5 ) - 0 .0 0 9 6 (L O C ) - 0 .0 3 8 7 (A S P R _ C A T ) - 0 .4 9 9 1 (A N T A _ C A T ) + O .I6 2 8 (L A X _ C A T ) + 0 .I2 0 8 (E D U C A T 3 ) + 0 .I3 1 0 (E D U C A T 4 ) - O.IOI7(ETH_CAT3) + 0.0109(AGE) + 0.0473(ALC_CAT2) + 0.0769(OTPR_CAT) - 0.020i(EDUCAT2) + O.I927(BMI_CAT) + 0 .2 0 7 3 (S M K _ C A T 2 ) + 0 .8 1 5 0 (S M K _ C A T 3 ) + 0.2991 (M E T * A N T A _ C A T ) 130 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 ; Interaction for vigorous physical activitv measures, unmatched subiects, Model 7 fcont.) After stratification bv Antacid Use Non Antacid Users 1 - 13 MET bi^wk 14 or more MET hrs/wk Test for Trend P OR 0.9 0. 6 95% C.l. (0.6 -ta) ( 0 . 4 - 0 . 8 ) P-Valuc 03607 0.0009 0.004 Antacid Users 1 — 13 MET hrs/wk 14 or more MET hrs/wk Test for Trend P 0 .9 1.1 (0.5-1.6) (0.7-1.7) 0 .7 9 1 3 0.7914 0.91 131 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activitv measures, unmatched subiects Tcont.) Model 8 - Includes Product Term: Intensity of Vigorous Recreational Activity X Antacid Use Covariates = AVI - Intensity of vigorous recreational activity; (Low intensity - < 3 times/wk. Moderate intensity - > 4 METS and > 3 times /wk. High intensity — > 6 METS and ^1 hr. /wk) ETH CAT2 - Asian ( Asian, Non-Asian) ETH CAT3 - Latino/Hispanic (Latino, Non-Latino) ETH CAT4 - African American ( African American, Non-African American) ETH_CATS - Other ( Other Ethnicity, Non- Other Ethnicity) AGE - Age of subject SEX - Sex (Male, Female) LOC - Kaiser Location (Sunset, BellHower) ALC CAT2 - Ave. Alcohol (g day '), (1-13 g/day, not 1-13 g/day) ALC CAT3 - Ave. Alcohol (g day"'), (> 14 g/day, < 1 4 g/day) ASPR CAT - Aspirin Use (Yes, No) OTPR CAT - Other Pain Relief Medication Use (Yes. No) ANTA CAT - Antacid Use (Yes. No) LAX CAT - Laxative Use (Yes. No) EDUCAT2 - High School ^ e s . No) EDUCAT3 - Technical School/Some College (Yes, No) EDUCAT4 - College/Graduate School (Yes, No) BMI CAT - Body Mass Index (kg m '), (> 14 g/day, < 14 g/day) SMK CAT2 - Ex-smoker (Yes, No) SMK CAT3 - Current Smoker (Yes, No) AVI* ANTA CAT - Intensity of vigorous recreational activity; (Low intensity - < 3 times/wk. Moderate intensity - > 4 METS and > 3 times /wk. High intensity — > 6 METS and >_1 hr. /wk) X Antacid Use (Yes. No) For Model 8: logitlpr(Y=l)| Bo + B,(AVI) + B4(ETH_CAT4) + B,(SEX) + B ,o (A L C _ C A T 3 ) + B ,j(A N T A _ C A T ) + B ,((E D U C A T 3 ) + B „ (S M K _ C A T 2 ) + B i(E T H _ C A T 2 ) + B s(E T H _ C A T 5 ) + B ,(L O C ) + B „ (A S P R _ C A T ) + B m(L A X _ C A T ) + B ,t(E D U C A T 4 ) + B z ,(S M K _ C A T 3 ) + B 3<E T H _C A T 3) + BoCAGE) + B ,(A L C _ C A T 2 ) + B ,i(O T P R _ C A T ) + B ,s(E D U C A T 2 ) + B ,a(B M I_ C A T ) + B z ,(A V I* A N T A C A T ) Fitted Model 8: Interaction P = 0.0200 logit|pr(V=I)l = -0.4212 - 0.4029(AVI) + 0.0I82(ETH_CAT4) - 0.2000(SEX) + 0.2514(ALC_CAT3) + 0 .I8 0 7 (E T H _ C A T 2 ) + 0 .1 9 6 3 (E T H _ C A T 5 ) - 0.0075(LOC) - 0 .0 3 9 4 (A S P R _ C A T ) - 0 .6 7 0 3 (A N T A _ C A T ) + 0 .1 6 5 3 (L A X _ C A T ) + 0 .1 1 3 0 (E D U C A T 3 ) + 0 .1 I9 0 (E D U C A T 4 ) - 0.0908(ETH_CAT3) + 0.0106(AGE) + 0.0564(ALC_CAT2) + 0.0838(OTPR_CAT) - 0.02i0(EDUCAT2) + 0.I759(BMI_CAT) + 0 .2 0 2 8 (S M K _ C A T 2 ) + 0 .8 0 6 0 (S M K _ C A T 3 ) + 0 .4 5 4 8 (A V I* A N T A C A T ) 132 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 15 : Interaction for vigorous physical activitv measures, unmatched subiects. Model Sfcont't After stratification bv Antacid Use OR 95% C I. P-Value Non A ntacid U sers Moderate Intensity - > 4 METS and > 3 times/wk 0.7 (0.5-0.9) 0.0110 High intensity - > 6 METS and hr. /wk 0.4 (0.2 - 0.7) 0.0010 Test for Trend P 0.0006 Antacid Users Moderate intensity - > 4 METS and > 3 times/wk 0.9 (0.6-1.4) 0.5638 High intensity-' > 6 METS and >_1 hr./w k 1.5 (0.6-4.0) 0.3917 Test for Trend P 0.54 133 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. The association of polyps with all three measures of vigorous physical activity varied with age. These included; frequency of activity, average MET hours per week, and intensity of activity (Interaction P=0.009, P=0.03, P=0.008 respectively). Using a multivariate model, the association between polyps and frequency of vigorous activity was significant for subjects aged 45 to 59 with an OR of 0.6 (95% C.I.=0.4-0.8). The association was not significant for subjects aged 60 and older. In the multivariate model, the association between polyps and average MET hours per week for vigorous activity was significant only among subjects aged 45 to 59, who performed vigorous recreational activity 1 to 13 MET hours per week and 14 or more MET per week (OR=0.7, 95% C.I.=0.4-1.0, OR=0.6, 95% C.I.=0.4-0.9, trend P=0.01). The association was not significant for remaining age groups (subjects aged 60 and older). The association between polyps and intensity of vigorous activity in the multivariate model was significant among subjects aged 45 to 59, who performed moderately intense and highly intense vigorous recreational activity (OR = 0.6, 95% C.I.=0.4-0.9, OR = 0.4, 95% C.I.=0.2-0.7, trend P=0.0009). The association was not significant in the remaining three age groups combined (subjects aged 60 and older). The association of polyps with vigorous recreational activity did vary by antacid use for all three measures: frequency of activity (Interaction P=0.006), average MET hours per week (P=0.03), and intensity of activity (P=0.02). For frequency of vigorous recreational activity, after stratification by antacid use, the association between frequency of physical activity and colorectal adenomas was strengthened among non-antacid use subjects. In the multivariate model, among non-antacid users, the OR for polyps among 1 3 4 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. those subjects who performed vigorous recreational activity (> 3 times per week) compared with inactive subjects (< 3 times per week) was 0.6 (95% Cl G.5-0.8). Average MET hours per week of vigorous recreational activity among non-antacid users showed a decreased odds across increasing categories of activity, odds ratios of 0.9 (for 1 to 13 hrs/wk) and 0.6 (for 14 or more hrs/wk), respectively (95% C.I.=0.6-1.2, and 95% C.I.=0.4-0.8, trend P=0.004). In addition, intensity of vigorous recreational activity among non-antacid users showed a decreased odds ratio across increasing categories of activity, OR=0.7 for moderate intensity compared to low (95% C.I.=0.5-0.9), and OR=0.4 for high intensity compared to low (95% C.I.=0.2-0.7, trend P=0.0006). Among antacid users, the association was not significant for all three measures of vigorous recreational activity. The association of polyps with vigorous physical activity did not vary by gender, smoking status, alcohol consumption, BMI, aspirin use, laxative use, or other pain relief medication use. 2.4.2.1 Summary of Interaction: There was a significant protective effect between polyps and frequent vigorous recreational activity among white non-Asian subjects, a suggestion of protective effect among Latino subjects (although less consistent than among whites), and no apparent effect in Asians and African Americans.. There was also a suggestion of heterogeneity by education level, age, and antacid use. 135 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 2.4.3 Correlation - Occupational and Recreational Physical Activitv Since some studies have only measured physical activity either by using occupational activity or recreational physical activity, it is of interest to measure the correlation between these two variables.^^"^^’ ^3, 90-94 Measures of correlation were calculated to evaluate the strength of the linear association between the average MET hours per day of occupational and vigorous recreational physical activity. The correlation matrix gives the results for the Pearson product-moment correlation coefficient and the Spearman correlation coefficient for the continuous and categorical measurement of these variables (Tables 16-22). The correlation coefficient measures the strength of the linear relationship between the two variables. A correlation of 0 implies that there is no linear association between two variables. A correlation of 1 (-1) means that there is an exact positive (negative) linear association between the two variables. The associated p value under the null hypothesis (r = 0) is shown on the tables. For comparison, measures of combined recreational and occupational activity were included in this analysis. The Pearson and Spearman correlation coefficients were estimated for all unmatched subjects (Table 16), across all ethnic groups (Table 17-20), and by gender (Table 21-22). 2.4.3.1 Total Subiects The Pearson and Spearman correlation coefficients for all unmatched subjects are shown in Table 16. For unmatched subjects, there was little to no association between vigorous recreational physical activity and occupational activity for either the Pearson or 136 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 16: The Correlation M atrix Table Between Recreational and Occupational Variables for all Unmatched Data, In Average MET Hours Per Week. Variable N Mean Std. Dev. Average MET Hrs/wk: Vigorous Recreational Activity: 1716 1.54429 0.80147 Occupational Activity 1716 2.50175 1.11836 Combined Occupational and Recreational Activity 1716 2.50175 1.11836 Pearson Correlation Coefficients. N = 1716 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 -0.04074 0.26956 0.0915* <.0001* Occu national -0.04074 1.00000 0.83963 0.0915* <0001* Combined 0.26956 0.83963 1.00000 <.0001* <0001* Prob > |r{ under HO: Rho=0 Spearman Correlation Coefficients. N = 1716 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 -0.04135 0.25220 0.0868* <0001* Occupational -0.04135 1.00000 0.83961 0.0868* <.0001* Combined 0.25220 0.83961 1.00000 <.0001* <0001* Prob > } r} under HO: Rho=0 137 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 17: The Correlation Matrix Table Between Recreational and Occupational Variables. In Average MET Hours P er Week. Ethnicitv=White. Variable N Mean Std. Dev. Average MET Hrs/wk: Vigorous Recreational Activity: 806 8.95163 18.59560 Occupational Activity 806 115.94541 51.79018 Combined Occupational and Recreational Activity 806 124.89704 54.66350 Pearson Correlation Coefficients. N = 806 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 -0.02073 032055 0.5568* <0001* Occupational -0.02073 1.00000 0.94039 0.5568* <.0001* Combined 032055 0.94039 1.00000 <0001* <0001* Prob > (r| under HO: Rho=0 Spearman Correlation Coefficients. N = 806 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 -0.04759 0.26163 0.1771* <0001* Occupational -0.04759 1.00000 0.82726 0.1771* <0001* Combined 0.26163 0.82726 1.00000 <•0001* <.0001* Prob > )r| under HO: Rho=0 138 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 18; The Correlation Matrix Table Between Recreational and Occupational Variables. In Average MET Hours Per Week. Ethnicitv=Afriean American. Variable N Mean Std. Dev. Average MET Hrs/wk: Vigorous Recreational Activity: 287 (>.31160 25.70024 Occupational Activity 287 120.82230 46.97053 Combined Occupational and Recreational Activity 287 127.13390 52.04423 Pearson Correlation Coefficients. N = 287 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 -0.06550 0.43470 0.2688* <.0001* Occunational -0.06550 1.00000 0.87017 0.2688* <0001* Combined 0.43470 0.87017 1.00000 <.0001* <0001* Prob > |r| under HO; RhoM) Spearman Correlation Coefficients. N = 287 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 -0.18642 0.13885 0.0015 0.0186 Occupational -0.18642 1.00000 0.84074 0.0015 <.0001 Combined 0.13885 0.84074 1.00000 0.186 <0001 Prob > |r| under HO: Rho=0 139 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 19: The Correlation Matrix Table Between Recreational and Occupational Variables, In Average MET Hours Per Week. Ethnicitv=Latino. Variable N Mean Std. Dev. Average MET Hrs/wk: Vigorous Recreational Activity: 304 Occupational Activity 304 Combined Occupational and Recreational Activity 304 8.94006 22.92363 125.25658 55.43908 134.19664 61.15845 Pearson Correlation Coefficients. N = 304 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 0.05562 0.42524 0.3338* <.0001* Occunational 0.05562 1.00000 0.92733 0.3338* <0001* Combined 0.42524 0.92733 1.00000 <.0001* <.0001* Prob > |r| under HO: Rho=0 Spearman Correlation Coefficients. N = 304 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 0.00373 0.29567 0.9484* <.0001* Occupational 0.00373 1.00000 0.83412 0.9484* <.0001* Combined 0.29567 0.83412 1.00000 <.0001* <.0001* Prob > )r| under HO: Rho=0 140 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 20: The Correlation Matrix Table Between Recreational and Occupational Variables. In Average MET Hours Per Week. Ethnicitv°Asian. Variable N Mean Std. Dev. Average MET Hrs/wk: Vigorous Recreational Activity: 187 Occupational Activity 187 Combined Occupational and Recreational Activity 187 7.51903 16.82079 101.19786 42.77194 108.71689 44.86000 Pearson Correlation Coefficients. N = = 187 Vigorous Recreational Occunational Combined Vigorous Recreational 1.00000 -0.06947 03448* 0.30873 <0001* Occunational -0.06947 03448* 1.00000 0.92741 <.0001* Combined 030873 <.0001* 0.92741 <0001* 1.00000 * Prob > |r| under HO: Rho=0 Snearman Correlation Coefficients. N = 187 Vigorous Recreational Occunational Combined Vigorous Recreational 1.00000 -0.00190 0.9795* 0.26336 0.0003* Occunational -0.00190 0.9795* 1.00000 0.86687 <.0001* Combined 0.26336 0.0003* 0.86687 <0001* 1.00000 * Prob > |r| under HO: Rho=0 141 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 21: The Correlation Matrix Table Between Recreational and Occupational Variables, In Average MET Hours Per Week, Gender=M ale. Variable N Mean Std. Dev. Average MET Hrs/wk: Vigorous Recreational Activity: 1114 9.41979 23.10505 Occupational Activity 1114 123.24057 59.81975 Combined Occupational and Recreational Activity 1114 132.66037 63.61049 Pearson Correlation Coefficients, N = = 1114 Vigorous Recreational Occunational Combined Vigorous Recreational 1.00000 -0.02386 034079 0.4263* <0001* Occunational -0.02386 1.00000 0.93174 0.4263* <.0001* Combined 0J4079 0.93174 1.00000 <0001* <0001* * Prob > |rj under HO: Rho=0 Snearman Correlation Coefficients. N = 1114 Vigorous Recreational Occunational Combined Vigorous Recreational 1.00000 -0.08654 0.17026 0.0038* <.0001* Occunational -0.08654 1.00000 0.85634 0.0038 <0001* Combined 0.17026 0.85634 1.00000 <0001 <0001 Prob > (r) under HO: Rho=0 142 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Table 22: The Correlation Matrix Table Between Recreational and Occupational Variables. In Average MET Hours Per Week. Gender=Fem ale. Variable N Mean Std. Dev. Average MET Hrs/wk: Vigorous Recreational Activity: 602 Occupational Activity 602 Combined Occupational and Recreational Activity 602 6.65088 15.59843 105.79734 29.37358 112.44823 33.33286 Pearson Correlation Coefficients. N = 602 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 Occupational 0.00541 0.8945* Combined 0.47273 <.0001* 0.00541 0.8945* 1.00000 0.88375 <.0001* 0.47273 <.0001* 0.88375 <0001* 1.00000 * Prob > IrJ under HO: Rho=0 Spearman Correlation Coefficients. N = 602 Vigorous Recreational Occupational Combined Vigorous Recreational 1.00000 0.01928 032169 0.6368* <.0001* Occupational 0.01928 1.00000 0.83260 0.6368* <.0001* Combined 032169 0.83260 1.00000 <.0001* <.0001* * Prob > |r| under HO: Rho=0 143 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Spearman coefïîcient (r=-0.041 and r=-0.041, respectively). In addition, the results were not significant for either the Pearson or Spearman coefficient (p=0.09 and p=0.09, respectively). 2.4.3 2 Stratified by Ethnicity The Pearson and Spearman correlation coefficients for various ethnic groups are shown in Table 17-20. The results indicate there was little to no association between vigorous recreational physical activity and occupational activity for either the Pearson or Spearman coefficient (-0.07<r< 0.06 and -0.19<r<0.07, respectively). The only significant value occurred among Afiican Americans, for the Spearman correlation coefficient (r=-0.19, p=0.002). Overall for ethnic groups, there is no evidence that vigorous recreational physical activity varies in a linear fashion with occupational activity for either the Pearson or Spearman coefficient. 2.4.3.3 Stratified bv Gender Examining the Pearson and Spearman correlation coefficient by gender (Table 21 and 22), there was little to no association between vigorous recreational physical activity and occupational activity. For males, the Pearson and Spearman coefficient was r=-0.024 and r=-0.087 respectively. The results for males were not significant for the Pearson coefficient (p=0.43); however, they were significant for the Spearman coefficient (p=0.004). Among females, the Pearson and Spearman coefficient was r=0.005 and 144 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. r=0.019, respectively. There is no evidence that vigorous recreational physical activity varies in a linear fashion with occupational activity (p=0.89 and p=0.64). 2.4.4 Measures of Impact Preventable measures of impact were also calculated for significant associations between physical activity and adenomatous polyps. The preventable numbers and fractions give an estimate of the number of cases or the proportion of cases, respectively, of adenomatous polyps that would be prevented by exposure to physical activity. The preventable measures of impact estimated in this analysis include: the prevented number (A®), the prevented fraction in the exposed population (PFE), the prevented fraction in the total population (PF), and the preventable fraction (PRF). The prevented number. A ® , reflects the additional number of cases that would have occurred in the absence of exposure. The prevented fraction in the exposed population, PFE, is the proportion of all potential cases in the exposed base population that were prevented by exposure. The PF, prevented fraction in the total population, gives the proportion of all potential cases in the total population that would have been prevented by exposure. The PRF, the preventable fraction, indicates the maximum proportion of all potential cases that could have been prevented in the future if everyone were exposed. The preventable numbers and fractions were estimated for significant associations for vigorous physical activity among all unmatched subjects (Table 23), across ethnic groups (Table 24-25), and by gender (Table 26-27). 145 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. ■ o I I c / ) o' = 3 Table 23. Preventable Fractions and Numbers for All Subjects = 3 CD CD ■ o I c a o = 3 ■ o o & o c Physical Activity Measure EXPOSED POLYP EXPOSED & POLYP N OR PF PFE A° PRF Vigorous R ecreational Activity; Three or M ore Tim es Per W eek 566 832 229 1716 0.60 0.16 0.40 153 0.29 Three or M ore Tim es Per W eek 566 832 229 1716 0.70 0.11 0.30 98 0.22 Average M ET H ours Per W eek: ltol3" 258 697 115 1378 0.70 0.07 0.30 49 0.25 1 4 o r m ore^ 338 717 135 1458 0.60 0.11 0.40 90 0.32 1 4 o r m ore 338 717 135 1458 0.70 0.07 0.30 58 0.24 Intensity of Vigorous A ctivity; M oderate In ten sity ^ 376 754 151 1526 0.70 0.08 0.30 65 0.24 M oderate In ten sity 376 754 151 1526 0.80 0.05 0.20 38 0.16 H igh In ten sity 89 630 27 1239 0.50 0.04 0.50 27 0.48 Occunational A ctivity; 100 M E T h rs/w k 429 394 180 857 0.70 0.16 0.30 77 0.16 C/) o' = 3 - Indicates Results of Univariate Analysis M* - Indicates Results of Multivariate Analysis U/M* - Indicates Results for Both Analyses (ie., same OR) Qj® - 2nd Quartile Q3 * - 3rd Quartile CD ■D O Q . C g Q . ■ D CD C/) o' 3 O 8 ( O ' 3. 3 " CD CD ■ D O Q . C a o 3 ■ D O CD Q . ■ D CD ( / ) C/) Table 24. Preventable Fractions and Numbers for Ethnicity = "White" U* ■ Indicates Results o f Univariate Analysis M* - Indicates Results o f Multivariate Analysis U/M* - Indicates Results for Both Analyses (ie., same OR) Physical Activity Measure EXPOSED POLYP EXPOSED & POLYP N OR PF PFE PRF Vigorous Recreational A ctivitv: Three or M ore Times Per W eek 289 391 115 806 0.60 0.16 0.401 77 0.28 Average M ET Hours Per W eek; 1 4 or m ore 1 4 or more‘ s* 176 333 66 678 0.50 176 333 66 678 0.60 0.17 0.50 66 0.40 0.12 0.40 44 0.32 Intensity of Vigorous A ctivity; M oderate Inten sity M oderate Intensity M J 245 372 99 758 0.60 245 372 99 758 0.70 0.15 0.40 66 0.29 0.10 0.30 42 0.22 7 ) CD ■ D O Q . C 8 Q . ■ D CD e n en o ' 3 O CD 8 Table 25. Preventable Fractions and Numbers for Ethnicity = "Latino" i 3 CD 3. 3 " CD CD ■ D O Q . C a O 3 ■D O Physical Activity Measure EXPOSED POLYP EXPOSED & POLYP N OR PF PFE A° PRF Vigorous Recreational A ctivitv; Three or M ore Tim es Per W eek : 103 139 38 304 0.60 0.15 0.40 25 0.29 - Indicates Results o f Univariate Analysis CD Q . O C ■ o CD cn cn o ' 3 4 ^ 0 0 CD ■D O Q . C g Q . ■ D CD C/) o" 3 O 8 ci' Table 26. Preventable Fractions and Numbers for Gender = "Male" 3. 3 " CD CD ■ D O Q . C a O 3 ■ D O CD Q . ■ D CD en en - Indicates Results of Univariate Analysis M* - Indicates Results of Multivariate Analysis U/M* - Indicates Results for Both Analyses (ie., same OR) Physical Activity Measure EXPOSED POLYP EXPOSED & POLYP N OR PF PFE A° PRF Vigorous Recreational A ctivitv: Three or M ore Tim es Per W eek 374 530 149 1114 0.60 0.16 0.40 99 0.29 Three or M ore Tim es Per W eek 374 530 149 1114 0.70 0.11 0.30 64 0.22 Average M ET Hours Per W eek: 1 4 o r M ore ^ 234 456 90 953 0.60 0.12 0.40 60 0.32 1 4 o r M ore 234 456 90 953 0.70 0.08 0.30 39 0.24 Intensity of Vigorous A ctivity: M oderate In ten sity ^ 305 501 126 1037 0.70 0.10 0.30 54 0.22 M oderate In ten sity 305 501 126 1037 0.80 0.06 0.20 32 0.15 H igh Inten sity ^ 77 404 29 809 0.60 0.05 0.40 19 0.37 CD ■D O Q . C g Q . ■ D CD C/) o" 3 O 8 ci' Table 27. Preventable Fractions and Numbers for Gender = "Female" 3. 3 " CD CD ■ D O Q . C a O 3 ■ D O CD Q . ■ D CD C/) C/) Physical Activity Measure EXPOSED POLYP EXPOSED & POLYP N OR PF PFE A° PRF Vigorous Recreational A ctivitv: Three or M ore Tim es Per W eek 192 302 80 602 0.60 0.15 0.40 53 0.29 Three or M ore Tim es Per W eek 192 302 80 602 0.70 0.10 0.30 34 0.22 Average M ET H ours Per W eek; 1.13"' 97 257 41 498 0.60 0.10 0.40 27 0.34 14 or M ore 104 261 45 505 0.70 0.07 0.30 19 0.25 Intensity of Vigorous Activity: M oderate In ten sity " 158 290 69 567 0.70 0.09 0.30 30 0.23 H igh In ten sity 35 233 12 444 0.40 0.07 0.60 18 0.57 ■ Indicates Results of Univariate Analysis M* - Indicates Results of Multivariate Analysis LA O 2.4.4.1 Total Subjects The preventable measures of impact for all unmatched subjects calculated utilizing significant odds ratios from the unconditional logistic regression analysis are shown in Table 23. Among these subjects, the highest prevented number, A°= 153, represents the number of additional cases that would have occurred among subjects who did vigorous recreational activity three or more times per week, had they not done that physical activity. The prevented fraetion in the total population, PF = 0.16, was also highest for this category, indicating that 16% of all potential cases were prevented by vigorous recreational activity three or more times per week. The highest prevented fraction among the exposed (PFE = 0.50) and the highest preventable fraction (PRP = 0.48), occurred in the highest category of intense recreational activity. This indicates that 50% of all potential cases among those who were exposed (did highly intense recreational activity) were prevented by that level of intense recreational activity, while 48% reflects the maximum proportion of potential cases that could be prevented in the future if all subjects had done highly intense recreational activity. 2.4.4 2 White Subjects The preventable numbers and fractions for white subjects were calculated similarly utilizing significant odds ratios (Table 24). The highest prevented number (A°= 77), occurred among white subjects who did vigorous recreational activity three or more times per week. The highest prevented fraction (PF = 0.17) and highest prevented fraction 1 5 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. among the exposed (PFE = 0.50) occurred among those white subjects who engaged in 14 or more MET hours of vigorous recreational activity per week. The highest preventable fraction (PRF = 0.40), was also given by an average of 14 or more MET hours per week. Of interest is that 77 additional cases that would have occurred in the absence of exposure and 40% of all potential cases among exposed white subjects were prevented by participation in an average of 14 or more MET hours of vigorous recreational activity per week. 2.4.4 3 African American Subjects For African American subjects, no significant associations were identified from the unconditional logistic regression analysis. Consequently, no preventable measures of impact were calculated for African American subjects. 2 4.4.4 Latino Subjects Utilizing significant odds ratios from the unconditional logistic regression analysis, preventable numbers and fi-actions for Latino subjects are shown in Table 25. Among Latino subjects, the category of vigorous recreational activity (> 3 times per week), gave the prevented number (A ® = 25) and prevented fraction among Latinos (PF = 0.15). For this category, the prevented fraction among the exposed (PFE = 0.40), and the preventable fraction (PRF = 0.29), occurred among Latino subjects who reported vigorous recreational activity (> 3 times per week). This implies that 29% of all potential cases among those who were exposed (did vigorous recreational activity) were prevented 152 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. by that level of vigorous recreational activity. Twenty-nine percent reflects the maximum proportion of all potential cases that could be prevented in the future if all Latino subjects had participated in vigorous recreational activity (> 3 times per week). 2.4.4.5 Asian Subjects For Asian subjects, no significant associations for vigorous physical activity were identified fi-om the unconditional logistic regression analysis. Consequently, no preventable measures of impact were calculated for Asian subjects. 2.4.4.6 Male Subjects The preventable measures of impact for all male subjects are shown in Table 26. Among male subjects the highest prevented number (A®= 99) occurred among subjects who did vigorous recreational activity three or more times per week. The highest preventable fraction (PRF = 0.37), occurred in the highest category for intensity of vigorous recreational activity. This indicates that 37% is the maximum proportion of potential cases that could be prevented in the future if all male subjects had done highly intense recreational activity. The highest prevented fraction among the exposed (PFE = 0.40), occurred for frequency of vigorous activity, average MET hours per week of vigorous recreational activity (14 or more) and highly intense recreational activity. This implies that 40% of all potential cases among those who were exposed, for either 14 or more average MET hours per week of vigorous activity or occupational activity, were prevented by that type of physical activity. The prevented fraction in the total population, 1 5 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PF = 0.16, was also highest for subjects who did vigorous recreational activity three or more times per week 2.4.4.7 Female Subjects For female subjects, the preventable measures of impact are shown in Table 27. The highest prevented number (A° = 53), and prevented fraction (PF = 0.15), occurred for subjects who did vigorous recreational activity three or more times per week. In addition, the highest prevented fraction among the exposed (PFE - 0.60), and the preventable fraction (PRF = 0.57), occurred among female subjects who did highly intense vigorous recreational activity. This implies that 60% of all potential cases among those who were exposed (did highly intense recreational activity) were prevented by that level of vigorous recreational activity. While 57% reflects the maximum proportion of all potential cases that could be prevented in the future if all female subjects had participated in highly intense recreational activity. 2.4.4.8 Summary of Measures of Impact In general, an interpretation of the measures of impact assumes a causal relationship and that biases are absent. Overall, for total subjects in this study, vigorous recreational activity of three or more times per week or at the highest level of intensity resulted in the greatest measures of impact. After controlling for covariates, these results remained consistent. Again, vigorous recreational activity (> 3 times/week) and highest level of intensity were most often associated with higher preventable numbers. For White 1 5 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. subjects, the highest prevented numbers and prevented fractions occurred among subjects who did vigorous recreational activity three or more times per week or an average of 14 or more MET hours per week. Latino subjects had higher measure of impact for vigorous recreational activity of three or more times per week. Comparing males and females, both had larger measures of impact for vigorous recreational activity three or more times per week and for high intensity of vigorous recreational activity. 2.5 Discussion This study investigated the relationship between physical activity and colorectal adenomas, as well as measures of impact and correlation. In this study population, vigorous recreational physical activity was found to be inversely associated with the prevalence of polyps. These vigorous recreational activity measures include: activity three or more times per week, average MET hours per week, and intensity of activity. Occupational activity and combined occupational and recreational activity were also found to be inversely associated with adenomatous polyps in some quartiles, but the effects were weak and there was no consistent pattern or trend of increasing effect with increasing activity levels. Previous epidemiological studies of physical activity and colorectal adenomas have suggested that smoking status, body mass index, educational status, alcohol, and medication use are potential confounding factors, 81, 84, 85, 89-100 since these factors may be associated with the risk of colorectal adenomas, their role as potential 155 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. confounders has been considered in this analysis. In most cases, after controlling for confounders, the inverse association for the measures of vigorous recreational physical activity with adenomatous polyps either resembled those of the univariate model, or the effect was attenuated only slightly. Comparing the results for matched versus unmatched subjects, significant multivariate results were similar for the inverse association of the measures of vigorous recreational physical activity with adenomatous polyps. There are some concerns in this study about misclassification of physical activity. Similar to past epidemiologic studies o f physical activity and cancer, there is difficulty in precisely assessing physical a c t i v i t y . ! 1 3 jjj this study, recreational physical activity has been used as a separate index o f physical activity, as well as combined with a corresponding measure o f occupational activity. Although many studies may give a reasonable measure o f physical activity, misclassification can occur when subjects have difficulty recalling exercise patterns a c c u r a te ly .ü!» Ü3 An accurate pattern of recreational physical activity may be hard to assess, as it is much more likely to change from week to week, season to season, and year to y e a r . ^ 3 , 64, 1 1 1 past studies, fi-equency o f vigorous recreational activity has been shown to he a valid measure of physical activity. !^0, 1 4 1 Previous research has indicated that the measures o f highly intense vigorous activity may be more valid than assessment o f light or moderately intense activities. *34, 142 this study population, frequency o f vigorous recreational activity and intensity o f vigorous recreational physical activity in the higher categories was found to be more protective against adenomatous polyps. There may be some misclassification bias among the moderate to low categories o f vigorous activity. If a 156 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. linear dose response relationship exists, it may not be possible to observe the moderate effects due to misclassification. Among the measures of vigorous recreational activity, intensity of vigorous activity shows a stronger association than average MET hours per week of vigorous recreational activity. While it is possible that intensity of vigorous activity may be more protective, it is a also probable that it is a more accurate measure than average MET hours per week of vigorous recreational activity. The assessment of occupational activity used in this study also relies on self reported information and MET coding based on job title. This has limitations, as job coding assumes that all persons in a particular job category expend similar levels of energy.^ Limitations that could have occurred with job coding in this study include: possible selection bias, job intensity misclassification, secular changes in job requirements, seasonal changes in job requirements, and vtithin-job classification variability. 65,11 1 The potential for recall and selection bias in this study is a possible concern. Since some eligible case and control subjects refused to participate there may be the potential for bias due to non-response. Although information is not available on the non responders to evaluate this bias, the response rate for both the Sigmoid I and Sigmoid II studies was relatively high. Therefore, we can assume the bias is minimal. Cases in this study were aware of their disease status prior to enrollment in the study. This may have affected their responses to the study questions regarding the exposures. In addition, subjects with mild or no gastrointestinal symptoms were eligible to participate in the study. There could be concern that subjects with mild symptoms may alter their 1 5 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. physical activity responses. However the proportion o f subjects with mild symptoms was similar for both cases and controls. In this study, all subjects were subjected to the same diagnostic procedure and only subjects with minor or no symptoms were eligible. This would reduce any selection bias. In addition, screened controls were used which would minimize potential disease misclassification. However, since all study participants were screened, the results may be more relevant to a screened population. Since this is a sigmoidoscopy-based study, where detectable polyps were in the rectosigmoid region, these results may be more applicable to the left-sided colon as opposed to the entire large bowl. The possibility does exist that some o f the controls could have had polyps in the right-sided colon, out o f sigmoidoscopic view. If the etiology o f right-sided polyps and left-sided polyps differ, then the inclusion o f controls with right-sided polyps would not bias these results for the left-sided colon. ^ ^ 3 However, if the etiology o f the right and left-sided polyps is similar, then the inclusion of “false-negative” controls would cause bias results toward the null, as it is estimated that 15 percent o f those subjects with no polyps detected by sigmoidoscopy will have polyps in a proximal location. ^ ^ 4 ’ 1 ^ 5 ju some studies it has been suggested that higher physical activity may lower the risk o f cancer in the left colon.36,41,88,89,92,98,101 The results o f this study are consistent with the findings for the left colon, and would be applicable to left-sided polyps. Several biologic mechanisms have been proposed through which increased physical activity can lead to a decreased risk o f the development o f colorectal polyps. 73, 76, 1 ® ^ . It is suggested that moderate physical activity may lead to decreased gastrointestinal 158 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. transit time.^®^’ 10 5 This shortened transit time may decrease colon cancer risk by reducing exposure time to carcinogens.^* 103, 106 increased physical activity of varying intensity has also been shown to stimulate the vagas nerve, leading to propulsive peristalsis and decreasing gastrointestinal transit time. 1 0 3 However, the association between decreased colon transit time and increased physical activity levels or reduced risk of colorectal adenomatous is uncertain. '^ l * ^3,104,146-148 Increased aerobic activity may also affect levels o f prostaglandins that alter colon cell proliferation. Physical activity has been shown to increase the F-series prostaglandins ( P G F 2 ), which decrease the rate o f colonic cell division and increase gut motility; and decrease the prostaglandin PGE2, which increases colonic cell proliferation, decreases gut motility, and is released in greater amounts from colonic t u m o r s . ^ ^ , 6 5 , 7 3 , 1 0 3 Strenuous aerobic exercise has been shown to increase the levels o f PGF2 , however the relationship between physical activity and PGE2 is less clear ^3, 1 0 3 Additional supporting evidence for the association o f prostaglandins with a reduced risk o f colon cancer has been suggested by laboratory studies on rats and evidence in humans, using prostaglandin synthesis inhibitors. 38, 39, 64 Heavy levels o f exercise may influence some immune functions. It has been suggested that exercise-induced increases o f interleukin-1 levels may reduce colon cancer risk by decreasing gastrointestinal transit time and bile acid excretion, thereby reducing exposure time to c a r c i n o g e n s . 7 3 ,1 0 3 it h a s also been suggested that elevated insulin levels (a growth factor for colonic mucosal cells) may account for an increased risk o f colon c a n c e r .'^ b 65, 109 Previous studies have 159 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. suggested that physical activity may decrease colon cancer risk through its impact on insulin levels, yet recent studies have not supported this finding.'* h 110 Jhe results of this study suggest a modest protective association between physical activity and colorectal polyps. However, the exact complex biological mechanisms responsible for the protective effect of physical activity on the development of adenomatous polyps remains uncertain and open for future research. In spite of these limitations, the combination of subjects from Sigmoid I and Sigmoid n makes this one of the largest studies of physical activity and adenomatous polyps to date. The results of this study support an inverse association between the physical activity and colorectal adenomas. The strongest inverse associations occurred for measures of vigorous physical activity which included activity three or more times per week, average MET hours per week of 14 or more, and highly intense vigorous activity. These findings are similar to previously published results, which indicate that there is an association between physical activity and colorectal adenomas. Overall, the results of our study substantiate earlier investigations. Adjustments for covariates only minimally reduced the association. Also of interest are the measures of impact for significant results, as the number of cases that could have been prevented through exposure to physical activity are not small. Comparing ethnic groups; Whites and Latinos showed a protective effect for vigorous recreational activity. Among Latinos, the association between vigorous recreational physical activity three or more times per week and adenomatous polyps was significant only for the univariate analysis, after controlling for the covariates these significant 160 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. results diminish. No significant effect was seen among Asians and African Americans. However, Whites and Latinos had a greater number of subjects in this study. More numbers may be needed to appropriately examine the various strata of activity within each ethnic group Additional research into the effects of physical activity on adenomatous polyps by ethnic group is warranted, as current incidence and mortality rates of colorectal cancer vary considerably among ethnic groups. Further research should focus on ethnic populations at increased risk for colon cancer, to provide more targeted recommendations for screening and prevention. If our results suggesting important heterogeneity by race are confirmed by other studies, then the underlying reasons for this heterogeneity would warrant further study. 161 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2.6 References 1. Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer Statistics, 2001. CA-A Cancer Journal for Clinicians 2001 ;51 ; 15-36. 2. Ries LA, Eisner MP, Kosaiy CL, et al. SEER Cancer Statistics Review, 1973-1997. 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Appendices 184 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Appendix A l. Sigmoid I - In-person Interview 185 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 960601 KAISER/USC STUDY OF RISK FACTORS FOR COLON POLYPS CONFIDENTIAL PATIENT SURVEY Respondent's Name_ Respondent's KAISER (ID) NUMBER _ Respondent’ s social security number_ _ Date of interview (MM/DD/YY)_______ !_ Interviewer's name:_________________ ^ OPENING COMMENTS TO RESPONDENT Thank you for filling out the "Diet and Health Questionnaire". I will take a few moments to look it over, and, as we discussed over the telephone, 1 will ask you some additional questions. This interview will last about 45 minutes and we will cover some of the same topics that you've already responded to, just in more depth. It is important that you do not tell me whether or not you had a polyp at your sigmoidoscopy. Since this interview is being done for the purposes of research, it is important that I ask exactly the same questions, exactly the same way, of people who did and did not have polyps. The best way to ensure that I do that is that 1 am not told, until after we finish the interview, whether you are a case or a control in this study. Before we begin, do you have any questions? 186 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 960601 1. LET’S START BY REVIEWING YOUR MARITAL STATUS. I am going to read a number of possible responses and you can tell me all that apply. You a re.... (R ead all p o ssib le resp o n ses and mark all that apply.) a. married now...................................... 1...skip to d; don’t a sk f. b. single and living in a marital-type relationship..............2 c. single and living with family or roommate.................................. 3 d. widowed.............................................4 .............don ’t a sk f. e. separated or divorced / . 5 J f. never married................................. 6 g. refusal.............................................7 2. You have marked that your mother was born in (Read recorded respon se on page 1 to #5 in the UOH questionnaire.) Is that your natural mother? Yes...................................................^ No........................................................2 3. You have marked that your father was bom in (Read recorded respon se on page 1 to #6 in the UOH questionnaire.) Is that your natural father? Yes.................................................. No........................................................2 (If the respondent d id not refer to a natural parent in questions 5 through 8 on the UOH questionnaire, make the appropriate corrections if possible.) 187 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 960601 (R eview recorded respon se on page 2 to #17 in the UOH questionnaire.) 4. Check here if respon se w as NO. W hether YES o r NO, ask: Have you smoked 100 cigarettes in your life? Yes.......................................................................................... No..............................................................................................2 .........skip to 11. 5. How old were you when you started smoking cigarettes fairly regularly? years old __________(year) 6. Do you smoke cigarettes now? Yes............................................................................................... 1........skip to 8. No..............................................................................................^ 2 y 7. How old were you when you last stopped smoking? years old (year) 8. How many years, in total, did you (or have you) smoked(d)? ^ years 9. On average, over the entire time you smoked, how many packs of cigarettes did you smoke each day? Prompt: There are 20 cigarettes in a pack. _________ packs per day OR / ^ cigarettes per day 10. Consider the kind of cigarettes that you have smoked the m ost during your life? What kind were they? (circle one o f each for a, b, c) a. Mainly filter.................................................. Mainly nonfilter....................................................2 b. Mainly menthol............................................. X Mainly not menthol............................................. c. Mainly regular length........................................ -CL;' Mainly “100" length.............................................. 2 188 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 960601 11. Have you ever smoked at least one cigar per month for at least 6 months? Yes............................................................................. 1 No......................................................... j£ j....sk ip to 14. 12. How old were you when you started smoking cigars fairly regularly? _____________years old_________________ (year) 13. How many years, in total, did you (or have you) smoke(d)?___________years 14. Have you ever smoked at least one pipe per month for at least 6 months? Yes............................................................................. 1 No............................................................................ (2^:....skip to 17. 15. How old were you when you started smoking pipes fairly regularly? _____________years old_________________ (year) 16. How many years, in total, did you (or have you) smoke(d)?__________ years 17. YOU HAVE ALREADY PROVIDED US WITH INFORMATION ABOUT WHETHER YOUR SKIN IS SENSITIVE TO SUN EXPOSURE AND HOW EASILY YOU TAN. Now I would like to see which color on this chart most closely matches your untanned skin color. {Have respon den t sh o w yo u som e untanned area, e.g., underside o f arm, and record the number from the color chart.) 1 189 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 960601 18. Consider your routine — not recreational — dally activities, such as waiting for the bus, walking to the store, or time spent outside while working. On average, how much time has your daily routine taken you outside between the hours of 10:00 am and 3:00 pm each day in the last month? Minutes per Day OR ^ Hours per Day Prompt: Please try your b est to think about your typical daily routine in the last month. 19. Now consider the amount of time you have spent out of doors in the last month while engaged in recreational activities. Approximately how much time in the last month did you engage in outdoor recreational activities between the hours of 10:00 am and 3:00 pm? (Record whichever time units respon den t u se s to com plete one o f the following:) . Minutes per Day _ Minutes per Week . Minutes per Month Hours per Day Hours per Week . Hours per Month Prompt: Include gardening and yard work, jogging or walking for exercise, playing golf or tennis, attending picnics or other outdoor events, or any other outdoor activities you participated in. {R espondent could n o t have been outdoors for greater than 5 hours p er day, i.e., 150 hours p er month.) 190 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 960601 20. In the last month, when you were outside for both routine and recreational activities, which of the following best describes how your skin was usually covered? Would you say you were..... Show flashcard A. Well-covered: with long pants/skirt and a closely-woven long- sleeved shirt............................................................1 Moderately-covered: with long pants/skirt and a short-sleeved or loosely-woven shirt................................................2 Lightly-covered: with shorts/short skirt (no tights/and a short- sleeved or loosely-woven shirt......................... Uncovered: with a sleeveless shirt and shorts or short skirt............................................................................ 4 21. In the last month, what percent of your total time outdoors were you dressed in a sleeveless shirt and shorts or short skirt? 22. When you went out in the sun last month, how much of the time did you wear a hat for protection? Look at this card and tell me, from 1 to 7, where you think you fall on the scale. Show Flashcard B and circle one. Always 1......... 2...........3................ 5............6 ............ 7 Never 191 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 960601 23. In the last month, how often did you use sunscreen products when you went outside between 10:00 am and 3:00 pm? Show Flashcard C. Not at all................................................................... (.1..Mkip to 26. Sometimes, such as when I was out in strong sunlight for more than half an hour................ 2 Usually when I went out in the sun, but not always 3 Each time, but only when I first went out in the sun........................................................... 4 Each time I went out in the sunshine, with repeated applications................................................5 24. Lotions and sunscreens have a skin protection factor (SPF) number on the container. When you do use sunscreen, what is the SPF number on the product you usually use? SPF Number__________ 25. When you used sunscreen, did you apply it to all areas of your body that were not covered by clothing? Yes, I applied it to all areas.................................................. 1 No, I only applied it to the following areas:......................... 2 {Write areas here) 26. {Review recorded responses on page 3 to #23 in the UOH questionnaire, if respondent marked "Gallbladder rem oved”, ask and record the year.) _________ (year gallbladder was removed) \j' (Check here if gallbladder was not removed.) 192 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 960601 27. 28. {Review recorded response to “Noodie C asseroles” a little more than half-way down p a g e 5 of the UOH questionnaire, if respondent marked using this food more often than “ never or hardly ever" over the past year, ask what kind of meat usually was in ft.) ___________(was the type of meat usually in noodle casserole. R ecord vegetarian also.) •J (Check here if noodle casserole was eaten “never or hardly ever".) (Review recorded response to “Orange or Grapefruit Juice” a little more than half way down p a g e 14 of the UOH questionnaire. If respondent marked using this food more often than "never or hardly ever" over the past year, ask:) You’ ve marked here that you d^ank orange or grapefruit juice. During the year before your sigmoidoscopy_cMyou drink orange juice supplemented with calcium? If WO, < circle, an d skip to 29. On average, how often did you drink this orange juice? (Mark the appropriate response.) Once a month ...........1 2 to 3 times a month.............. 2 Once a week............................3 supplemented with calcium.) 2 to 3 times a week............. 4 4 to 6 times a week............. 5 Once a day............................6 2 or more times a day..........7 Jwas the brand name of orange juice 29. (Review recorded responses to “Highly Fortified Cereais”, “Bran o r High Fiber Cereals", o r “Other Cold Cereals” in the three spaces at the top of p a g e 16 of the UOH questionnaire. If respondent marked using any cereal in any of these three categories more than "never or hardly ever" over the past year, ask and record the type of cereal usually used.) __________ (was the brand name and type of cold cereal usually eaten over the past year.) ][_ (Check here if cold cereal was eaten “never or hardly ever”.) 193 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 960601 30. {Review recorded responses to the dairy products on page 16 of the UOH questionnaire, beginning with “Yogurt" through “O ther C h eese” , if respondent marked using any of these foods more than “ never or hardiy ever" over the past year, ask: How much of the time when you used ....{read what respon den t recorded having u se d with resp e ct to any o f th ese dairy hjods) .... was (were) this (these) foods NONFAT? Show flashcard B. Always 1..........2 ..........3............4 ...........5......... 6..........7 Never 31. The next series of questions provide the study with more detaiied information on the intake and preparation of red meat, pouitry, and fish — sources of heterocyciic aromatic amines, if the respondent is a vegetarian, the next section can be skipped entirely. If a respon den t d o esn ’t ea t the foods in p a g es 5 through 9 on UOH, and on pa g e 20 respon den t m arks “Don’t eat m eat” and “Don’t ea t chicken”, m ake su re you don’t skip to page 19, question 53 without asking the foliowing question: During the year before your sigmoidoscopy, have you eaten any of the following? (Read the ch oices and circle all that apply.) a. red meat.................................................Yes ................................................No. b. bacon......................................................Yes c. sausage....................................... d. poultry.................................................... Yes e. fish................................................. Y es... O ..No..... 2 ..Yes... ..No..... 2 ..Yes... YTy ..No..... 2 ..Yes... ...No... 2 ...Yes....... 6 ^ ...No... 2 ...Yes... ...(.iy ...No... .....2 {If NO to all o f the above, skip to page 19, H53. ) 194 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 960601 IT IS IMPORTANT THAT I GET MORE INFORMATION ON YOUR INTAKE OF MPAT, POULTRY, AND FISH AND ON THE WAYS YOU COOK AND EAT THEM. I WILL ASK YOU ABOUT THE NUMBER OF TIMES YOU ATE CERTAIN FOOD ITEMS AND ALSO ABOUT HOW THEY WERE PREPARED. SOME OF THE INFORMATION MAY BE HARD TO REMEMBER, BUT PLEASE TRY TO GIVE YOUR MOST ACCURATE ESTIMATION. Common methods of cooking include pan-frying, deep frying, broiling, baking, grilling, and microwaving. By Pan-fry: we mean cooking meat in a preheated heavy frying pan or griddle (with or without added fat). By Grill/Barbecue: we mean cooking the meat by placing it on a grid over coals, open fire, or ceramic briquettes heated by gas. By Oven-broil: we mean cooking meat by placing it below the heat source such as in an oven after setting it on broil. A sk qu estion s a s follows: " In the year before your sigm oidoscopy, how often did you eat hamburgers and cheeseburgers?" " Of the hamburgers and cheeseburgers that you ate during the year before your sigm oidoscopy, how often were they pan-fried?" Make sure: -If so m eb o d y answ ers '1 p e r m onth'for tiie overall Intake of ham burgers/cheeseburgers the Intake o f a single preparation m ethod of th ese ham burgers/cheeseburgers cannot b e m ore frequent than '1 p er month'. Other than this rough control do no try to add the answ ers for single preparations up to the overall Intake frequency. -If a person n ever ea ts a food Item prepared In a specific way, m ake su re to mark 'never" for that preparation method. If the person d o es n ot know, m ake sure to mark 'don't know'. 10 195 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CD ■D O Q . C g Q . ■ D CD C/) C/) CD 8 CD 3. 3 " CD CD ■ D O Q . C a O 3 " O O CD Q . ■ D CD C/) C/) TYPE OF FOOD HOW MUCt- Code never 0 less than once per month 1 1 per month 2 2-3 per month 3 1 per week 4 2 per week 5 3-4 per week 6 5-6 per week 7 1 per day 8 2+ per day 9 don't know 99 Hamburgers, Cheeseburgers 32. Overall / 32a. Pan-fried 32b. Grilled/ BBQed 32c. Fast food , Specify restaurant; ; / 32d. Other Specify: Beef Steaks 33. Overall / 33a. Pan-fried 33b. Grilled/ BBQed 33c. Other Specify: 1 1 ON CD ■D O Q . C g Q . ■ D CD C/) C/) TYPE OF FOOD HOW MUCH 8 ( O ' 3. 3 " CD CD ■ D O Q . C a O 3 " O O CD Q . ■ D CD (/) (/) Code never 0 less than once per month 1 1 per month 2 2-3 per month 3 1 per week 4 2 per week 5 3-4 per week 6 5-6 per week 7 1 per day 8 2+ per day 9 don’t know 99 Pork Chops 34. Overall / 34a. Pan-fried 34b. Oven-broiled 34c. Baked/Roasted 34d. Other Specify: Bacon 35. Overall / 35a. Pan fried 35b. Microwaved 35c. Oven-broiled 35d. Other Specify: \o 1 2 CD ■D O Q . C g Q . ■ D C D C /) C /) 8 ci' 3 3 " (D (D T3 O Q . C a o 3 T3 O (D Q . T3 (D (/) (/) HOW MUCH TYPE OF FOOD 2-3 per month 3-4 per week 5-6 per week don't know less than once per month never per week per day per day per month per week Code Sausage (incl. breakfast, Italian, Polish) 36. Overall 36a. Pan-fried 36b. (GrilledABQed 36c. Oven-broiled 36d. Other Specijy: Fried ChicKen 37. Overall 37a. Pan-fried 37b. Deep fat-fried /fast food 37c, Other Specify: oo 1 3 CD ■D O Q . C g Q . ■ D CD C/) o" 3 CD 8 CD 3. 3 " CD CD ■ D O Q . C a O 3 ■ D O CD Q . ■ D CD C/) C/) TYPE OF FOOD HOW MUCH Code never 0 less than once per month 1 1 per month 2 2-3 per month 3 1 per week 4 2 per week 5 3-4 per week 6 5-6 per week 7 1 per day 8 2+ per day 9 don't know 99 Chicken or Turkey (Incl. sandwiches) 38. Overall / 38a. Baked/roasted 38b. Stewed 38c. Gven-brolled J 38d. Grilled/BBQed / 38e. Other Specify; Fried Fish /Fish Sandwich 39. Overall / 39a. Pan-fried 39b. Deep fat-fried /fast food 39c. Other Specify: M CD ■D O Q . C g Q . ■ D CD C/) C/) 8 ci' 3 3 " CD CD ■ D O Q . C a O 3 " O O Code never 0 less than once per month 1 1 per month 2 2-3 per month 3 1 per week 4 2 per week 5 3-4 per week 6 5-6 per week 7 1 per day 8 2+ - per day 9 don’t know 99 Other fish except fried 40. Overall J 40a. Oven-broiled V 40b. Grilled/BBQed \j 40c. Other Specify: Meat Gravies made with meat drippings 41. Overall \J CD Q . ■ D CD C/) C/) i 1 5 C D ■D O Q . C g Q . ■ D CD C/) C/) 8 ci' Now, I would like you to look at some photographs of meats which have been cooked to different degrees. Please decide which photograph most closely resembles the way the meat you eat is cooked. If you eat meat that looks to be between categories, you may indicate that. For example, you would select 2.5 to indicate that the meat you eat looks between pictures 2 and 3. 3 3 " CD CD ■ D O Q . C a o 3 " O o CD Q . ■ D CD C /) C /) Let's start with beef. Please pay special attention to the way hamburger and steaks look inside as well as the outside. For example, there is littie difference in the internal appearance of the meat between numbers 3 and 4 for both hamburgers and steaks but there is more browning and charring on the external surface of number 4 as compared to number 3. During the year before your sigmoidoscopy when you ate the following items, which picture most closely resembles the way they were usually cooked? did not eat 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Code 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Show photographs A1-A4 42. Hamburger, Cheeseburger 1/ Show photographs B1-B4 43. Steaks (Beef) / Show photographs C1-C3 44. Pork chops / Show photographs O f-03 45. Bacon 1 6 K ) o CD " O O Q . C g Q . ■ D CD (/) o" 3 8 ci' 3 3 " CD CD ■ D O Q . C a O 3 "D O CD Q . O C During the year before your sigmoidoscopy, when you ate the following items, how were they usually cooked? Show flashcard D. 46. Chicken; did not eat.................................................................0 just until done (no pink, but still juicy)...................... well-done (no pink,dry)..........................................2 very well-done (no pink, really dry, brown surface)....3 don't know................................................................. 99 Show flashcard E. (this question does not refer to sausage on pizza or in lasagne; does not refer to hot dogs) 47. Sausage: did not eat ...................... 0 just until done............................ A well-done/crisp..........................© charred.......................................3 don't know.................................99 Show flashcard F . 48. Gravies: did not eat................................ ( 6 / made from meat drippings......... T store-bought cans....................... 2 store-bought packets.................. 3 don't know.................................99. 49. During the year before your sigmoidoscopy, how often did you use the fat from fried bacon in your cooking? ■ D CD (/) C/) A never................................. (Oy 2-3 times per month........ 3 less than once per month.... 1 once per month.................... 2 once per week ............. 4 twice per week.............. 5 3-4 times per week.........6 5-6 times per week......... 7 once or more per day...... 8 17 N J § ■o o Q . C g Q . ■ O CD % 50, During the year before your sigmoidoscopy, how often did you eat grilled (barbecued) meats (Including g beef, pork, chicken, or fish)? o S ' ^ (If a person does not grill/BBQ year-round, tell him/her to average over year. o If a person mostly grills meat other than beef, pork, chicken, fish, he/she should stili answer this question) '< c 5 ' never 0 2-3 times per month........ ] 3-4 times per w eek...........6 less than once per month..,. 1 once per w eek M % 5-6 times per w eek...........7 I once per month 2 twice per w eek...............^ once or more per day.......8 o 3. 3 " CD CD Q . 7 3 CD C/) c n 8 51. During the year before your sigmoidoscopy, when you had griiied or barbecued meats how often were they charred? Show flashcard G. o (This question refers to any kind of grilled/BBQed meat) c a ° never.................................(û-?about 3/4 of the tim e..................................... 3 g about 1/4 of the time ........ 1 about 100% of the time.................................4 z about % of the time ..........2 did not eat grilled or barbecued meats........ 5 52. During the year before your sigmoidoscopy, when you had pan-fried or oven-broiled meats how often were they well browned? Show flashcard H. (This question refers to any kind of pan-fned/oven-broiled meats) never. .0 about 3/4 of the time ..................................................................... 3 about 1/4 of the time Æ about 100% of the time.......................................4 about V i of the time .72 did not eat pan-fried or oven-broiled meats 5 18 960601 53. {R eview recorded respon se to "Did you take any multivitamins or multivitamins with minerals during the year before your sigmoidoscopy?" a t the top o f page 21 o f the UOH questionnaire, if respon den t m arked “YES”, a sk and record the brand nam e and type o f muitivitamin preparation usuaiiy used, e.g„ Trader Darwin’ s High P oten cy Muitipie Vitamin & Minerai Sustained R eiea se... respondent sh ouid sh o w you bottle, if avaiiabie.) _ P û tJ /OtT I Ak C . (was the brand name and type of multivitamin preparation usually used). 54. During the year before your sigmoidoscopy, did you take folic acid by itself or vitamin D by itself at least once a week? 54. Yes. took folic acid .A 58. Yes, took vitamin D............1 No folic acid....................^Jskip to 58. No vitamin D...................(^ sk ip to 62. 55. How many folic acid tablets did you 59. How many vitamin D tablets did you take? take? 1 to 3 a week..................... 1 4 to 6 a week.....................2 1 a day................................ 3 2 a day................................ 4 3 or more a day..................5 1 to 3 a week..................... 1 4 to 6 a week.....................2 1 a day................................ 3 2 a day................................ 4 3 or more a day..................5 56. How many years did you take them? 60. How many years did you take them? 1 year or less...................... 1 2 to 4 years........................ 2 5 years or more................. 3 57. What was the dose per tablet? __________________ _mcg. 1 year or less....................... 1 2 to 4 years.........................2 5 years or more..................3 61. What was the dose per tablet? I.U. 19 2 0 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CD ■D O Q . C g Q . ■ D CD C/) C/) 8 3 3 " (D (D T3 62, {Review recorded responses on page 22 to #27 in the UOH questionnaire. We are asking more questions of the respondents who marked YES to taking one or more of the foiiowing: ASPIRIN OTHER PAIN RELIEF MEDICATIONS ANTACIDS LAXATIVES If respondent marked NO to all of these, skip to page 24, #83. Starting with ASPIRIN, if the respondent marked NO, skip to #68. You’ve indicated that you have taken asoion or an aspirin-containing product like Excedrin or Bufferin at least two times per week for one month or longer, (This question is dûî restricted to usage during the year prior to sigmoidoscopy,) This is a list of medications that contain aspirin. Please look over the list and tell me about (show me the bottle of) any items you have used. Show Flashcards I and J containing non-prescription and prescription items. o o. c a o 3 "O o 3 " C T 1 —H CD Q. a. (Aspirin) Brand Name (Circle one) Strength reg/extra | 62. Code 63. How old were you when you started using (brand)? I 1 1 64. How long did you take (brand)? 1 1 65. How often, on average, did you take (brand)? 1 1 66. How many tablets did you usuaiiy take? 1 i 67. What was the reason you took (brand)? 1 —H 3 " (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) O c b. reg/extra | I 1 1 1 . 1 1 i 1 1 "O CD (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) i . c. reg / extra | 1 1 1 1 1 1 1 1 1 (/) d (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) 20 U r CD ■D O Q . C g Q . ■ D CD C/) C/) 8 3 3 " CD CD ■ D O Q . C a O 3 " O O CD Q . "D CD (Aspirin) Brand Name {Circle one) Strength reg/extra | Code How old were you when you started using (brand)? 1 1 -.. - 1 How long did you take (brand)? 1 ........... 1 How often, on average, did you take (brand)? 1 1 How many tablets did you usuaiiy take? 1 1 What was the reason you took (brand)? (Code) (Age) {Months) (Times/Mo) (Tablets) (Reason) reg/extra | J L 1 1 . 1 1 .... 1 1 1 (Code) {Age) (Months) (Times/Mo) (Tablets) (Reason) 68. ]Mth respect to OTHER PAIN RELIEF MEDICA TIONS, If the respondent merked NO, skip to 74. You’ve indicated that you have used other pain relief medication such as Motrin or Ibuprofen at least tvi/o times per week for one month or longer. (This question is m l restricted to usage during the year prior to sigmoidoscopy.) This is a list of some pain relief medications other than aspirin. Please look over the list and teii me about (show me the bottle of) any items you have used. Prompt: We are interested in products which contain Ibuprofen. We are nfii interested in products such as Tylenoi that contain acetaminophen but do not contain ibuprofen. Show Flashcards K and L containing non-prescrlptlon and prescription Items. Interviewer: See Flashcard M fora list of products which contain acetaminophen but do not contain Ibuprofen. ( / > ( / ) 21 ON C D " O O Q . C g O . ■ D C D C/) C/) o 3 O 3 C D 8 (Ibuprofen) Brand Name (Cf/ic/e one) Strength 68. Code 69. How old were you when you started using (brand)? 70, How long did you take (brand)? 71. How often, on average, did you take (brand)? 72. How many tablets did you usually take? 73. What was the reason you took (brand)? (O ' 3" a. rea / extra 1 1 1 1 1 I 1 1 ........ 1 i (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) 3 C D b. rea / extra 1 1 1 i 1 1 ................. 1 I .......... 1 m (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) 3 . 3" c. tea / extra 1 1 ..........1 1 . . - ..1 1 ....................1 1 . 1 C D (Code) (Age) (Months) (TImes/Mo) (Tablets) (Reason) C D T 3 d. rea / extra 1 1 ....................1 1 1 1 1 1 1 O Q . C (Code) (Age) (Months) (TImes/Mo) (Tablets) (Reason) a e. rea / extra J 1 ........... 1 1 ..............1 1 1 1 1 3 (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) ■ D O C D Q . ■ D C D C / ) C / ) 74. With respect to ANTACIDS, if the respondent marked NO, skip to 78. You've indicated that you have used antacids at ieast two times per week for one month or longer. Now I am going to ask you about the antacids that you used the year prior to your sigmoidoscopy, in the year before your sigmoidoscopy, did you take any antacid preparations that contain calcium ? Yes............................................... 1 No................................................. 2.... skip to 78. Don't know.................................... 3.....Ask to see bottle, if available, then correct response 22 A ntacids containing calcium have calcium carbonate, betw een 400 and 800 m g., a s an active ingredient 0 f you are unsure about a p ro d u ct still write dow n the brand nam e and a s m any descriptions a s p o ssib le, e.g., “extra stren gtii”, “p lu s”, o r “a sso rted flavors”.) Tell me about (show me the bottle of) the calcium-containing antacids you have used. a. c. e. Antacid Name tbsp / tab tbsp / tab tbsp / tab tbsp / tab tbsp / tab |_ 75. Code 76. How often, on average, did you take (brand)? 1 1 1 77. How many (tbsp/tab) did you take each time? 1 1 (Code) (Times/Mo) 1 1 1 (tbsp/tab) 1 1 (Code) (Times/Mo) 1 I 1 (tbsp/lab) 1 1 (Cade) (Times/Mo) 1 1 1 (tbsp/tab) 1 1 (Cade) (Times/Mo) 1 1 1 (tbspAab) 1 1 (Code) (Times/Mo) (tbsp/lab) 78. With resp e c t to LAXATIVES, if the respondent m arked NO, sk ip to 83. You've indicated that you have used laxatives at least two times per week for one month or longer. (This question is net restricted to usage during the year prior to sigmoidoscopy.) This is a list of some laxatives. Please look over the list and tell me about (show me the bottle of) any items you have used. {NOTE: Correctoi m a k es both a sto o l softener and a laxative. Clarify which one w a s used.) Laxative Name Show flashcard N. 78. Code {Code) 79. How old were you when you started using (brand)? J L 80. How long did you take (brand)? 81. How often, on average, did you take (brand)? (Age) (Months) (Times/Mo) 82. How many tablets did you usually take? (Tablets) 208 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. b. c. d. e. Laxative Name Code 1 How old were you when you started using (brand)? 1 1 1 How long did you take (brand)? 1 1 How often, on average, did you take (brand)? 1 1 How many tablets did you usually take? 1 1 (Code) i (Age) 1 1 1 (Months) 1 1 (Times/Mo) 1 1 (Tablets) 1 1 (Cade) 1 (Age) 1 1 1 (Months) 1 1 (Times/Mo) 1 1 (Tablets) 1 1 (Code) 1 (Age) 1 1 1 (Months) 1 1 (Times/Mo) 1 1 (Tablets) 1 1 (Code) (Age) (Months) (Times/Mo) (Tablets) I HAVE A FEW QUESTIONS ABOUT YOUR PHYSICAL ACTIVITY. 83. {R eview recorded resp o n se on p a g e 22 to #28 in the UOH questionnaire. This question is m ost useful to the stu tty a s it pertains to the respon den t’ s level o f ph ysical activity. Therefore w e w ant a jo b description that will help u s determ ine the required energy expenditure.) You have marked that the occupational category in which you worked the longest was {Read recorded respon se to # 28 UOH).) We need to get an idea of how physically active you were on that job. Could you give me a precise job description? 84. You have already answered a question for us about how many hours a day you spent in sitting activities (such as sitting in a car or bus, sitting at work, watching TV, etc.). On the average, during the year before your sigmoidoscopy, did you spend more than one hour per day engaged in an activity when you were on your feet but not walking around much? Yes. No... 2^ ..skip to 86. 84a. What was (were) the activity(ies)? 2 4 2 0 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 85. On average, how many hours per day did you spend at this activity? hours/day 86. In the year before your sigmoidoscopy, did you participate in any vigorous activity that was not related to your job? Yes.. No... 91. 87. Which of these vigorous physical activities did you participate in? S how flashcard O, circle each activity the respondent nam es and com plete colum ns 87-90. Did you participate in any other vigorous nonyob related physical activity not listed here? (List other activities b elow and com plete colum ns 87-90.) 87. 88. 89. 90. NON-JOB RELATED A C TIV ITY # Months/ Year # Times/ Week #Min or Hrs/Time (spetilÿ) Total# Years a. Walking briskly b. Running/Jogging c. Swimming d. Bicycling e. Aerobic dance f. Racquet sports 9 Other (specify): h. i. 210 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 91. In the year before your sigmoidoscopy, did you participate in any vigorous work-related activi^ 92. Yes. No........................................ .^ .2 .L sk ip to p a g e 2 7 , m 6 for WOMEN, .skip to p a g e 31, #115 for MEN. Which of these vigorous work-related physical activities did you participate in? Show flashcard P, circle each activity the respon den t n am es and com plete colum ns 92-95. Did you participate in any other vigorous work-related physical activity not listed here? (List other acdvides below and com plete colum ns 92-95.) 92. 93. 94. 95. JOB-RELATED A C TIV ITY # Months/ Year # Times/ Week #Min or Hrs/Tbne (specify) Total# Years a. Walking brtekly (Le., matt carrier, parking attendant) b. Lifting or carrying heavy loads (Le., truck driver, mover) c. Construcdon or road- building (i.e., carpentry, painting,masoniy,nxding, driving heavy machinery, using power tools, ditch- digging) d. Landscapingfgatdening e. Other (specify) (eg., firef^hter,coaching athletics, mechanic, house- cleaning,etc.) f. 9 h. i. 26 211 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7 3 CD ■ D O Q . C g Q . " O CD C/) C/) 8 3. 3 " CD CD ■ D O Q . C a O 3 " O O CD Q . " O CD C / ) C / ) 96. (Review recorded responses on page 24 to #38 In the UOH questionnaire. NOTE: Pages 24-25 are for women only.) If the respondent marked No, skip to 102. You indicated that you took birth controi pilis for one month or longer. This is a list of birth control pills. Please try to remember any birth control pills you have taken and tell me about when you took them, including gaps (meaning starts and stops) in usage. Show Flashcard Q, a ilst of oral contraceptives. Probes for dosage; color, packaging Indicate gaps in usage by writing down brand name, as many times as necessary, for each period of use. (Birth control pilis) Brand Name 96. Dosage Code 97. How old were you when you started using (brand)? 98, How long did you take (brand)? 99. How often, on average, did you take (brand)? 100. How many tablets did you usually take? b. c. d. e. {Code) 101. What was the reason you took (brand)? 1............-.........J l ................ 1 1.................1 1.................1 1 1 1 1 {Code) 1 1 1................... 1 {Age) 1.... - 1 {Months) 1............ 1 (r/mesÆfo) 1 1 {Tablets) (Reason) {Code) 1..........................11 1 {Age) 1 i {Months) 1-............. 1 (Times/Mo) 1.................1 (Tablets) 1............. 1 (Reason) (Code) 1 II....................1 (Age) 1-...............1 {Months) 1 ..............1 {TImes/Mo) 1 1 (Tablets) 1 1 (Reason) {Code) 1 _ .,...11 _ ...1 {Age) 1 ..........1 {Months) 1 '..........1 {Times/Mo) I-.............J (Tablets) 1 .................1 (Reason) (Age) {Months) (T/me&tM o) {Tablets) (Reason) ro N ) 27 CD ■D O Q . C g Q . ■ D CD C/) C/) 8 ( O ' 102. (Review recorded response on page 25 to M l in the UOH questionnaire. If response is YES, <— circle, and skip to 103. If response Is No, make sure respondent has not taken eshrogen ( YES to M2). If respondent has taken estrogen, ask If menstrual period stopped before estrogen use, ask the age when this happened, and write notes here. 3. 3 " CD CD ■ D O Q . C a o 3 " O o CD Q . ■ D CD < / > C/) 103. (Review recorded response on page 25 to M 2 in the UOH questionnaire.) If response Is NO, skip to 109. Now I would like to ask you a few additional questions related to your use of estrogen. Please tell me about each brand of estrogen you took and when you took it, including any gaps (meaning starts and stops) in usage. Here is a list to help you remember names. Show Flashcard R, a list of estrogen products. Indicate gaps in usage by writing down brand name, as many times as necessary, for each period of use. a. (Estrogen) Brand Name 103. Dosage Code 104. How old were you when you started using (brand)? (Code) (Age) 105. How long did you take (brand)? (Months) 106. How often, on average, did you take (brand)? L (Times/Mo) 107. How many tablets did you usually take? (Tablets) 108. What was the reason you took (brand)? (Reason) 28 7 ) CD " O O Û . c 8 Q . ■ D CD C/) C/) CD 8 3 < 3 CD -n c 3 " CD (Estrogen) Brand Name Dosage Code How old were you when you started using (brand)? How long did you take (brand)? How often, on average, did you take (brand)? How many tablets did you usually take? What was the reason you took (brand)? 3 ■o b. 1 II 1 i 1 1 1 1 ...........1 1 1 o Q . (Code) (Age) (Months) (Ti/nes/Mo) (Tablsts) (Reason) a c. 1 ... I I ....... 1 I. 1 1 .......... 1 1 1 1 1 3 ■o (Code) (Age) (Months) (TImes/Mo) (Tal>lets) (Reason) O Z T d. 1 I I . ......... 1 1 - .................1 1 1 1 1 1 1 C S -' (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) a . g e. .. 1 .............. I I ....... 1 1 . 1 1 1 1 .... ... 1 1 1 g (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) O c " 8 C/) o' 3 to 4 ^ 29 7 3 CD ■ D O Q . C S Q . ■ D CD C/î C/) CD 8 CD 3. 3 " CD CD "D O a . c a o 3 " O o CD O . " O CD C/) O ) o ' 3 109. (Review recorded response on page 25 to #43 In the UOH questionnaire.) If response is NO, skip to 115. Now I would like to ask you a few additional questions related to your use of progesterone. Please tell me about each brand of progesterone you took and when you took it, including any gaps (meaning starts and stops) in usage. Here is a list to help you remember names. Show Flashcard S, a list of progesterone products. Indicate gaps in usage by writing down brand name, as many times as necessary, for each period of use. (Progesterone) Brand Name a. b. c. d. e. 109. Dosage Code 1 II........ 110. How old were you when you started using (brand)? I I 1 111. How long did you take (brand)? 1 1 112. How often, on average, did you take (brand)? 1 1 113. How many tablets did you usually take? 1 1 114. What was the reason you took (brand)? (Code) L ,JL (Age) - I 1 .......... 1 (Months) 1 1 (Times/Mo) 1 I (Tablets) 1 1 (Reason) (Code) 1______ -11.......... (Age) -1 1 .............. 1 (Months) 1 1 (Times/Mo) 1 . 1 (Tablets) 1 1 (Reason) (Code) (Age) 1 1 . 1 (Months) 1 . 1 (Tlmes/Mo) 1 1 (Tablets) 1 1 (Reason) (Code) I - ..........II (498) 1 1 ........- 1 (Months) 1 ..............1 (Times/Mo) 1 i (Tablets) I 1 (Reason) (Code) (Age) (Months) (Times/Mo) (Tablets) (Reason) N J L A 30 CD ■D O Q . C g Q . ■ D CD C/) C/) 8 ci' 3 3 " CD " O 115. Now, I need to get more information on your family history. Instructions: FoHow these steos in miina out the •‘FamUv History Chart". A. Fill in the "relation" column ~ S for sister; B for brother; D for daughter; S for son. B. Ask: in what year was (your relative) bom? C. Ask: is he/she stiii living? ■ 8 Yea skip to E; DO NOTASK D o Don’t know. skip to E; DO NOT ASK D D. in what year did he/she die? (record ail digits of year, e.g., 1989} § E. To your knowledge, did he/she ever have (has he/she ever had) colon or rectal cancer (CRC)? No ...................... skip to G. F. At what age was it first diagnosed? G. To your knowledge, did he/she ever have (has he/she ever had) any other type of cancer or tumor? No.............................. go tolls when last person completed. H. What type of cancer or tumor? I. How old was he/she (what year was it? - all digits) when it was first diagnosed? w 31 CD ■D O Q . C g Q . ■ D CD C/) C/) 8 ci' 3 3 " CD NATURAL PARENTS FAMILY HISTORY CHART A. B. C. D. E. F. G. H. 1 . Relation Year Born Living? (Y/N/DK) Year or Age Died CRC? (Y/N/DK) CRC Year or age Other Cancer? Specific Type Year or Age 1) Mother y n 1 fj 2) Father N b /|9? 7 u V 7 ^ CD ■ D O Q . C a O 3 " O O Siblings: {page 2, #11 and #12 In the UOH questionnaire contain Information on the number of siblings; flip back to take a look, but Just to make sure, ask: How many full (non-step, non-adoptive) brothers and sisters do you have?________________________(Write "OK" when applicable,) If none, check here CD Q . T3 CD (/) (/) FULL SIBLINGS A. B. E. F. B=BROTHER; 8-SISTER G. H. I. Relation Year Born Living? (Y/N/DK) Year or Age Died CRC? (Y/N/DK) CRC Year or age Other Cancer? Specific Type Year or Age 3) <; ih 7 _ y iJ A/ 4) f 5 ) 6 ) 32 C D ■D O Q . C g Q . ■ D CD C/) W o" 3 O 8 ci' 3 3 " CD CD ■ D O Q . C a O 3 ■ D O CD Q . FULL SIBLINGS.cont. Æ B, C. B«BROTHER; S»SISTER Q. H. Relation Year Born Living? (Y/N/DK) Year or Age Died CRC? (Y/N/DK) CRC Year or age Other Cancer? Specific Type Year or Age 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) ■ D CD C / ) C / ) Children: (page 2, #10 in the UOH questionnaire contains information on the number of children; flip back to take a look, but Just to make sure, ask: How many biological children do you have?________________________ (Write "DK" when appiicabie.) if none, check here ^ to 00 33 O S 1 1 1 < X < o II o « X O u. ii oiQ c 5 o CO C O CM CM CM CM C M C M 219 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 116. NEXT. I HAVE A QUESTION ABOUT THE NUMBER OF MEALS AND SNACKS YOU EAT. During the year before your sigmoidoscopy, on an average weekday, how many times did you eat something? Count both meals and snadrs. Include b ev er^ es containing lots of milk, sugar, or alcohol, such as capuccino, tieer, sodas, and juice. Dp not count beverages such as regular coffee, tea, diet sodas, or water. W " times per day.../f 3 tim es p e r d a y o r iess, skip to 118. 117. Give me one or two examples of foods you typically ate as snacks. If you usually ate two or three medium to large meals per day, a snack would be anything eaten outside of those meals (except coffee, tea, diet sodas, water). Write, for exam ple, “severa l sm all m eals” If respondent d o e s n o t typically ea t 2 to 3 large/medium m eals. . _ _ _ 118. NOW I NEED TO GET MORE INFORMATION ABOUT YOUR WEIGHT HISTORY. Since you were 18 years old, how often has your weight increased by at least 10 pounds within a fairly short time, meaning one year or less? (Do n o t read resp o n ses. Do n ot Include w eight changes due to pregnancy.) never gained 10 pounds or more within one year................................................y one or (wo times................................................. .................................................. 2 three or four times................................................................................................. 3 five or six times.......................................................................................................4 seven times or more..............................................................................................5 119. At the time of your sigmoidoscopy, approximately how much did you weigh? a. . d i C pounds b. What was your age at that time? years {Place a checkm ark b esid e the age in the weight chart on the n ext pa g e which Is c lo se st to b u t n ot greater than the resp o n d en fs age at sigm oidoscopy. Don’ t a sk the respon den t about weight b eyo n d this age.) 2 2 0 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 120. I am going to ask you about your weight at different times Siroughout your life. (For wom en: This would not include weights during pregnancy.) And, it might help you to remember if we talk a litUe about things that were going on in your life during these times. Approximately how much did you weigh when you were 18 years old? Prompt: This is around the age people graduate from high school. (Continue recording w eights for each age on the chart untii yo u reach the age with the checkmark.) Examples for prompts: Think about what you were doing at about age 25. What was your usual weight at around age 25? Prom pt for fem ales: If you were pregnant at this time, what was your usual weight ju st before you became pregnant? Prom pts for respondents having difficulty remembering: Do you think your weight w as more or less than it is now? More or less than it w as at age 18? What would you guess your weight w as? Weight Chart A B age weight what subject was doing (years) (pounds) 18 25 2 -a O 30 \i 35 u 40 Vi 45 ir\ 50 a i v •'1 55 60 65 70 75 36 2 2 1 R eproduced with perm ission o f the copyright owner. Further reproduction prohibited without perm ission. 121. AT THIS POINT, I ’D LIKE TO GET YOUR WAIST AND HIP MEASUREMENTS {You are going to have the respon den tperfoim d ie se m easurem ents. If respon den t is wearing thick clodting o r a ccesso ries a t an y o f the m easuring p o in ts — narrow est waist, navei, o r w id est hips — an d can’t Oft o r rem ove tiiem easily, estim ate the am ount o f thickness added, e.g., b elt 1 inch thick, sw ea ter 1/2 inch thick. R ecord the extra inches in the margins. Have respon den t slip tape m easure around his/her w aist (starting a t 1 inch) and locate the narrow est point o f w a ist If no one point o f w aist s e e m s n arrow est instruct the su b ject to locate his/her navei, and then find the p o in t approxim ately two inches above navel. Make su re the tape is n o t tw isted and that it is sn ug bu t n o t squ eezin g fiesh. G et m easurem ent to the n ea rest 1/4 inch.) NARROW WAIST MEASUREMENT:!^ 8 /L mches.check here if 2 ” above navei 122. (Now have the respon den t m easure his/her w aist a t the level o f the navel, if he/she is wearing a bett, a sk if it is p o ssib le to rem ove the b elt temporarily. G et m easurem ent to the n earest 1/4 inch.) WAIST MEASUREMENT AT LEVEL OF NAVEL: ^ inches 123. {Find te e w id est p a rt o f h ips -’approxim ately a t te e level o f te e buttocks. G et m easurem ent to tee n earest 1/4 inch.) WIDEST PART OF HIPS MEASUREMENT: b o inches (o THIS COMPLETES OUR INTERVIEW. THANK YOU FOR TAKING THE TIME TO ANSWER THESE QUESTIONS. DO YOU HAVE ANY COMMENTS YOU WOULD LIKE TO ADD? 222 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Interviewer’ s C om m ents (To b e filled ou t after leaving) GO TO NEXT PAGE. 124. Before or during the interview, did you become aware of whether or not this person had a polyp at his or her sigmoidoscopy? Yes.........................................1 No.........................................( £ ) 125. Do you believe the subject gave reliable information? Yes....................................^ 1 ) No...........................................2 If No, why not? Other commente: 3S 223 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. REMINDER TO INTERVIEWER: (Again) STRESS THE IMPORTANCE OF PARTICIPATING IN THIS STUDY. TALK TO THE RESPONDENT ABOUT THE APPOINTMENT FOR THE BLOOD DRAW. Make an appointment for the blood draw once ttie interview is completed. Work out the best arrangement you can. Home blood draws are an option — they need to be scheduled by the study office (213) 764-0493. Record the blood draw appointment both on the sheet that you give the Re spondent (stapled to the end of the interview) and on the last page of the interview. Appointments can be made at the two Kaiser labs at the following times: BELLFLOWER: W ednesdays - Fridays 9:30 AM - 2:00 PM. SUNSET: Mondays - Fridays 8:00 AM - 2:00 PM. Do not knowingly make appointments at a given location at the sam e time for more than one respondent AFTER YOU MAKE A BLOOD DRAW APPOINTTUIENT, PLEASE CAM THE STUDY OFFICE (213-764-0493) AND LEAVE A MESSAGE SAYING: (1 ) WHO THE APPOINTMENT IS FOR (2) WHICH KAISER LOCATION THE PERSON WILL GO TO (3) THE DATE OF THE APPOINTMENT (4) THE TIME OF THE APPOINTMENT It is important that we have this information before the blood draw so that we can inform the Kaiser lab to expect the patient. REMEMBER TO COMPLETE “Interviewer’ s Comments" SECTION, p. 38. 39 224 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. IMPORTANT REMINDER: Stress the fact that for a fasting blood draw, the Respondent can have nothing by mouth except water for 14 hours prior to the te st (not even tea or coffee) and no heavy alcohol intake for 48 hours prior to t e s t Most people will probably want to have their blood drawn early in the morning. In addition to the cholesterol test, we will be analyzing DNA and measuring blood nutrient levels (carotenoids, vitamins C. D. and E. and folate as examples). y / I o i r t y - ? BLOOD DRAW INFORMATION KAISER/USC SIGMOIDOSCOPY-BASED CASE-CONTROL STUDY OF POLYPS . has an appointment for a lasting blood draw as follows; Date: __________ Time: Location (check one): Kaiser Sunset 4700 Sunset Blvd. Building R 1st Floor Contact: Mila Hermogeno (213) 667-4961 or Zee Apelian (213) 667-7959 Kaiser Bellflower 9400 E. Rosecrans Ave. 1st Floor Contact: Lee Landman (310) 461-4481 40 225 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. BLOOD DRAW INFORMATION KAISER/USC SIGMOIDOSCOPY-BASED CASE-CONTROL STUDY OF POLYPS For a fasting blood draw, nothing can be taken by mouth except water for 14 hours prior to the test (not even tea or coffee) and there can be no heavy alcohol intake for 48 hours prior to the test. fasting blood draw as follows: Date: __________ Time: Location (check one): has an appointment for a Kaiser Sunset 4700 Sunset Blvd. Building R 1st Floor Contact: Mila Hermogeno (213) 667-4961 or Zee Apelian (213)667-7959 Kaiser Bellflower 9400 E. Rosecrans Ave. 1st Floor Contact: Lee Landman (310) 461-4481 41 226 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. Appendix A2. Sigmoid II - Semi-quantitative Food Frequency Questionnaire 227 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. CDCZDCDt Diet and Health Questionnaire Developed by: Epidemiology Program Cancer Research Center of Hawai'i Universilv of Hawai'i Is the address label correct? If not, please give the correct spelling of your name and your correct address. NAME STREET CITY STATE ..Z IP 228 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. MARKING INSTRUCTIONS Use Pencil only. One Is provided for your use. Do NOT use ink or baiipoint pens. Fill In the circle completely, c o r r e c t mark staying within the circle line. • C O G Erase cleanly any answer you wish to change. Do NOT make any stray marks in this booklet Marking Examples: If you are a female, you would fill in the circle like this: INCORRECT M ARKS V X ». 0 SEX Male I Female If your place of birth is Canada, which Is not listed, you would fill in the circle for "oUier" and write your answer in the box like this: KEEP HANDWRITING WITHIN THE BOX PLACE OF BIRTH C USA (includes Hawai'i) C Mexico G Central or South America C Europe C Africa C Cuba or Caribbean Islands O China, Hong Kong, or Taiwan O Japan (includes O l^ w a ) C Korea O Philippines Mother (w rite In ) Canada Sometimes questions are designed to help you line up numbem in certain columns. R>r questions like this, first write the numbers in the boxes, then fill in the correct circle In each column. If your birthdate is February 2,1906, you would write ttie day and the year in the boxes, and then fill in the circle for F^ruary, the circles 0 and 2 for the day, and the circles 0 and 6 for the year. i JAN I • FEB , O m a r ; O a p r ; O M A Y j O j u n Q j u l I O a u g ; O S E P I O O C T O nov O d e c PLEASE BEGIN THIS SURVEY ON PAGE 1. C opyright® 19M All R ^ h ts Reserved Worldwide. D A Y Y E A R 0 1 2 ; 1 ; 9 0 6 • 0 ; ■ • ® C O O 0 • ; © © .0 0 1 . i ® 0 ' ! ! ® © ® ® 1 ; 1 © • 1 ! ® ® 1 I 1 © ® 1 1 1 ® 229 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. BACKGROUND INFORMATION 1. WHAT IS YOUR SBC? r Male I Female 2. WHAT B YOUR CURRENT MARfTAL STATUS? O Married O Separated C Divorced O Widowed O Never Married 3. WHERE WERE YOU BORN? O USA (includes Hawaii) O Mextao O Cîenttal or South Ametfca O Europe O Africa O Cuba or Caribtrean Islands O China, Hong Kong, or Taiwan O Japan (includes Okinawa) O Korea O Philippines O Other: (wite in) 4. HOW MANY YEARS HAVE YOU UVED IN THE UNITED STATES? O 5 years or less 0 6 - 1 0 years O 11 -1 5 years O 16 - 25 years O 26 years or more S. WHERE WAS YOUR MOTHER BORN? O USA (includes Hawai i) O Mexico O Central or South Amerka O Europe O Africa O Cuba or Caribbean Islands O China, Hong Kong, or Tanvan Q Japan (Includes Okinawa) O Korea O Philippines O Ottien (wfite In) 6. WHERE WAS YOUR FATHER BORN? C USA (includes Hawai'i) 2 Mexico C Central or South America C Europe O Africa C Cuba or Caritibean Islands C Ctrfna, Hong Kong, or Taiwan C Japan (includes Okinawa) C Korea O Philippines 2 Other: (write in) , 7. WHAT IS YOUR ETHNIC OR RACIAL BACKGROUND? (Mark all ttmt apply) O Black or African-American O Chinese O Filipno C Hawaiian O Japanese (intrudes Okinawan) O Korean C Mexican or other Hispanic O White or Caucasian________________ O Ottien (write in) | 8. WHAT IS YOUR MOTHER'S ETHNIC OR RACIAL BACKGROUND? (Mark att that apply) O Black or African-American O Chinese O Filipino C Hawaiian O Japanese (inrriudes Okinawan) O Korean O Mexican or other Hispanic O White or Caucasian, O O th er (write in) 9. WHAT IS YOUR FATHER'S ETHNIC OR RACIAL BACKGROUND? (Mark all that apply) O Black or Afriran-Amertcan O Chinese O Filipino O Hawaiian C Japanese (includes Okinawan) O Korean O Mexican or other Hispanic O Wtiite or Caucasian O O ther (write in) 230 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. 10. HOW MANY CHILDREN HAVE YOU HAD? 15. HOW TALL ARE YOU? (Include any who may have died.) (Record height In teetdrmhes sc centlmeterdi O O 0 4 FEET INCHES OR CENTIMETERS O I 0 5 © © © © 0 2 0 6 © © © © 0 3 O 7 or more © © ® © © © © © ® © © © 11. HOW MANY FULL SISTERS DO YOU HAVE? © ® (Include any who may have died.) © © ® © ® © © © O O 0 4 © © ® OI 0 5 © © © 0 2 0 6 @ 0 3 O 7 o r more ® 12. HOW MANY FULL BROTHERS DO YOU HAVE? (Include any who may have died.) 00 01 02 0 3 0 4 0 5 06 0 7 or more 13. HOW MUCH DO YOU CURRENTLY WEIGH? (R ecord weight In pounds sc kilograms) — POUNDS OR KILOGRAMS © © © © © © 0 © © © © © © © © © © © © © © ® © © © © © © © © ® © © © © © © © © © © ® © © © © @ © 14. HOW MUCH OH) YOU WEIGH AT AGE 21? (R ecord w e ^ t In pounds sc kilogram!^ POUNDS OR KILOORAMS © © © © © © © © © © © © © @ © ® © ® © © © © © 0 © © © © © © © © © © © ® © © © © © © © © © © © - ■ 16. HOW MANY YEARS OF SCHOOL HAVE YOU FINISHED? ffdark the highest grade completed) O Did not complete 6th grade G 6th - 8lh grade O 9th - 10th grade O 11th - 12th grade O Vocational school O Some coNege C Graduated college O Graduate or professional sctrool 17. HAVE YOU EVER SMOKED A TOTAL OF 20 OR MORE PACKS OF CIGARETTES IN YOUR UFETIME? O No (go to guesfton 18) O Yes. and I currently smoke O Yes. but I quit smoking IF YES, WHAT IS THE TOTAL NUMBER OF YEARS YOU SMOKED? O 10 years or less O 11 - 20 years O 21 - 30 years O 31 - 40 years O 41 years or more WHAT IS THE AVERAGE NUMBER OF CIGARETTES THAT YOU SMOKED PER DAY? O 5 cigarettes or less O 21 - 30 cigarettes O 6 -1 0 cigarettes O 31 cigarettes or more O 11 -2 0 cigarettes IF YOU QUIT SMOKING, HOW LONG AGO DID YOU QUIT? O Less than 1 year O 1 - 2 years 0 3 - 5 years O 6 -1 0 years O 11 -1 5 years O 16 - 20 years O 21 years or more 231 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 18. WHAT WAS THE NATURAL COLOR OF YOUR HAIR AT A G E 7 O Black O fflonde O Light brown O Medium or dark brown O R e d 19. WHAT IS THE COLOR OF YOUR EYES? O Brown or black O B Iu e O Gray O Green 20. IF YOU HAD TO BE IW THE HOT SUN WiTHOUT PRorecnoN f o r o n e h o u r , y o u w o u l d GET A ... O Severe bum vrilh blistering O Severe bum without blistering O Mild bum, then tan or darken O No bum, but would tan or darken O No fMjm and no tan 21. IF YOU HAD TO BE IN THE SUN REPEATEDLY, YOUR SKIN WOULD TAN OR DARKEN.. . O Deeply O Moderately O UghOy O Not at all 22. HAVE YOU EVER BEEN SUNBURNED SEVERELY ENOUGH TO CAUSE BUSTERING? O No (go to q u e s tio n 23) O Yes IF YES, AT WHAT AGE DID THIS FIRST OCCUR? O 0 - 5 years 0 6 * 1 0 years O 11 -1 5 years O 1 6 -2 0 years O 21 - 25 years O 26 years or older HOW MANY TIMES HAS THIS OCCURRED? O 0 -5 tim e s O 6 -1 0 times O 11 -1 5 times O 1 6 -2 0 times O 21 -2 5 times O 26 limes or more 23. HAS YOUR DOCTOR EVER TOLD YOU THAT YOU HAD ANY OF THE FOLLOWING? (Mark all that apply) O High blood pressure O Heart attack or angina (diest pain on exertion that is relieved by mecfication) O stroke O Diabetes (high blood sugar) O Tuberculosis (TB) O Gout (high uric acid) O Polyps of intestines O Ulcer (stomach or d u o d e n ^ O Partial removal of stomach O Kidney stones O Gallstones C Gallbladder removed O Blood transfusions O Asthma, trayfever, skin allergy, food aHergy or any other allergy O Glaucoma O Cataract surgery O Colon or rectal cancer O Stomach cancer O Melanoma O Other skin cancer O Breast cancer O Prostate cancer (men only) O Cervix cancer (women only) O Other uterine cancer (women only) O Other cancer ( fill in circle and w rite in k in d ): O N o n e o f th e a b o v e MEMO.NLT O Vasectomy O Enlarged prostate O Surgery for enlarged prostate 232 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. EATING HABITS 24. î l i s next q uestions are about your usual eating habits DURING THE LAST YEAR. For each food group, p lease fill In th e circle th at b e st descrllies HOW OFTEN you ate th o se Items and th en fill In th e circle th at b est d escribes your USUAL SERVING SIZE. M ost categories Include exam ples. They are only su g g e stio n s, an d you m ay not e a t all of th e listed Item s. Som e ethnic foods are also listed. If you d o n t recognize th e nam e, you probably don't e a t that item. F or each Item, p lease Include any fresh, frozen, canned, an d packaged foo d s you ate, su c h a s TV dinners, frozen entrees, vegetables, o r sid e dishes. If you did not eat an item, o r If you ate an Item less than once a month, fill In th e circle In the first colum n. OO NOT LEAVE BLANK. It Is not necessary to ch o o se a serving size for th e se Items. For so m e categories, pictures of food on a dinner plate are Included to help you estim ate your usual serving size. Please note th at “1 cup" refers to an 8-ounce (240 m l) m easuring cup. " I For EACH F p o b GROUP, fill in th e e lrd e O th at b e st d sscrilie s HOW OFTEN you ate ttio se Item s during the last year. Then tin in th e circle O Utat iiest d escribes your USUAL SERVING SCE. I AVERAGE USE DURING LAST YEAR SOUPS, RAMEN, AND JOOK Never hardly ever Once a month month ZtoS ttmes a week week j ^ ■ YOUR USUAL more ' SERVING SIZE Umesa day j Cream Soup or Chowder o o o o o o o jcHOOSEONE j 0 c u p or less OR O lO Small bowl (about 1 cup) OR lO Large bowl (2 cups or mote) Dried Been or Pea (Legume) Soiqi (such as Portiquese bean, spM pea) o o o c o c o j CHOOSE ONE jO 1/2 cup or less OR O p Small bowl (alrout 1 cup) OR P Large bowl (2 cups or more) Tomato or Vegetable Soup (may inducfe meat, poultry, or fish) o o o o o o o {CHOOSE ONE p 1/2 cup or less OH O p Small bowl (about 1 ctgj) OR [O Large bowl (2 cups or more) Miso Soup 1 o o G o o o o CHOOSE ONE P 1/2ctg>orlessOR G p Small bowl (about 1 cup) OR lO Large bowl (2 cups or more) 1 Broth with Noodles or R ke (such as beef iKxxXa, 1 chicken doe, won tun mebi) o ! i 1 O O 1 O 1 o i ■ i o o jcHOOSEONE P 1/2 cup or less OR O p Small bowl (abouti cup) OR P Large bond (2 cups or more) ! Mexican Meat Soup or 1 Stew (such as menudo. 1 a & o n à ^ co cid o . 1 pozole) o I o I c ; o - o CHOOSE ONE jO 1/2 cup or less OR O iO Small bowl (about 1 cup) OR j o Large bowl (2 cups or more) Raman or Salmln 1 (Oriottal noodles with brattt) o o o { o o o o CHOOSE ONE P 1/Zcig>orlessOR O p SrrraX bowl (about 1 cup) OB P Largs bowl (2 cups or more) Jook (rice gruel - may Include meat, poultry, fish, or vegetatiles) . J J : L i 1 I - o o {CHOOSE ONE p 1/2 C IS) or less OR O P Small bowl (rdiout 1 cup) OR lO Large bowl (2 cups or more) 233 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I For EACH FOOD GROUP, fill in the circle O that best describes HOW OFTEN you ate those items during the I last year. Then fiii in the circle Q ttiat best describes your USUAL SERVING S I Z E .____________________ AVERAGE USE DURING LAST YEAR n u u u u a , SPAGHETTI. AND MIXED DISHES Never hardly Once m m offrtti 2to3 times a mimUl Once a M B H d S 2to3 times a wgak 4to6 times W ggK «to YOUR USUAL SERVING SIZE Chow Mein. Chow Fun. or Yakisobs (Oriental fried noodles) o o O O o o 1 (CHOOSE ONE j :C Photo A (1/2 cup or less) OR C ; C ,C Photo B (atmut 1 cup) OR i : 0 Photo 0 ( 2 cups or more) Spaghetti. Ravioli. Lasagne, or Other Pasta with Tomato Sauce o G o C 1 i CHOOSE ONE ! ' C Photo A (1/2 cup or less) OH C 1 J ! r , ” ' Photo B (about 1 cup) OH ! i C Photo C (2 cups or more) Macaroni and Cheese or Other Pasta and Chasse Casseroles o O o o o o o c CHOOSE ONE O Photo A (1/2 cup or less) OH O Photo B (about 1 cup) OR C Photo 0 (2 cups or more) Macaroni or Potato Salad (with mayonnaise) o o o o c ' CHOOSE ONE ' -L Photo A (1/2 cup or lass) OR C- i 2 C Photo B (about 1 cup) OH C Photo C (2 cups or more) Paata or Somen Salad o o o o o o O {CHOOSE ONE {O PItoto A (1/2 cup or less) OR O p Photo B (aixHit 1 cup) OR p Photo C (2 cups or more) Noodle Casseroles (with tuna, chicken or tuikey) o o o o o o jcHOOSEONE ■ C Photo A (1/2 cup or less) OR O ] C Photo 8 (about 1 cup) OR ■C Photo C (2 cups or more) Pasta with Cream Sauce (such as Sngulne with dam sauce, beet stnoganoR) o o o o o o O CHOOSE ONE O Photo A (1/2 cup or less) OH O Photo B (atmut 1 cup) OH G Photo C (2 cups or more) Arroz Con PoHo (rice with cMcken) o o o o o o c 2 CHOOSE ONE 2 Photo A (1C cup or less) OH C Photo B (about 1 cup) OR I Photo 0 (2 cups or more) Stew. Curry. Pot Pie. or Empanada (with beef or lamb) o o o o o o o jcHOOSEONE jo PhotoA(1/2ctq>or1 Empanad^OH O - O Photo B (aixaS 1 cup o r 1 pie) OR ;0 Pfioto G (2 cups or more) Slew, Curry, Pot Pie, or Empanada (with chicken or tuikey) o o o o Q ; CHOOSE ONE C Photo A (1/2 cup or t Em panada) OR C \ r C Photos (abouti cup or 1 pie) OB . ! C Photo 0 (2 cups or more) 2 3 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. For ËÂCH roOD GROUP, fill In the clnslé 0 # h M deserlbes HOW OFTEN you ate those items during the Wf last year. Then ffllln the circle Où-that best descriltss your USUAL SERVING SIZE. J MIXED DISHES AVERAGE U SE DURING LAST YEAR tefdiy ever O nce a month 2 to 3 m s & 4to6 Once a 2 o r d a y YOUR USUAL SERVING SIZE Stir-Fried Beef or Pork and Vegetables, or Fajitas I (such as beef broocolf, pork I tofu, chop suey.suki^Ki) o o o o o o o o CHOOSE ONE O Photo A (1/2 cup or less) OR O Photo B (about 1 cup) OR O Photo C (2 cups Of more) , SllrfH ed Chicken and M VegstsUra, or Fa|iias ■ I (such as sukiyaki, nishim e, J chldcen long rice) O O o o o o o o CHOOSE ONE o Photo A (t/2 cup or less) OR O Photo 8 (about 1 cup) OR O Photo C (2 c ^ s or more) ! SllrfM edShrbnporPlsh and Vegetables o o o o o o o o CHOOSE ONE O Photo A (1/2 cup or less) OH O Photo B (about 1 cup) OR O Ptmto 0 ( 2 cups or more) Stirfrled vegetables (no meat) O O O O O O O O CHOOSE ONE O Phrto A ( ia cup or less) OR O Photo B (about 1 cup) OR O Photo C (2 cups or more) " 4 Pork and Greens or — a Lautaus • bI o o o o o o d 2 Chill H ____ CHOOSE ONE O PholoA(1/2cuporless)OR O Photo B or 1 laulau OR Q Photo C or2 laulaus or more o o o o o o o o CHOOSE ONE O 1/2 cup or less OR O Small bowl (1 cup) OR O Large bowl (2 cups or more) Hamburgers (on a bun) o o o o o o o o CHOOSE ONE O 1 regtriarsizebuigerOR O 1 quaitsr-pound burger OR O 1 large double trurger_____ t Cheeseburgers (on a Irun) o o o o o o o o CHOOSE ONE O 1 regular size burger OB O 1 quarter^Mund burger OR O 1 large double burger______ Meat Loaf, Meatballs, or Patties (not hist-fbod hamburgers) O O o o o o o o CHOOSE ONE O 1 to 2 meatballs OR O 1 paltyorsficoorSmealbfSlsOB O 1 large patty or 5 m ealtralls J Pizza I o o o o o o o o CHOOSE ONE O 1 piece or slice or less OR O 2 to 3 pieces OR O 4 pieces or more_________ 235 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. For EACH FOOD CSROUB fill In the drele O that best describes HOW OFTEN you ate those Items during the test year. Then fill In the circle O fimt b ^ describes your USUAL SERVING S G C E . MEATS (NOT PART OF MIXED DISHES) AVERAGE USE DURING LAST YEAR Never hardly ever Once a monlh a to3 times a month Once a m A 2to3 flmea a week 4toS antes a week Once a dut 1 YOUR USUAL more 1 SERVING SIZE Umesa ' dax 1 Beef Steak or RoasL Veal or Lamb (imdudes beef teriyaki, cMIe ookxado, came asada) o o o o o o O G CHOOSE ONE 0 PfiotoA(1otmcaorless)OR , C Photo B(3oz. or 1 lamb chop) OR 0 Pfioto 0 (5 otaices or more) Shortribs o o c o o o CHOOSE ONE , O PholoA(1 ounceorlass)OR O C .0 Photo B (or 2 shortribs) OH ! i C Photo 0 (or 3 lit» or more) ' Corned Beef (fresh or canned) o o o o o o 0 jCHOOSEONE I 0 PfioloA(1 ounce or less) OR 0 P Photo B (or 1/4 12k> z. O n) OR . t o PItoto C(or1/212-oz. U n or more) : Corned Beef Hash o o o o o o 0 jcHOOSEONE , jo PftoloAori patlyOR , 0 p fUtotoBorgpalUesOR ! ;0 Photo 0 or 3 patties or more Pork Chops or Roasts, Kalua Pig, or Camltas (Includes ctiRe vanto) o o o o o o 0 jcHOOSEONE 1 t o Photo A (1 ounce or less) OR 0 t o Photo B (3 ounces) OR j t o Pfioto C (5 ounces or more) ji Ham (includes baked, fried, or sandwich) o o o o o o 0 CHOOSE ONE ) t o Pfioto A (1 ounce or less) OR J 0 t o Photo B (3 ounces) OR j 0 Pfioto C (5 ounces or more) Ham Hocks or Pig's Feet o o o o o o 0 0 CHOOSE ONE • 0 Photo A (1 ounce or less) OR k 0 Photo B (3 ounces) OR ji 0 Photo 0 ( 5 otsioss or mof^ __« Sparerlbs o o o o o o 0 c CHOOSE ONE ;• 0 3 small or Ikmg rib or less OR • 0 2 to 3 long rit» (5-7 inches) OR '• O ' 4 long lU» or more Liver o o o o o o 0 0 CHOOSE ONE 0 PfiotoA(1 ounce or less) OR 0 Pfioto B or 3 chicken Uvars OR 0 Photo 0 (5 ounces or more) CMcken or Turkey W ngs o o o o o o 0 G , CHOOSE ONE ^ 0 2cf»ckenwin(»orlessOR ; ■ 0 3 chicken wings OR ■ 0 lluikay or 4 chicken wings or mofBS 236 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. For EACH FOOD GROUP, fill bi the circle O ^that beat describes HOW OFTEN you ate those items during the - last year. Then fill In the d rc te O that b ^ t describes your USUAL SERVING Size . A B C POULTRY AND FISH (NOT PART OF MIXED DISHES) AVERAGE USE DURING LAST YEAR Never or hardly ever ! Once ■naoU i ! 2to3 j times mpolh Once a Ksek 2103 ; 4 to6 times i times a j a iKM k 1 mek to YOUR USUAL SERVING SIZE 1 FrW tailcken 1 (Includes Wed chicken sandwich, nuggets) o O O O O o O o CHOOSE ONE O Photo A (or 1 dnimstick) OH O Photo B (or 1 breast. 2 thighs, 3 wings, or 1 sandadch) OR O Photo C (ora breasts or 4 thighs) Roasted, Baked, Grilled or Stewed Chicken (includes grilled chicken sandwich) o o o O O o CHOOSE ONE C Photo A (or 1 dnimstick) OR C Photo 8 (or 1 breast, 2 thighs, 3 wmgs, or 1 sandwich) OR G Photo C (or2 breasts or4 Mghs) Turkey (includes roast ground, deR.style, or sarùwtch) o o o o o o o o CHOOSE ONE O Photo A (1 ounce or less) OR O Photo 8 (3 ounces) OR O Photo C @ ounces or more) Fried Shrimp or Other Shellfish (includes lempura. fried calamari or squid) o o o o o o o •0 CHOOSE ONE o 1 to 3 items OR O 4 to S items or 1/2 cup OR O 6 items or more Cooked, Canned, or Raw Shellfish (such as crab, squid, shrimp) o o o o o o o CHOOSE ONE b 5-6 Shrimp or 1/4 cup OR ' O b 1 crab or cup OR b 1 lobster tail or 1 cup or more Fried Fish (includes pan-fried fish, frozen fish slicks, fried fish sandwich) o o o o o o o (CHOOSE ONE b f%otoA(atiout 1 ounce) OR O jo Photo B (3 oz. or 1 sandwich) OR b Photo 0 (5 ounces or more) Balled, Broiled, Boiled or Raw Fish (such as red snapper, salmon, sashimI) o o o o o o o jcHOOSEONE b Pfido A (about 1 oimce) OR O b Photo B (3 ounces) OR b Photo C (5 ounces or more) Canned Tlinaflah (plain, salad, or sandwich) o o o o o o o 1 CHOOSE ONE |G 1/4 taip or 1/2 sandwich OR O jO 1/2 cup or 1 sandwich OR b 1 cup or 2 sandwiches Other Canned Fish (such as salmon, mackerel, sardnes) o o o o o o o jcHOOSEONE j o 3 smak sanfines or 1/4 cup OR O b 1/2 cup fish OR b 1 cup lish or mom Salted and Cried Fish (such as ike, cutHellsh, iriko) o o o o o c 1 1 CHOOSE ONE I jo 1 slice or strip or piece OB O I O lO 2 slices OR ! k C 4 slices or more 237 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PROCESSED MEATS AND MEXICAN DISHES AVERAGE USE DURING LAST YEAR | Never hardly Bacon (includes CanaiSan bacon) o i 1 C I O 1 o 1 o (aiOOSEONE ; 1 ' O f slice or strip or piece OR C 1 C O |C ZskcasOR ! 1 G 3 slices or more Regular Hot Dogs (beef or pork) o c 1 o c 1 CHOOSE ONE o 1/2 hot dog OR C 1 hot dog OR O 2 hot dogs or more Chicken or Rirfcey Hot Dogs or Luncheon Meats o o o o o ! O 1 Q o CtioOSEONE O 1/2 hot dog or 1 slice OR O 1 hot dog or 2 slices OR , ; 0 2 hot dogs or 3 slices or more Spam, Bologna, Salami, Pastrami or Other Luncheon Meats o o o o o O o : CHOOSE ONE ;C 1 sBce (1 ounce or loss) OR O j o 2 slices OR [Q 3 slices or more Sausage (such aa polk, beef, chorizo, PWsh. Vienna, Pw hwiese. hot Inks) o o o o o o o CHOOSE ONE jo 1 piece or link OR O jo 2-3 places or links ort patty OR lO 4 tMsces or 8nks or more Tacos, Tostadas, Sopes, or Taco Salad (with beef or poilO o o o o o o I I CHOOSE ONE ■ 'C 1 item or less OR , O 1 O I ' C 2 items OR ; ' O 3 items or more Tacos, Tostadas, Sopes, or Taco Salad (wRh chicken) o o o o o o O 1 CHOOSE ONE I P 1 item or less OR O j o 2 items OR p 3 items or more Meat Burrftos (Includes beef and bean and other conHiinations) o o o o o o o i CHOOSE ONE 1C 1 fast-food burrito OR j O jo 1 medium burrito OR ! p 1 large or 2 hist-food burritos ! Vegetable or Bean Burritos, Tacos, or Tostadas (no meat) o o o o o o o ICHOOSEONE jO 1 item or less OR O jo 2ilamsOR jo 3 items or more Enchiladas with Chicken o o o o G o o CHOOSE ONE j o 1 encfikada or less OR O jO 2 enchiladas OR !C 3 enchiladas or more . Enchiladas with Beef o o o o o o o ICHOOSEONE j o 1 enchilada or less OR O jo 2eneh#adasOH P 3 enchiladas or more Enchiladas with Cheese, Ouesadlltas, or thadios with C heese o o o o o o o o CHOOSE ONE Q 1 enctVladaorsmaHquesadlllaOR ;i 0 S en ch k ad aso rtsefv in g n ach o sO R ’ i C 3 enchiladas Tamales o o o o o o o o CHOOSE ONE O 1/2 tamale or less OH O 1 tamale OR O 2 tamales or more Chili Rellenos o o o o o o CHOOSE ONE O 1/2 chili relleno or less OR j > C 1 chiB relleno OR O 2 chili leHenos or more |r 238 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. For EACH FOOD GROUP, fill In the circle Q Aet best describes HOW OFTEN you ate those Items during the last yrar. Then flli in the circle O that best descril>es your USUAL SERVING SIZE. AVERAGE USE DURING LAST YEAR RICE, POTATOES, ; TARO, AND POI Once I h ard ly ! 2to 3 ! times : a I I 2 to 3 I 2 to 3 ! 4to6 times Anes a [ a Once : 2 or . tfanmia YOUR USUAL SERVING SIZE White Rice m m <uidudes musubi) o 1 o o i j j ; CHOOSE ONE 1 j 1 j 'C 1/2 cup or 1 scoop or less OR O 1 O 1 O ! O ] O o lik e bowl (1cup)or1musiai OR 1 1 ' : Q 2 Ike bowls or2 musuW or more Sushf or Barazushi o o o O o O 1 o 1 CHOOSE ONE iC 1-2 pieces or small cone OR C C 3-4 pieces or 1 large cone or 1/2 cup OR G 5 pieces or 1 cup or more Brown or Wild Rice o o o o o o o {CHOOSE ONE l O 1/2 cup or 1 scoop or less OR G 1 C 1 cup or 2 scoops OR !C 2 cups or more Mexican or Spanish Rice o o o o o o CHOOSE ONE O 1® cup or less OR O i C iC ic u p O R ! -C 2 cups or more ^ Fried Rice o o o o o o o o CHOOSE ONE O 1/2 cup or less OR 0 1 cup OH C ' 2 cups or more Frenchfried, i Hash-Browned or other I Fried Potetees o o o o o o 1 CHOOSE ONE i ; 0 fasMood small order or 1 cup OR O ! O ; 0 fast-food medium order OR ! ' . C j tast-lood large order or more Mashed, Scalloped or w Au G r^n Potatoes H o o o o o o o o CHOOSE ONE 0 1/2 cup or 1 scoop or less OR 0 1 cup or 2 scoops OR O 2cupsorm ore Baked or Bfriled White ■m t Potatoes o o o o c o o ICHOOSEONE 'C 1 small or 1/2 medium or less OR C ; 0 1 medium (about 5 Inches) OR i C - 1 large potato or more t " I YellowOrange Sweet ■ ssi Potatoes or Yams o o o o o o o Q CHOOSE ONE O 1 smNI or 1/2 medium or less OR O 1 medium (about S Inches) OR O 1 terge potato or more White or Purple Sweet ■M i Potatoes o o o o o o o O CHOOSE ONE C 1 small or 1/2 medium or less OR G 1 medium (atmut 5 inches) OH C 1 large potato or more ■M l — j o o o o o o o o CHOOSE ONE O 1/4tatoorlessO R O 1/2 taro OR C 1 whole taro or more o o o o O 1 o CHOOSE ONE ; G 1/4 cup or less OR c jC 1/2 cup OR :0 1 cup or more 239 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. For EACH FOOD GROUP, fill In the circle O that best describes HOW OFTEN you ate those Items during the last year. Then nil In the cirde Of that best descrRies your USUAL SERVING SIZE SALAD ITEMS, EGGS, AND OTHER NON-MEAT ITEMS AVERAGE USE DURING LAST YEAR Never hardly Once a fflfiom 2103 times month Once a W W K 2103 Umee srsgjt ; 4106 Umee e week Once a S tB K t 2or more times a dax YOUR USUAL SERVING SIZE UgM Green Lettuce or Tossed Salad (such as icetterg or head lettuce) o o o o O O o o CHOOSE ONE O Photo A (1/2 cup or less) OR O Photo B (about 1 cup) OR 0 Photo C (1-1/2 cups or more) Dark Green lettuce (such as romaine, red. iH itter, manoa, endive) o o o o o o o o CHOOSE ONE C Photo A (1/2 cup or less) OR O Pttoto B (about 1 cup) OR O Photo 0 (1-1/2 C U D S or more) Tomatoes o o o o o o o o CHOOSE ONE O 2 slices or wedges or 2 cherry tomatoes or less OR 0 4 slices or 1/2 inetftim tomafi) OR 0 1 medum tomato or more j Coleslaw o o o o o o c o CHOOSE ONE 0 1/4 cop or less OR | 0 1/2 cup OH 0 1 cup or more I Regular Salad Dressings or Mayonnaise Added to Salads o o o o o o o o CHOOSE ONE 0 2 teaspoons or less OR 0 1 Tablespoen OR O 2 Tablespoons or more Low-Calorle or Diet Dressings Added to Salads o o o o o o o o CHOOSE ONE 0 2 teaspoons or less OR j 0 1 TatUespoonOR j O 2 Tabtespoons or more Eggs, Cooked or Raw (includes egg salad) o o o o o o o o CHOOSE ONE 0 1/2 egg OR 0 1 egg or 1 sandwich OR O Z eoosorm ore i Egg Substitute o o o o o o o o CHOOSE ONE j O 2 Tablespoons OR i C l/4 c u p (= 1 e g g )O R j O l & cup ( = 2 eons) or more Tofu (soybean curd) o o o o o o o o CHOOSE ONE 0 2 cutms or 1/4 cup OR 0 1/4 Iriock or 1/2 cup OR 0 1/2 tilock or more vegetarian Meat Loaf. MeattmUs or Patties o o o o o o o - CHOOSE ONE 0 1 to 2 meatballs OR j > 0 1 patty or slice orSmeatbak OR '• O l iam epatty. Sm eattiallsorm ore ■ 2 4 0 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. F o r EACH FOOD GROUP, All In th e circle I Q ^ th a t b e s t d e s c rib e s HOW OFTEN y o u a te th o s e Ite m s d u rin g th e la s t y ear. T h en «II In th e c ircle Q Um t b e s t d e s c d b e s y o u r USUAL SERVING SIZE. v; AVERAGE U SE DURING LAST YEAR 1 VEGETABLES (NOT IN SOUPS OR • ; MIXED DISHES) Never or hardly Once a month 2to3 flllM S a month Once a week 2to3 times week 4to6 times a week Once {fay 2 or mwe timesa (ky YOUR USUAL SERVING SIZE 1 1 Broccoli 1 (raw or cooked) o o o o o o o o CHOOSE ONE O Photo A(1/4 cup or less) OR O Photo B (about 1/2 rarp) OR C Photo C(1 cup or more) Cabbage (such as head, Chinese or Napa cabbage, Brussels sprouts) o o o o o o c CHOOSE ONE O Photo A (1/4 cup or less) OH O Photo B (alxMit 1/2 cup) OR C Photo 0 (1 cup or more) Dark Leahr Greens j (such as spinach. coKaid, nuistaid ortumyr greens, bok choy, waleiciBss, chard) o o o o o o o o CHOOSE ONE O PIroto A (1/4 cup or less) OR O Photo B (about 1/2 cup) OR O PhotoC (1 cup or more) 1 Green Beans or Peas o o o o o o o o CHOOSE ONE O Photo A (1/4 cup or less) OR O Photo B (about 1/2 cup) OR O Photo C (1 cup or more) ' Other Green Vagetaliles (such as zuccMii, celery, i asparagus, green pepper, I okra) o o o o o o o o CHOOSE ONE O Photo A (1/4 cup or less) OR O Photo B (attout 1/2 cup) OR O Photo C(1 cup or more) Cauliflower o o o o o o o o taiOOSEONE O Photo A (1/4 cup or less) OR O Photo B (alxrul 1/2 cup) OR O Photo C (1 cup or more) Carrots (raw or cooked) o o o o o o o o CHOOSE ONE O Photo A (or 4-5 sticks orless) OR O Photo B (1/2 cup or 1 mod.) OR O Photo 0 (1 cup or more) Com (hesh, frozen, or canned) o o o o o o o o CHOOSE ONE O Photo A (1/4 cup or less) OR C Photo B (1/2 cup or 1 cob) OR O Photo C (1 cup or more) Pumpfcb) or Yellow- ! O rai^lW nter Squash o o o o o o o o CHOOSE ONE 3 Photo A (1/4 cup or less) OR O Photo B (alH M jt 1/2 cup) OR O P tiotoC d ctsiormore) Other Vegetables (su ^ as M Aite or dimmer squash, beefs, ^gpiant) o o o o o ° o - CHOOSE ONE O Ptioto A (1/4 cup or less) OH C Photo B (atxHJt 1/2 cup) OR O Photo C (1 cup or more) 2 4 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i Fbr EACH FOOD GROUP, fill in ttie c ird a O th at b e à describ es HOW OFTEN you a te th o rn Items during th e ; last year. Then fill in tiw circte Q;: th at jbest describ es your USUAL SERVING SIZE. DRIED BEANS (NOT IN SO UPS OR MIXED DISHES) AVERAGE USE DURING LAST YEAR “ Newr or hardly I Once 1 a month 2to3 dmea a month Once a week 2to3 times a week 4toB „ 1 2or YOUR USUAL - times ! more SERVING SIZE — nA k : j % = ; 2 Refried Beans (not in burritos or tostadas) o o o o o o o I ICHOOSEONE — jC Photo A (1/4 cup or less) OR " C jC Photo B (atX M it 1/2 cup) OH ■O Photo C (1 cup or more) Baked Beans or Pork and Beans o o o o o o 1 o I CHOOSE ONE — 'C Photo A (1/4 cup or less) OR " O j o Photo B (about 1/2 cup) OR 'em ! C Photo C (1 cup or more) me Betted Drted Beans or Peas (such as rad, lima, pinto or soy beans, bWMyed peas, kWasdelaolla) o o o o o o o ICHOOSEONE e s , j o Photo A (1/4 cup or less) OH .em Q j o Ptiolo B (about 1/2 cup) OR jsei lO Photo C (1 cup or more) — FRUITS AND JUICES AVERAGE USE DURING LAST YEAR YOUR USUAL e e SERVING SIZE — N ew hardly ever Once a month 2 to3 times a month Once a week 2103 times a week 4to6 times a wsek Once 2or O M re times a day Oranges o o o o o o o O CHOOSE ONE ,em 0 1/2 orange or 1/2 cup or less OR sei 0 1 orange or 1 cup OR !#e- O 2 oranges or more 'am Tbngerhtes or Mandarin Oranges o o o o o o o O CHOOSE ONE am O 1 tangerine or 1/2 cup or less OR am O 2 tangerines or 1 cup OR " O 3 tangerines or more Grapefruit or Pomelo o o o o o o o o CHOOSE ONE ,ma 0 1/4 cup orless OH em 0 1/2grapeliudor1/2cupOR j " 0 1 cup or more em Papaya o o o o o o o o CHOOSE ONE ,em O 1/4 papaya or less OR jam 0 1 / 2 papaya OR jsm O 1 papaya or more ma Pineapple (fresh or canned) o o o o o o o o CHOOSE ONE em 0 1 slica or wedge or less OR j " 0 1/2 ogi or 2 slices or wedges OR am 0 1 cup or more Peaches (fresh, canned, or dried) o o o o o o o o CHOOSE ONE me O 1/2 peach or less OR jam O 1 peach or 2 halves or 1/2 cup OR em O 2 peaches or 1 cup or more 'em Apricots (fresh, canned, or dried) o o o o o o o o CHOOSE ONE !em O 1 apricot or less OR m e 0 2 apricots or 1/2 cup OR ^ 0 3 apricots or more m m Pears (fresh, canned, or dried) o o o o o o o o CHOOSE ONE ,m m O 1/2 pear or 1/2 cup OR .«m O 1 pear or 1 cup OR jam, G 2 pears or more " 242 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. F o r EACH FOOD GROUP, fill in th e circ le O th a t b e s t d e s c rib e s HOW OFTEN y o u a te ttio s e Item s d u rin g th e fa st year. T h en fill in th e circle O t h a t b e s t d s s c rib e s y o u r USUAL SERVING SIZE. ■ ' " » ï V*'.**-' —t FRUITS AND JUICES " 4 (continued) AVERAGE USE DURING LAST YEAR j::::' ' wwK I wwK ^ 2or more timesa â a x YOUR USUAL SERVING SIZE Apples and Applesauce o o o o o o o ICHOOSEONE ) 1/2 apple or 1/2 cup OR O 1 apple or 1 cup OR ) 2 apples or more_______ 3 o o o o o o ICHOOSEONE 11/2 banana OR O O 1 banana OH O 2 bananas or more ^ Cantaloupe ^ (in season) o o o o o o o o CHOOSE ONE O 1/4 canlaloupe or less OR O 1/2 canlaloupe OR O 1 cantaloupe or more Watermelon (in season) o o o o o o o o CHOOSE ONE O 1 quarter slice or 1/2 cup OR O 1 ban slice or 1 cup OR O 1 ««hole slice or more_______ Mangoes (in season) o o o o o o o CHOOSE ONE O 1/2 cup slices OR O 1 mecBum or Pitie or 1 cup OR O 1 large or Hayden or more Avocados and Guacamole o o o o o o o o CHOOSE ONE O 2 slices or 2 Tablespoons OR O 1/4 avocado or 1/4 cup OR O 1/2 avocado or 1/2 cup or more Any Other Fruit (fresh, canned, or dried) O o o o o o o CHOOSE ONE O 1/2 cup or less OR O 1 1 n al or 1 cup OR OainiitsorniotB Orange or Grapehuil Juice (not orange drinks or orange soda) O o o o o o o o CHOOSE ONE O SmaU juice glass (1/2 cup) OR O Large glass (8 ounces) OH O 12<mnce can or more_______ J Tomato or 1F8 Juice o o o o o o o o CHOOSE ONE O Small juice glass (1/2 cup) OR O Large glass (8 ounces) OR O 12-ounce can or mote_______ 3 Other Fruit Juices or Fruit Drinks o o o o o o o o CHOOSE ONE O Small juice glass (1/2 cup) OR O Large glass (8 ounces) OR O 12 ounce can or more_______ 2 4 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. F o r EACH FOOD GROUP, fHI In th e c ir c le , O b e s t d e s c rib e s HOW OFTEN y o u a te th o s e Ite m s d u rin g th e j" la s t y ear. T h en till In th e c ircle Q th a t b e s t d e sc ritm s y o u r USUAL SERVING SIZE. i" AVERAGE U SE DURING LAST YEAR BREAD ITEMS Never hardly ! 1 Once ! a month rmroih | ] wffitk 4to6 times 1 ; : YOUR USUAL i : more ; SERVING SIZE j While Bread (includes sandwich, Fiench, souidouÿi, pan duha. Portuguese sweet bread) o o O o o o o , CHOOSE ONE jO 1 slice or less OR O ! 0 2 slices OR ! 0 3 slices or more Whole Wheat or Rye Bread (includes pumpernickel, whole wheat braacQ o o O o o o o {CHOOSE ONE ;0 1 slice or less OR O | 0 2 slices OR Î ;0 3 slices or more Other Bread (such as mixed grain, oat bran, raisin bread) o o o o o o o o CHOOSE ONE 0 1 sKce orless OR 0 2 s lic e s O R P 3 slices or mote Rolls, Buns, Biscuits, or Flour Tortillas (mdudas bagels, English muffins) o o o o o o o o CHOOSE ONE O 1 M em or less OR Q 2 Hems or 1 bagel or English muffin OR O 3 Hems or more Corn Tortillas, Com Muffins, or Comtnead (ffidudes corrdveml stuffing) o o o o o o o CHOOSE ONE P 1 tortilla or 1 piece combread or O 1/2 cup stuffing OR P 2 tortillas or 1 muffin OR j o 3 torlMas or 2 muffins or more Bran, Bluetrerry or Other Muffhis, Banana or Mango Bread o o o o o o o CHOOSE ONE j 0 1 regular muffin or 1 slice OR O p 1 large muffin or 2 sNces OR .p 3 muffins or slices or more Sweet Rolls, (hclssants. Doughnuts, Danish Pashy, or Coffee Cake o o o o o o o IcHOOSEONE P 1 item or less OR O 0 2 items OR ! 0 3 Hems or more Pancakes, Waffles, or French Toast o o o o o o o {CHOOSE ONE jo 1 Hem or less OR O p 2 H e m sO B iO 3 Hems or more Margarine Added to Bread items o o o o o o o ICHOOSEONE o P spread thin OR lO spread thick Butter Added to Bread Items o o o o o o o [CHOOSE ONE O p spread 11*) OH IO spread thick Peanut Butter Added to Bread Items o o o o o o o 1 CHOOSE ONE O jo spread thin OH lO spread Uik* Jam rrr Jelly Added to Bread Items o o o o o o o o CHOOSE ONE 3 spread thin OR O spread thick j Mayonnaise in Sandwiches o o o o o o o O CHOOSE ONE 1 3spread tl*iO R , O spread thick - t 2 4 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I i' -T AVERAGE USE DURING LAST YEAR DnCAIxr*Ao 1 CEREALS. MILK. A N D C H iæ SE Never or hardly Once a month 2to3 times month Once woek 2 to3 Umee a wesh 4 toe times a m # Once d û 2or more dmeea dax YOUR USUAL SERVING SIZE Highly Fortifled Cereals (such as Product 19. Total, Most) o o o o o O o o CHOOSE ONE O 1/2 cup or less OR O 1 cuporinrlivkhmlbaxOR O 1-1/2 cups or more Bran or High Fiber Cereals o o o o o o c o CHOOSE ONE O 1/2 cup or less OR 0 1 cup or individual tjox OR O 1-1/2 cups or more Other Cold Cereals (such as œ m flakes, Ctieerios. granola) o o o o o o o o CHOOSE ONE O IffictfliorlessOR O 1 cup or individual box OR O 1-1/2 cups or more Cooked Cwaals (such as oatmeal, «earn ol wheaL com grits) o o O o o o o o CHOOSE ONE O 1/2 cup orless OR O 1 cup or individual parricet OR O 1-1/2 cups or mrxe Whole Milk (as beverage or added to cereal) o o O o o o o o CHOOSE ONE o 1/2 cup or less OR 0 1 cup or half-pint carton OR O 2cupsormora Lowfat Milk (1% or 2%) (as beverage or added to cereal - Includes tactald and ackkjptiHus raU k) o o o o o o o o CHOOSE ONE O 1/2 cup or less OR O 1 cup or half-pint carton OR O 2 cups or more Nonbt or Skhn Milk or Buttermilk (as beverage or æMed to cereal) o o o o o o o o CHOOSE ONE O 1/2 cup or less OR O 1 cup or half-pint carton OR O 2 cups or more Yogurt (includes lowfat and nonW) o o o o o o o o CHOOSE ONE O 1/2 cup or 4-6 oz. carton OR O 1 cup or 8 oz. carton OH O 2 cups or more Chocolate Milk, Cocoa, or Ovaltlne o o o o o o o o CHOOSE ONE O 1/2 cup less OR O 1 cup OR O 2cupsormrXB Milkshakes or Malts o o o o o o o o CimOSEONE O 1/2 miScsfiake or mdt OR O 1 milkshake or malt (12 oz.) OR O 2 milksfiakes or malts Cottage Cheese (krduries farmer's and ricotta cheese) o o o o o o o o CHOOSE ONE O 1/4 cup or less OR O 1Æ cup or 1 scoop OR O 1 cup or more Lowfat Cheese (such as lowfat American, lowfat Sw ss. mozzarella) o o o o o o o o CHOOSE ONE O 1/2 slice OR O 1 sKce (1 ounce) OR O 2 slices (2 ounces) or more Other Cheese (such as American, Cheddar, cream choose) o o o o o o o o CHOOSE ONE 3 1/2 sKce or 1 Tablespoon OR 1 slfce (1 ounce) OR O 2 slices (2 ounces) or more ■ 16 ■ 245 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. AVERAGE USE DURING LAST YEAR \ DESSERTS AND SNACKS Never or h a n W y Once e m m # 2to3 tiroes a fflfiO Si! Once weflK 2h>3 timss a steek 4toS timss week Once a day 2 or more timesa Ay 1 YOUR USUAL ; SERVING SIZE ; tea Cream o o o o O o O o ICHOOSEONE iO 1 scoop (1/2 cup) or less OH jO 2 scoops (1 cup)or 1 tiarOR ! 0 3 to 4 scoops (1 pint) or more Ice Milk, Frozen Yogurt or Sherbet o o o o O o o o CHOOSE ONE jO 1 scoop (1/2 cup) or less OR |C 2 scoops (1 cup)or 1 barOR , 0 3 to 4 scoops (1 pint) or more Cookies, Browmles, or Fruit Baré o o o o O o o o CHOOSE ONE P 1 to 2 average size cookies OR j o 3 to 4 average or 1 extra large ! cookie ort brownie or fruit bar OH lO 2 large cookies <a brownies or more Cake o o o o O o o o CHOOSE ONE j o 1 small piece or cupcake OR p 1 average piece (1/12 of cake) OB IO 2 pieces or more Apple or Other Fruit Pies, Tarts, Coitblers, or Turnovers o o o o O o o o CHOOSE ONE P 1 small piece OR j o 1 piece (1/8 pie) or 1 item OR P 1/6 pie or more Pumpkin, Sweet Potato, or Carrot Pies o o o o O o o o jCHOOSEONE p 1 small piece OR p 1 average piece (1/8 pie) OR iO 1/6 pie or more Cream or Custard Pies, Eclairs, or Cream Puffs o o o o O o o o jcHOOSEONE p 1 small piece OR j o 1 average piece or 1 item OR P 1/6 pie or more Puddings or Custards (includes flan) o o o o O o o o CHOOSEONE p 1 snack-size or 1/2 cup OR P 2 snack-size or 1 cup OR lO 3 snack-size or 1-1/2 cups Chocoltto Candy o o o o O o o o CHOOSE ONE lO 1 toSpiecesO H j o 1 regular-size bar OR P 1 giant-sizebarorraora Olm Sum, such a s Bao or Manapua (Chinese bun with meat and vegetabies) o o o o O o o o CHOOSE ONE P 1/2 bao or less OR p 1 bao OR IO 2 bao or more Other Dim Sum (such as pork hash, gau gee, fried won ton, eggroli) o o o o O o o o CHOOSE ONE p 1 to 2 pieces OR p 3 to 4 pieces OR jO 5 pieces or more Crackers and Pretzels (such as soda, graham, Japanese rice crackers, wheat thins) o o o o o o o o {CHOOSE ONE [O 4 to 5 snack or 1 large cracker OR J o 6 to 10 snack or 2 large crackers OR p 3 large crackers or more Peanuts or Other Nuts o o o o o o o o CHOOSE ONE p 12 nuts orless OR jo 1/4 cup OR lO 1/2 cup or more 17 2 4 6 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. F o r EACH FOOD GROUP, All in W c ircle O th a t b e s t d e s c rib e s HOW OFTEN y o u a te th o s e Item s d u rin g th e *! la s t year. T h en fill In th e c ircle O th a t lie s t d e s c rib e s y o u r USUAL SERVING SIZE. AVERAGE USE DURING LAST YEAR — » SNACKS (continued) Once « rnsm 2to3 tiims a w e f i H 4to6 times ttgeK Once dax eor more tfmeaa dm YOUR USUAL SERVING SIZE j Potato, Com, Tortilla or 1 Other C h ^ , or " j Chlchanones (poifc rinds) , o j o o O o o o O CHOOSE ONE O 1 snack bag or 1/2 cup OR O 1-ounce bag (1 cup) OR O 1/2 twin-pack or more 3 Popcorn i c 1 o o o o o o CHOOSE ONE O 110 3 cups or less OH O 1 microwave bag OR O 1 medium theater tub or more ALCOHOLIC AND OTHER BEVERAGES AVERAGE USE DURING LAST YEAR YOUR USUAL SERVING SIZE Never or hardly month 2to3 times a munUt Once a Hseh 2to3 times a m sk 4to6 Urnes a meek Once a dsx 2103 Umee itox 4or more Umee a day Regular or Draft Beer o o O o O O o o o CHOOSE ONE 0 1 can or bottle or less OR O 2 cans or bottles OR O Scans or bottles OR O 4 cans or bottles or more Light Beer o o O o o O o o o CHOOSE ONE O 1 can or bottle or less OR O 2 cans or bottles OR O 3 cans or bottles OR O 4 cans or bottles or more White or Pink Wine (Includes champagne and sake) o o o o o o o o o (MOOSE ONE 0 1 glass or less OR 0 2 g la s se s O R O SglassesO R O 4 glasses or more Red Wine o o o o o o o o o CHOOSE ONE O 1 glass or less OR O 2 glasses OR 0 3 glasses OR (3 4 p asses or more Hard Liquor (such as tM uriXHi, scotrdi, gki, vodka, tequila, rum, cocktails) o o o o o o o o o CHOOSE (ME O 1 drink or less OR O 2 drinks OR O 3 drinks OR O 4 drinlcs or more Regular Sodas (such as Coca-Cola, Pepsi, 7-Up) o o o o o o o o o CHOOSE ONE O 1/2 can or smaU glass OR O 1 can or large glass OR O 2 cans or glasses OR O 3 cans or glasses or more Diet Sodas (such as Diet Coke, Diet Pepsi. DW 7-Up) o o o o o o o o o (MOOSE ONE O 1/2 can or small glass OR O 1 can or large glass OR 3 2 cans or glasses OR O 3 cans or glasses or more ■ 18 ■ 247 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. OTHER BEVERAGES AVERAGE USE DURING LAST YEAR WHAT DID YOU USUALLY ADD? " r 1 2 to3 times a month « s * j xA k 4t06 times a week Once t o 2to3 ; 4 or times j more a } times a day j day Cappuccino- 1 cup or mug ' O ' O (ndudes calé au lait, «tflè: j latte, catâ con lécha) • o O i O i O ! O ! O i O i 1 i MARK AtX THAT APPLY O Sugar or honey O Sugar subsUtute Regular Cofleo - 1 cup or mug (brewed or Instant) o o o o o o o o o MARK ALL THAT APPLY O Cream or half S hall OMHk O Non-daiiy cream C Sugar or honey O Sugar si*stltute Decaffeinated (“DecaT) Coffee- 1 cup or mug (brewed or Instant) o o o o o o o o o MARK ALL THAT APPLY C Cream or half & half OMilk O Non-daity cream O Sugar or honey O Sugar substitute Black Tea- 1 cup or glass (such as Upton's, oolong. Iced tea) o o o o ‘ O o o c o MARK ALL THAT APPLY 0 Cream or haK & halt C M ilk O Non-daliy cream C Sugaror honey O Sugar strbslKute Green, Herbal, or Other Tea -1 cup o o o o o o o o o Ë Foitmed Diet Beverages • 1 glass or can (such as srimlasl) o o o o o o o o o HOW OFTEN DID YOU EAT THE FOLLOWING ITEMS? AVERAGE USE DURING LAST YEAR Nover or hardly over Once a month 2to3 times a month Once a week 2to3 times a gggK 4to6 Umas a ytsak Once a t o 2 or mere tfmasa day Western Pickles or Relish (such as dU or sweet pickles) o o o o o o o o Olives o o o o o o o o j- Salsa or Hot Chill Peppers (red or green) o o o o o o o O L Garlic o o o o o o o o É Onions o o c o o o o o ! - Oriental Saltetl or Pickled Vtagetaliles (such as salted cabbage or lealy greens, takuwan, kim chee) o o o o o o o o Seaweed (fresh or dited) (such as ogo limu, hirStake) o o o o o o o O , J Gravy on meat, potatoes, rice o o o o o o o ° 2 4 8 R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission. AVERAGE USE DURING LAST YEAR w HOW OFTEN DID YOU ADD THE FOLLOWING ITEMS — ! TO YOUR FOODS AT THE TABLE.. . T i 13 Z 2 i i u Z : ! 1 I — Sait O 1 o o c o ! o I o o Shoyu (Soy Sauce) or Teriyaki Sauce C 1 o { o j o O 1 o o o Muatard O 1 O 1 o o O 1 o o o " Catsup o 1 c 1 ; c C 1 c o Sour Cream O 1 O 1 o o o C I o o HOW OFTEN DID YOU EAT YOUR MEAT. POULTRY, OR FISH PREPARED IN THE FOLLOWING WAYS.. . Never hardly ever Once a month 2tei3 times a auHiib Once ttfiSK 2to3 a week 4 io 6 Umas a «reek Once a 2or more Umeaa dsc "»j Charcoal-broiled o o O o o o c o *■ •} Oven-broiled o o o o o o o o Fried o o o Q c o o o • » Barbecued o o o o o o o o AVERAGE USE DURING LAST YEAR aa# HOW OFTEN DID YOU EAT MEAT. CHK:KEN, OR — i FISH COOKED WITH.. . - ! Never or hardly ever Ones month 2 to3 times a menUi Once a weA 2to3 times a m sk 4 te e times wask Once 2or more Umesa day •aal vegetable on o o O o o O o o aeij Salt Pork, Lard, or Bacon Fat o o O o o O o o " 1 vegetable Shortening (SiHdi a s Criaco) o o O o o O o o ^ Margarine o o o o o o o o " 1 Butter o o o o o o o o Vegetable spray, water, or non-stick pan o o o o o o o o ANSW ER TH E FOLLOWING FOR THE LAST YEAR: -w WHEN YOU ATE MEAT, HOW m m l WAS IT USUALLY PREPARED? eirè O Rare mm O Medium " 1 C Wall-done W O Dent eat meat WHEN YOU ATE MEAT, DID YOU EAT THE FAE o MostotBieUrr» O Some of the time O Never or hardly ever O Don't eat meat WHEN YOU ATE CHICKEN, DID YOU EAT THE SKIN: O Most of the Un» O Some of the Hme O Never or hartBy over O Dont eat rdtkken —j WHAT KIND OF MARGARINE DID YOU USUALLY USE? (mark only one) — O Regular suck OR sa^ O Regular Tub OR " 1 o Dretor^MBsdOR arm O Don't use margarine aw C Don't know WHAT KIND OF BUTTER DID YOU USUALLY USE? (mark only one) O Regular OR O Whipped OB O Dont uso butter O Don! know WHAT KIND O F VEGETABLE OIL DID YOU USUALLY USE? (mark only one) O Soyljean or rmm oil O OBveoil O Canota oB o Any other oil O Dont use oil O Donl know — ■ 20 ■ 249 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. VITAMINS AND MINERALS 25. DID YOU! least once a weekfî ! OR MULTIVITAMINS WITH MINERALS DURING THE LAST YEAR (at O N o OYes- r IF YES, HOW MANY VITAM IN TABLETS DID YOU TAKE? “ O 1 to 3 a week O 4 to 6 a week O 1 a day 0 2aday O 3 or more a day 26. DID YOU TAKE ANY OF THE FOLLOWING VITAMINS OH MINERALS BY ITSELF DURING THE LAST YEAR (at least once a weekjl? IF YES, HOW MANY YEARS HAVE YOU TAKEN THEM? O 1 y e a r or less 0 2 to 4 y e a rs O 5 y ears o r m ore VITAMIN A (BYrrSELF) O No O Y es -* IF YES, HOW MANY TABLETS DID YOU TAKE? 0 1 to 3 a week O 4 to 6 a week O 1 a day 0 2 a d a y 0 3 or more a day IF YES, HOW MANY YEARS HAVE YOU - TAKEN THEM? O 1 year or less O 2 to 4 years O 5 years or more IF YES, WHAT WAS THE DOSE EEB TABLET? O 5,000 I.U. (In tsm a tio n B i U n its) Or leSS 0 6 .0 0 0 to 1 0,0001.U. 0 1 1 .0 0 0 to 2 4 ,0 0 0 1.U. O 25,000 I.U. or more O Don't know P VITAMIN C (BYITSELF) ONo O Yes ■ O l to 3 a week O 4 to 6 a week O l a day - 0 2 a d a y O 3 or more a day 0 1 year or less 0 2 to 4 years — O 5 years or more O 250 mg (milligrams) or less O 300 to 500 mg. O 600 to 4,000 mg, 0 5 .0 0 0 to 9,000 mg. 0 10.000 mg. or more ODonTknow VITAMIN E (BYITSELF) O No O Y es ■ O 1 to 3 a week O 4 to 6 a week O l a day - O 2 a day O 3 or more a day O 1 year or less 0 2 to 4 y e a rs —' O 5 years or more O 200 I.U. (Inlem alwnal U nits) or lesS 0 2 5 0 to 800 I.U. 0 8 2 5 t o t ,2 0 0 1.U. O 1,250 I.U. or more O Cton't know BETA-CAROTENE ^ N o (BYITSELF) OYes> 0 1 to 3 a week 0 4 to 6 a w e e k O l a day - 0 2 a d a y O 3 or more a day 0 1 year or less 0 2 to 4 years —I O 5 years or more O 6,000 meg (m k ro g ram s) or less O 7,000 to 15,000 meg. 0 16,000 meg. or more O Don't know CALCIUM (BYITSELF) O N o O Y es ■ 0 1 to 3 a week O 4 to 6 a week O l a day - 0 2 a d a y O 3 or more a day 0 1 year or less 0 2 to 4 years —i O 5 years or more O 250 mg (milligrams) or less O 300 to 600 mg. O 625 to 1,000 mg. O 1,250 mg. or more O D ont know SELENIUM (BYITSELF) ONo OYes- 0 1 to 3 a week O 4 to 6 a week O l a day — O 2 a day O S orm oreaday 0 1 year or less 0 2 to 4 years —^ 0 5 years or more O 75 meg. (mlcragrams) or less 0 100 to 150 meg. O 200 to 225 meg. O 250 meg. o r more O D onl know IRON (BYITSELF) ONo O Yes ■ 0 1 to 3 a week O 4 to 6 a week O l a day - O 2 a day O 3 or more a day O 1 year or less 0 2 to 4 years —i O 5 years or more O 50 mg. (milligrams) or less O 51 to ISO mg. O 151 mg. or more O Don't know 250 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. MEDICATION HISTORY ■ » 27. HAVE YOU EVER TAKEN ANY OF THE FOLLOWING MEDIC/ " I (for one month or tongerfî IF YES, HOW MANY YEARS HAVE YOU EVER TAKEN THEM? Aspirin ^ (Anacin.Bufferin, Bayer, Excadrin. or (Xher) C No 0 Yes, but not a t this time 0 Yes, currently z l Z 1 y e a r o r le ss 0 6 to 10 y ears Z 2 to 3 y e a rs C 11 y e a rs o r m ore Z 4 to 5 y e a rs m i Acetaminoptien ^ (Tylenol. Anacin-3, Panadol, or other) C No C Yes, but not a t this time C Yes, currently 2 1 y e a r o r le ss Z 6 to 10 y ears 2 2 to 3 y ears 2 11 y e a rs or m ore 2 4 to 5 y ears "" Other Pain Relief Medication " j (Motrin, Nuprin, Advil, fndocin, Naprosyn, Medipren, Itx^rroten, or other) C N o 0 Yes, but not a t this time 0 Yes, currently 0 1 y e a r o r le ss C 6 to 10 years 0 2 to 3 ye a rs O i l y e a rs o r m ore 0 4 to 5 y ears Water Pills for High Blood Pressure or other Reasons ■wj (Diuril, Hydrodiurii, Oyazide, or other) 0 No C Yes. but not a t this time 0 Yes, currently — ► 0 1 y ear or le ss 2 6 to 10 years 2 2 to 3 y e a rs 0 11 y ears o r m ore 0 4 to 5 y ears ■ ■ j Reserplne (Ratxâin, Sor-Ap-fe, Hydiopres, red Rauwollia, Melatansin, or other) O N o 0 Yes, but n o t a t this time 0 Yes, currently 0 1 y e a r or le ss O 6 to 10 y e a rs I 0 2 to 3 y e a rs 0 11 y e a rs o r m ore 1 0 4 to 5 y ears " 1 outer Blood Pressure Medication n (Atdomel, Hygroton, Minipress, CarcUzem, e w i Procardia. Vasotec, or other) O N o 0 Yes, but not a t this time 0 Yes, currently 2 = 1 y e a r or le ss 0 6 to 10 y e a rs j G 2 to 3 y e a rs O 11 y ears o r m ore I 0 4 to 5 y e a rs ! “ j Antadds (Ttans. Retards, Digel, Maalox, Gahisil, se e AHca^Seltzer, or other) 0 No 0 Yes. but ntX a t this time 0 Yes, currently 0 1 y e a r o r le ss O 6 to 10 y e a rs 0 2 to 3 y e a rs O i l y e a rs o r m ore 0 4 to 5 y ears J Tagamet, Zantac, or Pepcid t for Peptic Ulcer 1 O N o 0 Yes, but not a t this time 0 Yes, currently — *- 0 1 y e a r o r le ss O 6 to 10 years 0 2 to 3 y e a rs O 11 y e a rs o r m ore 0 4 to 5 years J AHetgy PRIs or Shots (/MBiistamkies) O N o 0 Yes, but not a t this tim e 0 Yes, currently 0 1 y e a r o r le ss O 6 to 10 y e a rs 0 2 to 3 y e a rs O 11 y e a rs o r m ore 0 4 to 5 y e a rs d Laxatives 0 No 0 Yes, but not a t this time 0 Yes, currently —* 0 1 y e a r o r le ss O 6 to 10 years 0 2 to 3 y e a rs O i l y e a rs o r m ore 0 4 to 5 y ears 7 WORK HISTORY ^28. IN WHICH OCCUPATIONAL CATEGORY HAVE YOU WORKED THE LONGEST? (Mark only one) O Laborer o r Farm W orker O Factory W orker or M achine O perator O Clerical or Office W orker O S a le s O M anager o r Administrator Q C raftspeison O Sm all B u sin ess O w ner O Professional/Tectinical O U nem ployed O O ther (write in) H PLEASE MARK ANY OF THE FOLLOWING INDUSTRIES OR OCCUPATIONS IN WHICH YOU WERE EMPLOYED FOR 10 YEARS OR LONGER. (You may m arie more than arm.) O Metal production or processing O Mining, quarrying, rock crushing, or cem ent manufacturing O Cotton, wool, or textile processing O Plastic production or pr<x»ssinq O Gasoline refining o r distribution O Chemical production or u se O HutJber or lire manufacturing O Shipyard work O Farming _______________ O Furniture making or woodworking O Automotive repair O Pesticide production O Paint production or use C None of these 251 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PHYSICAL ACTIVITY 30. ON THE AVERAGE, DURING THE LAST YEAR, HOW MANY HOURS IN A DAY DID YOU SLEEP (Include naps)? O 5 hours o r less O 6 hours O 7 hours C 8 hours 9 hours ? 10 hours o r m ore 31. ON THE AVERAGE, DURING THE LAST YEAR, HOW MANY HOURS INADAYDID YOU SPEND IN THE FOLLOWING SITTING ACTIVITIES? NEVER Less tfian 1 hr. 1 to2 hrs. 3 to 4 hrs. 5 to 6 hrs. 710 10 lirs. 11 hrs. or sitting in car or bus o o o o o o o Sitting at work o o O o c o o H - «McMtigTV o o o o o o o Sitting at meais o o c o o o O r Ottter sitting activttioa _ (sucti as reading, piaying cards, sewing] o o O O o o O — 32. ON THE AVERAGE, DURING THE LAST YEAR, HOW MANY HOURS IN A WEEK DID YOU SPEND IN THE — FOLLOWING ACTIVITIES? — 11 lo 21 to 31 h rs. m t NEVER 112 t o i hr. 2 to 3 hrs. 4 to 6 hrs. 71010 his. 20 hrs. 30 hrs. or _ more Strenuous Sports (such as kW ng. bkycNng on hBIs, tennis, racquetball. swhiffling taps, aerobics) o o o o o o o Vigorous Work (such as moving heavy furniture, loading or unloading trocfcs. shoveling, w e ^ liftktg, orequivatent manual labor) o o o o o o o 1 Moderate Activity (such as housework, brisk walking, golfing, bowling, bicycling on level ground, gardening) o o o o o o o 33. ON THE AVERAGE, DURING THE LAST YEAR. HOW MANY TIMESA WEEK DID YOU TAKE PART IN VIGOROUS PHYSICAL ACTIVITY (STRENUOUS SPORTS OR WORK) LONG ENOUGH TO WORK UP A SWEAT? O NEVER O 1 tim e O 2 tim es O 3 tim es O 4 tim es O 5 tim es O 6 tim es O 7 tim es or m ore MEN, PLEASE GO TO PAGE 26 WOMEN, PLEASE GO TO NEXT PAGE 252 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. WOMEN ONLY (M EN, p le a s e g o t o page 26) 34. HOW OLD WERE YOU WHEN YOU HAD YOUR FIRST MENSTRUAL PERIOD? 37. WHAT ONE METHOD OF CONTRACEPTION HAVE YOU USED FOR THE LONGEST TIME? Less than 11 years 11 - 1 2 years 13-14 years 15 - 1 6 years 17 years or older 35. HOW OLD WERE YOU WHEN YOUR PERIODS BECAME REGULAR (ABOUT ONCE A MONTH)? O L ess than 11 years O 11-12 years O 1 3 - 14 years D 15-16 years 17 years or older 2 Never becam e regular 2 Bitih control pills _ Birih control injections 2 Condom J Diaphragm _ Spermicide : l U D C Partner has been sterilized (vasectomy) C I have been sterilized (tubes tied) O Withdrawal C None of the aljove 38. DID YOU EVER TAKE BIRTH CONTROL PILLS FOR ONE MONTH OR LONGER? C No (go to question 39) O Yes. and I am currently taking them _ Yes, but I no longer take them ^ 36. HAVE YOU EVER BEEN PREGNANT? " C No (go to question 37} — C Yes IF YES, WHAT WAS THE OUTCOME OF YOUR flSSTPREG NANCY? 2 Live birth O Stillbirth O Tubal pregnancy O Miscarriage O Induced atXHtion IF YOU EVER HAD CHILDREN. HOW OLD WERE YOU WHEN YOUR FIHSTCH O.D WAS BORN? C L ess than 15 years 2 15 - 17 years 2 18-20 years 2 21 - 25 years 2‘ 26 - 30 years C 31 - 35 years O 36 years or older IF YES, HOW OLD WERE YOU WHEN YOU STARTED TAKING THEM? O L ess than IS years O 15 - 1 7 years O 18-20 years O 21 - 25 years O 26 - 3 0 years C 3 1 -3 5 years O 36 years or older IF YES, HOW MANY YEARS DID YOU TAKE THEM IN TOTAL? O Less than o n e year C 1 - 2 years C 3 - 5 years C 6 - 9 years O 10 - 14 years O 15 - 19 years 2 20 years or more 39. HAVE YOU EVER HAD A HYSTERECTOMY (com p lete rem oval o f th e uterus)? O No O Vbs 253 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 40. HAVE YOU EVER HAD YOUR OVARIES REMOVED? O No O Yes, on e only O Yes. both ovaries O Yes, don't know how many O D o n tknow 41, HAVE YOUR MENSTRUAL PERIODS STOPPED PERMANENTLY? O No (go lo question 42) O Yes IF YES, HOW OLD WERE YOU WHEN THIS HAPPENED? O Less than 4 0 years O 4 0 - 4 4 years O 45 - 4 9 years O 5 0 - 54 years O 5 5 years or older IF YES. FOR WHAT REASON? O Natural m enopause O Surgery O RacSation O Medication 42. DID YOU EVER TAKE ESTROGEN (FEMALE HORMONES) BY PILL, INJECTION, OR PATCH FOR MENOPAUSE OR OTHER REASONS? O N o (go to question 44) O Yes. and I am currently taking it O Yes, but I no longer take it IF YES, HOW OLD WERE YOU WHEN YOU STARTED TAKING ESTROGEN? O L ess than 40 years O 40 - 44 years O 45 - 4 9 years O 50 - 5 4 years O 55 - 5 9 years O 6 0 years or older IF YES, HOW MANY YEARS DID YOU TAKE ESTROGEN? O lÆss than one year O 1 - 2 years 0 3 - 5 years 0 6 - 9 years O 1 0 - 14 years 0 1 5 - 1 9 years O 20 years or more IF YOU USED AN ESTROGEN PILL, DID YOU EVER TAKE PREMARIN? O No (go to question 43) O Yes IF YES, WHICH ONE OF THE FIVE PREMARIN PILLS DID YOU TAKE MOST OFTEN ? O Green (0.3 mg) O Brown or red (0.625 mg) Q White (0.9 mg) O Yellow or orange (1.25 mg) O Purple (2.5 mg) 43. DID YOU EVER TAKE PROGESTERONE (SUCH A S PROVERA) ALONG WITH ESTROGEN FOR MENOPAUSE OR OTHER REASONS? O N o (go to question 44) O Yes, and I am currently taking it O Yes, tnit I no longer take it IF YES, HOW OLD WERE YOU WHEN YOU STARTED TAKING PROGESTERONE? O L ess than 4 0 years O 4 0 - 4 4 years O 4 5 -4 9 years O 5 0 - 5 4 years O 55 - 59 years O 6 0 years or older IF YES, HOW MANY YEARS DID YOU TAKE PROGESTERONE IN TOTAL? O l-ess ttian o n e year 0 1 - 2 years 0 3 - 5 years 0 6 - 9 years O 10 - 1 4 years O 1 5 -1 9 years O 20 years or more 44. HAVE YOU EVER HAD ANY OF THE FOLLOWING m m TESTS? IF YES, PLEASE MARK HOW LONG IT — HAS BEEN SINCE YOU LAST HAD THE TEST. m m Ever had? Number ol Years Since Last Test No Yes Less than 1 year 1to2 yra. 3 ormora Mammogram (breast x-ray) o o o o o PAP smear o o o o O PLEASE GO TO NEXT PAGE 254 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ■ n q 45. HAVE YOUR MOTHER OR FULL SISTERS EVER HAD ANY OF THE FOLLOWING CANCERS? {Include any who may have died.) y e S . DID ANY OCCUR BEFORE IF YES, WHO? —* AGE 5 0? 47. I BREAST J CANCER O No (or Dont Know) O Yes — — O Mother O 1 sister —♦ O 2 or more sisters O N o Q Y e s O Don't know OVARIAN CANCER O No (or Dont Know) O Yes — O Mother O 1 sister O 2 or more sisters O No Q Y es O Don't know COLON CANCER O No (or Dont fOio»4 Q Y es — * O Mottier O 1 sister — * O 2 or more sisters Q No Q Y es O Don't Know OTHER CANCER O No (or Dont K now) O Yes — *■ JL O Mother O 1 sister — * O 2 or more sisters O No O Yes O Dont know (wrileinkmd) 46. HAVE YOUR FATHER OR FULL BROTHERS EVER HAD ANY OF THE FOLLOWING CANCERS? (Include any who m ay have died.) IF YES. DID ANY OCCUR BEFORE IF YES. WHO? — » AGE 50? PROSTATE ^ O Y e s ------- O Father O No O 1 brother — + O Yes O 2 or more brothers O Don't know COLON CANCER O No (or Dont K now) OYes —» O Father O 1 brother — O 2 or more brothers O N o O Y e s O Dont know OTHER CANCER O No (or Dont Know) O Yes — JL O Father O 1 brother —^ O 2 or more brothers O No O Yes O Dont know (wiitehiUntÿ WRITE IN YOUR BIRTHOATE AND FILL IN THE CIRCLES. (See example In Inslnicllons) M O N T H 1 D A Y 1 I Y E A R C JAN ! i i . Î j o FEB : 1 1 I O M AR y ® ® 0 !C APRj 0 0 © 0 O M AY! © © © © C JUN' © © © 0 O JUL ; 0 0 0 O augI ® C O ® OSEPj ® O OCT! ® © ® C novi @ ® ® iCDEC, 0 ® ® 46. 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M M h R M ie a A ty y N C S M M 9 W 4 6 2 3 2 1 P r in te d * n U .S .A . 26 255 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. NOTE TO USERS Copyrighted materials in this document have not been scanned at the request of the author. They are available for consultation in the author's university library. pg 256 This reproduction is the best copy available. UMI Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Compendium of Physical Activities: classification of energy costs of human physical activities BARBARA E. AINSWORTH. WILLIAM L. HASKELL. ARTHUR S. LEON. DAVID R. JACOBS. JR.. HENRY J. MONTOYE, JAMES F. SALUS. and RALPH S. PAFFENBARGER. JR. Division o f Epidemiology. School o f Public Health (B.E.A., D.R.J.. A.S.L.) and ■Division o f Kinesiology. School o f Kinesiology and Leisure Sciences (B.E-A., A.S.L.). University o f Minnesota, Minneapolis, M N55455: Stanford Center for Research in Disease Prevention, Stanford. CA 94305 (W.EH.): Biodynamics Laboratory, Department o f Physical Edttcation, Universit v o f Wisconsin-Madison, Madison Wt 53706 (H.J.M.): Child and Family Development Health Studies. Department o f Pediatrics, Universitv o f California-San Diego, La Jolla. CA 92093 (J.F.S.); and School o f Medicine, Stanford Universitv, Stanford, CA 94305 (R.S.P.) ABSTRACT AINSWORTH. B. E., W. L HASKELL A. S. LEON. D. R. JACOBS. « L H. J. MONTOYE. J. F. SALUS. and R. S. PAFFENBARCER. JR. Compcndnim of Physical Activhies: dasniicadon of oK vgy o a ts af human physical activiiies. A fai Sa'. Sports Exere.. Vol 25. No. I. fP. J l-w . 1993. A coding scheme is prescnied Ibr classifying physical aoiaiiy by rale of eneigy apenditm e. i e.. by iniensity. Enogy coa aasesiablished bya review o f puWished and wnpuMisbed dam. This “ ding scheme employs live digiis dial dassiN activity by pinpose anris, occupation, sdf-caie). the s ira lic type o f activity, atid its intensity as the ratio o f worlc metabolic rate to resting metabolic tate CM ETsJ, Eneigy expcndituic in fcihxalories or fcilocaktnes per Kkgram body weight can be estimated Ibr all activities, spedfic activnks. or activity types. General 'use of this coding system would enhance the comparability of results across studies using sd f reports nf physical activity. EXEROSE. E X E R T IO N . PH Y SICA L A C T IV IT Y The proliferation of self-report measures of physital activity reflects growing interest in the study of physical '^•vity and its relation to various health outcomes. A ^ mon problem faced by researchers is the coding of r'O'CINI ANDSaCNCI INSrORTS ANDEXtnCISE € 1 99} b jr iJw A m cncM C oH cic ef Spem Ih te ifttiQ e -------- r I 9 9 Î . fcf p u bfacaikm Septem ber 1 9 9 2 . 71 physical activities by type and by intensity. Each re searcher has devised a coding system to fit his or h er purposes. While there are similarities across puUished systems, there are also diflerences th at limit the com parability o f results across studies and ad d confusion to the field. The availability of a comprehensive list o f phyacat activities coded with a standardized system that is flexible enough to meet multiple needs of phys ical activity researchers would facilitate research in this area. This Compendium of Physical Activities has been developed to facilitate the aiding of physical activities and to promote comparability of coding across studies. The Compendium is designed to be useful for investi gators who collect data on physical activity by diary, recall, or direct oteervation methods. The physical activity data may be used to describe activity patterns of populations, to study determinants o f physical airtiv- iiy. or to investigate the relations between physical activity, health and disease. Because each aaivity can be coded by function, specific type, a n d intensity, th e same compendium can be ust d for many different purposes and in both clinical and epidemiologic studies. 257 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. C O M PEN D IU M OF PHYSICAL ACTIVITIES Official Journal of ffie American College of Sports Metlione 7 3 n" from published lists and selected unpublished data as previously m entioned. F o r activities not in the unginal lists, in ten sity was o b ta in e d from published literature, if possible, and assigned a MET value or estimated from sim ila r know n activiiies (3.4.11,16). Only data for a d u lts were in clu d ed in this C om pen dium. When ch ild ren ’s gam es a re listed in the Com pen dium. the intensity level is fo r ad u lts participating in children’ s activities. Further, th e C om pendium is not intended to be used for adults w ith m ajor neurom us cular handicaps o r o th e r co n d itio n s that would signifi cantly alter th eir m echanical o r m etabolic efficiency. Calculation of E n e rg y C ost Energy expenditure values c a n be expressed in kcal- kg*' body w eig h t-h "'. k cal-m in ” '. kcal h "'. o r kcal -34 h"'. Tfie m ost accurate way to d eterm in e the kilocalorie energy cost o f an activity is to m easure the kcal ex pended during rest (i.e.. the R M R ) and m ultiply that value by the M E T values listed in the C om pendium . Because RM R is fairly close to I k cal-kg body w eig h t"'• h"'. the energy cost o f activities m ay be expressed as multiples o f the R M R (15). By m ultiplying the body weight in kg by the M E T value a n d duration o f activity, it is possible to estim ate a kcal en erg y expenditure th at specific to a person’s body w eight. F or exam ple, /cling at a 4 M E T value ex p en d s 4 kcal-kg"' body wcight-h—I. A 60-kg individual bicycling for 40 m in expends the following: (4 M E T s x 6 0 kg body weight) X (40 m in/60 m in) = 160 kcal. D ividing 160 kcal by 40 m in equals 4 k cal-m in "'. U sin g the same form ula for an 80-kg person would yield a n energy expenditure o f2 l3 kcal o r 5.3 k cal-m in "'. H ow ever, it is im portant to note that to the extent th e R M R is not equal to I kcal kg body w eig b t"'-h “ ' fo r individuals, then esti mates o f energy expenditure th a t include weight will rrtore closelv reflect bodv w eight th an the m etabolic rate (2). Use of th e C om pendium fo r PA R e c o rd s o r D iaries For records o r diaries th e d a ta collection form s should be organized in a way to identify each activity's major heading, classify the in ten sity level, and the record the duration to ensure a ccu rate data entry. Fig ure I shows an exam ple o f a section o f a data collection form th at m ay be used for th is purpose. It is im portant th e participant com plete all questions except the space labded “ for clin ic use only." T h e clinic staff will use this space to record th e activity code o r M e t value for data analysis. T h e space labeled "reason activity" is to help the co d er decide under w hich -■rjor heading to place the activity. T h e im ensiiy rating is designed to help the coder in assigning the appropriate M e t value. Intensity term s o f light, m oderate, heavy or vigorous, and very heavy o r very vigorous should he T yp»4S AOrftf Rvaaeniw A o w f ) r C M anon Mtm«r UmI H oim .’ M m Co* or W ET le v e l rtvtfncuM o fW y ) F i ^ e 1— Exam ple o f a scciion o f rccordii^ f o r m th a t asks p a rlic i- paais to list ih« i>*pes o f physical a c iin iirs p e rfo rm e d , reastais f o r engagii^ in the actiW lirs. a r a t i ^ o f the (m rticip an is* impression o f the intensity level (light, m oderate, «igorous. v e r y «-igoroas). and t h e duration o f th e activities In hours and m inutes. used in classifying intensity. In the c a s e o f walking, t h e corresponding intensity term s are very slow . slow, m o d erate. brisk, and very brisk. If a co d er d o es not plan t o use the five digit code for data analysis, a space can b e provided on the questionnaire to re c o rd th e MET v a l ues to calculate kcal scores. D iscussion a n d Lim itations The C om pendium o f Activities i s a classification system th at groups physical activities by purpose a n d provides flexibility in determ ining e n e rg y cost. H o w ever. there are several factors that m a y lim it the use o f the C om pendium for determ ining t h e precise energy- cost o f PA. T he activity classification system was p r i marily based on previously published d a ta and as su c h m ay not reflect the exact energy c o s t o f all physical activities. Since often the values are m erely averages, they d o n o t take into account that s o m e people perform activities m ore vigorously th an others. In addition, th e M ET values o f som e activities were n o t derived fro m actual m easurem ents o f oxygen co n su m p tio n : in stead they w ere estim ated from the energy co st o f activities having sim ilar m ovem ent patterns. T h erefo re, the e s ti m ates m ay have ill-defined co n fid en ce lim its a ro u n d the m ean M E T values. F o r activ ities in which th e param eters are undefined, individual differences in e n ergy expenditure can be large and th e tru e energy c o s t for a person m ay o r m ay not be c lo s e to the sta te d m ean. T h is does not reduce the v alu e o f the sta n d ard intensity codes, but it is an im portant perspective fro m which to view the C om pendiuni. C alc u la tio n o f k c a l energy expenditure from body weight a n d MET v alu es m ay also affect the energy cost o f activ ities. T herefore, use o f th e kcal scores in correlation an a ly se s should b e used w ith caution since coefficients m a y reflect b o d y weight ra th e r th an th e actual energy c o st o f activities. Expression o f energy expenditure sc o re s as k cal-k g "' body w eig h t-h "' o r kcal-k g "' body w e ig h t-d a y "' w ill elim inate th is effect. Individual v a ria tio n in m o v em en t patterns a n d differences in the way a c tiv ity is rep o rted (i.e.. effort, pace. age. an d gender differences) m a y influence th e energy cost o f activities a ls o . F or exam ple, one person m ay rate his o r her w alk in g pace as "b risk " while a n o th e r classilles the sam e p a c e a s "slow ." T h e C om p en d iu m cannot account for in d iv id u al differences 258 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 72 OHiciai Journal ol me American College ol Spoils Medicine MEDICINE AND SCIENCE IN SPORTS AND EXERCISE The im ensiiy or en erg y cost values were derived from the best available p u b lish ed an d unpublished data. M ost sources have been used extensively by investigators in the past, but this C o m p e n d iu m has integrated these sources and offers a sin g le coding system that can serve as a com m on source fo r subsequent research. CODING SCHEME This activity classification system was a product o f a m uliicenier Request F o r A pplications from the Epide miology section o f the N a tio n a l H eart, Lung, and Blood Institute (NHLBI) for th e p u rp o se o f validating physical activity m easurem ent tech n iq u es. It provides a com pre hensive system for c o d in g physical data on physical activity by purpose an d energy cost. T he energy cost o f specific activities listed in th is C om pendium were o b tained prim arily from th e follow ing previously p u b lished physical activity energy expenditure lists: Tec- um seh O ccupational Q u estio n n aire (13.14). M innesota Leisure T im e P hyacal Activity Q uestionnaire (LTPA ) (5,10), M cArdle, K atcb, a n d K atch ’s physical activity list (7,9), the 7-Day R ecall Physical Activity Q uestion naire (2). and the A m erican H ealth Foundation's phys ical activity list (8). A ctivities from the LTPA w ere identified by a T fbllowed by a n u m b er (e g.. T l 15). By retaining the LTPA d esig n ato r codes, the new list m ay t e used to score the L T PA w ith its original physical activity intensity codes. As would be expected, th ere w as considerable overlap in energy expenditure values am o n g th e supplied lists. For exam ple, the M innesota L T P A , w hich was devel- ofwd from the T ecum seh L eisure T im e Q uestionnaire, identifies sim ilar activities; w hile the list o f activities from th e 7-Day Physical A ctivity Recall questionnaire is nearly identical to th at o f M cA rdle. K atch. an d K atch (9). In general, the m ajority o f th e energy expenditure lists were generated from Passm ore an d D u m in (I I): while McArdle. K atch. an d K atch (9) also used data derived from B annister and B row n ( I ) an d Howley an d G lover (6), T he intensity assigned to activities in th is publication were determ ined by selecting a m ean energy expendi ture value from the e i ^ l sources m entioned previously. T he representative intensity levels were determ ined by consensus o f the authors. O rganization T he C om pendium o f Physical A ctivities is organized to m axim ize flexibility in coding, d a ta entry, an d inter pretation o f energy cost for each class an d type o f activity. Actrvrly co d in g . T h e coding a rh cm c fo r the C om pen dium o f Activities em ploys a five-digit code in ord er to categorize activities by their m a jo r heading (first two digits on the left), specific activity (last three digits on the right), and intensity f.l-digit colum n). T he coding s ch em e is organized in the following way: 00 000 00.0 m ajor specific in te n s ity headings aciiviiy F o r exampfc: 01 009 08.5 bicycling bm x M E T s M ajor h ead in g s. The C om pendium is o rg a n iz e d by activity types o r purpose and in clu d es activities o f daily living o r self care, leisure a n d recreation, o ccu p atio n , an d rest (Table I). The m a jo r headings e x p la in ilir reason a person is engaging in a specific a c tiv ity and is useful in categorizing activity ty p es. Identification o f the p ro p e r m ajor h e ad in g is the initial step in classifying an activity. H o w ev er, it is (Kissible that there m ay be m o re than one re a so n for perform ing an activity: thus, a specific activity m a y be listed under m ore than one m a jo r heading. F o r exam ple. an individual m ay sit and re a d a book fo r pleasure in one situation and at a n o th e r tim e read a d o c u m e n t a s a jo b requirem ent. These m a y be classified u n d e r the m ajo r headings o f rest o r in a c tiv ity and o ccu p atio n depending on their purpose. A ssum ptions m a d e fo r the placem ent o f activities into m a jo r headings a re listed in A ppendix 2. S pecific activities. T he sp ecific activity descrip tio n s range from a general classification o f an a c tiv ity (e.g. tennis, general) to a detailed d escription th a t includes th e form and intensity o f th e activity (e.g., tennis, singles, vigorous effort) d e p en d in g o n the in fo rm atio n gathered by the survey m e th o d . Activiiies w ith o u t a specified intensity are classified as "general.” More detailed descriptions o f activ ities a re preferred sin c e an appropriate intensity can be assigned. G u id e lin e s for coding qrecific activities w ith in m ajor h e a d in g s arc listed in A ppendix 3. in ten sity of activ ities. All ac tiv itie s are a ssig n e d an intensity unit based on their ra te o f energy ex p en d itu re expressed a s M ETs. T h e in te n sity o f activities in the C om pendium are classified as m ultiples o f o n e M ET o r th e ratio o f th e associated m etab td ic ra te f o r the specific activity divided by th e resting m e ta b o lic rate (R M R ). F o r exam ple, a 2 -M E T activity re q u ire s two lim es th e m etabolic energy e x p en d itu re o f sittin g qui etly. O n e M E T is also defined as th e energy ex p en d itu re for sitting quietly, w hich fo r t h e average a d u lt is ap proxim ately 3.5 ml o f oxygen-kg body w eight"' - m in "' o r I k cal-k g "' body w eight-h"'. A M E T value was assigned t o each activity in the C o m pendium and w as based o n the “ best reprcsenia- TXBIE1. Major types ol activiiies ^cycling Lawn and garden Spots CondMoning exeretses MisoefianKiiis Transportation Otfidng Music plajfing Welfdng Flying and hunting Occupation Water activiiies Homeactnnbes Runniog Winter aciivHies Home repair SeV"Care Inactmty Sexual actwhy 259 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 74 OHîdal Journal ol t tie American College ol Sports Medidne tn movement efficien cy : however, variation in how physical activities a r e recorded can be reduced by pro viding instruction t o panicipanis on how to classify energy expenditure (i.e.. 3 mph is moderate walking), standardizing d a ta recording techniques, and having trained interviewers review the data with participants for clarity before e n e ig y costs are calculated. SUMMARY AND CONCLUSIONS The C om pendium of Physical Activities is a unique coding system th at classifies the eneigy cost of physical activities. Based o n previously published data, it groups activities by p u rpose and intensity expressed as METs. The Compendium is easy to use and provides flexibility in calculating the e n eig y cost o f various types o f phys ical activities. D esp ite its possible limitations, the Com- M EDICING AND SCIENCE IN SPORTS A ND EXERCISE pcndium o f Physical A ctiv ities is usefu I for coding physical activity q u estio n n a ires or records u s e d in phyv ical activity research, e d u c a tio n , and c lin ic settings. W e wish to thank M. Carl M c N a lly . Maik R ic h a ro s o n . Terri Han- m an. and Yvonne GuptV (U nrirersity ol U m e so ta ) a n d Martin Vee (StaN ord tM v ersil^ lor Iheir ix srurA utions « c r e a tin g a n d organiang the Compendium o l Physical A ctiv K ies. w e oHer a s p e c i a l thank you to C ad McNally lor wrWng th e S A S data a n a ^ p r o g r a m to score the Compendium o l Physical A ctiv itie s. This work w as supported b y g r a n t s N H U I(R F A -8 6 -9 0 -P ) to Ors. Leon and Jaco b s; NHLBI (5 -R 0 1 -HL-375Bt) to Dr. M o n to y e : NHLBi (HL-362-7Z) to Or. Haske»: a n d NH LBI (R F A < 6 4 IL -9 -P ) to Or. Salts. Or. Barbara Ainsworth w as a post-rloctoial a s s o c i a t e « the Divi sion olE pidem alogy. School o f P u b lic Heakh. tW v e r s lty o l Minnesola a t the time o l this project. Or. A in s w o rth is c m e n tly w i t h th e Applied Physiology L atxxatory. D e p a rtm e n t o l Physical E d u c a ti o n . Exercise a n d S port S cience. University o f N o rth Camtna a t C h a p e l Hill. A ddress lor co rresp o n d en ce: O r. Ainswodh. D e p a r tm e n t o l Phys ical Education. Exercise. S S p o r t Science. M # 8 7 0 0 . Fetzer Bym. Lttiversily o f North Carolina a t C h a p e l HA C hapel H ill. NO 27599- 8700. REFERENCES 1. B a n n is te r. £ . W . a n d S . R. B row .n. T he relative energy require m ents o f (Wiysical a c tiv ity . In: £xrrci.ie M riarnfriei. H . B. Falls (Ed.|. New York: A c a d e m ic Press. 1968. 2. B la ir . S. N .. W . L . H a s k e l l . P. H o . ei al. A ssessm ent o f hafaiiual |4iysical a a iv h y b y a 7-day recall in a com m untiy survey and controlled e x p e rim e n t. -Jm . J . EpitieminI- 122:794-804. 1985. 3. B u rk e . E . J.. J. A . A u c h in a c h ie . R . H a y o e n . an d J . M . L o e tin . Energy cost o f w h e e lc h a ir basketball. P hyiicim Spansmed. 1 3 S 9 -I0 5 . 4. F ish er. S. V. a n d R . P P a tte r s i» :. Eneigy cost o f am bulation with crutches. .4rcA. PJtys~ Aied. Re/rrthrf 6 2:250 -2 5 6 .1 9 8 1 - 5. Folsom . A. R .. C . J . C a s p e rs e n . H . L T a y l o r , el aL Leisure tim e physical a ctiv ity a n d its relationship to co ro n ary risk factors in a population-based sam ple: th e M innesota H eait Survey. Am. J. Epidemiol. 1 2 1 :5 7 0 -5 7 9 .1 9 8 5 . 6. H o w le v . E. T . a n d M. E. G lo v e r. T he c alo ric costs o f running and walking o n e m ile for m en a n d w om en. Med. Set. Spans Exere. 6:235. 1974. 7. K a tc h . F . I. a n d W . D . M c A r d le . Niarliion. Heighi Canind. oodE xem se. 3 rd E d . Philadelphia: L ea & Febiger. 1988. S. L eon. a . S. A p p ro x im a te energy expenditures a n d fitness values o f sports an d recreatio n al an d h o u sehold activities. In: T he Book td Health Physical Fitness. C hap. 5. E. L. W ynder (E d.). 1981. pp. 283-341. 9. McAROLE. W . D.. F . I- K a tc h . a n d V. L. K a t c i l E x m ise litysialiixy: E m rsy .lia riiiu n . an d Hnmm P er/o rin a m e. 2n d Ed. Philadelphia: Lea & F ebiger. 1988. pp. 642-649. 10. MINNESOTA LEISliRE TiME PHYSICAL ACHVTTV QuESTIO.N.NAIRI M a n u a l. D ivision o f E p id em io lo g y . School o f P u b lic Heahh. U niversity o f M innesota. M in n eap o liL M N 5 5 4 5 5 . II- O CoKNEU— E. R— P. C. T tto siA S - L D. C a d v . e t al. Encigi costs o f sim ulated stair d i tn b i n g as a jo b -re la te d task in fire lighting, y. O avp. .l/rr/. 2 8 :2 82-284.1986. 12. P assm o ril R. a n d 3. V. G . A . D u r n ln . H um an e n e ig y espendi- tu ie. Physiol. Her. 3 5 :8 0 1 -8 4 0 . 1955. 13. R eiff. C . G - H. j. M o n t o v e . R . D. Re u ik g t o n . J. a . N a pier H . L. M e tz n e r. an d H . H . E pstein . A ssessm en t o f phvsical activiiy by questionnaire a n d interview. In.- P h y s ic a l.ia ir iir and the Heart. M . J . K arvoncn a n d A. J. Barry ( E d s .) . Springfield. IL: C harles C T hom as. 1967. p p . 336-371. 14. Reiff. G . G .. H . J . M o n t o v e . R . D . Renino-t o n -. J . A. N apier. H. L. M e to c e r. an d F . H . EPSTEIN. A ssessm en t o f phvsical activity by questionnaire a n d interview, y S /n rr r a Med. Plixi «Virrax 7 :1-52. 1967. 15. T a y u w , H .. D . R . jACitas J r . . B. Siivcxer. J . K n - l'd s e n . A. S. L eo n , a n d G . D e B a c k e r A questionnaire for t h e assessm ent of leisure tim e physical a ctiv ities. J . ChmaicDis. 3 1 : 7 4 1.755. 1978. 16. Tow n. G . P_ N . Soi_ an d W . E. Sinnlvcl T h e e lfe c t o f rope skipping rate o n eneigy e x p e n d itu re o f males a n d fem ales. Ifcd S ti.S p .in Exere. 1 2 :2 9 5 -2 9 8 . 1980. APPENrni.IkxNiendmm of Physical Aclivities. 01009 8 5 Bicydng. 01010 4.0 Bkichig. 01020 8 0 Bkydng. 0)030 8.0 eicycbig. 01040 to o Bicyctng, 01050 12.0 BicycSng. Bcychig, BMX ff mountan Bicycfng.-ctOnph. general, feisuie. to w ok or lor pkasure (TII5] Bkyding. 10-tl5inph.lasore.slow . igMeHon Bkycing. 12-139 mph. leisure, modec- areeRort Bicydng. 14-159 mph. racing or lei sure. Iasi vigoRXis ellat Bicydng. 16-19 inpli racinghiol drah- n g o r> 1 9 mph dialtng. vary lasL radng general Bicycling. > 2 0 mph. racing, not drafting IMcyctog 01060 16.0 Bkydng. 01070 5.0 BicycBng, 02010 5.0 C m m anngam se. Bicychig. slatnnaiy. geneid 02011 3.0 CondtionngexrecisiL Scydng. slatnnaiy. 50 W. very Ighl (88)12 5 5 ComXEonngexeiose. 02013 7 9 (kxxHonng exercise. 02014 10.5 (kndhioning exercise. 02015 125 Conditioning exercise. 02IB0 8.0 Canditinning exercise. (H030 4 5 Gxiditionng exercise. 02040 8 9 ConMoning exercise. 02050 6.0 CondNioiingexeicrie. Bicydng. stahmay. too IN. «ghtetkxt Biqcing. slatimay. 150 W . moderate elhxt Bicyctng. stahxary. 20 0 W . vigcnxrs ehort Bicydng. statonary. 2 5 0 W . very vigor- au sem n Catsthenics leg. pushups, pulups. situps). hmiy. vigorous elton Catsthenics. Imie exercise, tgni or moderate etoiL general f f 1518 lex am p k hath axerdsesL going u p 8 down hem tocr Ciicul tra m g general WeighI thing |tee weight. nauMusor unversaHypel power kiting or Ixxly b u U n g vgoous ehort (T 210) 260 Repro(juce(j with permission of the copyright owner. Further reproctuction prohibitect without permission. f;';.tPEN01UM O F PH Y SIC A L ACTIVITIES Olfioal Joutnal ol the A m encan C cA eae ol S p o r ts Medicine 7 5 .sPEHBXiConiinued 02060 02065 02070 02071 02072 02073 02074 02080 02090 02100 02110 02120 02130 02136 8 S H 0 03015 03020 03021 03026 03830 56 Conditioningenetase. HetfllicluDe»efcise.geo»al|T 160) 6.0 Condilionm g etiemse, Slat-lieaOiMergameia. general 96 Condilioningexense. Aceeig. aaimnary ergomeier. generd 3 6 C ondiiioningeienàe. RotMig.siaiionaiy.SOW.iigrarilait 7.0 Conditioning n eicee, flowng. statonary. lOOW.mxIeraie erton 86 Conditioning exercise, flowing, statonary. 150 W. vigorous eF ton 12Ü Condilioning exercise. Rowiog statixiaiy. 200 w. very vigrx- ouseHan 96 condilioning exerrSse, SUniadiine. general 6 0 Conditioning exercise. Stmnastos 4j0 Conrtdoning exercise. Slieidiing.halti3)ioga 6 0 Condilioning exercise. TeadiaigesRiIlioexcnneclass WMeraerabies. waiercalistfienics Weigie fHing (bee. nautkis or riniversd- tyge). ig tl or nioiieraie e M . fgM worXtxA general WNt»oi.sMng AeroOic. OOM a inorleiiL twisi AeroOic. general Aermxc,lowimpaa AeroOic.liigliinpacl General Bakooni. last (rtscrx mik. sriuarel (T 1 % Salroaii, sUw (e.g.. wane, loxtrcn. sbw 4.0 Condilioning exercise. 3.0 Conditioning exercise. 1.0 COndrliorung exercise. 6.0 Dancing. 6.0 O andng. 5.0 O andng, 73) Dancing. 46 Oandng. 5 6 O andng. 03040 3.0 Oandng. 04001 4.0 RsNng and tuning. 04010 4.0 Fisting and hiiding. 04020 5.0 mslmg and tuning. 04030 2 6 Fishing andtumng. 04040 3 6 fisting and tuning. 04050 04060 04070 04080 04090 04100 04110 04120 6 0 F istn g a n d t m ^ 2.0 Fisting andtumng. 26 FaNng and tuning. 6 0 Fishing and tmtng. 2 6 Fisting andtumng. 6 0 Fishing and trattig, 6.0 Fishing and tm tng, 6 0 Fishing and turdng. 04130 2 6 Fishing and triming. 05010 05020 « 0 3 0 05040 2 6 Homeactvites. 4 6 Homeacdvilies. 35 Hcmeaciiwiies. 26 Hoitieaciivnes. 05041 2.3 Hmteactvilies. 2 6 Heine acW tes. 05050 2 6 Horne activiiies. 05051 2 6 Horne activités. 05052 05055 05056 05060 05065 2 6 Horne admilies. 2 6 Horneactvites. 8 .0 Home adnibes. 3 6 Honteaclwlies. 2.0 Homeactniiies. 05066 2 6 Homeactniiies. 05070 2.3 Homeactntes. Fistng.genent (Xggng wonts, wioi stovel FisNag tan t riverbai* and waUng Fistng tom to a l somg Fisting t o n liver bank, standng (T 6 6 0 F3stngnslieam,nwaders(rS7C8 Fisting, ice. silling tW n g , tow and arrow or dossbow Hunting, deer. ell. iaige game (T 71C8 Hurting, duck, wading Huo6og.geneid Hmmg. gteasanis a g ro is e (T £80) Hunting. rabbiL sgiinel. praine ctick. raccoon, smal game (T 690) Fista stoom g or trap shooting, stand- "S Carpet aieepiiig. sweeping Ooiirs Ckming. heavy or m *ir le g . wash cm. wash windows, mop. dean sp- ragel. vigorous eOixi dealing, house or cabin, general Cleaning, ig tl Oksliig^ staigMening up. vacuuming, (hanging bien, cany. n g out trash), moderate eW ort Wash rtstes^ianding or ki general |nol txoken into stand/walk components) Washdishes: dealing rfstes tom la- bkMuaNng Cooking or lood prepaalioii-siaiidhg or siding or ki general mol broken itio stanrVwdk onmponems) Senkig mod. selling labie-impied wak ing or slanring CaoÜng or mod preparatorvwakkig Aniktg away groceries |e.g.. carrying . grocaies. shopping wiOirwl a gro cery o Q Canystg giooeiies igislaiis Food stopping, wkh grocery carl Slandvigshopsiing (nomgiocery shop- P i n g l Waking-shoppngmorrgroceiy Stop ping Ironing 05080 16 Home activiiies. 05090 2.0 Homeadnnties. 05095 2 6 Homeadisitles. «1 0 0 05110 «120 « 1 3 0 « 1 4 0 « 1 4 5 « 1 4 6 2 6 Home activities. SO Home activities. 66 HomeacdvHies, 5 6 Home activiiies. 4.0 Home anémies. 7.0 Home activities. 3.5 Home activities. « 1 4 7 3-0 Home activities. « 1 5 0 9.0 Home activities. « 1 6 0 2 6 Home activiiies. ffi1 « 3.0 Home activities. « 1 7 0 2 6 HomeadviUes. «171 2 6 Homeadnnties. « 1 7 5 4.0 Home activities. « 1 8 0 5.0 Home activities. « 1 8 5 3.0 Home activities, « ! « 3 6 Home activities. 06010 06020 06040 06850 3 0 Homerqiair. 4 6 Homerepsr, 3 6 Home repair. 3 6 Home repair. 66 Homerepar. 06060 4 6 Home repair. « 0 7 0 06080 « 0 9 0 « 1« « 1 1 0 «120 « 1 3 0 « 1 4 0 « 1 5 0 « 1 6 0 7 6 Homeiepak, 5 0 Homeiepaw. 4 6 Home repair. 5 0 Homarepak, 5 0 Hnmeiepair. 5 0 Home repair, 4 6 Hnmeiepair. 4 6 Home repair. 5 0 Homerepar, 4 6 Home repair. « 1 7 0 06180 « 1 9 0 062M 06210 «220 3 0 Home repair. 8.0 Home repair. 4 6 Home repair. 4 6 Home repair. 5.0 Homerepar. 4 6 Homerepar. 06230 4 6 Homerepar. 06240 3.0 Homerepar. 07010 0.9 kiaclivily.quiel Sasngvrnwg. sew ing, kgtt wrapping ipestnisl imoMitariding.|aundry. Md or hang dims, pul o o lite s m washer or rkpr.packing srriicase k>pM «Aing.putting away dom es, gattemg c to tn e s to par*, putting aaagbundry M a k v g o r d M aple Sfnpktg/strgar busting (rtdud- stgcmykig tx rd re ts. carrying wvxxl) M oving hvnitire, household SmbOiiglorws. o n hands and knees Svietping garage, sidew an or outside ottnme Movviglousehold items, canying taxes Stanrtngpacking/unpaclikig boxes, oc- casind W ing o f household items Ightmoderate elfort lmpfedwaliing.|]utting away tauseAMd kcmsmnderale eltort Move household item s rmstaks. cany- ingbnts o r fumilure Snndngigtt (p u m p gas. change Ighi bi&elc.) WakvtglgM. nixtdeaning (ready m leave, stul/kxdr doors, dose wki- doivs.elc.) Sktrigf^ing w ith ctidlieriHghl Standngpaying wiihdiidoierÿiglit wakpisvflaying wOb dadgrer^mooer- M e Wak/niiflaying w im ctargrenFvigor- ous Chhtcae; sitling/lmeeingdressing. bakiig. groonving. leedkig. occa- skxelilkig o f chiktsgti e t m Chkfrane; standing-dtessing. batting, gromvng, feeding, occasional Wkig of dddSidit effo rt Akfksie repair Ainemobie body work Autoncbie repair Carpemty.genml, w rxkstopfr 620) Caqmiiy, dulside horiseCT 640), ki- statngrakt g u tte rs Caipenby, tniW ing o r tektidikig cabi- netsnrkimdure Catpeney, saw ing hatdworid Caokkig. d en tin g log cabin CarMi» except lo g cabki Cmnkig gutters Excavahig garag e Kangkig storm windaws layktger removing carpet L qingaeortnoleum flaknkig. outside h o u se (T 650) Pakitkig. papering, plasierkig. scraping, ktskfe house, hanging steel rock, re- modelng(T630) Put on and rem oval of tarpsaCnal flooling Smdkig «tors w idt a power sander Scrapeand paint saW oal or powerboat Sprâdng del w ith a stovel Wash and wax huO olsaknaL cat. poweitxaL airplane Wasting fence Wnog,pVimtirrg lying gÂlkr. redirm g (watch lelesi- siotO, Ifkig guielly ki bedewake 2 6 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 76 OHici^Joumalof the American College of Sports Medic^e MEDICINE AND SCIENCE IN SPORTS AND EXERCISE APPENDIX 1. Continued 07020 1.0 Wwtiwdy.qwet 07030 07040 07050 070G0 07070 08010 0.9 Mactiwty.quie* 1.2 Wiactiwty.qi^ 1.0 InactM ty.l^t 1Ü biadivOjf.fght 1 J > h a c O w l y , ^ 5.0 Lawn m d garden. 08020 6.0 Lawn and ginJen. OflW O Si} Lawn and garden. 08040 5 0 Lawn and gaden. 08050 5.0 Lawm and garden. 06060 6.0 Lawn and garden, 08M0 SuO Lawn and garden. 080X1 5.0 lawn and gawden. 08035 5.5 Lawn and ganten. 08100 Lawn and spnJen. 08110 6.0 Lawn and garden. 08120 4.5 Laaai and garden. 081.\ OBK 08150 08170 06180 06190 C Ô 2 » 60210 06215 0 K 2 Q 4.5 Lawn and garden. 4 0 Lawn 0 id garden. 4 j lawn and garder^ 4 0 L am and garden, 4.0 Lawn and garden. 3.0 Lawn and garden. 4.0 Lewnmd garden. 6.0 lawn and garden. 4.5 Lawnand garden. 3.5 Lawn and garden. 2.5 Lawn and garden. 06230 1.5 Lawn end garden. M240 4 J Lawn and garden. 08245 5.0 Lawn and ^rden. 08250 3.0 Lawn and garden. 09010 Mscrtaneous. 09020 2.0 MéceSaneous, SHling gu«liy (lidng h a car. iistenirig 3 leo u e or muse. m icR teiew* smnoramoviiO Sleeping Slandng qweiljr (standng in a ine) Redmemting Reding-ltfmg or Idling on phone fiedhe^readit^ C a r i) ^ toadng or siaduhg wood. loading/uniQacting « carrying lumber Chopping wood, spitting lo ^ Cleafing bnd. hailing branches DiggngsandkA O^ging. spading. Mng gvden (T 59(9 Gtfderwig wWi heavy power toob. til* vig a garden (see coci^raiion. âioveL kg) Laying crushed rock L^ingsod Mriwing lawn, general MoMông lawn, ridéig mower f r 550} Movwng fawm . wÉk. hand rnower (T 5 7 0 Mowing lawn. waft, powermower (T 59 0 (9)erating»iowblowtf. wtfdng nantingseedings. shn4 » Plaiting trees Rating lawn (T 600 Racing roof snow rake Rxtingsnowblow^ Sacking gra». leaves SxxvA g. snow, by hand (T 61 0 Trimming shrabs or trees, manual cutter Trimming shnitB or trees, power cutter Waftiig. applying teftiber or seeding a lawn W irin g imm or gmden. sltexft^ or 11020 11030 2.3 Occupation. 6 . 0 O o o g j ^ o a 09030 09040 09050 G S 0 5 S 09060 1.3 MisceBaneous. Mtsoelaneous. 1.8 MBCCfaneous. 1j Mseeianecus, 1 J MisceBaneous. 09065 U M isceBaneous. 10010 10020 10030 10040 10050 10060 10070 10060 10090 10100 10110 10120 10125 10130 1.8 Bfiscelaneous. 1 . 8 M u a e p t ^ f i n g . 2.0 Music playing. 2.5 Musk plying. 4.0 Muskpftyvig. ZO Musk plying. 2 0 Mtskpteymg, 2 5 Musk playing. 3.5 M u scp ^k g . 2.5 M u s k p la ^ . 2 3 M iiskpt^ng. 2 . 0 M u s k p i^ . 1 0 Muskpteyng. 3 3 Musk playing. 4 3 Musk plying. Weedng, o ^ a f t ig garden (T 580 Gardening, general frnpBed waUng/standkgiiickng up yard.Bght SMng. card playing, playkg board games StarMftig<lrawing (iM fain 0 , c a ^ gam- bSng Sffing-^Rjkg, book, newspaper, etc. > Sitting writing, desk work Standrig'itfking or taftiig on the phone 3 teig4afting or taüûng on die phone Sitiiig'Studying. general ncfcicftig read* kgand/lofvwiiing S iH ir^ class, general k c W n g r w 10135 3 3 Musk playing. 11010 4.0 Occupation. SiarMtingmadng Aceordkn CeBo Conducting Drums R d e (sitting) Horn Piano or organ Trombone Tfuhpet VkBn Woodwind GtMar. d assk al k ft (silting Guitar, rock and rol band (standkg) Marching bandl playing an àtstiument baton twirfrig(vmfting) Marching band, drun i n ^ (wafting) BAery. genera 11035 2 3 Occupation. 11040 3.5 Ooamation. 11050 8.0 Oocupalion. 11060 8.0 Occupation. 11070 11(00 11090 11100 11110 11129 11130 11140 11150 11160 11170 11180 11190 11200 11210 11220 11230 11240 11245 2.5 Ooodsoion. 6S Occupation. 6.5 OcRfation. 6.0 Occupation. 7.0 Occupation. 5 3 Occupation. 3 S Occupation. 8J) Ocdkation. 3 S Occ^ation. 2.5 Occupation, 2 S Occupation. 4.0 Occupation. 4.5 Ocokation. 8.0 Occupation. 3.0 Oodkmkn. 1 6 O cok^on. 5.5 Occupation. 12.0 Occupation. I I jO Oodkation. 11246 11250 11260 11270 11280 11290 11300 11310 11320 11330 11340 11350 11360 11370 11360 11390 11400 11410 11420 11430 IlkW 11450 11460 11470 114% 11%5 11490 8M O oeu paS oo. 17.0 Occupation. 5.0 Occtkation. 7.0 Occupation. H i) Occupation. 8 J 8 Occupation. 8i) Oooktition. 5.0 Occdpalkn. 6.0 Occupation. 7i) Occupation. 4 S Occupation. Oil Occupation, 4 .0 Oocikation. 4Ü Occupation. 6i) Occupation. &0 Occupation. 6S Occupation. 2.6 Oocupatkn. 3.5 Occupation. 2 6 Oookation. 3.0 Occupation. 5.0 OccikMkn. 4i) Occupation. 3Ü Occupation. 7 J8 Oookation. 4M Occupation. 7.0 Occupation. 11500 2.5 Oocupatkn. 11510 11520 11525 11526 11527 11528 11530 11540 11550 11560 11570 43 OcOkMkn, 2M Oookation, 2.5 Occupation, 2.0 Occupation. 1.3 Oodkatkn, 8 . 0 O c c u p y 2.5 OccupMkn, 8 3 Oocikation. 9.0 BooktMdmg Building road (aidudng hauling debns. dnvmg heavy machinery) Budding road, dicdiag traffic (standing) Carpentry, general C a ri^ ig fmavy kadi such a s bricks Carrying moderate toads i8> s ta irs, m ov* trig boxes (l6-4Opound0 Chrnnbermak (Zoalrntrmg. dating coal rock Coal mning, erectng supports Otelrrweng. general Com mining, showing mat (knstfwction, cwisde. remodeling ElBctiicalwQtk.ptihbn9 Farming, baling hay. deaning b a m . poultry work Farrrûig. chasing cattie. nonstrmiuous Farming, driving harvester Farming, Awing aacter Fammg.teeAmgsmM animate Fmnrir^. feeAng caate Fanriir^, loriüng straw bales Famting. nrikkg byhand Fanmrig. m icng byiaachine Farming, shovefinggtasi Feef^ter.gem end Pee i^hter.dirnbittg ladder with fun gear Are fighter, hauftig hoses on g ro u n d Forestry, ax chapping. Iasi Forestry, ax chopping, stew Forestry.baddngtiees Fbraby.carrymgtegs fbresby.teftr^bees Forestry, genera Forexry, hoeing Forestry, planting by hand Forestry, sawing by hand Forestry. sawkg,pmvw Forestry, trimming n e s Forestry, weedkg FiRieiy Horse grooming Horse racing, galoping Horse racing, hotting Horse radng. wafting Locksmith Machne tooBng. rnaehnng. working sheet metal Maehke tooting, operteingtithe Machine tooting, operating pwich p ress Machtee tooting, tappsig arte driBirig Machine tooting, weMrig Masonry, concrete 6J) Oocuymtkn. 7.0 Occupation. Moving, pushing heavy o l# ts . 75 ms or more (desks, moving van work) Operating heavy duty equipmerU/auto- mated. not Awing Orange grove woA Printing (stanAng) Potioe,ArectingtmWk(stanAng) Potice. Awing a squad car (siltirig) Poice, ridhg n a squad car fsBting) Potice. mafcti^ art arvest(stenAng) Shoe repair, general Shoveting. diggng Alches Shoveling, heavy (more tfian 16 lbs • m i n - ') Shovelng. tight pKS than lOks-m in-') Shoveing-moderaie(lO-l5 teS'fTvn-') 262 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. c o m p e n d iu m o f p h y s i c a l a c t iv it ie s OlficiaiJoumaloMhe American College 0 1 S p o rts Medicine 77 i ? P E N O I X l.C a » m je d 11580 Occupation. 11585 1.5 O cavaE on. 11590 2S Occupation. 11800 2.5 Occupation. 11610 3.0 Occupation. 11820 3 j Occupation. 11630 4.0 Occupation. 11640 11650 11660 11670 11680 11690 11700 11710 11720 11730 11740 11750 11760 11766 53) Occupation. 5.5 Occupation. 8.0 Occupation. 8.0 Occupation. 113) OccwaEon. 7 5 Occupation. 5 5 Occupation. 8.0 OccupaOotL 2 5 Occupation. 2 5 Ocoupatlan. 2.0 OocupaEon. 2 5 Occupation. 43) OccwpaOon. 6 5 Ocootalian. 11770 1 5 Occupation. 11760 6 5 Occupation. 11790 8 5 Occupation. 11791 2 5 Occupation. 11792 11793 11795 11800 11810 11820 11830 11840 11850 3 5 Occupation. 4.0 Occupation. 3.0 Occupation. 4 5 Occupation. 4 5 Occupation. 5 5 Occupation. 6 5 OccupatiiaL 7 5 Occupation. 8 5 Occupation. 11870 3 5 Occupation. 12010 6 5 Running. 12020 12030 12040 12050 12060 12070 12080 7.0 Running. 8.0 Ruining. 9.0 Ruining, la o Rioting. 115 Routing. 115 Ruining. 125 Ruutingi SMngiglil office waiii. in general 12090 135 Running. (clienesliyiaiw alLli^iiseol 12100 14.0 Running, lun)tocls.watclinpaaorincRKis- 12110 150 Rurmng. cenntilir.ligmasseoittijr/iepair) 12120 165 Running. SOtingmeeiings. general anO/anith 12130 18.0 Running. taking iiwolveci 12140 9.0 Ruiting. Sitting: inaletaie||iea«7 levers, lidng 12150 5 0 Hunrmg, mowec/iiirMlL crate operatioig 1218) 8 5 Ruining, Standing; ighlilnilenling. slo e derk. 12170 155 Ruinng. assen<i6 ng.Hng.>era>ing.puiup 12180 105 Running, CMstiiiasliee) 12190 5 0 Running. Standng; IgM/inoderate (assenple/re- pair Heavy parts. «ietiting.Stiiditiig. 12195 3.0 Runrvng. auo repair, pack tim es lor rnoving. 13000 2 5 Selticare. e1 c.|. patient care (as in nmingl Slanfng: moderate (asserntitng at last 13009 15 Seticare. rale, kiting 50 Its, lAcii/tviisting 13010 2.0 StScane. ropes) 13020 2.5 Sen<are. Standing; modtnite/lieasy (Ring more man 5 0 » . masonry. p a in tirn ,p ^ 13030 15 SeOcare, liangingl I3 8 Ë 2.0 Sedcare. Steel ntii.fettting Steel mKlcrging 13040 2 5 SeOdare. Steel ntil hand rottng Steel m l. merdianl n il roing SleeimR. removing slag 18150 4.0 SeiKare. Steel m l. lenrkngluiBCe 14010 15 Sesual activity, Steel ma. lipping molds 14020 1 5 Sexual activiiy. Sleel m i. «lorking in general 14030 1.0 SeniPactivOy. Talanng. cutting 15010 3 5 Sports. Taicrsig. general 15020 7 5 Sports. Taionng.landseimi9 15030 4 5 Spcrls. Taktring. madtine sewing Tkktiing. pressing 15040 8 5 Sports. Tiiidi driving, loating and unfciadng 15050 6.0 Spore. truck #andin@ 15060 7 5 Sports. 7ypmg.electiic; manual o r rmmikrler 15070 4 5 Spuds. UStiig heavy power tools sudi pneu 15075 6.5 Sfmrts. rustic tools Oackltammers.iHls. m e) 15080 2 5 Sports. Uang heavy tods mol power) sudi as 15090 3-0 Sports. shovd. pick, tunnel tier, spade 15100 12.0 Sports. WWkirigonioti.lessmao20mph)ii 151)0 6 5 Sports. oltice or lati area); very slow 15120 9 5 %icrts. waking on inti. 3 5 niph.m i#ce. mod- 15130 7.0 Sports. erale speed, m l canyinganyiting 151% 5 5 Sports, waking on job. 3 5 mph. P oSce. tirish speetl not eanystg anyming WlNng; 2 5 mph. slowly and canying Ightotiiecis less than 2 5 1 » 15140 4.0 Sports. Waking. 3.0 mph, ntoderalely s d car rying SghI objects less than 251», 15150 5.0 Sports. Watinng. 3 5 mph. briskly and carrying 15160 2.5 Sports, obieclsfess titan 2 5 1 » 15170 4 5 sixuls. Wakitg or teak downstairs or standng. 15180 2 5 Spoils. canyingoOieclsatiool 25-491» 15190 6.0 Sports. Waking or waSidownstmrs or standing. 15200 6.0 Sports. carrying otijecisaOoul 50-741» 15210 9 5 Spots. Waking o w ak d o m stairs or standing. 15230 8.0 Sports. canyngotifectsatiod 75-991» 15235 2 5 Spons. Wakmg or w ak downstairs or standmg. 15240 2 0 Sports, canytitgctiecls about 100 ti» and 15250 3 5 Spols. over 15255 4 5 Sports, Woking n scene Shop, theater actor. 15260 5 5 Sports. backstage, engiioyee 15270 3 5 ^loits. 3oti/wak combination gobtiingoontp» 15280 5 0 Simns. iteniofless than lDmin)rr 180) 15290 2 5 Sfons. Jogging, general 15308 4 5 Sports. Running. 5ntpli|l2ntin.nt8e-') 15310 4 5 Sports. Running. 5 2 mph (115 n tin.ntk") 15320 125 Sports. Running. 6 mph (10 ntin.ntle"') 15330 2 0 Sports. Ruining. 6.7mph (9 nwv m ae-g 15340 2 5 Sports. Running.7mph0 5 ntin.n«K-1 15350 8 5 Sports. Runnmg.75ntph0min.ntiie-') 15360 8.0 Sports. Ruvvng.6m pt% (7 .5 mm utile-') R um ng85m ph (7 mm-mile-') Runnng,9tnpli (6.5 ntin utile-') Runring. 18 m ph (6 m iri-ntie-') Running; |8 5 m p h ( 5 5 otinrnie') Rutritg. ao ss-o x m iiy Rutnhg. general (T 200) R a n t9 .nfSace Rintitg.nairs.iip Rimrtitg. on a track , team practice Ruining, taming, pushing wheelchair. utaratiton wheeling R untg. «meeting, general Standiggetting read y lor tied, m gen- crd Silting on ktiet Bmhhgtslting) Dressing, utdressing (standmg or sit ting) Eating p a tiig ) Taking and eating o r eating only (stand ing) Sdting or standmg-0 iociming (washing, shaving, timshing teeth, uihaling. waslting hands, p u t on make-up) Showemg. toweling o n (sranding) Active, vigitiausellort General, moderate ehort Passiie. iÿil eflOrt. kissing, hugging Archery (nonhunling) Badntiilan; competitive (T 450) Badnvrtim social singles and doubles. gtmeral 8asketi»6,game(T490| Baskdtidl nongam e, general (T <80) Basketi»lol6iÂrtirtg(T500) Basketiul. shooting baskets easkemalwheektitair BowtingdSSD) Boxing, firing, general Boxing, hutching bag Boxmg.spauing Chkten’ sgam es (hopsooMi, 4-sgtiaie. dodgetiA playground apparahB, I- bdltetiterbati. marbles, lacks, ar- cade games) (PatWngiloolM. soccer, basketbal, basetiAswtinmlng.eK Okket (bating, bowing) Croiuet Curting Darts, w atutaw n Oiag radng, pushing o r driving a car Fencing Fooitiati. competitive FootbA touch. Rag. gener»(T 510) Footbati or bascbai, playing catch Fnsbee playing, general Frisbee. tStimale Sotii general God. canyiig ckibs (T 09(1) GdLmMaam. driving range Gen pidtiig dubs (T 0 8 0 Goti. using power c a n (707(8 Gymnastics, genera) Hackysadt Hkidbdl général I? 526) Handbalteam Hang gating Hockey.lidd Hockey, me 263 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7S OHidal Journal ot the American Craege of Spons Medicine MEDICINE AND SCIENCE IN SPORTS AND EXERCISE APPENDIX t.ConSnued 4.0 Spons. 15 %XMS. 65 Spans. 1 5 Spots. 1 0 Spans. 5 4 » 110 % o m . 5430 TOO Spans. 5370 5380 5390 5400 5410 5440 5450 S4E0 5470 5480 4.0 Spans. l a Spons. 8.0 Sports. 4 j0 %XMS. _ O jO Spans. 5490 to o Spons. 5500 t o Sports. 5510 t o Spons. 5 5 » 100 Sports. 5530 7 0 Spans. 5535 110 Spons. 5540 8 0 Spans. 5550 110 Sports. 5551 n o » o n s . t o Sports, n o Sports. 1 0 Sports. SO Sports. 7 0 Spans, I S Spans, n o Sports. 10 7.0 Sports. 5 0 Sports. 4 0 Sports, t o Sports. 1 10 Sports. 4 0 Spons. 4 0 Spans. 7 0 Qpons. GO Sports. O jO Sports. 1 5 Spans. 4 0 Sports. 5552 5560 5570 55(0 5590 5500 0 1 0 Sports. t o Sports. 6 0 Sports. 7 0 Spam . I D TianspanaGon. 1 0 Tiaispanatioa I S T iatncnaSm . t o l ansp aueo n . 1 0 Tonspanalian, 7 0 «M âig, 1 5 vm àig. ITOB 9.0 WaPmg. 170» 5J0 «M ing. 17827 t o Waaiing. 1 70» t o «Mâtg 170 » 10.0 waning. 1 70 » 120 w aH ig. 17035 7 0 wasung 17040 7 0 Wabtog. 1 7 » 0 t o WeOw* 1 70 » 9 0 WaPie* 17070 3 0 WePikuk 1 7 0 » t o WMdngL 170 » 6 5 WdUtg. 17100 2 5 waeung. 17110 8 5 «Wksig. 171» 8 0 W ating H oatia*iang.ginti!t Haiselackntngj sadMig l» s e Hanebadifld«g.in)i«n9 Horsetaacli ittig . «alk«9 HamshaepOdiing. quails Jaalai JudA ppBH. Iianlej Kdi Posing, lae manna J i i g g k g KSAPuO R sd lM » t cam peUne P P d iO eP al. casual general (T 460) Polo RacSetftal competitive RackelPal. casual gensaKT470) Rock dntPng, asoendng n e k Rockdra(ing.apeMig Rope jumping. Iasi Rape jumping. noOente: general Rape jum im i smut Rwgiy SP uîSeP aard. law n D o w lin g SkatcOamdng SkaGng. «0=173601 -SIqrdMlg S o c c e r , c a v p e & m Soocer. casual genenl(T 540) SoM m or basebal last or slow piK ii. general (7441? SoMiataidaling Sa«M.pW6ng Squash (T 530) Table iennis,piig pang (7410) Tail* T enoG . general Temis. doublas (7430) Tenn8.ainglBs(742(J T ra m p o O n e V O ieybm icnpedew ,n0nnasini(7 m wombat n onau rap elitn a; 6-S m em ber ■ e a r n , general Voieybal. beach MeaOqilenenialdi-Oinkg MaVmt gen era # Ainomabker (gill Puck (nolasei4 rain in g E ^ a O p la n e M alar seooler. m olor qide P ua lâ n g plane Inandnuinl h angar OnvsignenynKk, Paocr.bus . Backpedraigjgeneral(705ig Canÿng iilW or 15* tad itg., siO- cas 4 iMigiaaid vitNnsiais Ca^mgluadiaslats.geaeral canyiig l- n 15« t a t upslara Canyaigie-iolMitatupsMts C a n a ls - 1049« mat upslan Canÿnglt 107440katupslaira Canyiig 74440 tad, qatais C M iq his w ##i 0-to 9*lamf CMaqhCtwiOi 10-102040 toad CSmOir^Mbnâdilt-»4240toad C O n O ng Ms wih 4K-to toad O aH nstans H&klg. cross otwlbyfT040) Maniiiig. laptoÿ. mMaiy or puBiig suoaer wkn cnan flacewaKng flock or maunlMi cBsbmg (7 0619 17130 to Wakn^ 17140 4j0 Wallông. 17150 10 wasmg. 17160 2 5 Wifting. 17170 1 0 wasiiog. 17160 1 0 MnBâig. 17190 I S WaBeng. 17200 4 0 Wailing. 17210 to Wag«^. 1 7 2 » 4 5 W atiig. 1 7 2 » 4 5 WaHig. 1 7 2 » 1 5 waging. 1 7 » 0 5 0 watnng. 17270 4 0 watimg. 18010 1 5 water acdwdes. I M » 4 0 water acHdnes. 1 8 0 » 7 0 water aamiies. 18040 1 0 VtoieraclMlies. 1 8 0 » 7 0 Hrararacdwlies. 1 8 0 » 120 Water aoinlies. 1 5 water acOniies. 1 8 0 » 110 WbnacliiitKS. 1 8 0 » 1 0 wateraoinGes. 1 8 1 » SO water actn a es. 18110 4 0 water araMbes. 181» 3 0 water aonilies. 1 8 1 » SO wateractiiiiies. 18140 3 0 Water actwiSes. 1 8 1 » t o Waleracbsities. 1 8 1 » 7 0 «WeraoinGes. 16170 120 water acbvitles. 1 8 1 » ISO W auraoM tos. 1 8 1 » 115 «M eracM lies. 1 8 2 » 7 0 wateraniitoes. 18210 5 0 WauraclMdes. 1 8 2 » 3 0 m a te rn e s. 182» to o water acOiiOies. 18240 8 0 water acM ies. 1 8 2 » 8 0 Water acOndes. 182» 10 0 «WeractoiHes. l e m 110 W atoradmBet is n o 1 1 0 Water adM ies. 1 8 2 » t o Water adnitoes. 1 8 3 » t o wawractiHties. 18310 t o lOateradirities. 1 8 3 » t o w ater a d Mtiea. 1 8 3 » 8 0 Water adhiies. 18340 ICO Water adenues. Up sta s s . usng or ranting u p ladder (7 030) Using cnildies Walking, less man 20 mph. level giound. siiuhng.hausehold walking, v e ry Stour WaOciiig. 1 0 mph. leiel slow p ace, tom su rta œ WaOting. 2 5 mph. km sw face Walking. 1 5 rap t dUMihai Walking. 1 0 m ph-terelniaderale pace. Grrnsteiaoe Waadng. 1 5 mph, tom brisk, ftm sur- la c e Walking. 3 5 mph. upti* Walking. 4.0 mph. Iwd. firm surface. v e ry brisk pace Walking. 4 5 n y tlto m Om surface. very, very bridi walking, tor pteasire.work break. «raürâtgnteitag. WaOdngj grass Path W aOdngjUwodiorrtassfT 015) Boating, power Canoeing, on campmg Pip (7 270) Canoeing, partogng Canoeing, roaangj 2 0 -1 9 m ph. (ghieP tart Canoeiing.m iiig.40G O m ph. moder a te efton Canoeing. iowtog.>6mph. vigorous efio n Canotoi>g.iaiinng.lar|#easure,geneira (r a s o ) Canoeing, rowiig. in om pediion. or d e w nr sadtog(T260| OM ig. sptmgbaardoriMlarm KayMing PBddtoboal Saitog. boat and bead sain g . wind- sur«ng.ioe s a w * general 235) Satotg.tocompeli6on S a in g . SunSi»Vlaser)HobbyCaI. keel b o ats, ocean saMg. yatM iig Shing, m tor(7220) S k to iM n g Skiidhringor scuba ttotog as leogman SMidnring.lasl Sklndhring. moderate StondMig. scuba ifnig. general (T 3109 aiarke6ng(732[g Suitoig.bndyorbnanl a w ttniiigttos. P e e s g k la s l vigoious efiart S a in m n g bp s. Peeslyle. stow, m oden aleo rlg lilellail Sniim ihig.badisltdm.genenl S»nmming.6rBast5trdte.9eneral S w it»iing.btina% . general Su6m m tog.crauttosl(Kyanls . nwi-lLvigomuseOiai Sw iianiig. craw l a ta te o yards- m ir % moderato nrkpaeltorl Senmmtag. lahe. ooean. lira (7 2 B a T 2 9 ^ Snanm iig. tosurely. ltd bp sw k m in g . general Swinmiiig.s|induunired Swimming, ueerang water. Iasi vigor ous edon 264 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. COMPENDIUM O F P H Y S IC A L ACTIVITIES Ollictal Journal ol ihe American College ol Spons M edicine 79 jipENOIX 1. Conuued 18350 4.0 Water admiies. 18360 laO W auradivilies. 18365 3 0 WaieraclMlies. I83Z0 5 0 Water adinlies. 18010 6 0 Winter aciivOies. 19020 19030 19040 19050 19060 19075 19080 5.5 IMnteractiviSes. 7.0 Winter aiamties. 9.0 WMeraclmOes, 15.0 WMeractnities. 7 0 WWeracWties. 7 0 WMeraiaMies. 7.0 Winter activities. Swenming. Irealng water, mooeiate el- 8X 1 . general Water pgb water voteytBl WMewaier rding. k a y ^ . nr ranoe- i n g Moving ice tmuse (set irpfiWl tides, efe) Skating, ce. 9 mph or less Skating. Ce. general (T 360) SfcatCg, Ce. rwKigr, m ne than 9 mph Skatng. speed. oompeMiw Ski jisnpingldmh up carrying ski^ Sklng. general SkCig. crosscountry, 2 5 mph. sknr (X ighlellcn.skiwdidng_____________ 19030 6.0 WfKer aciivrties. 19100 9.0 W iMer activities. 19110 19130 14.0 16.5 Vfinteradntes. Wnter acimties. 19150 19160 Si) 6i) MWefac6v*es. WMeradiy^ies. 19170 19160 U 7H MMer adwities. WMeractMtes. 19190 19900 &0 3 J & WMeractiMties. Winter acfiMfts. Sking. (nrsscomlry. 4 .0 - 4 .9 mph. moderate speen end e tlo rs. general Skiing, a o ssc n o y . 5 . 0 - 7 0 mpn, txisk speed, ngomus e fto n S k n g ,c m s s c ru a y .> 8 .0 mph.ncCg String, cmsscouBy. tia rd snow. upM. String, dCMiM. ighl e ffix t String, doeneil. m oderate elfarL gen eral Sking.rlOMM.«garous effon, rating Sledding, tdicgganing, Ixrbsledding, krge(T370 Snow shoeing SnownxMng IPPENOIX 2. Guidelines 8x assigning activities h y m * r purpose or intenl. 1 . DxrdhCnlng ermtdses iickrde activities whh the nieni of Cpnrvmg physical condHCn. This irckrdes stationary ergometers OrCycing. roiring madiiies. head, mis. etc.) health ckrh eserdstL caisdieracs. and aerchCs. 1 . Home repair nX udesalactM tyassoiiaH d with the repair oi a luuse and does not nSude houseimrk. TMs is not an occupaiional laA. X scaling, lying. sitlMg. and standing are Chssied as nactH ^. I Home actisihes iickrde aS activities associated widi maiilainsig the inside ol a house and siOMk m use demreig. laundry, gtooery shrippiig. and cooknig. j. lawn and garden ickides a8 acftily associated wilh maWaWng the yard and iickrdes yard work, gardereng. and snow lemmral__________ ____________ 6. Occupation nchides a( iatHClated pItysCal achnty «here o n e is paid ^aidul employmenO.SpecilC activities m ^ h e cross-relereiicedCotherialegones (such a s rearing, wrihng. driviig a a i. walking and d nM he ooeSed in this nugor heaifng ( related to emplaymem. Housework is oaxpwonal o n ly H the person is eanwig iinney lor the t a ^ 7. SelbcaieiKhrdesal activity rotated to groomng.eaenghathing. etc. 8. TransprxiatCninckides energy expended lor the prinery p urpose olgoCg some where iiamolorized vehicle. A F F E N O n C 3. Guideirres lor coding spedfc actwlies. A General guideines; AI acdvities shordd he coded as general 8 no other Mar- matCn aOout me ardivity is given. TMs apptes primariy to intensity ratings. II atgr additional irdormaticn is given, aedvhies should he coded acoordngly. B.Sped«cgtadeknes 1. BCycfng a Stahonary cycling using cydeergomewrslai types). wCd trainers, or other condiMnng devices should be dassilied reider die major headng ol OonddCning Exercise, stationary eyeing specKc acdvihes (codes 020108102015). h. The isl does not aooounl lor dWetencesn wild GomklCns. c. H txcyding is perlomied hi a race, rdass^ 8 a s general racmg rl no descrgncns are given ahoutdrahing|oode0t05l@. II hikemation is given ahorrtttiespeed or drattingcodeasOllBOlhicycling. 16-19 mph. rachig/ not drying or > 1 9 mph drahhig. very last) or 01060 (tiCycing. £20 mph, racing, not draMng). d. Usmgamouniain hike hi the city should hedassmedastxcydrng. general (code 01010). CycMg on mountain trais or on a BMX course is code) 01009. 2. Condhionmg Exercises a. d a caksiheivcs progran is destnhed as a Ight or moderate type ol activity (e.g.. perionning back exercises) hut indcales a vigtxous edon on me part ol the participanl. code the activdy as caisthenics. generd (code 02030). b. Exercise perkxmed at a health duh lhal-is-not desokied siioidd be ciassiliediah^club.general|codelEOEO|.OOierachviiiespeilormed at a hearth duh |e $ . weight Htvig. aerehic dance, cxcud training. treadmdnmnmg.elc. ataheaWduhlslioiAlheclassdiedunder separate nuiorheadvigs. c. Regaritessolvvhedier aerobic iaoce.ooniftxxiin8. calcul haWng. or water cafsthenics programs are desdibedby their component partsfLe- lOmaijoggnginpiaoe. lOminsilups. lOmsistreM jn9.eio.)icfdeine acteniy as one actrwiy ( e g . wawr aerobics, code 0218!). d. ENon. speed, or imensdy breakdowns kx the specdkacdvlties olsiair- deadmrn ergomeler (code 0206% ski machine (code 02080). water aerobxsorwatercaksdienics (code02120). drcudtraioiig^ode 020401. and simnaskcs (code 02090) are not given. Code these as generaL even though ebon or idensities may vary hi the descrgitions of the ackvity. 3. Oandng a. d the type oldanchig performed is not descnbed. c o d e it as dancing, general (code 0302% 4. HomeAodvities a. House cleaning shoukfhe coded a s IgM (code 0 5 0 4 0 ) o r heavy (code 0502(9. Examples tor each a re given « the descriplian of die specHic h. Mdiiig the bed on a dai^r basis is coded 05100. Changing the bed sheets is coded as cleaning, ight (code O SO H g. 5. Home Repair a. Any paiming outside of the hckise (le . knee, the hcxxse. ham) is coded. paMng, outside house (code 60150). 6. Inactivity A Sitikigandreadngahockor n e w s p ^ h ls ie d u n d e r themajtxhearhig ol Miscelaneous. reading, hook, newspaper, etc. (c o d e 09(00). b. S nng and wiWng is isied under the minr h eating olMhcclaneous. writing (oode09MO). 7. Lawn and Garden a. Working in the garden with a specbic type ol 8x8 (e .g ., hoe. spade) is coded as diggsig. spactng, IWrtg gardenlmde00050). h. Removing snow may he done try one ol «see m m hodK shovelng snow by hand (code OStOttt, wabdng and cpeitng a sn o w blower (code OOlOig. or rkkogasnow blower ^o d e 08181!). 6. Music Maying A kkoslvarialim kl music playing w# be aoccrdrig to th e setbng (Le. rock and ro8 band, onfiesaa. marching hand, oxioen b a n d , standng on the stage, performance, pracdoe. In a cfaedi etc). T h e cicxiwenikum does not consider tfderences in the setting (ercepl lor maroNng band and gukar playing). 9. Occupation a. Types of accupadonai activities not isled separately under specbic acdvities (eg., chemishy laboratory expennems). sh o u ld be pbcediMo the types ol energy expenrMxectassicaions b est descrW tg the activ ity. See sitting: Kght (code 1158(0. skkig: m odem re (oode 11590). standing: tght (code 11600), standing; ight to m o d erate (code 116% standng: moderate (code 11620). stanWg: m o d erate to heavy oode 11630). 265 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. AA F o m > A ppm vedT hieugii 2 # 2 e * > i 082^0001 Department of Health and Human Services Public Health Servies LEAVE BLANK—FOR PHS USE ONLY. Type [Activity Number Grant Application Fdowinslnjctkxacamhjt/. D o nal exceed character ItnathrBstriBlijnshdSBated on Ihe sample. Reiiewr Group iFormertv CoundVBcerd (M onth; Year) DeteRecehod 1 TITLE OF PROJECT The Devetopment and Assessment of a Culturally SensMve Questionnaire for African Ameitens________________ 2. RESPONSE TO SPECIFIC REQUEST FOR APPUCATIONS OR PROGRAM ANNOUNCEMENT [ J nO ^ Y E S Nunaier. PAR-98-023 Tüte Small Grants Program For Cancer EpMemtology__________________________ a. PRINCIPAL MVESTI6ATORA>ROeRAM DIRECTOR Newlnvegtinator B! YES 3 a NAME (Last * s t m k*M ) Elvin. Carolyn. Marie 3b. DEGREE(S) M.S., MPH, Ph.D. 3d. POSITION TITLE Assistant Professor 31. DEPARTMENT. æRVKZ. LABORATORY. OR EQUIVALENT Department of Mathematics__________________ 3g. MAJOR SUBDIVISION College of Science and Engineering 3 1 1 . TELEPHOIÆ AND FAX (Aim codn number and aslansionj Tat (310)338-5775 Fac (310)338-3768 3a M AILING ADDRESS (SbastcJy. SMB. zt>ood9j Loyola Maiymount UnkersNy Department of Mathematics 7900 Loyola Boulevard Los Angeles, CA 90045-8130 E-M AIL A D D R ^ ; cervin@hsc.usc.edu 4. HUMAN SUBJECTS 4 a IfYes,'ExBmpdon im. SC IRBappRMldale O _____________o n a m K 4b. Assurance d compliance na 5. VERTEBRATE ANIM ALS □ no □ ^ I'V W I' M C U C A3283-01 6. DATES OF PROPOSED PERK» OF SWPORT (m on th, yesr-MMDiyYY) m H m ugti 06/01/01 05/31/03 7. COSTS REQUESTED FOR IN T T IA L BUDGET. PERIOD 7a. m aa o m o ) 7a ToWCanm $50,000 & COSTS REQUESTED FOR PROPOSED PERIOD OF SUPPORT aa. OMacoa>(t) 1 * 1 $50,000 9. APPLICANT ORGANIZATION H a m a Loyola Maiymount Unhiersiÿ Department of Mathematics 7900 Loyola Boulevard Los Armeies, CA 90045-8220 i a TYPE OF OR Pubic: Piivals: For profit [Federal r iS M e □ Local Private Ncnpralit I General |~~] Smel Business 11. ORGANIZATIONAL COMPONENT CODE 20 12. ENTITY mENimCATION NUMBER 951643334 DUNS NO. Congrasaionel District 36 DUNSNO.ffavalab<s; 072946239 13. ADM INISTRATION OFFICIAL TO BE NOTIFKD IF AWARD IS MADE Blrute Anne Vlelsis, Ph.D. Associate Academic Vice President and Director Academic Grants Ofhce 7900 loyola Boulevard Los Angeles, CA 90045-8207 (310) 338:4599 (310) 338-5193 E m a » bv9eisi@lmuma8.lmu.edu 14. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION H a m a Joseph G. JaDtxa, Ph.D. T * m Academic Vice President 7900 Loyola Boulevard Los Angeles, CA 90045-6316 (310) 338-2733 F a > (310)338-1841 ljat>bra@lmumaM.lmu.edu IS. PRINCIPAL MVESTIGATORIPROGRAMDIiœCTOR ASSURANCE: I certify IM Itw statements herein a e true, compMe and accurate to the best cr my fcntMtodge I am aware IM arqr falsA ScttlDus, or fraudulenl statements or dehismey subject me to crinilnelcML or adn*tisbatlvB peneMes. I agree Id accqit lespcnsliay iorlhe scientific conduct cl the project end iDgmWe the requeed progress reports fegrent is awarded SIGNATURE OF PI / PD NAMED M 3a. (in ML 'Per'sfgnalus oof rrormptsMa) DATE 16. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certaytM the statements herein are tme, complete and aocurete to the I best of my knrwledgek and accept the obl^aSon to comp^ with Pubfc I lIcel h SerMcBlemis andcondteinslfaaiantisawantedasarBsmcfttiis I appfcedon. I am aware thetarvMsAllcilious. or ftaudulentstatenienis or claims may subiect me to ciimtnel, cM L cr admMstretiwe peroUes. SIGNATURE OF OFFICIAL NAMED IN 14. (in Mr TWaM'afuranofaoceptebte.) DATE PHS 388 (Raw 4(98) Face Page AA 266 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix A4. Grant Proposal 267 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. AA F cm * A p p « o v « d T hreugti 2/2801 0M B H o. 08250001 Department of HeaMi and Human Services Public HeafihSeraice LEAVE BLANK-FORPHS USE ONLY. Type 1 ActkAy 1 Number Grant Application FiolbH'nsburdions carefti^r. D a not exceed ctiarecter ia n Q t h restrxtions indcated on ttiessmpis. Review Group iFormerty CouncBIBaanl (M a n B t, Year) Date Received 1- Tm EOFPJKUECT The Development and Assessment of a CuHuraBy Sensitive Questionnaire for African Amerôans________________ 2. RESPONSE TO SPECIFIC REQUEST FOR APPUCATIONS OR PROGRAM ANNOUNCEMENT Q n O ^ Y E S N u m fc e r. PAR-98-023 Tag Small Grants Program For Cancer Epktemfaloqy__________________________ 3. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR Newlnrwestinator 0 YES 3 g NAME fts s t fist Efvw. Carolyn, Marie 3k OEGREE(£h M S .. M PH . P h.D . 3d. POSmON TITLE 3f. DEPARTMENT, SERVICE, LABORATORY. OR EQUIVALENT Department of Mathematics 3g. MAJOR SUBOMSICm College of Science and Engineering 3h. TELEPHONE AND FAX fAma codb, flui^ar and wCwisiiMj Tel: (310) 338-5775 Far (310) 338-3768 3 e M AILING ADLmESSfS*aet(eKaWgz*»«od4 Loyola Maiymount Univer^ Department of Mathematics 7900 Loyola Boulevard Los Angeles. CA 90045-8130 E4MAIL ADDRESS: cervin@hsausc.edu 4. HUMAN aiBJECTS IO% 4 a H*Yes,‘ Eaaqpfianna O ' IRB approval date O M R s a □ g “ 4b.Assiaanoeor campKanoena S. VERTEBRATE ANIMALS □ no □ y« & L M C U C 5b. A nM iM w M rm •ssM wioano. A3283-01 R DATES OF PROPOSED PERIOD OF SUWHMTT (mont), ymr-4MS^3ffY) I U treugh 06/01/01 05/31/03 7, COSTS REQUESTED FOR IN IT IA L aXXSET PERIOD 7a. OMaCoasOI 7b. IbWCoaaO) $50.000 a. COSTS œ O ieS T E O FOR PROPOSED PERKO OF SUPPORT aa.Oi>M Costs c> ) a t T bIsI costs 1 * 1 $50.000 a APPLICANT ORGAMZATION Lpyola Maiymount Univers^ Department of Mathematics 7900 Loyola Boulevard Los A isles. CA 90045-8220 i a TYPE OFOf®»aZAT10N P u M k Privale For prcfit Fédérai [~]aalB Privale Nonprofit General | | Smell Business □ Ltxal 11. ORGANIZATK»IALC(XaPONB€TCODE 2 0 12. ENTITY IDENTIFICATION NUMBER 951643334 OUNSNO.(7avsieU>/ 072946239 CoogressJooaJ District 36 13. ADMINISTRATION OFFICIAL TO BE NOTIFIED F AW/IRO IS MADE "• Blrute Anne Vgeisis. Ph D. ' Associate Academic Vice President and Dkector "«• /Academic Grants Office 7900 loyola Boulevard Los Angeles, CA 90045-8207 (310)338-4599 F« (310) 338-5193 E -itM Mebi@lmumaB.lmu.edu 14. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION Joseph G. Jabbra. PhD. ™ * Academic Vice President 7900 Loyola Boulevard Los Angeles. CA 90045-8316 (310) 338-2733 Fta (310) 338-1841 ÿabt>ra@lmumaB.lmu.edu IS. PRVICFM. BMESTIGATORIPROraWM DIRECTOR ASSURANCE: SIGNATURE OF PI / PD NAMED IN 3ai M l IRer'aignslur» not eccctpteMrJ scrcberamaystibjectimtocriinirial.civiLoratltiiWstialive penallies. laatsetoacei^ iBNXirisliatyfcrltieigiaSSic conduct cf the pgjeetand touiovide I heremtwdpnianessieponedagiant is awarded as a lesidt of mis appCraScn. DATE 1&APPLKANT0m3ANIZATK*l CBTTFICATIONAM7 ACCEPTANCE: IcemNBial r bestcrmyk I certiN that the statements hetein are bug cornplele and accurate to the .çMçliiiykncmledggaiidaco^meob^eiiintiiccinp^rriBlPliblc ! HeNbi Service terme and tMExtoons S a grata la aeremed as a lesrdl of this SIGNATURE OF OFFICIAL NAMED m 14. 'Per'signature not axepteth.) DATE appBcadon. I am aaore Hot any M sg ftâkws, or ftaurMant statements or dairns may simiect me to Criminal cM. or adminisbatlm penalties. MIS 3S8 (Rev. 4198) face Page AA 268 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. BB Prindpailnvesligaliii/PnigratnDHECtar (Last fist Carolyn, Marie DESCRIPTION. State the appScabon’ s broad, long-tenn obtecfivas and specific aims, making neference to the heeMi leWadnesa of If» project. Des gibe concteeÿ the leseanch design and methaËlor acMaùôn mese goals. Avoid summaries of pest accomplishmenls and the use of the fii« ijsison. This ÿ sciÿ tn n is rneam to serve as a succinid and aoiaaate descrtaHcn of the praposed sndi when setteraad fiom the ePIiOcalian. If the aogBcatlon te ftinded d f e ^ lio a as is, K iill become pubfic Wormadon. Theteja^ do not mclude pfoprietaqAxnRdsndai information. DO NOT EXCÜDTHE SPACE I The objective of this study is to identify barriers to preventive nutritional and lifestyle foctors among jw income African Americans who may be at risk for cancer. The specific aims of this study are to: 1) Conduct six focus groups comprised of 60 African Americans, 3 groups of 10 males and 3 groups of 10 females, to discuss barriers to compliance to suggested diet and lifestyle recommendations, such as those stated in the Nutritional Guidelines of the Anrmrican Cancer Society and Goals for Nutrition in the Year 2000. 2} Examine and summarize barriers for compliance to the suggested nutritional and lifestyle guidelines. 3) Develop a questionnaire in order to survey a broader sample based on the barriers identified within the focus groups. 4) Conduct a pilot study for the survey. Collect data for demographic and descriptive statistics, and perform related data analysis. 5) Provide a comprehensive narrative report describing the identified barriers, as well as the results of the pilot study and data analysis. PERFCXTMAbCE STE(s) (agam^Hon, dly. slate) Subject Recruitment & Focus Groups: T.H.E. - To Help Everyone Clinic. Inc. 3860 W. M artin Luther King Jr. Blvd. Los Angeles, CA 90008 Q u e stio n n a ire D ev elo p m en t & D ata A n aly sis: Department of Mathematics Loyola Marymount University 7900 Loyola Boulevard Los Angeles, CA 90045-8130 KEYrcRSONNEL S eeM m ctton son P ^ ell. (/secorrfihtfefoff/yagegasnoediedtoprovidetherequkedifrfOmiaBoninttiefofTretshowntaetow. Name Carolyn M . Ervin. M.S., MPH. Oiganizatian Department of Mathematics Loyola Marymount University 7900 Loyola Boulevard Los Angeles, CA 90045-8130 Role on Project Principal Investigator Lisa V. Smith, M.S., Dr.PH. Cheryl L. Marks, B.A., MA UCLA Department of Epidemiology University of California at Los Angeles Los Angeles, CA 90095 C.L. Marks Consulting 8401 Bay Crest Las Vegas, Nevada 89128 Co-Investigator Focus Group Consultant and Facilitator PHS 398 (Rev. 498) P%e2 NiBTihef p ^ e s consecutively a t tf»e bottom Ütroughout the appHcaSort DonofU 3asufSxa8xx±as3a.3b BB 269 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Princj»al Invesligatof/Pnogiani C»Belor(lasl. tint, middle): Type the name or the p rin c^ investigatar/pnigtafn (ftecia al <he top cf each printed page and each conAïuatian page. (For type specificatians, : instructions on page 6.) RESEARCH GRANT TABLE OF CONTENTS Face Page __________________________ Description, Performance Sites, and Personnel Tairle of Contents ______________________ Page Num bers Budget for Entile Proposed Period of Support --------------------------------------------------------------------------------------------------------- — & 1Q - Budgets Pertaining to Consorthan/Contractiiai Arrangenients BiographicslSketci»— Princ^lmestig^lorfPiiogramDjiectorfMaftbarcesiffmopsges; ________ _____ __________________ —1 Ü I 2 Other Biographical Sketctres (Not to exceed two pages for eactj) Other Support ________________________________________ Resowces ,,,,, , , , . .. ..... R e se a rc h P lan IntroductiDn to Rewised AppScadon f AM IP errceerf 3 papesj Intnxftjction to Suppiemental Application (Woffti exceed f paget a. Specific Akrrs 13-16 17 1 9 - b. Bacfcspound and Significance ______& -------------------------------------------------------------------------------------------------------- I —20-24_ c P W W r t e y a t e W P t e g r — R ip te , __________________________________ _______ < __________ , d. Research Oetign and Methods J .__________________________________________________________________ L 25-31 eHisiianSidiects -------------------------- f. Vertebrate Aiàrrals ____________.... g. Literature Cled _________________ li ConsortaanfContraclual Ar rangements i. Consumants _________________ 32 CheckSst_____________________________________________ :.______ 33 -Type density and hipe size of the entina application must confom to Biias prairided in instructions on page 6. Appendix (RteooUated sets. No page numbering necessary for Appendk.) j I Check If Nuirber of pubdcadons and manuscripts accepted or suhrrated for pubOcBdon prof fo exceed ft) __________ I Appendix Is Othw items (Is); included PHS398(fîe».4«B) (Form Page 3) Page _ i _ CC Number pages consecutive^ at the bottom throughout the appBcatkxi. Do not use suffixes such as 3a, 3b. 2 7 0 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. DETAILED BUDGET FOR INHIAL BUDGET PERIOD DIRECT C O STS ONLY FROM 06/01/2001 THROUGH 06/01/2002 perso nn el rAflPfcoof ofgBOK«fap ofik!) n (PE "F T . Ms) % EFFORT ON PROL INST. BASE SALARY DOLLAR AMOUNT REQUESTED (OIK cants; NAME ROLE ON PROJECT A F (h» SALARY REQUESTED FRINGE BENEFITS TOTALS Carolyn M. Ervin Ptinqpal Invesligalar 12 20% $45.490 $9.098 $2.411 $11,509 Lisa V. Smitti CoJmesligator 12 15% $46.984 $7.048 $1.868 $8.915 TEA Data Analyst 12 15% $31.200 $4.680 $1.240 $5.920 TEA Interviewer 12 15% $20.800 $3.120 $826 $3,946 SUBTOTALS----------------------------------------» $23.946 $6.345 $30.291 CONSULTANT COSTS Cheryl L M a rk s. F ocu s Group M oderahm < S ee a arutPMENT («aimes; Euukment: C ost Olympus VN180 Oiglal Voice R ecord s $100 U ached oin tin u atn n page> Equioment C ost $5.850 $100 SIP’P U K (Itemize by c^egor^ SuDolies: (:%!; Su ooies; C ost D el inspken 3600 Laptop Computer C orel P arad o x Softtmare Computer Manuals and Software H P 842C P rftiler 3 Printer T oner C artridges G eneral Supplies_____________ $1,129 $299 $250 $120 $97 $400 travel Interview er 100 subjects x (1 lrt)/1 0 su b ie c ts)x (1 2 mBes/trip) x ($0.31/m te)=$37.2 PATIBrr CARE COSTS MPATIENr CXTTPATENT ALTERATIONS AND RENOVATIONS pcgmtta byeatagoa O'nifcKEXPËrfôESptemgeiycaflrpwj^ Other: Cost: Other g o s t Focus Gip. St#end (60 subj x $50) $3.000 Pilot S kdy Stÿend (100 suW x $30) $3.000 Recalbiterv. Sfip.(7Ssub]x$30) $2.250 Refteshments: 6 Focus Groups $600 $8.850 SUBTOTAL O I R a r r C O ST S FO R MfTIAL BUDGET P B O O D 4 7.423 CONSORTHJMICOHIKACTUAL |DBtBCT(»STS COSTS iFAcojTms A W AOie^TRATTON COSTS c a lc u la W a t6 2 .5 % $ 29.639 TOTAL DIRECT CO STS FO R numAI BUDGET PERIOO latoe. 7» a » . i 77.062 PHS 398 (Rev. «96) num ber pages conseojtively a t the bottom tfgoughout the appficatfon. b o g g i u se suffixes w ikt a s 3a. 3b. ( A s m P a g e 4 ) ( % g e 4 _ DD 271 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. P r i n c i p a l I n v e s t i g a t o f / P f o g r a m D i r e c t o r ( l a s t , f i r s t , m i d d t e ) : En/in. C arolyn. M arie Consultant Costs: ...continMed Cherwl L. Marks Focus Group Moderaton Preparing Protocol & D e^ n for Focus Groups 24 hrs @ $65 per hr = $1560.00 ModeraUng for2 days @ $800 per day = $1600.00 Airfere from Las Vegas = $140.00 Hotel-2 nights @ $200 pernght = $400.00 Transportation-2 days @$50 per day = $100.00 Meals - 2days @ $50.00 per day = $100.00 Focus Group Final Report - 30 hrs @ $65 per hr = $1950.00 Total = $5850.00 PHS398(Rew.4«8) Page = Number pages consecutively 31 Ihe bcttcm throughout the appGc^kn. Do not use suffixes such as 3a. 3b. 272 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. E E P r i n c i p a l I n v e s B g a t o i j P r o g a i n K t e O o r ( L a s t , flisi, m i d d l e ) : Eivifl. C arolyn, Mai1g_ BUDGET FO R ENTIRE PROPOSED PERIOD O F SU PPO R T DHÎECT CO STS ONLY BUDGET CATEGORY TOTALS I N T R A L BUDGET PERIOD (ùom F om P age^ A D D IT IO N A L YEARS OF SUPPORT REQUESTED 2nd 3nd 4th 5th PERSCmNEU S ela ym iU n g e b em Ss ApptbantorgansraribnonV $30,291 $31,503 CONSULTANT COSTS $5,850 $2,704 EQUIPiœNT $100 $0 SW PUES $2,295 $416 T RAVEL $37 $2,132 PATIENT CARE 03STS INPATIENT OUTPATIENT ALTERATIONS A N D REWIVATKINS OTHER EXPENSES $8,850 SUBTOTAL DIRECT. COSTS $47,423 $36,755 CONSORTIUM CO NTR ACT UAL COSTS MRECT FSA $29,639 $22,972 TOTAL DIRECT COSTS $77,062 $59,727 TOTAL WRECT COSTS FOR ENTIRE PROPOSED PERIOD OF SUPPORT f / f B m 8a. F a c e P s g e J $ 136,7891 JUSTIFICATION: F P H cw the budgetjuslllicalicninstniciiotis exactly. Use continuaBoo pages as needed. See attached pages for budget justification (Fotm Page S) Page . 6 PHS39B(Re».4ffl8) . ____ _ ______ Number pages ccnsecutnsljr at the iKttom threughcut the appBcàicn. Do not lise siiflheee such as 3a, 3 1 ) . EE 273 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. P r i n d p a i I m a s t i g a t o r / P f o g r a m D i r e c l o f ( L a s t , f i r s t , m i d d t e ) : Ervin. C aro ly n . M arie BUDGET JUSTIFICATION BUDGET FOR ENTIRE PROPOSED PERIOD OF SUPPORT PERSONNEL Carolyo M. Ervin, M.S^ MPH., Principal Investigator: Carolyn Ervin will serve as the PJ. for this study. She will be responsible for the overall conduct and integrity o f the study. Ms. Ervin wfll take the lead in the design o f all focus groups, data collection instruments and data abstraction, study juotocols, sta£f training, and data analysis. In addition, she will collaborate with other investigators, assume responsibility for writing reports on the project, and prqrare jnesentations for scientific organizations. Ms. Ervin is currently congiletmg her degree requirements in Epidemiology at U.S.C. and on the mathematics fectilty at L.M.U. Ms. Ervin’s effort will be 20% in years 1 and 2. Lisa V, Smith, M .S., Dr PJH., Co-Investigator; Dr. Lisa Smith w ill contribute to the overall direction o f the study and will provide overs%ht for the focus groups. She will assist with: design o f data collection instruments, data analysis, and the writing o f reports. She will also help with the trainmg and supervision o f staff airi act as a liaison to the TJiJE. clinic. Dr. Smith will devote 13% effort to this project in years 1 and 2. Cheryl L. Marks, B.S., M .A., Consultant and Facilitator: Cheryl Marks will develop and conduct the focus groups at the T.H.E. clinic. Ms. Marks specializes in qualitative research and has extensive research erqrerience in dealing with Afiican American participants, m particular, in a focus group settmg. She w ill give direction on audio-ttqte and transcription o f focus group sessions, and develop focus group researdr reports, hfc. Mark’s effort in year 1 will be 20% and 10% in year 2. Data Analyst (to be named); The data analyst will be responsible for additional data editing, cleaning, and management o f all forms o f data (the revised culturally sensitive questiormaire, and fire 3 recall interviews). In addition, the data analyst will review the interviewee’s work, iocludmg qualhy control The data analyst effort will be 15% in year 1 and 15% in year 2. Subject Interviewer (to be named): The interviewer will administer the revised culturally sensitive diet and lifestyle questionnaire (CSDLQ) and the dietary and lifestyle fectors recall interview to members o f the target populatfon. The interviewer will have experience with patient in intmviewing and conducting research in ethnic populations. The intmviewer’s primary taric will be to travel to the TJLE. clinic and conduct the in- person interviews with patfents. utilizing the revised culturally sensitive diet and lifestyle questionnaire and following study protocols. In addition, the interviewer will conduct the diet and lifestyle recall interview via phorm itUerviews. The interviewers effort will be 15% in years I and 2. PHS398{Rw.4ffl8) Rage ‘ Number pages consecutively 31 the bottoin throughout the applicaSan. Do not use suffKes such æ 3a. 3b. 2 7 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. P r i n c i p a l i n v e s M g a l o i / P r o a r a m D i r e c l o f ( L a s t , f l f s t , m i d d l e ) : Ervin, C arolyn, M arie DATA COLLECTION ASSUMPTIONS: Focus Groups; A total o f 6 fi>cus groups will be conducted, consisting o f 60 Afiican American subjects recruited fi-om the T.H.E. Clinic. The focus groups will be comprised of: 3 groups o f 10 males and 3 groups o f 10 females. Focus groups will be held in two hour sessions over a two day period. The focus group moderator will require 24 hours o f preparation time to produce focus gtotq) protocol md design. The focus gm vp nKKkrator will require 30 hours to produce the final report for the research team evaluation. In-oerson and Phone Subject Interviews: We anticipate that the in-person interview and the three phone recall interviews will take 15 minutes per subject, per interview. For the in-person interview, is estimated that 10 subjects per trip to the T.H.E. Clinic can be interviewed. Equipment Focus groups sessions will be audio-taped for later revfew by the research team. An Olympus VNl 80 digital voice recorder will be u%d to tape the sessions. Consenting participants will receive a stÿend o f $40.00 and be served light refieshments for their participation. Editing; Data editing will be minimal, as data checks w ill be programmed into the data entry screens. The data analyst will review the interviewers data entry to insure quality control DATA COLLECTION TIME: Subject Interviews; 1 ® Year Interviews: 100subjects*(l tr^lO subjects) = 10trqjstoT.ILE. Clinic Editing Hoars; 1 ® Year Interviews: 100 subjects* 15 min/subject = 25 hours PHS 398 (Rev. 4«S) Page B Number pages ccnseoriively a( the botlcm throughout the appHcarion. Do not use suffixes such as 3a, 3b. 2 7 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. P l i n c i p a l I n v e s l ^ a t o f / P t p g i a t n D i r e c t o r ( L a s t , f t s t , i n i d i f l e ) : Epfo C arolyn. M arie CONSULTANT COSTS: Focus Group Moderator 1 * * Year - C. Marits Consultants; Preparing Protocol & Design for Focus G roi^ 24 hrs @ $65 per fa r = $1560.00 Moderating for 2 days @ $800 per day = $1600.00 Airforefiom Las Vegas = $140.00 Hofei - 2 n%hts @ $140 per night = $400.00 Transportation - 2 d a ]% @ $50 pa- day = $100.00 M eals-2days@ $30.00 per day = $100.00 Focus Giotq) Fiml Report - 30 hrs @ $65 per f a r _________________= $1950.00 Total = $5850.00 Focus Group Consultant 2"* Year — C. Marits Consultants: 2“^ Year Consultation for Final Rqwrt 40 hours @ $65 per hour+ 4% ' = $2704.00 SUPPLY EXPENSES; All equipment, supplies, travel, and other su pplia are increased at an annual rate of 4% annnallÿ for year 2. Equipment: Olympus VNl 80 Digital Voice Recorder = $100.00 SuDolies - Year 1; Dell In ch on 3800 Laptop Coirputer = $1129 Corel Paradox Softweue = $229 Computer Manuals and Software = $250 HP 842C Printer $120 3 Printer ToiKr Cartridges = $97 General Sutmlies = $400 Total $2295 SnoD lies-Y ear2: General Supplies $400 Total * 4% aas $16 Total $416 P H S 398(R w .4«) Pm e » Number pages consecuthely at the bottom throughout the appfcatkin. Do not use suffixes such as 3a. 3b. 276 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. P r i n c i p a l I n v e s B g a l o r i P f O f f l a m D i r e d o f ( L a s t f»st m i d d l e ) : Efvin. C arolyn, M arie_ TRAVEL; Subject Interviews: I " Year Interviews at the TJIÆ. Clinic: 100 subjects*(l trip /lO subjects)*( 12 miIes/trip)*(S0.31/mile)=$37.2 Principal Investigator: 2“* Year - Annual Investigator Meeting— 3days/nights 1 trip 2 " ^ year to prestait^dy results Airfete = $1200.00 Hotel - 3 nights @ $200 per nigltf = $600.00 Transportation— 2 days @ $50 per day = $100.00 Meals — 3days @ $50.00 per day = $150.00 Total * 4% = $82.00 Total = $2132.00 OTHER EXPENSES: Reimbursement and Refreshments; Focus Group Stipend (60 subj. x $50) = $3000.00 Pilot Study Stipend (100 subj. X $30) = $3000.00 Recall Interview Stipend (60 subj. X $50) = $2250.00 Refreshments: 6 Focus Groups__________ = $600.00 Total $8850.00 BUDGET SUMMARY: Year 1 Year 2 Total Personnel $30^91 $31,503 $61,794 Consultant Costs $5,850 $2,704 $8,554 Equipment $100 $0 $100 Supplies $2,295 $416 $2,711 Travel $37 $2,132 $2,169 Other Exnenses $8.850 $8.850 Total Directs $47,423 $36,755 $84,178 Total Indirects $29.639 $22.972 $52.611 Total Costs $77.062 $59.727 $136.789 10 PHS 398 (Rev. «98) Pa Number pages consecutively at the bodomthnxigrnut the appücatian. Do not use suffixes such as 3a. 3b. 2 7 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. FF P r i n c i p a l I m e s t j g a t o / P r e g i a n D i r e c t o f ^ L B s t f t s t n i a f c f t ÿ : C aro ly n , M an e BKK3RAPHICAL S K E T C H Provide the following Womtalion for the key personnel In the onierBsted on Form Page 2. Photooopylfiis page or fcaowt*iis format for each person. tA ME POSmONTtTLE Carolyn M. Ervin Assistant Professor EOUCATfONfTHAIHING (IBegh m O i beccalaumete cr other iniialpm fB SSiorM education, such a s nursrtg, and M udo postdrxtaral trainin g .) ItSm U T IO N AND tOCATION 0B3REE (Ta p p S a a U a ) VEARS(s} FIELD OF STUDY Western Michigan University B.S. 1980 Mathematics Western Michigan University M.S. 1983 Applied Mathematics University of California at Los Angeles MPH 1996 Epidemiology University of Southern California Ph.D. Summer 2001 Epidemiology RESEARCH AND PROFESSIONAL EXPERIENCE Concluding witfi present position, fist, in cfirortoloÿcal order, previous employment, experience, and honors. Include present memtjerstip on any Federal Goiffimment public advisory committee. Ust, in cfuonologicat order, the titles, atl authors, and complete references to all puliiicatkns d u tig the past th ise y e a s and to iBpnBsentathie eariisr pubScatians pertinent to th s applicatian. If ttie list of pubfcations in tire last three years exceeds two pages, select the most pertinent prjbBcatioos. DO NOT EXCEED TWO PAGES. PROFESSIONAL WORK EXPERIENCE; 1993-1995 PROGRAM COORDINATOR FOR C.L.U. MATH/SCIENCE UPWARD BOUND PROGRAM Callfomia Lutheran University - Thousand Oaks, CA. Assisted with the C.LU. Matti/Sdence Upward Bound Proposal, which resulted in a $714,138 grant from the U.S. Department of Education. Duties as program coordinator included; developng program cwritadum, teachirrg matti/computer science courses. assisHng with txillege application seminars, planning and scdieduKr^ of stuctent activities, student recruitment arxf intervention, and supervision of summer program and field t r ^ . Program maintained 100% acceptance rate of financial^ disadvantaged students into universities such as: UCLA, USC, Stanford, Howard, U.C. SanWi Bafyara, U.C. Inline, and Cal PrW y. Other milestCMies indude: first student accepted into MfT-Fall 19% and several student awards fd" summer internships with Rockwell. 1995 -1996 EPIDEMIOLOGIC STUDY DATA ANALYST Santa Monica Bay Beach Study - Santa Monica, CA. Performed data analysis and generated descriptive statistics fo r an epidemiologic cohort study coTNfucted to investigate the potentWI iN health ^ e d s of t>athing in Santa Monica Bay and risks of ill health outcomes associated with uriaan rundf from storm drains. Assisted with: cmnpulertscdtware purdtase, data dowitioading/dasstiication, core d d a andyds m d resolution of data tssies, methocMogy and productbm of prdiminaiy and final reports. Interfaced with study staff, attended staff m e ^ r^ s, and participated in periodfe study report reviews. 1994-1996 PART-TIME MATHBMATICS INSTRUCTOR Pepperdine University - M aD lH i, CA. Conducted courses in Intermediate Algetyra and Prot>at>ility vrith Unear Algebra. Responsibilities induded: creatir^ course curriculum and materials, administering examinations, attending related faculty meetings, and evaluating student progress and grading. 1989-1999 PART-TIME MATHEMATICS INSTRUCTOR Li^ola Marymount Urriversily - Los A rid es, CA. Tmght various matii courses irKkrding: Statistics for psychology mayors. Mathematical Analysis, and Calcuius for Life Sciences. Evaluated d u d art performance, interfaced with the Learning Resoiace Center. Other resporœi'bHities included: creating addendum course materials, supennskrg studmit tutors, grading students, and participation with Math/Sdence Irrterchange. PHS3SS(ltey’ .« 9 q (Ftrnn r^ageS) P ase 11 Number pages consecutnely at the bottom throughout the appDcalion. Do u se suffixes such a s 3a. 3b- FF 2 7 8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PttKjpdlnwstjaatoiilPmfflaniC&ector (Last, first. infcMe): EfVin. C aro ly n . M arie 1996-1999 COLON STIWY RKEARCH ASSISTANT G e n ^ c Epidemitrfc^ UNwasily of Southern Califomia - Los Angefes, CA. Managed datasets and performed data analysis for both the Sigmoidoscopy and Gene Enwronment Case-Control Studies. Interfaced with research staff to provide ongoing analyst support for colon cancer data within these studies. Created datasets, data entry screens, queries, reports, and programs for data handling. Maintained, updated, and cleaned datasets a s requested. Performed problem resolution and conversion of ctatasets for data analyses, attended study meetings, and maintained all study data documentation. 1998-P resen t BIOMETRYŒCTURER Division of Biostatistics, Keck School of Medicine. University of Southern California - Los Angeles, CA Teach Principles of Biometry course in the School of Medicine. Course materials include statistical methods, hypothesis testing, and applications for clinical/experimental research. I assist with the development of course materials, assess student progress and performance, and supervise laboratory and teaching assistant. 1999 - Present TENURE TRACK - ASSISTANT PROFESSOR Mathematics Department, Loyola Marymount University - Los Angeles, CA. Faculty responsibilities include: teaching Biometry, Calculus of Life Sciences, and Biometry and related math courses, evaluating student performance, and advising Biomath majors on curriculum requirements. Other full time duties involve: participation on department committees, attending faculty meetings, and supporting campus events. PUBUCATIONS: Levine AJ, Siegmund KS, Ervin CM, Lee ER, Frank! HD, Diep A, Haile RW. "Serum 25-hydroxy Vitamin O, Dietary Calcium Intake, and Ostal Colorectal Adenoma Risk". Nutrition and Cancer, Fetxuary îfflOI, 39:Z Haile RW, Gold M, Witte JS, Cressey R, MtÆee C, Milltkan RC, Glasser A Harawa N, Ervin CM, Harmon P, Harper J, Dermand J, Atamillo J, Barrett K. Nides M, Wang G. "The Health Effects of Swimmirg in Or*an Water Contaminated by Storm Drain Runoff. Epidemiology, July 1999, 10:4, 3S5-363. HONORS/AWARDS: Lovola Manwnount Univeraitv James Inmne Dissertatkm Fellowship Award Universitv of California. Los Angeles University of California Grant Graduate Advancement Prc^nam Award Public Health Traineeship University of Southern Califomia Graduate Research Assistantship Award W estern Michigan Univers Itv Thurgood Marshall Assistantship Award Western Michigan University Scholarship AFFILIATIONS: American Public Health Association, American C o llie of Sports Medicine, Mathematical Association of America 12 P H S398(ltev.4® 8) Number pages cooseculiuely 31 Ihe bottom I hroD^Kxil the appBcatlon. Do not u se suffi»es such a s 3a, 3b. 2 7 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. FF P d n c W I n v e s M g a t o f / P i o g i a n i D h e c b r (Last, Srsl, madh): Ervitl, C aro ly n , M aiig_ BIOGRAPHICAL SKETCH Provide the following Wormatianlbr the teypereom el in thaofderSstsd on Form PagoZ Photocopy this page or f o M o w this formai for each person posmoNTni£ Lisa V. Smith Co-Investigator EDUCATtOhtfrRAININGfgpgM wühhaccaiOurBele or other «rüBfpfotessânaredKaBO. such as nursing, and Include postdoctoral b^nhg.) mSTTTUnON AM) LOCATION DEGREE etaoolcaUBt YEARSCs) F ia O OF STUDY Loyola Marymount University BJK. 1979 Biology California State Unhrersify, Los Angeles M.S. 1992 Biology University of California, Los Angeles MPH. 1994 Epidemiology University of Califomia, Los Angeles Dr.P.H. 2000 Epidemiology RESEARCH AND PROFESSIONAL EXPERIENCE; CatitAjcliiig wilh present pcelion, tst, hi chtonakigâal order, ptB MO us ernpfcyrnent, ogretienoe, and honors. InrJude present rr r e r o b e r s tiip on any Federal Govetnrrrent prAlic advisory comr rr i ttee. Ust, in chrooologlcéS orrter, the titles, auttwrs, and complète refOtences to a l pubfic^ions during the past three years and to represertfatiie earlier pubOcations pertinent to tMs appBc aDo rL V th e Bst of puPlKalions ft) the last ta e e years e « ee d s I M D pages, select the most pertinent publications. iX> NOT EXCEED TWO PAGES. PROFESSIONAL WORK EXPERIENCE: 1997 - 1999 PROJECT MANAGER -CUNiCAL TRIAL/ HIV HOME T K T KITS BY STD CUNIC POPULATIONS Sexual^ Transmitted Disease Program - Los Angeles. CA • Collaborated with pharmaceutical company in identifying demographic and Itehavioral fectors contrfeuting to the acceptance of HIV home test kits by patients attencfing five Setually Transmitted C^sease clinics • Formulated research design based on current psychological and sociological theories and constructs. ■ Supervised inventory of the HIV home test ktts. • Trained COC Disease Intervention Specialist in the administration of informed consent and study questionnaire • Coordinated distribution of incentives for study participants • Entered qu^tionnaires using EPI Info database manager • Analyzed data using Statistical Analysis Systems (SAS), Version 6.12 1999 -1997 PROJECT MANAGER - GONORRHEA CCM M M U N ITY ACTION PROJECT (GCAP) Community Ffealth and Social EpMemiology- Long Beach, CA • Conrfcrnted qualitative interrnews with heeWi providers/crmimimity tiased orgarvzations • MrecUy superwsed the use of EZText in the coding and data entry of interwews of health providers, community-based organizations and district residents • Analyaæd data using EPI Info and SPSS software • Presented findings to ttie GCAP community advisory txrard • Co-authored successful reneviral application for Phase II of GO\P • Facilitated focus groups of teens, STD Program personnel and community groups • Designed randomized behavioral interventions for Phase II from the data collected in Phase I using ttie tretiavioral ttieories of Bandara arvl F ish li^ ■ Collaborated with field investigators in developing strategies to improve partner notiftcation of possiWe gonorrhea exposure • Devised procedures for monitoring and evaluating ttie proposed intervention • Conducted a cost-iienefit analysis of ttie eftidency of ttie proposed intervention for Phase II • Senred as a liaison tietween the STD Program, community-based organizations and the academic researdi community PHS 396 (R at 4 « a ) (F oim P age6)P age 13 Nunftier pages conseculivGiy at the b ottoiTi throughout the appCcaUoa OorvjiusesuffBoes such as 3a, 3b. FF 280 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Princ^ial InwesMgaloiffiograni D redor (Last firel, iriddte): Enan. C aro ly n , M arie 2000 -1996 TEACHING ASSISTANT - PRINCIPLES OF EPIDEMIOLOGY/ EPIDEMIOLOGIC METHODS UCLA School of PiAlic H ^ tth . Department of Epidemiology - Los Angeles, CA » Facilitated discussion of basic principles in epidemiology: concepts of incidence, prevalence, age-adjustment, risk and rate raflos, selection bias, confounding, epidemiologic study designs, laboratory screening procedures, sunreillance systems, outbreak investigations and evaluation of fœatth serwces • Facilitated discussion of advanced principles in epidemiology: standardization of risk and rate ratios, stratified analysis, matched analysis, nondifferential misdassification, effect modification, logistic regression analyses, statistical modeling, biological interaction, and sample size and power calculations • Administered and graded student eimminations 2000 -1999 LECTURER - PRINCIPLES OF EPIDEMIOLOGY CalifomiaState University, Dominguez Hills, Department of Health Sciences - Carson, CA • Instructed studente on aspects of infectious disease epidemiology and study design • Discussed disease prevention, health promotion and program evaluation • Administered and graded student examinations RESEARCH PROJECTS: PRINCIPAL INVESTIGATOR: Assessment of the Acceptance of HIV Rapid Tests in Ir^ection Drug Users (1999). Center for Behavioral Research and Services. Cal State University. Long Beach and UCLA Scht»l of PutJiic Health. CO-INVESTIGATOR: Assessment of the Acceptance of HIV Rapid Tests in Clinic Populations (1998). Center for Behavioral Research and Services. Cal Stete University, Long Beach. CO-INVESTIGATOR: Characteristics of medically underserved populations utilizing a motnie HIV testing and outreach >m n in Los Angeles Coun^1%8). CO-INVESTIGATOR: Characterises of adolescents and women seekir% STD-related senrices at the T H E. Clinic in Los /Xngeles County, UCLA Community Health Promotion Program (1998). PUBUCATIONS: 1. LV Smith, M L Larro, C K Malotte, JS St. Lawrence. Urine testing for gonorrhea and chlamydia great technology, trut will ttie community accept it? International Quarterly of Community Health Education (in press). 2. LV Smith. The Effect of the Dominant (I) (3ene on Avian Pigmentation. Masters Thesis. California State University Los Armeies, September 1992. 3. K Shoaf, LV Smith, D GliK E Berfcanovic. Final Report Evaluating Carpenters Union (Multisite) Training Program. l/CLA Tedinical Assistance Group. UCLA School of Puttiic Health, Octobo-1996. 4. LV Smith. Chapter 10: Citeen Preparedness. In: The impact of ttie Norttnidge Ewthquake on Los Angeles County: Health Effects and Responses. Eds: Shoaf Kl and Bourque LB. UCLA Center for Public Health and Disaster Relief. Presented to the Los Angeles County Department of HKtlth Services. Augu^ 1%8. HONORS/AWARDS: 2000 UCLA President's Post-Dortoral Fellowship 1995-98 CSULA Forgivable Loan Program Recipient 1998 Bevertee A Myers Memorial Award, APHA 1998 Fair & Open Academic Environment Award 1998 Community Health Promotion Pn^ram Grant 1998 Epidemiology of HIV/AIDS Training Program i 1994-99 NIDA Training Grant RedpienL AIDS Research AFFILIATIONS: UCLA CHversity Enrichment Task Force, UCLA School of Public Health Diversity Council, American Public Health Assodation (APHA), Public Health Student Association (PHSA), UCLA C h arts R. Drew Association PH S398(ltev.W 98) Page 1 4 NunOer pages conseculively at ttw Ixntcim tliRiiighcxit tt» amNcarian. I X > not u se su ffiiss su cti a s 3 ^ 3b. 2 8 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. FF P r i n d p a l I n v e s t i g a l o r / P r o g r a m O i r e d o f (Last, f i s t mklàb): E n g ^ C a fO ly n , M arie B IO G R A PH IE». SKETCH Provide the f o O c A v i n g informaikxi for the key personneJ in the order listed on Fofm Page 2. Photoccpy M s page or fo H c w this fonnat for each peracn. • <A M E posrrroNTntE Cheryl L. Marks, M.A. Focus Group Consulting W^KXnCXVlTWlNXt¥àlBoç^wnbaoBalaum^oc<ittKriae^()nilesâonaleàuc^an,sucii as nurâng, ant! indude posUoelaialtammg.) M S m tm O N AND L O C A T T O N Vappfcatk,) YEARS(s) FIELD OF STUDY Universify of Missouri B A 1979 Psychology Wayne State University MA 1985 Industry/Org. Psych. Wayne State University Ph.D. Cand. 2001 Industry/Org. Psych. RESEARCH AND PROFESSIONAL EXPERIENCE; Cooduifing wittt present position, Bst in chronological order, pteukxis employment. e»perienco, and IwtiOfSJiicliide piesei* iiw T itiefsliv on any federal G o en m a il piJbfc aclvisoiy cornnniltee. U st in iMonalqgical Older, the tilles, as authors, and com irietereleiences to ait pubUcalions during the past three years and to lepresentaUveearRsrputjIcationsperthient to this applicalian. tf ttie Est of pubBcations in ttie last three years exceeds two pages, select the most pertkieni pubScaBons. DO NOT EXCEED TWO PAGES. PROFESSIONAL WORK EXPERIENCE: 1979 -1981 PERSONNEL ANALYST-RESEARCH AND VAUDATION City of SL Louts Personnel Departmait Research & Development - S t Louis, MO Designed valid and effective methods for recruiting, screening, and selecting employees for a wide variety of jobs. Such methods included written tests, structured oral Intenriews, experience and training assessments, and physical agility tests. 1983-1986 PSYCHOLOGY INSTRUCTOR Wayne State University Psychology Department - Detroit, M l Taught undergraduate courses in introductory and industrial/organizational psychology. 1985 -1988 TEST VAUDATION MANAGER; CHIEF OF RECRUITMENT & EXAMINATIONS Wayne County D^iartment of Personnel/Human Resources - Detroit, Ml Directed staff in the design and administration of recruitment and selection procedures for all d^rartmarts in Wayne County government coverir% a wide variety of occupational categories including managenwnt, professional, technical, labor/trades, and clerical. 1988-1994 d ir e c t o r OF STAFF DEVELOPMENT Wayne Counfy Departmait of Personnel/Human Resources - Detroit, M l Established and directed the Staff Development Division which provided training and organizational development sevices to a divers base of 5,500 employees across 24 County departments. Ai«> admintetered organization-wride performance appraisal system, employee suggestion and awards prc^rams, and tintion rdmbursement program. 1994-Present CONSULTANT & FACIUTATOR C. L. Marks ConsuWng - Las Vegas, NV Design and implement qualitative and quantitative research with a focus on market and consumer analyses, public policy, and program evaluation, public opinion assessment, personnel and human resources, and organizational improvement Also conduct seminars and facilitate workshops for management and non-management employees on a variety of topics. PHS39B(Rew.4«B) (Fcm i P age G ) Page 15 Number pages consecutively al the tnrton ttwoughout the appEcatian. Do u se sirihxes such a s 3a. 3b. FF 282 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Princ^lmcstigatoriPKfflamCM rector(L3stftst.irtdi8e): Ervifl, C a ro ly n . M arie AREAS OF EXPERTISE: • Qualitative & Quantitative Research Design • Focus Group Moderation • Depth Interviews • Benchmarking/Best-Practices Research Meeting & Retreat Facilitation Training Seminars & Workshops Organizational Development Report & Proposal Writing Focus Groups • Ad Testing (Print, TV & Radio) • Product Concept Testing • Company & Brand Image Assessment • Customers Profiles and Needs Analyses • Public Opinion Assessment • Public Policy & Program Evaluation Meeting & R etreat Facilitation • Piannirig & Goal Setting • Teambuilding • Organizational Needs Assessmmit & ProtWem Diagnosis Seminars & Workshops « Effective Management & Supenmsion • Conflict Management • Planning/GoaFSetting & Time Management • Preventing Sexual Harassment • Communication & Listening Skills ■ Effective Performance Appraisal • Valuir^ Cultural Diversity • Dynamic Customer Service • Stress Managenent • Correcting Employee Performance Problems • Binldmg Effective Teams t4rS3S8(%v.4e% Nutiiier pages consecuthiEiy at the bottom throughout the appTicaHoa O o m tu sesu ffo ss such a s 3a, 3b. Page 16 283 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HH Principal Investig^aiPfogratn Director (Last f ts t mkkle): C aro ly n . M arie RESOURCES FACILfTIES: Specify the facilities to be used for the conduct of the proposed research, IfKücate the performance sites and descrftwcapadtios. pertinent ra^jabiiities. œbtiïB pr«Kiir%. and estent of araBabasy to Ihe picject Under XXher." idettffy support services such as inachine shop, eiecltionlcs shop, and -oecüy the extent to which wIB be available to the project U se coirittiualian pages Ï necessary. -aboratory: N/A CWcai: Focus Groups and In-oerson liitenriews: T.H.E. - To Help Everyone CItofc, Inc. 3860 W . M artin Luther King Jr. Blvd. Los A n g eles, CA 90006 Animal: N/A Com puter: Office: h er Data Entry and Analysis on Dell Inspiron 3800 Laptop Computer at: D epartm ent M athem atics Loyola M arym ount Unhreisity 7900 Loyola Boulevard Los A ngeles, CA 90045-8130 O ffice o f C a ro ly n M. E rvin at: D epartm ent M athem atics Loyola M arym ount University 7900 Loyola Boulevard ' Los A ngeles, CA 90045-8130 N/A MAJOR EQUIPMENT U st the m ost important eqr*m etS Kerns alreartyarWable tor this prpiecl, noting Ihe iocallon and perUnenl capabilities of each. N/A PHS 3 98(Rev. 4 9 8 ) (Fvam PagaS) Page "TT HH 2 8 4 Reprofjucetj with permission of the copyright owner. Further reproctuction prohibitect without permission. KK ____________________ Prindpal invesiigitoriProfflOTOMcciortfjstfct «»**!>-• Efvin, Qaxplyp, Marie— .. Place this Ibntt at the end o f O m en ed origmal socW SecuriivNoL 376-66-0668 copy nfihe appljcatmo. Do not dupficate. PERSONAL DATA ON PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR T h e Public H ealth Service h a s a continuing com m itm ent to monitor th e operation o f its review a n d aw ard p ro c e sse s to d etect—an d d eal appropriately witti— any instan ces of real o r a p p a r e n t inequities with re sp e c t to a g e . sex. race, o r ethnici^ of the pro p o sed prindpal Investgator/program director. To provide th e PH S with the information it n e e d s for this im portant task, c o m p le te th e form b elow and attach it to th e signed origbiai of th e application after th e C hecklist D o n o t a t t a c h c o p ie s o f th is fo rm to th e d u p lic a te d c o p ie s o f th e appK râtiork U pon r e c e n t o f th e application by ttie PH S. this form will b e se p a ra te d from th e application. T his form wül n o t tie duplicated, an d tt wBI n o t b e a p art o f th e rmriew p ro cess. D ata wiii tie confidential, a n d wOt be m akitained m Prrvaqr Act record sy ^ e m OS-25-0036, "G rants: IMPAC (G ra n tft^ n tra c t Information).* T he P H S re q u e sts S o d a i S e c u ri^ N um tiem for a œ u r a te identification, referral, a n d review o f applications and for m a n a g e m e n t of PH S grant program s. Provision of th e S o d a i S ecur% N u m tie r is voluntary. No bidM dual wttl b e denied an y right tieneftt. o r privHege provided by law tie c a u se o f refu sal to d is d o s e his o r h e r S ocial S ecu r% N um ber. T h e P H S re q u e d s ttie Social S e c u i% N um tier u n d e r S ectto n s 301 (a ) and 487 o f th e P H S Act a s am e n d e d (42 U SC 2 4 1 a a n d U SC 288). All a n a l y ^ c o n d u c te d on th e d a te of bkth a n d ra c e andfor ethnic origin d a ta will report a g g re g a te statistical Imdings o n ly a n d wRI n o t identify individuais. If you d e d in e to provide this information, it wHi in no w ay affect consideration o f y o u r application. Your cooperation wRI b e appreciated. "ATE OF BIRTH ( M S V D C V Y Y ) GENDER 06/02/1957 X Female | jw ale RACE ANDKIR ETHNIC ORIGIN rcftadc one; N o te; T h e category th at m o st d o se ly reflects the indhiiduars recognition k t the com m unity sh o u ld tie u se d w hen reporting mixed raciai and/or ethnic o r^b is. I I Aamrican Indian or Alaskan Naeva. A p erson haw ng origins in an y o f th e original p e o p le s o f North A m erica, an d — vriio m aintains a cultural fcientiflcatton through trttial afffliaSon o r com m unity recognition. I I Asian orPacMc Islander. A person having origins in an y o f th e origbial p e o p le s of th e F a r E ast, S o u th east Asia, the — Indian subcontinent, o r th e P acifk islands. This a re a in d u d e s, for exam ple. China. India. Ja p a n . Korea, th e Philippine telands. an d S am o a. Black, tna o f Hispanic ori^n. A p erson haw ng o rp in s ki a n y o f ttie black ra d a l g ro u p s o f Africa. I I Hispanic. A p e rso n o f Mexican. Puerto Rican. C uban. C entral o r S outh A m erican, or o th e r S panish culture o r origin. — reg ard le ss of race. I I WMte, not o f Hispanic or^in. A p erso n haw ng o rg in s in a n y o f th e original p eo p les o f E urope. North Africa, o r the '— ' M k ld leE ast j I C heck h ere if you d o not wish to provide so m e o r all o f th e a tio v e Informatton. PHS 3S8 (Rev. 4/98) Do net page m m ber this ftem KK 285 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. n Principal Imesli3atorff*rogram Dlreclor (Lasj A st iMOeX. C^rolyn, M afje_ CHECKUST TYPE OF APPLICATION (Check al IhetB fipIy.) ’ NEW application. «s suSmSted to tfiB PHS Ibrllie fe r fiiw j REVISION cf appBcatoi number (ms^f)lc^anæplacesaprioru^uadBdVBrsionofBnm>,conipelhgcxxilimalianorsi^^ilemefJtalapplcaBon.) INVBfnONSAND PATENTS (O oR pefiig cxnfiw atbn apptor I I œ iiffE T IN G CONTINUATION of grant ntgnber ________________________________ O no Pievhusÿiepom ed (Thisapi*:^k]nbloaclendeiimdedgrantb ^m d is cumntpniiectperiod.) Q ^ e s - lf*Yes,*-« < ^ [ ~ | N ctprewcuslyiiepcitsd ( I SUPPLEMENT to grant number ___________________________________________________________________ (TlmappSe^onisloredaiionalhindstosisviee’ anlaaama/hmdBdgrant) j I CHANGE ot principal invBsU galoriprogfam direcftx. NameoflbiinerpiincipNinMBsligatiK^wsram ______________________________________________________ I I FOREIGN appBcaB o n or signWcant foreign component 1. ASSWMNCESICEinViCATIONS Ttw esswancesAsftM caSans aiB made and veifled by Hw signaluiB or Oie OSkW Stoning fbr ^ipKcant Oiganizalian on the Face Page or Ihe appt o < i oaDBSOnpBonsorinclh*luatassuianoeaftertaicaB o n s lieÿ n o n p a g e 27 of Section I I I . » unable to certify compBance where apptcatHe. provide an eggjlanalian and plaoe > aAertMs page. •ftaman Subjeds: -Vertebrate Animals: -Oebamient and Suapenaion: "Dmg-f^ee W odflaoe fenPfcaM* f t > new /JJp e f j or m is e d (Type 1 ] apptcaSona onW; •LotAying; *DaBiquenl Fedecel OebC •Research Msconduct; •CM Rights (Forni HHS 441 or ffffS S9I% •Handicapped Indhiidiials (f=otm m s 641 or HHS SSO); «Sex Discrfminatian (FOim HHS 638A or HHS 690); -Age O isaM naean (Form HHS 680 or HHS 690); -Financial ConfSct of lid aiest 2. PROGRAM INCOME fS ae n sftu cd nA page 1st; All applications roust indicale wlwlher pm^am kicome is an6i%ialed during the perio(%s) for wlâch giant suppott is requested. H pragfam incon» is anbdpeled, use the foimal below to leflect ttie amoutil and soufco(s). a . P A O i:m E SA W A iM iw iiM iw iW N cm T S y a , A) hKSeate the appB cantoiganagtlon's most meant F & A cost late estapgshed with the appropriate o m s Regional Offioei or, hi the ca se o f for profit orgaahafions. the rate esIaU shad wHi the ammpriM e PHS Agency Cost AcMsoiy Office. « ttie appficanl oiganfeaBon s hi On process of htffishy daiM phig or renegotiating a latet, or has estafiishad a rateufih anoffier Federal agency, h stiould, mmedialely upon notification that an award w 9 be made; develop a ianlalhe P a A cost rate proposal T ills is to t» based on hs DHHS Agreement dated: 06(21/2000 Q DHHS Agreement behignegoliatod with _______ D No DHHS Agreemert. but rate estribSshed with ----------------------------------------------------------------------------- CALCULATION* (Ttie entre grant applcBtion.inclu<SnglhaChecJdist, w t be reptoduced and provided to peer reviewers a s conhdenlial Maanadan. Suppim gdiaktlaw ivM nmaSon onF SA eaetslsaptionallarkr p m llatganli elions.} roost recently coropleted lmcal year hi aooordancawhh th e principles s e t forth hi the paitinsnt &IHS làiride f O r EstaUM ihn Indhect Cost R ates, and submitted to file appropriate DFMS Regional O ffice or PHS Agency Cost Adrfsoiy O ffice. F a A costs wffi n o f b e paid on taefan giants, oonelnictian giants, anants to Federal otgan f a M llons , grants to tndMduab, and confaienee grams. F O B ow any addffionN insbucfions pm idad for Reseeroh Career Awards. Institutional National Research Serwce Awards, and spndateed !paM applications. I I No F ac ü iÜ G S and Administration Costs Requested. ______________________ Regional Office; Data a. Initial budget period; Amount of base $47,423 xR oteappSed 62.5% = F a A o o s ts (1 ) $29,639 $22,972 b. Erithe proposed project period: Amount of base $ 3 6 ,7 5 5 xR aleappfiad 6 2 .5 % = F & A co sis (2)___ _ _ (1)Add to total dhect cos ts fhxn form p age4and en ter i« w total on F ace PagftBam Tbi (2)Add to total dhect costs from form page 5 and enter new total on F ace Page, Item 8b. ^Checkeppropiiale brades): I I Salary and w ages trase Moifified total rSrect cost ta s e LJ Other b ase (Brplghi) F 3 OfFshet other special ral B ; or more than one rate hwclM sdfBiptitÿ iansBen (Attach s a p a r ^ sheet fneoassaiy.): Y ear 02 $ 3 6 ,7 5 5 x 6 2 .5 % = $ 2 2 ,9 7 5 4 . SMOKE-FREE WIORKPtACE " D r»m ur organizaliDn cunerhly proMde a smoke-hee workplace and/or promote the nonuse Of tobacco products or have plans to do SO ? 0^ Yes I INo (The response to tttsqaeshon ties no inpact on ItiereviBw or iundkigaHHsapptcaBryn.) PHS3S8<Flm.4/S8) H 286 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Research Plan; The Development and Assessment of a Culturally Sensitive Questionnaire for African Americans Table of Contents 21 1.2 BACKGROUND AND SIGNIFICANCE 22 1.2.1 E p id e m io l o g y OF C a n c e r - UNITED St a t e s 22 1.2.1.1 C a n c e r In c id e n c e 22 1.2.1.2 C a n c e r M o r t a l it y: 22 1.2.1.3 C a n c e r T r e n d s BY Et h n ic it y 23 1.2J1 E p id e m io lo g y o f C a n c e r - Los A n g e l e s C o u n t y 23 1.2.2.1 Ca n c e r In c id e n c e 23 1.2.2.2 Ca n c e r M o r t a l it y : 24 1.2.2.3 C a n c e r T r en d s b y E t h n ic it y 24 1.2.3 I m p a c t o f C a n c e r o n t h e A f r ic a n A m e r ic a n C o m m u n it y 25 1.2.4 C a n c e r P r e v e n t io n 25 1.2.4.1 D ie t 26 1J2.4.2 E x e r c ise 26 1.2.4.3 A lc o h o l 26 1.2.4.4 Ef f e c t o f P o v er ty 26 1.2.5 S u m m a r y 26 13 RESEARCH DESIGN AND METHODS 28 13.1 T h e So u t h w e s t H e a l t h D is t r ic t - C a t c h m e n t A r e a 28 1.3.1.1 D e m o g r a ph ic s 28 1.3.1.2 T h b T.HJE. C l in ic 29 1.33 T h e F o c u s G r o u p s 29 1.3.2.1 C u r r e n t N a t io n a l N u tr it io n a l G u id e l in e s a n d G o a ls 30 1.3.2.2 f o c u s G r o u p D isc u ssio n s: 33 133 D e v e l o p m e n t o f t h e in s t r u m e n t : 36 1.3.3.1 C o m pl ia n c e Q u e st io n n a ir e: 36 1.3.4 T h e P il o t St u d y : 37 1.3.4.1 St u d y po pu l a t io n : 37 1.3.4.2 S t a t is t ic a l A n a l y s is 37 1.4 LITERATURE CITED 39 20 287 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1-1 Introduction and Specific Aims The purpose of this research is to identify barriers to preventive nutritional and lifestyle factors that are protective against cancer among low income African Americans. This project will utilize the data obtained from focus groups and a quantitative survey, conducted at the T H E. (To Help Everyone) Clinic in Los Angeles, an inner-city clinic setting located within the Southwest Health District (SWHD) in Los Angeles County. The focus groups at the THE. Clinic will be comprised of African American male and female patients. The goal of the focus groups will be to discuss the barriers to compliance for suggested diet and lifestyle recommendations which would prevent cancer. The project will be the joint collaboration of Loyola Maiymount University in Los Angeles and the T.H.E. Clinic, of the Southwest H ^ th District in Los Angeles. The objective of this study is to identify barriers to preventive nutritional and lifestyle factors among low income African Americans who may be at risk for cancer. The specific aims of this study are to: 1) To conduct six focus groups consisting of African American males and females to discuss barriers to compliance to suggested diet and lifestyle recommendations, such as those stated in the Nutritional Guidelines of the American Cancer Society and Goals for Nutrition in the Year 2000. b 2 2) Examine and summarize barriers for compliance to the suggested nutritional and lifestyle guidelines. 3) Develop a questionnaire in order to survey a broader sample based on the barriers identified within the focus groups. 4) Conduct a pilot study utilizing the survey. Collect data for demographic and descriptive statistics, and perform related data analysis. 5) Provide a comprehensive narrative report describing the identified barriers, as well as the results of the pilot study and data analysis. 21 288 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.2 Background and Significance 1.2.1 Epidemiology of Cancer - United States 1.2.1.1 Cancer Incidence Cancer is an important public health concern in America. In the year 2001, it is estimated that 1,268,000 new cases of cancer will be diagnosed in the United States. ^ This estimate does not include more than a million cases of basal and squamous cell skin cancem, 46,400 cases of breast carcinoma in situ, and 31,400 cases o f in situ melanoma, anticipated to be diagnosed in 2001. Among females, the most eommon cancers in 2001 are predicted to be cancers of the breast, lung and bronchus, and colon and rectum. ^ Combined, these cancers will account for over 55% of new cancer cases among women. Breast cancer alone is expected to account for 31% of new cases in 2001. Among males, the most commonly diagnosed cancers are expected to be cancers of the prostate, lung and bronchus, and colon and rectum. In 2001, 198,100 new cases of prostate cancer, which will account for 31% of new cancer cases among males, are expected to be diagnosed. ^ For all cancer sites combined, age-adjusted cancer incident rates peaked in 1992 and decreased at an average of -2.2% per year from 1992 to 1996. ^ 1.2.1.2 Cancer Mortality; hi 2001, it is estimated that 553,400 Americans will die from cancer, or approximately 1,500 people a day. 3 Among males, 52% of all cancer deaths will be from cancers of the bronchus, prostate, and colon and rectum. Among females, more than 50% of cancer deaths will be caused by cancers of the lung and bronchus, breast, and colon and rectum. Lung cancer among females will account for 25% of all female cancer deaths. ^ Following more than 70 years of increase, total cancer deaths among males in the U.S. have recently declined, from a peak of 281,898 in 1996 to 281,110 in 1997. ^ This downward trend is the result of recent downturns in the top three causes of cancer deaths among males. These include: a decrease in lung and bronchus cancer deaths of 92,493 in 1993 to 91,278 in 1997, a decline in prostate and cancer deaths of 34,902 in 1994 to 32,891 in 1997, and a reduction in colon and rectum cancer deaths of 28,635 in 1990 to 28,075 in 1997. ^ Among females, although the total number of cancer deaths has increased, the rate of increase has declined in recent years. This is primarily due to the sustained increase among lung and bronchus cancer deaths. However, the number of 22 289 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. breast and colorectal cancer deaths among females has declined. Breast cancer deaths have decreased from a peak o f43,844 in 1995 to 41,943 in 1997, while colorectal cancer deaths among women have declined from 29,237 in 1995 to 28,621 in 1997. ^ 1.2.1.3 Cancer Trends by Ethnicity Cancer incidence rates vary considerably across racial and ethnic groups. African Americans have the highest cancer incidence rates. ^ African Americans are 60% more likely to develop cancer than Asian/Pacific Islanders and Hispanics, and are more than twice as likely to develop cancer as American Indians. Overall, from 1990 to 1996, cancer incidence rates decreased among Hispanics (-1.7% per year), whites (-1.2% per year), and American Indians (-0.7% per year). During the same period, they remained stable for African Americans and Asian/Pacific Islanders. ^ African American females are more likely to develop colorectal cancer than females of any other ethnic group, while white women are more likely to develop breast cancer. ^ African American males have the highest incidence rates for cancers of the colon and rectum, lung and bronchus, and prostate. They are also 50% more likely to develop prostate cancer Oran any other ethnic group. Overall African Americans are 33% more likely to die of cancer than whites, and are more than twice as likely to die from cancer than Hispanics, Asian/Pacific Islanders, and American Indians. During 1990 to 1996, cancer mortality rates decreased among African Americans (-0.9% per year), Hispanics (-0.6% per year), and whites (-0.5% per year). During that period, mortality rates for Asian/Pacific Islanders remained stable and may be increasing for American Indians. ^ African American fomales, however, are more likely to die of breast and colon and rectum cancers than any other ethnic group. Similarly, African American males have the highest mortality rates of colon and rectum, lung and bronchus, and prostate cancers. 6 1.2.2 Epidemiology of Cancer - Los Angeles County 1.2.2.1 Cancer Incidence In Los Angeles County, an estimated 329,002 cases of cancer were diagnosed between 1988 and 1996. ^ This estimate includes approximately 290,394 cases of invasive malignancies, 38,598 case of in situ malignancies, and 10 case of uncertain and unknown behavior. Similar to U.S. rates, for all cancer sites combined, cancer incident cancer rates peaked in 1992 and d%reased at an average of -2.0% per year from 1992 to 23 290 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1996. Age adjusted cancer incidence rates, as well as number of new cases, were higher among males for all races combined. ^ 1.2.2.2 Cancer Mortality; From 1988 to 1996, it is estimated that 121,874 Los Angeles County residents died fix > m cancer. ^ This includes 61,335 deaths among males and 60,539 deaths among females for all cancer sites combined, from 1988 to 1996. Overall, total cancer deaths have decreased among females in Los Angeles County from 6,882 in 1992, to 6,681 in 1996. Among males residents in Los Angeles County, total cancer deaths increased slightly to 6,991 in 1993 and 6,866 in 1995, followed by a decline to 6,631 in 1996. ^ 1.2.2.3 Cancer Trends by Ethnicity Cancer incidence rates in Los Angeles County also vary across racial and ethnic groups. From 1992 to 1996, African Americans have the highest cancer incidence rates. ^ In that time period, African Americans were roughly 62% more likely to develop cancer than Asian/Pacific Islanders and Hispanics. From 1992 to 1996, annual cancer incidence rates decreased an average of 8.6% per year, with the largest decrease occurring among Whites, followed by Hispanics, Asian/Pacific Islanders, and African Americans. ^ Annual cancer incidence rates for Los Angeles County from 1992 to 1996, vary considerably when both race and gender are examined. Overall, males have a higher incidence rate for all sites combined; 455 per 100,000, compared to females, 320.1 per 100,000. African American males have the highest incidence rate for that same time period (597 per 100,000), followed by White (501.5), Hispanic and Asian/Pacific Islander males (311.8 and 311.9 respectively). African American males are also the only group, by gender and ethnicity, in tlmt time period to experience an increase in average annual cancer incidence rates (3.28 per ye£ff). For the same time frame, white females had the highest incident rates (370.8 per 100,000), followed by African American (335.4), Hispanic( 227.1) and Asian/Pacific Islander females (241.9). ^ During 1992 to 1996, cancer mortality rates decreased for both male and female residents in Los Angeles County. However, African American males and females had the highest mortality rate for feat time period. Hie all cancer site combined mortality rate for African American males was 283.6 per 100,000, followed by White (196.8), Asian/Pacific Islander (139.5), and Hispanic males (125.0). For African American 24 291 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. females, the similar mortality rate was 170.4 per 100,000, followed by White (148.5), Hispanic (91.1), and Asian/Pacific Islander females (89.8). Examining mortality rates from 1992-1996 by race and gender in Los Angeles County, shows that both Asian/Pacific Islander and African American females have the slowest decrease in cancer mortality rates. ? Impact of Cancer on the African American Community An overview of cancer statistics in recent years shows a downward trend in cancer incidence and mortality rates. * Incidence rates of breast cancer in young women and lung cancer in men are down, as well as colon cancer incidence rates among men and women. However, a closer look at the data reveals that these gains have occurred mmnly in the majority community. Among ethnic groups, Afiican Americans still have the highest rate of cancer incidence, and are at greater risk o f dying from cancer than other ethnic groups. * The American Cancer Society has set a goal for the year 2015 which includes: a 50% reduction in cancer mortality, and a 25% reduction in cancer incidence rates. ^ Yet the magnitude of cancer incidence and mortality experienced by African Americans, as well as other under-served populations, poses a threat to achieving this goal. Although the Society has speculated on reasons for and solutions to these cancer incidence and mortality disparities, they have yet to successfiilly develop meaningfril tools to address diese disparities effectively. 9 The identification of barriers would assist in designing and implementing effective intervention strategies within the African American community. Although some studies have assessed the association of cancer prevention knowledge, belief and attitudes toward cancer prevention dietary behavior, none have directly addressed the barriers to dietary and lifestyle change in a community focus group setting. 1 0 -1 3 1.2.4 Cancer Prevention Cancer is to a large degree a preventable illness, as two thirds of cancer deaths in the United States can be linked to poor diet, tobacco use, obesity, and lack of exercise. l" l These are all factom which can be modified at an individual or societal level. However, public awareness of these modifiable frctors or appropriate compliance to existing preventive guidelines is still lacking. In contrast, public concern about environmental risk remains out of proportion to true risk, diverting public attention from larger more common modifiable risks. 1 4 25 292 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.2.4.1 Diet Although tobacco control has been one of the most effective means of cancer prevention, poor diet has also been a risk factor associated with cancers. It has been demonstrated that a diet high in fruit and vegetable consumption can reduce the risk for at least 10 different cancers. These include; cancers of the lung, stomach, colon, esophagus, and larynx. There is also evidence that increased consumption of legumes and grains can reduce the risk of stomach and pancreatic cancers. In contrast, red meat, total fat intake, and saturated animal fats have been linked to die occurrence of various cancers. 1J2.4.2 Exercise Increasing levels of physical activity have been shown to reduce the incidence of colorectal cancer, and may reduce prostate and breast cancer. 16,17 jt has been proposed that we would observe a 15% decrease in the incidence of colon cancer in the entire population, if the entire population increased their level of physical activity by the equivalent en er^ expenditure of 30 minutes of brisk walking per day. 1.2.4.3 Alcohol Alcohol use is synergistic with tobacco use in causing cancers of the gastointestinal tract and upper respiratory tract. 1 4 In addition, alcohol has also been associated with liver cancer, and cancers of the breast and colon. 1 4 1.2.4.4 Effect of Poverty Various cancers such as: lung, stomach, uterus, and otheis occur more commonly among the poor and underprivileged. However, poverty is often associated with greater tobacco use, poorer nutrition, high body weight, less exercise, alcoholism, and increased exposure to infectious agents. Therefore these are factors that should be considered as potential confounders in this relationship. 1 * 1.2.5 Summary Cancer statistics in recent years have shown that compared to other ethnic groups, African Americans have the highest rate of cancer incidence, and are at greater risk of dying from cancer. * Two thirds of cancer deaths in the United States can be linked to poor diet, tobacco use, obesity, and lack of exercise, all of which are modifiable risk factors. 1 4 Yet poverty is often associated with these modifiable risk factors. 1 * Poverty may have an impact on awareness of preventive cancer guidelines, as well as cause previously unidentified barriers to preventive diet and lifestyle changes. Several studies have assessed the association of cancer prevention knowledge, belief and attitudes toward cancer prevention dietary behavior. 1013 26 293 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TTiere is a need to directly address the barriers to dietary and lifestyle change among low income African Americans in a community focus group setting. Identification of these barriers in the community would assist in the implementation of effective intervention strategies for needed preventive diet and lifestyle changes. Developing meaningful preventive tools could decrease fire magnitude of cancer incidence and mortality experienced by African Americans, as well as other under-served populations. This could further assist the American Cancer Society in their goal of reducing cancer incidence and mortality rates by the year 2015. ^ 27 294 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.3 Research Design and Methods 1-3.1 The Seatfawest Health District - Catchment Area The T H E. Clinic, of the Southwest Health District (SWHD), will provide the catchment area for this study. The SWHD is one of 26 geographically defined health service areas in Los Angeles County, which covers 26.2 square miles and contains 73 census tracts. The boundaries of the district are: Century Blvd. on the south, the Santa Monica (10) Freeway on the north, the Harbor (110) Fieevray on the east, and include S. La Cienega Ave., Centinela Blvd., and Crenshaw Blvd. on the west. The SWHD provides comprehensive medical care to a community that is largely African American and Hispanic, predominantly low income, and underserved by health and social service. 1.3.1.1 Demographics Of an estimated 370,598 residents in the SWHD in 1995, 54.3% were African American, 38.4% were Hispanic, 3.8% were white, and 3.5% are Asian/Pacific Islander. The SWHD contains the largest percentage of African American residents among the LA County Health Districts. The Hispanic population in the district has more than doubled in the past decade due to an increase in immigrants to the U.S. Of the 370,598 SWHD residents in 1995,178,578 were males and 192,020 were females. Residents of the SWHD are predominantly low income. This is reflected in the district’s high rates of unemployment and poverty, which are higher than the overall rates for L.A. County. In 1990, the unemployment rate of the SWHD was 12.4%, 2.9% higher than the overall rate for L A. County (15.1%). In 1992, approximately one fourth (26.2%) of the districts residents lived in poverty, compared to 15.1% of those in L.A.County. The educational level of SWHD’s residents is 10% lower than the County average, with a higher number of residents not completing 12 years of school (41%), compared to L.A. County as a whole (31%). The Southwest Health District, one of the most densely populated in the County, su i^ rts three extremely large public high schools with a combined enrollment of 6,300 students. They are Dorsey, Manual Arts, and Crenshaw High School. In addition, the district also contains five public middle schools, two public continuation high schools, and two adult schools. Some of the notable landmarks included in the district are: the University of Southern California, the Los Angeles Coliseum and the Los Angeles Sports Arena. In 1992, the district was the epicenter of the civil disturbance that fbllowed the widely publicized Rodney King beating trial. 28 295 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. diet-related chronic conditions. No diet can guarantee full protection against any disease, however, the Society believes that these recommendations offer the best currœ t nutrition information to assist in reducing the risk of cancer. The recommendations are outlined as follows: Nutritional Guidelines of the American Cancg- Society^: 1) Choose most of the foods you eat from plant sources. • Eat five or more servings of fruits and vegetables each day. • Eat other foods from plant sources, such as bread, cereals, grain products, rice, pasta, or beans sevaal times each day. 2) Limit your intake o f high-fat foods, particularly from animal sources. • Choose foods low in fat • Limit consumption o f meats, especially high-fat meats. 3) Be physically active: Achieve and maintain a healthy weight. • Be at least moderately active for 30 minutes or more on most days of the week. • Stay within your healthy weight range. 4) Limit consumption of alcoholic beverages, if you drink at all. 13.2.1,2 Goals for Nutrition in the Year 2000 h The recommendations for the Goals for Nutrition in the Year 2000 by Willett are similar to the American Cancer Society’s Nutritional Guidelines with one notable addition. W illet’s recommendations include that a multivitamin containing folic acid be taken, particularly if alcohol is consumed daily. The goals for the year 2000 are stated as follows: Goals for Nutrition in the Year 2000 1) Avoiding overweight and w e i^ t gain during adulthood. Evidence supports the fact that excess body fat increases risk o f several important cancers and is also a major cause o f cardiovascular diseases and diabetes. For adult Americans, staying within the standard weight guidelines o f body mass index = 19 to 25 kg/m^, is not sufficient for cancer prevention. By this current criteria, many non-overweight people who gain 30 to 40 pounds upon entering 296 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. study. The data obtained from these focus groups will provide both sociological and psychological insight into the perceptions of dûs population subgroup, which will suggest answers to the “lack of compliance” questions raised by current national descriptive cancer data among low income African Americans. These data will assist in providing meaningful insight into barriers to nutritional compliance which exist in our communities. In addition, the use of focus groups will not only identify barriers to standard nutritional guidelines which may be an obstacle for the people in this community, but involve the community jointly with national organizations in the implementation of effective intervention strategies. Six focus groups will be conducted consisting of 60 Afiican American subjects recruited, with consent, from the TJI.E. Clinic of Los Angeles. The focus groups will include: 3 groups of 10 males and 3 groups of 10 females. The focus groups will be held in two hour sessions over a consecutive two day period. The scheduling of the focus groups will be contingent on feasibility with the T.H.E. clinics constraints and subject availability. All focus group scheduling, activities, and participant consent will be submitted to Ms. Donzella Lee, Director of Operations of the T.H.E. Clinic for approval, prior to implementation. The focus groups will be conducted by Ms. Cheryl Marks, an independent consultant. Carolyn Ervin of the University of Soutiiem California’s Department of Preventive Medicine will oversee the focus group portion of the research. Ms. Marks, who specializes in qualitative research, has extensive research experience in dealing with Afiican American participants, in particular, in a focus group setting. As the focus group leader, Ms. Marks will lead discussions following a structured protocol based on the current national nutritional guidelines. L 2 1.3.2.1 Current National Nutritional Guidelines and Goals The focus groups comprised of Afiican American male and female patients at the T.H.E. Clinic will discuss barriers to compliance for suggested cancer preventive diet and lifestyle recommendations, such as those stated in the Nutritional Guidelines of the American Cancer Society and the Goals for Nutrition in the Year 2000. L 2 13.2.1.1 Nutritional Guidelines of the American Cancer Society The Nutritional Guidelines of the American Cancer Society are based on the Society’s review of the scientific evidence. 1 The Society’s recommendations are consistent with the 1992 US Department of Agriculture (USDA) Food Guide Pyramid, the 1995 Dietary Guidelines for Americans, and dietary recommendations of other agencies involved in health promotion and for the prevention of diabetes, coronary heart disease, and other 30 297 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. diet-related chronic conditions. No diet can guarantee full protection against any disease, however, the Society believes that these recommendations offer the best current nutrition information to assist in reducing the risk of cancer. The recommendations are outlined as follows: Nutritional Guidelines of die American Cancer Society^ : 1) Choose most of the foods you eat from plant sources. • Eat five or more servings of finits and vegetables each day. • Eat other foods from plant sources, such as bread, cereals, grain products, lice, pasta, or beans several times each day. 2) Limit your intake of high-fat foods, particularly finm animal sources. • Choose foods low in fat. • Limit consumption of meats, especially high-fat meats. 3) Be physically active: Achieve and maintain a healthy weight. • Be at least moderately active for 30 minutes or more on most days of the week. • Stay within your healthy weight range. 4) Limit consumption of alcoholic beverages, if you drink at all. 1.3.2.1.2 Goals for Nutrition in the Year 2000 h The recommendations for the Goals for Nutrition in the Year 2000 by Willett are similar to the American Cancer Society’s Nutritional Guidelines with one notable addition. Willet’s recommendations include that a multivitamin containing folic acid be taken, particularly if alcohol is consumed daily. The goals for the year 2000 are stated as follows; Goals for Nutrition in the Year 2000 1) Avoiding overweight and weight gain during adulthood. Evidence supports the fact that excess body fat increases risk of several important cancers and is also a major cause of cardiovascular diseases and diabetes. For adult Americans, staying within the standard weight guidelines of body mass index = 19 to 25 kg'm \ is not sufficient for cancer prevention. By this current criteria, many non-overweight people who gain 30 to 40 pounds upon entering 31 298 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. adulthood still remain within the guidelines. Since many Americans have regarded major midlife weight gain as a normal part of aging, it is suggested that staying within five to 10 pounds of their weight at age 20 is a better guideline. 2) Being moderately to vigorously active for at least 30 minutes on most days. Physical activity is known as a primary means of weight control. In addition, evidence shows that physical activity reduces the risk of colon cancer, may reduce the risk of breast cancer, and assists in the prevention of cardiovascular disease. Although a half an hour per day of moderate to vigorous activity is the recommended goal, it is a minimum and very low in comparison to traditional societies 3) Consuming five servings of fruits and vegetables daily. Evidence has shown that a minimum consumption of five servings of fruits and vegetables a day may reduce the risk of some cancers. These include lung and esophageal cancer, and possibly breast cancer. The benefits may be minimal among nonsmokers, who are at low risk for these cancers. Additional research is needed fi-om prospective studies on specific fiuits and vegetables and their distinct biological effects, as some may be beneficial for prevention of certain cancers, yet harmful for others. Potatoes, such as firench fries, can classify as a vegetable by current U.S. nutrition guidelines and account for a large portion of increase in recent U.S. vegetable consumption However, increasing potato consumption or starch in general has not been shown to reduce cancer risk. 4) Replace red meat with chicken, fish, nuts, legumes, and consume dairy products at most in moderation. Although evidence is not conclusive, it is suggested that limiting the consumption of red meat to several times a month will reduce the risk of colon cancer and possibly prostate cancer. A dietary replacement of red meat with chicken, fish, legumes, and nuts will also improve blood lipids and reduce the risk of coronary heart disease. The role of dairy products in cancer and heart disease is not well established. Although increased consumption of dairy products has been associated with prostate cancer risk in many studies, recent studies have suggested that dairy fat may not be the cause. Since fat firom milk remains in the food supply and is ofien consumed in various forms, encouraging the consumption of low-felt dairy products will have little impact on population rates of any disease. Increasing calcium intake by consumption of dairy products is likely to increase rates of coronary disease. A suggested strategy would be to consume dairy products in modest amounts and use calcium supplements if higher levels are required. 32 299 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 5) Limit alcohol consumption to one drink a day for women and two for men. Evidence suggests that h i^ alcohol consumption increase the risk of many cancels. H i^ alcohol consumption in combination with cigarette smoking increased the risk of cancer of the oral cavity, larynx, esophagus, and liver. Several case-control and cohort studies have indicated that one or two drinks per day may increase the risk of breast cancer by increasing endogenous estrogen levels. Alcohol consumption also interferes with the availability of folic acid, which may account for its relationship to cancers of the colon and rectum. 6) Considering taking a multivitamin containing folic acid, particularly if alcohol is consumed daily. Multivitemin supplements containing folic acid have been shown to reduce the risk of colon cancer and coronary heart disease. Folic acid supplements are most beneficial for those who consume alcohol; which antagonizes the bioavailability of folic acid, on a daily basis. Increasing fruit and vegetable consumption will increase folic acid levels, yet folic acid supplements have a higher bioavailability. In addition, behavioral and economic barriers may exist which prevent increased consumption of fruits and vegetables. Additional evidence on other vitamin or mineral consumption for cancer prevention is insufficient. 7) Consuming cereal products in a minimally refined, whole grain form. Previous hypotheses have indicated that fiber reduces the risk of colon cancer through dilution of potential carcinogens and increasing colon transit time. As recent evidence accrued, the association o f dietary fiber with reduced colon cancer has become less clear. However, in these same studies, a strong consistent inverse relationship between cereal fiber consumption and risk of coronary heart disease and diabète has been noted. 1.3.2.2 Focus Group Discussions; The focus group discussions will encompass topics from the combined current national nutritional guidelines and goals; The questions posed to the focus groups will include the combined topics. Participants will be asked to identify problems or barriers they face in meeting national nutrition and lifestyle criteria, such as those suggested by these guidelines. The following major areas will be discussed in relation to these guidelines: 33 300 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I) Familiarity with the guidelines - • Were you aware of the guidelines? • If aware of the guidelines: • What venues increased your awareness of the guidelines? • What methods do you feel would increase community awareness with re^rd to guidelines? • If unaware of the guidelines: • Why do you feel you were unaware of the guidelines? • What venues would have made these guidelines more accessible to you? II) Current nutrition and lifestyle practices - • Which of the following are you doing that currently complies with the guidelines? • Physical Activity: • What is your current weight, height, and age? • Do you feel you have achieved and maintained a healthy w ei^t? • Have you ever been overweight? • Have you had weight gain during adulthood (> age 20)? • Are you m od^tely to vigorously active for at least 30 minutes on most days per week? • What barriers prevented you from maintaining a healthy weight through diet? • Lack of availability of healthy food options. • Lack of affordability of healthy food options. • Lack of knowledge of healthy food alternatives. • What barriers prevent you from performing regular physical activity? • Lack of safe outdoor environment or facility. • Lack of accessible outdoor environment or facility. • Lack of affordability of a facility. • Lack of time for physical activity. • Lack of knowledge in performing physical activities. 34 301 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Choice of foods: • Do you like to eat fiesh fruits and vegetables? • What barriers prevent you fiom choosing fresh fruits and vegetables? • Lack of availability of fresh fruits and vegetable. • Lack of affordability of fresh fronts and vegetable. • Do you consume five or more servings of fruits and vegetables daily. • If not what barriers prevent you from consuming five or more servings of fruits and vegetables daily. • Do you consume other foods from plant sources, such as breads, cereals, grain products, rice, pasta, or beans several times each day. • If not vdiat tim ers prevent you from consuming plant sources, such as breads, cereals, grain products, rice, pasta, or beans sevraral times each day. Limiting intake of high-fat foods (particularly high in animal fat). • What foods do you think are high in animal fat. • Do you replace red meat with chicken, fish, nuts, or legumes on a regular basis. • If not what barriers prevent you from replace red meat with chicken, fish, nuts, or legumes on a regular basis • Do you consume a lot of dairy products such as milk, cheese, ice cream, etc. • If not what barriers prevent you from consuming dairy products such as milk, cheese, ice cream, etc. • What foods do you consume which are low in fat. • If not what barriers prevent you from consuming foods which are low in fat. • Limiting consumption of alcoholic beverages. • Do you consume alcoholic beverages. • If so, what kinds of alcoholic beverages do you consume and how often. • What is your family history with alcohol consumption. 35 302 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Do you consume one drink a day for women and two for men. If you do have more than one drink per day, how much do you drink per day and what type of alcohol. Have you considered drinking less, but don’t know to change the habit. If you consume alcoholic beverages daily, have you considered taking a multivitamin? If not, what barriers prevent you from taking a multivitamin containing folic acid? The focus groups sessions will last for 2 hours, will be audio-t^>ed and observed by Ms. Ervin for later review. Consenting participants will receive a stipend of $50.00 and be served light refreshments for their participation. The outcome of this segment of the study will be a focus group report which will analyze and summarize the focus responses. The focus group research report will be generated by Ms. Marks and reviewed by Ms. Ervin at Loyola Maiymount Univeraity, and Dr. Smith at the University of California at Los Angeles. Based on die findings of the focus groups, the research team will conduct meetings to examine and summarize barriers for compliance to the suggested nutritional and lifestyle guidelines, vriiich vrill assist in developing a questionnaire to be utilized in the pilot study. 1.3J Pevelopment o f the Instrument; A questionnaire regarding the barriers to compliance to cancer preventive nutritional and lifestyle guidelines will be developed, based on the focus group findings and the consensus of research team meeting revisions. The questionnaire will be used in order to survey a broader sample based on the barriers identified. Ms. Ervin and the Data Analyst will work jointiy to develop data entry screens for the diet and lifestyle questionnaire interview. The data entry screens will be “user friendly” for the interviewer to enter data, screen edit controls will be implemented to minimize data entiy errors. Automatic data backup will be programming to retain integrity of data. The finalized data entry screens will be provided to the interviewer on the laptop. 1.3,3.1 Compliance Ouestioimaire: The study interviewer vrill be trained by Ms. Carolyn Ervin and Dr. Lisa Smith to conduct the in-person interview utilizing compliance questionnaire on the laptop. Study participants at the T.H.E. clinic will be given a hard copy of the survey to follow, as the interviewer conducts the in-person interview. The interviewer will enter the respondents information at the site and backup data after each 15 minute interview. 36 303 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.4 Literature Cited 1. Society AC. Cancer Facts and Figures - 1998. Atlanta, GA (USA):. American Cancer Society, 1998 1998. 2. Willett W. Goals for Nutrition in the Year 2000. CA-A Cancer Journal for Clinicians 1999;49:331-52. 3. Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer Statistics, 2001. CA- A Cancer Journal for Clinicians 2001;51:15-36. 4. Wingo PA, Ries LA, Giovino GAea. Annual report to the nation on the status of cancer, 1973-1996, widi a special section on lung cancer and tobacco smoking. Journal o f the National Cancer Institute 1999;91:675-690. 5. Wingo PA, Ries LA, Rosenburg HM, et al. Cancer incidence and mortality, 1973- 1995: A report card for the U.S. Cancer 1998;82:1197-1207. 6. Ries LA, Eisner MP, Kosaiy CL, et al. SEER Cancer Statistics Review, 1973- 1997. Bethesda, MD, National Cancer Institute. 2000.2000. 7. Liu L, Deapen D, Bernstein L, Ross R. Cancer in Los Angeles County: Incidence and Mortality by Race/Ethnicity 1988-1996. Los Angeles County Cancer Surveillance Program, University of Southern California 1999. 8. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA-A Cancer Journal for Clinicians 1999;49:8-11. 9. McDonald CJ. Cancer Statistics, 1999: Challenges in Minority Populations. CA-A Cancer Journal for Clinicians 1999;49:6-7. 10. Hamack L, Block G, Subar A, Lane S, Brand R. Association o f cancer prevention- related nutrition knowledge, beliefs, and attitudes to cancer prevention dietary behavior. Journal of the American Dietetic Association 1997;97:957-65. 11. Lowe JI, Barg FK, Bernstein MW. Educating African-Americans about cancer prevention and detection: a review of the literature. Social Work in Health Care 1995;21:17-36. 12. Lacey L. Cancer prevention and early detection strategies for reaching underserved urban, low-income black women. Barriers and objectives. Cancer 1993;72:1078-83. 13. Michielutte R, Diseker RA. Racial difkrences in knowledge of cancer: a pilot study. Social Science & Medicine 1982;16:245-52. 14. Bal DG, Woolham GL, Seffrin JR. Dietary Change and CancCT Prevention: What Don't We Know and When Didn't We Know It? CA-A Cancer Journal for Clinicians 1999;49:327-30. 15. Research: WCRFiAwAIfC. Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington, D C.: American Institute for Cancer Research, 1997. 16. Cancer Causes and Control. Harvard Center for Cancer Prevention November 1997;8:S47-S50. 17. Cancer Causes and Control. Harvard Center for Cancer Prevention November 1996;7:S55-S58. 39 304 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A comprehensive narrative report describing this study and the results of the data analysis will produced at the conclusion of this study for conference presentation, as well as peer-joumal submission. The T.H.E. clinic will be officially recognized in any publications as a result of this study. 38 305 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1.4 Literature Cited 1. Society AC. Cancer Facts and Figures - 1998. Atlanta, GA (USA):. American Cancer Society, 1998 1998. 2. Willett W. Goals for Nutrition in the Year 2000. CA-A Cancer Journal for Clinicians 1999;49:331-52. 3. Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer Statistics, 2001. CA- A Cancer Journal for Clinicians 2001;51:15-36. 4. Wingo PA, Ries LA, Giovino GAea. Annual report to the nation on the status of cancer, 1973-1996, with a special section on lung cancer and tobacco smoking. Journal of the National Cancer Institute 1999;91:675-690. 5. Wingo PA, Ries LA, Rosenburg HM, et al. Cancer incidence and mortality, 1973- 1995: A report card for the U.S. Cancer 1998;82:1197-1207. 6. Ries LA, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, 1973- 1997. Bethesda, MD, National Cancer Institute. 2000. 2000. 7. Liu L, Deapen D, Bernstein L, Ross R. Cancer in Los Angeles County: Incidence and Mortality by Race/Ethnicity 1988-1996. Los Angeles County Cancer Surveillance Program, University of Southern California 1999. 8. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA-A Cancer Journal for Clinicians 1999;49:8-11. 9. McDonald CJ. Cancer Statistics, 1999: Challenges in Minority Populations. CA-A Cancer Journal for Clinicians 1999;49:6-7. 10. Hamack L, Block G, Subar A, Lane S, Brand R. Association of cancer prevention- related nutrition knowledge, beliefs, and attitudes to cancer prevention dietary behavior. Journal of the American Dietetic Association 1997;97:957-65 11. Lowe JI, Barg FK, Bernstein MW. Educating African-Americans about cancer prevention and detection: a review of the literature. Social Work in Health Care 1995;21:17-36. 12. Lacey L. Cancer prevention and early detection strategies for reaching underserved urban, low-income black women. Barriers and objectives. Cancer 1993;72:1078-83. 39 306 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 13. Michielutte R, Diseker RA. Racial differences in knowledge of cancer: a pilot study. Social Science & Medicine 1982;16:245-52. 14. Bal DG, Woolham GL, Sefffin JR. Dietary Change and Cancer Prevention: What Don't We Know and When Didn't We Know It? CA-A Cancer Journal for Clinicians 1999;49:327-30. 15. Research: WCRF Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington, D C.: American Institute for Cancer Research, 1997. 16. Cancer Causes and Control. Harvard Center for Cancer Prevention November 1997;8:S47-S50. 17. Cancer Causes and Control. Harvard Center for Cancer Prevention November 1996;7:S55-S58. 18. Bal DG. Cancer in Afiican Americans. CA-A Cancer Journal for Clinicians 1992;49:5-6. 19. Willett W, Dietz WH, Colditz GA. Guidelines for Healthy Weight. New England Journal of Medicine 1999;341:427-34. 40 307 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ■ o I I c /) o ' =3 Table 1 ; Population Survey or Descriptive Study Using Random Sampling. Population Size ~ 201.235 8 â ’ i =3 CD CD ■o I c a o =3 ■o o S sm B te-S tet MD«cW Freoueneyi 40% 50% 60% 70% 80% 30% 40% 50% 60% 70% m s L or Lower Upper or Lower Upper or Lower Upper or Im S L K fiR S C or I m s L U e& Ë L LffiSl àcceotable: 50% CJL £sli 60% £ L 70% % % 80% % G * 90% 4 L 4 L 80% 39 0.337 0.463 41 0.436 0.564 39 0.537 0.663 34 0.641 0.759 26 0.749 0.851 90% 65 0.319 0.481 68 0.418 0.583 65 0.519 0.681 57 0.624 0.776 43 0.734 0.866 95% 92 0.304 0.496 96 0.402 0.598 92 0.504 0.696 81 0.610 0.790 61 0.722 0.878 99% 159 0.274 0.526 166 0.371 0.629 159 0.474 0.726 139 0.582 0.818 106 0.697 0.903 99.90% 260 0.236 0.564 270 0 J3 3 0.668 260 0.436 0,764 227 0.546 0.854 173 0.666 0.934 99.99% 363 0.231 0.569 378 0.328 0.673 363 0.431 0.769 317 0.542 0.858 242 0.662 0.938 & o c C/) o ' =3
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Creator
Ervin, Carolyn M.
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Core Title
Physical activity and adenomatous polyps: Measures of association and impact
Degree
Doctor of Philosophy
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Epidemiology
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University of Southern California
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biology, biostatistics,health sciences, oncology,health sciences, public health,OAI-PMH Harvest
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Ervin, Carolyn M.
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biology, biostatistics
health sciences, oncology
health sciences, public health