Health Examinees Study Research Articles

Dietary Patterns and the Risk of Dyslipidemia in Korean Adults: A Prospective Cohort Study Based on the Health Examinees (HEXA) Study

BackgroundIdentifying dietary patterns that contribute to dyslipidemia development can inform prevention, nutritional counseling, and other treatment recommendations. ObjectiveThis study aimed to identify major dietary patterns and examine the association between these dietary patterns and dyslipidemia incidence by sex among Koreans. DesignThe Health Examinees (HEXA) study is a community-based prospective cohort study. The baseline and follow-up surveys were conducted in 2004-2013, and 2012-2016, respectively, at 38 health examination centers and training hospitals located in eight regions in Korea. Dietary intake data were collected using a web-based, validated semiquantitative food frequency questionnaire (FFQ) at baseline. Participants/settingAmong 65,642 participants who completed the baseline and follow-up survey, data from 38,170 participants without dyslipidemia and other related chronic diseases at baseline were analyzed. Main outcome measuresIncidence of dyslipidemia and its components (hypercholesterolemia, hyper-low-density lipoprotein [LDL] cholesterolemia, hypo-high-density lipoprotein [HDL] cholesterolemia, and hypertriglyceridemia) after baseline but before the follow-up examination was examined. Statistical analysesFactor analysis was conducted on data from the semiquantitative FFQ to identify major dietary patterns for Korean adults. Cox proportional hazards regression analysis was performed to estimate the relative risk (RR) and 95% confidence interval (CI) according to the quintiles of three dietary pattern scores, after adjusting for potential confounders by sex. ResultsOf the three identified dietary patterns, the higher “prudent” pattern score was associated with a lower incidence of dyslipidemia (RR, 0.90; 95% CI, 0.82-0.99; P = .02) after adjusting for potential confounders in women. Higher “flour-based food and meats” pattern score was associated with a higher incidence of hypercholesterolemia (men: RR, 1.63; 95% CI, 1.21-2.20; P = .003; women: RR, 1.47; 95% CI, 1.30-1.67; P < .001), hyper-LDL cholesterolemia (men: RR, 1.45; 95% CI, 1.03-2.04, P = .06; women: RR, 1.35; 95% CI, 1.16-1.58, P < .001), and dyslipidemia (men: RR, 1.30; 95% CI, 1.09-1.54; P = .009; women: RR, 1.28; 95% CI, 1.16-1.42; P < .001) in both men and women. The “white rice” pattern score was associated with a lower incidence of hypo-HDL cholesterolemia (RR, 0.75; 95% CI, 0.58-0.96; P = .01) and dyslipidemia (RR, 0.90; 95% CI, 0.81-0.99; P = .07) in women. ConclusionsAdherence to the “prudent” and “white rice” patterns was associated with a lower dyslipidemia risk in Korean women, whereas adherence to the “flour-based food and meats” pattern was associated with increased risks of dyslipidemia and its components (hypercholesterolemia and hyper-LDL cholesterolemia) in both Korean men and women.

Factors Associated with Health Behaviors in Thyroid Cancer Survivors.

In this study, we compared health behaviors, including current smoking, drinking, and physical inactivity, in thyroid cancer survivors and non-cancer controls and investigated the factors associated with unhealthy behaviors among survivors. Baseline data from the Health Examinees study, collected from 2004 to 2013, were used. Thyroid cancer survivors (n = 942), defined as those who had received a clinical diagnosis of thyroid cancer, and 9,420 matched non-cancer controls without past history of any cancer were included in the analysis. The prevalence of smoking, alcohol consumption, and physical inactivity in thyroid cancer survivors were 2.3%, 26.6%, and 52.0%, respectively, with adjusted OR (aOR) and 95% CI between survivors and non-cancer controls of 0.35 (95% CI = 0.08-1.56), 0.46 (95% CI = 0.29-0.74), and 0.65 (95% CI = 0.44-0.96). The prevalence of unhealthy behaviors was higher among male thyroid cancer survivors than female thyroid cancer survivors. In thyroid cancer survivors, those who smoked were more likely to drink (aOR = 4.55 [95% CI = 1.61-12.85]) and those who were physically inactive were less likely to drink (aOR = 0.58 [95% CI = 0.42-0.82]). Current drinking and physical inactivity contributed to a higher likelihood of smoking (aOR = 4.31 [95% CI = 1.35-13.73] and 6.34 [95% CI = 1.65-24.34]). Thyroid cancer survivors had better health behaviors than the non-cancer controls. However, some survivors still had unhealthy lifestyles, especially displaying a clustering of unhealthy behaviors. Thus, health behavior promotion through medical intervention is important for thyroid cancer survivors.

Association of sleep duration and quality with elevated hs-CRP among healthy Korean adults.

This study aimed to investigate the association of sleep duration and quality with high-sensitivity C-reactive protein (hs-CRP) among middle-aged and elderly Koreans. Among a total of 74,867 participants (25,069 men and 49,798 women) recruited for the Health Examinees (HEXA) study, adjusted geometric means of hs-CRP level were compared across categories of sleep duration (<6, 6–7, 8–9, and ≥10 hours) and sleep quality (difficulty in initiating sleep and maintaining sleep) using ANCOVA models. Odds ratios (ORs) and 95% confidence intervals (CIs) for elevated hs-CRP (>3 mg/L) associated with sleep characteristics were estimated using multivariable-adjusted logistic regression models. Men who slept ≥10 hours per day were significantly associated with elevated hs-CRP (OR = 1.47, 95% CI 1.11–1.95). Whereas in women, difficulty in initiating sleep (OR = 1.28, 95% CI 1.04–1.57 for “Always”), and maintaining sleep was significantly associated with elevated hs-CRP levels (OR = 1.13, 95% CI 1.02–1.26 for “Often”; OR = 1.11, 95% CI 0.97–1.28 for “Always”). Additionally, women who experienced poor sleep quality presented an elevated level of hs-CRP (OR = 1.13, 95% CI 1.03–1.23). Our findings suggest that excessive sleep duration and poor sleep quality are significantly associated with the elevated inflammatory marker, specifically hs-CRP. Further research is needed to examine the effect of sleep interventions focused on these factors.

Adherence to the Recommended Intake of Calcium and Colorectal Cancer Risk in the HEXA Study.

PurposeDietary calcium intake has been suggested to be protective against the development of colorectal cancer. The mean dietary calcium intake of Koreans is 490 mg/day, which is far below the recommended calcium intake of 700-800 mg/day. In this study, we explored the relationship between dietary calcium intake and colorectal cancer development in Koreans with relatively low calcium intake compared with individuals in Western countries.Materials and MethodsThe Health Examinees Study, a large-scale genomic community-based prospective cohort study, was designed to identify the general characteristics of major chronic diseases in Koreans. A total of 119,501 participants aged 40-69 years recruited between 2004 and 2013 were included in this analysis. The calcium intake level was categorized using the Dietary Reference Intakes for Koreans (KDRIs). The Cox proportional hazards regression model was used to estimate the hazard ratio (HR) and the corresponding 95% confidence intervals (CIs) for colorectal cancer risk, adjusting for potential confounders.ResultsIn the multivariable-adjusted model, compared with the group that consumed less than the recommended amount of calcium, the group that consumed more than the recommended intake of calcium showed a significant reduction in the risk of colorectal cancer in women. (HR, 0.54; 95% CI, 0.31 to 0.95). Among men, however, no significant association was observed between dietary calcium intake and colorectal cancer risk (HR, 0.89; 95% CI, 0.54 to 1.45).ConclusionKorean women who adhere to the recommended intake of calcium showed a reduced risk of colorectal cancer.

Abstract LB-279: Multi-grain rice diet decreases risk of breast cancer in Korean women: Results from the Health Examinees study

Abstract Background: Several studies have examined associations between breast cancer risk and individual foods and nutrients. Most studies have evaluated risks associated with individual foods and nutrients, rather than measures of whole-diet. The objective of this study was to investigate the association between dietary patterns and the risk for breast cancer. Methods: A total of 93,306 women aged 40-69 years were enrolled in the prospective cohort study in the Health Examinees-Gem (HEXA-G) study between 2004 and 2013. Information on cancer diagnosis in the eligible cohort was retrieved from the Korea Central Cancer Registry through 31 December 2014. Dietary patterns were identified using factor analysis of data from a 106-item validated food frequency questionnaire. We conducted a multivariable Cox regression model to obtain the hazard ratio (HR) and 95% confidence interval (CI) for the risk of breast cancer according to the dietary pattern scores. Results: A total of 359 incident cases of breast cancer occurred over an average follow-up period of 6.3 years. Using a factor analysis, we identified three major dietary patterns, which explained 23.9% of the total variance, based on the daily total food intake (g/day) from 37 food groups: the Vegetables and seaweed pattern (greater intake of yellow-green and other vegetables, seaweed, lean fish, and shellfish), the Flour and meat pattern (greater intake of bread, pizza and hamburger, red meat, and poultry), the White rice and salt fermented fish pattern (greater intake of white rice and salt fermented fish). We found that the women who had higher white rice and salt fermented fish pattern scores tend to have higher risk of breast cancer. Multivariate HR (95% CI) comparing the highest with the lowest quintiles of White rice and salt fermented fish pattern scores was 1.35 (1.00, 1.84) (p for trend = 0.0384). Other two dietary patterns, the Vegetables and seaweed pattern and the Flour and meat pattern, showed no significant association with the breast cancer risk for women. Conclusion: The White rice and salt fermented fish pattern was associated with a increased risk of breast cancer, but further investigation involving subgroup analysis is warranted. Citation Format: Woo-Kyoung Shin, Hwi-Won Lee, Aesun Shin, Jong-koo Lee, Daehee Kang. Multi-grain rice diet decreases risk of breast cancer in Korean women: Results from the Health Examinees study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-279.

Abstract LB-157: Obesity at early adulthood increases subsequent risk of gastric cancer in high incidence nation: Results from the Health Examinees-Gem (HEXA-G) study

Abstract Background: The global trend of obesity, or the “obesity epidemic,” is not confined to adults. The increasing rates of obesity at young age signifies potential burden to our society as a whole, and requires prompt attention. Although emerging evidence has indicated a possible link of obesity in early life to subsequent cancer risks, the association with gastric cancer remains largely unknown, especially among the populations with high incidence rates of gastric cancer. Objective: Using data from the Health Examinees (HEXA) study of Korea, this study aimed to investigate the association of obesity at younger age (ages 18-20 and 35) with the later risk of gastric cancer in a population with high incidence rate of gastric cancer. Method: Included were 114,155 cancer-free subjects who participated in the large-scale prospective cohort study of the Health Examinees-Gem (HEXA-G) study during 2004-2013. Multivariate Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for gastric cancer risk associated with body mass index (BMI) at age 18-20 and 35. To consider substantial differences in incidence rates between men and women, the overall associations were further evaluated, separately by sex. Results: During a median follow-up period of 6.2 years, 851 gastric cancer cases (476 men and 375 women) were identified. When compared to normal BMI (18.5 - 23.0kg/m2), obesity (BMI ≥30kg/m2) at age 35 was significantly associated with increased risk of gastric cancer later in life: HR (95% CI) = 2.60 (1.57-4.33) for total participants, 2.11 (1.03-4.34) for men, and 3.82 (1.86-7.86) for women. No significant associations were found for obesity at late adolescence in both men and women. Conclusion: Our findings suggest that obesity in early adulthood may be associated with increased risk of gastric cancer. Preventing obesity in early life may help reduce the health burden of gastric cancer in later life. Citation Format: Hwi-Won Lee, Woo-Kyoung Shin, Jae Jeong Yang, Minkyo Song, Aesun Shin, Jong-koo Lee, Daehee Kang. Obesity at early adulthood increases subsequent risk of gastric cancer in high incidence nation: Results from the Health Examinees-Gem (HEXA-G) study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-157.

Dietary Protein and Fat Intake Affects Diabetes Risk with CDKAL1 Genetic Variants in Korean Adults.

Cyclin-dependent kinase 5 regulatory subunit-associated protein 1-like 1 (CDKAL1) is one of the strongest diabetes loci identified to date; evidence suggests that it plays an important role in insulin secretion. Dietary factors that affect insulin demand might enhance the risk of diabetes associated with CDKAL1 variants. Our aim was to examine the interactions between dietary protein and fat intake and CDKAL1 genetic variants in relation to the risk of diabetes in Korean adults. Single nucleotide polymorphisms (SNPs) were selected with a genome-wide association study (GWAS) for diabetes after adjustment for age, gender, and examination site. Using data from the Health Examinees (HEXA) Study of the Korean Genome and Epidemiology Study (KoGES), 3988 middle-aged Korean adults between 40–76 years of age (2034 men and 1954 women) were included in the study. Finally, rs7756992 located within the CDKAL1 gene region was selected from GWAS (p-value < 5 × 10−8). Multivariable logistic regression models were used to evaluate the interactions between genotypes and dietary protein and fat intake in relation to diabetes risk after adjustment for age, gender, BMI, waist circumference, physical activity, smoking status, drinking habits, and examination site. Significant interactions between CDKAL1 rs7756992 and dietary protein and fat intake for the risk of diabetes were observed in men (p-value < 0.05). In women, significant interactions between dietary protein and fat intake and CDKAL1 variants (rs7756992) were associated with increased risk of diabetes (p-value < 0.05). Dietary protein and fat intake interacted differently with CDKAL1 variants in relation to the risk of diabetes in Korean adults of both genders. These findings indicate that CDKAL1 variants play a significant role in diabetes and that dietary protein and fat intake could affect these associations.

Multi-Grain Rice Diet Decreases Risk of Breast Cancer in Korean Women: Results from the Health Examinees Study.

Although a number of studies explain the association between dietary patterns, which take into account that foods are eaten in combination, and breast cancer risk, the findings are inconsistent. We examined the association between dietary patterns and multi-grain rice intake, and the risk of breast cancer in a large-scale prospective cohort study in Korean women. A total of 93,306 women aged 40–69 years from the Health Examinees-Gem (HEXA-G) study (2004 and 2013) were included. We obtained Information on cancer diagnosis via linkage to the Korea Central Cancer Registry. Factor analysis was conducted to obtain dietary patterns, and Cox proportional models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (95% CI) for breast cancer risk. For 494,490 person-years, 359 new cases of breast cancer occurred. We identified three major dietary patterns, that explained 23.9% of the total variance based on daily total food intake (g/day) from 37 food groups: the meat dietary pattern (higher intake of bread and red meat), the white rice dietary pattern (higher intake of white rice and lower intake of multi-grain rice), and the other pattern. Women who had higher white rice dietary pattern scores had a 35% higher risk of breast cancer, than did women with lower white rice dietary pattern scores (multivariable HR 1.35; 95% CI 1.00–1.84 for the highest vs. lowest quartile of the white rice dietary pattern scores, p for trend = 0.0384). We found that women who consumed three or more servings of multi-grain rice per day had 33% lower risk of breast cancer than did those who consumed one or less multi-grain rice serving per day among women under 50 years of age (multivariable HR 0.67; 95% CI 0.45–0.99, p for trend = 0.0204). Our study suggests that a multi-grain rice diet may be associated with lower risk of breast cancer in Korean women.

Identifying Interactions between Dietary Sodium, Potassium, Sodium-Potassium Ratios, and FGF5 rs16998073 Variants and Their Associated Risk for Hypertension in Korean Adults.

Hypertension is affected by both genetic and dietary factors. This study aimed to examine the interaction between dietary sodium/potassium intake, sodium–potassium ratios, and FGF5 rs16998073 and link these with increased risk for developing hypertension. Using data from the Health Examinee (HEXA) Study of the Korean Genome and Epidemiologic Study (KoGES), we were able to identify a total of 17,736 middle-aged Korean adults who could be included in our genome-wide association study (GWAS) to confirm any associations between hypertension and the FGF5 rs16998073 variant. GWAS analysis revealed that the FGF5 rs16698073 variant demonstrated the strongest association with hypertension in this population. Multivariable logistic regression was used to examine the relationship between dietary intake of sodium, potassium, and sodium–potassium ratios and the FGF5 rs16998073 genotypes (AA, AT, TT) and any increased risk of hypertension. Carriers with at least one minor T allele for FGF5 rs16998073 were shown to be at significantly higher risk for developing hypertension. Male TT carriers with a daily sodium intake ≥2000 mg also demonstrated an increased risk for developing hypertension compared to the male AA carriers with daily sodium intake <2000 mg (adjusted odds ratio (AOR) = 2.41, 95% confidence intervals (CIs) = 1.84–3.15, p-interaction < 0.0001). Female AA carriers with a daily potassium intake ≥3500 mg showed a reduced risk for hypertension when compared to female AA carriers with a daily potassium intake <3500 mg (AOR = 0.75. 95% CIs = 0.58–0.95, p-interaction < 0.0001). Male TT carriers in the mid-tertile for sodium–potassium ratio values showed the highest odds ratio for hypertension when compared to male AA carriers in the lowest-tertile for sodium–potassium ratio values (AOR = 3.03, 95% CIs = 2.14–4.29, p-interaction < 0.0001). This study confirmed that FGF5 rs16998073 variants do place their carriers (men and women) at increased risk for developing hypertension. In addition, we showed that high daily intake of sodium exerted a synergistic effect for hypertension when combined with FGF5 rs16998073 variants in both genders and that dietary sodium, potassium, and sodium–potassium ratios all interact with FGF5 rs16998073 and alter the risk of developing hypertension in carriers of either gender among Koreans.

Patterns of leisure time and household physical activity and the risk of mortality among middle-aged Korean adults.

BackgroundAlthough many studies have focused on leisure time physical activity (LTPA), household physical activity (HPA) can contribute to health benefits. This study aimed to compare LTPA and HPA patterns and to examine the association of these types of activities with the risk of mortality in Korea.MethodsA total of 125,299 participants 40 to 69 years old and enrolled in the Health Examinees (HEXA) study from 2004 to 2012 were included in this study. The sex-specific LTPA and HPA categories were defined based on a questionnaire. A multinomial logistic regression was used to examine the LTPA and HPA correlates. Hazard ratios (HR) with 95% confidence intervals (95% CIs) of all-cause mortality were estimated using the Cox proportional hazard model.ResultsOverall, the LTPA and HPA patterns differed by age, income, and history of chronic diseases. LTPA reduced the risk of death, and lower risks were observed in more time spent engaged in or a vigorous LTPA intensity. The subjects who participated only in HPA and were not involved in LTPA also had lower risks of mortality (HR = 0.72, 95% CIs: 0.60–0.85 for men, and HR = 0.84, 95% CIs: 0.69–1.02 for women) than those who did not participate in both LTPA and HPA.ConclusionsHPA reduced the risks of mortality in middle-aged Korean adults and could even decrease the risk of death in those who did not participate in LTPA.

Increased awareness, inadequate treatment, and poor control of cardiovascular risk factors in American young adults: 2005-2016.

There are little contemporary data about cardiovascular risk factors among young adults. We defined trends in diabetes mellitus (DM), hypertension, and hypercholesterolemia in American adults aged 18-44 years. The National Health and Nutrition Examination Study serial cross-sectional surveys were used to define three time periods: 2005-2008, 2009-2012, and 2013-2016. Age-adjusted weighted trends of prevalence, awareness, treatment, and control of DM, hypertension, and hypercholesterolemia were calculated by linear regression modelling in the overall sample, males, and females. Trends were calculated after adjustment for age, race, body mass index, smoking status, education attainment, income, insurance status, and number of healthcare visits. From 2005-2008 to 2013-2016, 15,171 participants were identified. DM prevalence was stable ∼3%, hypertension prevalence was stable ∼11.0%, and hypercholesterolemia prevalence declined from 11.5% to 9.0% (ptrend = 0.02). DM awareness stayed stable between 61.1 and 74.1%, hypertension awareness increased from 68.7 to 77.7% (ptrend = 0.05), and hypercholesterolemia awareness was stable between 46.8 and 54.1%. DM and hypertension treatment improved markedly (ptrend < 0.001 and 0.05, respectively) but the hypercholesterolemia treatment was stable ∼30%. DM control improved across survey periods (7.7-17.4%, ptrend = 0.04) but hypertension control (∼50%) and hypercholesterolemia control (∼13%) remained stable. Prevalence, awareness, treatment, and control trends also differed between males and females. There is a stable prevalence of DM, high and stable prevalence of hypertension, and declining prevalence of hypercholesterolemia among young Americans. Despite stable or increasing awareness of diabetes and hypertension, there are inadequate treatment and control trends for DM, hypertension, and hypercholesterolemia.

The association between predicted inflammatory status and colorectal adenoma

We developed a diet and lifestyle score based on high sensitivity C-reactive protein (hsCRP), and investigated its association with odds of adenoma. We performed stepwise linear regression to develop the predicted hsCRP score among 23,330 participants in the Health Examinee Study and examined its association with colorectal adenoma among 1,711 participants in a cross-sectional study of colorectal adenoma. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) of colorectal adenoma using logistic regression models. Variances in hsCRP explained by body mass index were 61.1% in men and 64.5% in women in the prediction model. The increasing predicted hsCRP score was positively associated with colorectal adenoma (ORquartile 4 VS quartile 1 1.71, 95% CI: 1.12–2.62; Ptrend = 0.011 in men; ORquartile 4 VS quartile 1 2.86, 95% CI: 1.26–6.49; Ptrend = 0.019 in women). In subgroups, the associations differed by age and menopausal status among women, with stronger associations among women aged less than 50 years (OR≥median VS <median 3.74, 95% CI: 1.77–7.90, p for interaction 0.014) or premenopausal women (OR≥median vs <median 4.21, 95% CI: 2.12–8.36, p for interaction <0.001). The associations were more pronounced in the advanced or distal colon/rectum in men and in the advanced or proximal colon in women. The associations were attenuated after further adjustment for body mass index. In conclusion, we found that the predicted hsCRP score was positively associated with colorectal adenoma, suggesting that diet and lifestyle lowering inflammation may be a strategy to prevent colorectal neoplasia.

Mean Combined Relative Grip Strength and Metabolic Syndrome: 2011-2014 National Health and Nutrition Examination Survey.

Churilla, JR, Summerlin, M, Richardson, MR, and Boltz, AJ. Mean combined relative grip strength and metabolic syndrome: 2011-2014 National Health and Nutrition Examination Survey. J Strength Cond Res 34(4): 995-1000, 2020-The purpose of this study was to examine the relationships among mean combined relative grip strength (MCRGS), the metabolic syndrome (MetS), and the individual MetS criterion using a nationally representative sample of U.S. adults (≥20 years of age). The study sample included subjects from the 2011-2014 National Health and Nutrition Examination Study (NHANES). Subject MCRGS, using an average of 3 attempts per hand, was measured by a trained examiner using a handgrip dynamometer. All anthropometric, blood pressure, and serum blood measures used to diagnose the MetS were obtained in a Mobile Examination Center using a subsample of NHANES subjects (N = 4,664). Results suggest a favorable inverse dose-response relationship exists across quartiles of increased MCRGS and likelihood of MetS in both men and women (p < 0.0001 for trend). In analyses adjusted for age, race, education, and meeting aerobic physical activity recommendations, when compared with a referent group in the lowest quartile of MCRGS (MCRGS <2.66 kg/body mass index [BMI] in men; MCRGS <1.58 kg/BMI in women), those in the third (MCRGS >3.20-3.77 kg/BMI in men; MCRGS >1.99-2.38 kg/BMI in women) and fourth quartile (MCRGS >3.77 kg/BMI in men; MCRGS >2.38 kg/BMI in women), were significantly less likely to have the MetS, independent of gender (p ≤ 0.05 for all). Similar findings varied according to individual MetS criterion. These findings provide the first data suggesting that increased MCRGS may be inversely related to the MetS or the individual MetS criterion in a nationally representative sample of U.S. adults.

Zinc as a risk factor for myopia: Can we accurately assess status?

AbstractMyopia is one of the leading causes of preventable blindness in the world. Its prevalence has risen drastically over recent decades, and it is estimated that close to half the world population will be myopic by 2050.The rise in myopia is lifestyle related. Myopia occurs as a consequence of excessive eye growth, which may be related to general growth. Diet, therefore, is a potential risk factor. A number of Asian studies have reported lower levels of zinc in myopic adolescents, when compared to controls. Currently, there are no reliable indicators of zinc status. This study explores the association between zinc status and myopia using a combination of zinc assessment methods.Participants from two different population-based studies were used. Data from 1,095 adolescents aged 12–19 years, from the US National Health and Nutrition Examination Study were used to examine the relationship between dietary zinc intake and myopia. Data from 304 subjects of similar age from the Korean National Health and Nutrition Examination Study were used to examine the association between serum zinc levels and myopia using multivariate logistic regression.43% (NHANES) and 84% (KNHANES) of subjects were found to be myopic. Mean dietary intake of zinc was lower among myopes relative to non-myopes, but not significantly. In multivariate logistic regression, dietary zinc was not significantly associated with myopia. Among Korean subjects mean serum zinc was found to be higher in non-myopes v. myopes (p = 0.809). Multiple logistic regression did not show any significant relationship between serum zinc and myopia, after adjustment for confounders.In contrast to previous studies, no relationship was found between lower dietary zinc intake or lower serum zinc, and myopia. Currently the BOND Zinc Expert Panel recommend plasma zinc concentration to assess zinc status, despite its extreme sensitivity to both internal and external factors like; inflammation, fasting, pregnancy, oral contraception and diurnal rhythm. Biological samples are very easily contaminated, meaning strict quality controls and procedures are required. These factors severely impact reliability, and thus, comparison between studies is challenging, particularly in the case of contrasting findings.As zinc is a vital micronutrient and an estimated one-third of the population are affected by zinc deficiency. A reliable biomarker of status is important, for clinical and research needs.

Comparison of 24-hour Recalls with a Food Frequency Questionnaire in Assessing Coffee Consumption: The Health Examinees (HEXA) Study

Comparison of 24-hour Recalls with a Food Frequency Questionnaire in Assessing Coffee Consumption: The Health Examinees (HEXA) Study

Replacing Sedentary Time with Light or Moderate-Vigorous Physical Activity Across Levels of Frailty.

We sought to examine how much sedentary times needs to be replaced by light or moderate-vigorous physical activity in order to reduce frailty and protect against mortality. We built isotemporal substitution models to assess the theoretical effect of replacing sedentary behavior with and equal amount of light or moderate-vigorous activity on frailty and mortality in community-based adults aged 50 years and older. Controlling for age, sex, body mass index, marital status, race, education, employment status, and National Health and Nutrition Examination Study cycle, replacing one hour of sedentary time with moderate-vigorous or light physical activity daily was associated with a lower Frailty Index. For mortality, results varied based on frailty level. Replacing sedentary behavior with moderate-vigorous exercise was associated with lower mortality risk in vulnerable individuals, however, replacing sedentary behavior with light activity was associated with lower mortality risk in frailer individuals.

Milk Consumption Decreases Risk for Breast Cancer in Korean Women under 50 Years of Age: Results from the Health Examinees Study.

Epidemiologic studies regarding breast cancer risk related to milk consumption remain controversial. The aim of this study was to evaluate the association between milk consumption and the risk for breast cancer. A total of 93,306 participants, aged 40–69 years, were included in the prospective cohort study in the Health Examinees-Gem (HEXA-G) study between 2004 and 2013. Dietary intake was assessed using a validated food frequency questionnaire. Information on cancer diagnosis in the eligible cohort was retrieved from the Korea Central Cancer Registry through 31 December 2014. The Cox proportional hazards model was used to estimate multivariate hazard ratios (HRs) and 95% confidence intervals (CIs). A total of 359 breast cancer cases were observed over a median follow-up period of 6.3 years. Milk consumption was not associated with decreased risk for breast cancer in the total population (p for trend = 0.0687). In women under 50 years of age, however, milk consumption was inversely associated with breast cancer risk. In the comparison between highest (≥1 serving/day) and lowest (<1 serving/week) intake categories of milk, the multivariate HR (95% CI) was 0.58 (0.35–0.97, p for trend = 0.0195)) among women under 50 years of age. In conclusion, our findings show that milk consumption in Korean women aged 50 or younger is associated with a decreased risk for breast cancer, when compared to those who never or rarely consumed milk. Further studies need to be conducted to assess this relationship and confirm these results.

Estimating prediction error for complex samples

With a growing interest in using non‐representative samples to train prediction models for numerous outcomes it is necessary to account for the sampling design that gives rise to the data in order to assess the generalized predictive utility of a proposed prediction rule. After learning a prediction rule based on a non‐uniform sample, it is of interest to estimate the rule's error rate when applied to unobserved members of the population. Efron (1986) proposed a general class of covariance penalty inflated prediction error estimators that assume the available training data are representative of the target population for which the prediction rule is to be applied. We extend Efron's estimator to the complex sample context by incorporating Horvitz–Thompson sampling weights and show that it is consistent for the true generalization error rate when applied to the underlying superpopulation. The resulting Horvitz–Thompson–Efron estimator is equivalent to dAIC, a recent extension of Akaike's information criteria to survey sampling data, but is more widely applicable. The proposed methodology is assessed with simulations and is applied to models predicting renal function obtained from the large‐scale National Health and Nutrition Examination Study survey. The Canadian Journal of Statistics 48: 204–221; 2020 © 2019 Statistical Society of Canada

Trends in Prescription Analgesic Use Among Adults With Musculoskeletal Conditions in the United States, 1999-2016

Monitoring trends in prescription analgesic use among adults with musculoskeletal conditions provides insight into how changing prescribing practices, guidelines, and policy measures may affect those who need pain management. To evaluate trends in prescription opioid use and nonopioid analgesic use among adults with functional limitations attributable to musculoskeletal conditions. This repeated cross-sectional study uses data from the National Health and Nutrition Examination Study from 1999 to 2016. Data were analyzed from January to July 2019. The participants were adults aged 30 to 79 years who reported functional limitations due to back or neck problems and/or arthritis or rheumatism. Any use of a prescription opioid or exclusive use of a prescription nonopioid analgesic. In this population of 7256 adults with 1 or more functional limitations attributable to a musculoskeletal condition (4226 women [59.9%]; 3508 [74.4%] non-Hispanic white individuals; median [interquartile range] age, 63 [53-70] years), opioid use and exclusive nonopioid analgesic use exhibited approximately reciprocal patterns of change from 1999 to 2016. Opioid use increased significantly (difference in prevalence for 2015-2016 vs 1999-2000, 7.2%; 95% CI, 1.3% to 13%; P for trend = .002), and exclusive use of nonopioid analgesics decreased significantly (difference in prevalence for 2015-2016 vs 1999-2000, -13%; 95% CI, -19% to -7.5%; P for trend < .001) during this period. The increase in any opioid use was driven by long-term rather than short-term use. A crossover in the prevalence of opioid use and exclusive use of nonopioid analgesics occurred between 2003 and 2006, after which opioid use was more prevalent. Between 2013 and 2016, decreases in opioid use were observed among men (difference in prevalence for 2015-2016 vs 2013-2014, -11%; 95% CI, -21% to 1.8%) and participants with less than a high school education (difference, -15%; 95% CI, -24% to -6.1%). During this same period, exclusive nonopioid analgesic use also decreased markedly across the population (difference, -5.3%; 95% CI, -9.1% to -1.5%). The substitution of opioids for nonopioid analgesics between 2003 and 2006 may have occurred as evidence emerged on the cardiovascular risks associated with nonopioid analgesics. Reductions in opioid use between 2013 and 2016 were most substantial among those with low socioeconomic status, who may encounter barriers in accessing alternatives. Despite those decreases, opioid use remained more prevalent in 2015 to 2016 than in 1999 to 2000, suggesting a potentially long tail for the opioid epidemic.

Association of Subclinical Hearing Loss With Cognitive Performance

Age-related hearing loss (HL) is a common and treatable condition that has been associated with cognitive impairment. The level of hearing at which this association begins has not been studied to date. To investigate whether the association between hearing and cognition is present among individuals traditionally classified as having normal hearing. Cross-sectional study of 2 US epidemiologic studies (Hispanic Community Health Study [HCHS], 2008-2011, and National Health and Nutrition Examination Study [NHANES], 1999-2000, 2001-2002, and 2011-2012 cycles). The dates of analysis were November 2018 to August 2019. Multivariable generalized additive model (GAM) regression and linear regression were used to assess the association between HL (exposure) and cognition (outcome). Participants included 6451 individuals aged 50 years or older from the general Hispanic population (HCHS [n = 5190]) and the general civilian, noninstitutionalized US population (NHANES [n = 1261]). Audiometric HL (4-frequency pure-tone average). Neurocognitive performance measured by the Digit Symbol Substitution Test (DSST) (score range, 0-113), Word Frequency Test (range, 0-49), Spanish-English Verbal Learning Test (SEVLT) 3 trials (range, 5-40), SEVLT recall (range, 0-15), and Six-Item Screener (range, 0-6); higher scores indicated better cognitive performance. Among 6451 individuals, the mean (SD) age was 59.4 (6.1) years, and 3841 (59.5%) were women. The GAM regression showed a significant inverse association between hearing and cognition across the entire spectrum of hearing after adjusting for demographics and cardiovascular disease. In separate multivariable linear regressions stratified by the classic binary definition of HL, decreased hearing was independently associated with decreased cognition in adults with normal hearing (pure-tone average ≤25 dB) across all cognitive tests in the HCHS. For example in this group, a 10-dB decrease in hearing was associated with a clinically meaningful 1.97-point (95% CI, 1.18-2.75) decrease in score on the DSST. When using a stricter HL cut point (15 dB), an association was also present in NHANES. The associations between hearing and cognition were stronger or equivalent in individuals with normal hearing than among those with HL. For example, there was a 2.28-point (95% CI, 1.56-3.00) combined cohort DSST score decrease per 10-dB decrease among individuals with normal hearing vs a 0.97-point (95% CI, 0.20-1.75) decrease among those with HL, with a significant interaction term between continuous and binary hearing. An independent association was observed between cognition and subclinical HL. The association between hearing and cognition may be present earlier in HL than previously understood. Studies investigating whether treating HL can prevent impaired cognition and dementia should consider a lower threshold for defining HL than the current 25-dB threshold.