Southern Community Cohort Study Participants Research Articles

Abstract A019: Dietary polyphenols and the risk of lung cancer in the prospective Southern Community Cohort Study

Abstract Objective: We examined total polyphenol intake and intake of polyphenol classes and subclasses with risk of lung cancer in the Southern Community Cohort Study (SCCS). Background: In the US, lung cancer incidence is highest in the south and among underrepresented and underserved populations. Diet is strongly associated with the risk of developing cancer, including lung cancer. Polyphenols, commonly found in plant-based foods, are biologically active compounds with antioxidant and other properties. Several population-based studies have found that higher intakes of some polyphenols were associated with a decreased risk of lung cancer, but this has not been studied in predominantly Black or low-income populations, nor have polyphenol classes and subclasses been studied extensively. Methods: The SCCS is a large, prospective cohort study established in 2002-2009 to study the causes of cancer disparities in 12 southern states. Two-thirds of the cohort are Black and over 50% have an annual household income less than $15,000. Diagnosis of lung cancer was obtained from state cancer registries and death records. Polyphenol intakes derived from a food frequency questionnaire assessing diet in the previous year were adjusted for total energy intake and grouped into quintiles. Cox proportional hazard models adjusted for potential confounders were used to estimate hazard ratios and 95% confidence intervals to determine associations between polyphenol intakes and lung cancer risk. Multiple imputation was performed to account for participants with incomplete information. After exclusions, analyses included 71,569 participants, including 1,484 incident lung cancer cases. Results: Total polyphenols were associated with a statistically significant increased risk of lung cancer (HR, 1.25; 95% CI, 1.04-1.51; P=0.01, comparing the highest to lowest intake quintile). Additionally, three subclasses (phenolic acids, hydroxycinnamic acids, alkylmethoxyphenols) were associated with a similarly statistically significant increased risk of lung cancer. Most associations were similar between Black and White individuals but were largely only statistically significant among Black participants and there was no significant interaction by race. In stratified analysis by smoking status, the associations were primarily present among current and former smokers. Caffeinated or decaffeinated coffee consumption was a major contributor to intake of total polyphenols, phenolic acids, hydroxycinnamic acids, and alkylmethoxyphenols for SCCS participants overall. Conclusions: Total polyphenols and three subclasses of polyphenols were unexpectedly associated with increased lung cancer risk. Further studies should be conducted to evaluate whether some polyphenols may have an adverse effect on lung carcinogenesis, particularly among individuals who smoke. Citation Format: Grace Xu, Heather Munro, Danxia Yu, Qi Dai, Martha Shrubsole. Dietary polyphenols and the risk of lung cancer in the prospective Southern Community Cohort Study [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A019.

Abstract 12244: Loneliness, Social Isolation, and Incident Heart Failure in the Southern Community Cohort Study

Introduction: Loneliness and social isolation are associated with worse outcomes among individuals with prevalent heart failure (HF). Less is known regarding loneliness and incident HF, particularly among individuals of low socioeconomic position. Methods: We studied 26,666 Southern Community Cohort Study participants without prevalent HF enrolled between 2002-2009. At enrollment, loneliness was assessed via a 4-level question on the Center for Epidemiologic Studies Depression Scale. Incident HF was ascertained through CMS linkage using ICD-9 (428.x) and ICD-10 (I50.x) claims through 2016. Associations between loneliness and social isolation, e.g., marital status, household size, close friends or relatives, and help in emergency, with incident HF were examined with multivariable Cox regression. Results: The study population was predominantly middle-aged (median 54 years), female (63%), Black (69%), with low annual income (70% < $15,000) and education (92% < college graduate). Individuals reporting greater loneliness tended to be younger, female, with lower income and educational attainment. Over a median 9.8 years follow-up, 7,396 (27.7%) individuals developed HF. In Cox models adjusted for demographics and traditional CV risk factors, greater loneliness significantly associated with increased risk for HF (HR: 1.04, 95% CI: 1.01-1.06), which attenuated following adjustment for education and income (HR 1.02, 95% CI: 0.99-1.04) (Table) without evidence for effect modification by either education or income (p-interaction >0.19 for both). Education and income significantly and inversely associated with incident HF risk while social isolation measures did not. Conclusion: Among individuals of low-socioeconomic position, an association between loneliness or social isolation and incident HF did not persist after adjustment for education and income emphasizing the importance of socioeconomic status as a risk factor for incident HF.

Associations between serum vitamin D biomarkers and tumor expression of Ki67, p53, and COX-2 in colorectal cancer cases from the Southern Community Cohort Study

Higher 25-hydroxyvitamin D is associated with lower colorectal cancer (CRC) risk, with limited data from African Americans (AAs), who have greater risk for CRC and 25-hydroxyvitamin D deficiency. In a predominantly AA sample of CRC cases from the Southern Community Cohort Study (SCCS), we report associations between vitamin D biomarkers and tumor expression of proteins implicated in vitamin D’s anti-tumorigenic pathways (e.g. proliferation and inflammation) and CRC prognosis. SCCS participants with incident CRC were identified via state cancer registries. Serum 25-hydroxyvitamin D and vitamin D binding protein (VDBP) were measured at enrollment. ‘Free’ 25-hydroxyvitamin D was calculated via standard equation. Cellular Ki67, p53, and COX-2 were measured from tumor samples and categorized using literature-defined cut-points related to survival. Generalized linear models were used to measure associations between vitamin D exposures, tumor biomarkers, and stage. In total, 104 cases (40–79 years) were analyzed. 25-hydroxyvitamin D was not associated with high Ki67 (odds ratio (OR) per 1-standard deviation (SD) increase [95% confidence interval] 1.35[0.86–2.11]), p53 (0.75[0.47–1.20]), or COX-2 expression (1.25[0.78–2.01]), or metastatic disease (1.04[0.59–1.81]). Mean biomarker expression was unrelated to 25-hydroxyvitamin D (p-trend ≥.09). Null associations were observed for VDBP and free 25-hydroxyvitamin D. In AAs (n = 70), higher VDBP was associated with lower odds of high Ki67 expression (0.53[0.28–0.98], p-trend =.04). In conclusion, we observed no associations between 25-hydroxyvitamin D and prognostic marker expression in CRC. An inverse association between VDBP and tumor Ki67 in AAs is consistent with reports showing relationships with reduced CRC mortality.

Association of diabetes and exposure to fine particulate matter (PM2.5) in the Southeastern United States

Fine particulate matter (PM2.5) exposure can cause premature death and harmful chronic disease such as diabetes. The U.S. Environmental Protection Agency (EPA) sets annual PM2.5 standards to reduce these negative health effects. Currently, annual average exposure over 12 µg/m3 is considered unhealthy. This study tests whether individuals living in locations exposed to elevated ambient levels of PM2.5 concentrations were more likely to self-report diabetes. We examined the association of long-term exposure to PM2.5 and diabetes at enrollment (2002–2009) in a cohort of 44,610 individuals residing in 12 states, recruited into the Southern Community Cohort Study (SCCS). Annual average PM2.5 was estimated using remotely sensed satellite data integrated with ground monitoring data at participants’ residence in urban and rural locations. We used multilevel mixed-effects logistic regression models to estimate the associations between self-reported diabetes and historical exposure to elevated ambient levels of PM2.5. We found a 10.1% increase in odds of reported diabetes with exposure to unhealthful levels of PM2.5 exposure (>12 µg/m3 at enrollment) compared to respondents living in areas with lower annual PM2.5 concentrations. Participants with medical histories of hypertension, hypercholesterolemia, and smoking had an overall 384% higher odds of reported diabetes than those without these clinical risk factors. Black participants were more likely to live in locations with higher ambient PM2.5 concentrations, report high levels of clinical risk factors, and had a 29.1% increase in odds of reported diabetes than Whites. In SCCS participants, exposures to high ambient levels of PM2.5 were associated with self-reported diabetes at enrollment. Reduction in PM2.5 standards for the U.S. are recommended.

Abstract 026: Rurality And Incident Heart Failure Risk In The Southern Community Cohort Study

Background: Rural-urban disparities in cardiovascular mortality are increasing, with higher heart failure (HF) mortality among rural residents. Whether rurality is also associated with an increased risk of HF incidence is not known. Methods: A total of 27,119 Southern Community Cohort Study participants without prevalent HF receiving Centers for Medicare and Medicaid Services (CMS) at cohort enrollment (2002-2009) were included. Rurality at enrollment was classified by Rural-Urban Commuting Area codes based on participant census tract. Incident HF was defined using ICD 9/10 codes (428.x, I50x) via CMS linkage through 2016. The association between rurality and incident HF was tested in Cox models adjusted for age, sex, race, socioeconomic status, cardiovascular risk factors and comorbidities, with addition of a race-sex by rurality interaction term. Results: Overall, 20% (5,556) of participants resided in rural areas. Compared with urban-residing participants, individuals in rural areas were more likely to be older, female, married, less educated, and to have a higher burden of traditional cardiovascular risk factors, but were of similar race and income. Over median 13-years follow-up, 1,865 (33.6%) and 5,677 (26.3%) rural and urban individuals developed HF, respectively; p < 0.001. In adjusted analysis, rurality associated with a 19% greater risk of incident HF (HR 1.19, 95% CI 1.12-1.26). The association between rurality and HF risk varied by race-sex (p-interaction = 0.003), with a marked disparity between Black (HR 1.34, 95% CI 1.19-1.50) and white (HR 0.98, 95% CI 0.82-1.17) men (Figure). Conclusions: In this large biracial Southeastern US population, rural residence associated with a substantial excess risk of HF particularly for women and Black men. These disparities highlight need for further research into underlying determinants and public health interventions.

Depressive Symptoms and Incident Heart Failure Risk in the Southern Community Cohort Study

ObjectivesThis study aims to examine whether greater frequency of depressive symptoms associates with increased risk of incident heart failure (HF). BackgroundDepressive symptoms associate with adverse prognosis in patients with prevalent HF. Their association with incident HF is less studied, particularly in low-income and minority individuals. MethodsWe studied 23,937 Black or White Southern Community Cohort Study participants (median age: 53 years, 70% Black, 64% women) enrolled between 2002 and 2009, without prevalent HF, receiving Centers for Medicare and Medicaid Services coverage. Cox models adjusted for traditional HF risk factors, socioeconomic and behavioral factors, social support, and antidepressant medications were used to quantify the association between depressive symptoms assessed at enrollment via the Center for Epidemiologic Studies Depression Scale (CESD-10) and incident HF ascertained from Centers for Medicare and Medicaid Services International Classification of Diseases-9th Revision (ICD-9) (code: 428.x) and ICD-10 (codes: I50, I110) codes through December 31, 2016. ResultsThe median CESD-10 score was 9 (IQR: 5 to 13). Over a median 11-year follow-up, 6,081 (25%) participants developed HF. The strongest correlates of CESD-10 score were antidepressant medication use, age, and socioeconomic factors, rather than traditional HF risk factors. Greater frequency of depressive symptoms associated with increased incident HF risk (per 8-U higher CESD-10 HR: 1.04; 95% CI: 1.00 to 1.09; P = 0.038) without variation by race or sex. The association between depressive symptoms and incident HF varied by antidepressant use (interaction-P = 0.03) with increased risk among individuals not taking antidepressants. ConclusionsIn this high-risk, low-income, cohort of predominantly Black participants, greater frequency of depressive symptoms significantly associates with higher risk of incident HF.

Abstract PO-236: Examining racial disparities in lung cancer stage of diagnosis among low-income adults living in the southeastern U.S.

Abstract Purpose: Black Americans experience poorer lung cancer survival than White Americans. Racial disparities in stage at diagnosis may contribute to these survival differences, but few studies have explored factors leading to racial disparities in lung cancer stage at diagnosis. We aimed to identify multilevel factors contributing to racial disparities in stage of lung cancer presentation. Methods: Using data from the Southern Community Cohort Study (SCCS), we examined factors associated with distant stage among adults diagnosed with incident lung cancer. SCCS participants were prospectively enrolled, primarily from community health centers between 2002 and 2009 across a 12-state area. Incident cancers were identified by linkage with state cancer registries through end of follow-up in 2019. Self-reported social, behavioral, and medical history information were ascertained at baseline via questionnaire. Cumulative exposure smoking histories were identified using the most recent follow-up questionnaires. Residential addresses and National Cancer Institute Comprehensive Cancer Center locations were geocoded, and residential addresses were linked to census data. Logistic and multinomial regression models were used to identify factors predictive of distant stage diagnosis. Penalized regression was used to shrink the predictor space of these models when necessary. Findings were replicated in an independent population. Results: Among 1,672 incident SCCS lung cancer cases (35% White, 61% Black, and 3% other self-reported race), a greater percentage of Black participants than White participants were diagnosed with distant stage lung cancer (56.4% vs 49.4%, respectively). Overall, Black participants had greater odds of distant vs local stage compared to White participants (odds ratio (OR) = 1.28, 95% confidence interval (CI): 1.05-1.58). Greater area deprivation was also associated with distant lung cancer stage (OR = 1.55, 95% CI: 1.17-2.04). After controlling for individual and area-level factors, there was no significant difference in the odds of distant stage disease for Black participants compared to White participants (OR = 1.03, 95% CI: 0.80-1.33). Significant interactions between race and area deprivation index were not observed. However, greater residential distance from a comprehensive cancer center was significantly associated with increased odds of distant stage disease in the final model (OR = 1.04, 95% CI: 1.00-1.08). No significant differences were observed in the odds of distant stage lung cancer among Black and White participants in the independent population. Conclusions: A greater percentage of Black participants were diagnosed with distant stage lung cancer; however, this disparity dissipated after adjusting for individual and area-level factors. Our findings suggest racial disparities in lung cancer stage at diagnosis may be ameliorated with modifiable factors, such as patient access to high quality cancer centers. Citation Format: Jennifer Richmond, Megan Hollister, Cato M. Milder, Ann G. Schwartz, Jeffrey D. Blume, Melinda C. Aldrich. Examining racial disparities in lung cancer stage of diagnosis among low-income adults living in the southeastern U.S. [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-236.

Association of Cardiovascular Disease and Long-Term Exposure to Fine Particulate Matter (PM2.5) in the Southeastern United States

There is a well-documented association between ambient fine particulate matter air pollution (PM2.5) and cardiovascular disease (CVD) morbidity and mortality. Exposure to PM2.5 can cause premature death and harmful and chronic health effects such as heart attack, diabetes, and stroke. The Environmental Protection Agency sets annual PM2.5 standards to reduce these negative health effects. Currently above an annual average level of 12.0 µg/m is considered unhealthy. Methods. We examined the association of long-term exposure to PM2.5 and CVD in a cohort of 44,610 individuals who resided in 12 states recruited into the Southern Community Cohort Study (SCCS). The SCCS was designed to recruit Black and White participants who received care from Federally Qualified Health Centers; hence, they represent vulnerable individuals from low-income families across this vast region. This study tests whether SCCS participants who lived in locations exposed to elevated ambient levels of PM2.5 concentrations were more likely to report a history of CVD at enrollment (2002–2009). Remotely sensed satellite data integrated with ground monitoring data provide an assessment of the average annual PM2.5 in urban and rural locations where the SCCS participants resided. We used multilevel logistic regression to estimate the associations between self-reported CVD and exposure to elevated ambient levels of PM2.5. Results. We found a 13.4 percent increase in the odds of reported CVD with exposure to unhealthy levels of PM2.5 exposure at enrollment. The SCCS participants with medical histories of hypertension, hypercholesterolemia, and smoking had, overall, 385 percent higher odds of reported CVD than those without these clinical risk factors. Additionally, Black participants were more likely to live in locations with higher ambient PM2.5 concentrations and report high levels of clinical risk factors, thus, they may be at a greater future risk of CVD. Conclusions: In the SCCS participants, we found a strong relation between exposures to high ambient levels of PM2.5 and self-reported CVD at enrollment.

Medicaid Expansion Slowed Rates Of Health Decline For Low-Income Adults In Southern States.

Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans. We analyzed longitudinal survey and vital status data from the twelve-state Southern Community Cohort Study (SCCS) for 15,356 nonelderly adult participants with low incomes, 86percent of whom were enrolled at community health centers. In difference-in-differences analyses, we compared changes in self-reported health between participants in four expansion and eight nonexpansion states before (2008-13) and after (2015-17) Medicaid expansion. We found that a higher proportion of SCCS participants in expansion states reported increases in Medicaid coverage (a differential change of 7.6percentage points), a lower proportion experienced a health status decline (-1.8percentage points), and a higher proportion maintained their baseline health status (1.4percentage points). The magnitude of estimated reductions in health declines would meaningfully affect a nonexpansion state's health ranking in our sample if that state elected to expand Medicaid. Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits-even for those with established access to safety-net care.

Race and Sex Differences in Modifiable Risk Factors and Incident Heart Failure

ObjectivesThe purpose of this study was to examine race- and sex-based variation in the associations between modifiable risk factors and incident heart failure (HF) among the SCCS (Southern Community Cohort Study) participants. BackgroundLow-income individuals in the southeastern United States have high HF incidence rates, but relative contributions of risk factors to HF are understudied in this population. MethodsWe studied 27,078 black or white SCCS participants (mean age: 56 years, 69% black, 63% women) enrolled between 2002 and 2009, without prevalent HF, receiving Centers for Medicare and Medicaid Services. The presence of hypertension, diabetes mellitus, physical underactivity, high body mass index, smoking, high cholesterol, and poor diet was assessed at enrollment. Incident HF was ascertained using International Classification of Diseases-9th revision, codes 428.x in Centers for Medicare and Medicaid Services data through December 31, 2010. Individual risk and population attributable risk for HF for each risk factor were quantified using multivariable Cox models. ResultsDuring a median (25th, 75th percentile) 5.2 (3.1, 6.7) years, 4,341 (16%) participants developed HF. Hypertension and diabetes were associated with greatest HF risk, whereas hypertension contributed the greatest population attributable risk, 31.8% (95% confidence interval: 27.3 to 36.0). In black participants, only hypertension and diabetes associated with HF risk; in white participants, smoking and high body mass index also associated with HF risk. Physical underactivity was a risk factor only in white women. ConclusionsIn this high-risk, low-income cohort, contributions of risk factors to HF varied, particularly by race. To reduce the population burden of HF, interventions tailored for specific race and sex groups may be warranted.

Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers

The United States Preventive Services Task Force (USPSTF) recommends low-dose computed tomography screening for lung cancer. However, USPSTF screening guidelines were derived from a study population including only 4% African American smokers, and racial differences in smoking patterns were not considered. To evaluate the diagnostic accuracy of USPSTF lung cancer screening eligibility criteria in a predominantly African American and low-income cohort. The Southern Community Cohort Study prospectively enrolled adults visiting community health centers across 12 southern US states from March 25, 2002, through September 24, 2009, and followed up for cancer incidence through December 31, 2014. Participants included African American and white current and former smokers aged 40 through 79 years. Statistical analysis was performed from May 11, 2016, to December 6, 2018. Self-reported race, age, and smoking history. Cumulative exposure smoking histories encompassed most recent follow-up questionnaires. Incident lung cancer cases assessed for eligibility for lung cancer screening using USPSTF criteria. Among 48 364 ever smokers, 32 463 (67%) were African American and 15 901 (33%) were white, with 1269 incident lung cancers identified. Among all 48 364 Southern Community Cohort Study participants, 5654 of 32 463 African American smokers (17%) were eligible for USPSTF screening compared with 4992 of 15 901 white smokers (31%) (P < .001). Among persons diagnosed with lung cancer, a significantly lower percentage of African American smokers (255 of 791; 32%) was eligible for screening compared with white smokers (270 of 478; 56%) (P < .001). The lower percentage of eligible lung cancer cases in African American smokers was primarily associated with fewer smoking pack-years among African American vs white smokers (median pack-years: 25.8 [interquartile range, 16.9-42.0] vs 48.0 [interquartile range, 30.2-70.5]; P < .001). Racial disparity was observed in the sensitivity and specificity of USPSTF guidelines between African American and white smokers for all ages. Lowering the smoking pack-year eligibility criteria to a minimum 20-pack-year history was associated with an increased percentage of screening eligibility of African American smokers and with equitable performance of sensitivity and specificity compared with white smokers across all ages (for a 55-year-old current African American smoker, sensitivity increased from 32.2% to 49.0% vs 56.5% for a 55-year-old white current smoker; specificity decreased from 83.0% to 71.6% vs 69.4%; P < .001). Current USPSTF lung cancer screening guidelines may be too conservative for African American smokers. The findings suggest that race-specific adjustment of pack-year criteria in lung cancer screening guidelines would result in more equitable screening for African American smokers at high risk for lung cancer.

Association of Neighborhood Socioeconomic Context With Participation in Cardiac Rehabilitation.

BackgroundCardiac rehabilitation (CR) is underutilized in the United States, with fewer than 20% of eligible patients participating in CR programs. Individual socioeconomic status is associated with CR utilization, but data regarding neighborhood characteristics and CR are sparse. We investigated the association of neighborhood socioeconomic context with CR participation in the SCCS (Southern Community Cohort Study).Methods and ResultsThe SCCS is a prospective cohort study of 84 569 adults in the southeastern United States from 2002 to 2009, 52 117 of whom have Medicare or Medicaid claims. Using these data, we identified participants with hospitalizations for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery and ascertained their CR utilization. Neighborhood socioeconomic context was assessed using a neighborhood deprivation index derived from 11 census‐tract level variables. We analyzed the association of CR utilization with neighborhood deprivation after adjusting for individual socioeconomic status. A total of 4096 SCCS participants (55% female, 57% black) with claims data were eligible for CR. CR utilization was low, with 340 subjects (8%) participating in CR programs. Study participants residing in the most deprived communities (highest quintile of neighborhood deprivation) were less than half as likely to initiate CR (odds ratio 0.42, 95% confidence interval, 0.27–0.66, P<0.001) as those in the lowest quintile. CR participation was inversely associated with all‐cause mortality (hazard ratio 0.77, 95% confidence interval, 0.60–0.996, P<0.05).ConclusionsLower neighborhood socioeconomic context was associated with decreased CR participation independent of individual socioeconomic status. These data invite research on interventions to increase CR access in deprived communities.

Oral health and risk of colorectal cancer: results from three cohort studies and a meta-analysis

While studies have shown that poor oral health status may increase the risk of cancer, evidence of a specific association with the risk of colorectal cancer (CRC) is inconclusive. We evaluated the association between oral health and CRC risk using data from three large cohorts: the Shanghai Men's Health Study (SMHS), the Shanghai Women's Health Study (SWHS), and the Southern Community Cohort Study (SCCS), and carried out a meta-analysis of results from other relevant published studies. This study applied a nested case-control study design and included 825 cases/3298 controls from the SMHS/SWHS and 238 cases/2258 controls from the SCCS. The association between oral health status (i.e. tooth loss/tooth decay) and CRC risk was assessed using conditional logistic regression models. A meta-analysis was carried out based on results from the present study and three published studies. We found that tooth loss was not associated with increased risk of CRC. ORs and respective 95% CIs associated with loss of 1-5, 6-10, and >10 teeth compared with those with full teeth are 0.87 (0.69-1.10), 0.93 (0.70-1.24), and 0.85 (0.66-1.11) among SMHS/SWHS participants; and 1.13 (0.72-1.79), 0.87 (0.52-1.43), and 1.00 (0.63-1.58) for those with loss of 1-4, 5-10, and >10 teeth among SCCS participants. Data regarding tooth decay were available in the SCCS, but were not associated with CRC risk. Meta-analysis confirmed the null association between tooth loss/periodontal disease and CRC risk (OR 1.05, 95% CI 0.86-1.29). In this analysis of three cohorts and a meta-analysis, we found no evidence supporting an association between oral health and CRC risk.

Combined Impact of Health Behaviors on Mortality in Low-Income Americans.

African Americans and low-income whites have higher mortality than the U.S. general population. This study prospectively investigated the combined influence of major lifestyle factors and poverty on mortality in this vulnerable population. Data were collected in 2002-2009 from 79,101 Southern Community Cohort Study participants, of which 67% were African American and 55% had household incomes <$15,000. Mortality outcomes were identified from the National Death Index though December 31, 2011 (data analyzed in 2014-2015). Healthy behavior scores were created based on tobacco smoking, alcohol intake, diet, physical activity, and sedentary time. The primary analysis was performed based on the score created by counting each participant as having met/not met public health guidelines for each behavior. Healthy behavior scores were associated with reduced cancer, cardiovascular disease, and all-cause mortality. Associations were stronger for whites than African Americans: hazard ratios for all-cause mortality comparing participants meeting four or five guidelines versus participants meeting zero were 0.41 (95% CI=0.30, 0.55) for African American men; 0.36 (95% CI=0.24, 0.55) for white men; 0.46 (95% CI=0.36, 0.59) for African American women; and 0.27 (95% CI=0.18, 0.43) for white women. The association between healthy lifestyle and all-cause mortality was weaker among those with incomes <$15,000 than those with higher income, particularly in men (p<0.05 for interaction). This study demonstrates the importance of health behaviors on mortality among all groups, but highlights the need for additional research to identify factors contributing to high risk of mortality among low-income and African American populations.

Abstract A58: Interaction of diabetes and obesity in postmenopausal breast cancer risk among black women

Abstract Purpose: Meta-analyses of the association between diabetes and postmenopausal breast cancer have been conducted primarily among white women with summary relative risks [RR] of approximately 1.15 (95% confidence interval (CI) 1.07-1.24). The only related prospective cohort study among black women reported a RR of 0.93 (95% CI 0.73-1.19). We conducted a case-control study to examine whether diabetes was associated with subsequent breast cancer among postmenopausal black women and whether obesity modified this association. Methods: Women diagnosed with incident postmenopausal breast cancer between September 2009 and December 2012 were identified through statewide cancer registries in Georgia, South Carolina and Tennessee. One control per case, individually matched on age at enrollment, state and household income, were selected from Southern Community Cohort Study participants. Women whose breast cancer and diabetes were diagnosed within one year of each other were excluded to minimize detection bias resulting in 839 cases and 839 controls for analysis. Data on diabetes (cases n=244, controls n=336) and obesity (cases n=468, controls n=466) were obtained from baseline surveys; data on breast cancer histologic subtype (estrogen receptor (ER) positive n=556, ER negative n=216) were from cancer registry records. Results: Using conditional logistic regression with further adjustment for educational level and health insurance coverage, there was a reduced risk of breast cancer associated with self-reported diabetes (odds ratio (OR) 0.63, 95% CI 0.49-0.80). Obesity did not significantly modify the effect of diabetes on breast cancer, but there was a stronger risk reduction among non-obese women (OR 0.51, 95% CI 0.34-0.77) than obese women (OR 0.69, 95% CI 0.50-0.94) (p for interaction=0.25). The inverse association was more pronounced for ER positive breast cancer (OR 0.51, 95% CI 0.37-0.70) than ER negative breast cancer (OR 0.84, 95% CI 0.51-1.37). However, the difference was not statistically significant. Conclusions: In this large case-control study among black women, we found the first evidence suggesting a significant inverse association between diabetes and postmenopausal breast cancer risk. Future studies are needed to confirm our findings and to evaluate the underlying mechanisms, particularly regarding metformin use. Citation Format: Maureen Sanderson, Loren Lipworth, David Shen-Miller, Martha J. Shrubsole, Alicia Beeghly-Fadiel, Sarah Nechuta, Xiao-ou Shu, Wei Zheng. Interaction of diabetes and obesity in postmenopausal breast cancer risk among black women. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A58.

Abstract A33: Pizza and pasta consumption levels in relation to lycopene and other antioxidant nutrients status among a low-income population in Southeast USA

Abstract Purpose: Lycopene is regarded as a promising antioxidant, potentially protective against chronic diseases such as certain cancers. Unlike other antioxidant nutrients, lycopene mostly comes from tomato based processed foods, rather than from fresh vegetables and fruits. Herein we examine whether foods rich in lycopene offer a full spectrum of antioxidant nutrients needed for chronic disease prevention. Methods: Serum levels of lycopene and other antioxidant nutrients were measured in a representative cross-sectional sample of low-income Blacks (n=189) and Whites (n=183) age 40-79 years participating in the Southern Community Cohort Study (SCCS). Dietary intakes of lycopene, other nutrients, and individual foods were ascertained via a food frequency questionnaire (FFQ). Results: Pizza and pasta showed the strongest correlation with dietary lycopene (adjusted for age and total calories, R spearman = 0.54, P&amp;lt;0.0001), and were the only food sources significantly correlated with serum lycopene (adjusted for age and LDL-cholesterol, R spearman = 0.14, P=0.007). Across pizza and pasta consumption tertiles, estimated dietary lycopene intake increased from 4147±305 to 4983±287 to 8208±301 mcg (P&amp;lt;.0001) per day while serum lycopene concentrations were 27.8±1.3, 32.7±1.3 and 32.0±1.2 mcg (P=.01). There were no significant differences in key socio-demographic and lifestyle variables, except for slightly younger age in the highest tertile. Total caloric intake increased substantially with tertiles of consumption of pizza and pasta, rising from 1965±18 to 2294±114 to 3242±114 kcal (P&amp;lt;.0001). Adjusted for age and total calories, the consumption of protein, saturated fat, and trans fat were increased significantly at tertile 3 compared to tertile 1 and tertile 2 (e.g., saturated fat rose from 27.5±0.7 to 27.9±0.7 to 32.1±0.7 g, P&amp;lt;.0001), whereas fiber and sugar intake levels did not differ significantly across the tertiles. For micronutrients, the sodium and sodium to potassium ratio were much higher in tertile 3 than those in tertile 1 and tertile 2 (e.g., sodium tertile levels were 4179±90, 4095±85, 4635±89 mg, P&amp;lt;.0001). The majority of other antioxidant nutrients' intake levels, however, did not vary across tertiles, or even decreased significantly with higher intake of pizza and pasta (e.g., folate declined from 310.3±8.3 to 302.6±7.8 to 270.8±8.2 mcg, P=.003). Similarly, serum concentrations of other major antioxidants either did not change significantly or even decreased across tertiles of pizza and pasta (e.g., serum concentrations of carotene declined from 16.8±1.4 to 12.8±1.4 to 10.3±1.4 µg/dl, P=.0005). Conclusion: In the current study, pizza and pasta were shown to be the main contributors to dietary lycopene and predictive of serum lycopene levels. Pizza and pasta as consumed by the SCCS participants, however, may offer less antioxidation protection than expected based on their lycopene content alone, since such meals provide higher calories, more unhealthy fat and less overall antioxidants. Citation Format: Yuan Eva Zhou, Maciej S. Buchowski, David G. Schlundt, William J. Blot, Margaret K. Hargreaves. Pizza and pasta consumption levels in relation to lycopene and other antioxidant nutrients status among a low-income population in Southeast USA. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A33.

Abstract 310: Neighborhood Socioeconomic Context Predicts Cardiac Rehabilitation Participation Above and Beyond Individual Socioeconomic Status

Background: Cardiac rehabilitation (CR) is underutilized in the United States, with less than 20% of eligible patients participating in CR programs. Individual socioeconomic status is associated with CR utilization, but the effect of neighborhood socioeconomic context on CR use has not been described. We investigated the association of CR participation with neighborhood socioeconomic context in the Southern Community Cohort Study (SCCS). Methods: The SCCS is a prospective cohort study of 84,569 largely poor adults in the southeastern United States, of which 52,117 participants have Medicare or Medicaid claims. Using these claims data, we identified SCCS participants with hospitalizations for myocardial infarction, percutaneous coronary intervention, coronary artery bypass surgery or cardiac valve surgery and ascertained their CR utilization. Neighborhood socioeconomic context was assessed using a previously validated neighborhood deprivation index. This index was derived using 11 census-tract level variables including median household value and percentage of households with public assistance income. We used multivariable-adjusted logistic and Cox regression to evaluate the association of CR participation with neighborhood socioeconomic context and mortality. Results: A total of 4456 SCCS participants (56% female, 59% Black) were eligible for CR at a mean age of 60.5 + 9.1 years and an average of 4.0 + 2.5 years after study enrollment. CR utilization was low as expected, with 308 subjects (6.9%) participating in CR programs. CR participation is inversely associated with all-cause mortality (hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.39-0.70, p=&lt;0.0001) and cardiovascular disease (CVD) mortality (HR 0.38, 95% CI 0.22-0.65, p=&lt;0.001) after multivariable adjustment. Neighborhood socioeconomic context is strongly associated with CR participation after adjustment for individual socioeconomic status (educational level and household income) as well as rural status (Table). Conclusions: Neighborhood socioeconomic context predicts CR participation in addition to individual socioeconomic status. These data invite research on interventions to increase CR access in deprived communities.

Suicides, homicides, accidents, and other external causes of death among blacks and whites in the Southern Community Cohort Study.

Prior studies of risk factors associated with external causes of death have been limited in the number of covariates investigated and external causes examined. Herein, associations between numerous demographic, lifestyle, and health-related factors and the major causes of external mortality, such as suicide, homicide, and accident, were assessed prospectively among 73,422 black and white participants in the Southern Community Cohort Study (SCCS). Hazard ratios (HR) and 95% confidence intervals (CI) were calculated in multivariate regression analyses using the Cox proportional hazards model. Men compared with women (HR = 2.32; 95% CI: 1.87–2.89), current smokers (HR = 1.74; 95% CI: 1.40–2.17), and unemployed/never employed participants at the time of enrollment (HR = 1.67; 95% CI 1.38–2.02) had increased risk of dying from all external causes, with similarly elevated HRs for suicide, homicide, and accidental death among both blacks and whites. Blacks compared with whites had lower risk of accidental death (HR = 0.46; 95% CI: 0.38–0.57) and suicide (HR = 0.55; 95% CI: 0.31–0.99). Blacks and whites in the SCCS had comparable risks of homicide death (HR = 1.05; 95% CI: 0.63–1.76); however, whites in the SCCS had unusually high homicide rates compared with all whites who were resident in the 12 SCCS states, while black SCCS participants had homicide rates similar to those of all blacks residing in the SCCS states. Depression was the strongest risk factor for suicide, while being married was protective against death from homicide in both races. Being overweight/obese at enrollment was associated with reduced risks in all external causes of death, and the number of comorbid conditions was a risk factor for iatrogenic deaths. Most risk factors identified in earlier studies of external causes of death were confirmed in the SCCS cohort, in spite of the low SES of SCCS participants. Results from other epidemiologic cohorts are needed to confirm the novel findings identified in this study.

Discordance between Self-Report and Genetic Confirmation of Sickle Cell Disease Status in African-American Adults

Background: Sickle cell disease (SCD) is an autosomal recessive genetic disorder, with persons heterozygous for the mutation said to have the sickle cell trait (SCT). Serious adverse effects are mainly limited to those with SCD, but the distinction between disease and trait is not always clear to the general population. We sought to determine the accuracy of self-reported SCD when compared to genetic confirmation. Methods: From stratified random samples of Southern Community Cohort Study participants, we sequenced the β- globin gene in 51 individuals reporting SCD and 75 individuals reporting no SCD. Results: The median age of the group selected was 53 years (range 40-69) with 29% male. Only 5.9% of the 51 individuals reporting SCD were confirmed by sequencing, with the remaining 62.7% having SCT, 5.9% having hemoglobin C trait, and 25.5% having neither SCD nor trait. Sequencing results of the 75 individuals reporting no SCD by contrast were 100% concordant with self-report. Conclusions: Misreporting of SCD is common in an older adult population, with most persons reporting SCD in this study being carriers of the trait and a sizeable minority completely unaffected. The results from this pilot survey support the need for increased efforts to raise community awareness and knowledge of SCD.

Neighborhood socio-economic characteristics, African ancestry, and Helicobacter pylori sero-prevalence.

The authors recently reported high Helicobacter pylori sero-prevalence among African-Americans of high African ancestry. We sought to determine whether neighborhood-level socio-economic characteristics are associated with H. pylori prevalence and whether this helps explain the link between African ancestry and H. pylori. Antibodies to H. pylori proteins were assessed in the serum of 336 African-American and 329 white Southern Community Cohort Study participants. Prevalence odds ratios (ORs) and 95% confidence intervals (CIs) for CagA+ and CagA- H. pylori were calculated using polytomous logistic regression in relation to 10 Census block group-level measures of socio-economic status. After adjusting for individual-level characteristics, three neighborhood-level factors were significantly inversely related to CagA+ H. pylori: percent completed high school; median house values; and percent employed (comparing highest to lowest tertile, OR, 0.47, 95% CI, 0.26-0.85; OR, 0.56, 95% CI, 0.32-0.99; and OR, 0.59, 95% CI, 0.34-1.03, respectively). However, accounting for these measures did not attenuate the association between African ancestry and CagA+ H. pylori, with African-Americans of low, medium, and high African ancestry maintaining two-, seven-, and ninefold increased odds, respectively, compared to whites. Neighborhood-level measures of education, employment, and house values are associated with CagA+ H. pylori sero-prevalence, but do not explain the persistent strong relationship between African ancestry level and CagA+ H. pylori. The findings suggest that neighborhood socio-economic status can help to highlight high-risk areas for prevention and screening efforts and that the link between African ancestry and H. pylori may have a biological basis.