Colorectal cancer is the third most diagnosed cancer and second leading cause of cancer related deaths in Canada. As Ontario has the largest population in Canada, it also has great disparities in colorectal cancer incidence. The region of Timiskaming has the highest incidence for colorectal cancer, while the region of Peel has the lowest incidence for colorectal cancer in Ontario. The purpose of this study is to identify the dominant non-nutritional modifiable environmental risk factors in the region of Timiskaming compared to the region of Peel that may be associated with diverging colorectal cancer incidence rates. The three objectives of the study included performing a systematic review on available published literature, creating an assessment questionnaire tool regarding environmental exposures, and utilizing the questionnaire assessment tool within a pilot study group while expanding it into the communities of interest. Findings indicate that there are dominant non-nutritional modifiable environmental risk factors in the regions of Timiskaming and Peel that may be associated with colorectal cancer. The dominant factors identified are tobacco/smoking, alcohol use, pesticides/organochlorines, and metal toxins. Following this study, it is imperative that recommendations are directed at a community level and relate to the assessment of potential non-nutritional modifiable environmental risk factors. Future research should accompany a larger sample size, multiple participant communities, and catering of the questionnaire tool towards the communities of interest. / UOIT

Striking differences exist between countries in the incidence of breast cancer, with rates higher in the West than in Asian countries. The causes of these differences are unknown, but because incidence rates change in migrants, they are thought to be due to lifestyle rather than genetic differences. The objective of this thesis was to compare established breast cancer risk factors, physical activity, and diet in three groups of postmenopausal women at substantially different risks of developing breast cancer – Caucasians (N = 413), Chinese born in the West or who migrated to the West before age 21 (N = 216), and recent Chinese migrants, 99% of whom coming from urban China (N = 421). In this cross-sectional study, information on risk factors and diet were collected by telephone, and physical activity and anthropometric data were obtained at a home visit. Compared to Caucasians, recent Chinese migrants weighed on average 14 kg less, were 6 cm shorter, had menarche a year later, were more often parous, and less often had a family history of breast cancer or a benign breast biopsy. Estimating 5-year absolute breast cancer risks using the Gail Model showed that risk estimates in Caucasians would be reduced by only 11% if they had the risk factor profile of recent Chinese migrants for the variables in the Gail Model. Compared to Caucasians, recent Chinese migrants had lower average total physical activity over lifetime, and also spent less time on moderate- and vigorous-intensity activity. Compared to Caucasians, recent Chinese migrants consumed per day on average 175 fewer calories, 6 more grams of energy-adjusted protein, 16 more grams of energy-adjusted carbohydrates, and 5 fewer grams of energy-adjusted fat. Also, recent Chinese migrants consumed higher amounts of grains, fruits, vegetables, fish, and soy products, and lower amounts of alcohol, meat, dairy products, and sweets than Caucasians. Western born Chinese and early Chinese migrants had values intermediate between the other two groups for most of the variables. These results suggest that in addition to the established risk factors, some dietary factors may also contribute to the lower breast cancer risk in urban Chinese women.

Many children and their families who seek assistance for childhood behaviour disorders experience comorbid disorders, namely the presence of two or more disorders. Although comorbid disorders are recognized as a frequent clinical complication, minimal direction exists within the literature about the risk factors for comorbid conditions and how best to provide intervention services. In this study an ecological framework was used to compare the individual, family, and community environmental contexts of young girls who presented at intake at a children’s mental health centre with comorbid externalizing and internalizing disorders, and girls who presented at intake with externalizing disorders only. The treatment response to a cognitive-behavioural intervention for externalizing behaviour disorders was examined, by comparing externalizing scores over time between girls with comorbid externalizing and internalizing disorders and girls with externalizing disorders only. Additionally, internalizing scores over time for girls with comorbid disorders were examined. Results indicated that a history of abuse and a cluster of individual characteristics placed girls at higher risk to present with comorbid conditions. The results also indicated that girls with comorbid disorders experienced a reduction of both externalizing and internalizing symptoms. Only 1 in 7.4 girls, however, scored below the clinical range for both externalizing and internalizing disorders at the end of the treatment phase, in comparison to 1 in 5 girls scoring below the clinical range for externalizing disorders in the noncomorbid group.

Access to abstract permanently restricted to Ball State community only / Access to thesis permanently restricted to Ball State community only / School of Physical Education, Sport, and Exercise Science

Striking differences exist between countries in the incidence of breast cancer, with rates higher in the West than in Asian countries. The causes of these differences are unknown, but because incidence rates change in migrants, they are thought to be due to lifestyle rather than genetic differences. The objective of this thesis was to compare established breast cancer risk factors, physical activity, and diet in three groups of postmenopausal women at substantially different risks of developing breast cancer – Caucasians (N = 413), Chinese born in the West or who migrated to the West before age 21 (N = 216), and recent Chinese migrants, 99% of whom coming from urban China (N = 421). In this cross-sectional study, information on risk factors and diet were collected by telephone, and physical activity and anthropometric data were obtained at a home visit. Compared to Caucasians, recent Chinese migrants weighed on average 14 kg less, were 6 cm shorter, had menarche a year later, were more often parous, and less often had a family history of breast cancer or a benign breast biopsy. Estimating 5-year absolute breast cancer risks using the Gail Model showed that risk estimates in Caucasians would be reduced by only 11% if they had the risk factor profile of recent Chinese migrants for the variables in the Gail Model. Compared to Caucasians, recent Chinese migrants had lower average total physical activity over lifetime, and also spent less time on moderate- and vigorous-intensity activity. Compared to Caucasians, recent Chinese migrants consumed per day on average 175 fewer calories, 6 more grams of energy-adjusted protein, 16 more grams of energy-adjusted carbohydrates, and 5 fewer grams of energy-adjusted fat. Also, recent Chinese migrants consumed higher amounts of grains, fruits, vegetables, fish, and soy products, and lower amounts of alcohol, meat, dairy products, and sweets than Caucasians. Western born Chinese and early Chinese migrants had values intermediate between the other two groups for most of the variables. These results suggest that in addition to the established risk factors, some dietary factors may also contribute to the lower breast cancer risk in urban Chinese women.

Many children and their families who seek assistance for childhood behaviour disorders experience comorbid disorders, namely the presence of two or more disorders. Although comorbid disorders are recognized as a frequent clinical complication, minimal direction exists within the literature about the risk factors for comorbid conditions and how best to provide intervention services. In this study an ecological framework was used to compare the individual, family, and community environmental contexts of young girls who presented at intake at a children’s mental health centre with comorbid externalizing and internalizing disorders, and girls who presented at intake with externalizing disorders only. The treatment response to a cognitive-behavioural intervention for externalizing behaviour disorders was examined, by comparing externalizing scores over time between girls with comorbid externalizing and internalizing disorders and girls with externalizing disorders only. Additionally, internalizing scores over time for girls with comorbid disorders were examined. Results indicated that a history of abuse and a cluster of individual characteristics placed girls at higher risk to present with comorbid conditions. The results also indicated that girls with comorbid disorders experienced a reduction of both externalizing and internalizing symptoms. Only 1 in 7.4 girls, however, scored below the clinical range for both externalizing and internalizing disorders at the end of the treatment phase, in comparison to 1 in 5 girls scoring below the clinical range for externalizing disorders in the noncomorbid group.

Background - Current guidelines suggest that all cancer patients with venous thrombosis be treated with long-term low molecular weight heparin. Whether treatment strategies should vary according to clinical characteristics remains unknown. // Systematic review - A systematic review was performed to determine current understanding of the association between malignancy characteristics in patients with cancer-associated VTE and the risk of VTE recurrence. Four retrospective and 6 prospective studies were included. They suggest that lung cancer, metastases, and adenocarcinomas confer an increased the risk of recurrence and breast cancer a low risk. // Survey - I performed survey to evaluate thrombosis experts’ opinion about the low risk of VTE recurrence they would consider acceptable for patients with cancer- associated thrombosis 103 specialists participated. 80% of respondents agreed that a risk of recurrent VTE during anticoagulation below 7% is low enough. 92% agreed that a CPR that categorizes risk of recurrence is relevant. // Retrospective Study - I performed a single retrospective cohort study to assess the feasibility of derivation of a CPR that stratifies VTE recurrence risk in patients with cancer–associated thrombosis. The study included 543 patients. A multivariate analysis selected female, lung cancer and prior history of VTE as high risk predictors and breast cancer and stage I disease as low risk. // Conclusion - Patients with cancer-associated thrombosis do have varying risks of recurrent VTE depending on clinical characteristics.

The association between pain and depression is well documented across various populations, but not in puerperal women. This study examined the association of childbirth pain with postpartum depression (PPD) in a nationally representative sample of Canadian women. Data from the Canadian Maternity Experiences Survey (n=6421) was used. Multivariate logistic regressions and partial proportional odds models were fitted and included socio-demographic, obstetric, health, psychological, and psychosocial factors. Chronic pain sufferers at mean 7.3 months postpartum had adjusted odds of PPD of 2.4 (95% CI: 1.6, 3.6) compared to women without pain. Adjusted odds of PPD increased with the number of areas of chronic pain, reaching 4.2 (95% C.I.: 0.7, 25.0) for 3 or more areas. Immigration, obesity, cesarean section and social support increased the strength of the association while smoking and the use of pain relief were protective effect modifiers. Persistent postpartum pain is a major risk factor for PPD.

The central scientific objective of the current dissertation was to take a multidisciplinary approach to make use of the full potential information, both scientific and clinical to aid prevention and treatment of EDs. In our studies we assessed a.) social and individual risk factors in EDs (Study 1), b.) empirical ED subtypes based on drive for thinness (DT) and depression (Study 2) and c.) the classification based on these four different empirical ED subtypes without cluster analysis and based on the use of clinical cutoff scores of DT and depression. Finally, we assessed the predictive validity for this subtyping scheme with regard to dropout from CBT in an unselected BN-P population seeking treatment. Our first line of investigation (Study 1) assessed social and self-standards in EDs. The results of the study suggest that compared to healthy controls, standards for physical appearance, family standards and self-achievements were higher in individuals with EDs, that ED patients show higher self-discrepancy between their personal and social values and confidence to attain them and that the conflict with their significant others over these issues was higher. Furthermore, high social and self-standards was associated with developing an ED, which emphasize the importance of assessing risk factors in ED. Finally we also observed differences in the ED subtypes; physical appearance a greater risk factor in BN and EDNOS while social-other standards were more associated with AN. The second research area (Study 2 and 3) explored new empirical ED subtypes along DT and depression. In our initial study (Study 2) we found four new ED subtypes through cluster analysis; “DT”, “DT-Depressive”, “mild DT” and “depressive-moderate DT”. This result indicates that dieting and depression are useful for analyzing and identifying ED subtypes. Study 3 further assessed these empirical subtypes and found that the same subtypes emerged when basing them on scores from clinical well-validated questionnaires and moreover that attrition rates differed between subtypes and that the dropout rate was highest for the “DT-Depressive” subtype. Our findings agree with the growing body of research indicating the importance of dieting and comorbid depression as contributing factors in ED diagnoses. Finally, these findings will hopefully aid in resolving the current controversy surrounding current DSM-ED classifications. / El objetivo central de esta tesis ha sido, desde una perspectiva multidisciplinar, integrar los conocimientos clínicos y científicos para contribuir en el avance de la prevención y tratamiento de los Trastornos de la Conducta Alimentaria (TCA). En estos estudios, se han explorado una serie de aspectos como a) factores de riesgo sociales e individuales en los TCA (estudio 1), b) identificación de subtipos empíricos de los TCA, basados en el impulso a la delgadez y la realización de dietas y la depresión (estudio 2), y c) asociación entre los cuatro subtipos de TCA, basados en los factores descritos, y respuesta a un abordaje cognitivo-conductual, en una población con diagnóstico de bulimia nerviosa purgativa (BN-P), que solicitaron tratamiento por su trastorno (estudio 3). Nuestra primera línea de investigación (estudio 1) analizó la implicación de las expectativas sociales e individuales en los TCA. Los resultados de este trabajo sugirieron que las expectativas familiares, individuales y las relacionadas con la apariencia física, eran superiores en pacientes con TCA que en sujetos control. Asimismo, los pacientes con diagnóstico de TCA mostraban mayor discrepancia entre sus valores personales y sociales, menor confianza en poder alcanzarlos y mayor conflicto con sus familiares por estas cuestiones. Por otra parte, la presencia de elevadas expectativas sociales y personales se asociaba al desarrollo de un TCA, lo que enfatizaba la importancia de evaluar estos factores de riesgo. Finalmente, se observaron diferencias significativas entre los subtipos de TCA, siendo la apariencia física un factor de riesgo más presente en BN y en trastornos de la conducta alimentaria no especificados (TCANE), mientras que otras expectativas sociales se asociaban más a la anorexia nerviosa (AN). La segunda línea de investigación (estudios 2 y 3) exploraba nuevos subtipos empíricos de TCA, teniendo en cuenta las variables de impulso a la delgadez y realización de dietas (ID) y la depresión (D). En el primer trabajo (estudio 2), se obtuvieron cuatro nuevos subtipos a través de un análisis de cluster. Los subgrupos fueron “ID”, “IDDepresivo”, “ID moderado” y “D-ID moderado”. Estos resultados mostraban que la realización de dietas y la depresión eran útiles en el análisis e identificación de subtipos en los TCA. En el estudio 3 se exploraban estos subtipos con mayor profundidad, observando que se obtenían los mismos subgrupos, cuando nos basábamos en las puntuaciones de diversos cuestionarios clínicos validados. Asimismo, la respuesta al tratamiento era distinta en función de los subtipos de TCA, presentando tasas de abandonos más elevadas el subtipo “ID-Depresivo”. De este modo, los resultados estaban en concordancia con las evidencias empíricas, cada vez mayores, que indican la importancia de la realización de dietas y la depresión comórbida como factores que contribuyen a explicar características diagnósticas en los TCA. Finalmente, estos hallazgos podrían tener una relevancia destacada en la controversia actual sobre las clasificaciones diagnósticas en el próximo DSM. / L’objectiu central d’aquesta tesi ha estat, des d’una perspectiva multidisciplinar, integrar els coneixements clínics i científics per a contribuir a l’avenç de la prevenció i tractament dels trastorns de la conducta alimentària (TCA). En aquests estudis, s’han explorat una sèrie d’aspectes com a) factors de risc socials i individuals en els TCA (estudi 1), b) identificació de subtipus empírics dels TCA, i c) associació entre els quatre subtipus de TCA, basats en els factors descrits, i resposta a un abordatge cognitivoconductual, en una població amb diagnòstic de bulímia nerviosa purgativa (BN-P), que varen sol•licitar tractament pel seu trastorn (estudi 3). La nostra primera línia de recerca (estudi 1) va analitzar la implicació de les expectatives socials i individuals en els TCA. Els resultats d’aquest treball varen suggerir que les expectatives familiars, individuals i les relacionades amb l’aparença física, eren superiors en pacients amb TCA que en subjectes control. Alhora, els pacients amb diagnòstic de TCA mostraven major discrepància entre els seus valors personals i socials, menor confiança en poder aconseguir-los i major conflicte amb els seus familiars per aquestes qüestions. Per altra banda, la presència d’elevades expectatives socials i personals s’associava al desenvolupament d’un TCA, fet que emfatitzava la importància d’avaluar aquests factors de risc. Finalment, es varen observar diferències significatives entre els subtipus de TCA, sent l’aparença física un factor de risc més present en BN i en trastorns de la conducta alimentària no especificats (TCANE), mentre que altres expectatives socials s’associaven més a l’anorèxia nerviosa (AN). La segona línia de recerca (estudis 2 i 3) explorava nous subtipus empírics de TCA, tenint en compte les variables d’impuls a estar prim i realització de dietes (ID) i la depressió (D). En el primer treball (estudi 2), es varen obtenir quatre nous subtipus a través d’una anàlisi de cluster. Els subgrups foren “ID”, “ID-Depressiu”,“ID moderat” i “D-ID moderat”. Aquests resultants mostraven que la realització de dietes i la depressió eren útils en l’anàlisi i identificació de subtipus en els TCA. En l’estudi 3 s’exploraven aquests subtipus amb major profunditat, observant que s’obtenien els mateixos subgrups, quan ens basàvem en les puntuacions de diversos qüestionaris clínics validats. Alhora, la resposta al tractament era diferent en funció dels subtipus de TCA, presentant taxes d’abandonament més elevades el subtipus “IDDepressiu”. D’aquesta manera, els resultats estaven en concordança amb les evidències empíriques, cada vegada més grans, que indiquen la importància de la realització de dietes i la depressió comòrbida, com a factors que contribueixen a explicar les característiques diagnòstiques en els TCA. Finalment, aquestes troballes podrien tenir una rellevància destacada en la controvèrsia actual sobre les classificacions diagnòstiques en el proper DSM.

Objective: To compare individual risk behaviors in African American, Whites, and Hispanic women as found in the literature and support those findings by analyzing date available through NHANES in order to find out if the higher rate of HIV infection in African American women is a direct result of higher risk behaviors. Those risk behaviors include lower rates of condom use, higher rates of drug use including those taken intravenously, higher rates of risky sex habits, higher number of sexual partners over their lifetime, and a more extensive history of sexually transmitted infection. This study also aims to draw attention to larger factors that may foster the conditions for increased HIV rates in African American women. Results: The perception that higher rate of HIV infection is the result of increased risk factors among African American women is not supported either in the literature or in the analysis of NHANES data. For instance, results from data analysis found that African American women had fewer average sexual partners (P ≤ 0.05), lower overall rate of drug use (P ≤ 0.01), lower rates of risky sexual practices (P ≤ 0.01), but more likely to report a history of STIs (P ≤ 0.01) than Whites. The literature also confirmed that current HIV testing recommendations do not cover a large enough portion of the population to make significant impact on HIV incidence. In addition, socioeconomic situations further exacerbate the condition favorable to transmitting the disease. Conclusion: Methods that rely on individual risk behaviors alone may not be enough to reduce HIV rates in African American women, though those methods may be work in MSM. Socioeconomic programs that address disparities and testing recommendations that cover more people are needed in order to drive down HIV infection rates in African American women.