The aim of this dissertation was to explore the determinants of bone mineral density and weight change in a fit, college-aged population. Specifically, this dissertation is a series of four papers that examined the determinants of bone mineral density (BMD) at multiple skeletal sites in men and women at college entrance, BMD differences related to prior participation in sports, and lastly, weight changes in women during four years at university. The subjects were 891 students, 755 males and 136 females of various racial backgrounds, entering one class at the United States Military Academy (USMA) at West Point. This was a unique population because these college students are healthier, fitter and engage in more positive health behaviors than other college populations. The data for these papers came from a larger Department of Defense funded prospective study examining longitudinal changes in BMD and the risk factors for stress fractures. Upon arrival at USMA, a baseline questionnaire assessed prior exercise frequency, consumption of milk and other high calcium foods, caffeine and alcohol consumption, as well as tobacco and oral contraceptive use. Annual surveys assessed diet, menstrual function and contraceptive use. Academy staff measured height, weight and fitness annually. Varsity level sport specific information was collected from high school applications to assess skeletal differences in BMD associated with prior sport participation. Calcaneal BMD was measured by peripheral dual energy x-ray absorptiometry (pDXA). Peripheral-quantitative computed tomography (pQCT) was used to measure tibial bone density, circumference and cortical thickness. Spine and hip BMD were measured in all women and a subset of male cadets. Body composition was assessed using bio-electrical impedance. The Eating Disorder Inventory-2 was given to all participants in their final year of university to assess eating behaviors. Baseline BMD was approximately one standard deviation above young normal at the calcaneus and hip. There were significant gender and racial differences in baseline BMD at multiple skeletal sites. African American men had significantly higher hip, spine and heel BMD and greater tibial mineral content and cortical thickness than Caucasians and Asians men. Similarly, African American women had significantly higher calcaneal and spine BMD than Caucasians. Higher caffeine intake in men had a deleterious effect on BMD. Oral contraceptive use in women was associated with reduced BMD and bone size. Women who had approximately normal menstrual cycles evidenced higher BMD at all sites, greater tibial mineral content and tibial cortical thickness as compared to those who had 9 or less menstrual cycles in the year prior to entry. Sport specific differences in BMD were apparent. Prior participants of high loading sports (football) had significantly more BMD at multiple sites while participants in non-loading sports (swimming) had less BMD as compared to participants in other sports, even after controlling for body mass index (BMI). During their four years at university, the Caucasian women studied had small but significant weight, body fat and BMI increases, while fitness scores also significantly increased. Younger age of menarche was associated with increased body fat at graduation. The use of depot medroxyprogesterone acetate was positively associated with a change in body fat at graduation. A number of measures of eating disorders, including a sense of ineffectiveness, body dissatisfaction, interpersonal distrust and maturity fears, were associated with graduation weight, body composition, BMI and changes in these variables during the four years at university. The most significant predictors of graduation weight and change in weight were better performance on the standardized fitness test and entry weight. There was a small subset of women studied who gained weight, but not body fat. This study on weight change demonstrated that weight gain is a complex social, physical and psychological issue that can impact college-aged women. Both osteoporosis and obesity are life course diseases that may be influenced by existing behaviors in youth and those acquired in university. Therefore, studying the determinants of BMD and weight change in this population may help public health educators determine strategies that could positively influence the current obesity and osteoporosis epidemics.

Seasonality has a major effect on the spatiotemporal dynamics of natural systems and their populations and is a driving force behind the transmission of influenza in temperate regions. Although the seasonality of influenza in temperate countries is widely recognized, inter-state spread of influenza in the United States has not been well characterized. This dissertation characterized the seasonality of influenza throughout the United States by using monthly pneumonia and influenza (P and I) mortality to model inter-state movement of seasonal influenza in the continental United States between 1968 and 2008. The first chapter summarizes the current knowledge of the burden, morphology, and geography of influenza as well as limitations of prior studies. In the second chapter, weekly data on laboratory-confirmed influenza isolates from a national viral surveillance system (considered the "gold standard") is compared with weekly pneumonia and influenza (P and I) mortality data from a national mortality surveillance system in order to determine if the timing of mortality data correlated well with the timing of viral surveillance data and was, therefore, a good measurement for determining the timing of annual influenza epidemics. Sufficient viral surveillance data for influenza is not available for the majority of the study period and its quality most likely varies geographically. This made it necessary for this study to use mortality data as a substitute. It was, therefore, critical for this dissertation to assess the reliability of mortality data as a measurement to determine the timing of annual influenza waves. In the third chapter, an analysis of monthly P and I mortality data was conducted to identify an average underlying wave of seasonal influenza spread in the United States, the spatial and temporal patterns of seasonal influenza in the U.S. from 1968 to 2008, and the dependence of the timing and spread of influenza on the dominant circulating influenza type or subtype in a given influenza season. Source locations of influenza transmission in the U.S. were also identified. The dependence of the spread process of seasonal influenza in the U.S. on distance and/or population was assessed in chapter four. Additionally, spatial clusters of P and I mortality rates at different phases of an average influenza wave were identified. An assessment of the effect of the introduction or reintroduction of a novel influenza virus subtype on the spatiotemporal dynamics of influenza spread in the U.S. was performed in the fifth chapter. In the sixth and final chapter, I conclude by summarizing the findings of these four studies. This research found that P and I mortality was a valid measure used to assess the timing of influenza epidemics. Additionally, seasonal influenza in the U.S. typically began in November, peaked in February, and ceased in May. Annual influenza epidemics lasted an average of 6.7 months and produced a small, but significant southward traveling wave of influenza across the United States, originating from northern states in September-October and moving toward southern states over a 4-month period. H3N2-prominent seasons were significantly shorter and faster in progression than H1N1-prominent seasons. Moreover, influenza waves in the contiguous U.S. followed a general spatial contagion model, particularly at their peak, with high clusters of P and I rates found in Midwestern (North Dakota, Minnesota, South Dakota, Iowa, Nebraska, Kansas, Missouri, Arkansas, and Oklahoma), Southeastern (Kentucky, Tennessee, and West Virginia) and Northeastern States (New York, Vermont, Massachusetts, and Connecticut) at every phase of an epidemic. Finally, influenza waves that directly followed seasons that introduced or reintroduced a novel influenza subtype were significantly longer and slower in progression than the waves that introduced/reintroduced the novel virus. Identifying spatiotemporal patterns could improve epidemic prediction and prevention. This research determined the spatial and temporal characteristics of seasonal influenza in the U.S. and showed that these characteristics differed by dominant influenza subtype. Results of this research should aid public health professionals in refining influenza intervention strategies that include better placement and distribution of vaccines and other medicines.

Several studies in high-income countries (HIC) have shown that the experience of potentially traumatic events (PTE) is associated with increased health care service use. Information on patterns of health care use and expectations by this group of individuals can be useful for providing patient-centric care and improving health system accountability and responsiveness. Despite the necessity of this work, less research has been conducted in low and lower-middle income countries (LIC; LMIC), especially in countries with a recent history of conflict, which is problematic for several reasons. Experience of PTEs, especially assaultive violence and injuries, may be higher in LICs and LMICs compared to HICs, which may lead to poor physical and mental health and increased demand for health care services. The formal health care system in LICs and LMICs, especially in those countries emerging from conflict, however, may be in a process of renewal and improvement. Many necessary health services may remain unavailable for several years during this process, accountability is often lacking, and the health system may not have the capacity to respond to health care needs. Likely stemming from this lack of formal care, many LICs and LMICs have substantial informal care markets, and most individuals view both systems as complementary, despite the complete lack of regulation and training of informal care providers compared to formal care providers. In order for the formal care system to improve accountability and responsiveness, studies that assess the relation between PTE experience and use of both informal and formal care as well as patient preferences for formal care are critical. Such studies would shed light on where individuals with PTE experience are seeking care and what they expect from formal care. I conducted three investigations in order to better understand the association between experience of PTEs and health care service use in LICs and LMICs. In chapter one, I designed a systematic review of studies published on the topic using data from LICs and LMICs. I found only two studies that met eligibility criteria and suggested several considerations that future studies make, including the use of validated scales to measure PTE experience and the importance of including informal care use in this research. In chapter two, using cross-sectional, population-based data on adults from Nimba County, Liberia, I assessed the relation between lifetime PTE experience and formal and informal care service use. Lifetime PTE experience increased both formal and informal care use and most persons who experienced PTEs likely complemented their formal use with informal use. One exception to this latter finding was a small group of individuals who used no informal care, among whom a higher number of PTEs was associated with using formal care. In chapter three, using data from a discrete choice experiment carried out on the same sample of adults from Nimba county, I found that those with increased experience of PTEs had a higher preference for a facility that offered a high quality exam, had a lower preference for respectful treatment, and a higher preference for seeing a traditional healer instead of using the facility to obtain care when sick. Most individuals with increased experience of PTEs used both the informal and formal care system to meet their health care needs. Their reliance on the informal care system may be partially explained by symptoms of psychopathology, poor physical health, easier access to medications, and dissatisfaction with the formal care system. Higher preferences for a high quality medical exam and the traditional healer compared to formal clinics among those with high PTE experience suggest that the expectations of those arguably most in need of health care may not currently be met by the formal care system. Considering that informal care providers are untrained and unregulated, they are unlikely to provide adequate health care that can decrease disease burden in the population. It is likely that use of informal care reflects inadequate formal care; the formal care system must become more responsive to the needs of those with PTEs. There are several factors related to the PTE experience - health care use relation that merit further attention as well as several improvements that the formal care system should consider. One factor is whether mental health is a central reason why those with PTEs seek informal care. Currently, formal care providers in Liberia are unable to adequately treat mental health problems, which may be one reason why individuals rely on informal care providers. Whether this is a determinant of informal care use should be assessed by future studies as, if this is the case, then any referral program in which informal providers refer patients to formal care may not prove successful. Training formal care providers in treating mental health problems should be implemented, but another aspect that merits further research is whether informal care providers like traditional healers can be trained to screen for mental health problems or provide limited counseling services for individuals prior to giving referrals to alleviate some of the burden on formal care. Another aspect of future research should compare the access, perceptions, and expectations of both care systems of those who use only formal care to those who use both. Identifying whether these individuals have better access to formal care, whether they view formal care differently, or whether they have less access to informal care may improve formal care system responsiveness. Lastly the government of Liberia should continue improving access to the nearest facility, training providers to perform better exams, and improving the quality of clinics, including increasing the availability of medications and decreasing wait times, as these changes will likely increase use of formal care services by those with PTEs as well as the larger population.

Unintended pregnancy is prevalent and persistent in the United States, with significant public health costs. Paralleling disparities in other reproductive health outcomes, some population subgroups are more likely to have an unintended pregnancy than others. Use of highly effective contraceptive methods can reduce unintended pregnancy rates. Interventions to help those at highest risk of unintended pregnancy are of critical public health importance, yet few interventions have been found to significantly impact contraceptive method choice and use, and even fewer have been designed for populations with low educational attainment. The current dissertation research was designed to meet the need for interventions appropriate for women with low educational attainment, addressing a significant gap in the literature on interventions to improve contraceptive choice and use. A three-arm randomized controlled trial of a bilingual (Spanish/English) contraceptive assessment module using audio-computer-assisted self-interviewing technology and touchscreen computers was conducted from March 2008 - January 2011 among family planning patients seeking care at two federally-funded family planning clinics in New York City. The three-arm design was used to test separately the effect of the assessment module and the effect of tailored health materials: participants were randomized to complete the module and received health information materials tailored to their responses to the module questions (Intervention + Tailored); to complete the module and receive generic material (Intervention + Generic); or to a control condition (Control). Contraceptive method choice on the day of the family planning visit was the primary outcome. Follow-up analyses among a randomly-selected subset of patients examined secondary outcomes, including continuation and adherence to the chosen contraceptive method 4 months after the family planning visit. In intent-to-treat analyses adjusted for clinical recruitment site (n=2,231), family planning patients who used the module were significantly more likely to choose an effective contraceptive method (a method with fewer than 10 pregnancies among 100 women in one year typical use): 75% among those who received tailored materials [Intervention + Tailored OR=1.56 (95% CI: 1.23-1.98)] and 78% among those who received generic materials [Intervention + Generic OR=1.74 (95% CI: 1.35-2.25)], compared to 65% among control arm participants. Tailored health information materials, compared to generic materials, did not have significant impact on contraceptive method choice. These findings were consistent in as-treated analyses among participants who completed the module and data collection procedures on the day of their family planning visit, in analyses comparing different sources of outcome data, and in sensitivity analyses accounting for missing outcome data. In a subset of participants randomly selected for participation in a follow-up survey 4 months after their family planning visit (n=224), those in the Intervention + Tailored arm were significantly more likely to continue use of the contraceptive method chosen on the day of their family planning visit, with 95% continuing use, compared to 77% in the Control arm (OR adjusted for clinical site of recruitment = 5.48 [95%CI: 1.72-17.42]). No significant difference in continuation was found between the Intervention + Generic and Control arms. The dissertation research has numerous strengths. The easily replicable, single-session intervention was designed for use by populations with low educational attainment or low literacy skills. The randomized controlled trial included more than 2,000 family planning patients, half of whom were Spanish-speaking. Effectiveness research evaluating the impact of the intervention under "real-world" conditions of implementation, in a broadly defined population, is merited. Such evaluation should include measures not fully explored in this phase, including the impact of the module on provider visit time, and analyses of continuation and adherence outcomes over a longer period of time.

Despite decades of tremendous economic growth, health and longevity in the US has largely stalled in comparison with other high income countries. Traditional risk factors, such as access to healthcare, do not entirely explain this phenomenon leading some to question whether aspects of the US culture should be investigated. Materialism, an often cited characteristic of US culture, has been increasing since the 1960s and a growing body of research suggests materialism may harm psychological well-being and mental health. This dissertation investigated the association between materialism and physical health in order to determine whether materialism should be considered further as a potential explanation for the stalling health in the US. This study was conducted in three parts: a systematic review of the existing literature, an analysis of the association between materialism and self-reported health and chronic medical conditions, and a survival analysis to assess whether materialism affects longevity. The systematic review of the materialism literature identified gaps pertaining to the effect of materialism on physical health in particular. Overall, the analytic papers found little support for a meaningful effect of materialism on self-reported health, chronic medical conditions, or mortality. In addition, there was no support for meaningful mediation by psychological needs or effect modification by household income or education. However, there was some suggestion that materialism may affect self-reported health among young adults born in the 1970s and 1980s. Further research is needed to rule out a chance association and to monitor these young adults for health effects in later life.

People living with HIV in low- and middle-income countries, on average, initiate antiretroviral therapy (ART) in the advanced stages of the infection (i.e. when the CD4 cell count has dropped below the recommended threshold for ART initiation) despite more than a decade since the start of scale-up of ART [1-4]. Late ART initiation is associated with higher patient morbidity and mortality, increased risk of secondary transmission in the population and higher healthcare cost [5-10]. Knowledge of HIV status is a critical first step to initiate ART [11-14]. Yet, half of the people living with HIV in sub-Saharan Africa are not aware of their status [15]. The World Health Organization, the Joint United Nations Programme on HIV/AIDS and other institutions support adoption of active screening for HIV (i.e. testing asymptomatic people for HIV) to help identify and treat people living with HIV before progressing to the advanced stages of the infection [11, 14, 16, 17]. The role of active screening on earlier initiation of ART and patient survival has not been examined. In this dissertation, I reviewed and synthesized the literature to identify barriers to ART initiation operating in low- and middle-income countries. I examined the role of active screening on patient CD4 cell count at ART initiation (a measure of HIV-disease progression) and survival, and investigated patient CD4 cell count at ART initiation as a potential mediator of the active screening-patient survival association. The databases Ovid Medline, PsycINFO, CINAHL, Scopus and Cochrane Reviews were searched as part of the literature review. Of 265 articles reviewed, thirty-five met the eligibility criteria and were therefore selected for the review. Mixed linear regression models with random intercepts and Marginal Cox Proportional models with robust sandwich estimators of variance were fitted as part of the statistical analyses for this dissertation. Patient, programmatic, and contextual variables were considered for statistical adjustment. Data for the analyses came from twenty-nine HIV/AIDS care and treatment sites in Kenya, Uganda, and Tanzania participating in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) initiative. Patient level data were collected from 45,359 subjects who initiated ART between 2003 and 2008 in the twenty-nine sites. Site programmatic and contextual level data were collected via two structured questionnaires. The critical review of the literature led to the identification of 1) individual, programmatic and societal-level barriers to HIV testing, enrolling into care, and ART initiation; and 2) barriers pertaining to lack of knowledge of HIV/AIDS and ART (e.g. HIV/AIDS symptomatology, ART benefits, ART toxicity), limited accessibility to services, poor quality of services, shortage of staff, and HIV-related stigma as the most prominent barriers. Results of the analyses show that patients in sites with predominantly "Active Screening Entry Points" initiated ART, on average, with CD4 cell counts 24 cells/µL higher than patients in sites with mainly "non-Active Screening Entry Points." However, the gain in CD4 cell count did not translate into a statistically significant estimate of survival advantage for these patients [HR (95% CI): 0.82 (0.64 - 1.06)] though the results are in the expected directions. The modest gain in mean CD4 cell count, and the documented benefits of active screening (e.g. high acceptability, increased number of patients tested and higher rate of identification of previously undiagnosed people living with HIV) support adoption of this intervention particularly in regions with a high HIV burden and where a low proportion of the population is unaware of their HIV status.

Breast cancer is thought to develop through progression of benign breast lesions, atypical hyperplasia (AH) and/or carcinoma in situ (CIS). Benign breast disease (BBD) is a group of heterogeneous breast abnormalities. This dissertation investigated the association between BBD and breast cancer risk in order to determine whether BBD should be considered a causal intermediary or susceptibility marker of breast cancer risk. We addressed BBD as a modifier of risk in four parts: a comprehensive review of previous cohort studies examining the association between BBD and mammographic density, an analysis of interactions between BBD and established breast cancer risk factors, and validation of currently used risk assessment models in a population of women with BBD. We used two longitudinal cohorts to assess these relationships, the Early Determinants of Mammographic Density study and Woman At Risk registry. Mammographic density and BBD are both important risk factors of breast cancer. We found that women with a history of BBD on average had 3.5% higher percent density on their mammograms than women without a history of BBD. Women diagnosed with BBD prior to first pregnancy had 8.6% higher density than nulliparous women without a history of BBD. Few prior cohort studies have examined interactions between BBD and other breast cancer risk factors and all those that did only assessed multiplicative interactions, not additive interactions. BBD modified the association with parity and alcohol consumption. Nulliparous women with BBD had an almost 5-fold higher risk of breast cancer than nulliparous women without BBD. We found both multiplicative and additive interaction between alcohol use and BBD. Women with BBD who consumed alcohol had 2-fold higher risk of breast cancer compared to women without BBD who did not consume alcohol. We compared three widely used breast cancer risk assessment models, the Gail model, the International Breast Cancer Intervention Study (IBIS), and the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA). Mean estimated breast cancer risk based on IBIS model was significantly higher for women with any BBD as compared to mean predicted risk in Gail and BOADICEA models (IBIS 5.84%, Gail 4.79%, and BOADICEA 3.71%; p<0.001 for all pairwise comparisons). All three models tended to under predict the number of breast cancer events in our cohort. Discrimination was also poor in all three models, for the total population, women with BBD and women with atypical hyperplasia. Overall, we found an association between BBD and mammographic density, as well as interactions between BBD and parity, and BBD and alcohol use. Furthermore, current breast cancer risk models have moderate calibration and discrimination in a population of women with BBD, and we saw that differences in calibration depended on type of BBD. Risk assessment models should include not only BBD, but also the interactions between BBD and other risk factors in order to adequately predict subsequent risk of breast cancer. Current breast cancer screening guidelines recommend against MRI or conclude there is insufficient evidence to make decisions regarding MRI screening in women with BBD, even though these women are known to be at a higher risk of breast cancer. Improving breast cancer risk models by including BBD, mammographic density, and their interaction could improve risk assessment and as a result improve screening and clinical care of these women. Results from this dissertation support that BBD is more likely to be a susceptibility marker of breast cancer risk than a true precursor lesion. This suggests that changes in the BBD tissue that occur are more likely due to genetic or epigenetic factors that cause the breast to be more susceptible to the effects of other breast cancer risk factors.

Evidence has been mounting that exposures during fetal development and early postnatal life are important determinants of many adult health outcomes including. diabetes, obesity and cardiovascular disease. Critical periods of early development have been identified for certain outcomes. Early life factors are suspected as having a role in cognitive and psychiatric outcomes, but research to date is limited. Birth weight, considered a marker for fetal development, has been positively associated with cognitive abilities. A few postnatal studies provide evidence that early childhood height growth, an indicator of overall development, is also positively associated with cognitive abilities in adults under age 25 years. There has been no research on early childhood height growth and cognitive outcomes in middle age adults. Low birth weight has also been associated with a spectrum of neuropsychiatric disorders, including, in one study, affective disorders. There are no known studies of early childhood height growth and neuropsychiatric disorders. With this background, I made two hypotheses. First, I hypothesized that early childhood height growth is positively associated with working memory ability in middle age adults. Second, I hypothesized that early childhood height growth is inversely associated with lifetime major depressive disorder in middle age adults. I also explored effect modification by sex and by small for gestational age status. I tested these hypotheses using data from the Early Determinants of Adult Health (EDAH) study and its sister study Fetal Antecedents of Major Depression and Cardiovascular Disease (MDCVD). These studies were adult follow-up studies of two birth cohorts recruited in the 1960’s: the Child Health and Development Studies (CHDS) and the New England Family Study (NEFS); both followed subjects from birth through childhood. Birth length and successive early childhood height measures were available enabling a study of three height growth periods, birth to 4 months, 4 months to 1 year and 1 to 4 years. The adult follow up study included 4 measures of different aspects of working memory ability as well as a structured interview that assessed neuropsychiatric outcomes including lifetime major depressive disorder. We found some evidence that early childhood height growth was positively associated with adult working memory ability in specific growth periods. Results of the analysis of early childhood height growth and adult lifetime MDD do not support the association between early childhood height growth and lifetime MDD.

INTRODUCTION: Polycystic ovary syndrome (PCOS) is characterized by hyperandrogenemia, oligoanovulation, and numerous ovarian cysts. Although the most common cause of female factor infertility, its characteristics and metabolic risks are difficult to study due to its heterogeneity. Additionally, ethnic-specific data is scarce. Hospital electronic medical records and the diverse patient population at Boston Medical Center (BMC) may provide an avenue for investigating the longitudinal nature of PCOS and its race-specific characteristics. OBJECTIVES: 1. Describe the Clinical Data Warehouse (CDW) dataset available for studying PCOS. 2. Develop an automated method for extracting ovarian features from written ultrasound reports. 3. Identify PCOS patients from their record of the three cardinal PCOS features. METHODS: Patients evaluated on at least one of the three cardinal PCOS features, between October 1, 2003 and September 30, 2015 were queried from the BMC CDW. This thesis describes methods for cleaning the data, as well as the development of an ultrasound classifier based on natural language processing techniques. RESULTS: On a validation set of 1000 random ultrasounds, the automatic ultrasound classifier had a recall and precision for the presence of PCOM, 99.0% and 94.2%, respectively. Overall, 2421 cases of PCOS were identified, with 1010 not receiving a diagnosis. Black patients had twice the odds of being underdiagnosed compared to White patients (OR: 2.09; 95% CI: 1.69–2.59). CONCLUSIONS: Ascertaining PCOS through the medical record offers advantages over self-reported PCOS, including documentation of disease and recorded measurements. In the future, this PCOS dataset can be used in conjunction with cardiovascular and metabolic outcomes for developing a predictive model.

Alzheimer's disease (AD) is the most common progressive, neurodegenerative disease and form of dementia. The hallmarks of AD are extracellular accumulation of amyloid beta protein, resulting in neuritic, senile plaques and intracellular accumulation of tau protein. AD mainly arises from imbalance of amyloid beta protein production and its clearance in the brain. Testosterone modulates production of amyloid beta protein by decreasing its accumulation. Prostate cancer remains a substantial public health challenge in the United States. While androgen deprivation therapy (ADT) is an effective treatment for prostate cancer, it may be associated with cognitive impairment due to decreased levels of testosterone. The purpose of this study was to explore the association between ADT and the development of AD. This study was a retrospective, quantitative cohort study of subjects diagnosed with prostate cancer from a large population database, SEER Medicare-linked database. Data were analyzed using descriptive statistics along with correlation and multiple logistic regression analysis to evaluate the association between ADT use for prostate cancer and AD risk. The sample consisted of 27,913 men with a mean age of 72 years, majority being Caucasian with multiple comorbidities. Subjects who had received ADT were 20% more likely to develop AD than subjects who had not received ADT (OR, 1.20; 95% CI, 1.09, 1.32; p < .001) after controlling for race, ethnicity, prostate cancer stage, prostate cancer risk groups, and comorbidities. This association did not appear to vary by race or PCa risk group. Given an aging population and increased incidence and prevalence of prostate cancer and AD, these results may lead to positive social change by furthering AD prevention.