Academic Appointments

All Publications

  • Bias and Accuracy of Glomerular Filtration Rate Estimating Equations in the US: A Systematic Review and Meta-Analysis. JAMA network open Yan, A. F., Williams, M. Y., Shi, Z., Oyekan, R., Yoon, C., Bowen, R., Chertow, G. M. 2024; 7 (3): e241127


    There is increasing concern that continued use of a glomerular filtration rate (GFR) estimating equation adjusted for a single racial group could exacerbate chronic kidney disease-related disparities and inequalities.To assess the performance of GFR estimating equations across varied patient populations.PubMed, Embase, Web of Science,, and Scopus databases were systematically searched from January 2012 to February 2023.Inclusion criteria were studies that compared measured GFR with estimated GFR in adults using established reference standards and methods. A total of 6663 studies were initially identified for screening and review.Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 authors independently extracted data on studies that examined the bias and accuracy of GFR estimating equations. For each outcome, a random-effects model was used to calculate pooled estimates. Data analysis was conducted from March to December 2023.The primary outcomes were bias and accuracy of estimated GFRs in Black vs non-Black patients, as well as in individuals with chronic conditions. Bias was defined as the median difference between the measured GFR and the estimated GFR. Accuracy was assessed with P30 (the proportion of persons in a data set whose estimated GFR values were within 30% of measured GFR values) and measures of heterogeneity.A total of 12 studies with a combined 44 721 patients were included. Significant heterogeneity was found in the bias of various GFR estimation equations. Race-corrected equations and creatinine-based equations tended to overestimate GFR in Black populations and showed mixed results in non-Black populations. For creatinine-based equations, the mean bias in subgroup analysis was 2.1 mL/min/1.73 m2 (95% CI, -0.2 mL/min/1.73 m2 to 4.4 mL/min/1.73 m2) in Black persons and 1.3 mL/min/1.73 m2 (95% CI, 0.0 mL/min/1.73 m2 to 2.5 mL/min/1.73 m2) in non-Black persons. Equations using only cystatin C had small biases. Regarding accuracy, heterogeneity was high in both groups. The overall P30 was 84.5% in Black persons and 87.8% in non-Black persons. Creatinine-based equations were more accurate in non-Black persons than in Black persons. For creatinine-cystatin C equations, the P30 was higher in non-Black persons. There was no significant P30 difference in cystatin C-only equations between the 2 groups. In patients with chronic conditions, P30 values were generally less than 85%, and the biases varied widely.This systematic review and meta-analysis of GFR estimating equations suggests that there is bias in race-based GFR estimating equations, which exacerbates kidney disease disparities. Development of a GFR equation independent of race is a crucial starting point, but not the sole solution. Addressing the disproportionate burden of kidney failure on Black individuals in the US requires an enduring, multifaceted approach that should include improving diagnostics, tackling social determinants of health, confronting systemic racism, and using effective disease prevention and management strategies.

    View details for DOI 10.1001/jamanetworkopen.2024.1127

    View details for PubMedID 38441895

  • Prevalence and correlates of pre-diabetes in Sub-Saharan Africa using Demographic and Health Survey Data: a cross-sectional study. BMJ open Walker, R. J., Thorgerson, A. M., Yan, A., Williams, J. S., Campbell, J. A., Dawson, A. Z., Renta, V., Egede, L. E. 2023; 13 (10): e069640


    The objective is to investigate the prevalence of pre-diabetes in Namibia and South Africa and to determine sociodemographic correlates of disease using population data.Cross-sectional study.Demographic and Health Survey for emerging (Namibia) and established (South Africa) economies in Sub-Saharan Africa collected laboratory data that allowed determination of pre-diabetes status.3141 adults over age 18 from the 2013 Namibia survey, weighted to a population of 2176, and 4964 adults over age 18 from the 2016 South Africa survey, weighted to a population of 4627 had blood glucose/glycated haemoglobin (HbA1c) and diabetes information were included in the analysis.Pre-diabetes was defined as not being diagnosed with diabetes and having a blood sugar measurement of 100-125 mg/dL in Namibia or an HbA1c measurement of 5.7%-6.4%. Logistic models were run for each country separately, with pre-diabetes as the outcome and a series of sociodemographic variables (age, gender, urban/rural residence, number of children, employment status, wealth index, education level, and ethnicity (in South Africa) or religion (in Namibia)) entered as variables to investigate the independent relationship of each.The weighted prevalence of pre-diabetes was 18.7% in Namibia and 70.1% in South Africa. Rural residence was independently associated with higher odds of pre-diabetes in Namibia (1.47, 95% CI 1.05 to 2.06), while both younger age (0.98, 95% CI 0.97 to 0.99) and urban residence (0.80, 95% CI 0.66 to 0.99) were independently associated with odds of pre-diabetes in South Africa.The prevalence of pre-diabetes was 18.7% in Namibia and 70.1% in South Africa. Correlates of pre-diabetes differed between the two countries with rural residents having higher odds of pre-diabetes in Namibia and urban residents with higher odds in South Africa. Aggressive interventions, including population level education and awareness programmes, and individual level education and lifestyle interventions that account for country-specific contextual factors are urgently needed to prevent progression to diabetes.

    View details for DOI 10.1136/bmjopen-2022-069640

    View details for PubMedID 37852767

  • Health equity: A concept analysis. Nursing outlook Lewis, C. L., Yan, A., Williams, M. Y., Apen, L. V., Crawford, C. L., Morse, L., Valdez, A. M., Alexander, G. R., Grant, E., Valderama-Wallace, C., Beatty, D. 2023; 71 (5): 102032


    Although health equity is critically important for healthcare delivery, there are inconsistencies in its definitions or lack of definitions.Develop a comprehensive understanding of health equity to guide nursing practice and healthcare policy.Walker and Avant's concept analysis method was used to establish defining attributes, antecedents, consequences, and empirical referents of health equity.Health equity defining attributes are grounded in ethical principles, the absence of unfair and avoidable differences, and fair and just opportunities to attain a person's full health potential. Health equity antecedents are categorized into environmental; financial or economic; law, politics, and policy; societal and structural; research; and digital and technology.Health equity's antecedents are useful to distinguish health disparities from health outcomes resulting from individual preferences. To achieve health equity, organizations need to focus on addressing the antecedents.

    View details for DOI 10.1016/j.outlook.2023.102032

    View details for PubMedID 37683597

  • A systematic review for the impacts of global approaches to regulating electronic nicotine products. Journal of global health Yan, D., Wang, Z., Laestadius, L., Mosalpuria, K., Wilson, F. A., Yan, A., Lv, X., Zhang, X., Bhuyan, S. S., Wang, Y. 2023; 13: 04076


    Background: The rapid increase in electronic nicotine product (ENP) use among young people has been a global public health challenge, given the potential harm of ENPs and nicotine dependence. Many countries have recently introduced legislations to regulate ENPs, but the impacts of these policies are poorly understood. This systematic review aims to critically synthesise empirical studies on the effects of global regulations regarding ENPs on the prevalence of use, health outcomes and their determinants, using the 4A marketing mix framework (acceptability, affordability, accessibility and awareness).Methods: Following the PRISMA guideline, we searched PubMed, Embase, Scopus, Web of Science, Academic Search Complete, Business Source Complete, and APA PsycINFO databases from inception until June 14, 2022 and performed citation searches on the included studies. Reviewed literature was restricted to peer-reviewed, English-language articles. We included all pre-post and quasi-experimental studies that evaluated the impacts of e-cigarette policies on the prevalence of ENP use and other health outcomes. A modified Joanna Briggs Institute (JBI) Critical Appraisal checklist for quasi-experimental studies was used for quality assessment. Due to heterogeneity of the included studies, we conducted a narrative synthesis of evidence.Results: Of 3991 unduplicated records screened, 48 (1.2%) met the inclusion criteria, most were from high-income countries in North America and Europe and 26 studies measured self-reported ENPs use. Flavour restrictions significantly decreased youth ENP use and taxation reduced adult use; mixed results were found for the impacts of age restrictions. Indoor vaping restrictions and the European Tobacco Products Directive (TPD) did not seem to reduce ENP use based on existing studies. Changes in determinants such as sales and perceptions corroborated our conclusions. Few studies assessed the impacts of other regulations such as advertising restrictions and retail licensing requirements.Conclusions: Flavour restrictions and taxes have the strongest evidence to support effective control of ENPs, while others need powerful enforcement and meaningful penalties to ensure their effectiveness. Future research should focus on under-examined policies and differential impacts across sociodemographic characteristics and countries.Registration: PROSPERO CRD42022337361.

    View details for DOI 10.7189/jogh.13.04076

    View details for PubMedID 37622721

  • Association and potential mediators between socioeconomic status and childhood obesity in China: findings from a national cohort study Global Health Journal Zhou, H., Gao, L., Wu, Y., Wen, X., Peng, W., Yan, N., Yan, A. F., Wang, Y. 2023
  • The Association between Methionine Intake and Diabetes in Chinese Adults-Results from the China Health and Nutrition Survey NUTRIENTS Sun, X., Chen, Y., Shu, J., Li, Z., Yu, D., Peng, W., Yan, A. F., Wang, Y., Shi, Z. 2023; 15 (1)


    This study aimed to evaluate the association between methionine intake and diabetes prevalence in Chinese adults and explore whether the association was source-specific. Data from 12,849 adults aged ≥20 years old were used from the China Health and Nutrition Survey during 1997-2011. Diabetes was diagnosed as self-reported and/or when blood tests results met the diagnostic criteria. A 3-day, 24-h recall was used to assess different sources of methionine. Multivariable mixed linear regression was used to examine the associations. Across the quartiles of total methionine intake, the odds ratio (ORs, 95% CI) of diabetes were 1.00, 1.49 (1.21 to 1.82), 1.72 (1.37 to 2.15), and 2.53 (1.97 to 3.23). In the subgroup analysis, similar trends were observed in both animal and plant methionine. There was a significant interaction between urbanization and diabetes. The positive association was only significant in those who lived in low or medium urbanization areas. The ORs (95% CI) were 1.00, 1.27 (0.85 to 1.88), 1.56 (1.01 to 2.39), and 1.79 (1.09 to 2.95) for medium urbanization, respectively. No interaction was identified when stratified by different methionine sources. In conclusion, methionine intake was positively associated with diabetes independent of food source, and it was modified by urbanization levels.

    View details for DOI 10.3390/nu15010116

    View details for Web of Science ID 000909028700001

    View details for PubMedID 36615773

    View details for PubMedCentralID PMC9823418

  • Income loss and subsequent poor psychological well-being among the Chinese population during the early COVID-19 pandemic International Journal for Equity in Health Lai, S., Lu, ., Shen, C., Yan, A. F., Lei, ., Zhou, Z., Wang, Y. 2023; 22 (1)
  • A systematic review for the impacts of global approaches to regulating electronic nicotine products JOURNAL OF GLOBAL HEALTH Yan, D., Wang, Z., Laestadius, L., Mosalpuria, K., Wilson, F. A., Yan, A., Lv, X., Zhang, X., Bhuyan, S. S., Wang, Y. 2023; 13
  • A comparison study of prevalence, awareness, treatment and control rates of hypertension and associated factors among adults in China and the United States based on national survey data A comparison study of prevalence, awareness, treatment and control rates of hypertension and associated factors among adults in China and the United States based on national survey data Sun, X., Chen, X., Shi, Z., Yan, A. F., Li, Z., Chen, S., Zhao, B., Peng, W., Li, X., Zhang, M., Wang, L., Wu, J., Wang, Y. 2023; 7 (1)
  • Higher Serum Testosterone Level Was Associated with a Lower Risk of Prediabetes in US Adults: Findings from Nationally Representative Data. Nutrients Wang, J., Yan, A. F., Cheskin, L. J., Shi, Z. 2022; 15 (1)


    Low testosterone may be a novel risk factor for prediabetes. We assessed the associations between prediabetes and total serum testosterone (TT), and whether the associations were modified by population characteristics. The data from 5330 adults aged ≥ 20 years, who participated in the 2011-2016 National Health and Nutrition Examination Survey in the United States, were used. Prediabetes was based on fasting plasma glucose, HbA1c, or OGTT. Sociodemographic, obesity, co-morbidities, and lifestyle factors were included in logistic regression models. A dose-response relationship was found between prediabetes and the testosterone quartiles. The odds ratio (OR and 95% CI) for prediabetes across the quartiles of TT were: 1.00, 0.68 (0.50-0.92), 0.51 (0.36-0.72), and 0.48 (0.34-0.70) in men; and 1.00, 1.06 (0.81-1.40), 0.81 (0.61-1.06), and 0.68 (0.49-0.93) in women. The results changed marginally if the models were adjusted for additional variables such as BMI. The subgroup analyses showed differences in the association, which was stronger in some groups (for men: age < 50, white and black, overweight/obese, adequate physical activity, never-smoking; and for women: age ≥ 50, black). A higher testosterone level was associated with a lower risk of prediabetes among US adults. The strength of the association varied by population characteristics, weight status, gender, and lifestyle factors.

    View details for DOI 10.3390/nu15010009

    View details for PubMedID 36615670

  • Intersectionality Impacts Survivorship: Identity-Informed Recommendations to Improve the Quality of Life of African American Breast Cancer Survivors in Health Promotion Programming. International journal of environmental research and public health Garza, R. H., Williams, M. Y., Ntiri, S. O., Hampton, M. D., Yan, A. F. 2022; 19 (19)


    (1) Background: African American women breast cancer survivors face unique experiences that impact their quality of life as they transition beyond treatments. Experiences may be complicated by living at the intersection of systemically oppressed identities, including gender, race, social class, and cancer-related disability. Using the Black Feminist Thought (BFT) framework and the PEN-3 cultural model, this qualitative study sought to: (a) understand African American women breast cancer survivors' lived experiences; (b) examine how the multiple intersecting factors of race, gender, social class/socioeconomic status, and cancer-related disability impact their quality of life; and (c) inform future health promotion programming that is culturally relevant to AAWBCS to improve their quality of life. (2) Methods: Seven focus groups were conducted with 30 African American breast cancer survivors in a Midwestern metropolitan region. Focus groups were audiotaped and transcribed verbatim. Framework analyses were conducted to identify themes with NVivo qualitative analysis software. (3) Results: Four themes emerged: (a) caregiving roles provide both support and challenges for survivors, (b) the "strong Black woman" is inherent in survivor experiences, (c) intersectionality impacts survivorship, and (d) African American women resist oppression through culturally specific supports and advocacy. (4) Conclusions: The intervention point of entry should be at the peer support group level and centered on family and provide community-based support and services. Future research should move upstream to address social determinants of health, including racism, sexism, and ableism; there is a critical need to discuss how structural racism affects health care and develop interventions to address racial discrimination and racial bias in health care.

    View details for DOI 10.3390/ijerph191912807

    View details for PubMedID 36232105

  • Health consequences of obesity and projected future obesity health burden in China. Obesity (Silver Spring, Md.) Sun, X., Yan, A. F., Shi, Z., Zhao, B., Yan, N., Li, K., Gao, L., Xue, H., Peng, W., Cheskin, L. J., Wang, Y. 2022; 30 (9): 1724-1751


    This study examined the effects of overweight/obesity on mortality and morbidity outcomes and the disparities, time trends, and projected future obesity health burden in China.Cohort studies that were conducted in China and published in English or Chinese between January 1, 1995, and July 31, 2021, were systematically searched. This study focused on overweight/obesity, type 2 diabetes mellitus (T2DM), hypertension, cardiovascular diseases, metabolic syndrome, cancers, and chronic kidney disease.A total of 31 cohorts and 50 cohort studies reporting on mortality (n = 20) and morbidities (n = 30) associated with obesity met study inclusion criteria. Overall, BMI was nonlinearly (U-shaped) associated with all-cause mortality and linearly associated with risks of T2DM, cardiovascular diseases, hypertension, cancer, metabolic syndrome, and chronic kidney disease. In 2018, among adults, the prevalence of overweight/obesity, hypertension, and T2DM was 51.2%, 27.5%, and 12.4%, respectively. Their future projected prevalence would be 70.5%, 35.4%, and 18.5% in 2030, respectively. The projected number of adults having these conditions would be 810.65 million, 416.47 million, and 217.64 million, respectively. The urban-rural disparity in overweight/obesity prevalence was projected to shrink and then reverse over time.The current health burden of obesity in China is high and it will sharply increase in coming years and affect population groups differently. China needs to implement vigorous interventions for obesity prevention and treatment.

    View details for DOI 10.1002/oby.23472

    View details for PubMedID 36000246

  • Prevalence, Management, and Associated Factors of Obesity, Hypertension, and Diabetes in Tibetan Population Compared with China Overall INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Peng, W., Li, K., Yan, A. F., Shi, Z., Zhang, J., Cheskin, L. J., Hussain, A., Wang, Y. 2022; 19 (14)


    Tibetans' life expectancy lags behind China's average. Obesity and noncommunicable diseases (NCDs) contribute to health disparity, but NCD patterns among Tibetans are unknown. To examine the prevalence, management, and associated factors for obesity, hypertension, and diabetes among Tibetans, compared with China's average, we systematically searched PubMed and China National Knowledge Infrastructure databases for studies between January 2010 and April 2021. Thirty-nine studies were included for systematic review, among thirty-seven that qualified for meta-analysis, with 115,403 participants. Pooled prevalence was 47.9% (95% CI 38.0-57.8) for overweight/obesity among adults (BMI ≥ 24 kg/m2) and 15.4% (13.7-17.2) among children using Chinese criteria, which are lower than the national rates of 51.2% and 19.0%, respectively. The estimate for hypertension (31.4% [27.1-35.7]) exceeded China's average (27.5%), while diabetes (7.5% [5.2-9.8]) was lower than average (11.9%). Men had a higher prevalence of the three conditions than women. Residents in urban areas, rural areas, and Buddhist institutes had monotonically decreased prevalence in hypertension and diabetes. Awareness, treatment, and control rates for hypertension and diabetes were lower than China's average. Urban residence and high altitude were consistent risk factors for hypertension. Limited studies investigated factors for diabetes, yet none exist for obesity. Tibetans have high burdens of obesity and hypertension. Representative and longitudinal studies are needed for tailored interventions. There are considerable variations in study design, study sample selection, and data-analysis methods, as well as estimates of reviewed studies.

    View details for DOI 10.3390/ijerph19148787

    View details for Web of Science ID 000832434500001

    View details for PubMedID 35886633

    View details for PubMedCentralID PMC9316255

  • Factors associated with the double burden of malnutrition at the household level: A scoping review. Critical reviews in food science and nutrition Guevara-Romero, E., Flórez-García, V., Egede, L. E., Yan, A. 2022; 62 (25): 6961-6972


    The double burden of malnutrition (DBM) at the household level has been defined as the coexistence of underweight children and overweight mothers within the same household. The objective of the scoping review was to identify and understand factors associated with DBM. We conducted the scoping review of published, peer-reviewed journal articles in two major databases used in public health research (PubMed and Web of Science). A total of 70 articles met the eligibility criteria. The following factors were identified: mother's age, height, educational level, occupation, food intake, breastfeeding, family income, family size, and urbanization type. Overall, results were heterogeneous. Two scenarios have been identified. The first scenario is those obese women with a job, having a sufficient income, a high educational level, the ability to purchase food, and live either in rural or urban areas. The second scenario is obese women without a job, having an insufficient income, a low educational level, without the ability to purchase food, and live either in rural or urban areas. The DBM at the household level is a complex public health problem. There is a need for target-specific interventions to address child undernutrition and maternal overweight/obesity simultaneously.

    View details for DOI 10.1080/10408398.2021.1908954

    View details for PubMedID 33840313

  • Exposure to Chinese Famine during Early Life Increases the Risk of Fracture during Adulthood. Nutrients Shi, Z., Shi, X., Yan, A. F. 2022; 14 (5)


    This study focused on identifying whether exposure to the Chinese Great Famine (1959-1961) in early life amplified the potential for fractures in adulthood. The survey was conducted using data from the 1997-2015 China Health and Nutrition Survey (CHNS)-5235 adults born between 1954 and 1964 were selected as the sample size. Fracture was defined based on self-report. Those born from 1962-1964 were treated as non-exposure group. Those with exposure to famine were divided into four subgroups: Fetal, early childhood, mid-childhood, and late childhood cohorts. The association between the groups and fracture was determined using Cox regression. In follow-up data (mean of 11 years), fractures were identified in 418 of the participants. The incidence of fracture was 8.7 in late childhood, 8.1 in mid-childhood, 8.3 in early childhood, 7.0 in fetal, and 5.4 in non-exposed cohorts per 1000 person-year. Compared with the non-exposed group, the famine-exposed groups had an increased risk of developing fracture in adulthood with hazard ratio (HR) and 95% CI of 1.29 (0.90-1.85), 1.48 (1.08-2.03), 1.45 (1.02-2.06), and 1.54 (1.08-2.20), respectively. The positive link of famine exposure to risk of fracture occurred primarily in those participants with a modern diet who lived in urban areas. In conclusion, the risk of fracture in Chinese adults is associated with famine exposure.

    View details for DOI 10.3390/nu14051060

    View details for PubMedID 35268035

    View details for PubMedCentralID PMC8912709

  • Engaging veteran stakeholders to identify patient-centred research priorities for optimizing implementation of lung cancer screening. Health expectations : an international journal of public participation in health care and health policy Yan, A., Hooyer, K., Asan, O., Flower, M., Whittle, J. 2022; 25 (1): 408-418


    Patient engagement in research agenda setting is increasingly being seen as a strategy to improve the responsiveness of healthcare to patient priorities. Implementation of low-dose computed tomography (LDCT) screening for lung cancer is suboptimal, suggesting that research is needed.This study aimed to describe an approach by which a Veteran patient group worked with other stakeholders to develop a research agenda for LDCT screening and to describe the research questions that they prioritized.We worked with Veterans organizations to identify 12 Veterans or family members at risk for or having experience with lung cancer to form a Patient Advisory Council (PAC). The PAC met repeatedly from June 2018 to December 2020, both independently and jointly, with stakeholders representing clinicians, health administrators and researchers to identify relevant research topics. The PAC prioritized these topics and then identified questions within these areas where research was needed using an iterative process. Finally, they ranked the importance of obtaining answers to these questions.PAC members valued the co-learning generated by interactions with stakeholders, but emphasized the importance of facilitation to avoid stakeholders dominating the discussion. The PAC prioritized three broad research areas-(1) the impact of insurance on uptake of LDCT; (2) how best to inform Veterans about LDCT; and (3) follow-up and impact of screening results. Using these areas as guides, PAC members identified 20 specific questions, ranking as most important (1) innovative outreach methods, (2) the impact of screening on psychological health, and (3) the impact of outsourcing scans from VA to non-VA providers on completion of recommended follow-up of screening results. The latter two were not identified as high priority by the stakeholder group.We present an approach that facilitates co-learning between Veteran patients and providers, researchers and health system administrators to increase patient confidence in their ability to contribute important information to a research agenda. The research questions prioritized by the Veterans who participated in this project illustrate that for this new screening technology, patients are concerned about the practical details of implementation (e.g., follow-up) and the technology's impact on quality of life.Veterans and Veteran advocates contributed to our research team throughout the entire research process, including conceiving and co-authoring this manuscript.

    View details for DOI 10.1111/hex.13401

    View details for PubMedID 34890474

    View details for PubMedCentralID PMC8849265

  • Effectiveness of Social Needs Screening and Interventions in Clinical Settings on Utilization, Cost, and Clinical Outcomes: A Systematic Review. Health equity Yan, A. F., Chen, Z., Wang, Y., Campbell, J. A., Xue, Q., Williams, M. Y., Weinhardt, L. S., Egede, L. E. 2022; 6 (1): 454-475


    Objective: This systematic review examined and synthesized peer-reviewed research studies that reported the process of integrating social determinants of health (SDOH) or social needs screening into electronic health records (EHRs) and the intervention effects in the United States.Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, a systematic search of Scopus, Web of Science Core Collection, MEDLINE, and Cochrane Central Register of Clinical Trials was performed. English language peer-reviewed studies that reported the process of integrating SDOH or social needs screening into EHRs within the U.S. health systems and published between January 2015 and December 2021 were included. The review focused on process measures, social needs changes, health outcomes, and health care cost and utilization.Results: In total, 28 studies were included, and half were randomized controlled trials. The majority of the studies targeted multiple SDOH domains. The interventions vary by the levels of intensity of their approaches and heterogeneities in outcome measures. Most studies (82%, n=23) reported the findings related to the process measures, and nearly half (43%, n=12) reported outcomes related to social needs. By contrast, only 39% (n=11) and 32% (n=9) of the studies reported health outcomes and impact on health care cost and utilization, respectively. Findings on patients' social needs change demonstrated improved access to resources. However, findings were mixed on intervention effects on health and health care cost and utilization. We also identified gaps in implementation challenges to be overcome.Conclusion: Our review supports the current policy efforts to increase U.S. health systems' investment toward directly addressing SDOH. While effective interventions can be more complex or resource intensive than an online referral, health care organizations hoping to achieve health equity and improve population health must commit the effort and investment required to achieve this goal.

    View details for DOI 10.1089/heq.2022.0010

    View details for PubMedID 35801145

  • Dietary Patterns and Changes in Weight Status Among Chinese Men and Women During the COVID-19 Pandemic. Frontiers in public health Xu, X., Yan, A. F., Wang, Y., Shi, Z. 2021; 9: 709535


    Aims: To identify dietary patterns during the coronavirus disease-2019 (COVID-19) pandemic and to examine their association with changes in weight status in the Chinese population. Methods: The 2020 China COVID-19 cross-sectional survey is an anonymous 74-item survey administered via social media across 31 provinces in mainland China between April and May 2020. Dietary data were assessed by a Food Frequency Questionnaire and the changes in weight status were self-reported. Exploratory factor analysis using the principal component analysis method was applied to identify dietary patterns. The multinomial regression models were conducted, and forest plots were used to present the associations between dietary patterns and changes in weight status. Results: Of a total of 10,545 adults (aged ≥18 years), more than half of participants reported to have weight gain, with 18.6% of men and 16.3% of women having weight gain >2.5 kg. Approximately 8% of participants reported to have weight loss, with 2.1% of men and 2.5% women having weight loss >2.5 kg. Two dietary patterns, namely, the modern and prudent dietary patterns, were identified during the COVID-19 pandemic. The modern dietary pattern was loaded heavily with soft drinks, fried foods, pickles, and inversely with fresh vegetables. The prudent dietary pattern was characterized by high intake of fresh fruits, vegetables, and inversely with soft drinks and fried food. The modern dietary pattern was positively associated with weight gain in men and women, while the prudent dietary pattern was negatively associated with both weight gain and loss in men and women during the COVID-19 pandemic. Conclusion: Dietary patterns during COVID-19 are significantly associated with the changes in weight status, which may subsequently increase the risk of diet-related non-communicable disease among the Chinese population.

    View details for DOI 10.3389/fpubh.2021.709535

    View details for PubMedID 34966710

    View details for PubMedCentralID PMC8710477

  • Accessibility of Medicare Diabetes Prevention Programs and Variation by State, Race, and Ethnicity JAMA NETWORK OPEN Yan, A., Chen, Z., Wang, M., Mendez, C. E., Egede, L. E. 2021; 4 (10): e2128797


    This cross-sectional study examines the accessibility of the Medicare Diabetes Prevention Program and investigates whether there are disparities in access among racial and ethnic minority beneficiaries at the state level.

    View details for DOI 10.1001/jamanetworkopen.2021.28797

    View details for Web of Science ID 000704860200007

    View details for PubMedID 34623412

    View details for PubMedCentralID PMC8501393

  • Mental distress and its associations with behavioral outcomes during the COVID-19 pandemic: a national survey of Chinese adults. Public health Ma, L., Gao, L. W., Lau, J. T., Rahman, A., Johnson, B. T., Yan, A. F., Shi, Z. M., Ding, Y. X., Nie, P., Zheng, J. G., Wang, Y. F., Wang, W. D., Xue, Q. L. 2021; 198: 315-323


    This study aimed to evaluate associations between mental distress and COVID-19-related changes in behavioral outcomes and potential modifiers (age, gender, educational attainment) of such associations.This was a cross-sectional study.An online survey using anonymous network sampling was conducted in China from April to May 2020 using a 74-item questionnaire. A national sample of 10,545 adults in 31 provinces provided data on sociodemographic characteristics, COVID-19-related mental distress, and changes in behavioral outcomes. Structural equation models were used for data analyses.After adjusting for covariates, greater mental distress was associated with increased smoking (odds ratio [OR] = 1.42, 95% confidence interval [CI]: 1.20-1.68 and OR = 1.54, 95% CI: 1.31-1.82 per one standard deviation [SD] increase in mental distress) and alcohol consumption (OR = 1.67, 95% CI: 1.45-1.92 and OR = 1.47, 95% CI: 1.24-1.75 per one SD increase in mental distress) among current smokers and drinkers and with both increased and decreased physical activity (ORs ranged from 1.32 to 1.56). Underweight adults were more likely to lose body weight (≥1 kg; OR = 1.63, 95% CI: 1.30-2.04), whereas overweight adults were more likely to gain weight (OR = 1.61, 95% CI: 1.46-1.78) by the same amount. Association between mental distress and change in physical activity was stronger in adults aged ≥40 years (ORs ranged from 1.43 to 2.05) and those with high education (ORs ranged from 1.43 to 1.77). Mental distress was associated with increased smoking in males (OR = 1.60, 95% CI: 1.37-1.87) but not females (OR = 1.11, 95% CI: 0.82-1.51).Greater mental distress was associated with some positive and negative changes in behavioral outcomes during the pandemic. These findings inform the design of tailored public health interventions aimed to mitigate long-term negative consequences of mental distress on outcomes.

    View details for DOI 10.1016/j.puhe.2021.07.034

    View details for PubMedID 34507138

    View details for PubMedCentralID PMC8424018

  • Navigator Role for Promoting Adaptive Sports and Recreation Participation in Individuals With Disabilities. American journal of physical medicine & rehabilitation Iverson, M., Ng, A. V., Yan, A. F., Zvara, K., Bonk, M., Falk-Palec, D., Sylla, C., Strickland, M., Preston, R., Braza, D. W. 2021; 100 (6): 592-598


    The aims of the study were to gain a better understanding of the resources, barriers, and facilitators of participation in adaptive sport and recreational activities as a means of achieving physical activity recommendations in individuals with disability and to understand preferences for a patient navigator service to help mitigate the barriers.Clinical, academic, and community stakeholders applied a community-engaged research approach to develop online surveys and focus group questions for adults with a disability or parents of a child with a disability to meet study objectives.One hundred ninety-eight adults and 146 parents completed the online surveys. Sixteen adults and 18 parents took part in focus groups. Many participants lacked knowledge of available adaptive sport and recreational resources; other barriers were expense, limited number of trained volunteers, and need for instruction. Conversely, persons were facilitated by community, socialization, and words of encouragement/motivation. Participants strongly preferred a patient navigator to be a person active in adaptive sport and recreational or an informative resource-filled website.Our findings suggest that physical activity programs including adaptive sport and recreational should be designed to offer people with disabilities opportunities to build social networks and strengthen social support. A patient navigator service could help increase participation in adaptive sport and recreational and physical activity within a community context.

    View details for DOI 10.1097/PHM.0000000000001533

    View details for PubMedID 32675707

    View details for PubMedCentralID PMC9552926

  • COVID-19, Diabetes, and Associated Health Outcomes in China: Results from a Nationwide Survey of 10 545 Adults. Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et metabolisme Shi, Z., Yan, A., Zimmet, P., Sun, X., Cristina do Vale Moreira, N., Cheskin, L. J., Wang, L., Qu, W., Yan, H., Hussain, A., Wang, Y. 2021; 53 (5): 301-310


    This study examined the associations between diabetes and self-reported/familial COVID-19 infection and investigated health-related outcomes among those with diabetes during China's nationwide quarantine. The 2020 China COVID-19 Survey was administered anonymously via social media (WeChat). It was completed by 10 545 adults in all of mainland China's 31 provinces. The survey consisted of 74 items covering sociodemographic characteristics, preventive measures for COVID-19, lifestyle behaviors, and health-related outcomes during the period of quarantine. Regression models examined associations among study variables. Diabetes was associated with a six-fold increased risk of reporting COVID-19 infection among respondents or their family members. Among people with diabetes, individuals who rarely wore masks had double the risk of suspected COVID-19 infection compared with those who always wore masks, with an inverse J-shaped relationship between face mask wearing and suspected COVID-19 infection. People with diabetes tended to have both poor knowledge of COVID-19 and poor compliance with preventive measures, despite perceiving a high risk of personal infection (40.0% among respondents reporting diabetes and 8.0% without diabetes). Only 54-55% of these respondents claimed to consistently practice preventive measures, including wearing face masks. Almost 60% of those with diabetes experienced food or medication shortages during the quarantine period, which was much higher than those without diabetes. Importantly, respondents who experienced medication shortages reported a 63% higher COVID-19 infection rate. Diabetes was associated with an increased risk of self-reported personal and family member COVID-19 infection, which is mitigated by consistent use of face masks.

    View details for DOI 10.1055/a-1468-4535

    View details for PubMedID 33962477

  • Relative Contribution of Individual, Community, and Health System Factors on Glycemic Control Among Inner-City African Americans with Type 2 Diabetes. Journal of racial and ethnic health disparities Campbell, J. A., Yan, A., Walker, R. E., Weinhardt, L., Wang, Y., Walker, R. J., Egede, L. E. 2021; 8 (2): 402-414


    Health disparities disproportionately impact inner-city African Americans; however, limited information exists on the contribution of individual, community, and health system barriers on diabetes outcomes in this population.A cross-sectional study collected primary data from 241 inner-city African Americans with type 2 diabetes. A conceptual framework was used to specify measurements across the individual level, such as age and comorbidities; community level, such as neighborhood factors and support; and health system level such as access, trust, and provider communication. Based on current best practices, four regression approaches were used: sequential, stepwise with forward selection, stepwise with backward selection, and all possible subsets. Variables were entered in blocks based on the theoretical framework in the order of individual, community, and health system factors and regressed against HbA1c.In the final adjusted model across all four approaches, individual-level factors like age (β = - 0.05; p < 0.001); having 1-3 comorbidities (β = - 2.03; p < 0.05), and having 4-9 comorbidities (β = - 2.49; p = 0.001) were associated with poorer glycemic control. Similarly, male sex (β = 0.58; p < 0.05), being married (β = 1.16; p = 0.001), and being overweight/obese (β = 1.25; p < 0.01) were associated with better glycemic control. Community and health system-level factors were not significantly associated with glycemic control.Individual-level factors are key drivers of glycemic control among inner-city African Americans. These factors should be the key targets for interventions to improve glycemic control in this population. However, community and health system factors may have indirect pathways to glycemic control that should be examined in future studies.

    View details for DOI 10.1007/s40615-020-00795-7

    View details for PubMedID 32588396

    View details for PubMedCentralID PMC7759592

  • Quantifying the Influence of Individual, Community, and Health System Factors on Quality of Life Among Inner-City African Americans With Type 2 Diabetes SCIENCE OF DIABETES SELF-MANAGEMENT AND CARE Campbell, J. A., Yan, A., Walker, R. E., Weinhardt, L., Wang, Y., Walker, R. J., Egede, L. E. 2021; 47 (2): 124-143


    The purpose of this study is to examine the association of individual, community, and health system factors on quality of life among inner-city African Americans with type 2 diabetes.Primary data from a cross-sectional study with a community sample of 241 inner-city African Americans with type 2 diabetes were analyzed. Paper-based surveys were administered in which the SF-12 was used to capture the physical component (PCS) and mental component (MCS) of quality of life. Four regression approaches (sequential, stepwise with backward and forward selection, and all possible subsets regression) were used to examine the influence of individual, community, and health system factors on PCS and MCS after adjusting for relevant covariates using a conceptual framework.In fully adjusted models, having less than a high school education and having major depression were associated with lower quality-of-life scores for MCS across all 4 regression approaches. Being employed was positively associated with better quality-of-life scores for PCS across all 4 regression approaches. PCS was higher across all 4 regression approaches for those reporting a history of trauma. At the health systems level, usual source of care was associated with better PCS across 3 regression approaches.These results highlight key factors that influence quality of life among inner-city African Americans with type 2 diabetes that could be targets for interventions in this population. However, additional research is needed to understand existing pathways that may be driving many of these relationships.

    View details for DOI 10.1177/0145721721996287

    View details for Web of Science ID 000626154700001

    View details for PubMedID 34078179

    View details for PubMedCentralID PMC8192081

  • Bidirectional relationships between weight stigma and pediatric obesity: A systematic review and meta-analysis OBESITY REVIEWS Ma, L., Chu, M., Li, Y., Wu, Y., Yan, A., Johnson, B., Wang, Y. 2021; 22 (6): e13178


    This study for the first time quantified concurrent and bidirectional relationships between weight stigma and weight status in children, with age and gender as moderators. A literature search was conducted in PubMed, Web of Science, and PsycINFO for studies examined associations between weight stigma and weight status among children aged 6-18 years. Twenty-five studies (20 cross-sectional studies and five longitudinal studies) from six countries with 101,036 participants were included in review, and 18 were included in meta-analysis. Weight and height were self-reported in nine studies, otherwise objectively measured. With data from 17 cross-sectional studies and baseline portions of four longitudinal studies, meta-analysis showed weight stigma and overweight/obesity were associated (pooled OR = 3.12, 95% CI: 2.71, 3.60), they were also associated across age and gender. Body mass index (BMI) was associated with greater weight stigma (pooled r = 0.38, 95% CI: 0.32, 0.43). Age modified such association. Weight stigma predicted increased BMI from three longitudinal studies (pooled β = 1.12, 95% CI: 0.78, 1.45); another two longitudinal studies reported BMI predicted greater weight stigma. Data were inadequate for age- or gender-stratified analyses. Findings supported positive concurrent and bidirectional relationships between weight stigma and weight status. Timely obesity and weight stigma interventions to protect children well-being are needed.

    View details for DOI 10.1111/obr.13178

    View details for Web of Science ID 000613949800001

    View details for PubMedID 33533189

  • Community-Based Participatory Research Interventions to Improve Diabetes Outcomes: A Systematic Review. The Diabetes educator Campbell, J. A., Yan, A., Egede, L. E. 2020; 46 (6): 527-539


    The purpose of this study was to conduct a systematic evaluation of community-based participatory research (CBPR) interventions on diabetes outcomes. Understanding of effective CBPR interventions on diabetes outcomes is limited, and findings remain unclear.A reproducible search strategy was used to identify studies testing CBPR interventions to improve diabetes outcomes, including A1C, fasting glucose, blood pressure, lipids, and quality of life. Pubmed, PsychInfo, and CINAHL were searched for articles published between 2010 and 2020. Using a CBPR continuum framework, studies were classified based on outreach, consulting, involving, collaborating, and shared leadership.A total of 172 were screened, and a title search was conducted to determine eligibility. A total of 16 articles were included for synthesis. Twelve out of the 16 studies using CBPR approaches for diabetes interventions demonstrated statistically significant differences in 1 or more diabetes outcomes measured at a postintervention time point. Studies across the spectrum of CBPR demonstrated statistically significant improvements in diabetes outcomes.Of the 16 studies included for synthesis, 14 demonstrated statistically significant changes in A1C, fasting glucose, blood pressure, lipids, and quality of life. The majority of studies used community health workers (CHWs) to deliver interventions across group and individual settings and demonstrated significant reductions in diabetes outcomes. The evidence summarized in this review shows the pivotal role that CHWs and diabetes care and education specialists play in not only intervention delivery but also in the development of outward-facing diabetes care approaches that are person- and community-centered.

    View details for DOI 10.1177/0145721720962969

    View details for PubMedID 33353510

    View details for PubMedCentralID PMC7901040

  • Dietary Supplements: Are Current Policies Adequate for Promoting Health? Nutrients Shi, Z., Yan, A. 2020; 12 (11)


    Globally, there has been a dramatic increase in the use of dietary supplements over recent decades [...].

    View details for DOI 10.3390/nu12113449

    View details for PubMedID 33187062

    View details for PubMedCentralID PMC7696274

  • Growing Burden of Hypertension in China: Causes, Challenges, and Opportunities. China CDC weekly Shi, Z., Sun, X., Yan, A. F., Wang, Y. 2020; 2 (40): 776-779

    View details for DOI 10.46234/ccdcw2020.210

    View details for PubMedID 34594765

    View details for PubMedCentralID PMC8393029

  • Perceived risk, behavior changes and Health-related outcomes during COVID-19 pandemic: Findingsamong adults with and without diabetesin China. Diabetes research and clinical practice Yan, A. F., Sun, X., Zheng, J., Mi, B., Zuo, H., Ruan, G., Hussain, A., Wang, Y., Shi, Z. 2020; 167: 108350


    To examine perceived infection risk of COVID-19 and the health and related behavior changes among people with diabetes, compared with people without diabetes, and to examine factors associated with self-reported health during the national quarantine period in China.The 2020 China COVID-19 Survey is an anonymous 74-item survey administered via social media across China. A national sample of 10,545 adults in all 31 provinces in mainland China provided data on sociodemographic characteristics, awareness, attitudes towards COVID-19, lifestyle factors, and health outcomes during the quarantine. Regression models tested associations among study variables adjusting for covariates.Among the 9,016 total participants (42.6% men and 57.4% women), 585 reported having diagnosed diabetes and 8,431 had no diabetes. Participants with diabetes perceived themselves to be at higher risk and were more worried about being infected with COVID-19 when compared to non-diabetic individuals (p < 0.001). During the COVID-19 pandemic, participants with diabetes were more likely to experience food and drug shortages and to increase their physical activity, compared to their counterparts. Among diabetic respondents, a high proportion of current smokers (74.1%) and drinkers (68.5%) reported increased amounts of smoking and drinking. People with diabetes were 11% less likely to report excellent or very good health. Having 150 min/week physical activity was positively associated with excellent or very good health (prevalence ratio, PR = 1.14, 95%CI 1.11-1.16).A high proportion of people with diabetes perceived risk of COVID-19 infection and increased their smoking and drinking during the pandemic.

    View details for DOI 10.1016/j.diabres.2020.108350

    View details for PubMedID 32710996

    View details for PubMedCentralID PMC7375325

  • Engaging young African American women breast cancer survivors: A novel storytelling approach to identify patient-centred research priorities. Health expectations : an international journal of public participation in health care and health policy Yan, A., Millon-Underwood, S., Walker, A., Patten, C., Nevels, D., Dookeran, K., Hennessy, R., Knobloch, M. J., Egede, L., Stolley, M. 2020; 23 (2): 473-482


    Patient-centredness is considered an essential aspiration of a high-quality health-care system, and patient engagement is a critical precursor to patient-centred care.To engage patients, health-care providers and stakeholders in identifying recommendations to address research and practice gaps that impact young African American breast cancer survivors.This paper reported an approach for research priority setting. This approach applies an engagement process (January-September 2018) of using patient and stakeholder groups, patient storytelling workshops and a culminating storytelling conference in Wisconsin to generate relevant research topics and recommendations. Topics were prioritized using an iterative engagement process. Research priorities and recommendation were ranked over the conference by counting participants' anonymous votes.One hundred attendees (43 patients/family members, 20 providers/researchers and 37 community members) participated in the conference. Five topics were identified as priorities. The results showed that three priority areas received the most votes, specifically community outreach and education, providing affordable health care and engaging in complementary care practice. Stakeholders also agreed it is critical to 'include youth in the conversation' when planning for cancer support and educational programmes for caregivers, friends and family members.Storytelling as a patient engagement approach can build trust in the patient-research partnership, ensure that patients are meaningfully engaged throughout the process and capture the diversity of patient experiences and perspectives.

    View details for DOI 10.1111/hex.13021

    View details for PubMedID 31916641

    View details for PubMedCentralID PMC7104646

  • Double Burden of Malnutrition: Examining the Growth Profile and Coexistence of Undernutrition, Overweight, and Obesity among School-Aged Children and Adolescents in Urban and Rural Counties in Henan Province, China. Journal of obesity Zhou, S., Ye, B., Fu, P., Li, S., Yuan, P., Yang, L., Zhan, X., Chao, F., Zhang, S., Wang, M. Q., Yan, A. 2020; 2020: 2962138


    To examine the gender, age, and region of residence in the anthropometric and nutritional profiles of children and adolescents aged 6-18 in Henan Province, China's third most populous province.This cross-sectional study of the China National Nutrition and Health survey (2010-2013) used a multistage cluster sampling technique. The sample included Chinese schoolchildren and adolescents aged 6 to 18 years (1,660 boys and 1,561 girls). Multiple logistic regression models were used to estimate the associations between sociodemographic correlates and overweight or obesity and stunting. Setting. Nine districts/counties in Henan Province. Participants. 3,221 subjects completed the questionnaire. Sociodemographic information was obtained. Body weight and height were measured.There were statistically significant regional differences in average height and weight for boys in all age groups. Girls followed the same trends except for height when 15-18 years old. The urban-rural residence differences were found in relation to prevalence of stunting and weight status. Subjects in poor rural areas (15.43%) and ordinary rural areas (15.34%) had higher rates of stunting compared to their urban counterparts. Prevalence of overweight or obesity was highest in big city areas (15.71%) and lowest in ordinary rural areas (6.37%). Being a boy (OR = 1.69, 95% CI = 1.314-2.143), living in a big city (OR = 2.10, 95% CI = 1.431-3.073), or in a small-medium city (OR = 2.28, CI = 1.606-3.247), or being in a younger age group was associated with being overweight or obese. In addition, being a boy, living in a big city, or in a small-medium city, or being younger in age meant they were less likely to be stunted.A substantial dual burden of malnutrition among children and adolescents in Henan Province was revealed. The urban-rural differences in nutritional status were found. Stunting was more prevalent in rural areas than in urban. In contrast, while the rising problem of childhood and adolescent obesity still exists in the big city, we also found a great spike in obesity in small-medium cities. Evidence also indicated that boys were more likely to be overweight or obese. Our findings suggest that nutrition education, as well as environmental and policy interventions, is needed to target specific geographic regions.

    View details for DOI 10.1155/2020/2962138

    View details for PubMedID 32148952

    View details for PubMedCentralID PMC7054782

  • Association of childhood blood lead levels with firearm violence perpetration and victimization in Milwaukee. Environmental research Emer, L. R., Kalkbrenner, A. E., O'Brien, M., Yan, A., Cisler, R. A., Weinhardt, L. 2020; 180: 108822


    Childhood lead exposure impairs future decision-making and may influence criminal behavior, but its role in future firearm violence is unclear. Using public health, education, and criminal justice datasets linked at the individual level, we studied a population-based cohort of all persons born between June 1, 1986 and December 31, 2003 with a valid blood lead test before age 6 years and stable Milwaukee residency (n = 89,129). We estimated associations with firearm violence perpetration (n = 553) and victimization (n = 983) using logistic regression, adjusting for temporal trends, child sex, race, and neighborhood socioeconomic status. Increasing risks for firearm violence perpetration and victimization were found in each higher category of blood lead compared to the lowest, after adjusting for confounding. For perpetration, risk ratios (RR) for increasing comparisons of mean blood lead in categories of ≥5 < 10, ≥10 < 20, and ≥20 μg/dL compared to persons with mean blood lead < 5 μg/dL, were: RR 2.3 (95% CI 1.6, 3.3), RR 2.5 (95% CI 1.7, 3.9), and RR 2.8 (95% CI 1.8, 4.4). For victimization, the same increasing categoric comparisons were: RR 1.8 (95% CI 1.4, 2.3), RR 2.4 (95% CI 1.8, 3.2), RR 3.3 (95% CI 2.4, 4.5). The proportion of firearm violence attributable to blood lead ≥5 μg/dL was 56% for perpetration and 51% for victimization. In Milwaukee, during a period of high lead exposures, childhood levels may have substantially contributed to adult firearm violence. While we cannot definitively conclude causality, the possibility that over half of firearm violence among this sample might be due to lead exposure suggests the potential importance of lead exposure reduction in firearm violence prevention efforts.

    View details for DOI 10.1016/j.envres.2019.108822

    View details for PubMedID 31654907

  • Bioethical Issues in Biostatistical Consulting Study: Additional Findings and Concerns. JDR clinical and translational research Wang, M. Q., Fan, A. Y., Katz, R. V. 2019; 4 (3): 271-275


    To determine the frequency and severity of 17 requests for inappropriate analysis and reporting of data that biostatisticians received from researchers in statistical consultations, as indirectly experienced (i.e., either heard about or observed being asked of other biostatisticians).A randomly drawn sample of 522 members of the American Statistical Association who self-identified as consulting biostatisticians were selected to participate in an online survey with the Bioethical Issues in Biostatistical Consulting Questionnaire, specifically developed for this study.Of the 522 consulting biostatisticians contacted, 390 (74.7%) completed the survey. The top 4 most frequently reported indirectly experienced inappropriate requests rated as "high severity" by at least 50% of the respondents were as follows: 1) proposing a study with a flawed design, including insufficient power; 2) setting aside values when the outcome turns on a few outliers; 3) reporting results of data analysis from only subsets of the data; and 4) overstating the statistical findings well beyond what the data support so that readers are misled.This article is a follow-up report to our recently published article on 18 directly experienced inappropriate and/or unethical requests by biomedical researchers of their consulting biostatisticians. These additional survey findings from the Bioethical Issues in Biostatistical Consulting Questionnaire on 17 indirectly experienced inappropriate requests show the following: 1) the widespread nature of inappropriate, if not, frankly unethical requests made by biomedical researchers of their consulting biostatisticians and 2) the urgent need to develop and offer educational programs for biomedical researchers in training to correct these behaviors-be they intentional or accidental. This report speaks to the urgency for developing training programs for new and existing researchers to reduce the frequency of these inappropriate bioethical requests during biostatistical consultations.The findings from this U.S. national survey of biostatisticians on inappropriate requests for data analyses by biomedical researchers strongly suggest a need for remedial actions, including 1) new educational modules for in-development and currently employed biomedical researchers, 2) improved institutional environments by research universities and companies regarding job and publication pressures, and 3) inclusion of a collaborating biostatistician as a working research team member from the early planning stages of all biomedical studies.

    View details for DOI 10.1177/2380084419837294

    View details for PubMedID 31009581

  • Functional Corticomuscular Signal Coupling Is Weakened during Voluntary Motor Action in Cancer-Related Fatigue. Neural plasticity Jiang, C., Yang, Q., Chen, T., Siemionow, V., Ranganathan, V. K., Yan, A. F., Yue, G. H. 2019; 2019: 2490750


    Cancer-related fatigue (CRF) is widely recognized as one of the most common symptoms and side effects of cancer and/or its treatment. However, neuropathological mechanisms contributing to CRF are largely unknown, and the lack of knowledge makes CRF difficult to treat. Recent research has shown dissociation between changes in the brain and muscle signals during voluntary motor performance in cancer survivors with CRF, and this dissociation may be caused by an interruption in functional coupling (FC) of the two signals. The goal of this study was to assess the FC between EEG (cortical signal) and EMG (muscular signal) in individuals with CRF and compare the FC with that of healthy controls during a motor task that led to progressive muscle fatigue.Eight cancer survivors with CRF and nine healthy participants sustained an isometric elbow flexion contraction (at 30% maximal level) until self-perceived exhaustion. The entire duration of the EEG and EMG recordings was divided into the first-half (less-fatigue stage) and second-half (more-fatigue stage) artifact-free epochs without overlapping. The EEG-EMG coupling (measured by coherence of the two signals) in each group and stage was computed. Coherence values at different frequencies were statistically analyzed using a repeated-measure general linear model.The results demonstrated that compared to healthy controls, CRF participants sustained the contraction for a significantly shorter time and exhibited robust and significantly lower EEG-EMG coherence at the alpha (8~14 Hz) and beta (15~35 Hz) frequency bands. Both the CRF and healthy control groups exhibited significantly decreased EEG-EMG coherence from the less-fatigue to more-fatigue stages at the alpha and beta frequency bands, indicating fatigue-induced weakening of functional corticomuscular coupling.Impaired functional coupling between the brain and muscle signals could be a consequence of cancer and/or its treatment, and it may be one of the contributing factors to the abnormal feeling of fatigue that caused the early failure of sustaining a prolonged motor task.

    View details for DOI 10.1155/2019/2490750

    View details for PubMedID 31346330

    View details for PubMedCentralID PMC6617923

  • Recreational Ballroom Dance and Multiple Sclerosis Piacentine, L. B., Yan, A. F., Ng, A. V. LIPPINCOTT WILLIAMS & WILKINS. 2019: 363
  • Culture, identity, strength and spirituality: A qualitative study to understand experiences of African American women breast cancer survivors and recommendations for intervention development. European journal of cancer care Yan, A. F., Stevens, P., Holt, C., Walker, A., Ng, A., McManus, P., Basen-Enguist, K., Weinhardt, L. S., Underwood, S. M., Asan, O., Wang, M. Q. 2019: e13013


    Despite advancements in cancer treatment, racial disparities in breast cancer survival persist, with African American women experiencing lower survival rates and poorer quality of life than non-Hispanic White women. Using a social cognitive model of restorative well-being as a framework, this qualitative study sought: (a) to examine strength- and culture-related factors associated with African American female breast cancer survivors' cancer coping and post-treatment experiences and (b) to make recommendations for culturally sensitive intervention.Eight focus groups occurred with a total of 40 local African American breast cancer survivors. Focus groups were audiotaped and transcribed verbatim. Framework analyses were used to identify themes. NVivo qualitative analysis software-managed data.Two major themes emerged from the focus group discussions: (a) God enables breast cancer survivorship and works every day in our lives and (b) the healthiest thing about us is that we are strong African American women. Recommendations for intervention planning and implementation were made towards intervention structure, content development and language framing in a local context.Findings suggest a need for community-based participatory survivorship interventions that are culturally and spiritually consonant and peer-based. Such interventions may respond to the cancer-related and personal needs of the target population.

    View details for DOI 10.1111/ecc.13013

    View details for PubMedID 30761637

  • Mismatch in Children's Weight Assessment, Ideal Body Image, and Rapidly Increased Obesity Prevalence in China: A 10-Year, Nationwide, Longitudinal Study. Obesity (Silver Spring, Md.) Min, J., Fang Yan, A., Wang, Y. 2018; 26 (11): 1777-1784


    This study examined secular trends in children's weight-status assessment, measured weight status, and ideal body image and their associations with subsequent changes in BMI, and it explored the differences between sociodemographic groups in China.Longitudinal data from the China Health and Nutrition Survey of 4,605 children aged 6 to 17 collected between 2000 and 2011 were used and fitted to mixed models.From 2000 to 2011, overweight/obesity prevalence increased from 6.5% to 16.8%, but the percentage of children with self-perceived weight status as "fat" remained around 2.0%; 49.0% of children underestimated their weight status at baseline. Self-perceived body image of most participants was tracked during follow-up. Children who perceived themselves as being fat at baseline had a higher BMI increase over time during follow-up than those with an average body image (β [SE] = 0.99 [0.14] kg/m2 per year, P < 0.001). Boys, young children, recent cohorts, and rural children had higher BMI increases than their counterparts. Over time, the thin-body silhouette became more desirable (8.4 percentage points higher, P < 0.001).Chinese children experience a large incongruence between their weight-status assessment, ideal body image, and actual weight status. Health promotion programs should examine their role in assisting children in developing a healthy body image and gaining greater self-motivation toward promoting a healthy lifestyle.

    View details for DOI 10.1002/oby.22310

    View details for PubMedID 30281208

    View details for PubMedCentralID PMC6202186

  • Researcher Requests for Inappropriate Analysis and Reporting: A U.S. Survey of Consulting Biostatisticians. Annals of internal medicine Wang, M. Q., Yan, A. F., Katz, R. V. 2018; 169 (8): 554-558


    Inappropriate analysis and reporting of biomedical research remain a problem despite advances in statistical methods and efforts to educate researchers.To determine the frequency and severity of requests biostatisticians receive from researchers for inappropriate analysis and reporting of data during statistical consultations.Online survey.United States.A randomly drawn sample of 522 American Statistical Association members self-identifying as consulting biostatisticians.The Bioethical Issues in Biostatistical Consulting Questionnaire soliciting reports about the frequency and perceived severity of specific requests for inappropriate analysis and reporting.Of 522 consulting biostatisticians contacted, 390 provided sufficient responses: a completion rate of 74.7%. The 4 most frequently reported inappropriate requests rated as "most severe" by at least 20% of the respondents were, in order of frequency, removing or altering some data records to better support the research hypothesis; interpreting the statistical findings on the basis of expectation, not actual results; not reporting the presence of key missing data that might bias the results; and ignoring violations of assumptions that would change results from positive to negative. These requests were reported most often by younger biostatisticians.The survey provides information on the reported frequency of inappropriate requests but not on how such requests were handled or whether the requests reflected researchers' maleficence or inadequate knowledge about statistical and research methods. In addition, other inappropriate requests may have been made that were not prespecified in the survey.This survey suggests that researchers frequently make inappropriate requests of their biostatistical consultants regarding the analysis and reporting of their data. Understanding the reasons for these requests and how they are handled requires further study.U.S. Department of Health and Human Services.

    View details for DOI 10.7326/M18-1230

    View details for PubMedID 30304365

  • Physical activity and annual medical outlay in U.S. colorectal, breast and prostate cancer survivors. Preventive medicine reports Yan, A. F., Wang, Y., Ng, A. V. 2018; 9: 118-123


    Multiple chronic conditions in cancer survivors are highly prevalent and may increase health care costs for both patients and the health care system. Studies of cancer survivors reveal positive effects of physical activity (PA) on reducing risk of cancer recurrence, other chronic conditions, and secondary cancer. Few nationally representative studies have examined how physical activity levels have affected survivors' annual economic burden in the United States. Leisure-time physical activity data from the National Health Interview Survey was linked to health care expenditure data from the Medical Expenditure Panel Survey data (2008-2012). We calculated per-person annual total medical expenditures for identified colorectal, breast, and prostate cancer survivors. We conducted multivariable analyses controlled for survival years and other sociodemographic variables. Generalized linear models were performed to measure correlation between medical expenditure and PA level using STATA 14. All analyses considered the complex survey design and were conducted in 2017. Of 1015 cancer survivors sampled, 30% (n = 305) adhered to physical activity recommendation, while the other 70% (n = 710) did not. Multivariable-adjusted expenditure in adherence group was $9108.8 (95% CI 7410.9-10,806.7) versus 12,899.1 (95% CI 11,450.2-14,348) in non-adherence group. Stratified analyses revealed cancer survivors who adhered to their PA recommendation saved $4686.1 (1-5 years' survival time) and $2874.5 (11 or more years' survival time) on average for total health care expenditure, respectively. Analyses of the national representative sample revealed that the economic burden of survivors from the three most prevalent cancers is substantial. Increasing survivor's PA to guidelines may reduce U.S. health care expenditure.

    View details for DOI 10.1016/j.pmedr.2018.01.003

    View details for PubMedID 29527464

    View details for PubMedCentralID PMC5840848

  • Obesity, body image, and its impact on children's eating and exercise behaviors in China: A nationwide longitudinal study. Preventive medicine Min, J., Yan, A. F., Wang, V. H., Wang, Y. 2018; 106: 101-106


    Body image seems to mediate the association between obesity and health behaviors as well as weight control attempts. We examined the distribution of children's body image by demographic characteristics and their subsequent associations with eating, exercise, and weight change. Child body image and health behaviors from the China Health National Survey 2000-2011 were assessed at baseline and in follow-up for 6- to 17-year-old children during 2000-2011 using mixed models. There was a large discrepancy between children's actual weight status (overweight: 16.9%) vs. self-rated body image (fat: 2.4% in 2011). Less than 1% of children desired a fat body; girls were more likely to want to be thin (52.5% vs. 40.9%) than boys. About 11% of children needed to lose weight in order to be at their desired baseline. During follow-up, those needing weight loss to be as desired were more likely to attempt dieting to change their weight (OR, 95% CI=1.9, 1.1-3.5 in boys; 1.7, 1.1-2.5 in girls) and less likely to feel they had enough physical activity (OR, 95% CI=0.5, 0.4-0.7 in boys; 0.6, 0.5-0.9 in girls), although their weight gain had been significantly higher than those having consistent self and desired body images (β [SE]=0.4 [0.1] in boys; 0.2 [0.1] in girls, all p<0.05). However, no significant difference was shown in subsequent health behaviors among overweight children by body image discrepancy. The discrepancy in self vs. desired body image motivated children to change their obesity-related health behaviors among non-overweight children in China.

    View details for DOI 10.1016/j.ypmed.2017.10.024

    View details for PubMedID 29066373

    View details for PubMedCentralID PMC5962018

  • Differences in verbal and nonverbal communication between depressed and non-depressed elderly patients Journal of Communication in Healthcare Asan, O., Kim, S. C., Iglar, P., Yan, A. 2018; 11 (4): 297-306
  • Identifying bioethical issues in biostatistical consulting: findings from a US national pilot survey of biostatisticians. BMJ open Wang, M. Q., Yan, A. F., Katz, R. V. 2017; 7 (11): e018491


    The overall purposes of this first US national pilot study were to (1) test the feasibility of online administration of the Bioethical Issues in Biostatistical Consulting (BIBC) Questionnaire to a random sample of American Statistical Association (ASA) members; (2) determine the prevalence and relative severity of a broad array of bioethical violations requests that are presented to biostatisticians by investigators seeking biostatistical consultations; and (3) establish the sample size needed for a full-size phase II study.A descriptive survey as approved and endorsed by the ASA.Administered to a randomly drawn sample of 112 professional biostatisticians who were ASA members.The 18 bioethical violations were first ranked by perceived severity scores, then categorised into three perceived severity subcategories in order to identify seven 'top tier concern violations' and seven 'second tier concern violations'.Methodologically, this phase I pilot study demonstrated that the BIBC Questionnaire, as administered online to a random sample of ASA members, served to identify bioethical violations that occurred during biostatistical consultations, and provided data needed to establish the sample size needed for a full-scale phase II study. The No. 1 top tier concern was 'remove or alter some data records in order to better support the research hypothesis'. The No. 2 top tier concern was 'interpret the statistical findings based on expectation, not based on actual results'. In total, 14 of the 18 BIBC Questionnaire items, as judged by a combination of 'severity of violation' and 'frequency of occurrence over past 5 years', were rated by biostatisticians as 'top tier' or 'second tier' bioethical concerns.This pilot study gives clear evidence that researchers make requests of their biostatistical consultants that are not only rated as severe violations, but further that these requests occur quite frequently.

    View details for DOI 10.1136/bmjopen-2017-018491

    View details for PubMedID 29146653

    View details for PubMedCentralID PMC5695368

  • Child and parental perspectives on diet and physical activity decisions: implications for childhood obesity prevention in China. Asia Pacific journal of clinical nutrition Wang, Y., Yan, A. F., Shi, X., Wang, H., Wang, Z., Gittelsohn, J., Xu, F. 2017; 26 (5): 888-898


    Obesity has become a global epidemic. In China, 42% of adults and about onefifth of children are overweight or obese. In major cities, about one-third of boys are overweight or obese. This study aimed to understand how children and parents in China make eating and physical activity (PA) decisions, considering individual, family, community, social, and environmental factors, and to collect parents' recommendations for interventions to promote healthy eating and physical activity.Children (n=41, aged 10-15 years) and their parents (n=41) participated in eight semi-structured focus groups (FGs) in Beijing (in North China) and Nanjing (South China). Each site conducted two FGs with children and two FGs with parents. A framework analysis of FG data was conducted with NVivo.Three main themes were identified: Children chose food based on flavor, and consumption of unhealthy snacks was prevalent; there were inconsistent standards and practices of school lunch services across schools; students had limited PA time due to academic demand. Students favored high-calorie snacks over fruits or vegetables. Students' and parents' perceptions of school lunch services varied among schools in terms of operation, price, quality, nutritious options, and food taste. Most students reported enjoying PA but spent little time in PA, due to study burdens. Parents made recommendations for improving school food services and increasing PA during and after school.These findings will help develop family- and school-targeted health promotion interventions. Intervention framing must consider the unique Chinese social and cultural context.

    View details for DOI 10.6133/apjcn.112016.01

    View details for PubMedID 28802299

  • Mixed-Method Quasi-Experimental Study of Outcomes of a Large-Scale Multilevel Economic and Food Security Intervention on HIV Vulnerability in Rural Malawi. AIDS and behavior Weinhardt, L. S., Galvao, L. W., Yan, A. F., Stevens, P., Mwenyekonde, T. N., Ngui, E., Emer, L., Grande, K. M., Mkandawire-Valhmu, L., Watkins, S. C. 2017; 21 (3): 712-723


    The objective of the Savings, Agriculture, Governance, and Empowerment for Health (SAGE4Health) study was to evaluate the impact of a large-scale multi-level economic and food security intervention on health outcomes and HIV vulnerability in rural Malawi. The study employed a quasi-experimental non-equivalent control group design to compare intervention participants (n = 598) with people participating in unrelated programs in distinct but similar geographical areas (control, n = 301). We conducted participant interviews at baseline, 18-, and 36-months on HIV vulnerability and related health outcomes, food security, and economic vulnerability. Randomly selected households (n = 1002) were interviewed in the intervention and control areas at baseline and 36 months. Compared to the control group, the intervention led to increased HIV testing (OR 1.90; 95 % CI 1.29-2.78) and HIV case finding (OR = 2.13; 95 % CI 1.07-4.22); decreased food insecurity (OR = 0.74; 95 % CI 0.63-0.87), increased nutritional diversity, and improved economic resilience to shocks. Most effects were sustained over a 3-year period. Further, no significant differences in change were found over the 3-year study period on surveys of randomly selected households in the intervention and control areas. Although there were general trends toward improvement in the study area, only intervention participants' outcomes were significantly better. Results indicate the intervention can improve economic and food security and HIV vulnerability through increased testing and case finding. Leveraging the resources of economic development NGOs to deliver locally-developed programs with scientific funding to conduct controlled evaluations has the potential to accelerate the scientific evidence base for the effects of economic development programs on health.

    View details for DOI 10.1007/s10461-016-1455-1

    View details for PubMedID 27350305

    View details for PubMedCentralID PMC5306183

  • mHealth text messaging for physical activity promotion in college students: a formative participatory approach. American journal of health behavior Yan, A. F., Stevens, P., Wang, Y., Weinhardt, L., Holt, C. L., O'Connor, C., Feller, T., Xie, H., Luelloff, S. 2015; 39 (3): 395-408


    To develop mobile-based physical activity promotion text messages, understand users' preferences, and assess feasibility and acceptability in a college student sample.Five focus groups (N = 33) were conducted using a participatory approach. An Audience Response System was adopted for data collection to ensure confidentiality and for directing the discussion foci. A framework analysis of transcribed focus group discussions was conducted. Atlas. ti qualitative analysis software was used to manage the data.Participants were uniformly enthusiastic about a text message-based intervention to encourage regular physical activity. They also preferred positive, supportive personally tailored messages. Participants placed a high value on messages related to establishing and monitoring realistic and achievable goals.mHealth text messaging was well received. The results support the feasibility and acceptance of such an intervention.

    View details for DOI 10.5993/AJHB.39.3.12

    View details for PubMedID 25741684

  • Methods and protocol of a mixed method quasi-experiment to evaluate the effects of a structural economic and food security intervention on HIV vulnerability in rural Malawi: The SAGE4Health Study. SpringerPlus Weinhardt, L. S., Galvao, L. W., Mwenyekonde, T., Grande, K. M., Stevens, P., Yan, A. F., Mkandawire-Valhmu, L., Masanjala, W., Kibicho, J., Ngui, E., Emer, L., Watkins, S. C. 2014; 3: 296


    Poverty and lack of a predictable, stable source of food are two fundamental determinants of ill health, including HIV/AIDS. Conversely, episodes of poor health and death from HIV can disrupt the ability to maintain economic stability in affected households, especially those that rely on subsistence farming. However, little empirical research has examined if, and how, improvements in people's economic status and food security translate into changes in HIV vulnerability.In this paper, we describe in detail the methods and protocol of an academic-NGO collaboration on a quasi-experimental, longitudinal study of the mechanisms and magnitude of the impact of a multilevel economic and food security program (Support to Able-Bodied Vulnerable Groups to Achieve Food Security; SAFE), as implemented by CARE. Primary outcomes include HIV vulnerability (i.e., HIV risk behaviors, HIV infection), economic status (i.e., income, household assets) and food security (including anthropometric measures). We recruited participants from two types of areas of rural central Malawi: traditional authorities (TA) selected by CARE to receive the SAFE program (intervention group) and TAs receiving other unrelated CARE programming (controls). In the intervention TAs, we recruited 598 program participants (398 women, 200 men) and interviewed them at baseline and 18- and 36-month follow-ups; we interviewed 301 control households. In addition, we conducted random surveys (n = 1002) in the intervention and control areas with a 36-month assessment interval, prior to and after implementation of SAFE. Thus, we are examining intervention outcomes both in direct SAFE program participants and their larger communities. We are using multilevel modeling to examine mediators and moderators of the effects of SAFE on HIV outcomes at the individual and community levels and determine the ways in which changes in HIV outcomes feed back into economic outcomes and food security at later interviews. Finally, we are conducting a qualitative end-of-program evaluation consisting of in-depth interviews with 90 SAFE participants.In addition to examining pathways linking structural factors to HIV vulnerability, this research will yield important information for understanding the impact of a multilevel environmental/structural intervention on HIV, with the potential for other sustainable long-term public health benefits.

    View details for DOI 10.1186/2193-1801-3-296

    View details for PubMedID 25019044

    View details for PubMedCentralID PMC4082534

  • A social ecological assessment of physical activity among urban adolescents. American journal of health behavior Yan, A. F., Voorhees, C. C., Beck, K. H., Wang, M. Q. 2014; 38 (3): 379-91


    To examine the physical, social and temporal contexts of physical activity, as well as sex variations of the associations among 314 urban adolescents.Three-day physical activity recall measured contextual information of physical activities. Logistic regressions and generalized estimating equation models examined associations among physical activity types and contexts, and sex differences.Active transportation was the most common physical activity. Home/neighborhood and school were the most common physical activity locations. School was the main location for organized physical activity. Boys spent more time on recreational physical activity, regardless of the social context, compared to girls. The average physical activity level was significantly lower for girls than for boys after school.Physical activity promotion interventions need to target physical activity environments and social contexts in a sex-specific manner.

    View details for DOI 10.5993/AJHB.38.3.7

    View details for PubMedID 24636034