Considerations for Dietary Assessment in the Canadian Partnership for Tomorrow Project

Dietary factors are leading contributors to chronic disease and mortality globally and in Canada (1–3), and have been recognized as modifiable risk factors for certain cancers (4). However, much remains to be learned about how dietary factors interact with other modifiable and nonmodifiable exposures and physiologic variables to influence disease risk in humans (5,6). Information collected from large prospective cohorts plays an important role in furthering our understanding of diet-disease relationships (7,8). To advance knowledge on how to promote health and prevent disease, it is critically important to use robust tools for collecting dietary information from participants in such cohorts (9). This guide is intended to be utilized by researchers designing nutritional epidemiological research and in particular, to guide the implementation of dietary assessment tools within the CPTP cohorts. The aim is to provide guidance on method selection, data collection, and analyses of dietary data, as well as stimulate discussions of harmonization of methods across cohorts to advance the evidence base. Because objective measures such as biomarkers of diet are currently few, burdensome, costly, and limited in the information they provide about the types of foods and beverages people consume (5,6), researchers typically rely upon self-report tools. However, it has long been recognized that self-reported dietary data are affected by error, including systematic error or bias (9,10), leading some commentators to suggest that research should no longer rely on selfreport approaches (11,12). However, much work has been conducted to better understand and address error in self-report dietary intake data (9,10). Such work has informed the development of novel technology-enabled tools to allow collection of the least-biased data possible, as well as the development of rigorous statistical approaches to mitigate the effects of error (13–16). Based on what is known about sources and types of error in data captured using different types of tools, it has been recommended that a combination of tools may be the optimal way forward for cohort studies. Specifically, multiple 24-hour recalls (24HRs), administered in combination with a food frequency questionnaire (FFQ), may allow researchers to leverage the strengths of each instrument (10,14,17). Data from 24HRs provide comprehensive detail on intake and measure consumption with less bias than FFQs. On the other hand, FFQs measure intake over a longer period (e.g. past month or year) (18–20), meaning they are better able to capture intake of foods and beverages that may be consumed more episodically (e.g., whole grains, dark-green vegetables) but that may be important to diet-disease relationships. The availability of weband mobile device-based dietary assessment tools for use in Canada and emerging statistical techniques to analyze the resulting data makes this multiple-tool scenario a realistic consideration for Alberta’s Tomorrow Project (21), other cohorts within the Canadian Partnership for Tomorrow Project (CPTP) (22), and other health-related studies. With comprehensive and standardized measurement of dietary exposures across cohorts, the identification of promising strategies to reduce diet-related disease risk among Canadians can be furthered (9)

Validating Self-reported Chronic Conditions in Alberta’s Tomorrow Project Cohort: Data Linkage to Administrative Healthcare Data

Introduction Alberta’s Tomorrow Project (ATP) is a province-wide cohort study of cancer and chronic diseases in Canada. Approximately 55,000 Albertans aged 35-69 years with no history of cancer, other than non-melanoma skin cancer, had joined the ATP. Nearly all (>96%) ATP participants consented to data linkage to administrative healthcare databases. Objectives and Approach To validate chronic conditions self-reported by the ATP participants, individual-level data of a total of 52,851 ATP participants were linked to Alberta Health (AH) administrative datasets using Personal Health Number. Cases of chronic conditions, including diabetes, cardiovascular diseases and gastrointestinal disorders, were identified by algorithms for disease diagnosis using International Classification of Diseases (ICD) codes in administrative healthcare data. Cases were identified as “prevalent” if the index date of diagnosis was before or within 6 months of ATP enrollment date. Self-reported chronic conditions were validated by the cases identified as “prevalent” using the linked AH datasets. Results Among the ATP cohort, 804 participants self-reported ever being diagnosed with myocardial infarction (MI), 451 with stroke, 2,907 with diabetes, 566 with ulcerative colitis, 362 with Crohn’s disease and 112 with liver cirrhosis before or at the time of ATP enrollment. Using the linked AH administrative data, 339 participants were identified as prevalent cases with MI, 200 with stroke, 2,702 with diabetes, 208 with ulcerative colitis, 283 with Crohn’s disease and 55 with liver cirrhosis. The sensitivity and specificity of self-reporting having chronic conditions by the ATP participants were 71.1% and 97.0% for MI, 44.4% and 99.3% for stroke, 78.1% and 98.4% for diabetes, 73.6% and 99.2% for ulcerative colitis, 65.7% and 99.7% for Crohn’s disease and 50.9% and 99.8% for liver cirrhosis. Conclusion/Implications By linking with administrative healthcare data, we were able to validate the accuracy of self-reporting chronic conditions in ATP participants. The sensitivity of self-reporting was acceptable for MI, diabetes, ulcerative colitis and Crohn’s disease, but low for stroke and liver cirrhosis. The specificity was high for all chronic conditions

Cross-validation of Drug Use Records in Two Pharmaceutical Databases: A Population-based Study of Alberta’s Tomorrow Project Cohort

Introduction Pharmaceutical Information Network (PIN, 2008-now) is a provincial database collecting patients’ medication information in Alberta, Canada. Alberta Blue Cross (ABC), the largest health benefit provider in Alberta, has been managing pharmaceutical records for senior patients (65+ years) whose medications are covered by Alberta’s government-sponsored health benefit plan since 1970s. Objectives and Approach Over 96% of participants in Alberta’s Tomorrow Project (ATP), a province-wide cohort study of cancer and chronic diseases in Canada, consented to data linkage to healthcare databases. To cross-validate medication records in the two pharmaceutical databases in Alberta, individual-level data of ATP participants aged 65+ years were cross-linked between PIN and ABC databases (2008-2015) using Personal Health Numbers. Concordant and discordant records were identified by whether or not a specific record co-existed in the two databases. Concordance and discordance (discrepancy) rates, i.e. percentage of concordant or discordant records, were estimated by years and drug types. Results During 2008-2015, there were 1,116,176 records collected by PIN, 1,005,548 records collected by ABC, and a total of 1,218,191 records collected by both for 13,413 ATP participants. The average discrepancy rate between PIN and ABC was 25.8%, and the rate was significantly lower for drugs commonly prescribed for health conditions in seniors, including cardiovascular diseases (18.7% for statin), hypertension (18.9% for beta blockers, ace inhibitors and diuretics), diabetes (23.8% for glucose lower drugs), COPD (20.2% for inhalers) and stomach disorders (22.3% for H2 antagonists and proton pump inhibitors), compared to other drugs (34.4%). For insured drugs, using ABC as reference database, 88.6% of ABC records were concordant with (co-existing in) PIN. The concordance rate for insured drug use was improved by 10% over 2008-2015. Conclusion/Implications By cross-linking two pharmaceutical databases in Alberta for senior ATP participants, we found remarkable discrepancies in pharmaceutical records between PIN and ABC, although there was noticeable improvement over the years. The discrepancy rate between PIN and ABC was drug-specific and significantly lower for drugs commonly prescribed in senior patients

Associations between neighborhood walkability and walking following residential relocation: Findings from Alberta's Tomorrow Project

IntroductionCross-sectional studies consistently find that the neighborhood built environment (e.g., walkability) is associated with walking. However, findings from the few existing longitudinal residential relocation studies that have estimated associations between changes in neighborhood built characteristics and walking are equivocal. The study objective was to estimate whether changes in neighborhood walkability resulting from residential relocation were associated with leisure, transportation, and total walking levels among adults.MethodsThis study included longitudinal data from the “Alberta's Tomorrow Project”—a province-wide cohort study (Alberta, Canada). The analysis included data collected at two time points (i.e., baseline and follow-up) from 5,977 urban adults. The International Physical Activity Questionnaire (IPAQ) captured self-reported walking. We estimated neighborhood walkability, an index capturing intersection, destination, and population counts for the 400 m Euclidean buffer around participants' homes. Using household postal codes reported at baseline and follow-up, we categorized participants into three groups reflecting residential relocation (“non-movers:” n = 5,679; “movers to less walkability:” n = 164, and; “movers to more walkability:” n = 134). We used Inverse-Probability-Weighted Regression Adjustment to estimate differences [i.e., average treatment effects in the treated (ATET)] in weekly minutes of leisure, transportation, and total walking at follow-up between residential relocation groups, adjusting for baseline walking, sociodemographic characteristics, and walkability. The median time between baseline and follow-up was 2-years.ResultsThe three residential relocation groups mainly included women (61.6–67.2%) and had a mean age of between 52.2 and 55.7 years. Compared to “non-movers” (reference group), weekly minutes of transportation walking at follow-up was significantly lower among adults who moved to less walkable neighborhoods (ATET: −41.34, 95 CI: −68.30, −14.39; p < 0.01). We found no other statistically significant differences in walking between the groups.DiscussionOur findings suggest that relocating to less walkable neighborhoods could have detrimental effects on transportation walking to the extent of adversely affecting health. Public health strategies that counteract the negative impacts of low walkable neighborhoods and leverage the supportiveness of high walkable neighborhoods might promote more walking

Evaluating the feasibility of administering a combination of online dietary assessment tools in a cohort of adults in Alberta, Canada

Purpose: Evidence suggests that combining tools, such as 24-hour recalls and food frequency questionnaires, may allow more accurate assessment of diet in epidemiologic studies. Webbased technology should make this approach more feasible than in the past, but it is important to explore response rates and acceptability of such an approach in real-world settings. We sought to determine the feasibility of using a combination of online tools (Automated SelfAdministered 24-hour (ASA24) Dietary Assessment Tool and Diet History Questionnaire-II (DHQ-II)) in a sub-set of participants in Alberta’s Tomorrow Project (ATP); a prospective cohort of 55,000 adults >35y in Alberta, Canada. Methods: Invitations to the feasibility study were mailed to 550 ATP participants. Those who consented (n=331) were asked to complete a health questionnaire, four ASA24 recalls (approximately three weeks apart over a four month period, with staggered start dates between June and December 2016), followed by the DHQ-II, and an evaluation survey. Results: The majority of participants [mean (SD) age =57.1 (10.1)] were women (70.7%), urban residents (84.8%) and non-smokers (95.7%). Of the 229 participants who completed at least one ASA24, roughly equal proportions completed one (24.8%), two (24.5%), three (24.5%) and four recalls (26.2%). One third (n=102) of consenting participants did not respond to any ASA24 recall requests, with “lack of time” given as the primary reason. Only 41% of consenting participants (n=136) completed the DHQ-II; of these, 40% (n=55) completed all four recalls. Median (25th-75th percentile) completion times were 46 (26-64) minutes for the first ASA24 recall and 50 (40-90) minutes for the DHQ-II. Conclusions: Over half of participants completed at least two or more ASA24 recalls, and those who completed a greater number of recalls also completed the DHQ-II, demonstrating that the approach is feasible in the ATP cohort. However, response rates may be sensitive to the timing and frequency of recall administration. Future investigations will (i) evaluate the dietary data collected from each tool; (ii) explore methods of combining the data to optimize assessment of diet in the cohort, while accounting for the fact that not all participants will complete the entire dietary assessment protocol

Harnessing the power of data linkage to enrich the cancer research ecosystem in Canada.

Objectives We will enrich the cancer research ecosystem in Canada through linking cancer registry and administrative health data to the Canadian Partnership for Tomorrow’s Health (CanPath) cohort and biobank. CanPath is Canada’s largest population health study, including 1% of the Canadian population, which seeks to investigate cancer development. Approach We are achieving record-level linkage of the CanPath harmonized dataset to provincial cancer registry data, and hospitalization and ambulatory care data from the Canadian Institutes of Health Information (CIHI). The CanPATH harmonized dataset includes comprehensive genetics, environment, lifestyle, and behaviour data. Our linkage activities will result in interprovincial data sharing, with centrally-held linked data, a first in Canadian history. We will demonstrate the CanPath-cancer registry-CIHI linkage potential by investigating the impact of the COVID-19 pandemic on healthcare utilization and outcomes among those with cancer. Results The linkage is ongoing and anticipated to be completed by September 2022. Linked data will be made available through the CanPath Data Safe Haven, a cloud-based solution that meets the legal requirements of the data sharing agreements and provincial privacy policies, and is accessible to researchers through secure access. The CanPath Data Safe Haven will be a federated data platform for Canadian researchers to access, analyze, and contribute research in a collaborative environment. By linking these datasets, this project will: address concerns related to accessibility of cancer data in Canada; bring more value to existing data; support an enhanced understanding of the impacts of cancer on marginalized populations; and create a more integrated approach to cancer data access and management. Conclusion CanPath will be the first program in Canadian history to combine the wealth of cohort resources with cancer registry and administrative health data in a central location at a national scale. We will provide a single point of access for researchers to conduct novel investigations into cancer development and outcomes

Reduced Cognitive Assessment Scores Among Individuals With Magnetic Resonance Imaging-Detected Vascular Brain Injury

Background and Purpose- Little is known about the association between covert vascular brain injury and cognitive impairment in middle-aged populations. We investigated if scores on a cognitive screen were lower in individuals with higher cardiovascular risk, and those with covert vascular brain injury. Methods- Seven thousand five hundred forty-seven adults, aged 35 to 69 years, free of cardiovascular disease underwent a cognitive assessment using the Digital Symbol Substitution test and Montreal Cognitive Assessment, and magnetic resonance imaging (MRI) to detect covert vascular brain injury (high white matter hyperintensities, lacunar, and nonlacunar brain infarctions). Cardiovascular risk factors were quantified using the INTERHEART (A Global Study of Risk Factors for Acute Myocardial Infarction) risk score. Multivariable mixed models tested for independent determinants of reduced cognitive scores. The population attributable risk of risk factors and MRI vascular brain injury on low cognitive scores was calculated. Results- The mean age of participants was 58 (SD, 9) years; 55% were women. Montreal Cognitive Assessment and Digital Symbol Substitution test scores decreased significantly with increasing age

Cardiovascular risk scoring and magnetic resonance imaging detected subclinical cerebrovascular disease

AIMS: Cardiovascular risk factors are used for risk stratification in primary prevention. We sought to determine if simple cardiac risk scores are associated with magnetic resonance imaging (MRI)-detected subclinical cerebrovascular disease including carotid wall volume (CWV), carotid intraplaque haemorrhage (IPH), and silent brain infarction (SBI). METHODS AND RESULTS: A total of 7594 adults with no history of cardiovascular disease (CVD) underwent risk factor assessment and a non-contrast enhanced MRI of the carotid arteries and brain using a standardized protocol in a population-based cohort recruited between 2014 and 2018. The non-lab-based INTERHEART risk score (IHRS) was calculated in all participants; the Framingham Risk Score was calculated in a subset who provided blood samples (n = 3889). The association between these risk scores and MRI measures of CWV, carotid IPH, and SBI was determined. The mean age of the cohort was 58 (8.9) years, 55% were women. Each 5-point increase (∼1 SD) in the IHRS was associated with a 9 mm3 increase in CWV, adjusted for sex (P \u3c 0.0001), a 23% increase in IPH [95% confidence interval (CI) 9-38%], and a 32% (95% CI 20-45%) increase in SBI. These associations were consistent for lacunar and non-lacunar brain infarction. The Framingham Risk Score was also significantly associated with CWV, IPH, and SBI. CWV was additive and independent to the risk scores in its association with IPH and SBI. CONCLUSION: Simple cardiovascular risk scores are significantly associated with the presence of MRI-detected subclinical cerebrovascular disease, including CWV, IPH, and SBI in an adult population without known clinical CVD

Differences in the carcinogenic evaluation of glyphosate between the International Agency for Research on Cancer (IARC) and the European Food Safety Authority (EFSA)

The International Agency for Research on Cancer (IARC) Monographs Programme identifies chemicals, drugs, mixtures, occupational exposures, lifestyles and personal habits, and physical and biological agents that cause cancer in humans and has evaluated about 1000 agents since 1971. Monographs are written by ad hoc Working Groups (WGs) of international scientific experts over a period of about 12 months ending in an eight-day meeting. The WG evaluates all of the publicly available scientific information on each substance and, through a transparent and rigorous process,1 decides on the degree to which the scientific evidence supports that substance's potential to cause or not cause cancer in humans. For Monograph 112,2 17 expert scientists evaluated the carcinogenic hazard for four insecticides and the herbicide glyphosate.3 The WG concluded that the data for glyphosate meet the criteria for classification as a probable human carcinogen. The European Food Safety Authority (EFSA) is the primary agency of the European Union for risk assessments regarding food safety. In October 2015, EFSA reported4 on their evaluation of the Renewal Assessment Report5 (RAR) for glyphosate that was prepared by the Rapporteur Member State, the German Federal Institute for Risk Assessment (BfR). EFSA concluded that ?glyphosate is unlikely to pose a carcinogenic hazard to humans and the evidence does not support classification with regard to its carcinogenic potential?. Addendum 1 (the BfR Addendum) of the RAR5 discusses the scientific rationale for differing from the IARC WG conclusion. Serious flaws in the scientific evaluation in the RAR incorrectly characterise the potential for a carcinogenic hazard from exposure to glyphosate. Since the RAR is the basis for the European Food Safety Agency (EFSA) conclusion,4 it is critical that these shortcomings are corrected

Associations between the neighbourhood characteristics and body mass index, waist circumference, and waist-to-hip ratio: findings from Alberta’s Tomorrow Project

This study estimated the associations between neighbourhood characteristics and self-reported body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) risk categories among Canadian men and women. Using data from the Alberta’s Tomorrow Project (n=14,550), we estimated 3- and 4-way intersections, business destinations, population count, and normalized difference vegetation index (NDVI) within a 400m radius of participant's home. Intersections, business destinations, and population count (z-scores) were summed to create a walkability score. Four-way intersections and walkability were negatively associated with overweight and obesity. Walkability was negatively associated with obesity. NDVI was negatively associated with high-risk WHR and population count and walkability positively associated with high-risk WHR. Among men, population count and walkability were negatively associated with obesity, and business destinations and walkability were negatively associated with overweight and obesity. Among women, NDVI was negatively associated with overweight (including obesity), obesity, and high-risk WC. Interventions promoting healthy weight could incorporate strategies that take into consideration local built environment characteristics