Epidemiology

HE 300/KP 434 - Fall 2017

Critical Review Assignment

Instructions:

Download one of the following peer-reviewed research articles from the MyLearningSpace
Critical Review Assignment folder:

1. Friberg, E., Mantzoros, C. S., & Wolk, A. (2006). Physical activity and risk of endometrial cancer: a
population-based prospective cohort study. Cancer Epidemiology and Prevention
Biomarkers, 15(11), 2136-2140.

2. Hu, F. B., Leitzmann, M. F., Stampfer, M. J., Colditz, G. A., Willett, W. C., & Rimm, E. B. (2001).
Physical activity and television watching in relation to risk for type 2 diabetes mellitus in
men. Archives of Internal Medicine, 161(12), 1542-1548.

3. Lindstrom, H. A., Fritsch, T., Petot, G., Smyth, K. A., Chen, C. H., Debanne, S. M., ... & Friedland, R. P.
(2005). The relationships between television viewing in midlife and the development of Alzheimers
disease in a case-control study. Brain and Cognition, 58(2), 157-165.

After reading and reviewing one of these article, answer each of the questions developed by
Aschengrau & Seage (2014), outlined on the following page, in relation to the paper you chose.
The chapter by Aschegrau & Seage (2014), also posted in the Critical Review Assignment
folder on MyLearningSpace, provides examples of answers to the questions you are to answer.
Please review this chapter as you are completing this assignment.

Your responses should be typed for electronic submission to the course dropbox. Please submit
your assignment as a Microsoft Word document, using 12-point font (using either Times New
Roman, Arial, or Calibri), with 1.5 paragraph spacing for your responses. You may work in
groups to answer questions, however, you will be marked individually and turnitin will be
used to assess each assignments originality. You may (and are encouraged to) use external
sources of information to answer questions, however, these should be cited using APA
formatting with a reference list included at the end of your document.

This assignment is worth 15% of your final grade, and will be graded out of a total of 100 marks.
The assignment is due at 11:59PM on November 30th, 2017.

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Collection of Data (50 marks)

1. What was the context of the study? (5 marks)

Previously, there was ample epidemiological evidence that supported increased physical
activity as a major factor for reducing type 2 diabetic risk. However, little focus was on
sedentary behaviors, especially TV watching, in relation to diabetic risk.

2. What were the objectives of the study? (5 marks)

The objective of this study was to determine whether long periods of TV watching was
associated with a type 2 diabetic risk in adult males. This objective was carried out
independent of physical activity.

3. What was the primary exposure of interest? Was this accurately measured? (6 marks)
The exposure of interest was TV watching. Although continued personal questionnaires
were required, the diagnosis for diabetes was accurately measured. Cases of diabetes were
identified if the patient confirmed at least one of the following symptoms: excessive thirst,
loss in weight, polyuria and/or one fasting plasma glucose level of at least 7.8 mmol/L. The
validity of self-report had been verified in a subsample of seventy-one men from the same
cohort. The National Diabetes Data Group for 1986-1996 proposed a set of criteria for
diabetes symptoms, which the questionnaire followed consistently, showing further
accuracy in results obtained. Finally, cases were accurately measured because 98% of
questionnaire-reported diabetic cases were confirmed through a medical record review from
a subsample of participants from the Nurse Health Study.

4. What was the primary outcome of interest? Was this accurately measured? (6 marks)
The outcome of interest was the risk of type 2 diabetes mellitus. Symptom and
diagnostic test questionnaires were sent to the adult males participating in the study to
identify diabetes. The outcome was accurately measured due to many of the same reasons
as the exposure. The National Diabetes Data Group (1986-1996) classification for diabetes
symptoms are consistent with findings from the questionnaire. Finally, 97% of diabetic cases
had complete records confirming type 2 diabetes mellitus diagnosis.

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5. What type of study was conducted? (4 marks)
The study type conducted was a prospective cohort study.

6. Describe the source of the study population, process of subject selection, sample size, and
ratio of propositi to comparison subjects. (Propositi are exposed subjects in a cohort
study and cases in a case-control study.) (6 marks)
The study population source was the HPFS (Health Professionals Follow-up Study)
started in 1986. 51,529 United States health professionals from 40-75 years of age answered
a detailed questionnaire of diet, lifestyle and medical history. Process selection was carried
out as followed: men with a previous CVD diagnosis, cancer, and/or diabetes, were
excluded, and amounted in 4,639, 1,638 and 1,796 men, respectively. Participants who had
missed information on the questionnaire or had implausible energy intake on the Food
questionnaire, 5,538 men, were excluded. Finally, a sample size of 37, 918 men were
followed for the 10-year study.

7. Could there have been bias in the selection of the study subjects? How likely was this
bias? (6 marks)
Gender bias was found since only adult males were selected for the study. Women also
have susceptible risks of type 2 diabetes mellitus and prolonged sedentary behaviors, so they
could have been possible cases also, although men and women had different risks of
diabetes onset. Finally, another bias found was professional bias. Medical professionals with
ample knowledge of health and risks were selected for the study out of the entire general
population. This created error in randomization, thus leading to selection bias in the study.
This selection bias was very likely. The HPFS individuals did not adequately represent the
entire population for this study.

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8. Could there have been bias in the collection of information? How likely was this bias? (6
marks)
A possible bias could be information bias. This is because the study conducted relied on
self-report questionnaires that the adult males filled out, regarding diabetes symptoms,
physical activity hours, and/or hours spent watching TV per week. The cases could have
conformed to the healthy general public and stated a false number of hours watching TV
or exercising to appear healthy, to avoid mental images of being labelled as unhealthy
and/or socially excluded. Finally, a lost to follow up error could have been likely. This is
because of the fact that the study conducted was ten years long, and that cases could have
passed away, dropped out of the study, moved locations, changed contact information
(hospital records) and/or felt less enthused to participate in the study and started to fill in
false information.

9. What provisions were made to minimize the influence of confounding factors prior to the
analysis of the data? Were these provisions sufficient? (6 marks)
Confounding factors were third variables that could have had a significant impact in
preventing or resulting in the outcome of interest. Some of the confounding factors that the
authors collected were age, BMI, parental history of diabetes, smoking and dietary intakes
of fats and fiber. Multiple subsample Relative Risk analyses were carried out for each
variable. The authors conducted subgroup analyses with each confounding factor and
outcome separately, but noted that further adjustment for these variates did not
appreciably change RRs. This indicated that although adjustments were made for each
confounding factor to be ruled out and/or measured separately, these factors did not
significantly change the Relative Risk results collected across quintiles, and that the inverse
relation of physical activity and risk of type 2 diabetes mellitus was strongly correlated. No
other residual confounding could have been present due to extensive confounding factor
collection and separation by the authors, although none made a difference on results
obtained.

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Analysis of Data (13 marks)

1. What methods were used to control confounding bias during data analysis? Were these
methods sufficient? (5 marks)
Physical Activity was a confounding factor found in this study. Separate subsample RRs
were calculated for physical activity, moderate and vigorous, and diabetes to ensure no
confounding. Also, the variables were categorized into quartiles instead of quintiles to be
sufficient. Finally, when compared to RRs for all other adjusted variables, the RRs remained
similar, meaning that the controls carried out were sufficient. Other controlled confounding
variables are mentioned in Q.9 above.
2. What measures of association were reported in this study? (4 marks)
Relative Risks were reported in this prospective cohort study, between time spent
watching TV and type 2 diabetes risk.
3. What measures of statistical stability (variance/error) were reported in this study? (4
marks)
The study reported p-values and 95% CI for statistical stability measures.

Interpretation of data (32 marks)

1. What were the major results of this study? (5 marks)
Increasing physical activity significantly substantially reduced the risk of type 2 diabetes
mellitus. Relative Risks across MET score quintiles from total physical activity were 1.00,
0.76, 0.61, 0.55 and 0.47 (p-value: <0.001). These RRs showed little deviation when
adjustments for smoking, diabetic history, diet, alcohol and BMI were made, indicating a
strong inverse association between physical activity scores and diabetic risk. Similar scores
were found for subgroup analysis such as age (<65, 65, >65), smoking (ever/never) and BMI
(<25.0, 25.0, >25.0). Indications of reduced obesity levels were also found when physical
activity levels were increased. Following age adjustments and adjusting all other covariates,
such as vigorous physical activity, a higher inverse association between increased physical
activity levels and diabetic risk, with RR MET scores across quintiles being 1.00, 1.02, 0.80,
0.76, 0.72 (P-value: <0.001). RRs are almost halved across the entire MET score quintiles,
from totally sedentary (1.00), to physically active (0.76). It was also observed than men
who spent more time watching TV (sedentary) were more prone to alcohol consumption

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 and smoking than physically active men were. Results for average TV watching categories
per week (0-1, 2-10, 11-20, 21-40 and >40) were 1.00, 1.62, 1.61, 2.22 and 3.35 (95% CI

(1.71, 6.55), indicating that the risk for type 2 diabetes mellitus increased for men who
spent more time watching TV. Finally, men who were active for more than 46 MET hours
per week (>46 MET-hours/week) had the lowest time for watching TV, on average, per
week (<3.5 hours/week).
2. How is the interpretation of these results affected by information bias, selection bias, and
confounding? Discuss both the direction and magnitude of any bias. (6 marks)
Selection bias affected these results because health professionals were picked for this
study, and did not represent the general population, so that the RRs calculated across
quintiles could have been lower than the ones calculated if a randomized cohort was used,
where the general population might not have had as much knowledge about the exposure
and outcome. Also, information bias would also affect the results in the same way because
cases that reported false values for physical activity and time spent watching TV per week
could have conformed to the publics view of a healthy lifestyle, which could have
distorted results and lowered the RRs found across quintiles. The error in gender bias might
also have lowered the RRs found across quintiles for diabetes risk because women have a
smaller risks of diabetes prevalence than men (known asides from study, not actually
mentioned in study, see References).
3. How is the interpretation of these results affected by nondifferential misclassification?
Discuss both the direction and magnitude of this misclassification. (5 marks)
The nondifferential misclassification of outcome and exposure was small because both
outcome and exposure measurements were accurate. Confirmations of questionnaire
answers were found using medical records. Finally, 85% of men in this study visited a doctor
for a physical examination for any conditions that pre-existed the study. When the analysis
was focused on type 2 diabetes symptoms, findings were similar. Conclusively,
nondifferential misclassification of outcome and exposure was not likely to affect study
results.
4. Did the discussion section adequately address the limitations of the study? (6 marks)
Yes, the author addressed the possibilities of surveillance bias, selection bias and
confounding (Discussed above).

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 5. What were the authors main conclusions? Were they justified by the findings? (5 marks)
To conclude, the author stated that ample data collected through RRs found that
prolonged TV watching, a sedentary behavior, increases the risk of type 2 diabetes mellitus,
which is indicated by the strong associated relative risk of 2.92. Also, a strong inverse
relationship was found between physical activity and diabetic risk, with data found proving
this mentioned above. An increase in physical activity largely reduced the risk of type 2
diabetes mellitus.
6. To what larger population can the results of this study be generalized? (5 marks)
Although the participants used in this study were health professionals, this study can be
generalized to populations in poverty. These not only have to be developing countries, but
also western societies with areas of mild-to-severe food insecure households. People in these
areas rely on cheap processed foods, smoking and alcohol consumption due to lack of
income and resources. They also have heavy sedentary lifestyles due to lack of employment
or productivity. HOWEVER, due to the selection bias and gender bias found in this study, it
cant be generalized to any population, because no population is comprised of just health
professionals.

References (5 marks)

Frank B. Hu, MD; Michael F. Leitzmann, MD; Meir J. Stampfer, MD; Graham A. Colditz, MD; Walter
C. Willett, MD; Eric B. Rimm, ScD. Physical Activity and Television Watching in Relation to
Risk for Type 2 Diabetes Mellitus in Men. Departments of Nutrition. American Medical
Association, 2001. All Rights Reserved. Last Accessed: Dec. 1, 2017

Total Marks /100 marks

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