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India is a developing country with one of the most diverse populations and diets in the world. Cancer rates in India are lower than those seen in Western countries, but are rising with increasing migration of rural population to the cities, increase in life expectancy and changes in lifestyles. In India, rates for oral and oesophageal cancers are some of the highest in the world. In contrast, the rates for colorectal, prostate, and lung cancers are one of the lowest. Studies of Indian immigrants in Western societies indicate that rates of cancer and other chronic diseases, such as coronary heart disease and diabetes, increase dramatically after a generation in the adopted country. Change of diet is among the factors that may be responsible for the changing disease rates. Diet in India encompasses diversity unknown to most other countries, with many dietary patterns emanating from cultural and religious teachings that have existed for thousands of years. Very little is known, however, about the role of the Indian diet in causation of cancer or its role, if any, in prevention of cancer, although more attention is being focused on certain aspects of the Indian diet, such as vegetarianism, spices, and food additives. Of particular interest for cancer prevention is the role of turmeric (curcumin), an ingredient in common Indian curry spice. Researchers also have investigated cumin, chilies, kalakhar, Amrita Bindu, and various plant seeds for their apparent cancer preventive properties. Few prospective studies, however, have been conducted to investigate the role of Indian diet and its various components in prevention of cancer. From a public health perspective, there is an increasing need to develop cancer prevention programs responsive to the unique diets and cultural practices of the people of India.

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Persons living with HIV/AIDS face many issues that make them highly vulnerable to a number of health and social problems. As the demographics of the epidemic have shifted in recent years, many members of traditionally underserved groups have encountered barriers to entering the services system. This article uses data from seven national demonstration projects funded to enroll persons with HIV/AIDS who tend to "fall through the cracks" and help them access needed services. Data on the initial perceptions of the participants about barriers to accessing services were related to 17 indicators of traditionally underserved status including demographic characteristics and behavioral variables using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Through the modeling methods, the groups most likely to experience a large number of barriers to service participation are identified. Having children needing care is particularly predictive of the level of barriers to care.

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Over the course of the HIV epidemic, the demographics of the populations of affected individuals have changed. Groups that traditionally have been underserved in systems of care have a number of unmet service needs. This article presents results based on data from 478 patients in five national demonstration projects which were funded to enroll individuals from traditionally underserved groups and to help them access services using different strategies. The participants in these programs had a high level of unmet need prior to enrolling in care. Data on client service needs were related to 17 indicators of traditionally underserved status including demographic characteristics and risk behaviors, using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Crack cocaine users with HIV/AIDS were more likely than other patient groups to have unmet service needs. Patients who were homeless or in precarious housing also were vulnerable. Results are discussed in terms of designing and evaluating innovative service models to close these service gaps.

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The demographic, behavior, and background characteristics of 4,804 participants in 17 national demonstration projects for HIV medical and/or psychosocial support services were coded for an index of "service need" or possible under-representation in the traditional healthcare system. Fifteen items were coded including status as a person of color, lack of private insurance, unemployment/disability, problem drinking, crack cocaine use, heroin use, other illicit drug use, less than 12 years of education, criminal justice system involvement, children requiring care while the patient receives services, sex work, being the sex partner of an injection drug user, unstable housing, primary language not English, and age less than 21 or over 55 years. Most (87.7%) of the program participants had four or more of these factors present. Through CHAID modeling, those groups with the highest levels of service need and vulnerability were identified. These data suggest that these projects, designed to attract and serve individuals potentially underrepresented in the health services system, had in fact achieved that goal. Implications of the changing demographics of the HIV epidemic for the health service delivery system are discussed.

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As the demographics of the populations of affected individuals have changed, systems of care have needed to adapt to be responsive to client needs. This article examines client satisfaction data from seven national demonstration projects funded to enroll individuals from traditionally underserved groups and help them access services using different strategies. Data on client satisfaction ratings were related to indicators of traditionally underserved status, including demographic characteristics, behaviors, and other risk factors using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Client groups that were most likely to experience relatively higher and lower levels of satisfaction with services are identified. Overall, all client groups were highly satisfied with the innovative HIV/AIDS services received. The findings illustrate the success of these innovative HIV care models in being responsive and sensitive to the needs of their target populations.

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Dietary nutrients can influence cancer risk by inhibiting or enhancing carcinogenesis through diverse mechanisms of action. The identification and elucidation of their sites of action have been a focus of nutrition and cancer research for more than four decades. Transforming nutrition and cancer research from a predominantly observational to a molecular approach offers exciting opportunities for truly identifying those who will and will not benefit from dietary intervention strategies. The emerging field of nutritional genomics, defined here as the study of any genetic or epigenetic interaction with a nutrient, will be key to this evolution. Unraveling which genetic upregulation or downregulation leads to subsequent phenotype changes will not be easy. There is evidence that genetic polymorphisms can influence the dynamics between nutrients and molecular targets and, thus, contribute to variation in response among individuals. Because many molecular targets will likely be identified, it may be necessary to credential nutrients, that is, to determine which specific nutrient-related genetic and epigenetic changes bring about phenotypic changes, to establish which interactions are the most important and under what circumstances. Vitamin D, calcium, folate, selenium, genistein, and resveratrol are highlighted, because they represent specific classes of nutrients and illustrate the need to credential various nutrients to understand their physiological significance in cancer prevention. As the science of nutrition unfolds, a clearer understanding will emerge about how nutrients can modulate cancer risk through molecular interactions and how foods might be changed by agronomic approaches and/or biotechnology. Undeniably, embracing new genomic technologies offers exciting opportunities for advances in the broad area of nutrition, especially those related to cancer prevention.

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This article develops a typology of 2,038 participants in 13 innovative HIV/AIDS treatment model service demonstration projects targeted to traditionally underserved populations. The typology is based on self-reported health-related quality of life levels. Eight clusters were identified that classify HIV/AIDS patients based on their reported health-related quality of life. Participants were clustered based on their overall levels of quality of life, as well as by deficits in specific areas of functioning such as energy level, physical impairment, and role impairment. However, factor analysis suggests that health-related quality of life as perceived by the HIV-positive participants is best represented as a single underlying dimension and an ordering of the types shows that they are consistently related, in the same order, to several criterion measures of impairment. The results suggest that a general categorization of patients with HIV in terms of quality of life is more meaningful than an assessment of the relative areas of impairment. Since the impairment ratings were also self-reported, analyses relating quality of life clusters to actual symptom levels and healthcare utilization are needed. Implications for the assessment of health-related quality of life and the evaluation of service delivery programs for persons living with HIV are discussed.

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This article explores the relationships of HIV risk factors, service needs, and vulnerabilities to health-related quality of life in a sample of 1,371 participants newly enrolled into 13 innovative HIV/AIDS treatment model service demonstration projects. These projects targeted services to traditionally underserved populations. Eight distinct quality of life clusters of HIV patients were used in this analysis along with patient self-identified risk factors. The quality of life clusters were based on patient self-reported quality of life dimensions. The eight clusters were differentiated based on relative strengths and weaknesses in physical functioning, energy levels, and social functioning. Data on patient need-vulnerability factors and demographic characteristics were related to these eight clusters using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Through this method, the characteristics most likely to be associated with higher and lower levels of quality of life at the time of enrollment into services were identified. The results provide further support that quality of life assessment is a useful clinical tool for monitoring patient progress.

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Dietary fat is a likely important determinant of postmenopausal breast cancer as part of an intricate and inseparable interaction of lifestyle cancer risk factors that include dietary fat, type of fat, energy intake and expenditure, and obesity. These factors possibly build upon individual susceptibilities derived from a complex array of polygenetic risk determinants. Epidemiologic studies have not provided conclusive evidence for a dietary fat-breast cancer association, partly because studies that focus on a single nutrient cannot always evaluate readily the interactive effects of other lifestyle factors. Further, persons generally underestimate their usual dietary intake, measured by either food frequency questionnaires (FFQs) or diet records. A dietary measurement model that accounts for this underreporting demonstrated that FFQs and diet records may not be able to detect a dietary fat-breast cancer association because of measurement error biases. Although meta-analysis of epidemiologic data across individual studies suggests only a week association between breast cancer and dietary fat, this result is compatible with the dietary measurement model and does not rule out a contributing role for dietary fat, either alone or with other causative factors. Research is needed that focuses on a comprehensive approach to dietary lifestyle choices and breast cancer risk and that emphasizes a fat-caloric intake-obesity linkage. The best hope for a definitive answer may rest with randomized, controlled clinical trials. Two such trials, the Women's Health Initiative and the Women's Intervention Nutrition Study, are under way.

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Progress in development of a genetic model for colorectal tumorigenesis and human chemoprevention research may allow the mechanism-based identification of targets and chemopreventive agents that will protect against colorectal cancer. For example, numerous mutagenic events can occur throughout colorectal carcinogenesis, including loss of heterozygosity in tumor suppressor genes such as APC, MCC, DCC, and p53, as well as in oncogenes such as K-ras. Chemopreventive agents that inhibit mutagenic activity such as N-acetyl-l-cysteine, oltipraz, and nonsteroidal anti-inflammatory drugs may protect against these mutations. Also, agents such as perillyl alcohol and lovastatin that interfere with protein isoprenylation and, hence, inhibit oncogene activation may protect against aberrant K-ras expression. Hyperproliferation in normal mucosa, leading to growth and progression of neoplasia, are also aspects of colorectal carcinogenesis that can be controlled by chemopreventive agents. Calcium is a chemopreventive agent for which there is both clinical and experimental evidence of inhibition of cell proliferation in colon mucosa. Other examples of antiproliferative agents with potential chemopreventive efficacy in colon are 2-difluoromethylornithine, dehydroepiandrosterone, and selenium. Differentiating agents such as retinoids and deltanoids also may slow proliferation and progression. Antioxidants have potential for interfering with both mutagenicity and proliferation (e.g., by preventing oxidative activation of carcinogens and scavenging activated oxygen species generated during inflammation). The same mechanistic principles apply to identification of dietary chemopreventive intervention for colorectal carcinogenesis. For example, lowering dietary fat and increasing dietary fiber lead to lower colorectal mucosal proliferation, and cruciferous vegetables contain agents such as indoles and dithiolthiones that have shown antimutagenic activity.

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An estimated one in five Americans is functionally illiterate; they lack the literacy skills to access information or to perform many other basic tasks vital to their health and well-being. The National Cancer Institute and its Cancer Information Service have been working since 1990 to develop cancer-education strategies and materials to reach people with limited literacy skills. This paper reviews the link between cancer and illiteracy, the magnitude of the problem, and the association between cancer, certain health-related behaviors, and educational attainment. It also examines innovative National Cancer Institute and Cancer Information Service programs and materials designed to reach this high-risk population.

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Diet and cancer research at the National Cancer Institute has grown from a budget of $2.5 million in 1974 to $55 million in 1988. The emphasis is partially on demonstrations of prevention strategies and chemoprevention trials. Studies to disseminate dietary goals in practical ways are undertaken with the aid of the food industry.

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National Analysts conducted primary research with rheumatologists--specifically, two panel discussions, 25 in-depth telephone interviews, and a mail survey of conference (Auranofin Symposium and Workshop) participants--to examine current treatment practices and to probe the rationale and motivations underlying treatment strategies in rheumatoid arthritis. The research identified important areas of consensus in drug perceptions, therapeutic approaches, and disagreements. Physicians differ regarding the minimum time they wait after diagnosing rheumatoid arthritis before initiating remittive therapy, some beginning immediately and others waiting six months or longer. Younger physicians are quicker to initiate remittive treatment than their older colleagues, but both younger and older practitioners are initiating remittive therapy earlier than in the past. Some noteworthy differences between hospital-based and office-based practitioners were discerned with respect to factors that figure in their decisions to initiate remittive therapy. Differences were also found among physicians in the way they pose drug options to their patients; "authoritarian," "libertarian," and "guided democracy" were names given to the three styles identified. In general, however, physicians report that patients are more directly involved in treatment selection than previously, a trend that may in part be due to the use of more aggressive treatment strategies than in the past and a desire to share the psychologic burden of those decisions. Findings suggest that gold compounds will continue to be a mainstay first-line disease-modifying agent in the treatment of rheumatoid arthritis but that there may be less reluctance to use other agents as physicians become increasingly familiar and comfortable with alternative options, especially penicillamine and immunosuppressive agents.

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