The Relationship between Native American Ancestry,Body Mass Index and Diabetes Risk among Mexican-Americans

Higher body mass index (BMI) is a well-established risk factor for type 2 diabetes, and rates of obesity and type 2 diabetes are substantially higher among Mexican-Americans relative to non-Hispanic European Americans. Mexican-Americans are genetically diverse, with a highly variable distribution of Native American, European, and African ancestries. Here, we evaluate the role of Native American ancestry on BMI and diabetes risk in a well-defined Mexican-American population. Participants were randomly selected among individuals residing in the Houston area who are enrolled in the Mexican-American Cohort study. Using a custom Illumina GoldenGate Panel, we genotyped DNA from 4,662 cohort participants for 87 Ancestry-Informative Markers. On average, the participants were of 50.2% Native American ancestry, 42.7% European ancestry and 7.1% African ancestry. Using multivariate linear regression, we found BMI and Native American ancestry were inversely correlated; individuals with <20% Native American ancestry were 2.5 times more likely to be severely obese compared to those with >80% Native American ancestry. Furthermore, we demonstrated an interaction between BMI and Native American ancestry in diabetes risk among women; Native American ancestry was a strong risk factor for diabetes only among overweight and obese women (OR = 1.190 for each 10% increase in Native American ancestry). This study offers new insight into the complex relationship between obesity, genetic ancestry, and their respective effects on diabetes risk. Findings from this study may improve the diabetes risk prediction among Mexican-American individuals thereby facilitating targeted prevention strategies.     

School-Based Internet Obesity Prevention Programs for Adolescents: A Systematic Literature Review

In response to the childhood obesity epidemic, numerous studies on school-based Internet obesity prevention interventions have been conducted. The purpose of this systematic review is to describe, synthesize, and evaluate the research on school-based Internet obesity prevention programs for adolescents. Medline, CINAHL, and PsycInfo were searched from January 1995 to August 2012 to locate relevant studies. Ninety-one reports were initially identified, with 12 meeting the inclusion criteria. Studies had variable control groups, program content, and sample characteristics. Though few authors reported on implementation processes or body mass index (BMI) outcomes, the majority of studies were effective in improving health behaviors in the short term. Most studies were judged to have a high or unclear risk of bias in at least two domains, thus the quality of evidence for this body of literature is moderate. Further research is needed to examine programs of longer duration, optimal dose and timing of programs, cost-effectiveness, and mediators and moderators of intervention outcomes.     

Overweight and obesity in an ethnically diverse rural school district: the Healthy Kids Project

Objective: Data on Native American children and adolescents are rarely reported along with other racial and ethnic groups. The Healthy Kids Project is part of an effort to describe the prevalence of overweight and obesity in a racially mixed rural area where Native American, Hispanic, African American, and white children reside. Methods and Procedures: We measured height and weight of students in Anadarko, Oklahoma public schools (n = 1,980) in 2002–2003. All available students (95.7%) whose parents had not opted out of school health assessments were included. From these data, we calculated BMI (weight (kg) / height (m²)) and used the International Obesity Task Force reference to classify children into BMI categories. Results: Native American, Hispanic, African American, and white children who live and attend school in the same surroundings are at risk of overweight and obesity. White children had the lowest combined prevalence of overweight and obesity (37.6%), and Native American children had the highest (53.8%) followed closely by African American (51.7%) and Hispanic children (50.5%). Discussion: The childhood obesity epidemic includes all racial and ethnic groups to different degrees. In a rural public school, Native American, Hispanic, and African children had higher rates of overweight/obesity than white children.     

Trends of overweight and obesity among white and american indian school children in south dakota, 1998–2010

Objective:

To investigate the prevalence of overweight and obesity among white and American Indian children in a predominantly rural state.

Design and Methods:

Using a repeated, cross‐sectional design of school children's height and weight, the study sample included 361,352 measures of children who were 5.0–19.9 years, attending school across 13 academic calendar years. Trained staff measured height, weight, and recorded gender, age, and race. Data were voluntarily reported to the State Department of Health.

Results:

American Indian children consistently had higher rates of overweight and obesity compared to white children. Across the years, 16.3% of white students were overweight, whereas 19.3% of American Indian students were overweight. In addition, 14.5% of white children were obese and 25.9% of American Indian children were obese. Examining by rural versus urban schools, prevalence of overweight had been increasing among white male and female students and American Indian female students living in rural areas. Obesity is also increasing among rural white females and male and female American Indian children.

Conclusions:

The findings here suggest that although American Indian children are at higher risk, in general, compared to white children, rural populations in general are experiencing increases in childhood overweight and obesity. Targeted rural interventions beginning at an early age are necessary to improve the health of rural children, especially in American Indian communities.     

Racial admixture and its impact on BMI and blood pressure in African and Mexican Americans

Admixed populations such as African Americans and Hispanic Americans present both challenges and opportunities in genetic epidemiologic research. Because of variation in admixture levels among individuals, case-control association studies may be subject to stratification bias. On the other hand, admixed populations also present special opportunities both for examining the role of genetic and environmental factors for observed racial/ethnic differences, and for possibly mapping alleles that contribute to such differences. Here we examined the distribution and relationship of individual admixture (IA) estimates with BMI and three measures of blood pressure in two admixed populations in the NHLBI Family Blood Pressure Program (FBPP): African Americans and Mexican Americans. For the African Americans, we observed modest but significant differences in average African IA among four recruitment sites. We observed a slight excess of African IA among hypertensives compared to normotensives, and a positive (non-significant) regression of African IA on blood pressure in untreated participants. Within Mexican Americans, we found no difference in average IA between hypertensives and normotensives, but a positive (marginally significant) regression of African IA on diastolic blood pressure. We also observed a significant positive regression of Caucasian IA (and negative regression of Native American IA) on BMI. Our results are suggestive of genetic differences between Africans and non-Africans that influence blood pressure, but such effects are likely to be modest compared to environmental ones. Excess obesity among Native Americans compared to whites is not consistent with a simple genetic explanation.     

Ethnic Differences in Correlates of Obesity between Latin‐American and Black Women

Objective: To date, no studies have examined dietary intake, physical activity, and body image in a large sample of Latin‐American and black women recruited using the same methodology. The aim of this study was to examine three potential correlates of obesity (dietary intake, body image, and physical activity) in a large sample of Latin‐American and black women across the weight spectrum. Research Methods and Procedures: Participants were black (n = 271) and Latin‐American (n = 234) adult women who completed a 24‐hour dietary recall and physical activity and body image questionnaires. Results: After controlling for BMI, education, marital status, and number of children, black women consumed more kilocalories, dietary fat (grams), and percent calories from fat than Latin‐American women, who consumed more carbohydrates (grams) and dietary fiber (total and soluble). Black women engaged in more sedentary behavior than Latin‐American women. Although Latin‐American women weighed less than black women, they perceived their current body image as heavier and reported greater body image dissatisfaction than black women. Black women also reported a higher ideal body image than Latin‐American women. Discussion: The combined effect of a diet higher in calories and fat, increased sedentary behavior, and more accepting body image could account for higher rates of obesity among black women. Future studies should further explore cultural attitudes and beliefs related to weight that could provide information for the development of culturally competent obesity interventions.     

Community Programs for Obesity Prevention: The Minnesota Heart Health Program

Community intervention strategies for obesity that were developed and evaluated in the Minnesota Heart Health Pro-gram (MHHP) are described. The MHHP was a 13-year research and demonstration project involving 6 communities that was designed to evaluate whether a sustained multicomponent education campaign could reduce population-wide risk factors for cardiovascular disease. MHHP weight control activities included adult education classes for weight control, exercise, and cholesterol reduction, a worksite weight control program, a home correspondence course for weight loss and a weight gain prevention program. In separate component evaluation studies each of the programs was shown to facilitate favorable changes in weight among individuals choosing to participate in them. Compared to more intensive interventions, weight changes produced by these methods were modest in magnitude, but the number of individuals participating in some of them was quite large. The overall effects of the MHHP program on population levels of obesity were disappointing. Over 7 years of intervention there was a strong upward trend in weight in all communities, independent of age, demographics, smoking habits, or other potential confounding variables. This trend was not different in communities receiving education than in comparison communities. Possible reasons for these results are discussed.     

Temporal trends in femoral diaphyseal torsional asymmetry among the Arikara associated with postural behavior

Average femoral torsion has been reported to differ among populations, and several studies have observed a relatively high prevalence of femoral anteversion asymmetry in Native Americans, especially females. This study investigates sexual dimorphism and temporal trends in femoral torsional asymmetry among the Arikara from the seventeenth to the early nineteenth century. To establish if there are population differences, femoral torsion was first measured using a direct method on a diverse comparative sample of Native Americans from the Southwest, Midwest, and Great Plains as well as American Whites and Blacks. To examine temporal trends among the Arikara, femoral torsion was examined using the orientation of the maximum bending rigidity at subtrochanteric in 154 females and 164 males from three temporal variants of the Arikara Coalescent tradition. There is significant sexual dimorphism in femoral torsional directional and absolute asymmetry among most Native American samples, but not among American Whites and Blacks. Among the Arikara there is significant sexual dimorphism in femoral torsional asymmetry in all three temporal variants, and asymmetry in femoral torsional asymmetry increased significantly from the protohistoric to the early historic period among females. The increased femoral torsional asymmetry is likely associated with a common side‐sitting posture observed in historic photographs of Great Plains females. Historic Arikara females may have habitually sat in this compulsory position for extended periods while conducting domestic chores. The dramatic change from the protohistoric to historic period suggests a cultural change in sitting posture among females that was widespread across the Northern Plains. Am J Phys Anthropol 154:512–524, 2014. © 2014 Wiley Periodicals, Inc.     

Further data on the microsatellite locus D12S67 in worldwide populations: an unusual distribution of D12S67 alleles in Native Americans

We report the frequencies of alleles at the microsatellite locus D12S67 in 2 widely separated ethnic groups of the world: 2 populations from Sulawesi, an island in the Indonesian archipelago, and 5 Native American tribes of Colombia, South America. The allele frequencies in the Minihasans and Torajans of Sulawesi are similar to each other (but the modal class allele is different) and in general agreement with those reported in mainland Asian groups, but different from both Europeans and Chinese Han of Taiwan. The 5 Native American tribes (Arsario, Kogui, Ijka, Wayuu, and Coreguaje) display different allele frequencies from those seen in Sulawesi populations, in other groups from Europe and mainland Asia, and in Chinese Han of Taiwan. Native Americans exhibit a bimodal distribution of alleles, unlike other groups, with significant differences among the tribes. The Arsario and Kogui have no admixture with Europeans or Africans and are the most distinctive, while the Wayuu have the most admixture and show most similarity to other groups. The data suggest that nonadmixed Native Americans may be quite distinctive with respect to this marker. The most common allele varies across the 5 tribes, from 249 base pairs to 261 base pairs. All samples exhibit Hardy-Weinberg genotype proportions; heterozygosities are lowest in the 2 nonadmixed Native American tribes. Examination of all the available data indicates that some east Asian and southeast Asian groups are characterized by a high frequency of smaller sized D12S67 alleles, while other populations have a greater proportion of the larger sized alleles. The cumulative, though still highly restricted, population data on locus D12S67 demonstrate that it may be of considerable value in anthropological genetic studies of ethnic groups. Data are required on Native Americans outside Colombia before this marker can be used in admixture studies of this group.     

Phylogenetic relationships among JC virus strains in Japanese/Koreans and Native Americans speaking Amerind or Na-Dene

Many genetic studies using human mtDNA or the Y chromosome have been conducted to elucidate the relationships among the three Native American groups speaking Amerind, Na-Dene, and Eskimo-Aleut. Human polyomavirus JC (JCV) may also help to gain insights into this issue. JCV isolates are classified into more than 10 geographically distinct genotypes (designated subtypes here), which were generated by splits in the three superclusters, Types A, B, and C. A particular subtype of JCV (named MY) belonging to Type B is spread in both Japanese/Koreans and Native Americans speaking Amerind or Na-Dene. In this study, we evaluated the phylogenetic relationships among MY isolates worldwide, using the whole-genome approach, with which a highly reliable phylogeny of JCV isolates can be reconstructed. Thirty-six complete sequences belonging to MY (10 from Japanese/Koreans, 24 from Native Americans, and 2 from others), together with 54 belonging to other subtypes around the world, were aligned and subjected to phylogenetic analysis using the neighbor-joining and maximum-likelihood methods. In the resultant phylogenetic trees, the MY sequences diverged into two Japanese/Korean and five Native American clades with high bootstrap probabilities. Two of the Native American clades contained isolates mainly from Na-Denes and the others contained isolates mainly from Amerinds. The Na-Dene clades were not clustered together, nor were the Amerind clades. In contrast, the two Japanese/Korean clades were clustered at a high bootstrap probability. We concluded that there is no distinction between Amerinds and Na-Denes in terms of indigenous JCVs, although they are linguistically distinguished from each other.     

Phylogenetic Relationships Among JC Virus Strains in Japanese/Koreans and Native Americans Speaking Amerind or Na-Dene

Abstract Many genetic studies using human mtDNA or the Y chromosome have been conducted to elucidate the relationships among the three Native American groups speaking Amerind, Na-Dene, and Eskimo-Aleut. Human polyomavirus JC (JCV) may also help to gain insights into this issue. JCV isolates are classified into more than 10 geographically distinct genotypes (designated subtypes here), which were generated by splits in the three superclusters, Types A, B, and C. A particular subtype of JCV (named MY) belonging to Type B is spread in both Japanese/Koreans and Native Americans speaking Amerind or Na-Dene. In this study, we evaluated the phylogenetic relationships among MY isolates worldwide, using the whole-genome approach, with which a highly reliable phylogeny of JCV isolates can be reconstructed. Thirty-six complete sequences belonging to MY (10 from Japanese/Koreans, 24 from Native Americans, and 2 from others), together with 54 belonging to other subtypes around the world, were aligned and subjected to phylogenetic analysis using the neighbor-joining and maximum-likelihood methods. In the resultant phylogenetic trees, the MY sequences diverged into two Japanese/Korean and five Native American clades with high bootstrap probabilities. Two of the Native American clades contained isolates mainly from Na-Denes and the others contained isolates mainly from Amerinds. The Na-Dene clades were not clustered together, nor were the Amerind clades. In contrast, the two Japanese/Korean clades were clustered at a high bootstrap probability. We concluded that there is no distinction between Amerinds and Na-Denes in terms of indigenous JCVs, although they are linguistically distinguished from each other.     

mtDNA haplogroup X: An ancient link between Europe/Western Asia and North America?

On the basis of comprehensive RFLP analysis, it has been inferred that approximately 97% of Native American mtDNAs belong to one of four major founding mtDNA lineages, designated haplogroups "A"-"D." It has been proposed that a fifth mtDNA haplogroup (haplogroup X) represents a minor founding lineage in Native Americans. Unlike haplogroups A-D, haplogroup X is also found at low frequencies in modern European populations. To investigate the origins, diversity, and continental relationships of this haplogroup, we performed mtDNA high-resolution RFLP and complete control region (CR) sequence analysis on 22 putative Native American haplogroup X and 14 putative European haplogroup X mtDNAs. The results identified a consensus haplogroup X motif that characterizes our European and Native American samples. Among Native Americans, haplogroup X appears to be essentially restricted to northern Amerindian groups, including the Ojibwa, the Nuu-Chah-Nulth, the Sioux, and the Yakima, although we also observed this haplogroup in the Na-Dene-speaking Navajo. Median network analysis indicated that European and Native American haplogroup X mtDNAs, although distinct, nevertheless are distantly related to each other. Time estimates for the arrival of X in North America are 12,000-36,000 years ago, depending on the number of assumed founders, thus supporting the conclusion that the peoples harboring haplogroup X were among the original founders of Native American populations. To date, haplogroup X has not been unambiguously identified in Asia, raising the possibility that some Native American founders were of Caucasian ancestry.     

Socioeconomic and nutritional factors account for the association of gastric cancer with amerindian ancestry in a latin american admixed population

Gastric cancer is one of the most lethal types of cancer and its incidence varies worldwide, with the Andean region of South America showing high incidence rates. We evaluated the genetic structure of the population from Lima (Peru) and performed a case-control genetic association study to test the contribution of African, European, or Native American ancestry to risk for gastric cancer, controlling for the effect of non-genetic factors. A wide set of socioeconomic, dietary, and clinic information was collected for each participant in the study and ancestry was estimated based on 103 ancestry informative markers. Although the urban population from Lima is usually considered as mestizo (i.e., admixed from Africans, Europeans, and Native Americans), we observed a high fraction of Native American ancestry (78.4% for the cases and 74.6% for the controls) and a very low African ancestry (<5%). We determined that higher Native American individual ancestry is associated with gastric cancer, but socioeconomic factors associated both with gastric cancer and Native American ethnicity account for this association. Therefore, the high incidence of gastric cancer in Peru does not seem to be related to susceptibility alleles common in this population. Instead, our result suggests a predominant role for ethnic-associated socioeconomic factors and disparities in access to health services. Since Native Americans are a neglected group in genomic studies, we suggest that the population from Lima and other large cities from Western South America with high Native American ancestry background may be convenient targets for epidemiological studies focused on this ethnic group.     

Genetic admixture and gallbladder disease in Mexican Americans

Gallbladder disease is a common source of morbidity in the Mexican American population. Genetic heritage has been proposed as a possible contributor, but evidence for this is limited. Because gallbladder disease has been associated with Native American heritage, genetic admixture may serve as a useful proxy for genetic susceptibility to the disease in epidemiologic studies. The objective of our study was to examine the possibility that gallbladder disease is associated with greater Native American admixture in Mexican Americans. This study used data from the Hispanic Health and Nutrition Examination Survey and was based on 1,145 Mexican Americans who underwent gallbladder ultrasonography and provided usable phenotypic information. We used the GM and KM immunoglobulin antigen system to generate estimates of admixture proportions and compared these for individuals with and without gallbladder disease. Overall, the proportionate genetic contributions from European, Native American, and African ancestries in our sample were 0.575, 0.390, and 0.035, respectively. Admixture proportions did not differ between cases and noncases: Estimates of Native American admixture for the two groups were 0.359 and 0.396, respectively, but confidence intervals for estimates overlapped. This study found no evidence for the hypothesis that greater Native American admixture proportion is associated with higher prevalence of gallbladder disease in Mexican Americans. Reasons for the finding that Native American admixture proportions did not differ between cases and noncases are discussed. Improving our understanding of the measurement, use, and limitations of genetic admixture may increase its usefulness as an epidemiologic tool as well as its potential for contributing to our understanding of disease distributions across populations. Am. J. Phys. Anthropol. 106:361–371, 1998. Published 1998 Wiley-Liss, Inc.     

More than black and white: differences in predictors of obesity among Native Hawaiian/Pacific Islanders and European Americans

Although Native Hawaiians and Pacific Islanders exhibit the highest rates of obesity and associated chronic diseases of any racial/ethnic group, they remain vastly underrepresented in health research. In a cross-sectional survey of college students (N = 402) we examined BMI and health outcomes in an ethno-racially diverse rural sample of Native Hawaiian/Pacific Islanders (25.1%), Asian Americans (39.8%), and European Americans (35.1%). Measures assessed BMI, health status, health behaviors, frequency of exercise, and symptoms of psychiatric disorders (i.e., depression, anxiety, posttraumatic stress, and substance abuse and dependence). Regression analyses revealed that an overall model of five predictors (gender, race, regular exercise, difficulty sleeping, and anxiety) was significantly associated with obesity (P < 0.001) and correctly classified 84.2% of cases. A 30.7% of Native Hawaiians/Pacific Islanders were obese as compared with 9.2% of European Americans and 10.6% of Asian Americans. These findings suggest that Native Hawaiian/ Pacific Islanders are at high risk for obesity and associated medical comorbidities, but that regular physical activity may ameliorate this risk. Further, these results support the consideration of Native Hawaiians/Pacific Islanders as a distinct racial/ethnic subgroup separate from other Asian populations.     

Brief communication: Evolution of a specific O allele (O1vG542A) supports unique ancestry of Native Americans

In this study, we explore the geographic and temporal distribution of a unique variant of the O blood group allele called O1v^G542A, which has been shown to be shared among Native Americans but is rare in other populations. O1v^G542A was previously reported in Native American populations in Mesoamerica and South America, and has been proposed as an ancestry informative marker. We investigated whether this allele is also found in the Tlingit and Haida, two contemporary indigenous populations from Alaska, and a pre‐Columbian population from California. If O1v^G542A is present in Na‐Dene speakers (i.e., Tlingits), it would indicate that Na‐Dene speaking groups share close ancestry with other Native American groups and support a Beringian origin of the allele, consistent with the Beringian Incubation Model. If O1v^G542A is found in pre‐Columbian populations, it would further support a Beringian origin of the allele, rather than a more recent introduction of the allele into the Americas via gene flow from one or more populations which have admixed with Native Americans over the past five centuries. We identified this allele in one Na‐Dene population at a frequency of 0.11, and one ancient California population at a frequency of 0.20. Our results support a Beringian origin of O1v^G542A, which is distributed today among all Native American groups that have been genotyped in appreciable numbers at this locus. This result is consistent with the hypothesis that Na‐Dene and other Native American populations primarily derive their ancestry from a single source population. Am J Phys Anthropol 151:649–657, 2013. © 2013 Wiley Periodicals, Inc.     

Male lineages in South American native groups: evidence of M19 traveling south

With this study, we aimed to determine the different male ancestral components of two Native American communities from Argentina, namely Toba and Colla. The analysis of 27 Y-chromosome SNPs allowed us to identify seven different haplogroups in both samples. Chromosomes carrying the M3 mutation, which typically defines the Native American haplogroup Q1a3a, were seen most frequently in the Toba community (90%). Conversely, Q1a3a was represented in 34% of the Colla Y-chromosomes, whereas haplogroup R1b1, the main representative of western European populations, exhibited the highest frequency in this population (41%). Different M3 sublineages in the Toba community could be identified by observing point mutations at both DYS385 and M19 loci. A microvariant at DYS385, named 16.1, has been characterized, which helps to further subdivide Q1a3a. It is the first time the M19 mutated allele is described in a population from Argentina. This finding supports the old age of the lineages carrying the M19 mutation, but it contradicts the previous hypothesis that the M19 mutated allele is confined to only two Equatorial-Tucano population groups from the north region of South America. The detection of M19 further south than previously thought allows questioning of the hypothesis that this lineage serves as an example of isolation after colonization. This observation also affirms the strong genetic drift to which Native Americans have been subjected. Moreover, our study illustrates a heterogeneous contribution of Europeans to these populations and supports previous studies showing that most Native American groups were subjected to European admixture that primarily involved immigrant men.     

Genetic variation in Native Americans, inferred from Latino SNP and resequencing data

Analyses of genetic polymorphism data have the potential to be highly informative about the demographic history of Native American populations, but due to a combination of historical and political factors, there are essentially no autosomal sequence polymorphism data from any Native American group. However, there are many resequencing studies involving Latinos, whose genomes contain segments inherited from their Native American ancestors. In this study, we introduce a new method for estimating local ancestry across the genomes of admixed individuals and show how this method, along with dense genotyping and targeted resequencing, can be used to assay genetic variation in ancestral Native American groups. We analyze roughly 6 Mb of resequencing data from 22 Mexican Americans to provide the first large-scale view of sequence level variation in Native Americans. We observe low levels of diversity and high levels of linkage disequilibrium in the Native American-derived sequences, consistent with a recent severe population bottleneck associated with the initial peopling of the Americas. Using two different computational approaches, one novel, we estimate that this bottleneck occurred roughly 12.5 Kya; when uncertainty in the estimation process is taken into account, our results are consistent with archeological estimates for the colonization of the Americas.     

Mammography screening and breast self-examination among minority women in public housing projects: the impact of physician recommendation.

This exploratory study examined the impact of physician recommendations and other factors on mammography screening and breast-self examination (BSE) among African American and Hispanic women in public housing communities. We surveyed a randomly selected sample of low-income households from three low-income communities (n = 291), which included both African Americans and Hispanic women. Data for this paper are reported only on women who were 40 years and older head of the households (n = 120 women, including 74 Hispanics and 46 African Americans), since they meet the age criterion for mammography screening. Our analyses indicated that only 46% of women obtained mammography in the previous 12 months, with no significant differences between the Hispanic and African American women in mammography rates. Physicians' recommendations were among the most significant and substantial predictors of obtaining a mammogram or performing BSE. Further, odds were also higher for those who had insurance coverage. In addition, our data also indicated that almost one out of four women, aged 40 and older participants in this study, claimed that their health care providers never told them they needed a mammogram or never told them that they should perform BSE, with no significant differences between Hispanic and African Americans. Our analyses points to an urgent need for intervention to inform and motivate the service providers in underserved communities to motivate breast cancer screening (BCS) among minority women. Additionally, our examination points to the need for urgent interventions targeting minority women, particularly women with no medical insurance for breast cancer screening.