Yvonne L Michael

Drexel University, Filadelfia, Pennsylvania, United States

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Publications (105)314.25 Total impact

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    Habib Chaudhury · Michael Campo · Yvonne Michael · Atiya Mahmood
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    ABSTRACT: Rationale.: The neighbourhood socio-physical environment has effects on health in later life including health behaviours, chronic illnesses, mental health and mortality. Few studies have examined the relationship of both physical environmental features and social aspects of neighbourhood with older adults' physical activity. Objective: This study examined the relationship of neighbourhood physical and social environment with physical activity among older adults. Methods: A cross-sectional telephone survey was conducted with 434 older adults in eight neighbourhoods in greater Vancouver, Canada and Portland, United States. Data included participants' perceptions of their neighbourhood built and social environment factors and levels of physical activity. A logistic regression analysis was conducted to understand the relationship between these factors. Results: Participants engaged in physical activity most frequently at home (87.1%) or in close proximity of home (76.5%). Neighbourhood walkability, presence of amenities and accessibility were not significantly associated with meeting physical activity requirements. Participation in a recreational program with friends was associated with increased likelihood of physical activity. Conclusion: The home and its immediate physical environmental context has potentially important relevance in supporting physical activity in older adults. Also, neighbourhood social aspects have a positive influence on activity levels.
    Full-text · Article · Jan 2016 · Social Science & Medicine
  • Aimee Palumbo · Yvonne Michael · Terry Hyslop
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    ABSTRACT: Purpose Neighborhood-level socioeconomic status (NSES) can influence breast cancer mortality and poorer health outcomes are observed in deprived neighborhoods. Commonly used NSES indexes are difficult to interpret. Latent class models allow for alternative characterization of NSES for use in studies of cancer causes and control. Methods Breast cancer data was from a cohort of women diagnosed at an academic medical center in Philadelphia, PA. NSES variables were defined using Census data. Latent class modeling was used to characterize NSES. Results Complete data was available for 1,664 breast cancer patients diagnosed between 1994 and 2002. Two separate latent variables, each with 2-classes (LC2) best represented NSES. LC2 demonstrated strong associations with race and tumor stage and size. Conclusions Latent variable models identified specific characteristics associated with advantaged or disadvantaged neighborhoods, potentially improving our understanding of the impact of socioeconomic influence on breast cancer prognosis. Improved classification will enhance our ability to identify vulnerable populations and prioritize the targeting of cancer control efforts.
    No preview · Article · Jan 2016 · Cancer Causes and Control
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    ABSTRACT: Objective: Larger social networks have been associated with better breast cancer survival. To investigate potential mediators, we evaluated associations of social network size and diversity with lifestyle and treatment factors associated with prognosis. Methods: We included 9331 women from the After Breast Cancer Pooling Project who provided data on social networks within approximately two years following diagnosis. A social network index was derived from information about the presence of a spouse or intimate partner, religious ties, community participation, friendship ties, and numbers of living relatives. Diversity was assessed as variety of ties, independent of size. We used logistic regression to evaluate associations with outcomes and evaluated whether effect estimates differed using meta-analytic techniques. Results: Associations were similar across cohorts though analyses of smoking and alcohol included US cohorts only because of low prevalence of these behaviors in the Shanghai cohort. Socially isolated women were more likely to be obese (OR = 1.21, 95% CI:1.03-1.42), have low physical activity (<10 MET-hours/week, OR = 1.55, 95% CI:1.36-1.78), be current smokers (OR = 2.77, 95% CI:2.09-3.68), and have high alcohol intake (≥15 g/d, OR = 1.23, 95% CI:1.00-1.51), compared with socially integrated women. Among node positive cases from three cohorts, socially isolated women were more likely not to receive chemotherapy (OR = 2.10, 95% CI:1.30-3.39); associations differed in a fourth cohort. Other associations (nonsignificant) were consistent with less intensive treatment in socially isolated women. Low social network diversity was independently associated with more adverse lifestyle, but not clinical, factors. Conclusions: Small, less diverse social networks measured post-diagnosis were associated with more adverse lifestyle factors and less intensive cancer treatment. Copyright © 2016 John Wiley & Sons, Ltd.
    No preview · Article · Jan 2016 · Psycho-Oncology
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    ABSTRACT: Objectives: The purpose of this study was to investigate associations between use of β-2-adrenergic receptor (B2AR) agonist drugs during pregnancy and risk for autism spectrum disorders (ASD). Methods: A case-control study was conducted by using Denmark's health and population registers. Among children born between 1997 and 2006, 5200 cases with ASD admission diagnoses and 52 000 controls without ASD were identified and individually matched on month and year of birth. Conditional logistic regression models were used to estimate odds ratios (OR) and confidence intervals (CI) for any B2AR agonist exposure during pregnancy, preconception, and by trimester. Results: In total, 3.7% of cases and 2.9% of controls were exposed to B2ARs during pregnancy. Use of B2ARs during pregnancy was associated with increased risk of ASD, even after adjustment for maternal asthma and other covariates (OR: 1.3, 95% CI: 1.1-1.5). The elevated risk was observed with use of B2AR during preconception (OR: 1.3, 95% CI: 1.0-1.6), first trimester (OR: 1.3, 95% CI: 1.1-1.5), second trimester (OR: 1.5, 95% CI: 1.1-1.7), and the third trimester (OR: 1.4, 95% CI: 1.1-1.7). There was some evidence that longer B2AR within-pregnancy use was associated with the increased risk. Conclusions: B2AR agonist exposure during pregnancy may be associated with an increased risk for ASD. If the effect is real, any intervention must be balanced against benefits of indicated medication use by pregnant women.
    Preview · Article · Jan 2016 · PEDIATRICS
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    ABSTRACT: Data from the Women's Health Initiative were used to quantify the relationship between the loss of trees to an invasive forest pest-the emerald ash borer-and cardiovascular disease. We estimated a semi-parametric Cox proportional hazards model of time to cardiovascular disease, adjusting for confounders. We defined the incidence of cardiovascular disease as acute myocardial infarction requiring overnight hospitalization, silent MI determined from serial electrocardiograms, ischemic or hemorrhagic stroke, or death from coronary heart disease. Women living in a county infested with emerald ash borer had an increased risk of cardiovascular disease (HR=1.25, 95% CI: 1.20-1.31). Published by Elsevier Ltd.
    Full-text · Article · Aug 2015 · Health & Place
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    ABSTRACT: Hip fractures are leading causes of disability, morbidity and mortality among older women. Since physical activity helps maintain physical functioning and bone mineral density, occupational physical demand may influence fracture risk. This study investigates the association of occupational physical demand with hip fracture incidence among women. The Women's Health Initiative Observational Study is a multiethnic cohort of 93 676 postmenopausal women, 50-79 years of age at enrolment, enrolled from 1994 to 1998 at 40 geographically diverse clinical centres throughout the USA. Outcomes including hip fractures were assessed annually and up to 3 jobs held since age 18 years were reported by each woman. Occupational physical demand levels were assigned for each job through linkage of occupational titles with Standard Occupational Codes and the Occupational Information Network. Average, cumulative and peak physical demand scores both before and after menopause and throughout women's work life were estimated. Women were followed through 2010 for an average of 11.5 years; 1834 hip fractures occurred during this time. We did not observe an overall association of occupational physical demand with subsequent risk of hip fracture after adjusting for age, race/ethnicity, birth region and education. Previous research on occupations and hip fracture risk in women is inconclusive. This study was able to take critical risk periods into account and control for confounding factors in a large cohort of older women to show that overall occupational physical demand neither increases nor decreases risk of hip fracture later in life. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    No preview · Article · May 2015 · Occupational and environmental medicine
  • S. L. Mayne · A. H. Auchincloss · Y. L. Michael
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    ABSTRACT: Policies and changes to the built environment are promising targets for obesity prevention efforts and can be evaluated as 'natural'- or 'quasi'-experiments. This systematic review examined the use of natural- or quasi-experiments to evaluate the efficacy of policy and built environment changes on obesity-related outcomes (body mass index, diet or physical activity). PubMed (Medline) was searched for studies published 2005-2013; 1,175 abstracts and 115 papers were reviewed. Of the 37 studies included, 18 studies evaluated impacts on nutrition/diet, 17 on physical activity and 3 on body mass index. Nutrition-related studies found greater effects because of bans/restrictions on unhealthy foods, mandates offering healthier foods, and altering purchase/payment rules on foods purchased using low-income food vouchers compared with other interventions (menu labelling, new supermarkets). Physical activity-related studies generally found stronger impacts when the intervention involved improvements to active transportation infrastructure, longer follow-up time or measured process outcomes (e.g. cycling rather than total physical activity), compared with other studies. Only three studies directly assessed body mass index or weight, and only one (installing light-rail system) observed a significant effect. Studies varied widely in the strength of their design and studies with weaker designs were more likely to report associations in the positive direction. © 2015 World Obesity.
    No preview · Article · Apr 2015 · Obesity Reviews
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    Yvonne L Michael · Irene H Yen
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    ABSTRACT: The articles in this special issue make it clear that there are interesting and policy-relevant research to identify place-based strategies to improve health and reduce health disparities among older adults. The articles also reveal important areas of future research and policy innovation that are needed related to place and aging.
    Preview · Article · Dec 2014 · Journal of Aging and Health
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    ABSTRACT: Evaluate associations of neighborhood social capital and mobility of older adults. A community-based survey (Philadelphia, 2010) assessed mobility (Life-Space Assessment [LSA]; range = 0-104) of older adults (n = 675, census tracts = 256). Social capital was assessed for all adults interviewed from 2002-2010 (n = 13,822, census tracts = 374). Generalized estimating equations adjusted for individual- and neighborhood-level characteristics estimated mean differences and 95% confidence intervals (CIs) in mobility by social capital tertiles. Interactions by self-rated health, living arrangement, and race were tested. Social capital was not associated with mobility after adjustment for other neighborhood characteristics (mean difference for highest versus lowest tertile social capital = 0.79, 95% CI = [-3.3, 4.8]). We observed no significant interactions. In models stratified by race, Black participants had higher mobility in high social capital neighborhoods (mean difference = 7.4, CI = [1.0, 13.7]). Social capital may not contribute as much as other neighborhood characteristics to mobility. Interactions between neighborhood and individual-level characteristics should be considered in research on mobility. © The Author(s) 2014.
    No preview · Article · Dec 2014 · Journal of Aging and Health
  • Aimee Palumbo · Yvonne Michael · Terry Hyslop

    No preview · Article · Oct 2014 · Cancer Research
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    ABSTRACT: Background: Informal caregiving is common for older women and can negatively affect health, but its impact on physical function remains unclear. Using inverse probability weighting methods, we quantified the association of caregiving with physical function over 6 years. Methods: Study participants were 5,649 women aged 65 years and older at baseline of the Woman's Health Initiative Clinical Trial (multicenter recruitment, 1993-1998) with complete caregiving data and function at baseline and at least one follow-up. Caregiving was self-reported (low-frequency if ≤2 times per week and high-frequency if ≥3 times per week). Performance-based measures of physical function including timed walk (meters/second), grip strength (kilograms), and chair stands (number) were measured at baseline and years 1, 3, and 6. Associations and 95% confidence intervals of baseline caregiving with physical function were estimated by generalized estimating equations with inverse probability weighting by propensity and attrition scores, calculated by logistic regression of baseline health and demographic characteristics. Results: Over follow-up, low-frequency caregivers had higher grip strength when compared with noncaregivers (mean difference = 0.63kg, confidence interval: 0.24, 1.01). There were no observed differences between high-frequency caregivers and noncaregivers on grip strength or for either caregiver group when compared with noncaregivers on walk speed or chair stands. Rates of change in physical function measures did not differ by caregiving status. Conclusions: Caregiving was not associated with poorer physical function in this sample of older women. Low-frequency caregiving was associated with better grip strength at baseline which persisted through follow-up. This study supports the concept that informal caregiving may not have universally negative health consequences.
    No preview · Article · Jul 2014 · The Journals of Gerontology Series A Biological Sciences and Medical Sciences
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    ABSTRACT: Background: The purpose of this study was to describe the longitudinal trajectories and bidirectional relationships of the physical-social and emotional functioning (EF) dimensions of positive aging and to identify their baseline characteristics. Methods: Women age 65 and older who enrolled in one or more Women's Health Initiative clinical trials (WHI CTs) and who had positive aging indicators measured at baseline and years 1, 3, 6, and 9 were included in these analyses (N = 2281). Analytic strategies included latent class growth modeling to identify longitudinal trajectories and multinomial logistic regression to examine the effects of baseline predictors on these trajectories. Results: A five-trajectory model was chosen to best represent the data. For Physical-Social Functioning (PSF), trajectory groups included Low Maintainer (8.3%), Mid-Low Improver (10.4%), Medium Decliner (10.7%), Mid-High Maintainer (31.2%), and High Maintainer (39.4%); for EF, trajectories included Low Maintainer (3%), Mid-Low Improver (9%), Medium Decliner (7.7%), Mid-High Maintainer (22.8%), and High Maintainer (57.5%). Cross-classification of the groups of trajectories demonstrated that the impact of a high and stable EF on PSF might be greater than the reverse. Low depression symptoms, low pain, and high social support were the most consistent predictors of high EF trajectories. Conclusion: Aging women are heterogeneous in terms of positive aging indicators for up to 9 years of follow-up. Interventions aimed at promoting sustainable EF might have diffused effects on other domains of healthy aging.
    Full-text · Article · Apr 2014 · International Psychogeriatrics
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    ABSTRACT: This study aims to determine whether vitamin D levels are associated with menopause-related symptoms in older women. A randomly selected subset of 1,407 women, among 26,104 potentially eligible participants of the Women's Health Initiative Calcium and Vitamin D trial of postmenopausal women aged 51 to 80 years, had 25-hydroxyvitamin D [25(OH)D] levels measured at the Women's Health Initiative Calcium and Vitamin D trial baseline visit. Information about menopause-related symptoms at baseline was obtained by questionnaire and included overall number of symptoms and composite measures of sleep disturbance, emotional well-being, and energy/fatigue, as well as individual symptoms. After exclusions for missing data, 530 women (mean [SD] age, 66.2 [6.8] y) were included in these analyses. Borderline significant associations between 25(OH)D levels and total number of menopausal symptoms were observed (with P values ranging from 0.05 to 0.06 for fully adjusted models); however, the effect was clinically insignificant and disappeared with correction for multiple testing. No associations between 25(OH)D levels and composite measures of sleep disturbance, emotional well-being, or energy/fatigue were observed (P's > 0.10 for fully adjusted models). There is no evidence for a clinically important association between serum 25(OH)D levels and menopause-related symptoms in postmenopausal women.
    No preview · Article · Apr 2014 · Menopause (New York, N.Y.)
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    ABSTRACT: Epidemiologists typically collect narrative descriptions of occupational histories because these are less prone than self-reported exposures to recall bias of exposure to a specific hazard. However, the task of coding these narratives can be daunting and prohibitively time-consuming in some settings. The aim of this manuscript is to evaluate the performance of a computer algorithm to translate the narrative description of occupational codes into standard classification of jobs (2010 Standard Occupational Classification) in an epidemiological context. The fundamental question we address is whether exposure assignment resulting from manual (presumed gold standard) coding of the narratives is materially different from that arising from the application of automated coding. We pursued our work through three motivating examples: assessment of physical demands in Women's Health Initiative observational study, evaluation of predictors of exposure to coal tar pitch volatiles in the US Occupational Safety and Health Administration's (OSHA) Integrated Management Information System, and assessment of exposure to agents known to cause occupational asthma in a pregnancy cohort. In these diverse settings, we demonstrate that automated coding of occupations results in assignment of exposures that are in reasonable agreement with results that can be obtained through manual coding. The correlation between physical demand scores based on manual and automated job classification schemes was reasonable (r = 0.5). The agreement between predictive probability of exceeding the OSHA's permissible exposure level for polycyclic aromatic hydrocarbons, using coal tar pitch volatiles as a surrogate, based on manual and automated coding of jobs was modest (Kendall rank correlation = 0.29). In the case of binary assignment of exposure to asthmagens, we observed that fair to excellent agreement in classifications can be reached, depending on presence of ambiguity in assigned job classification (κ = 0.5-0.8). Thus, the success of automated coding appears to depend on the setting and type of exposure that is being assessed. Our overall recommendation is that automated translation of short narrative descriptions of jobs for exposure assessment is feasible in some settings and essential for large cohorts, especially if combined with manual coding to both assess reliability of coding and to further refine the coding algorithm.
    No preview · Article · Feb 2014 · Annals of Occupational Hygiene
  • Yvonne L Michael · Corey L Nagel · Rachel Gold · Teresa A Hillier
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    ABSTRACT: Neighborhood environment is consistently associated with obesity; changes to modifiable aspects of the neighborhood environment may curb the growth of obesity in the US and other developed nations. However, currently the majority of studies are cross-sectional and thus not appropriate for evaluating causality. The goal of this study was to evaluate the effect of a neighborhood-changing intervention on changes in obesity among older women. Over the past 30 years the Portland, Oregon metropolitan region has made significant investments in plans, regulatory structures, and public facilities to reduce sprawl and increase compact growth centers, transit-oriented development approaches, and green space. We used geocoded residential addresses to link data on land-use mix, public transit access, street connectivity, and access to green space from four time points between 1986 and 2004, with longitudinal data on body mass index (BMI) from a cohort of 2003 community-dwelling women aged 66 years and older. Height and weight were measured at clinic visits. Women self-reported demographics, health habits, and chronic conditions, and self-rated their health. Neighborhood socioeconomic status was assessed from census data. Neighborhood walkability and access to green space improved over the 18-year study period. On average there was a non-significant mean weight loss in the cohort between baseline (mean age 72.6 years) and the study's end (mean age 85.0 years). We observed no association between neighborhood built environment or change in built environment and BMI. Greater neighborhood socioeconomic status at baseline was independently associated with a healthier BMI at baseline, and protected against an age-related decline in BMI over time. BMI decreases with age reflect increased frailty, especially among older adults with complex morbidities. Future research should consider the influence of the neighborhood environment on additional relevant health outcomes and should include measures of the social environment in conjunction with built environment measures.
    No preview · Article · Feb 2014 · Social Science [?] Medicine
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    ABSTRACT: Background Whether or not they allow smoking in their own homes, residents of multi-unit housing are exposed to significant second hand smoke (SHS). Exposure may be greater for families living in public housing, due to higher rates of tobacco use in these communities. Since 2009, HUD has supported local public housing authorities to enact policies to reduce SHS exposure, and many PHAs are working to develop and implement smoke-free policies. In Philadelphia, formative work was conducted in partnership with the Philadelphia Housing Authority (PHA) and the Philadelphia Department of Public Health, to better understand stakeholder readiness for smoke-free public housing. Methods During 2012, we conducted in-depth interviews (n=6) with PHA staff, resident leaders and other tobacco control stakeholders and focus groups (n=2) with public housing residents, both smokers and non-smokers. Data were transcribed and analyzed to identify themes related to current tobacco use in public housing communities, and stakeholder views on barriers and facilitators of smoke-free policy implementation. Results Current tobacco use in communities was perceived to be significant. Smoking and non-smoking residents were aware of SHS-related health risks, but less knowledgeable about the properties of SHS. Many used inadequate strategies for controlling SHS in homes (i.e., odor-reducing fragrances, having non-smoking rooms), or common areas (extinguishing cigarettes when children enter elevators) Smokers described motivation to quit. All residents welcomed health education and community forums on policy development. Staff concerns focused on resident attitudes, and resources for enforcement. Overall, stakeholders agreed that ideal processes for implementation relied on investments in resident education on SHS, cessation services tailored to resident needs, and collaborative policy development. Conclusions Implementation of smoke-free public housing policies requires cessation services, and considerable public health education, building on existing awareness of SHS-related health risks.
    No preview · Conference Paper · Nov 2013
  • Amy E Leader · Yvonne L Michael
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    ABSTRACT: To examine the association between social capital and adherence to cancer screening exams. Data from a population-based survey assessed perceived neighborhood social capital as well as cancer screening behavior. We analyzed the influence of social capital on adherence to screening guidelines for cervical, breast, and colorectal cancer. Data from 2668 adults documented that those with greater perceived neighborhood social capital were more likely to be screened for cancer. The effect was strongest for colorectal cancer and weakest for cervical cancer. Research on understanding the effect of the neighborhood social environment on efforts related to cancer screening behavior may be helpful for increasing cancer screening rates.
    No preview · Article · Sep 2013 · American journal of health behavior
  • Nancy E. Findholt · Melinda M. Davis · Yvonne L. Michael
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    ABSTRACT: PurposeTo explore the perceived barriers, resources, and training needs of rural primary care providers in relation to implementing the American Medical Association Expert Committee recommendations for assessment, treatment, and prevention of childhood obesity.Methods In‐depth interviews were conducted with 13 rural primary care providers in Oregon. Transcribed interviews were thematically coded.ResultsBarriers to addressing childhood obesity fell into 5 categories: barriers related to the practice (time constraints, lack of reimbursement, few opportunities to detect obesity), the clinician (limited knowledge), the family/patient (family lifestyle and lack of parent motivation to change, low family income and lack of health insurance, sensitivity of the issue), the community (lack of pediatric subspecialists and multidisciplinary/tertiary care services, few community resources), and the broader sociocultural environment (sociocultural influences, high prevalence of childhood obesity). There were very few clinic and community resources to assist clinicians in addressing weight issues. Clinicians had received little previous training relevant to childhood obesity, and they expressed an interest in several topics.Conclusions Rural primary care providers face extensive barriers in relation to implementing recommended practices for assessment, treatment, and prevention of childhood obesity. Particularly problematic is the lack of local and regional resources. Employing nurses to provide case management and behavior counseling, group visits, and telehealth and other technological communications are strategies that could improve the management of childhood obesity in rural primary care settings.
    No preview · Article · Aug 2013 · The Journal of Rural Health
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    ABSTRACT: Diversity of neighborhood amenities may promote the mobility of older adults. A 2010 community-based sample of 510 adults aged ≥65 years in Philadelphia, Pennsylvania, and geospatial data from the Esri Business Analyst database (Esri, Inc., Redlands, California) were used to assess associations of neighborhood amenity diversity with mobility. Neighborhoods were defined by census tract, and diversity of amenities was derived by using the Leadership in Energy and Environmental Design's neighborhood development index (US Green Building Council, Washington, DC). Generalized estimating equations adjusted for demographic, socioeconomic, and neighborhood characteristics were used to estimate differences in mobility score by tertile of amenity diversity. Analyses were stratified by participants' routine travel habits (stayed at home, stayed in home zip code, or traveled beyond home zip code). We found that for those who spent most of their time in their home neighborhoods, mobility scores (from the Life-Space Assessment, which ranges from 0 to 104 points) were 8.3 points higher (95% confidence interval: 0.1, 16.6) among those who lived in neighborhoods with the most amenity diversity compared with those who lived in neighborhoods with the least amenity diversity. No significant associations between amenity diversity and mobility were observed for those who did not leave home or who regularly traveled outside their neighborhoods. Neighborhoods with a high diversity of amenities may be important promoters of mobility in older adults who do not routinely travel outside their neighborhoods.
    Preview · Article · May 2013 · American journal of epidemiology
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    Jennifer A Taylor · Ravi S Pandian · Lu Mao · Yvonne L Michael
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    ABSTRACT: The development of systematic and sustainable surveillance systems is necessary for the creation of patient safety prevention programs and the evaluation of improvement resulting from innovations. To that end, inpatient hospital discharges collected by the Pennsylvania Health Care Cost Containment Council were used to investigate patient safety events (PSEs) in Pennsylvania in 2006. PSEs were identified using external cause of injury codes (E-codes) in combination with the Agency for Healthcare Research and Quality's patient safety indicators (PSIs). Encounters with and without PSEs were compared with regard to patient age, sex, race, length of stay, and cost. Approximately 9% of all Pennsylvania inpatient discharges had a PSE in 2006. Patients with a PSE were on average older, male, and white. The average length of stay for a PSE was 3 days longer and $35 000 more expensive than a non-PSE encounter. It was concluded that E-codes and PSIs were useful tools for the surveillance of PSEs in Pennsylvania, and that administrative data from healthcare organizations provide a consistent source of standardized data related to patient encounters, creating an opportunity to describe PSEs at the population level.
    Full-text · Article · Apr 2013

Publication Stats

3k Citations
314.25 Total Impact Points

Institutions

  • 2009-2016
    • Drexel University
      • Department of Epidemiology and Biostatistics
      Filadelfia, Pennsylvania, United States
  • 2009-2012
    • Philadelphia University
      Filadelfia, Pennsylvania, United States
  • 2004-2010
    • Oregon Health and Science University
      • Department of Public Health & Preventive Medicine
      Portland, Oregon, United States
  • 2006
    • University of Texas at San Antonio
      San Antonio, Texas, United States
  • 2001-2002
    • Portland State University
      • School of Community Health
      Portland, Oregon, United States
  • 2000-2001
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
    • Harvard University
      • Department of Nutrition
      Cambridge, Massachusetts, United States