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Published in final edited form as: Cancer Causes Control. 2021 Apr 12;32(6):645–651. doi: 10.1007/s10552-021-01418-0

Variation in diet quality across sexual orientation in a cohort of U.S. women

Alexa L Solazzo 1,2,7, Mariel Arvizu 5, Nicole A VanKim 3, Jorge Chavarro 1,4,5, Ariella R Tabaac 2,6, Brittany M Charlton 1,2,4,6
PMCID: PMC8425716  NIHMSID: NIHMS1726514  PMID: 33846853

Abstract

Purpose:

Extensive prior research has shown that sexual minority women are more likely to have a number of cancer risk factors, thereby putting them at higher risk for cancer than heterosexual women. However, there has been little research evaluating the association between sexual orientation and diet quality.

Methods:

Data come from participants (aged 24–54 years) enrolled in Nurses’ Health Study 3, an ongoing, U.S.-based cohort study (N=15,941). We measured diet using recommendations from the Dietary Approach to Stop Hypertension (DASH) and American Health Association (AHA) 2020 Strategic Impact Goals.

Results:

We found limited evidence of differences across diet quality by sexual orientation. When examining predicted DASH scores, mostly heterosexual [predicted mean score (95% confidence interval), 24.0 (23.8, 24.3)] and lesbian [24.3 (23.8, 24.9)] women had healthier predicted DASH scores than the reference group of completely heterosexual women with no same-sex partners [23.6 (23.5, 23.7)]. Even though certain sexual minority women had overall healthier predict DASH scores, their consumption of certain food groups—low-fat dairy and fruit—was lower than completely heterosexual women with no same-sex partners. When measuring AHA scores, most sexual minority groups (completely heterosexual women with same-sex partners, mostly heterosexual women, and lesbian women) had higher diet quality compared to the reference group of completely heterosexual women with no same-sex partners.

Conclusion:

Sexual minority women, particularly mostly heterosexual women and lesbian women, had healthier diet quality than completely heterosexual women with no same-sex partners. These data suggest that cancer risk factors (e.g., smoking, drinking, and inactivity) other than diet would drive higher cancer rates among sexual minority compared to heterosexual women. Nonetheless, it is critical for all women to improve their diet quality since diet quality was poor among participants of all sexual orientations.

BACKGROUND

Nearly half of cancer deaths in the United States can be attributed to smoking, drinking, high body weight, physical inactivity, and diet [1]. Sexual orientation disparities in a number of cancer risk factors are well established. For example, sexual minority women (i.e., bisexual/gay-identified women or those with same-sex partners or same-sex attractions) are more likely than heterosexual women to smoke, binge drink, and have high body weight [2–9]. These disparities stem from structural level factors such as laws and cultures that marginalize and exclude sexual minorities [10]. These structural factors can reduce sexual minority’s ability to obtain resources, take advantage of opportunities, and maintain physical and mental well-being [11]. For example, people may use smoking, drinking, or unhealthy eating as part of a stress response after being exposed to stigma or discrimination based on their sexual orientation [12–14].

While sexual orientation-related disparities have been documented for certain cancer risk factors, there has been little research into sexual orientation and diet quality. Diet and diet-related factors account for nearly a third of cancer cases in the United States [15]. A diet high in fruit and vegetable intake alongside low amounts of red and processed meat reduces the risk of cancer [15–17]. By not understanding this crucial component of cancer-related risks, scholars may be misunderstanding fundamental patterns of sexual orientation and cancer risk.

Research is limited on the extent to which diet varies across sexual orientation, with contradictory findings on whether or not differences exist. Some evidence suggests that bisexual and lesbian women consume more sugary drinks than heterosexual women, are more likely to eat out, and that lesbian women eat fewer vegetables than heterosexual women [18, 19]. In contrast, other research finds no differences in the prevalence of fruit intake across sexual orientation for women [20, 21]. Data from the longitudinal cohort study Nurses’ Health Study 2 (NHS2) shows that lesbian and bisexual women have better diet quality than heterosexual women, while more recent research using the Growing Up Today Study (GUTS) finds that mostly heterosexual women have higher diet quality than completely heterosexual women with no differences between bisexual and lesbian women compared to heterosexual women [22, 23]. These are notably the only studies to examine overall diet quality based on nutritional guidelines rather than focusing on specific food groups, and only one of the studies examines adult women.

Several gaps remain in our knowledge on sexual orientation and diet. First, most of the research tests single measures of diet (i.e., number of fruit servings per day or sugary sodas) rather than adherence to broad nutritional guideline [18–21]. Additionally, prior research has been limited by incomplete sexual orientation data. Sexual orientation is a multi-dimensional construct that includes an individual’s identity, behavior, and attractions. Sexual orientation-related health disparities often vary across these three dimensions. For instance, sexual minority adolescents smoke more than heterosexual adolescents, but the magnitude of this disparity differs based on whether sexual orientation is defined by identity or behavior [24]. Research that operationalized sexual orientation using only identity rather than behavior or attraction could have misclassified participants who identify as heterosexual but who have had same-sex partners, and thus potentially missed potential nuances in the association between sexual orientation and diet.

In response to these gaps, this paper examined differences in diet quality using the Dietary Approach to Stop Hypertension (DASH) and American Health Association (AHA) scores across sexual orientation. We used data from a cohort study, the Nurses’ Health Study 3 (NHS3), which contains detailed information on sexual orientation identity, attraction, and behavior along with a food frequency questionnaire (FFQ) among women across a broad age range.

MATERIALS AND METHODS

Study Population

Data come from an ongoing, U.S.-based open cohort study of women nurses aged 24 to 51 years. The NHS3 is on ongoing, open cohort and we send participants an online questionnaire every six months. Therefore, participants receive questionnaires based on an individualized timeframe given their own enrollment date. A total of 44,896 women completed the first questionnaire at the time of data analysis (May 30, 2020), of which 16,205 women had progressed to and completed the FFQ in the second questionnaire and the sexual orientation items in the fifth questionnaire. Other participants who have yet to progress through to the fifth questionnaire could not be included in the study because they did not yet have the opportunity to provide sexual orientation and diet data (i.e., they were still working through the earlier modules). Participants who were pregnant at the time of the FFQ were excluded due to possible changes in diet during pregnancy (n=264), resulting in a final analytic sample of 15,941 women. The study protocol was approved by the Institutional Review Boards of the Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health. The data is available for collaborators, but is not publicly available.

Measures

Dietary assessment

Food frequency measures were collected in NHS3 via a validated FFQ in the second biannual questionnaire [25, 26]. Members were considered to have completed the FFQs if they had a total energy intake >600 calories/d and <3,500 calories and were not missing 70 or more individual food frequency items. Nutritional components were calculated by multiplying reported food serving size with consumption frequency and the food’s nutritional value of interest, and summed across food intake. Food frequency and nutritional measures were used to calculate adherence to two dietary patterns based on the dietary recommendations from the DASH diet [27] and the AHA 2020 Strategic Impact Goals [28, 29]. We use both DASH and AHA to check the robustness of our findings.

The DASH diet was created by the National Heart, Lung, and Blood Institute to lower or control blood pressure. It focused on reducing sodium intake, and eating foods with nutrients that can lower blood pressure [27]. The DASH diet encouraged intakes of whole grains, vegetables, fruits, low fat dairy, and nuts, seeds, and legumes alongside limited intakes of red and processed meats, sodium, and sugar sweetened beverages (SSBs). To create the DASH diet score, we replicated previous methods, and summed all responses for each food and nutritional component, and then created quintiles based on component’s sample distribution [22]. Then, each participant’s quintiles were added together to create a score with possible values from 8 to 40, with 40 representing the healthiest diet.

The AHA’s dietary recommendations included eating nutrient rich foods (e.g., fruits and vegetables, whole grains, fish), and limiting sodium intake and SSBs [28, 29]. To calculate participant’s diet quality, we used a method similar to previous work [30–32]. The highest possible score—thus, the healthiest diet—was 50 points.

Finally, we also created dichotomous variables measuring ideal adherence (>= 80% of highest possible score) to DASH and AHA diet recommendations.

Sexual orientation

Sexual orientation was collected on the fifth biannual questionnaire, using a measure adapted from the Minnesota Adolescent Health Survey [33]. This question item asked about feelings of attraction and identity with six mutually exclusive response options (“completely heterosexual”, “mostly heterosexual”, “bisexual”, “mostly homosexual”, “completely homosexual”, and “unsure”). Due to small sample sizes, mostly homosexual and completely homosexual were combined into a single group (i.e., lesbian). Mostly heterosexual respondents, however, were categorized separately from completely heterosexual respondents due to potential experiences of minority stress. A question about the sex of sexual partners was combined with a question of sexual attraction and identity to create an additional sexual minority group (completely heterosexuals with same-sex partners). Too few participants who identified as lesbian had never had different-sex sexual partners to include as a separate category. In total, there were five sexual orientation groups: “completely heterosexual with no same-sex partners (reference)”, “completely heterosexual with same-sex partners”, “mostly heterosexual”, “bisexual”, and “lesbian”. Participants who said they were unsure were excluded. This operationalization of sexual orientation is consistent with other papers using the Minnesota Adolescent Health Survey measure [34–36].

Covariates

Potential confounders were included in all models, and consisted of age at baseline (continuous), race/ethnicity (non-Hispanic white [reference], another race/ethnicity), region (Northeast [reference], Midwest, West, South), annual household income (less than $50,000 [reference], between $50,000 and $100,000, between $100,000 and $150,000, and more than $150,000), and energy intake (continuous). Household income and energy intake were collected during the second biannual questionnaire and all other potential confounders were collected on the baseline questionnaire. Missing covariates were multiply imputed using fully conditional statements and 20 stacked data sets.

Statistical analysis

Age-standardized distributions of covariates for each sexual orientation group were calculated (Table 1). Although sexual orientation was collected at a different time than the FFQ, we are not testing longitudinal changes in diet but rather differences in diet quality across sexual orientation. To assess sexual orientation differences in diet quality scores, we used multivariable linear regression adjusted for all covariates. We next calculated least square means (LS-means) of DASH scores, individual DASH components, AHA scores, and individual AHA components for each sexual orientation group (Table 2) by linear regression models adjusted for potential confounders. All data management and analyses were conducted with SAS 9.4 Software.

Table 1:

Age-standardized characteristics by sexual orientation among a cohort of U.S. female nurses (N=15,941)

% (N), unless noted Completely heterosexual with no same-sex partners (N=13,101) Completely heterosexual with same-sex partners (N=379) Mostly heterosexual (N=1,866) Bisexual (N=315) Lesbian (N=280)
Age at baseline (range: 20 to 51 years) a 34.8 (7.1) 34.8 (7.1) 34.7 (7.1) 34.5 (6.7) 34.7 (7.1)
Race/ethnic identity
 Non-Hispanic white 90.5 (10,158) 94.2 (308) 88.1 (1,315) 88.3 (212) 87.9 (200)
Region of residence
 Northeast 25.4 (2,757) 23.6 (74) 28.0 (410) 33.0 (76) 28.8 (64)
 Midwest 31.1 (3,377) 22.6 (71) 22.4 (327) 21.9 (50) 20.1 (45)
 West 19.4 (2,111) 27.6 (87) 29.0 (423) 27.1 (62) 31.4 (70)
 South 24.1 (2,614) 26.2 (82) 20.6 (301) 18.0 (41) 19.7 (44)
Household income
 Less than $50,000 28.7 (3,238) 23.9 (79) 25.7 (386) 31.2 (75) 24.8 (57)
 Between $50,000 and $100,000 23.6 (2,671) 22.4 (74) 28.7 (431) 31.1 (75) 32.2 (74)
 Between $100,000 and $150,000 25.1 (2,836) 26.0 (86) 23.9 (358) 16.6 (40) 19.4 (44)
 More than $150,000 22.6 (2,550) 27.7 (91) 21.7 (325) 21.2 (51) 23.6 (54)
Total energy intake (range: 600 to 3,500 kcal/day) a 1,759.5 (560.4) 1,796.0 (585.3) 1,854.0 (570.6) 1,862.9 (592.3) 1,727.5 (562.6)
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a

mean (standard deviation)

Table 2:

Adjusted least square means and odds ratios of diet quality score across sexual orientation among a cohort of U.S. women aged 24 to 51 years (N=15,941)

Completely heterosexual with no same-sex partners (N=13,101) Completely heterosexual with same-sex partners (N=379) Mostly heterosexual (N=1,866) Bisexual (N=315) Lesbian (N=280)
DASH score 23.6 (23.5, 23.7) 23.5 (23.1, 24.0) 24.0 (23.8, 24.3) 23.9 (23.4, 24.4) 24.3 (23.8, 24.9)
DASH components
 Whole grains 3.1 (3.1, 3.1) 3.1 (2.9, 3.2) 3.1 (3.0, 3.2) 3.0 (2.9, 3.2) 3.1 (2.9, 3.2)
 Fruit 3.0 (3.0, 3.0) 3.0 (2.8, 3.1) 2.8 (2.8, 2.9) 2.7 (2.6, 2.9) 3.0 (2.8, 3.1)
 Vegetables 3.0 (3.0, 3.0) 3.0 (2.9, 3.1) 3.1 (3.1, 3.2) 3.3 (3.1, 3.4) 3.2 (3.0, 3.3)
 Nuts and legumes 3.1 (3.1, 3.1) 3.2 (3.0, 3.3) 3.3 (3.3, 3.4) 3.5 (3.3, 3.6) 3.4 (3.3, 3.6)
 Low-fat dairy 3.0 (3.0, 3.1) 2.9 (2.7, 3.0) 2.8 (2.7, 2.8) 2.6 (2.5, 2.8) 2.8 (2.6, 3.0)
 Processed meats 2.9 (2.9, 3.0) 2.9 (2.8, 3.1) 3.1 (3.1, 3.2) 3.2 (3.0, 3.3) 3.3 (3.1, 3.4)
 Sodium 2.9 (2.9, 2.9) 3.0 (2.9, 3.0) 3.0 (3.0, 3.0) 3.0 (2.9, 3.1) 3.0 (2.9, 3.1)
 Sugar-sweetened beverages 2.6 (2.5, 2.6) 2.6 (2.5, 2.7) 2.7 (2.6, 2.8) 2.6 (2.5, 2.7) 2.6 (2.5, 2.8)
Ideal DASH adherencea 1.0 0.9 (0.6, 1.3) 1.1 (0.9, 1.3) 0.8 (0.5, 1.2) 1.6 (1.2, 2.3)
AHA score 30.8 (30.6, 31.0) 31.6 (30.9, 32.3) 31.3 (31.0, 31.6) 31.3 (30.5, 32.0) 31.8 (31.0, 32.5)
AHA components
 Fruit and vegetables 6.9 (6.8, 6.9) 6.9 (6.6, 7.2) 6.9 (6.7, 7.0) 6.9 (6.5, 7.2) 7.1 (6.7, 7.4)
 Whole grains 5.7 (5.6, 5.8) 5.9 (5.6, 6.2) 5.7 (5.5, 5.8) 5.9 (5.5, 6.2) 5.9 (5.5, 6.2)
 Fish 4.2 (4.1, 4.3) 4.3 (4.0, 4.6) 4.1 (4.0, 4.3) 4.0 (3.7, 4.4) 4.1 (3.7, 4.5)
 Sodium 5.2 (5.1, 5.3) 5.2 (5.0, 5.5) 5.5 (5.4, 5.7) 5.6 (5.3, 5.8) 5.5 (5.2, 5.8)
 Sugar-sweetened beverages 8.9 (8.8, 9.0) 9.3 (9.0, 9.6) 9.1 (9.0, 9.2) 8.9 (8.6, 9.2) 9.2 (8.9, 9.5)
Ideal AHA adherencea 1.0 0.9 (0.7, 1.3) 1.0 (0.8, 1.1) 1.0 (0.7, 1.4) 1.2 (0.9, 1.7)
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DASH Dietary Approach to Stop Hypertension, AHA American Heart Association

a

Odds ratios. All estimates are adjusted for age, race/ethnicity, region, household income, and total energy intake with 95% confidence intervals in parentheses; All values are odds ratios (95% CI) unless noted; Least square mean values represent points for diet scores, with higher values representing healthier diets; Bolded values refer to estimates with p-value<.05 in reference to completely heterosexual with no same-sex partners

RESULTS

Descriptive characteristics of participants at baseline are presented in Table 1. On average, women in the sample were 34.8 years old (7.1), and approximately 90% identified as non-Hispanic white. There was relatively equal distribution of the sample across region of U.S. residence and categories of annual household income, with a slight majority residing in the Midwest or Northeast or having a household income of less than $50,000 per year. The average participant consumed 1,727–1,862 calories per day.

Table 2 presents predicted means and 95% CI of diet quality scores based on DASH and AHA total scores and components across sexual orientation groups. Mostly heterosexual [LS-means (95% confidence interval): 24.0 (23.8, 24.3)] and lesbian [24.3 (23.8, 24.9)] women had statistically significantly higher, and therefore healthier, predicted DASH scores than completely heterosexual women with no same-sex partners [23.6 (23.5, 23.7)]. Individual DASH components similarly differed across sexual orientation groups. Certain sexual minority women had healthier food consumption in several food groups than completely heterosexual women with no same-sex partners. Mostly heterosexual, bisexual, and lesbian women had healthier vegetable, nuts and legumes, processed meats and salt intake than completely heterosexual women with no same-sex partners. Mostly heterosexual women additionally had healthier sugar intake than completely heterosexual women with no same-sex partners. However, there were several food groups for which certain sexual minority women had less healthy consumption than completely heterosexual women with no same-sex partners. Mostly heterosexual, bisexual, and lesbian women consumed less healthy low-fat dairy intake and mostly heterosexual and bisexual women had lower fruit intake than completely heterosexual women with no same-sex partners. There were no statistically significant differences in DASH score or DASH components between completely heterosexual women with same-sex partners and completely heterosexual women with no same-sex partners. Lesbian women, but not mostly heterosexual women, had higher odds of ideal adherence to DASH than completely heterosexual women with no same-sex partners.

When we examined the AHA diet and its individual components across sexual orientation, there were more differences in overall diet quality, but fewer differences by individual components. Completely heterosexual women with same-sex partners, [31.6 (30.9, 32.3)], mostly heterosexual [30.4 (30.1, 30.8)], and lesbian women [31.8 (31.0, 32.5)] had healthier diets as measured by total AHA scores than completely heterosexual women with no same-sex partners [30.8 (30.6, 31.0)]. These differences likely reflected completely heterosexual healthier intakes of sodium (among mostly heterosexual and lesbian women) and SSBs (among completely heterosexual women same-sex partners, mostly heterosexual, and lesbian). Bisexual women also had healthier sodium intake compared to completely heterosexual women with no same-sex partners, but bisexual women still had a similar overall AHA diet quality score as completely heterosexual women with no same-sex partners. There was no difference in ideal adherence to AHA across sexual orientation.

CONCLUSION

Nearly half of cancer deaths are due to modifiable risk factors and therefore are preventable [1]. Chief among these modifiable risk factors is diet [15–17]. There is increasing evidence that sexual minority women are more likely to participate in many cancer-related risk factors than heterosexual women and that sexual minority women have higher incidence of cancer, particularly breast cancer, compared to heterosexual women [2–9]. Yet, although there is increasing evidence regarding sexual orientation differences in many cancer risk factors, little is known about diet quality differences across sexual orientation. Prior research that examined sexual orientation-related differences in diet has had contradictory findings. Bisexual and lesbian women had worse diet quality than heterosexual women when testing single components of diet such as fruit, vegetables, or sugar-sweetened beverages [18, 19]. On the other hand, bisexual and lesbian women had higher diet quality than heterosexual women when using measures of overall diet in NHS2 [22].

Our findings suggested that mostly heterosexual, bisexual, and lesbian women had higher diet quality scores based on DASH, AHA, and their components than completely heterosexual women with no same-sex partners. However, our exact findings varied slightly by which diet measures we utilized. Mostly heterosexual and lesbian women had higher quality diet scores than completely heterosexual women with no same-sex partners as measured by DASH and DASH component scores. Completely heterosexual women with same-sex partners, mostly heterosexual women, and lesbian women additionally had higher AHA scores than completely heterosexual women with no same-sex partners. Bisexual women had higher diet quality scores than heterosexual women with no same-sex partners as measured by many DASH components and an AHA component, but had similar overall diet quality scores. Notably, although these findings were statistically significant, the overall difference in diet quality scores were relatively low (e.g., DASH score was 23.6 for completely heterosexual women with no same-sex partners and 24.3 for lesbian women). The exception to this is lesbian women who had 1.6 times higher odds of having ideal adherence to DASH compared to completely heterosexual women with no same-sex partners.

Based on these data, diet quality does not appear to be contributing to the proposed higher cancer rates among sexual minority women compared to heterosexual women, nor do the reported higher diet quality among mostly heterosexual women appear to be large enough to be protective from disease risk. A possible exception to this is lesbian women, who have higher odds of ideal adherence to DASH than completely heterosexual women with no same-sex partners.

It is not clear exactly why mostly heterosexual and lesbian women may have slightly higher diet quality scores than heterosexual women. One possible explanation is that some subgroups of sexual minority women, particularly lesbian women, are less likely to have children, and thus may be able to dedicate more time to eating healthier foods [37]. An additional explanation is that women who identify as sexual minorities are more likely to have liberal attitudes, which public opinion surveys have shown to be associated with healthier eating patterns [38, 39].

Our findings most closely support previous NHS2 research using diet quality that found mostly heterosexual, bisexual, and lesbian women had better diet quality scores, based on the Alternative Healthy Eating Index, than heterosexual women [22]. Similar to NHS2 data, this paper used a validated food frequency questionnaire that captured a wide variety of dietary intake and calculated an overall measure of dietary quality [40]. In spite of the many strengths of the NHS2 and GUTS data, VanKim and colleagues’ measure of sexual orientation included only a limited measure of identity (i.e., heterosexual, mostly heterosexual, bisexual, and lesbian [22]) and no measures of behavior or attraction. The measure of sexual orientation in this analysis included not only heterosexual, bisexual, and lesbian identified participants but also those who identified as mostly heterosexual as well as those participants who can be categorized as sexual minorities based on same-sex partners (i.e., completely heterosexual with had same-sex partners). Detailed measures of sexual orientation are needed since previous research has found that completely heterosexual women with same-sex partners and mostly heterosexual women were at higher risk of engaging in cancer-related risk factors such as drinking, smoking, and exercise than completely heterosexual women with no same-sex partners [2–9]. In contrast to research on other cancer-related risk factors, we found that there was overall little difference in diet quality across sexual orientation, and differences that did appear indicated that sexual minority women were advantaged. This demonstrated that in many ways diet quality differences function differently than other cancer-related risk factors.

Our findings are not consistent with some earlier research which found that bisexual and lesbian women consume more sugary drinks than heterosexual women, and that lesbian women eat fewer vegetables than heterosexual women [18, 19]. While the earlier studies differed from each other regarding measurement of sexual orientation and sample representativeness—one used national, population-based data and the other surveyed college students in Minnesota—both studies differentiated between bisexual and lesbian women and used survey measurements based on food intake in the past week [18, 19]. In this study, food intake was assessed in the past year, and differences in the recall period may explain some of the variation in findings. However, validation studies comparing seven day diet records to FFQs for a whole year shows FFQs based on year-long recall are reliable and so this unlikely to be a cause for differences [40].

This article has significant strengths, including comparisons of heterosexual and sexual minority women, measurement of sexual orientation using aspects of behavior and attraction in addition to identity, and the use of two validated diet quality measures. However, it is also limited by the sample population, which is 90% white and relatively high income. The results presented may differ among racial/ethnic minorities or women with lower incomes. Additionally, we measured dietary quality only at a single moment of time and were not able to track how dietary quality may change with experiences of sexual orientation-related discrimination or over time.

Although mostly heterosexual and lesbian women had higher diet quality scores compared to heterosexual women with no same-sex partners, diet quality scores were low among all participants. For DASH, the average diet quality score was 24 out of 40 and AHA diet quality was scored at 30 out of 50. Ideal adherence to these measures, or approximately 80% of highest possible score, would be 32 for DASH and 40 for AHA. As has been the case for several decades, healthcare practitioners and public health interventions should continue to encourage a diet that is high in whole grains, fruits, and vegetables and low in processed meats and sugar.

These data suggest that other cancer risk factors (e.g., smoking, drinking, and inactivity), rather than diet, are driving higher cancer rates among sexual minority compared to heterosexual women. Nonetheless, it is critical for all women to improve their diet quality since diet plays a critical role in cancer prevention and diet quality is so poor among women of all sexual orientations. Future research should explore any potential unique needs of sexual minority women may have in improving their dietary quality. Additionally, better interventions to improve diet quality are needed for all women, and these interventions may need to be tailored to women of different sexual orientations.

Acknowledgements:

This work was supported by the National Institutes of Health (T32CA009001, U01HL145386, R24ES028521) and American Cancer Society (MRSG CPHPS 130006). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Funding:

This work was supported by the National Institutes of Health (T32CA009001, U01HL145386, R24ES028521) and American Cancer Society (MRSG CPHPS 130006). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Conflicts of Interest: There are no conflicts of interest to report.

Availability of data and material: The data is available for collaborators, but is not publicly available.

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