Embed Size (px)
Citation preview
www.elsevier.com/locate/ypmed
Preventive Medicine 38 (2004) 28–38
Associations between breast cancer risk factors and religious
practices in Utah
Melissa Daniels, M.S.P.H.,a Ray M. Merrill, Ph.D., M.P.H.,a,b,* Joseph L. Lyon, M.D., M.P.H.,a
Joseph B. Stanford, M.D., M.S.P.H.,a and George L. White Jr., Ph.D., M.S.P.H.a
aDepartment of Family and Preventive Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84108, USAbDepartment of Health Science, College of Health and Human Performance, Brigham Young University, Provo, UT 84602, USA
Abstract
Background. Utah has the lowest female malignant breast cancer incidence rates in the United States, due in part to low rates among
women who are members of the Church of Jesus Christ of Latter-day Saints (LDS or Mormon). Several established reproductive and non-
reproductive breast cancer risk factors may be lower among LDS women because of their religious doctrine related to marriage, family, and
health. This paper investigates the association between selected breast cancer risk factors and religious preference and religiosity in Utah.
Methods. A 37-item anonymous cross-sectional telephone survey was developed and conducted during March and April 2002. Results are
based on 848 non-Hispanic white female respondents.
Results. Number of births (parity), prevalence of breastfeeding, and lifetime total duration of breastfeeding were highest among LDS
women who attended church weekly. Average months of breastfeeding per child were greatest among weekly church attendees, regardless of
religious preference. Oral contraceptive use and total duration of hormone replacement therapy use were greatest for individuals of any
religion attending church less than weekly and for individuals with no religious preference. Comparisons of divergent reproductive behaviors
between LDS and non-LDS, and between weekly and less than weekly church goers, provide strong support for the relatively low breast
cancer incidence rates previously identified among LDS and, therefore, in Utah.
Conclusions. High parity and breastfeeding coincide with comparatively low breast cancer incidence rates among LDS and are consistent
with recent findings of the Collaborative Group on Hormonal Factors in Breast Cancer, showing the primary role parity and breastfeeding
play in reducing breast cancer.
D 2003 American Health Foundation and Elsevier Inc. All rights reserved.
Keywords: Breast cancer; Parity; Breastfeeding; Religion; Oral contraceptives; Hormone replacement
among white women in Utah were 119.0, with the next two
IntroductionBreast cancer is the most frequently diagnosed cancer
among women in the United States, representing an esti-
mated 31% (203,500) of all new cancer cases among
women in 2002 [1]. Breast cancer incidence rates have
historically been higher among white women than other
racial and ethnic groups [2]. The lowest rates among the 12
U.S. Surveillance, Epidemiology, and End Results (SEER)
registries are in Utah [2], despite its population being over
85% white, non-Hispanic [3]. Age-adjusted (using the 2000
U.S. population) breast cancer incidence rates per 100,000
0091-7435/$ - see front matter D 2003 American Health Foundation and Elsevie
doi:10.1016/j.ypmed.2003.09.025
* Corresponding author. Department of Health Science, College of
Health and Human Performance, Brigham Young University, 213 Richards
Building, Provo, UT 84602. Fax: +1-801-422-0273.
E-mail address: [email protected] (R.M. Merrill).
lowest rates being 126.4 in New Mexico and 130.4 in Los
Angeles [2]. The national average was 139.0 for whites and
134.1 for all races combined [2].
Epidemiologic studies have linked several risk factors to
breast cancer: reproductive factors (e.g., age at first birth,
number of births [parity], lifetime duration of breastfeeding,
etc.) and non-reproductive behaviors (e.g., alcohol drink-
ing). In Utah, breast cancer rates have been shown to differ
greatly among religious groups and according to church
attendance. Specifically, members of the state’s dominant
religion, The Church of Jesus Christ of Latter-day Saints
(LDS or Mormon), have been shown to have breast cancer
rates substantially below the state average [4,5]. Between
1971 and 1985, age-adjusted (using the 1970 U.S. popula-
tion) breast cancer incidence rates among LDS women in
Utah were 20% lower than in the U.S. (71.9 vs. 89.9),
r Inc. All rights reserved.
M. Daniels et al. / Preventive Medicine 38 (2004) 28–38 29
whereas rates in non-LDS women in Utah were 17% higher
(105.3 vs. 89.9) [4]. Specific reproductive and non-repro-
ductive behaviors influenced by the LDS Church probably
contribute to this difference.
In 1847, LDS pioneers settled the Salt Lake Valley in
northern Utah [6]. Over the next several years, LDS Church
members settled over 350 communities throughout the
territory. Today, about 70% of Utah’s 2.3 million popula-
tion are members of the LDS Church [7,8]. Religious
doctrine espoused by the Church that encourages marriage
and family [9,10] and discourages use of tobacco and
alcohol consumption [11] likely contributes to the compar-
atively low breast cancer incidence rates. The purpose of
this study is to identify whether religious preference and
church attendance in Utah are associated with selected
breast cancer risk factors, including reproductive risk fac-
tors, demographic factors (age, race, income, education),
and non-reproductive breast cancer risk factors like height
[12], family history of breast cancer [13], and alcohol
drinking [14]. We also consider cigarette smoking, which
has been associated with a small increased risk of breast
cancer [15].
Materials and methods
Survey instrument
Prevalence among Utah women for both reproductive
and non-reproductive risk factors was obtained through a
statewide, random-digit-dialed survey. The survey also
collected information on demographics, religious prefer-
ence, and church attendance. Because normative influences
in the LDS Church may cause LDS compared with non-
LDS to more or less accurately respond to certain questions
directly related to their religious doctrine (e.g., church
attendance, cigarette smoking, and alcohol drinking), par-
ticipants were informed at the beginning of the interview
that this was an anonymous survey and the two questions
about religious preference and church activity were not
asked until the end of the survey. Telephone numbers were
computer generated, lending credibility to randomization
and providing numbers that are representative of households
throughout the state of Utah. These numbers included listed,
unlisted, and non-published numbers. Every potential tele-
phone number within the sampling frame had a known and
equal probability of selection. The sample was administered
electronically and was randomly assigned to interviewers by
the Computer Assisted Telephone Interview (CATI) system.
All Utah women aged 18 years and older were eligible for
participation in the survey. Upon contacting a household
with eligible women, interviewers requested to speak to the
oldest woman in the household who was available. If no
woman was available, interviewers continued to call until
one became available or 15 attempts were made. All
selected phone numbers were called 15 times or until
resident eligibility and willingness to participate could be
determined.
The 37-item survey instrument for this study was designed
to assess risk factors identified through a literature review.
The Utah Health Status Survey (1996) [16] served as a model
for question design. To establish content and face validity, the
instrument was reviewed by the authors, whose training
represents epidemiology, biostatistics, and women’s health
issues, and two other individuals with extensive experience in
survey sampling. A pilot version of the survey was tested on
27 women, selected from the Utah population, to assess the
instrument for clarity of questions and ease of administration.
Pegus Research, a Salt Lake City-based firm specializing in
survey research, administered the questionnaire.
Risk factors
Reproductive and non-reproductive risk factors common-
ly associated with breast cancer were identified from several
epidemiologic studies and meta-analyses. Reproductive risk
factors considered in this study include: age at first birth
[17,18]; age at menarche and age at menopause [12]; use of
hormone replacement therapy (HRT) [19,20]; number of
births, also called parity [21]; induced abortions [22]; use of
oral contraceptives (OC), which has been shown to increase
the risk of breast cancer in some studies but not others [23];
and lifetime duration of breastfeeding [21,24]. Non-repro-
ductive risk factors also considered in the analyses were
height [12], family history of breast cancer [13], and alcohol
drinking [14]. We also consider cigarette smoking, which
may slightly increase the risk of breast cancer [15]. A brief
description of the reproductive risk factors is given here:
Age at first birth—This is defined as the age at the end of
a woman’s first pregnancy of at least 20 weeks’
gestation. Pregnancies terminating before 20 weeks were
classified as either spontaneous or induced abortions.
Age at menarche—This is defined as a woman’s age at
her first menstrual period.
Age at menopause—This variable is derived from the
reported month and year of last menstrual period plus 1
year among women no longer having menstrual periods.
Months were randomly selected within the year, or
within the remembered season for women who could
only remember the year. Some women reporting a
probable menopausal status had continued periods due to
HRT use. Because of ambiguity in menopausal status
introduced by hysterectomies and various types of HRT,
age at menopause was assessed in three ways: (a) Gross
age at menopause, including all women who reported a
conclusion of their periods whether due to natural or
artificial processes, measured from the date of last
period; (b) age at menopause among women who had not
had a hysterectomy; and (c) age at menopause among
women who had not had a hysterectomy and had never
used hormone replacement therapy.
M. Daniels et al. / Preventive Medicine 38 (2004) 28–3830
Use of hormone replacement therapy (HRT)—Women
were asked if they had ever used hormone replacement
therapy such as Premarin or Estrogen. Interviewers were
instructed to consult a list of all major brands of HRT in
the event that a woman was unsure that her medication
was HRT, but was able to provide its name.
Number of children (parity)—This was defined as the
total number of live births, plus stillbirths, in a woman’s
pregnancy history. All births after 20 weeks’ gestation
were classified as either live or stillbirths.
Number of abortions—Because of the sensitive nature of
the topic and LDS doctrine forbidding abortion, except in
cases of rape or threat to the mother’s health [25], this
was not asked directly but derived as presented in
Appendix A.
Use of oral contraceptive (OC)—This variable included
only women who reported using standard birth control
pills. Women reporting use of other hormonal methods,
such as Depo-Provera and Norplant, were not considered
oral contraceptive users.
There were 1,316 women aged 18 years or older deter-
mined to be eligible for the study. Of these eligible women
we were not allowed to speak directly with 78 of them, and
311 directly refused participation. An additional subject
terminated the telephone call before we were able to
complete half the survey. We completed interviews with
926 women; that is, the proportion of completed interviews
among eligible women contacted was 70.4% (based on the
formula defined by the American Association for Public
Opinion Research [26]). Of these, 33 who had been previ-
ously diagnosed with breast cancer were excluded from the
study to focus on women at risk of developing the disease.
There were 69.5% who identified themselves as LDS. This
percentage is almost identical to the percentage identified as
LDS in Utah in a previous survey [7] and the 70% identified
as LDS in Utah from LDS church records (Larry Elkington,
director of the LDS Church Management Information Cen-
ter, personal communication).
Interviewers conducted the survey in English. Language
difficulties prevented 87 respondents from identifying their
household status and eligibility. Because of the small
number of non-whites surveyed and the predominance of
white non-Hispanics in Utah (85.3%) [3], only white non-
Hispanics (n = 848) have been included in the analyses.
Statistical methods
Breast cancer risk factor data were described using cross-
tabulations, multivariate regression, and logistic regression
techniques. Odds ratios from the logistic model were
adjusted for age, education, income, smoking, and alcohol
drinking. Statistical significance was evaluated using the
Pearson chi-square test, the Fisher’s exact test, the Mantel–
Haenszel chi-square test, the F test, and confidence inter-
vals. Tests of significance were evaluated against the null
hypothesis of no association, using the 0.05 level. Analyses
were performed with standard packages of the Statistical
Analysis System, Release 8.2 (SAS, 2001) [27].
Results
Demographic information and non-reproductive breast
cancer risk factors are summarized in Table 1. Variables are
stratified by religious preference (LDS, non-LDS, and no
religion) and church attendance. Individuals attending church
weekly or more than weekly were classified as ‘‘active.’’
Those attending church less than weekly were classified as
‘‘less active.’’ The terms ‘‘active’’ and ‘‘less active’’ represent
levels of religious participation, while recognizing that they
do not necessarily capture all aspects of religiosity. The
combined variable in Table 1, which describes both church
preference and activity, is hereafter referred to as ‘‘religion.’’
All individuals reporting no religious preference also
reported less than weekly church attendance. By these
definitions, there were 55.9% active LDS, 13.9% less active
LDS, 7.8% active non-LDS, 12.3% less active non-LDS, and
10.2% with no religious preference. Religion was signifi-
cantly associated with each demographic variable, with the
exception of income, as well as smoking and alcohol drink-
ing. Religion was not significantly associated with family
history of breast cancer and height. Post-graduate degrees
were most common in non-LDS who were less active and
among those with no religious preference. Conversely, edu-
cation among active LDS was higher than among less active
LDS, with 30.9% of active LDS obtaining a bachelor’s
degree or higher, compared with 8.6% of less active LDS.
Income did not significantly differ by religion, although
less active LDS were poorer. Cigarette smoking was lower
among active church members, particularly among LDS,
where 0% reported current smoking. Church preference and
attendance did not statistically affect the presence of
alcohol consumption among non-LDS. However, among
LDS there was a pronounced difference of 0.4% for active
LDS compared with 29.3% for less active LDS.
A summary of reproductive risk factor prevalence by
religion is presented in Table 2. Being parous (having given
birth) was associated with religious preference. LDS wom-
en, regardless of activity level, were most likely to have
given birth. Women of no religious preference were least
likely to have given birth. Likewise, parity (live births and
still births) was highest among LDS women and lowest
among women of no religious preference (see also Average
Pregnancies and Average Parity variables in the table).
Church activity was directly correlated with having more
children for LDS. The LDS do not have lower average age
at first birth, despite their larger family size. Pregnancies
before age 20 were significantly less common among active
LDS (25% vs. 40–47% for the other religion categories).
Mean age at first birth was calculated with and without
teenage pregnancies included (see continuous variables).
Table 1
Summary of demographic and other variables by religion
Categorical variables Religious preference and church activity P values v2 CMHa
LDS Non-LDSFisher’s exact
Active Less active Active Less active None
No. % No. % No. % No. % No. %
Education
Less than high school 8 1.7 7 6.0 0 0.0 6 5.8 5 5.9
High school or GED 87 18.7 43 37.1 13 20.0 23 22.3 21 24.7
Some college or tech 169 36.3 48 41.4 21 32.3 34 33.0 25 29.4
Associates or tech degree 58 12.5 8 6.9 11 16.9 8 7.8 8 9.4
Bachelors degree 101 21.7 5 4.3 12 18.5 14 13.6 12 14.1 < 0.0001
Some post-graduate work 20 4.3 3 2.6 4 6.2 6 5.8 5 5.9 0.0468
Post-graduate degree 23 4.9 2 1.7 4 6.2 12 11.7 9 10.6 < 0.0001
Annual household income
<US$15,000 45 10.5 20 17.7 10 16.1 4 4.2 8 9.5
US$15,000 to <US$30,000 63 14.7 31 27.4 10 16.1 19 20.0 14 16.7
US$30,000 to <US$45,000 104 24.2 22 19.5 8 12.9 21 22.1 17 20.2 0.0106
US$45,000 to <US$60,000 97 22.6 22 19.5 13 21.0 23 24.2 16 19.1 0.1356
US$60,000 or greater 120 28.0 18 15.9 21 33.9 28 29.5 29 34.5 < 0.0001
Family history of breast cancerb
Yes 145 31.6 35 30.4 19 29.7 38 36.9 30 35.7 0.7493
No 314 68.4 80 69.6 45 70.3 65 63.1 54 64.3 0.1565
0.7464
Cigarette smokingc
Current smoker 0 0.0 23 19.8 7 10.8 26 25.2 18 21.2 < 0.0001
Former smoker 28 6.0 19 16.4 12 18.5 30 29.1 25 29.4 < 0.0001
Never smoker 439 94.0 74 63.8 46 70.8 47 45.6 42 49.4 < 0.0001
Alcohol monthlyd
Yes 2 0.4 34 29.3 34 52.3 58 56.3 45 53.6 < 0.0001
No 465 99.6 82 70.7 31 47.7 45 43.7 39 46.4 < 0.0001
< 0.0001
Continuous variablese Mean SE Mean SE Mean SE Mean SE Mean SE P value
Age 46.07 0.754 50.33 1.511 48.60 2.018 46.37 1.603 44.05 1.765 0.0475
Height (in.) 65.15 0.123 64.78 0.248 64.73 0.330 64.72 0.262 64.65 0.289 0.2551
a Cochran Mantel–Haenszel chi-square, adjusted for age.b On the basis of the question, ‘‘Have one or more of your blood relatives developed breast cancer?’’.c On the basis of the question, ‘‘If people who have smoked less than 100 cigarettes in their lives are considered ‘never smokers,’ would you say you are a
current, former, or never smoker?’’.d On the basis of the question, ‘‘In the last year have you consumed alcoholic beverages at least once per month?’’.e Age-adjusted continuous with least squares F statistic P value.
M. Daniels et al. / Preventive Medicine 38 (2004) 28–38 31
After teenage pregnancies were removed, less active LDS
maintained the lowest age at first birth and those with no
religious preference maintained the highest age at first birth.
Breastfeeding was most common among active LDS
(81.1%), least common among those of no religious prefer-
ence (51.6%), and was positively correlated with religious
activity. Average months of breastfeeding per child were
highest among active women (8.0–8.1), lower among less
active women (6.0–6.3), and lowest among women with no
religious preference (5.7). Use of oral contraceptives was
negatively associated with religious activity; use was lowest
among LDS and highest among those with no religious
preference. Among those who use oral contraceptives, age
at first use was lowest for less active non-LDS (20.0) and
highest for active LDS (23.0). Least squares P values for all
groups (except no religious preference), compared with
active LDS, were statistically significant. Less active LDS
were least likely to use contraceptives before first term
pregnancy, although there was very little difference among
the other categories of religion. Higher parity among active
LDS did not lead to an increased rate of hysterectomies.
Hysterectomy rates among active LDS matched those
among active non-LDS (24%), but there was a relatively
high hysterectomy rate (41.4%) among less active LDS.
Induced abortion rates were highest among less active non-
LDS and among those with no religious preference. There
were no differences among categories of religion in age at
menarche or age at menopause.
Table 2
Summary of reproductive variables by religion
Variable Religious preference and church activity P values v2 CMHa
LDS Non-LDSFisher’s exact
Active Less active Active Fisher’s exact None
No. % No. % No. % No. % No. %
Parous
Yes 405 86.7 102 87.9 55 84.6 79 76.7 63 74.1 0.0063
No 62 13.3 14 12.1 10 15.4 24 23.3 22 25.9 0.0576
0.0085
Parity
1 41 10.1 11 10.8 8 14.6 16 20.3 17 27.0
2 65 16.0 36 35.3 22 40.0 30 38.0 20 31.8
3 71 17.5 21 20.6 15 27.3 18 22.8 21 33.3
4 91 22.5 18 17.7 3 5.5 9 11.4 3 4.8 < 0.0001
5 67 16.5 5 4.9 3 5.5 2 2.5 0 0.0 < 0.0001
6 + 70 17.3 11 10.8 4 7.3 4 5.1 2 3.2 < 0.0001
Age at first birth
< 20 116 24.8 51 44.0 26 40.0 44 42.7 40 47.1
20– < 22 95 20.3 28 24.1 8 12.3 25 24.3 9 10.6
22– < 25 141 30.2 20 17.2 13 20.0 11 10.7 11 12.9 < 0.0001
25– < 30 83 17.8 10 8.6 13 20.0 14 13.6 14 16.5 0.0067
z 30 32 6.9 7 6.0 5 7.7 9 8.7 11 12.9 < 0.0001
Ever breastfed (BF)b
Yes 322 81.1 67 66.3 38 69.1 49 63.6 32 51.6 < 0.0001
No 75 18.9 34 33.7 17 30.9 28 36.4 30 48.4 0.0008
< 0.0001
Ever used hormone replacement (HRT)
Yes 148 68.2 46 66.7 24 64.9 44 78.6 21 67.6 0.5648
No 69 31.8 23 33.3 13 35.1 12 21.4 10 32.3 0.6003
0.5478
Ever used oral contraceptives (OC)
Yes 312 67.0 90 77.6 50 76.9 85 82.5 73 85.9 0.0002
No 154 33.1 26 22.4 15 23.1 18 17.5 12 14.1 0.0001
< 0.0001
OC Use
Current 55 11.8 9 7.8 5 7.7 14 13.6 19 22.4 < 0.0001
Former 256 55.1 81 69.8 45 69.2 71 68.9 54 63.5 0.0016
Never 154 33.1 26 22.4 15 23.1 18 17.5 12 14.1 < 0.0001
OC before 1st term pregnancy
Yes 183 44.6 1 29.8 25 43.1 45 51.7 33 51.6 0.0160
No 227 55.4 73 70.2 33 56.9 42 48.3 31 48.4 0.3140
0.0145
Hysterectomy
Yes 112 24.0 48 41.4 16 24.6 32 31.1 17 20.0 0.0015
No 355 76.0 68 58.6 49 75.4 71 68.9 68 80.0 0.0379
0.0022
Induced abortion
Yes 16 4.1 2 2.0 3 5.3 9 10.7 7 11.1 0.0166
No 371 95.9 96 98.0 54 94.7 75 89.3 56 88.9 0.0771
0.0175
Continuous variables Mean SE Mean SE Mean SE Mean SE Mean SE P valuec
Average pregnanciesb 4.5 0.106 3.5 0.211 3.1 0.283 3.1 0.231 2.9 0.269 < 0.0001
Average parityb 3.9 0.080 3.0 0.159 2.7 0.216 2.6 0.180 2.4 0.202 < 0.0001
(continued on next page)
M. Daniels et al. / Preventive Medicine 38 (2004) 28–3832
Table 2 (continued)
Continuous variables Mean SE Mean SE Mean SE Mean SE Mean SE P valuec
Age at first birthb 23.4 0.219 21.4 0.437 22.9 0.594 22.9 0.495 23.7 0.555 0.0012
Age at first birthb
(not including teen births)
24.1 0.214 23.4 0.498 25.0 0.641 24.5 0.521 26.1 0.597 0.0070
Total years breastfeeding (BF)b,d 2.1 0.108 1.0 0.214 1.3 0.289 0.8 0.244 0.6 0.273 < 0.0001
Average months BF per childe 8.0 0.298 6.0 0.655 8.1 0.867 6.3 0.763 5.7 0.945 0.0004
Age at menarche 13.1 0.079 13.1 0.158 13.2 0.210 12.9 0.167 13.0 0.187 0.7548
Age at menopausef
Gross age 44.5 0.676 42.7 1.154 45.2 1.672 43.0 1.270 43.4 1.763 0.5072
No hysterectomy 50.5 0.755 51.2 1.566 50.2 1.602 50.8 1.472 52.0 1.993 0.9515
No HRT, No hysterectomy 49.1 1.108 52.1 2.016 53.1 2.265 53.6 2.383 49.3 3.329 0.2535
Total years HRT useg 9.8 0.773 13.8 1.372 7.3 1.900 10.6 1.406 15.5 2.031 0.0051
Age at first OC use 23.0 0.310 21.2 0.579 20.9 0.767 20.0 0.587 21.8 0.638 < 0.0001
Age last OC use (former users) 28.0 0.479 27.1 0.858 29.1 1.119 29.0 0.891 29.3 1.062 0.3479
Age at hysterectomy 50.5 0.755 51.2 1.566 50.2 1.602 50.8 1.472 52.0 1.993 0.1335
a Cochran Mantel Haenszel chi-square, adjusted for age.b Among parous women only.c Age-adjusted variables with P values corresponding to least squares F statistics.d On the basis of the question, ‘‘Throughout your life, how many years have you breastfed?’’.e Among parous and breastfeeding women only.f Calculated by age at terminal menstrual period plus 1 year.g On the basis of the question, ‘‘In your lifetime, how long [# years] have you used hormone replacement therapy?’’.
M. Daniels et al. / Preventive Medicine 38 (2004) 28–38 33
Selected odds ratios and means are presented to describe
the association between religion and reproductive risk
factors after adjusting for age, education, income, smoking,
and alcohol use (Table 3). All variables from the previous
table were included in this analysis. Only significant vari-
ables at the 0.1 level are reported in this table. Of repro-
Table 3
Adjusted measures of the association between reproductive breast cancer risk fac
Religion Activity Ever breastfedb (no/yes) O
OR 95% CI O
LDS Active 1.00
LDS Less active 1.67 0.97 2.89
Other Active 1.82 0.92 3.62
Religion Less active 2.12 1.10 4.07
No religious Preference 4.14 2.10 8.16
Religion Activity Average pregnanciesb A
Average SE P valuec A
LDS Active 4.51 0.12
LDS Less active 3.36 0.22 < 0.0001
Other Active 3.20 0.29 < 0.0001
Religion Less active 3.25 0.25 < 0.0001
No religious Preference 3.04 0.29 < 0.0001
Religion Activity Months breastfeeding/childd T
Average SE P valuec A
LDS Active 7.89 0.34
LDS Less active 6.52 0.70 0.0947 1
Other Active 7.85 0.92 0.9688
Religion Less active 6.19 0.69 0.0997 1
No religious Preference 5.53 1.01 0.0342 1
a Odds after adjusting for age, education, income, smoking, and alcohol drinkingb Among parous women only.c Least squares F statistic P values comparing each religion category to active LDd Among parous and breastfeeding women only.e Includes women who’s periods have stopped or who are over 50 years of age.
ductive risk factors, breastfeeding habits and parity stand
out with the largest differences between LDS and non-LDS.
Breastfeeding variables were positively associated with
activity. Among parous women, likelihood of breastfeeding
was highest among active LDS and lowest among individ-
uals of no religious preference. Lifetime total years of
tors and religiona
C use (ever/never) Hysterectomy (yes/no)
R 95% CI OR 95% CI
1.00 1.00
2.42 1.35 4.33 2.05 1.18 3.58
1.80 0.88 3.70 0.95 0.46 1.97
1.99 0.98 4.02 1.54 0.80 2.95
2.41 1.11 5.24 0.91 0.44 1.91
verage parityb Total years breastfeedingb
verage SE P valuec Average SE P valuec
3.88 0.09 2.05 0.12
2.91 0.16 < 0.0001 1.18 0.22 0.0013
2.77 0.22 < 0.0001 1.34 0.30 0.0367
2.66 0.20 < 0.0001 0.83 0.27 0.0002
2.54 0.22 < 0.0001 0.70 0.30 < 0.0001
otal years HRT usee Age at first OC use
verage SE P valuec Average SE P valuec
9.77 0.91 22.66 0.36
3.69 1.43 0.0285 21.52 0.60 0.1228
6.94 2.02 0.2247 21.08 0.79 0.0806
0.76 1.58 0.6203 20.40 0.64 0.0046
6.06 2.19 0.0133 22.11 0.68 0.5120
.
S.
M. Daniels et al. / Preventive Medicine 38 (2004) 28–3834
breastfeeding were likewise highest among active LDS
(2.05) and lowest among individuals with no religious
preference (0.70). Average months breastfeeding per child
was highest among active women, both LDS and non-LDS,
when limited to women who breastfed. Average number of
pregnancies and parity were also higher among active LDS
(4.51 and 3.88), with little difference among the other
categories of religion with ranges of 3.0–3.4 and 2.5–2.9,
respectively. Likelihood of oral contraceptive use was lower
among active LDS compared with less active LDS and those
with no religious preference (both with odds ratios of 2.4).
Likelihood of hysterectomy remained high among less
active LDS and non-LDS. Individuals of no religious
preference had hysterectomy levels similar to active church
members. Age at first oral contraceptive use and total years
of hormone replacement therapy changed very little after
adjusting for other variables in the model.
To assess whether associations between each of the
outcome variables and the religion variable were dependent
on the level of the other independent variables in the
multivariate logistic models, interaction terms between reli-
gion and these other variables were also included in the
models. Only income had an interaction effect in a few of the
models. In particular, the odds of having children increased
significantly with increasing income levels among active
LDS, but not among the other religion categories. Similarly,
total lifetime breastfeeding among women who breastfed
was positively associated with higher income levels among
active LDS, but not among the other religion categories.
Parity and breastfeeding stratified by approximate meno-
pausal status ( < 50 vs. z 50 years of age) and adjusted for
age, education, smoking, and alcohol use are given in Table 4.
Pregnancy and parity rates were consistently higher among
Table 4
Selected reproductive variables stratified by agea
Variable Religious preference/church activity
LDS Non-LDS
Active Less active Active
Mean SE Mean SE Mean SE
Pregnancies
< 50 3.76 0.139 2.81 0.271 2.81 0.34
z 50 5.44 0.201 4.07 0.338 3.47 0.46
Parityb
< 50 3.18 0.097 2.53 0.195 2.43 0.25
z 50 4.67 0.153 3.45 0.258 3.08 0.36
Lifetime years of breastfeedingb
< 50 2.00 0.141 1.14 0.277 1.28 0.35
z 50 2.09 0.211 1.27 0.356 1.37 0.49
Months breastfeeding per infantc
< 50 8.40 0.436 6.93 0.980 7.07 1.26
z 50 7.03 0.544 6.19 1.041 8.30 1.33
a Odds after adjusting for age, education, income, smoking, and alcohol drinkingb Average for parous women.c Among parous women who have breastfed.
active LDS, followed by less active LDS. For menopausal
women, parity was approximately 35% higher among active
LDS than among less active LDS (4.67 vs. 3.45). Women
with no religious preference consistently experienced the
lowest levels of pregnancy and parity. Lifetime years of
breastfeeding were highest among active LDS in both men-
opausal categories and were similar between the two catego-
ries for all but one religion group; premenopausal women of
no religious preference reported significantly less total breast-
feeding than their postmenopausal counterparts. Months of
breastfeeding per infant were generally higher among women
in the premenopausal generation.
Discussion
Differential reproductive and non-reproductive risk fac-
tors for breast cancer between LDS and non-LDS are
consistent with the previously identified low breast cancer
rates among LDS and the overall low rates in Utah [2,4]. A
study of general cancer risk factors in Utah, based on data in
the 1980s, likewise identified LDS as having more preg-
nancies, a later age at first pregnancy, less likelihood of oral
contraceptive use, and fewer hysterectomies than their non-
LDS counterparts [28]. The primary differences among
religious groups in this study involved parity and breast-
feeding (both overall and average time breastfed per child),
with active LDS displaying the highest levels of parity and
breastfeeding. High parity among LDS contributes to Utah
having the highest fertility rates in the nation. Based on the
Behavior Risk Factor Surveillance System (BRFSS; CDC,
2001) [29], in 1999 Utah women had 93.1 live births per
1000 women aged 15–44 years, followed by Arizona with
Least squares F
statistic P value
Less active None
Mean SE Mean SE
3 2.72 0.282 2.66 0.292 0.0024
6 3.84 0.438 3.06 0.590 < 0.0001
0 2.06 0.215 2.13 0.210 < 0.0001
2 3.41 0.338 2.82 0.452 < 0.0001
5 0.98 0.310 0.68 0.298 0.0019
0 0.74 0.466 0.54 0.634 0.0722
8 7.89 1.143 5.92 1.147 0.3146
9 4.62 1.450 5.53 2.110 0.4118
.
M. Daniels et al. / Preventive Medicine 38 (2004) 28–38 35
81.1 live births, and Texas with 77.6 live births. The
national average was 65.9 live births.
Average years of total lifetime breastfeeding are signif-
icantly higher among parous, active LDS women compared
with women in other categories of religion. Average months
of breastfeeding per infant were similar between active LDS
and non-LDS women when the analysis was restricted to
just parous women who breastfed. Previous studies have
shown that church activity is associated with multiple
healthy behaviors [30,31] and, in our study, also appears
to be associated with breastfeeding.
A meta-analysis conducted by the Collaborative Group
on Hormonal Factors in Breast Cancer showed that parity
and breastfeeding are the primary factors influencing breast
cancer, independent of other known risk factors (e.g., early
age at menarche, older age at first birth, later age at
menopause) [21]. The study found a 7.0% decrease in the
relative risk of breast cancer for each birth (live or stillbirth)
and a 4.3% decrease in the relative risk of breast cancer for
every 12 months increase in breastfeeding. Therefore, com-
paratively high parity and breastfeeding among active LDS,
who comprise 55.9% of the state’s female population, helps
explain the marked differences observed in breast cancer
incidence rates between Utah and the U.S. and between LDS
and non-LDS.
According to a recent report by the Center for Disease
Control and Prevention, breastfeeding in the U.S. between
1993 and 1999 increased in 10 of 12 states evaluated for
trends in breastfeeding [32]. Our results also show an
increase in breastfeeding; that is, similar lifetime duration
of breastfeeding observed between premenopausal and
postmenopausal women indicates increased breastfeeding
among younger women. Average months of breastfeeding
per infant were also higher for premenopausal than post-
menopausal women.
Previous studies have shown that oral contraceptive use
and hormone replacement therapy may also be associated
with breast cancer risk, albeit at lower levels than parity and
breastfeeding [19,20,23,33]. The recent Women’s Health
Initiative study found a 1.26 relative risk of breast cancer
with daily use of hormone replacement therapy [19]. We
showed that women who were active in church were less
likely to use oral contraceptives and had shorter overall use
of hormone replacement therapy. Increased health con-
sciousness among the religiously active LDS and non-LDS
may help explain reduced rates of oral contraceptive use
among both groups, and the desire for more children helps
explain why active LDS have the lowest use overall. The
lower duration of hormone replacement therapy use among
religiously active individuals may indicate better health at
menopause leading to lower incidence of menopausal symp-
toms. A previous study found that menopausal symptoms
were more common among women of poorer health at age
36 [34].
Hysterectomy may influence breast cancer risk indirectly
by influencing parity and use of hormone replacement
therapy. However, we found that the average age of hyster-
ectomy was similar (ages 50–51) among the categories of
religion. Less active LDS had significantly higher hysterec-
tomy rates compared with active LDS, despite their having
the lowest income. This might be explained by their having
poorer general health earlier in life, as weekly church
attendance has been linked with increased health mainte-
nance and survival rates [35]. Despite active LDS having
high parity, which might indicate wear on the uterus leading
to hysterectomy, these women did not have the highest
levels of hysterectomy.
The Utah population is unique in that it represents the
highest level of a single religious concentration of any state in
the nation [36]. Consistent with the LDS Church’s doctrine
on marriage, children, and abstention from tobacco use and
alcohol drinking, Utah has historically had the highest
percentage of adults 18 years and older in the nation who
are married and with children living in the household, as well
as the lowest percentage of current smokers, binge drinkers,
or chronic drinkers, according to the BRFSS [37,38]. A
comparison of prevalence estimates for these and other
factors between Utah and the U.S. is presented in Table 5.
Further, not only are adults in Utah more likely to have
children in the home, they have more children. For example,
in 2001, the percentage in Utah who had three, four, or five or
more children living in the household was 9.7% (8.5–
10.8%), 5.3% (4.3–6.2%), and 3.2% (2.4–3.9%) respective-
ly compared with 6.1%, 1.8%, and 0.7% nationally.
LDS doctrine teaches that marriage is ordained of God
and that the basic unit of the church is the family [39,40].
They believe that life is more secure and joyous when
experienced in family relationships, and that marital and
family bonds can extend beyond this life if the relationships
are based on love and righteous living [41]. Consistent with
this doctrine is the comparatively high percentage of reli-
giously active LDS adults who are married and who have
large family sizes. Not only do LDS adults reflect higher
percentages who are married than non-LDS [7], but they are
more likely to marry spouses of the same faith [28]. A recent
study showed that within selected age and education strata in
Utah, the mean number of children born to religiously active
LDS women was significantly higher than among other
women in the state [42]. The positive relation between parity
and income in this study only existed among active LDS.
Although there may be higher social acceptance of large
family sizes in LDS communities, this may be further
reinforced by frequent church attendance, where recently
over 70% of the LDS adult population in Utah has identified
themselves as attending church weekly compared with less
than 40% of the non-LDS [42]. Several studies have iden-
tified comparatively low smoking and alcohol drinking
among LDS in Utah [7,28,42]. Although the LDS Church
has discouraged use of tobacco and alcohol drinking since
1833 [11], not until the early 1900s did total abstention from
these products become required of all members for full
fellowship and admittance to LDS temples [43]. The slightly
Table 5
Prevalence data on marriage, children, smoking, alcohol drinking, physical
activity, and weight for adults 18 years and older in Utah and the United
States, based on the Behavior Risk Factor Surveillance System [43,44]
Utah United States
Married
1995 69.4% (67.0–71.8%) 62.4%
2001 69.0% (67.0–70.9%) 59.2%
Children in the household
1995 51.3% (49.7–53.9%) 39.7%
2001 49.8% (47.7–52.0%) 39.8%
Currently pregnant
1995 7.7% (5.5–10.0%) 4.7%
2000 7.2% (5.0–9.3%) 4.6%
Current smoking
1990 16.7% (14.7–18.7%) 23.0%
2001 13.2% (11.8–14.5%) 22.8%
Binge drinkinga
1990 10.4% (18.6–12.2%) 15.3%
2001 9.7% (8.5–10.8%) 14.7%
Chronic drinkingb
1990 2.0% (1.2–2.8%) 3.2%
2001 3.1% (2.5–3.6%) 5.1%
Participated in physical activity in past month
1996 82.9% (81.2–84.6%) 72.3%
2001 83.5% (81.9–85.0%) 74.2%
No leisure physical activity in past month
1990 23.2% (21.0–25.4%) 28.7%
2001 16.5% (14.9–18.0%) 25.7%
Overweight (BMI 25–29.9)
1990 33.6% (31.3–36.0%) 33.1%
2001 35.6% (33.6–37.5%) 37.2%
Obese (BMI 30 or more)
1990 9.9% (7.7–10.9%) 11.6%
2001 19.1% (17.3–20.8%) 21.0%
BMI: Body mass index calculated as weight in kilograms divided by height
in meters squared.a Consumption of five or more drinks of alcohol on an occasion, one or
more times in the past month.b Consumption of an average of two or more drinks of alcohol per day in
the past month.
M. Daniels et al. / Preventive Medicine 38 (2004) 28–3836
older age at first birth observed among religiously active
LDS is consistent with an older study comparing LDS and
non-LDS in Utah in the late 1970s [28] and with the
Church’s culture that emphasizes the importance of attaining
an education. The church has historically encouraged its
members to pursue knowledge and has sponsored several
institutions of higher learning [42]. Consequently, acquiring
more education may have caused some LDS women to put
off having children.
There is no LDS Church doctrine that directly explains
why LDS women are more likely than non-LDS women to
have breastfed (overall and on average time breastfed per
child). It may be that the strong emphasis on having children
is associated with a larger proportion of LDS women not
working outside the home, such that breastfeeding is more
practical. It may also be that higher levels of income and
educational attainment among LDS women may influence
this behavior.
This study did not address other potential risk factors for
breast cancer, such as body mass index (BMI) and exercise.
Adults in Utah compared with the U.S. have a higher
percentage of those who have been physically active in the
past month (Table 5). There is no significant difference in the
prevalence of being overweight, but there is some evidence
that adults in Utah have a lower prevalence of obesity. To
assess whether there is a difference in BMI between LDS and
non-LDS in Utah we referred to the 2000 Utah BRFSS, to
which we added a supplemental question on religious pref-
erence. There were 766 adults who completed the religion
question, as described elsewhere [42]. The percentage of LDS
women who had a BMI < 25 (normal) was 57.2%, a BMI 25
to < 30 (overweight) was 27.9%, and a BMI 30 or greater
(obese) was 14.9%. Corresponding percentages for non-LDS
were not significantly different: 63.7%, 22.6%, and 13.7%
(chi-square P= 0.6220). Despite the comparatively high level
of physical activity observed in Utah, previous research has
shown that LDS tend to be less physically active than their
non-LDS counterparts in the state [7]. This may be because
LDS Church doctrine does not specifically address the issue
of physical activity as it does other items, such as encouraging
family and marriage and abstaining from tobacco and alcohol
consumption. If BMI is positively associated with breast
cancer and physical activity is negatively associated, these
factors do not appear to explain the lower breast cancer
incidence observed in previous studies among LDS in Utah
[4,5].
Biologic predisposition toward breast cancer resistance
among Utah LDS does not appear to be a plausible
explanation for the comparatively low breast cancer rates
among LDS. A study by Jorde [44] on Utah pedigrees
showed that LDS have less inbreeding than should occur
randomly, given a population of their size and migration
patterns. This suggests that LDS avoid inbreeding and are
not genetically different from the general population. Bio-
logic similarity among the religion categories is supported in
our study by similar levels of height, age at menarche, and
age at menopause.
Limitations of this study are characteristic of samples
obtained from telephone surveys in general. Estimates based
on the survey sample may differ from results of a complete
census of adults in Utah, because of sampling and non-
sampling error. Sampling error, resulting from variability that
occurs from sample to sample, is reflected in the test statistics
and confidence intervals. Nonsampling error that may have
been introduced by individual respondent interpretation of
the survey questions, variation in interviewer techniques,
nonresponse, coding errors, recall bias, and so on, are difficult
to quantify. But several steps were taken to minimize this
M. Daniels et al. / Preventive Medicine 38 (2004) 28–38 37
error, as discussed above. According to the 2000 U.S.
Census, 2.19% (90% confidence interval 1.44–2.93) of white
non-Hispanic Utah households did not have phone service
[45]. These households may represent primarily lower in-
come. This potential bias was minimized, at least in part, by
restricting our analysis to the white female population.
Polygamy in Utah originated in the LDS religion. How-
ever, since 1890, the Church has not taught polygamy nor
permitted its members to practice it such that individuals
involved in the practice are cut off from the Church [46].
Nevertheless, it is estimated that the number of current and
former polygamists and their wives in the state may be as
high as 8000. If women in this group were included in our
sample, they would lower the average age at first birth and
increase the average number of children among non-LDS,
given this practice tends to be associated with young age at
first birth and several births. Yet this is likely to have a very
small influence if any, on the results because of the small
number of these women expected to be included in the
sample. Specifically, if we assume 5000 women have a
history of polygamy and that they could all be reached by
our telephone survey, and given that the state adult female
population in 2002 is an estimated 785,211, then the
probability of selecting one of these women is 0.0064. This
means that of our sample of 848 women, only about 5 or 6
would have a history of polygamy.
Conclusion
Comparatively high parity and breastfeeding among
active LDS women are the primary factors contributing to
the low breast cancer incidence rates in Utah. These findings
are consistent with the important role parity and breastfeed-
ing play in reducing breast cancer risk, as identified by the
Collaborative Group on Hormonal Factors in Breast Cancer.
Lower levels of alcohol and possibly smoking among active
LDS women also help explain the lower breast cancer
incidence rates. Differences in age at first pregnancy, height,
use of oral contraceptives, and hormone replacement ther-
apy were small and played minor roles in explaining the
differential breast cancer incidence rates among the catego-
ries of religion considered in this study. LDS culture related
to marriage, family, education, and health are consistent
with these findings.
Appendix A
The following equation was used to derive number of
abortions:
P0 � P1 � ðB0 � B1Þ � ðS0 � S1Þ � M
where P0 = total number of pregnancies reported (all preg-
nancies were to be reported whether the outcome was live
birth, still birth, miscarriage, or ‘‘some other pregnancy
outcome’’); P1 = number of pregnancies resulting in multiple
births (i.e., twins, triplets, etc.); B0 = total number of live
births reported; B1 = total number of live births due to
multiple birth pregnancies; S0 = total number of stillbirths
reported; S1 = total number of stillbirths due to multiple birth
pregnancies; M = total number of pregnancies resulting in
miscarriage (multiple birth pregnancies resulting in a single
birth due to miscarriage were included with single birth
pregnancies).
References
[1] Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA
Cancer J Clin 2002;52:23–47.
[2] Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L,
et al, editors. SEER cancer statistics review, 1973–1999. Bethesda,
MD: National Cancer Institute, 2002. Available at: http://seer.cancer.
gov/csr/1973_1999/ (Accessed July 26, 2002).
[3] U.S. Census Bureau. Basic facts: Utah. Available at: http://factfinder.
census.gov/bf/_lang=en_vt_name=DEC_2000_SF1_U_DP1_geo_
id=04000US49.html (2000) (Accessed July 26, 2002).
[4] Lyon JL, Gardner K, Gress RE. Cancer incidence among Mormons
and non-Mormons in Utah (United States) 1971–85. Cancer Causes
Control 1994;5:149–56.
[5] Lyon JL, Gardner JW, West DW. Cancer incidence in Mormons and
Non-Mormons in Utah during 1967–75. J Natl Cancer Inst 1980;65:
1055–61.
[6] McCormick JS. Salt Lake City. In: Powell AK, editor. Utah history
encyclopedia. Available at: http://www.media.utah.edu/UHE/s/
SALTLAKECITY.html;1999. (Accessed July 25, 2002).
[7] Merrill RM, Thygerson AL. Religious preference, church activity, and
physical exercise. Prev Med 2001;33:38–45.
[8] U.S. Census Bureau. Annual population estimates by state. Available
at: http://eire.census.gov/popest/data/states/tables/ST-EST2002-01.
php (2002) (Accessed August 14, 2003).
[9] Grassli MP. Roles of children. In: Ludlow DH, editor. Encyclopedia
of Mormonism, vol. 1. New York, NY: Macmillan; 1992. p. 266–8.
[10] Duke JT. Eternal marriage. In: Ludlow DH, editor. Encyclopedia of
Mormonism, vol. 2. New York, NY: Macmillan; 1992. p. 557–9.
[11] Doctrine and Covenants of the Church of Jesus Christ of Latter-day
Saints. Salt Lake City, UT: The Church of Jesus Christ of Latter-day
Saints, Section 89; 1986. Available at: http://scriptures.lds.org/dc/89
(Accessed July 29, 2002).
[12] Hsieh C, Trichopoulos D, Kasoutanni K, Yuasa S. Age at menarche,
age at menopause, height and obesity as risk factors for breast cancer:
associations and interactions in an international case control study. Int
J Cancer 1992;46:796–800.
[13] Slattery ML, Kerber RA. A comprehensive evaluation of family his-
tory and breast cancer risk. J Am Med Assoc 1993;270:1563–8.
[14] Lash TL, Aschengrau A. Active and passive cigarette smoking in the
occurrence of breast cancer. Am J Epidemiol 1999;149:5–12.
[15] Tseng M, Weinberg CR, Umbach DM, Longnecker MP. Calculation
of population attributable risk for alcohol and breast cancer (United
States). Cancer Causes Control 1999;10:119–23.
[16] 1996 Utah Health Status Survey Codebook, 2nd ed. Bureau of Sur-
veillance and Analysis, Office of Public Health Data, Utah Depart-
ment of Health.
[17] Madigan MP, Ziegler RG, Benichou J, Byrne C, Hoover RN. Propor-
tion of breast cancer cases in the United States explained by well-
established risk factors. J Natl Cancer Inst 1995;87:1681–5.
[18] Ewertz M, Duffy SW, Adami HO, Kvale G, Lund E, Meirik O, et
al. Age at first birth, parity and risk of breast cancer: a meta-anal-
ysis of 8 studies from the Nordic Countries. Int J Cancer
1990;46:597–603.
M. Daniels et al. / Preventive Medicine 38 (2004) 28–3838
[19] Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg
C, Stefanick ML, et al. Risks and benefits of estrogen plus proges-
tin in healthy post-menopausal women. J Am Med Assoc 2002;288:
321–33.
[20] Collaborative Group on Hormonal Factors in Breast Cancer. Breast
cancer and hormone replacement therapy: collaborative reanalysis of
data from 51 epidemiologic studies of 52,705 women with breast
cancer and 108,411 women without breast cancer. Lancet 1997; 350:
1047–59.
[21] Collaborative Group on Hormonal Factors in Breast Cancer. Breast
cancer and breastfeeding: collaborative reanalysis of individual data
from 47 epidemiological studies in 30 countries, including 50,302
women with breast cancer and 96,973 women without the disease.
Lancet 2002;360:187–95.
[22] Brind J, Chinchilli VM, Severs WB, Summy-Long J. Induced abor-
tion as an independent risk factor for breast cancer: a comprehensive
review and meta-analysis. J Epidemiol Community Health 1996;50:
481–96.
[23] Beral V, Bull D, Reeves G, Peto R. Breast cancer and hormonal
contraceptives: collaborative reanalysis of individual data on 53297
women with breast cancer and 100,239 women without breast cancer
from 54 epidemiologic studies. Lancet 1996;347:1713–27.
[24] Lipworth L, Bailey LR, Trichopoulos D. History of breast-feeding in
relation to breast cancer risk: a review of the epidemiologic literature.
J Natl Cancer Inst 2000;92:302–12.
[25] The Church of Jesus Christ of Latter-day Saints. What is the Church’s
position on abortion? Available at: http://www.mormon.org/question/
faq/category/answer/0,9777,1601-1-61-1,00.html (Accessed October
19, 2002).
[26] The American Association for Public Opinion Research. Standard
definitions: final dispositions of case codes and outcomes rates for
RDD telephone surveys and in-person household surveys. Ann Arbor,
MI: AAPOR; 1998.
[27] The SAS System for Windows, Proprietary Software Release 8.2,
Copyright n 1999–2001 by SAS Institute Inc., Cary, NC, USA.
[28] West DW, Lyon JL, Gardner JW. Cancer risk factors: an analysis
of Utah Mormons and non-Mormons. J Natl Cancer Inst 1980;65:
1083–95.
[29] U.S. Center for Disease Control, National Center for Health Statistics.
National Vital Statistics Report 2001;49(50):11. Available at: http://
www.cdc.gov/nchs/about/major/natality/nvsr49_05-4.pdf (Accessed
July 27, 2002).
[30] Strawbridge WJ, Cohen RD, Shema SJ, Kaplan GA. Frequent attend-
ance at religious services and mortality over 28 years. Am J Public
Health 1997;87:957–61.
[31] Merrill RM, Lyon JL, Madanat H. Active religion and health in Utah.
Dialogue J Mormon Thought 2002;35:78–90.
[32] Beck LF, Morrow B, Lipscomb LE, Johnson CH, Gaffield ME, Rog-
ers M, et al. Prevalence of selected maternal behaviors and experi-
ences, Pregnancy Risk Assessment Monitoring System (PRAMS),
1999. Morbidity and Mortality Weekly Report CDC Surveillance
2002;26:1–27.
[33] Dupont WD, Page DL. Menopausal estrogen replacement therapy and
breast cancer. Arch Intern Med 1991;151:67–72.
[34] Young BY. In: Widtsoe JA, editor. Discourses of Brigham Young. Salt
Lake City, UT: Deseret Book; 1925. p. 197.
[35] Doctrine and Covenants of the Church of Jesus Christ of Latter-day
Saints. Salt Lake City, UT: The Church of Jesus Christ of Latter-day
Saints, Section 20; 1986. Available at: http://scriptures.lds.org/dc/20
(Accessed July 29, 2002).
[36] Young LA. The religious landscape. In: Heaton TB, Hirschl TA,
Chadwick BA, editors. Utah in the 1990s: a demographic perspective.
Salt Lake City, Utah: Signature Books; 1996.
[37] Behavior Risk Factor Surveillance System Prevalence Data. Centers
for Disease Control and Prevention website. Available at http://
apps.nccd.cdc.gov/brfss/ (Accessed April 23, 2003).
[38] Behavior Risk Factor Surveillance System Trends Data. Centers for
Disease Control and Prevention website. Available at http://
apps.nccd.cdc.gov/brfss/Trends/TrendData.asp (Accessed April 23,
2003).
[39] Kuh DL, Wadsworth M, Hardy R. Women’s health at midlife: the
influence of the menopause, social factors and health in earlier life. Br
J Obstet Gynaecol 1997;104:923–33.
[40] Strawbridge WJ, Shema SJ, Cohen RD, Kaplan GA. Religious attend-
ance increases survival by improving and maintaining good health
behaviors, mental health, and social relationships. Ann Behav Med
2001;23:68–74.
[41] Duke JT. Eternal marriage. In: Ludlow DH, editor. Encyclopedia of
Mormonism, vol. 2. New York, NY: Macmillan; 1992. p. 855–7.
[42] Merrill RM, Lyon JL, Jensen WJ. Lack of a secularizing influence of
education on religious activity and parity among Mormons. J Sci Stud
Relig 2003;42:113–24.
[43] Alexander TG. The Word of Wisdom: from principle to requirement.
Dialogue 1981;14:78–88.
[44] Jorde LB. Inbreeding in the Utah Mormons: an evaluation of esti-
mates based on pedigrees, isonomy, and migration matrices. Ann
Hum Genet 1989;53:339–55.
[45] U.S. Census Bureau (2000). Census 2000 Supplementary Survey
Summary Tables: HCT019A Telephone Service Available (White
Alone Householder). Available at: http://factfinder.census.gov/servlet/
DTTable?_ts=46090299710 (Accessed July 30, 2002).
[46] The Church of Jesus Christ of Latter-day Saints. Official declara-
tion—1. Available at: http://scriptures.lds.org/od/1 (Accessed August
14, 2003).
