REASERCH DESIGN AND STATISTICS

BMS815

EXPERIMENTAL DESIGN AND INTERPRETATION

ELEFTHERIA KOLIOU
R.N.: 32553605
Msc FOOD BIOTECHNOLOGY
UNIVERSITY OF ULSTER

QUESTION 1
Diet plays a major role in cancer development and prevention. According to
Greenwald et al. (2001) epidemiological studies have contributed in providing
knowledge between diet and cancer prevention. Diets that are low in carbohydrates, fibre
and vitamins are very dangerous and have a high risk of cancer development. There are
many examples of the reduction of the risk of colorectal cancer when equilibrated diets
are followed. Epidemiology suggests that colorectal cancer risk may be decreased by
increasing the intake of dietary fibre and fibre-rich foods, including vegetables, fruits,
cereals and whole grains (World Cancer Research Fund, 1997). Experimental data
suggest also that calcium and vitamin D may influence the risk for colorectal cancer
(Platz et al. 1999). Moreover, a meta-analysis reported that high intake of raw and cooked
garlic may reduce the risk for colorectal cancers (Fleischauer et al., 2000). Regular
physical activity is associated with a reduced risk for colorectal cancer in both men and
women. A recent casecontrol study in Switzerland reported that, in men over age 30
years, those with the highest level of physical activity showed a 3756% decrease in risk
(Levi et al., 1999). In addition, there is a direct association of alcohol intake with this
type of cancer (World Cancer Research Fund, 1997). Last but not least, significant
exposure to cigarette smoke is associated with an elevated risk for colorectal cancer, even
though the mechanisms, by which colorectal cancer is caused, remain obscure (Yi N. Ye
et al., 2005).From the above elements, it is clear that a balanced diet, rich in fruits and
vegetables and fibre, with a tendency for more fish and chicken rather than red meat,
accompanied by a physical activity will reduce the risk of colorectal cancer. This is the
first evidence that the colorectal cancer is not necessarily developed by the consumption
of the protein power bars, but there is a greater possibility that its development is
because of the low carbohydrate diet, which means a diet poor in fruits and vegetables.
Moreover the development of colorectal cancer is not caused only from the poor
diet but also by hormonal factors. Endogenous and exogenous sexual hormones may be
elements in the etiology of colorectal tumors (Ponz et al., 2000). So we cannot be sure
that the protein power bars is the product that has caused the colorectal cancer. We
must know first if the people that have developed colorectal cancer have any hormonal
disturbances. In addition, patients affected by ulcerative colitis and other diseases like
Crohns disease are at risk for this type of cancer (Ponz et al., 2000). Thus, before coming
into any conclusion, we must be sure that the people that suffer from colorectal cancer are
completely healthy or if in the past have undergone any similar disease.
Furthermore, there is evidence for the known familiar colorectal cancer. There
are genes that are inherited from the parents to the children, which determine the fraction
of them who will become affected (Ponz et al., 2000). So, there is a possibility also that
those genes are present in some members of the family. The role of family history and of
hereditary cancer syndromes has become clear. Thus, it would be a good idea to identify
that the individuals who developed colorectal cancer are at high risk.
In conclusion, we cannot take for granted that the cause of the colorectal cancer is
the consumption of the power protein bars. Before making this conclusion further
factors must be checked such as the diet, the consumption of alcohol and tobacco, the
family history for hereditary cancer and the medical history of each person who suffers
from this type of cancer.

References:
(1) Fleischauer, A.T., Poole, C., Arab, L., Garlic consumption and cancer prevention:
meta-analyses of colorectal and stomach cancers, Am J Clin Nutr, vol. 72, (2000), p.
10471052.
(2) Levi, F., Pasche, C., Lucchini, F., Tavani, A., La Vecchia C. Occupational and leisure
time physical activity and the risk of colorectal cancer, Eur J Cancer Prev, vol. 8, (1999),
p. 487493.
(3) Platz, E.A., Giovannucci, E., Vitamin D and calcium in colorectal and prostate
cancers, In Heber D, Blackburn GL, Go VLW, eds., Nutritional Oncology, San Diego,
Academic Press, 1999, 223 252.
(4) Ponz, M., de Leon, Roncucci, L., The cause of colorectal cancer, clinical review, vol.
32, (2000), p. 426-39.
(5) World Cancer Research Fund, Food, Nutrition and the Prevention of Cancer: A Global
Perspective, Washington, DC, American Institute for Cancer Research, 1997.
(6) Yi N. Ye, William, K.K., Wu b, Vivian, Y. Shin, b, Chi H. Cho, A mechanistic study of
colon cancer growth promoted by cigarette smoke extract, European Journal of
Pharmacology, vol. 519, (2005), p. 52 57.

QUESTION 2
The study that should be performed in order to investigate whether there is any
statistical evidence for the complaint is a case-control study. Case control studies are
studies in which patients who already have a certain condition are compared with people
who do not. In this case, colorectal cancer patients are asked how much they ate the
protein power bars in the past and in what frequency, as well as their diet and family
history, and the answers are compared with a sample of controls. Just because there might
be a statistical relationship between two conditions does not mean that one condition
actually caused the other. For instance, lung cancer rates are higher for people without a
college education (who tend to smoke more), but that does not mean that someone can
reduce his or her cancer risk just by getting a college education
http://servers.medlib.hscbklyn.edu/ebm/toc.html).
The main advantages are:

They can be done quickly. By asking patients about their past history, effects can
be discovered that otherwise would take many years to show themselves.
No need special methods. Researchers just take the people with a particular
condition and ask them a few questions.

The next diagram shows how the case-control study will be conducted. Patients
who have developed colorectal cancer are identified and their past exposure to the
protein power bars (suspected etiological factor) is compared with that of controls
that do not have the disease.

Diagram 1: The outline design of the case-control study for colorectal cancer patients
(http://servers.medlib.hscbklyn.edu/ebm/toc.html).

We should collect detailed information about the age, the town or the village that
both cases and control live. The environmental conditions of the place (if they live near
an industrial area, they live in a rural area etc.) must be clear.
Moreover the researchers should ask:
The marital status
The diet
Consumption of protein power bars (frequency, quantity)
The general life-style (e.g. smoking, alcohol consumption, physical activity,
extended night-life etc.)
Medications
Family history
Working environment
Education
Socio-economic profile
Personal environment
Nutritive supplements
For the cases, the following information should be obtained:
Year of diagnosis
Information about the supervising doctor ( e.g. if they are colorectal specialist or
general gastrointestinal surgeon or general surgeon)
Time of treatment
Surgeries
Time of accommodation in the hospital
Medication during staying in the hospital
It must be clear to the cases and the controls that the above information given is
going to be confidential and their data will stay anonymous. The investigators will have
to get consent from the patients, this will involve information on why they need the
patients information and for what purpose the information will be used for. Moreover,
investigators will need to get the patient to sign a form that states that they give their
consent, it would be best if the patient got a copy of the form to keep as well.

THE STUDY POPULATION

SELECTION OF CASES
The cases must be selected in a way that it will not permit bias arose. If we take
all the samples from the hospitals of N. Ireland, the results will be misleading. Admission
in a hospital is not only influenced by the severity of the disease, but also from the social
class of the patient. It is called Berksons Bias: Cases and controls experience different
hospital admission rates. On the other hand, if the cases are based on population,
Neymans Bias is occurred (Case group not representative of the intended population). In
other words we have two ways of selecting the cases for the study:
1.
Persons with the disease seen at a care facility in a specified period of
time.
2.
Persons with the disease in a more general population in a period of time.
In the preset study the cases are going to be sampled by the following way: We
are going to pick our samples from four different geographic places of N. Ireland, Belfast,
which is a bid industrial city, Derry, which is a smaller city, Coleraine that is a relatively
small town and Portstewart which is a village. From each one of the above places we will
select colorectal cancer patients from hospitals and from private practitioners offices. By
this way, we include people in our sampling of all possible socio-economic profiles.
Moreover, the patients must be male and female in an equal proportion. The ages of both
male and female cases will be divided in two parts. We will sample males and females
between the age of 20-40 years old and between the ages of 40-60 years old.
The following diagram shows the selection of cases.

Diagram 2: Schematic representation of the selection of the cases.

SELECTION OF CONTROLS
Selection of controls is more problematic because the exposures of the controls
should be measurable with the same accuracy to those of the cases. So the controls
should be drawn from the population of which the cases represent the affected
individuals. The controls can be:
1. Population of an administrative area
2. Hospital patients
3. Relatives of the cases (spouses and siblings)
4. Associates of the cases (neighbors, co-workers, etc)
The sampling can be made by four different ways:
1. Total population no sampling (very difficult)
2. Random and systematic sampling (the results will be general and non-related with the
cases)
3. Matching deliberately select the controls in such a way as to make them similar to
the cases with respect to certain confounding variables.
4. Multiple control groups.
For the present study, we will choose the matching sampling. We will pick our
controls deliberately in a way to make them similar to the cases. Thus we will chose
relatives and associates of the cases. In this way it will be easier to understand if the
colorectal cancer is owed to genetic factors or even to environmental factors apart from
the consumption of the protein power bars.
Pairing of the cases with the controls must be done according to the age and sex.
It is vital to compare the results of the male cases with the results of the male controls. It
will be wrong if we compare a male patient with a female control and vice versa. The
same exactly comparison should be done with the ages.
Measurement of exposure can be made more comparable by using patients with
other diseases as controls, especially if they are not told the aim of the investigation.
Sometimes though, their exposures may be unrepresentative.
CALCULATION OF THE SAMPLE SIZE
There are specific techniques for calculating sample sizes, with specified
precision, the mean value of a variable, or for identifying a given difference in prevalence
or mean values between two populations. One of the most widely used formulas used for
determining the sample size, does not depend on the size N of the population but on the
desired confidence level, the desired margin of error E, and the value of standard
deviation is given below.
2
z a / 2
n=

za/2 = critical z score based on the desired confidence level

E = desired margin or error
= population standard deviation.

Sample-size planning is often important and difficult. It requires care in finding

suitable quantitative information prior to the study. Sample-size problems are contextdependent. For example, how important it is to increase the sample size to account for
such uncertainty depends on practical and ethical criteria. Moreover, sample size is not
always the main issue; it is only one aspect of the quality of a study design (Russel,
2001).
THE OUTCOME MEASURE
The outcome under study can be included in a 3x3 array of a simple form. For
example, the following table shows how the results should be represented.

EXPOSED
NOT EXPOSED
SUBOTAL

CASE
A
C
A+C

CONTROL
B
D
B+D

SUBTOTAL
A+B
C+D
A+B+C+D

For a Case-Control study, we report the odds ratio:

A /( A C )
C /( A C ) A / C AD
OR

B /( B D) B / D BC
D /( B D)

Odds of exposure in diseased subjects = A/C

Odds of exposure in control subjects = B/D
OR= odds of exposure in cases/ odds of exposure in control
It can be demonstrated that the exposure OR for cases versus controls equals to
disease OR for exposed versus unexposed.
A, B, C, D represent numbers. A is the number of the patients and are exposed to
the factor under investigation, for example the consumption of the protein power bars
or the exposure to smoking. B is the number of the people that are exposed to the
investigating factor but they are not patients. C is the number of patients that are not
exposed, while D is the number of controls that are not exposed to the investigating factor
as well.
It must be clear that the factors that will be under investigation will not be only
the quantity and the frequency of the consumption of the protein power bars, but also
the exposure to smoking, to unhealthy diet, to alcohol consumption and the exposure of
other factors that can contribute to the development of colorectal cancer.
APROXIMATE TIME REQUIRED FOR THE STUDY
In case-control studies the time is very short compared to the other studies. For
this study, the time required will be approximately one to six months. The time required
is only for the collection of the cases and for the controls as well as for the conduction of
the interviews from the researchers. There is no need for setting controls and cases to a
specific scientific programme and observe the results of the study. The only time

consuming factor in this study is the conduction of the interviews and the analysis of the
results. With the assistance software packages and of an experienced statistician, further
checks can be made to ensure that all codes are valid.
PROBLEMS IN CONDUCTING THE STUDY
As it is known information on exposure is based primarily on interview and then
to questionnaires. This simply means that there is a possibility of recall bias, unless the
investigators are well trained for impartial interviews. Moreover, the controls might be
unwilling to participate in the study and even if they will be persuaded to participate it
will be difficult for them to recall all the past exposure to the product.
In addition it is hard to calculate incidence rates and is completely impossible to
control extraneous variables.
As far as methodology concerned, interpretation of findings may be difficult for
non-epidemiologists.
PRECAUTIONS FOR REDUCTION POSSIBLE BIAS
It is possible that an error in the design of the case-control study may result in a
wrong estimate of the association between exposure and outcome. The association may
be overestimated or underestimated.
We have to select an appropriate control group in order to avoid the so-called
selection bias. Also the researchers should be accurate with the questions they make to
the cases and the controls and they have to be objective without inferring their opinion
during the interview. The investigators should be very careful with typing the questions
and the answers especially when questions can be answered with a yes or no, it is very
common to get an error.
Cases, when interviewed on past exposure report more accurately than nondiseased subjects (controls). A healthy person may not be very in the study and many
times, recalling data from their past is very difficult. Thus, the researchers should make
precise questions.
In simple words to avoid bias we should very careful and able to determine
whether bias is present, know its direction and consider its magnitude.

QUESTION 3
In this case we are going to conduct a randomized controlled study. Randomized
controlled trials are designed to compare different treatments. Here we are going to
compare a group of people which is going to be fed with the protein power bars and
another group which will have the same diet as the first, with the difference that is not
going to be fed with the protein power bars. Subjects are randomly allocated to two
groups so that groups are comparable at the beginning of the study in terms of their
distribution of potential confounding factors e.g. age and sex. The treatment with the
protein power bars is then administered and the results are compared at the end of a
specific period. There will be two groups, the treatment group and one control group.
The control group may receive a placebo treatment to aid blinding of treatment allocation
from both the study subjects and those assessing outcome. This is considered unethical
though and in the current study we are not going to use it.

Diagram 3: The outline design of the randomized controlled

(http://servers.medlib.hscbklyn.edu/ebm/toc.html).

Assigning patients at random reduces the risk of bias. Having a control group
allows us to compare the treatment with alternative choices. For instance, the statement
that eating great amounts of the protein power bars helps people lose 40% of weight,
tells us very little unless we also know how many cases can lose this percentage of
weight on their own, or with a different treatment.

STUDY POPULATION
We are going to select people in order to create a group. In order to create this
group, we are going to use the controls from the previous study. Both male and female
are going to participate with an age range varying from 20 to 60 years old. The people
that are going to participate must have similar characteristics. They have to follow a low
carbohydrate diet (all of them) by their free will. People can be paid for this type of study
because by participating in this experiment, they contribute to the science.
After collecting the people to a big group, we are going to divide them in two
groups. The division must be done by chance in order to provide to the investigators the
certainty that both the control and the treatment group contain people with similar
average ages and similar number of males and females. The treatment group is going to
follow a low carbohydrate diet and consume the protein power bars, while the control
group is going to follow only the same low carbohydrate diet.
OUTCOME MEASURES
The outcome measures seem to be simpler than those of the previous control
study because we have not many parameters and factors to analyze. The results can be
assayed in two simple tables after the end of the experiment. We will control if both
groups have lost weight and how much weight have lost. Then we can make assumptions
and conclusions and see if the protein power bars have assisted for the weight loss. Of
course this is going to be made by a specific computer programme.
The outcome measures should have the following characteristics. They should be:
objective
reproducible
responsive to changes caused by treatment
APPROXIMATE TIME REQUIRED FOR THE STUDY
In this case the things are more complicated. The time for the conduction of the
randomized controlled studies is longer. This is because this study is more like a pure
experiment. So the approximate time required varies from 6 months to a year. This is one
of the main disadvantages of this type of study.
CALCULATION OF THE SAMPLE SIZE
We will calculate the sample size in Minitab. The analysis is called ANOVA.
ANOVA is appropriate for completely randomized designs (as in this case), because it
extends the two-group t-test.
PROBLEMS IN CONDUCTING THE STUDY

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In this type of study we face some problems as well. A main problem is the
generalization of this type of study. Moreover, if the investigation will be conducted
by inexperienced scientists, unethical issue may be occurred, especially when
placebos are used. The study may also be converted to a very complicated process,
since the time for the conduction of the experiment is very long. Last but not least,
those kinds of investigations are not always possible, because they are experiments,
and in experiments there is always the possibility of failure. For example, many
people can quit their contribution in the middle of the whole process.
PRECAUTIONS FOR REDUCTION POSSIBLE BIAS
In order to avoid the possible bias, other types of randomization should be
selected. Furthermore blinding can be performed in order to keep the treatment
allocation hidden from the investigators and/or the study subjects (not always ethical).
References:
http://servers.medlib.hscbklyn.edu/ebm/toc.html
Russell, V., Lenth, Some Practical Guidelines for Effective Sample-Size Determination,
Department of Statistics, University of Iowa, March 1, 2001.

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