Prevalence of Hypertension and Associated Risk Factors in Western Alaska Native People: The Western Alaska Tribal Collaborative for Health (WATCH) Study

The Impact of COVID-19 on Hypertension and Hypertension Medication Adherence Among Underrepresented Racial and Ethnic Groups: A Scoping Review

PURPOSE OF REVIEW

To conduct a scoping review of articles which examined the impact of COVID-19 on HTN and HTN medication adherence among underrepresented racial/ethnic minorities.

RECENT FINDINGS

Seven studies were included in this review and impact of COVID-19 was examined at 4 levels: patient, provider, health system and society. The results indicated that patient level factors, such as high unemployment and inequitable access to telemedicine due to society factors- lack of access to high-speed Internet and variation in the offering of telehealth by health systems, were most impactful on adherence. Additionally, provider level clinical inertia may have further impacted adherence to HTN medication. Our review showed that the COVID-19 pandemic did not introduce new barriers but exacerbated preexisting barriers. Ongoing efforts are needed to change policies at the state and local levels to dismantle inequities in underrepresented communities to ensure access to health care with telemedicine to promote health equity.

Alaska Native Parents' Decision-Making About Food, Beverages, and Screen Time for Young Children: Formative Insights From the "Got Neqpiaq?" Project

With rising childhood obesity rates, ensuring children adopt healthy habits early is imperative. Given the unique context for Alaska Native families living in rural remote communities, who are concurrently experiencing changes in traditional practices, we investigated what impacts parents' decisions as they relate to daily living before revising a preschool curriculum focused on healthy habits. The objective of this study was to explore factors influencing parents' decisions about their children's foods, beverages, and activities. In focus group discussions with AN parents of young children across 12 communities, we asked about meals, traditional foods, beverages, physical activity, and screen time. All sessions were recorded, transcribed, and analyzed using open and selective coding to allow the most important themes to emerge. As parents discussed how they make decisions, several trends emerged related to adults' and children's food and beverage preferences; the impact of adult modeling on children; and how convenience, seasonality, access, and a reluctance to engage in conflict all impact decision-making. Parents and other community members shared important perspectives on exposing children to traditional subsistence foods and activities and passing important traditional knowledge to them at an early age. These perspectives will form the basis for preschool curricula in these communities.

Obesity-Associated Dyslipidemia Is Moderated by Habitual Intake of Marine-Derived n-3 Polyunsaturated Fatty Acids in Yup'ik Alaska Native People: A Cross-Sectional Mediation-Moderation Analysis

BACKGROUND

Obesity leads to insulin resistance, altered lipoprotein metabolism, dyslipidemia, and cardiovascular disease. The relationship between long-term intake of n-3 polyunsaturated fatty acids (n-3 PUFAs) and prevention of cardiometabolic disease remains unresolved.

OBJECTIVES

The aim of this study was to explore direct and indirect pathways between adiposity and dyslipidemia, and the degree to which n-3 PUFAs moderate adiposity-induced dyslipidemia in a population with highly variable n-3 PUFA intake from marine foods.

METHODS

In total, 571 Yup'ik Alaska Native adults (18-87 y) were enrolled in this cross-sectional study. The red blood cell (RBC) nitrogen isotope ratio (15N/14N, or NIR) was used as a validated objective measure of n-3 PUFA intake. EPA and DHA were measured in RBCs. Insulin sensitivity and resistance were estimated by the HOMA2 method. Mediation analysis was conducted to evaluate the contribution of the indirect causal path between adiposity and dyslipidemia mediated through insulin resistance. Moderation analysis was used to assess the influence of dietary n-3 PUFAs on the direct and indirect paths between adiposity and dyslipidemia. Outcomes of primary interest included plasma total cholesterol (TC), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), non-HDL-C, and triglycerides (TG).

RESULTS

In this Yup'ik study population, we found that up to 21.6% of the total effects of adiposity on plasma TG, HDL-C, and non-HDL-C are mediated through measures of insulin resistance or sensitivity. Moreover, RBC DHA and EPA moderated the positive association between waist circumference (WC) and TC or non-HDL-C, whereas only DHA moderated the positive association between WC and TG. However, the indirect path between WC and plasma lipids was not significantly moderated by dietary n-3 PUFAs.

CONCLUSIONS

Intake of n-3 PUFAs may independently reduce dyslipidemia through the direct path resulting from excess adiposity in Yup'ik adults. NIR moderation effects suggest that additional nutrients contained in n-3 PUFA-rich foods may also reduce dyslipidemia.

Patient and primary care perspectives on hypertension management: short report of a qualitative study in a tribal health system

The prevalence of self-reported hypertension is higher among Alaska Native and American Indian (ANAI) individuals than in the majority USA population. Although hypertension is the primary modifiable risk factor for cardiovascular disease and stroke, it can be difficult to manage successfully. The objective of this study was to explore patients' and providers' perspectives about hypertension, hypertension management strategies, and patient-provider communication strategies within a tribally-owned and operated health system in Alaska. We conducted four focus groups that included 16 ANAI patients and five primary care providers. Patient participants tended to consider hypertension a transient state, in contrast with providers' understanding of hypertension as a chronic condition. Differences were noted in participants' perceptions regarding providers' counselling and education efforts, with providers feeling that current strategies are effective and patients desiring a more personalised discussion about hypertension. Patients expressed preferences for behaviour change approaches compared with pharmacotherapy; providers often resorted to medication as a first step towards controlling blood pressure. Our findings suggest areas of potentially promising future research with respect to patient-provider communication and treatment of hypertension.

Aging and Health of American Indians and Alaska Natives: Contributions from the Native Investigator Development Program

Objectives: To describe recent advances in our knowledge regarding the health and illness of older American Indians and Alaska Natives, and factors underlying why this special population lives 5.5 years less than the 78.5 years of U.S. all races. Methods: The articles in this supplemental issue, authored by participants in a National Institutes of Health-sponsored early research career development program, examine high priority health concerns that contribute to the increased risk of Native elders for chronic disease and resulting impairment that compromise their life expectancy. Results: Important insights into the roles that racial discrimination, food security, hypertension, alcohol consumption, memory problems, and military service play in the health and well-being of older American Indians and Alaska Natives. Discussion: Early career faculty development programs focused on increasing the diversity of the scientific workforce not only promote greater racial and ethnic minority representation in the field of aging, but can simultaneously add to the knowledge base regarding the health status and function of often ignored, vulnerable older members of communities that suffer significant health disparities.

Home Blood Pressure Monitoring Devices: Device Performance in an Alaska Native and American Indian Population

Objectives: Home blood pressure monitoring (HBPM) is an important component of blood pressure (BP) management. We assessed performance of two HBPM devices among Alaska Native and American Indian people (ANAIs). Methods: We measured BP using Omron BP786 arm cuff, Omron BP654 wrist cuff, and Baum aneroid sphygmomanometer in 100 ANAIs. Performance was assessed with intraclass correlation, paired t-tests, and calibration models. Results: Compared to sphygmomanometer, average BP was higher for wrist cuff (systolic = 4.8 mmHg and diastolic = 3.6 mmHg) and varied for arm cuff (systolic = -1.5 mmHg and diastolic = 2.5 mmHg). Calibration increased performance from grade B to A for arm cuff and from D to B for wrist cuff. Calibration increased false negatives and decreased false positives. Discussion: The arm HBPM device is more accurate than the wrist cuff among ANAIs with hypertension. Most patients are willing to use the arm cuff when accuracy is discussed.

The effect of gotu kola (Centella asiatica L.) tea on blood pressure of hypertension

Hypertension is an increase in systolic or diastolic blood pressure that exceeds the threshold. In this research used gotu kola (Centella asiatica L.), which is contains several compounds that can act as anti-hypertension. The aim of this research is to determine the effect of gotu kola tea on blood pressure in hypertension patients. Analytical, quasi-experimental, time series design. The sample size calculation used the proportion of hypertension parameters from 22 people aged 60-70 years, simple random sampling technique. Data anayzed by T pair test analysis. There are a decrease of systolic and diastolic blood pressure in most respondents before and after consuming Centella asiatica tea. The T pair test results on blood pressure before and after consuming Centella asiatica tea showed a significant value of p=0.000 in systolic and p=0.002 in diastolic (α=0.05) which means that in this study H1 results were accepted and H0 was rejected. The conclusion of this study is gotu kola tea can decrease blood pressure of hypertension patients.

Systemic Disease and Ocular Comorbidity Analysis of Geographically Isolated Federally Recognized American Indian Tribes of the Intermountain West

BACKGROUND

The American Indian Navajo and Goshute peoples are underserved patient populations residing in the Four Corners area of the United States and Ibupah, Utah, respectively.

METHODS

We conducted a cross-sectional study of epidemiological factors and lipid biomarkers that may be associated with type II diabetes, hypertension and retinal manifestations in tribal and non-tribal members in the study areas (n = 146 participants). We performed multivariate analyses to determine which, if any, risk factors were unique at the tribal level. Fundus photos and epidemiological data through standardized questionnaires were collected. Blood samples were collected to analyze lipid biomarkers. Univariate analyses were conducted and statistically significant factors at p < 0.10 were entered into a multivariate regression.

RESULTS

Of 51 participants for whom phenotyping was available, from the Four Corners region, 31 had type II diabetes (DM), 26 had hypertension and 6 had diabetic retinopathy (DR). Of the 64 participants from Ibupah with phenotyping available, 20 had diabetes, 19 had hypertension and 6 had DR. Navajo participants were less likely to have any type of retinopathy as compared to Goshute participants (odds ratio (OR) = 0.059; 95% confidence interval (CI) = 0.016-0.223; p < 0.001). Associations were found between diabetes and hypertension in both populations. Older age was associated with hypertension in the Four Corners, and the Navajo that reside there on the reservation, but not within the Goshute and Ibupah populations. Combining both the Ibupah, Utah and Four Corners study populations, being American Indian (p = 0.022), residing in the Four Corners (p = 0.027) and having hypertension (p < 0.001) increased the risk of DM. DM (p < 0.001) and age (p = 0.002) were significantly associated with hypertension in both populations examined. When retinopathy was evaluated for both populations combined, hypertension (p = 0.037) and living in Ibupah (p < 0.001) were associated with greater risk of retinopathy. When combining both American Indian populations from the Four Corners and Ibupah, those with hypertension were more likely to have DM (p < 0.001). No lipid biomarkers were found to be significantly associated with any disease state.

CONCLUSIONS

We found different comorbid factors with retinal disease outcome between the two tribes that reside within the Intermountain West. This is indicated by the association of tribe and with the type of retinopathy outcome when we combined the populations of American Indians. Overall, the Navajo peoples and the Four Corners had a higher prevalence of chronic disease that included diabetes and hypertension than the Goshutes and Ibupah. To the best of our knowledge, this is the first study to conduct an analysis for disease outcomes exclusively including the Navajo and Goshute tribe of the Intermountain West.

Development and Validation of Two Self-Reported Tools for Insulin Resistance and Hypertension Risk Assessment in A European Cohort: The Feel4Diabetes-Study

Early identification of type 2 diabetes mellitus (T2DM) and hypertension (HTN) risk may improve prevention and promote public health. Implementation of self-reported scores for risk assessment provides an alternative cost-effective tool. The study aimed to develop and validate two easy-to-apply screening tools identifying high-risk individuals for insulin resistance (IR) and HTN in a European cohort. Sociodemographic, lifestyle, anthropometric and clinical data obtained from 1581 and 1350 adults (baseline data from the Feel4Diabetes-study) were used for the European IR and the European HTN risk assessment index respectively. Body mass index, waist circumference, sex, age, breakfast consumption, alcohol, legumes and sugary drinks intake, physical activity and sedentary behavior were significantly correlated with Homeostatic Model Assessment of IR (HOMA-IR) and/or HTN and incorporated in the two models. For the IR index, the Area Under the Curve (AUC), sensitivity and specificity for identifying individuals above the 75th and 95th of HOMA-IR percentiles were 0.768 (95%CI: 0.721-0.815), 0.720 and 0.691 and 0.828 (95%CI: 0.766-0.890), 0.696 and 0.778 respectively. For the HTN index, the AUC, sensitivity and specificity were 0.778 (95%CI: 0.680-0.876), 0.667 and 0.797. The developed risk assessment tools are easy-to-apply, valid, and low-cost, identifying European adults at high risk for developing T2DM or having HTN.

Tpeak-Tend, Tpeak-Tend dispersion and Tpeak-Tend/QT in children and its relationship with clinical variables

Aim

To characterize the Tpeak-Tend, the Tpeak-Tend dispersion and Tpeak-Tend/QT in children and its relationship with clinical variables.

Methods

Cross-sectional study in 126 children between 9 and 12 years of the Camilo Cienfuegos School in Santa Clara, Cuba. Clinical and anthropometric variables were obtained to determine their relationship with electrocardiographic parameters: Tpeak-Tend V5, Tpeak-Tend dispersion and Tpeak-Tend/QT ratio V5. In addition, laboratory tests were conducted.

Results

Age and systolic blood pressure are associated with an increased probability of having values of Tpeak-Tend/QT V5 ≥75 percentile for both sexes (OR: 1.72, CI 95%: 1.02-2.91; p= 0.043), (OR: 1.08, CI 95%: 1.01-1.16; p= 0.017) respectively. The body mass index and systolic blood pressure are linearly and significantly correlated with the Tpeak-Tend/QT V5 (r= 0.224; p= 0.012) and (r= 0.220; p= 0.014) respectively.

Conclusions

The age of the patients and the systolic blood pressure figures are factors that increase the probability of having values of the Tpeak-Tend/QT V5 ≥75 percentile. There was a significant linear correlation between the Tpeak-Tend/QT V5 with the body mass index and the systolic blood pressure.

Alaska Native Traditional Food and Harvesting Activity Patterns over 10 Years of Follow-Up

BACKGROUND

Alaska Native (AN) traditional foods and associated harvesting activities are beneficial to human health.

OBJECTIVE

This study assessed longitudinal self-reported traditional food use and harvesting activities among Alaska Native and American Indian (AN/AI) participants in the Alaska Education and Research Towards Health (EARTH) study.

METHODS

In 2004-2006, southcentral Alaska EARTH study participants (n = 1320) completed diet and activity questionnaires which were repeated in 2015-2017; results were compared between participants who completed both questionnaires (n = 388).

RESULTS

In the follow-up questionnaire, >93% of participants reported eating ≥1 traditional food in the past year. The top 3 traditional foods were fish (75%), moose (42%), and shellfish (41%). Women were more likely than men to consume traditional foods, especially fish, gathered berries, shellfish, and seal oil (P < 0.05). Participants aged ≥60 y in the original cohort were significantly more likely to consume fish and shellfish at follow-up, whereas those aged 40-59 y were the most likely of the 3 age groups to consume seal oil (P < 0.05). Between the original cohort and follow-up, there was a significant decline in the mean number of traditional foods eaten from 6.3 to 5.5, as well as reduced consumption of multiple traditional foods (P < 0.001). Over 59% of participants reported ≥1 traditional harvesting activity in the past year; this proportion did not significantly change between baseline and follow-up. Picking berries/greens (44%), cutting/smoking fish or meat (33%), and fishing (30%) were the most common activities. Participation in traditional harvesting activities was greater among women than men (P < 0.05), but did not differ by age.

CONCLUSIONS

Longitudinal follow-up demonstrated that AN/AI people maintained participation in traditional harvesting activities, but the variety of traditional foods declined significantly among both men and women. Promotion of traditional foods and harvesting activities that serve as protective factors against chronic diseases may benefit this population.

The Xavante Longitudinal Health Study in Brazil: Objectives, design, and key results

OBJECTIVE

The Xavante Longitudinal Health Study was developed to permit granular tracking of contemporary health challenges faced by indigenous communities in Brazil, taking into consideration ongoing historical processes that may be associated with increases in child undernutrition, adult obesity, and cardiovascular disease risks.

METHODS

This was an open-cohort study with six semiannual data collection waves from 2009 to 2012. The study was undertaken in two Xavante villages, Pimentel Barbosa and Etênhiritipá, State of Mato Grosso, Central Brazil. No sampling technique was used. Data collection placed emphasis on growth and nutrition of children under five and nutrition status, blood pressure, and blood glucose levels of adolescents and adults.

RESULTS

Baseline data collection began in July/August 2009 with a population census (656 individuals). Between the first and final waves, the study population increased by 17%. At baseline, stunting and wasting was elevated for most age groups <10 years. Overweight, obesity, and increased risk of metabolic complications were expressive among individuals >17 years, disproportionately affecting females. Anemia was elevated in most age groups, especially among females. Mean systolic and diastolic blood pressure was moderate. The overall prevalence of high blood pressure was relatively low.

CONCLUSIONS

Our findings reveal marked health disparities relative to the Brazilian national population and a complex dietary health epidemiology involving the double burden of malnutrition, rapidly changing nutritional indicators, and elevated metabolic disease risk. The topically broad multidisciplinary focus permitted construction of the richest longitudinal data set of socio-epidemiological information for an indigenous population in Brazil.

Prevalence and correlates of diagnosed and undiagnosed hypertension in the indigenous Kuna population of Panamá

BACKGROUND

To determine the prevalence of hypertension and investigate sociodemographic correlates in an indigenous Kuna community living on the San Blas islands of Panama.

METHODS

Data was collected from adults using a paper-based survey using a cross sectional study design. Blood pressure was measured, and hypertension defined at two cut-points: 130/80 mmHg and 140/90 mmHg. Individuals with undiagnosed hypertension had a blood pressure measurement that indicated hypertension, however, the individual had not been told by a doctor they had hypertension. Whereas individuals with diagnosed hypertension had been told by a healthcare provider that they had hypertension. Univariate tests compared diagnosed and undiagnosed hypertension by sociodemographic categories and logistic regression models tested individual correlates adjusting for all sociodemographic factors.

RESULTS

Two hundred and eleven adult indigenous Kuna participated in the study. Overall prevalence of hypertension was 6.2% (95%CI:3.32-10.30) as defined by 140/90 mmHg, and 16.6% (95%CI:11.83-22.31) as defined by 130/80 mmHg. Hypertension was significantly higher in men (31.6, 95% CI:19.90-45.24, compared to 11.0, 95% CI:6.56-17.09). Individuals with low income were 3 times more likely to be hypertensive (OR = 3.13, 95% CI:1.02-9.60) and 3.5 times more likely to have undiagnosed hypertension (OR = 3.42, 95% CI:1.01-11.52); while those with moderate income were 6 times more likely to be hypertensive (OR = 7.37, 95% CI:1.76-30.90) compared to those who were poor.

CONCLUSION

The prevalence of diagnosed and undiagnosed hypertension is higher in men and those with higher income. Investigating these factors remains vitally important in helping improve the health of the Kuna through targeted interventions to address chronic disease.

Genetic Epidemiologic Analysis of Hypertensive Retinopathy in an Underrepresented and Rare Federally Recognized Native American Population of the Intermountain West

Understanding disease risk is challenging in multifactorial conditions as it can differ by environment, ethnicity and race. The Confederated Tribes of the Goshute Reservation are one of the most isolated populations in the United States. Retinal changes are a reliable indicator for systemic disease. We conducted a cross-sectional study to identify correlations between genetic data and epidemiological risk factors for blinding retinal disease in this tribe. As part of the "Supporting Prediction and Prevention Blindness Project (SPBPP)" in the Native American Population of the Intermountain West, we found that hypertensive retinopathy was the most prevalent retinal disease. We found that forty-two percent of the Goshute population was affected. Blood samples, fundus photos and intraocular pressure were obtained for all participants. In addition, a standardized questionnaire was administered. DNA and total cholesterol, HDL, LDL, VLDL, triglycerides and HbA1c were also evaluated. Our study interrogated genetic variants from the PAGE study (ARMS2 rs10490924, CFH rs800292, rs1061170) and additional studies that looked at previously associated genetic variants with retinal disease associated with cardiovascular disease. We conducted univariate and multivariate logistic regression in Stata v15.0. We found an association between hypertriglyceridemia and HTR (adjp = .05) within the Goshute population. To the best of our knowledge, this is the first study to demonstrate the prevalence of hypertensive retinopathy in a Native American population. Moreover, our study is the first to demonstrate an independently predictive relationship between hypertriglyceridemia and hypertensive retinopathy in an American Indian population. This study furthers our knowledge about prevalent blinding eye disease within the most geographically isolated federally recognized native United States American tribe, for which nothing has been published with respect to any disease. Although, this study furthers our understanding about the prevalence of genetic epidemiological risk factors within this population, it has greater implications for the screening of blinding diseases in underserved populations in general. This study can inform public health on planning and delivering of quality, accessible and relevant care to this population.

Exploring racial/ethnic disparities in hypertension care among patients served by health centers in the United States

Some racial/ethnic minorities are more likely to have hypertension and experience increased hypertension-related morbidity and mortality compared to whites. Health Resources and Services Administration-funded health centers care for over 27 million patients, 62 percent of whom are racial/ethnic minorities. We assessed the presence of racial/ethnic disparities in (a) hypertension management and (b) hypertension outcomes among health center patients. We used data from the 2014 Health Center Patient Survey and performed multilevel logistic regression models to predict hypertension management counseling, patient adherence to counseling and medication regimen, management plan receipt, high blood pressure at last clinical visit, confidence in hypertension self-management, and hypertension-related emergency department (ED) episodes or hospitalizations in the past year. We controlled for patient characteristics including age, sex, education, nativity, health behaviors, health care access, and comorbidities. We found significantly higher odds of diet counseling (African Americans, OR: 1.87; Asian Americans, OR: 3.02, AIAN, OR: 2.01), reduced sodium intake (African American, OR: 2.42), and adherence to exercise counseling (African American, OR: 3.52; Asian Americans, OR: 2.93). We also found lower odds of taking hypertension control medication (AIAN, OR: 0.50) and higher odds of hypertension-related ED visits (African Americans, OR: 3.61, AIAN, OR: 5.31). These results highlight the success of health centers in managing hypertension by race/ethnicity but found adverse hypertension outcomes for some groups. Racial/ethnically tailored efforts might be required to manage hypertension and improve outcomes.