Knowledge Gaps, Challenges, and Opportunities in Health and Prevention Research for Asian Americans, Native Hawaiians, and Pacific Islanders: A Report From the 2021 National Institutes of Health Workshop

Asian Americans (AsA), Native Hawaiians, and Pacific Islanders (NHPI) comprise 7.7% of the U.S. population, and AsA have had the fastest growth rate since 2010. Yet the National Institutes of Health (NIH) has invested only 0.17% of its budget on AsA and NHPI research between 1992 and 2018. More than 40 ethnic subgroups are included within AsA and NHPI (with no majority subpopulation), which are highly diverse culturally, demographically, linguistically, and socioeconomically. However, data for these groups are often aggregated, masking critical health disparities and their drivers. To address these issues, in March 2021, the National Heart, Lung, and Blood Institute, in partnership with 8 other NIH institutes, convened a multidisciplinary workshop to review current research, knowledge gaps, opportunities, barriers, and approaches for prevention research for AsA and NHPI populations. The workshop covered 5 domains: 1) sociocultural, environmental, psychological health, and lifestyle dimensions; 2) metabolic disorders; 3) cardiovascular and lung diseases; 4) cancer; and 5) cognitive function and healthy aging. Two recurring themes emerged: Very limited data on the epidemiology, risk factors, and outcomes for most conditions are available, and most existing data are not disaggregated by subgroup, masking variation in risk factors, disease occurrence, and trajectories. Leveraging the vast phenotypic differences among AsA and NHPI groups was identified as a key opportunity to yield novel clues into etiologic and prognostic factors to inform prevention efforts and intervention strategies. Promising approaches for future research include developing collaborations with community partners, investing in infrastructure support for cohort studies, enhancing existing data sources to enable data disaggregation, and incorporating novel technology for objective measurement. Research on AsA and NHPI subgroups is urgently needed to eliminate disparities and promote health equity in these populations.

Association of abdominal muscle area and density with glucose regulation: The multi-ethnic study of atherosclerosis (MESA)

AIMS

Previous characterisation of body composition as a type 2 diabetes mellitus (T2DM) risk factor has largely focused on adiposity, but less is known about the independent role of skeletal muscle. We examined associations between abdominal muscle and measures of glucose regulation.

MATERIALS AND METHODS

Cross-sectional analysis of 1,891 adults enrolled in the Multi-Ethnic Study of Atherosclerosis. Multivariable regression assessed associations between abdominal muscle area and density (measured by computed tomography) with fasting glucose, homeostasis model assessment of insulin resistance (HOMA-IR), and prevalent T2DM (fasting glucose ≥126 mg/dL or medication use).

RESULTS

In minimally adjusted models (age, sex, race/ethnicity, income), a 1-SD increment in abdominal muscle area was associated with higher HOMA-IR (β = 0.20 ± SE 0.03; 95%CI: 0.15, 0.25; P < 0.01) and odds of T2DM (OR = 1.47; 95%CI: 1.18, 1.84; P < 0.01), while higher density was associated with lower fasting glucose (-4.49 ± 0.90; -6.26, -2.72; P < 0.01), HOMA-IR (-0.16 ± 0.02; -0.20, -0.12; P < 0.01), and odds of T2DM (0.64; 0.52, 0.77; P < 0.01). All associations persisted after adjustment for comorbidities and health behaviours. However, after controlling for height, BMI, and visceral adiposity, increasing muscle area became negatively associated with fasting glucose (-2.23 ± 1.01; -4.22, -0.24; P = 0.03), while density became positively associated with HOMA-IR (0.09 ± 0.02; 0.05, 0.13; P < 0.01).

CONCLUSIONS

Increasing muscle density was associated with salutary markers of glucose regulation, but associations inverted with further adjustment for body size and visceral adiposity. Conversely, after full adjustment, increasing muscle area was associated with lower fasting glucose, suggesting some patients may benefit from muscle-building interventions.

Adiposity, related biomarkers, and type 2 diabetes after gestational diabetes: The Diabetes Prevention Program

OBJECTIVE

This study investigated associations of adiposity and adiposity-related biomarkers with incident type 2 diabetes (T2D) among parous women.

METHODS

Among women in the Diabetes Prevention Program (DPP) who reported a previous live birth, circulating biomarkers (leptin, adiponectin, sex hormone-binding globulin, and alanine aminotransferase; n = 1,711) were measured at enrollment (average: 12 years post partum). Visceral (VAT) and subcutaneous adipose tissue areas at the L2-L3 region and the L3-L4 region were quantified by computed tomography (n = 477). Overall and stratified (by history of gestational diabetes mellitus [GDM]) adjusted Cox proportional hazards models were fit.

RESULTS

Alanine aminotransferase, L2-L3 VAT, and L3-L4 VAT were positively associated (hazard ratio [HR] for 1-SD increases: 1.073, p = 0.024; 1.251, p = 0.009; 1.272, p = 0.004, respectively), and adiponectin concentration was inversely associated with T2D (HR 0.762, p < 0.001). Whereas leptin concentration was not associated with T2D overall, in GDM-stratified models, a 1-SD higher leptin was positively associated with risk of T2D in women without GDM (HR: 1.126, p = 0.016) and inversely in women with a history of GDM (HR: 0.776, p = 0.013, interaction p = 0.002).

CONCLUSIONS

Among parous women, alanine aminotransferase and VAT are positively associated with incident T2D, whereas adiponectin is inversely associated. Leptin is associated with higher risk of T2D in women with a history of GDM but a lower risk in women without a history of GDM.

Health Advantages and Disparities in Preterm Birth Among Immigrants Despite Disparate Sociodemographic, Behavioral, and Maternal Risk Factors in San Diego, California

INTRODUCTION

Reproductive health advantages have been reported among selected immigrants, but few studies have included new immigrants and refugees, nor simultaneously adjusted for socioeconomic, behavioral, and medical disparities.

METHODS

We examined the risk of preterm birth (PTB, < 37 weeks' gestation) among singleton live births in San Diego County from 2007 to 2012. Multivariable regression was used to compare PTB (1) by nativity within racial/ethnic groups and (2) among immigrants compared to United States (US) born Whites, while adjusting for sociodemographic, behavioral, reproductive and medical variables.

RESULTS

Among 230,878 singleton live births, overall PTB prevalence was highest among parturient women who were US-born Blacks (10.9%), Philippine (10.8%) and US-born Filipinas (10.7%), and US-born Asians (8.6%) despite differences in socioeconomic and maternal risk factors, and lowest among Somali (5.5%) migrants. Blacks born in Somalia or outside of the US, had significantly lower overall PTB prevalence compared to US-born Blacks (5.5% vs 7.6% vs 10.9%). Compared to US-born Whites, spontaneous PTB risk was significantly lower among Somali migrants (4.8% vs 3.7%, adjusted relative risk, aRR 0.7 [95% Confidence Intervals 0.5-0.9]), but higher among Philippine migrants (4.8% vs 7.7%, aRR 1.4 [1.3-1.6]). The strongest risk factor for overall PTB among nulliparous US-born Blacks was preexisting diabetes (aRR 3.81 [2.05-7.08]), and preexisting hypertension among Filipinas (aRR: 3.27 [2.36-4.54] and US-born Asians (aRR: 3.64 [1.61-8.24]).

CONCLUSION

Black migrants had lower PTB prevalence compared to US-born Blacks, but this immigrant advantage was not observed in other racial/ethnic groups. Compared to US-born Whites, Somali migrants had significantly lower risk of spontaneous PTB while Filipinas had elevated risk.

Burden of Peripheral Artery Disease on Mortality and Incident Cardiovascular Events

Using data from the Multi-Ethnic Study of Atherosclerosis (United States, 2000-2015), 6,527 racially/ethnically diverse adults (mean age, 62 (standard deviation, 10) years) free of known cardiovascular (CVD) had ankle brachial index (ABI) assessment of their bilateral dorsalis pedis/posterior tibial arteries (4 vessels total) and were followed for total mortality and incident CVD events/mortality. Individuals were classified into categories of 0-, 1-, 2-, 3- or 4-vessel peripheral artery disease (PAD) (ABI of ≤0.9). There were 1,202 deaths (18%), 656 incident CVD events (10%), and 282 CVD deaths (4.3%). Of the 6,527 individuals, 5,711 (87.5%) had 0-, 460 (7.0%) had 1-, 218 (3.3%) had 2-, 69 (1.1%) had 3-, and 69 (1.1%) had 4-vessel PAD, respectively. In multivariable Cox models, higher number of vessels with PAD was associated with higher risk of mortality (P for trend <0.001), CVD events (P for trend = 0.002), and CVD mortality (P for trend = 0.001). Compared with individuals who had 0-vessel disease, hazard ratios for mortality were 1.29 (95% confidence interval (CI): 1.06, 1.59) for 1-, 1.45 (95% CI: 1.14, 1.86) for 2-, 1.58 (95% CI: 1.13, 2.21) for 3-, and 2.15 (95% CI: 1.58, 2.94) for 4-vessel disease. A similar pattern was seen for CVD events/mortality. These results suggest the importance of accounting for ABI values of all 4 leg arteries in clinical practice and research.

Sugar-Sweetened Beverage Intake and Cardiovascular Disease Risk in the California Teachers Study

Background Sugar-sweetened beverage (SSB) consumption has been associated with cardiometabolic risk. However, the association between total and type of SSB intake and incident cardiovascular disease (CVD) end points such as myocardial infarction, stroke, and revascularization is limited. Methods and Results We examined the prospective association of baseline SSB consumption with incident CVD in 106 178 women free from CVD and diabetes mellitus in the CTS (California Teachers Study), a cohort of female teachers and administrators, followed since 1995. SSBs were defined as caloric soft drinks, sweetened bottled waters or teas, and fruit drinks, and derived from a self-administered food frequency questionnaire. CVD end points were based on annual linkage with statewide inpatient hospitalization records. Cox proportional hazards models were used to assess the association between SSB consumption and incident CVD. A total of 8848 CVD incident cases were documented over 20 years of follow-up. After adjusting for potential confounders, we observed higher hazard ratios (HRs) for CVD (HR, 1.19; 95% CI, 1.06-1.34), revascularization (HR, 1.26; 95% CI, 1.04-1.54]), and stroke (HR, 1.21; 95% CI, 1.04-1.41) in women who consumed ≥1 serving per day of SSBs compared with rare/never consumers. We also observed a higher risk of CVD in women who consumed ≥1 serving per day of fruit drinks (HR, 1.42; 95% CI, 1.00-2.01 [P trend=0.021]) and caloric soft drinks (HR, 1.23; 95% CI, 1.05-1.44 [P trend=0.0002]), compared with rare/never consumers. Conclusions Consuming ≥1 serving per day of SSB was associated with CVD, revascularization, and stroke. SSB intake might be a modifiable dietary target to reduce risk of CVD among women.

Interaction Between Type 2 Diabetes Prevention Strategies and Genetic Determinants of Coronary Artery Disease on Cardiometabolic Risk Factors

Coronary artery disease (CAD) is more frequent among individuals with dysglycemia. Preventive interventions for diabetes can improve cardiometabolic risk factors (CRFs), but it is unclear whether the benefits on CRFs are similar for individuals at different genetic risk for CAD. We built a 201-variant polygenic risk score (PRS) for CAD and tested for interaction with diabetes prevention strategies on 1-year changes in CRFs in 2,658 Diabetes Prevention Program (DPP) participants. We also examined whether separate lifestyle behaviors interact with PRS and affect changes in CRFs in each intervention group. Participants in both the lifestyle and metformin interventions had greater improvement in the majority of recognized CRFs compared with placebo (P < 0.001) irrespective of CAD genetic risk (P interaction > 0.05). We detected nominal significant interactions between PRS and dietary quality and physical activity on 1-year change in BMI, fasting glucose, triglycerides, and HDL cholesterol in individuals randomized to metformin or placebo, but none of them achieved the multiple-testing correction for significance. This study confirms that diabetes preventive interventions improve CRFs regardless of CAD genetic risk and delivers hypothesis-generating data on the varying benefit of increasing physical activity and improving diet on intermediate cardiovascular risk factors depending on individual CAD genetic risk profile.

Prevalence of Diabetes by Race and Ethnicity in the United States, 2011-2016

IMPORTANCE

The prevalence of diabetes among Hispanic and Asian American subpopulations in the United States is unknown.

OBJECTIVE

To estimate racial/ethnic differences in the prevalence of diabetes among US adults 20 years or older by major race/ethnicity groups and selected Hispanic and non-Hispanic Asian subpopulations.

DESIGN, SETTING, AND PARTICIPANTS

National Health and Nutrition Examination Surveys, 2011-2016, cross-sectional samples representing the noninstitutionalized, civilian, US population. The sample included adults 20 years or older who had self-reported diagnosed diabetes during the interview or measurements of hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), and 2-hour plasma glucose (2hPG).

EXPOSURES

Race/ethnicity groups: non-Hispanic white, non-Hispanic black, Hispanic and Hispanic subgroups (Mexican, Puerto Rican, Cuban/Dominican, Central American, and South American), non-Hispanic Asian and non-Hispanic Asian subgroups (East, South, and Southeast Asian), and non-Hispanic other.

MAIN OUTCOMES AND MEASURES

Diagnosed diabetes was based on self-reported prior diagnosis. Undiagnosed diabetes was defined as HbA1c 6.5% or greater, FPG 126 mg/dL or greater, or 2hPG 200 mg/dL or greater in participants without diagnosed diabetes. Total diabetes was defined as diagnosed or undiagnosed diabetes.

RESULTS

The study sample included 7575 US adults (mean age, 47.5 years; 52% women; 2866 [65%] non-Hispanic white, 1636 [11%] non-Hispanic black, 1952 [15%] Hispanic, 909 [6%] non-Hispanic Asian, and 212 [3%] non-Hispanic other). A total of 2266 individuals had diagnosed diabetes; 377 had undiagnosed diabetes. Weighted age- and sex-adjusted prevalence of total diabetes was 12.1% (95% CI, 11.0%-13.4%) for non-Hispanic white, 20.4% (95% CI, 18.8%-22.1%) for non-Hispanic black, 22.1% (95% CI, 19.6%-24.7%) for Hispanic, and 19.1% (95% CI, 16.0%-22.1%) for non-Hispanic Asian adults (overall P < .001). Among Hispanic adults, the prevalence of total diabetes was 24.6% (95% CI, 21.6%-27.6%) for Mexican, 21.7% (95% CI, 14.6%-28.8%) for Puerto Rican, 20.5% (95% CI, 13.7%-27.3%) for Cuban/Dominican, 19.3% (95% CI, 12.4%-26.1%) for Central American, and 12.3% (95% CI, 8.5%-16.2%) for South American subgroups (overall P < .001). Among non-Hispanic Asian adults, the prevalence of total diabetes was 14.0% (95% CI, 9.5%-18.4%) for East Asian, 23.3% (95% CI, 15.6%-30.9%) for South Asian, and 22.4% (95% CI, 15.9%-28.9%) for Southeast Asian subgroups (overall P = .02). The prevalence of undiagnosed diabetes was 3.9% (95% CI, 3.0%-4.8%) for non-Hispanic white, 5.2% (95% CI, 3.9%-6.4%) for non-Hispanic black, 7.5% (95% CI, 5.9%-9.1%) for Hispanic, and 7.5% (95% CI, 4.9%-10.0%) for non-Hispanic Asian adults (overall P < .001).

CONCLUSIONS AND RELEVANCE

In this nationally representative survey of US adults from 2011 to 2016, the prevalence of diabetes and undiagnosed diabetes varied by race/ethnicity and among subgroups identified within the Hispanic and non-Hispanic Asian populations.

Sugar-sweetened beverages and colorectal cancer risk in the California Teachers Study

BACKGROUND

The association between sugar-sweetened beverage (SSB) consumption and colorectal cancer (CRC) risk remains unclear and published data are limited.

METHODS

The analytic cohort included 99,798 women, free of cancer at baseline, from the California Teachers Study, a longitudinal cohort comprised of 133,477 female teachers and administrators who were active or recently retired members of the California State Teachers Retirement System in 1995. SSB consumption constituted caloric soft drinks, sweetened bottled waters and teas, and fruit drinks, derived from a self-administered food frequency questionnaire. Consumption was divided into four categories: Rare or never, >rare/never to <1 serving/week, ≥1 serving/week to <1 serving/day, and ≥1 serving/day. CRC endpoints were based on annual linkage with California Cancer Registry, defined as first diagnosis of CRC, and classified following the Surveillance, Epidemiology, and End Results Program coding system. Multivariable-adjusted Cox proportional hazards models were used to generate hazard ratios (HR) and 95% confidence intervals (CI) for assessing the association between SSB consumption and incident CRC.

RESULTS

A total of 1,318 incident CRC cases were identified over 20 years of follow-up (54.5% proximal colon and 45.5% distal colorectum). Compared with rare/never consumers, the multivariable-adjusted HRs (95% CI) were 1.14 (0.86, 1.53) for total CRC; 1.11 (0.73, 1.68) for proximal colon; and 1.22 (0.80, 1.86) for distal colorectum cancers among women consuming ≥ 1 serving/day of SSBs.

CONCLUSION

SSBs were not significantly associated with CRC risk. The biological effects of high SSB consumption make it important to continue to evaluate whether SSBs are associated with CRC. Additionally, future studies should further assess SSBs in large, racial/ethnically diverse cohorts of males and females, and, if feasible, address changes in SSB consumption over time.

Prevalence and Risk Factors for Human Immunodeficiency Virus (HIV) and Syphilis Infections Among Military Personnel in Sierra Leone

CONTEXT

HIV and syphilis infections are common in military personnel in sub-Saharan Africa, which impact combat preparedness and increase demands on the military health care system. The prevalence of HIV is estimated at 1.5% among the general population (15-49 years of age) of Sierra Leone, and the estimated syphilis prevalence ranged from 1.5% to 5.2% based on regional studies. We examined the prevalence and risk factors for these two common sexually transmitted infections in the Sierra Leone military personnel.

METHODS

This cross-sectional study examined 1157 randomly selected soldiers from the Republic of Sierra Leone Armed Forces in 2013 using computer-assisted personal interviews and rapid testing algorithms. Descriptive statistics and logistic regression models were implemented to identify risk factors for HIV and syphilis separately.

RESULTS

The mean age of participants was 38 years, 11.1% were female, and 86.5% were married. The seroprevalence of HIV and syphilis were 3.3% (95% confidence interval [CI]: 2.3%-4.3%) and 7.3% (95% CI: 5.9%-8.8%), respectively. Lower educational attainment in women, multiple sexual partners, unintended sex after alcohol use and use of condoms were independently associated with HIV status (p&lt;0.05). After adjustment, HIV infection was associated with female gender, unintended sex after alcohol use, condom use at last sex, having multiple sexual partnerships in the same week and HIV testing outside of military facilities (p&lt;0.05). Increasing age, positive HIV status and rural regions of residence were associated with syphilis seropositivity.

CONCLUSION

The prevalence of sexually transmitted infections among military personnel was higher than the general population of Sierra Leone. Several high-risk sexual behaviors that expose soldiers to HIV and syphilis could be addressed through prevention interventions.

Comparison of the QuantiFERON TB Gold In-tube Assay With Tuberculin Skin Test for the Diagnosis of Latent Tuberculosis Infection Among HIV-infected and Uninfected Children

BACKGROUND

Diagnosis of latent tuberculosis infection (LTBI) is facilitated by tuberculin skin testing (TST) or interferon-gamma release assays such as the QuantiFERON TB Gold In-Tube (QTF-GIT) assays. Limited data exist on the utility of interferon-gamma release assays in HIV-infected children, which may be falsely negative due to immunosuppression.

METHODS

A cross-sectional study comparing TST to QTF-GIT for the diagnosis of suspected LTBI was performed in children in Tijuana, Mexico, and in San Diego, California. Concordance between TST (≥5 mm for HIV infected and ≥10 mm for HIV uninfected) and QTF-GIT was evaluated utilizing kappa coefficients. Multivariate logistic regression assessed factors influencing the results.

RESULTS

One hundred sixty-five children (70 HIV infected and 95 HIV uninfected) were evaluated (median age, 8.0 years). Among HIV-infected children, the median CD4 cell count was 913 cells/μL, with 92.9% of subjects on antiretroviral treatment and 80.0% with an HIV RNA load <400 copies/mL (76% <50 copies/mL). Among HIV-infected children with no history of tuberculosis, 12 HIV had either a positive QTF-GIT or TST ≥ 5 mm or both, giving a suspected LTBI prevalence of 20.3% (compared with 61.3% among HIV-uninfected children). Moderate concordance was demonstrated in HIV-infected children (both tests positive, κ = 0.42; 95% confidence interval: 8.9%-75.4%) and HIV-uninfected children (both tests positive, κ = 0.59; 95% confidence interval: 43.0%-76.5%).

CONCLUSIONS

A moderate correlation exists between TST and QTF-GIT among HIV-infected and uninfected children with preserved immune function in an area of moderate tuberculosis endemicity.

International chicken trade and increased risk for introducing or reintroducing highly pathogenic avian influenza A (H5N1) to uninfected countries

Every year billions of chickens are shipped thousands of miles around the globe in order to meet the ever increasing demands for this cheap and nutritious protein source. Unfortunately, transporting chickens internationally can also increase the chance for introducing zoonotic viruses, such as highly pathogenic avian influenza A (H5N1) to new countries. Our study used a retrospective analysis of poultry trading data from 2003 through 2011 to assess the risk of H5N1 poultry infection in an importing country. We found that the risk of infection in an importing country increased by a factor of 1.3 (95% CI: 1.1-1.5) for every 10-fold increase in live chickens imported from countries experiencing at least one H5N1 poultry case during that year. These results suggest that the risk in a particular country can be significantly reduced if imports from countries experiencing an outbreak are decreased during the year of infection or if biosecurity measures such as screening, vaccination, and infection control practices are increased. These findings show that limiting trade of live chickens or increasing infection control practices during contagious periods may be an important step in reducing the spread of H5N1 and other emerging avian influenza viruses.

Folic acid supplement use and the risk of gestational hypertension and preeclampsia

BACKGROUND

Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality. Studies suggest that the use of folic acid may lower the risk of hypertensive disorders in pregnant women.

AIM

The aim of this study was to assess the effects of timing and duration of folic acid-containing supplement use on the risk for gestational hypertension and preeclampsia.

METHODS

Exposures and outcomes data were obtained through interviews and review of participant's medical records from the MotherToBaby cohort studies across the United States and Canada. Demographics, medical history, lifestyle factors, substance use, and fetal sex were assessed as potential confounders. Unadjusted and adjusted risks for gestational hypertension and preeclampsia were examined using odds ratios and 95% confidence intervals.

FINDINGS

3247 women were included in the study. Compared to non-supplement use, early and late supplement use were not significantly associated with the development of gestational hypertension or preeclampsia. The odds of developing gestational hypertension and preeclampsia were significantly reduced as the duration of folic acid-containing supplement use increased.

CONCLUSION

Findings from this study suggest that the use of folic acid-containing supplements may mitigate the risk for gestational hypertension and preeclampsia.

The CardioMetabolic Health Alliance: Working Toward a New Care Model for the Metabolic Syndrome

The Cardiometabolic Think Tank was convened on June 20, 2014, in Washington, DC, as a "call to action" activity focused on defining new patient care models and approaches to address contemporary issues of cardiometabolic risk and disease. Individual experts representing >20 professional organizations participated in this roundtable discussion. The Think Tank consensus was that the metabolic syndrome (MetS) is a complex pathophysiological state comprised of a cluster of clinically measured and typically unmeasured risk factors, is progressive in its course, and is associated with serious and extensive comorbidity, but tends to be clinically under-recognized. The ideal patient care model for MetS must accurately identify those at risk before MetS develops and must recognize subtypes and stages of MetS to more effectively direct prevention and therapies. This new MetS care model introduces both affirmed and emerging concepts that will require consensus development, validation, and optimization in the future.

Associations of Abdominal Muscle Area with 4-Year Change in Coronary Artery Calcium Differ by Ethnicity Among Post-Menopausal Women

OBJECTIVE

To examine the association of abdominal muscle area with coronary artery calcium (CAC) presence, extent, and progression in a multi-ethnic cohort of older, community-dwelling post-menopausal women.

DESIGN AND SETTING

Cross-sectional and longitudinal population-based cohort.

PARTICIPANTS

The sample comprised 179 non-Hispanic White women, 116 Filipina women and 144 African American women, all without known CVD, who underwent chest and abdominal computed tomography (CT) scans twice about four years apart for abdominal muscle and fat, as well as CAC.

MAIN OUTCOME MEASURES

CAC presence, extent and progression.

RESULTS

There was a significant interaction of ethnicity with baseline oblique muscle area (p-for-interaction .01), and marginally significant interactions with baseline total and paraspinal muscle for change in CAC (p-for-interactions both .09). Among Filipina women, each standard deviation (SD) greater total muscle area was associated with a 26% (95% CI (-43%, -4%), P=.02) reduced rate of change in CAC; higher paraspinal and oblique muscle area were associated with a 24% (-38%, -6%, P=.01) and a 37% (-53%, -16%, P=.0002) reduced rate of change in CAC, respectively. These associations were not significant in African American or non-Hispanic White women. There were no significant associations of abdominal muscle with CAC presence or extent, nor were there significant ethnicity by muscle interactions in these models.

CONCLUSIONS

Among Filipina women, greater abdominal muscle mass is associated with a decreased rate of CAC progression. Higher muscle mass may be important for this group in reducing CVD outcomes.

Can increased visceral adiposity without body weight changes accelerate carotid atherosclerosis in South Korean participants with type 2 diabetes?

AIMS

Type 2 diabetes mellitus (T2DM) and visceral obesity are associated with each other and with cardiovascular diseases. We determined whether increased visceral adiposity without weight gain was associated with sex-specific accelerated carotid atherosclerosis in South Koreans with T2DM.

METHODS

From 2003 to 2012, we recruited 280 participants with T2DM for the Seoul Metabolic Syndrome cohort who had body weight, visceral fat thickness (VFT), and carotid intima-media thickness (CIMT) measured at intervals of 2years. According to VFT change, sex-specific quartiles of clinical characteristics and changes of CIMT were determined. Logistic regression models predicted the odds of the progression of CIMTs in each quartile.

RESULTS

During 2years of observation, VFTs fell by 5.2±13.5mm in men (P<0.001) and 3.4±10.5mm in women (P<0.001). Progression of CIMT was only significant for women's maximal CIMT (0.031±0.145mm, P=0.012), while significant improvements in HbA1c were found (0.9%; P<0.001 in both sexes). There were no significant differences in clinical characteristics, or in progression of CIMT in men or women according to 2-year quartiles of VFT change.

CONCLUSIONS

Our results do not suggest that increased visceral adiposity without body weight changes impacts the CIMT progression in South Korean men or women with T2DM.

Optimum BMI cut points to screen asian americans for type 2 diabetes

OBJECTIVE

Asian Americans manifest type 2 diabetes at low BMI levels but may not undergo diagnostic testing for diabetes if the currently recommended BMI screening cut point of ≥25 kg/m(2) is followed. We aimed to ascertain an appropriate lower BMI cut point among Asian-American adults without a prior diabetes diagnosis.

RESEARCH DESIGN AND METHODS

We consolidated data from 1,663 participants, ages ≥45 years, without a prior diabetes diagnosis, from population- and community-based studies, including the Mediators of Atherosclerosis in South Asians Living in America study, the North Kohala Study, the Seattle Japanese American Community Diabetes Study, and the University of California San Diego Filipino Health Study. Clinical measures included a 2-h 75-g oral glucose tolerance test, BMI, and glycosylated hemoglobin (HbA1c).

RESULTS

Mean age was 59.7 years, mean BMI was 25.4 kg/m(2), 58% were women, and type 2 diabetes prevalence (American Diabetes Association 2010 criteria) was 16.9%. At BMI ≥25 kg/m(2), sensitivity (63.7%), specificity (52.8%), and Youden index (0.16) values were low; limiting screening to BMI ≥25 kg/m(2) would miss 36% of Asian Americans with type 2 diabetes. For screening purposes, higher sensitivity is desirable to minimize missing cases, especially if the diagnostic test is relatively simple and inexpensive. At BMI ≥23 kg/m(2), sensitivity (84.7%) was high in the total sample and by sex and Asian-American subgroup and would miss only ∼15% of Asian Americans with diabetes.

CONCLUSIONS

The BMI cut point for identifying Asian Americans who should be screened for undiagnosed type 2 diabetes should be <25 kg/m(2), and ≥23 kg/m(2) may be the most practical.

Body adiposity index as a risk factor for the metabolic syndrome in postmenopausal Caucasian, African American, and Filipina women

AIMS

To investigate the utility of the body adiposity index (BAI) and its association with the metabolic syndrome (MetS) in older Caucasian (n=369), African American (n=336) and Filipina (n=275) women.

METHODS

Dual energy X-ray absorptiometry, anthropometric measures, plasma glucose and medical history were assessed in 1993-1999.

RESULTS

Despite smaller body size, 32.7% of Filipina women had higher MetS compared to African American and Caucasian women based on the National Cholesterol Education Program (NCEP) (32.7% vs 19.6% and 13.3%, respectively) or the International Diabetes Federation (IDF) (42.6% vs 33.0% and 18.7%, respectively ps<0.05). BAI had higher positive correlations with BMI, %body fat (%BF), and %truncal fat in Caucasian than African American and Filipina women. Adjusted for age, smoking, estrogen use, exercise, and alcohol intake, odds of the MetS (NCEP) were 2.08 (95%CI: 1.52-2.85) by BAI, 3.04 (95%CI: 2.11-4.38) by BMI, and 2.13 (95%CI: 1.52-3.00) by %BF for Caucasian women; 0.92 (95%CI: 0.69-1.23) by BAI, 1.44 (95%CI: 1.09-1.90) by BMI, and 1.12 (95%CI: 0.84-1.50) by %BF for African American women; and 1.14 (95%CI: 0.88-1.47) by BAI, 1.51 (95%CI: 1.15-1.97) by BMI, and 0.96 (95%CI: 0.74-1.25) by %BF for Filipinas.

CONCLUSION

BAI was better able to assess adiposity in postmenopausal Caucasian women compared to African American and Filipina women. This index can distinguish ethnic differences in MetS confirmed by %BF.

The association between abdominal muscle and type II diabetes across weight categories in diverse post-menopausal women

CONTEXT

Despite the key role of muscle in glucose regulation, little is known about the association between muscle area and prevalence of metabolic disorders, or the role low muscle may play in normal weight metabolic obesity.

OBJECTIVE

The objective was to assess the independent associations between both abdominal muscle and fat depositions (measured by computed tomography) and the prevalence of type II diabetes, and to explore the modifying role of weight category.

DESIGN

We conducted a cross-sectional analysis of the 2001-2002 visit for the Rancho Bernardo Study, Filipino Women's Health Study, and Health Assessment Study of African American Women.

SETTING AND PARTICIPANTS

Participants were 392 community-dwelling older women (mean age = 64) free of clinical cardiovascular disease.

MAIN OUTCOME MEASURE

The main outcome was prevalence of type II diabetes, defined as use of anti-diabetes medication, fasting plasma glucose ≥ 126 mg/dL, and/or OGTT ≥ 200 mg/dL.

RESULTS

Adjusting for demographics, hypertension, estrogen use, lipids, smoking, physical activity, visceral fat area, and height, a greater muscle-to-total abdominal area ratio (MAR) was associated with lower odds of diabetes [OR = 0.63 per standard deviation, 95% CI (0.43-0.92), p = .02]. Higher visceral fat was associated with greater odds of diabetes in fully adjusted models including total muscle area [OR = 1.48, 95% CI (1.09, 2.01), p = .01]. Associations between MAR and diabetes were stronger for normal weight (BMI 18.5-24.9; OR = 0.32) than overweight/obese women (BMI ≥ 25, OR = 0.71, p-for-interaction = 0.046). Associations with visceral fat did not differ by BMI (p-for-interaction = 0.71).

CONCLUSIONS

In older women, abdominal muscle area is inversely associated with type II diabetes independent of visceral adiposity, particularly for normal weight women.

Ethnic-specific associations of sleep duration and daytime napping with prevalent type 2 diabetes in postmenopausal women

OBJECTIVE

The objective of this study was to evaluate ethnic differences in the associations of nighttime sleep and daytime napping durations with prevalent type 2 diabetes.

METHODS

Samples of White (n = 908), Filipina (n = 330), and Black (n = 371) community-dwelling, postmenopausal women aged 50-86 years were evaluated with cross-sectional data obtained during 1992-1999 including self-reported duration of nighttime sleep and daytime napping, behaviors, medical history, and medication use. The prevalence of type 2 diabetes was evaluated with a 2-h 75-g oral glucose tolerance test.

RESULTS

Overall, 10.9% of White, 37.8% of Filipina, and 17.8% of Black women had type 2 diabetes. Average sleep durations were 7.3, 6.3, and 6.6 h and napping durations were 16.8, 31.7, and 25.9 min for White, Filipina, and Black women, respectively. Sleep duration showed a significant (p < 0.01) nonlinear association with type 2 diabetes in Filipina women, with increased odds of diabetes at both low and high sleep durations independent of age, body mass index (BMI), triglyceride to high-density lipoprotein (HDL) ratio, hypertension, and daytime napping duration. Daytime napping duration was associated with type 2 diabetes only among White women; those napping ≥ 30 min/day had 74% (95% confidence interval (CI) = 10%, 175%) higher odds of diabetes compared to non-nappers independent of covariates including nighttime sleep duration.

CONCLUSIONS

Results suggest ethnic-specific associations of nighttime sleep and daytime napping durations with type 2 diabetes.

Effect of restorative yoga vs. stretching on diurnal cortisol dynamics and psychosocial outcomes in individuals with the metabolic syndrome: the PRYSMS randomized controlled trial

PURPOSE

Chronic stimulation and dysregulation of the neuroendocrine system by stress may cause metabolic abnormalities. We estimated how much cortisol and psychosocial outcomes improved with a restorative yoga (relaxation) versus a low impact stretching intervention for individuals with the metabolic syndrome.

METHODS

We conducted a 1-year multi-center randomized controlled trial (6-month intervention and 6-month maintenance phase) of restorative yoga vs. stretching. Participants completed surveys to assess depression, social support, positive affect, and stress at baseline, 6 months and 12 months. For each assessment, we collected saliva at four points daily for three days and collected response to dexamethasone on the fourth day for analysis of diurnal cortisol dynamics. We analyzed our data using multivariate regression models, controlling for study site, medications (antidepressants, hormone therapy), body mass index, and baseline cortisol values.

RESULTS

Psychosocial outcome measures were available for 171 study participants at baseline, 140 at 6 months, and 132 at 1 year. Complete cortisol data were available for 136 of 171 study participants (72 in restorative yoga and 64 in stretching) and were only available at baseline and 6 months. At 6 months, the stretching group had decreased cortisol at waking and bedtime compared to the restorative yoga group. The pattern of changes in stress mirrored this improvement, with the stretching group showing reductions in chronic stress severity and perseverative thoughts about their stress. Perceived stress decreased by 1.5 points (-0.4; 3.3, p=0.11) at 6 months, and by 2.0 points (0.1; 3.9, p=0.04) at 1 year in the stretching compared to restorative yoga groups. Post hoc analyses suggest that in the stretching group only, perceived increases in social support (particularly feelings of belonging), but not changes in stress were related to improved cortisol dynamics.

CONCLUSIONS

We found significant decreases in salivary cortisol, chronic stress severity, and stress perception in the stretching group compared to the restorative yoga group. Group support during the interactive stretch classes may have contributed to these changes.

Associations of physical activity and sedentary behavior with regional fat deposition

INTRODUCTION

Increased sedentary behavior predicts greater cardiovascular morbidity and mortality and does so independently of physical activity (PA). This association is only partially explained by body mass index (BMI) and overall body fat, suggesting mechanisms besides general increased adiposity. The purpose of this study was to explore associations of self-reported leisure PA and sitting time with regional fat depositions and abdominal muscle among community-dwelling older adults.

METHODS

Participants were 539 diverse adults (mean age = 65 yr) who completed a study visit in 2001-2002. Areas of pericardial, intrathoracic, subcutaneous, visceral, and intermuscular fat, as well as abdominal muscle, were measured using computed tomography. Leisure PA and sitting hours were entered simultaneously into multivariate regression models to determine associations with muscle and fat areas.

RESULTS

After adjusting for demographics, smoking, diabetes, hypertension, triglycerides, and cholesterol, greater PA was associated with less intrathoracic, visceral, subcutaneous, and intermuscular fat (for all P < 0.05), while greater sedentary time was associated with greater pericardial and intrathoracic fat (for both P < 0.05). After further adjusting for BMI, each hour of weekly PA was associated with 1.85 cm less visceral fat (P < 0.01) but was not associated with other fat depositions. Conversely, each hour of daily sitting was associated with 2.39 cm more pericardial fat (P < 0.05) but was not associated with any other fat depositions. There were no associations with abdominal muscle area. Adjusting for common inflammatory markers had little effect. Associations between fat and PA were stronger for men.

CONCLUSIONS

Sitting and PA have distinct associations with regional fat deposition in older adults. The association between sitting and pericardial fat could partially explain the link between sitting and coronary heart disease.

Restorative yoga and metabolic risk factors: the Practicing Restorative Yoga vs. Stretching for the Metabolic Syndrome (PRYSMS) randomized trial

AIMS

Intensive lifestyle change prevents type 2 diabetes but is difficult to sustain. Preliminary evidence suggests that yoga may improve metabolic factors. We tested a restorative yoga intervention vs. active stretching for metabolic outcomes.

METHODS

In 2009-2012, we conducted a 48-week randomized trial comparing restorative yoga vs. stretching among underactive adults with the metabolic syndrome at the Universities of California, San Francisco and San Diego. We provided lifestyle counseling and a tapering series of 90-min group classes in the 24-week intervention period and 24-week maintenance period. Fasting and 2-h glucose, HbA1c, triglycerides, HDL-cholesterol, insulin, systolic blood pressure, visceral fat, and quality of life were assessed at baseline, 6- and 12-months.

RESULTS

180 participants were randomized and 135 (75%) completed the trial. At 12 months, fasting glucose decreased more in the yoga group than in the stretching group (-0.35 mmol/L vs. -0.03 mmol/L; p=0.002); there were no other significant differences between groups. At 6 months favorable changes within the yoga group included reductions in fasting glucose, insulin, and HbA1c and an increase in HDL-cholesterol that were not sustained at 1 year except changes in fasting glucose. The stretching group had a significant reduction in triglycerides at 6 months which was not sustained at 1 year but had improved quality of life at both time-points.

CONCLUSIONS

Restorative yoga was marginally better than stretching for improving fasting glucose but not other metabolic factors.

Associations of pericardial and intrathoracic fat with coronary calcium presence and progression in a multiethnic study

OBJECTIVE

Body mass index (BMI) may not accurately or adequately reflect body composition or its role in the development of cardiovascular disease (CVD). Ectopic adipose depots may provide a more refined representation of the role of adiposity in CVD. Thus, the association of pericardial and intra-thoracic fat with coronary artery calcium (CAC) was examined.

DESIGN AND METHODS

Nearly 600 white men and women, as well as Filipina women and African-American women, all without known CVD, had abdominal and chest computed tomography (CT) scans at two time points about 4 years apart from which CAC presence, severity and progression, as well as pericardial and intrathoracic fat volumes were obtained. Logistic and linear regression models with staged adjustment were used to assess associations of pericardial and intra-thoracic fat with CAC presence, severity, and progression.

RESULTS

After adjustment for age, BMI, sex/ethnic group, ever smoking, and lipids, each standard deviation higher increment of intra-thoracic fat, but not pericardial fat, was significantly associated with 3.84-fold higher odds of prevalent CAC (95% CI (1.54, 9.58), P = 0.004) and a 38.4% higher CAC score (95% CI (3.5%, 90.0%), P = 0.03). Neither pericardial nor intrathoracic fat were associated with CAC progression.

CONCLUSIONS

Contrary to previous reports, pericardial fat was not associated with the presence, severity or progression of CAC. However, a significant association between intrathoracic fat and both the presence and severity of CAC was demonstrated. Studies measuring fat in the thoracic cavity may consider defining intrathoracic fat as a separate entity from pericardial fat.

Prevalence of PTSD and depression, and associated sexual risk factors, among male Rwanda Defense Forces military personnel

OBJECTIVES

To assess depression and PTSD prevalence among the Rwanda Defense Forces (RDF) and evaluate whether sexual risk behaviour, STIs, HIV and alcohol use were significantly higher among those who screened positive.

METHODS

Consenting active-duty male RDF personnel, aged ≥21 years, completed an anonymous sexual risk survey linked to HIV rapid testing that included standardised assessments for PTSD (PCL-M), depression (CES-D) and alcohol use (AUDIT). PTSD and depression prevalence were calculated (data available for 1238 and 1120 participants, respectively), and multivariable regression analyses were conducted.

RESULTS

22.5% screened positive for depression, 4.2% for PTSD and 3.4% for both. In adjusted analyses, odds of either depression or PTSD were significantly higher in participants reporting STI symptoms (OR = 2.27, 2.78, respectively) and harmful alcohol use (OR = 3.13, 3.21, respectively). Sex with a high-risk sex partner, lower rank and never deploying were also significantly associated with depression in adjusted analyses.

CONCLUSIONS

Nearly one-fourth of RDF participants screened positive for PTSD or depression, which impacts sexual risk behaviour, HIV acquisition risk and military readiness. Findings may extend to other deploying militaries and provide additional evidence of an association between mental health status and sexual risk behaviour. Effective mental health treatment interventions that also include alcohol use assessments, STI identification/treatment and sexual risk behaviour reduction are needed.

Parallel rapid HIV testing in pregnant women at Tijuana General Hospital, Baja California, Mexico

The objectives of this study were to evaluate the performance of parallel rapid HIV testing and the presence of HIV-associated risk factors in pregnant women with unknown HIV status in Baja California, Mexico. Pregnant women attending the delivery unit or the prenatal clinic at Tijuana General Hospital had blood drawn for parallel rapid HIV testing with Determine™ HIV-1/2 and Uni-Gold™ Recombigen(®) HIV. The parallel rapid HIV test performance was compared to the enzyme immunoassay (EIA) and western blot. From September 2007 to July 2008, 1,383 (94%) of 1,464 women in labor and 1,992 (96%) of 2,075 women in prenatal care were enrolled. The HIV seroprevalence among women screened during labor (19/1,383, 1.37%, 95% CI: 0.85-2.18%) was significantly higher compared to those seeking prenatal care (5/1,992, 0.25%, 95% CI: 0.09-0.62%; p<0.001). Of 25 pregnant women testing positive by parallel rapid HIV testing 24 had a positive confirmatory western blot and one (0.03%) was confirmed as false positive. Additionally, two (0.06%) women had parallel rapid HIV discordant testing results; both tested negative by western blot. All women who tested negative by rapid testing had negative results on pooled EIA antibody testing. The overall sensitivity, specificity, and positive and negative predictive values of parallel rapid HIV testing were 100%, 99.9%, 96%, and 100%, respectively. These findings document a very high acceptance rate and an excellent performance of the parallel rapid HIV testing strategy during pregnancy.

Clinical Outcomes and Hospitalizations among Children Perinatally Infected with HIV-1 in Baja California, Mexico

This study characterizes temporal trends in HIV disease progression among perinatally infected children at a clinic in Baja California, Mexico. A total of 73 children were followed, 52% were categorized under US Centers for Disease Control and Prevention (CDC) classification group C with a mean age of 2.3 years (SD ± 3.16) at HIV diagnosis. For the years 1998 to 2001, 2002 to 2003, 2004 to 2005, and 2006 to 2007, highly active antiretroviral therapy (HAART) use increased to 60%, 75%, 83%, and 94% ( P < .001) as did mean CD4 percentage of 23.4%, 23.2%, 26.9%, and 29.0%, respectively ( P = .009), while HIV plasma RNA log10 decreased significantly (4.49, 4.23, 4.00, and 3.79, respectively; P = .019). Overall mortality was 31% (23 of 73), with pneumonia being the most common cause of death (43% of all deaths) followed by tuberculosis (22%). Mortality rates declined from 30.4% to 25%, 8.9%, and 9.3% ( p = 0.035) for the years 1998 to 2001, 2002 to 2003, 2004 to 2005, and 2006 to 2007, respectively. Kaplan-Meier survival analysis showed that median survival was 11.2 years; 1-, 2-, and 5-year survival was 87%, 83%, and 67%, respectively. These findings document a high but improving trend in morbidity and mortality of children perinatally infected with HIV in Tijuana, Baja California, Mexico.

Dietary factors associated with adiponectin in Filipino-American women

OBJECTIVE

To explore the cross-sectional association of nutrient intake with adiponectin in Filipino-American women who had completed a validated food frequency questionnaire.

DESIGN

One hundred and sixty-one Filipino women aged 40 to 82 years were recruited from the University of California, San Diego Filipino Women's Health Study. Dietary information was assessed by a validated Harvard-Willet food frequency questionnaire. Plasma adiponectin was measured by radioimmunoassay.

RESULTS

The median adiponectin value of the study population is 5.8 microg/dL (interquartile range, 3.9-8.4). Women in the highest adiponectin tertile had a lower dietary intake of omega-3-fatty acid compared to those with lower adiponectin levels (P < .005). In linear models controlling for potential confounders, a significant negative correlation was also observed between adiponectin and dietary intake of monounsaturated fat intake (partial r = -.12, P = .04), polyunsaturated fat (partial r = -.17, P = .02), omega-3-fatty acid (partial r = -.19, P = .01), and omega-6 fatty acids (partial r = -.14, P = .4),

CONCLUSION

Our findings suggest that increased nutrient intake of monounsaturated and polyunsaturated fat, as well as omega-3 and omega-6 fatty acids is associated with a decreased demand or requirement for adiponectin. More studies are warranted to evaluate the causal relationship between adiponectin and nutrient intake, including the use of specific food items, to confirm any associations.

A1C and diabetes diagnosis among Filipino Americans, Japanese Americans, and Native Hawaiians

OBJECTIVE

To examine the sensitivity and specificity of A1C ≥ 6.5% to diagnose diabetes among Filipino Americans, Japanese Americans, and Native Hawaiians.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study among middle-aged adults without prior diagnosis of type 2 diabetes who completed a 2-h 75-g oral glucose tolerance test (OGTT) and A1C measures.

RESULTS

The 933 participants had a mean age of 54.2 years, and 73% were women. A total of 425 (45.5%) subjects had impaired fasting glucose or impaired glucose tolerance, 145 (15.5%) had type 2 diabetes (by OGTT), and 83 (8.9%) had A1C ≥ 6.5%. The sensitivity and specificity of A1C ≥ 6.5% to define diabetes (by OGTT) was 40.0 and 96.8% and 68.9 and 95.3%, respectively (by fasting plasma glucose only). However, (64.8%) of Filipino and Japanese subjects with diabetes had isolated postchallenge hyperglycemia; AIC ≥ 6.5% sensitivity and specificity was 19.1 and 92.1%, respectively, to define isolated postchallenge hyperglycemia in the total sample.

CONCLUSIONS

A1C ≥ 6.5% had low sensitivity and may delay diagnosis of type 2 diabetes without OGTT. This limitation is exacerbated by isolated postchallenge hyperglycemia in Asian Americans.

Report of a National Heart, Lung, And Blood Institute Workshop: heterogeneity in cardiometabolic risk in Asian Americans In the U.S. Opportunities for research

The Asian and Pacific Islander population (Asian Americans) in the U.S. has increased dramatically in the last few decades. Yet, data on cardiovascular disease (CVD) in this population are scarce. The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health conducted an Expert Workshop to: 1) assess the importance of studying CVD in Asian Americans in the U.S.; and 2) consider strategic options for further investigations of CVD in this population. There is considerable geographical, ethnic, cultural, and genetic diversity within this population. Limited data also suggest striking differences in the risk of CVD, obesity, type 2 diabetes mellitus, and other CVD risk factors across the Asian-American population. The Asian-American population is a new diverse pool with less contemporary genetic and cultural admixture relative to groups that have lived in the U.S. for generations, plus it is diverse in lifestyle including culture, diet, and family structure. This diversity provides a window of opportunity for research on genes and gene-environment interactions and also to investigate how acculturation/assimilation to U.S. lifestyles affects health and CVD risk among relatively homogenous groups of recent immigrants. Given the heterogeneity in body weight, body size, and CVD risk, the Asian-American population in the U.S. offers a unique model to study the interaction and relationships between visceral adiposity and adipose tissue distribution and beta cell function, insulin resistance, and atherosclerosis.

Grand multiparity is associated with type 2 diabetes in Filipino American women, independent of visceral fat and adiponectin

OBJECTIVE

To determine whether multiparity is associated with type 2 diabetes, independent of visceral adipose tissue (VAT) and adipokines.

RESEARCH DESIGN AND METHODS

Participants were from the University of California San Diego Filipino Women's Health Study with at least one live birth. A 2-h 75-g oral glucose tolerance test was administered; adiponectin, leptin, ghrelin, reproductive history, family history of diabetes, VAT, and lifestyle behaviors were measured between 1995 and 2002.

RESULTS

Among 152 women, mean age was 59.5 years (range 48-73 years) and mean parity was 4.3 (range 1-12 births). Type 2 diabetes prevalence increased by parity group (low parity, 1-2 births, 25%; medium parity, 3-5 births, 30.3%; and grand multiparity: 6-12 births, 50%; P = 0.048). Family history of diabetes, exercise, insulin resistance, and leptin and ghrelin levels did not differ by parity group. Compared with women in the low parity group, women with > or =6 births were significantly older (62 vs. 57 years), had lower college completion (22 vs. 58%, P = 0.006), more hypertension (72 vs. 55%), higher VAT (74.9 vs. 58.4 cm(3)), and lower adiponectin concentration (5.79 vs. 7.61 microg/ml). In multivariate analysis adjusting for adiponectin, VAT, family history of diabetes, age, education, hypertension, and estrogen use, grand multiparous women had a threefold higher odds of type 2 diabetes (adjusted odds ratio 3.40 [95% CI 1.13-10.2]) compared with low parity women. No differences were observed in the odds of diabetes between women in the medium (1.10 [0.41-2.91]) and low parity groups.

CONCLUSIONS

Having > or =6 children was associated with type 2 diabetes, independent of adiponectin, VAT, family history, and other measured diabetes risk factors.

A1C and diabetes diagnosis: The Rancho Bernardo Study

OBJECTIVE

To examine the sensitivity and specificity of A1C as a diagnostic test for type 2 diabetes in older adults.

RESEARCH DESIGN AND METHODS

Cross-sectional study of community-dwelling adults without known diabetes who had an oral glucose tolerance test and A1C measured on the same day.

RESULTS

Mean age of the 2,107 participants was 69.4 +/- 11.1 years; 43% were men. Based on the American Diabetes Association (ADA) criteria, 198 had previously undiagnosed type 2 diabetes. The sensitivity/specificity of A1C cut point of 6.5% was 44/79%. Results were similar in age- and sex-stratified analyses. Given the A1C cut point of 6.5%, 85% of participants were classified as nondiabetic by ADA criteria.

CONCLUSIONS

The limited sensitivity of the A1C test may result in delayed diagnosis of type 2 diabetes, while the strict use of ADA criteria may fail to identify a high proportion of individuals with diabetes by A1C > or =6.5% or retinopathy.

Probable NAFLD, by ALT levels, and diabetes among Filipino-American women

BACKGROUND

Studies have shown alanine aminotransferase (ALT), a marker for non-alcoholic fatty liver disease (NAFLD), predicts type 2 diabetes (T2DM).

OBJECTIVE

To examine the association between probable NAFLD and T2DM in non-obese, non-alcoholic consuming Filipino-American women aged 48-73 years.

RESEARCH DESIGN AND METHODS

The UCSD Filipino Women's Health Study measured glucose, hepatic enzymes, adiponectin and visceral fat (VAT) during clinical visits (1995-2002). We defined T2DM by 1999 WHO criteria and probable NAFLD as ALT >31 U/L.

RESULTS

Prevalence of T2DM was 34.4% and probable NAFLD was 17.2%. Women with T2DM (n=56) had higher VAT, total:HDL cholesterol, SBP, fasting glucose and insulin, postchallenge glucose, ALT (28.7 U/L versus 19.1 U/L, p<0.0001), GGT, AST, and probable NAFLD (32.1% versus 9.35%, p=0.0002) and lower adiponectin than those without T2DM (n=107). GGT (p=0.0008) and ALT (p=0.002) were associated with increasing VAT levels. Probable NAFLD was independently associated with T2DM (AOR 6.32, 95% CI 2.2-18.0), after adjusting for risk factors.

CONCLUSION

Probable NAFLD was elevated and associated with T2DM, independent of VAT, adiponectin and other risk factors. ALT may serve as a useful marker for NAFLD or diabetes risk in Filipino women.

Cardiovascular disease prevalence, associated risk factors, and plasma adiponectin levels among Filipino American women

OBJECTIVES

This cross-sectional study was designed to examine the association between adiponectin and cardiovascular disease (CVD) among an understudied ethnic group of Filipino American women.

METHODS

We recruited 266 Filipino women aged 40-86 years from the University of California, San Diego Filipino Women's Health Study (1995-1999). Plasma adiponectin was extracted from archive blood samples and measured by radioimmunoassay. CVD was defined as coronary heart disease, angina, myocardial infarction, or stroke by history, electrocardiogram (Minnesota coding), or Rose questionnaire.

RESULTS

CVD prevalence among Filipinas was 20.7% (n=55), of which 85.5% were newly diagnosed. Filipinas with versus without CVD had more antihypertensive medication use (44.4% vs 26.7%), more parental history of myocardial infarction (38.2% vs 21.8%), higher proinsulin levels (13.2 vs 11.0 pmol/L), lower adiponectin levels (5.09 vs 6.15 microg/mL), and higher prevalences of the metabolic syndrome (34.6% vs 28.0%) and microalbuminuria (24.0% vs 12.2%). Adiponectin (adjusted OR .46, 95% CI .23-.89, P=.021) was independently associated with CVD in multivariate analysis that adjusted for age, exercise, family history, diabetes, hypertension, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and microalbuminuria.

CONCLUSIONS

Independent of known risk factors, adiponectin was associated with CVD among Filipinas. This finding suggests that adiponectin may be a useful CVD indicator among this ethnic population.

Adiponectin and ghrelin levels and body size in normoglycemic Filipino, African-American, and white women

OBJECTIVE

Prior studies have reported ethnic differences in adiponectin and ghrelin, but few have assessed the role of body size in normoglycemic women. We compared fasting adiponectin and ghrelin concentrations in normoglycemic 40- to 80-year-old Filipino, African-American, and white women.

METHODS

Participants included women from the Rancho Bernardo Study (n = 143), the University of California-San Diego Filipino Women's Health Study (n = 136), and the Health Assessment Study of African-American Women (n = 212). A 2-hour oral glucose tolerance test was administered; glucose, insulin, lipid, and anthropometric measurements were obtained. Fasting adiponectin and ghrelin were measured by radioimmunoassay.

RESULTS

Whites and Filipinas had similar BMI (23.7 and 24.3 kg/m(2), respectively), waist girth (75.6 and 77.2 cm, respectively), and total body fat (27.4 and 28.5%, respectively); African-Americans had significantly larger BMI (28.8 kg/m(2)), waist girth (86.3 cm), and body fat (39.6%, p < 0.0001). Adiponectin was lower in Filipinas (8.90 mug/mL) and African-Americans (9.67 mug/mL) compared with whites (15.6 mug/mL, p < 0.001) after adjusting for age, homeostasis model assessment of insulin resistance (HOMA-IR), and waist-to-hip ratio. Compared with whites, Filipinas (beta = -5.06, p < 0.0001) and African-Americans (beta = -6.85, p < 0.0001) had significantly lower adiponectin levels after adjusting for age, waist-to-hip ratio, HOMA-IR, triglycerides, high-density lipoprotein (HDL) cholesterol, exercise, and alcohol use. Ghrelin was significantly lower in Filipinas compared with African-Americans (1146.9 vs. 1412.2 pg/mL, p < 0.001), and this observation persisted in multivariable analysis (beta = -245.4, p < 0.0001). Ghrelin levels did not differ between whites (1356.9 pg/mL) and either ethnic group.

DISCUSSION

Normoglycemic Filipino and African-American women had significantly lower adiponectin concentrations than white women, and Filipinas had lower ghrelin levels than African-Americans, independently of body size or indices of insulin resistance or lipids.

Unprotected anal intercourse and substance use before and after HIV diagnosis among recently HIV-infected men who have sex with men

OBJECTIVE

The objective of this study was to assess associations between unprotected anal intercourse (UAI) and substance use before and after HIV diagnosis among recently HIV-infected MSM.

STUDY DESIGN

Two hundred seven MSM completed computer-assisted self-interviews regarding type and timing of sexual activity and substance use with their last 3 partners. Date of HIV diagnosis was extracted from medical records. Generalized estimating equations, including interaction terms, were used to assess associations between substance use and UAI before and after HIV diagnosis.

RESULTS

Among partners with whom sexual activity occurred before diagnosis, UAI was associated with methamphetamine use alone (odds ratio = 7.12) and a combination of methamphetamine and other substances (odds ratio = 4.06). However, after HIV diagnosis, UAI was associated with use of substances other than methamphetamine (odds ratio = 3.36), but not methamphetamine alone.

CONCLUSIONS

Use of illicit substances may be differentially associated with UAI based on knowledge of HIV status and could have implications for prevention of HIV transmission.

Performance of rapid HIV testing using Determine HIV-1/2 for the diagnosis of HIV infection during pregnancy in Tijuana, Baja California, Mexico

The aim of this study was to evaluate the performance of the rapid antibody test Determine HIV-1/2, in pregnant women at Tijuana General Hospital. Pregnant women seeking prenatal care or admitted in labour had blood drawn for a rapid HIV test (Determine HIV-1/2), enzyme immunoassay (EIA) and Western blot. Between March and November 2003, 1068 women in labour and 1529 women in prenatal care were enrolled. The sensitivity, specificity, positive and negative predictive values were 100%, 99.8%, 77% and 100%, respectively. For women in labour, the mean time between blood collection and rapid test results was 92 minutes (range: 20-205 minutes) compared with 41 hours (range 24-120 hours) for HIV EIA (P = 0.012). All HIV-exposed infants received oral zidovudine. These findings indicate that the rapid test Determine HIV-1/2 has a high sensitivity and specificity in pregnant women. Rapid HIV testing greatly diminishes the time to diagnosis and enables prompt intervention with antiretrovirals at delivery.

Diabetes and coronary heart disease in Filipino-American women: role of growth and life-course socioeconomic factors

OBJECTIVE

To investigate associations between adult markers of childhood growth and the prevalence of diabetes and coronary heart disease (CHD) in Filipino-American women and to determine the role of social and educational differences, including the influence of social mobility between childhood and adulthood.

RESEARCH DESIGN AND METHODS

Socioeconomic disadvantage and poor infant growth, resulting in short leg length, may contribute to the dramatically increased risk of diabetes and CHD in Filipino-American women, but this has not been investigated. This study is a cross-sectional study of 389 Filipino-American women (age 58.7 +/- 9.4 years [mean +/- SD]). Diabetes was defined by 1999 World Health Organization criteria and CHD by ischemic electrocardiogram changes, Rose angina, a history of myocardial infarction, or revascularization surgery. A score of social mobility (0-4) was calculated by summarizing childhood and adult financial circumstances.

RESULTS

Diabetes prevalence (31.4%) was not associated with measures of growth but was significantly lower in women with greater education, childhood and adult income, or social mobility score. Compared with Filipinas who were poorest in childhood and adulthood, respective odds ratios (95% CI) for diabetes were 0.55 (0.18-1.68), 0.19 (0.06-0.62), and 0.11 (0.03-0.42), down to 0.07 (0.01-0.51) in the most advantaged women (P < 0.0001). Family history of diabetes [5.14 (2.72-9.70)] and larger waist [1.07 per cm (1.03-1.10)] were also significant predictors in multiple adjusted models. In contrast, CHD prevalence (22.4%) was most strongly associated with leg length, but not trunk length; compared with individuals with the shortest legs, respective odds ratios (95% CI) for CHD were 0.60 (0.31-1.19), 0.53 (0.26-1.05), and 0.44 (0.22-0.91) in the tallest group, in age- (P(trend) = 0.02) and multiple-adjusted models (P(trend) = 0.01).

CONCLUSIONS

Socioeconomic disadvantage contributes to the high prevalence of diabetes in Filipinas. Factors limiting early growth of the legs may increase the risk of CHD in this comparatively short population.

Unprotected anal intercourse and substance use among men who have sex with men with recent HIV infection

OBJECTIVES

To examine within-subjects and combined between- and within-subjects associations between substance use and unprotected anal intercourse (UAI) among men who have sex with men (MSM) with recent HIV infection.

METHODS

One hundred ninety-four MSM who were recently infected with HIV completed a computer-assisted questionnaire regarding sexual behaviors and substance use with their last 3 partners. Associations between UAI and substance use were assessed using conditional logistic regression (CLR) to assess associations among the 116 MSM reporting UAI with some but not all partners and generalized linear mixed effects models (GLMMs) to examine a combination of within- and between-subjects associations in the entire sample (N = 194).

RESULTS

In multivariate CLR models and GLMMs, UAI was associated with the use of methamphetamine (odds ratio [OR] = 4.9 and OR = 3.5, respectively), marijuana (OR = 4.0 and OR = 2.2, respectively) and erectile dysfunction medications (EDMs) when used with a main partner (OR = 13.8 and OR = 10.1, respectively).

CONCLUSIONS

Results indicate that a direct association may exist between specific substances and UAI and provide evidence that the use of methamphetamine and EDMs may contribute to HIV transmission.

Hyperglycemia and type 2 diabetes among Filipino women in the Philippines, Hawaii, and San Diego

BACKGROUND

Diabetes risk increases as immigrant populations adopt western lifestyles. We compared the prevalence of fasting hyperglycemia among Filipino women aged 40-79 years in the Philippines, Hawaii, and San Diego.

METHODS

Data were obtained from the (1) Philippine National Nutrition Survey (1998), (2) Native Hawaiian Health Research Project (1997-2001), and (3) University of California San Diego Filipino Women's Health Study (1995-1999). Fasting glucose after an 8h fast, blood pressure, and body mass index (BMI) were measured in all three regions; a 75 g oral glucose tolerance test was performed in San Diego and Hawaii.

RESULTS

The proportion of Filipinas with BMI > or = 30 kg/m2 was higher in Hawaii (20%) compared to women in San Diego (9.3%) or the Philippines (5.2%, p<0.001). Fasting hyperglycemia prevalence (fasting plasma glucose > or = 126 mg/dl or fasting whole blood glucose > or = 110 mg/dl) did not differ among Filipinas in the Philippines (11.8%), San Diego (14.1%), and Hawaii (14.7%, p = 0.323). Type 2 diabetes prevalence was similar among Filipinas in San Diego (31.6%) and Hawaii (24.9%, p = 0.79).

CONCLUSIONS

Despite regional differences in obesity, fasting hyperglycemia was similar among Filipinas in the Philippines, San Diego, and Hawaii and type 2 diabetes prevalence was similar among Filipinas in San Diego and Hawaii.

Perinatal HIV Counseling and Rapid Testing in Tijuana, Baja California, Mexico

OBJECTIVE

To evaluate the acceptance of counseling and rapid HIV testing and to determine the associated risk factors for HIV infection in pregnant women in Baja California, Mexico.

METHODS

Pregnant women attending Tijuana General Hospital who consented to participate in the study had blood drawn for a rapid HIV test (Determine HIV-1/2; Abbott Diagnostics, North Chicago, IL). A confirmatory enzyme immunoassay and Western blot were performed and demographic and risk factor data were obtained.

RESULTS

From March to November 2003, 1529 (92.5%) of 1653 women who sought prenatal care and 1068 (95.2%) of 1122 women in labor consented to participate. HIV seroprevalence was significantly higher among women screened during labor (12/1068, 1.12%) compared with those seeking prenatal care (5/1529, 0.33%). HIV-infected women were significantly more likely to use injection drugs (12% vs. 1%, P = 0.02), "other" drugs, including methamphetamine, marijuana, and cocaine (65% vs. 6%, P < 0.001), to have more sex partners (3.6 vs. 2.6, P = 0.0002), to not have received prenatal care (41% vs. 13%, P = 0.03), and to have a spouse/partner who used injection drugs (36% vs. 4%, P < 0.001) or "other" drugs (73% vs. 23%, P < 0.001). In multivariate regression analysis, use of methamphetamine (adjusted odds ratio, 17.8, 95% CI, 5.6-56) was independently associated with the risk of HIV infection.

CONCLUSIONS

These findings indicate a wide acceptance of HIV counseling and testing and document a higher HIV seroprevalence among pregnant women delivering at Tijuana General Hospital than current established estimates in Mexico.

Ethnic differences in visceral adipose tissue and type 2 diabetes: Filipino, African-American, and white women

OBJECTIVE

To compare ethnic differences in visceral adipose tissue (VAT), assessed by computed tomography, and type 2 diabetes risk among 55- to 80-year-old Filipino, African-American, and white women without known cardiovascular disease.

RESEARCH METHODS AND PROCEDURES

Subjects were participants in the Rancho Bernardo Study (n = 196), the Filipino Women's Health Study (n = 181), and the Health Assessment Study of African-American Women (n = 193). Glucose and anthropometric measurements were assessed between 1995 and 2002.

RESULTS

African-American women had significantly higher age-adjusted BMI (29.7 kg/m(2)) and waist girth (88.1 cm) compared with Filipino (BMI, 25.5 kg/m(2); waist girth, 81.9 cm) or white (BMI: 26.0 kg/m(2); waist girth: 80.7 cm) women. However, VAT was significantly higher among Filipino (69.1 cm(3)) compared with white (62.3 cm(3); p = 0.037) or African-American (57.5 cm(3), p < 0.001) women. VAT correlated better with BMI (r = 0.69) and waist (r = 0.77) in whites, compared with Filipino (r = 0.42; r = 0.59) or African-American (r = 0.50; r = 0.56) women. Age-adjusted type 2 diabetes prevalence was significantly higher in Filipinas (32.1%) than in white (5.8%) or African-American (12.1%) women. Filipinas had higher type 2 diabetes risk compared with African Americans [adjusted odds ratio, 2.30; 95% confidence interval (CI), 1.09 to 4.86] or whites (adjusted odds ratio, 7.51; 95% CI, 2.51 to 22.5) after adjusting for age, VAT, exercise, education, and alcohol intake.

DISCUSSION

VAT was highest among Filipinas despite similar BMI and waist circumference as whites. BMI and waist circumference were weaker estimates of VAT in Filipino and African-American women than in whites. Type 2 diabetes prevalence was highest among Filipino women at every level of VAT, but VAT did not explain their elevated type 2 diabetes risk.

Subclinical Coronary Atherosclerosis in Asymptomatic Filipino and White Women

Background— Coronary heart disease (CHD) is the leading cause of morbidity and mortality in persons with type 2 diabetes mellitus (T2DM). Electron-beam computed tomography (EBCT) detects coronary artery calcium (CAC), a marker of atherosclerotic plaque. Few studies have described EBCT-defined CHD among ethnic minorities with elevated T2DM prevalence. The objective of this study was to compare EBCT-defined CAC in Filipino and white women without known cardiovascular disease.

Methods and Results— Subjects were participants aged 55 to 78 years in the Rancho Bernardo Study (n=196) and the University of California at San Diego’s Filipino Women’s Health Study (n=181). Glucose, blood pressure, lipids, anthropometric measurements, and lifestyle factors were measured from 1995 to 1999. EBCT-defined CAC scores, visceral and subcutaneous fat, and statin use were assessed in 2001 to 2002. Compared with whites, Filipinas had a significantly higher prevalence of T2DM (32.6% versus 6.1%, P <0.001) and the metabolic syndrome (32.6% versus 13.8, P <0.001). Filipinas were younger (64.4 versus 66.7 years), had higher triglyceride levels (155 versus 135 mg/dL), had a higher ratio of total cholesterol to HDL cholesterol (4.3 versus 3.5), more frequently used statins (31% versus 19%), and had more visceral fat (69.4 versus 62.1 cm 3 ) and lower HDL cholesterol levels (54 versus 66 mg/dL) than whites. Exercise frequency, body mass index, and waist girth did not differ by ethnicity. Nevertheless, extensive (CAC score ≥400; 9% versus 9%) and moderate (CAC score 150 to 399; 13% versus 11%) atherosclerotic plaque did not differ by ethnicity, even after adjustment for age, T2DM, hypertension, estrogen use, statin use, smoking, lipids, and visceral fat.

Conclusions— Filipinas had no excess of subclinical atherosclerosis despite their significantly higher prevalence of T2DM, the metabolic syndrome, hypertension, and visceral adiposity.

Conception and pregnancy during the Persian Gulf War: the risk to women veterans

PURPOSE

To enumerate Gulf-War (GW) exposed conceptions and to compare reproductive outcomes of GW-exposed pregnancies with postwar conceptions of women Gulf War veterans (GWV) and women nondeployed veterans (NDV).

METHODS

Deployment data and inpatient records from 153 military hospitals identified servicewomen who were pregnant between August 1990 and May 1992 and belonged to military units that were deployed to the Gulf War. Postal surveys were used in 1997 and 1998 to elicit reproductive history; responses were validated against military hospitalization records. Reproductive outcomes of GW-exposed pregnancies were compared with postwar conceptions of women GWVs and NDVs.

RESULTS

3285 women had a pregnancy-related admission; of these, 1558 completed the questionnaire. Self-reported reproductive outcomes and dates, gestational data, and individual deployment dates identified 415 Gulf War-exposed pregnancies, 298 GWV postwar conceptions, and 427 NDV conceptions. Compared with NDV conceptions, adverse reproductive outcomes were similar among GW-exposed pregnancies. However, spontaneous abortions [NDV: 9.1%, GWV postwar: 22.8%, adjusted odds ratio (OR)=2.92, 95% confidence interval (CI): 1.9, 4.6] and ectopic pregnancies (NDV: 1.4%, GWV postwar: 10.7%, adjusted OR=7.70, 95% CI, 3.0, 20) were elevated for GWV postwar conceptions.

CONCLUSION

GW-exposed conceptions and nondeployed conceptions had similar outcomes. However, GWV postwar conceptions were at increased risk for ectopic pregnancies and spontaneous abortions.