Telemedicine for the Underserved Racial and Ethnic Minorities During COVID-19 and Beyond

Objective: To demonstrate that a culturally and linguistically appropriate telehealth protocol can be implemented to improve the glycemic control of patients as an extension of regular clinical services and provide continuity of care. Methods: A telehealth platform was established during COVID-19 pandemic and from numerous telehealth encounters we sampled 498 patients who received telehealth intervention over a 12-month period for specific services: Rx refill, consultation for laboratory results, wellness evaluation and education, and acute or sick visits with appropriate referrals. This telehealth platform was integrated with a remote patient monitoring system utilizing a Bluetooth-enabled glucometer for patients with diabetes compared to their abnormal baseline hemoglobin A1C (HgA1C). The Blood sugar values were recorded at predefined intervals to monitor controls for diabetes. The ethnic diversity and level of education of patients required addressing the digital divide, language interpretation, and navigation at each monitoring step. Results: This method demonstrated that a culturally and linguistically appropriate telehealth protocol can be implemented to improve the glycemic control of patients in an intervention group compared with a control group. Validation of the glycemic control was based on 70 patients identified as eligible for participation based on the inclusion criteria: a HgA1C level of 7% or higher obtained within the last 10 months. Informed consent was obtained for 42 participants based on patient participation constraints during the COVID-19 pandemic. Conclusions: We conclude that telemedicine procedures utilized for patients with little or no prior knowledge of remote self-monitoring methods can support their treatment of chronic diseases, such as diabetes. The outcomes from the implementation of telemedicine services were observed in a well-defined group of underserved racial and ethnic minority patients at our clinic. We now have a protocol to expand this to other chronic diseases and used as a regular clinical procedure.

The epidemiology of acne vulgaris in a multiethnic adolescent population from Rotterdam, the Netherlands: A cross-sectional study

BACKGROUND

Although acne is a prevalent multifactorial inflammatory skin condition, few studies were performed in multiethnic populations.

OBJECTIVES

To study the prevalence and determinants of acne in a multiethnic study at the start of puberty.

METHODS

This cross-sectional study is embedded in Generation R, a population-based prospective study from Rotterdam, the Netherlands. Three-dimensional facial photos at the center visit in 2016-2019 (of ∼13-year-olds) were used to grade acne severity using the Global Evaluation of the Acne Severity (GEA). Analyses were stratified by biological sex and explored through chi-square tests and multivariable ordinal logistic regression.

RESULTS

A total of 4561 children (51% girls) with a median age of 13.5 (IQR 13.3-13.6) were included. The visible acne prevalence (GEA 2-5) for girls vs boys was 62% vs 45% and moderate-to-severe acne (GEA 3-5) 14% vs 9%. Higher puberty stages (adjusted odds ratios: 1.38 [1.20-1.59] and 2.16 [1.86-2.51] for girls and boys, respectively) and darker skin colors V and VI (adjusted odds ratios: 1.90 [1.17-3.08] and 2.43 [1.67-3.56]) were associated with more severe acne in both sexes, and being overweight in boys (adjusted odds ratio: 1.58 [1.15-2.17]).

LIMITATIONS

Cross-sectional design.

CONCLUSIONS

Acne prevalence was high at the age of 13 years and was associated with advanced puberty, darker skin color, and weight status.

Incidence, clinical features, and outcomes of posterior circulation ischemic stroke: insights from a large multiethnic stroke database

Background

Posterior cerebral circulation ischemic stroke (PCS) comprises up to 25% of all strokes. It is characterized by variable presentation, leading to misdiagnosis and morbidity and mortality. We aim to describe PCS in large multiethnic cohorts.

Methods

A retrospective review of a large national stroke database from its inception on the 1st of January 2014 till 31 December 2020. Incidence per 100,000 adult population/year, demographics, clinical features, stroke location, and outcomes were retrieved. We divided the cohort into patients from MENA (Middle East and North Africa) and others.

Results

In total, 1,571 patients were identified. The incidence of PCS was observed to be rising and ranged from 6.3 to 13.2/100,000 adult population over the study period. Men were 82.4% of the total. The mean age was 54.9 ± 12.7 years (median 54 years, IQR 46, 63). MENA patients comprised 616 (39.2%) while others were 954 (60.7%); of these, the majority (80.5%) were from South Asia. Vascular risk factors were prevalent with 1,230 (78.3%) having hypertension, 970 (61.7%) with diabetes, and 872 (55.5%) having dyslipidemia. Weakness (944, 58.8%), dizziness (801, 50.5%), and slurred speech (584, 36.2%) were the most commonly presenting symptoms. The mean National Institute of Health Stroke Score (NIHSS) score was 3.8 ± 4.6 (median 3, IQR 1, 5). The overall most frequent stroke location was the distal location (568, 36.2%). The non-MENA cohort was younger, less vascularly burdened, and had more frequent proximal stroke location (p < 0.05). Dependency or death at discharge was seen in 39.5% and was associated with increasing age, and proximal and multilocation involvement; while at 90 days it was 27.4% and was associated with age, male sex, and having a MENA nationality (p < 0.05).

Conclusion

In a multiethnic cohort of posterior circulation stroke patients from the MENA region and South Asia, we noted a rising incidence over time, high prevalence of vascular risk factors, and poor outcomes in older men from the MENA region. We also uncovered considerable disparities between the MENA and non-MENA groups in stroke location and outcome. These disparities are crucial factors to consider when tailoring individualized patient care plans. Further research is needed to thoroughly investigate the underlying reasons for these variations.

Genome-wide polygenic risk score for rheumatoid arthritis prediction in postmenopausal women

BACKGROUND

Rheumatoid arthritis (RA), a common autoimmune disease, exhibits a vital genetic component. Polygenic risk scores (PRS) derived from genome-wide association studies (GWAS) offer potential utility in predicting disease susceptibility. The present study aimed to develop and validate a PRS for predicting RA risk in postmenopausal women.

METHODS

The study developed a novel PRS using 225,000 genetic variants from a GWAS dataset. The PRS was developed in a cohort of 8967 postmenopausal women and validated in an independent cohort of 6269 postmenopausal women. Among the development cohort, approximately 70% were Hispanic and approximately 30% were African American. The testing cohort comprised approximately 50% Hispanic and 50% Caucasian individuals. Stratification according to PRS quintiles revealed a pronounced gradient in RA prevalence and odds ratios.

RESULTS

High PRS was significantly associated with increased RA risk in individuals aged 60-70 years, ≥ 70 years, and overweight and obese participants. Furthermore, at age 65 years, individuals in the bottom 5% of the PRS distribution have an absolute risk of RA at 30.6% (95% confidence interval = 18.5%-42.6%). The risk increased to 53.8% (95% confidence interval = 42.8%-64.9%) for those in the top 5% of the PRS distribution.

CONCLUSIONS

The PRS developed in the present study is significantly associated with RA risk, showing the potential for early screening of RA in postmenopausal women. This work demonstrates the feasibility of personalized medicine in identifying high-risk individuals for RA, indicating the need for further studies to test the utility of PRS in other populations.

Novel Size-Based High-Density Lipoprotein Subspecies and Incident Vascular Events

Background High-density lipoprotein (HDL) particle concentration likely outperforms HDL cholesterol in predicting atherosclerotic cardiovascular events. Whether size-based HDL subspecies explain the atheroprotective associations of HDL particle concentration remains unknown. Our objective was to assess whether levels of specific size-based HDL subspecies associate with atherosclerotic cardiovascular disease in a multiethnic pooled cohort and improve risk prediction beyond traditional atherosclerotic cardiovascular disease risk factors. Methods and Results Seven HDL size-based subspecies were quantified by nuclear magnetic resonance (LP4 algorithm; H1=smallest; H7=largest) among participants without prior atherosclerotic cardiovascular disease in ARIC (Atherosclerosis Risk in Communities), MESA (Multi-Ethnic Study of Atherosclerosis), PREVEND (Prevention of Renal and Vascular Endstage Disease), and DHS (Dallas Heart Study) cohorts (n=15 371 people). Multivariable Cox proportional hazards models were used to evaluate the association between HDL subspecies and incident myocardial infarction (MI) or ischemic stroke at follow-up (average 8-10 years) adjusting for HDL cholesterol and risk factors. Improvement in risk prediction was assessed via discrimination and reclassification analysis. Within the pooled cohort (median age 57 years; female 54%; Black 22%) higher H1 (small) and H4 (medium) concentrations were inversely associated with incident MI (hazard ratio [HR]/SD, H1 0.88 [95% CI, 0.81-0.94]; H4 0.89 [95% CI, 0.82-0.97]). H4 but not H1 improved risk prediction indices for incident MI. Increasing H2 and H4 were inversely associated with improved risk prediction indices for composite end point of stroke, MI, and cardiovascular death (HR/SD, H2 0.94 [95% CI, 0.88-0.99]; H4 0.91 [95% CI, 0.85-0.98]). Levels of the large subspecies (H6 and H7) were not associated with any vascular end point. Conclusions Two of 7 HDL size-based subspecies modestly improved risk prediction for MI and composite vascular end points in a large multiethnic pooled cohort. These findings support assessment of precise HDL subspecies for future studies regarding clinical utility.

Association of Endocrine Disrupting Chemicals With the Metabolic Syndrome Among Women in the Multiethnic Cohort Study

Metabolic syndrome (MetS) is associated with a high risk of cardiovascular disease, a leading cause of death among women. MetS is a diagnosis of at least 3 of the following: high blood pressure, high fasting glucose, high triglycerides, high waist circumference, and low high-density lipoprotein cholesterol. Epidemiological studies suggest that endocrine disrupting chemical (EDC) exposure is positively associated with individual components of MetS, but evidence of an association between EDCs and MetS remains inconsistent. In a cross-sectional analysis within the Multiethnic Cohort Study, we evaluated the association between 4 classes of urinary EDCs (bisphenol A [BPA], triclosan, parabens, and phthalates) and MetS among 1728 women. Multivariable logistic regression was used to estimate odds ratios and 95% CI for the association between tertiles of each EDC and MetS adjusting for age, body mass index (BMI), racial and ethnic group, and breast cancer status. Stratified analyses by race and ethnicity and BMI were conducted. MetS was identified in 519 (30.0%) women. We did not detect statistically significant associations of MetS with BPA, triclosan, or phthalate metabolite excretion. MetS was inversely associated with total parabens (Ptrend = .002). Although there were suggestive inverse associations between EDCs and MetS among Latino and African American women, and women with BMI < 30 kg/m2, there was no statistically significant heterogeneity in associations by race and ethnicity or BMI. These findings suggest an inverse association between parabens and MetS in larger multiethnic studies. Prospective analyses to investigate suggested differences in associations by race, ethnicity, and BMI are warranted.

Clinical Outcomes and Quantitative HBV Surface Antigen Levels in Diverse Chronic Hepatitis B Patients in Canada: A Retrospective Real-World Study of CHB in Canada (REVEAL-CANADA)

BACKGROUND

Hepatitis B surface antigen (HBsAg) loss is associated with improved clinical outcomes for individuals with chronic hepatitis B (CHB); however, the effects of varying HBsAg levels on clinical outcomes in diverse cohorts are understudied.

METHODS

In this cross-sectional, multicentre, retrospective study, the data on adult subjects enrolled in the Canadian HBV Network with CHB seen from 1 January 2012 to 30 January 2021 with the treatment and virologic data within 1 year of HBsAg testing were analyzed. Patients were tested for HBsAg using qualitative (for HBsAg-negative samples) and/or commercial quantitative assays. Fibrosis or hepatic necroinflammation was determined by the liver stiffness measurement (LSM). The baseline data were summarized using descriptive statistics and compared by using univariable/multivariable analyses.

RESULTS

This study included 844 CHB patients, with a median age of 49.6 years (IQR 40.1-60.5), and 37% were female. In total, 751 patients (78.6%) had known ethnicity data, and 76.7% self-reported as Asian, 11.4% as Black, 6.8% as White, and 4.8% as other. Among the 844 patients, 237 (28.0%) were HBsAg (-) (<LLOQ), 190 (22.5%) had qHBsAg 1-100, 91 (10.8%) had qHBsAg 100-500, 54 (6.4%) had qHBsAg 500-1000, and 272 (32.2%) had qHBsAg >1000 IU/mL. Overall, 80% (682) had known HBeAg status at the last follow-up, and the majority (87.0%) were HBeAg-negative. In addition, 54% (461/844) had prior antiviral therapy, 19.7% of which (16.3, 23.7, n = 91) were HBsAg (-). The treated patients had a lower risk of cirrhosis (16.46, 95% CI 1.89-143.39, p = 0.01) or HCC (8.23, 95% CI 1.01-67.39, p = 0.05) than the untreated patients. A lower proportion of the HBsAg-loss group had cirrhosis (5.7% vs. 10.9%, p = 0.021) and HCC (0.9% vs. 6.2%, p = 0.001).

CONCLUSION

In this retrospective, ethnically diverse cohort study, CHB patients who received antiviral therapy and/or had HBsAg loss were less likely to develop cirrhosis and HCC, confirming the results of the studies in less diverse cohorts. No association was found between the qHBsAg level and fibrosis determined with LSM. Individuals who achieved HBsAg loss had low-level qHBsAg within 1 year of seroclearance.

Racial, ethnic, and socioeconomic differences in a deficit accumulation frailty index in the Multiethnic Cohort Study

BACKGROUND

Frailty status has been sparsely studied in some groups including Native Hawaiians and Asian Americans.

METHODS

We developed a questionnaire-based deficit accumulation frailty index (FI) in the Multiethnic Cohort (MEC), and examined frailty status (robust, FI 0-<0.2, prefrail, FI 0.2-<0.35, and frail FI ≥0.35) among 29,026 men and 40,756 women.

RESULTS

After adjustment for age, demographic, lifestyle factors and chronic conditions, relative to White men, odds of being frail was significantly higher (34% to 54%) among African American, Native Hawaiian and other Asian American men while odds was significantly lower (36%) in Japanese American men and did not differ in Latino men. However, among men who had high school or less, none of the groups displayed significantly higher odds of prefrail or frail compared to White men. Relative to White women, odds of being frail were significantly higher (14% to 33%) in African American and Latino women, did not differ for other Asian American women and lower (14% to 36%) in Native Hawaiian and Japanese American women. These racial and ethnic differences in women were observed irrespective of education. Risk of all-cause mortality was higher in prefrail and frail men than robust men (adjusted hazard ratio (HR)=1.69, 1.59-1.81; HR=3.27, 3.03-3.53); results were similar in women. All cause-mortality was significantly positively associated with frailty status and frailty score across all sex, race and ethnic groups.

CONCLUSIONS

Frailty status differed significantly by race and ethnicity and was consistently associated with all-cause mortality. The FI may be a useful tool for aging studies in this multiethnic population.

Phenome-Wide Association Study of UMOD Gene Variants and Differential Associations With Clinical Outcomes Across Populations in the Million Veteran Program a Multiethnic Biobank

Introduction

Common variants in the UMOD gene are considered an evolutionary adaptation against urinary tract infections (UTIs) and have been implicated in kidney stone formation, chronic kidney disease (CKD), and hypertension. However, differences in UMOD variant-phenotype associations across population groups are unclear.

Methods

We tested associations between UMOD/PDILT variants and up to 1528 clinical diagnosis codes mapped to phenotype groups in the Million Veteran Program (MVP), using published phenome-wide association study (PheWAS) methodology. Associations were tested using logistic regression adjusted for age, sex, and 10 principal components of ancestry. Bonferroni correction for multiple comparisons was applied.

Results

Among 648,593 veterans, mean (SD) age was 62 (14) years; 9% were female, 19% Black, and 8% Hispanic. In White patients, the rs4293393 UMOD risk variant associated with increased uromodulin was associated with increased odds of CKD (odds ratio [OR]: 1.22, 95% CI: 1.20-1.24, P = 5.90 × 10-111), end-stage kidney disease (OR: 1.17, 95% CI: 1.11-1.24, P = 2.40 × 10-09), and hypertension (OR: 1.03, 95% CI: 1.05-1.05, P = 2.11 × 10-06) and significantly lower odds of UTIs (OR: 0.94, 95% CI: 0.92-0.96, P = 1.21 × 10-10) and kidney calculus (OR: 0.85, 95% CI: 0.83-0.86, P = 4.27 × 10-69). Similar findings were observed across UMOD/PDILT variants. The rs77924615 PDILT variant had stronger associations with acute cystitis in White female (OR: 0.73, 95% CI: 0.59-0.91, P = 4.98 × 10-03) versus male (OR: 0.99, 95% CI: 0.89-1.11, P = 8.80 × 10-01) (P interaction = 0.01) patients. In Black patients, the rs77924615 PDILT variant was significantly associated with pyelonephritis (OR: 0.65, 95% CI: 0.54-0.79, P = 1.05 × 10-05), whereas associations with UMOD promoter variants were attenuated.

Conclusion

Robust associations were observed between UMOD/PDILT variants linked with increased uromodulin expression and lower odds of UTIs and calculus and increased odds of CKD and hypertension. However, these associations varied significantly across ancestry groups and sex.

Trajectories of e-cigarette advertising exposure, e-cigarette use and cigarette smoking in a sample of young adults from Hawaii

AIM

To test whether intrapersonal growth in e-cigarette advertising exposure over time is associated with growth in e-cigarette use and/or cigarette smoking.

DESIGN

Longitudinal study using four waves of data were collected in 6-month intervals between 2018 and 2020.

SETTING AND PARTICIPANTS

Participants were 2327 young adults recruited from colleges in Hawaii, USA.

MEASUREMENTS

Data were collected on demographics, e-cigarette advertising exposure measured using the cued- recall method and recent (past 30-day) cigarette and e-cigarette use.

FINDINGS

The average trajectory for e-cigarette advertising exposure over time was significant and upward [M slope = 0.18 (0.14-0.22), P < 0.0001]. However, average trajectories for e-cigarette [M slope = -0.08 (-0.18 to 0.02), P = 0.09] and cigarette [M slope = -0.14 (-0.30 to 0.02), P = 0.07] use were not. There were significant differences in individual level trajectories across participants for advertising exposure [σ2  = 0.12 (0.10-0.14), P < 0.0001], e-cigarette use [σ2  = 0.22 (0.14-0.30), and cigarette smoking (σ2  = 0.17 [0.09-0.25], P < 0.0001). Individuals with an increasing rate of advertising exposure showed an increasing rate of e-cigarette use [B = 0.63 (0.36-0.90), P < 0.0001). Neither initial level of, nor rate of change in, advertising exposure was significantly associated with cigarette smoking growth factors (P > 0.05). Higher initial level of e-cigarette use was associated with higher initial level of cigarette smoking [B = 0.89 (0.69-1.09), P < 0.0001] but decreased rate of cigarette smoking over time [B = -0.12 (-0.20 to -0.04) P = 0.003]. Rate of change in e-cigarette use was not associated with the rate of change in cigarette smoking (P > 0.05).

CONCLUSIONS

Increased exposure to e-cigarette advertising appears to be associated with increased e-cigarette use but not with increased cigarette smoking. Higher initial level of e-cigarette use appears to be associated with higher initial level of cigarette smoking but may be associated with a decreasing rate of cigarette smoking over time.

The Incidence and Anatomic Variation of Os Naviculare in a Multiethinic Asian Population

The incidence of asymptomatic os naviculare ranges from 4% to 21%, varying between different ethnicities, with majority of studies performed in Caucasians. The aim of this study was to document the incidence of asymptomatic os naviculare in an Asian population stratified by ethnicity, and to characterize the features of each type. The records of all patients who underwent dorsoplantar and oblique foot radiographs between July and December 2017 were reviewed. We excluded patients with medial-sided foot pain. The radiographs of the remaining patients were reviewed and the incidence and type of os naviculare according to Coughlin's classification were recorded. About 439 patients were included. The overall incidence of asymptomatic os naviculare was 46.0%, of which 76.7% were bilateral. The prevalence of type Ia, Ib, and Ic os was 7.5%, 6.2%, and 5.9%, respectively. The prevalence of type IIAa, IIAb, IIAc, IIBa, IIBb, and IIBc was 2.7%, 0.7%, 0.2%, 16.6%, 5.9%, and 2.1%, respectively. The prevalence of type IIIa, IIIb, and IIIc was 1.1%, 8.4%, and 0.2%. Type IIBa had the highest prevalence of 16.6% out of 439 patients. The highest incidence of os naviculare was in the Chinese population (n = 145, p = .034) at 50.2%. There was no significant gender difference in the incidence of asymptomatic os naviculare. The incidence of asymptomatic os naviculare in a multiethnic Asian population is higher than that reported in other populations, and particularly in the Chinese. Type IIBa was the most prevalent type, which differs from previous reports. When treating patients of Chinse ethnicity who present with pain over the medial aspect of the foot, the diagnosis of a symptomatic os naviculare should be considered.

Associations of the Dietary Inflammatory Index with total adiposity and ectopic fat through the gut microbiota, LPS, and C-reactive protein in the Multiethnic Cohort-Adiposity Phenotype Study

BACKGROUND

Mechanisms linking a proinflammatory diet to obesity remain under investigation. The ability of diet to influence the gut microbiome (GM) in creating chronic low-grade systemic inflammation provides a plausible connection to adiposity.

OBJECTIVES

Assess whether any associations seen between the Energy-Adjusted Dietary Inflammatory Index (E-DII score), total fat mass, visceral adipose tissue (VAT), or liver fat (percentage volume) operated through the GM or microbial related inflammatory factors, in a multiethnic cross-sectional study.

METHODS

In the Multiethnic Cohort-Adiposity Phenotype Study (812 men, 843 women, aged 60-77 y) we tested whether associations between the E-DII and total adiposity, VAT, and liver fat function through the GM, LPS, and high-sensitivity C-reactive protein (hs-CRP). DXA-derived total fat mass, MRI-measured VAT, and MRI-based liver fat were measured. Participants provided stool and fasting blood samples and completed an FFQ. Stool bacterial DNA was amplified and the 16S rRNA gene was sequenced at the V1-V3 region. E-DII score was computed from FFQ data, with a higher E-DII representing a more proinflammatory diet. The associations between E-DII score, GM (10 phyla, 28 genera, α diversity), and adiposity phenotypes were examined using linear regression and mediation analyses, adjusting for confounders.

RESULTS

There were positive total effects (c) between E-DII and total fat mass (c = 0.68; 95% CI: 0.47, 0.90), VAT (c = 4.61; 95% CI: 2.95, 6.27), and liver fat (c = 0.40; 95% CI: 0.27, 0.53). The association between E-DII score and total fat mass was mediated by LPS, Flavonifractor, [Ruminococcus] gnavus group, and Tyzzerella. The association between E-DII score and ectopic fat occurred indirectly through Fusobacteria, Christensenellaceae R-7 group, Coprococcus 2, Escherichia-Shigella, [Eubacterium] xylanophilum group, Flavonifractor, Lachnoclostridium, [Ruminococcus] gnavus group, Tyzzerella, [Ruminococcus] gnavus group (VAT only), and α diversity (liver fat only). There was no significant association between E-DII score and adiposity phenotype through hs-CRP.

CONCLUSIONS

Associations found between E-DII and adiposity phenotypes occurred through the GM and LPS.

Metformin use and mortality and length of stay among hospitalized patients with type 2 diabetes and COVID-19: A multiracial, multiethnic, urban observational study

INTRODUCTION

Diabetes mellitus is a common comorbidity among patients with coronavirus disease 2019 (COVID-19). Diabetic patients with COVID-19 have a two-fold increased risk of death and tend to have more severe infection compared to the general population. Metformin, a first-line medication for diabetes management, has anti-inflammatory and immunomodulatory effects. Previous studies focusing on metformin and COVID-19 clinical outcomes have had mixed results, with some showing a mortality benefit or decreased complications with metformin use. To date, few studies have analyzed such outcomes among a diverse, multiracial community.

METHODS

This was a retrospective review of patients with Type 2 diabetes and a confirmed COVID-19 infection admitted to an urban academic medical center from January 1, 2020 to May 7, 2020. Baseline characteristics were collected. The primary outcomes of the study were in-hospital mortality and length of stay (LOS).

RESULTS

A total of 4462 patients with Type 2 diabetes and confirmed COVID-19 were identified. 41.3% were Black, and 41.5% were Hispanic. There were 1021 patients in the metformin group and 3441 in the non-metformin group. Of note, more participants in the metformin group had comorbid disease and/or advanced diabetes. We found no statistically significant differences between the metformin and non-metformin group in in-hospital mortality (28.1% vs 25.3%, P=0.08) or length of hospital stay in days (7.3 vs. 7.5, P=0.59), even after matching patients on various factors (29.3% vs. 29.6%, P=0.87; 7.7 vs. 8.1, P=0.23).

CONCLUSION

While patients had more comorbid disease and advanced diabetes in the metformin group, there were no significant differences with regard to in-hospital mortality or length of stay due to COVID-19 compared to the non-metformin group. Prospective studies are needed to determine if there is clinical benefit for initiating, continuing, or re-initiating metformin in patients hospitalized with COVID-19.

Multiethnic genome-wide and HLA association study of total serum IgE level

BACKGROUND

Total serum IgE (tIgE) is an important intermediate phenotype of allergic disease. Whole genome genetic association studies across ancestries may identify important determinants of IgE.

OBJECTIVE

We aimed to increase understanding of genetic variants affecting tIgE production across the ancestry and allergic disease spectrum by leveraging data from the National Heart, Lung and Blood Institute Trans-Omics for Precision Medicine program; the Consortium on Asthma among African-ancestry Populations in the Americas (CAAPA); and the Atopic Dermatitis Research Network (N = 21,901).

METHODS

We performed genome-wide association within strata of study, disease, and ancestry groups, and we combined results via a meta-regression approach that models heterogeneity attributable to ancestry. We also tested for association between HLA alleles called from whole genome sequence data and tIgE, assessing replication of associations in HLA alleles called from genotype array data.

RESULTS

We identified 6 loci at genome-wide significance (P < 5 × 10^-9), including 4 loci previously reported as genome-wide significant for tIgE, as well as new regions in chr11q13.5 and chr15q22.2, which were also identified in prior genome-wide association studies of atopic dermatitis and asthma. In the HLA allele association study, HLA-A∗02:01 was associated with decreased tIgE level (P_discovery = 2 × 10^-4; P_replication = 5 × 10^-4; P_{discovery+replication} = 4 × 10^-7), and HLA-DQB1∗03:02 was strongly associated with decreased tIgE level in Hispanic/Latino ancestry populations (P_{Hispanic/Latino discovery+replication} = 8 × 10^-8).

CONCLUSION

We performed the largest genome-wide association study and HLA association study of tIgE focused on ancestrally diverse populations and found several known tIgE and allergic disease loci that are relevant in non-European ancestry populations.

Risk of breast cancer and prediagnostic urinary excretion of bisphenol A, triclosan and parabens: The Multiethnic Cohort Study

Exposure to bisphenol A (BPA), triclosan and parabens is widespread but their impact on breast cancer risk remains unclear. This nested case-control study investigated endocrine-disrupting chemicals (EDCs) and breast cancer risk within the Multiethnic Cohort (MEC). We measured prediagnostic urinary BPA, triclosan and parabens in 1032 postmenopausal women with breast cancer (48 African American, 77 Latino, 155 Native Hawaiian, 478 Japanese American and 274 White) and 1030 individually matched controls, using a sensitive and validated liquid chromatography mass spectrometry assay. Conditional logistic regression was used to examine risk with these EDCs with adjustment for creatinine and potential confounders. In all women, breast cancer risk was not associated with BPA (P_trend  = 0.53) and was inversely associated with triclosan (OR_{T3 vs T1}  = 0.83, 95% CI: 0.66-1.04, P_trend  = 0.045) and total parabens (OR_{T3 vs T1}  = 0.77, 95% CI: 0.62-0.97, P_trend  = 0.03). While risk of hormone receptor positive (HR+) cancer was 20% to 23% lower among women in the upper two tertiles of paraben exposure (P_trend  = 0.02), risk of HR negative (HR-) was reduced 27% but only among those in the upper tertile of exposure. Although risk associations did not differ significantly by ethnicity or by body mass index (BMI), the inverse association with triclosan was observed mainly among overweight/obese women (OR_{T3 vs T1}  = 0.76, 95% CI: 0.56-1.02, P_trend  = 0.02). In summary, breast cancer risk in a multiethnic population was unrelated to BPA and was weakly inversely associated with triclosan and paraben exposures. Studies with multiple urine samples collected before breast cancer diagnosis are needed to further investigate these EDCs and breast cancer risk.

Comparison of Pregnancy Outcomes Using Different Gestational Diabetes Diagnostic Criteria and Treatment Thresholds in Multiethnic Communities between Two Tertiary Centres in Australian and New Zealand: Do They Make a Difference?

Introduction: Australia, but not New Zealand (NZ), has adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria to diagnose gestational diabetes (GDM). We compared pregnancy outcomes using these different diagnostic approaches. Method: Prospective data of women with GDM were collected from one NZ (NZ) and one Australian (Aus) hospital between 2007–2018. Aus screening criteria with 2-step risk-based 50 g Glucose Challenge Testing (GCT) followed by 75 g-oral glucose tolerance testing (OGTT): fasting ≥ 5.5, 2-h ≥ 8.0 mmol/L (ADIPS98) changed to a universal OGTT and fasting ≥5.1, 1-h ≥ 10, 2-h ≥ 8.5 mmol/L (IADPSG). NZ used GCT followed by OGTT with fasting ≥ 5.5, 2-h ≥ 9.0 mmol/L (NZSSD); in 2015 adopted a booking HbA1c (NZMOH). Primary outcome was a composite of macrosomia, perinatal death, preterm delivery, neonatal hypoglycaemia, and phototherapy. An Aus subset positive using NZSSD was also defined. RESULTS: The composite outcome odds ratio compared to IADPSG (1788 pregnancies) was higher for NZMOH (934 pregnancies) 2.227 (95%CI: 1.84–2.68), NZSSD (1344 pregnancies) 2.19 (1.83–2.61), and ADIPS98 (3452 pregnancies) 1.91 (1.66–2.20). Composite outcomes were similar between the Aus subset and NZ. Conclusions: The IADPSG diagnostic criteria were associated with the lowest rate of composite outcomes. Earlier NZ screening with HbA1c was not associated with a change in adverse pregnancy outcomes.

Genome-Wide Association Study of Non-syndromic Orofacial Clefts in a Multiethnic Sample of Families and Controls Identifies Novel Regions

Orofacial clefts (OFCs) are among the most prevalent craniofacial birth defects worldwide and create a significant public health burden. The majority of OFCs are non-syndromic and vary in prevalence by ethnicity. Africans have the lowest prevalence of OFCs (~ 1/2,500), Asians have the highest prevalence (~1/500), Europeans and Latin Americans lie somewhere in the middle (~1/800 and 1/900, respectively). Thus, ethnicity appears to be a major determinant of the risk of developing OFC. The Pittsburgh Orofacial Clefts Multiethnic study was designed to explore this ethnic variance, comprising a large number of families and individuals (~12,000 individuals) from multiple populations worldwide: US and Europe, Asians, mixed Native American/Caucasians, and Africans. In this current study, we analyzed 2,915 OFC cases, 6,044 unaffected individuals related to the OFC cases, and 2,685 controls with no personal or family history of OFC. Participants were grouped by their ancestry into African, Asian, European, and Central and South American subsets, and genome-wide association run on the combined sample as well as the four ancestry-based groups. We observed 22 associations to cleft lip with or without cleft palate at 18 distinct loci with p-values < 1e-06, including 10 with genome-wide significance (<5e-08), in the combined sample and within ancestry groups. Three loci - 2p12 (rs62164740, p = 6.27e-07), 10q22.2 (rs150952246, p = 3.14e-07), and 10q24.32 (rs118107597, p = 8.21e-07) are novel. Nine were in or near known OFC loci - PAX7, IRF6, FAM49A, DCAF4L2, 8q24.21, NTN1, WNT3-WNT9B, TANC2, and RHPN2. The majority of the associations were observed only in the combined sample, European, and Central and South American groups. We investigated whether the observed differences in association strength were (a) purely due to sample sizes, (b) due to systematic allele frequency difference at the population level, or (c) due to the fact certain OFC-causing variants confer different amounts of risk depending on ancestral origin, by comparing effect sizes to observed allele frequencies of the effect allele in our ancestry-based groups. While some of the associations differ due to systematic differences in allele frequencies between groups, others show variation in effect size despite similar frequencies across ancestry groups.

A longitudinal multiethnic study of biomarkers in systemic lupus erythematosus: Launching the GLADEL 2.0 Study Group

Introduction: After more than 20 years of sustained work, the Latin American Group for the Study of Lupus (GLADEL) has made a significant number of contributions to the field of lupus, not only in the differential role that race/ethnicity plays in its course and outcome but also in several other studies including the beneficial effects of using antimalarials in lupus patients and the development of consensus guidelines for the treatment of lupus in our region. Methods: A new generation of "Lupus Investigators" in more than 40 centers throughout Latin America has been constituted in order to continue the legacy of the investigators of the original cohort and to launch a novel study of serum and urinary biomarkers in patients with systemic lupus erythematosus. Results: So far, we have recruited 807 patients and 631 controls from 42 Latin-American centers including 339 patients with SLE without renal involvement, 202 patients with SLE with prevalent but inactive renal disease, 176 patients with prevalent and active renal disease and 90 patients with incident lupus nephritis. Conclusions: The different methodological aspects of the GLADEL 2.0 cohort are discussed in this manuscript, including the challenges and difficulties of conducting such an ambitious project.

Cardiotoxicity After Anthracycline Chemotherapy for Childhood Cancer in a Multiethnic Asian Population

Background: Anthracyclines are widely used to treat childhood cancers; however, they cause cardiotoxicity. To address the paucity of clinical data from Asian populations, this study investigated the epidemiology of pediatric anthracycline-induced cardiotoxicity, during and after chemotherapy, in a multiethnic Asian population. Procedure: This was a single-center, retrospective analysis of 458 anthracycline-treated pediatric oncology patients at KK Women's and Children's Hospital, a tertiary children's hospital in Singapore from 2005 through 2015. We investigated cardiotoxicity (defined as left ventricular fractional shortening <28% on echocardiography) and its risk factors using univariate logistic regression as well as survival estimates through the Kaplan-Meier method to compare survival distribution between patients with and without cardiotoxicity. Results: Over a follow-up period of almost 4 years, we found that 7% (32/458) of the cohort developed cardiotoxicity, with 37.5% (12/32) of these manifesting as clinical heart failure, whilst the rest were asymptomatic. The cardiotoxic cohort demonstrated a significantly higher mortality rate compared to the non-cardiotoxic group at 46.9 vs. 19.2% (p < 0.001), of whom 3 (9.4%) died from end-stage heart failure. We found that traditional predictors such as female sex, age at diagnosis, and cumulative doxorubicin equivalent dose were not predictors of cardiotoxicity. Conclusion: Our study reaffirms that freedom from symptoms does not ensure normal heart function and suggests that children with abnormal ventricular systolic function have higher mortality risk compared to those with normal systolic function. The findings contribute to improved understanding of the Asian burden to aid development of measures to prevent or reduce the risk of cardiotoxicity.

LRRK2 Gene Variants Associated With a Higher Risk for Alcohol Dependence in Multiethnic Populations

Background: Genetics influence the vulnerability to alcohol use disorders, and among the implicated genes, three previous studies have provided evidences for the involvement of LRRK2 in alcohol dependence (AD). LRRK2 expression is broadly dysregulated in postmortem brain from AD humans, as well as in the brain of mice with alcohol dependent-like behaviors and in a zebrafish model of alcohol preference. The aim of the present study was to evaluate the association of variants in the LRRK2 gene with AD in multiethnic populations from South and North America. Methods: Alcohol-screening questionnaires [such as CAGE and Alcohol Use Disorders Identification Test (AUDIT)] were used to determine individual risk of AD. Multivariate logistic regression analyses were done in three independent populations (898 individuals from Bambuí, Brazil; 3,015 individuals from Pelotas, Brazil; and 1,316 from the United States). Linkage disequilibrium and conditional analyses, as well as in silico functional analyses, were also conducted. Results: Four LRRK2 variants were significantly associated with AD in our discovery cohort (Bambuí): rs4768231, rs4767971, rs7307310, and rs1465527. Two of these variants (rs4768231 and rs4767971) were replicated in both Pelotas and US cohorts. The consistent association signal (at the LRRK2 locus) found in populations with different genetic backgrounds reinforces the relevance of our findings. Conclusion: Taken together, these results support the notion that genetic variants in the LRRK2 locus are risk factors for AD in humans.

Transitioning gender, transitioning race: Transgender people and multiracial positionality

Background: While research on trans People of Color's experiences has been increasing in recent years, this intersectional work has often not included a focus on the specificities of multiracial and multiethnic trans experiences. Aims: This study explores shifts in racial identity by multiracial/multiethnic trans people as they transition gender and the ways Whiteness and nationalist ideology shape their racialized gender experiences. Methods: This paper is based on six in-depth, semi-structured interviews with self-identified multiracial, multiethnic, and multi-heritage trans people in the USA. Data collection centered participants' experiences of self-identification and interactions with others (e.g., family, acquaintances, and strangers). Results: As participants transitioned gender and were acknowledged by others in their gender identity, shifts in their embodiment were used by others to ascribe a new racialized gender. This often resulted in participants reflecting on their sense of self and racialized gender identities in new ways. Discussion: Multiracial and multiethnic transgender people's experiences in transitioning race confirm the importance of intersectional analysis, reveal the intersectional fluidity of social categories, explicate how social understandings of one category (e.g., race) influence another category (e.g., gender), demonstrate that the meanings associated with racialized gender are based in relations of power, and show that, in transgender studies particularly, we must attend to the ways that the concept of transition implicates not only gender, but also other categories such as race and nationality.

Diet Quality and Visceral Adiposity among a Multiethnic Population of Young, Middle, and Older Aged Adults

BACKGROUND

Visceral adiposity, more so than overall adiposity, is associated with chronic disease and mortality. There has been, to our knowledge, little research exploring the association between diet quality and visceral adipose tissue (VAT) among a mulitethnic population aged 18-80 y.

OBJECTIVE

The primary objective of this cross-sectional analysis was to examine the association between diet quality [Healthy Eating Index-2010 (HEI-2010) scores] and VAT among a multiethnic population of young, middle, and older aged adults in the United States. Secondary objectives were to repeat these analyses with overall adiposity and blood-based biomarkers for type 2 diabetes and cardiovascular disease risk as outcome measures.

METHODS

A total of 540 adults (dropped out: n = 4; age: 18-40 y, n = 220; 40-60 y, n = 183; 60-80 y, n = 133) were recruited across 3 sites (Honolulu County, San Francisco, and Baton Rouge) for the Shape Up! Adults study. Whole-body DXA, anthropometry, fasting blood draw, and questionnaires (food frequency, physical activity, and demographic characteristics) were completed. Linear regression was used to assess the associations between HEI-2010 tertiles and VAT and secondary outcome measures among all participants and age-specific strata, while adjusting for known confounders.

RESULTS

VAT, BMI (kg/m2), body fat percentage, total body fat, trunk fat, insulin, and insulin resistance were inversely related to diet quality (all P values < 0.004). When stratified by age, diet quality was inversely associated with VAT among participants aged 60-80 y (P < 0.006) and VAT/subcutaneous adipose tissue (SAT) among participants aged 40-60 y (P < 0.008).

CONCLUSIONS

Higher-quality diet was associated with lower VAT, overall adiposity, and insulin resistance among this multiethnic population of young, middle, and older aged adults with ages ranging from 18 to 80 y. More specifically, adherence to a high-quality diet may minimize VAT accumulation in adults aged 60-80 y and preferentially promote storage of SAT compared with VAT in adults aged 40-60 y.This study was registered at clinicaltrials.gov as NCT03637855.

Predictive Utility of Polygenic Risk Scores for Coronary Heart Disease in Three Major Racial and Ethnic Groups

Because polygenic risk scores (PRSs) for coronary heart disease (CHD) are derived from mainly European ancestry (EA) cohorts, their validity in African ancestry (AA) and Hispanic ethnicity (HE) individuals is unclear. We investigated associations of "restricted" and genome-wide PRSs with CHD in three major racial and ethnic groups in the U.S. The eMERGE cohort (mean age 48 ± 14 years, 58% female) included 45,645 EA, 7,597 AA, and 2,493 HE individuals. We assessed two restricted PRSs (PRS_Tikkanen and PRS_Tada; 28 and 50 variants, respectively) and two genome-wide PRSs (PRS_metaGRS and PRS_LDPred; 1.7 M and 6.6 M variants, respectively) derived from EA cohorts. Over a median follow-up of 11.1 years, 2,652 incident CHD events occurred. Hazard and odds ratios for the association of PRSs with CHD were similar in EA and HE cohorts but lower in AA cohorts. Genome-wide PRSs were more strongly associated with CHD than restricted PRSs were. PRS_metaGRS, the best performing PRS, was associated with CHD in all three cohorts; hazard ratios (95% CI) per 1 SD increase were 1.53 (1.46-1.60), 1.53 (1.23-1.90), and 1.27 (1.13-1.43) for incident CHD in EA, HE, and AA individuals, respectively. The hazard ratios were comparable in the EA and HE cohorts (p_interaction = 0.77) but were significantly attenuated in AA individuals (p_interaction= 2.9 × 10^-3). These results highlight the potential clinical utility of PRSs for CHD as well as the need to assemble diverse cohorts to generate ancestry- and ethnicity PRSs.

Fecal Microbial Diversity and Structure Are Associated with Diet Quality in the Multiethnic Cohort Adiposity Phenotype Study

BACKGROUND

Variation in gut microbial community structure is partly attributed to variations in diet. A priori dietary indexes capture diet quality and have been associated with chronic disease risk.

OBJECTIVES

The aim of this study was to examine the association of diet quality, as assessed by the Healthy Eating Index, Alternative Healthy Eating Index-2010, alternate Mediterranean Diet, and the Dietary Approaches to Stop Hypertension Trial, with measures of fecal microbial community structure assessed in the Adiposity Phenotype Study (APS), an ethnically diverse study population with varied food intakes.

METHODS

Multiethnic Cohort Study members completed a validated quantitative food frequency questionnaire (QFFQ) at cohort entry (1993-1996) and, for the APS subset, at clinic visit (2013-2015), when they also provided a stool sample. DNA was extracted from stool, and the V1-V3 region of the 16S rRNA gene was amplified and sequenced. Dietary index scores were computed based on the QFFQ and an extensive nutritional database. Using linear regression adjusted for relevant covariates, we estimated associations of dietary quality with microbiome measures and computed adjusted mean values of microbial measures by tertiles of dietary index scores.

RESULTS

The 858 men and 877 women of white, Japanese American, Latino, Native Hawaiian, and African American ancestry had a mean age of 69.2 years at stool collection. Alpha diversity according to the Shannon index increased by 1-2% across tertiles of all 4 diet indexes measured at clinic visit. The mean relative abundance of the phylum Actinobacteria was 13-19% lower with higher diet quality across all 4 indexes (difference between tertile 3 and tertile 1 divided by tertile 1). Of the 104 bacterial genera tested, 21 (primarily from the phylum Firmicutes) were positively associated with at least 1 index after Bonferroni adjustment.

CONCLUSION

Diet quality was strongly associated with fecal microbial alpha diversity and beta diversity and several genera previously associated with human health.

Validity and Reliability of an Expanded Vegetable Questionnaire Among Elementary School Children

BACKGROUND

The purpose of this study was to expand the School Physical Activity and Nutrition questionnaire to include a greater variety of vegetables and to evaluate the relative validity and reliability of these revised items.

OBJECTIVES

This study utilized 2 convenience samples of third to fifth graders for an analysis: validity (n = 70) and reliability (n = 76). Validity was assessed by comparing questionnaire items with vegetable intake reported from a 24-hour dietary recall covering the same reference period. Reliability estimates were assessed via same-day test-retest.

RESULTS

Agreement correlations ranged from 0.35 to 0.71. Kappa statistics varied from 0.16 to 0.66. Percentage agreements ranged from 57% to 87%. Test-retest Spearman coefficients were greater than 0.50 for 6 items, weighted Kappa values were greater than 0.40 for all 7 items, and percentage agreement exceeded 75% for 5 items.

CONCLUSIONS

Results suggest that the questionnaire is a valid and reliable measure of the previous day's vegetable intake in third- to fifth-grade students. This trial was registered at ClinicalTrials.gov as NCT02668744.

The effect of melanin on in vivo optical coherence tomography of the skin in a multiethnic cohort

BACKGROUND

Noninvasive real-time assessment of living tissue is quickly becoming invaluable for bolstering histologic and dermatoscopic measures of cutaneous conditions. While many skin researchers have explored the utility of noninvasive imaging in inflammatory and malignant skin conditions, there is yet to be a definitive and direct assessment of the effects of melanin on the quality of optical coherence tomography (OCT) imaging and its accuracy in multiethnic patient populations. We conducted a study to evaluate the effects of melanin on the quality of in vivo OCT imaging.

METHODS

Volunteers of all Fitzpatrick skin types were imaged once in five skin regions. Images were analyzed for quality, defined quantitatively as depreciation of light as it passes through the depth of skin, and qualitatively as depth and contrast ranked by blinded clinicians.

RESULTS

Our analysis of sixteen subjects shows that there is a significant difference in quantitative OCT image quality between light (Fitzpatrick I-III) and dark (IV-VI) skin types for both epidermal (p 0.0328) and dermal levels (p 0.0021). However, there was no significant difference in qualitative blinded rater measures of image clarity (p 0.11) or perceived depth (p 0.13).

CONCLUSION

Based on our definition of image quality, our study shows that OCT images taken from darker skin types have slightly lower quality than those taken from lighter skin. However, because blinded rater assessment showed no differences in clarity or perceived depth, we conclude that OCT may be used without hesitation for manual visualization of skin and its appendages in all Fitzpatrick skin types. Further studies are required to more extensively characterize the effects of melanin on OCT imaging. Lasers Surg. Med. 51:407-411, 2019. © 2019 Wiley Periodicals, Inc.

Validation of the World Health Organization Disability Assessment Schedule 2.0 among older adults in an Asian country

INTRODUCTION

As populations age globally and the burden of chronic illnesses increases, valid measures of disability are needed for assessment in the older adult population. The aim of the current analysis was to explore the psychometric properties and validity of the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in an epidemiological survey of older adults in Singapore.

METHODS

The study comprised secondary data analysis of the Well-being of the Singapore Elderly study. Inclusion criteria for the study were Singapore residents (Singapore citizens and permanent residents) aged 60 years and above. The 12-item interviewer-administered version of the WHODAS 2.0 was used to assess disability in the study. Data on cognition, health status and sociodemographic information were collected. Depression was assessed using the Automated Geriatric Examination for Computer Assisted Taxonomy.

RESULTS

The study found a one-factor model solution for WHODAS 2.0 with a high internal consistency of all items. The internal consistency for the overall scale was 0.92. The WHODAS 2.0 score positively correlated with multimorbidity, perceived overall health status, depression and subsyndromal depression. There was a significant inverse association between the WHODAS 2.0 score and the cognitive status. After adjustment for all sociodemographic variables in the multiple linear regression analysis, these measures remained significantly associated with the WHODAS 2.0 score.

CONCLUSION

WHODAS 2.0 was found to be a valid measure of disability among older adults. However, further research is required to determine its usefulness as a responsive instrument that can detect change following interventions.

The association between allostatic load and anthropometric measurements among a multiethnic cohort of children

OBJECTIVE

This study investigated if levels of allostatic load (ALoad) differed according to race/ethnicity in children and if ALoad was associated with obesity-related measures.

METHODS

A multiethnic sample of 307 children aged seven to 12 was evaluated, composed of 39% European American (EA), 35% African American (AA), and 26% Hispanic American (HA) youth. Anthropometric measurements were evaluated by dual-energy X-ray absorptiometry, and other measurements included body mass index (BMI) and waist circumference (WC). Allostatic load scores were estimated based on two different calculations, including seven and eight biomarkers (ALoad1 and ALoad2), respectively. Analyses of variance, independence tests, and multiple regression models were performed.

RESULTS

From the total sample, 22.80% (n = 70) of children were characterized as "no load," 46.58% (n = 143) "low load," and 30.62% (n = 94) "high load." Hispanic American children showed the highest ALoad scores (2.07 ± 1.54; 95% CI, 1.73-2.41) compared with AA children (1.71 ± 1.43; 95% CI, 1.43-1.99) and EA children (1.56 ± 1.34; 95% CI, 1.32-1.80) (P < 0.05). Higher scores of ALoad (using both ALoad1 and ALoad2 calculations) were associated with higher BMI, total body fat mass, body percent fat, and WC (P < 0.05).

CONCLUSION

Significant differences in ALoad were observed in children according to race/ethnicity. Increased exposure to stressors captured by ALoad may result in increased risk for excessive adiposity and potential health risk in children. Further, ALoad may serve as a preventive marker for conditions known to continue throughout adulthood.

The Future of Genomic Studies Must Be Globally Representative: Perspectives from PAGE

The past decade has seen a technological revolution in human genetics that has empowered population-level investigations into genetic associations with phenotypes. Although these discoveries rely on genetic variation across individuals, association studies have overwhelmingly been performed in populations of European descent. In this review, we describe limitations faced by single-population studies and provide an overview of strategies to improve global representation in existing data sets and future human genomics research via diversity-focused, multiethnic studies. We highlight the successes of individual studies and meta-analysis consortia that have provided unique knowledge. Additionally, we outline the approach taken by the Population Architecture Using Genomics and Epidemiology (PAGE) study to develop best practices for performing genetic epidemiology in multiethnic contexts. Finally, we discuss how limiting investigations to single populations impairs findings in the clinical domain for both rare-variant identification and genetic risk prediction.

Estimating cross-population genetic correlations of causal effect sizes

Recent studies have examined the genetic correlations of single-nucleotide polymorphism (SNP) effect sizes across pairs of populations to better understand the genetic architectures of complex traits. These studies have estimated ρ g , the cross-population correlation of joint-fit effect sizes at genotyped SNPs. However, the value of ρ g depends both on the cross-population correlation of true causal effect sizes ( ρ b ) and on the similarity in linkage disequilibrium (LD) patterns in the two populations, which drive tagging effects. Here, we derive the value of the ratio ρ g / ρ b as a function of LD in each population. By applying existing methods to obtain estimates of ρ g , we can use this ratio to estimate ρ b . Our estimates of ρ b were equal to 0.55 ( SE = 0.14) between Europeans and East Asians averaged across nine traits in the Genetic Epidemiology Research on Adult Health and Aging data set, 0.54 ( SE = 0.18) between Europeans and South Asians averaged across 13 traits in the UK Biobank data set, and 0.48 ( SE = 0.06) and 0.65 ( SE = 0.09) between Europeans and East Asians in summary statistic data sets for type 2 diabetes and rheumatoid arthritis, respectively. These results implicate substantially different causal genetic architectures across continental populations.

Successful ageing in Singapore: prevalence and correlates from a national survey of older adults

INTRODUCTION

The current study aimed to estimate the overall prevalence and sociodemographic correlates of successful ageing, as defined by Rowe and Kahn, among a national sample of multiethnic adults aged 60 years and older in Singapore.

METHODS

Data from older adults who participated in the Well-being of the Singapore Elderly study was analysed. Successful ageing was defined with five indicators: no major diseases; no disability; high cognitive functioning; high physical functioning; and active engagement with life.

RESULTS

The prevalence of successful ageing was 25.4% in this older population. Older adults aged 75-84 years and ≥ 85 years had 0.3 times and 0.1 times the odds of successful ageing, respectively, than those aged 60-74 years. Compared to older adults of Chinese ethnicity, those of Malay (odds ratio [OR] 0.6) and Indian (OR 0.5) ethnicities were less likely to be associated with successful ageing. Older adults with lower education levels, who had no formal education (OR 0.2), some schooling but did not complete primary education (OR 0.4) or only primary education (OR 0.5), had lower odds of ageing successfully than those with tertiary education.

CONCLUSION

Older adults in Singapore tend to have much more active engagement with life as compared to their counterparts from other countries. Further research into this population is needed, both in terms of qualitative research to gain a better understanding of successful ageing from the older adult's perspective, as well as longitudinal studies that explore behavioural determinants of successful ageing.

Testing the Predictive Validity of the Healthy Eating Index-2015 in the Multiethnic Cohort: Is the Score Associated with a Reduced Risk of All-Cause and Cause-Specific Mortality?

The Healthy Eating Index-2015 (HEI-2015) was created to assess conformance of dietary intake with the Dietary Guidelines for Americans (DGA) 2015–2020. We assessed the association between the HEI-2015 and mortality from all-cause, cardiovascular disease (CVD), and cancer in the Multiethnic Cohort (MEC). White, African American, Native Hawaiian, Japanese American, and Latino adults (n > 215,000) from Hawaii and California completed a quantitative food-frequency questionnaire at study enrollment. HEI-2015 scores were divided into quintiles for men and women. Radar graphs were used to demonstrate how dietary components contributed to HEI-2015 scores. Mortality was documented over 17–22 years of follow-up. Hazard ratios (HRs) and 95% confidence intervals (CIs) were computed using Cox proportional hazards models. High HEI-2015 scores were inversely associated with risk of mortality from all-cause, CVD, and cancer for men and women (p-trend <0.0001 for all models). For men, the HRs (CIs) for all-cause, CVD, and cancer comparing the highest to the lowest quintile were 0.79 (0.76, 0.82), 0.76 (0.71, 0.82), and 0.80 (0.75, 0.87), respectively. For women, the HRs were 0.79 (0.76, 0.82), 0.75 (0.70, 0.81), and 0.84 (0.78, 0.91), respectively. These results, in a multiethnic population, demonstrate that following a diet aligned with the DGAs 2015–2020 recommendations is associated with lower risk of mortality from all-cause, CVD, and cancer.

Health literacy and current CD4 cell count in a multiethnic U.S. sample of adults living with HIV infection

Hispanic and Black adults are disproportionately affected by HIV and experience poorer HIV-related health outcomes relative to non-Hispanic White adults. The current study adopted Sørensen's integrated model to test the hypothesis that lower functional and critical health literacy competencies contribute to poorer HIV-related health and CD4 cell count for Hispanic and Black individuals. Eighty-one non-Hispanic White, Hispanic, and Black HIV seropositive individuals from a large, Southwestern metropolitan area were administered measures of health literacy, including the Expanded Numeracy Scale, Newest Vital Sign, Rapid Estimate of Adult Literacy in Medicine, Test of Functional Health Literacy (TOHFLA)-numeracy, and TOHFLA-reading. Hispanic and Black individuals demonstrated less HIV knowledge than non-Hispanic White individuals. Black participants demonstrated fewer health literacy appraisal skills. Importantly, lower levels of health literacy were linked to poorer CD4 cell count (an index of immune functioning) for Hispanic and Black individuals and not for non-Hispanic White individuals. These findings suggest race group differences for health literacy on current CD4 cell count such as very specific dimensions of low health literacy (e.g. poorer judgment of health-related information), but not other presumed deficits (e.g. motivation, access), play an important role in clinical health outcomes in HIV.

Multiethnic Meta-Analysis Identifies RAI1 as a Possible Obstructive Sleep Apnea-related Quantitative Trait Locus in Men

Obstructive sleep apnea (OSA) is a common heritable disorder displaying marked sexual dimorphism in disease prevalence and progression. Previous genetic association studies have identified a few genetic loci associated with OSA and related quantitative traits, but they have only focused on single ethnic groups, and a large proportion of the heritability remains unexplained. The apnea-hypopnea index (AHI) is a commonly used quantitative measure characterizing OSA severity. Because OSA differs by sex, and the pathophysiology of obstructive events differ in rapid eye movement (REM) and non-REM (NREM) sleep, we hypothesized that additional genetic association signals would be identified by analyzing the NREM/REM-specific AHI and by conducting sex-specific analyses in multiethnic samples. We performed genome-wide association tests for up to 19,733 participants of African, Asian, European, and Hispanic/Latino American ancestry in 7 studies. We identified rs12936587 on chromosome 17 as a possible quantitative trait locus for NREM AHI in men (N = 6,737; P = 1.7 × 10-8) but not in women (P = 0.77). The association with NREM AHI was replicated in a physiological research study (N = 67; P = 0.047). This locus overlapping the RAI1 gene and encompassing genes PEMT1, SREBF1, and RASD1 was previously reported to be associated with coronary artery disease, lipid metabolism, and implicated in Potocki-Lupski syndrome and Smith-Magenis syndrome, which are characterized by abnormal sleep phenotypes. We also identified gene-by-sex interactions in suggestive association regions, suggesting that genetic variants for AHI appear to vary by sex, consistent with the clinical observations of strong sexual dimorphism.

Diet Quality in Midadulthood Predicts Visceral Adiposity and Liver Fatness in Older Ages: The Multiethnic Cohort Study

OBJECTIVE

The relationship of diet quality assessed by established indices (HEI-2010, AHEI-2010, aMED, DASH) with adiposity measures was examined, especially visceral adipose tissue (VAT) and nonalcoholic fatty liver (NAFL).

METHODS

Close to 2,000 participants of the Multiethnic Cohort completed validated food frequency questionnaires at cohort entry (1993-1996) and clinic visit (2013-2016) when they underwent whole-body dual-energy x-ray absorptiometry and abdominal magnetic resonance imaging scans. Linear regression was used to estimate mean values of adiposity measures by dietary index tertiles at baseline and standardized regression coefficients (β_s ) after adjusting for total adiposity and other covariates. Logistic regression of VAT and NAFL on dietary indices was also performed.

RESULTS

Higher dietary quality scores at cohort entry were inversely related to all adiposity measures, with the strongest associations for percent liver fat (β_s  = -0.14 to -0.08), followed by VAT (β_s  = -0.11 to -0.05), BMI (β_s  = -0.11 to -0.06), and total body fat (β_s  = -0.09 to -0.05). Odds ratios adjusted for total adiposity ranged between 0.57 and 0.77 for NAFL and between 0.41 and 0.65 for high VAT when comparing the highest versus lowest tertiles of diet quality.

CONCLUSIONS

These longitudinal findings indicate that maintaining a high-quality diet during mid-to-late adulthood may prevent adverse metabolic consequences related to VAT and NAFL.

A Randomized Controlled Trial Comparing the Letter Project Advance Directive to Traditional Advance Directive

BACKGROUND

Simpler alternatives to traditional advance directives that are easy to understand and available in multiple formats and can be initiated by patients and families will help facilitate advance care planning. The goal of this study was to compare the acceptability of the letter advance directive (LAD) to the traditional advance directive (TAD) of the state of California.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

A web-based, randomized controlled trial was conducted, in which the participants were randomized to one of two types of advance directives (ADs): the LAD (intervention) or the TAD (control). Primary outcomes were participant ratings of the ease, value, and their level of comfort in the AD document they completed.

RESULTS

A total of 400 participants completed the study, with 216 randomized to the LAD and 184 to the TAD by a computerized algorithm. Overall, participants preferred the LAD to the TAD (success rate difference [SRD] = 0.46, 95th percentile confidence interval [CI]: 0.36-0.56, p < 0.001). The participants felt that, compared to the TAD, the LAD was easier to read and understand (SRD = 0.56, CI: 0.47-0.65, p < 0.001); better reflected what matters most to them (SRD = 0.39, CI: 0.29-0.48, p < 0.001); helped stimulate their thinking about the types of treatments they wanted at the end of life (SRD = 0.32, CI: 0.23-0.42, p < 0.001); allowed them to describe how they made medical decisions in their family (SRD = 0.31, CI: 0.21-0.40, p < 0.001); and could help their doctor(s) (SRD = 0.24, CI: 0.13-0.34, p < 0.001) and their families (SRD = 0.19, CI: 0.08-0.28, p < 0.001) understand their end-of-life treatment preferences.

CONCLUSIONS

Patients reported the letter advance directive to be a better alternative to the traditional advance directive form.

Increased Aortic Calcification Is Associated With Arterial Stiffness Progression in Multiethnic Middle-Aged Men

Arterial stiffness is established as an independent predictor of cardiovascular morbidity and mortality. The objective was to prospectively evaluate association of aortic calcification burden with progression of arterial stiffness in population-based samples of healthy middle-aged men from ERA JUMP cohort (Electron-Beam Computed Tomography and Risk Factor Assessment in Japanese and US Men in the Post-World War II Birth Cohort). Men (n=635) aged 40 to 49 years (207 white American, 45 black American, 142 Japanese American, and 241 Japanese in Japan) were examined at baseline and 4 to 7 years later. Aortic calcification was evaluated from level of aortic arch to iliac bifurcation. Arterial stiffness progression was measured as annual change in brachial-ankle pulse wave velocity. Multivariable-adjusted general linear models were applied to investigate associations of longitudinal change in aortic calcification with arterial stiffness progression in participants overall, as well as in subgroups without or with prevalent aortic calcification at baseline. Annual change in aortic calcification was positively and significantly associated with arterial stiffness progression. In participants with annual changes in aortic calcium score of ≤0, 1 to 10, 11 to 100, and >100, the adjusted means (SD) for the annual change in brachial-ankle pulse wave velocity were 3.8 (2.2), 7.2 (2.2), 12.2 (1.8), and 15.6 (2.6) cm/s, respectively (P for trend <0.01) adjusted for baseline aortic calcification, arterial stiffness, and standard cardiovascular risk factors. Arterial stiffness was associated with the incidence of aortic calcification over the follow-up period among participants without aortic calcification (n=297) and with an increase in aortic calcification among participants with prevalent aortic calcification at baseline (n=388). Our findings suggest aortic calcification may be causally linked to arterial stiffness.

Ethnic Difference in Proximal Aortic Stiffness: An Observation From the Dallas Heart Study

OBJECTIVES

This study aims to compare ethnic difference in proximal aortic pulse wave velocity (PWV) and characteristic impedance (Zc).

BACKGROUND

Increased aortic stiffness is an independent predictor of target organ damage, incident hypertension, and all-cause mortality. However, previous studies have not directly assessed proximal aortic function in Blacks, the ethnic population with disproportionately high risk for incident hypertension and target organ complications.

METHODS

We evaluated the multiethnic, population-based DHS (Dallas Heart Study) participants (N = 2,544, 54.2% women, 49.7% Black) who underwent cardiac magnetic resonance at 1.5-T. Aortic stiffness and Zc were determined from aortic arch PWV and lumen area measurements. Linear regression was used to evaluate ethnic differences in proximal aortic wall stiffness using aortic arch PWV and Zc as dependent variables with and without adjustment for traditional cardiovascular risk factors. Because cardiac output was significantly higher in Blacks compared to Whites and Hispanics, additional comparisons of PWV and Zc were performed after adjustment for cardiac output and peripheral vascular resistance.

RESULTS

Compared with Whites, both Blacks and Hispanics had higher levels of aortic arch PWV (4.25, 95% confidence interval [CI]: 4.15 to 4.35 m/s, vs. 4.72, 95% CI: 4.64 to 4.81 m/s, vs. 4.48, 95% CI: 4.33 to 4.63 m/s, respectively, both p < 0.05 vs. White), and Zc (64.9, 95% CI: 63.3 to 66.6 dyne·s/cm⁵, vs. 75.6, 95% CI: 74.0 to 77.2 dyne·s/cm⁵, vs. 70.1, 95% CI: 67.6 to 72.8 dyne·s/cm⁵, respectively, both p < 0.01 vs. White) after adjustment for age, age squared, sex, body mass index, height, mean arterial blood pressure, antihypertensive treatment, heart rate, total cholesterol, diabetes mellitus, and smoking. Compared with Hispanics, Blacks also had higher level of both PWV and Zc (both p < 0.01). Ethnic differences in PWV and Zc persisted after adjustment for cardiac output and peripheral vascular resistance.

CONCLUSIONS

In a multiethnic population-based-sample, Blacks and Hispanics had higher proximal aortic stiffness compared with Whites independent of blood pressure and relevant risk factors.

Harmonization of Food-Frequency Questionnaires and Dietary Pattern Analysis in 4 Ethnically Diverse Birth Cohorts

BACKGROUND

Canada is an ethnically diverse nation, which introduces challenges for health care providers tasked with providing evidence-based dietary advice.

OBJECTIVES

We aimed to harmonize food-frequency questionnaires (FFQs) across 4 birth cohorts of ethnically diverse pregnant women to derive robust dietary patterns to investigate maternal and newborn outcomes.

METHODS

The NutriGen Alliance comprises 4 prospective birth cohorts and includes 4880 Canadian mother-infant pairs of predominantly white European [CHILD (Canadian Healthy Infant Longitudinal Development) and FAMILY (Family Atherosclerosis Monitoring In earLY life)], South Asian [START (SouTh Asian birth cohoRT)-Canada], or Aboriginal [ABC (Aboriginal Birth Cohort)] origins. CHILD used a multiethnic FFQ based on a previously validated instrument designed by the Fred Hutchinson Cancer Research Center, whereas FAMILY, START, and ABC used questionnaires specifically designed for use in white European, South Asian, and Aboriginal people, respectively. The serving sizes and consumption frequencies of individual food items within the 4 FFQs were harmonized and aggregated into 36 common food groups. Principal components analysis was used to identify dietary patterns that were internally validated against self-reported vegetarian status and externally validated against a modified Alternative Healthy Eating Index (mAHEI).

RESULTS

Three maternal dietary patterns were identified-"plant-based," "Western," and "health-conscious"-which collectively explained 29% of the total variability in eating habits observed in the NutriGen Alliance. These patterns were strongly associated with self-reported vegetarian status (OR: 3.85; 95% CI: 3.47, 4.29; r² = 0.30, P < 0.001; for a plant-based diet), and average adherence to the plant-based diet was higher in participants in the fourth quartile of the mAHEI than in the first quartile (mean difference: 46.1%; r² = 0.81, P < 0.001).

CONCLUSION

Dietary data collected by using FFQs from ethnically diverse pregnant women can be harmonized to identify common dietary patterns to investigate associations between maternal dietary intake and health outcomes.

Diet and Physical Activity Intervention Strategies for College Students

OBJECTIVES

To understand perceived barriers of a diverse sample of college students and their suggestions for interventions aimed at healthy eating, cooking, and physical activity.

METHODS

Forty students (33% Asian American, 30% mixed ethnicity) were recruited. Six focus groups were audio-recorded, transcribed, and coded. Coding began with a priori codes, but allowed for additional codes to emerge. Analysis of questionnaires on participants' dietary and physical activity practices and behaviors provided context for qualitative findings.

RESULTS

Barriers included time, cost, facility quality, and intimidation. Tailoring towards a college student's lifestyle, inclusion of hands-on skill building, and online support and resources were suggested strategies.

CONCLUSIONS

Findings provide direction for diet and physical activity interventions and policies aimed at college students.

Target Organ Complications and Cardiovascular Events Associated With Masked Hypertension and White-Coat Hypertension: Analysis From the Dallas Heart Study

BACKGROUND

Multiple epidemiological studies from Europe and Asia have demonstrated increased cardiovascular risks associated with isolated elevation of home blood pressure (BP) or masked hypertension (MH). Previous studies have not addressed cardiovascular outcomes associated with MH and white-coat hypertension (WCH) in the general population in the United States.

OBJECTIVES

The goal of this study was to determine hypertensive target organ damage and adverse cardiovascular outcomes associated with WCH (high clinic BP, ≥140/90 mm Hg; normal home BP, <135/85 mm Hg), MH (high home BP, ≥135/85 mm Hg; normal clinic BP, <140/90 mm Hg), and sustained hypertension (high home and clinic BP) in the DHS (Dallas Heart Study), a large, multiethnic, probability-based population cohort.

METHODS

Associations among WCH, MH, sustained hypertension, and aortic pulsed wave velocity by magnetic resonance imaging; urinary albumin-to-creatinine ratio; and cystatin C were evaluated at study baseline. Then, associations between WCH and MH with incident cardiovascular outcomes (coronary heart disease, stroke, atrial fibrillation, heart failure, and cardiovascular death) over a median follow-up period of 9 years were assessed.

RESULTS

The study cohort comprised 3,027 subjects (50% African Americans). The sample-weighted prevalence rates of WCH and MH were 3.3% and 17.8%, respectively. Both WCH and MH were independently associated with increased aortic pulsed wave velocity, cystatin C, and urinary albumin-to-creatinine ratio. Both WCH (adjusted hazard ratio: 2.09; 95% confidence interval: 1.05 to 4.15) and MH (adjusted hazard ratio: 2.03; 95% confidence interval: 1.36 to 3.03) were independently associated with higher cardiovascular events compared with the normotensive group, even after adjustment for traditional cardiovascular risk factors.

CONCLUSIONS

In a multiethnic U.S. population, both WCH and MH were independently associated with increased aortic stiffness, renal injury, and incident cardiovascular events. Because MH is common and associated with an adverse cardiovascular profile, home BP monitoring should be routinely performed among U.S. adults.

A systematic assessment of the association of polysomnographic indices with blood pressure: the Multi-Ethnic Study of Atherosclerosis (MESA)

STUDY OBJECTIVE

Blood pressure (BP) may be adversely affected by a variety of sleep disturbances, including sleep fragmentation, hypoxemia, respiratory disturbances, and periodic limb movements. We aim to identify which polysomnography indices are most strongly and consistently associated with systolic and diastolic blood pressure (SBP, DBP) levels in a population-based sample.

DESIGN

Cross-sectional analysis of data from 2,040 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) who underwent polysomnography at MESA Exam 5 in 2011-2013.

SETTING

Multisite cohort study.

PARTICIPANTS

Participants were mean age 68 y (54% females; 28% African American, 24% Hispanic, 11% Chinese).

MEASUREMENTS

Thirty-two candidate polysomnography predictors were identified representing the domains of breathing disturbance frequency, hypoxemia, sleep architecture, and periodic limb movements. Cluster analysis was used for variable reduction. Statistical models, adjusted for potential confounders, were derived using stepwise regression. Final models were selected using cross-validation techniques.

RESULTS

The apnea-hypopnea index (AHI) defined using a 4% desaturation hypopnea criterion (AHI4P) was most consistently associated with SBP level. The AHI and periodic limb movement index (associated with arousals; PLMIA) were significantly associated with DBP. Estimated adjusted differences in SBP and DBP levels between an individual with no sleep apnea (AHI4P = 0) and one with moderately severe sleep apnea (AHI4P = 30) were 2.2 mm Hg and 1.1 mm Hg, respectively. Each 10-unit increase in the PLMIA was associated with an increase in DBP of 1.2 mm Hg.

CONCLUSION

Our results support the use of a currently recommended apnea-hypopnea index definition as a marker of blood pressure risk and indicate that measurement of limb movements with arousals is also independently associated with diastolic blood pressure.

Cooperation and tensions in multiethnic corporate societies using Teotihuacan, Central Mexico, as a case study

In this paper, I address the case of a corporate society in Central Mexico. After volcanic eruptions triggered population displacements in the southern Basin of Mexico during the first and fourth centuries A.D., Teotihuacan became a multiethnic settlement. Groups from different backgrounds settled primarily on the periphery of the metropolis; nevertheless, around the core, intermediate elites actively fostered the movement of sumptuary goods and the arrival of workers from diverse homelands for a range of specialized tasks. Some of these skilled craftsmen acquired status and perhaps economic power as a result of the dynamic competition among neighborhoods to display the most lavish sumptuary goods, as well as to manufacture specific symbols of identity that distinguished one neighborhood from another, such as elaborate garments and headdresses. Cotton attire worn by the Teotihuacan elite may have been one of the goods that granted economic importance to neighborhood centers such as Teopancazco, a compound that displayed strong ties to the Gulf Coast where cotton cloth was made. The ruling elite controlled raw materials that came from afar whereas the intermediate elite may have been more active in providing other sumptuary goods: pigments, cosmetics, slate, greenstone, travertine, and foreign pottery. The contrast between the corporate organization at the base and top of Teotihuacan society and the exclusionary organization of the neighborhoods headed by the highly competitive intermediate elite introduced tensions that set the stage for Teotihuacan's collapse.

Associations of key diet-quality indexes with mortality in the Multiethnic Cohort: the Dietary Patterns Methods Project

BACKGROUND

Healthy dietary patterns have been linked positively with health and longevity. However, prospective studies in diverse populations in the United States addressing dietary patterns and mortality are limited.

OBJECTIVE

We assessed the ability of the following 4 diet-quality indexes [the Healthy Eating Index-2010 (HEI-2010), the Alternative HEI-2010 (AHEI-2010), the alternate Mediterranean diet score (aMED), and the Dietary Approaches to Stop Hypertension (DASH)] to predict the reduction in risk of mortality from all causes, cardiovascular disease (CVD), and cancer.

DESIGN

White, African American, Native Hawaiian, Japanese American, and Latino adults (n = 215,782) from the Multiethnic Cohort completed a quantitative food-frequency questionnaire. Scores for each dietary index were computed and divided into quintiles for men and women. Mortality was documented over 13-18 y of follow-up. HRs and 95% CIs were computed by using adjusted Cox models.

RESULTS

High HEI-2010, AHEI-2010, aMED, and DASH scores were all inversely associated with risk of mortality from all causes, CVD, and cancer in both men and women (P-trend < 0.0001 for all models). For men, the HEI-2010 was consistently associated with a reduction in risk of mortality for all causes (HR: 0.75; 95% CI: 0.71, 0.79), CVD (HR: 0.74; 95% CI: 0.69, 0.81), and cancer (HR: 0.76; 95% CI: 0.70, 0.83) when lowest and highest quintiles were compared. In women, the AHEI and aMED showed large reductions for all-cause mortality (HR: 0.78; 95% CI: 0.74, 0.82), the AHEI showed large reductions for CVD (HR: 0.76; 95% CI: 0.69, 0.83), and the aMED showed large reductions for cancer (HR: 0.84; 95% CI: 0.76, 0. 92).

CONCLUSION

These results, in a US multiethnic population, suggest that consuming a dietary pattern that achieves a high diet-quality index score is associated with lower risk of mortality from all causes, CVD, and cancer in adult men and women.

Genetic variation predicts serum lycopene concentrations in a multiethnic population of postmenopausal women

BACKGROUND

The consumption and blood concentrations of lycopene are both positively and inversely associated with the risk of several chronic diseases. The inconsistences in lycopene disease association studies may stem from a lack of knowledge about the genetic variation in the synthesis, metabolism, and deposition of transport and binding proteins, which potentially influence serum lycopene concentrations.

OBJECTIVE

We examined the association between variation across the genome and serum concentrations of lycopene in a multiethnic population.

METHODS

Participants included African (n = 914), Hispanic (n = 464), and European (n = 1203) American postmenopausal women from the Women's Health Initiative. We analyzed ∼7 million single nucleotide polymorphisms (SNPs). Linear regression models were used to assess associations between each SNP and serum concentrations (log transformed, continuous) of lycopene; we adjusted for age, body mass index, and population substructure. Models were run separately by ethnicity, and results were combined in a transethnic fixed-effects meta-analysis.

RESULTS

In the meta-analysis, the scavenger receptor class B, member 1 (SCARB1) gene, which encodes for a cholesterol membrane transporter, was significantly associated with lycopene concentrations (rs1672879; P < 2.68 × 10(-9)). Each additional G allele resulted in a 12% decrease in lycopene concentrations for African Americans, 20% decrease for Hispanic Americans, and 9% decrease for European Americans. In addition, 2 regions were significantly associated with serum lycopene concentrations in African Americans: the slit homolog 3 gene (SLIT3), which serves as a molecular guidance cue in cellular migration, and the dehydrogenase/reductase (SDR family) member 2 (DHRS2) gene, which codes for an oxidoreductase that mitigates the breakdown of steroids.

CONCLUSIONS

We found 3 novel loci associated with serum lycopene concentrations, 2 of which were specific to African Americans. Future functional studies looking at these specific genes may provide insight into the metabolism and underlying function of lycopene in humans, which may further elucidate lycopene's influence on disease risk and health. This trial was registered at clinicaltrials.gov as NCT00000611.

Differences in IGF-axis protein expression and survival among multiethnic breast cancer patients

There is limited knowledge about the biological basis of racial/ethnic disparities in breast cancer outcomes. Aberrations in IGF signaling induced by obesity and other factors may contribute to these disparities. This study examines the expression profiles of the insulin-like growth factor (IGF)-axis proteins and the association with breast cancer survival across a multiethnic population. We examined the expression profiles of the IGF1, IGF1R, IGFBP2 (IGF-binding proteins), and IGFBP3 proteins in breast tumor tissue and their relationships with all-cause and breast cancer-specific survival up to 17 years postdiagnosis in a multiethnic series of 358 patients in Hawaii, USA. Native Hawaiians, Caucasians, and Japanese were compared. Covariates included demographic and clinical factors and ER/PR/HER2 (estrogen receptor/progesterone receptor/human epidermal growth factor receptor-2) status. In Native Hawaiian patients, IGFBP2 and IGFBP3 expression were each independently associated with overall and breast cancer mortality (IGFB2: HR_mort = 10.96, 95% CI: 2.18–55.19 and HR_mort = 35.75, 95% CI: 3.64–350.95, respectively; IGFBP3: HR_mort = 5.16, 95% CI: 1.27–20.94 and HR_mort = 8.60, 95% CI: 1.84–40.15, respectively). IGF1R expression was also positively associated with all-cause mortality in Native Hawaiians. No association of IGF-axis protein expression and survival was observed in Japanese or Caucasian patients. The interaction of race/ethnicity and IGFBP3 expression on mortality risk was significant. IGF-axis proteins may have variable influence on breast cancer progression across different racial/ethnic groups. Expression of binding proteins and receptors in breast tumors may influence survival in breast cancer patients by inducing aberrations in IGF signaling and/or through IGF-independent mechanisms. Additional studies to evaluate the role of the IGF-axis in breast cancer are critical to improve targeted breast cancer treatment strategies.

B-type natriuretic peptides improve cardiovascular disease risk prediction in a cohort of women

BACKGROUND

Although N-terminal pro-B-type natriuretic peptide (NT-proBNP) has a strong relationship with incident cardiovascular disease (CVD), few studies have examined whether NT-proBNP adds to risk prediction algorithms, particularly in women.

OBJECTIVES

This study sought to evaluate the relationship between NT-proBNP and incident CVD in women.

METHODS

Using a prospective case-cohort within the WHI (Women's Health Initiative) observational study, we selected 1,821 incident cases of CVD (746 myocardial infarctions, 754 ischemic strokes, 160 hemorrhagic strokes, and 161 other cardiovascular [CV] deaths) and a randomly selected reference cohort of 1,992 women without CVD at baseline.

RESULTS

Median levels of NT-proBNP were higher at study entry among incident cases (120.3 ng/l [interquartile range (IQR): 68.1 to 219.5 ng/l]) than among control subjects (100.4 ng/l [IQR: 59.7 to 172.6 ng/l]; p < 0.0001). Women in the highest quartile of NT-proBNP (≥140.8 ng/l) were at 53% increased risk of CVD versus those in the lowest quartile after adjusting for traditional risk factors (1.53 [95% confidence interval (CI): 1.21 to 1.94]; p for trend <0.0001). Similar associations were observed after adjustment for Reynolds Risk Score covariables (1.53 [95% CI: 1.20 to 1.95]; p for trend <0.0001); the association remained in separate analyses of CV death (2.66 [95% CI: 1.48 to 4.81]; p for trend <0.0001), myocardial infarction (1.39 [95% CI: 1.02 to 1.88]; p for trend = 0.008), and stroke (1.60 [95% CI: 1.22 to 2.11]; p for trend <0.0001). When added to traditional risk covariables, NT-proBNP improved the c-statistic (0.765 to 0.774; p = 0.0003), categorical net reclassification (0.08; p < 0.0001), and integrated discrimination (0.0105; p < 0.0001). Similar results were observed when NT-proBNP was added to the Reynolds Risk Score.

CONCLUSIONS

In this multiethnic cohort of women with numerous CV events, NT-proBNP modestly improved measures of CVD risk prediction.