Type 2 diabetes and later cognitive function in older American Indians: The Strong Heart Study.

OBJECTIVES: Insulin resistance is a substantial health issue for American Indians, with type 2 diabetes overrepresented in this population as compared with non-Hispanic whites. Insulin resistance and its related conditions in turn increase risk for dementia and cognitive impairment. The aim of the current study was to determine whether type 2 diabetes and insulin resistance at midlife was associated with later-life cognitive testing in a large sample of older American Indians, aged 65 and older. METHODS: American Indian participants who underwent both fasting blood draw as part of the Strong Heart Study and had subsequent cognitive testing as part of the later adjunct Cerebrovascular Disease and its Consequences in American Indians study were included (n = 790). Regression models examined type 2 diabetes and impaired fasting glucose and subsequent cognitive test performance as part of a longitudinal study design. The relationship between a continuous measure of insulin resistance and later cognitive test performance was assessed using generalized estimating equations. RESULTS: Controlling for demographic and clinical factors, verbal fluency and processing speed/working memory were significantly negatively associated with having type 2 diabetes and with insulin resistance, but not with impaired fasting glucose. CONCLUSION: In this sample of American Indians, type 2 diabetes at midlife was associated with subsequent lower performance on measures of executive function. These results may have important implications for future implementation of diagnostic and intervention services in this population.

Traumatic Stress, Social Support, and Health Among Older American Indians: The Native Elder Care Study.

OBJECTIVES: To estimate the prevalence of lifetime traumatic experiences, describe related symptoms of traumatic stress, and examine their association with perceived social support and physical and mental health among older American Indians. METHOD: Analyses of existing interview data from the Native Elder Care Study, a random age-stratified sample of 505 tribal members ≥55 years of age conducted in partnership with a large Southeastern tribe. Interviews assessed trauma exposure, traumatic stress, measures of social support, and physical and mental health status. RESULTS: Overall, 31% of participants had experienced a traumatic event; of these, 43% reported traumatic stress at the time of the interview. Higher perceived social support was associated with a reduced prevalence of traumatic stress. Compared to their counterparts without traumatic stress, women participants reporting traumatic stress reported more symptoms of depression, and both symptomatic men and women had a higher prevalence of cardiovascular disease and chronic pain. DISCUSSION: Traumatic stress was associated with less perceived social support and poorer health. Social support was not found to moderate the relationship between traumatic stress and physical and mental health.

Risk factors for pre-diabetes and diabetes in adolescence and their variability by race and ethnicity.

Adolescent risk factors for pre-diabetes and diabetes in young adulthood were examined in three minority groups and compared to those in non-Hispanic Whites. Retrospective cohort study with data on 8337 adolescent respondents from Add Health (1994-2008). Participants included 5131 non-Hispanic Whites, 1651 non-Hispanic Blacks, 1223 Hispanics, and 332 American Indians/Alaska Natives. Diabetes was defined as: hemoglobin A1C ≥ 6.5%, glucose > 125 mg/dl, self-reported diabetes, or self-reported diabetes medication use, in Wave 4 data. Pre-diabetes was defined as hemoglobin A1C ≥ 5.7%. Relative risk regression models were used to evaluate the association between risk factors and risk of diabetes and pre-diabetes, controlling for body mass index, sedentary and physical activity habits, fast food consumption, and parental education, parental diabetes status, and financial stability. 484 participants developed diabetes; 2878 developed pre-diabetes between 1994 and 2008. Pre-diabetes and diabetes were more prevalent in non-Hispanic Blacks (55% and 12%, respectively) than in American Indians/Alaska Natives (43% and 11%), Hispanics (37% and 6%), and non-Hispanic Whites (27% and 3%). In all races, higher body mass index and parental diabetes were associated with higher risk of pre-diabetes and diabetes, while female sex was associated with lower risk of pre-diabetes. Efforts to reduce the risk of pre-diabetes and diabetes in adolescents should emphasize parental diabetes and BMI in all races, independent of physical activity, sedentary behaviors, or fast food consumption. Future interventions might be interested in targeting households, rather than individuals, to prevent pre-diabetes and diabetes in adolescents and young adults.

Physical Examination for Men and Women With Urologic Chronic Pelvic Pain Syndrome: A MAPP (Multidisciplinary Approach to the Study of Chronic Pelvic Pain) Network Study.

OBJECTIVE: To examine the feasibility of implementing a standardized, clinically relevant genitourinary examination for both men and women, and to identify physical examination findings characteristic of urologic chronic pelvic pain syndrome (UCPPS). MATERIALS AND METHODS: This study analyzed 2 samples: men and women with UCPPS who participated in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network Epidemiology and Phenotyping (EP) Study, and age-matched controls who were either positive for chronic fatigue syndrome or healthy (pain-free). We compared physical examination findings in both positive and healthy controls with UCPPS cases: findings from both the EP examinations and from an extended genitourinary examination. RESULTS: EP and extended examinations were performed on 143 participants: 62 UCPPS cases (30 women, 32 men), 42 positive controls (15 women, 27 men), and 39 healthy controls (22 women, 17 men). EP examinations showed that pelvic floor tenderness was more prevalent in cases (55.0%) than in positive (14.6%) or healthy controls (10.5%). Extended examinations revealed specific areas of tenderness in the pelvic floor musculature. Cases were also more likely than healthy controls to report tenderness in multiple areas, including suprapubic, symphysis pubis, and posterior superior iliac spine, and on bimanual examination. No comparative findings were specific to biological sex, and no evidence of pudendal neuropathy was observed on extended examination of cases or controls. CONCLUSION: The extended genitourinary examination is an easily administered addition to the assessment of men and women during evaluation for UCPPS. Physical findings may help to better categorize patients with UCPPS into clinically relevant subgroups for optimal treatment.

Diabetes prevention among American Indians: the role of self-efficacy, risk perception, numeracy and cultural identity.

BACKGROUND: According to the Risk Perception Attitude (RPA) framework, classifying people according to their perceptions of disease risk and their self-efficacy beliefs allows us to predict their likelihood for engaging in preventive behaviors. Health interventions can then be targeted according to RPA group. We applied the framework to type 2 diabetes prevention behaviors among American Indians and expanded it to include culture and numeracy. METHODS: Using a cross-sectional study design, we surveyed a sample of Northern Plains American Indians in a reservation community setting on self-reported perceptions of diabetes risk, objective diabetes risk, self-efficacy, engagement in healthy behaviors, knowledge of diabetes risk factors, and covariates including demographics, numeracy, and cultural identity. We used the RPA framework to classify participants into four groups based on their perceptions of risk and self-efficacy. Analyses of variance and covariance estimated inter-group differences in behaviors associated with type 2 diabetes prevention. RESULTS: Among 128 participants, our only finding consistent with the RPA framework was that self-efficacy and risk perception predicted knowledge about diabetes risk factors. We found limited evidence for the influence of cultural identity within the RPA framework. Overall, participants had lower numeracy skills which tended to be associated with inaccurate perceptions of higher levels of risk. CONCLUSIONS: The theoretical framework may benefit from inclusion of further contextual factors that influence these behaviors. Attention to numeracy skills stands out in our study as an important influence on the RPA framework, highlighting the importance of attending to numeracy when targeting and tailoring risk information to participants segmented by the RPA framework.

Left Ventricular Mass, Brain Magnetic Resonance Imaging, and Cognitive Performance: Results From the Strong Heart Study.

Left ventricular mass (LVM) has been shown to serve as a measure of target organ damage resulting from chronic exposure to several risk factors. Data on the association of midlife LVM with later cognitive performance are sparse. We studied 721 adults (mean age 56 years at baseline) enrolled in the Strong Heart Study (SHS, 1993-1995) and the ancillary CDCAI (Cerebrovascular Disease and Its Consequences in American Indians) Study (2010-2013), a study population with high prevalence of cardiovascular disease. LVM was assessed with transthoracic echocardiography at baseline in 1993 to 1995. Cranial magnetic resonance imaging and cognitive testing were undertaken between 2010 and 2013. Generalized estimating equations were used to model associations between LVM and later imaging and cognition outcomes. The mean follow-up period was 17 years. A difference of 25 g in higher LVM was associated with marginally lower hippocampal volume (0.01%; 95% confidence interval, 0.02-0.00; P=0.001) and higher white matter grade (0.10; 95% confidence interval, 0.02-0.18; P=0.014). Functionally, participants with higher LVM tended to have slightly lower scores on the modified mini-mental state examination (0.58; 95% confidence interval, 1.08-0.08; P=0.024). The main results persisted after adjusting for blood pressure levels or vascular disease. The small overall effect sizes are partly explained by survival bias because of the high prevalence of cardiovascular disease in our population. Our findings emphasize the role of cardiovascular health in midlife as a target for the prevention of deleterious cognitive and functional outcomes in later life.

Assessing HPV and Cervical Knowledge, Preference and HPV Status Among Urban American Indian Women.

INTRODUCTION: To evaluate whether or not an educational intervention would lead to a change in knowledge and attitudes about human papillomavirus (HPV), HPV vaccines, and cervical cancer. The HPV status was also investigated for interested participants. METHODS: We provided HPV and cervical cancer education to urban American Indian (AI) women 18 and older using a pre and post-knowledge exam to assess knowledge and attitudes. Women were also given the option to perform vaginal self-tests for high risk HPV (hrHPV) analysis immediately after the education. RESULTS: Ninety-six women participated in our educational sessions. Improvement in performance on a knowledge exam increased from 61.6 to 84.3 percent. Ninety-three women performed the vaginal self-test with 63.1 percent of women preferring vaginal self-testing over conventional screening methods. Thirty-five out of 91 women (38.5 percent) had hrHPV types with 12 of the 35 harboring multiple hrHPV types (13 percent overall). CONCLUSION: HPV and cervical cancer education was beneficial for urban AI women with the majority of women preferring vaginal self-testing. HPV self-testing may be a strategy to improve screening rates for cervical cancer. Urban AI women had high rates of hrHPV compared to rural AI populations as reported in previous studies.

Total Brain and Hippocampal Volumes and Cognition in Older American Indians: The Strong Heart Study.

BACKGROUND: Estimates of hippocampal volume by magnetic resonance imaging have clinical and cognitive correlations and can assist in early Alzheimer disease diagnosis. However, little is known about the relationship between global or regional brain volumes and cognitive test performance in American Indians. MATERIALS AND METHODS: American Indian participants (N=698; median age, 72 y) recruited for the Cerebrovascular Disease and its Consequences in American Indians study, an ancillary study of the Strong Heart Study cohort, were enrolled. Linear regression models assessed the relationship between magnetic resonance imaging brain volumes (total brain and hippocampi) and cognitive measures of verbal learning and recall, processing speed, verbal fluency, and global cognition. RESULTS: After controlling for demographic and clinical factors, all volumetric measurements were positively associated with processing speed. Total brain volume was also positively associated with verbal learning, but not with verbal recall. Conversely, left hippocampal volume was associated with both verbal learning and recall. The relationship between hippocampal volume and recall performance was more pronounced among those with lower scores on a global cognitive measure. Controlling for APOE ε4 did not substantively affect the associations. CONCLUSIONS: These results support further investigation into the relationship between structural Alzheimer disease biomarkers, cognition, genetics, and vascular risk factors in aging American Indians.

Breastfeeding in Infancy Is Associated with Body Mass Index in Adolescence: A Retrospective Cohort Study Comparing American Indians/Alaska Natives and Non-Hispanic Whites.

BACKGROUND: American Indians and Alaska Natives have the highest obesity prevalence in the United States, but the influence of early childhood variables on body mass index (BMI; calculated as kg/m2) is not well understood. Previous studies have investigated the association between breastfeeding in infancy and offspring BMI, but rarely included American Indians and Alaska Natives. OBJECTIVE: This study investigated the association between breastfeeding in infancy and BMI in American Indians and Alaska Native and non-Hispanic white adolescents and young adults. DESIGN: Longitudinal analysis based on data from the National Longitudinal Study of Adolescent to Adult Health (1994 to 2008). PARTICIPANTS: Adolescent respondents who self-identified as American Indians and Alaska Native or non-Hispanic white, and whose parents completed the parental questionnaire, reported their height and weight. The final sample included 655 American Indians and Alaska Native and 10,305 non-Hispanic white respondents. STATISTICAL ANALYSES PERFORMED: Generalized estimating equations were used to measure the mean differences, 95% CIs, and P values of the association between breastfeeding in infancy and offspring BMI in adolescence, stratifying by race, and adjusting for demographic and socioeconomic variables. RESULTS: The length of breastfeeding was inversely associated with BMI in both populations. American Indians and Alaska Natives that were breastfed for 6 to 12 months or for more than 12 months had a mean BMI of 2.69 (95% CI -3.46 to -1.92; P<0.01) and 1.54 (95% CI -2.75 to -0.33; P<0.05) units lower than those that were never breastfed. Non-Hispanic whites that were breastfed for 3 to 6 months, 6 to 12 months, or more than 12 months had a mean BMI of 0.71 (95% CI -0.93 to -0.50; P<0.01), 0.68 (95% CI -0.87 to -0.50; P<0.01), and 0.85 (95% CI -1.09 to -0.62; P<0.01) units lower than those that were never breastfed. The association between the length of breastfeeding and offspring BMI varied by race (P<0.01). CONCLUSIONS: Breastfeeding in infancy is associated with lower mean BMI. Future research should investigate causal pathways and whether interventions promoting breastfeeding in American Indians and Alaska Natives can prevent increasing BMI.

Access to Care and Diabetes Management Among Older American Indians With Type 2 Diabetes.

OBJECTIVE: To examine the relationship between health care access and diabetes management among a geographically diverse sample of American Indians (AIs) aged 50 and older with type 2 diabetes. METHOD: We examined the relationship between access to care and diabetes management, as measured by HbA1c, using 1998-1999 data from the Strong Heart Family Study. A series of bivariate and multivariate linear models examined the relationships between nine access-related variables and HbA1c levels. RESULTS: In bivariate analyses, out-of-pocket costs were associated with higher HbA1c levels. No other access-related characteristics were significantly associated with diabetes management in bivariate or in multivariate models. DISCUSSION: Access-related barriers were not associated with worse diabetes management in multivariate analyses. The study concludes with implications for clinicians working with AI populations to enhance opportunities for diabetes management.

The Role of Language Use in Reports of Musculoskeletal Pain Among Hispanic and Non-Hispanic White Adolescents.

OBJECTIVE: This study examined the role of English language use in the reported frequency of musculoskeletal pain among Hispanic and non-Hispanic White youth. METHOD: This is a secondary data analysis using a cross-sectional sample of 12,189 Hispanic and non-Hispanic White adolescents recruited for the National Longitudinal Study of Adolescent to Adult Health. Respondents were classified into three groups: (a) English-speaking non-Hispanic Whites, (b) English-speaking Hispanics, and (c) Spanish-speaking Hispanics. RESULTS: After controlling for body mass index and demographic, socioeconomic, and behavioral variables, Spanish-speaking Hispanics reported the least frequent musculoskeletal pain ( OR = 0.415, 95% CI [0.361, 0.477]; p < .001), followed by English-speaking Hispanics ( OR = 0.773, 95% CI [0.690, 0.865]; p < .001). CONCLUSION: The experience of musculoskeletal pain is a physiological as well as a cultural phenomenon. IMPLICATIONS FOR PRACTICE: Health care providers should consider the role of language use in reports of pain in Hispanic and non-Hispanic White adolescents.

Barriers to Cancer Care among American Indians and Alaska Natives.

INTRODUCTION: Cancer is among the leading causes of death in American Indians and Alaska Natives (AI/ANs), with rates increasing over the last two decades. Barriers in accessing cancer screening and treatment likely contribute to this situation. METHODS: We administered structured clinical interviews and conducted descriptive and multiple linear regression analyses of demographic, health, spiritual, and treatment factors associated with self-reported barriers to cancer care among 143 adult AI/AN oncology patients. RESULTS: High levels of satisfaction with cancer care, older age, positive mental health quality of life, and positive physical health quality of life were all significantly associated with lower scores for cancer care barriers, explaining 27% of the total model variance. CONCLUSION: Addressing barriers to cancer care might help to reduce health disparities among AI/AN oncology patients. Future research should determine whether reducing barriers improves engagement with cancer treatment and overall health outcomes.

A Multi-faceted Approach to Improving Breast Cancer Outcomes in a Rural Population, and the Potential Impact of Patient Navigation.

UNLABELLED: The mastectomy rate in rural areas of the Northern Plains of the U.S. was 64 percent from 2000 through 2005. We implemented a breast cancer patient navigation (BPN) program in May 2007 to increase breast conservation (BC) rates. METHODS: We analyzed mastectomy and BC rates among our 1,466 patients with either ductal carcinoma in situ (DCIS) or stage I/II invasive breast cancer treated from 2000 through 2012. We used interrupted time series (ITS) to compare rates in treatment following implementation of BPN. In addition, breast conservation rates were compared to population data from the Surveillance, Epidemiology, and End Results (SEER) database. RESULTS: The BC rates were 56 percent for navigated patients versus 37 percent for non-navigated patients (95 percent CI for difference: 14.8 to 25.6 percent). There was a consistent annual increase in treatment with BC versus a mastectomy (+2.9 percent/year, p-trend < 0.001). The BC rate of 60 percent in 2012 now mirrors those observed in the SEER database. The ITS did not find that the change in BC rates over time was significantly attributable to implementation of the BPN. Other secular trends may have contributed to the change in BC rates over time. CONCLUSIONS: A number of factors may have contributed to an increase of BC rates over time, including physician and patient education, more radiation therapy options, and possibly a dedicated breast cancer PN program. This analysis demonstrates that overall breast cancer care among this rural and medically-underserved population is improving in our region and now parallels other regions of the country.

Caregiving among American Indians and Alaska Natives with cancer.

PURPOSE: Caregivers are an important source of support for oncology patients during cancer diagnosis and treatment, often helping patients manage barriers to care. Our study had three goals: to describe the characteristics of caregivers for American Indian and Alaska Native (AI/AN) oncology patients, to assess the similarities and differences between the perceptions of caregivers and patients regarding barriers to cancer care, and to compare AI/AN caregivers to non-AI/AN caregivers on perceived barriers to cancer care. METHODS: We conducted a structured interview that assessed perceived barriers to cancer care with a paired sample of 98 adult caregivers and 98 AI/AN oncology patients and to assess the degree of agreement between these two groups. We also investigated whether AI/AN and non-AI/AN caregivers had differing perceptions of barriers to cancer care. RESULTS: Caregivers reported that their role was very meaningful and not highly stressful. Caregivers and patients agreed 70 % of the time on specific barriers to cancer care. Both groups overwhelmingly reported financial and family or work issues as major barriers to care, whereas trust in providers was the least frequently endorsed barrier. A comparison of AI/AN and non-AI/AN caregivers revealed that AI/AN caregivers identified confidentiality among clinical staff as a significant barrier, whereas non-AI/AN caregivers perceived financial barriers as more significant. CONCLUSIONS: Finances, family, and work are perceived as the largest barriers to the receipt of cancer care for AI/AN oncology patients. Both patients and caregivers trusted health-care providers. Assessing barriers to care early in the assessment process may result in better engagement with cancer treatment by patients and their caregivers.

A national study of social networks and perceptions of health among urban American Indian/Alaska Natives and non-Hispanic Whites.

Using data from The National Epidemiologic Survey on Alcohol and Related Conditions, the strength of social networks and the association of self-reported health among American Indians and Alaska Natives (AI/AN) and non-Hispanic Whites (NHW) were compared. Differences in social network-health relationships between AI/ANs and NHWs were also examined. For both groups, those with fewer network members were more likely to report fair or poor health than those with average or more network members, and persons with the fewest types of relationships had worse self-reported health than those with the average or very diverse types of relationships. Furthermore, small social networks were associated with much worse self-reported health in AI/ANs than in NHWs.