Elder women's perceptions around optimal perinatal health: a constructivist grounded-theory study with an Indigenous community in southern Ontario.

BACKGROUND: Women play important roles in translating health knowledge, particularly around pregnancy and birth, in Indigenous societies. We investigated elder Indigenous women's perceptions around optimal perinatal health. METHODS: Using a methodological framework that integrated a constructivist grounded-theory approach with an Indigenous epistemology, we conducted and analyzed in-depth interviews and focus groups with women from the Six Nations community in southern Ontario who self-identified as grandmothers. Our purposive sampling strategy was guided by a Six Nations advisory group and included researcher participation in a variety of local gatherings as well as personalized invitations to specific women, either face-to-face or via telephone. RESULTS: Three focus groups and 7 individual interviews were conducted with 18 grandmothers. The participants' experiences converged on 3 primary beliefs: pregnancy is a natural phase, pregnancy is a sacred period for the woman and the unborn child, and the requirements of immunity, security (trust), comfort, social development and parental responsibility are necessary for optimal postnatal health. Participants also identified 6 communal responsibilities necessary for families to raise healthy children: access to healthy and safe food, assurance of strong social support networks for mothers, access to resources for postnatal support, increased opportunities for children to participate in physical activity, more teachings around the impact of maternal behaviours during pregnancy and more teachings around spirituality/positive thinking. We also worked with the Six Nations community on several integrated knowledge-translation elements, including collaboration with an Indigenous artist to develop a digital story (short film). INTERPRETATION: Elder women are a trusted and knowledgeable group who are able to understand and incorporate multiple sources of knowledge and deliver it in culturally meaningful ways. Thus, tailoring public health programming to include elder women's voices may improve the impact and uptake of perinatal health information for Indigenous women.

Interrelation of saturated fat, trans fat, alcohol intake, and subclinical atherosclerosis.

BACKGROUND: Intake of saturated fat, trans fat, and alcohol alter cardiovascular disease risk, but their effect on subclinical atherosclerosis remains understudied. OBJECTIVE: The objective was to examine and quantify the interrelation of saturated fat, trans fat, alcohol intake, and mean carotid artery intimal medial thickness (IMT). DESIGN: We conducted a population-based, cross-sectional study among 620 persons of Aboriginal, South Asian, Chinese, or European origin aged 35-75 y, who had lived in Canada for >or=5 y. Mean IMT was calculated from 6 well-defined segments of the right and left carotid arteries with standardized B-mode ultrasound, and saturated fat, trans fat, and alcohol intakes were measured with validated food-frequency questionnaires. RESULTS: For every 10-g/d increase in saturated fat intake, IMT was 0.03 mm higher (P=0.01) after multivariate adjustment. A 1-g/d higher intake of trans fat was associated with a 0.03-mm higher IMT (P=0.02) after multivariate adjustment. The ratio of polyunsaturated to saturated fat (P:S) was inversely associated with IMT after multivariate adjustment (change in IMT: -0.06 mm; P<0.01). Saturated and trans fat intakes were independently associated with IMT thickness (change in IMT: 0.03 mm; P<0.01 and 0.02, respectively; P for interaction=0.01). Polyunsaturated, monounsaturated, cholesterol, and total fat intakes were unrelated to IMT. The relation between saturated fat intake and IMT strengthened (beta=0.0066, P<0.001) in persons who never or rarely consumed alcohol as compared with moderate or heavy drinkers (beta=0.0001, P=0.79, P for interaction=0.01). CONCLUSION: Higher habitual intakes of saturated and trans fats are independently associated with increased subclinical atherosclerosis, and alcohol intake may attenuate the relation between saturated fat and subclinical atherosclerosis.

Defining obesity cut points in a multiethnic population.

BACKGROUND: Body mass index (BMI) is widely used to assess risk for cardiovascular disease and type 2 diabetes. Cut points for the classification of obesity (BMI >30 kg/m2) have been developed and validated among people of European descent. It is unknown whether these cut points are appropriate for non-European populations. We assessed the metabolic risk associated with BMI among South Asians, Chinese, Aboriginals, and Europeans. METHODS AND RESULTS: We randomly sampled 1078 subjects from 4 ethnic groups (289 South Asians, 281 Chinese, 207 Aboriginals, and 301 Europeans) from 4 regions in Canada. Principal components factor analysis was used to derive underlying latent or "hidden" factors associated with 14 clinical and biochemical cardiometabolic markers. Ethnic-specific BMI cut points were derived for 3 cardiometabolic factors. Three primary latent factors emerged that accounted for 56% of the variation in markers of glucose metabolism, lipid metabolism, and blood pressure. For a given BMI, elevated levels of glucose- and lipid-related factors were more likely to be present in South Asians, Chinese, and Aboriginals compared with Europeans, and elevated levels of the blood pressure-related factor were more likely to be present among Chinese compared with Europeans. The cut point to define obesity, as defined by distribution of glucose and lipid factors, is lower by approximately 6 kg/m2 among non-European groups compared with Europeans. CONCLUSIONS: Revisions may be warranted for BMI cut points to define obesity among South Asians, Chinese, and Aboriginals. Using these revised cut points would greatly increase the estimated burden of obesity-related metabolic disorders among non-European populations.

Carbohydrate intake and HDL in a multiethnic population.

BACKGROUND: Ethnic differences in serum lipids are not explained by genetics, central adiposity, lifestyle, or diet, possibly because dietary carbohydrate has not been considered. OBJECTIVE: The aim was to evaluate the relation between carbohydrate intake and HDL and triacylglycerol concentrations in a multiethnic population. DESIGN: We conducted a population-based cross-sectional study of 619 Canadians of Aboriginal, South Asian, Chinese, and European origin with no previously diagnosed medical conditions. Energy-adjusted carbohydrate intake was measured by a validated food-frequency questionnaire. RESULTS: South Asians consumed the most carbohydrate, followed by European, Aboriginal, and Chinese persons. Mean (95% CI) HDL concentrations in the lowest and highest categories of carbohydrate intake after adjustment for age, sex, ethnicity, physical activity, smoking, the waist-to-hip ratio, body mass index, alcohol intake, and intakes of total energy, protein, and fiber were 1.21 mmol/L (1.16, 1.27 mmol/L) and 1.08 mmol/L (1.02, 1.13 mmol/L), respectively, and HDL cholesterol was significantly (P < 0.01) higher in the lowest tertile of carbohydrate intake than in the highest tertile. High carbohydrate intake was associated with higher fasting triacylglycerols (P = 0.04); the adjusted mean fasting triacylglycerol concentrations in the lowest and highest categories of carbohydrate intake were 1.43 mmol/L (1.28, 1.60 mmol/L) and 1.71 mmol/L (1.57, 1.87 mmol/L), respectively. Fewer servings of sugar-containing soft drinks, juices, and snacks were associated with higher HDL (P for trend = 0.02); the multivariate-adjusted mean HDL in the lowest and highest categories of carbohydrate intake was 1.22 mmol/L (1.17, 1.27 mmol/L) and 1.11 mmol/L (1.06, 1.26 mmol/L), respectively. CONCLUSIONS: Differences in HDL and triacylglycerols observed in different ethnic groups may be due in part to carbohydrate intake. Reducing the frequency of intake of sugar-containing soft drinks, juices, and snacks may be beneficial.

A family-based intervention to promote healthy lifestyles in an aboriginal community in Canada.

CONTEXT: Obesity is a major public health problem in North America, particularly in Aboriginal people. OBJECTIVE: To determine if a household-based lifestyle intervention is effective at reducing energy intake and increasing physical activity among Aboriginal families after 6 months. DESIGN, PARTICIPANTS, AND INTERVENTION: Randomized, open trial of 57 Aboriginal households recruited between May 2004 and April 2005 from the Six Nations Reserve in Ohsweken, Canada. Aboriginal Health Counsellors made regular home visits to assist families in setting dietary and physical activity goals. Additional interventions included provision of filtered water, a physical activity program for children, and educational events about healthy lifestyles. RESULTS: 57 households involving 174 individuals were randomized to intervention or usual care. Intervention households decreased consumption of fats, oils and sweets compared to usual care households (-4.9 servings per day vs. -3 servings/day, p=0.006), and this was associated with a reduction in trans fatty acids (-0.2 vs. +0.6 grams/day, p=0.02). Water consumption increased (+0.3 vs. -0.1 servings/day, p<0.04) and soda pop consumption decreased (-0.3 vs. -0.1 servings/day, p=0.02) in intervention households compared to usual care. A trend toward increased knowledge about healthy dietary practices in children, increased leisure-time activity and decreased sedentary behaviours was observed, although these differences were not statistically significant. CONCLUSION: A household-based intervention is associated with some positive changes in dietary practices and activity patterns. A larger and longer-term intervention which addresses both individual change and structural barriers in the community is needed.

Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects.

BACKGROUND: Social disadvantage is defined by adverse socio-economic characteristics and is distributed unequally by age, sex, and ethnicity. We studied the relationship between social disadvantage, cardiovascular risk factors, and cardiovascular disease (CVD) among men and women from diverse ethno-racial backgrounds. METHODS: A total of 1227 men and women of South Asian, Chinese, Aboriginal, and European ancestry were randomly selected from four communities in Canada to undergo a health assessment. Socio-economic factors, conventional and novel CV risk factors, atherosclerosis, and CVD were measured. A social disadvantage index was generated and included employment status, income, and marital status. Social disadvantage was examined in relation to risk factors for CVD, atherosclerosis, and prevalent CVD. RESULTS: Social disadvantage was higher among older people, women, and non-white ethnic groups. Cigarette smoking, glucose, overweight, abdominal obesity, and CRP were higher among individuals with higher social disadvantage, whereas systolic blood pressure, lipids, norepinephrine, and atherosclerosis were not. Social disadvantage is an independent predictor of CVD after adjustment for conventional and novel risk markers for CVD (OR for 1 point increase = 1.25; 95% CI 1.06-1.47). CONCLUSION: The social disadvantage index combines social and economic exposures into a single continuous measure. Significant variation in social disadvantage by age, sex, and ethnic group exists. Increased social disadvantage is associated with an increased burden of some CV risk factors, and is an independently associated with CVD.

Protein intake is inversely associated with abdominal obesity in a multi-ethnic population.

Abdominal obesity is related to significant morbidity and mortality and differs by ethnicity; however, the relation between diet and abdominal obesity has not been extensively studied. The aim of this study was to evaluate the dietary and lifestyle determinants of abdominal obesity in a multi-ethnic population. We conducted a cross-sectional study among 617 Canadians of Aboriginal, South Asian, Chinese, and European origins, with diet evaluated using validated, culture specific, interviewer-administered FFQs, and abdominal obesity measured as waist-hip ratio (WHR). The mean proportion of energy intake from protein in the diet was 17.4 vs. 15.8% comparing the lowest and highest tertiles of WHR. Energy-adjusted protein substituted for an equivalent amount of carbohydrate was associated with a reduction in WHR (difference in WHR for every g/d increase in protein intake = -0.0005, P = 0.01) after accounting for age, sex, ethnicity, smoking status, BMI, alcohol intake, height, physical activity, and total energy. Fat or total energy were not related to WHR in the same linear regression model. Smoking was positively and physical activity inversely related to WHR in the multivariate model independent of BMI and other potential confounders. Substituting a modest amount of protein for carbohydrate may reduce abdominal obesity in a diverse multi-ethnic population. Smoking was positively related to abdominal obesity after accounting for BMI.

C-reactive protein as a screening test for cardiovascular risk in a multiethnic population.

BACKGROUND: Small increases in the inflammatory marker C-reactive protein (CRP) are predictive of vascular events among asymptomatic individuals. There are few data supporting the use of CRP as a risk marker among nonwhite individuals. METHODS AND RESULTS: 1250 adults of South Asian, Chinese, European, and Aboriginal ancestry were randomly sampled from 4 communities in Canada. Participants provided fasting blood samples for CRP, glucose, lipids, and coagulation factors, and they had undergone a carotid B-mode ultrasound. Cardiovascular disease was determined by history and electrocardiogram. The age- and sex-adjusted mean CRP was 3.74 mg/L (standard error, 0.14) among Aboriginals, 2.59 mg/L (0.12) among South Asians, and 1.18 mg/L (0.13) among Chinese compared with 2.06 mg/L (0.12) among Europeans (overall P<0.0001). Differences in the CRP concentration between ethnic groups were substantially diminished, but not abolished, after adjustment for metabolic factors. CRP was independently associated with CVD after adjusting for the Framingham risk factors, atherosclerosis, anthropometric measurements, and ethnicity (OR=1.03 for a 0.1-increase in CRP; P=0.02). CONCLUSIONS: CRP varies substantially between people of different ethnic origin and is influenced by their differences in metabolic factors. Prospective validation of CRP as a risk predictor for cardiovascular disease among nonwhite ethnic groups is required.

Relationship of metabolic syndrome and fibrinolytic dysfunction to cardiovascular disease.

BACKGROUND: The clustering of impaired glucose metabolism, elevated triglycerides, low HDL cholesterol, and abdominal obesity is known as the metabolic syndrome. Individuals with this syndrome suffer an excess of cardiovascular disease (CVD) for reasons that are unclear. METHODS AND RESULTS: We randomly sampled 1276 adults of South Asian, Chinese, European, and Native Indian ancestry from 4 communities in Canada. Participants provided fasting blood samples for glucose, lipids, and fibrinolytic measurements; had an oral glucose tolerance test; and underwent a B-mode carotid ultrasound examination. CVD was determined by history and ECG. The prevalence of the metabolic syndrome was 25.8% (95% CI, 23.5 to 28.2) and varied substantially by ethnic group: 41.6% among Native Indians, 25.9% among South Asians, and 22.0% among Europeans, compared with 11.0% among the Chinese (overall, P=0.0001). People with the metabolic syndrome had more atherosclerosis (maximum intimal medial thickness, 0.78+/-0.18 versus 0.74+/-0.18 mm; P=0.0005), CVD (17.2% versus 7.0%; P=0.0001), and elevated plasminogen activator inhibitor-1 (24.2 versus 14.6 U/mL; P=0.001) compared with levels among people without the metabolic syndrome. For the same amount of atherosclerosis, people with the metabolic syndrome had a greater prevalence of CVD, even among nondiabetic individuals. This difference in CVD prevalence among the groups was attenuated after adjustment for plasminogen activator inhibitor-1 levels, suggesting that fibrinolytic dysfunction mediates the increased risk of CVD in individuals with the metabolic syndrome. CONCLUSIONS: CVD among people with the metabolic syndrome is explained by their excess of atherosclerosis and impaired fibrinolysis. Interventions to prevent atherosclerosis progression and improve fibrinolytic function require evaluation in this high-risk group.