Perspective: Beyond the Mediterranean Diet-Exploring Latin American, Asian, and African Heritage Diets as Cultural Models of Healthy Eating

The Mediterranean diet is a well-studied cultural model of healthy eating, yet research on healthy models from other cultures and cuisines has been limited. This perspective article summarizes the components of traditional Latin American, Asian, and African heritage diets, their association with diet quality and markers of health, and implications for nutrition programs and policy. Though these diets differ in specific foods and flavors, we present a common thread that emphasizes healthful plant foods and that is consistent with high dietary quality and low rates of major causes of disability and deaths. In this perspective, we propose that nutrition interventions that incorporate these cultural models of healthy eating show promise, though further research is needed to determine health outcomes and best practices for implementation.

Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Peripheral artery disease (PAD) affects 200 million individuals worldwide. In the United States, certain demographic groups experience a disproportionately higher prevalence and clinical effect of PAD. The social and clinical effect of PAD includes higher rates of individual disability, depression, minor and major limb amputation along with cardiovascular and cerebrovascular events. The reasons behind the inequitable burden of PAD and inequitable delivery of care are both multifactorial and complex in nature, including systemic and structural inequity that exists within our society. Herein, we present an overview statement of the myriad variables that contribute to PAD disparities and conclude with a summary of potential novel solutions.

Obesity interventions in African American faith-based organizations: a systematic review

African Americans, especially women, have higher obesity rates than the general US population. Because of the importance of faith to many African Americans, faith-based organizations (FBOs) may be effective venues for delivering health messages and promoting adoption of healthy behaviours. This article systematically reviews interventions targeting weight and related behaviours in faith settings. We searched literature published through July 2012 for interventions in FBOs targeting weight loss, diet and/or physical activity (PA) in African Americans. Of 27 relevant articles identified, 12 were randomized controlled trials; seven of these reported a statistically significant change in an outcome. Four of the five quasi-experimental and single-group design studies reported a statistically significant outcome. All 10 pilot studies reported improvement in at least one outcome, but most did not have a comparison group. Overall, 70% of interventions reported success in reducing weight, 60% reported increased fruit and vegetable intake and 38% reported increased PA. These results suggest that interventions in African American FBOs can successfully improve weight and related behaviours. However, not all of the findings about the success of certain approaches were as expected. This review identifies gaps in knowledge and recommends more rigorous studies be conducted to strengthen the comparative methodology and evidence.

Rationale and design of Faith-based Approaches in the Treatment of Hypertension (FAITH), a lifestyle intervention targeting blood pressure control among black church members

BACKGROUND

Uncontrolled hypertension (HTN) is a significant public health problem among blacks in the United States. Despite the proven efficacy of therapeutic lifestyle change (TLC) on blood pressure (BP) reduction in clinical trials, few studies have examined their effectiveness in church-based settings-an influential institution for health promotion in black communities.

METHODS

Using a cluster-randomized, 2-arm trial design, this study evaluates the effectiveness of a faith-based TLC intervention vs health education (HE) control on BP reduction among hypertensive black adults. The intervention is delivered by trained lay health advisors through group TLC sessions plus motivational interviewing in 32 black churches. Participants in the intervention group receive 11 weekly TLC sessions targeting weight loss, increasing physical activity, fruit, vegetable and low-fat dairy intake, and decreasing fat and sodium intake, plus 3 monthly individual motivational interviewing sessions. Participants in the control group attend 11 weekly classes on HTN and other health topics delivered by health care experts. The primary outcome is change in BP from baseline to 6 months. Secondary outcomes include level of physical activity, percent change in weight, and fruit and vegetable consumption at 6 months, and BP control at 9 months.

CONCLUSION

If successful, this trial will provide an alternative and culturally appropriate model for HTN control through evidence-based lifestyle modification delivered in churches by lay health advisors.

An Assessment of nutrition education in selected counties in New York State elementary schools (kindergarten through fifth grade)

OBJECTIVE

To assess the extent to which nutrition education is implemented in selected counties in New York State elementary schools (kindergarten through fifth grade) and explore how nutrition knowledge is presented in the classroom and what factors support it.

DESIGN

Cross-sectional, self-administered survey.

SETTING

New York State elementary schools in selected counties.

PARTICIPANTS

New York State elementary school teachers (n = 137).

MAIN OUTCOME MEASURES

Hours spent teaching nutrition; nutrition topics, methods of teaching, education resources, and aspects of the school environment that may influence nutrition education.

ANALYSIS

Crosstabs with a chi-square statistic and ANOVA.

RESULTS

Eighty-three percent of teachers taught some nutrition (9.0 ± 10.5 hours) during the academic year. Teachers taught lessons about finding and choosing healthy food (61%), relationship between diet and health (54%), and MyPyramid (52%) most often. Suburban teachers (12.4 ± 12.5 hours) taught significantly (P = .006) more hours of nutrition than rural teachers (4.2 ± 3.9 hours). Teachers at schools with fewer than 80% nonwhite students taught significantly (P = .02) more (10.4 ± 11.4 hours) compared to schools with greater than 80% nonwhite students (5.6 ± 6.4 hours).

CONCLUSIONS AND IMPLICATIONS

Teachers reported that nutrition education is important and that they are willing to teach nutrition. Efforts should be made that support integrated nutrition topics, methods of instruction, and availability of resources.

Association between self-monitoring of blood glucose and diet among minority patients with diabetes

BACKGROUND

Self-monitoring of blood glucose (SMBG) is used to regulate glucose control. It is unknown whether SMBG can motivate adherence to dietary recommendations. We predicted that participants who used more SMBG would also report lower fat and greater fruit and vegetable consumption.

METHODS

The present study was a cross-sectional study of 401 primarily minority individuals living with diabetes in East Harlem, New York. Fat intake and fruit and vegetable consumption were measured with the Block Fruit/Vegetable/Fiber and Fat Screeners.

RESULTS

Greater frequency of SMBG was associated with lower fat intake (r(s) = -0.15; P < 0.01), but not fruit and vegetable consumption. The effects of SMBG were not moderated by insulin use; thus, the relationship was significant for those individuals both on and not on insulin. A significant interaction was found between frequency of SMBG and changing one's diet in response to SMBG on total fat intake. The data suggest that participants who use SMBG to guide their diet do not have to monitor multiple times a day to benefit.

CONCLUSION

The present study found that the frequency of SMBG was associated with lower fat intake. Patients are often taught to use SMBG to guide their self-management. This is one of the first studies to examine whether SMBG is associated with better dietary intake.

Factors related to perceived diabetes control are not related to actual glucose control for minority patients with diabetes

OBJECTIVE

To examine variables associated with perceived diabetes control compared with an objective measure of glucose control (A1C).

RESEARCH DESIGN AND METHODS

Beliefs about diabetes were assessed among 334 individuals with diabetes living in a primarily low-income, minority, urban neighborhood. Regression analyses tested associations between disease beliefs and both participants' perceptions of control and actual control (A1C).

RESULTS

Poorer perceived diabetes control was associated with perceiving a greater impact of diabetes, greater depressive symptoms, not following a diabetic diet, A1C, and a trend toward less exercise. Variables associated with better actual control (A1C) included higher BMI, older age, and not using insulin.

CONCLUSIONS

Patients' perceptions of their diabetes control are informed by subjective diabetes cues (e.g., perceived impact of diabetes and adherence to a diabetic diet), which are not related to A1C. Clinicians should take into account what cues patients are using to assess their diabetes control.

Built environment and health behaviors among African Americans: a systematic review

CONTEXT

An overall understanding of environmental factors that affect weight-related behaviors and outcomes in African American adults is limited. This article presents a summarization of the literature on the built environment and its association with physical activity, diet, and obesity among African Americans.

EVIDENCE ACQUISITION

A systematic review was conducted by searching the PubMed electronic database from inception to July 31, 2007, reviewing bibliographies of eligible articles, and searching authors' personal databases using various search terms for the built environment, physical activity, diet, and obesity. Eligible articles were observational studies that included a study population >or=90% African American (or subgroup analysis), adults (>or=18 yrs), and were published in English; final article data abstraction occurred from October 2007 through February 2008.

EVIDENCE SYNTHESIS

A total of 2797 titles were identified from the initial search, and 90 were deemed eligible for abstract review. Of these, 17 articles were eligible for full review and ten met all eligibility criteria. The median sample size was 761 (234 to 10,623), and half of the articles included only African Americans. Light traffic, the presence of sidewalks, and safety from crime were more often positively associated with physical activity, although associations were not consistent (OR range = 0.53-2.43). Additionally, perceived barriers to physical activity were associated with obesity. The presence of supermarkets and specialty stores was consistently positively associated with meeting fruit and vegetable guidelines.

CONCLUSIONS

With relatively few studies in the literature focused on African Americans, more research is needed to draw conclusions on features of the built environment that are associated with physical activity, diet, and obesity.

A model for using community-based participatory research to address the diabetes epidemic in East Harlem

OBJECTIVE

Diabetes prevalence and mortality are increasing, with minority populations disproportionately affected. Despite evidence that weight loss due to improved nutrition and increased physical activity can prevent or control diabetes, there is often a disconnect between this evidence and individuals' lifestyles.

METHODS

East Harlem is a predominantly African-American and Latino neighborhood that has the highest rates of diabetes prevalence and mortality in New York City. The East Harlem Diabetes Center of Excellence is a community-centered coalition. To help direct their work, the coalition used their experiences, research, outreach, and literature review to build a conceptual model describing how local factors affect health behaviors and health outcomes such as obesity and diabetes.

RESULTS

This model describes the relationship between the physical environment, the social/medical environment and individual factors including demographic data, food and exercise beliefs and behaviors, and health outcomes. The coalition inserted local data from surveys and focus groups into the model to identify targets for future interventions, research, and activism.

CONCLUSIONS

This type of collaboration and the model may be useful tools to help communities identify and address the deficits that prevent their residents from enjoying the health benefits of improved nutrition and increased physical activity, and that also lead to racial and ethnic disparities in health.

Acceptability of sodium-reduced research diets, including the Dietary Approaches To Stop Hypertension diet, among adults with prehypertension and stage 1 hypertension

OBJECTIVE

Examine the acceptability of sodium-reduced research diets.

DESIGN

Randomized crossover trial of three sodium levels for 30 days each among participants randomly assigned to one of two dietary patterns.

PARTICIPANTS/SETTING

Three hundred fifty-four adults with prehypertension or stage 1 hypertension who were participants in the Dietary Approaches to Stop Hypertension (DASH-Sodium) outpatient feeding trial.

INTERVENTION

Participants received their assigned diet (control or DASH, rich in fruits, vegetables, and low-fat dairy products), each at three levels of sodium (higher, intermediate, and lower) corresponding to 3,500, 2,300, and 1,200 mg/day (150, 100, and 50 mmol/day) per 2,100 kcal.

MAIN OUTCOME MEASURES

Nine-item questionnaire on liking and willingness to continue the assigned diet and its level of saltiness using a nine-point scale, ranging from one to nine.

STATISTICAL ANALYSES PERFORMED

Generalized estimating equations to test participant ratings as a function of sodium level and diet while adjusting for site, feeding cohort, carryover effects, and ratings during run-in.

RESULTS

Overall, participants rated the saltiness of the intermediate level sodium as most acceptable (DASH group: 5.5 for intermediate vs 4.5 and 4.4 for higher and lower sodium; control group: 5.7 for intermediate vs 4.9 and 4.7 for higher and lower sodium) and rated liking and willing to continue the DASH diet more than the control diet by about one point (ratings range from 5.6 to 6.6 for DASH diet and 5.2 to 6.1 for control diet). Small race differences were observed in sodium and diet acceptability.

CONCLUSIONS

Both the intermediate and lower sodium levels of each diet are at least as acceptable as the higher sodium level in persons with or at risk for hypertension.

Expanding the obesity research paradigm to reach African American communities

Obesity is more prevalent among African Americans and other racial and ethnic minority populations than among whites. The behaviors that determine weight status are embedded in the core social and cultural processes and environments of day-to-day life in these populations. Therefore, identifying effective, sustainable solutions to obesity requires an ecological model that is inclusive of relevant contextual variables. Race and ethnicity are potent stratification variables in U.S. society and strongly influence life contexts, including many aspects that relate to eating and physical activity behaviors. This article describes a synthesis initiated by the African American Collaborative Obesity Research Network (AACORN) to build and broaden the obesity research paradigm. The focus is on African Americans, but the expanded paradigm has broader implications and may apply to other populations of color. The synthesis involves both community and researcher perspectives, drawing on and integrating insights from an expanded set of knowledge domains to promote a deeper understanding of relevant contexts. To augment the traditional, biomedical focus on energy balance, the expanded paradigm includes insights from family sociology, literature, philosophy, transcultural psychology, marketing, economics, and studies of the built environment. We also emphasize the need for more attention to tensions that may affect African American or other researchers who identify or are identified as members of the communities they study. This expanded paradigm, for which development is ongoing, poses new challenges for researchers who focus on obesity and obesity-related health disparities but also promises discovery of new directions that can lead to new solutions.

Achieving healthy weight in African-American communities: research perspectives and priorities

The longstanding high burden of obesity in African-American women and the more recent, steeper than average rise in obesity prevalence among African-American children constitute a mandate for an increased focus on obesity prevention and treatment research in African-American communities. The African-American Collaborative Obesity Research Network (AACORN) was formed to stimulate and support greater participation in framing and implementing the obesity research agenda by investigators who have both social and cultural grounding in African-American life experiences and obesity-related scientific expertise. AACORN's examination of obesity research agenda issues began in 2003 in conjunction with the Think Tank on Enhancing Obesity Research at the National Heart, Lung, and Blood Institute (NHLBI). The assessment was subsequently expanded to take into account the overall NIH strategic plan for obesity research, literature reviews, and descriptions of ongoing studies. In identifying priorities, AACORN members considered the quality, quantity, focus, and contextual relevance of published research relevant to obesity prevention and treatment in African-American adults or children. Fifteen recommended research priorities are presented in five categories adapted from the NHLBI Think Tank proceedings: health effects, social and environmental context, prevention and treatment, research methods, and research training and funding. These recommendations from an African-American perspective build on and reinforce certain aspects of the NHLBI and overall NIH research agendas by providing more specific rationale and directions on areas for enhancement in the type of research being done or in the conceptualization and implementation of that research.

Dietary intake and risk of coronary heart disease differ among ethnic subgroups of black Americans

Coronary heart disease (CHD) morbidity and mortality are more prevalent in Blacks than Whites in the United States. Most studies evaluate the dietary intake and health of Black Americans as one group and do not consider possible differences among ethnic subgroups within the U.S. Black population. We used data from NHANES III to assess whether dietary intake, CHD risk factors, and predicted 10-y risk of CHD differed between non-Hispanic Black adults born in the United States (NHB-US), and non-Hispanic and Hispanic Black adults born outside of the United States (NHB-non US, HB-non US). Data were provided from single 24-h dietary recalls, biochemical measures, the medical examination, and self-reported responses to survey questions. NHB-US had higher intakes of energy, fat, protein, meat, added sugars, and sodium, and lower intakes of fruits, fiber, and most micronutrients. NHB-US also had higher predicted 10-y risk of developing CHD (5.8%) than NHB-non US (3.7%, P<0.001) or HB-non US (4.7%, P=0.017). Both immigrant groups had better CHD risk profiles and lower proportions of persons with metabolic syndrome and other CHD-related conditions. Our findings show differences in dietary intake and risk of CHD and related health conditions among ethnic subgroups of Blacks living in the United States. Future studies of diet and health should consider cultural differences within the Black population to better understand and reduce overall health disparities in the United States.

Characteristics influencing daily consumption of fruits and vegetables and low-fat dairy products in older adults with hypertension

The objective of this study ws to examine the characteristics that may influence fruit, vegetable, and dairy intake in older adults with hypertension. A cross-sectional survey was conducted in a random sample of older adults who participate in a Pennsylvania pharmaceutical assistance program. Among those who reported having hypertension (N = 592), daily fruit/vegetable intake was more prevalent among women, those who were older, and those who spent more time with others. Daily intake of dairy foods was more prevalent among women and whites as well as those who exhibited certain health-conscious behaviors and those who spent more time with others.

Hypertension-related dietary patterns of rural older adults

BACKGROUND

Prevalence of hypertension is greater in older adults, and increased intake of fruits, vegetables, and dairy-good sources of potassium, calcium, and magnesium-can reduce blood pressure. This study examined the hypertension-related dietary patterns of older adults.

METHODS

A cohort of 180 Pennsylvania adults (aged >/=65), 90 with hypertension, were randomly selected from the Geisinger Rural Aging Study (GRAS). Data were collected by trained interviewers at a home visit. Dietary assessment used five 24-h recalls. We compared the characteristics and dietary intake of people with hypertension to those without hypertension and compared their intakes to current recommendations.

RESULTS

Mean intakes of all participants were less than two thirds of the DRI for calcium and magnesium and fell far short of the 3,500 mg of potassium recommended for prevention and treatment of hypertension. Participants with hypertension consumed less sodium than controls. Both groups ate fewer fruits and vegetables than recommended but reached the dairy recommendation. Calcium intake was mainly from high-fat dairy products, beans were the top source of potassium and magnesium.

CONCLUSIONS

Older adults with hypertension should be guided to choose more low-fat dairy products and other low-fat calcium sources and to increase intakes of beans, dark green leafy vegetables, and other potassium and magnesium sources.

Dietary treatment of blood pressure in kidney disease

Most patients with chronic kidney disease (CKD) also have hypertension. It is critical to control blood pressure in CKD to decrease the risk of negative outcomes. Modification of diet can reduce blood pressure, most notably in people with hypertension and in older adults. Current guidelines recommend reducing sodium intake to less than 2.4 g/day and increasing potassium and calcium intakes. Sodium reduction is supported for CKD patients in general. However, increasing potassium intake should be restricted in patients with glomerular filtration rate (GFR) less than 60 mL/min/1.73 m(2). In addition, because of the high phosphorus levels of many calcium-rich foods such as dairy products, calcium intake also should be limited in this low-GFR population. There is increasing evidence for the association of other nutrients such as omega-3 polyunsaturated fatty acids and vitamin C with blood pressure. Those nutrients are also discussed here.

Dehydration in black and white older adults using diuretics

PURPOSE

To assess the association between dehydration and ethnicity in older adults; and to determine if diuretic use can help explain the disparity between blacks and whites in diagnosis of dehydration.

METHODS

We conducted a case-control study in black and white older adults in a pharmaceutical assistance program who were hospitalized during 1997. Cases were all those diagnosed with dehydration (N=9186). Randomly selected controls were 4:1 frequency matched to cases by sex and age group (N(Total)=45585).

RESULTS

Patients taking loop, potassium-sparing, thiazide or combination diuretics were more likely to have a diagnosis of dehydration. Dehydration diagnosis was associated with being black (odds ratio (OR)=1.49, 95% confidence interval (CI), 1.36-1.63, p<.001), independent of diuretic use or dosage. That association remained when examining loop (OR=1.36, 95% CI, 1.10-1.63, p<.004) and thiazide diuretic users (OR=1.59, 95% CI, 1.09-2.34, p=.017), but not potassium-sparing or combination diuretic users.

CONCLUSION

Diuretic use is significantly associated with dehydration diagnosis, but the greater likelihood of older blacks being diagnosed with dehydration is independent of diuretic use. The increased risk of morbidity and mortality associated with dehydration suggests that further examination of the root cause of this disparity in risk is warranted.

Heparin-associated thrombocytopenia and thrombosis as the cause of a fatal thrombus on extracorporeal membrane oxygenation

A rare state of acquired hypercoagulability known as heparin-associated or heparin-induced thrombocytopenia and thrombosis (HATT, HITT) exists. It appears to be caused by an antibody reaction with heparin-platelet factor 4 complexes. A mild and severe form exist, but both varieties occur after exposure to heparin. The authors describe a fatal neonatal case of hypercoagulability on extracorporeal membrane oxygenation, and their evaluation that determined the etiology as type II HATT. They discuss the pathophysiology of HATT as well as possible alternative anticoagulation approaches.

Ischemic fasciitis. Report of a case with fine needle aspiration findings

BACKGROUND

Ischemic fasciitis, also called atypical decubital fibroplasia, was recently described as a distinctive fibroblastic proliferation occurring predominantly in elderly, bed-ridden individuals. This entity can easily be misdiagnosed as a malignant process.

CASE

A 70-year-old, white male presented with an enlarging right hip mass. Fine needle aspiration yielded spindled and ovoid cells with ample cytoplasm and occasional nuclear atypia. The histologic features of a subsequent biopsy and resection specimen included a zonal pattern of fibrinoid necrosis with surrounding reactive fibroblasts, histiocytes and vascular proliferation, which are characteristic of ischemic fasciitis.

CONCLUSION

Ischemic fasciitis can be mistaken clinically, cytologically and histologically for sarcoma. The cytologic findings seen in this case, when combined with the clinical history, were sufficient to avoid misdiagnosis of malignancy in a benign, proliferative lesion.

Goblet cell carcinoid arising in a mature teratoma of the mediastinum

Goblet cell carcinoid (GCC) is a rare but distinctive neoplasm with features of both adenocarcinoma and carcinoid tumor. Most cases described in the literature have occurred in the appendix. An additional well-defined location is the ovary, and these tumors have been associated with a mature teratoma of the ovary. GCC arising within a mature teratoma of the mediastinum has not been described in the English-language literature. We report a case of this previously undescribed entity and provide a review of the literature on mediastinal teratomas with malignant transformation. The histologic findings included uniform, smooth-bordered glandular nests lined by goblet cells and admixed endocrine and Paneth cells. Occasional tubular glands were present, as were transitional type glands with both goblet cell and tubular features. Cytologic atypia was minimal, and mitotic activity was rare. Immunohistochemical studies showed positive staining of GCC tumor cells with chromogranin, cytokeratin, neuron-specific enolase, serotonin (focal), and Leu-7 (focal). The GCC component was entirely contained within the mature teratoma.