Racial Misclassification, Discrimination, Consciousness, and Self-Rated Health Among Native Hawaiian and Pacific Islander Adults in the USA

BACKGROUND

Medical researchers have historically utilized the variable of race uncritically, rarely defining race, rarely acknowledging it as a social construct, and often omitting information about how it was measured. In this study, we use the following definition of race: "a system of structuring opportunity and assigning value based on the social interpretation of how one looks." We examine the influence of racial misclassification, racial discrimination, and racial consciousness on the self-rated health of Native Hawaiian and Pacific Islanders (NHPI) living in the United States of America (USA).

METHODS

Our analysis used online survey data from a subgroup of NHPI adults living in the USA (n = 252) who were oversampled as part of a larger study of US adults (N = 2022). Respondents were recruited between September 7, 2021 and October 3, 2021, from an online opt-in panel of individuals across the USA. Statistical analyses include weighted and unweighted descriptive statistics for the sample, as well as a weighted logistic regression for poor/fair self-rated health.

RESULTS

Odds of poor/fair self-rated health were greater for women (OR = 2.72; 95% CI [1.19, 6.21]) and those who experienced racial misclassification (OR = 2.90; 95% CI [1.20, 7.05]). No other sociodemographic, healthcare, or race-related variables were significantly associated with self-rated health in the fully adjusted results.

CONCLUSIONS

Findings suggest that racial misclassification may be an important correlate of self-rated health among NHPI adults in the US context.

Prevalence of cardiovascular disease among Asian, Pacific Islander and multi-race populations in Hawai'i and California

BACKGROUND

Cardiovascular disease (CVD) remains the leading cause of death in the US. CVD incidence is influenced by many demographic, clinical, cultural, and psychosocial factors, including race and ethnicity. Despite recent research, there remain limitations on understanding CVD health among Asians and Pacific Islanders (APIs), particularly some subgroups and multi-racial populations. Combining diverse API populations into one study group and difficulties in defining API subpopulations and multi-race individuals have hampered efforts to identify and address health disparities in these growing populations.

METHODS

The study cohort was comprised of all adult patients at Kaiser Permanente Hawai'i and Palo Alto Medical Foundation in California during 2014-2018 (n = 684,363). EHR-recorded ICD-9 and ICD-10 diagnosis codes were used to indicate coronary heart disease (CHD), stroke, peripheral vascular disease (PVD), and overall CVD. Self-reported race and ethnicity data were used to construct 12 mutually exclusive single and multi-race groups, and a Non-Hispanic White (NHW) comparison group. Logistic regression models were used to derive prevalence estimates, odds ratios, and confidence intervals for the 12 race/ethnicity groups.

RESULTS

The prevalence of CHD and PVD varied 4-fold and stroke and overall CVD prevalence varied 3-fold across API subpopulations. Among Asians, the Filipino subgroup had the highest prevalence of all three CVD conditions and overall CVD. Chinese people had the lowest prevalence of CHD, PVD and overall CVD. In comparison to Native Hawaiians, Other Pacific Islanders had significantly higher prevalence of CHD. For the multi-race groups that included Native Hawaiians and Other Pacific Islanders, the prevalence of overall CVD was significantly higher than that for either single-race Native Hawaiians or Other Pacific Islanders. The multi-race Asian + White group had significantly higher overall CVD prevalence than both the NHW group and the highest Asian subgroup (Filipinos).

CONCLUSIONS

Study findings revealed significant differences in overall CVD, CHD, stroke, and PVD among API subgroups. In addition to elevated risk among Filipino, Native Hawaiian, and Other Pacific Islander groups, the study identified particularly elevated risk among multi-race API groups. Differences in disease prevalence are likely mirrored in other cardiometabolic conditions, supporting the need to disaggregate API subgroups in health research.

Health outcomes and healthcare utilization of Native Hawaiians and other Pacific Islanders living with HIV in Hawai'i: A mixed-methods study

OBJECTIVES

Past research shows mixed outcomes in terms of HIV-related disparities among Native Hawaiians and Pacific Islanders (NHOPI). This study investigates HIV-related disparities among NHOPI living with HIV in Hawai'i.

DESIGN

An explanatory sequential design was utilized. The quantitative portion analyzed survey data from a statewide Ryan White Needs Assessment (N = 398) to examine the differences in viral suppression and satisfaction with care between NHOPI and other ethnic groups. Utilizing the behavioral model for vulnerable populations (BMVP), semi-structured interviews (N = 16) were conducted next to explain what factors play a role in satisfaction with care and viral suppression when it comes to NHOPI living with HIV in Hawai'i.

RESULTS

Among the 398 participants 13% were NHOPI. NHOPI were more likely to have a viral load of ≥10,000 copies/mL compared to those who didn't identify as NHOPI. However, there were no significant differences for other viral load levels (20-199 or 200-9999), and only 20 participants (5.2%) had a viral load of 10,000 copies/mL or more. No significant ethnic differences were found in satisfaction with medical care. In the qualitative phase, factors from all domains of the BMVP were represented within the four themes identified: (1) Care coordination is essential- with AIDs service organizations taking the lead; (2) HIV care, as well as overall health, is defined by the effectiveness of medication; (3) Initial diagnosis is a critical moment for intervention; and (4) Aspects of culture are intangible.

CONCLUSION

Among NHOPI in Hawai'i who are engaged in case management, there appears to be no substantial disparities in either viral load or satisfaction with care compared to other ethnic groups. Despite this, qualitative findings provide insights on how ethnicity and culture may still be playing a role. Addressing all domains of the BMVP is crucial to addressing this.

Examining the Relationship Between Physical Activity and Self-Efficacy for Exercise Among Overweight and Obese Marshallese Adults

This study examined associations between physical activity frequency and self-efficacy for exercise (SEE) among Marshallese adults in the United States. Data were collected from overweight and obese Marshallese participants (N = 378) enrolled in a Diabetes Prevention Program trial. Logistic and ordinal logistic regressions were employed to examine associations between physical activity and SEE, adjusting for covariates. SEE was significantly associated with engaging in sufficient total physical activity [odds ratio (OR) = 1.70], moderate physical activity (OR = 2.23), and vigorous physical activity (OR = 2.13). Unemployment was associated with less frequent moderate physical activity (OR = 0.59). Younger age (OR = 0.98), being male (OR = 2.67), and reporting excellent health (OR = 3.14) or good health (OR = 2.06) were associated with more frequent vigorous physical activity. Physical activity is a modifiable lifestyle behavior associated with many chronic disease disparities faced by the Marshallese community, and the study results will be useful for practitioners and researchers working to address these disparities.

A Cultural Dance Program Improves Hypertension Control and Cardiovascular Disease Risk in Native Hawaiians: A Randomized Controlled Trial

BACKGROUND

Native Hawaiians have higher hypertension (HTN) and cardiovascular disease (CVD) rates than non-Hispanic whites, calling for culturally responsive interventions to close this gap.

PURPOSE

We tested the effects of a 6-month behavioral intervention, a cultural dance program based on hula (the customary dance of Hawai'i), for improving blood pressure (BP) and CVD risk among Native Hawaiians with uncontrolled HTN.

METHODS

In a randomized controlled trial, we tested the effects of the hula-based intervention among 263 Native Hawaiians with uncontrolled HTN (systolic ≥ 140 or ≥ 130 mmHg if diabetes) and no CVD at enrollment. All participants received a brief culturally tailored heart health education before random assignment to the hula-based intervention (n = 131) or the education-only waitlist control (n = 132). Intervention received hula lessons and group-based activities for 6 months. Control received only 1-week education through 6 months.

RESULTS

Intervention yielded greater reductions in systolic (-15.3 mmHg) and diastolic (-6.4 mmHg) BP than control (-11.8 and -2.6 mmHg, respectively) from baseline to 6 months (p < .05). At 6 months, 43% of intervention participants compared to 21% of controls achieved a HTN stage <130/80 mmHg (p < .001). The 10-year CVD risk reduction was two times greater for the intervention group than the control group based on the Framingham Risk Score calculator. All improvements for intervention participants were maintained at 12 months.

CONCLUSIONS

This trial represents one of the few rigorously conducted examinations of an Indigenous practice leveraged for health promotion, with implications for other ethnic populations.

Ethnic and Gender Differences in 10-Year Coronary Heart Disease Risk: a Cross-Sectional Study in Hawai'i

Background

Cardiovascular disease (CVD) is the leading cause of death in the US. In Hawai‘i, Filipinos and Native Hawaiians have the highest rates of CVD-related risk factors. CVD risk across these ethnic groups has not been examined. This cross-sectional study examines 10-year CVD risk as determined by the Framingham Risk Score (FRS) across ethnic groups in Hawai‘i, controlling for clinical, demographic, and psychosocial factors.

Methods

This study includes secondary data analysis of the Kohala Health Research Project dataset. All non-pregnant adults (≥ 18 years of age) who resided in the community of interest during the study period were eligible to participate with 1462 participants completing the clinical examination and surveys. This analysis included clinical, demographic, and psychosocial variables. Ethnic differences were examined using the chi-squared test and one-way ANOVA. Multiple linear regression on FRS was conducted and least square means of FRS were calculated.

Results

Data from 1146 individuals were analyzed. Participants were 44.4% Native Hawaiian, 15.4% Filipino, 15.3% Japanese, and 25% non-Hispanic White; 55.4% were female and had a mean age of 48.8 years. For males, the unadjusted Japanese mean FRS was significantly higher compared with the other ethnic groups. For females, Filipino and Japanese mean FRS were significantly higher compared with Native Hawaiians and non-Hispanic Whites. In the fully adjusted model, there were no ethnic group differences in FRS among males and Filipinos had significantly higher FRS compared with non-Hispanic White among females.

Conclusions

This cross-sectional community-based epidemiological study examined ethnic differences in CVD risk after adjusting for age, depression, social support, and acculturation. The results suggest that some ethnic differences in CVD risk persist even after controlling for confounders but that recalibration of risk assessment is necessary.

Cultural dance significantly improves hypertension management

Hypertension (HT), uncontrolled blood pressure (&gt;140/90 mmHg), is the leading preventable cause of premature death globally and a major risk factor for coronary heart disease, stroke, and other conditions. European and African regions have the highest prevalence rates at about 40% of adults. The U.S. has comparable rates and disturbing disparities in non-White minority groups. Native Hawaiians (NH), an indigenous U.S. population, are 70% more likely to have HT; 4 times more likely to have coronary heart disease or stroke than Whites. Hula, the cultural dance of NH, offers promise of a culturally responsive strategy for HT control.

We conducted a randomized clinical trial with a waitlist control to test the impact of a hula-based cultural dance intervention (CDI) on systolic blood pressure (SBP) in 263 NH with HT. All participants received HT education (e.g. diet, exercise, medication) during 3 1-hr sessions over 2 weeks, then randomly assigned to CDI (n = 131) or waitlist control (WC; n = 132). The CDI received 6 months of hula (2 1-hr sessions/week x 3 months, then 1 lesson/mth x 3 months with self-directed practice), with group activities to reinforce HT education. WC only received the initial HT education, then offered hula after the study. Assessments were done at 0-, 3- and 6-month, with 12-month for CDI only.

Baseline characteristics were balanced between groups, except for weight. Adjusting for weight and baseline SBP in intent-to-treat analysis, CDI achieved significant reductions (p &lt; .05) in SBP (-15.3 mmHg; SE = 1.6) compared to WC (-11.8 mmHg, SE = 1.7). From 6 to 12 months, CDI maintained their SBP (mean change: 1.47 mmHg, SE = 1.26; p = .16) improvements at 12 months. CDI were more likely to achieve SBP reduction ≥ 10 mmHg than WC, 60% vs 48% (p = .03), respectively.

A CDI based on the NH cultural dance significantly improved HTN management in NH with uncontrolled SBP. Improvements were comparable to the best proven non-medication treatment of HT.

Key messages

Improving elevated blood pressure control with at-risk populations can be effectively and innovatively achieved by utilizing culturally responsive strategies, such as cultural dance interventions. Leveraging and aligning community strengths and health objectives leads to innovation and empowerment.

Prevention Research with Indigenous Communities to Expedite Dissemination and Implementation Efforts

Effectively translating evidence-based interventions into clinic and community settings is an increasing priority for health researchers. The successful dissemination and implementation (D&I) of interventions found efficacious ensures that major health funders such as the National Institutes of Health can demonstrate a return on investment in biomedical and behavioral research and that all populations receive maximum benefit from scientific discoveries. However, the products of research efficacy trials, the evidence-based interventions, are rarely designed with D&I in mind, rendering these interventions fundamentally misaligned with real-world settings. Further, while some evidence-based interventions have been successfully adapted for implementation in indigenous communities, few such examples have been published. Literature regarding the adoption and implementation of evidence-based interventions in indigenous communities is scarce, and the feasibility of scaling up successful interventions is poorly understood, potentially widening health disparities. The Intervention Research to Improve Native American Health (IRINAH) partners are generating efficacy data on community-responsive and engaged interventions that are also designed to facilitate D&I efforts, reducing the time between research to practice to benefit indigenous communities, should these interventions prove effective. In this manuscript, we provide an overview and key challenges of D&I science with indigenous communities. We then use IRINAH case studies to highlight strategies that IRINAH partners are using to plan for the scale-up and implementation of the studies. We conclude with recommendations to inform the next phase of IRINAH research efforts.

The Imperative for Research to Promote Health Equity in Indigenous Communities

Health disparities exact a devastating toll upon Indigenous people in the USA. However, there has been scant research investment to develop strategies to address these inequities in Indigenous health. We present a case for increased health promotion, prevention, and treatment research with Indigenous populations, providing context to the recent NIH investment in the Intervention Research to Improve Native American Health (IRINAH) network. We discuss the disproportionate costs and consequences of disparities borne by Indigenous groups, the limited evidence base on effective intervention for this population, how population uniqueness often makes transfer of existing intervention models difficult, and additional challenges in creating interventions for Indigenous settings. Given the history of colonial disruption that has included genocide, forced removal from lands, damaging federal, state and local policies and practices, environmental contamination, and most recently, climate change, we conclude research that moves beyond minor transformations of existing majority population focused interventions, but instead truly respects Indigenous wisdom, knowledge, traditions, and aspirations is needed, and that investment in intervention science to address Indigenous health disparities represent a moral imperative.

Growing from Our Roots: Strategies for Developing Culturally Grounded Health Promotion Interventions in American Indian, Alaska Native, and Native Hawaiian Communities

Given the paucity of empirically based health promotion interventions designed by and for American Indian, Alaska Native, and Native Hawaiian (i.e., Native) communities, researchers and partnering communities have had to rely on the adaptation of evidence-based interventions (EBIs) designed for non-Native populations, a decidedly sub-optimal approach. Native communities have called for development of Indigenous health promotion programs in which their cultural worldviews and protocols are prioritized in the design, development, testing, and implementation. There is limited information regarding how Native communities and scholars have successfully collaborated to design and implement culturally based prevention efforts "from the ground up." Drawing on five diverse community-based Native health intervention studies, we describe strategies for designing and implementing culturally grounded models of health promotion developed in partnership with Native communities. Additionally, we highlight indigenist worldviews and protocols that undergird Native health interventions with an emphasis on the incorporation of (1) original instructions, (2) relational restoration, (3) narrative-[em]bodied transformation, and (4) indigenist community-based participatory research (ICBPR) processes. Finally, we demonstrate how culturally grounded interventions can improve population health when they prioritize local Indigenous knowledge and health-positive messages for individual to multi-level community interventions.

Integrating Native Hawaiian tradition with the modern technology of aquaponics

Prior to western arrival in 1778, Native Hawaiians possessed a sophisticated culture and resource management system conducive to an island ecosystem. However, disenfranchisement from ancestral lands and traditional food sources as a result of colonization led to Native Hawaiians being forced to abandon many of their traditional practices. Today, many Native Hawaiians experience food insecurity, placing them at further risk for obesity and other nutrition-related chronic diseases. Consequently, there is a growing need for place-based and culturally relevant strategies rooted in Hawaiian epistemology to address these issues. This paper describes the history and development of one such intervention - the MALAMA study - in the community of Waimānalo that innovatively merges the modern technology of aquaponics with traditional Native Hawaiian practices and values.

Diabetes Disparities and Promising Interventions to Address Diabetes in Native Hawaiian and Pacific Islander Populations

PURPOSE OF REVIEW

The Native Hawaiian and Pacific Islander (NHPI) population is rapidly growing in the USA. NHPIs face significant health disparities and have a high prevalence of diabetes compared to the general US population.

RECENT FINDINGS

Recent culturally-adapted diabetes interventions have shown promise in addressing these disparities among NHPI communities. The interventions showed success by utilizing a community-based approach that honored NHPIs' collectivist culture, addressed social determinants of health that influence disease control and prevention, and utilized NHPI community health workers (CHWs) and peer educators for key roles in implementation of the intervention. To address health disparities in the NHPI community, much can be learned from existing, successful interventions. Promising interventions share several attributes. The interventions were: culturally adapted using a community-based participatory research approach; addressed specific social determinants of health (i.e., cost of healthy food, transportation, access to health care) that influence disease control and prevention; honored the collectivist culture of NHPI communities by integrating social networks and extended family members; and utilized NHPI community members, including peer educators and CHWs, for intervention implementation. Further investment to scale these interventions for regional and national implementation is needed to address the significant diabetes disparities that NHPIs face.

A Preliminary Study of the Relationship between Perceived Racism and Cardiovascular Reactivity and Recovery in Native Hawaiians

Native Hawaiians, compared to other ethnic groups in Hawai‘i, have significantly higher mortality rates and die at a younger average age from cardiovascular disease (CVD). This may be partially explained by elevated cardiovascular responses to racial stressors. Our study examined the degree to which blood pressure (BP) and heart rate (HR) reactivity and recovery, and ratings of subjective distress to racial stressors, differ as a function of Native Hawaiian college students’ levels of perceived racism. This study had three phases. Phase 1 involved the development of a blatant and subtle racial stressor. Phase 2 involved assigning 132 students into high- or low-perceived racism groups based on scores on two perceived interpersonal racism measures. Phase 3 involved a psychophysiology laboratory experiment conducted with 35 of the 132 students. BP, HR, and subjective distress were measured during exposure to the blatant and subtle racial stressors. Systolic blood pressure (SBP) recovery following exposure to both stressors was significant for both groups. Although not significant, three trends were observed among the high-perceived racism group, which included: (1) greater reactivity to exposure to the subtle stressor than to the blatant stressor, (2) incomplete HR recovery following exposure to both stressors, and (3) incomplete SBP and diastolic blood pressure recovery following exposure to the subtle stressor. Participants also reported significantly greater subjective distress following exposure to the blatant than to the subtle stressor. Specific interventions, such as increased self-awareness of physiological responses to racial stressors, targeted at at-risk individuals are necessary to reduce a person’s risk for CVD.

Comparing Weight Loss-Maintenance Outcomes of a Worksite-Based Lifestyle Program Delivered via DVD and Face-to-Face: A Randomized Trial

BACKGROUND

Native Hawaiians and other Pacific Islanders have high rates of overweight and obesity compared with other ethnic groups in Hawai'i. Effective weight loss and weight loss-maintenance programs are needed to address obesity and obesity-related health inequities for this group.

AIMS

Compare the effectiveness of a 9-month, worksite-based, weight loss-maintenance intervention delivered via DVD versus face-to-face in continued weight reduction and weight loss maintenance beyond the initial weight loss phase.

METHOD

We tested DVD versus face-to-face delivery of the PILI@Work Program's 9-month, weight loss-maintenance phase in Native Hawaiian-serving organizations. After completing the 3-month weight loss phase, participants ( n = 217) were randomized to receive the weight loss-maintenance phase delivered via trained peer facilitators or DVDs. Participant assessments at randomization and postintervention included weight, height, blood pressure, physical functioning, exercise frequency, and fat intake.

RESULTS

Eighty-three face-to-face participants were retained at 12 months (74.1%) compared with 73 DVD participants (69.5%). There was no significant difference between groups in weight loss or weight loss maintenance. The number of lessons attended in Phase 1 of the intervention (β = 0.358, p = .022) and baseline systolic blood pressure (β = -0.038, p = .048) predicted percent weight loss at 12 months.

DISCUSSION AND CONCLUSION

Weight loss maintenance was similar across groups. This suggests that low-cost delivery methods for worksite-based interventions targeting at-risk populations can help address obesity and obesity-related disparities. Additionally, attendance during the weight loss phase and lower baseline systolic blood pressure predicted greater percent weight loss during the weight loss-maintenance phase, suggesting that early engagement and initial physical functioning improve long-term weight loss outcomes.

The PILI@Work Program: a translation of the diabetes prevention program to Native Hawaiian-serving worksites in Hawai'i

A previously translated Diabetes Prevention Program Lifestyle Intervention (DPP-LI) was adapted for delivery as a worksite-based intervention, called PILI@Work, to address obesity disparities in Native Hawaiians/Pacific Islanders. This study examined the effectiveness of PILI@Work and factors associated with weight loss at post-intervention. Overweight/obese employees of 15 Native Hawaiian-serving organizations received the 3-month component of PILI@Work. Assessments included weight, systolic/diastolic blood pressure, physical activity and functioning, fat intake, locus of weight control, social support, and self-efficacy. Weight, systolic/diastolic blood pressure, physical functioning, physical activity frequency, fat intake, family support, and eating self-efficacy improved from pre- to post-intervention. Regression analysis indicated that worksite type, decreased diastolic blood pressure, increased physical activity, and more internalized locus of weight control were significantly associated with 3-month weight loss. PILI@Work initiated weight loss in Native Hawaiians/Pacific Islanders. DPP-LI translated to worksite settings and tailored for specific populations can be effective for addressing obesity.

Kā-HOLO Project: a protocol for a randomized controlled trial of a native cultural dance program for cardiovascular disease prevention in Native Hawaiians

Background

As a major risk factor for cardiovascular and cerebrovascular disease (CVD), hypertension affects 33% of U.S. adults. Relative to other US races and ethnicities, Native Hawaiians have a high prevalence of hypertension and are 3 to 4 times more likely to have CVD. Effective, culturally-relevant interventions are needed to address CVD risk in this population. Investigators of the Kā-HOLO Project developed a study design to test the efficacy of an intervention that uses hula, a traditional Hawaiian dance, to increase physical activity and reduce CVD risk.

Methods

A 2-arm randomized controlled trial with a wait-list control design will be implemented to test a 6-month intervention based on hula to manage blood pressure and reduce CVD risk in 250 adult Native Hawaiians with diagnosed hypertension. Half of the sample will be randomized to each arm, stratified across multiple study sites. Primary outcomes are reduction in systolic blood pressure and improvement in CVD risk as measured by the Framingham Risk Score. Other psychosocial and sociocultural measures will be included to determine mediators of intervention effects on primary outcomes. Assessments will be conducted at baseline, 3 months, and 6 months for all participants, and at 12 months for intervention participants only.

Discussion

This trial will elucidate the efficacy of a novel hypertension management program designed to reduce CVD risk in an indigenous population by using a cultural dance form as its physical activity component. The results of this culturally-based intervention will have implications for other indigenous populations globally and will offer a sustainable, culturally-relevant means of addressing CVD disparities.

Trial registration

ClinicalTrials.gov: NCT02620709, registration date November 23, 2015.

Self-Reported Experiences of Discrimination and Depression in Native Hawaiians

Discrimination is an acute and chronic stressor that negatively impacts the health of many ethnic groups in the United States. Individuals who perceive increased levels of discrimination are at risk of experiencing psychological distress and symptoms of depression. No study to date has examined the relationship between perceived discrimination and mental health in Native Hawaiians. The purpose of this study is to explore the relationship between perceived discrimination and depression based on the Homestead Health Survey mailed to Native Hawaiian residents of Hawaiian Home Lands. This study also explores the role of cultural identity and how it may impact experiences of discrimination and symptoms of depression. Based on cross-sectional data obtained from 104 Native Hawaiian residents, a significant positive correlation was found between perceived discrimination and symptoms of depression (r= 0.32, P<.001). Cultural identity did not significantly correlate with discrimination or depression. Multiple linear regression analyses indicate that the relationship between depression and discrimination remained statistically significant (coefficient estimate of 0.18; P<.01), after accounting for differences in socio-demographics and degree of identification with the Native Hawaiian and American cultures. These findings are consistent with other studies that have focused on the effects of discrimination on psychological wellbeing for other ethnic minority populations.

Social Network Characteristics, Social Support, and Cigarette Smoking among Asian/Pacific Islander Young Adults

Cigarette smoking may be one of the factors contributing to the high levels of cancer-related mortality experienced by certain Asian/Pacific Islander (A/PI) subgroups (e.g., Native Hawaiian). Given the collectivist cultural orientation attributed to A/PI groups, social strategies are recommended for substance abuse or smoking cessation treatment among A/PI. However, research examining how social network characteristics and social support relate to smoking across A/PI subgroups has been lacking. This study investigated the associations between social network characteristics (e.g., size, composition), perceived social support, and recent cigarette use across Native Hawaiian, Filipino, and East Asian (e.g., Japanese, Chinese) young adults (18-35 year old). Cross-sectional, self-report data were collected from N = 435 participants (M age = 25.6, SD = 8.3; 61% women). Ethnic differences were found in a number of pathways linking social network characteristics, perceived social support, and cigarette smoking. Larger network size was strongly associated with higher perceived social support and lower recent cigarette smoking among Native Hawaiians but not Filipinos or East Asians. Higher perceived social support was associated with lower recent smoking among East Asians and Filipinos but not Native Hawaiians. Implications are discussed with regard to smoking prevention and cessation among A/PI.

Considering the Role of Stress in Populations of High-Risk, Underserved Community Networks Program Centers

BACKGROUND

Cancer disparities are associated with a broad range of sociocultural determinants of health that operate in community contexts. High-risk populations may be more vulnerable to social and environmental factors that lead to chronic stress. Theoretical and empirical research indicates that exposure to contextual and sociocultural stress alters biological systems, thereby influencing cancer risk, progression, and, ultimately, mortality.

OBJECTIVE

We sought to describe contextual pathways through which stress likely increases cancer risk in high-risk, underserved populations.

METHODS

This review presents a description of the link between contextual stressors and disease risk disparities within underserved communities, with a focus on 1) stress as a proximal link between biological processes, such as cytokine responses, inflammation, and cancer and 2) stress as a distal link to cancer through biobehavioral risk factors such as poor diet, physical inactivity, circadian rhythm or sleep disruption, and substance abuse. These concepts are illustrated through application to populations served by three National Cancer Institute-funded Community Networks Program Centers (CNPCs): African Americans in the Deep South (the South Carolina Cancer Disparities Community Network [SCCDCN]), Native Hawaiians ('Imi Hale-Native Hawaiian Cancer Network), and Latinos in the Lower Yakima Valley of Washington State (The Center for Hispanic Health Promotion: Reducing Cancer Disparities).

CONCLUSIONS

Stress experienced by the underserved communities represented in the CNPCs is marked by social, biological, and behavioral pathways that increase cancer risk. A case is presented to increase research on sociocultural determinants of health, stress, and cancer risk among racial/ethnic minorities in underserved communities.

Relationship of resting heart rate and physical activity with insulin sensitivity in a population-based survey

BACKGROUND

Resting heart rate (RHR) has been identified as an independent risk factor for cardiovascular disease and mortality, contributing to atherosclerosis, the progression of heart failure, and myocardial ischemia and infarction. This study examines the association RHR and physical activity has with insulin resistance and insulin secretion in a multiethnic cohort from North Kohala, Hawai'i.

METHODS

Cross-sectional data from 1,440 participants of Native Hawaiian, Japanese, Filipino, Caucasian, and mixed ethnic ancestries were analyzed for the study to include anthropometric measurements, and biochemical markers. Body fat was estimated by calculating body mass indices (BMI); body fat distribution by waist-hip ratios (WHR); and fasting plasma glucose and insulin levels were used to calculate insulin resistance using the Homeostasis Model (HOMA-IR). First phase insulin response was estimated using the insulin secretion ratio (ISR). Associations were estimated using general linear models (GLM).

RESULTS

Caucasians had lower mean RHR than all other ethnic groups; there were no statistically significant differences between other ethnic groups on mean RHR. HOMA-IR was associated with ethnic group, BMI and WHR, PA and RHR, while ISR was associated with age, ethnic group and BMI, but none of the primary risk factors. Both RHR and physical activity level remained significant for insulin resistance.

CONCLUSIONS

In a multiethnic cohort from a rural community in Hawai'i, increased RHR and a lower level of physical activity were both independently associated with increased risk for the development of insulin resistance, suggesting cardiovascular fitness may be as important as physical activity in preventing insulin resistance.

Biomarkers of tobacco smoke exposure in racial/ethnic groups at high risk for lung cancer

OBJECTIVES

We examined biomarkers of tobacco smoke exposure among Native Hawaiians, Filipinos, and Whites, groups that have different lung cancer risk.

METHODS

We collected survey data and height, weight, saliva, and carbon monoxide (CO) levels from a sample of daily smokers aged 18-35 (n = 179). Mean measures of nicotine, cotinine, cotinine/cigarettes per day ratio, trans 3' hydroxycotinine, the nicotine metabolite ratio (NMR), and expired CO were compared among racial/ethnic groups.

RESULTS

The geometric means for cotinine, the cotinine/cigarettes per day ratio, and CO did not significantly differ among racial/ethnic groups in the adjusted models. After adjusting for gender, body mass index, menthol smoking, Hispanic ethnicity, and number of cigarettes smoked per day, the NMR was significantly higher among Whites than among Native Hawaiians and Filipinos (NMR = 0.33, 0.20, 0.19, P ≤ .001). The NMR increased with increasing White parental ancestry. The NMR was not significantly correlated with social-environmental stressors.

CONCLUSIONS

Racial/ethnic groups with higher rates of lung cancer had slower nicotine metabolism than Whites. The complex relationship between lung cancer risk and nicotine metabolism among racial/ethnic groups needs further clarification.

Kumu hula perspectives on health

To prepare for research studies that would evaluate the impact of hula as part of a clinical intervention, including cardiovascular disease (CVD) prevention and management programs, kumu hula defined as "culturally recognized hula educators and experts," were interviewed. Investigators sought to elicit their views regarding hula's traditional and contemporary connections to health and well-being, assess the cultural appropriateness of such projects, and suggest ways to maintain hula's cultural integrity throughout clinical intervention programs. Six prominent kumu hula from five different Hawaiian Islands participated in semi-structured key informant interviews lasting between 60 and 90 minutes. Each was asked open-ended questions regarding their attitudes, beliefs, and experiences regarding the connections of hula to health as well as their recommendations on maintaining the integrity of the dance's cultural traditions when developing and implementing a hula-based CVD program. All kumu hula endorsed the use of hula in a CVD intervention program and articulated the strong, significant, and enduring connections of hula to health and well-being. Each kumu hula also recognized that health is the full integration of physical, mental, emotional, and spiritual well-being. When care is taken to preserve its cultural integrity, hula may be an effective integrated modality for interventions designed to improve health and wellness.

The PILI 'Ohana Project: a community-academic partnership to achieve metabolic health equity in Hawai'i

Native Hawaiians and Pacific Islanders (NHPI) have higher rates of excess body weight and related medical disorders, such as diabetes and cardiovascular disease, compared to other ethnic groups in Hawai'i. To address this metabolic health inequity, the Partnership for Improving Lifestyle Intervention (PILI) 'Ohana Project, a community-academic partnership, was formed over eight years ago and developed two community-placed health promotion programs: the PILI Lifestyle Program (PLP) to address overweight/obesity and the Partners in Care (PIC) to address diabetes self-care. This article describes and reviews the innovations, scientific discoveries, and community capacity built over the last eight years by the PILI 'Ohana Project's (POP) partnership in working toward metabolic health equity. It also briefly describes the plans to disseminate and implement the PLP and PIC in other NHPI communities. Highlighted in this article is how scientific discoveries can have a real-world impact on health disparate populations by integrating community wisdom and academic expertise to achieve social and health equity through research.

Ethnic and gender differences in ideal body size and related attitudes among Asians, Native Hawaiians, and Whites

Often overlooked explanations for the varied obesity rates across ethno-cultural groups include differences in attitudes toward excess weight, with certain populations assumed to have larger ideal body sizes (IBS). Past studies found ethnic and gender difference in IBS across and within different groups. This study examined the effects of ethnicity and gender, and their interaction, in accounting for differences in IBS and attitudes toward those ideals. Multiple regression analyses were used to better understand the effects of ethnicity and gender in accounting for differences in perceived IBS according to ethnic-specific and Western ideals and attitudes in 1,124 people of Native Hawaiian, Filipino, Japanese, and White ancestry. The analyses controlled for socio-demographics, body mass index, health-related behaviors, and psychosocial variables. The results indicated that Native Hawaiians selected larger ethnic IBS, Filipinos selected smaller ethnic IBS, and Native Hawaiians selected slightly smaller Western IBS than other ethnic groups. Overall, males selected larger IBS compared to females. Interaction analyses indicated that the relationship between ethnic IBS and attitude toward that IBS varied as a function of ethnicity, such that Native Hawaiians who selected a larger ethnic IBS held less favorable attitudes toward that IBS. The discrepancy between Native Hawaiians' selection of larger ethnic IBS as ideal and their less positive attitude toward that selection warrants more investigation. However, it does suggest that Native Hawaiians, on a personal level, do not prefer larger body sizes, which contradicts their perceptions of social norms. These findings have important implications for obesity interventions among Native Hawaiians.

Translating the Diabetes Prevention Program in Native Hawaiian and Pacific Islander communities: the PILI 'Ohana Project

Native Hawaiians/Pacific Islanders experience a high prevalence of overweight/obesity. The Diabetes Prevention Program Lifestyle Intervention (DPP-LI) was translated into a 3-month community-based intervention to benefit these populations. The weight loss and other clinical and behavioral outcomes of the translated DPP-LI and the socio-demographic, behavioral, and biological factors associated with the weight loss were examined. A total of 239 Native Hawaiian/Pacific Islander adults completed the translated DPP-LI through four community-based organizations (CBOs). Changes from pre- to post-intervention assessments in weight, blood pressure, physical functioning, exercise frequency, and fat in diet were measured. Significant improvements on all variables were found, with differences observed across the four CBOs. CBOs with predominately Native Hawaiian and ethnically homogenous intervention groups had greater weight loss. General linear modeling indicated that larger baseline weight and CBO predicted weight loss. The translated DPP-LI can be effective for Native Hawaiians/Pacific Islanders, especially when socio-cultural, socio-economic, and CBO-related contextual factors are taken into account.

Patient perspectives on the Hula Empowering Lifestyle Adaptation Study: benefits of dancing hula for cardiac rehabilitation

BACKGROUND

The Hula Empowering Lifestyle Adaption Study, funded by the National Institute on Minority Health and Health Disparities, was a 5-year research trial evaluating the impact of the traditional Native Hawaiian dance form, hula, as an exercise modality for cardiac rehabilitation, compared with usual care, on individuals recently hospitalized for a cardiac event or who had recently undergone coronary artery bypass surgery.

METHOD AND RESULTS

Seeking to learn what physical, mental, spiritual, and social effects the intervention may have had for participants, we interviewed 20 of a total of 35 patients who were enrolled in the dance arm of the study. Classical thematic triangulation analysis was used. Participants recognized that hula's coordination of body, mind, and spirit as a group activity deepened their appreciation of and connections to Hawaiian culture. This was true for those who were Native Hawaiian, connecting to their own cultural heritage, as well as for non-Native Hawaiians, who found that it improved their appreciation of the surrounding cultural traditions of the host culture where they now live.

CONCLUSIONS

Not only was hula a safe activity that improved functional capacity, participants also regarded its significant sociocultural aspects-even for participants who are not Native Hawaiian -as enhancing its value and meaningfulness. Learning the words of well-known Hawaiian songs provided additional long-term cues that encouraged "ownership" of the therapy and acted as practical reminders of the importance of exercise and lifestyle moderation while also offering new spiritual connections to the surrounding social environment.

Metabolic equivalent determination in the cultural dance of hula

Ethnic minorities share an unequal burden of cardiometabolic syndrome. Physical activity (PA) has been shown to be an important factor for improving the outcomes of these diseases. While metabolic equivalents (METs) have been calculated for diverse activities, most cultural activities have not been evaluated. Hula, the traditional dance of Native Hawaiians, is practiced by men and women of all ages but its MET value is unknown. To our knowledge, this is the first scientific evaluation of energy expenditure of hula. 19 competitive hula dancers performed 2 dance sets of low- and high-intensity hula. METs were measured with a portable indirect calorimetry device. Mean and standard deviations were calculated for all the variables. A 2-way ANOVA was conducted to identify differences for gender and intensity. The mean MET were 5.7 (range 3.17-9.77) and 7.55 (range 4.43-12.0) for low-intensity and high-intensity, respectively. There was a significant difference between intensities and no significant difference between genders. This study demonstrates that the energy expenditure of both low- and high-intensity hula met the recommended guidelines for moderate and vigorous intensity exercise, respectively, and that hula can be utilized as a prescribed PA.

Sociodemographic, behavioral, and biological variables related to weight loss in native Hawaiians and other Pacific Islanders

OBJECTIVE

Native Hawaiians and other Pacific Islanders (NHs/PIs) have a high obesity prevalence compared to other ethnic groups. We examined socio-demographic, behavioral, and biological factors related to ≥3% weight loss in 100 overweight/obese NHs/PIs who completed a lifestyle intervention.

DESIGN AND METHODS

Data were from 56 Native Hawaiians, 22 Chuukese, and 22 Other Pacific Islanders who participated in a randomized controlled trial of the Partnership for Improving Lifestyle Intervention (PILI) 'Ohana Project. All completed a 3-month weight loss program (WLP) to initiate weight loss and were then randomized into either a 6-month family/community focused WLP called the PILI Lifestyle Program (PLP; n = 49) or a standard behavior WLP (SBP; n = 51). We collected baseline, 3- and 9-month follow-up data on socio-demographics, weight (kg), a 6-min. walk test, dietary fat, exercise frequency, and blood pressure.

RESULTS AND CONCLUSION

Based on ANCOVA or logistic fit, ethnicity, sex, initial weight loss, fat in diet at baseline, change in systolic blood pressure, and intervention type were significantly associated (P ≤ .05) with ≥3% weight loss at 9-month follow-up. A logistic regression model indicated that Chuukese (OR = 6.04; CI = 1.14-32.17) and participants who had more weight loss in the first 3-months (OR = 1.47; CI = 1.22-1.86) and who were in the PLP (OR = 4.50; CI = 1.50-15.14) were more likely to achieve ≥3% weight loss [model; χ(2) (7, N = 100) = 45.50, P < .0001]. The same lifestyle intervention does not benefit all NHs/PIs equally, possibly due to differences in acculturation status and social support. The findings also point to the importance of initial weight loss to sustain motivation toward long-term weight loss maintenance.

A family and community focused lifestyle program prevents weight regain in Pacific Islanders: a pilot randomized controlled trial

Preventing weight regain after the loss of excess weight is challenging for people, especially for ethnic minorities in the United States. A 6-month weight loss maintenance intervention designed for Pacific Islanders, called the PILI Lifestyle Program (PLP), was compared with a 6-month standard behavioral weight loss maintenance program (SBP) in a pilot randomized controlled trial using a community-based participatory research approach. Adult Pacific Islanders (N = 144) were randomly assigned to either PLP (n = 72) or SBP (n = 72) after completing a 3-month weight loss program. Successful weight maintenance was defined as participants' postintervention weight change remaining ≤ 3% of their preintervention mean weight. Both PLP and SBP participants achieved significant weight loss maintenance (p ≤ .05). Among participants who completed at least half of the prescribed sessions, PLP participants were 5.1-fold (95% confidence interval = 1.06, 24; p = .02) more likely to have maintained their initial weight loss than SBP participants. The pilot PLP shows promise as a lifestyle intervention to address the obesity disparities of Pacific Islanders and thus warrants further investigation.

Translating diabetes prevention into native Hawaiian and Pacific Islander communities: the PILI 'Ohana Pilot project

BACKGROUND

Native Hawaiians (NH) and Other Pacific Islanders (OPI) bear an excess burden of diabetes health disparities. Translation of empirically tested interventions such as the Diabetes Prevention Program Lifestyle Intervention (DPP-LI) offers the potential for reversing these trends. Yet, little is known about how best to translate efficacious interventions into public health practice, particularly among racial/ethnic minority populations. Community-based participatory research (CBPR) is an approach that engages the community in the research process and has recently been proposed as a means to improve the translation of research into community practice.

OBJECTIVES

To address diabetes health disparities in NHOPIs, CBPR approaches were used to: (1) culturally adapt the DPP-LI for NHOPI communities; and (2) implement and examine the effectiveness of the culturally-adapted program to promote weight loss in 5 NHOPI communities.

METHODS

Informant interviews (n=15) and focus groups (n=15, with 112 NHOPI participants) were completed to inform the cultural adaptation of the DPP-LI program. A team of 5 community investigators and 1 academic research team collaboratively developed and implemented the 12-week pilot study to assess the effectiveness of the culturally adapted program.

RESULTS

A total of 127 NHOPIs participated in focus groups and informant interviews that resulted in the creation of a significantly modified version of the DPP-LI, entitled the PILI 'Ohana Lifestyle Intervention (POLI). In the pilot study, 239 NHOPIs were enrolled and after 12 weeks (post-program), mean weight loss was -1.5 kg (95%CI -2.0, -1.0) with 26% of participants losing > or = 3% of their baseline weight. Mean weight loss among participants who completed all 8 lessons at 12 weeks was significantly higher (-1.8 kg, 95%CI -2.3, -1.3) than participants who completed less than 8 lessons (-0.70 kg, 95%CI -1.1, -0.29).

CONCLUSION

A fully engaged CBPR approach was successful in translating an evidence based diabetes prevention program into a culturally relevant intervention for NHOPI communities. This pilot study demonstrates that weight loss in high risk minority populations can be achieved over a short period of time using CBPR approaches.

Effects of perceived racism and acculturation on hypertension in Native Hawaiians

OBJECTIVE

To examine the effects of perceived racism and acculturation on the hypertension status of Native Hawaiians.

DESIGN

Cross-sectional data from 94 Native Hawaiian adults were obtained which included the following: 1) socio-demographic variables and self-reported hypertension status; 2) a 5-item Hawaiian cultural identity subscale (HCSS) and a 5-item American cultural identity subscale (ACSS); and 3) perceived racism based on a 6-item modified version of the 32-item Oppression Questionnaire (OQ).

RESULTS

Based on logistic regression analysis, the ACSS scores and OQ scores had significant (p<.05) and independent effects on hypertension status, after considering the effects of age, sex, and education level, and HCSS scores. Of the variables examined, OQ scores had the greatest magnitude of effect on hypertension status.

CONCLUSION

More perceived racism and a greater identification with the American mainstream culture were both, independently, related to self-reported hypertension in Native Hawaiians. These findings have important clinical and public health implications.

Cardiometabolic health disparities in native Hawaiians and other Pacific Islanders

Elimination of health disparities in the United States is a national health priority. Cardiovascular disease, diabetes, and obesity are key features of what is now referred to as the "cardiometabolic syndrome," which disproportionately affects racial/ethnic minority populations, including Native Hawaiians and other Pacific Islanders (NHOPI). Few studies have adequately characterized the cardiometabolic syndrome in high-risk populations such as NHOPI. The authors systematically assessed the existing literature on cardiometabolic disorders among NHOPI to understand the best approaches to eliminating cardiometabolic health disparities in this population. Articles were identified from database searches performed in PubMed and MEDLINE from January 1998 to December 2008; 43 studies were included in the review. There is growing confirmatory evidence that NHOPI are one of the highest-risk populations for cardiometabolic diseases in the United States. Most studies found increased prevalences of diabetes, obesity, and cardiovascular risk factors among NHOPI. The few experimental intervention studies found positive results. Methodological issues included small sample sizes, sample bias, inappropriate racial/ethnic aggregation of NHOPI with Asians, and a limited number of intervention studies. Significant gaps remain in the understanding of cardiometabolic health disparities among NHOPI in the United States. More experimental intervention studies are needed to examine promising approaches to reversing the rising tide of cardiometabolic health disparities in NHOPI.

Cardiometabolic health disparities in native Hawaiians and other Pacific Islanders

Elimination of health disparities in the United States is a national health priority. Cardiovascular disease, diabetes, and obesity are key features of what is now referred to as the "cardiometabolic syndrome," which disproportionately affects racial/ethnic minority populations, including Native Hawaiians and other Pacific Islanders (NHOPI). Few studies have adequately characterized the cardiometabolic syndrome in high-risk populations such as NHOPI. The authors systematically assessed the existing literature on cardiometabolic disorders among NHOPI to understand the best approaches to eliminating cardiometabolic health disparities in this population. Articles were identified from database searches performed in PubMed and MEDLINE from January 1998 to December 2008; 43 studies were included in the review. There is growing confirmatory evidence that NHOPI are one of the highest-risk populations for cardiometabolic diseases in the United States. Most studies found increased prevalences of diabetes, obesity, and cardiovascular risk factors among NHOPI. The few experimental intervention studies found positive results. Methodological issues included small sample sizes, sample bias, inappropriate racial/ethnic aggregation of NHOPI with Asians, and a limited number of intervention studies. Significant gaps remain in the understanding of cardiometabolic health disparities among NHOPI in the United States. More experimental intervention studies are needed to examine promising approaches to reversing the rising tide of cardiometabolic health disparities in NHOPI.

Partnerships to address obesity disparities in Hawai'i: the PILI 'Ohana Project

Community-based participatory research (CBPR) is an approach to scientific research that is gaining broader application to address persistent problems in health care disparities and other hypothesis-driven research. However, information on how to form CBPR community-academic partnerships and how to best involve community partners in scientific research is not well-defined. The purpose of this paper is to share the experience of the Partnership for Improving Lifestyle Interventions (PILl) 'Ohana Project in forming a co-equal CBPR community-academic partnership that involved 5 different community partners in a scientific research study to address obesity disparities in Native Hawaiians and other Pacific Peoples (i.e., Samoans, Chuukese, and Filipinos). Specifically, the paper discusses (1) the formation of our community-academic partnership including identification of the research topic; (2) the development of the CBPR infrastructure to foster a sustainable co-equal research environment; and (3) the collaboration in designing a community-based and community-led intervention. The paper concludes with a brief summary of the authors' thoughts about CBPR partnerships from both the academic and community perspectives.

Association between acculturation modes and type 2 diabetes among Native Hawaiians

OBJECTIVE

To examine the association between acculturation modes (integrated, assimilated, traditional, and marginalized) and type 2 diabetes prevalence in Native Hawaiians.

RESEARCH DESIGN AND METHODS

Cross-sectional data were analyzed from 495 Native Hawaiians, including acculturation modes, diabetes status, triglycerides, fasting insulin, BMI, age, and education level. Acculturation modes were assessed using an eight-item cultural affiliation questionnaire.

RESULTS

Native Hawaiians in a traditional mode of acculturation were more likely to have type 2 diabetes (27.9%) than those in integrated (15.4%), assimilated (12.5%), or marginalized (10.5%) modes.

CONCLUSIONS

The higher prevalence of type 2 diabetes among Native Hawaiians in a traditional mode of acculturation could not be attributed to any of the sociodemographic or biological factors included in this study. We discuss the role of psychosocial factors as possible mediators in the relationship between acculturation modes and type 2 diabetes.

Pacific Islanders' perspectives on heart failure management

OBJECTIVE

To identify the health beliefs, attitudes, practices, and social and family relations important in heart failure treatment among Pacific Islanders.

METHODS

Four focus groups were convened with 36 Native Hawaiians and Samoans with heart failure and their family caregivers. Thematic data analysis was used to categorize data into four domains: health beliefs and attitudes, preferred health practices, social support systems, and barriers to heart failure care.

RESULTS

Common coping styles and emotional experiences of heart failure in this population included avoidance or denial of illness, hopelessness and despair, and reliance on spiritual/religious beliefs as a means of support. Among study participants, more Samoans preferred to be treated by physicians whereas more Native Hawaiians preferred traditional Hawaiian methods of healing. Two types of social support (informational and tangible-instrumental) were identified as important in heart failure care. Barriers to heart failure care included poor knowledge of heart failure, lack of trust in physicians' care, poor physician-patient relations, finances, dietary changes, and competing demands on time.

CONCLUSION

The recruitment, retention, and adherence of Pacific Islanders to heart failure interventions is affected by an array of psychosocial and socio-cultural factors.

PRACTICE IMPLICATIONS

Interventions might be improved by offering participants accurate and detailed information about heart failure and its treatment, engaging the extended family in providing necessary supports, and providing tools to facilitate physician-patient relationships, among others, within the context of a larger socio-cultural system.

Discussion of Crabbe: Restoring Balance to Hawaii: “Kūpa'a i Ke Kāhua o Hawai'i”

Dr Crabbe presents a broad overview of the sociohistory of Hawaii following western contact and its colonisation by the United States (US). He describes the constant political, societal, and psychological struggles of Kānaka Maoli (native Hawaiians) against the never-ending tides of foreign influences to the shores of Hawaii. Within his sociohistorical overview, three significant issues for Kānaka Maoli are emphasised. One issue is that of ' Āina land. (The word ' Āina is capitalised throughout because, in the Native Hawaiian worldview, ' Āina is a living entity who gives and sustains life; it is an ancestor of the Hawaiian people, and it is important to the existence of Kānaka Maoli.) The second issue has to do with Kānaka Maoli is identity, which has been impacted by various foreign contacts and US colonisation that has negatively impacted traditional Hawaiian practices, customs, beliefs, language, and society. The constant struggle of Kānaka Maoli in regaining sovereignty, or self-determination, is a third issue of significance in Dr Crabbe's article. This article will briefly discuss the interplay among, and significance of, these three issues: ' Āina, Kānaka Maoli, and sovereignty, focusing on the importance and relevance of the first for the second and third.

Prevalence of diabetes and glucose intolerance in an ethnically diverse rural community of Hawaii

BACKGROUND

We report the prevalence of diabetes in a rural, multiethnic community in Hawaii, of predominantly Asian and Native Hawaiian ancestry, by using 1997 World Health Organization diagnostic criteria applied to a two-hour oral glucose tolerance test.

METHODS

This cross-sectional survey included 1452 men and nonpregnant women who were >18 years of age. Blood was drawn in the fasting and postchallenge states. Individuals under pharmacologic treatment for diabetes were excluded. Information obtained included demographics, medical history, dietary intake, physical activity, and anthropometric measurements.

RESULTS

Prevalence of diabetes was approximately three-fold higher among Asian and Native Hawaiian ancestry groups than among Caucasians, even after adjusting for other risk factors. Furthermore, diabetes prevalence was similar among all non-Caucasian ethnic groups despite significant differences in body mass indices.

CONCLUSIONS

These findings indicate that earlier reports of high prevalence of diagnosed diabetes among Asians and Hawaiian ethnic groups were not due to detection bias, since our study revealed similar prevalence of previously unrecognized diabetes. Furthermore, similar prevalence among these groups was observed despite significant differences in body mass indices, diet, and physical activity. This apparent paradox may reflect limitations in the measurement of these risk factors; differences in the impact of these risk factors on diabetes risk in different ethnic groups; or ethnic differences in lifestyle, biochemical, or genetic factors that were not examined in this study.

Ethnic-by-gender differences in cigarette smoking among Asian and Pacific Islanders

We examined the interaction between ethnicity and gender in predicting the likelihood of having ever smoked (vs. having never smoked) and being a current smoker (vs. being a former smoker) and in predicting years spent as a regular smoker. These relationships were examined while controlling for the possible confounding effects of sociodemographics, psychosocial factors, and chronic medical conditions. The analysis examined cross-sectional data from 1,158 people of Native Hawaiian, Filipino, Japanese, and White ethnic ancestry, finding large ethnic and gender-ethnic differences in the prevalence of former and current smoking. Multiple regression analyses showed significant gender x ethnicity interactions in predicting the likelihood of having ever smoked but not in the likelihood of being a current smoker (vs. having quit) or in the duration of years spent smoking. The results of the present study have important implications for smoking prevention programs among men and women in three distinct Asian and Pacific Islander ethnic groups.

Ethnic differences in perinatal outcome of gestational diabetes mellitus

OBJECTIVE

Despite the high rates of gestational diabetes mellitus (GDM) among certain Pacific Islander and Asian ethnic groups in the U.S., little is known about the risk for adverse perinatal outcomes in these populations. We sought to examine ethnic differences in perinatal outcome among Asian and Pacific-Islander women with GDM.

RESEARCH DESIGN AND METHODS

A retrospective review of all women referred to the largest outpatient GDM program in the state of Hawai'i from 1995 to 2005 was conducted. Patients of Native-Hawaiian/Pacific-Islander, Japanese, Chinese, Filipino, and Caucasian ethnicity were included (n = 2,155). Treatment of all patients consisted of an outpatient education class, dietary management, self-monitoring of blood glucose, and insulin instruction (if indicated). Demographics, maternal and neonatal characteristics, and delivery information were evaluated.

RESULTS

Neonates born to Native-Hawaiian/Pacific-Islander mothers and Filipino mothers had 4 and 2 times the prevalence of macrosomia, respectively, compared with neonates born to Japanese, Chinese, and Caucasian mothers. These differences persisted after adjustment for other statistically significant maternal and fetal characteristics. Ethnic differences were not observed for other neonatal or maternal complications associated with GDM, with the exception of neonatal hypoglycemia and hyperbilirubinemia.

CONCLUSIONS

Significant ethnic differences in perinatal outcomes exist across Asian and Pacific-Islander women with GDM. This finding emphasizes the need to better understand ethnic-specific factors in GDM management and the importance of developing ethnic-tailored GDM interventions to address these disparities.

Ethnic differences in the relationship between depressive symptoms and health-related quality of life in people with type 2 diabetes

OBJECTIVE

To examine ethnic differences in the relationship between depressive symptoms and specific aspects of heath-related quality of life in people with type 2 diabetes.

DESIGN

Cross-sectional data from 190 people with type 2 diabetes of Native Hawaiian (50%), Filipino (16%), Japanese (18%), and mixed-ethnic (16%) ancestries from the rural community of North Kōhala, Hawai'i were examined in this study. Depressive symptoms were measured with the Center for Epidemiological Studies-Depression (CES-D) scale. Health-related quality of life was measured with the Short Form-36 Health Survey (SF-36). Eight health-related quality of life constructs were examined: Physical Functioning, Role-Physical Functioning, Role-Emotional Functioning, Social Functioning, Bodily Pain, Vitality, General Health, and Health Transition.

RESULTS

Hierarchical regression analyses of the interaction between ethnicity and the SF-36 subscales of Physical Functioning, Role-Emotional Functioning, Bodily Pain, Vitality, and General Health indicated statistically significant associations with CES-D scores after controlling for sociodemographic factors, glycemic status, and social support.

CONCLUSION

Ethnicity moderated the relationship between depressive symptoms and the health-related quality of life aspects of physical and role-emotional functioning, bodily pain, vitality, and general health perception in people with type 2 diabetes. This relationship was strongest for Filipinos followed by Native Hawaiians and people of mixed-ethnic ancestries.

Biological, psychosocial, and sociodemographic variables associated with depressive symptoms in persons with type 2 diabetes

Studies have found an association between glycemic status and indices of health-related quality of life in people with diabetes mellitus and comorbid depression. No study to date has examined the relative strength of influences of glycemic status and health-related quality of life on depression in people with diabetes mellitus, nor have important moderators in this relationship been examined. This study examined the relative strength of correlations between glycemic status and health-related quality of life and depressive symptoms and the degree to which those correlations were moderated by sociodemographic variables in 146 people with type 2 diabetes. Depressive symptoms were measured with the Centers for Epidemiological Studies--Depression (CES-D) scale. Health-related quality of life was measured with the SF-36 Health Survey. Hemoglobin A1c (HbA1c) was used as a measure of glycemic status and body mass index and waist-hip ratio were measured. Results indicated that SF-36 scores accounted for a greater proportion of the variance in CES-D scores. The association between CES-D and SF-36 scores was moderated by HbA1c, sex, education, marital status, and social support. The implications and limitations of these results were discussed in the context of past studies.