Knowledge Gaps, Challenges, and Opportunities in Health and Prevention Research for Asian Americans, Native Hawaiians, and Pacific Islanders: A Report From the 2021 National Institutes of Health Workshop.

Asian Americans (AsA), Native Hawaiians, and Pacific Islanders (NHPI) comprise 7.7% of the U.S. population, and AsA have had the fastest growth rate since 2010. Yet the National Institutes of Health (NIH) has invested only 0.17% of its budget on AsA and NHPI research between 1992 and 2018. More than 40 ethnic subgroups are included within AsA and NHPI (with no majority subpopulation), which are highly diverse culturally, demographically, linguistically, and socioeconomically. However, data for these groups are often aggregated, masking critical health disparities and their drivers. To address these issues, in March 2021, the National Heart, Lung, and Blood Institute, in partnership with 8 other NIH institutes, convened a multidisciplinary workshop to review current research, knowledge gaps, opportunities, barriers, and approaches for prevention research for AsA and NHPI populations. The workshop covered 5 domains: 1) sociocultural, environmental, psychological health, and lifestyle dimensions; 2) metabolic disorders; 3) cardiovascular and lung diseases; 4) cancer; and 5) cognitive function and healthy aging. Two recurring themes emerged: Very limited data on the epidemiology, risk factors, and outcomes for most conditions are available, and most existing data are not disaggregated by subgroup, masking variation in risk factors, disease occurrence, and trajectories. Leveraging the vast phenotypic differences among AsA and NHPI groups was identified as a key opportunity to yield novel clues into etiologic and prognostic factors to inform prevention efforts and intervention strategies. Promising approaches for future research include developing collaborations with community partners, investing in infrastructure support for cohort studies, enhancing existing data sources to enable data disaggregation, and incorporating novel technology for objective measurement. Research on AsA and NHPI subgroups is urgently needed to eliminate disparities and promote health equity in these populations.

Reflections on Dr. Donald A.B. Lindberg and Native Voices.

Personal reflections on Donald A.B. Lindberg M.D. are offered by four Native American leaders who were instrumental in the successful development of the National Library of Medicine's (NLM) Native Voices Exhibition: Stories of Health and Wellness from American Indians, Alaska Natives and Native Hawaiians. A uniquely collaborative effort, the exhibition features nearly 100 videographed interviews conducted by Dr. Lindberg with Native elders, healers, leaders, and people. He is credited with the incorporation of indigenous peoples' healing knowledge in a personal and relational way, making for a wonderful journey together that was a very large chapter in his life and that of the authors.

Preventable Tooth Loss in Hawai'i: The Role of Socioeconomic Status, Diabetes, and Dental Visits.

INTRODUCTION: Tooth preservation in adults and children is one of the Healthy People 2020 goals for oral health. Although the overall prevalence of tooth loss has been declining in the United States, substantial racial/ethnic differences in preventable tooth loss persist as a public health problem. We examined the strength of the association of health risk factors and tooth loss in Hawai'i. METHODS: We used data from the Hawai'i Behavioral Risk Factor Surveillance System survey collected from 2011 through 2014. Participant responses were included if they self-identified as Native Hawaiian, white, Japanese, or Filipino. Differences in excess tooth loss (6 or more teeth) and known risk factors (demographics, diabetes, and dental visits) were analyzed by using univariate analyses and adjusted stepwise, logistic regression models. RESULTS: We identified oral health inequity among the 4 ethnic groups studied; among the groups, Native Hawaiians had the largest proportion of excess tooth loss. The univariate analyses found differences in the strength of these associations among the 4 racial/ethnic groups. The stepwise analyses found that the associations of excess tooth loss and race/ethnicity were not significant after adjusting for demographics, diabetes status, and dental visits. CONCLUSION: Findings suggest a need for programs and policies that improve access to oral health care in Hawai'i for those with low levels of income and education and those with diabetes.

Exploring perspectives and insights of experienced voyagers on human health and Polynesian oceanic voyaging: A qualitative study.

BACKGROUND: The Worldwide Voyage (WWV) was a 3-year (2014-2017) open-ocean voyage to circumnavigate the world using Indigenous knowledge and navigational skills aboard Hokule'a, a traditionally designed Native Hawaiian (NH) voyaging canoe (wa'a kaulua). Each WWV segment included experienced crew and leadership who were recognized by their voyaging peers as highly experienced in Polynesian oceanic voyaging. This study explored the perceptions and insights of WWV-experienced ocean voyagers on the interconnection between human health and oceanic voyaging. METHODOLOGY: A constructivist approach with a storytelling-based moderator guide was used to conduct focus groups and informant interviews of experienced crew and voyaging leadership. Participants were interviewed and recorded transcripts were analyzed using content analysis. Triangulation of analysis included secondary thematic review by two independent NH cultural practitioners and participant member checking. Purposive sampling was used to enroll 34 of 66 eligible highly experienced voyagers (leadership n = 6; crew n = 28) in 5 focus groups and 4 informant interviews. RESULTS: Six themes emerged: 1) Indigenous context (spiritual and natural environment); 2) Importance of relationships and community; 3) Description of life on the canoe; 4) Holistic health; 5) Mindfulness, stress reduction and emotional health; and 6) Opportunities for intervention. Themes 1-5 were inductive and intricately interrelated, and theme 6 was deductive in that it directly resulted from a moderator guide question. Theme 6 offers strategies to improve the impact of voyaging and health well beyond the physical voyage with recommendations for improved transition back to land and developing a wa'a community context, which reflects a traditional voyaging experience. CONCLUSIONS: Polynesian oceanic voyaging is strongly perceived as a positive and transformative holistic-health-promoting experience. SIGNIFICANCE: Recommendations to promote generalizable health benefits of a voyaging lifestyle offers a promising and culturally grounded approach warranting future studies to understand mechanism and potential impact for improving health inequities.

Resources, roadblocks and turning points: a qualitative study of American Indian/Alaska Native adults with type 2 diabetes.

Type 2 diabetes is a worldwide health problem that has reached epidemic proportions in some communities. Alaska Native and American Indian (AN/AI) people are disproportionately diagnosed with type 2 diabetes and incidence is increasing in many Alaska communities. Developing effective interventions requires understanding the social and psychological factors that impact effective management of diabetes, yet little is known about these factors in AN/AI communities. The objective of this study was to explore perceived psychosocial needs and barriers to management of diabetes among AN/AI adults with type 2 diabetes receiving care at the Alaska Native Primary Care Center (ANPCC) to inform programmatic efforts and potential future research. We conducted three focus groups and five interviews with 13 AN/AI adults with type 2 diabetes. Interview and focus group questions elicited perceived factors that affect management of diabetes, with a focus on the psychological, social and spiritual impacts of diabetes. Data were transcribed, coded and analyzed using thematic analysis. Key themes that emerged from these data included resources and roadblocks, as well as turning points in the trajectory of diabetes. Resources are factors with a perceived positive impact on management of diabetes, including: (1) knowledge and education about diabetes, (2) social support from other people with diabetes, (3) spirituality, and (4) self-efficacy. Roadblocks are factors with a perceived negative impact on management of diabetes and include: (1) self-reported lack of knowledge about nutrition and diet, (2) social difficulties caused by dietary restrictions, and (3) co-morbid medical conditions. Finally, turning points are experiences described by participants as having transformed roadblocks in resources and thus facilitating improvement in the management of diabetes. Future programmatic interventions to improve management of diabetes with this population should focus on improving dietary education and social support opportunities for newly-diagnosed individuals. Also, educational and support opportunities for family members and friends of individuals with diabetes should also be offered to facilitate understanding and support of their loved ones' management of diabetes, especially with regard to dietary restrictions in social settings. Efforts should also focus on strengthening newly-diagnosed individuals' self-efficacy and providing ongoing support as individuals progressively adjust to the illness over time and make behavioral changes. Future research with this population should explore the effects of family support groups and the possibility of Web-based or other alternative interventions for improving psychosocial health and management of diabetes efforts.

Ethnic differences in potentially preventable hospitalizations among Asian Americans, Native Hawaiians, and other Pacific Islanders: implications for reducing health care disparities.

OBJECTIVES: A serious challenge to eliminating US health disparities stems from the inability to reliably measure outcomes, particularly for numerically small populations. Our study aimed to produce reliable estimates of health care quality among Native Hawaiian (NH), Other Pacific Islander (PI), and Asian American (AA) subgroups. DESIGN: Prevention Quality Indicators (PQIs) from the Agency for Healthcare Research and Quality were used to calculate 3 PQI composites and 8 individual chronic condition indicators. Data sources were the Healthcare Cost and Utilization Project State Inpatient Databases and the Hawaii Health Survey. MAIN OUTCOME MEASURES: Risk-adjusted PQI rates for adults were computed for 2005 through 2007. Relative rates for 2007 were calculated for each racial/ethnic group and compared to Whites. Statistical significance was based on P < .05 from a two-sided t test. RESULTS: The combined AANHPI group had higher overall and chronic PQI composite rates than Whites in 2007. When disaggregated into discrete racial/ethnic subgroups, Chinese and Japanese had lower rates than Whites for all 3 composites, whereas NH and Other PI subgroups typically had the worst health outcomes. Trends in PQI rates from 2005 through 2007 showed persistent gaps between groups, especially across chronic PQIs. CONCLUSIONS: Despite recent efforts to reduce racial/ethnic health care disparities, significant gaps remain in potentially preventable hospitalization rates. Practical tools that measure inequities across diverse, numerically small populations may suggest ways to optimally funnel limited resources toward improving racial/ethnic differences in health outcomes.

Depression and type 2 diabetes among Alaska Native primary care patients.

OBJECTIVES: To assess whether type 2 diabetes mellitus (DM2) and DM2 complications are associated with presence and severity of depression among Alaska Native and American Indian people (AN/Als). DESIGN: Retrospective, cross-sectional analysis of medical records. SETTING: Southcentral Foundation Primary Care Center (SCF-PCC) in Anchorage, Alaska. PARTICIPANTS: Total of 23,529 AN/AI adults. PRIMARY OUTCOME MEASURES: Patient Health Questionnaire (PHQ) scores (0-9 negative, 10-14 mild, 15-19 moderate, 20+ severe) and DSM-IV depression diagnosis. RESULTS: DM2 prevalence was 6% (n=1,526). Of those with DM2, 19% (n = 292) had one or more DM2 complications and average HbAlc was 7.1%. Prevalence of depression diagnosis was similar between AN/Als with and without DM2 (P = .124). Among those screened for depression (n = 12,280), there were similar rates of PHQ severity between those without and with DM2; respectively 4% (n = 452) vs 4% (n = 42) mild, 4% (n = 404) vs 3% (n = 29) moderate, and 4% (n = 354) vs 4% (n = 38) severe. In multivariable logistic regression, DM2 was not associated with PHQ severity (OR 1.02, 95% CI 0.81-1.27) or depression diagnosis (OR 1.27, 95% CI 1.00-1.62). Increased odds of depression and higher depression severity were associated with female sex, younger age, being unmarried, substance abuse/dependence, and increased ambulatory visits. Depression was associated with number of other chronic conditions among AN/Als with DM2 but not with number of complications. CONCLUSIONS: Presence and severity of depression among AN/Al primary care patients was not significantly associated with DM2 nor DM2 complications, despite a slightly higher rate of depression diagnosis among those with DM2.

A Qualitative Study on Preventing Gestational Diabetes in Native Hawaiian and Pacific Islander Adolescent Females: Perspectives from an Expert Panel of Health Care Providers.

The authors examined perspectives of health care providers (HCPs) who serve Native Hawaiian and Pacific Islander (NH/PI) adolescents to inform the adaption of an existing American Indian and Alaska Native-specific gestational diabetes mellitus (GDM) risk reduction and preconception counseling program entitled Stopping GDM, for NH/PI adolescents. Hawai'i-based HCPs (n=14) who care for NH/PI adolescent females volunteered for this expert panel focus group study. These HCP participants served as an expert panel specific to their experiences in providing primary care and reproductive health care/family planning, and their perspectives regarding GDM risk reduction for NH adolescents. Several key themes emerged from these expert panel focus groups: (1) importance of multi-generational family involvement and support; (2) need to address the social determinants of health; (3) strengths-based strategies and recommendations to engage adolescents in a preconception counseling and GDM risk-reduction education program. Findings will inform the adaptation of Stopping GDM into a more holistic, multi-level, strengths-based, culturally tailored GDM risk reduction intervention that fosters empowerment and builds on the resilience of NH/PI communities.

"Community 101 for researchers": an online training program to build capacity for ethical community-engaged research with Native Hawaiians and Pacific Islanders.

To address the history of unethical research and community distrust in research among Native Hawaiian and Pacific Islander communities, we developed the "Community 101 for Researchers" training program, which was launched in 2014 to enhance the capacity of researchers to engage in ethical community-engaged research. The purpose of this paper is to describe the development of this training program as well as its reach and feedback from participants. The Community 101 training program is a self-paced, 2-h online training program featuring community-engaged researchers from the University of Hawai'i and their longstanding community partners. Throughout the five modules, we highlight the historical context of Native Hawaiians and Pacific Islander populations in Hawai'i related to research ethics and use examples from the community as well as our own research projects that integrate community ethics, relevance, benefits, and input. To determine reach and gather participant feedback on the training, we extracted data from the user accounts. The training has been completed by 697 users to-date since its launch. Despite very little advertisement, an average of nearly 70 users have completed the Community 101 Program each year. The majority of the participants were located in Hawai'i though participants were also from other states and territories in the US, and international locations. The majority of participants were from universities in Hawai'i in 51 different departments demonstrating multidisciplinary relevance of the program's training. The general feedback from the 96 participants who completed an optional anonymous evaluation survey given at the end of the training was positive. The "Community 101 for Researchers" Training program is an accessible and relevant tool that can be used to advance ethical community engaged research, specifically with Native Hawaiian and Pacific Islander communities.

I kua na'u "Let me carry out your last wishes" Clinical trial protocol to promote advance care planning among native Hawaiian populations.

Advance Care Planning (ACP) is a communication process about serious illness decision making designed to inform patients of possible medical options. Native Hawaiians consistently have low rates of ACP and low use of palliative and hospice care services. Our multidisciplinary community and research group partnered to create I kua na'u "Let Me Carry Out Your Last Wishes," an ACP intervention featuring culturally tailored videos and are now testing its efficacy. Focus groups and informant interviews were conducted with Native Hawaiian community members to ensure the curriculum honored the history, opinions, and culture of Native Hawaiians. Native Hawaiian culture has traditionally been an oral culture; the spoken word transmitted the mo'olelo, stories, traditions, histories and genealogies, which merges seamlessly with video media. The I kua na'u intervention included multiple educational sessions enhanced with videos (informational and personal). The specific aims are to compare ACP knowledge (primary outcome) and readiness for ACP engagement, ACP preferences, decisional conflict, and ACP completion rates via electronic medical record review (secondary outcomes) in 220 Native Hawaiians over age 55 in: (a) a randomized controlled trial of 110 people recruited from ambulatory clinics, and (b) a pre-post study design among 110 people living on Hawaiian Homestead communities located on lands set aside for Native Hawaiians or assisted living. Our protocol aims to evaluate the efficacy of our video-based educational intervention for Native Hawaiians to support decision making in this community and decrease disparities in serious illness care. Clinical Trial Registration Number: NCT04771208.

Association between perceived racism and physiological stress indices in Native Hawaiians.

The association between racism and the physical health of native U.S. populations has yet to be examined despite their high risk for stress-related disorders and a history of discrimination toward them. We examined the correlation between perceived racism and the two physiological stress indices of cortisol level and blood pressure in 146 adult Native Hawaiians. Attributed and felt racism were assessed with a 10-item shortened version of the Oppression Questionnaire. Height, weight, blood pressure, and salivary cortisol samples (AM and PM) were collected and analyzed along with information on Hawaiian ancestry, BMI, age, sex, marital status, education level, general psychological stress, and ethnic identity. The results indicated that Native Hawaiians reporting more attributed racism had significantly (P < .05) lower average cortisol levels than those reporting less attributed racism, after adjusting for socio-demographic, biological, and psychosocial confounders. Native Hawaiians reporting more felt racism had a significantly higher systolic blood pressure than those reporting less, but this association was not significant after adjusting for the aforementioned confounders. Racism appears to be a chronic stressor that can "get under the skin" of Native Hawaiians by affecting their physical health and risk for stress-related diseases, possibly, through mechanisms of cortisol dysregulation.

A Scoping Review on Gestational Diabetes in Hawai'i: A "Window of Opportunity" to Address Intergenerational Risk for Type 2 Diabetes Mellitus.

The health of women over the entire span of their reproductive years is crucial - beginning in adolescence and extending through the postpartum period. This paper provides a scoping review of the relevant literature on risk factors for gestational diabetes mellitus (GDM) and progression from GDM to type 2 diabetes mellitus (T2DM), particularly among women of Native Hawaiian and Pacific Islander (NHPI) and Asian racial/ethnic backgrounds in Hawai'i, using the PubMed database (July 2010 to July 2020). NHPI and Asian populations have a greater likelihood of developing GDM compared to their White counterparts. Risk factors such as advanced maternal age, high maternal body mass index, and lack of education about GDM have varying levels of impact on GDM diagnosis between ethnic populations. Mothers who have a history of GDM are also at higher risk of developing T2DM. Common risk factors include greater increase in postpartum body mass index and use of diabetes medications during pregnancy. However, few studies investigate the progression from GDM to T2DM in Hawai'i's Asian and NHPI populations, and no studies present upstream preconception care programs to prevent an initial GDM diagnosis among Hawai'i's women. Thus, updated reports are necessary for optimal early interventions to prevent the onset of GDM and break the intergenerational cycle of increased susceptibility to T2DM and GDM in both mother and child. Further attention to the development of culturally sensitive interventions may reduce disparities in GDM and improve the health for all affected by this condition.

Reflections on Dr. Donald A.B. Lindberg and Native Voices.

Personal reflections on Donald A.B. Lindberg M.D. are offered by four Native American leaders who were instrumental in the successful development of the National Library of Medicine's (NLM) Native Voices Exhibition: Stories of Health and Wellness from American Indians, Alaska Natives and Native Hawaiians. A uniquely collaborative effort, the exhibition features nearly 100 videographed interviews conducted by Dr. Lindberg with Native elders, healers, leaders, and people. He is credited with the incorporation of indigenous peoples' healing knowledge in a personal and relational way, making for a wonderful journey together that was a very large chapter in his life and that of the authors.

Engaging Community Health Centers to understand their perceptions and interest in longitudinal cohort research on diabetes mellitus in Native Hawaiian communities: Initial insights from the Waimanalo community.

Introduction: Despite decades of research on diabetes mellitus (DM) and other health disparities affecting Native Hawaiian and Pacific Islander (NHPI) populations, little is known about the disease mechanisms that underlie these health disparities. Ideally, a longitudinal cohort study is one of the best research design tools to examine underlying mechanisms of disease in health disparity conditions such as DM. The study purpose is to understand the perspectives and insights of people (n = 29) living in NHPI communities about conducting longitudinal cohort studies aimed at understanding mechanisms of health disparities in NHPI populations. Methods: All interviews were audio-recorded, transcribed and de-identified into written transcripts for thematic content analysis. Results: Four major themes emerged: 1) Diabetes and other health disparities is a community priority because these diseases touch nearly everyone; 2) Cohort-type research and its outcomes should extend beyond data collection to include data sharing using a cultural context approach; 3) Cohort-type research can directly benefit everyone, especially youth, through education on new, locally-derived knowledge; 4) A longterm benefit of cohort-type research should be to support "generational change" in the community. Discussion: In summary, potential "cohort-type research" (a.k.a. longitudinal cohort study designs) was perceived as a worthy endeavor because health disparities, such as DM, affects nearly everyone in the community. Cohort-type research is important to NHPI communities as it holds promise for impacting "generational change" on health and wellbeing through the sharing of new community-derived knowledge.

Shifts in the immunoepigenomic landscape of monocytes in response to a diabetes-specific social support intervention: a pilot study among Native Hawaiian adults with diabetes.

BACKGROUND: Native Hawaiians are disproportionately affected by type 2 diabetes mellitus (DM), a chronic metabolic, non-communicable disease characterized by hyperglycemia and systemic inflammation. Unrelenting systemic inflammation  frequently leads to a cascade of multiple comorbidities associated with DM, including cardiovascular disease, microvascular complications, and renal dysfunction. Yet few studies have examined the link between chronic inflammation at a cellular level and its relationship to standard DM therapies such as diabetes-specific lifestyle and social support education, well recognized as the cornerstone of clinical standards of diabetes care. This pilot study was initiated to explore the association of monocyte inflammation using epigenetic, immunologic, and clinical measures following a 3-month diabetes-specific social support program among high-risk Native Hawaiian adults with DM. RESULTS: From a sample of 16 Native Hawaiian adults with DM, monocytes enriched from peripheral blood mononuclear cells (PBMCs) of 8 individuals were randomly selected for epigenomic analysis. Using the Illumina HumanMethylation450 BeadChip microarray, 1,061 differentially methylated loci (DML) were identified in monocytes of participants at baseline and 3 months following a DM-specific social support program (DM-SSP). Gene ontology analysis showed that these DML were enriched within genes involved in immune, metabolic, and cardiometabolic pathways, a subset of which were also significantly differentially expressed. Ex vivo analysis of immune function showed improvement post-DM-SSP compared with baseline, characterized by attenuated interleukin 1ß and IL-6 secretion from monocytes. Altered cytokine secretion in response to the DM-SSP was significantly associated with changes in the methylation and gene expression states of immune-related genes in monocytes between intervention time points. CONCLUSIONS: Our pilot study provides preliminary evidence of changes to inflammatory monocyte activity, potentially driven by epigenetic modifications, 3 months following a DM-specific SSP intervention. These novel alterations in the trajectory of monocyte inflammatory states were identified at loci that regulate transcription of immune and metabolic genes in high-risk Native Hawaiians with DM, suggesting a relationship between improvements in psychosocial behaviors and shifts in the immunoepigenetic patterns following a diabetes-specific SSP. Further research is warranted to investigate how social support influences systemic inflammation via immunoepigenetic modifications in chronic inflammatory diseases such as DM.

Qualitative study on voyaging and health: perspectives and insights from the medical officers during the Worldwide Voyage.

OBJECTIVE: To examine the potential association of ocean voyaging with human health and well-being from the perspectives and experiences of the medical officers (MOs) who served during the Worldwide Voyage (WWV). DESIGN: Using a phenomenology framework, focus group and individual interviews were conducted and analysed by three diverse core researchers and then reviewed by three external researchers to enhance triangulation. Analysis used the Framework Method and Atlas-ti software (V.8.4.4) to facilitate coding, identify categories and develop an analytical matrix. The matrix was applied to all data using the constant comparative method to construct major themes and subthemes. Synthesised member checking was performed. SETTING: In 2014-2017, the WWV began in Hawai'i on a traditional voyaging canoe, known as Hokule'a, using a non-instrument navigational method, 'wayfinding', powered only by natural forces and guided by traditional ecological knowledge. Each segment of the voyage included ~12 individuals, including an MO physician. The entire WWV included 172 ports-of-call, 36 legs and 250+ crew members. PARTICIPANTS: We purposively sampled all MO physicians who participated in the WWV and enrolled 87% of eligible MOs (n=20 of 23). We conducted two focus groups (n=17=11+6, 85%) and three individual informant interviews (n=3, 15%). RESULTS: The four major themes: (1) Relationships; (2) Preventive Care to Enhance Health; (3) Holistic Health and Wellbeing beyond Voyaging and (4) Spiritual Transformative Experience, strongly suggest that ocean voyaging aboard a traditional voyaging canoe enhanced human health and well-being. The overall impact to perceived health and well-being extended beyond any increase in physical exercise. Essentially, traditional Polynesian ocean voyaging provided a cultural-based context for holistic health and well-being that influenced multiple levels and multiple dimensions. CONCLUSION: Polynesian ocean voyaging was perceived as positively associated with holistic health and overall well-being and it may offer a new approach to confront complex health disparities.

Mortality patterns of Native Hawaiians across their lifespan: 1990-2000.

OBJECTIVES: We examined mortality patterns across the lifespan of Native Hawaiians and compared mortality disparities across races. METHODS: We determined the age-specific and age-adjusted mortality rates of Native Hawaiians from 1990 to 2000 by using national census and vital registration data. RESULTS: Among Native Hawaiians aged younger than 1 year, expected deaths were 15% lower than for Blacks and 50% higher than for Whites. Among older adults, Native Hawaiians had higher rates of mortality compared with the general population, particularly in 1990 and 1995. Crude death rates for Native Hawaiians were similar to those for Blacks in 1990 and 1995 but were 20% lower than those for Blacks by 2000. Crude death rates for Native Hawaiians were 30% higher than for Whites in 1990 and 1995 and more than 40% higher than for Whites in 2000. CONCLUSIONS: Compared with Whites, Native Hawaiians and Blacks face similar challenges regarding infant and early-life mortality and increasing risks of mortality in mid-life and early old age. Our analyses document a need for renewed efforts to identify the determinants of ill health and commitment to address them.

Detecting cardiometabolic syndrome using World Health Organization public health action points for Asians and Pacific Islanders.

OBJECTIVE: To assess the screening characteristics of World Health Organization (WHO) body mass index action points for cardiometabolic syndrome (CMS) in Native Hawaiians and people of Asian ancestry (ie, Filipino and Japanese). DESIGN AND SETTING: Cross-sectional data were collected from 1,452 residents of a rural community of Hawai'i between 1997 and 2000, of which 1,198 were analyzed in this study. Ethnic ancestry was determined by self-report. MAIN OUTCOME MEASURES: Metabolic status was assessed using National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATPIII) criteria. Screening characteristics of WHO criteria for overweight and obesity were compared to WHO public health action points or to WHO West Pacific Regional Office (WPRO) cut-points. RESULTS: Among Asian-ancestry participants, WHO public health action points improved both sensitivity and specificity for detecting CMS. However, similar improvements were not observed for WPRO criteria for Native Hawaiians. Moreover, predictive values were high regardless of which criteria were utilized due to high CMS prevalence. CONCLUSIONS: WHO public health actions points for Asians provide a significant improvement in sensitivity in detection of CMS. However, predictive value, which varies greatly with disease prevalence, should be considered when deciding which criteria to apply.

Diabetes care in a predominantly Native Hawaiian and Pacific Islander outpatient population.

PURPOSE: Racial differences in diabetes care and outcomes, particularly among African Americans and Hispanics, have been well-recognized. The goal of this study was to evaluate the quality of diabetes care, using nationally recognized standards of care, in a multispecialty, hospital-based clinic that cares for a predominantly Native Hawaiian and Pacific Islander population. METHODS: We identified patients with a new primary or secondary diagnosis of diabetes during a visit (baseline visit) between January 2005 and June 2006 at the Queen Emma Clinics. Each patient's medical record was reviewed to obtain demographic and clinical information related to diabetes, including laboratory and test results and medications, from the baseline visit through 12 months follow-up. Performance indicators were selected from those recommended by the National Diabetes Quality Improvement Alliance and included selected 8 measures: 1) Hemoglobin A1c ≥9.0%; 2) Annual lipid panel checked; 3) Systolic blood pressure <140 mmHg; 4) LDL cholesterol <130 mg/dL) 5) Annual fundoscopic examination; 6) Foot examination; 7) Aspirin use; 8) Annual evaluation for urine protein. RESULTS: We identified 364 patients, the majority Pacific Islanders (58%), with Asians (15%) and Native Hawaiians (17%) more frequent than Caucasians (10%). Compared with Caucasians, Native Hawaiians and Pacific Islanders were significantly more likely to have poor glucose control. There were no significant differences between groups for the other measures. Patients compared favorably when compared with national benchmarks. For 2 indicators, adherence was significantly higher for the total study population compared with the US average (systolic blood pressure <140 mmHg, aspirin therapy). For 2 indicators, there were no significant difference (LDL cholesterol <130 mg/dL, annual foot exam) and for 2 indicators, adherence was significantly lower for the study population (hemoglobin A1c >9%, annual fundoscopic examination). CONCLUSIONS: Native Hawaiians and Pacific Islanders with diabetes have poorer blood glucose control compared with Caucasians and Asians, but the overall care is otherwise generally similar. The diabetes care received by patients in this clinic that treats a generally underserved population compares favorably with national benchmarks.

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.