All-cause, cardiovascular, and cancer mortality in western Alaska Native people: western Alaska Tribal Collaborative for Health (WATCH).

OBJECTIVES: We determined all-cause, cardiovascular disease (CVD), and cancer mortality in western Alaska Native people and examined agreement between death certificate information and adjudicated cause of deaths. METHODS: Data from 4 cohort studies were consolidated. Death certificates and medical records were reviewed and adjudicated according to standard criteria. We compared adjudicated CVD and cancer deaths with death certificates by calculating sensitivity, specificity, predictive values, and κ statistics. RESULTS: Men (n = 2116) and women (n = 2453), aged 18 to 95 years, were followed an average of 6.7 years. The major cause of death in men was trauma (25%), followed by CVD (19%) and cancer (13%). The major cause of death in women was CVD (24%), followed by cancer (19%) and trauma (8%). Stroke rates in both genders were higher than those of US Whites. Only 56% of deaths classified as CVD by death certificate were classified as CVD by standard criteria; discordance was higher among men (55%) than women (32%; κs = 0.4 and 0.7). CONCLUSIONS: We found lower rates for coronary heart disease death but high rates of stroke mortality. Death certificates overestimated CVD mortality; concordance between the 2 methods is better for cancer mortality. The results point to the importance of cohort studies in this population in providing data to assist in health care planning.

Comparison of fecal occult blood tests for colorectal cancer screening in an Alaska Native population with high prevalence of Helicobacter pylori infection, 2008-2012.

INTRODUCTION: Alaska Native colorectal cancer (CRC) incidence and mortality rates are the highest of any ethnic/racial group in the United States. CRC screening using guaiac-based fecal occult blood tests (gFOBT) are not recommended for Alaska Native people because of false-positive results associated with a high prevalence of Helicobacter pylori-associated hemorrhagic gastritis. This study evaluated whether the newer immunochemical FOBT (iFOBT) resulted in a lower false-positive rate and higher specificity for detecting advanced colorectal neoplasia than gFOBT in a population with elevated prevalence of H. pylori infection. METHODS: We used a population-based sample of 304 asymptomatic Alaska Native adults aged 40 years or older undergoing screening or surveillance colonoscopy (April 2008-January 2012). RESULTS: Specificity differed significantly (P < .001) between gFOBT (76%; 95% CI, 71%-81%) and iFOBT (92%; 95% CI, 89%-96%). Among H. pylori-positive participants (54%), specificity of iFOBT was even higher (93% vs 69%). Overall, sensitivity did not differ significantly (P = .73) between gFOBT (29%) and iFOBT (36%). Positive predictive value was 11% for gFOBT and 32% for iFOBT. CONCLUSION: The iFOBT had a significantly higher specificity than gFOBT, especially in participants with current H. pylori infection. The iFOBT represents a potential strategy for expanding CRC screening among Alaska Native and other populations with elevated prevalence of H. pylori, especially where access to screening endoscopy is limited.

Giant inflatable colon and community knowledge, intention, and social support for colorectal cancer screening.

INTRODUCTION: Colorectal cancer (CRC) is the second-leading cause of deaths from cancer in the United States. Screening decreases CRC deaths through early cancer detection and through removal of precancerous lesions. We investigated whether a health exhibit consisting of a giant inflatable colon was an effective educational tool to increase community members' knowledge, intention, and social support for CRC screening and prevention. METHODS: Alaska adults (N = 880) attending community events statewide from March 2011 through March 2012 completed a short survey to assess knowledge about CRC, intention to get screened, and level of social support before and after walking through a giant interactive model of a human colon. The survey used a combination of open-ended questions and a Likert scale, where 1 was "very unlikely," 2 was "somewhat unlikely," 3 was "neutral," 4 was "somewhat likely," and 5 was "very likely." The model depicted CRC stages from normal tissue to advanced adenocarcinoma and displayed signs with CRC prevention tips. We used the McNemar test and paired sample t tests for univariate analyses. RESULTS: Respondents significantly improved their CRC knowledge (P < .05), intention to get screened (mean score increased from 4.3 to 4.5, P < .001), and comfort with talking to others about CRC screening (mean level of comfort increased from 3.8 to 3.9, P < .001). Multivariate analysis showed no significant differences by sex, age, or race for improvements in CRC screening knowledge, intention, or comfort. CONCLUSION: Interactive exhibits can improve public knowledge and interest in CRC screening, which may lead to increased CRC screening rates and decreased CRC incidence and deaths.

Strategies for successful retention of Alaska Native and American Indian study participants.

This paper reports the strategies used to track and follow 3,828 Alaska Native and American Indian study participants in the city of Anchorage and more rural areas of Alaska and provides characteristics of respondents and non-respondents. Over 88% were successfully followed-up, with 49% of respondents completed in three or fewer attempts. Follow-up completion rates were significantly higher for women, those living in a rural area, over age 55, married, employed, having a higher household income, and at current residence for more than five years. Follow-up of large numbers of Alaska Native and American Indian people living in geographically diverse areas is feasible, although challenging. Successful strategies to avoid attrition include using telephones as the primary method of contact; using a computerized contact relationship management system to track efforts and manage data; obtaining contact information from participant contact networks, medical records, and community networks; using local village interviewers to contact participants without telephone service; and mailing paper questionnaires to participants who are incarcerated or use social services.

Chronic disease risk factors among Alaska Native and American Indian people, Alaska, 2004-2006.

INTRODUCTION: The Alaska Education and Research Towards Health (EARTH) Study is being conducted to determine the prevalence of clinically measured chronic disease risk factors in a large population of American Indian/Alaska Native people (AI/AN). We report these estimates and compare them with those for the overall US population, as assessed by the National Health and Nutrition Examination Survey (NHANES). METHODS: We measured blood pressure, height, weight, and fasting serum lipids and glucose in a prospective cohort of 3,822 AI/AN participants who resided in Alaska during 2004 through 2006. We categorized participants as having chronic disease risk factors if their measurements exceeded cutoffs that were determined on the basis of national recommendations. We analyzed the prevalence of risk factors by sex and age and compared the age-adjusted prevalence with 1999-2004 NHANES measurements. RESULTS: EARTH participants were significantly more likely than NHANES participants to be overweight or obese and to have impaired fasting glucose, low high-density lipoprotein cholesterol, high low-density lipoprotein cholesterol, and hypertension. The prevalence of high total cholesterol and triglycerides was not significantly different between the 2 study populations. CONCLUSION: We provide baseline clinical measurements for chronic disease risk factors for a larger study sample than any previous study of AI/AN living in Alaska. The prevalence of most risk factors measured exceeded national rates. These data can be used to tailor health interventions and reduce health disparities.

Diabetes prevalence, incidence, complications and mortality among Alaska Native people 1985-2006.

OBJECTIVES: To examine trends in diabetes prevalence, incidence, complications and mortality between 1985 and 2006 among Alaska Native people. STUDY DESIGN: We used data from the population-based Alaska Native Diabetes Registry, which includes all people who receive care in the Alaska Tribal Health System. METHODS: We compared the periods of 1986-1990 and 2002-2006 for diabetes-related amputations, renal replacement and mortality using Poisson regression. Complications and mortality data were examined for trends using Poisson regression. Survival analyses for those diagnosed since 31 December 1985 were performed using the Cox proportional hazard model. RESULTS: Age-adjusted diabetes prevalence increased from 17.3 in 1985 to 47.6/1,000 in 2006. The number of Alaska Native people living in Alaska with diabetes increased from 610 in 1985 to 3,386 in 2006. Diabetes incidence rates have also increased. Comparing age-adjusted rates for the 5-year periods 1986-1990 and 2002-2006, amputations decreased from 5.3 to 2.6/1,000, renal replacement decreased from 3.3 to 1.2/1,000 and mortality decreased from 41.7 to 33.2/1,000. Yearly analyses showed a downward trend for amputations, renal replacement and mortality rates. Survival analyses showed a significantly higher hazard ratio for any amputations, major amputations and renal replacement for the earlier time period compared to the most recent time period. CONCLUSIONS: An increase in risk factors, awareness, funding and case-finding may be contributing to the increase in prevalence and incidence of diagnosed diabetes. While diabetes prevalence and incidence are increasing among Alaska Native people, our results suggest that even in remote, rural areas, complications and mortality can be reduced.

Physical activity patterns of American Indian and Alaskan Native people living in Alaska and the Southwestern United States.

PURPOSE: Assessment of self-reported physical activity (PA) and effects on health measures. DESIGN: Cross-sectional analysis of baseline data from a cohort study. SETTING: Education and Research Towards Health study participants from Alaska and the Southwestern United States enrolled from 2004 to 2007. SUBJECTS: Total of 10,372 American Indian and Alaskan Native people (AI/AN) of at least 18 years. MEASURES: Participants completed computer-assisted, self-administered questionnaires, and anthropometric and health measurements were taken of each participant. ANALYSIS: Analysis of variance, chi2 tests, and multiple linear regressions were used. RESULTS: Almost 23% of participants reported less than 30 minutes per week of moderate or vigorous activities. Half (49%) reported no vigorous activities. Characteristics associated with more time spent performing vigorous activity were male gender, age less than 40 years, higher income and education levels, and living in a rural area. Almost 70% of Alaskan participants and 36% of Southwest participants engaged in wild food-harvesting activities. Participants with higher levels of activity had significantly better clinical characteristics (high-density lipoprotein cholesterol, triglycerides, body mass index, and waist circumference). CONCLUSION: AI/AN people engage in many different physical activities, including traditional harvesting activities. Women had lower levels of PA than men, and participation in vigorous PA was associated with better clinical characteristics. These data can be used to guide health promotion efforts in AI/AN populations.

Developing a validated Alaska Native food frequency questionnaire for western Alaska, 2002-2006.

OBJECTIVES: The purpose of this study was to develop a dietary instrument (food frequency questionnaire [FFQ]) that measured total dietary intake over 1 year among Alaska Native people in 2 regions. Ways of assessing diet are needed in order to accurately evaluate how the diets of Alaska Natives relate to their health. STUDY DESIGN: Seasonal 24-hour (24-h) diet recalls were collected for developing an FFQ that described the average dietary foods and nutrients consumed. Alaska Native people living in 12 small communities in 2 regions of the state were eligible to participate. METHODS: Each participant was to provide 4 24-h diet recalls, 1 per season. Recalls were used to develop an FFQ using regression techniques. The FFQ was administered to 58 of the 333 original participants. Responses to the FFQ were compared to the averages of their 24-h recalls using the Spearman Correlation Coefficient. RESULTS: Energy-adjusted correlations ranged from 0.15 for protein to 0.49 for monounsaturated fatty acids. Fifteen of 26 nutrients examined were significantly correlated (total carbohydrates, sucrose, fructose, total fat, fatty acids [monounsaturated, polyunsaturated, omega 3, EPA, DHA], folate, vitamins A, C, D, potassium and selenium). CONCLUSIONS: The FFQ can be used to evaluate intakes of Alaska Natives in western Alaska for the correlated nutrients.

Dietary intake of Alaska Native people in two regions and implications for health: the Alaska Native Dietary and Subsistence Food Assessment Project.

OBJECTIVES: To calculate the energy and nutrient intake in 2 regions of Alaska and to describe the implications for development of chronic disease among Alaska Native people (AN). STUDY DESIGN: Cross-sectional observation; 10 villages and 2 hub communities in rural Alaska; 333 participants ages 13 to 88 years old. METHODS: Trained interviewers collected 24-hour diet recalls during 4 seasons. RESULTS: In both regions, AN reported a combination of traditional Native foods and store bought foods; most of the energy comes from store-bought foods; a high proportion of nutrients come from Native foods, especially protein, iron and omega-3 fatty acids. Mean intakes of omega-3 fatty acids, from fish and sea mammals, are over twenty times greater than those of the general U.S. population. Mean intakes of protein, iron, selenium, vitamin A, vitamin C (men) and folate (men) met recommended levels; intakes of calcium and fiber were below recommended levels; carbohydrate and saturated fat (% energy) were above. CONCLUSIONS: Traditional foods continue to contribute a significant amount of nutrients to the diet in rural Alaska. Excess simple sugars may be contributing to the rise in obesity and diabetes. Low intakes of calcium, dietary fiber, fruits and vegetables may contribute to the increased incidence of cancers of the digestive system. Emphasis on the positive aspects of Native foods and increased consumption of fruits, vegetables and calcium-rich foods are warranted.

Effect of special diabetes program for Indians funding on system changes in diabetes care and outcomes among American Indian/Alaska Native people 1994-2004.

OBJECTIVES: The Alaska Native Medical Center diabetes program analysed Diabetes Care and Outcomes Audit data from 1994-2004 to evaluate the impact of the Special Diabetes Program for Indians (SDPI) funding on process and intermediate outcomes. STUDY DESIGN: We conducted a retrospective analysis of data from standardized medical records reviews conducted between 1994 and 2004 from regional sites in Alaska. METHODS: We analysed 7,735 randomly selected records for trends over three time periods (pre-SDPI, transition and SDPI). RESULTS: Hemoglobin A1c, total and LDL cholesterol, triglycerides and blood pressure significantly improved from the pre-SDPI to the SDPI period. However, as the number of people with diabetes increased, the percentage of patients receiving foot, eye and dental exams decreased, as did the percentage receiving nutrition, exercise and diabetes education. CONCLUSIONS: SDPI funding provided resources for interventions necessary to improve the effectiveness of diabetes care. This was associated with improved intermediate outcomes in American Indian/Alaska Native patients with diabetes. Further observations are needed to evaluate whether or not intermediate outcomes result in decreased cardiovascular disease, amputations, dialysis and retinopathy.

Stool DNA Testing for Screening Detection of Colorectal Neoplasia in Alaska Native People.

OBJECTIVE: To assess the accuracy of a multitarget stool DNA test (MT-sDNA) compared with fecal immunochemical testing for hemoglobin (FIT) for detection of screening-relevant colorectal neoplasia (SRN) in Alaska Native people, who have among the world's highest rates of colorectal cancer (CRC) and limited access to conventional screening approaches. PATIENTS AND METHODS: We performed a prospective, cross-sectional study of asymptomatic Alaska Native adults aged 40-85 years and older undergoing screening or surveillance colonoscopy between February 6, 2012, and August 7, 2014. RESULTS: Among 868 enrolled participants, 661 completed the study (403 [61%] women). Overall, SRN detection by MT-sDNA (49%) was superior to that by FIT (28%; P<.001); in the screening group, SRN detection rates were 50% and 31%, respectively (P=.01). Multitarget stool DNA testing detected 62% of adenomas 2 cm or larger vs 29% by FIT (P=.05). Sensitivity by MT-sDNA increased with adenoma size (to 80% for lesions ≥3 cm; P=.01 for trend) and substantially exceeded FIT sensitivity at all adenoma sizes. For sessile serrated polyps larger than 1 cm (n=9), detection was 67% by MT-sDNA vs 11% by FIT (P=.07). For CRC (n=10), detection was 100% by MT-sDNA vs 80% by FIT (P=.48). Specificities were 93% and 96%, respectively (P=.03). CONCLUSION: The sensitivity of MT-sDNA for cancer and larger polyps was high and significantly greater than that of FIT for polyps of any size, while specificity was slightly higher with FIT. These findings could translate into high cumulative neoplasm detection rates on serial testing within a screening program. The MT-sDNA represents a potential strategy to expand CRC screening and reduce CRC incidence and mortality, especially where access to endoscopy is limited.

Agreement Between Self-Report and Medical Record Prevalence of 16 Chronic Conditions in the Alaska EARTH Study.

The gold standard for health information is the health record. Hospitalization and outpatient diagnoses provide health systems with data on which to project health costs and plan programmatic changes. Although health record information may be reliable and perceived as accurate, it may not include population-specific information and may exclude care provided outside a specific health care facility. Sole reliance on medical record information may lead to underutilization of health care services and inadequate assessment of population health status. In this study, we analyzed agreement, without assuming a gold standard, between self-reported and recorded chronic conditions in an American Indian/Alaska Native cohort. Self-reported health history was collected from 3821 adult participants of the Alaska EARTH study during 2004-2006. Participant medical records were electronically accessed and reviewed. Self-reported chronic conditions were underreported in relation to the medical record and both information sources reported the absence more reliably than the presence of conditions (across conditions, median positive predictive value = 64%, median negative predictive value = 94%). Agreement was affected by age, gender, and education. Differences between participant- and provider-based prevalence of chronic conditions demonstrate why health care administrators and policy makers should not rely exclusively on medical record-based administrative data for a comprehensive evaluation of population health.

Factors related to fruit, vegetable and traditional food consumption which may affect health among Alaska Native People in Western Alaska.

OBJECTIVES: Determine intake of fruits, vegetables and traditional foods (TF), availability of foods, and attitudes towards increasing their consumption. STUDY DESIGN: Establish community baseline through a cross-sectional sample of residents who were weighed, measured and interviewed. Village stores were surveyed for food availability, price and quality. METHODS: Eighty-eight respondents self-identified as the household member primarily responsible for food shopping and cooking were surveyed in 3 Western Alaska Native villages using a food frequency questionnaire, and village stores were evaluated using food environment surveys. RESULTS: Overweight (BMI[kg/m(2)] > 25) was present in 68% of participants. Fruit and vegetable intake (3.3 median servings/day) was low in comparison to recommended intakes of 5-9 servings/d. Seventy-two per cent were eating less than 5 servings/d of fruits and vegetables combined. Thirty-four per cent of respondents were trying to eat more vegetables; 41% were trying to eat more fruits. The median number of servings of TF was 3.2/d (mean 4.3/d). Seventy-seven per cent of respondents reported that they ate enough TF. CONCLUSION: Recommendations to continue use of TF and increase intake of fruits and vegetables are consistent with local attitudes. Our findings indicate that increasing the availability of fruits and vegetables would be well received. Information from this study provides a basis for nutrition education and food supplement programs that is responsive to the needs and perceptions of the residents. Continued TF intake and increased fruit and vegetable intake have the potential to benefit the health of rural residents.

Innovative primary care delivery in rural Alaska: a review of patient encounters seen by community health aides.

BACKGROUND: For more than 50 years, Community Health Aides and Community Health Practitioners (CHA/Ps) have resided in and provided care for the residents of their villages. OBJECTIVES: This study is a systematic description of the clinical practice of primary care health workers in rural Alaska communities. This is the first evaluation of the scope of health problems seen by these lay health workers in their remote communities. STUDY DESIGN: Retrospective observational review of administrative records for outpatient visits seen by CHA/Ps in 150 rural Alaska villages (approximate population 47,370). METHODS: Analysis of electronic records for outpatient visits to CHA/Ps in village clinics from October 2004 through September 2006. Data included all outpatient visits from the Indian Health Service National Patient Information Reporting System. Descriptive analysis included comparisons by region, age, sex, clinical assessment and treatment. RESULTS: In total 272,242 visits were reviewed. CHA/Ps provided care for acute, chronic, preventive, and emergency problems at 176,957 (65%) visits. The remaining 95,285 (35%) of records did not include a diagnostic code, most of which were for administrative or medication-related encounters. The most common diagnostic codes were: pharyngitis (11%), respiratory infections (10%), otitis media (8%), hypertension (6%), skin infections (4%), and chronic lung disease (4%). Respiratory distress and chest pain accounted for 75% (n=10,552) of all emergency visits. CONCLUSIONS: CHA/Ps provide a broad range of primary care in remote Alaskan communities whose residents would otherwise be without consistent medical care. Alaska's CHA/P program could serve as a health-care delivery model for other remote communities with health care access challenges.