Risk of Food Insecurity in Young Adulthood and Longitudinal Changes in Cardiometabolic Health: Evidence from the National Longitudinal Study of Adolescent to Adult Health.

BACKGROUND: Studies have demonstrated relations between food insecurity, the lack of access to enough nutritious food, and greater risk of diet-sensitive chronic diseases. However, most prior evidence relies on cross-sectional studies and self-reported disease. OBJECTIVES: The objective was to assess the longitudinal relation between risk of food insecurity in young adulthood and changes in diet-sensitive cardiometabolic health outcomes across 10 y among non-Hispanic white, non-Hispanic black, American Indian or Alaska Native, and Hispanic adults. METHODS: Data from the fourth and fifth waves (n = 3992) of the National Longitudinal Study of Adolescent to Adult Health were used. Measures included risk of food insecurity, body weight, diabetes, and sociodemographic characteristics. Body weight and diabetes were assessed with direct measures. Mixed-effects models assessed the association of risk of food insecurity with BMI, obesity, and diabetes while accounting for sociodemographic characteristics and the complex survey design. RESULTS: Risk of food insecurity was associated with increases in BMI as well as incidence of obesity and diabetes from young to middle adulthood in unadjusted and adjusted models (all P < 0.01). In models stratified by race and ethnicity, the relations of risk of food insecurity with body weight outcomes and diabetes varied. CONCLUSIONS: Risk of food insecurity in young adulthood was related to BMI and obesity during young and middle adulthood but not in changes over time. Risk of food insecurity in young adulthood related to an increased incidence of diabetes in middle adulthood. However, the relations among specific racial and ethnic groups were unclear. Estimates of the relation between food insecurity and cardiometabolic health outcomes within racial and ethnic groups experiencing the highest prevalence of these conditions should be refined.

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.

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.

Development and Evaluation of a Blood Glucose Monitoring YouTube Video for Marshallese Patients Using a Community-Based Participatory Research Approach.

The purpose of this study was to (a) describe the development of a culturally appropriate glucose monitoring video using a community-based participatory research approach and (b) assess the cultural appropriateness and effectiveness of the video. The topic of the video-using a glucometer and the importance of performing blood glucose checks-was chosen by Marshallese community stakeholders. The video was produced in Marshallese with English subtitles and disseminated through YouTube. Participants were recruited from August 16, 2016 to September 12, 2016 in a diabetes clinic that serves Marshallese patients in northwest Arkansas. Fifty participants completed a survey at pre- and postintervention, with questions capturing demographic information and questions on glucose monitoring self-efficacy using an adapted version of the Stanford Patient Education Research Center's Diabetes Self-Efficacy Scale. Twenty of those participants who completed the survey also completed semistructured interviews that assessed cultural appropriateness and effectiveness of the video. Participants reported significant increases in self-efficacy related to glucometer use and the importance of performing blood glucose checks (p < .001) and a 1.45% reduction in A1C between preintervention and 12 weeks postintervention (p = .006). Qualitative results indicated the video was both culturally appropriate and effective. The findings of this study were consistent with evidence in the literature, which shows health education videos can be effective at improving health behaviors. Using a community-based participatory research approach to prioritize video topics, and including members of the community in the creation and dissemination of the videos, could aid in ensuring the videos are effective and culturally appropriate.

Risk factors for pre-diabetes and diabetes in adolescence and their variability by race and ethnicity.

Adolescent risk factors for pre-diabetes and diabetes in young adulthood were examined in three minority groups and compared to those in non-Hispanic Whites. Retrospective cohort study with data on 8337 adolescent respondents from Add Health (1994-2008). Participants included 5131 non-Hispanic Whites, 1651 non-Hispanic Blacks, 1223 Hispanics, and 332 American Indians/Alaska Natives. Diabetes was defined as: hemoglobin A1C ≥ 6.5%, glucose > 125 mg/dl, self-reported diabetes, or self-reported diabetes medication use, in Wave 4 data. Pre-diabetes was defined as hemoglobin A1C ≥ 5.7%. Relative risk regression models were used to evaluate the association between risk factors and risk of diabetes and pre-diabetes, controlling for body mass index, sedentary and physical activity habits, fast food consumption, and parental education, parental diabetes status, and financial stability. 484 participants developed diabetes; 2878 developed pre-diabetes between 1994 and 2008. Pre-diabetes and diabetes were more prevalent in non-Hispanic Blacks (55% and 12%, respectively) than in American Indians/Alaska Natives (43% and 11%), Hispanics (37% and 6%), and non-Hispanic Whites (27% and 3%). In all races, higher body mass index and parental diabetes were associated with higher risk of pre-diabetes and diabetes, while female sex was associated with lower risk of pre-diabetes. Efforts to reduce the risk of pre-diabetes and diabetes in adolescents should emphasize parental diabetes and BMI in all races, independent of physical activity, sedentary behaviors, or fast food consumption. Future interventions might be interested in targeting households, rather than individuals, to prevent pre-diabetes and diabetes in adolescents and young adults.

Culturally responsive approaches to health promotion for Native Hawaiians and Pacific Islanders.

CONTEXT: Obesity, diabetes and cardiovascular disease (CVD) have reached epidemic proportions among Native Hawaiians/Pacific Islanders (NHPI). Culturally responsive interventions that account for their interpersonal, sociocultural and socioeconomic realities are a public health priority. OBJECTIVE: To describe cultural adaptation and culturally grounded approaches to developing health interventions for NHPI and to review the culturally responsive approaches used by, and outcomes from, two long-standing community-based participatory research projects (CBPR) in Hawai'i: PILI 'Ohana and KaHOLO Projects. METHODS: A literature review of 14 studies from these two projects was done to exemplify the methods applied to culturally adapting existing evidence-based interventions and to developing novel interventions from the 'ground up' to address health disparities in NHPI. Of the 14 studies reviewed, 11 were studies of the clinical and behavioural outcomes of both types of interventions. RESULTS: Both culturally adapted and culturally grounded approaches using community-based assets and NHPI cultural values/practices led to establishing sustainable and scalable interventions that significantly improved clinical measures of obesity, diabetes and hypertension. CONCLUSION: Several recommendations are provided based on the lessons learned from the PILI 'Ohana and KaHOLO Projects. Multidisciplinary and transdisciplinary research using CBPR approaches are needed to elucidate how human biology is impacted by societal, environmental and psychological factors that increase the risk for cardiometabolic diseases among NHPI to develop more effective health promotion interventions and public health policies.

Ka-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 Ka-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.

Infant-feeding practices and American Indian infants' gut microbiome: Rationale of the pilot study.

This study aims to examine the relationship between infant-feeding practices and American Indian infants' gut microbiome--laying the foundation of a research program aimed at identifying potential aetiologies of childhood obesity in this population. Previous studies have emphasised the high prevalence of obesity in American Indian infants, but its underlying causes remain unclear. We received funding from the University of Washington to examine attitudes towards breastfeeding and formula feeding in American Indian mothers, their dietary and physical activity habits and the yield, quality and diversity of their infants' gut microbiome. Our study combines the strengths of qualitative and quantitative data with DNA sequencing. Results will be used to propose a larger study aimed at clarifying aetiologies of childhood obesity in this population and to identify prevention strategies. This protocol describes the theoretical basis of the study, rationale for the target population, study design, participant recruitment and data analysis plan.

Moana: Alternate surveillance for COVID-19 in a Unique Population (MASC-UP).

Objective: Create a longitudinal, multi-modal and multi-level surveillance cohort that targets early detection of symptomatic and asymptomatic COVID-19 cases among Native Hawaiian and Pacific Islander adults in the Continental US and identify effective modalities for participatory disease surveillance and sustainably integrate them into ongoing COVID-19 and other public health surveillance efforts. Materials and methods: We recruited cohorts from three sites: Federal Way, WA; Springdale, AR; and remotely. Participants received a survey that included demographic characteristics and questions regarding COVID-19. Participants completed symptom checks via text message every month and recorded their temperature daily using a Kinsa smart thermometer. Results: Recruitment and data collection is ongoing. Presently, 441 adults have consented to participate. One-third of participants were classified as essential workers during the pandemic. Discussion: Over the past 18 months, we have improved our strategies to elicit better data from participants and have learned from some of the weaknesses in our initial deployment of this type of surveillance system. Other limitations stem from historic inequities and barriers which limited Native Hawaiian and Pacific Island representation in academic and clinical environments. One manifestation of this was the limited ability to provide study materials and support in multiple languages. We hope that continued partnership with the community will allow further opportunities to help restore trust in academic and medical institutions, thus generating knowledge to advance health equity. Conclusion: This participatory disease surveillance mechanism complements traditional surveillance systems by engaging underserved communities. We may also gain insights generalizable to other pathogens of concern.

Outcomes from a diabetes self-management intervention for Native Hawaiians and Pacific People: Partners in Care.

BACKGROUND: Culturally adapted interventions are needed to reduce diabetes-related morbidity and mortality among Native Hawaiian and Pacific People. PURPOSE: The purpose of this study is to pilot test the effectiveness of a culturally adapted diabetes self-management intervention. METHODS: Participants were randomly assigned in an unbalanced design to the Partners in Care intervention (n = 48) or wait list control group (n = 34). Assessments of hemoglobin A1c, understanding of diabetes self-management, performance of self-care activities, and diabetes-related distress were measured at baseline and 3 months (post intervention). Analysis of covariance was used to test between-group differences. The community steering committee and focus group data informed the cultural adaptation of the intervention. RESULTS: There were significant baseline adjusted differences at 3 months between the Partners in Care and wait list control group in intent-to-treat (p < 0.001) and complete case analyses (p < 0.0001) for A1c, understanding (p < 0.0001), and performing diabetes self-management (p < 0.0001). CONCLUSIONS: A culturally adapted diabetes self-management intervention of short duration was an effective approach to improving glycemic control among Native Hawaiian and Pacific Islanders.

Gestational Diabetes and Breastfeeding Among Women of Different Races/Ethnicities: Evidence from the Pregnancy Risk Assessment Monitoring Surveys.

OBJECTIVE: To examine risk factors for gestational diabetes mellitus (GDM) and factors associated with breastfeeding patterns among women with GDM from different racial/ethnic groups. METHODS: We used data from Phase 8 (2016-2018) of the Pregnancy Risk Assessment Monitoring System. We used logistic regression to estimate factors associated with GDM and with breastfeeding initiation, and conducted survival analysis using Kaplan-Meier curves, and Cox proportional hazards regression to analyze early cessation of breastfeeding. RESULTS: Among American Indian and Alaska Native (AI/AN) women, higher education reduced odds (aOR = 0.33; 95% CI: 0.19-0.59) and being married increased odds (aOR = 1.35; 95% CI: 1.02-1.79) of GDM. AI/AN women who received WIC benefits had lower odds of initiating breastfeeding (aOR = 0.70; 95% CI: 0.51-0.95). While there was no association between GDM and initiation of breastfeeding, only a third of AI/AN women with GDM were still breastfeeding by 36 weeks postpartum, compared to more than half of non-Hispanic White and Hispanic women. CONCLUSIONS FOR PRACTICE: Efforts to reduce GDM among those most at risk are needed, especially among racial and ethnic minorities. Increasing support for women with GDM to continue to breastfeed may improve maternal and child health outcomes and reduce health disparities, particularly among AI/AN women.

Native opportunities to stop hypertension: study protocol for a randomized controlled trial among urban American Indian and Alaska Native adults with hypertension.

Introduction: American Indian and Alaska Native (AI/AN) adults experience disproportionate cardiovascular disease (CVD) morbidity and mortality compared to other races, which may be partly attributable to higher burden of hypertension (HTN). Dietary Approaches to Stop Hypertension (DASH) is a high-impact therapeutic dietary intervention for primary and secondary prevention of CVD that can contribute to significant decreases in systolic blood pressure (BP). However, DASH-based interventions have not been tested with AI/AN adults, and unique social determinants of health warrant independent trials. This study will assess the effectiveness of a DASH-based intervention, called Native Opportunities to Stop Hypertension (NOSH), on systolic BP among AI/AN adults in three urban clinics. Methods: NOSH is a randomized controlled trial to test the effectiveness of an adapted DASH intervention compared to a control condition. Participants will be aged ≥18 years old, self-identify as AI/AN, have physician-diagnosed HTN, and have elevated systolic BP (≥ 130 mmHg). The intervention includes eight weekly, tailored telenutrition counseling sessions with a registered dietitian on DASH eating goals. Intervention participants will be provided $30 weekly and will be encouraged to purchase DASH-aligned foods. Participants in the control group will receive printed educational materials with general information about a low-sodium diet and eight weekly $30 grocery orders. All participants will complete assessments at baseline, after the 8-week intervention, and again 12 weeks post-baseline. A sub-sample of intervention participants will complete an extended support pilot study with assessments at 6- and 9-months post-baseline. The primary outcome is systolic BP. Secondary outcomes include modifiable CVD risk factors, heart disease and stroke risk scores, and dietary intake. Discussion: NOSH is among the first randomized controlled trials to test the impact of a diet-based intervention on HTN among urban AI/AN adults. If effective, NOSH has the potential to inform clinical strategies to reduce BP among AI/AN adults. Clinical trials registration: https://clinicaltrials.gov/ct2/show/NCT02796313, Identifier NCT02796313.

Measuring Food Security among American Indian and Alaska Native Adults: Validity Evidence Supports the Use of the US Department of Agriculture Module.

BACKGROUND: Inequities in access, availability, and affordability of nutritious foods produced by settler colonialism contribute to high rates of food insecurity among American Indian and Alaska Native (AI/AN) households. Efforts to understand the influences of food security programming among AI/AN individuals in the United States are constrained by the absence of validity evidence for food security assessments for this population. OBJECTIVE: This study assessed whether AI/AN adult responses on the Food Security Survey Module provide an accurate assessment of food security prevalence, especially when compared with other racial and ethnic groups. DESIGN: A correlational design with the cross-sectional 2019 National Health Interview Survey was used to address the research objective. PARTICIPANTS AND SETTING: The 2019 National Health Interview Survey contains a sample (N = 30,052) representative of the resident civilian noninstitutionalized population. MAIN OUTCOME MEASURES: The primary outcome was food security, as characterized by the 10-item US Department of Agriculture Adult Food Security Survey Module. The module evaluates whether insufficient finances result in perceived food shortages and a reduction in the quantity and/or quality of food intake during the prior 30 days. STATISTICAL ANALYSES PERFORMED: Data were analyzed by racial and ethnic subsamples to assess scale dimensionality (confirmatory factor analysis), Item Response Theory item analysis, differential item functioning, and external validity (χ2 tests). RESULTS: Results supported the use of the 10-item module for racial and ethnic groups. However, differential item functioning effect sizes exceeded criteria for the Asian, AI/AN, and Hispanic respondents when compared with White respondents. Food security was not significantly related to all expected correlates in the AI/AN subsample. CONCLUSIONS: Compelling evidence is presented for validity of the FSSM scores in determining food security status of AI/AN adults. Qualitative inquiry that explores how culture influences the way food security is conceptualized and experienced is warranted.

Effectiveness of a culturally tailored diabetes education curriculum with real-time continuous glucose monitoring in a Latinx population with type 2 diabetes: the CUT-DM with CGM for Latinx randomised controlled trial study protocol.

INTRODUCTION: The prevalence of type 2 diabetes (T2D) is increasing in the Latinx community. Despite telehealth and technology becoming more available, these resources are not reaching the Latinx population. Diabetes education is a cornerstone of treatment; however, access to culturally tailored content is a barrier to the Latinx population. Real-time continuous glucose monitoring (RT-CGM) is a patient-empowering tool that can improve glycaemic control, but it is not readily available for Latinx patients with T2D. We aim to evaluate a culturally tailored diabetes self-management education and support (DSMES) curriculum, using a team-based approach to improve glycaemic control, promote healthy behaviours and enhance patient access with the use of telehealth in Latinx individuals. The primary aim of the study is to evaluate the additive effectiveness of RT-CGM on glycaemia and behavioural changes among Latinx patients undergoing a culturally tailored DSMES. A sub aim of the study is to evaluate family members' change in behaviours. METHODS: We propose a randomised controlled trial of blinded versus RT-CGM with 100 Latinx participants with T2D who will receive DSMES via telemedicine over 12 weeks (n=50 per group). The study will be conducted at a single large federally qualified health centre system. The control group will receive culturally tailored DSMES and blinded CGM. The intervention group will receive DSMES and RT-CGM. The DSMES is conducted by community health educators weekly over 12 weeks in Spanish or English, based on participant's language preference. Patients in the RT-CGM group will have cyclical use with a goal of 50 days wear time. The primary outcomes are changes in haemoglobin A1c and CGM-derived metrics at 3 and 6 months. The secondary outcomes include participants' self-management knowledge and behaviour and household members' change in lifestyle. ETHICS AND DISSEMINATION: The study proposal was approved by the University of Washington ethics/institutional review board (IRB) Committee as minimal risk (IRB ID: STUDY00014396) and the Sea Mar IRB committee. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT05394844.

Social Determinants of Health and Body Mass Index in American Indian/Alaska Native Children.

Objective: To examine the associations between social determinants of health (SDOH) and prevalent overweight/obesity status and change in adiposity status among American Indian and Alaska Native (AI/AN) children. Methods: The study sample includes 23,950 AI/AN children 2-11 years of age, who used Indian Health Service (IHS) from 2010 to 2014. Multivariate generalized linear mixed models were used to examine the following: (1) cross-sectional associations between SDOH and prevalent overweight/obesity status and (2) longitudinal associations between SDOH and change in adiposity status over time. Results: Approximately 49% of children had prevalent overweight/obesity status; 18% had overweight status and 31% had obesity status. Prevalent severe obesity status was 20% in 6-11-year olds. In adjusted cross-sectional models, children living in counties with higher levels of poverty had 28% higher odds of prevalent overweight/obesity status. In adjusted longitudinal models, children 2-5 years old living in counties with more children eligible for free or reduced-priced lunch had 15% lower odds for transitioning from normal-weight status to overweight/obesity status. Conclusions: This work contributes to accumulating knowledge that economic instability, especially poverty, appears to play a large role in overweight/obesity status in AI/AN children. Research, clinical practice, and policy decisions should aim to address and eliminate economic instability in childhood.

Association of food security with cardiometabolic health during young adulthood: cross-sectional comparison of American Indian adults with other racial/ethnic groups.

OBJECTIVES: Our aim was to assess the cross-sectional associations between food insecurity and cardiometabolic health indicators in American Indian young adults compared with non-Hispanic white, black, Asian or Pacific Islander and Hispanic young adults. DESIGN: Data from the fourth wave of the National Longitudinal Study of Adolescent to Adult Health (Add Health) were used. Variables included a self-assessed measure of risk of food insecurity, indicators of cardiometabolic health (body mass index, haemoglobin A1c, blood pressure) and sociodemographic characteristics. Multivariable regression models were used to assess the association of risk of food insecurity with cardiometabolic health, while controlling for sociodemographic variables. All analyses were weighted and accounted for the complex survey design. PARTICIPANTS: The analytical sample of n=12 799 included mostly non-Hispanic white respondents (n=7900), followed by n=2666 black, n=442 American Indian, n=848 Asian or Pacific Islander and n=943 Hispanic. RESULTS: Risk of food insecurity was more common among respondents who were female, Black, American Indian, had lower educational attainment, and were classified as having obesity or diabetes. In unadjusted models, risk of food insecurity was significantly associated with greater odds of obesity (OR=1.39; 95% CI 1.20 to 1.60) and diabetes (OR=1.61; 95% CI 1.23 to 2.11). After adjusting for sociodemographic factors (age, sex, education, income, household size, tobacco smoking, alcohol intake and race/ethnicity), only the association between risk of food insecurity and obesity remained (OR=1.19; 95% CI 1.03 to 1.38). Relationships among risk of food insecurity, sociodemographic characteristics and diabetes varied across models stratified by race and ethnicity. CONCLUSIONS: Results suggest that elevated risk of food insecurity is present in young American Indian adults, but its relationship with cardiometabolic health is unclear. Future work should capitalise on longitudinal data and the US Department of Agriculture's Food Security Survey Modules.

Online Food Security Discussion Before and During the COVID-19 Pandemic in Native Hawaiian and Pacific Islander Community Groups and Organizations: Content Analysis of Facebook Posts.

Background: The Native Hawaiian and Pacific Islander (NHPI) population experiences disproportionately higher rates of food insecurity, which is a risk factor for cardiometabolic diseases such as cardiovascular disease, type 2 diabetes, obesity, and hypertension, when compared to white individuals. Novel and effective approaches that address food insecurity are needed for the NHPI population, particularly in areas of the continental United States, which is a popular migration area for many NHPI families. Social media may serve as an opportune setting to reduce food insecurity and thus the risk factors for cardiometabolic diseases among NHPI people; however, it is unclear if and how food insecurity is discussed in online communities targeting NHPI individuals. Objective: The objective of this study was to characterize the quantity, nature, and audience engagement of messages related to food insecurity posted online in community groups and organizations that target NHPI audiences. Methods: Publicly accessible Facebook pages and groups focused on serving NHPI community members living in the states of Washington or Oregon served as the data source. Facebook posts between March and June 2019 (before the COVID-19 pandemic) and from March to June 2020 (during the COVID-19 pandemic) that were related to food security were identified using a set of 36 related keywords. Data on the post and any user engagement (ie, comments, shares, or digital reactions) were extracted for all relevant posts. A content analytical approach was used to identify and quantify the nature of the identified posts and any related comments. The codes resulting from the content analysis were described and compared by year, page type, and engagement. Results: Of the 1314 nonduplicated posts in the 7 relevant Facebook groups and pages, 88 were related to food security (8 in 2019 and 80 in 2020). The nature of posts was broadly classified into literature-based codes, food assistance (the most common), perspectives of food insecurity, community gratitude and support, and macrolevel contexts. Among the 88 posts, 74% (n=65) had some form of engagement, and posts reflecting community gratitude and support or culture had more engagement than others (mean 19.9, 95% CI 11.2-28.5 vs mean 6.1, 95% CI 1.7-10.4; and mean 26.8, 95% CI 12.7-40.9 vs mean 5.3, 95% CI 3.0-7.7, respectively). Conclusions: Food security-related posts in publicly accessible Facebook groups targeting NHPI individuals living in Washington and Oregon largely focused on food assistance, although cultural values of gratitude, maintaining NHPI culture, and supporting children were also reflected. Future work should capitalize on social media as a potential avenue to reach a unique cultural group in the United States experiencing inequitably high rates of food insecurity and risk of cardiometabolic diseases.

Strong Men, Strong Communities: Revision of a Diabetes Prevention Intervention for American Indian and Alaska Native Men During the COVID-19 Pandemic.

This paper describes the revision of the in-person Strong Men, Strong Communities (SMSC) study to a remote protocol and highlights key successes, challenges, and critical lessons learned applicable to remote trial implementation. The SMSC study is the first randomized controlled trial to exclusively recruit American Indian and Alaska Native men into a diabetes prevention intervention. The five-year randomized controlled trial was in its 42nd month with 99 subjects enrolled when the COVID-19 pandemic ceased all in-person research. The study protocol was revised to accommodate remote implementation which required multiple protocol and procedural changes, including the use of Facebook for national recruitment of participants; alteration of the informed consent process; use of REDCap for independent participant completion of informed consent; revised eligibility criteria; and use of Zoom to deliver intervention classes. The remote study protocol proved superior to the in-person protocol in terms of recruitment, retention, engagement in intervention classes, and efficiency of data collection. Challenges to participation and retention included competing demands of participant's jobs as essential workers and for some, the trauma of the losing a loved one(s) to COVID-19. Future studies are needed to evaluate the effectiveness of a remote protocol in the absence of a pandemic.

Cost Effectiveness of a Cultural Physical Activity Intervention to Reduce Blood Pressure Among Native Hawaiians with Hypertension.

OBJECTIVE: The aim of this study was to calculate the costs and assess whether a culturally grounded physical activity intervention offered through community-based organizations is cost effective in reducing blood pressure among Native Hawaiian adults with hypertension. METHODS: Six community-based organizations in Hawai'i completed a randomized controlled trial between 2015 and 2019. Overall, 263 Native Hawaiian adults with uncontrolled hypertension (≥ 140 mmHg systolic, ≥ 90 mmHg diastolic) were randomized to either a 12-month intervention group of hula (traditional Hawaiian dance) lessons and self-regulation classes, or to an education-only waitlist control group. The primary outcome was change in systolic blood pressure collected at baseline and 3, 6, and 12 months for the intervention compared with the control group. Incremental cost-effectiveness ratios (ICERs) were calculated for primary and secondary outcomes. Non-parametric bootstrapping and sensitivity analyses evaluated uncertainty in parameters and outcomes. RESULTS: The mean intervention cost was US$361/person, and the 6-month ICER was US$103/mmHg reduction in systolic blood pressure and US$95/mmHg in diastolic blood pressure. At 12 months, the intervention group maintained reductions in blood pressure, which exceeded reductions for usual care based on blood pressure outcomes. The change in blood pressure at 12 months resulted in ICERs of US$100/mmHg reduction in systolic blood pressure and US$93/mmHg in diastolic blood pressure. Sensitivity analyses suggested that at the estimated intervention cost, the probability that the program would lower systolic blood pressure by 5 mmHg was 67 and 2.5% at 6 and 12 months, respectively. CONCLUSION: The 6-month Ola Hou program may be cost effective for low-resource community-based organizations. Maintenance of blood pressure reductions at 6 and 12 months in the intervention group contributed to potential cost effectiveness. Future studies should further evaluate the cost effectiveness of indigenous physical activity programs in similar settings and by modeling lifetime costs and quality-adjusted life-years. TRIAL REGISTRATION NUMBER: NCT02620709.

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.