Weight Loss in Underserved Patients - A Cluster-Randomized Trial.

BACKGROUND: Evidence of the effectiveness of treatment for obesity delivered in primary care settings in underserved populations is lacking. METHODS: We conducted a cluster-randomized trial to test the effectiveness of a high-intensity, lifestyle-based program for obesity treatment delivered in primary care clinics in which a high percentage of the patients were from low-income populations. We randomly assigned 18 clinics to provide patients with either an intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, or usual care. Patients in the intensive-lifestyle group participated in a high-intensity program delivered by health coaches embedded in the clinics. The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients in the usual-care group received standard care from their primary care team. The primary outcome was the percent change from baseline in body weight at 24 months. RESULTS: All 18 clinics (9 assigned to the intensive program and 9 assigned to usual care) completed 24 months of participation; a median of 40.5 patients were enrolled at each clinic. A total of 803 adults with obesity were enrolled: 452 were assigned to the intensive-lifestyle group, and 351 were assigned to the usual-care group; 67.2% of the patients were Black, and 65.5% had an annual household income of less than $40,000. Of the enrolled patients, 83.4% completed the 24-month trial. The percent weight loss at 24 months was significantly greater in the intensive-lifestyle group (change in body weight, -4.99%; 95% confidence interval [CI], -6.02 to -3.96) than in the usual-care group (-0.48%; 95% CI, -1.57 to 0.61), with a mean between-group difference of -4.51 percentage points (95% CI, -5.93 to -3.10) (P<0.001). There were no significant between-group differences in serious adverse events. CONCLUSIONS: A high-intensity, lifestyle-based treatment program for obesity delivered in an underserved primary care population resulted in clinically significant weight loss at 24 months. (Funded by the Patient-Centered Outcomes Research Institute and others; PROPEL ClinicalTrials.gov number, NCT02561221.).

Thresholds for Ambulatory Blood Pressure Among African Americans in the Jackson Heart Study.

BACKGROUND: Ambulatory blood pressure (BP) monitoring is the reference standard for out-of-clinic BP measurement. Thresholds for identifying ambulatory hypertension (daytime systolic BP [SBP]/diastolic BP [DBP] ≥135/85 mm Hg, 24-hour SBP/DBP ≥130/80 mm Hg, and nighttime SBP/DBP ≥120/70 mm Hg) have been derived from European, Asian, and South American populations. We determined BP thresholds for ambulatory hypertension in a US population-based sample of African American adults. METHODS: We analyzed data from the Jackson Heart Study, a population-based cohort study comprised exclusively of African American adults (n=5306). Analyses were restricted to 1016 participants who completed ambulatory BP monitoring at baseline in 2000 to 2004. Mean SBP and DBP levels were calculated for daytime (10:00 am-8:00 pm), 24-hour (all available readings), and nighttime (midnight-6:00 am) periods, separately. Daytime, 24-hour, and nighttime BP thresholds for ambulatory hypertension were identified using regression- and outcome-derived approaches. The composite of a cardiovascular disease or an all-cause mortality event was used in the outcome-derived approach. For this latter approach, BP thresholds were identified only for SBP because clinic DBP was not associated with the outcome. Analyses were stratified by antihypertensive medication use. RESULTS: Among participants not taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mm Hg were 134/85 mm Hg, 130/81 mm Hg, and 123/73 mm Hg, respectively. The outcome-derived thresholds for daytime, 24-hour, and nighttime SBP corresponding to a clinic SBP ≥140 mm Hg were 138 mm Hg, 134 mm Hg, and 129 mm Hg, respectively. Among participants taking antihypertensive medication, the regression-derived thresholds for daytime, 24-hour, and nighttime SBP/DBP corresponding to clinic SBP/DBP of 140/90 mm Hg were 135/85 mm Hg, 133/82 mm Hg, and 128/76 mm Hg, respectively. The corresponding outcome-derived thresholds for daytime, 24-hour, and nighttime SBP were 140 mm Hg, 137 mm Hg, and 133 mm Hg, respectively, among those taking antihypertensive medication. CONCLUSIONS: On the basis of the outcome-derived approach for SBP and regression-derived approach for DBP, the following definitions for daytime, 24-hour, and nighttime hypertension corresponding to clinic SBP/DBP ≥140/90 mm Hg are proposed for African American adults: daytime SBP/DBP ≥140/85 mm Hg, 24-hour SBP/DBP ≥135/80 mm Hg, and nighttime SBP/DBP ≥130/75 mm Hg, respectively.

A Patient-Held Smartcard With a Unique Identifier and an mHealth Platform to Improve the Availability of Prenatal Test Results in Rural Nigeria: Demonstration Study.

BACKGROUND: Community-based strategies to test for HIV, hepatitis B virus (HBV), and sickle cell disease (SCD) have expanded opportunities to increase the proportion of pregnant women who are aware of their diagnosis. In order to use this information to implement evidence-based interventions, these results have to be available to skilled health providers at the point of delivery. Most electronic health platforms are dependent on the availability of reliable Internet connectivity and, thus, have limited use in many rural and resource-limited settings. OBJECTIVE: Here we describe our work on the development and deployment of an integrated mHealth platform that is able to capture medical information, including test results, and encrypt it into a patient-held smartcard that can be read at the point of delivery without the need for an Internet connection. METHODS: We engaged a team of implementation scientists, public health experts, and information technology specialists in a requirement-gathering process to inform the design of a prototype for a platform that uses smartcard technology, database deployment, and mobile phone app development. Key design decisions focused on usability, scalability, and security. RESULTS: We successfully designed an integrated mHealth platform and deployed it in 4 health facilities across Benue State, Nigeria. We developed the Vitira Health platform to store test results of HIV, HBV, and SCD in a database, and securely encrypt the results on a Quick Response code embedded on a smartcard. We used a mobile app to read the contents on the smartcard without the need for Internet connectivity. CONCLUSIONS: Our findings indicate that it is possible to develop a patient-held smartcard and an mHealth platform that contains vital health information that can be read at the point of delivery using a mobile phone-based app without an Internet connection. TRIAL REGISTRATION: ClinicalTrials.gov NCT03027258; https://clinicaltrials.gov/ct2/show/NCT03027258 (Archived by WebCite at http://www.webcitation.org/6owR2D0kE).

Evaluation of Physician Prescribing Patterns For Antibiotics in the Treatment of Nonnecrotizing Skin and Soft Tissue Infections.

PURPOSE: Skin and soft tissue infections (SSTIs) cause about 15 million cases of infection that result in more than 869,000 annual hospitalizations in the United States. Cellulitis accounted for 63% of all patients hospitalized with SSTIs between 2009 and 2011. The primary objective of this study was to evaluate physician adherence rates to evidence-based practice guidelines. Secondary objectives included evaluating antibiotic selection preferences and duration of therapy. The goal of the project was to generate data to inform the development of a hospital-based protocol for nonnecrotizing SSTI treatment. METHODS: This study was a single-center, retrospective, electronic chart review of patients admitted to the hospital for nonnecrotizing SSTI. We reviewed charts of patients who were admitted with a diagnosis of cellulitis and abscess infection from August 2014 to August 2015. RESULTS: Vancomycin, piperacillin/tazobactam, and clindamycin were the initial empiric antibiotics used most frequently. The adherence rates to guideline-recommended empiric antibiotic therapy and duration of treatment were about 40% and 70%, respectively. The median duration of antibiotic therapy was 12 days. Male gender and presence of purulent discharge as independent variables led to poor adherence to guideline-recommended empiric antibiotic therapy (male versus female gender, 35% versus 50.8%; P = 0.045; purulent discharge [yes versus no], 23.9% versus 60.4%; P < 0.0001). CONCLUSIONS: The results showed substantial noncompliance with guideline recommendations on empiric antibiotic selection for the treatment of nonnecrotizing SSTIs. There is a substantial opportunity for clinical pharmacist intervention in ensuring the efficient utilization of hospital resources to improve guideline compliance; promote appropriate antibiotic selection; reduce unnecessary antibiotic exposure; and reduce cost of hospitalization.

Differential increase in prevalence estimates of inadequate sleep among black and white Americans.

BACKGROUND: The National Health Interview Survey (NHIS) was used to ascertain whether increases in inadequate sleep differentially affected black and white Americans. We tested the hypothesis that prevalence estimates of inadequate sleep were consistently greater among blacks, and that temporal changes have affected these two strata differentially. METHODS: NHIS is an ongoing cross-sectional study of non-institutionalized US adults (≥18 years) providing socio-demographic, health risk, and medical factors. Sleep duration was coded as very short sleep [VSS] (<5 h), short sleep [SS] (5-6 h), or long sleep [LS] (>8 h), referenced to 7-8 h sleepers. Analyses adjusted for NHIS' complex sampling design using SAS-callable SUDAAN. RESULTS: Among whites, the prevalence of VSS increased by 53% (1.5% to 2.3%) from 1977 to 2009 and the prevalence of SS increased by 32% (19.3% to 25.4 %); prevalence of LS decreased by 30% (11.2% to 7.8%). Among blacks, the prevalence of VSS increased by 21% (3.3% to 4.0%) and the prevalence of SS increased by 37% (24.6 % to 33.7%); prevalence of LS decreased by 42% (16.1% to 9.4%). Adjusted multinomial regression analysis showed that odds of reporting inadequate sleep for whites were: VSS (OR = 1.40, 95% CI = 1.13-1.74, p < 0.001), SS (OR = 1.34, 95 % CI = 1.25-1.44, p < 0.001), and LS (OR = 0.94, 95% CI = 0.85-1.05, NS). For blacks, estimates were: VSS (OR = 0.83, 95% CI = 0.60-1.40, NS), SS (OR = 1.21, 95% CI = 1.05-1.50, p < 0.001), and LS (OR = 0.84, 95% CI = 0.64-1.08, NS). CONCLUSIONS: Blacks and whites are characteristically different regarding the prevalence of inadequate sleep over the years. Temporal changes in estimates of inadequate sleep seem dependent upon individuals' race/ethnicity.

Tipping the scales on obesity: church-based health promotion for African American women.

Research suggests that over 80% of U.S. adult African American (AA) women are at risk for hypertension, cardiovascular disease, and diabetes. In 2011-2012, 56.6% of non-Hispanic Black women were obese (BMI ≥ 30 kg/m2). Project TEACH--Transforming, Empowering, and Affecting Congregation Health was designed to determine the effectiveness of a faith-based, culturally competent, nutrition and exercise program targeting AA women in a church setting.

Gene-environment interaction between SCN5A-1103Y and hypokalemia influences QT interval prolongation in African Americans: the Jackson Heart Study.

BACKGROUND: African-American ancestry, hypokalemia, and QT interval prolongation on the electrocardiogram are all risk factors for sudden cardiac death (SCD), but their interactions remain to be characterized. SCN5A-1103Y is a common missense variant, of African ancestry, of the cardiac sodium channel gene. SCN5A-1103Y is known to interact with QT-prolonging factors to promote ventricular arrhythmias in persons at high risk for SCD, but its clinical impact in the general African-American population has not been established. METHODS: We genotyped SCN5A-S1103Y in 4,476 participants of the Jackson Heart Study, a population-based cohort of African Americans. We investigated the effect of SCN5A-1103Y, including interaction with hypokalemia, on QT interval prolongation, a widely-used indicator of prolonged myocardial repolarization and predisposition to SCD. We then evaluated the two sub-components of the QT interval: QRS duration and JT interval. RESULTS: The carrier frequency for SCN5A-1103Y was 15.4%. SCN5A-1103Y was associated with QT interval prolongation (2.7 milliseconds; P < .001) and potentiated the effect of hypokalemia on QT interval prolongation (14.6 milliseconds; P = .02). SCN5A-1103Y had opposing effects on the two sub-components of the QT interval, with shortening of QRS duration (-1.5 milliseconds; P = .001) and prolongation of the JT interval (3.4 milliseconds; P < .001). Hypokalemia was associated with diuretic use (78%; P < .001). CONCLUSIONS: SCN5A-1103Y potentiates the effect of hypokalemia on prolonging myocardial repolarization in the general African-American population. These findings have clinical implications for modification of QT prolonging factors, such as hypokalemia, in the 15% of African Americans who are carriers of SCN5A-1103Y.

Predictors of racial differences in weight loss: the PROPEL trial.

OBJECTIVE: Studies have consistently shown that African American individuals lose less weight in response to behavioral interventions, but the mechanisms leading to this result have been understudied. METHODS: Data were derived from the PROmoting Successful Weight Loss in Primary CarE in Louisiana (PROPEL) study, which was a cluster-randomized, two-arm trial conducted in primary care clinics. In the PROPEL trial, African American individuals lost less weight compared with patients who belonged to other racial groups after 24 months. In the current study, counterfactual mediation analyses among 445 patients in the intervention arm of PROPEL were used to determine which variables mediated the relationship between race and weight loss. The mediators included treatment engagement, psychosocial, and lifestyle factors. RESULTS: At 6 months, daily weighing mediated 33% (p = 0.008) of the racial differences in weight loss. At 24 months, session attendance and daily weighing mediated 35% (p = 0.027) and 66% (p = 0.005) of the racial differences in weight loss, respectively. None of the psychosocial or lifestyle variables mediated the race-weight loss association. CONCLUSIONS: Strategies specifically targeting engagement, such as improving session attendance and self-weighing behaviors, among African American individuals are needed to support more equitable weight losses over extended time periods.

Medication adherence and blood pressure control: A preliminary assessment of the role of health insurance in Nigeria and Ghana.

Objectives: This study sought to assess the current impact of health insurance coverage on medication adherence and blood pressure control of patients being managed for hypertension in Ghana and Nigeria. Methods: The study was a prospective study among 109 patients with hypertension in two health facilities with similar population dynamics in Ghana and Nigeria. Patients were systematically selected, categorized as having health insurance coverage or not, and followed up monthly for 6 months. The outcome variables (medication adherence and blood pressure control) were then measured and compared at 6 months. Analysis was done using Stata with level of significance set at p ⩽ 0.05. Results: There was a 90% insurance coverage among participants from Ghana compared to 15% from Nigeria. National Health Insurance Authority enrolees in both countries had better blood pressure control and medication adherence compared to non-enrolees (adjusted odds ratio = 2.6 and 4.5, respectively). Conclusion: National Health Insurance Authority enrolment was found to be poor among respondents in Nigeria compared to Ghana. Enrolment into the National health financing schemes in both countries led to better blood pressure control and medication adherence among patients with hypertension at primary health facilities. There is therefore the need for system strengthening to improve their sustainability.

Clinical trial participation among underserved communities: Insights from the Louisiana Community Engagement Alliance.

BACKGROUND: Diverse, equitable and inclusive participation in clinical research is needed to ensure evidence-based clinical practice and lessen disparities in health outcomes. Yet, clinical trial participation remains critically low in minoritized communities, particularly among Blacks. The Louisiana Community Engagement Alliance against COVID-19 Disparities (LA-CEAL) was launched in response to the disproportionate impact of COVID-19 on Black Louisianans to understand community barriers and preferences and increase inclusive participation in research. This study aims to understand perceptions regarding COVID-19 trial participation among underrepresented Louisianans. METHODS: A rapid assessment integrating cross-sectional, surveys among federally qualified health center (FQHC) patients and community residents, and focus group discussions (FGDs) from community representatives was conducted in 2020-2021. Factors and perceptions underlying trial participation were identified using logistic regression models and thematic analyses, respectively. RESULTS: Quantitative findings (FQHC: N=908, mean age=46.6 years, 66.4% Black; community: N=504, mean age=54.2 years, 93.7% Black) indicated that 0.9% and 3.6%, respectively, ever participated in a COVID-19 trial. Doctors/Healthcare providers were most trusted (FQHC=55.1%; community=59.3%) sources of information about trials. Advancing age was associated with increased odds of being very willing to participate (ORFQHC=1.03, 95% CI 1.02-1.05; ORCommunity=1.02, 95% CI 1.00-1.04). Qualitative data (6 FGDs, 29 attendees) revealed limited awareness, experimentation/exploitation-based fears, and minimal racial/ethnic representation among trialists as barriers to participation. CONCLUSION: COVID-19 trial participation rates were low in our sample. Altruism was a key facilitator to participation; fear, mistrust, and low awareness were predominant barriers. Community-centered approaches, engaging informed providers and trusted community members, may facilitate inclusive trial participation.

The effect of mobile health technology on blood pressure control among patients with hypertension in Ghana and Nigeria.

Background: More than half of patients with hypertension in sub-Saharan African do not achieve blood pressure control. This study determined the effect of mobile health technology on systolic blood pressure reduction and blood pressure (BP) control among patients with hypertension in Nigeria and Ghana. Methods: A randomised control trial of 225 adults with hypertension attending two General/Medical Outpatient Clinics each in Nigeria and Ghana was randomized into intervention (n = 116) and control (n = 109) arm respectively. Patients in the intervention arm received messages twice weekly from a mobile app for six months in addition to the usual care while the control arm received usual care only. The study outcomes were systolic blood pressure (SBP) reduction and blood pressure control at six months, while the secondary outcome was medication adherence at six months. Data were collected at 0 and 6 months, it was analysed using SPSS-21 software at a significance level of p < 0.05. Binary logistic regression was used to generate the predictors of good blood pressure control. Results: The mean age for the control and intervention were 60.2 ± 13.5 and 62.6 ± 10.8 years respectively; p-value = 0.300. The intervention group had greater reductions in SBP (-18.7mmHg vs -3.9mmHg; p < 0.001) and greater BP control rate (44.3% vs 24.8%; p-value 0.002). Conclusions: The mobile health intervention resulted in significant SBP reduction rate and improvement in BP control rate in the 6th month. However, improvement in adherence level in the 3rd month and was not sustained in the 6th month. The addition of mobile health technology may be extended for use in the national hypertension control plan. Female gender, formal education and being in the intervention arm were predictors of blood pressure control.

Fine mapping of the association with obesity at the FTO locus in African-derived populations.

Genome-wide association studies have identified many common genetic variants that are associated with polygenic traits, and have typically been performed with individuals of recent European ancestry. In these populations, many common variants are tightly correlated, with the perfect or near-perfect proxies for the functional or true variant showing equivalent evidence of association, considerably limiting the resolution of fine mapping. Populations with recent African ancestry often have less extensive and/or different patterns of linkage disequilibrium (LD), and have been proposed to be useful in fine-mapping studies. Here, we strongly replicate and fine map in populations of predominantly African ancestry the association between variation at the FTO locus and body mass index (BMI) that is well established in populations of European ancestry. We genotyped single nucleotide polymorphisms that are correlated with the signal of association in individuals of European ancestry but that have varying degrees of correlation in African-derived individuals. Most of the variants, including one previously proposed as functionally important, have no significant association with BMI, but two variants, rs3751812 and rs9941349, show strong evidence of association (P = 2.58 x 10(-6) and 3.61 x 10(-6) in a meta-analysis of 9881 individuals). Thus, we have both strongly replicated this association in African-ancestry populations and narrowed the list of potentially causal variants to those that are correlated with rs3751812 and rs9941349 in African-derived populations. This study illustrates the potential of using populations with different LD patterns to fine map associations and helps pave the way for genetically guided functional studies at the FTO locus.

Social patterning of cumulative biological risk by education and income among African Americans.

OBJECTIVES: We examined the social patterning of cumulative dysregulation of multiple systems, or allostatic load, among African Americans adults. METHODS: We examined the cross-sectional associations of socioeconomic status (SES) with summary indices of allostatic load and neuroendocrine, metabolic, autonomic, and immune function components in 4048 Jackson Heart Study participants. RESULTS: Lower education and income were associated with higher allostatic load scores in African American adults. Patterns were most consistent for the metabolic and immune dimensions, less consistent for the autonomic dimension, and absent for the neuroendocrine dimension among African American women. Associations of SES with the global allostatic load score and the metabolic and immune domains persisted after adjustment for behavioral factors and were stronger for income than for education. There was some evidence that the neuroendocrine dimension was inversely associated with SES after behavioral adjustment in men, but the immune and autonomic components did not show clear dose-response trends, and we observed no associations for the metabolic component. CONCLUSIONS: Findings support our hypothesis that allostatic load is socially patterned in African American women, but this pattern is less consistent in African American men.

The associations of multiple dimensions of discrimination and abdominal fat in African American adults: the Jackson Heart Study.

BACKGROUND: Discrimination may be adversely associated with abdominal obesity, but few studies have examined associations with abdominal fat. PURPOSE: The purpose of this study was to examine whether discrimination was independently associated with visceral (VAT) and subcutaneous (SAT) fat and whether these associations differed by sex and age. METHODS: Participants self-reported experiences of everyday and lifetime discrimination. The main reason for and the coping response to these experiences were also reported. VAT and SAT were quantified by computed tomography. RESULTS: In fully adjusted models, higher reports of everyday discrimination were associated with greater SAT, but not VAT, volumes in men only: SAT increased by 3.6 (standard error = 1.8) cm(3) for each unit increase in the everyday discrimination score. In women, higher reports of lifetime non-racial discrimination were associated with greater VAT (71.6 ± 32.0, P < 0.05) and SAT (212.6 ± 83.6, P < 0.05), but these relationships were attenuated after controlling for body mass index. CONCLUSIONS: These cross-sectional findings do not fully support the independent hypothesis of discrimination and abdominal fat. Additional investigations involving longitudinal designs are warranted.

A1C Reduction in Patients Who Declined Pharmacist-Led Diabetes Management Services.

INTRODUCTION: The purpose of this research is to assess the mean change in A1C associated with patients who declined a pharmacy-led diabetes management program and to evaluate effects of predictor variables on the odds of achieving improved A1C in these patients. STUDY DESIGN: Retrospective, single-center, single-group, cohort study. METHODS: Patients 18 years or older with uncontrolled type 2 diabetes (defined as A1C ≥ 9%) who declined pharmacy-led diabetes management services were included in the study. The primary outcome of the study was to assess the mean change in A1C from time of phone call offering pharmacy management services (initial) to last observed A1C (final recorded A1C). RESULTS: A total of 91 patients were included, 46 males and 45 females. The significant reduction in the mean change from baseline A1C to the final measured A1C was -0.59 (95% CI, -0.9327% to -0.2447%, P-value = 0.0010). This resulted in 8.79% of patients' final A1C falling into the range of < 7%. CONCLUSION: Our study found a paradoxical reduction in A1C among patients who declined pharmacy-led diabetes management services, however, our study is limited by having no comparison group. Further research needs to be conducted to identify correlations between characteristics of patients declining diabetes management services in order to assist with identifying patient-specific methods for improving patient outcomes.

Research Infrastructure Core Facilities at Research Centers in Minority Institutions: Part I-Research Resources Management, Operation, and Best Practices.

Funded by the National Institutes of Health (NIH), the Research Centers in Minority Institutions (RCMI) Program fosters the development and implementation of innovative research aimed at improving minority health and reducing or eliminating health disparities. Currently, there are 21 RCMI Specialized (U54) Centers that share the same framework, comprising four required core components, namely the Administrative, Research Infrastructure, Investigator Development, and Community Engagement Cores. The Research Infrastructure Core (RIC) is fundamentally important for biomedical and health disparities research as a critical function domain. This paper aims to assess the research resources and services provided and evaluate the best practices in research resources management and networking across the RCMI Consortium. We conducted a REDCap-based survey and collected responses from 57 RIC Directors and Co-Directors from 98 core leaders. Our findings indicated that the RIC facilities across the 21 RCMI Centers provide access to major research equipment and are managed by experienced faculty and staff who provide expert consultative and technical services. However, several impediments to RIC facilities operation and management have been identified, and these are currently being addressed through implementation of cost-effective strategies and best practices of laboratory management and operation.

Geographic representation of the jackson heart study cohort to the African-American population in Jackson, Mississippi.

Recent advances in geographic information systems software and multilevel methodology provide opportunities for more extensive characterization of "at-risk" populations in epidemiologic studies. The authors used age-restricted, geocoded data from the all-African-American Jackson Heart Study (JHS), 2000-2004, to demonstrate a novel use of the Lorenz curve and Gini coefficient to determine the representativeness of the JHS cohort to the African-American population in a geographic setting. The authors also used a spatial binomial model to assess the geographic variability in participant recruitment across the Jackson, Mississippi, Metropolitan Statistical Area. The overall Gini coefficient, an equality measure that ranges from 0 (perfect equality) to 1 (perfect inequality), was 0.37 (95% confidence interval (CI): 0.30, 0.45), indicating moderate representation. The population of sampled women (Gini coefficient = 0.34, 95% CI: 0.30, 0.39) tended to be more representative of the underlying population than did the population of sampled men (Gini coefficient = 0.49, 95% CI: 0.35, 0.61). Representative recruitment of JHS participants was observed in predominantly African-American and mixed-race census tracts and in the center of the study area, the area nearest the examination clinic. This is of critical importance as the authors continue to explore novel approaches to investigate the geographic variation in disease etiology.