Validating Constructs of the Depression, Anxiety, and Stress Scale-21 and Exploring Health Indicators to Predict the Psychological Outcomes of Students Enrolled in the Pacific Islands Cohort of College Students.

The Depression, Anxiety, and Stress Scale-21 (DASS-21) has been used in various countries to assess the mental states of individuals. The objectives of this study were to validate the DASS-21 for use in Guam, an island that endures a high burden of mental health challenges, such as suicide, and examine the predictive impact of selected health indicators on DASS-21 variables. Three years of data (2017-2019) were pooled from the Pacific Islands Cohort of College Students (PICCS) study conducted annually at the University of Guam. In total, 726 students were included in the secondary data analysis. MPlus statistical software was used to perform a confirmatory factor analysis (CFA) for the validation and structural equation modeling (SEM) for the predictive modeling. The results from the CFA suggested an acceptable model fit (RMSEA: 0.073, CFI: 0.901, TLI: 0.889, RMR: 0.044), while SEM suggested that sleep quality and physical activity were significant predictors of DASS-21 variables. Therefore, the DASS-21 is a valid instrument for measuring depression, anxiety, and stress among emerging adults in Guam.

Building capacity to conduct genetic epidemiology research on hyperuricaemia and gout in an Indigenous community in Guam.

Background: Gout, the most common inflammatory arthritis disease, and hyperuricaemia onset are influenced by environmental and genetic factors. We sought to investigate these factors in an Indigenous community in Guam. Methods: In this cross-sectional study, the University of Guam led the qualitative inquiry with the native community, training (pre-screening of participants, data collection methods, and biospecimen handling), study implementation (outreach and recruitment, data collection, and DNA extraction and quantification), and qualitative and epidemiologic data analyses. Recruitment targets were based on demographic representation in current census data. The University of Otago collaborated on ethics guidance, working with Indigenous communities, and led the genetic sequencing and genetic data analysis. Participants were recruited in Guam from Fall 2019 to Spring 2022. Results: Of the 359 participants, most self-identified as Native CHamorus (61.6%) followed by Other Micronesians (22.0%), and Filipinos (15.6%). The prevalence of metabolic conditions from highest to lowest were obesity (55.6%), hyperuricaemia (36.0%), hypertension (27.8%), gout (23.0%), diabetes (14.9%), cardiovascular disease (8.4%), kidney disease (7.3%), and liver disease (3.4%). Compared to Filipinos and Other Micronesians, significantly more CHamorus had hyperuricaemia (42.1% versus 26.8% in Filipinos and 25.3% in Other Micronesians), gout (28.5% versus 21.4% and 8.9%), diabetes (19.5% versus 8.9% and 6.3%), and hypertension (33.9% versus 19.6% and 16.5%). Conclusions: We estimated the prevalence of metabolic conditions, especially gout and hyperuricaemia, and found statistical differences among major ethnic groups in Guam, all while obtaining the Indigenous community's feedback on the genetic study and building gout research capacity. The results of ongoing genetic sequencing will be used to understand molecular causes of gout in Guam.

Facilitator experiences and lessons learned from the Betel nut intervention trial (BENIT).

BACKGROUND: The Betel Nut Intervention Trial (BENIT; ClinicalTrials.gov - NCT02942745) is the first known randomized intervention trial specifically designed for areca nut chewers in the western Pacific region who want to quit. The current study is a separate, exploratory study that examined the experiences of the BENIT facilitators during its implementation in Guam and Saipan of the Northern Mariana Islands and the extent to which the BENIT protocol was adapted to meet the participants' and facilitators' needs. METHODS: All six BENIT program facilitators completed an online survey consisting of quantitative (Likert scale) and qualitative (open-ended) questions. Survey items were grouped as follows: facilitator demographics, prior training and preparation, BENIT experience, beliefs about the program's effectiveness, and beliefs about protocol adaptations. RESULTS: Most of the facilitators felt prepared to deliver the BENIT program after several weeks of moderately intensive training. Facilitators felt the BENIT program was generally effective and that the "trigger logs" and "self-monitoring logs" worked as intended. However, they also noted that more time and support would have been helpful to overcome some of the obstacles inherent to implementing a novel program. CONCLUSION: The current findings can be used to inform, modify, and tailor subsequent areca nut cessation programs in Micronesian communities and to improve future versions of BENIT.

The Betel Nut Intervention Trial (BENIT)-A Randomized Clinical Trial for Areca Nut and Betel Quid Cessation: Primary Outcomes.

BACKGROUND: Areca nut and betel quid (ANBQ) chewing is a widespread carcinogenic habit. The BENIT (ClinicalTrials-NCT02942745) is the first known randomized trial designed for ANBQ chewers. METHODS: We compared the intensive behavioral treatment intervention condition (IC) with the control condition (CC) in the BENIT and included a 5-stage early stopping rule. We report the primary analysis at stage 3. English-literate adults in Guam and Saipan who self-identified as ANBQ chewers with tobacco were enrolled between August 2016 and August 2020. IC participants (n = 88) received five in-person sessions over 22 days and a brochure containing quitting advice. CC participants (n = 88) received only the brochure. Participants were assessed at baseline and on day 22 of follow-up. Self-reported chewing status at day 22 was determined by a composite of two survey items with disparate wording and response options for cross-verification. RESULTS: Cessation rates were 38.6% (IC) and 9.1% (CC). Proportional hazards regression revealed a p = 0.0058, which met the Stage 3 criteria for significance, and an estimated reduction in ANBQ chewing for IC compared to the CC of 71% (95% CI: 41%-88%). CONCLUSIONS: Robust self-reported intervention effects at day 22 suggest that intensive cessation programs such as BENIT should be further developed and implemented on a larger scale.

Salivary Areca and tobacco alkaloids for bioverification in the Betel Nut Intervention Trial.

BACKGROUND: The Betel Nut Intervention Trial (BENIT) is the first known randomized controlled intervention trial designed to help minority Pacific Islanders in Guam and Saipan quit chewing the carcinogenic Areca catechu nut (AN). We report the BENIT's saliva bioverification results against the self-reported chewing status ("quitter" or "chewer") at day 22 follow-up. MATERIAL AND METHODS: AN-specific (arecoline, arecaidine, guvacoline, and guvacine) and tobacco-specific (nicotine, cotinine, and hydroxycotinine) alkaloids were analyzed in saliva from 176 BENIT participants by an established and sensitive liquid chromatography mass spectrometry-based assay. RESULTS: The combined four AN alkaloid levels decreased from baseline in quitters (n = 50) and chewers (n = 108) by 32% and 9%, respectively. In quitters, decreases were significant for arecoline (p = 0.044)-the most prominent AN alkaloid, along with arecaidine (p = 0.042) and nicotine (p = 0.011). In chewers, decreases were significant only for hydroxycotinine (p = 0.004). Similar results were obtained when quitters and chewers were stratified by treatment arm. DISCUSSION: Salivary AN alkaloid levels generally agreed with self-reported chewing status, which suggests the former can be used to verify the latter. CONCLUSION: Our results can help to objectively evaluate compliance and program effectiveness in AN cessation programs.

Knowledge and Attitudes of Guam Residents towards Cancer Clinical Trial Participation.

(1) Background: Currently there are no cancer clinical trials in Guam, where CHamoru people suffer the highest rates of cancer mortality, and interest to do so is growing. This study investigated the knowledge and attitudes of Guam residents towards cancer clinical trial participation prior to implementation. (2) Methods: A telephone survey was developed, tested, and conducted among Guam resident adults, 18 years of age and older. Survey questions were summarized by descriptive statistics. Logistic regression models were used to investigate the associations between Guam residents' demographics and their clinical trial knowledge and attitudes. Adjusted odds ratios (aOR) and associated 95% confidence intervals (CI) were calculated. (3) Results: One hundred fifty-two people participated in the survey, most of whom were CHamoru (47.0%). Fifty-three percent had heard the term 'clinical trial'; 73.7% would take part in a trial if they had cancer; and 59.9% believed they would receive good quality treatment from a trial offered in Guam. CHamoru were more likely than Whites to associate out-of-pocket expenses with clinical trial participation (aOR = 5.34, 95% CI = 1.68-17.00). Physician ethnicity was important to 30% of non-Whites and significantly associated with those who spoke a language other than English (aOR = 3.40, 95% CI = 1.29-8.95). Most people (65.0%) did not believe clinical trials participants were 'guinea pigs'. (4) Conclusion: Though knowledge about cancer clinical trials is limited, attitudes were primarily positive towards participating in cancer clinical trials offered in Guam. Future delivery of cancer clinical trials will benefit from identifying potential barriers to recruitment and adopting an approach suited to Guam's population.

Development and evaluation of an undergraduate curriculum on non-communicable disease research in Guam: The Pacific Islands Cohort of College Students (PICCS).

BACKGROUND: The non-communicable disease (NCD) epidemic among Pacific Islanders prompted the declaration of a regional state of NCD emergency throughout the United States-Affiliated Pacific Islands (USAPIs) in 2010. Subsequently, the University of Guam Health Science Program launched a pilot study on NCD research in its undergraduate curriculum modeled after the Pacific Data for Decision Making (DDM) framework - a field epidemiology training program employed in the USAPIs. The primary objective of the research is to conduct annual assessments of student health indicators with plans for longitudinal follow-up. Here, development and evaluation of the undergraduate research curriculum are described. METHODS: The Pacific DDM framework covering knowledge and skills in resourcing, types of data and indicators, data sources, data management, information products, and data dissemination and use were incorporated in undergraduate core courses of the Health Science Program. During the data collection pilot years, 2013 and 2014, a survey containing questions predominantly on NCD risk factors was launched at the university. The survey was administered by upperclassmen in the Health Science Program and evolved into the Pacific Islands Cohort of College Students (PICCS) research study. The initial years were spent developing the infrastructure. Program outputs were tracked annually to measure program success. RESULTS: Students in the Health Science Program obtained research knowledge and skills through various courses while enrolled in the program. The PICCS data collection continued annually as a cross-sectional survey from 2015 to current. Numerous successes have resulted including student abstracts and publications, acceptances to summer programs and fellowships, a sustained annual health fair for college students, a grant award, and other program-related impacts. CONCLUSION: The PICCS framework provided the organizational structure and documented tools, protocols, roles, and responsibilities to enhance consistency and reproducibility. Undergraduate students applied their knowledge and skills to an ongoing study focused on NCD risk factor surveillance of college students. Additionally, multiple research successes have been achieved through the PICCS curriculum. Plans are underway to begin the longitudinal design of the PICCS research study and sustain it through the curriculum, with room for adaptation as courses are updated over time.

Prevalence and Predictors of Overweight and Obesity among Young Children in the Children's Healthy Living Study on Guam.

This study is part of the Children's Healthy Living program in U.S. Affiliated Pacific region. The objectives were to estimate overweight and obesity (OWOB) prevalence and identify possible related risk factors among ethnic groups in Guam. In 2013, 865 children (2-8 years) were recruited via community-based sampling from select communities in Guam. Children's demographic and health behavior information; dietary intake; and anthropometric measurements were collected. Logistic regression, odds ratio, t-tests, and chi-square tests were used to determine differences and assess covariates of OWOB. The results indicate that 58% of children were living below the poverty level, 80% were receiving food assistance, and 51% experienced food insecurity. The majority of children surveyed did not meet recommendations for: sleep duration (59.6%), sedentary screen-time (83.11%), or fruit (58.7%) and vegetable (99.1%) intake, and consumed sugar sweetened beverages (SSB) (73.7%). OWOB affected 27.4% of children. Children affected by OWOB in this study were statistically more likely (p = 0.042) to suffer from sleep disturbances (p = 0.042) and consume marginally higher amounts (p value = 0.07) of SSB compared to children with healthy weight. Among Other Micronesians, children from families who considered themselves 'integrated' into the culture were 2.05 (CI 0.81-5.20) times more likely to be affected by OWOB. In conclusion, the OWOB prevalence among 2-8-year-olds in Guam was 27.4%; and compared with healthy weight children, children with OWOB were more likely to have educated caregivers and consume more SSBs. Results provide a basis for health promotion and obesity prevention guidance for children in Guam.

Smoking, Nutrition, Alcohol, Physical Activity, and Obesity (SNAPO) Health Indicators Among College Students in Guam.

Background/Purpose: The Guam Non-Communicable Disease (NCD) Consortium developed action teams as part of their strategic plan to reduce the risk of NCDs. Smoking, Nutrition, Alcohol, Physical Activity, and Obesity (SNAPO) health indicators were targeted. The primary objective of this study was to describe SNAPO among students at the University of Guam. Methods: A cross-sectional study was conducted from September to December 2015 on a non-random sample of students (n=378; 185 males, 193 females) ≥18 years old attending the University of Guam. Information on SNAPO indicators (smoking/tobacco-related uses, poor nutritional behaviors, alcohol use, physical inactivity, and obesity) were collected using questions from the Guam Behavioral Risk Factor Surveillance System and other local studies. Statistical tests were used to determine sex-specific differences. Results: The overall prevalence of SNAPO health indicators included cigarette smoking (9.1%), smokeless tobacco use (6.7%), areca nut chewing (7.5%), alcohol consumption (44.3%) and binge drinking (24.6%), physical inactivity (54.5%), infrequent fruit (77.5%) and vegetable (68.0%) consumption, frequent fast food consumption (31.5%), inadequate water intake (89.1%) and obesity (22.6%). Sex-specific statistical differences were marginal for cigarette smoking and smokeless tobacco use and significant for physical inactivity and obesity. Conclusion: The SNAPO health indicators provide an updated status of substance use and obesity-related risk factors of college students in Guam. Continued collection of the data is encouraged to inform campus-wide policies or programs that promote student health, monitor student health trends, and evaluate the Guam NCD Strategic Plan over time.

Rationale and design of a randomized, controlled, superiority trial on areca nut/betel quid cessation: The Betel Nut Intervention Trial (BENIT).

BACKGROUND: Areca nut (AN) is the seed endosperm of the Areca catechu L. palm and a Group 1 carcinogen chewed by 10-20% of the world population. AN is often chewed with Piper betle L. leaf, slaked lime, and tobacco to form a betel quid (BQ). The negative health effects associated with AN/BQ consumption warrant the need for an evidence-based cessation program. However, systematic research on AN/BQ cessation is rare. METHODS/DESIGN: The Betel Nut Intervention Trial (BENIT; trial #NCT02942745) is a randomized controlled trial designed to test the efficacy of an intensive AN/BQ cessation program. The trial is ongoing in Guam and Saipan with adult chewers who include tobacco in their BQ. Enrolled participants are assessed for their primary (chewing status) and secondary (saliva bio-verification) outcome at baseline, 22 days, and 6 months. Participants randomized into the control arm receive an educational booklet while those randomized into the intervention arm receive the educational booklet and a 22-day cessation program modeled after a smoking cessation program and led by trained facilitators. Information on chewing behavior (history, reasons for chewing, and AN/BQ composition and dependency) are collected. The intervention effectiveness is assessed using the logistic mixed model to compare cessation status between randomization groups. DISCUSSION: AN/BQ chewing affects a large population of people, many of whom live in low and moderate income countries in the Asia-Pacific region. Although the BENIT focuses on chewers in Guam and Saipan, it has the potential for greater regional and global importance.

Barriers to Quitting Areca Nut Consumption and Joining a Cessation Program as Perceived by Chewer and Nonchewer Populations in Guam.

Background: Areca nut (AN) is a carcinogenic substance consumed by roughly 600 million individuals worldwide with increasing popularity in Guam. In response, a cessation program was developed and implemented in Guam and Saipan. However, to improve its delivery, it is necessary to understand the reasons influencing recruitment and participation, such as why a chewer may not want to quit or join a cessation program. Objective: To explore barriers inhibiting chewers from quitting AN chewing and from participating in a cessation program. Methods: Nine individual and group discussions were facilitated with a convenience sample of 17 chewers and nonchewers in Guam in 2017. The mean age of the participants was 36.4 years. Recurring themes relating to reasons for not quitting and not joining a cessation program were extracted. Results: Results produced three general categories-Sociocultural, Behavioral, and Accessible. Each category encompasses different attributes concerning reasons not to quit chewing (e.g. addiction, enabling community, or belief that AN is harmless), and reasons influencing lack of participation in a cessation program (e.g. time, transportation, or relatability). Conclusions: Current findings suggest chewers are unaware of the harmful effects of AN. Also, they may not comprehend the purpose of a cessation program. In addition, the likelihood of chewers participating in a cessation program is influenced by their level of comfort with the program and personnel, and whether a program addresses their time and transportation limitations.

Areca (betel) nut chewing practices of adults and health behaviors of their children in the Freely Associated States, Micronesia: Findings from the Children's Healthy Living (CHL) Program.

BACKGROUND: Chewing areca (betel) nut has been deemed carcinogenic. The practice has become a public health concern in Micronesia. The Children's Healthy Living (CHL) Program included an areca (betel) nut questionnaire in a survey of household characteristics in the Freely Associated States (FAS). This paper describes areca (betel) nut chewing practices of adults and the health behaviors of their children. METHODS: A cross-section of 1200 children (2-8 year-olds) and their caregivers in Chuuk, Kosrae, Pohnpei, Republic of Palau, Republic of the Marshall Islands (RMI), and Yap were recruited. Socio-demographics, adult areca (betel) nut chewing practices, and other health behaviors of children and adults were assessed. Child anthropometric measurements were collected to estimate weight status. RESULTS: The FAS areca (betel) nut chewing prevalence was 42%, ranging from 3% (RMI) to 94% (Yap). Among chewers, 84% added tobacco, 97% added slaked lime, 85% added betel leaf, and 24% mixed the components with alcohol. Among FAS children, 95% practiced daily teeth-brushing and 53% visited the dentist annually. Compared to non-chewing households, areca (betel) nut chewing households were more likely to have very young children enrolled, more highly educated adults, and members that used tobacco and alcohol. CONCLUSION: The FAS areca (betel) nut chewing prevalence (42%) is above the world prevalence of 10-20%, with wide variability across the islands. The oral health findings in this study may inform future oral cancer prevention programs or policies. Regular monitoring of areca (betel) nut use is needed to measure the impact of such programs or policies.

Epidemiology of areca (betel) nut use in the mariana islands: Findings from the University of Guam/University of Hawai`i cancer center partnership program.

BACKGROUND: Areca (betel) nut is considered a Group 1 human carcinogen shown to be associated with other chronic diseases in addition to cancer. This paper describes the areca (betel) nut chewing trend in Guam, and health behaviors of chewers in Guam and Saipan. METHODS: The areca (betel) nut module in the Guam Behavioral Risk Factor Surveillance Survey was used to calculate the 5-year (2011-2015) chewing trend. To assess the association between areca (betel) nut chewing and health risks in the Mariana Islands, a cross-section of 300 chewers, ≥18years old, were recruited from households in Guam and Saipan. Self-reported socio-demographics, oral health behaviors, chronic disease status, diet, and physical activity were collected. Anthropometry was measured. Only areca (betel) nut-specific and demographic information were collected from youth chewers in the household. RESULTS: The 5-year areca (betel) nut chewing prevalence in Guam was 11% and increased among Non-Chamorros, primarily other Micronesians, from 2011 (7%) to 2015 (13%). In the household survey, most adult chewers (46%) preferred areca nut with betel leaf, slaked lime, and tobacco. Most youth chewers (48%) preferred areca nut only. Common adult chronic conditions included diabetes (14%), hypertension (26%), and obesity (58%). CONCLUSION: The 5-year areca (betel) nut chewing prevalence in Guam is comparable to the world estimate (10-20%), though rising among Non-Chamorros. Adult and youth chewers may be at an increased risk for oral cancer. Adult chewers have an increased risk of other chronic health conditions. Cancer prevention and intervention strategies should incorporate all aspects of health.

Betel nut chewing, oral premalignant lesions, and the oral microbiome.

Oral cancers are attributed to a number of causal agents including tobacco, alcohol, human papillomavirus (HPV), and areca (betel) nut. Although betel nut chewing has been established as an independent cause of oral cancer, the mechanisms of carcinogenesis are poorly understood. An investigation was undertaken to evaluate the influence of betel nut chewing on the oral microbiome and oral premalignant lesions. Study participants were recruited from a dental clinic in Guam. Structured interviews and oral examinations were performed. Oral swabbing and saliva samples were evaluated by 454 pyrosequencing of the V3- V5 region of the 16S rRNA bacterial gene and genotyped for HPV. One hundred twenty-two adults were enrolled including 64 current betel nut chewers, 37 former chewers, and 21 with no history of betel nut use. Oral premalignant lesions, including leukoplakia and submucous fibrosis, were observed in 10 chewers. Within-sample bacterial diversity was significantly lower in long-term (≥10 years) chewers vs. never chewers and in current chewers with oral lesions vs. individuals without lesions. Between-sample bacterial diversity based on Unifrac distances significantly differed by chewing status and oral lesion status. Current chewers had significantly elevated levels of Streptococcus infantis and higher and lower levels of distinct taxa of the Actinomyces and Streptococcus genera. Long-term chewers had reduced levels of Parascardovia and Streptococcus. Chewers with oral lesions had significantly elevated levels of Oribacterium, Actinomyces, and Streptococcus, including Streptococcus anginosus. In multivariate analyses, controlling for smoking, oral HPV, S.anginosus, and S. infantis levels, current betel nut chewing remained the only predictor of oral premalignant lesions. Our study provides evidence that betel nut chewing alters the oral bacterial microbiome including that of chewers who develop oral premalignant lesions. Nonetheless, whether microbial changes are involved in betel nut-induced oral carcinogenesis is only speculative. Further research is needed to discern the clinical significance of an altered oral microbiome and the mechanisms of oral cancer development in betel nut chewers.

Anthropometric measurement standardization in the US-affiliated pacific: Report from the Children's Healthy Living Program.

OBJECTIVES: Anthropometric standardization is essential to obtain reliable and comparable data from different geographical regions. The purpose of this study is to describe anthropometric standardization procedures and findings from the Children's Healthy Living (CHL) Program, a study on childhood obesity in 11 jurisdictions in the US-Affiliated Pacific Region, including Alaska and Hawai'i. METHODS: Zerfas criteria were used to compare the measurement components (height, waist, and weight) between each trainee and a single expert anthropometrist. In addition, intra- and inter-rater technical error of measurement (TEM), coefficient of reliability, and average bias relative to the expert were computed. RESULTS: From September 2012 to December 2014, 79 trainees participated in at least 1 of 29 standardization sessions. A total of 49 trainees passed either standard or alternate Zerfas criteria and were qualified to assess all three measurements in the field. Standard Zerfas criteria were difficult to achieve: only 2 of 79 trainees passed at their first training session. Intra-rater TEM estimates for the 49 trainees compared well with the expert anthropometrist. Average biases were within acceptable limits of deviation from the expert. Coefficient of reliability was above 99% for all three anthropometric components. CONCLUSIONS: Standardization based on comparison with a single expert ensured the comparability of measurements from the 49 trainees who passed the criteria. The anthropometric standardization process and protocols followed by CHL resulted in 49 standardized field anthropometrists and have helped build capacity in the health workforce in the Pacific Region. Am. J. Hum. Biol. 28:364-371, 2016. © 2015 Wiley Periodicals, Inc.

Overweight and Obesity Prevalence among Public School Children in Guam.

BACKGROUND: The Government of Guam passed Public Law 28-87, which established the collection of child Body Mass Index (BMI) measurements in the Guam Department of Education (GDOE). This paper aimed to analyze the BMI data and report the childhood obesity prevalence on Guam. METHODS: Secondary analysis was performed on a repeated cross-section of 106,827 children in the GDOE from 2010 to 2014. Age- and sex-specific prevalence estimates and 95% Confidence Intervals (CI) by weight status were calculated for each year. Test for trends in the high weight status were performed. RESULTS: The childhood obesity prevalence was 23.1% (95% CI, 22.9%-23.4%). It declined from 23.6% (95% CI, 23.1%-24.1%) in 2010-2011 to 22.6% (95% CI, 22.1%-23.0%) in 2013-2014 (p=.007). CONCLUSION: Childhood obesity on Guam has declined, though it remains higher than the U.S. Mainland. Continued BMI data collection is needed to monitor childhood obesity and measure the impact of Public Law 28-87.

Screening for oral potentially malignant disorders among areca (betel) nut chewers in Guam and Saipan.

BACKGROUND: The Mariana Islands, including Guam and Saipan, are home to many ethnic subpopulations of Micronesia. Oral cancer incidence rates vary among subpopulations, and areca (betel) nut chewing, a habit with carcinogenic risks, is common. Our objectives were to conduct a screening program to detect oral potentially malignant disorders (OPMD) in betel nut chewers, measure their betel nut chewing practices, and assess the prevalence of the oral human papillomavirus (HPV) infection in a subset of betel nut chewers in these islands. METHODS: A cross-section of 300 betel nut chewers ≥18 years old [in Guam (n = 137) and in Saipan (n = 163)] were recruited between January 2011-June 2012. We collected demographic, socioeconomic, and oral behavioural characteristics. Latent class analysis was used to identify chewing patterns from selected chewing behaviours. Following calibration of OPMD against an expert, a registered oral hygienist conducted oral examinations by house to house visits and referred positive cases to the study dentist for a second oral examination. Buccal smears were collected from a subset (n = 123) for HPV testing. RESULTS: Two classes of betel nut chewers were identified on 7 betel nut behaviours, smoking, and alcohol use; a key difference between the two Classes was the addition of ingredients to the betel quid among those in Class 2. When compared on other characteristics, Class 1 chewers were older, had been chewing for more years, and chewed fewer nuts per day although chewing episodes lasted longer than Class 2 chewers. More Class 1 chewers visited the dentist regularly than Class 2 chewers. Of the 300 participants, 46 (15.3%; 3.8% for Class 1 and 19.4% for Class 2) had OPMD and one (0.3%) was confirmed to have squamous cell carcinoma. The prevalence of oral HPV was 5.7% (7/123), although none were high-risk types. CONCLUSIONS: We found two patterns of betel nut chewing behaviour; Class 2 had a higher frequency of OPMD. Additional epidemiologic research is needed to examine the relationship between pattern of chewing behaviours and oral cancer incidence. Based on risk stratification, oral screening in Guam and Saipan can be targeted to Class 2 chewers.

Women in Guam consume more calories during feast days than during non-feast days.

Parties (feast days) have become increasingly frequent and abundant, in terms of food, on the island of Guam. Considering the potential impact of this frequency and abundance on food intake, this study compared food intake during feast days and non-feast days of women in Guam (25 Chamorros; 24 Filipinas). The women (≥40 yr) recalled foods they usually consumed during feast days. Subsequently, a 24-hour dietary recall for a non-feast day was completed by a subsample (n=25). Height, weight, and waist circumference were measured to assess obesity status. Statistical analyses (paired t-test, ANOVA, and chi-square test) were performed with SPSS. Compared to a non-feast day, the women reported higher intakes of dietary energy (2645.0 ± 1125.8 versus 1654.0 ± 718.8 kcal/day), carbohydrates (43.8 ± 11.5% versus 51.8 ± 10.2% of kcal), total fat (34.1 ± 7.8% versus 27.5 ± 9.6% of kcal), saturated fat (11.4 ± 4.7% versus 7.9 ± 3.4% of kcal), and sugar (89.5 ± 62.8 versus 47.3 ± 42.2 g/day) on feast days. Chamorros, compared to Filipinas, reported higher dietary energy density (1.7 ± 0.4 versus 1.4 ± 0.3 kcal/g), total fat (35.3 ± 8.9% versus 30.7 ± 6.8% of kcal), and saturated fat (12.4 ± 4.9% versus 9.4 ± 3.3% of kcal); and lower servings of fruit (0.5 ± 1.0 versus 2.7 ± 1.8) on feast days. Fourteen Chamorros (56.0%) and one Filipina (4.1%) were classified as obese. Current feasting behaviors of women in Guam may contribute to obesity if continued for a long period. The women would benefit by choosing more fruit and vegetable dishes in place of high-energy dishes. Chamorro women would particularly benefit by reducing saturated fat intake. Traditional foods, such as taro, breadfruit, seafood, fruits, and vegetables, would help accomplish this and thus should be promoted at parties on Guam.

Areca (Betel) Nut Chewing Practices in Micronesian Populations.

OBJECTIVE: To describe the areca nut/betel quid chewing practices of Micronesian chewers living in Guam. DESIGN: Two studies were conducted using qualitative data from focus groups and quantitative cross-sectional data from the 2007 Guam Behavioral Risk Factor Surveillance System (BRFSS). Ten focus groups included 49 men and women aged 18-60 years living in Guam in 2007. Participants were areca nut/betel quid chewers selected to reflect Guam's age and ethnic group (Chamorro, Chuukese, Palauan, and Yapese) distributions. Salient themes were extracted from transcripts of the sessions by three expert reviewers. A second method, latent class analysis, was used to identify unique groups of chewers. The groups were then compared on demographics and chewing-related behaviors. RESULTS: Areca nut and betel quid recipes collected from the focus groups showed that Chamorros had a preference for the ripe nut and swallowed the nut, whereas, the Chuukese, Palauan, and Yapese groups preferred the unripe nut and did not swallow it. Similarly, latent class analysis resulted in the identification of two groups of areca nut/betel quid chewers. Group 1 was all Chamorros. Compared to Group 2, the chewers in Group 1 preferred red and ripe nuts, did not add slake lime (calcium hydroxide) or tobacco, and swallowed the masticated areca nut (with or without Piper betle leaf). CONCLUSION: The quantitative analysis confirmed the qualitative exploration of areca nut/betel quid chewers in Guam, thus providing evidence that chewing practices vary among Micronesian populations. IMPLICATION: If future research should include an intervention, the differences in chewing practices among Micronesian populations should be taken into consideration to ensure programmatic success.

Guam's influenza epidemic(s) of 2009.

OBJECTIVE: To characterize syndromic and laboratory surveillance for influenza on Guam during 2009, including the relation of cases to the timing of swine flu-related stories published in a local newspaper. METHODS: Data utilized in the study included clinical diagnoses of acute respiratory infection (ARI) in the Emergency Department log of Guam's only civilian hospital (syndromic surveillance) and laboratory confirmed cases of Influenza A (rapid test) and novel 2009 H1N1 influenza virus (RT-PCR subtyping) from both civilian and military sources. In addition, the number of "swine flu" stories appearing weekly in a local paper were tallied. RESULTS: What initially appeared to be an epidemic occurring in 2 distinct waves was shown to be separate epidemics of "seasonal flu" and "swine flu." There was a strong correlation between the timing of "swine flu" stories appearing in local media and the diagnosis of ARI. CONCLUSION: Syndromic surveillance is useful for the early detection of disease outbreaks but laboratory results may be necessary in order to gain a clear epidemiologic picture of a disease incident.