The role of the complement system in traumatic brain injury: a review.

Traumatic brain injury (TBI) is an important cause of disability and mortality in the western world. While the initial injury sustained results in damage, it is the subsequent secondary cascade that is thought to be the significant determinant of subsequent outcomes. The changes associated with the secondary injury do not become irreversible until some time after the start of the cascade. This may present a window of opportunity for therapeutic interventions aiming to improve outcomes subsequent to TBI. A prominent contributor to the secondary injury is a multifaceted inflammatory reaction. The complement system plays a notable role in this inflammatory reaction; however, it has often been overlooked in the context of TBI secondary injury. The complement system has homeostatic functions in the uninjured central nervous system (CNS), playing a part in neurodevelopment as well as having protective functions in the fully developed CNS, including protection from infection and inflammation. In the context of CNS injury, it can have a number of deleterious effects, evidence for which primarily comes not only from animal models but also, to a lesser extent, from human post-mortem studies. In stark contrast to this, complement may also promote neurogenesis and plasticity subsequent to CNS injury. This review aims to explore the role of the complement system in TBI secondary injury, by examining evidence from both clinical and animal studies. We examine whether specific complement activation pathways play more prominent roles in TBI than others. We also explore the potential role of complement in post-TBI neuroprotection and CNS repair/regeneration. Finally, we highlight the therapeutic potential of targeting the complement system in the context of TBI and point out certain areas on which future research is needed.

Correction to: the role of the complement system in traumatic brain injury: a review.

After publication of the article [1], it was brought to our attention that Tables 1 and 2 were missing from the final manuscript, These tables can be seen below and have now been added to the revised version of the article.

Members of Minority and Underserved Communities Set Priorities for Health Research.

Policy Points Engaging and involving underrepresented communities when setting research priorities could make the scientific research agenda more equitable, more just, and more responsive to their needs and values. Groups and individuals from minority and underserved communities strongly prioritized child health and mental health research, often choosing to invest at the highest possible level. Groups consisting of predominantly Native American or Arab American participants invested in culture and beliefs research at the highest level, while many groups did not select it at all. The priority given to culture and beliefs research by these groups illustrates the importance of paying special attention to unique preferences, and not just commonly held views, when getting public input on spending priorities for research. CONTEXT: A major contributor to health disparities is the relative lack of resources-including resources for science-allocated to address the health problems of those with disproportionately greater needs. Engaging and involving underrepresented communities in setting research priorities could make the scientific research agenda more equitable, more just, and more responsive to their needs and values. We engaged minority and underserved communities in informed deliberations and report here their priorities for health research. METHODS: Academic-community partnerships adapted the simulation exercise CHAT for setting health research priorities. We had participants from minority and medically underserved communities (47 groups, n = 519) throughout Michigan deliberate about health research priorities, and we used surveys and CHAT software to collect the demographic characteristics and priorities selected by individuals and groups. FINDINGS: The participants ranged in age (18 to 88), included more women than men, and were overrepresented by minority groups. Nearly all the deliberating groups selected child health and mental health research (93.6% and 95.7%), and most invested at the highest level. Aging, access, promote health, healthy environment, and what causes disease were also prioritized by groups. Research on mental health and child health were high priorities for individuals both before and after group deliberations. Access was the only category more likely to be selected by individuals after group deliberation (77.0 vs 84.0%, OR = 1.63, p = .005), while improve research, health policy, and culture and beliefs were less likely to be selected after group deliberations (all, p < .001). However, the level of investment in many categories changed after the group deliberations. Participants identifying as Black/African American were less likely to prioritize mental health research, and those of Other race were more likely to prioritize culture and beliefs research. CONCLUSIONS: Minority and medically underserved communities overwhelmingly prioritized mental health and child health research in informed deliberations about spending priorities.

Knowledge, attitudes, and beliefs of Arab-American women regarding inherited cancer risk.

The increasing incidence of breast cancer in the Arab world, coupled with a relatively early age of onset, raises concern for the presence of hereditary risk factors in this population. However, due to potential structural and cultural barriers, Arab Americans make up the smallest percentage of individuals tested for Hereditary Breast and Ovarian Cancer Syndrome in the United States. The objectives of this qualitative pilot focus group of 13 Arab-American women were to explore attitudes, knowledge and beliefs regarding hereditary breast cancer in the Arab-American community in metropolitan Detroit, identify barriers that would prevent women from seeking hereditary cancer screening/testing and determine who women would talk to about inherited cancer. Results indicated that cultural beliefs and personal experiences with cancer influenced the women's perspectives on hereditary cancer risk. A high level of secrecy about cancer within Arab-American families was present, which may prevent accurate risk assessment and referral for genetic services. Other identified barriers that may influence hereditary risk assessment included stigma, fears and misconceptions of cancer. While these barriers were present, participants also expressed a strong need for education and tailored cancer risk information for their community.

Differences in knowledge of breast cancer screening among African American, Arab American, and Latina women.

INTRODUCTION: We examined differences in knowledge and socioeconomic factors associated with 3 types of breast cancer screening (breast self-examination, clinical breast examination, and mammogram) among African American, Arab, and Latina women. METHODS: Community health workers used a community-based intervention to recruit 341 women (112 Arab, 113 Latina, and 116 African American) in southeastern Michigan to participate in a breast cancer prevention intervention from August through October 2006. Before and after the intervention, women responded to a previously validated 5-item multiple-choice test on breast cancer screening (possible score range: 0 to 5) in their language of preference (English, Spanish, or Arabic). We used generalized estimating equations to analyze data and to account for family-level and individual correlations. RESULTS: Although African American women knew more about breast cancer screening at the baseline (pretest median scores were 4 for African American, 3 for Arab and 3 for Latina women), all groups significantly increased their knowledge after participating in the breast cancer prevention intervention (posttest median scores were 5 for African American and 4 for Arab and Latina women). Generalized estimating equations models show that Arab and Latina women made the most significant gains in posttest scores (P < .001). CONCLUSION: Racial/ethnic differences in knowledge of breast cancer screening highlight the need for tailored information on breast cancer screening for African American, Arab, and Latina women to promote adherence to breast cancer screening guidelines.

Cultural Barriers to Breast Cancer Screening and Medical Mistrust Among Arab American Women.

Breast cancer is a common cancer among women in the US and cultural barriers and medical mistrust have been associated with breast cancer screening (BCS) rates among minority populations. A heterogeneous sample of Arab women (N = 196) were recruited from across the Detroit metropolitan area and administered a questionnaire. Multiple regression analyses revealed an association between Arab Cultural Specific Barriers (ACSB) to BCS and Group-Based Medical Mistrust Scale. The environmental ACSB to BCS was associated with the medical mistrust-suspicion of HC providers (ß = 0.363, p = 0.01), lack of HC provider support (ß = 0.396, p = 0.001), and Arab inequities (ß = 0.250, p = 0.05). Findings suggest that ACSB to BCS are predictive of medical mistrust for Arab American women. This study illuminates the need to emphasize strategies that will target the medical care system and the cultural barriers to BCS that Arab American women face in the health care system.

A community-based approach to translating and testing cancer literacy assessment tools.

BACKGROUND: To address the issue of cancer disparities among women whose first language is not English, researchers and public health educators are challenged to develop culturally and linguistically appropriate material and instruments. METHODS: This study documents the process used to linguistically and culturally translate breast and cervical cancer literacy assessment tools from English to Spanish and from English to Arabic by using a community-based method. RESULTS: Results from field testing the assessments demonstrated good reliability for overall cancer literacy in English (Cronbach's alpha .99), Spanish (Cronbach's alpha .99), and Arabic (Cronbach's alpha .81). CONCLUSION: Using a community-based approach to translate the cancer assessments helped to insure they were culturally appropriate.

Health Effects Reported by Adolescent Water Pipe and/or Cigarette Smokers Compared to Nonsmokers.

PURPOSE: The purpose of this study was to determine the prevalence of respiratory and/or physical fitness health problems in adolescent (ages 18-21) water pipe (WP) smokers (with or without cigarette smoking), cigarette-only smokers, and nonsmokers. METHODS: A comparative four-group study design was used to recruit a non-probability sample of 153 WP smokers only, 103 cigarette smokers only, and 102 cigarette+WP smokers along with 296 nonsmokers. Our hypothesis was that youth who smoked WPs and/or cigarettes would report more respiratory problems and/or poorer physical fitness than those who did not smoke. RESULTS: The results showed that coughs were significantly associated with smoking in all three of the smoking groups (p < .05). Cigarette-only smokers reported the most adverse outcomes with more wheezing, difficulty breathing, and less ability to exercise without shortness of breath. A dose-response analysis showed similar patterns of adverse health effects for both WP and cigarette smokers. The combined use of both products was not appreciably worse than smoking one product alone. This could be due to cigarette+WP smokers' reporting using less of the respective products when only one product was smoked. CONCLUSIONS: Even during the adolescent years, WP and/or cigarette smoking youth experienced reportable negative health effects.

Comparison of cigarette and water-pipe smoking by Arab and non-Arab-American youth.

BACKGROUND: Water-pipe smoking is a rapidly growing form of tobacco use worldwide. Building on an earlier report of experimentation with cigarette and water-pipe smoking in a U.S. community sample of Arab-American youth aged 14-18 years, this article examines water-pipe smoking in more detail (e.g., smoking history, belief in harmfulness compared to cigarettes, family members in home who smoke water pipes) and compares the water-pipe-smoking behaviors of Arab-American youth with non-Arab-American youth in the same community. METHODS: A convenience sample of 1872 Arab-American and non-Arab-American high school students from the Midwest completed a 24-item tobacco survey. Data were collected in 2004-2005 and analyzed in 2007-2008. RESULTS: Arab-American youth reported lower percentages of ever cigarette smoking (20% vs 39%); current cigarette smoking (7% vs 22%); and regular cigarette smoking (3% vs 15%) than non-Arab-American youth. In contrast, Arab-American youth reported significantly higher percentages of ever water-pipe smoking (38% vs 21%) and current water-pipe smoking (17% vs 11%) than non-Arab-American youth. Seventy-seven percent perceived water-pipe smoking to be as harmful as or more harmful than cigarette smoking. Logistic regression showed that youth were 11.0 times more likely to be currently smoking cigarettes if they currently smoked water pipes. Youth were also 11.0 times more likely to be current water-pipe smokers if they currently smoked cigarettes. If one or more family members smoked water pipes in the home, youth were 6.3 times more likely to be current water-pipe smokers. The effects of ethnicity were reduced as a result of the explanatory value of family smoking. CONCLUSIONS: Further research is needed to determine the percentages, patterns, and health risks of water-pipe smoking and its relationship to cigarette smoking among all youth. Additionally, youth tobacco prevention/cessation programs need to focus attention on water-pipe smoking in order to further dispel the myth that water-pipe smoking is a safe alternative to cigarette smoking.

Communication from Learned to Innate Olfactory Processing Centers Is Required for Memory Retrieval in Drosophila.

The behavioral response to a sensory stimulus may depend on both learned and innate neuronal representations. How these circuits interact to produce appropriate behavior is unknown. In Drosophila, the lateral horn (LH) and mushroom body (MB) are thought to mediate innate and learned olfactory behavior, respectively, although LH function has not been tested directly. Here we identify two LH cell types (PD2a1 and PD2b1) that receive input from an MB output neuron required for recall of aversive olfactory memories. These neurons are required for aversive memory retrieval and modulated by training. Connectomics data demonstrate that PD2a1 and PD2b1 neurons also receive direct input from food odor-encoding neurons. Consistent with this, PD2a1 and PD2b1 are also necessary for unlearned attraction to some odors, indicating that these neurons have a dual behavioral role. This provides a circuit mechanism by which learned and innate olfactory information can interact in identified neurons to produce appropriate behavior. VIDEO ABSTRACT.

A survey of skin disease and skin-related issues in Arab Americans.

BACKGROUND: There is a paucity of knowledge relating to dermatologic conditions in Arab Americans. OBJECTIVE: To assess common skin diseases and concerns and to evaluate access to dermatologic care and perception of skin in Arab Americans. METHODS: Arab Americans from 3 Southeast Michigan locations (community health center [n = 207], mosque [n = 95], and church [n = 99]) completed a survey questionnaire. RESULTS: The most common self-reported skin conditions were acne, eczema/dermatitis, warts, fungal skin infections, and melasma. The most pressing skin concerns were uneven skin tone, skin discoloration, dry skin, acne, and facial hair. Significant associations exist between socioeconomic status and having seen a dermatologist. Attitudes surrounding skin perception were related to the number of years of residence in the United States. LIMITATIONS: The skin condition data were gathered from a self-reported survey. CONCLUSIONS: Skin conditions and other related issues that affect Arab Americans are similar to those which affect other skin-of-color populations.

Health issues in the Arab American community. The use of glucose-lowering agents and aspirin among Arab Americans with diabetes.

OBJECTIVE: Little is known about the health outcomes or the quality of care among Arab American patients with diabetes. The objective of this study is to examine the use of glucose-lowering agents and aspirin therapy in this population compared to the drug utilization patterns reported in nationally representative surveys. RESEARCH DESIGN AND METHODS: A random sample of adult Arab American patients with self-reported diabetes was selected. Complete medication histories were recorded during a face-to-face interview. Medication utilization of the glucose-lowering agents and aspirin were compared to data from the Third National Health and Nutrition Examination Survey (NHANES) and the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: The study sample consisted of 53 participants (20 males, 33 females) with mean age +/- SD of 59.4 +/- 12 years and A1C levels of 8.0 +/- 2%. Compared to US adults, Arab American patients with diabetes were less likely to be treated with insulin (27% vs 17%) and more likely to receive oral hypoglycemic agents (65% vs 81%). Similar proportions of participants were maintained on insulin-oral hypoglycemic-combined therapy (10% US adults vs 9% Arab Americans). Aspirin use was significantly lower among the study participants (23%) compared to the reported national prevalence of aspirin intake (64%). CONCLUSION: The therapeutic management of diabetes in the Arab-American patients with diabetes is suboptimal. The use of insulin and aspirin was lower than that reported by participants in the NHANES and BRFSS national databases. More aggressive approaches for the management of hyperglycemia and the prevention of cardiovascular diseases are needed to improve health outcomes in the Arab-American community.

Health issues in the Arab American community. Tobacco use patterns among high school students: do Arab American youth differ?

OBJECTIVE: To determine tobacco use rates (cigarette, water pipe smoking [WPS] or narghile) in Arab American compared to non-Arab youth. DESIGN/SETTING: A convenience sample of 2,782 14- to 18-year-old high school students from a midwest community completed a 21-item tobacco use history survey. RESULTS: Seventy-one percent of the participants were ArA. Grades 9 through 12 were equally represented. Results included 'ever tried cigarettes [narghile]' (20%, 39%); 'smoked cigarettes [narghile] in the past 30 days' (7%, 22%); and 'regular smoking [narghile]' (3%, 15%) for ArA and non-Arab youths, respectively. Each was significantly related to grade and ethnicity. WPS for ArA and non-Arab youths was (38%, 21%); (17%, 11%); and (7%, 5%) for 'ever used,' 'used in the past 30 days,' and 'regular use,' respectively. Grade, ethnicity, and sex were significantly related to WPS. CONCLUSIONS: Cigarette smoking rates for non-Arab youth were lower than current national youth smoking rates but significantly higher than ArA youth. Rates for ArA youth were much lower than current national reported data. Rates of WPS for US youth, regardless of race or ethnicity, are not known. Findings from this study indicate that both ArA and non-Arab youth are experimenting and using WPS regularly. These results underscore the importance of assessing novel forms of tobacco use, particularly WPS, a growing phenomenon among US youth.

Mental health symptoms in Iraqi refugees: posttraumatic stress disorder, anxiety, and depression.

Refugees suffer from a higher rate of mental health symptoms than the general population since they have experienced extreme suffering and the accumulated effects of trauma. Because of the diversity of regions from which refugees originate, there is a need to understand some of the unique experiences that are specific to each sub-groups of immigrants. The purpose of the present study was to explore mental health symptoms in Iraqi refugee clients who immigrated to the United States after the Gulf War of the early 1990's. As part of a larger study, 116 adult Iraqi immigrants to the United States (46 male, 70 females) who were seeking mental health services completed measures of anxiety, depression, and posttraumatic stress disorder. As expected, the majority of refugees reported intense anxiety and depression, and many met the DSM IV criteria for posttraumatic stress disorder. Like refugees from other countries-of-origin, Iraqi refugees are in need of culturally sensitive assessment and mental health treatment. The results are discussed in light of the treatment needs of Iraqi refugee clients, their resilience and motivation for a better life, and the ways that health professionals can assist in optimizing their adjustment.

Anthropometric status in Palestinian children living in refugee camps in Lebanon.

OBJECTIVE: To study the relationship between anthropometric measurements and living conditions in infants and children living in refugee camps. DESIGN: Cross-sectional study. SETTING: Four Palestinian refugee camps in Lebanon. SUBJECTS: Thirty-three infants younger than two years of age and 234 children (106 males) younger than 15 years of age. METHODS: Weight and height were measured. Body mass index (BMI) was calculated as weight (kg)/length squared (m2). A parent of the subject answered a questionnaire on employment status, household size, food, and financial assistance as well as child's food consumption. RESULTS: Anthropometric measurements were standardized to the National Center of Health Statistics (NCHS) growth data as age- and sex-specific Z scores. No significant difference was seen between males and females. For all sites studied, the Z scores for weight (WAZ) and height (HAZ) of infants were not significantly different from zero. Among older children, WAZ, HAZ, and Z scores for BMI (BMIZ) were significantly less than zero. In infants, exclusive breast feeding, in addition to receiving financial help, correlated positively while meat and fruit consumption of less than three times per week correlated negatively with WAZ and HAZ. In older children, a mixed relationship was seen among the number of children younger than 10 years of age in a household, the child's meat, vegetable, and fruit consumption less than three times per week, and WAZ and HAZ. CONCLUSION: Living conditions and socioeconomic restrictions on Palestinian refugees living in Lebanon do not appear to influence growth of infants younger than two years of age but may contribute to the growth deficit in older children.

The State as Community in Community-Based Participatory Research.

BACKGROUND: Community-based participatory research (CBPR) typically defines communities by geography, ethnicity, shared health needs, or some combination. OBJECTIVES: We describe a CBPR project aiming to engage diverse minority and underserved communities throughout Michigan in deliberations about health research priorities. METHODS: A steering committee (SC) with 15 members from minority and underserved communities and 4 members from research organizations led the project, with the help of regional advisory groups (RAGs) formed at the SC's request. Evaluation of the SC used questionnaires, focused group discussion, and review of SC meetings to describe engagement, partnership, and communication. LESSONS LEARNED: An academic-community partnership with a diverse, dispersed, and broadly defined community found value in RAGs, dedicated academic staff, face-to-face meetings, varied communication modalities, capacity building tailored to varying levels of CBPR experience, and ongoing evaluation. CONCLUSIONS: A geographically and culturally diverse partnership presents challenges and opportunities in representativeness, relationship building, capacity building, and communication.

Profiles of trace elements in toenails of Arab-Americans in the Detroit area, Michigan.

Exposure to environmental contaminants is complicated by factors related to socioeconomic status, diet, and other culturally conditioned risk behaviors. Determination of a trace element profile in toenails can be used as a tool in biomonitoring the exposure history or assessing the deficiency of a particular element in a study population, which can lead to a better understanding of environmental and disease risks. Toenail clippings from 259 Arab Americans (163 adults, 96 children) residing in a highly industrialized area were analyzed for Al, V, Cr, Mn, Co, Ni, Cu, As, Se, Mo, Cd, Ba, Tl, and Pb using an inductively coupled plasma-mass spectrometer. Mean concentrations were compared with published values, and the influence of age, gender, and other demographic factors were explored. Elevated levels of Ni in this population warrant further investigation. Significant differences in the mean concentration of Al, V, Cr, Mn, Cd, Pb, and Se exist between toenails of adults and children. Pearson correlation coefficients reveal strong significant associations among Cd, Cr, and Tl (p<0.05), in addition to other elements. These investigations provide insight into exposures and factors influencing exposures in this population while adding to the growing fund of knowledge surrounding use of toenails as a marker of exposure.

Lack of acculturation is a risk factor for diabetes in arab immigrants in the US.

OBJECTIVE: To examine the relationship between dysglycemia (impaired fasting glucose, impaired glucose tolerance, and diabetes) and acculturation, physical activity, and perceived stress in Arab immigrants in the U.S. RESEARCH DESIGN AND METHODS: In a cross-sectional population-based study, we examined 520 Arab Americans, aged 20-75 years, who were born in the Middle East and immigrated to southeastern Michigan. Dysglycemia was assessed by history and with a 2-h 75-g oral glucose tolerance test. Acculturation, physical activity, and perceived stress were measured with standardized questionnaires. RESULTS: Associations were found between dysglycemia in men and older age at immigration, unemployment, speaking Arabic with friends, being less active in Arabic organizations, more frequent consumption of Arabic food, and less integration into American society. Dysglycemia in women was associated with being raised in rural areas of the Middle East, older age at immigration, longer length of stay in the U.S., not being employed outside the home, less than high school education, not attending Arabic or American schools, and not being able to read Arabic. Among men, older age at immigration, shorter length of stay in the U.S., less activity in Arab organizations, and eating Arabic food were associated with dysglycemia independent of age and BMI. Among women, acculturation was very low and was confounded with age and BMI as powerful risk factors for dysglycemia. No association was found between physical activity, perceived stress, and the risk of dysglycemia in either sex. CONCLUSIONS: Lack of acculturation is an important risk factor for dysglycemia in immigrant Arab Americans. Intervention programs aimed at diabetes prevention should consider the acculturation process.

The prevalence of the metabolic syndrome among arab americans.

OBJECTIVE: To estimate the prevalence of the metabolic syndrome in Arab Americans by age, sex, and BMI and to examine the association between insulin resistance and each of the components of the metabolic syndrome. RESEARCH DESIGN AND METHODS: We studied a representative, cross-sectional, population-based sample of 542 Arab Americans aged 20-75 years. The metabolic syndrome was defined by Adult Treatment Panel III (ATP III) and World Health Organization (WHO) diagnostic criteria. Insulin resistance was estimated by homeostasis model assessment (HOMA-IR). RESULTS: The age-adjusted prevalence of the metabolic syndrome was 23% (95% CI 19-26%) by the ATP III definition and 28% (24-32%) by the WHO definition. Although the prevalence increased significantly with age and BMI in both sexes by both definitions, differences in estimates were noted. With ATP III, the age-specific rates were similar for men and women aged 20-49 years but were significantly higher for women aged >/=50 years. With WHO, rates were higher for men than women aged 20-49 years and similar for those aged >/=50 years. The most common component of the metabolic syndrome in men and women was low HDL cholesterol with the ATP III and the presence of glucose intolerance and HOMA-IR with the WHO. Strong associations between HOMA-IR and individual components of the metabolic syndrome were observed. After fitting a model with HOMA-IR as the outcome, waist circumference, triglyceride level, and fasting plasma glucose level were significantly associated with HOMA-IR. CONCLUSIONS: The metabolic syndrome is common among Arab Americans and is related to modifiable risk factors.

Epidemiology of diabetes among Arab Americans.

OBJECTIVE: To examine the prevalence of diabetes and glucose intolerance by age and sex in the Arab-American community of Dearborn, Michigan. RESEARCH DESIGN AND METHODS: Participants were randomly selected adult Arab Americans, 20-75 years of age, from randomly selected households in Dearborn, Michigan. Demographic and anthropometric data were recorded. Glucose tolerance was assessed with 2-h 75-g oral glucose tolerance tests and classified according to 1997 American Diabetes Association and 1998 World Health Organization criteria. RESULTS: A total of 626 eligible adults were selected, and 542 participated (87% response rate). Because prevalence increases with age and the overall response rate for women (328/352; 93%) was higher than that for men (214/274; 78%), prevalence rates were adjusted for age and sex. The overall prevalence of diabetes was 15.5% (95% CI 12.2-18.7%) in women and 20.1% (15.0-25.2%) in men (P = 0.13). The prevalence of previously diagnosed diabetes was similar to that of undiagnosed diabetes. Impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG) were present in 16.8% (12.8-20.8%) of women and 29.7% (23.4-35.9%) of men (P = 0.0007). The combined rates of glucose intolerance (diabetes, IGT, and IFG) were 32.3% (27.8-36.7%) for women and 49.8% (43.1-56.4%) for men (P < 0.0001). Among younger adults, the prevalence in men was higher than that in women. As expected, subjects with diabetes or IGT/IFG were older and had greater BMI and waist-to-hip ratios than subjects with normal glucose tolerance. CONCLUSIONS: The prevalence of diabetes and glucose intolerance is extremely high among adult Arab Americans in Michigan and represents a major clinical and public health problem. Community-based intervention programs to prevent and treat diabetes are urgently needed.