American Indian Alaska Native (AIAN) adolescents and obesity: the influence of social determinants of health, mental health, and substance use.

OBJECTIVE: To explore the prevalence of obesity among American Indian and Alaska Native (AIAN) adolescents aged 12-19 years in association with social determinants of health (SDOH), and mental health and substance use disorders. METHODS: Guided by the World Health Organization's Social Determinants of Health Framework, we examined data from the Indian Health Service (IHS) Improving Health Care Delivery Data Project from Fiscal Year 2013, supplemented by county-level data from the U.S. Census and USDA. Our sample included 26,226 AIAN adolescents ages 12-19 years. We described obesity prevalence in relationship to SDOH and adolescents' mental health and substance use disorder status. We then fit a multivariable logit generalized linear mixed model to estimate the relationships after adjusting for other individual and county level characteristics. RESULTS: We observed a prevalence of 32.5% for obesity, 13.8% for mental health disorders, and 5.5% for substance use disorders. Females had lower odds of obesity than males (OR = 0.76, p < 0.001), which decreased with age. Having Medicaid coverage (OR = 1.09, p < 0.01), residing in a county with lower education attainment (OR = 1.17, p < 0.05), and residing in a county with higher rates of poverty (OR = 1.51, p < 0.001) were each associated with higher odds of obesity. Residing in a county with high access to a grocery store (OR = 0.73, p < 0.001) and residing in a county with a higher proportion of AIANs (OR = 0.83, p < 0.01) were each associated with lower odds of obesity. Those with mental health disorders had higher odds of obesity (OR = 1.26, p < 0.001); substance use disorders were associated with decreased odds of obesity (OR = 0.73, p < 0.001). CONCLUSIONS: Our findings inform future obesity prevention and treatment programs among AIAN youth; in particular, the need to consider mental health, substance use, and SDOH.

Social determinants of obesity in American Indian and Alaska Native peoples aged ≥ 50 years.

OBJECTIVE: American Indian and Alaska Native peoples (AI/ANs) have a disproportionately high rate of obesity, but little is known about the social determinants of obesity among older AI/ANs. Thus, our study assessed social determinants of obesity in AI/ANs aged ≥ 50 years. DESIGN: We conducted a cross-sectional analysis using multivariate generalized linear mixed models to identify social determinants associated with the risk of being classified as obese (BMI ≥ 30.0 kg/m2). Analyses were conducted for the total study population and stratified by median county poverty level. SETTING: Indian Health Service (IHS) data for AI/ANs who used IHS services in FY2013. PARTICIPANTS: 27,696 AI/ANs aged ≥ 50 years without diabetes. RESULTS: Mean BMI was 29.8 ± 6.6 with 43% classified as obese. Women were more likely to be obese than men, and younger ages were associated with higher obesity risk. While having Medicaid coverage was associated with lower odds of obesity, private health insurance was associated with higher odds. Living in areas with lower rates of educational attainment and longer drive times to primary care services were associated with higher odds of obesity. Those who lived in a county where a larger percentage of people had low access to a grocery store were significantly less likely to be obese. CONCLUSIONS: Our findings contribute to the understanding of social determinants of obesity among older AI/ANs and highlight the need to investigate AI/AN obesity, including longitudinal studies with a life course perspective to further examine social determinants of obesity in older AI/ANs.

Associations Between Rurality, pre-pregnancy Health Status, and Macrosomia in American Indian/Alaska Native Populations.

OBJECTIVES: To examine the relationships between pre-pregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), pre-pregnancy body mass index (BMI) and county-level social determinants of health, with infant macrosomia within a sample of American Indian/Alaska Native (AI/AN) women receiving Indian Health Service (IHS) care. METHODS: The sample included women-infant dyads representing 1,136 singleton births from fiscal year 2011 (10/1/2019-9/30/2011). Data stemmed from the IHS Improving Health Care Delivery Data Project. Multivariate generalized linear mixed models were fitted to assess the association of macrosomia with pre-pregnancy health status and social determinants of health. RESULTS: Nearly half of the women in the sample were under age 25 years (48.6%), and most had Medicaid health insurance coverage (76.7%). Of those with a pre-pregnancy BMI measure, 66.2% were overweight or obese. Although few women had pre-pregnancy DM (4.0%), GDM was present in 12.8% of women. Most women had a normal term delivery (85.4%). Overweight, obesity, pre-pregnancy DM, and county-level rurality were all significantly associated with higher odds of infant macrosomia.

The costs of treating all-cause dementia among American Indians and Alaska native adults who access services through the Indian Health Service and Tribal health programs.

INTRODUCTION: Little is known about treatment costs for American Indian and Alaska Native (AI/AN) adults with dementia who access services through the Indian Health Service (IHS) and Tribal health programs. METHODS: We analyzed fiscal year 2013 IHS/Tribal treatment costs for AI/ANs aged 65+ years with dementia and a matched sample without dementia (n = 1842) to report actual and adjusted total treatment costs and costs by service type. Adjusted costs were estimated using multivariable regressions. RESULTS: Mean total treatment cost for adults with dementia were $13,027, $5400 higher than for adults without dementia ($7627). The difference in adjusted total treatment costs was $2943 (95% confidence interval [CI]: $1505, $4381), the majority of which was due to the difference in hospital inpatient costs ($2902; 95% CI: $1512, $4293). DISCUSSION: Knowing treatment costs for AI/ANs with dementia can guide enhancements to policies and services for treating dementia and effectively using health resources.

Patient Outcomes Associated With Utilization of Education, Case Management, and Advanced Practice Pharmacy Services by American Indian and Alaska Native Peoples With Diabetes.

BACKGROUND: The burden of diabetes is exceptionally high among American Indian and Alaska Native (AI/AN) peoples. The Indian Health Service (IHS) and Tribal health programs provide education, case management, and advanced practice pharmacy (ECP) services for AI/ANs with diabetes to improve their health outcomes. OBJECTIVE: The objective of this study was to evaluate patient outcomes associated with ECP use by AI/AN adults with diabetes. RESEARCH DESIGN: This observational study included the analysis of IHS data for fiscal years (FY) 2011-2013. Using propensity score models, we assessed FY2013 patient outcomes associated with FY2012 ECP use, controlling for FY2011 baseline characteristics. SUBJECTS: AI/AN adults with diabetes who used IHS and Tribal health services (n=28,578). MEASURES: We compared health status and hospital utilization outcomes for ECP users and nonusers. RESULTS: Among adults with diabetes, ECP users, compared with nonusers, had lower odds of high systolic blood pressure [odds ratio (OR)=0.85, P<0.001] and high low-density lipoprotein cholesterol (OR=0.89, P<0.01). Among adults with diabetes absent cardiovascular disease (CVD) at baseline, 3 or more ECP visits, compared with no visits, was associated with lower odds of CVD onset (OR=0.79, P<0.05). Among adults with diabetes and CVD, any ECP use was associated with lower odds of end-stage renal disease onset (OR=0.60, P<0.05). ECP users had lower odds of 1 or more hospitalizations (OR=0.80, P<0.001). CONCLUSIONS: Findings on positive patient outcomes associated with ECP use by adults with diabetes may inform IHS and Tribal policies, funding, and enhancements to ECP services to reduce disparities between AI/ANs and other populations in diabetes-related morbidity and mortality.

Disparities in Potentially Preventable Hospitalizations Between American Indian and Alaska Native and Non-Hispanic White Medicare Enrollees.

OBJECTIVE: A number of health care initiatives seek to improve health outcomes by increasing access to outpatient services while reducing preventable acute events. We evaluated disparities between American Indian and Alaska Native (AI/AN) and non-Hispanic white (white) Medicare enrollees in access to outpatient preventive, primary, and specialty services by comparing their potentially preventable hospitalizations (PPHs). RESEARCH DESIGN: The study population included 121,311 adult AI/AN Medicare enrollees registered to use services funded by the Indian Health Service and 5,915,011 adult white enrollees living in the same counties. Medicare 2010 data and a nationally recognized algorithm were used to identify PPHs. RESULTS: Among AI/AN Medicare enrollees, 58.6% had either diabetes, cardiovascular disease, or both conditions; the AI/AN age-adjusted prevalence of either or both conditions was 1.2 times that of the white enrollees (P<0.001). The age-adjusted PPH rate for all AI/ANs was 74 admissions per 1000 adults, 1.5 times that of white enrollees (P<0.001). Nearly 90% of AI/AN PPHs were among AI/ANs with diabetes, cardiovascular disease, or both conditions; their PPH rate was 114 admissions per 1000 adults, 1.2 times that of white enrollees (P<0.001) with those conditions. CONCLUSIONS: Differences in disease burden and access to outpatient services may partly explain the higher PPH rates for AI/AN Medicare enrollees. The health care quality measure used in this study (PPH) was developed for the US general population. It is important to consider AI/AN socioeconomic and other characteristics when interpreting findings for such measures and enhancing programs and policies to improve AI/AN health outcomes.

Potential Effects of Long-Term Exposure to Air Pollution on Dementia: A Longitudinal Analysis in American Indians Aged 55 Years and Older.

(1) Background: American Indians are disproportionately affected by air pollution, an important risk factor for dementia. However, few studies have investigated the effects of air pollution on the risk of dementia among American Indians. (2) Methods: This retrospective cohort study included a total of 26,871 American Indians who were 55+ years old in 2007, with an average follow-up of 3.67 years. County-level average air pollution data were downloaded from land-use regression models. All-cause dementia was identified using ICD-9 diagnostic codes from the Indian Health Service's (IHS) National Data Warehouse and related administrative databases. Cox models were employed to examine the association of air pollution with dementia incidence, adjusting for co-exposures and potential confounders. (3) Results: The average PM2.5 levels in the IHS counties were lower than those in all US counties, while the mean O3 levels in the IHS counties were higher than the US counties. Multivariable Cox regressions revealed a positive association between dementia and county-level O3 with a hazard ratio of 1.24 (95% CI: 1.02-1.50) per 1 ppb standardized O3. PM2.5 and NO2 were not associated with dementia risk after adjusting for all covariates. (4) Conclusions: O3 is associated with a higher risk of dementia among American Indians.

The Relationship between All-Cause Dementia and Acute Diabetes Complications among American Indian and Alaska Native Peoples.

BACKGROUND: American Indian and Alaska Native people (AI/AN) bear a disproportionate burden of diabetes. Growing evidence shows significant associations between several acute diabetes complications and dementia among diabetes patients. However, little is known about these relationships among AI/AN adults. Here, we aim to investigate these associations among AI/AN adults. METHODS: This cross-sectional study extracted data from the Indian Health Service's (IHS) National Data Warehouse and related administrative databases. A total of 29,337 IHS actual users with diabetes who were 45+ years old during fiscal year 2013 were included. All-cause dementia and diabetes complications were identified using ICD-9 diagnostic codes. Negative binomial regression models were used to evaluate the associations of interest. RESULTS: Nearly 3% of AI/AN diabetes patients had a dementia diagnosis. After controlling for covariates, dementia was associated with a 94% higher rate of severe hypoglycemia (Incidence Rate Ratio [IRR = 1.94, 95% CI:1.50-2.51), 52% higher rate of severe hyperglycemia (IRR = 1.52, 95% CI, 1.11-2.08), and 92% higher rate of any acute complication (IRR = 1.92, 95% CI:1.53-2.41). CONCLUSIONS: AI/AN diabetes patients with dementia suffered from considerably higher rates of acute diabetes complications than their counterparts without dementia. The clinical management of patients with comorbid diabetes and dementia is particularly challenging and may require individualized treatment approaches.

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

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

The costs of treating American Indian adults with diabetes within the Indian Health Service.

OBJECTIVES: We examined the costs of treating American Indian adults with diabetes within the Indian Health Service (IHS). METHODS: We extracted demographic and health service utilization data from the IHS electronic medical reporting system for 32 052 American Indian adults in central Arizona in 2004 and 2005. We derived treatment cost estimates from an IHS facility-specific cost report. We examined chronic condition prevalence, medical service utilization, and treatment costs for American Indians with and without diabetes. RESULTS: IHS treatment costs for the 10.9% of American Indian adults with diabetes accounted for 37.0% of all adult treatment costs. Persons with diabetes accounted for nearly half of all hospital days (excluding days for obstetrical care). Hospital inpatient service costs for those with diabetes accounted for 32.2% of all costs. CONCLUSIONS: In this first study of treatment costs within the IHS, costs for American Indians with diabetes were found to consume a significant proportion of IHS resources. The findings give federal agencies and tribes critical information for resource allocation and policy formulation to reduce and eventually eliminate diabetes-related disparities between American Indians and Alaska Natives and other racial/ethnic populations.

Design of a randomized controlled trial of a web-based intervention to reduce cardiovascular disease risk factors among remote reservation-dwelling American Indian adults with type 2 diabetes.

We describe a randomized controlled trial, the Lakota Oyate Wicozani Pi Kte (LOWPK) trial, which was designed to determine whether a Web-based diabetes and nutritional intervention can improve risk factors related to cardiovascular disease (CVD) among a group of remote reservation-dwelling adult American Indian men and women with type 2 diabetes who are at high risk for CVD. Enrollment on a rolling basis of 180 planned participants began during 2009; an average 18-month follow-up was completed by June 2011. The primary outcome variable is change in glycosylated hemoglobin level after an average 18-month follow-up period. Secondary outcome variables include changes in low-density lipoprotein cholesterol, systolic blood pressure, body mass index, and smoking status, as well as an evaluation of intervention cost-effectiveness. If effective, the LOWPK trial may serve as a guide for future chronic disease intervention trials in remote, technologically challenged settings.

Metformin and Dementia Risk: A Systematic Review with Respect to Time Related Biases.

Background: When studying drug effects using observational data, time-related biases may exist and result in spurious associations. Numerous observational studies have investigated metformin and dementia risk, but have reported inconsistent findings, some of which might be caused by unaddressed time-related biases. Immortal time bias biases the results toward a "protective" effect, whereas time-lag and time-window biases can lead to either a "detrimental" or "protective" effect. Objective: To conduct a systematic review examining time-related biases in the literature on metformin and dementia. Methods: The electronic databases PubMed, Web of Science, and ProQuest were searched for the terms "Metformin" AND ("dementia" OR "Alzheimer's Disease" OR "cognitive impairment"). These databases were searched from inception through 09/24/2021. Only English language articles and human research were eligible. Results: Seventeen studies were identified: thirteen cohort studies, two case-control studies, and two nested case-control studies. Eleven (64.7%) studies reported a reduced risk of dementia associated with metformin use; two (11.8%) suggested metformin increased dementia risk, while four (23.5%) concluded no significant associations. Eight (61.5%) of thirteen cohort studies had immortal time bias or did not clearly address it. Fifteen (88.2%) of seventeen reviewed studies had time-lag bias or did not clearly address it. Two (50.0%) of four case-control studies did not explicitly address time-window bias. The studies that addressed most biases concluded no associations between metformin and dementia risk. Conclusion: None of the reviewed studies clearly addressed relevant time-related biases, illustrating time-related biases are common in observational studies investigating the impact of anti-diabetic medications on dementia risk.

American Indian and Alaska Native veterans in the Indian Health Service: Health status, utilization, and cost.

PURPOSE: Many rural American Indian and Alaska Native (AIAN) veterans receive care from the Indian Health Service (IHS). United States Department of Veterans Affairs (VA) has reimbursement agreements with some IHS facilities and tribal programs and seeks to expand community partnerships in tribal areas, but details of how AIAN veterans use IHS are unknown. We aimed to assess the health status, service utilization patterns, and cost of care of veterans who use IHS. METHODS: We used comprehensive and integrated IHS data to compare health status, health service utilization and treatment cost of veterans (n = 12,242) to a matched sample of non-veterans (n = 12,242). We employed logistic, linear, or negative binomial regressions as appropriate, by sex and overall. FINDINGS: Compared to non-veterans, veterans had lower odds of having hypertension, renal disease, all-cause dementia, and alcohol or drug use disorders, but had similar burden of other conditions. In service utilization, veterans had lower hospital inpatient days; patterns were mixed across outpatient services. Unadjusted treatment costs for veterans and non-veterans were $3,923 and $4,145, respectively; veteran adjusted treatment costs were statistically lower. Differences in significance by sex were found for health conditions and service use. CONCLUSIONS: AIAN veterans, compared to AIAN non-veterans, were not less healthy, nor did they require more intensive or more costly care under IHS. Our results indicate the viability and importance of expanding IHS-VA partnerships in community care.

Use of clinical pharmacy services by American Indians and Alaska Native adults with cardiovascular disease.

Introduction: The Indian Health Service (IHS) and Tribal health programs provide clinical pharmacy services to improve health outcomes among American Indian and Alaska Native (AI/AN) adults with cardiovascular disease (CVD). Objectives: The study's primary objective was to describe characteristics, including social determinants of health (SDOH), associated with clinical pharmacy utilization by AI/ANs with CVD who accessed IHS/Tribal services. A secondary objective assessed changes in systolic blood pressure (SBP) associated with such utilization. Methods: Analysis included IHS data for 9844 adults aged 18 and older with CVD who lived in 5 locations. Multivariable logistic regression was used to examine patient characteristics (eg, age, sex, health status, SDOH) associated with clinical pharmacy utilization in fiscal year (FY) 2012. A propensity score model was employed to estimate the association of elevated SBP in FY2013 with FY2012 clinical pharmacy utilization. Results: Nearly 15% of adults with CVD used clinical pharmacy services. Among adults with CVD, the odds of clinical pharmacy use were higher among adults diagnosed with congestive heart failure (adjusted odds ratio [OR] = 1.22; 95% CI:1.01-1.47), other types of heart disease not including ischemia (OR = 1.40; 95% CI: 1.18-1.65), and vascular disease (OR = 1.23; 95% CI: 1.04-1.46), compared to adults without these conditions. Diabetes (OR = 4.05, 95% CI: 3.29-5.00) and anticoagulation medication use (OR = 20.88, 95% CI: 16.76-20.61) were associated with substantially higher odds of clinical pharmacy utilization. Medicaid coverage (OR = 0.72; 95% CI: 0.56-0.93) and longer travel times to services (OR = 0.87; 95% CI: 0.83-0.92) were each associated with lower odds. FY2012 clinical pharmacy users had lower odds of elevated SBP (OR = 0.71 95% CI: 0.58-0.87) in FY2013 than nonusers. Conclusion: In addition to health status, SDOH (eg, Medicaid coverage, longer travel times) influenced clinical pharmacy utilization. Understanding characteristics associated with clinical pharmacy utilization may assist IHS/Tribal health programs in efforts to support optimization of these services.

Cardiometabolic Conditions and All-Cause Dementia Among American Indian and Alaska Native People.

BACKGROUND: Diabetes, hypertension, and cardiovascular disease (CVD) are modifiable lifestyle-related cardiometabolic conditions associated with dementia. Yet, little is known regarding these associations among American Indian and Alaska Native (AI/AN) people. Thus, we examined the association of diabetes, hypertension, and CVD with all-cause dementia among AI/ANs aged 65 years and older. METHOD: This was a cross-sectional analysis of the Indian Health Service Improving Health Care Delivery Data Project. Our study population was a 1:1 matched sample of 4 074 AI/ANs aged 65 years and older and Indian Health Service active users during fiscal year 2013. We employed International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for all-cause dementia, hypertension, and CVD. Diabetes was measured with a validated algorithm to identify adults with diabetes that uses diagnoses, laboratory test results, and medication criteria. RESULTS: Multivariable analyses revealed that diabetes and CVD were associated with increased odds of all-cause dementia and hypertension was not. Cardiovascular disease types associated with all-cause dementia differed with cerebrovascular disease having the strongest association. Analyses stratified by gender revealed that diabetes and CVD were associated with increased odds of all-cause dementia for women and only CVD was associated with all-cause dementia for men. CONCLUSIONS: Training and support of primary care clinicians, addressing cultural considerations, and ensuring inclusion of AI/ANs in research are steps that could help meet AI/AN people's needs. Our findings underscore to the importance of improved management and control of diabetes and CVD, which may lead to the prevention of dementia among older AI/ANs.

Overview of methods in economic analyses of behavioral interventions to promote oral health.

BACKGROUND: Broad adoption of interventions that prove effective in randomized clinical trials or comparative effectiveness research may depend to a great extent on their costs and cost-effectiveness (CE). Many studies of behavioral health interventions for oral health promotion and disease prevention lack robust economic assessments of costs and CE. OBJECTIVE: To describe methodologies employed to assess intervention costs, potential savings, net costs, CE, and the financial sustainability of behavioral health interventions to promote oral health. METHODS: We provide an overview of terminology and strategies for conducting economic evaluations of behavioral interventions to improve oral health based on the recommendations of the Panel of Cost-Effectiveness in Health and Medicine. To illustrate these approaches, we summarize methodologies and findings from a limited number of published studies. The strategies include methods for assessing intervention costs, potential savings, net costs, CE, and financial sustainability from various perspectives (e.g., health-care provider, health system, health payer, employer, society). Statistical methods for estimating short-term and long-term economic outcomes and for examining the sensitivity of economic outcomes to cost parameters are described. DISCUSSION: Through the use of established protocols for evaluating costs and savings, it is possible to assess and compare intervention costs, net costs, CE, and financial sustainability. The addition of economic outcomes to outcomes reflecting effectiveness, appropriateness, acceptability, and organizational sustainability strengthens evaluations of oral health interventions and increases the potential that those found to be successful in research settings will be disseminated more broadly.

The association between substance use disorders and early and combined use of alcohol and marijuana in two American Indian populations.

OBJECTIVE: To study the relationships between early and combined use of alcohol and marijuana with diagnoses of alcohol and marijuana use disorders in two American Indian (AI) populations. METHOD: Data were drawn from a psychiatric epidemiologic study of 3084 AIs living on or near two reservations. We analysed data for adults aged 18-54 years at the time of interview (n = 2739). Logistic regression models were estimated to examine associations between early and combined use of alcohol and marijuana with lifetime diagnoses of abuse and dependence. RESULTS: Overall, younger AIs (18-29 years old) were more likely than older AIs (40-54 years old) to initiate substance use early and initiate use with marijuana, with or without alcohol. Persons who initiated alcohol use before age 14 were more than twice as likely as those who initiated use at older ages to meet criteria for alcohol or marijuana use disorders (p < 0.01). The odds of abuse or dependence were two to five times higher among persons who reported combined use of alcohol and marijuana (p < 0.01) than among those who reported use of either substance. CONCLUSIONS: These findings document the need to address both early and combined use of alcohol and marijuana in prevention and treatment programmes.

The Prevalence of Cardiovascular Disease and Other Comorbidities Among American Indian and Alaska Native Adults with Diabetes.

AIMS: American Indians and Alaska Native (AI/ANs) peoples experience significant health disparities compared to the U.S. general population. We report comorbidities among AI/ANs with diabetes to guide efforts to improve their health status. METHODS: Drawing upon data for over 640,000 AI/ANs who used services funded by the Indian Health Service, we identified 43,518 adults with diabetes in fiscal year 2010. We reported the prevalence of comorbidities by age and cardiovascular disease (CVD) status. Generalized linear models were estimated to describe associations between CVD and other comorbidities. RESULTS: Nearly 15% of AI/AN adults had diabetes. Hypertension, CVD and kidney disease were comorbid in 77.9%, 31.6%, and 13.3%, respectively. Nearly 25% exhibited a mental health disorder; 5.7%, an alcohol or drug use disorder. Among AI/ANs with diabetes absent CVD, 46.9% had 2 or more other chronic conditions; the percentage among adults with diabetes and CVD was 75.5%. Hypertension and tobacco use disorders were associated with a 71% (95% CI for prevalence ratio: 1.63 - 1.80) and 33% (1.28 - 1.37) higher prevalence of CVD, respectively, compared to adults without these conditions. CONCLUSION: Detailed information on the morbidity burden of AI/ANs with diabetes may inform enhancements to strategies implemented to prevent and treat CVD and other comorbidities.

Sex Differences in Diabetes Prevalence, Comorbidities, and Health Care Utilization among American Indians Living in the Northern Plains.

BACKGROUND: The American Indian (AI) population experiences significant diet-related health disparities including diabetes and cardiovascular disease (CVD). Owing to the relatively small sample size of AIs, the population is rarely included in large national surveys such as the NHANES. This exclusion hinders efforts to characterize potentially important differences between AI men and women, track the costs of these disparities, and effectively treat and prevent these conditions. OBJECTIVE: We examined the sex differences in diabetes prevalence, comorbidity experience, health care utilization, and treatment costs among AIs within a Northern Plains Indian Health Service (IHS) service unit. METHODS: We assessed data from a sample of 11,144 persons using an IHS service unit in the Northern Plains region of the United States. Detailed analyses were conducted for adults (n = 7299) on prevalence of diabetes by age and sex. We described sex differences in comorbidities, health care utilization, and treatment costs among the adults with diabetes. RESULTS: In our sample, adult men and women had a similar prevalence of diabetes (10.0% and 11.0%, respectively). The prevalence of CVD among men and women with diabetes was 45.7% and 34.0%, respectively. Among adults with diabetes, men had a statistically higher prevalence of hypertension and substance use disorders than women. The men were statistically less likely to have a non-substance use mental health disorder. Although men had higher utilization and costs for hospital inpatient services than women, the differences were not statistically significant. CONCLUSIONS: In this AI population, there were differences in comorbidity profiles between adult men and women with diabetes, which have differential mortality and cost consequences. Appropriate diabetes management addressing gender-specific comorbidities, such as substance use disorders for men and non-substance use mental health disorders for women, may help reduce additional comorbidities or complications to diabetes.

Reflections on a proposed theory of reservation-dwelling American Indian alcohol use: comment on Spillane and Smith (2007).

In their recent article, N. Spillane and G. Smith suggested that reservation-dwelling American Indians have higher rates of problem drinking than do either non-American Indians or those American Indians living in nonreservation settings. These authors further argued that problematic alcohol use patterns in reservation communities are due to the lack of contingencies between drinking and "standard life reinforcers" (SLRs), such as employment, housing, education, and health care. This comment presents evidence that these arguments were based on a partial review of the literature. Weaknesses in the application of SLR constructs to American Indian reservation communities are identified as is the need for culturally contextualized empirical evidence supporting this theory and its application. Cautionary notes are offered about the development of literature reviews, theoretical frameworks, and policy recommendations for American Indian communities.