From the Editor-in-Chief: Section Previews
Keith C. Norris, MD

Original Reports: Health Policy
Evolving Demographics and Disparities in an Urban Diabetes Clinic: Implications for Diabetes Education and Treatment
Virginia G. Dunbar, BS; Esther C. King, BSN; Christopher D. George, MS; Imad M. El-Kebbi, MD; David C. Ziemer, MD; Daniel L. Gallina, MD; Curtiss B. Cook, MD

Dunbar et al evaluated demographic and disease characteristics among 8,551 patients in a multiethnic urban diabetes clinic population over 10 years. There was a significant shift in the demographic and disease profiles (eg, age, glycemic control, body mass index) within and across patients by race and ethnicity in this urban diabetes clinic. Being attentive to such shifts is important for modifying treatment and education approaches for both the clinic population as well as the surrounding community.

Chronic Pain in Older Black Americans: The Influence of Health and Psychosocial Factors
Tamara A. Baker, PhD

Chronic pain may differentially affect racial and ethnic minorities. Dr. Baker examined the relationship between pain intensity, health variables, various demographic characteristics, and psychosocial factors among 189 older Black Americans. She found depressive symptoms, greater physical impairment, and being younger were significant indicators of pain intensity, accounting for 27% of its variation. This study highlights the need to develop new models that assess how socio-cultural, environmental, physical, and psychological factors influence the daily experience of pain in diverse populations.

Addressing Oral Health Disparities in Settings Without a Research-Intensive Dental School: Collaborative Strategies
David Easa, MD; Rosanne Harrigan, EdD; Zoe` Hammatt, Esq; Mark Greer, DMD; Carolyn Kuba, MS; James Davis, PhD; James D. Beck, PhD; Steven Offenbacher, DDS, PhD

Easa and colleagues describe a community-based approach to address oral health (an emerging cardiovascular disease risk factor) in high-risk communities in Hawaii. The partnership includes the Waimanalo Health Center, the University of Hawaii, the National Institute of Dental and Craniofacial Research, the University of North Carolina at Chapel Hill School of Dentistry, and the Hawaii State Department of Health. This unique strategy overcomes the lack of a dental school at the University of Hawaii and describes the role of multidisciplinary partnering with geographically distant partners.

Original Reports: Cardiovascular Health
Endothelial Nitric Oxide Synthase Intron 4 Polymorphism Is a Marker for Coronary Artery Disease in African-American and Caucasian Men

Swapna Rao, BS; Harland Austin, DSc; Madalyn N. Davidoff, MD; A. Maziar Zafari, MD, PhD

Genetic alterations in the gene encoding for eNOS may contribute to the development of CAD. Rao and coworkers genotyped for the eNOS intron 4 polymorphism in 194 African American and Caucasian subjects undergoing coronary angiography and brachial ultrasonography to assessendothelial function. They found the 4a-allele was linked to multi-vessel coronary disease but not endothelial function. The eNOS intron 4 polymorphism may be a new biomarker of multi-vessel CAD in African-Americans and Caucasians.

Race-Ethnic Differences in the Extent, Prevalence, and Progression of Coronary Calcium
Miwa Kawakubo, MS; Laurie LaBree, MS; Min Xiang, MS; Terence M. Doherty, BA; Nathan D. Wong, PhD; Stanley Azen, PhD; Robert Detrano, MD, PhD

Kawakubo et al examined the prevalence, extent, and progression of coronary artery calcium in 1,289 participants without coronary heart disease who underwent baseline risk factor screening and computed tomography for coronary calcification. Eight hundred and twenty-eight participants returned for seven-year follow-up evaluations. Among those returning for follow-up evaluations, African-Americans and Hispanics had a lower prevalence of baseline and follow-up coronary calcium compared to Whites. There were no differences between Whites and Asian/Pacific Islanders. This study provides the foundation for future investigations to examine the reasons that underlie racial and ethnic differences in the prevalence and rate of progression of coronary calcification.

Racial and Ethnic Disparities in the Pharmacologic Management of Diabetes Mellitus Among Long-Term Care Facility Residents
Jenifer E. Allsworth, PhD; Rebecca Toppa, PhD; Nicole C. Palin, BA; Kate L. Lapane, PhD

Allsworth and colleagues evaluated 50,427 elderly nursing home residents with diabetes across five states. They found that both race and ethnicity of the nursing home resident, as well as the geographic location, appear to influence the clinical decisions around the use of antidiabetic medications. Implications for further studies around this issue are discussed.

Risk Factors for Coronary Heart Disease Among Immigrant Women from Iran and Turkey, Compared to Women of Swedish Ethnicity
Achraf Daryani, BSc; Lars Berglund, BSc;A°ree; sa Andersson, BSc; Tahire Kocturk, PhD; Wulf Becker, PhD; Bengt Vessby, MD, PhD

Using a health survey of 157 randomly selected foreignborn women (from Iran and Turkey) living in Sweden for at least three years and native Swedish women, Daryani and colleagues examined the prevalence of pre-selected cardiovascular risk factors. There was a less beneficial cardiovascular risk profile among immigrant women who had substantially higher body mass index, larger waist, higher waist/hip ratio, higher levels of serum triglycerides, and lower HDL cholesterol concentration compared with natives. This profile provides an opportunity for targeted community education and screening to reduce the risk of cardiovascular disease.

Genetic Predictors of Coronary Heart Disease Risk Factors in Pre-menopausal African-American Women
Joyce Newman Giger, EdD, RN, CS; Ora L. Strickland, PhD, RN; Michael Weaver, PhD, RN; Herman Taylor, MD; Ronald T. Acton, PhD

Giger and co-workers examined several pre-selected candidate genes for potential association with coronary heart disease (CHD) risk factors in more than 200 premenopausal African-American women. They found APOE, DRB1, D689 and TNFa alleles were associated with risk of CHD in this cohort. These markers may provide a tool for early intervention strategies to reduce CHD in the future.

Metabolic Syndrome in a Multiethnic Population in Rural Hawaii
Andrew Grandinetti, PhD; Healani K. Chang, DrPH; Andre Theriault, PhD; Joanne Mor, MS

Using diagnostic criteria for metabolic syndrome, defined by the National Cholesterol Education Program Adult Treatment Panel III, the estimated overall US prevalence is 21.8%. Grandinetti et al examined 1,450 ethnically diverse adult residents in the rural community of North Kohala, Hawaii and, using the same criteria, found a prevalence of 33.4%. Rates among each ethnic group were higher than the estimated US average, even among groups with traditionally low rates of cardiovascular disease mortality. They postulate a differential effect of cardiovascular risk factors on mortality across ethnic groups and, they speculate, future mortality rates may increase among those ethnic groups that currently enjoy low mortality rates.

Dietary Intake, Perceptions Regarding Body Weight, and Attitudes Toward Weight Control of Normal Weight, Overweight, and Obese Black Females in a Rural Village in South Africa
Mieke Faber, PhD; H. Salome Kruger, PhD

Cultural differences in perceptions and behaviors may have significant impact on cardiovascular risk factors. Faber and Kruger examined dietary intake and attitude toward weight control using a convenience sample of nearly 200 normal weight, overweight, and obese adult Black women in a rural village in KwaZulu province, South Africa. They found dietary intake did not differ among groups, and overweight and obese women did not view weight control differently than women of normal weight. Most rural women were unconcerned about their weight and most overweight and obese women did not want to lose weight. The acceptance of overweight and obesity can hinder the effectiveness of weight control programs as an effective cardiovascular risk reduction strategy. New educational strategies for cardiovascular risk are necessary prior to considering weight reduction programs in rural South African woman.

Church-Based Obesity Treatment for African-American Women Improves Adherence
Tracy Sbrocco, PhD; Michele M. Carter, PhD; Evelyn L. Lewis, MA, MD; Nicole A. Vaughn, PhD; Kimberly L. Kalupa, PhD; Sandra King, MS; Sonia Suchday, PhD; Robyn L. Osborn, MA; Jennifer A. CintroŽn, MA

Sbrocco et al compared the results of Behavioral Choice Treatment, a 12-week obesity treatment program that promotes weight loss and exercise, between women (Caucasian and African American) in a university setting to women (African American) in a church setting. While all groups lost weight and maintained these losses at 12-month follow-up, the church group exhibited less disordered eating attitudes and experienced significantly greater weight loss than the university group. These results suggest treatment setting may play an important role in treatment success for weight-loss programs.

Physical Activity of Aboriginals with Type 2 Diabetes: An Exploratory Study
Stephanie Brunet, MSc; Ronald C. Plotnikoff, PhD; Kim Raine, RD, PhD; Kerry Courneya, PhD

To better understand the role of physical activity among Canadian Aboriginals, a group with a high rate of diabetes, Brunet and colleagues surveyed 34 Aboriginals with diabetes to assess: 1) the perceived meaning of physical activity; 2) physical activity behavior; and 3) Social Cognitive Theory constructs. They found the majority perceived that leisure-time activities were only for youth. Based on energy expenditure estimates, nearly two-thirds of participants were categorized as sedentary. However, when accounting for occupational and household activities only one-third were categorized as sedentary. Their findings suggest that specific Social Cognitive Theory construct items may help understanding physical activity behaviors and strategies for change.

Alcohol Use and Adherence to Prescribed Therapy Among Under-Served Latino and African-American Patients Using Emergency Department Services
Shahrzad Bazargan-Hejazi, PhD; Mohsen Bazargan, PhD; Eugene Hardin, MD; Eric G. Bing, MD, PhD, MPH

Many patients report to emergency rooms because they have been non-compliant with a prescribed therapy. However, Bazargan-Hejazi, colleagues and others have found that patients who seek health care from inner-city emergency departments are among those experiencing health disparities. For these marginalized patients, emergency departments can play an important role in complementing the process of individualized care to achieve successful health outcomes. This article recommends further research to examine socio-psychological characteristics and correlates of health care utilization of emergency department service users among under-served minority patients.

Influence of Nativity on Neonatal Survival of Black Twins in the United States
Hamisu M. Salihu, MD, PhD; Wanda S. Mardenbrough- Gumbs, MPH; Muktar H. Aliyu, MD, MPH; Jeanine E. Sedjro, BS; Bosny J. Pierre-Louis, CRT, MPH; Russell S. Kirby, MS, PhD; Greg R. Alexander, MPH, ScD

US-born Black infants have exceptionally high neonatal mortality rates. Salihu and colleagues examined the association between maternal nativity and neonatal survival of twins among 70,884 individual twin live births to USborn and those of foreign-born Black mothers. Twins of US-born mothers were nearly 25% more likely to die within the neonatal period, as compared to those of foreign-born mothers. The higher mortality rate resulted mainly from lower gestational age at birth and the preponderance of small-for-gestational-age babies among US-born Black mothers.

Original Reports: Research Design
Using Focus Groups of Older African Americans and Latinos with Diabetes to Modify a Self-Care Empowerment Intervention

Catherine A. Sarkisian, MD, MSPH; Rebecca J. Brusuelas; W. Neil Steers, PhD; Mayer B. Davidson, MD; Arleen F. Brown, MD, PhD; Keith C. Norris, MD; Robert M. Anderson, EdD; Carol M. Mangione, MD, MSPH

Cultural and age-specific modifications to self-care empowerment interventions are crucial to optimize effectiveness. Sarkisian et al employed focus groups with selfadministered surveys to 16 health educators and nearly 80 African Americans and Latinos aged $55 years with diabetes. Older African Americans and Latinos endorsed the intervention but desired an expanded dietary educational component. They also identified disability as an important missing content area and rejected the use of an audio learning tool. Another important finding was that participants did not believe that matching group-facilitator sociodemographic characteristics was important, as long as facilitators demonstrated cultural competency. This study highlights the importance of a participatory research approach in which researchers and community members work together to develop an empowerment intervention. Modifying the intervention in accordance with community input should enhance the relevance and impact of the self-care intervention.

Perceptions of African-American Culture and Implications for Clinical Trial Design Jamy D. Ard, MD; Raegan W. Durant, MD; Lori Carter Edwards, PhD; Laura P. Svetkey, MD, MHS

To help identify cultural factors that might limit the effectiveness of behavioral interventions in clinical trials, Ard and co-workers utilized focus groups to assess 26 African-American men and women who completed the screening process but were ineligible for a randomized clinical trial that studies the effects of lifestyle intervention to reduce blood pressure. Seven themes were consistently identified: 1) extensive use of nontraditional support systems; 2) general mistrust of European Americans; 3) African Americans being undervalued as human beings and members of American society; 4) effective use of improvisation; 5) uneven playing field as a result of persistent discrimination; 6) preservation of a unique ethnic identity; 7) socioeconomic status as a major influence and predictor of behaviors. Using these themes, investigators can better design trials and interventions that capitalize on certain cultural factors that are important for African Americans and avoid strategies that conflict with the factors.

The Informed Consent Process in a Cross-Cultural Setting: Is the Process Achieving the Intended Result?
Melvina McCabe, MD; Frank Morgan, BA; Helen Curley; Rick Begay; Dorothy M. Gohdes, MD

The informed consent has been challenged around appropriateness for culturally diverse and limited-English reading populations. McCabe et al go further and report on the experiences of Navajo interpreters working in a diabetes clinical trial and describe the problems encountered in translating the standard research consent across both cultural and linguistic barriers. The interpreters met with a language and a diabetes expert to review their experiences in presenting the translation in the initial phases of recruitment. Their experiences suggest that the consent process often leads to embarrassment, confusion, and misperceptions that promoted mistrust. The formal processes that have been mandated to protect human subjects may create barriers to research in cross-cultural settings and may discourage participation. More attention needs to be given to ensuring that both translations and cross-cultural communications are effective.

Original Reports: Cancer
Prevalence and Predictors of Smoking Behavior Among Samoans in Three Geographical Regions
Shiraz I. Mishra, MBBS, PhD; Kathryn Osann, PhD; Pat H. Luce, MS

The high smoking and low cessation rates indicate that smoking-related diseases will be significant causes of morbidity and mortality for Samoans for many years. Mishra et al compared smoking behavior among 1,834 Samoans across three geographically distinct areas, US Territory of American Samoa, Hawaii, and Los Angeles, California. They found low cessation rates and relatively similar smoking rates (;25%). Predictors of smoking included being younger, male, married, less educated, with lower income, and more acculturated. They suggest several strategies to assist the Samoan community to meet the Healthy People 2010 tobacco goals.

Ethnic Differences in Trends and Determinants of Cigarette Smoking in Hawaii
Gertraud Maskarinec, MD, PhD; Sanjaya Dhakal, MS; Ian Pagano, PhD; Linda Carlin, PhD; Marc T. Goodman, PhD; Loic Le Marchand, MD, PhD; Abraham Nomura, MD, DrPH; Lynne Wilkens, DrPH; Laurence N. Kolonel, MD, PhD

Maskarinec et al investigated the trends and predictors of cigarette smoking among a population of Caucasians, Japanese, Chinese, Filipino, and Native Hawaiians reported in 19 earlier studies conducted in Hawaii between 1975 and 2001. Men were more likely to smoke than women throughout the study period, but they experienced a greater decline in smoking until 1994. A small increase in smoking prevalence was observed thereafter. Native Hawaiians reported the highest smoking prevalence, Japanese the lowest, and Caucasians intermediate levels. Graduate-level education had the strongest inverse association with current and past smoking. Their data suggest a modest reversal in the declining smoking prevalence during the late 1990s and the need to re-examine public health strategies to reduce smoking in Hawaii.

On the Coding and Reporting of Race and Ethnicity in New Hampshire for Purposes of Cancer Reporting
Bruce L. Riddle, PhD

The collection of demographically accurate cancer data is critical for assessing incidence and prevalence trends, treatment response and for developing public health strategies. Riddle investigated the mechanisms used by the New Hampshire State Cancer Registry to collect information on race and ethnicity. He found many hospitals lack policies on collection, computer systems fail to support national guidelines, and staff relied on visual inspection. His study suggests a new framework is needed that improves the reliability of accuracy of data collection to ensure the utility of the registry.

Disparities in the Coverage of Cancer Information in Ethnic Minority and Mainstream Mass Print Media
Laurie Hoffman-Goetz, PhD, MPH; Daniela B. Friedman, MSc

It is well known that there are significant disparities in cancer mortality burden as a function of ethnicity and race in North America. Hoffman-Goetz and Friedman examined the presentation of cancer information in mass media that targets ethnic minority groups. They found cancer coverage in ethnic and mainstream newspapers did not accurately reflect the leading causes of cancer death in Canada, being heavily weighted toward breast cancer and little or no coverage of prostate, colorectal, or lung cancer. Importantly, there was little cultural tailoring of cancer articles, and the reading level was exceptionally high (;13th grade) in both ethnic and mainstream media, and even slightly higher in ethnic newspapers. There is an important need for the Canadian media to re-assess how it presents cancer information in newspapers if it is to be a useful educational vehicle.

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