Elvin Asay

Dietary intake of Alaska Native people in two regions and implications for health: the Alaska Native Dietary and Subsistence Food Assessment Project

Abstract Objectives. To calculate the energy and nutrient intake in 2 regions of Alaska and to describe theimplications for development of chronic disease among Alaska Native people (AN). Study design. Cross-sectional observation; 10 villages and 2 hub communities in rural Alaska;333 participants ages 13 to 88 years old. Methods. Trained interviewers collected 24-hour diet recalls during 4 seasons. Results. In both regions, AN reported a combination of traditional Native foods and store boughtfoods; most of the energy comes from store-bought foods; a high proportion of nutrients comefrom Native foods, especially protein, iron and omega-3 fatty acids. Mean intakes of omega-3fatty acids, from fish and sea mammals, are over twenty times greater than those of the generalU.S. population. Mean intakes of protein, iron, selenium, vitamin A, vitamin C (men) and folate(men) met recommended levels; intakes of calcium and fiber were below recommended levels;carbohydrate and saturated fat (% energy) were above. Conclusions. Traditional foods continue to contribute a significant amount of nutrients to the dietin rural Alaska. Excess simple sugars may be contributing to the rise in obesity and diabetes. Lowintakes of calcium, dietary fiber, fruits and vegetables may contribute to the increased incidenceof cancers of the digestive system. Emphasis on the positive aspects of Native foods and increasedconsumption of fruits, vegetables and calcium-rich foods are warranted.

Diabetes prevalence, incidence, complications and mortality among Alaska Native people 1985–2006

Objectives. To examine trends in diabetes prevalence, incidence, complications and mortality between 1985 and 2006 among Alaska Native people. Study design. We used data from the population-based Alaska Native Diabetes Registry, which includes all people who receive care in the Alaska Tribal Health System. Methods. We compared the periods of 1986–1990 and 2002–2006 for diabetes-related amputations, renal replacement and mortality using Poisson regression. Complications and mortality data were examined for trends using Poisson regression. Survival analyses for those diagnosed since 31 December 1985 were performed using the Cox proportional hazard model. Results. Age-adjusted diabetes prevalence increased from 17.3 in 1985 to 47.6/1,000 in 2006. The number of Alaska Native people living in Alaska with diabetes increased from 610 in 1985 to 3,386 in 2006. Diabetes incidence rates have also increased. Comparing age-adjusted rates for the 5-year periods 1986–1990 and 2002–2006, amputations decreased from 5.3 to 2.6/1,000, renal replacement decreased from 3.3 to 1.2/1,000 and mortality decreased from 41.7 to 33.2/1,000. Yearly analyses showed a downward trend for amputations, renal replacement and mortality rates. Survival analyses showed a significantly higher hazard ratio for any amputations, major amputations and renal replacement for the earlier time period compared to the most recent time period. Conclusions. An increase in risk factors, awareness, funding and case-finding may be contributing to the increase in prevalence and incidence of diagnosed diabetes. While diabetes prevalence and incidence are increasing among Alaska Native people, our results suggest that even in remote, rural areas, complications and mortality can be reduced.

Effect of special diabetes program for Indians funding on system changes in diabetes care and outcomes among American Indian/Alaska Native people 1994-2004.

OBJECTIVES: The Alaska Native Medical Center diabetes program analysed Diabetes Care and Outcomes Audit data from 1994–2004 to evaluate the impact of the Special Diabetes Program for Indians (SDPI) funding on process and intermediate outcomes. STUDY DESIGN: We conducted a retrospective analysis of data from standardized medical records reviews conducted between 1994 and 2004 from regional sites in Alaska. METHODS: We analysed 7,735 randomly selected records for trends over three time periods (pre-SDPI, transition and SDPI). RESULTS: Hemoglobin A1c, total and LDL cholesterol, triglycerides and blood pressure significantly improved from the pre-SDPI to the SDPI period. However, as the number of people with diabetes increased, the percentage of patients receiving foot, eye and dental exams decreased, as did the percentage receiving nutrition, exercise and diabetes education. CONCLUSIONS: SDPI funding provided resources for interventions necessary to improve the effectiveness of diabetes care. This was associated with improved intermediate outcomes in American Indian/Alaska Native patients with diabetes. Further observations are needed to evaluate whether or not intermediate outcomes result in decreased cardiovascular disease, amputations, dialysis and retinopathy.

Physical Activity Patterns of American Indian and Alaskan Native People Living in Alaska and the Southwestern United States

Purpose. Assessment of self-reported physical activity (PA) and effects on health measures. Design. Cross-sectional analysis of baseline data from a cohort study. Setting. Education and Research Towards Health study participants from Alaska and the Southwestern United States enrolled from 2004 to 2007. Subjects. Total of 10,372 American Indian and Alaskan Native people (AI/AN) of at least 18 years. Measures. Participants completed computer-assisted, self-administered questionnaires, and anthropometric and health measurements were taken of each participant. Analysis. Analysis of variance, χ2 tests, and multiple linear regressions were used. Results. Almost 23% of participants reported less than 30 minutes per week of moderate or vigorous activities. Half (49%) reported no vigorous activities. Characteristics associated with more time spent performing vigorous activity were male gender, age less than 40 years, higher income and education levels, and living in a rural area. Almost 70 % of Alaskan participants and 36% of Southwest participants engaged in wild food—harvesting activities. Participants with higher levels of activity had significantly better clinical characteristics (high-density lipoprotein cholesterol, triglycerides, body mass index, and waist circumference). Conclusion. AI/AN people engage in many different physical activities, including traditional harvesting activities. Women had lower levels of PA than men, and participation in vigorous PA was associated with better clinical characteristics. These data can be used to guide health promotion efforts in AI/AN populations.

Factors related to fruit, vegetable and traditional food consumption which may affect health among Alaska Native People in Western Alaska.

Objectives: Determine intake of fruits, vegetables and traditional foods (TF), availability of foods, and attitudes towards increasing their consumption. Study design: Establish community baseline through a cross-sectional sample of residents who were weighed, measured and interviewed. Village stores were surveyed for food availability, price and quality. Methods: Eighty-eight respondents self-identified as the household member primarily responsible for food shopping and cooking were surveyed in 3 Western Alaska Native villages using a food frequency questionnaire, and village stores were evaluated using food environment surveys. Results: Overweight (BMI[kg/m2] > 25) was present in 68% of participants. Fruit and vegetable intake (3.3 median servings/day) was low in comparison to recommended intakes of 5–9 servings/d. Seventy-two per cent were eating less than 5 servings/d of fruits and vegetables combined. Thirty-four per cent of respondents were trying to eat more vegetables; 41% were trying to eat more fruits. The median number of servings of TF was 3.2/d (mean 4.3/d). Seventy-seven per cent of respondents reported that they ate enough TF. Conclusion: Recommendations to continue use of TF and increase intake of fruits and vegetables are consistent with local attitudes. Our findings indicate that increasing the availability of fruits and vegetables would be well received. Information from this study provides a basis for nutrition education and food supplement programs that is responsive to the needs and perceptions of the residents. Continued TF intake and increased fruit and vegetable intake have the potential to benefit the health of rural residents.OBJECTIVES Determine intake of fruits, vegetables and traditional foods (TF), availability of foods, and attitudes towards increasing their consumption. STUDY DESIGN Establish community baseline through a cross-sectional sample of residents who were weighed, measured and interviewed. Village stores were surveyed for food availability, price and quality. METHODS Eighty-eight respondents self-identified as the household member primarily responsible for food shopping and cooking were surveyed in 3 Western Alaska Native villages using a food frequency questionnaire, and village stores were evaluated using food environment surveys. RESULTS Overweight (BMI[kg/m2] > 25) was present in 68% of participants. Fruit and vegetable intake (3.3 median servings/day) was low in comparison to recommended intakes of 5-9 servings/d. Seventy-two per cent were eating less than 5 servings/d of fruits and vegetables combined. Thirty-four per cent of respondents were trying to eat more vegetables; 41% were trying to eat more fruits. The median number of servings of TF was 3.2/d (mean 4.3/d). Seventy-seven per cent of respondents reported that they ate enough TF. CONCLUSION Recommendations to continue use of TF and increase intake of fruits and vegetables are consistent with local attitudes. Our findings indicate that increasing the availability of fruits and vegetables would be well received. Information from this study provides a basis for nutrition education and food supplement programs that is responsive to the needs and perceptions of the residents. Continued TF intake and increased fruit and vegetable intake have the potential to benefit the health of rural residents.OBJECTIVES Determine intake of fruits, vegetables and traditional foods (TF), availability of foods, and attitudes towards increasing their consumption. STUDY DESIGN Establish community baseline through a cross-sectional sample of residents who were weighed, measured and interviewed. Village stores were surveyed for food availability, price and quality. METHODS Eighty-eight respondents self-identified as the household member primarily responsible for food shopping and cooking were surveyed in 3 Western Alaska Native villages using a food frequency questionnaire, and village stores were evaluated using food environment surveys. RESULTS Overweight (BMI[kg/m2] > 25) was present in 68% of participants. Fruit and vegetable intake (3.3 median servings/day) was low in comparison to recommended intakes of 5-9 servings/d. Seventy-two per cent were eating less than 5 servings/d of fruits and vegetables combined. Thirty-four per cent of respondents were trying to eat more vegetables; 41% were trying to eat more fruits. The median number of servings of TF was 3.2/d (mean 4.3/d). Seventy-seven per cent of respondents reported that they ate enough TF. CONCLUSION Recommendations to continue use of TF and increase intake of fruits and vegetables are consistent with local attitudes. Our findings indicate that increasing the availability of fruits and vegetables would be well received. Information from this study provides a basis for nutrition education and food supplement programs that is responsive to the needs and perceptions of the residents. Continued TF intake and increased fruit and vegetable intake have the potential to benefit the health of rural residents.

Innovative primary care delivery in rural Alaska: a review of patient encounters seen by community health aides

Background. For more than 50 years, Community Health Aides and Community Health Practitioners (CHA/Ps) have resided in and provided care for the residents of their villages. Objectives. This study is a systematic description of the clinical practice of primary care health workers in rural Alaska communities. This is the first evaluation of the scope of health problems seen by these lay health workers in their remote communities. Study design. Retrospective observational review of administrative records for outpatient visits seen by CHA/Ps in 150 rural Alaska villages (approximate population 47,370). Methods. Analysis of electronic records for outpatient visits to CHA/Ps in village clinics from October 2004 through September 2006. Data included all outpatient visits from the Indian Health Service National Patient Information Reporting System. Descriptive analysis included comparisons by region, age, sex, clinical assessment and treatment. Results. In total 272,242 visits were reviewed. CHA/Ps provided care for acute, chronic, preventive, and emergency problems at 176,957 (65%) visits. The remaining 95,285 (35%) of records did not include a diagnostic code, most of which were for administrative or medication-related encounters. The most common diagnostic codes were: pharyngitis (11%), respiratory infections (10%), otitis media (8%), hypertension (6%), skin infections (4%), and chronic lung disease (4%). Respiratory distress and chest pain accounted for 75% (n=10,552) of all emergency visits. Conclusions. CHA/Ps provide a broad range of primary care in remote Alaskan communities whose residents would otherwise be without consistent medical care. Alaskas CHA/P program could serve as a health-care delivery model for other remote communities with health care access challenges. To access the supplementary material to this article: ‘NPIRS Categorical Hierarchy’ please see the Supplementary files under Article Tools online

Giant inflatable colon and community knowledge, intention, and social support for colorectal cancer screening.

Introduction Colorectal cancer (CRC) is the second-leading cause of deaths from cancer in the United States. Screening decreases CRC deaths through early cancer detection and through removal of precancerous lesions. We investigated whether a health exhibit consisting of a giant inflatable colon was an effective educational tool to increase community members’ knowledge, intention, and social support for CRC screening and prevention. Methods Alaska adults (N = 880) attending community events statewide from March 2011 through March 2012 completed a short survey to assess knowledge about CRC, intention to get screened, and level of social support before and after walking through a giant interactive model of a human colon. The survey used a combination of open-ended questions and a Likert scale, where 1 was “very unlikely,” 2 was “somewhat unlikely,” 3 was “neutral,” 4 was “somewhat likely,” and 5 was “very likely.” The model depicted CRC stages from normal tissue to advanced adenocarcinoma and displayed signs with CRC prevention tips. We used the McNemar test and paired sample t tests for univariate analyses. Results Respondents significantly improved their CRC knowledge (P < .05), intention to get screened (mean score increased from 4.3 to 4.5, P < .001), and comfort with talking to others about CRC screening (mean level of comfort increased from 3.8 to 3.9, P < .001). Multivariate analysis showed no significant differences by sex, age, or race for improvements in CRC screening knowledge, intention, or comfort. Conclusion Interactive exhibits can improve public knowledge and interest in CRC screening, which may lead to increased CRC screening rates and decreased CRC incidence and deaths.

Developing a validated Alaska Native food frequency questionnaire for western Alaska, 2002-2006

Abstract Objectives. The purpose of this study was to develop a dietary instrument (food frequency questionnaire [FFQ]) that measured total dietary intake over 1 year among Alaska Native people in 2 regions. Ways of assessing diet are needed in order to accurately evaluate how the diets of Alaska Natives relate to their health. Study design. Seasonal 24-hour (24-h) diet recalls were collected for developing an FFQ that described the average dietary foods and nutrients consumed. Alaska Native people living in 12 small communities in 2 regions of the state were eligible to participate. Methods. Each participant was to provide 4 24-h diet recalls, 1 per season. Recalls were used to develop an FFQ using regression techniques. The FFQ was administered to 58 of the 333 original participants. Responses to the FFQ were compared to the averages of their 24-h recalls using the Spearman Correlation Coefficient. Results. Energy-adjusted correlations ranged from 0.15 for protein to 0.49 for monounsaturated fatty acids. Fifteen of 26 nutrients examined were significantly correlated (total carbohydrates, sucrose, fructose, total fat, fatty acids [monounsaturated, polyunsaturated, omega 3, EPA, DHA], folate, vitamins A, C, D, potassium and selenium). Conclusions. The FFQ can be used to evaluate intakes of Alaska Natives in western Alaska for the correlated nutrients.

All-Cause, Cardiovascular, and Cancer Mortality in Western Alaska Native People: Western Alaska Tribal Collaborative for Health (WATCH)

OBJECTIVES We determined all-cause, cardiovascular disease (CVD), and cancer mortality in western Alaska Native people and examined agreement between death certificate information and adjudicated cause of deaths. METHODS Data from 4 cohort studies were consolidated. Death certificates and medical records were reviewed and adjudicated according to standard criteria. We compared adjudicated CVD and cancer deaths with death certificates by calculating sensitivity, specificity, predictive values, and κ statistics. RESULTS Men (n = 2116) and women (n = 2453), aged 18 to 95 years, were followed an average of 6.7 years. The major cause of death in men was trauma (25%), followed by CVD (19%) and cancer (13%). The major cause of death in women was CVD (24%), followed by cancer (19%) and trauma (8%). Stroke rates in both genders were higher than those of US Whites. Only 56% of deaths classified as CVD by death certificate were classified as CVD by standard criteria; discordance was higher among men (55%) than women (32%; κs = 0.4 and 0.7). CONCLUSIONS We found lower rates for coronary heart disease death but high rates of stroke mortality. Death certificates overestimated CVD mortality; concordance between the 2 methods is better for cancer mortality. The results point to the importance of cohort studies in this population in providing data to assist in health care planning.

Agreement Between Self-Report and Medical Record Prevalence of 16 Chronic Conditions in the Alaska EARTH Study

The gold standard for health information is the health record. Hospitalization and outpatient diagnoses provide health systems with data on which to project health costs and plan programmatic changes. Although health record information may be reliable and perceived as accurate, it may not include population-specific information and may exclude care provided outside a specific health care facility. Sole reliance on medical record information may lead to underutilization of health care services and inadequate assessment of population health status. In this study, we analyzed agreement, without assuming a gold standard, between self-reported and recorded chronic conditions in an American Indian/Alaska Native cohort. Self-reported health history was collected from 3821 adult participants of the Alaska EARTH study during 2004-2006. Participant medical records were electronically accessed and reviewed. Self-reported chronic conditions were underreported in relation to the medical record and both information sources reported the absence more reliably than the presence of conditions (across conditions, median positive predictive value = 64%, median negative predictive value = 94%). Agreement was affected by age, gender, and education. Differences between participant- and provider-based prevalence of chronic conditions demonstrate why health care administrators and policy makers should not rely exclusively on medical record–based administrative data for a comprehensive evaluation of population health.