Miyong T. Kim

A corner store intervention in a low-income urban community is associated with increased availability and sales of some healthy foods

OBJECTIVE While corner store-based nutrition interventions have emerged as a potential strategy to increase healthy food availability in low-income communities, few evaluation studies exist. We present the results of a trial in Baltimore City to increase the availability and sales of healthier food options in local stores. DESIGN Quasi-experimental study. SETTING Corner stores owned by Korean-Americans and supermarkets located in East and West Baltimore. SUBJECTS Seven corner stores and two supermarkets in East Baltimore received a 10-month intervention and six corner stores and two supermarkets in West Baltimore served as comparison. RESULTS During and post-intervention, stocking of healthy foods and weekly reported sales of some promoted foods increased significantly in intervention stores compared with comparison stores. Also, intervention storeowners showed significantly higher self-efficacy for stocking some healthy foods in comparison to West Baltimore storeowners. CONCLUSIONS Findings of the study demonstrated that increases in the stocking and promotion of healthy foods can result in increased sales. Working in small corner stores may be a feasible means of improving the availability of healthy foods and their sales in a low-income urban community.

Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months*

BACKGROUND African American men with hypertension in low socioeconomic urban populations achieve poor rates of hypertension control and suffer early from its complications. METHODS In a randomized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years, we evaluated the effectiveness of a more intensive comprehensive educational-behavioral-pharmacologic intervention by a nurse practitioner-community health worker-physician (NP/CHW/MD) team and a less intensive education and referral intervention in controlling blood pressure (BP) and minimizing progression of left ventricular hypertrophy (LVH) and renal insufficiency. Changes in BP, left ventricular mass (LVM), and serum creatinine from baseline to 36 months were compared between groups. RESULTS At 36 months, the mean systolic BP/diastolic BP change from baseline was -7.5/-10.1 mm Hg for the more intensive group and +3.4/-3.7 mm Hg for the less intensive group (P =.001 and.005 for between-group differences in systolic BP and diastolic BP, respectively). The proportion of men with controlled BP (<140/90 mm Hg) was 44% in the more intensive group and 31% in the less intensive group (P =.045). The LVM was significantly lower in the more intensive group than in the less intensive group (more intensive, 274 g; less intensive, 311 g; P =.004). There was a trend toward slowing of the progression of renal insufficiency (incidence of 50% increase in serum creatinine) in the more intensive group compared to the less intensive group (more intensive, 5.2%; less intensive, 8.0%; P =.08). CONCLUSIONS During 36 months, the more intensive intervention led to a lower BP and decreased progression of LVH in a sample of hypertensive young African American men.

Depression, substance use, adherence behaviors, and blood pressure in urban hypertensive Black men

Relationships between depression, alcohol and illicit drug use, adherence behaviors, and blood pressure (BP) were examined in 190 urban hypertensive Black men enrolled in an ongoing hypertension control clinical trial. More than one fourth (27.4%) of the sample scored greater than 16 on the Center for Epidemiological Studies- Depression Scale (CES-D), indicating a high risk of clinical depression. Depression was significantly associated with an increased likelihood of meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for alcohol abuse or dependence (odds ratio = 5.2; 95% confidence interval = 1.897–14.214). The level of depression was significantly correlated with poor medication (r = .301) and poor dietary compliance (r = .164). Both alcohol intake and illicit drug use were significantly correlated with poor dietary compliance (r = .195 and .185, respectively) and smoking (r = .190 and .269, respectively). Although no direct relationship between depression and the level of BP was substantiated by multivariate analysis, findings of descriptive analyses revealed statistically significant associations among depression, substance use, poor adherence, and poor BP outcomes. Given the harsh environment in which a large number of young urban Black men live, the high prevalence of substance abuse might be an attempt to fight off depression. Further in- depth investigation is needed to identify the role of depression and BP control in urban young Blacks in order to construct effective interventions that address their unique needs.

Effect of lifetime lactation on breast cancer risk: a Korean women's cohort study.

The objective of our study was to examine the effect of lifetime lactation on breast cancer risk among premenopausal women. The data were from a prospective cohort study with a follow‐up period of 6 years in Korea (1995–2000). The cohort was composed of 110,604 premenopausal parous Korean women, aged 20 years and older, who received health insurance from the Korea Medical Insurance Corporation and who had medical evaluations in 1992 and 1994. Multivariate Cox proportional hazard models were tested, controlling for age, age at menarche, number of children, age at first pregnancy, oral contraceptive use, smoking, exercise and obesity. At baseline, 57,440 (51.9%) reported breastfeeding and 4,584 (4.1%) reported breastfeeding more than 24 months. From 1995–2000, 360 incident cases of breast cancer (61.8/100,000 person‐years) occurred. Compared to parous women who had no history of lactation, a period of lactation of 13–24 months decreased the risk of breast cancer (RR, 0.7; 95% CI, 0.5–1.1), and this risk was decreased even further for those who breastfed for more than 24 months (RR, 0.6; 95% CI, 0.3–1.0). There was a clear trend of decreasing breast cancer risk with the duration of lactation (p for trend <0.001). In conclusion, our study of a large Korean cohort provides additional empirical evidence to current theoretical conjecture that lactation decreases the risk of breast cancer among premenopausal women.

Barriers to hypertension care and control in young urban black men.

Barriers to high blood pressure (HBP) care and control have been reported in the literature for > 30 years. Few reports on barriers, however, have focused on the young black man with HBP, the age/sex/race group with the highest rates of early severe and complicated HBP and the lowest rates of awareness, treatment, and control. In a randomized clinical trial of comprehensive care for hypertensive young urban black men, factors potentially associated with care and control were assessed at baseline for the 309 enrolled men. A majority of the men encountered a variety of barriers including economic, social, and lifestyle obstacles to adequate BP care and control, including no current HBP care (49%), risk of alcoholism (62%), use of illicit drugs (45%), social isolation (47%), unemployment (40%), and lack of health insurance (51%). Having health insurance (odds ratio = 7.20, P = .00) and a negative urine drug screen (odds ratio = .56, P = .04) were significant predictors of being in HBP care. Low alcoholism risk and employment were identified as significant predictors of compliance with HBP medication-taking behavior. Men currently using illicit drugs were 2.64 times less likely to have controlled BP compared with their counterparts who did not use illicit drugs, and men currently taking HBP medication were 63 times more likely have controlled BP compared with men not taking HBP medication. Comprehensive interventions are needed to address socioeconomic and lifestyle issues as well as other barriers to care and treatment, if HBP care is to be salient and effective in this high risk group.

Tailored lay health worker intervention improves breast cancer screening outcomes in non-adherent Korean-American women.

Despite rapidly increasing incidence rates of breast cancer, recent immigrants such as Korean-American (KA) women report disproportionately lower utilization of screening tests compared with other ethnic groups. Early screening of breast cancer for this population may be greatly facilitated by indigenous lay health workers (LHWs). We conducted an intervention trial with a 6-month follow-up. Trained LHWs recruited 100 KA women 40 years of age or older who had not had a mammogram during the past 2 years. Ninety-three completed follow-up questionnaires. A 120-min, in-class education combined with LHW follow-up counseling and navigation assistance through the health care system was provided. Rates of breast cancer screening behaviors significantly increased at 6 months (P < 0.001); changes between pre- and post-intervention were 31.9% for mammography, 23% for clinical breast examination and 36.2% for breast self-examination. Modesty toward screening significantly decreased over time, but we did not find any significant differences in breast cancer knowledge and beliefs before and after the intervention. Results support the efficacy of this neighborhood-based, culturally sensitive intervention. Further research should seek to replicate these findings and to incorporate more self-care skills such as health literacy when designing an intervention program for linguistically and culturally isolated immigrant women.

Serum uric acid and risk of death from cancer, cardiovascular disease or all causes in men.

Objective Although many epidemiological studies have suggested that increased serum uric acid levels are a risk factor for mortality, this relationship remains uncertain. This cohort study examined the effects of serum uric acid level on death from cancer, atherosclerotic cardiovascular disease (ASCVD) or all causes in men. Method A 9-year, prospective cohort study was carried out with 22 698 Korean men, aged 30 to 77 years, who received health insurance from the National Health Insurance Corporation and who underwent biennial, secondary medical evaluations in 1992–1996. The main outcome measures were death from cancer, ASCVD or all causes, compared by quintiles of serum uric acid level. At baseline, the mean (SD) level of serum uric acid was 354.4 (98.1) μmol/l. Results During 199 746 person-years of follow-up, there were 387 cancer deaths, 323 ASCVD (99 ischaemic heart disease, 192 stroke) deaths and 1625 all-cause deaths. In multivariate Cox proportional hazards models, having controlled for age, current smoking, diabetes, hypertension and hypercholesterolaemia, uric acid levels were not associated with mortality from cancer, ASCVD or all causes. However, for those with diabetes, uric acid levels were associated with mortality from all causes even after full adjustment of the covariates. When the interaction term was included in the multivariate model, there was significant interactive effect of uric acid with diabetes (RR = 1.26, 95% confidence interval 1.02–1.55) on the risk of all cause of death, whereas the effects of uric acid itself did not attain significance. Conclusion These findings indicate that uric acid level is not an independent risk factor for death from cancer, ASCVD or all causes.

Cardiovascular Disease Risk Factors in Korean American Elderly

An in-depth cardiovascular risk factor assessment was carried out in a sample of 205 Korean American elderly in Maryland, consisting of 75 males and 130 females aged 60 to 89 years (mean age = 69.9±6.5 years). Six risk factors were assessed in each participant: high blood pressure, current smoking, high blood cholesterol, overweight, sedentary lifestyle, and diabetes. The findings of this cross-sectional study suggested that high blood pressure was the leading cardiovascular disease risk factor among Korean American elderly (71%), followed by high blood cholesterol (53%), overweight (43%), sedentary life style (24%), diabetes (18%), and smoking (7%). Two thirds of the sample had multiple cardiovascular disease risk factors. The pattern of prevalence and risk factors that was observed was consistent with the distribution of multiple risk factors in that the combination of high blood pressure, high blood cholesterol, and overweight was most common in Korean American elderly (62%). These findings indicate that culturally relevant and salient strategies are needed to reduce multiple risk factors in this population.

A Community-Based, Culturally Tailored Behavioral Intervention for Korean Americans With Type 2 Diabetes

Purpose The purpose of this study is to test the efficacy of a culturally tailored comprehensive type 2 diabetes management intervention for Korean American immigrants (KAIs) with type 2 diabetes. Methods A randomized controlled pilot trial with 2 parallel arms (intervention vs control) with a delayed intervention design was used. A total of 79 KAIs, recruited from the Baltimore-Washington area, completed baseline, 18-week, and 30-week follow-ups (intervention, n = 40; control, n = 39). All participants had uncontrolled type 2 diabetes (hemoglobin A1C ≥7.5%) at baseline. The authors’ comprehensive, self-help intervention program for type 2 diabetes management (SHIP-DM) consisted of a 6-week structured psychobehavioral education, home glucose monitoring with teletransmission, and bilingual nurse telephone counseling for 24 weeks. The primary outcome of the study was A1C level, and secondary outcomes included an array of psychobehavioral variables. Results Using analysis of covariance, the findings support that the proposed intervention was effective in significantly lowering A1C and fasting glucose and also in improving psychosocial outcomes in the sample. Specifically, the amount of reduction in A1C among intervention group participants was 1.19% at 18 weeks and 1.31% at 30 weeks, with 10% and 15.5% of the participants achieving the suggested goal of A1C <7% at 18 and 30 weeks of follow-up, respectively. Conclusions The results highlight the clinical efficacy of the SHIP-DM intervention composed of a 6-week education program, self-monitoring, and follow-up counseling, in terms of maintaining the improved intervention effects obtained and in terms of glucose control.

Does knowledge matter? Intentional medication nonadherence among middle-aged Korean Americans with high blood pressure

Aim: To examine predictors of intentional and unintentional nonadherence to antihypertensive medication regimens and their relationships to blood pressure outcomes. Background: Although poor adherence to medical regimens is a major concern in the care of patients with high blood pressure (HBP), our understanding of the complex behavior related to adherence is limited. Moreover, few studies have been devoted to understanding adherence issues in ethnic minority groups, such as the interplay between cultural beliefs and HBP medication-taking behaviors. Design: A cross-sectional analysis was performed to assess the factors affecting nonadherence to antihypertensive medication regimens. Methods: The data used in this analysis came from an ongoing HBP intervention trial involving middle-aged (40-64 years) Korean Americans with HBP. A total of 445 Korean Americans with HBP was enrolled in the trial at baseline. Of these, 208 participants who were on antihypertensive medication were included in the analysis. Using multivariate logistic regression, we examined theoretically selected variables to assess their relationships to intentional and unintentional nonadherence in this sample. Results: Approximately 53.8% of the subjects endorsed 1 or more types of nonadherent behaviors. After controlling for demographic variables, multivariate analysis revealed that a greater number of side effects from the medication (adjusted odds ratio [OR], 1.19; 95% confidence interval [CI], 1.07 to 1.33) and a lower level of HBP knowledge (adjusted OR, 0.89; 95% CI, 0.79 to 0.99) were significantly associated with intentional nonadherence. Unintentional nonadherence was less strongly associated with the study variables examined in the analysis. Conclusion: Our findings indicate that intentional nonadherence to antihypertensive medication that stems from incomplete knowledge of HBP treatment is prevalent among middle-aged Korean Americans with HBP. The results highlight the strong need for an intervention that focuses on increasing patient knowledge about HBP, including the benefits and side effects of antihypertensive medication. This type of focused intervention may help reduce intentional nonadherence to antihypertensive medications and ultimately result in achieving adequate BP control in this high-risk group.