CANHR I Findings and Influence On Present Research Efforts

This presentation of the CANHR findings will begin with an overview of obesity, diabetes, and the nutritional status of ANs. A very brief overview of the CANHR I study will follow along with notation of key variables on which data was collected. Discussions of findings for each of the three component investigations that comprised the CANHR I study are then offered. Finally, the key results of a participant feedback survey and community key informant interviews are shared.

Obesity in Alaska Natives. ANs are experiencing increases in both prevalence of diabetes and mortality rates from cardiovascular disease^{[8, 9]}. The incidence of obesity is increasing dramatically in ANs and is now at or higher than national averages^{[10] [11-14]}. The CDC’s ^[9] estimate for American Indian and AN populations is 28%. Explanatory factors for the recent increase in health problems related to obesity are needed. A genetic hypothesis, for example, suggests that a harsh environment with an unstable food supply has led to maximizing storage of surplus energy for survival ^[15]. Traditional coastal Eskimo diets consist of 40-50% fat, yet cardiovascular disease and stroke risks were low until recently ^[16]. Conserving excess energy may have been advantageous earlier but may now be maladaptive. Moreover, a more sedentary lifestyle, increased alcohol consumption, more smoking, and a shift towards a Western diet have been observed^[16] yet prevalence remains lower than in other Native groups.

Diabetes among Alaska Natives. Although the prevalence of type 2 diabetes in Alaskan Eskimos is still low (3.8% reported for region), the prevalence of diabetes among other Native American groups has skyrocketed in the last 3 - 4 decades ^{[19, 20]}. Within Alaska, the prevalence of diabetes is increasing dramatically with a ten-year increase of 118% among the Yup’ik of the region in which we work ^[21]. Prevalence has increased by 85% among all ANs compared to 29% among all Native Americans ^[22]. Our data show that 24% of our participants had impaired fasting glucose. Other risk factors include low levels of physical activity, high levels of nicotine exposure, high stress, and a diet high in trans-fatty acids and nutrient-poor liquids high in sugar ^{[3, 9, 10, 21]}. If CANHR studies can identify the most important risk and/or protective factors, the expected epidemic of diabetes in ANs might be avoided through translational research to provide evidence-based prevention strategies that are effective with these populations.

Nutritional status of Alaska Natives and Yup’ik Eskimos. The prevalence of the parameters for metabolic syndrome have increased and may even be higher among ANs than non-ANs ^{[23, 24]}. Diet and physical activity are changing^[25]. However, few studies have reported on the nutritional status of ANs^[26-28]. Nevertheless, they document a unique nutritional profile, characterized by both theoretically beneficial and risky behaviors ^{[16, 29]}. CANHR II proposes to continue to develop a better understanding of diet-disease and diet-genetic relationships through the establishment of a Nutrition and Physical Activity (NPA) Core and interactions between it and other cores.

Store-bought, or market foods, are more available and tend to be highly processed, energy dense, and nutrient poor ^[30], characteristics that are associated with an increased risk for obesity. Estimates of the proportion of daily nutrient intake derived from traditional foods from the earliest studies in the 1950 until present suggest that market food intake is increasing, particularly among youth ^{[29, 31, 32]}. Specifically, Nobmann ^[29] reported that ANs consumed twice the amount of table sugar, slightly more sweetened soft drinks, and more trans-fatty acids (derived primarily from market foods) than a national sample. The NPA Core proposed in this application will assist existing and new researchers in designing studies to explore the risk and benefit of subsistence and market foods (Project 3: Contaminants and Nutrients in Alaskan Subsistence Foods: Striking a Balance) as well as ways to measure subsistence and market foods (Project 2: Developing a Novel Set of Diet Pattern Biomarkers Based on Stable Isotope Ratios) and the meanings of food, weight, and chronic disease (Project 1: Yup’ik Perceptions of Body Weight and Diabetes: Cultural Pathways to Prevention). The CANHR is in a unique position to produce solid evidence on nutrition for the promotion of a healthy lifestyle.

As with nutrition, information regarding rates and patterns of physical activity among ANs is scarce ^[33]. One study was found that investigated physical activity in an AN population and reported an inverse association between self-reported physical activity and glucose intolerance, adjusted for age, ethnicity, BMI, and gender ^[34].

CANHR can add valuable information on AN diet and physical activity.

Overview of the CANHR I study and data. The research theme of the CANHR I study focused on obesity and its relationship to diabetes and cardiovascular disease among ANs. The study design was cross-sectional. We randomly sampled households in each village that had agreed to participate. Household rates of participation by village varied from 35% to 65% with an average of 45%. We visited three villages a second time and doubled the number of participants from these villages. All who were ≥14 years old were invited to participate and were enrolled after obtaining assigned an informed consent form (approved by the UA IRB, Alaska Area IRB, National Indian Health Service IRB, and the YKHC Human Studies Committee).

Data for all three projects were obtained at the same contact times enhancing inter-project synergy and between projects and cores. Additional data were collected for projects at other times. Key data were health histories, family structure, sitting blood pressure and pulse, standing height, weight, and percent body fat, body circumferences, skin fold, nutrient intake, and physical activity. A blood sample was analyzed for glucose, HbA1c, LDL, HDL, Triglycerides, VLDL, Total Cholesterol, adiponectin, leptin, ghrelin, C-reactive protein. Where needed, we used translated questionnaires and interviews. Demographic data and medical conditions were obtained from medical charts. We enrolled and collected data on a total of 1,050 participants.

Obesity and diabetes among the CANHR sample. The average BMI of our Yup’ik study participants 18 and older was 28.0; females had a significantly higher BMI, percent body fat, waist circumference, and abdominal skin folds than males (p≤0.05). The percent fat levels assessed by bioimpedance were not statistically different from percent fat calculated from skin fold measurements. Collectively, these data suggest that there is considerable central body fat accumulation in Yup’ik females. We estimated levels of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) using two-dimensional circular model equations and our waist circumference and abdominal skinfold data^[35]. From these calculations we can see that the total abdominal area (p≤0.05) and SAT (p≤0.001) in females is significantly greater than in males, while the visceral compartment area (p≤0.001) and VAT (p≤ 0.01) of males is significantly greater than in females. While these estimates are based on calculations derived from measurements of waist circumference and abdominal skinfold measurements, there is reasonable agreement between the circular model equations used in our analysis and MRI estimates of total abdominal area (r² = 0.98) and between subcutaneous abdominal area and MRI (r² = 0.72), but not between visceral compartment area calculations and MRI estimates (r² = 0.31). The prevalence of diabetes was low, 2.6% reported having type 2.

Genetics of obesity. We used two different approaches for the search of genes affecting obesity related traits: performing 1) a genome scan using variance component analysis (VCA), and 2) candidate gene analysis. In the following, we describe our preliminary results for both approaches.

Human Genome Screen of Chromosomes 3, 7, 10, and 17: For variance component analysis (VCA), currently a total of 7,926 relative pairs are available belonging to 56 pedigrees including 564 participants. Forty-five percent (25) of the pedigrees consisted of at least 6 individuals (range: 3-529; average: 22.5 participants). Preliminary linkage analysis was performed with markers from the ABI Prism Linkage Mapping Set vers. 2.5 (average distance: 10cM). All linkage analyses, quality control, and utility programming for pedigree preparation were performed at the EB Core^[36]. Phenotypic data were analyzed regarding normality and appropriate transformations were applied to reduce kurtosis and skewness. Results of multipoint analyses on selected obesity phenotypes (including age, sex, and BMI as covariates) are summarized in Figure 4 on the previous page. Even though maximum LOD scores in candidate regions were <3.0, we obtained remarkably high LOD scores for specific phenotypes in several candidate regions including: adiponectin levels and BMI on 3q28 at the adiponectin gene locus (LOD=1.9 and 1.0 respectively); fasting plasma glucose on 7q32 at the NRF1 locus (LOD=2.3) and near AMPK (7q36.1); BMI on 10p14 (LOD=1.4) and adiponectin level on 10q23 (LOD=1.4 at the SCD locus) respectively; percent body fat on 17p11.2 at the SREBF1 locus (LOD=1.6), with a smaller LOD score (1.0) at the GLUT 4 locus (17p13). VCA allows to investigate whether a specific gene affects multiple phenotypes, i.e., whether pleiotropy is present. When we included pleiotropy on BMI & HDL-cholesterol in our analysis, multipoint analysis resulted in an increased lod=2.1 on 10p14.

Resequencing progress: We have completed resequencing of the genes ADIPOQ, NRF1, HNF4A, and SLC2A4. Based on a calculated aggregate phenotype for obesity, 30 unrelated individuals (15 obese and 15 lean) were selected from seven villages for resequencing. 57 were selected for the analysis. 52 had Hardy Weinberg p value >5% and a minor allele frequency >1%; 22 (42%) had not been previously identified. A case control analysis with the resequenced samples revealed that two SNPs in the adiponectin gene were marginally significant (p=0.07).

To compare the transferability of tagSNPs from the HapMap to our study we determined how many of the SNPs identified in Yup’iks would have been tagged as proxies if we would have used the Chinese or Caucasian HapMap tagSNPs on Yup’ik samples. We used the Tagger server (http://www.broad.mit.edu/mpg/tagger/server.html) to determine the proportion of common Yup’ik SNPs (MAF>5%; 42 SNPs) that would have been captured with HapMap tagSNPs. The HapMap tagSNPs only pick up only 33% of the common variation found in the Yup’ik resequenced regions. However, the portability of the HapMap tagSNPs was highly dependent on the genomic region in our evaluation. For example, 60% of the common alleles would have been captured in SLC2A4, and 40% in HNF4A using a pairwise r² threshold of 0.8, but none of the common variation in NRF1 and ADIPOQ would have been captured by HapMap tagSNPs. Therefore, we conclude that it is very important to resequence our candidate genes in Yup’ik Eskimos.

Fasting glucose. We used ADA 2003 criteria (FG≥100 mg/dl) and HOMA-IR based on fasting glucose/insulin tests ^[37]and found the age-adjusted prevalences among non diabetic adults to be 78.5% normoglycemic (NG) and 21.5% to have impaired fasting glucose (IFG). The latter had a higher BMI, waist circumference, blood pressure, and were older (Table 3). This group also had higher total cholesterol, LDL, VLDL, and TG levels, but there were no significant differences regarding gender or HDL levels. We estimated HOMA-IR for 351 participants (fasting insulin levels are not yet available for the full study sample). HOMA-IR was significantly different among participants with normal BMI (2.7), versus those that are overweight (3.3) or obese (5.2; Exact Mann-Whitney with Bonferroni correction, nominal p≤0.02).

To follow up these findings, the EB Core leader and epidemiology consultants will design a case/control study during the current year for an exploratory grant submission to follow a group of participants who have had impaired fasting glucose and a random sample of normoglycemic participants. Results could then guide the development of a larger cohort study and for research to prevent the progression toward diabetes.

Nutrition and physical activity among CANHR participants. In this section, we summarize key findings that are relevant to the aims and hypotheses of the nutrition and physical activity component of CANHR I. These are results from analyses of 24-hour recalls from 576 participants and 3-day food records and pedometer logs from a sub-sample (n= 282). A considerable achievement of CANHR I was modifying existing nutritional instruments and data bases to better reflect the actual types of food intake of ANs.

A primary objective of the nutrition component was to assess the relationship between a Westernizing diet, diet quality and health. Significant differences were observed in nutrient intake and level of traditional food intake (Table 4). Although the majority of nutrient intakes were significantly higher among participants consuming the most traditional foods, intake of vitamin C, fiber, and calcium was notably lower among these participants.

Compared with a Western diet which emphasizes n-6 fatty acids (n-6 to n-3 ratio ~ 10-30:1 ^[38]) the traditional Alaska Native diet provided significantly more n-3 fatty acids, such that the ratio was closer to 1:1 in the diets of participants consuming more than 32% of their diet from traditional foods. The n-6 to n-3 ratio decreased with increasing quintile of traditional food intake, which is likely to have important health consequences (Figure 5) ^{[38, 39]}. Of particular interest, the percentage of EPA and DHA combined in the diet was significantly higher among participants in the highest (36.8%) versus lowest (3.9%) quintile of traditional food intake (P<0.001). Analyses of red blood cell membrane phospholipids support these findings. A more favorable lipid profile was observed in participants consuming a diet high in traditional foods. Traditional food intake was not related to adiposity or glucose control.

Age was the most important demographic predictor of traditional food intake.

Physical activity is at least as important to energy balance as diet, yet no study to date has objectively measured physical activity levels in an AN population. An analysis of pedometer data from 167 male and female participants showed that mean steps/day were significantly higher among men (9177 ± 3196 steps/day) compared with women (5823 ± 3308 steps/day) (P<0.001). A significant positive relationship was observed between pedometer-determined steps per day and health indicators among women. Among women, mean steps per day was significantly inversely correlated with BMI (r = -0.34), percent body fat (r = -0.36), and waist circumference (r = -0.37) (P<.001 for all), controlling for age. Fasting glucose was inversely (r = -0.30, P= 0.01) and HDL-C concentration was positively associated pedometer counts (r = 0.23, P= 0.03). Although these findings support the construct validity of using pedometers to measure physical activity in women, they may not adequately capture high intensity activities which may be more commonly practiced by men. More sophisticated physical activity techniques should be validated in this population.

By refining our ability to measure diet and physical activity in CANHR II, we can more fully understand the relationship between the biological, lifestyle and psychosocial changes associated with an epidemiological transition and health.

Psychosocial correlates of health markers. In the spring of 2003, information from six focus groups was analyzed to identify both major and sub- themes. The focus group analysis guided the study protocol and development of the Yup’ik Wellness Questionnaire. The details of our analysis can be found in Wolsko, Lardon, Hutchison, and Ruppert^[40].

Our sample consisted of 494 Yup’ik and Cup’ig participants. Two hundred eighty-nine (52%) participants were women; 205 (42%) were men. They ranged in age from 14 to 94 (M = 38.6, SD = 17.12). Our participants had completed an average of 10.2 years of schooling (SD = 3.04); 51% and 9% reported having completed 12 years of schooling and college, respectively.

The Yup’ik Wellness Questionnaire (YWQ) has 24 items describing activities, behaviors, and beliefs related to staying healthy and well in Yup’ik culture. Each item is rated on separately on Frequency Importance. Internal consistency was good, α=.82 for Frequency and α=.88 for Importance.

Other measures included a general question about happiness and linguistically adapted versions of Oetting and Beauvais’ measure of cultural orientation ^[41], the Perceived Stress Scale ^[42], the COPE ^[43], the Social Support Questionnaire ^[44], the Communal Mastery Scale ^[45], and the Self Mastery Scale ^[46].

The subscales of the YWQ correlated with age (r₍₄₉₁₎ = .21 for Frequency and r₍₄₉₀₎ = .31 for Importance). Not surprisingly, older participants scored higher on the Frequency and Importance subscales. Older participants identified more with a Yup’ik way of life. Women scored higher than men on Importance while men scored higher than women on a Euro-American cultural orientation, suggesting that women are more traditional in their cultural norms and beliefs. The lack of a significantly different score on the Wellness Frequency subscale suggests that men and women do not differ in the degree to which they practice Yup’ik health behaviors.

We examined the patterns of relationships between the YWQ and other culture-oriented measures. As expected, the correlations in Table 5 indicate positive relationships between Communal Mastery and a Yup’ik cultural orientation but absent or negative relationships with a Euro-American orientation. Stepwise regressions on both Wellness subscales show that these relationships are independent of age and gender. Analyses of our data also indicate that active coping, religion/spirituality, and social support are important constructs related to wellness in Yup’ik culture. Furthermore, Wellness Frequency and Importance predicted higher percent body fat in our sample, even when controlling for age and gender. On the other hand, neither Wellness subscale predicted total cholesterol.

Participants who felt more stressed and unable to handle personal problems over the past month displayed the following psychological profile: less satisfaction with their social support network, r(483)=-.12, p<.01; a weaker sense of personal mastery, r(492)=-.22, p<.001; greater sadness, r(491)=.48, p<.001, less vitality, r(490)=-.13, p<.01; and poorer overall physical health, r(492)=-.19, p<.001. Greater perceived stress was also associated with higher Body Mass Index, r(487)=.14, p<.01; greater percent body fat, r(487)=.15, p<.001; and elevated diastolic blood pressure, r(446)=.13, p<.01. The relationships between perceived stress and physiology remained significant when controlling for diet and exercise.

Wellness and health promotion: A model for preventive interventions. A culturally-based community development health promotion project (Piciryaratggun Calritllerkaq, or Healthy Living through a Healthy Lifestyle) targeted at increasing behaviors related to cardiovascular health (nutrition, physical activity, and stress) in one of the CANHR study villages is underway. The long-term goal is to develop this project into a model for conducting health promotion in the region. The project will examine the specific ways in which this approach to cardiovascular health can develop a local infrastructure, knowledge base, and process to encourage and maintain lifestyle improvements.

Piciryaratggun Calritllerkaq has utilized a CBPR process of engaging members of the community in identifying the health issues to focus on and in setting goals for health promotion ^[47-55]. For Piciryaratggun Calritllerkaq, three core elements are emphasized: (1) building infrastructure for health promotion; (2) developing local expertise in health promotion and community change; and (3) developing a process that combines elements of strategic planning, program evaluation, and health education with traditional Yup’ik health practices and leadership styles. An indication of our success in these elements is a recent independent grant for community health promotion awarded by the YKHC to our two village-based field research assistants.

The effectiveness on nutrition, physical activity, and stress of Piciryaratggun Calritllerkaq is being examined at six-month intervals to control for seasonal variations in subsistence lifestyle. Lardon has been awarded an R21 grant which will allow continued funding for Piciryaratggun Calritllerkaq.

Feedback from the participants of CANHR I
The evaluation of participants’ reactions indicated some important findings. Perhaps the most important was the perception that CANHR had attended very appropriately to linguistic and cultural factors and that this attention led to participants’ high satisfaction with the process. Most individuals (84%) chose to participate in the research because they were genuinely interested in learning more about their health status. Almost half sought diet and nutrition information, and more than a third wanted to contribute information that might further knowledge of AN health issues and lead to better prevention and treatment. Ninety-five percent of the respondents reported having learned “at least something” about their health, and 53% felt that they had learned “a lot.” The mean ranking by all respondents on this three-point scale is 2.5. Nearly all respondents (95%) considered their participation “worthwhile,” and more than half felt it was “quite valuable” to them (overall mean, 2.4). The three most useful benefits of participation all had to do with “learning”: about health status, about how to be healthy, and about healthy and unhealthy foods. It is important to note that by participating in epidemiological research, individuals indicated that they had used feedback to change their behavior.

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