Cardiometabolic Health Disparities in Native Hawaiians and OtherPacific Islanders

Marjorie K. Mau, Ka‘imi Sinclair, Erin P. Saito, Kau‘i N. Baumhofer, and Joseph Keawe‘aimokuKaholokulaCenter for Native and Pacific Health Disparities Research, Department of Native Hawaiian Health,John A. Burns School of Medicine, University of Hawai‘i at Manoa, Honolulu, Hawai‘i

AbstractElimination of health disparities in the United States is a national health priority. Cardiovasculardisease, diabetes, and obesity are key features of what is now referred to as the “cardiometabolicsyndrome,” which disproportionately affects racial/ethnic minority populations, including NativeHawaiians and other Pacific Islanders (NHOPI). Few studies have adequately characterized thecardiometabolic syndrome in high-risk populations such as NHOPI. The authors systematicallyassessed the existing literature on cardiometabolic disorders among NHOPI to understand the bestapproaches to eliminating cardiometabolic health disparities in this population. Articles wereidentified from database searches performed in PubMed and MEDLINE from January 1998 toDecember 2008; 43 studies were included in the review. There is growing confirmatory evidencethat NHOPI are one of the highest-risk populations for cardiometabolic diseases in the United States.Most studies found increased prevalences of diabetes, obesity, and cardiovascular risk factors amongNHOPI. The few experimental intervention studies found positive results. Methodological issuesincluded small sample sizes, sample bias, inappropriate racial/ethnic aggregation of NHOPI withAsians, and a limited number of intervention studies. Significant gaps remain in the understandingof cardiometabolic health disparities among NHOPI in the United States. More experimentalintervention studies are needed to examine promising approaches to reversing the rising tide ofcardiometabolic health disparities in NHOPI.

Keywordscardiovascular diseases; diabetes mellitus; healthcare disparities; health status disparities; metabolicsyndrome X; minority groups; minority health; obesity

INTRODUCTIONThe prevalence of cardiometabolic disorders, including cardiovascular disease, diabetes, andobesity, has reached epidemic proportions worldwide. Prevalences of diabetes andcardiovascular disease among ethnic minorities in the United States exceed those seen in thegeneral population (1–7). Because of the excess health burden of cardiovascular disease anddiabetes in ethnic minorities, cardiometabolic risk, as the precursor of these diseases, providesa specific target for conducting investigations that aim to reverse and/or eliminate these

© The Author 2009. Published by the Johns Hopkins Bloomberg School of Public Health.Correspondence to Dr. Marjorie K. Mau, Department of Native Hawaiian Health, John A. Burns School of Medicine, University ofHawai‘i at Manoa, 677 Ala Moana Blvd., Suite 1016B, Honolulu, HI 96813 (mmau@hawaii.edu).Conflict of interest: none declared.

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Published in final edited form as:Epidemiol Rev. 2009 ; 31: 113–129. doi:10.1093/ajerev/mxp004.

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disparities. Moreover, obesity, as one of the central pathophysiologic mechanisms underlyingthe syndrome of cardiometabolic risk, might constitute an earlier “upstream” target fortreatment and prevention that could be effective in reducing excess morbidity.

In this review, we focused on cardiometabolic health disparities among Native Hawaiians andother Pacific Islanders (NHOPI). As a federal designation, “Native Hawaiian or Other PacificIslander” refers to persons with origins in any of the original peoples of the islands of Polynesia,Micronesia, and Melanesia (8). The first Polynesian settlers of the Hawaiian Islands are thoughtto have migrated from the Marquesas Islands as early as 100 B.C.E., some 2,000 years ago(9). Hawaiians lived in isolation until 1778, when European explorers brought with them deadlyforeign infectious diseases that decimated the Native population. Colonization and the eventualoverthrow of the Hawaiian monarchy resulted in a loss of land and political power, as well astraditional practices and customs, including the near extinction of the Hawaiian language (9).

Events such as the cultural revival referred to as the “Hawaiian Renaissance,” the return of theisland of Kahoolawe to the Hawaiian people, the formation of political bodies such as the Officeof Hawaiian Affairs, the public recognition of the illegal overthrow of the Hawaiian monarchy,and the ongoing voyages of the Hokule‘a using historical navigation techniques of NativeHawaiians serve to highlight the resiliency and strength of this population. However, despitethese positive social and political developments, NHOPI are overrepresented in lowersocioeconomic groups, report greater difficulties in obtaining health care, and may be affectedby internalized racism as a consequence of their historical experience of disenfranchisementand loss of power within their traditional homeland (10–12). In addition, NHOPI continue tobear a disproportionate burden of disease, including cardiovascular disease and diabetes.

Today, the state of Hawai‘i has the largest population of Native Hawaiians in the United States,followed by California. Among ethnic subgroups in Hawai‘i, Native Hawaiians have thehighest prevalence of diagnosed diabetes (11.5%), with reported prevalences ranging from19% to 22% for type 2 diabetes and from 16% to 35% for impaired glucose tolerance (5,13,14). Cardiovascular disease mortality among Native Hawaiians in 2004 was more than twicethat in Japanese, who had the lowest rates (372 per 100,000 population vs. 167 per 100,000population), and diabetes-related mortality was 3 times higher in Native Hawaiians than inCaucasians (39 per 100,000 population vs. 13 per 100,000 population) (6). The NativeHawaiian Health Research (NHHR) Project examined the relation between a clustering ofcardiovascular risk factors and biochemical markers of insulin resistance (fasting insulin andC-peptide levels) (7). The investigators found that fasting insulin concentrations werecorrelated with body mass index, waist-to-hip ratio, blood pressure, and levels of triglyceride,high density lipoprotein cholesterol, and glucose. A significant correlation was also foundbetween increasing insulin resistance and increased clustering of cardiovascular disease riskfactors. The NHHR study, in addition to a limited number of other studies on NHOPI, suggeststhat significant disparities occur between and among these populations. The purpose of thisreview was to systematically assess the state of the science related to cardiovascular disease,diabetes, and adiposity among NHOPI.

METHODSDatabase searches were performed in PubMed and MED-LINE for the time period of January1998 to December 2008, with keyword combinations of the following racial/ethnic groups inan “OR” search term: Native Hawaiian, Hawaiian, Pacific Islander, Samoan, Tongan,Micronesian, New Zealand, Maori, Melanesia, Chamorro, Guamanian, Fijian, andPolynesian (Figure 1). The racial/ethnic groups were then included in combination with thefollowing terms defined as an “OR” function: minority, minorities, groups, ethnicity, andethnicities. The above racial/ethnic AND minorities search term was identified as a “Set A”

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keyword search. Results from the Set A keyword search were then combined with Set Bkeywords as an “OR” search term which included the following: inequity, inequality, healthdisparities, health differences, cardiovascular, hypertension, heart, heart failure, heartdisease, heart disease risk factors, cardiac, cardiomyopathy, diabetes, syndrome X, metabolicsyndrome, insulin resistance, glucose intolerance, prediabetes, cardiometabolic, obesity,adiposity, overweight, physical inactivity, physical activity, nutrition, diet, and smoking incombination with United States.

Additional studies (n = 21) were also extracted from the reference lists of the articles identifiedin the initial search using Set A AND Set B keywords; these studies were reviewed forinclusion/exclusion. The searches were restricted to English-language articles on humans aged≥19 years that had been published in peer-reviewed scientific journals. Articles were excludedfrom the review if they were letters, editorials, or literature reviews without new data; if theyhad been published in a foreign language; or if they were nonempirical.

Using this search strategy, we identified 311 citations, of which 98 were deemed relevantthrough review of the article title (performed by a single reviewer). All 98 articles underwentabstract review by 2 independent reviewers, using a standard checklist adapted from otherreviews of the health-disparities literature (15). Of the 98 abstracts reviewed, 71 articles wereselected for a full text review, which was performed by 2 independent reviewers to ensurecompliance with all inclusion criteria, as well as ranking on the following study design criteria:1) use of appropriate indicators for patient characteristics (e.g., race, ethnicity, or ancestry, sex,age, education, income); 2) inclusion of objective measures of the outcomes of interest (i.e.,measured height, weight, and systolic and diastolic blood pressure; self-report of or medicalchart review to determine obesity, cardiovascular disease, and/or diabetes status, etc.); 3)inclusion of well-defined measures of disease status; and 4) appropriate adjustment for patientcomorbid conditions (i.e., age, sex, body mass index for diabetes outcomes, blood pressure forcardiovascular outcomes, etc.).

After full text review, a joint review meeting was convened to determine the final selection ofarticles to be included in this study. A total of 28 articles were excluded for 1 or more of thefollowing reasons: 1) NHOPI were aggregated with other racial/ethnic groups (i.e., “Asiansand Pacific Islanders” was a single category) (18% of articles); 2) the article was a review oreditorial (36%); 3) the study included NHOPI but there was no specified outcome related tocardiometabolic diseases (21%); 4) the NHOPI study population lived outside of the UnitedStates (14%); 5) the study population was under age 19 years (i.e., children or youths) (7%);and 6) there was another miscellaneous reason for study exclusion (the article had beenpublished in a non-peer-reviewed journal, no NHOPI population was included, etc.) (4%).Thus, the final number of articles included in this literature review of cardiometabolic healthand health-care disparities among NHOPI was 43.

RESULTSCardiovascular disease

Study characteristics—A total of 12 papers pertaining to cardiovascular disease or its riskfactors were reviewed (Table 1). The majority of studies (n = 10) were cross-sectional. In 4 ofthe 10 cross-sectional studies, investigators had prospectively collected new data, and in 2 theyhad used retrospective data collected from administrative databases. A single prospective studyincluded a cohort that had been followed for over 4 years. One study included qualitative datacollected through focus groups of NHOPI. The only study in which researchers had proposedtesting an intervention had had a quasi-experimental, pre-post study design without controlsfor testing of a Native Hawaiian cultural intervention designed to improve hypertension

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profiles. Fifty percent of the papers included a study sample of at least 300 participants ofNHOPI ancestry.

Study findings—NHOPI women were found to have a high frequency of hypertension andhigh cholesterol in comparison with whites and other ethnic groups (16,17). Studies thatexamined hypertension along with other covariates in NHOPI found that hypertension wassignificantly related to degree of Hawaiian ancestry and especially diastolic blood pressureafter controlling for other covariates (18). The sole genetic study found that increased correctedQ–T interval (Q-Tc), which has been associated with heart disease and sudden death, wasassociated with the angiotensin-converting enzyme insertion/insertion (ACE II) genotype,which is found with greater frequency among Native Hawaiians than in other ethnic groups(19). Verderber et al. (20) compared post-coronary artery bypass graft (CABG) complicationsacross ethnic groups and found that NHOPI had similar early post-CABG complications (first20 hours after CABG) but experienced significantly more ventricular arrhythmias requiringmedical treatment on postoperative day 2 than Japanese. In another study, NHOPI men withacute coronary syndrome were significantly more likely to receive CABG (odds ratio = 1.8,95% confidence interval: 1.2, 2.7) and less likely to receive percutaneous coronary interventionfollowing their first hospitalization than were whites (21). No ethnic differences inendovascular treatment for acute coronary syndrome were found in women (21).

In the only longitudinal prospective cohort study, investigators were interested in examiningmeasures of socioeconomic status and cardiovascular disease risk factors in American Samoansversus Western Samoans. Ezeamama et al. (22) found that high socioeconomic status wasassociated with increased odds of cardiovascular disease risk factors in Western Samoa butdecreased odds in more developed American Samoa. The authors attributed this differentialeffect of socioeconomic status on cardiovascular disease risk factors to the heterogeneity acrossthe Samoan Islands in specific exposures to economic development and the natural history ofindividual cardiovascular disease risk profiles.

Study limitations—The cardiovascular disease literature reviewed had a number oflimitations. First, nearly all of the studies were observational studies with cross-sectional data,which does not permit a clear understanding of cause and effect for significant associationsbetween outcomes and exposures. Half of the studies reviewed had relatively small samplesizes or had serious sample biases that confounded the study’s findings. Finally, several of thestudies of sufficient quality were drawn from 2 research groups that have established cohortsin rural communities in Hawai‘i (Grandinetti et al. (19,23)) and in Western and AmericanSamoa (Ezeamama et al. (22)); those findings may not be generalizable to other NHOPIpopulations in the United States.

Type 2 diabetes mellitusStudy characteristics—A total of 16 diabetes-related studies were reviewed. Most werecross-sectional investigations (10 studies), although 1 study was descriptive and 2 wereretrospective (Table 2). Nine of the cross-sectional studies examined the population-based dataof the NHHR Project, including a quasi-experimental study that was a nonrandomizedconcurrent intervention which included Native Hawaiians with diabetes or at risk for diabetes.Another quasi-experimental study compared “before” and “after” hemoglobin A1c levels in asmall sample of Native Hawaiian, Samoan, and Tongan participants undergoing an interventiondelivered by community health workers. Sample sizes ranged from 78 participants to morethan 3,000. The 2 retrospective studies examined the incidence of macrosomia and gestationalhypertension among NHOPI women.

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Study findings—Among studies using the NHHR data, Grandinetti et al. (5) foundprevalences of type 2 diabetes and impaired glucose tolerance to be higher among NHOPI thanamong Caucasian participants. The overall prevalence of diabetes was 4 times higher in theNHHR participants than in the Second National Health and Nutrition Examination Surveypopulation, and the prevalence of diabetes was also significantly higher among full Hawaiiansthan among part-Hawaiians. In comparison with global estimates of standardized prevalencerates (24), 1 study revealed that the prevalences of diabetes and impaired glucose toleranceamong Hawaiians in the NHHR study were among the highest reported, except for Pima andNauruan populations (5). Grandinetti et al. (5) also found that the age-adjusted prevalence ofimpaired glucose tolerance was higher in Hawaiian women than in men and was significantlyassociated with measures of adiposity (i.e., body mass index, waist circumference, and waist-to-hip ratio). Similarly, Kaholokula et al. (18) reported that increased Hawaiian blood quantumwas significantly associated with higher fasting glucose concentration, body mass index, andwaist-to-hip ratio.

Three studies examined the relation between ethnicity, depressive symptoms, and diabetesamong NHHR participants. Among Native Hawaiians with diabetes, depressive symptomswere associated with poorer physical functioning, poorer perception of general health, moresevere and limiting bodily pains, less energy, and more emotional problems (25). NHHRparticipants with elevated hemoglobin A1c levels reported more depressive symptoms and alower quality of life than participants with normal hemoglobin A1c levels (26,27). Anothercross-sectional study of NHHR participants examined dietary patterns, ethnicity, and theprevalence of diabetes and found that consumption of local ethnic foods was positivelycorrelated with body mass index, smoking, waist-to-hip ratio, fasting glucose, and 2-hourglucose (28). Native Hawaiians were found to have significantly higher consumption of thesefoods and the highest total energy intake in comparison with all other ethnic groups. Theseresults suggest that total energy intake may be a more significant risk factor for diabetes thana specific dietary pattern among Native Hawaiians (28). In the nonrandomized concurrentintervention study that enrolled Native Hawaiians with diabetes or at risk for diabetes,participants in a family support intervention were more likely than a standard interventiongroup to advance from the pre-action stage of change to the action/maintenance stage withregard to fat intake and physical activity (29).

Three additional studies examined diabetes-related conditions. Mau et al. (30) found that theprevalence of chronic kidney disease was higher among Native Hawaiians than among Asianand Pacific Islander participants in the National Kidney Foundation’s Kidney Early EvaluationProgram community screening. In a retrospective study of perinatal outcomes in NHOPIwomen by Silva et al. (31), a higher percentage of NHOPI women required insulin duringpregnancy and before 20 weeks’ gestation, suggesting that there may be a larger subset ofNHOPI women with preexisting undiagnosed diabetes.

Study limitations—A major limitation of the diabetes-related research with NHOPIpopulations is the lack of studies that have tested the efficacy of interventions. A large numberof studies were observational, cross-sectional studies that precluded causal inferences. Severalof the studies also had small sample sizes, resulting in limited generalizability.

ObesityStudy characteristics—There were 15 obesity-related studies reviewed (Table 3). Fourstudies examined data from the Multiethnic Cohort Study, a population-based cohort studydesigned to examine risk factors for cancer (i.e., obesity) that included Asian, black, Hawaiian,Latino, and white adults from Hawai‘i and California. One additional study was a population-based prospective cohort study of ethnic groups residing in Hawai‘i. Another study pooled data

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from 18 population-based epidemiologic studies conducted in Hawai‘i over a period of 25years to examine trends in body mass index among different ethnic groups in Hawai‘i and toexplore associations between food intake and excess weight. Seven studies were cross-sectional. Two studies, 1 cross-sectional and 1 longitudinal, examined genetic associationswith body mass index among Samoans residing in American Samoa. One study was qualitative;the researchers conducted focus groups with 32 Native Hawaiian community college studentsto explore facilitators and barriers to living a healthy lifestyle.

Study findings—Prevalences of overweight and obesity were consistently higher amongNative Hawaiians than in other ethnic groups (whites, blacks, Latinos, Asians, and Filipinos)across studies. Grandinetti et al. (32) reported a combined prevalence of 82% for overweightand obesity in NHHR study participants, as compared with a national prevalence of 53%; 49%were obese as compared with 21% nationally. Body mass index was also higher in personswith an ethnic admixture that included Native Hawaiian ancestry, as compared with most otherethnic combinations (32,33). In pooled data from 18 population-based studies carried out over25 years, Native Hawaiians had the highest prevalence of excess weight at all times (34).

Energy intake was consistently higher among NHOPI than in other ethnic groups in Hawai‘i.Both the NHHR and Multiethnic Cohort studies found that total dietary energy intake wassignificantly associated with Native Hawaiian ancestry and increased body mass index (32,34). In 2 large population-based prospective studies, Native Hawaiians had the highest chronicdisease risk scores in comparison with other ethnic groups, primarily because of highprevalences of overweight and obesity, higher rates of smoking, and chronic alcohol use (35).In the NHHR study, increased body weight was strongly associated with glucose intolerance(5). Despite the high prevalence of overweight and obesity, NHOPI reported a higherprevalence of physical activity in the 2001 Hawai‘i Behavioral Risk Factor SurveillanceSystem survey than did other ethnic groups (36).

Study limitations—The obesity-related studies reviewed had several limitations. First, thecross-sectional design of many of the studies did not allow for determination of causal relations.Second, many of the studies were questionnaire-based and may have been vulnerable to recallbias or a propensity towards giving socially desirable answers. Finally, investigators in severalstudies were unable to measure confounding variables, which limited the potential forunderstanding the true association between exposure and disease.

DISCUSSIONStudies of cardiometabolic disparities among NHOPI are sparse. The 43 studies in this reviewwere published in the last 10 years and provide growing evidence that NHOPI are one of thehighest-risk US populations affected by cardio-metabolic diseases. Some progress has beenmade in addressing these disparities, as evidenced by the handful of studies that have shiftedfrom observational research towards program development and then to experimental andclinical trial-type studies that include NHOPI. However, there were a number ofmethodological issues apparent during the course of this literature review. For example, therewere several studies that were limited by sample bias (convenience samples, etc.) and relativelysmall sample sizes (i.e., <50 subjects). NHOPI comprise less than 1% of the US population,and thus recruitment of NHOPI into research studies remains a challenge. Despite thesechallenges, a number of research teams have been successful in enrolling sufficient-sizedsamples or have taken advantage of existing data or administrative databases to betterunderstand cardiometabolic diseases in this population. Moreover, recent developments in theuse of community engagement approaches have served to increase the participation of thispopulation in research activities and ensure that studies are relevant and translatable to NHOPIcommunities.

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Aggregation of NHOPI with Asian Americans in several publications limited the number ofavailable studies for this review. There was also a paucity of experimental studies that wereadequately designed to reduce treatment bias (i.e., randomization) and longitudinal prospectivecohort studies that would allow elucidation of cause-and-effect relations in cardiometabolicdiseases. However, a few focus groups and quasi-experimental studies provided preliminarydata that offer potential for designing intervention studies in the future.

Several studies (29,37–40) provided initial insights on promising approaches in NHOPIpopulations, such as social and/or family support and the inclusion of cultural and/or traditionalhealing methods as alternatives or supplements to conventional medical regimens. Otherstudies provided empirical evidence with which to develop scientifically informed andculturally specific diet-based interventions for prevention and treatment of cardiometabolicdisparities. Health care differences in cardiovascular disease treatment suggest that more studyis needed in order to determine the best medical treatments for high-risk ethnic groups such asNHOPI (20,21). Further investigation is needed to examine both provider factors and patientfactors that may underlie the treatment differentials between patients who may receive differenttreatments and hence have different outcomes.

There remain significant gaps in our understanding as to why cardiometabolic diseases occurmore frequently in the NHOPI population in the United States (Figure 2). Any number offactors, alone or in combination, may contribute to the creation of disparities in health withinthis population. Compared with most other US ethnic groups, NHOPI are overrepresented inthe lower socioeconomic strata, under-represented in higher education, and more likely to bemarginalized from the larger society (41). Behavioral risk factors for diabetes andcardiovascular disease, such as tobacco use and psychological distress, are highly prevalent inNHOPI (42). In the case of Native Hawaiians, many health professionals have suggested thatthe health disparities experienced by Native Hawaiians are associated with their lower socialstatus and adverse historical relations with Western governments (43,44). Thus, it would seemappropriate in future studies to explore psychosocial stressors that may contribute to healthdisparities in NHOPI.

Future research aimed at eliminating cardiometabolic disparities in health and health careamong NHOPI needs to move beyond observational studies into intervention studies that willengage NHOPI communities in the process while maintaining scientific rigor. Researchersshould consider the whole spectrum of types of scientific studies—ranging from genetic, benchstudies to clinical studies to effectiveness studies that test interventions in real-world settings.NHOPI can participate in this research not only as study subjects but also as investigators. Inthis way, they can both obtain health equity and, more importantly, help to promote health andwellness for all.

Abbreviations

CABG coronary artery bypass graft

NHHR Native Hawaiian Health Research

NHOPI Native Hawaiians and other Pacific Islanders

AcknowledgmentsThis work was supported by the Center for Native and Pacific Health Disparities Research, Department of NativeHawaiian Health, John A. Burns School of Medicine, University of Hawai‘i at Manoa; The Myron Pinky ThompsonEndowed Chair (grant S21 MD 000228); the National Center on Minority Health and Health Disparities (grants P20MD000173 and R24 MD 001660); and the National Heart, Lung, and Blood Institute (grant U01HL 079163).

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48. Grandinetti A, Chang HK, Theriault A, et al. Metabolic syndrome in a multiethnic population in ruralHawaii. Ethn Dis 2005;15(2):233–237. [PubMed: 15825969]

49. Wu PL, Sadler GR, Nguyen V, et al. Diabetes management in San Diego’s Chamorro community.Diabetes Educ 2005;31(3):379–390. [PubMed: 15919638]

50. Beckham S, Bradley S, Washburn A, et al. Diabetes management: utilizing community health workersin a Hawaiian/Samoan population. J Health Care Poor Underserved 2008;19(2):416–427. [PubMed:18469413]

51. Kaholokula JK, Nacapoy AH, Grandinetti A, et al. Association between acculturation modes and type2 diabetes among Native Hawaiians. Diabetes Care 2008;31(4):698–700. [PubMed: 18202248]

52. Maskarinec G, Meng L, Kolonel L. Alcohol intake, body weight, and mortality in a multiethnicprospective cohort. Epidemiology 1998;9(6):654–661. [PubMed: 9799177]

53. Galanis DJ, McGarvey ST, Quested C, et al. Dietary intake of modernizing Samoans: implicationsfor risk of cardiovascular disease. J Am Diet Assoc 1999;99(2):184–190. [PubMed: 9972185]

54. McGarvey ST, Forrest W, Weeks DE, et al. Human leptin locus (LEP) alleles and BMI in Samoans.Int J Obes Relat Metab Disord 2002;26(6):783–788. [PubMed: 12037648]

55. Henderson KD, Goran MI, Kolonel LN, et al. Ethnic disparity in the relationship between obesityand plasma insulin-like growth factors: the Multiethnic Cohort. Cancer Epidemiol Biomarkers Prev2006;15(11):2298–2302. [PubMed: 17119061]

56. Howarth NC, Murphy SP, Wilkens LR, et al. Dietary energy density is associated with overweightstatus among 5 ethnic groups in the Multiethnic Cohort Study. J Nutr 2006;136(8):2243–2248.[PubMed: 16857848]

57. Dai F, Keighley ED, Sun G, et al. Genome-wide scan for adiposity-related phenotypes in adults fromAmerican Samoa. Int J Obes (Lond) 2007;31(12):1832–1842. [PubMed: 17621312]

58. Novotny R, Nabokov V, Derauf C, et al. BMI and waist circumference as indicators of health amongSamoan women. Obesity (Silver Spring) 2007;15(8):1913–1917. [PubMed: 17712106]

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Figure 1.Procedures used to review the literature on cardiometabolic health disparities among NativeHawaiians and other Pacific Islanders, January 1998–December 2008. Set A: inclusion ofNative Hawaiian, Hawaiian, Pacific Islander, Samoan, Tongan, Micronesian, New Zealand,Maori, Melanesia, Chamorro, Guamanian, Fijian, and Polynesian in an “OR” search termalong with the following racial/ethnic terms: minority, minorities, groups, ethnicity, andethnicities, defined as an “OR” search term. Set B: inequity, inequality, health disparities,health differences, cardiovascular, hypertension, heart, heart failure, heart disease, heartdisease risk factors, cardiac, cardiomyopathy, diabetes, syndrome X, metabolic syndrome,insulin resistance, glucose intolerance, prediabetes, cardiometabolic, obesity, adiposity,overweight, physical inactivity, physical activity, nutrition, diet, and smoking in combinationwith United States.

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Figure 2.Conceptual model of health and health-care disparities.

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Mau et al. Page 13

Tabl

e 1

Lite

ratu

re o

n C

ardi

ovas

cula

r Hea

lth D

ispa

ritie

s Am

ong

Nat

ive

Haw

aiia

ns a

nd O

ther

Pac

ific

Isla

nder

s, Ja

nuar

y 19

98–D

ecem

ber 2

008

Stud

y A

utho

rsan

dY

ear

(Ref

. No.

)Sa

mpl

e an

dN

o. o

f Sub

ject

s

% o

fT

otal

Sam

ple

Who

Wer

eN

HO

PI

Age

,ye

ars

Stud

y D

esig

nM

ain

Goa

l and

Out

com

es/F

indi

ngs

Lim

itatio

ns

Nov

otny

et a

l., 1

998

(16)

66 N

ativ

e H

awai

ian

wom

en o

ut o

f a to

tal m

ultie

thni

c s

ampl

e of

421

1625

–35

Obs

erva

tiona

l, cr

oss-

sect

iona

l, c

linic

al re

sear

ch sa

mpl

eEx

amin

e an

thro

pom

etric

var

iatio

ns b

etw

een

mul

tieth

nic

wom

en a

nd th

eir

rel

atio

n to

blo

od p

ress

ure

and

cho

lest

erol

.

Sam

ple b

ias;

rela

tivel

y sm

all s

tudy

.

Nat

ive

Haw

aiia

n w

omen

had

the

high

est

mea

sure

s of a

dipo

sity

. Cho

lest

erol

was

not

ass

ocia

ted

with

adi

posi

ty. B

lood

pre

ssur

e w

as a

ssoc

iate

d w

ith a

dipo

sity

but

did

not

var

y by

eth

nici

ty.

Ver

derb

er e

t al.,

199

9 (2

0)23

Pac

ific

Isla

nder

s out

of

a to

tal m

ultie

thni

c sa

mpl

e o

f 60

3840

–85

Obs

erva

tiona

l, cr

oss-

sect

iona

l, h

ospi

tal s

urge

ry sa

mpl

eD

escr

ibe

risk

fact

ors f

or c

ardi

ac d

isea

se a

nd p

ost-C

AB

G o

utco

mes

and

com

plic

atio

ns in

mul

tieth

nic

patie

nts.

Sam

ple

bias

(sin

gle

hosp

ital,

rela

tivel

y s

mal

l sam

ple)

. No

adju

stm

ent f

or p

hysi

cian

as c

ovar

iate

.N

o et

hnic

diff

eren

ces i

n po

stop

erat

ive

com

plic

atio

ns in

firs

t 20

hour

s. A

t 48

hou

rs p

ost-C

AB

G, P

acifi

c Is

land

ers

req

uire

d si

gnifi

cant

ly m

ore

care

than

Jap

anes

e (P

< 0

.01)

.

Taira

et a

l., 2

001

(21)

361

Nat

ive

Haw

aiia

ns o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 2

,962

11≥1

8O

bser

vatio

nal,

cros

s-se

ctio

nal,

adm

inis

trativ

e da

taba

se s

ampl

e

Exam

ine

diff

eren

ces i

n re

vasc

ular

izat

ion

and

mor

talit

y ra

tes f

ollo

win

g ac

ute

cor

onar

y sy

ndro

me

in a

mul

tieth

nic

pat

ient

pop

ulat

ion.

Cro

ss-s

ectio

nal;

clai

ms d

ata

fro

m si

ngle

hea

lth in

sure

r.

Ethn

ic d

iffer

ence

s in

type

s of p

roce

dure

s r

ecei

ved

wer

e si

gnifi

cant

onl

y fo

r men

. N

ativ

e H

awai

ian

men

wer

e le

ss li

kely

to r

ecei

ve p

ercu

tane

ous c

oron

ary

int

erve

ntio

n (a

djus

ted

OR

= 0

.51,

95%

CI:

0.34

, 0.7

5) a

nd m

ore

likel

y to

rece

ive

CA

BG

(adj

uste

d O

R =

1.8

, 95%

CI:

1.2,

2.7

) tha

n w

hite

s. N

o si

gnifi

cant

eth

nic

diff

eren

ces i

n w

omen

.

Gra

ndin

etti

et a

l., 2

002

(18)

572

Nat

ive

Haw

aiia

ns;

non

preg

nant

100

≥30

Obs

erva

tiona

l, re

trosp

ectiv

e c

ohor

t, po

pula

tion-

base

d s

ampl

e

Exam

ine

degr

ee o

f Haw

aiia

n an

cest

ry a

nd b

lood

pre

ssur

e an

d re

latio

n to

oth

er c

ovar

iate

s.

Perc

enta

ge o

f Haw

aiia

n an

cest

ry w

as se

lf-re

porte

d; c

ross

-sec

tiona

l d

esig

n; sa

mpl

e po

pula

tion

only

from

rur

al lo

catio

n. A

sses

smen

t of

ade

quat

e bl

ood

pres

sure

con

trol

with

med

icat

ions

not

des

crib

ed.

Adj

uste

d pr

eval

ence

of h

yper

tens

ion

inc

reas

ed w

ith d

egre

e of

Haw

aiia

n a

nces

try, e

xcep

t for

100

% H

awai

ian

anc

estry

. Haw

aiia

n an

cest

ry w

as s

igni

fican

tly a

ssoc

iate

d w

ith sy

stol

ic a

nd d

iast

olic

blo

od p

ress

ure

(P <

0.0

001)

. A

fter a

djus

tmen

t for

all

sign

ifica

nt

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Mau et al. Page 14

Stud

y A

utho

rsan

dY

ear

(Ref

. No.

)Sa

mpl

e an

dN

o. o

f Sub

ject

s

% o

fT

otal

Sam

ple

Who

Wer

eN

HO

PI

Age

,ye

ars

Stud

y D

esig

nM

ain

Goa

l and

Out

com

es/F

indi

ngs

Lim

itatio

ns

cov

aria

tes,

only

dia

stol

ic b

lood

pre

ssur

e w

as a

ssoc

iate

d w

ith H

awai

ian

ance

stry

(P

= 0.

008)

.

Sund

aram

et a

l., 2

005

(17)

510

NH

OPI

wom

en o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 1

20,0

35

<1≥1

8O

bser

vatio

nal,

cros

s-se

ctio

nal

tel

epho

ne su

rvey

, 200

1 B

RFS

S

Det

erm

ine

prev

alen

ce o

f car

diov

ascu

lar

dis

ease

risk

fact

ors a

mon

g m

ultie

thni

c w

omen

in 2

001

BR

FSS.

All

data

wer

e se

lf-re

porte

d. C

ross

- s

ectio

nal;

rela

tivel

y sm

all s

ampl

e c

ompa

red

with

oth

er e

thni

cgr

oups

.N

HO

PI w

omen

had

seco

nd h

ighe

st p

reva

lenc

e of

hyp

erte

nsio

n at

33.

7% (

age-

adju

sted

) and

hig

hest

pre

vale

nce

of h

igh

chol

este

rol (

23.9

%).

Yeo

et a

l., 2

005

(45)

377

Paci

fic Is

land

ers o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 2

,598

14≥1

8O

bser

vatio

nal,

case

-con

trol,

hos

pita

l adm

inis

trativ

e d

atab

ase

sam

ple

Exam

ine

ethn

ic d

iffer

ence

s in

per

cuta

neou

s cor

onar

y in

terv

entio

n s

ucce

ss a

nd/o

r com

plic

atio

ns in

hos

pita

lized

pat

ient

s.

Sam

ple

bias

(rec

ruite

d fr

om a

sing

le h

ospi

tal).

Cro

ss-s

ectio

nal d

ata;

no

lon

g-te

rm o

utco

mes

ava

ilabl

e.

Des

pite

hig

her r

ates

of d

iabe

tes,

hyp

erte

nsio

n, o

besi

ty, a

nd re

nal f

ailu

re in

NH

OPI

, the

re w

as n

o di

ffer

ence

in p

ercu

tane

ous c

oron

ary

inte

rven

tion

com

plic

atio

ns c

ompa

red

with

whi

tes o

r J

apan

ese.

Chi

em e

t al.,

200

6 (4

6)22

8 C

ham

orro

s10

0≥1

8O

bser

vatio

nal,

cros

s- s

ectio

nal t

elep

hone

surv

ey,

com

mun

ity a

dmin

istra

tive

dat

abas

e sa

mpl

e

Des

crib

e ca

rdio

vasc

ular

dis

ease

risk

fac

tors

in C

ham

orro

com

mun

ity to

aid

in d

evel

opin

g pr

ogra

ms.

Sam

ple

bias

(rec

ruite

d fr

omco

mm

unity

dat

abas

e). N

o ad

just

men

t for

cov

aria

tes.

Cro

ss-s

ectio

nal d

ata.

Sel

f-re

porte

d he

alth

risk

fact

ors.

Cru

de fr

eque

ncie

s of h

yper

tens

ion,

dia

bete

s, hy

perli

pide

mia

, and

phy

sica

l i

nact

ivity

wer

e hi

gher

in C

ham

orro

s tha

n i

n U

S w

hite

s. C

ham

orro

wom

en w

ere

mor

e lik

ely

to h

ave

hype

rtens

ion

and

dia

bete

s. M

en w

ere

mor

e lik

ely

to h

ave

ele

vate

d bo

dy m

ass i

ndex

and

cho

lest

erol

.

Ezea

mam

a et

al.,

200

6 (2

2)1,

289

Sam

oans

(Am

eric

an a

nd W

este

rn S

amoa

n)10

025

–58

Obs

erva

tiona

l, pr

ospe

ctiv

e c

ohor

t, po

pula

tion-

base

d s

ampl

e

Inve

stig

ate

cros

s-se

ctio

nal a

nd p

rosp

ectiv

e as

soci

atio

ns b

etw

een

SES

and

car

diov

ascu

lar d

isea

se ri

sk fa

ctor

s a

nd p

redi

ct th

e pr

obab

ility

of r

isk

fact

ors

by

SES

leve

l bet

wee

n A

mer

ican

Sam

oa a

nd S

amoa

.

Rel

ativ

ely

larg

e sa

mpl

e of

Sam

oan

par

ticip

ants

; sub

ject

s wer

eyo

unge

r a

nd th

us th

ere w

ere f

ewer

case

s of

car

diov

ascu

lar d

isea

se ri

sk fa

ctor

s. M

en lo

st to

follo

w-u

p in

bot

h l

ocat

ions

wer

e m

ore

likel

y to

be

em

ploy

ed in

the

wag

e-la

bor

mar

ket

and

may

hav

e in

trodu

ced

attri

tion

bia

s.

Hig

h SE

S w

as a

ssoc

iate

d w

ith in

crea

sed

odd

s of r

isk

fact

ors i

n le

ss d

evel

oped

Wes

tern

Sam

oa a

nd d

ecre

ased

odd

s of

ris

k fa

ctor

s in

mor

e de

velo

ped

Am

eric

an S

amoa

. Inv

erse

ass

ocia

tion

betw

een

SES

and

risk

fact

ors i

n W

este

rn S

amoa

vs.

Am

eric

an S

amoa

is a

ttrib

utab

le to

het

erog

enei

ty a

cros

s the

Sam

oan

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Stud

y A

utho

rsan

dY

ear

(Ref

. No.

)Sa

mpl

e an

dN

o. o

f Sub

ject

s

% o

fT

otal

Sam

ple

Who

Wer

eN

HO

PI

Age

,ye

ars

Stud

y D

esig

nM

ain

Goa

l and

Out

com

es/F

indi

ngs

Lim

itatio

ns

Isl

ands

in sp

ecifi

c ex

posu

res t

o e

cono

mic

dev

elop

men

t and

nat

ural

his

tory

of i

ndiv

idua

l ris

k fa

ctor

s.

Gra

ndin

etti

et a

l., 2

006

(19)

185

Nat

ive

Haw

aiia

ns o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 5

88; n

onpr

egna

nt

31≥3

0O

bser

vatio

nal,

retro

spec

tive

coh

ort;

rand

omly

sele

cted

nes

ted

stud

y of

pop

ulat

ion-

bas

ed sa

mpl

e

Exam

ine

angi

oten

sin-

conv

ertin

g e

nzym

e ge

ne p

olym

orph

ism

s and

inc

reas

ed Q

-Tc

(ass

ocia

ted

with

hea

rt d

isea

se) b

etw

een

ethn

ic g

roup

s.

Cro

ss-s

ectio

nal p

reva

lenc

e C

ases

may

lead

to b

ias.

Incr

ease

d Q

-Tc

was

hig

hest

am

ong

per

sons

with

the

ACE

II g

enot

ype.

AC

E II

gen

otyp

e w

as h

ighe

r in

Nat

ive

Haw

aiia

ns (

50.3

%) t

han

in w

hite

s (21

%).

Afte

r a

djus

tmen

t, pr

eval

ence

of i

ncre

ased

Q-

Tc

was

sign

ifica

ntly

ass

ocia

ted

with

AC

E I

I gen

otyp

e in

depe

nden

tly o

f eth

nici

ty (

P <

0.01

).

Kre

tzer

et a

l., 2

007

(40)

15 N

ativ

e H

awai

ians

out

of

a to

tal m

ultie

thni

c sa

mpl

e o

f 23

65≥3

0Q

uasi

-exp

erim

enta

l (no

con

trol g

roup

), pr

e-po

st i

nter

vent

ion,

com

mun

ity s

ampl

e

Eval

uate

whe

ther

a c

lass

on

self-

iden

tity

via

ho‘

opon

opon

o w

ould

impr

ove

high

blo

od p

ress

ure.

No

cont

rol g

roup

, sm

all s

ampl

esi

ze,

and

pot

entia

lly b

iase

d sa

mpl

e. N

o a

djus

tmen

t for

med

icat

ion

chan

ges.

Ho‘

opon

opon

o in

terv

entio

n (4

-hou

r g

roup

cla

ss) r

educ

ed m

ean

syst

olic

and

dia

stol

ic b

lood

pre

ssur

e, w

hich

was

sus

tain

ed fo

r 2 m

onth

s afte

r int

erve

ntio

n. R

esul

ts fo

r the

15

Nat

ive

Haw

aiia

ns w

ere

agg

rega

ted

with

thos

e fo

r the

rem

aini

ng 8

oth

er n

on-H

awai

ian

parti

cipa

nts.

Taira

et a

l., 2

007

(47

)3,

746

Nat

ive

Haw

aiia

ns o

ut o

f a to

tal m

ultie

thni

c s

ampl

e of

28,

395

13≥1

8O

bser

vatio

nal,

cros

s- s

ectio

nal;

heal

th in

sura

nce

adm

inis

trativ

e da

taba

se s

ampl

e

Exam

ine

fact

ors a

ssoc

iate

d w

ith a

ntih

yper

tens

ive

med

icat

ion

adhe

renc

e w

ithin

a m

ultie

thni

c pa

tient

pop

ulat

ion

usi

ng a

dmin

istra

tive

clai

ms d

ata.

Cro

ss-s

ectio

nal c

laim

s dat

a fr

om a

sing

le h

ealth

insu

ranc

e pl

an.

Pat

ient

adh

eren

ce w

as m

easu

red

by fill

ing

of p

resc

riptio

ns, n

ot a

tpa

tient

lev

el. L

ack

of in

form

atio

n on

impa

ct o

f com

orbi

d co

nditi

ons o

n m

edic

atio

n ad

here

nce.

Ove

rall

adhe

renc

e in

all

ethn

ic g

roup

s w

as le

ss th

an 6

5%. A

fter a

djus

tmen

t, N

ativ

e H

awai

ians

wer

e le

ss li

kely

to a

dher

e th

an w

hite

s (O

R =

0.8

4, 9

5% C

I: 0

.78,

0.9

1), a

nd th

is w

as c

onsi

sten

t a

cros

s the

rape

utic

cla

sses

. Oth

er p

atie

nt f

acto

rs a

ssoc

iate

d w

ith lo

wer

adh

eren

ce:

you

nger

age

, hig

her m

orbi

dity

, and

his

tory

of h

eart

dise

ase.

See

ing

a p

hysi

cian

of t

he sa

me

ethn

icity

did

not

im

prov

e ad

here

nce.

Kah

olok

ula

et a

l., 2

008

(39)

36 N

HO

PI a

nd fa

mily

car

egiv

ers

100

≥18

Focu

s gro

up, c

omm

unity

sam

ple

Iden

tify

heal

th b

elie

fs, a

ttitu

des,

pra

ctic

es, a

nd so

cial

and

fam

ily re

latio

ns i

mpo

rtant

in h

eart

failu

re tr

eatm

ent

am

ong

NH

OPI

.

Smal

l sam

ple

size

, and

onl

y 30

% w

ere

hear

t fai

lure

pat

ient

s. Q

ualit

ativ

e st

udy

desi

gn w

ith p

oten

tially

subj

ectiv

e re

spon

ses.

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 16

Stud

y A

utho

rsan

dY

ear

(Ref

. No.

)Sa

mpl

e an

dN

o. o

f Sub

ject

s

% o

fT

otal

Sam

ple

Who

Wer

eN

HO

PI

Age

,ye

ars

Stud

y D

esig

nM

ain

Goa

l and

Out

com

es/F

indi

ngs

Lim

itatio

ns

Nat

ive

Haw

aiia

ns w

ith h

eart

failu

re r

epor

ted

copi

ng e

xper

ienc

es o

f den

ial o

f i

llnes

s, ho

pele

ssne

ss, a

nd d

espa

ir an

d r

elie

d on

spiri

tual

/relig

ious

bel

iefs

for

sup

port.

Sam

oans

pre

ferr

ed b

eing

tre

ated

by

phys

icia

ns, w

hile

Nat

ive

Haw

aiia

ns p

refe

rred

trad

ition

al h

eale

rs.

Bar

riers

to h

eart

failu

re c

are

incl

ude

poor

kno

wle

dge,

lack

of t

rust

of t

he p

hysi

cian

, a

poo

r pat

ient

-phy

sici

an re

latio

nshi

p, f

inan

ces,

diet

ary

chan

ges,

and

incr

ease

d d

eman

ds o

n tim

e.

Abb

revi

atio

ns: A

CE

II, a

ngio

tens

in-c

onve

rting

enz

yme

inse

rtion

/inse

rtion

; BR

FSS,

Beh

avio

ral R

isk

Fact

or S

urve

illan

ce S

yste

m; C

AB

G, c

oron

ary

arte

ry b

ypas

s gra

ft; C

I, co

nfid

ence

inte

rval

; NH

OPI

, Nat

ive

Haw

aiia

ns a

nd o

ther

Pac

ific

Isla

nder

s; O

R, o

dds r

atio

; Q-T

c, c

orre

cted

Q–T

inte

rval

; SES

, soc

ioec

onom

ic st

atus

.

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 17

Tabl

e 2

Lite

ratu

re o

n D

iabe

tes H

ealth

Dis

parit

ies A

mon

g N

ativ

e H

awai

ians

and

Oth

er P

acifi

c Is

land

ers,

Janu

ary

1998

–Dec

embe

r 200

8

Stud

y A

utho

rs a

ndY

ear

(Ref

. No.

)Sa

mpl

e an

dN

o. o

f Sub

ject

s%

of T

otal

Sam

ple

Who

Wer

e N

HO

PIA

ge,

year

sSt

udy

Des

ign

Mai

n G

oal a

ndO

utco

mes

/Fin

ding

sL

imita

tions

Gra

ndin

etti

et a

l., 1

998

(5)

574

Nat

ive

Haw

aiia

ns fr

om 2

rur

al c

omm

uniti

es in

Haw

ai‘i;

non

preg

nant

100

≥30

Obs

erva

tiona

l, re

trosp

ectiv

e c

ohor

t, po

pula

tion-

base

d s

ampl

e

To e

stim

ate

prev

alen

ces o

f typ

e 2

dia

bete

s and

impa

ired

gluc

ose

tol

eran

ce.

Cro

ss-s

ectio

nal;

self-

repo

rted

anc

estry

, con

tribu

ting

to p

ossi

ble

mis

clas

sific

atio

n.

Prev

alen

ce o

f im

paire

d gl

ucos

e t

oler

ance

was

16%

; dia

bete

s, 20

%.

Pre

vale

nce

of im

paire

d gl

ucos

e t

oler

ance

was

sign

ifica

ntly

hig

her i

n w

omen

and

sign

ifica

ntly

ass

ocia

ted

with

bod

y m

ass i

ndex

, wai

st c

ircum

fere

nce,

and

wai

st-to

-hip

ratio

. A

ge-a

djus

ted

prev

alen

ce o

f dia

bete

s w

as 4

tim

es h

ighe

r tha

n in

the

Sec

ond

Nat

iona

l Hea

lth a

nd N

utrit

ion

Exam

inat

ion

Surv

ey p

opul

atio

n.

Gra

ndin

etti

et a

l., 2

000

(26)

581

Nat

ive

Haw

aiia

ns fr

om 2

rur

al c

omm

uniti

es in

Haw

ai‘i;

non

preg

nant

100

≥30

Obs

erva

tiona

l, re

trosp

ectiv

e c

ohor

t, po

pula

tion-

base

d a

mpl

e

To e

xam

ine

the

asso

ciat

ion

betw

een

dia

bete

s and

CES

-D d

epre

ssiv

e s

ympt

oms.

Cro

ss-s

ectio

nal d

esig

n; th

us, t

he t

empo

ral r

elat

ion

betw

een

gly

cem

ic c

ontro

l and

CES

-D d

epre

ssiv

e sy

mpt

oms c

ould

not

be

dete

rmin

ed.

Am

ong

parti

cipa

nts r

epor

ting

a pr

ior

his

tory

of d

iabe

tes,

both

mea

n C

ES-D

sco

re a

nd d

epre

ssiv

e sy

mpt

om p

reva

lenc

e w

ere

sign

ifica

ntly

hig

her

tha

n in

par

ticip

ants

with

no

prio

r h

isto

ry o

f chr

onic

illn

ess,

afte

r a

djus

tmen

t for

age

and

soci

al su

ppor

t. H

igh

hem

oglo

bin

A1c

leve

l (≥7

%) w

as a

lso

asso

ciat

ed w

ith h

ighe

r p

reva

lenc

e of

CES

-D-a

sses

sed

dep

ress

ive

sym

ptom

s. R

esul

ts s

ugge

st th

at h

yper

glyc

emia

may

exp

lain

the

high

pre

vale

nce

of d

epre

ssiv

e sy

mpt

oms a

mon

g p

artic

ipan

ts w

ith k

now

n an

d ne

wly

ide

ntifi

ed d

iabe

tes.

Mau

et a

l., 2

001

(29)

147

Nat

ive

Haw

aiia

ns w

ith d

iabe

tes o

r met

abol

ic s

yndr

ome

and

thei

r ‘oh

ana

(fa

mily

) sup

port

pers

on

100

≥30

Qua

si-e

xper

imen

tal,

non

rand

omiz

ed, c

ontro

lled

tria

l; su

bjec

ts re

crui

ted

from

pop

ulat

ion-

base

d sa

mpl

e

To e

xam

ine

asso

ciat

ion

of st

age

of c

hang

e w

ith d

iet a

nd e

xerc

ise

in r

espo

nse

to li

fest

yle

inte

rven

tion.

Non

rand

omiz

ed in

terv

entio

n; l

ack

of tr

ue c

ontro

l gro

up.

Stag

e of

cha

nge

was

sign

ifica

ntly

ass

ocia

ted

with

pos

itive

die

tary

and

exe

rcis

e be

havi

ors.

Parti

cipa

nts

in

the

fam

ily su

ppor

t int

erve

ntio

n g

roup

wer

e m

ore

likel

y to

adv

ance

fro

m p

re-a

ctio

n to

act

ion/

mai

nten

ance

reg

ardi

ng fa

t int

ake

and

phys

ical

act

ivity

than

the

stan

dard

inte

rven

tion

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 18

Stud

y A

utho

rs a

ndY

ear

(Ref

. No.

)Sa

mpl

e an

dN

o. o

f Sub

ject

s%

of T

otal

Sam

ple

Who

Wer

e N

HO

PIA

ge,

year

sSt

udy

Des

ign

Mai

n G

oal a

ndO

utco

mes

/Fin

ding

sL

imita

tions

gro

up.

Gra

ndin

etti

et a

l., 2

002

(18)

578

Nat

ive

Haw

aiia

ns fr

om 2

rur

al c

omm

uniti

es in

Haw

ai‘i;

non

preg

nant

100

≥30

Obs

erva

tiona

l, re

trosp

ectiv

e c

ohor

t, po

pula

tion-

base

d s

ampl

e

To in

vest

igat

e th

e re

latio

n be

twee

n g

luco

se a

nd p

erce

ntag

e of

Haw

aiia

n b

lood

qua

ntum

.

Cro

ss-s

ectio

nal s

urve

y; se

lf- r

epor

ted

ance

stry

, con

tribu

ting

to p

ossi

ble

mis

clas

sific

atio

n; se

lf- r

epor

ted

lifes

tyle

beh

avio

urs

Incr

ease

d H

awai

ian

bloo

d qu

antu

m w

as s

igni

fican

tly a

ssoc

iate

d w

ith in

crea

sed

fas

ting

gluc

ose

leve

l, bo

dy m

ass

ind

ex, w

aist

-to-h

ip ra

tio, a

nd a

ge. F

ull

Haw

aiia

ns h

ad h

ighe

r glu

cose

con

cent

ratio

ns th

an p

art-H

awai

ians

afte

r adj

ustm

ent f

or a

ge, s

ex, b

ody

mas

s ind

ex, a

nd w

aist

-to-h

ip ra

tio.

Kah

olok

ula

et a

l., 2

003

(27)

59 N

ativ

e H

awai

ians

out

of

a to

tal m

ultie

thni

c sa

mpl

e of

141

; non

preg

nant

41≥3

0O

bser

vatio

nal,

nest

ed c

ase

stu

dy fr

om a

pop

ulat

ion-

bas

ed sa

mpl

e

To e

xam

ine

corr

elat

ions

bet

wee

n g

lyce

mic

stat

us a

nd h

ealth

-rel

ated

qua

lity

of li

fe a

nd d

epre

ssiv

e s

ympt

oms.

Lim

ited

gene

raliz

abili

ty; l

ittle

var

iabi

lity

in b

ody

mas

s ind

ex a

nd w

aist

-to-h

ip ra

tio.

No

corr

elat

ion

betw

een

depr

essi

ve s

ympt

oms a

nd g

lyce

mic

stat

us w

as o

bser

ved.

Hea

lth-r

elat

ed q

ualit

y of

life

had

the

grea

test

mag

nitu

de o

f eff

ect

on

depr

essi

ve sy

mpt

oms i

n pe

ople

with

dia

bete

s com

pare

d w

ith g

lyce

mic

sta

tus a

nd k

now

ledg

e of

dia

bete

s d

iagn

osis

. Rel

atio

n be

twee

n d

epre

ssiv

e sy

mpt

oms a

nd h

ealth

- r

elat

ed q

ualit

y of

life

was

influ

ence

d by

gly

cem

ic st

atus

, sex

, edu

catio

n, m

arita

l sta

tus,

and

soci

al su

ppor

t.

Gra

ndin

etti

et a

l., 2

005

(48)

510

Nat

ive

Haw

aiia

ns o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 1

,447

; non

preg

nant

35≥3

0O

bser

vatio

nal,

retro

spec

tive

coh

ort,

popu

latio

n-ba

sed

sam

ple

To e

stim

ate

the

prev

alen

ce o

f met

abol

ic s

yndr

ome.

Cro

ss-s

ectio

nal

Prev

alen

ce o

f met

abol

ic sy

ndro

me

was

sig

nific

antly

hig

her a

mon

g N

ativ

e H

awai

ians

and

all

othe

r min

ority

eth

nic

gro

ups t

han

amon

g C

auca

sian

s. P

reva

lenc

es w

ere

sim

ilar i

n al

l non

- C

auca

sian

gro

ups.

Prev

alen

ce o

f a

bdom

inal

obe

sity

and

low

hig

h d

ensi

ty li

popr

otei

n ch

oles

tero

l was

hig

hest

in N

ativ

e H

awai

ians

.

Wu

et a

l., 2

005

(49)

228

Cha

mor

ros i

n Sa

n D

iego

, Cal

iforn

ia10

0≥1

8O

bser

vatio

nal,

cros

s- s

ectio

nal t

elep

hone

surv

ey,

adm

inis

trativ

e da

taba

se

To a

sses

s dia

bete

s ris

k s

tatu

s, in

cide

nce,

and

mor

bidi

ty.

Dat

a w

ere

popu

latio

n- a

nd g

eogr

aphy

-spe

cific

and

may

not

be

gene

raliz

able

. Sel

f-re

porte

d d

ata.

Dia

bete

s pre

vale

nce

was

16.

2%; 6

0% o

f r

espo

nden

ts w

ith d

iabe

tes w

ere

obe

se a

s com

pare

d w

ith 2

1% o

f tho

se w

ithou

t dia

bete

s. R

espo

nden

ts w

ithou

t dia

bete

s rep

orte

d m

ore

days

of m

oder

ate

phys

ical

act

ivity

than

tho

se w

ith d

iabe

tes.

Mor

e th

an h

alf o

f

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 19

Stud

y A

utho

rs a

ndY

ear

(Ref

. No.

)Sa

mpl

e an

dN

o. o

f Sub

ject

s%

of T

otal

Sam

ple

Who

Wer

e N

HO

PIA

ge,

year

sSt

udy

Des

ign

Mai

n G

oal a

ndO

utco

mes

/Fin

ding

sL

imita

tions

all

men

and

wom

en re

porte

d c

onsu

min

g le

ss th

an th

e r

ecom

men

ded

5 or

mor

e fr

uits

and

veg

etab

les p

er d

ay. P

reva

lenc

e of

hig

h bl

ood

pres

sure

was

42.

5%,

hig

her t

han

the

natio

nwid

e 20

03 B

ehav

iora

l Ris

k Fa

ctor

Sur

veill

ance

Sys

tem

pre

vale

nce

of 2

4.8%

.

Kah

olok

ula

et a

l., 2

006

(25)

80 N

ativ

e H

awai

ians

out

of

a m

ultie

thni

c to

tal s

ampl

e of

190

; non

preg

nant

, with

dia

bete

s

50≥3

0O

bser

vatio

nal,

nest

ed c

ase

stu

dy fr

om p

opul

atio

n- b

ased

sam

ple

To e

xam

ine

rela

tion

betw

een

dep

ress

ive

sym

ptom

s and

asp

ects

of h

ealth

-rel

ated

qua

lity

of li

fe i

n ty

pe 2

dia

bete

s.

Cro

ss-s

ectio

nal s

urve

y, s

mal

l sam

ple

size

s.

Ethn

icity

mod

erat

ed th

e r

elat

ion

betw

een

depr

essi

ve s

ympt

oms a

nd q

ualit

y-of

-life

asp

ects

of p

hysi

cal a

nd ro

le-e

mot

iona

l f

unct

ioni

ng, b

odily

pai

n, v

italit

y, a

nd g

ener

al h

ealth

.

Silv

a et

al.,

200

6 (3

1)61

4 N

HO

PI w

omen

out

of

a m

ultie

thni

c to

tal s

ampl

e of

2,1

55 w

omen

28≥1

8O

bser

vatio

nal,

retro

spec

tive

coh

ort,

med

ical

-rig

ht-

bas

ed sa

mpl

e

To e

xam

ine

ethn

ic d

iffer

ence

s in

per

inat

al o

utco

mes

am

ong

wom

en w

ith g

esta

tiona

l dia

bete

s.

Ret

rosp

ectiv

e st

udy;

eth

nici

ty w

as s

elf-

repo

rted.

Bei

ng N

HO

PI w

as a

sign

ifica

nt p

redi

ctor

of f

etal

mac

roso

mia

. Hig

her

per

cent

age

of N

HO

PI w

omen

requ

ired

ins

ulin

dur

ing

preg

nanc

y an

d be

fore

20

wee

ks’ g

esta

tion,

sugg

estin

g th

at t

here

may

be

a la

rger

subs

et o

f NH

OPI

wom

en w

ith p

reex

istin

g un

diag

nose

d d

iabe

tes.

Gra

ndin

etti

et a

l., 2

007

(13)

510

Nat

ive

Haw

aiia

ns o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 1

,452

; non

preg

nant

35≥3

0O

bser

vatio

nal,

retro

spec

tive

coh

ort,

popu

latio

n-ba

sed

sam

ple

To a

sses

s pre

vale

nces

of d

iabe

tes a

nd g

luco

se in

tole

ranc

e.C

ross

-sec

tiona

l; se

lf-re

porte

d l

ifest

yle

beha

vior

s.

Thre

efol

d hi

gher

pre

vale

nce

of d

iabe

tes

am

ong

Asi

an a

nd N

ativ

e H

awai

ian

gro

ups t

han

amon

g C

auca

sian

s; d

iabe

tes p

reva

lenc

es w

ere

sim

ilar

acr

oss n

on-C

auca

sian

eth

nic

grou

ps d

espi

te d

iffer

ence

s in

body

mas

s i

ndex

.

Mau

et a

l., 2

007

(32

)19

6 N

ativ

e H

awai

ians

out

of a

tota

l mul

tieth

nic

sam

ple

of 7

93

25≥1

8O

bser

vatio

nal,

cros

s- s

ectio

nal,

com

mun

ity c

lust

ered

sam

ple

To e

xam

ine

asso

ciat

ions

bet

wee

n f

acto

rs a

ssoc

iate

d w

ith c

hron

ic k

idne

y d

isea

se.

Cro

ss-s

ectio

nal;

com

mun

ity sa

mpl

e m

ay h

ave

been

bia

sed.

Chr

onic

kid

ney

dise

ase

was

hig

hest

am

ong

Nat

ive

Haw

aiia

ns. D

iabe

tes,

hyp

erte

nsio

n, a

nd lo

wer

edu

catio

n w

ere

sign

ifica

ntly

ass

ocia

ted

with

inc

reas

ed c

hron

ic k

idne

y di

seas

e in

Nat

ive

Haw

aiia

ns.

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 20

Stud

y A

utho

rs a

ndY

ear

(Ref

. No.

)Sa

mpl

e an

dN

o. o

f Sub

ject

s%

of T

otal

Sam

ple

Who

Wer

e N

HO

PIA

ge,

year

sSt

udy

Des

ign

Mai

n G

oal a

ndO

utco

mes

/Fin

ding

sL

imita

tions

Bec

kham

et a

l., 2

008

(50)

78 N

ativ

e H

awai

ians

, S

amoa

ns, a

nd T

onga

ns o

ut o

f a to

tal s

ampl

e of

116

dia

bete

s clin

ic p

atie

nts

67≥1

8Q

uasi

-exp

erim

enta

l, re

fusa

l c

ontro

l gro

up, p

re-p

ost

int

erve

ntio

n w

ith la

ck o

f c

ontro

l for

num

ber o

f vis

its,

clin

ic sa

mpl

e

To e

xam

ine

the

effe

ctiv

enes

s of a

cul

tura

lly ta

ilore

d di

abet

es m

anag

emen

t pro

gram

del

iver

ed b

y c

omm

unity

hea

lth w

orke

rs, u

sing

int

erve

ntio

n re

fuse

rs a

s the

com

paris

on g

roup

.

Smal

l sam

ple

size

, pre

-pos

t stu

dy d

esig

n, b

iase

d sa

mpl

e w

ithou

t tru

e c

ontro

l gro

up. 4

2% o

f the

con

trol

gro

up v

s. 10

% o

f the

inte

rven

tion

gro

up w

as lo

st to

follo

w-u

p. I

nter

vent

ion

grou

p re

ceiv

ed m

ore

vis

its th

an c

ontro

ls.

72 o

f 80

parti

cipa

nts i

n th

e co

mm

unity

- h

ealth

-wor

ker-

deliv

ered

inte

rven

tion

had

a p

ostin

terv

entio

n de

crea

se in

hem

oglo

bin

A1c

leve

l of 2

.2%

(SD

, 1

.8),

as c

ompa

red

with

21

of 3

6 p

artic

ipan

ts w

ho d

eclin

ed c

omm

unity

hea

lth w

orke

r int

erve

ntio

n, w

ho h

ad a

0.2

% (S

D, 1

.5) d

ecre

ase

in h

emog

lobi

n A

1c.

Elst

ad e

t al.,

200

8 (3

8)64

Sam

oans

(35

with

dia

bete

s and

29

care

give

rs)

100

≥18

Focu

s gro

ups,

com

mun

ity s

ampl

eTo

stud

y pe

rcep

tions

of d

iabe

tes t

o d

esig

n a

cultu

rally

app

ropr

iate

pro

gram

.

Smal

l sam

ple

size

; foc

us g

roup

s w

ere

mix

ed w

ith p

erso

ns w

ith d

iabe

tes a

nd c

areg

iver

s, w

hich

may

hav

e bi

ased

resp

onse

s.A

mer

ican

Sam

oans

with

type

2 d

iabe

tes

exp

erie

nced

mul

tiple

type

s of s

tress

. E

nviro

nmen

tal a

nd fa

mili

al st

ress

wor

sene

d th

eir g

luco

se le

vels

. D

espi

te th

e ef

fect

s of f

amily

stre

ss o

n d

iabe

tes,

fam

ily m

embe

rs w

ere

ofte

n t

he p

rimar

y ca

regi

vers

.

Kah

olok

ula

et a

l., 2

008

(51)

495

Nat

ive

Haw

aiia

ns fr

om 2

rura

l com

mun

ities

in H

awai

‘i; n

onpr

egna

nt

100

≥30

Obs

erva

tiona

l, re

trosp

ectiv

e c

ohor

t, po

pula

tion-

base

d s

ampl

e

To e

xam

ine

asso

ciat

ions

bet

wee

n m

odes

of a

ccul

tura

tion

and

diab

etes

pre

vale

nce.

Cro

ss-s

ectio

nal s

urve

y. M

odes

of

acc

ultu

ratio

n in

clud

ed o

nly

Nat

ive

Haw

aiia

n vs

. Am

eric

an; o

ther

eth

nic

cultu

res w

ere

not i

nclu

ded.

Nat

ive

Haw

aiia

ns w

ith a

trad

ition

al m

ode

of a

ccul

tura

tion

wer

e m

ore

likel

y to

hav

e di

abet

es (2

7.9%

) tha

n pe

rson

s w

ith in

tegr

ated

(15.

4%),

assi

mila

ted

(12

.5%

), or

mar

gina

lized

(10.

5%)

mod

es.

Kim

et a

l., 2

008

(28)

434

Nat

ive

Haw

aiia

ns o

ut o

f a

mul

tieth

nic

tota

l sam

ple

of 1

,257

; non

preg

nant

35≥3

0O

bser

vatio

nal,

retro

spec

tive

coh

ort,

popu

latio

n-ba

sed

sam

ple

To e

xam

ine

asso

ciat

ions

of

dia

bete

s with

die

tary

pat

tern

and

eth

nici

ty.

Cro

ss-s

ectio

nal;

poss

ible

reca

ll bi

as o

n fo

od fr

eque

ncy

ques

tionn

aire

; m

easu

rem

ent e

rror

in e

stim

atio

n of

foo

d po

rtion

s.C

onsu

mpt

ion

of lo

cal e

thni

c fo

ods w

as c

orre

late

d w

ith b

ody

mas

s ind

ex,

sm

okin

g, w

aist

-to-h

ip ra

tio, a

nd g

luco

se. C

onsu

mpt

ion

of th

ese

food

s w

as h

ighe

r for

Nat

ive

Haw

aiia

ns th

an f

or o

ther

eth

nic

grou

ps. N

ativ

e H

awai

ians

had

the

high

est t

otal

ene

rgy

inta

ke.

Abb

revi

atio

ns: C

ES-D

, Rig

ht fo

r Epi

dem

iolo

gic

Stud

ies D

epre

ssio

n Sc

ale;

NH

OPI

, Nat

ive

Haw

aiia

ns a

nd o

ther

Pac

ific

Isla

nder

s; S

D, s

tand

ard

devi

atio

n.

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 21

Tabl

e 3

Lite

ratu

re o

n O

besi

ty H

ealth

Dis

parit

ies A

mon

g N

ativ

e H

awai

ians

and

Oth

er P

acifi

c Is

land

ers,

Janu

ary

1998

–Dec

embe

r 200

8

Stud

y A

utho

r(s)

and

Yea

r (R

ef. N

o.)

Sam

ple

and

No.

of S

ubje

cts

% o

fT

otal

Sam

ple

Who

Wer

eN

HO

PI

Age

,ye

ars

Stud

y D

esig

nM

ain

Goa

l and

Out

com

es/F

indi

ngs

Lim

itatio

ns

Mas

karin

ec e

t al.,

199

8 (5

2)4,

321

Nat

ive

Haw

aiia

ns o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 2

7,67

8

16>3

0O

bser

vatio

nal,

pros

pect

ive

coh

ort,

popu

latio

n-ba

sed

sam

ple

of 2

% o

f the

Haw

ai‘i

Sta

te p

opul

atio

n

To in

vest

igat

e ef

fect

s of a

lcoh

ol in

take

and

bod

y w

eigh

t on

mor

talit

y fr

om a

ll ca

uses

, c

ance

r, ce

rebr

ovas

cula

r dis

ease

, and

cor

onar

y he

art d

isea

se.

No

info

rmat

ion

on p

reex

istin

g c

ardi

ovas

cula

r dis

ease

, ser

um c

hole

ster

ol le

vel,

hype

rtens

ion,

dia

bete

s, or

fam

ily h

isto

ry.

Nat

ive

Haw

aiia

ns h

ad th

e hi

ghes

t mor

talit

y r

ate

and

a hi

gher

pre

vale

nce

of o

besi

ty.

BM

Ia >

29.3

was

ass

ocia

ted

with

50%

hig

her r

isk

of d

eath

. Cor

onar

y he

art

dis

ease

mor

talit

y w

as h

ighe

r in

Nat

ive

Haw

aiia

ns w

ith B

MIs

>29

.3.

Gal

anis

et a

l., 1

999

(53)

946

Sam

oans

in W

este

rn S

amoa

and

Am

eric

an S

amoa

100

25–5

5O

bser

vatio

nal,

cros

s- s

ectio

nal,

retro

spec

tive

coh

ort,

com

mun

ity a

nd w

orkp

lace

sam

ple

To d

escr

ibe

diet

ary

inta

ke a

s mea

sure

d b

y 24

-hou

r rec

all o

f Am

eric

an S

amoa

ns a

nd W

este

rn S

amoa

ns.

No

bioc

hem

ical

mea

sure

men

t of

car

diov

ascu

lar d

isea

se ri

sk o

r c

orre

latio

ns w

ith a

nthr

opom

etric

mea

sure

men

ts; p

oten

tial s

ampl

e b

ias;

reca

ll bi

as o

n di

etar

y a

sses

smen

t.A

mer

ican

Sam

oans

con

sum

ed a

gre

ater

pro

porti

on o

f car

bohy

drat

es a

nd p

rote

in b

ut le

ss fa

t or s

atur

ated

fat t

han

Wes

tern

Sam

oans

. The

mea

n B

MI o

f A

mer

ican

Sam

oans

was

35.

2 as

com

pare

d w

ith 3

0.3

for W

este

rn S

amoa

ns.

Gra

ndin

etti

et a

l., 1

999

(32)

567

Nat

ive

Haw

aiia

ns in

2 r

ural

com

mun

ities

in H

awai

‘i; n

onpr

egna

nt

100

≥30

Obs

erva

tiona

l, re

trosp

ectiv

e c

ohor

t, po

pula

tion-

base

d s

ampl

e

To a

sses

s the

rela

tion

of d

egre

e of

Nat

ive

Haw

aiia

n an

cest

ry w

ith B

MI a

nd w

aist

- t

o-hi

p ra

tio.

Cro

ss-s

ectio

nal;

self-

repo

rted

anc

estry

and

die

tary

reca

ll.

Com

bine

d pr

eval

ence

of o

verw

eigh

t and

/ o

r obe

sity

was

81.

5% in

Nat

ive

Haw

aiia

ns a

s com

pare

d w

ith th

e U

S p

reva

lenc

e of

52.

6%. 4

9% o

f Nat

ive

Haw

aiia

ns w

ere

obes

e as

com

pare

d w

ith th

e U

S pr

eval

ence

of 2

1%

Incr

ease

d w

aist

circ

umfe

renc

e w

as f

ound

in 5

1% o

f Nat

ive

Haw

aiia

ns. M

ore

wom

en (5

9%) t

han

men

(39%

) had

inc

reas

ed w

aist

circ

umfe

renc

e. A

ge,

per

cent

age

of N

ativ

e H

awai

ian

ance

stry

, a

nd to

tal d

ieta

ry e

nerg

y in

take

wer

e s

igni

fican

tly a

ssoc

iate

d w

ith in

crea

sed

BM

I and

wai

st-to

-hip

ratio

. Adi

posi

ty i

ncre

ased

with

per

cent

age

of N

ativ

e H

awai

ian

ance

stry

.

McG

arve

y et

al.,

200

2 (5

4)18

1 Sa

moa

ns a

nd A

mer

ican

Sam

oans

100

25–5

5O

bser

vatio

nal,

nest

ed st

udy

in

a pr

ospe

ctiv

e co

hort;

To te

st th

e as

soci

atio

n of

6 g

enet

ic m

icro

sate

llite

mar

kers

rela

ted

to th

eFu

nctio

nal s

igni

fican

ce o

f pre

sent

fin

ding

rem

ains

unc

lear

.

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 22

Stud

y A

utho

r(s)

and

Yea

r (R

ef. N

o.)

Sam

ple

and

No.

of S

ubje

cts

% o

fT

otal

Sam

ple

Who

Wer

eN

HO

PI

Age

,ye

ars

Stud

y D

esig

nM

ain

Goa

l and

Out

com

es/F

indi

ngs

Lim

itatio

ns

pop

ulat

ion-

base

d sa

mpl

e h

uman

lept

in (L

EP) l

ocus

and

the

pro-

opi

omel

anoc

ortin

gen

e re

gion

in a

dult

Sam

oans

and

Am

eric

an S

amoa

ns.

Sign

ifica

ntly

gre

ater

freq

uenc

y of

alle

le 2

26 a

t the

LEP

locu

s in

the

nono

bese

Sam

oans

than

in th

e ob

ese

subj

ects

.

Mam

pilly

et a

l., 2

005

(36)

585

Nat

ive

Haw

aiia

ns o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 3

,732

16≥1

8O

bser

vatio

nal,

cros

s- s

ectio

nal t

elep

hone

surv

ey;

Beh

avio

ral R

isk

Fact

or S

urve

illan

ce S

yste

m p

opul

atio

n sa

mpl

e

To a

sses

s the

phy

sica

l act

ivity

leve

ls o

f m

ultie

thni

c gr

oups

in H

awai

‘i.Te

leph

one

surv

ey; s

elf-

repo

rt of

phy

sica

l act

ivity

. Sel

f-re

porte

d w

eigh

t and

hei

ght.

Nat

ive

Haw

aiia

ns w

ere

mor

e a

ctiv

e (3

9% m

oder

ate,

24%

vig

orou

s) t

han

othe

r Asi

ans a

nd P

acifi

c Is

land

ers

but

less

act

ive

than

whi

tes.

48%

of

Nat

ive

Haw

aiia

ns re

porte

d be

ing

ove

rwei

ght a

s com

pare

d w

ith 5

8% o

f w

hite

s, 42

% o

f Fili

pino

s, an

d 41

% o

f J

apan

ese.

Hen

ders

on e

t al.,

200

6 (5

5)15

9 N

ativ

e H

awai

ians

out

of

a ra

ndom

subs

ampl

e of

811

per

sons

from

Haw

ai‘i

and

Cal

iforn

ia

2045

–74

Obs

erva

tiona

l, ne

sted

stud

y i

n a

pros

pect

ive

coho

rt; r

ando

mly

sele

cted

sam

ple

To e

xam

ine

the

rela

tion

betw

een

circ

ulat

ing

leve

ls o

f 2 p

rimar

y pr

otei

ns (

IGF-

1 an

d IG

FBP-

3) in

the

insu

lin-li

ke g

row

th fa

ctor

pat

hway

and

obe

sity

in 5

rac

ial/e

thni

c gr

oups

usi

ng B

MI a

s an

ind

icat

or o

f adi

posi

ty.

Unm

easu

red

conf

ound

ing

fact

ors;

rac

ial/e

thni

c di

ffer

ence

s in

BM

I c

utpo

ints

may

hav

e co

nfou

nded

stu

dy. P

lasm

a IG

F-I a

nd IG

FBP-

3 w

ere

mea

sure

d at

a si

ngle

tim

e p

oint

.

No

sign

ifica

nt in

tera

ctio

n w

as f

ound

bet

wee

n IG

F-1

and

BM

I in

Nat

ive

Haw

aiia

ns a

s com

pare

d w

ith Ja

pane

se a

nd L

atin

os, i

n w

hom

dec

reas

ed IG

F-1

was

ass

ocia

ted

with

incr

easi

ng B

MI.

How

arth

et a

l., 2

006

(56)

433

Nat

ive

Haw

aiia

ns o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 2

,326

per

sons

from

Haw

ai‘i

and

Cal

iforn

ia

1945

–74

Obs

erva

tiona

l, pr

ospe

ctiv

e c

ohor

t; po

pula

tion-

base

d s

ampl

e

To d

eter

min

e w

heth

er d

ieta

ry e

nerg

y de

nsity

was

rela

ted

to c

urre

nt B

MI a

nd ri

sk o

f ove

rwei

ght/o

besi

ty in

a m

ultie

thni

c po

pula

tion.

Food

freq

uenc

y as

sess

men

t of d

ieta

ry e

nerg

y de

nsity

bas

ed o

n re

call.

Die

tary

reca

ll m

ay v

ary

by b

ody

wei

ght.

Nat

ive

Haw

aiia

n m

en h

ad th

e hi

ghes

t BM

I; w

eigh

t and

die

tary

ene

rgy

dens

ity w

ere

sig

nific

antly

rela

ted

to B

MI.

Nat

ive

Haw

aiia

n w

omen

wer

e se

cond

-hea

vies

t a

fter A

fric

an A

mer

ican

s. H

ighe

r ene

rgy

den

sity

was

sign

ifica

ntly

ass

ocia

ted

with

gre

ater

like

lihoo

d of

bei

ng o

verw

eigh

t in

all

ethn

ic a

nd se

x gr

oups

. Nat

ive

Haw

aiia

ns w

ere

unus

ual i

n th

at lo

w e

nerg

y de

nsity

was

ass

ocia

ted

with

hig

h B

MI.

Mas

karin

ec e

t al.,

200

6 (3

4)9,

994

Nat

ive

Haw

aiia

ns o

ut o

f a

tota

l mul

tieth

nic

sam

ple

of 7

6,16

3

13≥1

8O

bser

vatio

nal,

pros

pect

ive

coh

ort;

pool

ed d

ata

from

18

pop

ulat

ion-

base

d st

udie

s

To d

escr

ibe

trend

s in

BM

I and

the

rela

tions

of n

utrie

nt a

nd fo

od in

take

with

exc

ess

Lim

ited

in co

mpa

rabi

lity

of n

utrit

iona

l m

easu

res a

cros

s stu

dies

ove

r tim

e, m

ainl

y be

caus

e di

etar

y as

sess

men

t

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 23

Stud

y A

utho

r(s)

and

Yea

r (R

ef. N

o.)

Sam

ple

and

No.

of S

ubje

cts

% o

fT

otal

Sam

ple

Who

Wer

eN

HO

PI

Age

,ye

ars

Stud

y D

esig

nM

ain

Goa

l and

Out

com

es/F

indi

ngs

Lim

itatio

ns

car

ried

out o

ver 2

5 ye

ars i

n H

awai

‘i w

eigh

t. m

etho

ds h

ave

impr

oved

ove

r the

yea

rs; r

ecal

l bia

s.N

ativ

e H

awai

ians

had

the

high

est

pre

vale

nce

of e

xces

s wei

ght a

t all

times

. C

arbo

hydr

ates

wer

e po

sitiv

ely

ass

ocia

ted

with

exc

ess w

eigh

t am

ong

Nat

ive

Haw

aiia

ns. N

utrit

iona

l d

eter

min

ants

of e

xces

s wei

ght w

ere

sim

ilar a

mon

g w

hite

s, Ja

pane

se, a

nd N

ativ

e H

awai

ians

, des

pite

mar

ked

diff

eren

ces i

n B

MI.

Alb

right

et a

l., 2

007

(33)

12,3

06 N

ativ

e H

awai

ians

out

of a

mul

tieth

nic

tota

l sam

ple

of 2

00,0

03

645

–74

Obs

erva

tiona

l, pr

ospe

ctiv

e c

ohor

t; po

pula

tion-

base

d s

ampl

e

To e

xam

ine

BM

I in

pers

ons w

ith e

thni

c a

dmix

ture

as c

ompa

red

with

per

sons

who

wer

e m

onor

acia

l but

shar

ed a

com

mon

eth

nici

ty/ra

ce.

Self-

repo

rted

heig

ht, w

eigh

t, an

d e

thni

city

; una

ble

to q

uant

ify th

e g

enet

ic c

ontri

butio

n of

eac

h et

hnic

ity r

epor

ted.

Nat

ive

Haw

aiia

ns h

ad th

e hi

ghes

t BM

I c

ompa

red

with

oth

er e

thni

c gr

oups

. E

thni

c ad

mix

ture

s tha

t inc

lude

d N

ativ

e H

awai

ian

herit

age

had

high

er B

MIs

than

mos

t oth

er e

thni

c co

mbi

natio

ns.

Boy

d, 2

007

(37)

32 N

ativ

e H

awai

ian

com

mun

ity c

olle

ge st

uden

ts10

018

–25

Focu

s gro

up, u

nive

rsity

con

veni

ence

sam

ple

To a

sses

s per

cept

ions

of h

ealth

y lif

esty

les

and

supp

orts

for a

nd b

arrie

rs to

hea

lthy

liv

ing.

Smal

l sam

ple

size

; bia

sed

sam

ple.

Dem

andi

ng li

fest

yle

and

lazi

ness

wer

e c

ited

as b

arrie

rs to

bei

ng p

hysi

cally

act

ive.

Pre

fere

nces

for g

roup

-orie

nted

and

col

lege

-cou

rse-

base

d op

portu

nitie

s t

o le

arn

abou

t hea

lthy

livin

g an

d ho

w to

bec

ome

mor

e ph

ysic

ally

act

ive.

Dai

et a

l., 2

007

(57)

583

Am

eric

an S

amoa

ns10

0≥1

8O

bser

vatio

nal,

nest

ed st

udy

in

a pr

ospe

ctiv

e co

hort;

ran

dom

sele

ctio

n sa

mpl

e

To d

etec

t tra

it lo

ci in

fluen

cing

adi

posi

ty-

rel

ated

phe

noty

pes u

sing

a w

hole

gen

ome

linka

ge sc

an a

ppro

ach

in f

amili

es fr

om A

mer

ican

Sam

oa.

No

adju

stm

ent f

or o

ther

impo

rtant

gen

etic

and

env

ironm

enta

l fac

tors

tha

t con

tribu

te to

adi

posi

ty, s

uch

as d

iet a

nd p

hysi

cal a

ctiv

ity.

Stro

ng e

vide

nce

for a

maj

or lo

cus o

n c

hrom

osom

e 6q

23.2

influ

enci

ng se

rum

lep

tin le

vels

. Ano

ther

gen

etic

regi

on,

16q

21, a

ppea

rs to

be

a su

scep

tibili

ty l

ocus

that

aff

ects

phe

noty

pes f

or B

MI,

per

cent

age

of b

ody

fat,

lept

in le

vels

, and

wai

st c

ircum

fere

nce.

Mas

karin

ec e

t al.,

200

7 (3

5)16

,079

Nat

ive

Haw

aiia

ns o

ut o

f a m

ultie

thni

c to

tal s

ampl

e o

f 117

,065

14≥4

0O

bser

vatio

nal,

pros

pect

ive

coh

ort;

popu

latio

n-ba

sed

sam

ple

To in

vest

igat

e ch

ange

s in

risk

fact

ors i

n H

awai

‘i ov

er 2

0 ye

ars a

nd c

ompa

re h

ealth

beh

avio

rs a

mon

g et

hnic

gro

ups.

Diff

eren

ces i

n da

ta c

olle

ctio

n ac

ross

2 st

udie

s; im

prov

emen

ts in

nut

ritio

nal a

sses

smen

t ove

r tim

e; v

alid

ity o

f eth

nici

ty a

ssig

nmen

t (se

lf- r

epor

ted)

; litt

le in

form

atio

n on

soc

ioec

onom

ic st

atus

.N

ativ

e H

awai

ians

had

the

high

est c

hron

ic d

isea

se ri

sk sc

ores

in c

ompa

rison

with

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Mau et al. Page 24

Stud

y A

utho

r(s)

and

Yea

r (R

ef. N

o.)

Sam

ple

and

No.

of S

ubje

cts

% o

fT

otal

Sam

ple

Who

Wer

eN

HO

PI

Age

,ye

ars

Stud

y D

esig

nM

ain

Goa

l and

Out

com

es/F

indi

ngs

Lim

itatio

ns

oth

er g

roup

s. B

MI w

as h

ighe

st fo

r Nat

ive

Haw

aiia

ns.

Nov

otny

et a

l., 2

007

(58)

55 S

amoa

n w

omen

100

18–2

8O

bser

vatio

nal,

cros

s- s

ectio

nal,

conv

enie

nce

sam

ple

To e

xam

ine

anth

ropo

met

ric c

utof

f poi

nts

as i

ndic

ator

s of c

hron

ic d

isea

se ri

sk.

Cro

ss-s

ectio

nal,

smal

l sam

ple

of S

amoa

n w

omen

; bia

sed

sam

ple.

80%

of s

ampl

e w

as o

verw

eigh

t or o

bese

. B

MI a

nd d

ual-e

nerg

y X

-ray

abs

orpt

iom

etry

lean

mas

s wer

e s

igni

fican

tly a

nd p

ositi

vely

ass

ocia

ted

with

glu

cose

leve

ls.

Mas

karin

ec e

t al.,

200

8 (5

9)25

4 N

ativ

e H

awai

ian

wom

en o

ut o

f a m

ultie

thni

c to

tal

sam

ple

of 1

,418

18≥2

1O

bser

vatio

nal,

cros

s- s

ectio

nal,

brea

st-c

ance

r- r

elat

ed p

artic

ipan

t sam

ple

To e

xam

ine

rela

tion

of so

y in

take

with

bod

y w

eigh

t ove

r the

life

span

of w

omen

.Se

lf-re

porte

d he

ight

, wei

ght,

and

diet

dat

a; li

fetim

e re

call

of so

y in

take

was

diff

icul

t.M

eat a

nd v

eget

able

inta

ke a

nd to

tal e

nerg

y in

take

(kca

l/day

) wer

e h

ighe

r for

Nat

ive

Haw

aiia

ns. E

atin

g m

ore

soy

food

s in

adul

thoo

d di

d no

t pre

dict

low

er B

MI o

r low

er a

nnua

l wei

ght g

ain

for

Nat

ive

Haw

aiia

ns.

Abb

revi

atio

ns: B

MI,

body

mas

s ind

ex; I

GF-

1, in

sulin

-like

gro

wth

fact

or 1

; IG

FBP-

3, in

sulin

-like

gro

wth

fact

or b

indi

ng p

rote

in 3

; NH

OPI

, Nat

ive

Haw

aiia

ns a

nd o

ther

Pac

ific

Isla

nder

s.

a Wei

ght (

kg)/h

eigh

t (m

)2.

Epidemiol Rev. Author manuscript; available in PMC 2010 June 28.