Oral exams - public health problem

What are the obesity rates in the general US populations?

2011-2 NHANES data 35.1% adults >20 years are obese 16.9% of children and youth 2-19 years

What is the recommended daily fiber intake?

25g for women, 38 g for men.

Who is Sheila Fleischhaker? Describe the work she has done in AI policy. What strategies did she use? JG

AIHE FR that integrated qualitative, spatial, and policy analyses. Formative project - healthy Native North Carolinians at UNC. Now based at the NIH.

Was AIHE successful? What could have been done differently? GA

AIHE was formative research, developing strategies, research focused more on the eating side but asked about obesity prevention in general. Successful in identifying strategies for state-recognized tribal level action. Disseminated toolkit, which provides technical assistance and tools on areas identified as having the most potential to facilitate Project transitioned to Healthy Native North Carolinians was capacity-building project to develop community action plans and implement sustained community changes. Key approaches include: tribally owned and operated community gardens and farmers options and providing healthy pow wow food and beverage options, healthy store, mobile and vending initiatives, healthy families, healthy food activities. Approaches that came of that may not be generalizable to all communities. AIHE and HNNC worked with state-recognized tribes. This collared the approaches, used more informal tribal resolutions. the first GIS investigation of AI food environment. First study working directly with tribes to explore potential for tribally-led efforts to maximize env and policy strategies to improve access to healthy affordable foods.Anecdotal evidence, not rigorous evaluation of multisectoral strategies.

Tell me about your aims and how you developed them. AB

Aim 1 - GT and theoretical foundation for intervention Aim 2 - look at existing health policies Aim 3 - process eval of pilot

What is the history of alcohol use in AI/AN?

Before, no alcohol, but were other intoxicants which were very respected and used for ceremonial purposes. Power of these substances recognized and respected. Teaching balance. Mosher, 1975. Alcohol regulation in the US follows the frontier. White traders relied on cheap alcohol products, often heavily adulterated, to promote exchange of valued native commodities. Active promotion of alcohol among indigenous peoples disrupted tribal cultures and lines of authority (pariahs have more cash). Once disruption accomplished, alcohol trade suppressed and alcohol control used as a means of subjugating the tribes, through repressive alcohol legislation. Also related to the slave trade. The triangle, use rum to buy slaves in Africa, get them on work on plantations to harvest molasses, molasses brought to NE to make rum, rum brought to Africa to trade for slaves. §Four modes of production of alcohol in developing societies: -Traditional/indigenous -Industrialized traditional/indigenous -Industrialized cosmopolitan -Globalized cosmopolitan Trend is towards the latter, particularly in distilled spirits and beer The commodity chain approach rests in part on a simple assumption: alcohol must be made available to be used (it cannot except in rare circumstances be plucked from trees or from the ground). The structure of alcohol availability in turn has important implications for how, when and in what amounts alcohol is consumed. Culture is not a negligible influence. But particularly in the case of the marketing-driven commodity chain, forces from the economic and political fields may in turn act to shape the cultural field and decision-making within that field. Recognizing the tremendous diversity among regions and cultures, I have nonetheless tried to identify three historical commodity chains for alcohol. These roughly correspond to three historical eras, although they certainly overlap in many cases. The slide lays out the characteristics of these three chains by analyzing them at the following stages: design, raw materials, manufacturing, import, distribution, marketing and advertising. In most traditional societies, the "design" of or recipe for alcoholic beverages tended to be the property of the community, whether that be a family, a village or an empire. The means of producing alcohol would be passed from generation to generation among those in the society designated as alcohol producers. Raw materials for alcohol production were obtained locally, and the products produced depended on what agricultural inputs were locally available. Manufacture was local, and of a low technological level, with the result that producing in bulk or excess of immediate need was often impossible. Primitive means of storage and transport also generally meant that very little alcohol traveled very far from its point of production. Rather, distribution of alcohol occurred at the point of production, and was usually carried out by the producer or the producing family or community. To the extent that a market existed for alcohol, it was tied to the exchange of labor, as in the organization of brewing to celebrate the completion of the harvest or a joint work project. People knew where and when alcohol would be available by word of mouth or by customary association of drinking with particular festivals or community events.

How can diabetes be prevented?

DPP tested three approaches to prevent diabetes: lifestyle changes (exercise=walking 30 min a day for five days a week, lowered fat and calorie intake), metformin + education, education only. Lifestyle group did the best. Losing an avg of 15 pounds in first year, reduced risk by 58% over 3 years. benefits last for at least 10 years. http://www.niddk.nih.gov/health-information/health-topics/Diabetes/insulin-resistance-prediabetes/Pages/index.aspx#relate

WC and waist to hip ratio

Description: Anthropometric measurement indicative of central adiposity. Established WHO cutoffs WC: obesity>40 inches (102 cm) in men, >35 inches (88 cm) in women; WHR: obesity>1.0 in men; >0.8 in women. Ethnic central and south american and asian obesity: >=90 cm for men and >=80 cm for women Strengths: -Provide more information on fat distribution. -More reliable measures than BMI -Cheap and easy -Associated with higher body composition and health risks, even moreso than BMI -More related to diabetes than bmi among Pima (Gohdes ch 34). Navajo women - association between increasted WH ratio and t2dm risk. Limitations: -indirect measures of adiposity -Waist measurements vary by different guidelines, so results may not be directly comparable -WC alone doesn't provide info about fat distribution elsewhere on the body like WHR but does provide indication of amount of visceral fat.

What is the obesity paradox?

Despite the fact that obesity has a strong association with risk of cardiovascular disease incidence, there has been consistent documentation of improved prognosis among overweight and obese patients with cardiovascular disease (Lavie, Milani, & Ventura, 2009). The potential mechanisms of this phenomenon, called the obesity paradox, are not confirmed. Some possible mechanisms include Article by Uretsky: "Several mechanisms could explain this paradox in patients with cardiovascular disease. First, studies have shown that normal-weight patients have a significantly higher percentage of high-risk coronary anatomy (left main disease or triple vessel disease) compared with obese patients.23 Coronary artery calcification area measured by electron-beam computed tomography was found to be significantly greater in overweight patients compared with obese patients.24 These findings provide a possible anatomic substrate for an obesity paradox. Second, leaner patients with heart failure have been shown to have increased levels of tumor necrosis factor and other inflammatory cytokines compared with obese patients.25 Adipose tissue has been shown to produce soluble tumor necrosis factor receptor that is thought to neutralize the deleterious effects of tumor necrosis factor-alpha on the myocardium, which may explain a protective effect of obesity in patients with heart failure.13,26 Third, obese patients display a readily identifiable phenotype that is believed to reflect a high risk for cardiovascular disease, and they may receive or seek treatment earlier in the time course of disease, thereby altering the natural history of their disease when compared with lean patients (lead time bias). Fourth, it has been well documented that the hemodynamics of obesity hypertension are characterized by a high cardiac output, an expanded blood volume, and a lower systemic vascular resistance when compared with normal-weight patients.27-31 Because systemic resistance reflects the severity of hypertensive cardiovascular disease, the comparatively low values in obesity may translate into a better outcome in this population. Fifth, there are conflicting data whether obesity itself confers an increased risk for cardiovascular disease apart from its associated metabolic derangements.11,32 If these risk factors are well managed, such as hypertension and coronary artery disease, this may negate any increased risk associated with obesity. In the INVEST cohort, the blood pressure control was excellent and may negate the deleterious effects of obesity. Sixth, BMI itself has been questioned as the optimal measurement to use for assessing health risk associated with obesity. Other measures, such as waist-to-hip ratio and visceral fat measurement, may be better, and it has been postulated that "it is time to throw BMI out."33,34 In some studies, BMI predicted mortality in women less well than in men.35 Ashton et al.36 found BMI to be a poor discriminator of cardiovascular heart disease risk in women compared with men despite a worse metabolic profile in those with increased BMI." http://apps.webofknowledge.com/full_record.do?product=WOS&search_mode=GeneralSearch&qid=1&SID=3CVbyW9gw2LyZBdoz6Q&page=2&doc=15&cacheurlFromRightClick=no

What are Native conceptualizations of health, obesity, and chronic diseases?

Divergent Models of Diabetes among American Indian Elders

What are the obesity rates in different American Indian populations?

IHS 2008 reported that over 80% of adults 20-74 are OW/OB; 50% are OB 45-51% of children/youth 2-19 OW/OB; 25% OB California 2011 Pr(MOB|female)=11.6% Pr(OB|female)=37.3% Chippewa 1994 (st. croix, lco, red cliff, bad river)=54% LCO 1999 Pr(BMI>27.3 or OW)=43% women Pr(BMI>27.8 for OW)=49% men

What are the rates of complications in AI/AN?

IR of kidney failure due to diabetes is 2 times higher than the general US population (2008). Adults with diabetes have HD death rates and risk of stroke that is 2-4 times higher than adults w/o diabetes. SHS suggest that risk for CVD in AI adults w/ diabetes may be 3-8 times higher than those w/o diabetes. http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/FactSheets/Fact_sheet_AIAN_508c.pdf 41% of AI/AN died before 65, compared with 23% of whites.

What is a disease?

Longstanding debate 1) Biostatistical theory - Deviation from the average. 2) Evolutionary function - disease occurs when an organ is not performing the job that allowed it to evolve via natural selection.

Would you call OPREVENT2 a structural intervention? JJS

Multilevel - works both at individual/household and environment level. Upstream work increases access to food and PA resources, this work is structural interventions.

NHIS

National Health Interview Survey. Cross-sectional HH interview survey since 1956. Multistage area probability design sampling. Data obtained about all HH members.

Why is obesity a problem?

Obesity is a risk factor for non-communicable diseases later in life. Including CVD, type II diabetes, cancers, and chronic respiratory diseases. Combined with the increasing prevalence of obesity, this is a problem that needs to be addressed.

What are the obesity rates for the tribes OPREVENT2 is working with?

Overall AI/AN - over 80% 20-74 are overweight and 54% are obese. Pilot communities: Hannahville: 75.9% Alamo: 75.9% based on post data n=~50. Chippewa 1994 (st. croix, lco, red cliff, bad river)=54%

What are the sources of drinking water for the communities you're working with and how will this impact your intervention strategy?

Pipe water system in MI, Partial pipe system NM. Environmental contaminants will need to be taken into consideration, so that we can understand the extent that we can promote traditional foods and tap water as healthy alternatives.

What is the difference between program and policy?

Programs are: -generally short-lived -may include policy implementation but not usually about policies Policies: -seek to make them permanent -may mandate programs Ex: screening and brief intervention. Can have a policy providing this, then must choose a program to provide. Both should be evidence-based

REACH

Racial and Ethnic Approaches to Community Health project. Started by 2001 by CDC to increase sampling among minority populations. Telephone interviews and in person interviews where telephone coverage was believed to be <80%. Questionnaire is identical to BRFSS. Repeated in 2009. Included AI comm from OK, NC, MI.

What are the reasons for this variation? PW

Reasons for hte variation are the nevironment>genes. Thrifty gene hypothesis genes that were historically advantageious became detrimental in modern environments.

Are SSB taxes effective in changing intake and weight?

Recent lit review of SSB price elasticity suggests that an increase in SSB price will decrease consumption. Can lead to modest reductions in weight in the population. Higher the price increase, the more the decrease. For a 1% increase in SSB price, the point prevalence ofr obesity would reduce in men -0.34 more than in women -0.05. Increases consumption of fruit juice and whole milks. Additional benefits are that consumption of diet drinks may also decrease (hyp that bottlers equaliser prices between products, other drink diet in presence of others drinking SSB). Taxes also generate revenue, Even a modest tax in the US could generate billions of dollars (soft drink revenue is approximately $70 bill). Cabrera Escobar_BMC PH_2013

What are diabetes rates in AI/AN youth?

SEARCH Study - multicenter observational study with population-based ascertainment of cases of physician-diagnosed DM in 2002-2003 among youth aged younger than 20 years. Included 3 AI reservations in AZ and NM and Pima study. T2DM is still relatively infrequent in the US youth; however the highest rates are observed among 15-19 year old adolescent minorities, especially AI youth (49.4 per 100,000 PY) (Writing Group for the SEARCH_JAMA_2007) HIgher probability of developing costly and disabling diabetes-related complications later in life (Acton_Am J PH_2002, Gohdes Ch33)

What is a structural intervention? JJS

Structural intervention refers to interventions that work by altering the context within which health is produced. Changes to the food and PA environments. http://www.ncbi.nlm.nih.gov/pubmed/10981470

Why should we postpone alcohol initiation?

Those who begin drinking before age 15 are four times more likely to become heavy consumers than those who wait until age 21. Underage drinkers consume 10%-19% of the alcohol market (almost all of which is consumed in binge drinking episodes), producing $10-$20 billion annually.

What is transferability? How do you make it happen? JG

Transferability is applying your results to others. Not something that you can make happen, a process of the reader being able to understand whether the research and conclusions apply to their contexts. We can facilitate this by providing rich description of the case, process, etc.

What is a key limitation of your study? AB

Transferability of conceptual framework, given the heterogeneity and number of tribes in the US. However, we are working with a heterogeneous group of tribes, which will hopefully improve the transferability.

Which of these changes are most viable in communities that you are working with? JJS

Unlikely to get support for a tax. Institutional policies and other changes the food environment are possible.

HbA1C

reflect average blood glucose levels

What are some participatory methods that you think you will use?

social mapping, modified talking circles, free listing,

How do food and agricultural policies reflected in the farm bills passed by the US Congress affect obesity in AI communities? PW

Farm bill is large policy, many impacts on food environment. Reauthorized every 4-6 years, annual funds appropriated by Congress. Other policies, more focused. Moving to state and local levels (food policy councils) - mess and gridlock at fed level. Includes food assistance, Child nutrition act (WIC, school lunches), food safety policy, regulations on food labeling and marketing, dietary guidelines, procurement policies, tax policy, trade policy, lawsuits. Historically an agriculture bill. 1973 - food stamps program is brought in. Give excess production - addresses needs of farmer's and low income. People get coupons/ebt card to buy food products. Emergency food program to give commodity foods. Commodity is something where all items are interchangeable. Most spending on Nutrition, SNAP. 14.5% are classified as food insecure (US households 2012) associated with obesity and CDs. SNAP reduced food insecurity by 18-30%. SNAP spending doubled 2007-2012 because of recession. Pressure to reduce. SNAP - $8.5 bllion cut, prohibits government-sponsored SNAP outreach (letting people know about eligibility) Cut 90$ a month for 850,000 people. SNAP stores have to have seven items of each of four categories (fV, grain, dairy, and meat). Perishable items in at least three of these. Food Insecurity Nutrition Initiative: legislation in farm bill. point of purchase matching money for SNAP recipients buying produce, details to be worked out, including amount. SNAP-ED: fully funded nutrition education for snap recipients. SNAP benefits for food delivery into a low-food access area. Healthy foods and local/regional foods. Need to increase production of FV, but also need to increase demand. Investing in research on production methods, having access to insurance, marketing, fresh fruit and vegetable program, encouraging bringing grocery stores to areas of need. commodities - corn soybean, wheat rice, cotton FDPIR - inclusion of traditional and loclaly-grown foods from native farmers, ranchers, producers in FDPIR. Pilot project with one or more tribes. Traditional foods in food service programs - can be donated. Includes waiver for tribe against civil action. https://tlpi.wordpress.com/2014/02/04/ncai-alert-congress-passes-farm-bill/

What is the IHS? How does it function? How has its role changed in recent years?

Federal health services began under War Department in early 1800s. Moved to the Department of the Interior to deal with Nation's resources. Federal construction of hospitals and infirmaries began in the early 1880 to originally serve Indian boarding schools students almost exclusively. Now in the DHHS. Responsible for providing medical and PH services to federally recognized tribal members. Gives money to tribes using equation (RAM), which calculated health budgets based on population age distribution and burdens of disease. Gives more funding to those below the mean. Functions with 12 IHS service areas. Annual budget review by congress. Don't get sick afterJune" https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_pc_p1c3

What are commodity foods?

Food Distribution Program on Indian Reserves provides USDA supplemental foods to low-income HH on reservations. Distribute canned fruits, vegetables, meats. Pastas, rice. A survey of AI participants indicate that foods are not supplemental - majority of meals

What's a food desert?

Food deserts are areas with limited access to affordable and nutritious food, particularly among low income communities.3 We define food deserts using four criteria: distance from a supermarket, median household income, vehicle ownership and the availability of healthy food in stores.4 http://www.jhsph.edu/research/centers-and-institutes/teaching-the-food-system/curriculum/_pdf/Food_Environments-Vocabulary.pdf

Is glycemic index the same as fiber?

Glycemic index is not the same as fiber, but GI of food is impacted by fiber. Higher fiber foods tend to have lower GI values. Reducing fat can increase the GI

What is glycemic load?

Glycemic load takes into consideration both the glycemic index of a food and the amount of carbohydrate in the portion of food eaten. Calculated by multiplying the GI by the number of g of carbs, then dividing by 100. Low=1-10; Med=11-19; High=>20 http://www.diabetesselfmanagement.com/nutrition-exercise/meal-planning/carbohydrate-counting-glycemic-index-and-glycemic-load-putting-them-all-together/

What are the benefits of combining waist circumference and BMI as a screening measure?

In 1998, the NHLBI additionally recommended measuring WC in individuals with BMI below 35 (increased risk for women with WC>88 cm and men >102 cm). Above 35, WC adds little clinical information. Endorsed by many other organizations, including CDC, AHA. -Beneficial to to combine WC in populations predisposed to central adiposity. -Both, simple, rapid, inexpensive -Individually, are not useful sole indicators of individual's disease risk. (APA_Council on Science and PH_Utility BMI)

What is the prevalence of gestational diabetes?

In the general US population - as high as 9.2%. Ranges from 4.6-9.2%, depending on how data are collected (lower for birth certificate, higher for self-report). http://www.cdc.gov/pcd/issues/2014/13_0415.htm 95% of AI/AN with diabetes have type 2 (as opposed to type 1) http://www.diabetes.org/living-with-diabetes/treatment-and-care/high-risk-populations/treatment-american-indians.html?referrer=https://www.google.com/

What is insulin?

Insulin is a hormone made by the Beta cells in the pancreas. Insulin is released into blood after a meal when blood glucose levels rise. Allows muscle, fat and liver cells to absorb glucose from the bloodstream, lowering blood glucose levels. Encourages the storage of glucose in the liver and muscle tissue (in the form of glycogen). It also reduces glucose production in the liver. http://www.niddk.nih.gov/health-information/health-topics/Diabetes/insulin-resistance-prediabetes/Pages/index.aspx#relate

What is insulin resistance? (PW)

Insulin resistance is a condition in which the body produces insulin but does not use it effectively, leading to high blood sugar. Can lead to prediabetes, type 2 diabetes, or metabolic syndrome. Caused by excess weight, physical activity (muscle helps to balance glucose levels by increasing sensitivity).

Is obesity a disease?

Investigated by a white paper on evidence commissioned by the council of the obesity society. Allison 2008. Reviewed 3 broad arugment classes: scientific, forensic, and utilitarian. Scientific: 1) identify the characteristics of diseases and 2) examine empirical evidence to determine whether obesity has these characteristics. "Is obesity a disease". Found that the question is ill posed because of a lack of a clear, specific, widely accepted, and scientifically applicable definition that allows one to objectively and empirically determine whether a condition is a disease. Forensic approach - Looking to public statements of authoritative bodies as evidence for the validity of a proposition. Opinions are insufficient to tell us what is true or what is right. Utilitarian approach - Recognizing that there is no clear definition of disease, conditions come to be defined as diseases as the result of a social process when it is assessed to be beneficial to the greater good. Must assume values. "should obesity be considered a disease?" Decided that the + outweight the -. More resources for prevention, trt, research. Encourage action by health providers and reducing stigma and discrimination.

What is the Three Streams Model?

Kingdon's Three Streams Model, focuses on the role of policy entrepreneurs/champions who take advantage of policy windows to promote an item on the agenda. These policy windows present a "window of opportunity" and are opened when three streams of activity or processes: the problem stream, the policy stream, and the politics stream58. The problem stream refers to characteristics and perceptions of the problem, which is influenced by data characterizing the problem (surveillance, anecdotal evidence), feedback from programs, sudden focusing events which bring the issue into the limelight, as well as the government's previous successes in addressing the issue58. The policy stream refers to the characteristics of the solution, including the feasibility of the solutions, along with resources and technical knowledge required to address the issue58. The politics stream refers to the support and prioritization of the issue, which are influenced by changes in government, changes of national mood and campaigns by interest groups.

What is the diabetes rates among the Pima Indians?

Lancet paper by Bennett (1971) estimated T2DM prevalence between 1965-9. Used oral glucose tolerance test and cutoff of >= 160 mg per 100 mL. Pr(t2dm|among those 25+) = 42% Pr(t2dm|among those 35+)=50%

Where does the term obese come from?

Latin obesus "having eaten until fat" Gay, Hunger

What does environmental encompass?

Laws, regulations, rules, taxation levels What about norms, mass media messages, etc. - are these environmental?

How is AI food and PA environments different from rural environments? GA

Lot of similarities and overlap, because many AI reservations and thus food and PA environments are located in rural areas. In fact, rural adults and children are at increased risk of obesity than urban counterparts (after adjustment for individual-level behaviors). Limited active living built environments and unique rural barriers to PA may contribute to higher Pr(OB) compared to urban populations. (Hansen_Curr Obes Rep_2015) There are some commonalities: more risk for environmental toxins, like As, without water systems. Cultural limitations specific to rural areas: higher dietary fat and calorie consumption in rural areas, lower rates of exercise, higher rates of screen time, and lack of adequate health education. Structural limitations specific to rural areas: lack of nutrition education poor access to nutritionists, limited resources, and fewer outlets for exercise. Demographic differences: poorer, less education than urban counterparts, both associated with higher rates of OW. (Davis, 2011 and Rural healthy People 2010) What is different: culture (norms of eating, body weight, pa) segregation creates contextual differences (association between BMI and segregation) (Kenney, 2014)

What is metabolic syndrome?

MS is a clustering of cardiometabolic risk factors that co-occur greater than chance alone would predict. Various diagnostic criteria have been proposed by different organizations in the past decade. There is general agreement that five main variables are important: obesity, high triglycerides, low HDLD, high BP, and high glucose, but disagreement about the cutpoints that should be used to define them, the appropriate way to weight and combine them, and the role of microalbuminaria. These factors are associated with an elevated risk of CHD and T2dm. But there are still many unknowns about its etiology and mechanisms of action. Controversy exists over the value of the syndrome label in clinical practice. Additional resources: Gade W, Schmit J, Collins M, Gade J. Beyond obesity: the diagnosis and pathophysiology of metabolic syndrome. Clin Lab Sci 2010;23:51-61; quiz 62.

What is the DASH diet?

May lead to improvement in insulin sensitivity independent of weight loss. http://www.ncbi.nlm.nih.gov/pubmed/23473733

How do patterns of obesity and diabetes vary between Pima Indians in AZ versus Mexico? PW

Mexican Pima have dramatically decreased prevalences of both obesity and diabetes. BMI, wc, hc, and %BF were similar in mexican groups but greater in the AZ group. Obesity was 10 times more frequent in AZ Pima men and 3x more for women than mexican counterparts. Mex Pima 6.5-19.8%; 63.8-74.8%. Diabetes. Mex Pima 5.6-8.5% prevalence, AZ Pima 34.2-40.8%. What is interesting about these groups is that they share common ancestry, supported by genetic analysis. Valencia_Nutr Rev_1999

What are examples in the world for structural interventions? JJS

Mexico soda tax. SSB and junk food tax. Aimed to discourage SSB consumption. Excise tax = one peso (1 cents) per liter, equivalent to a 10% increase in price. Preliminary results indicate a 6% average reduction in SSB purchase in 2014. Reduction increased over the course of the year to reach 12% by Dec 2014. Increased across all SE levels, with greatest reduction in the lowest SE group. Reduced by 9% on avg and 17% by Dec 2014). PAHO and other groups advocating for an increase in tax to 20% for signifant reduction. Nutritional Health Alliance also working to push government to use revenue for boesity prevention. Revenue = $1.3 billion. What is the involvement of research? Came from policy. http://www.insp.mx/epppo/blog/3666-reduccion-consumo-bebidas.html New York City. Former Mayor Bloomberg passed several policies to change the food and PA environment, including: ban on SSB >16 oz with fines as high as $200. Also banned public smoking in bars and restaurants, ban on trans fats for restaurants and vendors. New York required food service to post calorie counts on menus. Attempted soda tax in 2010, failed. FDA orders food manufacturers to stop using trans fat w/in 3 years. http://www.cnn.com/2015/06/16/health/fda-trans-fat/ Overstepped legislature. Criticized b/c loopholes. Wouldn't affect convenience stores or grocery stores and wouldn't apply to diet drinks, fruit juices, dairy-based drinks like milkshakes and starbucks. http://healthland.time.com/2012/05/31/bloombergs-soda-ban-and-other-sweeping-health-measures-in-new-york-city/ http://www.reuters.com/article/us-sodaban-lawsuit-idUSBRE96T0UT20130730 Increase in positive health behaviors, like decrease in adults who drink >1 SSB per day dropped from 36 to 28% in 2007. Increase in PA and eating vegetables. However, obesity rate increased to 25% from 20% since he took office in 2002. http://nypost.com/2013/09/30/obesity-up-25-percent-in-nyc/

Define Nutrition Transition. PW

Nutrition Transition is the shift from local traditional diets and activity patterns to a diet that is lower in carbs, fiber, and whole grains, higher in refined carbs, animal fats, sweeteners, and animal protein. Focuses on structure and overall diet composition. This transition is fueled by industrialization and urbanization. Before, income was associated with nutrition composition (higher GNP levels assoc w/ greater % of E from sugars, veg/animal fat, animal>veg proteins), leads to classical definition of obesity and related diseases as "diseases of affluence". Fat consumption is less dependent on GNP. Urbanization has accelerated the nutrition transition. Westernization/urbanization/modernization? has increased availability of prepared, fatty foods (increased food variety and decreased prep time). Stages of nutrition transition based on income, urbanization. Parallel transitions in changes in disease burden (epidemiologic shift) and socioeconomic and demographic changes.

What is the difference between OPR1 and OPR2 communities? JJS

OPR1 Round 2 communities=OPR2 pilot communities.

How will you evaluate the community action component?

OPREVENT2 pre/post Community action pre/post - evaluate change in . Combine with in-depth interviews with participants to understand change in self-efficacy, ownership of program, potential sustainability, number of changes enacted, change in number of participants over time. change in group composition over time.

What is CBPR and what methods do you think will be useful?

Paradigm shift in ways of doing research with communities. Potential activities include: Social mapping, Transect walks, ranking and scoring, agent-based modelling. embracing_participitation_en Also, photovoice,

What are symptoms of diabetes?

Related to hyperglycemia. Frequent urination (polyuria), excessive thirst (polydipsia), extreme hunger (polyphagia), sudden weight loss, extreme fatigue, irritability, blurred vision ketoacidosis (DKA)- body is unable to use sugar as fuel b/c no insulin or not enough insulin, so uses fat for fuel instead. Causes ketone build up. Marked by fruity smelling breath. More typical in T1DM. nonketotic hyperosmolar syndrome - extremely high BG levels w/o ketones. Can cause coma. More typical in T2DM. https://umm.edu/health/medical/reports/articles/diabetes-type-1 Committee Report_Dia Care_2003 https://www.nlm.nih.gov/medlineplus/ency/article/000320.htm

How to improve the credibility/quality of qualitative work?

Rigor in quantitative work, contrast to rigor in qualitative work. Fairness: balance of beliefs and opinions (incorporating many kinds of leaders). Triangulation of participants. Participatory research increases participant's access to research inquiry. Participant validation. Negative cases. Evocation: intellectual impact. prolonged engagement leads to more evocative results. Triangulation of methods. Critical change: research has action - results in policy-based intervention component, sustained intervention activities.

What is the GI of alcoholic beverages?

Spirits <15 Red wine<15 White wine<15 Beer<15 http://www.lowglycemicload.com/glycemic_table.html

SHS

Strong Heart Study. Objective is to understand CVD and risk factors in AI. Recruited from 13 tribes in three areas (Phoenix, AZ, SW OK and Dakotas). Recruited 45-74 year olds between 1989-1992. Four phases of research. Fifth currently underway. Largest study of CVD and rf in AIs and has been working with these communities for more than 25 years. The SHS findings highlight the need to prevent As exposure in these populations, especially in North and South Dakota, where naturally occuring arsenic in private well water is often above the current US EPA safety standard of 10 micro g/L. Installing As removal devices in homes over the EPA safety standard. Testing two communication strategies, visit program. Using CABs to select final interventions Water study:

What is metformin?

Targeting Aging with Metformin (TAME) human trials. The TAME test is for metformin, which suppresses glucose production by the liver and increases sensitivity to insulin. The drug has been used for more than 60 years and is safe and prolongs healthy life and lifespan in worms3 and in some mouse strains1. Data also suggest that it could delay heart disease, cancer, cognitive decline and death in people with diabetes4. Plans call for the trial to enrol 3,000 people aged 70-80 years at roughly 15 centres around the United States. The trial will take 5-7 years and cost US$50 million, Barzilai estimates, although it does not yet have funding. http://www.nature.com/news/anti-ageing-pill-pushed-as-bona-fide-drug-1.17769

Is obesity a disability?

Temporary or long-term reduction of a person's capacity to function. WHO - any restriction or lack (resulting form an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. Can be temporary/permanent, (ir)reversible, pro/regressive. Particularly relates to impacting every day life. Obesity classified as an impairment of physique (WHO, 1980). A recent analysis of the Framingham Offspring Study used longitudinal data to estimate the association between obesity-years and risk of physical disability and found that obesity for longer periods during mid-life increases risk for later life disability (Wong_Obesity_2015). Disabilities related to sequelae of T2DM.

What is the cost of obesity?

The most recent estimate puts the cost of obesity-related medical spending alone in the United States at $147 billion per year in 2008, compared with $78.5 billion in 1998. This accounts for almost 10 percent of all medical spending https://www.ihs.gov/healthyweight/index.cfm/trends/

What is the prevention paradox?

"Prevention paradox" there is a small group of people that drinks very heavily, but this small proportion is dwarfed by those who drink occasionally in a substantial way. If you focus on this small group, you miss the large part of the problem. (AHS)

FV intake?

- When compared to white students, American Indian/Alaska Natives are more likely to eat five or more fruits and vegetables in a day. About one out of four (25.5%) American Indian/Alaska Natives youths ate five or more; only one out of five (19.8%) of white students ate this many. However, American Indian/Alaska Native youth are more likely to be overweight or obese, and are more likely to engage in other risk behaviors, such as not getting enough physical activity, watching three or more hours of TV a day, or using cigarettes or alcohol. - Source: Everett Jones S, Anderson K, Lowry R, Conner H. Risks to Health Among American Indian/Alaska Native High School Students in the United States. Preventing Chronic Disease. 2011;8(4):A76.

Should different populations have a different obesity cutoff?

-Risk is not homogeneous within a population. There is considerable variation in association between lower BMI and risk of NCDs between Asian populations. Applies to Hong Kong Chinese, Singaporean Chinese, Japanese, Indonesians, while Polynesians have lower body fat. So there is no clear categories for all Asians. Cutoff may not be helpful, when can think of obesity as a continuous variable. And also that change in BMI is important Disadvantages: -Confusing, especially if mixed cultural, ethnic, racial heritage. (APA_Council on Science and PH_Utility BMI)

What are contributors to health inequality in this population?

-SES (including worse living conditions, lower income, and greater barriers to health services compared to other minority US populations). Education - AI/AN have 2x the proportion not completing HS compared to NH whites (20 and 10%). Unemployment rates are 3x higher. 25% of AI/AN live below the federal poverty line (143% higher than NH whites). AI/AN have nearly 2x rate of inadequate housin (moderate or severe physical problems). Food security. Despite the fact that 60% of AI/AN currently live outside of their home reservatinos, only 1% of the IHS budget is used for healthcare there. Even thosewho use IHS services, per capita funding is less than half of what is provided to medicaid and/or incarcerated populations. Per cap funding is just over 1/3 of what is allocated to the general population overall (1351 compared with 3766) Hutchinson_PLoS ONE_2014

What is emergent design and its strengths/limitations?

-no preconceived notions,

What are some potential structural interventions? JJS

1) Strategies to promote the availability of healthy food and bev (increase avail of healthy options in public service venues, schools, gov buildings; relative price of healthy options; encourage opening of supermarkets; healthy options at stores); 2) support healthy food and bev choices (restrict availability of junk in public service venues, smaller portion sizes, limit advertising of junk, discourage consumption of SSB); 3) encourage PA among children and youth, (require PE, increase PA in PE, increase community resources for PA, reduce screen time in public service venues, social, regular exercise) 4) create safe communities that support PA (improve access to outdoor PA facilities, enhance infrastructure for walking/biking, promote walking to school, public transpo, traffic safety rez dogs, lighting, social/regular exercise CDC Recommended community strategies_2009

What are the t2dm rates in different AI populations?

AI/AN have the highest rate of diagnosed diabetes (15.9%) based on ADA 2012 data. (State of obesity, 2015) Pima Indians have the highest ever recorded prevalence. From 1990-1997, prevalence of t2dm increased by 29% to 5.4% Prevalence increased with age (45-65) and for females. Ranged from 3% in Alaska region to 17.4% in Atlantic region in 1997. From 1990-8, total number diagnosed increased among those <35 by 71% and prevalence increased by 46% (to 9.3 per 1000). Increases were greater among adolescents and young men. (Acton_AJPH_2002) Prevalence among <35 varies by region, with 3.0 per 1000 in Alaska region to 34.9 per 1000 in the Southeast region. Prevalence tends to be higher for females (males tend ot have higher impaired FG) and for increased age. CA Indian adults (2011) = 18.4% Pr(Cherokee in 2004)=4.3% Pr(Jicarilla in 1989)=9.8% aged 35+

What is glycosylated hemoglobin? PW

AKA hemoglobin A1C. Hemoglobin which is bound to glucose. Tested to monitor the long-term control of diabetes. Increased levels with poorly controlled diabetes. Glucose stays attached to hemoglobin for the life of the red blood cell (~120 days), the level of glysylated hemoglobin reflects the average blood glucose level over the past 3 months.

How much of OPREVENT2 is set and how much is changeable based on what you find? JJS

Activities in stores, worksites, schools, media is "set" - adapting from previous OPR1 intervention and to new settings. Policy work is open right now. Will also likely work to complement work going on in other components. policy to sustain programs, new policy to promote new initiatives.

Describe the Nutrition transition for AA.

African Diaspora occurred 1533-1870 and captured and transported 11-13 million Africans from predominantly western ports. About 5% of these slaves went to US and experienced rapid "natural expansion". Diaspora was organized by a systematic triangular trade in which the English transported goods to the west coast of Africa, exchanged for people, then brought to america, where they were exchanged for agricultural produce, which was brought back to England. Triangular trade network also transferred cultural, agricultural, and dietary practices. African foods: sorghum, pearl millet, African rice, black-eyed peas, African yams, okra, watermelon, bottle gourd, fluted pumpkin. Possibly deep frying (could be from the middle east). Contemporary diet of AAs is characterized as high in fat and salt and low in FV. In US, African influence of foods has been submerged by commercial food patterns. Represent the late stage of the nutrition transitions. Chronic, degenerative diseases of nutrition excess are the leading causes of ill health. Availability of energy for adults has increased in Nigeria, Jamaica, and US. Obesity, cvd, and diabetes sees a similar trend.

What is alcohol policy? (DJ)

Alcohol policy is any authoritative decision on the part of governments or non-government groups to minimize or prevent alcohol-related consequences. Policies may involve the implementation of a specific strategy with regard to alcohol problems (e.g., increase alcohol taxes), or the allocation of resources that reflect priorities with regard to prevention or treatment efforts. Policies that unintentionally increase harm should also be examined, in order to provide insight into the public health risks associated with ill-advised policy decisions. Alcohol policies serve the interests of public health through their impact on: -drinking patterns -drinking environment -health services available to treat problem drinkers

Describe the three component model

Body wt = FM + TBW + FFM(dry) Combines two methods to better distinguish composition of FFM (e.g., isotope dilution (Total Body Water) and underwater weighing (Fat Mass) Assumes: 1) constant ratio of bone to muscle mass Does not assume: constant hydration of FFM.

Describe the four component model

Body wt = FM + TBW + Muscle Mass (protein) + Bone Mass (mineral) Currently the "Gold Standard" Combines 2 methods plus DXA scan for bone mineral density.

What is the theoretical gold standard for assessing body composition?

Cadaver analysis is the most accurate way to differentiate components of the body, but very not feasible on a large scale. Grind up and do bomb calorimetry. http://www.iub.edu/~k561/bodycomp.html#compart

What is the glycemic index of food? Name some foods high and low

Can categorize into low (0-55), med (56-69), high (70-100). http://www.hsph.harvard.edu/nutritionsource/carbohydrates/carbohydrates-and-blood-sugar/ High: White potato baked w/o skin (98), watermelon (80), white bread (75), white rice (83), instant oatmeal (83) Med: beer (66), sweet potato, boiled (61), wild rice (57), 100% whole wheat bread Low: carrots raw, diced (35) pearled barley (22), peanuts (7), 100% whole wheat bread, oatmeal, rolled (50). Alcohol: Alcoholic beverages contain very little carbs. In fact, most wines and spirits contain virtually none, although beer contains some (3 or 4 grams per 100 mL). A middy of beer (10 ounces) contains about 10 grams of carbohydrate compared with 36 grams in the same volume of soft drink. For this reason, a beer will raise glucose levels slightly. If you drink beer in large volumes (not a great idea) then you could expect it to have a more significant effect on blood glucose. As for enjoying an occasional drink, researchers from the University of Sydney found that a pre-dinner drink tends to produce a 'priming' effect, flicking the switch from internal to external sources of fuel and keeping blood-sugar levels low. Breads: What about sprouted grain breads? What should you do with your own baking? Try to increase the soluble fibre content by partially substituting flour with oat bran, rice bran or rolled oats and increase the bulkiness of the product with dried fruit, nuts, muesli, All-Bran or unprocessed bran. Don't think of it as a challenge. It's an opportunity for some creative cooking. Bread made from sprouted grains might well have a lower blood-glucose raising ability than bread made from normal flour. When grains begin to sprout, carbohydrates stored in the grain are used as the fuel source for the new shoot. Chances are that the more readily available carbs stored in the wheat grain will be used up first, thereby reducing the amount of carbs in the final product. Furthermore, if the whole kernel form of the wheat grain is retained in the finished product, it will have the desired effect of lowering the blood glucose level.

How does obesity lead to cancer?

Cancers: breast (post-menopausal women), endometrium, kidney, esophagus. Mechanisms: increased levels of endogenous hormones (sex steroids, insulin and insulin-like growth factor), gastroesophageal reflux and esophageal adenocarcinoma.

Examples of Alcohol marketing to Native North Americans?

Crazy Horse Malt Liquor sued by Oglala Sioux, settled in good terms with apology. http://news.minnesota.publicradio.org/features/200104/26_stawickie_crazyhorse/?refid=0 Thunderbird wine, Black Hawk Stout, and Chief OshKosh Red Lager. Crazy Horse's name has been used for tobacco products, strip joints and saloons.https://www.google.com/search?q=crazy+horse+malt+liquor&oq=crazy+horse&aqs=chrome.0.69i59j0l5.1680j0j7&sourceid=chrome&es_sm=93&ie=UTF-8#q=crazy+horse+ Budweiser used NA image to market in UK. http://articles.sun-sentinel.com/1996-07-23/news/9607220109_1_indians-budweiser-alcoholism https://www.youtube.com/watch?v=K3ykIys_aKQ Budweiser Beer Lithograph - Custer's Last Fight

Densitometry

Description: Uses the density formula (D=MV) and Archimides' Principle (weight of fluid displaced is equal to weight of object) to estimate the percent body fat of a participant using the displacement of water and the dry mass of an individual. Strengths: -Gives a very accurate assessment of %BF, since it more directly measures adiposity. Limitations: -Based on the two component model -Not easy to use on larger participants (chair has fixed size) -Expensive and time intensive -Uncomfortable (bathing suits, sit still) -Underestimates body fat in non-whites, athletes; overestimates in elderly.

Air displacement plethymography

Description: Uses the density formula (D=MV) and Boyle's Law to estimate %BF using a bod pod. Strengths: -More accurate because a direct measure of adiposity -Not difficult to operate -Short measurement time -Wel-suited for special populations (children, obese, elderly and disabled) Limitations: -Can't accommodate sizes larger than the bodpod. -More expensive and time intensive

What is diabetes? (PW)

Diabetes mellitus (latin: a passer through; a siphon (excessive discharge of urine) + honey-sweet (sweet taste of urine)) is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Caused by autoimmune destruction of beta cells or deficient insulin action (caused by impaired insulin secretion and/or reduced insulin sensitivity - it's often unclear which, if either alone, is the primary cause of hyperglycemia) Committee Report_Dia Care_2003 Five types: t1dm (beta cell destruction, usually leading to absolute insulin deficiency); t2dm (ranges from insulin resistance to relative insulin deficiency to a predominantly secretory defect with insulin resistance); t3dm (other - genetic, due to diseases of the pancreas, endocrinopathy, drug or chemical-induced, due to infections, immune-mediated, genetic syndromes associated with diabetes); t4dm (gestational diabetes); Diabetes is characterized by chronic high blood glucose levels (hyperglycemia) due to the body's failure to produce any or enough insulin to regulate high glucose levels. Type 1 when body is unable to produce insulin. type 2 is insulin resistance: cannot use insulin effectively. 90% is t2dm.

What are the main complications of diabetes? PW

Diabetic retinopathy (blindness), kidney disease (nephropathy), diabetic neuropathy (nerve damage, foot and leg amputations), and macrovascular problems plaque buildup in large blood vessels, leading to heart attack, stroke, or peripheral vascular disease.

Have any structural interventions been sustained through policies? JJS

Difference between policy and sustain. In a way, they are very different. Policy can help sustain, but policy itself doesn't guarantee implementation. Policy can be the first step towards sustaining. Means that you have political support, priority for work. Increasing access to healthy foods - can be sustained with policies. Encouraging stores to become registered for WIC. Ensuring continued use of curriculum - school board approval and policy to back this up (similar to PE requirements). Other examples of policy I think are ways to sustain regular activities, as a way to institutionalize actions. People, employees change, but policies can promote sustained change. For example - policy change for tribal government buildings to have healthy food options for organized lunches/meals.

What is the difference between type 1 and 2 diabetes and are these good terms? (PW)

Different kinds of diabetes differ markedly in pathogenesis, natural history, response to therapy, and prevention. Type 1 diabetes (AKA Insulin-dependent diabetes; juvenile diabetes). Can develop at any age. Symptoms are more abrupt and severe. Type 1A is considered an autoimmune disorder that involves: gradual destruction of beta cells (until complete destruction); hyperglycemia; loss of sugar in urine; symptoms; require daily insulin for survival. Beta cells are slowly destroyed by the body's own immune system and results in absolute deficiency of insulin secretion. Tested by presence of autoanitibodies in 85-90%. Type 1B Idiopathic an unusual form of phenotypic type 1 diabetes with almost complete insulin deficiency, a strong hereditary component, and no evidence of autoimmunity, and unknown etiology. Reported mainly in Africa and Asia. Type 1 is more prone to ketoacidosis Causes aren't completely understood and so prevention isn't understood; could be related to both genetic predisposition and environmental factors, such as a viral infection (mostly enteric viruses, like Coxsackie, mumps, congenital rubella). Cases have been increasing for past several decades. Type 2 diabetes (AKA non-insulin dependent diabetes; maturity-onset diabetes) is caused by a combination of insulin resistance and inadequate compensatory insulin secretory response. Type 2 diabetes: insulin resistance with preserved endogenous insulin secretion but inadequate to overcome the resistance (insulin secretory defect). About 90-95% of all diabetes, more common type in ethnic minorities. Clinical features: older onset (often >35 years old, though recently occurring more often in youth), overweight or obese (predominantly abdominal region), strong family history of diabetes, response to oral agents usually for some years, and relatively stable blood glucose levels, gradual onset. Stronger genetic association than t1A Assigning a type of diabetes to an individual often depends on the circumstances present at the time of diagnosis, and many diabetic individuals do not easily fit into a single class. For example, a person with GDM may continue to be hyperglycemic after delivery and may be determined to have, in fact, t1dm. Alternatively a person who acquires diabetes b/c of large doses of exogenous steroids may become normoglycemic once the glucocorticoids are discontinued, but then may develop diabetes many years later after recurrent episodes of pancreatitis. Another example would be a person treated with thiazides who develops diabetes years later. B/c thiazides in themselves seldom cause severe hyperglycemia, such individuals probably have t2dm that is exacerbated by the drug. Thus, for the clinician and patient, it is less important to label the particular type of diabetes than it is to understand the pathogenesis of the hyperglycemia and to treat it effectively. Drugs may not cause diabetes by themselves, but may precipitate diabetes in individuals with insulin resistance. In such cases, the classification is unclear b/c the sequence or relative importance of Beta cell dysfunction and insulin resistance is unknown. But this is rare. https://umm.edu/health/medical/reports/articles/diabetes-type-1 Committee Report_Dia Care_2003 http://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Diabetes_Guide/547038/all/Diagnosis_and_Classification_of_Diabetes

What are competing theories to energy balance theory for explaining the occurrence of obesity? PW

Energy balance is based on the first law of thermodynamics, states that weight gain comes from more energy intake than energy expenditure. Total Energy Expenditure = PAL x BMR (70%) + TEF (10). Emphasizes that a calorie is a calorie. There has been some research into whether macronutrient distribution matters. In a recent review (Sacks) testing the impact of low/high fat and low/high carb diets, review found that macronutrient distribution made little difference, was explained more by energy intake. On the other hand, the Microbiome theory, emphasizes the role of the human microbiota in causing obesity and related chronic diseases. These two theories also suggest similar solutions - shifting to diets higher in fiber, lower in fat, lower in sugar. Some of the more extreme interventions based on microbiome have not been tested in humans and are not feasible. (fecal transplants). Energy balance is the best bet right now until the microbiome model is better understood.

What's Glycemic Index and why is it important? PW

Enumerates glycemic response on a scale of 0 to 100, with higher values given to foods that cause the most rapid rise in blood sugar. About 10 people ingest samples and samples are taken 15-30 minute intervals over the next 2 hours. Pure glucose is the reference and has a GI of 100. Spikes dangerous for those with t2dm. GI affected by preparation method. Any significant food processing will elevate GI values for certain foods because it makes food quicker and easier to digest.

What's the difference between excise and sales tax and which is better?

Excise taxes increase price based on the unit, while sales tax increase price based on price. Excise tax is better because companies could get wise and reduce the pre tax price of the product hence lowering the tax level and undermining health impacts. can provide incentive for companies to reduce sugar. The downside is that excise tax alone is regressive (higher burden for poor). Cabrera Escobar_BMC PH_2013

How does smoking influence adiposity?

The relation between smoking and obesity is incompletely understood. On the one hand, nicotine acutely increases energy expenditure (EE) (4) and could reduce appetite, which likely explains why smokers tend to have lower body weight than do nonsmokers and why smoking cessation is frequently followed by weight gain (5, 6). Moreover, a belief popular among both smokers and nonsmokers is that smoking is an efficient way to control body weight (7). On the other hand, studies indicate that heavy smokers (ie, those smoking a greater number of cigarettes/d) have greater body weight than do light smokers (8 -10) and that there is a clustering of smoking, obesity, and lower socioeconomic status, at least in developed countries (11). Finally, there is increasing evidence that smoking affects body fat distribution and that it is associated with central obesity and insulin resistance (12, 13). Do smokers have lower body weight than nonsmokers? Numerous cross-sectional studies indicate that body weight, or body mass index (BMI; in kg/m2), is lower in cigarette smokers than in nonsmokers Does smoking increase waist circumference? Waist circumference or waist-to-hip ratio (WHR) is an indicator of the amount of visceral adipose tissue (VAT). A greater amount of VAT is related to the metabolic syndrome, diabetes, and cardiovascular diseases (71). Cross-sectional studies indicate that WHR is higher in smokers than in nonsmokers (8, 14, 72-76). WHR is positively associated with the number of packyears of smoking (74), and there is a dose-response relation between WHR and the number of cigarettes smoked (14, 73). In former smokers, WHR is negatively associated with the time since smoking cessation (74). In particular, smokers tend to have both a larger waist circumference and a smaller hip circumference than do nonsmokers (74, 75); these findings reflect not only greater abdominal fat deposition but also less muscle mass at hip level. The combination of a high WHR with a low BMI, which some authors consider a "paradox" (76), is more frequent in smokers than in nonsmokers.

How can modest reductions in a prevalent risk factor result in big changes for the population?

The seminal work of Rose laid out the foundations of population-based prevention on the premise that "a large number of people at a small risk may give rise to more cases of disease than a small number who are at a high risk" 31. G. Rose, Int. J. Epidemiol. 14, 32 (1985).

What is impaired glucose tolerance?

The terms IGT and IFG refer to a metabolic stage intermediate between normal glucose homeostasis and diabetes, now referred to as pre-diabetes. This stage includes individuals who have IGT and individuals with fasting glucose levels >=110 mg/dl (6.1 mmol/l) but <126 mg/dl (7.0 mmol/l). Plasma glucose levels are above normal but below the level to define diabetes. In the absence of pregnancy, IFG and IGT are not clinical entities in their own right but rather risk factors for future diabets and cvd and associated with insulin ressistance syndrom aka MS. Correlated with insulin resistance. Committee Report_Dia Care_2003

What is the relationship between SES and obesity?

Theory predicts an inverted U-shape relationship between unearned income and weight (Lakdawalla and Philipson 2009). As income increases, households and individuals increase their consumption of food, and consequently we see an increase in weight. Beyond a certain threshold, the wealthiest households are either able to purchase higher quality foods that are more nutritious or pursue health-related activities, so theincome-BMI curve starts sloping downward (Akee_Am Econ Assoc_2013) Per capita payments associated with increased obesity risk in poorest households (Akee, 2013).

What are compartment models of the human body and why are they used?

There are several compartment models for the human body. They range from a simple two compartment model to a four compartment model. The goal in body composition is to measure one of these compartments and assume that the relationship between the compartments is constant to estimate another compartment. http://www.iub.edu/~k561/bodycomp.html#compart

How did the WHO develop BMI classes?

These classifications were based on the relationship between BMI and mortality, particularly for choosing the cutoff of 30 kg/m2, above which there was an observed natural threshold for increased mortality risk. Other cutoffs are somewhat arbitrary (1993). In 1997 the WHO recommended an additional cutpoint at 35 kg/m2 as part of a three-tiered obesity classification system, where obesity >=30; obese class I: 30-34.99; class 2: 35-39.99; class 3 >=40. (APA_Council on Science and PH_Utility BMI) in 1998 NHLBI lowered threshold for normal bodies to below 25 (Gay, Hunger)

What does this tell us about the Nutrition Transition? PW

These two groups were examined because of the different environments that they live while having similar heritage and therefore genetic risk for diabetes. Mexican Pima were isolated - no road access, no electricity or running water. Significant energy expenditure as part of daily life. Traditional diets. Cultivate corn, beans, potatoes, peaches. Wood milling, livestock breeding. >50 g of fiber daily, ate very little animal proteins, very low fat diets (23%). high carb diet. Very little fruit and vegetables. Stapes are corn tortillas, beans, and potatoes. On the other hand the AZ Pima experienced a very fast transition from traditional lifestyles. When they moved to AZ adapted to desert environment. Irrigation system. Water access cut off. Facilitated rapid shift to commodity foods and western diet. this tells us that the food and physical activity environments can have a dramatic difference in obesity and diabetes prevalence.

What is the relationship between alcohol consumption and diabetes and other NCDs?

Two meta-analyses: Compared with minimal alcohol consumption, light and moderate alcohol consumption was associated with a lower T2D risk. Heavy alcohol consumption had no effect on T2D risk. Schrieks, 2015 and Li, 2016 Lit review on evidence from animal and human models show that alcohol consumption may trigger T2D development/progression through impaired glucose metabolism and pancreatic beta cell dysfunction and apoptosis (Kim, 2015) Mechanism for alcohol-induced decreases in T2D risk is not clear. Could be that moderate alcohol consumption improves insulin sensitivity and decrease fasting insulin and glycated hemolobin concentrations. No association for heavy drinkers could have stopped because of illness, biasing association towards null. (Schrieks_Dia Care_2015). drinking patterns that promote frequent and heavy alcohol consumption associated with NCDs like liver cirrhosis, CVD, depression, diabetes. Relationship is related to toxic effects and dependence. Dependence also leads to social problems and ACE. Mokdad et al, JAMA, 2004. leading vs. actual causes of death. substantial evidence of some protective ffect, particularly for CHD. Effect disappears at higher levels of consumption. Effect requires regular daily light drinking (rare pattern in the US). No protective effect under 45, Challenging to find effect at aggregate level, although do find it at individual level.

What are the WHO classes for BMI?

Underweight (<18.5), Normal range (18.5-24.9), Grade 1 overweight ( "OW", 25.0-29.9), Grade 2 overweight (i.e., "OB", 30.0-39.9), Grade 3 overweight (i.e., "morbid OB", ≥40.0)

Is alcohol an ordinary commodity?

Unlike other commodities, the benefits connected with the production, sale and use of this commodity come at an enormous cost to society. Causes medical, psychological, and social harm via 1) physical toxicity 2) intoxication 3) dependence. Problems vary by use patterns

What environmental contaminants are relevant to the populations that you're working with?

Ur in the NN. Used to mine uranium for nuclear weapons 1944-1986. Many Navajo people worked the mines and lived close by with their families. Mines are now closed, but legacy of contamination remains, including over 500 abandoned uranium mines as well as homes and drinking water with elevated radiation levels. Health effects include lung cancer from inhalation, bone cancer and impaired kidney function from exposure in drinking water. https://www3.epa.gov/region9/superfund/navajo-nation/

Why do diabetics get hypoglycemia?

When blood glucose begins to fall, glucagon—another hormone made by the pancreas—signals the liver to break down glycogen and release glucose into the bloodstream. Blood glucose will then rise toward a normal level. In some people with diabetes, this glucagon response to hypoglycemia is impaired and other hormones such as epinephrine, also called adrenaline, may raise the blood glucose level. But with diabetes treated with insulin or pills that increase insulin production, glucose levels can't easily return to the normal range.

What is a commodity

a basic good used in commerce that is interchangeable with other commodities of the same type. Often used as production inputs. Quality may differ slightly, but essentially uniform across producers. http://www.investopedia.com/terms/c/commodity.asp

What is health policy? How is this different from a structural change?

a healthy policy is a way to make a structural change. Not all structural changes are formal policy.

What is the potential role of agent-based modeling in this work? JG

a kind of computational modeling which simulates the actions and interactions of autonomous individuals and the environment to assess effects on the system as a whole. Useful to use explicit models that identify assumptions, use data, to understand how things fit together (instead of implicit mental models). Useful for understanding how an intervention will work, how to scale up program, sustain program. Can be used as a participatory method to engage stakeholders. Can help understand unanticipated consequences and what to do about them.

How can obesity have multigenerational transmission?

association between larger maternal weights, larger birth weights, and diabetes risk among offspring. Mechanisms include transmission of overweight and obesity and social inheritance (familial dietary and activity habits) and epigenetic mechanisms. Schell_ Am J Hum Bio_2012

What is prediabetes?

condition in which blood glucose levels or A1C levels are higher than normal, but not high enough for a diabetes diagnosis. Characterized by insulin resistance, beta cells no longer able to produce enough insulin, elevated blood glucose levels. Increased risk of CVD and t2dm (after about 10 years). (Cite) 30% of AI/AN have prediabetes http://www.diabetes.org/living-with-diabetes/treatment-and-care/high-risk-populations/treatment-american-indians.html?referrer=https://www.google.com/

What are saunder's process eval components?

fidelity, dose delivered, dose received, reach, recruitment, context.

What's the difference between an instrumental and an intrinsic case?

instrumental case study - research on a case to gain understanding of something else intrinsic - when the case itself is of primary, not secondary interest. We find this case using extreme or deviant case sampling. Learning from highly unusual manifestations of hte phenomenon of interest, such as outstanding successes/notable failures, top of hte class/dropouts, exotic events, crises. (Patton 1990 sampling)

Price elasticity of alcoholic beverages?

price elasticity of demand = change in demand/change in price. Alcoholic products are somewhat inelastic. Price inelastic, because <-1. Considered essential and when the price increases, ppl will continue to buy or go to an alternative. Efficacy of taxes varies by income level. A 10% increase in the price of beer will lead to a 5% drop in consumption. A 10% increase in the price of wine wine will lead to a 6.5% drop in consumption. A 10% increase in the price of distilled spirits will lead to a 8% drop in consumption. Empirical evidence suggests that producers pass alcohol excise taxes on to consumers at a ratio ranging from 1 to 2 - i.e. a 10% increase in tax leads to a 10-20% increase in price. Cook (2007) uses data sets covering multiple phenomena over time (panel data) in the 50 states from 1981 to 2000 to estimate the impact of an increase of 10 cents per ounce, or approximately a nickel a drink, in alcohol excise taxes. Motor vehicle fatalities would decline by 7% and mortality from liver cirrhosis by 32%. Severe violence towards children - for every 10% increase in the beer excise tax rates, the probability of this decreases by 2.3% Alcohol dependence Male suicides - higher beer taxes are associated with fewer suicides among males ages 10 to 24 useful tidbits: Equalize based on alcohol content Index for inflation Set minimum price Important for discounting Taxes reduce for severe drinking, but no impact on possible health benefits among moderate drinkers.

What are some social harms of alcohol?

violence, vandalism, public disorder, family problems: divorce/marital problems, child abuse, other interpersonal problems, financial problems, work related problems other than accidents, educational difficulties

What are benefits of alcohol and related development?

§Employment and income generation §Government revenue - justifiable for: -Public health - reduce consumption -Revenue raising - as high as 24% of some state revenues §Quality improvement §Sourcing of inputs and balance of payment issues (contributes to GDP) §MNCs and technology transfer §Early form of foreign direct investment

What is the smoking rate of AI/AN generally and in the communities you're working with?

BRFSS data (2000-2010), Approximately 30% of AI/ANs are current smokers, compared to about 20% in White. Less likely to be never smoker 10% reduced prevalence compared to whites. (Cobb_AJPH_2014)

Where does AI/AN surveillance data come from?

Behavior Risk Factor Surveillance System (BRFSS), National Health Interview Survey (NHIS), Racial and Ethnic Approaches to Community Health (REACH) project, Strong Heart Study. Hutchinson_PLoS ONE_2014 Can also get CD data from IHS -trends in Indian health - latest is 2014, but will be updated soon (2/16/18). State of obesity report - includes AI/AN data from NHIS and BRFSS and YBRFS. Limited Data For Racial And Ethnic Populations. The total sample sizes for BRFSS in states is often 600-800 people. Many states do not have large enough populations of Asian/Pacific Islanders and American Indian/Alaska Natives to be reflected in the survey findings

BRFSS

Behavior Risk Factor Surveillance System. Annual cross-sectional random-digit dialing telephone survey administered to adults >18.

Describe the two component model

Body is divided in to fat and fat free mass (FFM) or lipid and lipid-free mass (LFM), more commonly called lean body mass. The difference between fat free mass and lean body mass is essential lipid (Le) (Lipid>Fat). Essential lipids are those needed to keep the integrity of the cell membrane. Non-essential lipids are those commonly found in fat stores. FFM includes essential lipids, whereas lean body mass does not. http://www.iub.edu/~k561/bodycomp.html#compart Assumes: 1) constant hydration of FFM, ratio of bone mass to muscle. Likely to be violated for ill, malnourished, metabolic alterations, pregnant/growing 2) Measure one aspect of FFM, calculate others based on assumptions of hydration of FFM, determine fat by difference.

What are different CVD rates

Pr(hypertension|CA Indian adults (2011) = 25.1%

Describe the Nutrition Transition for AI

Primary health risk for AI population around 1970 was undernutrition, have shifted to obesity in all age groups. 1926-7 Indian affairs survey, review of AI boarding schools, 1969 conference on nutrition, growth, and development of AI children, IHS hospitals. Historically - AI people lived in environments with limited and variable energy supply and intense requirements for PA to survive. E Intake: Consistent pattern of greater fat and saturated fat intake, with reduced intake of lower E but higher nutrient-dense fruits and vegetables is reported. Pima, Ojibwe, Catawba, Reach 2010. PA: reduced PA with greater acculturation. AI people have been confined to reservations, limiting ability to hunt for game. forcing AI people to give up weapons. increasing development and somewhat improved economic circumstances have resulted in increased TV viewing. More examined in AI children. Reach 2010, SHS. Barriers to PA - busy, time and space constraints. Pathways - lack of facilities, equipment, trained PE teachers noted in school setting. Weather conditions, safety, time for homework and chores for children. There is a revitalization of AI traditional culture, language, and diets. Urban diets are characterized by consumption of superior and polished grains, more fats and animal products, more sugar, more processed foods, and more foods consumed away from home. Native communities are rural, though many are forced to find work off rez. (Compher_J Transcult Nurs_2006)

What are the pros and cons of calling obesity a disease and not a risk factor to other diseases? GA

Pros: More resources for prevention, trt, and research. Can change insurance coverage for obese patients. Encourage action by health providers and reducing stigma (reduce view of obesity as a lifestyle choice stereotypes of laziness, poor character, and encourage more complex views of the disease and interaction between genes, behavioral, and environment, like other diseases) and discrimination. Cons: stigma (obese individuals could be visually identified as having a disease. Once labeled as a disease, can combat unjust stigmatization more effectively and aggressively) acceptance/excuse (once labeled as a disease, individuals would stop trying to manage their weight and accept as inevitable. Could be offset by communicating the severity of the disease, which could make some take it more seriously). Innaccurate (a risk factor, not a disease. Difference is one of emphasis. Labeling a disease will help to direct resources if labeled as a disease) (Allison, 2008)

What is SCT?

Psychological theory developed by Bandura in the 70s. Evolved from SLT, which focused on how people learn by observing others actions and their outcomes. SCT, three factors affect individual behavior: self-efficacy, goals, outcome expectations. Reciprocal determinism - There is a dynamic interaction between the person, behavior, and the environment. Interventions: improving SE (incremental goals, behavioral contracting, monitoring and reinforcement), working to promote behavior in multiple ways (env and attitudes).

Are type 1 and 2 good terms?

An improvement from the nomenclature that was based on treatment or on onset period. New names type 1 and type 2 are based on disease etiology. Patient advocates in 2013 have pushed for revision to rename type 1 as Autoimmune Beta Cell Apoptosis (BCA) Diabetes and type 2 as Insulin Resistance Diabetes (IRD) to differentiate the causes of the diseases. 1979 - recommendation to move away from "juvenile-" and "adult onset" by an international task force sponsored by the NIH's National Diabetes Data Group. The ADA, Australian Diabetes Society, British Diabetic Association, and the European Association for the Study of Diabetes (EASD) signed on. With provisos, the World Health Organization eventually signed on as well (although they went farther and actually "created" five types of diabetes, of which only the first two had numbers). Between 1979 and 1995, we got the terms insulin-dependent diabetes mellitus type 1 (IDDM) and non-insulin-dependent diabetes mellitus type 2 (NIDDM), which were treatment-based but confusing nonetheless. During the 1990s, another international Expert Committee sponsored by the ADA re-organized the whole scheme and gave us the numerical terms of Type 1 and Type 2 that we use today, although they specified using Arabic numerals, rather than the medically traditional Roman Numerals, supposedly to eliminate even more confusion. http://www.healthline.com/diabetesmine/the-kerfuffle-over-new-names-for-type-1-and-type-2-diabetes#2 Committee Report_Dia Care_2003

What was Healthy Children, Strong Family's impact on obesity? GA

Anecdotal evidence, not rigorous evaluation of multisectoral strategies.

BMI can vary for different groups, like Asians. Please explain

Central obesity is characteristic of AI and FN people. Because of this, risk of obesity-related disorders have been reported to begin at lower BMIs. Asian populations also tend to have higher %BF at the same age, gender, BMI. (APA_Council on Science and PH_Utility BMI). There is mixed support for analyzing whether race is related to body composition: No Association: - Another study, The First Nations bone health study, found that mean trunk fat tissue mass fraction and total body fat mass fraction was greater in FN women than white women. Trunk lean tissue was also greater in FN women. (Leslie_Applied Physiology_2007) - Gautier also examined fat distribution comparing a small population of Pimas and Caucasians (20 age, sex and BMI matched) and found that abdominal visceral and subcutaneous adipose tissue areas were similar in the two groups. Association: - Recent study M-CHAT analyzed multiple ethnicities from one metropolitan area to assess whether body fat distribution differs according to ethnicity and found that there were no observed differences between Aboriginal and European Canadian participants using DXA (Lear_Am J Clin Nutr_2007). - Study by Katzmarzyk compared body disributions in a larger sample of Canadians of FN (n=118) and European ancestry (n=472) and found that FN had greater subcutaneous adiposity, indicating greater centralization of subcutaneous fat.

What is the food environment

Collction of physical, biological, social factors affecting individual or group eating habits and patterns.

What is an anthropometric index?

Combinations of measurements essential for interpretation. For example, weight has no meaning without relation to a person's height. WHO_Definition of obesity_1995.

What media advocacy approaches will you use?

Communication strategies, like piggybacking, social math, framing (ex: food sovereignty, diabetes prev)

What is obesity?

Conceptually - obesity is an excess of body fat. Excess of adipose tissue large enough to result in shortened lifespan or reduced health. Operationally defined using BMI categories.

What are drinking patterns of AI/ANs?

Consumption patterns, 1984. AI/AN preference for beer, drinking in private places, like homes. (Hughes, 1984) AI/AN youth tend to have highest use: -Any alcohol use highest for AI/AN 12-17: 20.5% and among the highest for 18-25: 50.7%, -highest binge drinking AI/AN 12-17 (>=1 in month): 13.2%, second highest for 18-25 (43.9%). Mulye, NSDUH, 2007. AI/AN (NSDUH 2009-2011) - 9% AI/AN past-year alcohol dependence (>3/7: tolerance, withdrawal, impaired control, unsuccessful cuts/stops, continued use despite problems, neglect of activities, time spent alc activities) (Esser_Prev Chronic Dis_2015) High prevalence of abstainers - 60% AI/AN (NSDUH 2009-2013) Heavy (5+ in one occasion 5+ days) - 8.3% (highest) Binge (5+ in one occasion 1-4 days) - 17.3% (2nd highest, hispanic) No binge, no heavy: 14.5% (lowest) Typically no binge, no heavy: 24.7% (lowest) Abstainer (last month): 59.9% AI/AN (BRFSS 2011-2013) Excessive: 17.1% (mid) Typically-Light/Moderate: 30.0% Abstainer: 57.5% US - among drinkers, men drink heavily much more often than women. Abstinence and infrequent drinking are more prevalent in older age groups and frequent intoxication is more prevalent among young adults. Most alcohol in a society is consumed by a relatively small minority of drinkers When alcohol consumption levels increase in a country, there tends to be an increase in the prevalence of heavy drinking. Data: CDC: BRFSS, YRBS, SAMHSA: NSDUH.

Can you describe Social Ecological Model

Created by bronfenbrenner to understand human development. Bridge between structure (anthropology) and agency (behavioral theories). Emphasizes that individuals and environment influence behavior. Reciprocal causation - individual behaviors shape and are shaped by the environment (via social norms) McLeroy differentiates five different levels of factors influencing and influenced by a given individual behavior, including: intrapersonal, interpersonal, organizational, community, and public policy levels. Downside: not clear where culture, racism fit in. Bronfenbrenner - four levels: microsystem (relationships and interactions in immediate surrounding including family, school neighborhood, childcare), mesosystem (connect >2 systems in which child, parent, family live ex: church and neighborhood), exosystem (move beyond direct systems, work schedule workplace,, macrosystem )cultural values, customs, laws). Structural interventions aim to modify health-related behaviors by changing factors external to the control of the individual, and therefore focus activities on upstream levels beyond the intrapersonal level. The goal of such interventions is to change behavior of the entire population rather than to focus on individuals with high risk behaviors. Figure 1 as macro-system (cultural identity); mezzo-system (institutional/community support); micro-system (secure bonds in the family network); and intrapersonal level (cognitive developmental stage, self-esteem, self-efficacy, knowledge, and actions as change agents [leading by example, speaking up]).

What are other ways that obesity can be assessed?

Criterion methods: Hydrometry, Densitometry, DXA Gold standard: four component model (not useful for large studies) Methods requiring comparison to criterion methods: Anthropometric measures (BMI, BAI, WC, WHR, weight, skinfolds) BIA

What did AI traditional diets consist of?

DeGonzague, 1999 - Ojibwe communities (Mille Lacs, Minn and LCO, WI). Ojibwe ceded large tracts of land for mining and timber, establishment of state boundaries and establishment of reservations. Limited land base reduced are for harvesting food, disrupted patterns of subsistence. Not allowed to hunt or fish off rez and from carrying harvested foods across state or rez boundaries, further increasing reliance on gov assistance. Food is considered a gift from the creator. Wild rice is tied to identity of the ojibwe."manoomin" Other traditional foods include deer meat, maple syrup. Now, traditional food used for ceremonies, occasionally. Prev of HH w/ at least 1 person who hunts, fishes, gathers - about 50% Gardening about 20%. LCO had 81% of HH in survey using USDA commodities. Met RDA for energy and consistent w/ NHANES data. % E from fat and saturated fat was above recommended levels. Fat intake was higher and carb intake lower than general US dietary pattern. Compared with NHANES men, Ojibwe men had lower folate, fiber, and vitamin C and higher saturated fat. Compared with NHANES women, Ojibwe women had higher protein, saturated fat, and fat and lower carb, vit C, folate, Ca, dietary fiber, Vit A. These results suggest that diets of Ojibwe may be less nutrient dense and lower quality than diets of the general US. Traditional food items were among the top 10 food sources of protein, iron zin, folate, and sucrose. Navajo traditional foods - farmed corn, beans, and squash and hunted animals such as deer and prairie dogs. Wild celery, corn silk, wild onion, wolfberry, wax currant, pino nuts, yucca bananas. New -sheep and goat. No fish or fowl because of reliigious beliefs regarding fish and birds.

What are the advantages and disadvantages of using BMI?

Description: Anthropometric index that characterizes weight independent of height in adults. Calculated by weight per height^2. Related to body fat, but also fat free mass and body type. Strengths: -Related to CD risk. -Commonly used -Established cutoffs -Cheap and easy -Useful to assess trends in adiposity in populations. Limitations: -BMI is an indirect measure of adiposity and FM -Not able to assess adipose tissue distribution (BMI is a measure of overall obesity). -Not able to distinguish fat from lean mass (mass includes all tissues) -Not able to distinguish between types of fat on a person's body -Ethnic variations in BMI (Asian). -Not as useful for individuals unless used with other clinical indicators.

BAI

Description: Anthropometric index. Body Adiposity Index =hip circumference/ height^1.5- 18 Strengths: -Correlated with DXA (0.85) -High concordance with DXA (95%) -Useful when accurate body weight isn't possible -Created and validated in two minority populations MA and AA. -Provides %BF in both males and females without statistical correction. -May be more able to understand risk because hip size reflects both visceral and subcutaneous adiposity Limitations: -somewhat more difficult to calculate

Skinfolds

Description: Anthropometric measurement. Useful for assessing subcutaneous fat. Measures skinfolds in triceps (most common), biceps, subscapular, suprailiac, midaxillary, chest, abdomen, thigh, calf. Most equations use the sum of at least 3 skinfolds to estimate body density from which body fat may be calculated. Age and sex specific. Equations to relate skinfold measurements to body composition developed in large, mainly Caucasian populations. Assumes: distribution of subcutaneous fat and internal fat is similar for all individuals.

BIA

Description: Bioelectrical Impedance Analysis (BIA). Electrodes are attached to a subject's body and a small electrical current is passed through the body. Body's FM acts as a resistor and the FFM acts as a conductor of electricity. Based on Ohm's Law, one can calculate electrical impedance and thus the body composition of the individual (%BF). Strengths: -More accurate for those with higher muscle mass (than BMI) -Estimates amount of body fat in the area tested -Portable, safe, convenient, cheap Limitations: -Measure depends on the placement of the electrodes (most accurate is from shoulder and foot). -Harder to assess bias (compared to BMI or WC, where you can simply remeasure) -Does not provide information about fat distribution in area measured. -Samples must be normally hydrated.

CT

Description: Computed tomography. Horizontal scans of abdominal, thighs or calf (muscle area). Distinguishes bone, fat, and lean mass. Strengths: can differentiate subcutaneous and visceral fat.

DXA

Description: Duel-energy X-ray Absorptiometry (DXA). Measures differential attenuation of two X-rays, differing in energy as they pass through the body. Uses two two-compartment models. First distinguishes bone from soft tissue and the second subdivides soft tissue into fat and lean tissue mass. Estimates %BF using vertical cross-sections. Strengths: -Fast -Direct assessment of fat mass -Can distinguish between fat mass, lean mass, and bone mass and thus can look at distribution of fat mass -Assess by body region. Limitations: -Expensive and time consuming than indirect measures. -tends to overestimate fat mass because there are problems extrapolating from 2D to 3D. Primarily designed to assess Bone mass. -radiation exposure limits use

Hydrometry (Dilution method)

Description: Uses naturally occurring stable isotope to measure the total body water (TBW). Collect pre and post biospecimen (urine, saliva, blood). Measure enrichment of isotope after it has equilibrated in body and solve for volume of water in the body (EV(sample)=EV(body)). Calculate FFM based on ratio to TBW to FFM. Calculate FM by the difference. Strengths: -Useful for all ages -Relatively inexpensive -Direct assessment of fat mass Limitations: -Assumes water content of FFM is 73% - fails if person is pregnant or growing. -Doubly labeled water is expensive -Makes patients uncomfortable to drink doubly labeled water -Special analysis - infrared spectroscopy or mass spec

What tobacco policies are being done in the communities that you're working with?

Distinction between commercial and traditional tobacco. HIC: Commercial tobacco prohibited at main buildings, like tribal admin, health clinic, school. Allowed at casino. ANC: Commercial tobacco free environment for gov't employees and members of the public visiting/occupying NN facilities. Prohibited within 25 ft. Executive order by Ben Shelly 8/14/. http://www.navajo-nsn.gov/News%20Releases/OPVP/2014/aug/Executive%20Order%20No.%2013-2014.pdf. Cheyenne River Sioux Tribal Council passed the Smoke-free Air Act in 2015. First tribe in SD to make sure indoor public places are smoke-free. 50 ft zone. Also bans e-cigarettes. SD passed similar law in November 2010, but sovereignty. 51% smoking rate. 19 % national avg. http://indiancountrytodaymedianetwork.com/2015/06/09/cheyenne-river-sioux-tribe-goes-smoke-free-160648 Tobacco tax, 1995. NN. Also a source of cadmium and As.

Tell me about how food insecurity is thought to contribute to obesity. Think about food insecurity at the individual level. People respond to short or long form questionnair that there hasn't been enough food. How is that thought to be related to obesity? JJS

Food insecurity is defined as the state of either having limited or uncertain access to food that is nutritionally adequate, culturally acceptable, and safe or having an uncertain ability to acquire acceptable foods in socially acceptable ways (Baueer_Am J PH_2012). The concurrent existence of food insecurity and obesity has been examined in several US populations. Some studies indicate that food insecurity drives the purchase and consumption of cheap, energy-dense foods to get the most kilojoules when money is limited, as well as overeating when foods become available after periodic food shortages(14-18). (Mullany, 2013) Compared to other populations, AIs are more likely to be poor, unemployed, and have higher food insecurity. CDs associated with poor diets. Those who are food insecure are eligible for commodity food programs. Programs offers supplemental foods, like canned vegetables, meats, pastas, rice. Foods higher in fat, calories and lower in fiber. There is some evidence that these foods are not supplemental. These foods also shape food preferences, shifting preferences away from traditional foods. Also, when food insecure, makes sense to buy cheaper, energy-dense foods with long shelf lives. "survival foods". Created food security, but not healthy foods. Chino_2009 AI have higher level of food insecurity than non-AI. Useful charts. Gunderson_2008 Among this sample of 425 AI families from four Southwestern reservation communities, food insecurity rates were very high (45% adult food insecurity and 29% child food insecurity), approximately three times the levels seen in the general US population. Factors associated with food insecurity included transportation barriers, concerns about high costs of foods and fewer visits to grocery stores. Having recently visited a convenience store or fast-food restaurant was associated with some household eating patterns (i.e. less likely to have daily family meals), but not others (i.e. availability of healthy foods in the home) Larger household size was associated with increased food insecurity and worse eating patterns. Contrary to our initial hypothesis, older respondents were more likely than younger respondents to be at risk for both food insecurity and poorer eating patterns, even after adjusting for household size. (Mullany, 2013)

What is food sovereignty?

Food sovereignty is the right of peoples to define their own policies and strategies for sustainable production, distribution, and consumption of food, with respect for their own cultures and their own systems of managing natural resources and rural areas, and is considered to be a precondition for food security." Declaration of Atitlán, Guatemala, Indigenous Peoples' Consultation on the Right to Food: A Global Consultation, (2002).

How does the glycemic index change with serving size? (PW)

GI always remains the same, even if you double the amount of carbs in your meal. This is because the GI is a relative ranking of foods containing the "same amount" of carbohydrate. But if you double the amount of food you eat, you should expect to see a higher blood glucose response - ie, your glucose levels will reach a higher peak and take longer to return to baseline compared with a normal serving. http://www.glycemicindex.com/faqsList.php#6 One MA found a potential benefit of increased feeding frequencies, mostly due to one study. http://www-ncbi-nlm-nih-gov.ezp.welch.jhmi.edu/pubmed/26024494

Describe the Alamo Navajo Community

Geography: Located 2-3 hours southwest of Albuquerque. 60 miles Northwest of Socorro, 30 miles North of Magdalena. Tribe: Dine ("The people"). Language: Dine Bizaad. Athabaskan language family, southern athabaskan group (not northern athabaskan or pacific coast athabaskan). Government structure: Alamo Chapter is one of 110 chapters of the NN. Has power in local planning and development. President, VP and Sec/Treas elected for four year term. NN organized into three branches: executive, judicial, and legislative. Chapter planning meetings on 2nd Tuesday. Chapter meetings on the 3rd Tuesday. Food outlets: On-reservation, there is one convenience store (Tiis Tsoh). One small food store in Magdalena. Several grocery stores in Socorro. Disease prevalences: 75% OB, 2% CVD, 35% HBP, 25% T2DM, 6% cancer

Describe the Hannahville Indian Community.

Geography: Located in the UP, about 20 miles West of Escanaba, off of Lake Michigan. Rural area - mostly residential houses, less businesses, more green space. Tribe: Potawatami, speak Ojibwe. Algonquian Language family. Government structure: 12 member tribal council, 2 alternates responsible for oversight of community operation, including establishing laws and ordinances policies, and procedures. Council members elected every 3 years. Community meetings on 3rd Monday. Council meetings on the 1st Monday. Food outlets: On-reservation, there is one convenience store adjacent to the casino. Casino has several restaurants. Grocery store about 5 miles east. Several grocery stores in Escanaba. Disease prevalences: ~75% OB, 15% CVD, 30% HBP, 25% T2DM, 4% cancer

What's gestational diabetes and why is it important?

Gestational diabetes is any degree of glucose intolerance with onset or first recognition during pregnancy. The definition applies regardless of whether insulin or only diet modification is used for treatment or whether the condition persists after pregnancy. 6 weeks or more after pregnancy, the woman should be reclassified into either: 1) diabetes, 2) IFG 3) IGT or 4) norm. Blood sugar typically returns to normal after delivery. Deterioration of GT occurs normally during pregnancy, particularly in the 3rd trimester. Use data from OGTT performed on pregnant women 2 SD above the mean (set based on risk of diabetes later). Do not test low rf group. Low rf group=<25 yr+no family history+no history of abnormal glucose metabolism/poor obstetric outcome + not member of ethnic/race group with high diabetes prevalence 4% of all US pregnancies annually (Committee Report_Dia Care_2003). Creates more immediate risk for adverse birth outcomes, due to pre-eclampsia and low blood sugar during delivery. Influence on babies, babies are heavier, low blood glucose at birth, at risk for obesity during childhood and increased risk for t1, t2, ifg or igt for mom. Importance: increases risk of t2dm later in life, rf for GD include family history, obesity, non-white. http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html

What parts of the study are you most worried about? AB

IRB has deemed this non-human subjects research and interviewing in the workplace. Limitation of this is that I'm getting the party line. Describe nonverbal behavior. Potential solutions: interview in another setting, interview w/o recorder, change format to focus group/talking circle.

Success of alcohol policy? (DJ)

Good (effective) policies (e.g. CDC reviews): -Restrictions on hours and days of alcohol sales -High taxes on alcohol (effectiveness depends on who drinks) Bad (ineffective) policies: -Removing restrictions on hours of sale in pubs in UK -Permission to sell alcohol in supermarkets -Failure to enforce effective policies Prevention strategies reviewed and evaluated: -pricing and taxation is most cost-effective ways to reduce harm. Evidence suggests that ppl (including adolescents and problem drinkers) increase their drinking when prices are lowered and vice versa (assumes increasing cost relative to alternative commodities will reduce demand) -regulating physical availability (time, place, density of outlets) (assumes reducing supply by restricting availability will increase effort and therefore vol consumed) -altering the drinking context (creating env and social constraints will limit alcohol consumption) -education and persuasion using social influence model (health information that increases knowledge and changes attitudes will prevent drinking problems) -regulating alcohol promotion (reducing E to marketing which normalizes drinking and links it with social aspirations will slow recruitment of drinkers and reduce heavier drinking by young persons) -drinking-driving countermeasures (deterrence, punishment and social pressure will reduce drink-driving) -treatment and early intervention (alcohol dependence will be prevented by motivating heavy drinkers to drink moderately, increase abstinence among dependent). 17 Strategies with >2+ across effectiveness, breadth of research support, cross-national testing, and cost to implement. Pricing and taxation: Alcohol taxes, Regulating physical availability: ban on sales, min age of purchasing laws, rationing, gov't monopolies, restrictions on hours/days of sale, reductions in number of outlets, Modifying the drinking environment: enhanced enforcement of on-premise laws and regulations, community action projects, Drink-driving countermeasures: sobriety checkpoints, lower BAC limits, administrative license suspension, graduated licensing, Marketing: legal restrictions on E to marketing, TRT and early intervention: brief interventions, mutual self-help, talk therapies. ¤Justifications of government intervention - correcting a market failure and negative externalities

What is the connection between the gut microbiome and obesity? PW

Growing area of research looking at the microbiome community structure and its relation to obesity. Gut microflora have a role in calibrating immune and metabolic function. Observing that populations who eat higher amounts of fiber (particularly those who stick to traditional diets) tend to have a more complex microbiome. It is theorized that these microbiomes help to digest fiber (increase efficiency of energy extraction from foods) and promote reduced inflammation. Chronic inflammation contributes to cvd, t2dm, weight gain. Inflammation is caused by defective gut barrier that allows toxins form bacteria and increase insulin resistance, weight gain. These microbiomes are impacted by western diets that are high in sugar and fats and refined carbs. Also impacted by antibiotic overuse. Eating foods that promote healthy microbiome,high fiber prebiotics to susain. also specific theories such as fecal transplants. http://www.huffingtonpost.com/gerard-e-mullin-md/gut-microbiome_b_7548632.html http://nautil.us/issue/30/identity/how-the-western-diet-has-derailed-our-evolution

What are the cvd rates for the tribes OPREVENT2 is working with?

HIC: 15.4% reported HD diagnosis. Alamo: 1.8%

What are the t2dm rates for the tribes OPREVENT2 is working with?

HIC: 25% reported diagnosis. Alamo: 24.1% reported diagnosis Pr(Jicarilla in 1989)=9.8% aged 35+

How is diabetes diagnosed?

HbA1C measures average blood sugar level for the past 2-3 months. Measures the % of blood sugar attached to hemoglobin. >=6.5% on two tests indicates diabetes; 5.7-6.4% indicates prediabetes. <5.7% is normal. Random blood sugar test >= 200 mg/dL suggests diabetes Fasting Plasma Glucose: Fasting blood sugar test taken after overnight fast. FBS <100 mg/dL is normal; 100-125 mg/dL prediabetes; 126mg/dL or higher on two tests indicates diabetes. Oral glucose tolerance test taken after fasting blood sugar level is measured. Then you drink sugary liquid and tested over next 2 hours. BSL<140 mg/dL is normal. BSL>=200 mg/dL after two hours indicates diabetes. Between indicates prediabetes. (Cite?) FPG recommended because easier to perform, more convenient and acceptable to patients, more reproducible, and less expensive. t1dm screening not advised. t2dm screening advised for those who are 45+ every 3 years. Done in younger if: family history, inactive, race/ethnicity, GDM, hypertensive, high cholesteral, previous IGT or IFG, cvd. (Committee Report_Dia Care_2003)

What is HTT?

Historical trauma is akin to individual level trauma, but is experienced as a result of trauma at the collective or group level (e.g., colonialism, slavery, war) and can be experienced even generations after the traumatic event9,53. Historical trauma has been defined as, "cumulative emotional and psychological wounding across generations, including the life span, which emanates from massive trauma"54 and is also referred to as "intergenerational trauma", "soul wound", and "collective unresolved grief" in the literature55. Historical Trauma Theory looks more broadly at the concept of historical trauma by connecting it to higher prevalence of disease and thus health inequity in populations that have experienced historical trauma9. Although generally not recognized in the literature, this theory has implicit origins in Marxist or critical theory9. In particular, this theory highlights the domination and exploitation of colonialist population over Aboriginal people56. While social control and maintenance of the status quo is possible through many ways (e.g. brute force, colonialism, genocidal policies), it is powerfully enforced using structural violence. Galtung describes structural violence as a kind of indirect violence, where there is not a clear subject who acts on another57. He emphasizes that this kind of violence leads to real consequences, allowing groups of people to be marginalized and suffer more than they otherwise would57. Structural violence is not a characteristic at the intrapersonal level, but is a phenomenon of society, in which both resources and power to distribute these resources are themselves unevenly distributed57. It is in these indirect and pernicious ways that historical trauma is inflamed and exacerbated, since exploited populations not only experienced the original trauma, but now the structure of society has put these populations in a position of systematically undermined power and resources.

If you had all the funding in the world, what would you propose for an obesity prevention program?

I think that ultimately, I think that what drives overconsumption is our food system and capitalism, which makes highly accessible and normal for us to eat foods that are not locally sourced. Incompatible with traditional values, of balance. I think that the solution lies within food sovereignty and cultural development, which can encourage culture and local knowledge and ties to food.

How does obesity lead to type II diabetes?

Plain language: BMI is the dominant predictor of t2dm incidence - NHS. Increased amounts of adipose tissue effects whole-body sensitivity to the actions of insulin and glucose tolerance. First, elevated adipose tissue results in increased fat breakdown into FFAs. These FFAs inhibit insulin uptake and throw off the production of lipoprotein in the liver. To compensate for the inhibited insulin uptake, circulatory insulin concentrations increase and insulin sensitivity in skeltal muscle descreases (insulin resistance) with reduced glucose intake. Initially, the beta cells compensate by producing more insulin. Over time these beta cells fail and person becomes hyperglycemic and develops t2dm. Full description: 1) Increased amounts of adipose tissue results in elevated rates of fat breakdown (lipolysis) lead to the release of FFAs. 2) FFAs have a detrimental action on the uptake of insulin by the liver, which in turn results in increased gluconeogenesis (breakdown of AAs and conversion to glucose), production of glucose by the liver, and systemic dyslipidemia (lipoprotein overproduction or deficiency). These factors contribute to the prevailing systemic hyperinsulinemia (raised circulatory insulin concentrations) and decreased skeletal muscle insulin sensitivity (i.e., insulin resistance) with reduced glucose uptake. Initially, the Beta-cells of the pancreas compensate for these processes by producing more insulin. In time, there is failure of the Beta cells and the development of a raised circulating blood glucose concentration (hyperglycemia), and hence t2dm.

How does obesity lead to CVD?

Plain language: Increasing body weight results in increase in LM, FM and surface area, requiring more blood volume to sustain these tissues. Higher blood volume means that heart is pushing through more volume for each heart beat. This increase in volume results in stress on the LV wall and over time results in a thickening wall that is disproportionate to the chamber radius and increase in blood pressure. In time the atria and ventricles begin to fail. Full description: Increasing body weight is associated with an increase in both lean and fat mass and in surface area. This, and the associated increase in total blood volume, is in turn accompanied by an increase in stroke volume (volume per beat) and cardiac output. The increase in circulatory preload (LV wall stress at end diastole) and afterload (LV wall stress during ejection2) lead to left ventricular (LV) dilation and eccentric hypertrophy (thickening wall proportional to chamber radius ). An increase in systemic vascular resistance seen in some obese individuals results in a sustained rise in blood pressure (hypertension) and concentric LV hypertrophy (thickening wall without increase in chamber radius). In time the atria and ventricles begin to fail with the development of heart failure.

How does obesity lead to chronic respiratory diseases?

Plain language: The impact of increased FM on respiratory function is mostly mechanical (due to the added weight). This is even more pronounced when laying down. During sleep the added weight makes it difficult to breath and result in reduced oxygen and increased CO2 levels. Over time this can lead to pulmonary hypertension, heart failure and respiratory failure. Full description: Respiratory function is compromised in obese subjects, especially when they lie flat. During sleep, there is alveolar hypoventilation and transient episodes of apnea that are accompanied by a all in arterial oxygen saturation (hypoxia) and a rise in arterial carbon dioxide (hypercapnia). In some individuals, these factors lead to daytime sleepiness (hypersomnolence) with persistent hypoxia and hypercapnia accompanied by the development of pulmonary hypertension, heart failure, and eventually, respiratory failure.

What are the policy implications for this? PW

Policy implications are that 1) we should incorporate more exercise in daily life, and create more opportunity for physical activity. particularly in the workplace. OPR worksites. 2) Shift to traditional foods when possible. Difficult to fully rely on these sources, seasonal, expensive. Extent that they are available to everyone is difficult depending on the setting. 3) Shift to higher fiber diets. with lower fat and sugar than before. Fits in with promoted foods

What environmental contaminants are related to NCD risk?

SHS - Arsenic and cadmium E levels are higher in SHS participants than US population and related to CVD, T2D, cancer incidence and mortality. Developing a drinking water intervention. http://www.jhsph.edu/departments/environmental-health-sciences/faculty/faculty-research/navas-acien/strong-heart-study.html Inorganic As exposure (total urine concentrations) was associated w/ Pr(DM). (Gribble, 2012). iAs is mythylated primarily in the liver to form monomethylated and dimethylated arsenic compounds monomethylarsonate (MMA) and dimethylarsinate (DMA), which are excreted in the urine along with iAs. Helps to discriminate from As from organic arsenicals in seafood (arenobetaine, nontoxic). As metabolism, but not iAs exposure, was prospectively associated with DM incidence in SHS. Higher iAs and DMA in urine, due to lower MMa was associated with DM (Kuo, 2015). Persistent organic pollutants (POPs). POPs are lipophilic, persist in tissue and in the environment. POPs including PCB (diabetes), dioxin, DDT (diabetes), hexachlorobenzene (OW/OB, DM) and T2D. Lee, Park. Dioxins particularly PCBs linked with MS. Possible mechanisms is through thyroid regulated pathways. (Schell, 2010). TSH was significantly elevated in relation to PCBs and unbound thyroxin was depressed in relation to PCB exposure (classic pattern for depressed thyroid activity). Hypothyroidism related to weight gain. Noted weight gain in Akwesasne alongside elevated PCB exposure. Mercury a potential risk factor in ischemic HD. Important for Inuit who normally consume large amounts of fish and marine mammals (Hansen, 2005) Environmental contaminants common in NAs - wastes distributed to rural areas, including minority comm. Akwesasne is by 3 superfund sites. Example of structural violence - individuals cannot clean up on their own, cannot move, and responsibility to clean is up to governments and responsible parties. Negative impacts of this: dilemma between continuing to eat contaminated food or choosing prepared foods, another factor pushing nutrition transition. Culture defined not only by food, but by methods and values regarding food acquisition and preparation. Implications for culture: breast feeding, traditions and oral history.(Schell, 2012). Need to consider the role of environmental contaminants when developing intervention strategies, in particular the promotion of drinking water, growing crops, traditional foods.

What is the history of the IHS?

Services provided to AI/AN persons (e.g., housing, education, health care) have been guaranteed through treaties, executive orders and other legal bases...These are the "supreme law of the land". The result is that there is a trust responsibility on behalf of the federal government to provide services to AI/AN persons. (trust responsibility is a legally administrated financial obligation on the part of the US government to defend treaty rights, lands, assets, and resources, as well as a duty to provide health services. However, longstanding underfunding of IHS and predecessors, since last treaties were signed in 1871. Underfunding continues, though numerous laws passed in the 20th century have had a significant impact on the way health services are provided. Snyder Act (1955) - allowed Congress to appropriate funds to (BIA) address AI/AN health on a recurring basis. Transfer Act (1954) - Authorities in Snyder Act transferred to the Sec of Health, Education, and Welfare (now HHS). Also recognized tribal self-determination in health policy decision-making. Indian Self-Determination and Education Assistance Act (1975) - authorized tribes to assume mgmt of BIA and IHS programs. Assumed by the tribe under a "638 contract". Increases flexibility to meet local health needs. More than half of the IHS budget is now managed by the tribes. Some success, but concerns over contracting for services that are chronically/significantly underfunded. Indian Health Care Improvement Act (1976) - established Urban Indian Health Programs. Allowed HS and tribal 638 programs to bill medicare and medicaid. Expanded access to services. I/T/U system - IHS, tribal 638, urban health centers Underfunding - AI/AN persons 46% less funding than for federal employee health benefits plan. Affordable Care Act - health insurance reform. b/c IHS is not health insurance Warne_AJPH_2013 The responsibility for health care of American Indians and Alaska Natives was given to a federal agency, the Division of Indian Health, Public Health Service, in August of 1954 under the PL 83-568 Transfer Act (IHS, 1995). The Division of Indian Health later became the Indian Health Service. (Abbott_Substance Use Misuse_1998) Despite the existence of the IHS, which theoretically provides universal health services to AI/AN, there is a surprising number of AI/AN who report being uninsured. In fact, AI/AN are more likely than non-Hispanic whites to report no usual source of healthcare or health insurance, particularly those who live off of reservation land [13]. Despite the fact that 60% of AI/AN currently live outside of their home reservations, only 1% of the IHS budget is used for AI/AN healthcare off of the reservations[52]. Even for those who receive care through Indian Health Services, the per capita funding for IHS is less than half of what is provided to edicaid and/or incarcerated populations [52]. The amount of money allocated to each IHS patient is just over one third of what is allocated to the general population overall (1351 compared with 3766) [53]. Cultural differences between the mostly non-AI/AN providers in the IHS and AI/AN patients may contribute to distrust in doctors and the medical system, which has been implicated as a possible cause for poorer health outcomes in other disadvantaged populations [54]. (Hutchinson_PLoS ONE_2014)

How is BMI used for children?

Sex and age-specific references. BMI changes with age as children grow. BMI is not independent of height; its relationship with height varies across childhood. Body proportions and body composition change during childhood. Has low SE for obesity, some obese kids may be missed. CDC: >=85th percentile = OW >=95th percentile = OB WHO: +1 z score, risk of OW +2 z score, OW +3 z score, OB

In what ways does the Nutrition Transition for AIs differ from that of AAs? PW

Similar in a few ways: both experienced historical trauma which caused the nutrition transition, both forced from their homelands, disrupting traditional harvesting practices. Difference: timing of transition (hundreds of years ago, versus in the last 100 years), unique situation of AI/AN tribes, who were able maintain traditional ways because of reservations, AI/AN people moved to lands with poor quality, role of commodity food program. ability to gather traditional fods. Catalyst - the historical trauma which caused the nutrition transition is different: for AIs: slow process of extermination, assimilation, reservations. Extent of assimilation/westernization - because of rezervations, AIs able to keep culture, traditional practices. REvitilization of culture. Water rights. Hila River. Pima. Ability to rely on traditional foods in contemporary times. And so potential solutions for AIs could potentially include a return to traditional foods. Commodity foods. 60s rapid exposure to media, fast food chains. Think of 3 points and condense.

How will this impact CD risk?

Smoking associated with CVD, cancer. Could increase risk of CVD among population with high DM. Smoking inversely associated with weight. Potentially could promote anti smoking for OPR2, could also influence weight if participants stop smoking.

Can you give an example of a tribe that has prohibited alcohol sales, possession completely?

Some tribes prohibit alcohol completely. One example is the Oglala Lakota Pine Ridge Rez, which, except for a brief early 1970s, has always been dry until 2013 (http://america.aljazeera.com/articles/2013/8/15/pine-ridge-indianreservationvotestoendalcoholban.html). The town of Whiteclay, NE, is 400 yards off rez border in a contested "buffer" zone has 14 residents (but no schools, churches, civic orgs, parks, fire service, law enforcement) but sells over 4.1 million cans of bear annually. Second largest rez, about the size of CT. Very high unemployment (85-95%). Over 37% is diabetic (almost 50% over 40 years). School dropout rate is over 70%. Alcoholism affects 8/10 families. Death rate from alcohol related problems is 300% higher. Prohibition and it's effectiveness. http://www.4aihf.org/id40.html Pine ridge is suing merchants b/c there is no place in whiteclay to legally consume alcohol, resale of alcohol in nebraska is illegal, illegal to sell to intoxicated person. amount of beer sold in whiteclay exceeds the amount that could be legally sold and consumed. Smuggled to pine ridge. Illegal activity. Lawsuit dismissed finding that the tribe's claims did not involve questions of federal law (http://america.aljazeera.com/articles/2013/8/15/pine-ridge-indianreservationvotestoendalcoholban.html) 1/4 children have FASD. 90% of arrests are alcohol-related. Sales violate NE laws, and impact native communities. Request an order to limit total volume of beer sold by whiteclay stores to an amount that can be reasonable consumed in accordance with the laws of NE and the OST. protect the balance of contemplated. https://www.documentcloud.org/documents/310215-amended-complaint.html

Adverse Child Events and Obesity study in Pine Ridge.

The ACE Pyramid represents the conceptual framework for the study. During the time period of the 1980s and early 1990s information about risk factors for disease had been widely researched and merged into public education and prevention programs. However, it was also clear that risk factors, such as smoking, alcohol abuse, and sexual behaviors for many common diseases were not randomly distributed in the population. In fact, it was known that risk factors for many chronic diseases tended to cluster, that is, persons who had one risk factor tended to have one or more other risk factors too. Because of this knowledge, the ACE Study was designed to assess what we considered to be "scientific gaps" about the origins of risk factors. These gaps are depicted as the two arrows linking Adverse Childhood Experiences to risk factors that lead to the health and social consequences higher up the pyramid. Specifically, the study was designed to provide data that would help answer the question: "If risk factors for disease, disability, and early mortality are not randomly distributed, what influences precede the adoption or development of them?" By providing information to answer this question, we hoped to provide scientific information that would be useful for developing new and more effective prevention programs. The ACE Study takes a whole life perspective, as indicated on the orange arrow leading from conception to death. By working within this framework, the ACE Study began to progressively uncover how adverse childhood experiences (ACE) are strongly related to development and prevalence of risk factors for disease and health and social well-being throughout the lifespan Western theories are individuals and linear/rational. http://www.cdc.gov/violenceprevention/acestudy/pyramid.html

Advocacy Coalitions

To read: Framewor - Sabatier and Jenkins-Smith, 1993 -Scientific and technical information play a central role in the policy process -A time perspective of 10 years or more is required to understand policy change -The policy subsystem (defined by policy topic, geographic scope, and influencing actors) is the most useful and primary unit of analysis -The set of policy subsystem actors includes all levels of government, scientists, and members of the media -Policies and programs can be viewed as translations of beliefs What does it take? - Articulation of a socially (as well as scientifically) credible threat -Ability to mobilize a diverse organizational constituency -Convergence of political opportunities with larger vulnerabilities Nathanson, 1999 Stages of grassroots organizing - listening (how problem is defined, what do people care about, how solutions defined, what can be done, who can do it, who has power), relationship building (trust, role of outsider, maintaining good relationships) , challenge (Challenge peopel to act, work against hopelessness, lies in collective action, challenge to lead) , action (immediate, specific, winnable, worthwhile) , evaluation (what was good about today, what to do differently, trusting group perceptions, did what we said, what gained, what changed, how to better allocate resources, what isn't working), reflection (put things in larger context, creating critical consciousness about the way the world is, celebration (consolidate victories, recognize leadership and initiative, build positive affect for future action, the world is never the same after we have acted)