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Native Health Initiative Program Plan and Evaluation Strategy

A Manual for Program Leaders: A. PROGRAM CONTEXT 1. American Indians and their health in the United States a. Overview: American Indians and Alaska Natives (AIAN) are heterogeneous groups of peoples whose ancestors were the original peoples of the Americas and who maintain tribal affiliation with one of the 569 federally recognized tribes or more than 300 state recognized tribes in the United States (Note 1). In all, this group represents more than 200 indigenous languages, with approximately 10% of AIAN households speaking a language other than English at home. Current estimates suggest that the AIAN population consists of 4.1 million people, approximately 1.5% of the U.S. population. While AIAN are often associated with reservations, land appropriated for tribes by the U.S. government, the majority live in cities and towns where indigenous peoples are the minority. Overall, AIAN are more likely to live in poverty (26% vs 13%), less likely to have a high school education (66% vs. 75% in 1990), and twice as likely to be unemployed than the average American citizen. b. Indian Health Service: Federally recognized tribes enjoy a government-to-government relationship with the United States. Through treaties, congressional laws (Synder Act of 1921, Indian Health Care Improvement Act of 1976), and court decisions the U.S. government agreed to provide health care for AIAN, a duty currently carried out through the Indian Health Service (IHS). A program under the Department of Health and Human Services (DHHS), the IHS cares for 1.8 million AIAN and describes itself as the "principal Federal health care provider and health advocate for Indian people. However, the IHS is poorly under-funded; a review that compared the IHS to mainstream health plans, accounting for other forms of coverage and payments fund AIAN health care, revealed that the IHS expenditure of $1,385 per user was 52$2687 it would take to provide benefits similar to what the average plan offers. For those moving off their respective reservations, problems of access to care mirror those seen in other minority populations. Currently, the IHS allocates less than 1% of its budget to providing urban AIAN health care, despite the fact that more than 50% of the AIAN population live in these settings, suggesting that the government's promise of health care is an absent one for many AIAN.Master of Public Healt

807-2 Effect of Age on Left Ventricular Diastolic Filling Patterns During Orthostatic Stress

Although numerous studies have demonstrated reduced early diastolic left ventricular (LV) peak filling velocity IE) and accentuated late filling velocity (A) with advancing age in the supine position, the effect of orthostatic stress on age-associated diastolic filling patterns is unknown. Accordingly, 30 healthy normotensive volunteers ages 19 to 90 years from the Baltimore Longitudinal Study of Aging underwent sequential Doppler echocardiography after 3 minutes each in the supine, seated, and standing positions. In the overall sample, standing was accompanied by an increase in heart rate (HR) of 8.8±1.7 beats/min, and decreases in E(20.6±2.7cm/sl. A 150±2.7cm/s)and LV diastolic dimension (LVDD) (7.8±0.8mm), x±SEM, each p<0.001 versus supine values. Systolic blood pressure (SBP) and atrial filling fraction (AFF) were unaffected by posture. Correlation coefficients versus age for relevant Doppler and hemodynamic variables are shown.EAE/AAFFHRSBPLVDDSupine-0.58†0.80†-0.78†0.84†0.010.56†-0.14Sit-0.360.77†-0.83†0.78†-0.040.37*-0.07Stand-0.240.60†-0.69†0.71†-0.320.47†0.09ΔSupine → Stand0.53†-0.46†0.56†-0.17-0.61†0.220.40**p<005†p<001Thus, orthostatic stress abolishes the reduction of E and attenuates the exaggerated A observed with advancing age in the supine position. probably because of the blunted standing-induced HR increase in older subjects. However, the supine age-associated increase in AFF is unaffected by orthostasis

Statins and Exercise Training Response in Heart Failure Patients: Insights From HF-ACTION.

OBJECTIVES: The aim of this study was to assess for a treatment interaction between statin use and exercise training (ET) response. BACKGROUND: Recent data suggest that statins may attenuate ET response, but limited data exist in patients with heart failure (HF). METHODS: HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) was a randomized trial of 2,331 patients with chronic HF with ejection fraction ≤35% who were randomized to usual care with or without ET. We evaluated whether there was a treatment interaction between statins and ET response for the change in quality of life and aerobic capacity (peak oxygen consumption and 6-min walk distance) from baseline to 3 months. We also assessed for a treatment interaction among atorvastatin, simvastatin, and pravastatin and change in these endpoints with ET. Multiple linear regression analyses were performed for each endpoint, adjusting for baseline covariates. RESULTS: Of 2,331 patients in the HF-ACTION trial, 1,353 (58%) were prescribed statins at baseline. Patients treated with statins were more likely to be older men with ischemic HF etiology but had similar use of renin angiotensin system blockers and beta-blockers. There was no evidence of a treatment interaction between statin use and ET on changes in quality of life or exercise capacity, nor was there evidence of differential association between statin type and ET response for these endpoints (all p values \u3e0.05). CONCLUSIONS: In a large chronic HF cohort, there was no evidence of a treatment interaction between statin use and short-term change in aerobic capacity and quality of life with ET. These findings contrast with recent reports of an attenuation in ET response with statins in a different population, highlighting the need for future prospective studies. (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure; NCT00047437)

Relationship of Beta-Blocker Dose With Outcomes in Ambulatory Heart Failure Patients With Systolic Dysfunction Results From the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) Trial

ObjectivesThis study sought to examine the association between baseline beta-blocker (BB) dose and outcomes in the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial.BackgroundBeta-blockers reduce morbidity and mortality in chronic heart failure (HF) patients with reduced ejection fraction, but it is unclear whether titrating to higher BB doses improves outcomes in this setting.MethodsThe HF-ACTION trial was a randomized, multicenter trial enrolling 2,331 ambulatory HF patients with systolic dysfunction (New York Heart Association functional class II to IV, left ventricular ejection fraction <0.35) randomized to exercise training versus usual care, with median follow-up of 2.5 years. The BB dose at baseline was standardized with carvedilol equivalents and analyzed as a continuous variable and by discrete dose groups. The relationship between BB dose and the primary endpoint of all-cause mortality or all-cause hospitalization and other cardiovascular secondary endpoints was determined before and after adjustment for variables significantly associated with outcomes in the HF-ACTION cohort.ResultsNinety-five percent of patients were receiving a BB. There was a significant inverse relationship between BB dose and all-cause death or hospitalization but not other cardiovascular endpoints after adjustment for other predictors of outcome, with a linear benefit up to the 50-mg daily dose. There was a significant association between BB dose and change in peak VO2 at 3 months. There was no increase in bradycardia with higher doses of BB.ConclusionsThere was a significant inverse relationship between BB dose and the endpoint of all-cause death or all-cause hospitalization in this well-treated HF cohort with systolic dysfunction, supporting recommendations that titrating doses up to 50 mg/day might confer a benefit in such patients. (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure; NCT00047437

Effects of Aerobic Exercise Training in Community-Based Subjects Aged 80 and Older: A Pilot Study

To assess the ability of sedentary, frail subjects aged 80 and older to train in a community-based exercise program and to evaluate clinical factors that predict improvements in peak oxygen consumption (VO 2 peak). DESIGN: Pretest, posttest. SETTING: Charlestown Retirement Community, Catonsville, Maryland PARTICIPANTS: Twenty-two (11 male, 11 female; mean age ± standard deviation = 84 ± 4.0, range 80–92) self-referred. INTERVENTION: Six months of moderate-intensity aerobic exercise training, two to three sessions/week, 20 to 30 minutes per session. Training modes included treadmill walking and/or stationary cycling. MEASUREMENTS: Baseline and follow-up maximal exercise treadmill tests (ETTs) with electrocardiogram monitoring and respiratory gas analysis. RESULTS: Six months of aerobic exercise training resulted in significant increases (mean ± standard deviation) in ETT duration (11.9 ± 3.3 vs 15.9 ± 4.3 minutes; P = .01), VO 2 peak (1.23 ± 0.37 vs 1.31 ± 0.36 L/min; P = .04), and oxygen pulse (9.3 ± 2.8 vs 10.1 ± 3.2; P = .03). Mean heart rate was significantly lower during submaximal ETT stages 1 through 4 ( P < .05), and resting systolic blood pressure decreased (146 ± 18 vs 133 ± 14 mmHg; P = .01) after training. Multiple regression analysis indicated that baseline VO 2 peak ( r = 0.75, P = .002) and the total amount of time spent in exercise training ( r = 0.55, P = .008) were independent predictors of the training-related improvements in VO 2 peak. CONCLUSION: Subjects aged 80 and older can increase aerobic capacity and reduce systolic blood pressure in a community-based exercise program of moderate intensity. The most important predictors of change in VO 2 peak were baseline VO 2 peak and the time spent in exercise training. Subjects with a lower baseline VO 2 peak had the greatest improvements in VO 2 peak after training.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65501/1/j.1532-5415.2002.50613.x.pd

Sedentary time in older men and women: an international consensus statement and research priorities

Sedentary time is a modifiable determinant of poor health, and in older adults, reducing sedentary time may be an important first step in adopting and maintaining a more active lifestyle. The primary purpose of this consensus statement is to provide an integrated perspective on current knowledge and expert opinion pertaining to sedentary behaviour in older adults on the topics of measurement, associations with health outcomes, and interventions. A secondary yet equally important purpose is to suggest priorities for future research and knowledge translation based on gaps identified. A five-step Delphi consensus process was used. Experts in the area of sedentary behaviour and older adults (n=15) participated in three surveys, an in-person consensus meeting, and a validation process. The surveys specifically probed measurement, health outcomes, interventions, and research priorities. The meeting was informed by a literature review and conference symposium, and it was used to create statements on each of the areas addressed in this document. Knowledge users (n=3) also participated in the consensus meeting. Statements were then sent to the experts for validation. It was agreed that self-report tools need to be developed for understanding the context in which sedentary time is accumulated. For health outcomes, it was agreed that the focus of sedentary time research in older adults needs to include geriatric-relevant health outcomes, that there is insufficient evidence to quantify the dose-response relationship, that there is a lack of evidence on sedentary time from older adults in assisted facilities, and that evidence on the association between sedentary time and sleep is lacking. For interventions, research is needed to assess the impact that reducing sedentary time, or breaking up prolonged bouts of sedentary time has on geriatric-relevant health outcomes. Research priorities listed for each of these areas should be considered by researchers and funding agencies

Stop Atherosclerosis in Native Diabetics Study (SANDS): Baseline Characteristics of the Randomized Cohort

Objectives: To present baseline characteristics of American Indians in the Stop Atherosclerosis in Native Diabetics Study (SANDS) and compare them with population-based data from American Indians and other ethnic groups. Design: 499 people with type 2 diabetes ≥ age 40, without known CVD, were recruited for a randomized 3-year trial to evaluate treatment targets for LDL-C (70 vs. 100 mg/dL) and systolic blood pressure (BP) (115 vs. 130 mmHg). Baseline evaluations included physical exam, collection of blood and urine samples, and carotid ultrasound and echocardiographic measures. Results: Mean age was 56 years; 66% were female. Average BMI was 33 kg/m2. Average duration of both hypertension and diabetes was 10 years, average A1c was 8.0 %, and mean LDL-C was 104 mg/dL. Participants in the conventional treatment group had slightly higher systolic BPs than participants in the aggressive treatment group (133 mm Hg vs. 128 mm Hg, p \u3c 0.002). Compared with the population-based cohorts of the Strong Heart Study (SHS), NHANES, and the TRIAD registry, SANDS participants had similar values for lipids, BP, and CRP, as well as degree of obesity, smoking rates, and renal function as indicated by estimated glomerular filtration rate. Conclusions: The baseline characteristics of the SANDS cohort are similar to those of a population-based sample of American Indian diabetic men and women and closely resemble diabetic men and women of other ethnic groups. Results from this study can be used to identify appropriate targets for LDL-C and BP lowering in diabetic American Indians and diabetic patients in other ethnic groups