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The aim of this study was to understand whether the paradoxical association of missense variant rs373863828 in CREB3 regulatory factor (CREBRF) with higher BMI but lower odds of diabetes is explained by either metabolically favorable body fat distribution or greater fat-free mass.This study explored the association of the minor allele with dual-energy x-ray absorptiometry-derived body composition in n = 421 Samoans and used path analysis to examine the mediating role of fat and fat-free mass on the relationship between rs373863828 and fasting glucose.Among females, the rs373863828 minor A allele was associated with greater BMI. There was no association of genotype with percent body fat, visceral adiposity, or fat distribution in either sex. In both females and males, lean mass was greater with each A allele: 2.16 kg/copy (p = 0.0001) and 1.73 kg/copy (p = 0.02), respectively. Path analysis showed a direct negative effect of rs373863828 genotype on fasting glucose (p = 0.004) consistent with previous findings, but also an indirect positive effect on fasting glucose operating through fat-free mass (p = 0.027).The protective effect of rs373863828 in CREBRF, common among Pacific Islanders, on type 2 diabetes does not operate through body composition. Rather, the variant's effects on body size/composition and fasting glucose likely operate via different, tissue-specific mechanisms.

A missense variant, rs373863828, in CREBRF is associated with obesity in Polynesians. We investigate whether rs373863828 and other factors are associated with body mass index (BMI) rate-of-change between 2010 and 2017-19 in Samoans.We used sex-stratified models to test whether BMI rate-of-change was associated with rs373863828, baseline BMI, age, residence, physical activity, and household asset score in a cohort study of 480 Samoan adults measured in both 2010 (mean age 43.8 years) and 2017-19.Mean BMI increased from 32.1 to 33.5 kg/mIn Samoans, the minor A allele of rs373863828 is associated with an increased rate-of-change in BMI in females. On average, BMI of females with the AA genotype increased 0.30 kg/m

Background We compared individuals’ self-reported water contact from a questionnaire to direct observation of water contact. Questionnaires that accurately capture water contact are necessary to risk-stratify individuals and communities at high risk for schistosomiasis. Methods Individuals (N=677) ages 7–30 y were included from three Schistosoma japonicum–endemic villages in Leyte, The Philippines. Each individual was observed for 12 d over the course of the 18-month study and the questionnaire was administered six times. A questionnaire index was derived that captured the number of self-reported contacts with water bodies for any purpose. An exposure index was created based on the sum of contacts that was weighted by the percentage of body surface area (BSA) exposed and exposure duration. Results Of 16 water contact activities, only bathing and washing clothes exhibited a significant, positive correlation between self-reported contacts and the observed exposure index related to those contacts. Conclusions We found that only the reported frequencies of bathing and washing clothes were significantly related to an individual's overall observed exposure index, while use of all reported contacts was not related to the observed exposure. This study further supports the need for questionnaires to be augmented by some measure of how much BSA is exposed and/or time is spent in the water on average for a specific activity.

BACKGROUND: The Samoan population has experienced rapid increases in the prevalence of non-communicable diseases (NCDs) and NCD risk factors over the last 30 years. However, understanding how increased awareness and treatment of these conditions in reducing disease burden remains understudied. AIM: Using data from a longitudinal study (2010–2019) of cardiometabolic health among Samoan adults, we assess the impact of a referral for elevated blood pressure (BP) on changes in BP, physician’s diagnoses of hypertension and medication use, body mass index (BMI), and other risk factors for elevated BP. SUBJECTS AND METHODS: Analyses compared adult Samoans (n=328) who in 2010 either (1) received a referral for elevated blood pressure (BP ≥140/90 mmHg) or (2) had measured BP indicative of pre-hypertension (BP ≥120/80 mmHg) but were not referred. Data were analysed using linear and logistic regression, paired T- and McNemar’s tests, and Wilcoxon Rank Sum assessments. RESULTS: Referrals in 2010 significantly increased the odds of reporting a physician’s diagnosis of hypertension (OR 2.16; 1.18, 3.95) and hypertension medication use (OR 3.52; 1.86, 6.73) in 2018; however, referrals, medication use and diagnoses were not associated with BP values or reduced odds of having elevated BP. CONCLUSION: Despite the referral having positive effects on hypertension-related health care, our results demonstrate that other factors are influencing effective BP/ hypertension control. We advocate for greater engagement of health researchers with local health sector actors to improve the probability that researcher-provided health referrals will result in long-term health improvements.

BACKGROUND/OBJECTIVES: In Samoa, where 80% of the adult population is living with obesity, understanding the determinants of adiposity and growth during infancy may inform prevention efforts. We examined the association of a missense variant, rs373863828, in the CREBRF gene with body composition in Samoan infants. Adults with one or more copies of the rs373863828 minor allele (A) have higher odds of obesity, based on body-mass index (BMI), but paradoxically decreased odds of diabetes compared to those without the allele. Our study may offer novel insight into the natural history and pathogenesis of this unexpected relationship. SUBJECTS/METHODS: In a prospective study, we measured body composition in early infancy, and at 2- and 4-months of age using anthropometry and Dual-Energy X-Ray Absorptiometry (DXA). We genotyped subjects at the CREBRF rs373863828 locus and compared infants with (AA/AG) and without (GG) the variant. In longitudinal analyses, we calculated the absolute change in each outcome from the early infant to the 4-month assessment, adjusting for baseline and other covariates. RESULTS: In cross-sectional analyses, there was no significant difference in infant BMI or fat mass by genotype. After adjusting for covariates, infants with the variant had 4.0 ± 1.8g more bone mass (p=0.026) and 210.9 ±79.6g more lean mass (p=0.009) at 4-months and accumulated 176.9 ± 73.0g more lean mass between the early infant and 4-month assessment (p=0.017). CONCLUSIONS: The CREBRF rs373863828 minor allele (A) was not associated with increased BMI or adiposity in Samoan infants, but instead with increased lean and bone mass. Our findings suggest that lean (i.e. muscle) and bone mass accretion should be explored as pathways to explain the ‘protective’ effect of the CREBRF variant against diabetes.

The current understanding of the genetic architecture of lipids has largely come from genome-wide association studies (GWAS). To date, few GWAS have examined the genetic architecture of lipids in Polynesians, and none have in Samoans, whose unique population history, including many population bottlenecks, may provide insight into the biological foundations of variation in lipid levels. Here we performed a GWAS of four fasting serum lipid levels: total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides (TG) in a sample of 2849 Samoans, with validation genotyping for associations in a replication cohort comprising 1798 Samoans and American Samoans. We identified multiple genome-wide significant associations (P < 5 × 10(−8)) previously seen in other populations—APOA1 with TG, CETP with HDL, and APOE with TC and LDL—and several suggestive associations (P < 1 × 10(−5)), including an association of variants downstream of MGAT1 and RAB21 with HDL. However, we observed different association signals for variants near APOE than what has been previously reported in non-Polynesian populations. The association with several known lipid loci combined with the newly identified associations with variants near MGAT1 and RAB21 suggest that while some of the genetic architecture of lipids is shared between Samoans and other populations, part of the genetic architecture may be Polynesian-specific.

AimsWe aim to describe alcohol consumption and related problems from a nationwide survey in 2010 in Samoa in association with sociodemographic variables as part of an intervention development.MethodsThe sample consisted of 3463 adults, 25–65 years of age. Participants self-reported alcohol consumption in the previous 12 months, patterns of drinking and alcohol-related psychosocial problems. Data about age, census region of residence, highest attained education level, employment, marital status, household assets score and current smoking status were gathered.ResultsMore than one-third of men, 36.1%, and 4.1% of women consumed alcohol in the past year. There were greater proportions of alcohol users among younger adults, 4 drinks for women and >5 drinks for men at least once per episode in the prior week. More men than women, 51% versus 26%, felt that alcohol consumption had interfered with their daily life.ConclusionOur analyses identified correlates of alcohol consumption and associated problems that can help guide the development of targeted interventions for different sex and age groups to mitigate the social and physiological harms of alcohol misuse.

OBJECTIVES C-reactive protein (CRP) has been associated with adiposity and cardiometabolic disease risk in many populations but remains remarkably understudied in Pacific Islander populations. Here, we provide the first examination of correlates of CRP in adult Samoans (n = 108, ages 35-55 years) to test the hypotheses that CRP exhibits sex-dependent associations with measures of BMI, adiposity, and cardiometabolic disease risks. METHODS We analyzed associations between measures of adiposity (total fat mass, visceral fat mass, percent total body fat), body mass index (BMI), cardiometabolic risks, behaviors, demographics, and CRP. Unadjusted analyses of CRP were undertaken using Pearson's pairwise, and Spearman's rank correlations; one-way analysis of variance and Kruskal-Wallis tests assessed variables by CRP quartiles. Adjusted analyses of CRP correlates were examined using generalized linear regression. RESULTS Serum CRP ranged from 0.08 to 13.3 mg/L (median 1.4 mg/L) and varied significantly by sex t (108) = -2.47, p = .015. CRP was weakly to moderately associated with measures of adiposity and BMI (r and ρ ranged between 0.25 and 0.50, p

BACKGROUND: As the non-communicable disease (NCD) burden is rising in regions with high HIV prevalence, patients with comorbid HIV and chronic NCDs may benefit from integrated chronic disease care. There are few evaluations of the effectiveness of such strategies, especially those that directly leverage and extend the existing HIV care system to provide co-located care for NCDs. SETTING: Academic Model of Providing Access to Healthcare (AMPATH), Kenya, provides care to over 160,000 actively enrolled patients in catchment area of 4 million people. METHODS: Using a difference-in-differences design, we analyzed retrospective clinical records of 3603 patients with comorbid HIV and hypertension during 2009–2016 to evaluate the addition of chronic disease management (CDM) to an existing HIV care program. Outcomes were blood pressure (BP), hypertension control, and adherence to HIV care. RESULTS: Compared to the HIV standard of care, the addition of CDM produced statistically significant, though clinically small improvements in hypertension control, decreasing systolic BP by 0.76mmHg (p1 year improved by 7 percentage points (p6months increased by 10.5 percentage points (p

Background Although the baby-friendly community initiative (BFCI) has been proposed as a community-level approach to improve infant feeding practices, there is little data on its variation in effectiveness by HIV status. We conducted a study to determine the effectiveness of BFCI in changing knowledge and attitudes towards exclusive breastfeeding (EBF) and increasing the rates among HIV negative and HIV positive women in rural Kenya. Methods A community-based cluster-randomized controlled trial was implemented from April 2015 to December 2016 among 901 women enrolled across 13 clusters. The intervention groups received a minimum of 12 personalized home-based counselling sessions on infant feeding by trained community health volunteers from their first or second trimester of pregnancy until 6 months postpartum. Other interventions included education sessions at maternal child clinics, mother-to-mother support group meetings and bi-monthly baby-friendly gatherings targeting influencers. The control group received standard health education at the facility and during monthly routine home visits by community health volunteers not trained on BFCI. Primary outcome measures were the rates of EBF at week 1, months 2, 4 and 6 postpartum. Secondary outcomes included knowledge and attitudes regarding breastfeeding for HIV-exposed infants. Statistical methods included analysis of covariance and logistic regression. Results At 6 months, EBF rates among HIV negative mothers were significantly higher in the BFCI intervention arm compared to the control arm (81.7% versus 42.2% p = 0.001). HIV positive mothers in the intervention arm had higher EBF rates at 6 months than the control but the difference was not statistically significant (81.8% versus 58.4%; p = 0.504). In HIV negative group, there was greater knowledge regarding EBF for HIV-exposed infants in the intervention arm than in the control (92.1% versus 60.7% p = 0.001). Among HIV positive mothers, such knowledge was high among both the intervention and control groups (96% versus 100%, p > 0.1). HIV negative and positive mothers in the intervention arm had more favourable attitudes regarding EBF for HIV-exposed infants than the control (84.5% versus 62.1%, p = 0.001) and (94.6% versus 53.8% to p = 0.001) respectively. Conclusions BFCI interventions can complement facility-based interventions to improve exclusive and continued breastfeeding knowledge, attitudes, and behaviours among HIV negative and positive women.

BackgroundTuberculosis (TB) stigma remains a barrier to early diagnosis and treatment completion. Increased understanding of stigma is necessary for improved interventions to minimise TB stigma and its effects. The purpose of this study is to quantitatively measure TB stigma and to explore qualitatively its manifestation among TB patients in a rural Kenyan community.MethodsThis hospital based study using explanatory sequential mixed methods approach was conducted in 2016. In the quantitative part of the study, a questionnaire containing socio-demographic characteristics and scales measuring perceived TB stigma and experienced TB stigma, was administered to 208 adult pulmonary TB patients receiving treatment in West Pokot County. Respondents with high stigma were purposively selected to take part in in-depth interviews and focus group discussions. The qualitative data were collected through 15 in-depth interviews and 6 focus group discussions with TB patients. Descriptive and bivariate analysis was done for the quantitative data while the thematic analysis was done for qualitative data.ResultsThe internal consistency reliability coefficients were satisfactory with Cronbach alphas of 0.87 and 0.86 for the 11-item and 12-item stigma measurement scale. The investigation revealed that TB stigma was high. The key drivers of TB stigma were the association of TB with HIV/AIDS and the fear of TB transmission. TB stigma was exemplified through patients being isolated by others, self-isolation, fear to disclose TB diagnosis, association of TB with human immunodeficiency virus (HIV) and lack of social support. Being a woman was significantly associated with high levels of both experienced stigma (p = 0.007) and perceived stigma (p = 0.005) while age, marital status, occupation and the patient's religion were not.ConclusionThere is a need to implement stigma reduction interventions in order to improve TB program outcomes.

ObjectivesStudies have demonstrated that rs373863828, a missense mutation in CREBRF, is associated with a number of anthropometric traits including body mass index (BMI), obesity, percent body fat, hip circumference, and abdominal circumference. Given the biological relationship between height and adiposity, we hypothesized that the effect of this variant on BMI might be due in part to a previously untested association of this variant with height.MethodsWe tested the hypothesis that minor allele of rs373863828 is associated with height in a Samoan population in two adult cohorts and in a separate cohort of children (age 5 - 18 years old) using linear mixed modeling.ResultsWe found evidence of a strong relationship between rs373863828 and greater mean height in Samoan adults (0.77 cm greater average height for each copy of the minor allele) with the same direction of effect in Samoan children.ConclusionsThese results suggest that the missense variant rs373863828 in CREBRF, first identified through an association with larger BMI, may be related to an underlying biological mechanism affecting overall body size including stature.

Objective To understand how body size preferences changed in Samoa between 1995 and 2017 to 2019. Methods Data were from adults aged from 31 to 59 years, who participated in two separate cross-sectional studies of obesity and cardiometabolic risk conducted in Samoa in 1995 and 2017 to 2019. Participants nominated line drawings representing their current size, ideal size, the most attractive and healthiest size, and the lower/upper limits of "normal" size. Results In both sexes, body size preferences and perceived current average body size have increased, yet preference for bodies smaller than one's perceived current size has persisted. Furthermore, the range of body sizes that people considered "normal" has narrowed, suggesting decreased tolerance for extremes of body size. Conclusions These findings may have implications for mental and physical health outcomes, inform development of future health initiatives, and contribute to a deeper understanding of how body norms and weight-related public health efforts interface.

Objectives American Samoa has one of the highest rates of obesity worldwide, making it a population at high risk for pelvic organ prolapse (POP). The primary objective of this study was to describe the presence of POP symptoms and associated degree of bother in American Samoan women. The secondary objective was to determine which characteristics are associated with POP symptoms in this cohort. Methods We performed a cross-sectional survey of women presenting to the waiting room of the emergency department of the Lyndon B. Johnson Tropical Medical Center in Faga'alu, American Samoa from February to March 2017. Questions included self-described characteristics and the Pelvic Organ Prolapse Distress Inventory 6. Univariate distributions were described and comparisons of social and health characteristics were made between women without POP symptoms and those with at least 1 POP symptom. Results Two hundred eighty-four women were approached and 225 women completed the survey (79% response rate). The mean (SD) age was 40.5 (14.7), the mean (SD) body mass index was 36.4 (8.7), and the median (range) number of vaginal births was 2 (0-14). A total of 44.2% endorsed at least 1 POP symptom, most commonly pelvic pressure (29.9%) and feeling of incomplete bladder emptying (26.7%). The number of vaginal births was associated with lower abdominal pressure (P = 0.04) and hysterectomy was associated with pelvic heaviness (P = 0.05). Conclusions This is the first study investigating POP in American Samoa. Almost half of women reported at least 1 pelvic floor symptom, demonstrating the need for further research on pelvic floor disorders within this high-risk population.

Background To analyse trends over the period 1991–2013 in systolic blood pressure (SBP), diastolic blood pressure (DBP) and the prevalence of hypertension in adults aged 25–64 years in Samoa; and to assess the contribution of rising obesity levels to period trends. Methods Unit record data from seven population-based surveys (n = 10,881) conducted between 1991 and 2013 were included for analysis. Surveys were adjusted to the nearest previous census to improve national representativeness. Hypertension was defined as SBP ≥140 mmHg and/or DBP ≥90 mmHg and/or on medication for hypertension. Obesity was measured by body mass index (BMI). Poisson, linear and meta-regression were used to assess period trends. Results Over 1991–2013 mean SBP and DBP (mmHg), and the prevalence of hypertension (%) increased in both sexes. Increases in hypertension were: from 18.3 to 33.9% (p

Background American Samoan women are particularly at risk of obesity-related non-communicable disease (NCD), requiring efficacious interventions to protect their health and that of their infants. Prior studies have identified pregnancy as an ideal time for behavior change interventions related to NCD. Aim This study aimed to understand American Samoan women’s conceptions of health during pregnancy, their motivations for pregnancy behavior change, and the role of their family in both enabling and preventing these changes. Methods Eighteen women (2–19 weeks post-partum) completed semi-structured interviews that explored their experiences of pregnancy-related behavior change and social support. A thematic analysis identified prominent themes. A stages of change framework was used to describe the sample’s readiness for behavior change. Findings Participants expressed a Westernized conception of health during pregnancy that focused on eating a balanced diet and exercising regularly; behaviors that would usually be stigmatized outside of pregnancy. Many were in the contemplative/pre-contemplative stages of change, although some reported initiating healthful behaviors in pregnancy. Participants overwhelmingly described external motivations for adopting healthy behaviors, most notably the perceived benefit to their baby. During pregnancy, women reported protective treatment from their families as a result of communal ownership over the baby that is potentially limiting for women’s agency over their health. Conclusions This study confirmed pregnancy as an opportune moment for health behavior intervention, especially within the context of Samoan culture. Future efforts should capitalize on external motivations for behavior change but also encourage the development of internal motivators to sustain changes initiated in pregnancy post-partum.

Background The island country of Samoa (population 188,000 in 2011) forms part of Polynesia in the South Pacific. Over the past several decades Samoa has experienced exceptional modernization and globalization of many sectors of society, with noncommunicable diseases (NCD) now the leading cause of morbidity and mortality. The evolution of risk factor prevalence underpinning the increase in NCDs, however, has not been well described, including tobacco smoking which is related to cardiovascular disease, lung cancer, and chronic obstructive pulmonary disease. Methods The present study examines tobacco smoking in relation to different forms and effects of globalization in Samoa using 7 population-based surveys (n = 9223) over 1978–2013. Results The prevalence of daily tobacco smoking steadily decreased over 1978–2013 from 76% to 36% in men, and from 27% to 15% in women (p

Objectives This study estimates type 2 diabetes (T2DM) incidence in Samoans aged 25–64 years from sequential, irregularly spaced, cross-sectional population prevalence surveys. Methods T2DM prevalence from eight population surveys conducted over 1978–2013 (n = 12,516) was adjusted for census region, sex, and 5-year age group to the nearest previous census. Annual T2DM incidence was calculated from adjusted prevalences (by sex), using birth cohorts constructed from age-period matrices. Projections of T2DM incidence to 2020 were estimated, based on various scenarios of population weight change using Poisson regression. Results Over 1978–2013, T2DM incidence was estimated to increase from 1.12 to 8.44 per 1000 person-years in men and from 2.55 to 8.04 per 1000 in women. Based on regression modeling, if mean population weight was stabilized from 2013, absolute incidence reductions of 0.9 per 1000 person-years (7% lower) are predicted in 2020, compared to the current period trend in weight gain. Conclusions T2DM incidence can be calculated from irregularly conducted population risk factor surveys which may be useful in developing countries with limited resources. Electronic supplementary material The online version of this article (doi:10.1007/s00038-017-0961-x) contains supplementary material, which is available to authorized users.

© 2020, The Author(s), under exclusive licence to Springer Nature Limited. Age is the dominant risk factor for most chronic human diseases, but the mechanisms through which ageing confers this risk are largely unknown1. The age-related acquisition of somatic mutations that lead to clonal expansion in regenerating haematopoietic stem cell populations has recently been associated with both haematological cancer2–4 and coronary heart disease5—this phenomenon is termed clonal haematopoiesis of indeterminate potential (CHIP)6. Simultaneous analyses of germline and somatic whole-genome sequences provide the opportunity to identify root causes of CHIP. Here we analyse high-coverage whole-genome sequences from 97,691 participants of diverse ancestries in the National Heart, Lung, and Blood Institute Trans-omics for Precision Medicine (TOPMed) programme, and identify 4,229 individuals with CHIP. We identify associations with blood cell, lipid and inflammatory traits that are specific to different CHIP driver genes. Association of a genome-wide set of germline genetic variants enabled the identification of three genetic loci associated with CHIP status, including one locus at TET2 that was specific to individuals of African ancestry. In silico-informed in vitro evaluation of the TET2 germline locus enabled the identification of a causal variant that disrupts a TET2 distal enhancer, resulting in increased self-renewal of haematopoietic stem cells. Overall, we observe that germline genetic variation shapes haematopoietic stem cell function, leading to CHIP through mechanisms that are specific to clonal haematopoiesis as well as shared mechanisms that lead to somatic mutations across tissues.

Hypertension prevalence is on the rise in low- and middle-income countries (LMICs) like South Africa, and migration and its concomitant urbanization are often considered to be associated with this rise. However, relatively little is known about the relationship between blood pressure (BP) and internal migration – a highly prevalent population process in LMICs. This study employed data for a group of 194 adult men and women from an original pilot dataset drawn from the Agincourt Health and Demographic Surveillance System in north-east South Africa conducted in 2012. Migrants in the sample were identified, tracked and interviewed. The relationship between BP and migration distance and the number of months an individual spent away from his/her home village was estimated using robust OLS regression, controlling for a series of socioeconomic, health and behavioural characteristics. It was found that migrants who moved a longer distance and for longer durations had significantly higher systolic and diastolic blood pressures compared with shorter-term migrants and those who remained nearby or in their home village. These associations remained robust and statistically significant when adjusting for measures of socioeconomic conditions, as well as body mass index and the number of meals consumed per day. Migration, both in terms of distance and time away, explained significant variation in the blood pressure of migrants in this typical South African context. The findings suggest the need for further studies of the nutritional and psycho-social factors associated with geographic mobility that may be important to understand rising hypertension levels in LMICs.

Background Type 2 diabetes mellitus (T2DM) is highly prevalent in American Samoa. Community health worker (CHW) interventions may improve T2DM care and be cost-effective. Current cost-effectiveness analyses (CEA) of CHW interventions have either overlooked important cost considerations or not been based on randomized clinical trials (RCTs). The Diabetes Care in American Samoa (DCAS) intervention which occurred in 2009–2010 was a cluster-randomized, culturally tailored, home-visiting CHW intervention and improved HbA1c levels. Objective To analyze the cost-effectiveness of the DCAS intervention against standard care using a RCT in a low-resource setting. Methods We collected clinical, utilization, and cost data over 2 years and modeled quality-adjusted life years (QALYs) gained based on the RCT glycated hemoglobin (HbA1c) improvements. We calculated an incremental cost-effectiveness ratio (ICER) from the societal perspective over a 2-year time horizon and reported all costs in 2012 USD ($). Results Two hundred sixty-eight American Samoans diagnosed with T2DM were cluster randomized into the CHW (n = 104) or standard care control (n = 164) arms. The CHW arm had a mean reduction of 0.53% in HbA1c, an increase of $594 in cost, and an increase of 0.05 QALYs. The ICER for the CHW arm compared to the control arm was $1121 per percentage point HbA1c reduced and $13 191 per QALY gained. Conclusions Compared to a variety of willingness-to-pay thresholds from $39 000 to $154 353 per QALY gained, this ICER shows that the CHW intervention is highly cost-effective. Future studies of the cost-effectiveness of CHW T2DM interventions in similar settings should model lifetime costs and QALYs gained to better assess long-term cost-effectiveness. Trial registration ClinicalTrials.gov, ID NCT00850824. Registered 9 February 2009, https://clinicaltrials.gov/ct2/show/NCT00850824. Electronic supplementary material The online version of this article (10.1186/s12960-019-0356-6) contains supplementary material, which is available to authorized users.

Health systems in sub-Saharan Africa are facing an ongoing HIV epidemic and increasing burden of noncommunicable disease. With the focus shifting to the development of comprehensive primary health care and chronic disease treatment, multidisease modeling is integral to estimating future health care needs. We extended an established agent-based model of HIV transmission to include hypertension in two rural settings: KwaZulu-Natal, South Africa, and western Kenya. We estimated that from 2018 to 2028 hypertension prevalence would increase from 40 percent to 46 percent in KwaZulu-Natal and from 29 percent to 35 percent in western Kenya, while HIV prevalence is stabilizing and predicted to decrease. As the health system burden in sub-Saharan Africa is changing, innovative chronic disease treatment and the broadening of successful programs, such as integrated HIV and noncommunicable disease care, are necessary to reach universal health care coverage.

Aims Population surveys of Type 2 diabetes mellitus and obesity conducted in Samoa over three decades have used varying methodologies and definitions. This study standardizes measures, and trends of Type 2 diabetes mellitus and obesity for 1978–2013 are projected to 2020 for adults aged 25–64 years. Methods Unit records from eight surveys (n = 12 516) were adjusted to the previous census for Division of residence, sex and age to improve national representativeness. Type 2 diabetes mellitus is defined as a fasting plasma glucose ≥ 7.0 mmol/l and/or on medication. Obesity is defined as BMI ≥ 30 kg/m2. Random effects meta‐regression was employed to assess time trends following logit transformation. Poisson regression from strata was used to assess the effects of mean BMI changes on Type 2 diabetes mellitus period trends. Results Over 1978–2013, Type 2 diabetes mellitus prevalence increased from 1.2% to 19.6% in men (2.3% per 5 years), and from 2.2% to 19.5% in women (2.2% per 5 years). Obesity prevalence increased from 27.7% to 53.1% in men (3.6% per 5 years) and from 44.4% to 76.7% (4.5% per 5 years) in women. Type 2 diabetes mellitus and obesity prevalences increased in all age groups. From period trends, Type 2 diabetes mellitus prevalence in 2020 is projected to be 26% in men and women. Projected obesity prevalence is projected to be 59% in men and 81% in women. Type 2 diabetes mellitus period trends attributable to BMI increase are estimated as 31% (men) and 16% (women), after adjusting for age. Conclusion This is the first study to produce trends of Type 2 diabetes mellitus and obesity in Samoa based on standardized data from population surveys. Type 2 diabetes mellitus is equally prevalent in both sexes, and obesity is widespread. Type 2 diabetes mellitus prevalence in Samoa is likely to continue to increase in the near future., What's new? This is the first study to standardize previously conducted, disparate population‐based measures of Type 2 diabetes mellitus and obesity from unit records of empirical surveys to produce period trends in Samoa.Prevalences of Type 2 diabetes mellitus and obesity have increased over 35 years (1978–2013), and are projected to continue to increase in the near future.The increase in Type 2 diabetes mellitus is partially attributed to the rise in obesity and effective interventions to reduce obesity are urgently required.

Samoans are a unique founder population with a high prevalence of obesity, making them well suited for identifying new genetic contributors to obesity. We conducted a genome-wide association study (GWAS) in 3,072 Samoans, discovered a variant, rs12513649, strongly associated with body mass index (BMI) (P = 5.3 × 10(-14)), and replicated the association in 2,102 additional Samoans (P = 1.2 × 10(-9)). Targeted sequencing identified a strongly associated missense variant, rs373863828 (p.Arg457Gln), in CREBRF (meta P = 1.4 × 10(-20)). Although this variant is extremely rare in other populations, it is common in Samoans (frequency of 0.259), with an effect size much larger than that of any other known common BMI risk variant (1.36-1.45 kg/m(2) per copy of the risk-associated allele). In comparison to wild-type CREBRF, the Arg457Gln variant when overexpressed selectively decreased energy use and increased fat storage in an adipocyte cell model. These data, in combination with evidence of positive selection of the allele encoding p.Arg457Gln, support a 'thrifty' variant hypothesis as a factor in human obesity.

The A (minor) allele of CREBRF rs373863828 has been associated with increased BMI and reduced risk of type 2 diabetes in the Samoan populations of Samoa and American Samoa. Our aim was to test rs373863828 for associations with BMI and the odds of type 2 diabetes, gout and chronic kidney disease (CKD) in Māori and Pacific (Polynesian) people living in Aotearoa/New Zealand. Linear and logistic regression models were used to analyse the association of the A allele of CREBRF rs373863828 with BMI, log-transformed BMI, waist circumference, type 2 diabetes, gout and CKD in 2286 adults. The primary analyses were adjusted for age, sex, the first four genome-wide principal components and (where appropriate) BMI, waist circumference and type 2 diabetes. The primary analysis was conducted in ancestrally defined groups and association effects were combined using meta-analysis. For the A allele of rs373863828, the effect size was 0.038 (95% CI 0.022, 0.055, p = 4.8 × 10−6) for log-transformed BMI, with OR 0.59 (95% CI 0.47, 0.73, p = 1.9 × 10−6) for type 2 diabetes. There was no evidence for an association of genotype with variance in BMI (p = 0.13), and nor was there evidence for associations with serum urate (β = 0.012 mmol/l, pcorrected = 0.10), gout (OR 1.00, p = 0.98) or CKD (OR 0.91, p = 0.59). Our results in New Zealand Polynesian adults replicate, with very similar effect sizes, the association of the A allele of rs373863828 with higher BMI but lower odds of type 2 diabetes among Samoan adults living in Samoa and American Samoa.

Background Organophospate flame retardants (PFRs) are chemicals of emerging concern due to restrictions on polybrominated diphenyl ether flame retardant formulations. We describe the occurrence, variability, and predictors of urinary metabolites of PFRs among pregnant women. Methods In 2014–2015, 59 women from Providence, RI provided up to 3 spot urine samples during pregnancy (~12, 28, and 35 weeks’ gestation). We created a pooled urine sample per woman and measured nine relevant metabolites in individual and pooled samples. We used linear mixed models to calculate intraclass correlation coefficients (ICCs) across the 3 measurements and to assess sociodemographic and dietary predictors of PFRs. Results The median (IQR) of bis-2-chloroethyl phosphate (BCEP), bis(1,3-dichloro-2-propyl) phosphate (BDCPP), and diphenyl phosphate (DPhP), the metabolites most frequently detected, from pooled samples were: 0.31 μg/L (0.17–0.54), 1.18 μg/L (0.64–2.19), 0.93 μg/L (0.72–1.97), respectively. We observed fair to good reproducibility for BCEP (ICC = 0.50), BDCPP (ICC = 0.60), and DPhP (ICC = 0.43), and excellent agreement between the urinary flame retardant metabolite concentrations averaged across pregnancy versus pooled urine sample concentrations for BCEP (ICC = 0.95), BDCPP (ICC = 0.89), and DPhP (ICC = 0.93). Adjusting for pertinent sociodemographic factors and gestational week of urine collection, each 1 kg increase in pre-pregnancy weight was associated with greater BCEP (1.1%; 95% CI: 0.1, 2.1), BDCPP (1.5%; 95% CI: 0.3, 2.7), and DPhP (0.5%; 95% CI: 0.0, 1.1). Dietary factors were generally not associated with urinary flame retardant metabolites. Conclusions Urinary concentrations of BCEP, BDCPP, and DPhP were frequently detected among women in this pilot study and had fair reproducibility across pregnancy. Body size may be an important predictor of urinary flame retardant metabolite concentrations. Electronic supplementary material The online version of this article (doi:10.1186/s12940-017-0247-z) contains supplementary material, which is available to authorized users.

Source at: http://doi.org/10.1056/NEJMoa1614362 Background: Although the rising pandemic of obesity has received major attention in many countries, the effects of this attention on trends and the disease burden of obesity remain uncertain. Methods: We analyzed data from 68.5 million persons to assess the trends in the prevalence of overweight and obesity among children and adults between 1980 and 2015. Using the Global Burden of Disease study data and methods, we also quantified the burden of disease related to high body-mass index (BMI), according to age, sex, cause, and BMI in 195 countries between 1990 and 2015. Restults: In 2015, a total of 107.7 million children and 603.7 million adults were obese. Since 1980, the prevalence of obesity has doubled in more than 70 countries and has continuously increased in most other countries. Although the prevalence of obesity among children has been lower than that among adults, the rate of increase in childhood obesity in many countries has been greater than the rate of increase in adult obesity. High BMI accounted for 4.0 million deaths globally, nearly 40% of which occurred in persons who were not obese. More than two thirds of deaths related to high BMI were due to cardiovascular disease. The disease burden related to high BMI has increased since 1990; however, the rate of this increase has been attenuated owing to decreases in underlying rates of death from cardiovascular disease. Conclusions: The rapid increase in the prevalence and disease burden of elevated BMI highlights the need for continued focus on surveillance of BMI and identification, implementation, and evaluation of evidence-based interventions to address this problem.

SUMMARYThe role that animals play in the transmission of Schistosoma japonicum to humans in the Philippines remains uncertain and prior studies have not included several species, adjustment for misclassification error and clustering, or used a cohort design. A cohort study of 2468 people providing stool samples at 12 months following praziquantel treatment in 50 villages of Western Samar, the Philippines, was conducted. Stool samples from dogs, cats, rats, and water buffaloes were collected at baseline (2003–2004) and follow-up (2005). Latent-class hierarchical Bayesian log-binomial models adjusting for misclassification errors in diagnostic tests were used. The village-level baseline and follow-up prevalences of cat, dog, and rat S. japonicum infection were associated with the 12-month cumulative incidence of human S. japonicum infection, with similar magnitude and precision of effect, but correlation between infection levels made it difficult to divide their respective effects. The cumulative incidence ratios associated with a 1% increase in the prevalence of infection in dogs at baseline and in rats at follow-up were 1·04 [95% Bayesian credible interval (BCI) 1·02–1·07] and 1·02 (95% BCI 1·01–1·04), respectively, when both species were entered in the model. Dogs appear to play a role in human schistosomiasis infection while rats could be used as schistosomiasis sentinels.

Background. Social and behavioral risk markers (e.g., physical activity, diet, smoking, and socioeconomic position) cluster; however, little is known whether clustering is associated with coronary heart disease (CHD) risk. Objectives were to determine if sociobehavioral clustering is associated with biological CHD risk factors (total cholesterol, HDL cholesterol, systolic blood pressure, body mass index, waist circumference, and diabetes) and whether associations are independent of individual clustering components.Methods. Participants included 4,305 males and 4,673 females aged ≥20 years from NHANES 2001–2004. Sociobehavioral Risk Marker Index (SRI) included a summary score of physical activity, fruit/vegetable consumption, smoking, and educational attainment. Regression analyses evaluated associations of SRI with aforementioned biological CHD risk factors. Receiver operator curve analyses assessed independent predictive ability of SRI.Results. Healthful clustering (SRI = 0) was associated with improved biological CHD risk factor levels in 5 of 6 risk factors in females and 2 of 6 risk factors in males. Adding SRI to models containing age, race, and individual SRI components did not improve C-statistics.Conclusions. Findings suggest that healthful sociobehavioral risk marker clustering is associated with favorable CHD risk factor levels, particularly in females. These findings should inform social ecological interventions that consider health impacts of addressing social and behavioral risk factors.

The objective of this study is to describe the utilization of prenatal care in American Samoan women and to identify socio-demographic predictors of inadequate prenatal care utilization. Using data from prenatal clinic records, women (n = 692) were categorized according to the adequacy of prenatal care utilization index as having received adequate plus, adequate, intermediate or inadequate prenatal care during their pregnancy. Categorical socio-demographic predictors of the timing of initiation of prenatal care (week of gestation) and the adequacy of received services were identified using one way analysis of variance and independent samples t tests. Between 2001 and 2008 85.4 % of women received inadequate prenatal care. Parity (P = 0.02), maternal unemployment (P = 0.03), and both parents being unemployed (P = 0.03) were negatively associated with the timing of prenatal care initiation. Giving birth in 2007–2008, after a prenatal care incentive scheme had been introduced in the major hospital, was associated with earlier initiation of prenatal care (20.75 vs. 25.12 weeks; P < 0.01) and improved adequacy of received services (95.04 vs. 83.8 %; P = 0.02). The poor prenatal care utilization in American Samoa is a major concern. Improving healthcare accessibility will be key in encouraging women to attend prenatal care. The significant improvements in the adequacy of prenatal care seen in 2007–2008 suggest that the prenatal care incentive program implemented in 2006 may be a very positive step toward addressing issues of prenatal care utilization in this population.

To determine whether social and behavioral risk factors for coronary heart disease, including education, physical activity, fruit/vegetable intake, and smoking, cluster (i.e., co-occur more than expected as the result of chance) in U.S. adults.The study included 4305 male and 4673 female subjects aged ≥20 years from the National Health and Nutrition Examination Survey. Risk factors included: ≤high school diploma/general educational development certificate;150 minutes of moderate/vigorous physical activity per week;3 or2 servings of vegetables and fruit, respectively, per day; and smoking cigarettes. Indicator variables were summed into a sociobehavioral risk index (SRI, range 0 [no risk factors] to 4 [all risk factors]). Ratios of observed-to-expected prevalence (under the assumption of independence) of the SRI were assessed. Statistical significance was evaluated by the use of randomly permuted average observed-to-expected SRI ratios and 95% confidence intervals (95% CIs).In male subjects, the ratio of observed-to-expected prevalence of SRI = 0 was 1.70 (permuted ratio = 1.00; 95% CI: 0.92-1.08), and SRI = 4 was 2.10 (permuted ratio = 1.00, 95% CI: 0.86-1.14), demonstrating significant clustering. In females, the ratio of observed-to-expected prevalence of SRI = 0 was 1.67 (permuted ratio = 1.00, 95% CI: 0.92-1.08), and SRI = 4 was 1.86 (permuted ratio = 1.00, 95% CI: 0.85-1.15).Social and behavioral risk factors for coronary heart disease cluster in this sample of U.S. adults.

OBJECTIVE To evaluate the effectiveness of a culturally adapted, primary care–based nurse–community health worker (CHW) team intervention to support diabetes self-management on diabetes control and other biologic measures. RESEARCH DESIGN AND METHODS Two hundred sixty-eight Samoan participants with type 2 diabetes were recruited from a community health center in American Samoa and were randomly assigned by village clusters to the nurse-CHW team intervention or to a wait-list control group that received usual care. RESULTS Participants had a mean age of 55 years, 62% were female, mean years of education were 12.5 years, 41% were employed, and mean HbA1c was 9.8% at baseline. At 12 months, mean HbA1c was significantly lower among CHW participants, compared with usual care, after adjusting for confounders (b = −0.53; SE = 0.21; P = 0.03). The odds of making a clinically significant improvement in HbA1c of at least 0.5% in the CHW group was twice the odds in the usual care group after controlling for confounders (P = 0.05). There were no significant differences in blood pressure, weight, or waist circumference at 12 months between groups. CONCLUSIONS A culturally adapted nurse-CHW team intervention was able to significantly improve diabetes control in the U.S. Territory of American Samoa. This represents an important translation of an evidence-based model to a high-risk population and a resource-poor setting.

Background Pregnant women in American Samoa have a high risk of complications due to overweight and obesity. Prenatal care can mitigate the risk, however many women do not seek adequate care during pregnancy. Low utilization of prenatal care may stem from low levels of satisfaction with services offered. Our objective was to identify predictors of prenatal care satisfaction in American Samoa. Methods A structured survey was distributed to 165 pregnant women receiving prenatal care at the Lyndon B Johnson Tropical Medical Center, Pago Pago. Women self-reported demographic characteristics, pregnancy history, and satisfaction with prenatal care. Domains of satisfaction were extracted using principal components analysis. Scores were summed across each domain. Linear regression was used to examine associations between maternal characteristics and the summed scores within individual domains and for overall satisfaction. Result Three domains of satisfaction were identified: satisfaction with clinic services, clinic accessibility, and physician interactions. Waiting ≥ 2 h to see the doctor negatively impacted satisfaction with clinic services, clinic accessibility, and overall satisfaction. Living > 20 min from the clinic was associated with lower clinic accessibility, physician interactions, and overall satisfaction. Women who were employed/on maternity leave had lower scores for physician interactions compared with unemployed women/students. Women who did not attend all their appointments had lower overall satisfaction scores. Conclusions Satisfaction with clinic services, clinic accessibility and physician interactions are important contributors to prenatal care satisfaction. To improve patient satisfaction prenatal care clinics should focus on making it easier for women to reach clinics, improving waiting times, and increasing time with providers. Electronic supplementary material The online version of this article (10.1186/s12884-017-1563-6) contains supplementary material, which is available to authorized users.

Objective To define biochemical hyperandrogenemia (HA) among a population-based sample of reproductive-aged Samoan women, taking into consideration their high BMI levels. Design and methods A secondary analysis was performed among a cross-sectional sample of Samoan women aged 25–39 years (n = 494) who were part of a larger genome-wide association study (GWAS) of adiposity. Women indicating pregnancy/lactation, hysterectomy, oophorectomy, cancer treatment, or use of contraceptive injections were excluded from the study. We analyzed the distribution of free androgen index (FAI) values to establish normative androgen data among Samoan women of reproductive age. Using the lowest tertile of body mass index (BMI), we defined HA as free androgen index (FAI) values > 95th FAI percentile in that subsample. We compared the anthropometric and metabolic characteristics of women with HA to women with normal androgen levels. Results HA was defined as FAI > 8.5. Using this definition, 14% of women were classified as hyperandrogenemic. Women with HA had significantly higher average BMI values, abdominal circumferences, fasting triglycerides, and insulin levels as well as significantly lower adiponectin levels. Conclusion This study is the first to define normative androgen values among Samoan women with a quantitative assessment of the relationship between adiposity and androgen levels. The uniquely high BMI levels in the population not only provide important clinical insight into normative androgen values among Samoan women, but they also serve as references for the clinical assessment of HA, taking into consideration BMI, in other populations.

We conducted a large population-based survey among adults measuring weight, height, and blood pressure nested within an HIV survey in rural KwaZulu-Natal, South Africa, to identify and characterize clusters of overweight and hypertension in a typical rural African population and to explore whether geographic clusters can be accounted for by established individual-level risk factors. 58.4% of the participants were overweight and 22.6% were hypertensive. One cluster of high prevalence of overweight (RR=1.50, p, Highlights ► Determinants and spatial patterns of chronic diseases in rural South Africa. ► Localized clustering of overweight identified, but no clustering for hypertension. ► Additional insights into chronic disease control for rural South Africa were provided.

Lower levels of LINE-1 methylation in peripheral blood have been previously associated with risk of developing non-communicable conditions, the most well-explored of these being cancer, although recent research has begun to link altered LINE-1 methylation and cardiovascular disease. We examined the relationship between LINE-1 methylation and factors associated with metabolic and cardiovascular diseases through quantitative bisulfite pyrosequencing in DNA from peripheral blood samples from participants of the Samoan Family Study of Overweight and Diabetes (2002–03). The sample included 355 adult Samoans (88 men and 267 women) from both American Samoa and Samoa. In a model including all sample participants, men had significantly higher LINE-1 methylation levels than women (p = 0.04) and lower levels of LINE-1 methylation were associated with higher levels of fasting LDL (p = 0.02) and lower levels of fasting HDL (p = 0.009). The findings from this study confirm that DNA “global” hypomethylation (as measured by methylation at LINE-1 repeats) observed previously in cardiovascular disease is associated with altered levels of LDL and HDL in peripheral blood. Additionally, these findings strongly argue the need for further research, particularly including prospective studies, in order to understand the relationship between LINE-1 DNA methylation measured in blood and risk factors for cardiovascular disease.

background: American Samoa and Samoa are now characterized by one of the world’s highest levels of adult overweight and obesity. Our objective was to investigate patterns of menstrual cyclicity reported by Samoan women and examine the relationship to adiposity and select hormone levels. methods: A cross-sectional analysis was performed among Samoan women, aged 18 –39 years (n ¼ 322), using anthropometric and biomarker measures of adiposity and reproductive health, including insulin, adiponectin, testosterone, sex hormone-binding globulin, free androgen index (FAI) and mullerian-inhibiting substance (MIS). Menstrual regularity was assessed from self-reported responses. Multivariable models were estimated to adjust for potential confounding of the associations between menstrual patterns and other measures. results: A high proportion of the women (13.7%) reported oligomenorrhea or amenorrhea (OM/AM). More than three-quarters, 80.7%, of women were either overweight or obese, using Polynesian-specific criteria, and OM/AM was significantly associated with higher BMI. Abdominal circumference and insulin levels were significantly higher, and adiponectin levels were lower, in those who reported OM/AM versus regular menstruation. The FAI was higher in women with increased BMI. MIS levels declined with age, more slowly in those reporting OM/AM. conclusions: Self-reported OM/AM was associated with an elevated BMI, abdominal adiposity and serum insulin, and with reduced adiponectin levels. These findings support a high rate of metabolic syndrome, and perhaps PCOS and reproductive dysfunction, among Samoan women.

Background. Schistosomes infect 200 million individuals annually and cause significant hepatic fibrosis in up to 20%. Little is known regarding the mechanisms of schistosome-associated hepatic fibrosis in humans, and few biomarkers for risk of fibrosis have been identified. Methods. We treated 611 Schistosoma japonicum–infected Filipinos with praziquantel (PZQ) and performed ultrasound to quantify hepatic fibrosis at baseline and 12 months after PZQ treatment. We developed a multiplexed assay (FibroPlex) that quantifies predictors and effect modifiers of fibrosis. We measured FibroPlex analytes produced by peripheral blood mononuclear cells stimulated with schistosome egg antigen 4 weeks after PZQ treatment and related these levels to risk of fibrosis 1 year after PZQ treatment. Results. After adjusting for potential confounders, including baseline grade of fibrosis, individuals with detectable tissue inhibitor of matrix-metalloprotease–1 (TIMP-1) had a 3.5-fold greater risk of fibrosis 1 year after PZQ treatment, compared with individuals with undetectable levels (odds ratio, 3.48; 95% confidence interval, 1.41–8.43; P = .007). Discussion Because TIMP-1 inhibits most matrix metalloproteases, which are responsible for collagen degradation, these data suggest that schistosome-associated hepatic fibrosis results, in part, from excessive inhibition of collagen remodeling. These data further suggest that TIMP-1 is a promising biomarker for assessing risk of hepatic fibrosis in schistosomiasis and, potentially, other infectious and noninfectious causes of liver disease.

One small previous study found that praziquantel reduced hookworm infection. In this study, 607 subjects were enrolled in a longitudinal study. At enrollment and every 3 months for 18 months, three stool samples were collected, and the intensity of infection with Schistosoma japonicum and soil-transmitted helminths (STHs) was quantified. All subjects were treated with 60 mg/kg praziquantel at baseline. Three months post-treatment, the percent of subjects who were hookworm-infected decreased to 46.5% from 61% at baseline. The putative cure rate was 23.7%. The 95% confidence interval around the change in hookworm egg counts from baseline to 6 and 12 months post-treatment was negative and did not include zero. The percent reduction in hookworm egg counts from baseline to 3 months post-treatment was 40.8%. Praziquantel treatment did not decrease the infection intensity of STHs. Control programs using praziquantel may have the added benefit of reducing hookworm infection and anemia in areas of coendemnicity.

OBJECTIVES: Obesity leads to deleterious effects on not only cardiovascular health but also on the reproductive health of women. We estimate the prevalence of menstrual irregularity and of polycystic ovarian syndrome (PCOS) in Samoan women, among whom obesity prevalence is extremely high. We explore the association of these reproductive health conditions with adiposity, cardiometabolic risk factors, and androgen levels. METHODS: A cross-sectional sample of Samoan women 25–39 years of age (n=470) from a larger population-based genome-wide association study (GWAS) of adiposity and cardiometabolic disease was assessed for the prevalence of oligomenorrhea/amenorrhea (OM/AM) using a self-reported questionnaire. Serum androgens and anti-Müllerian hormone (AMH) levels were assayed to determine hyperandrogenemia and presence of polycystic ovaries, respectively, using criterion values. PCOS was classified using NIH criteria of having at least two of the three conditions: menstrual irregularity, hyperandrogenism, and polycystic ovaries. We contrasted socio-demographic, reproductive health, and cardiometabolic risk factors between those with and without OM/AM and similarly for PCOS. RESULTS: The prevalence of OM/AM was 7.4% (95% CI: 5.1, 9.8), and women with OM/AM had significantly higher central adiposity. PCOS was estimated at 6.8% (95% CI: 4.5, 9.1), and those with PCOS were younger but had higher overall and central adiposity measures, higher triglycerides, and higher prevalence of insulin resistance than women without PCOS. CONCLUSIONS: The prevalence of menstrual irregularity and PCOS are less than hypothesized given the high levels of adiposity in this population. Nevertheless, Samoan women with menstrual irregularity and other features of PCOS have significantly poorer metabolic health.

The accuracy of the Kato-Katz technique in identifying individuals with soil-transmitted helminth (STH) infections is limited by day-to-day variation in helminth egg excretion, confusion with other parasites and the laboratory technicians’ experience. We aimed to estimate the sensitivity and specificity of the Kato-Katz technique to detect infection with Ascaris lumbricoides, hookworm and Trichuris trichiura using a Bayesian approach in the absence of a ‘gold standard’. Data were obtained from a longitudinal study conducted between January 2004 and December 2005 in Samar Province, the Philippines. Each participant provided between one and three stool samples over consecutive days. Stool samples were examined using the Kato-Katz technique and reported as positive or negative for STHs. In the presence of measurement error, the true status of each individual is considered as latent data. Using a Bayesian method, we calculated marginal posterior densities of sensitivity and specificity parameters from the product of the likelihood function of observed and latent data. A uniform prior distribution was used (beta distribution: α = 1, β = 1). A total of 5624 individuals provided at least one stool sample. One, two and three stool samples were provided by 1582, 1893 and 2149 individuals, respectively. All STHs showed variation in test results from day to day. Sensitivity estimates of the Kato-Katz technique for one stool sample were 96.9% (95% Bayesian Credible Interval [BCI]: 96.1%, 97.6%), 65.2% (60.0%, 69.8%) and 91.4% (90.5%, 92.3%), for A. lumbricoides, hookworm and T. trichiura, respectively. Specificity estimates for one stool sample were 96.1% (95.5%, 96.7%), 93.8% (92.4%, 95.4%) and 94.4% (93.2%, 95.5%), for A. lumbricoides, hookworm and T. trichiura, respectively. Our results show that the Kato-Katz technique can perform with reasonable accuracy with one day’s stool collection for A. lumbricoides and T. trichiura. Low sensitivity of the Kato-Katz for detection of hookworm infection may be related to rapid degeneration of delicate hookworm eggs with time.

The prevalence of metabolic syndrome has reached epidemic levels in the Samoan Islands. In this cross-sectional study conducted in 2002-2003, dietary patterns were described among American Samoan (n = 723) and Samoan (n = 785) adults (> or =18 y) to identify neo-traditional and modern eating patterns and to relate these patterns to the presence of metabolic syndrome using Adult Treatment Panel III criteria. The neo-traditional dietary pattern, similar across both polities, was characterized by high intake of local foods, including crab/lobster, coconut products, and taro, and low intake of processed foods, including potato chips and soda. The modern pattern, also similar across both polities, was characterized by high intake of processed foods such as rice, potato chips, cake, and pancakes and low intake of local foods. The neo-traditional dietary pattern was associated with significantly higher serum HDL-cholesterol in American Samoa (P-trend = 0.05) and a decrease in abdominal circumference in American Samoa and Samoa (P-trend = 0.004 and 0.01, respectively). An inverse association was found with metabolic syndrome, although it did not reach significance (P = 0.23 in American Samoa; P = 0.13 in Samoa). The modern pattern was significantly positively associated with metabolic syndrome in Samoa (prevalence ratio = 1.21 for the fifth compared with first quintile; 95% CI: 0.93.1.57; P-trend = 0.05) and with increased serum triglyceride levels in both polities (P < 0.05). Reduced intake of processed foods high in refined grains and adherence to a neo-traditional eating pattern characterized by plant-based fiber, seafood, and coconut products may help to prevent growth in the prevalence of metabolic syndrome in the Samoan islands.

Summary We conducted a genome-wide scan in 46 pedigrees, with 671 phenotyped adults, from the independent nation of Samoa to map quantitative trait loci (QTLs) for adiposity-related phenotypes, including body mass index (BMI), abdominal circumference (ABDCIR), percent body fat (%BFAT), and fasting serum leptin and adiponectin. A set of 378 autosomal and 14 X chromosomal microsatellite markers were genotyped in 572 of the adults. Significant genetic correlations (0.82–0.96) were detected between pairs of BMI, ABDCIR, %BFAT and leptin. Suggestive linkages were found on 13q31 (LOD = 2.30 for leptin, LOD = 2.48 for %BFAT, LOD = 2.04 for ABDCIR, and LOD = 2.09 for BMI) and on 9p22 (LOD = 3.08 for ABDCIR and LOD = 2.53 for %BFAT). Furthermore, bivariate linkage analyses indicated that the genetic regions on 9p22 (bivariate LOD 2.35–3.10, LODeq (1df) 1.88–2.59) and 13q31 (bivariate LOD 1.96–2.64, LODeq 1.52–2.21) might harbor common major genes with pleiotropic effects. Other regions showing suggestive linkage included 4q22 (LOD = 2.95) and 7p14 (LOD = 2.64) for %BFAT, 2q13 for adiponectin (LOD = 2.05) and 19q12 for BMI-adjusted leptin (LOD = 2.03). Further fine mapping of these regions may help identify the genetic variants contributing to the development of obesity in Samoan adults.

To detect quantitative trait loci influencing adiposity-related phenotypes assessed by body mass index (BMI), abdominal circumference (ABDCIR), percent body fat (%BFAT) and fasting serum leptin and adiponectin using a whole genome linkage scan of families from American Samoa. Family-based linkage analysis, the probands and family members were unselected for obesity. A total of 583 phenotyped American Samoan adults, of which 578 were genotyped in 34 pedigrees. A total of 377 autosomal and 18 X chromosome microsatellite markers were typed at an approximate average spacing of 10 cM spanning the genome. Multipoint LOD (logarithm of the odds) scores were calculated using variance-components approaches and SOLAR/LOKI software. The covariates simultaneously evaluated were age, sex, education, farm work and cigarette smoking, with a significance level of 0.1. Due to the stochastic nature of LOKI, we report the average of maximum LOD scores from 10 runs. Significant linkage to leptin was found at 6q32.2 with LOD of 3.83. Suggestive linkage to leptin was found at 16q21:LOD=2.98, 1q42.2:LOD=1.97, 5q11.2:LOD=2.08, 12q24.23:LOD=2.00, 19p13.3:LOD=2.05; adiponectin was linked to 13q33.1–q22.1:LOD=2.41; %BFAT was linked to 16q12.2–q21, LOD=2.24; ABDCIR was linked to 16q23.1:LOD=1.95; %BFAT-adjusted leptin to 14q12, LOD=2.01; %BFAT-adjusted ABDCIR to 1q31.1, LOD=2.36, to 3q27.3–q28, LOD=2.10 and to 12p12.3, LOD=2.04. We found strong evidence for a major locus on 6q23.2 influencing serum leptin levels in American Samoans. The 16q21 region appears to harbor a susceptibility locus that has significant pleiotrophic effects on phenotypes BMI, %BFAT, leptin and ABDCIR as shown by bivariate linkage analyses. Several other loci of varying significance were detected across the genome.

Early nutrition is critical for later health and sustainable development. We determined potential effectiveness of the Kenyan Community Health Strategy in promoting exclusive breastfeeding (EBF) in urban poor settings in Nairobi, Kenya. We used a quasi-experimental study design, based on three studies [Pre-intervention (2007–2011; n=5824), Intervention (2012–2015; n=1110) and Comparison (2012–2014; n=487)], which followed mother–child pairs longitudinally to establish EBF rates from 0 to 6 months. The Maternal, Infant and Young Child Nutrition (MIYCN) study was a cluster randomized trial; the control arm (MIYCN-Control) received standard care involving community health workers (CHWs) visits for counselling on antenatal and postnatal care. The intervention arm (MIYCN-Intervention) received standard care and regular MIYCN counselling by trained CHWs. Both groups received MIYCN information materials. We tested differences in EBF rates from 0 to 6 months among four study groups (Pre-intervention, MIYCN-Intervention, MIYCN-Control and Comparison) using a χ2 test and logistic regression. At 6 months, the prevalence of EBF was 2% in the Pre-intervention group compared with 55% in the MIYCN-Intervention group, 55% in the MIYCN-Control group and 3% in the Comparison group (P

Introduction Diabetes Care in American Samoa (DCAS) was a randomized controlled trial of a 12-month intervention facilitated by community health workers (CHWs) that demonstrated improved HbA1c levels compared with usual care at trial completion. We sought to evaluate the long-term impact of this intervention on diabetes control. Methods We retrospectively collected HbA1c measurements from medical records of DCAS participants (n = 268). The study group received the intervention during the trial, and the control group received the intervention after the trial. We used mixed-effects longitudinal regression models to assess change in HbA1c within each trial arm during 3 time periods: DCAS (12 months of the study group’s intervention), the first year after DCAS (control group’s intervention), and the second year after DCAS. Models were adjusted for baseline characteristics that differed significantly for participants with a low number of HbA1c measurements from those with a high number of HbA1c measurements. Results After adjustment for confounders, the experiment group experienced a decrease in HbA1c of 0.28 units per year (95% confidence interval [CI], −0.64 to 0.07) during DCAS (intervention). HbA1c decreased by 0.88 units per year (95% CI, −1.31 to −0.45) during the year after the intervention. No significant change was observed the following year. HbA1c of the control group did not significantly change during DCAS (usual care) but decreased by 1.31 units per year (95% CI, −1.72 to −0.91) during its intervention. During the year after the control group’s intervention, HbA1c increased by 1.18 units per year (95% CI, 0.42 to 1.93). Conclusion Both groups had initial improvements in glycemic control, but HbA1c later plateaued or increased. These results suggest that time-limited CHW programs improve diabetes control in the short term, but ongoing programs are needed for sustained impact.

Background In American Samoa, initiation of breastfeeding is almost universal but exclusive breastfeeding, a promising target for obesity prevention, is short in duration. Aims (1) To examine American Samoan mothers’ feeding experiences and attitudes and beliefs about infant feeding and (2) to identify potential barriers to exclusive breastfeeding. Methods Eighteen semi-structured interviews were conducted with American Samoan mothers at 16–32 days postpartum. Interviews focused on mother's knowledge and beliefs about infant feeding, how their infants were fed, why the mother had chosen this mode of infant feeding, and how decisions about feeding were made within her social surroundings. A thematic qualitative analysis was conducted to identify salient themes in the data. Findings Intention to exclusively breastfeed did not predict practice; most women supplemented with formula despite intending to exclusively breastfeed. The benefits of breastfeeding were well-recognized, but the importance of exclusivity was missed. Formula-use was not preferred but considered an innocuous “back-up option” where breastfeeding was not possible or not sufficient for infant satiety. Identified barriers to exclusive breastfeeding included: the convenience of formula; perceptions among mothers that they were not producing enough breast milk; and pain while breastfeeding. The important support role of family for infant feeding could be utilized in intervention design. Conclusion This study identified barriers to exclusive breastfeeding that can be immediately addressed by providers of breastfeeding support services. Further research is needed to address the common perception of insufficient milk in this setting.

Background As obesity has increased worldwide, so have levels of obesity during pregnancy and excess gestational weight gain (GWG). The aim of this paper was to describe GWG among American Samoan women and examine the association between GWG and four adverse pregnancy and infant outcomes: cesarean delivery, small- and large-for-gestational age (SGA/LGA), and infant overweight/obesity. Methods Data were extracted from prenatal care records of 632 Samoan women. Mixed-effects growth models were used to produce individual weight-for-gestational week curves from which second and third trimester weight gain was estimated. Binary logistic regression was used to examine associations between GWG and the outcomes of interest. Results Most women were overweight/obese in early pregnancy (86%) and 78% exceeded the Institute of Medicine GWG guidelines. Greater GWG in the second trimester and early pregnancy weight were independently associated with increased odds of a c-section (OR 1.40 [95% CI: 1.08, 1.83]) and OR 1.51 [95% CI: 1.17, 1.95], respectively). Risk of delivering a LGA infant increased with greater third trimester weight gain and higher early pregnancy weight, while second trimester weight gain was negatively associated with SGA. Risk of infant overweight/obesity at 12 months increased with early pregnancy weight (OR: 1.23 [95% CI: 1.01, 1.51]) and infant birthweight. Conclusions The high levels of pregnancy obesity and excessive GWG in American Samoa suggest that it is important for physicians to encourage women into prenatal care early and begin education about appropriate GWG and the potential risks of excess weight gain for both the mother and baby.

OBJECTIVES: The aim of this study was to determine the association between violent conflict and HIV incidence within and across 36 sub-Saharan Africa countries between 1990 and 2012. METHODS: We used generalized linear mixed effect modeling to estimate the effect of conflict periods on country-level HIV incidence. We specified random intercepts and slopes to account for across and within country variation over time. We also conducted a sub-analysis of countries who experienced conflict to assess the effect of conflict intensity on country-level HIV incidence. All models controlled for level of economic development, number of refugees present in the country, and year. RESULTS: We found that, compared to times of peace, the HIV incidence rate increased by 2.1 per 1000 infections per year (95%CI: 0.39, 3.87) in the 5 years prior to conflict. Additionally, we found a decrease of 0.7 new infections per 1000 people per year (95%CI: -1.44, -0.01) in conflicts with 25 to 1000 battle-related deaths and a decrease of 1.5 new infections per 1000 people per year (95%CI:-2.50, -0.52) for conflict with more than 1000 battle-related deaths, compared to conflicts with less than 25 battle-related deaths. CONCLUSIONS: Our results demonstrate that HIV infection rates increase in the years immediately prior to times of conflict; however, we did not identify a significant increase during and immediately following periods of violent conflict. Further investigation, including more rigorous data collection, is needed, as is increased aid to nations at risk of violent conflict to help in the fight against HIV/AIDS in sub-Saharan Africa. Language: en

There is a relationship between schistosomiasis and anemia, although the magnitude and exact mechanisms involved are unclear. In a cohort of 580 Schistosoma japonicum -infected 7- to 30-year-old patients from Leyte, The Philippines, we evaluated the impact of reinfection with S. japonicum after treatment with praziquantel on the mean hemoglobin level, iron-deficiency (IDA) and non-iron-deficiency anemia (NIDA), and inflammatory markers. All participants were treated at baseline and followed up every 3 months for a total of 18 months. At each follow-up, participants provided stools to quantify reinfection and venous blood samples for hemograms and measures of iron status and inflammation. After 18 months, reinfection with S. japonicum was associated with a lower mean hemoglobin level (−0.39 g/dl; 95% confidence interval [95% CI], −0.63 to −0.16) and 1.70 (95% CI, 1.10 to 2.61) times higher odds of all-cause anemia than those without reinfection. Reinfection was associated with IDA for high reinfection intensities only. Conversely, reinfection was associated with NIDA for all infection intensities. Reinfection was associated with serum interleukin-6 responses ( P < 0.01), and these responses were associated with NIDA ( P = 0.019) but not with IDA ( P = 0.29). Our results provide strong evidence for the causal relationship between S. japonicum infection and anemia. Rapidly reinfected individuals did not have the positive treatment effect on hemoglobin seen in nonreinfected individuals. The principle mechanism involved in S. japonicum -associated anemia is that of proinflammatory cytokine-mediated anemia, with iron deficiency playing a role in high-intensity infections. Based on the proposed mechanism, anemia is unlikely to be ameliorated by iron therapy alone.