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South Asians have the highest rates of premature atherosclerotic cardiovascular disease amongst all ethnic groups in the world; however this risk cannot be fully explained by traditional risk factors. Participants from the Mediators of Atherosclerosis in South Asians Living in America Study were included in this cross-sectional analysis. The purpose of this study was to investigate the association of psychosocial factors (including anger, anxiety, depressive symptoms, current and chronic stress, and everyday hassles) with carotid intima-media thickness (CIMT). Three multivariate models were examined to evaluate the association between the psychosocial factors and CIMT. Findings suggest that the impact of psychosocial factors on subclinical atherosclerosis is differential for South Asian men and women. For men, anxiety and depression were associated; while for women, stress was associated with common carotid intima media thickness, independent of traditional CVD risk factors, diet and physical activity.

Purpose: The purpose of this study was to explore how adults with prediabetes perceive their risk of developing diabetes and examine their preferences for evidence-based treatment options to prevent diabetes., Methods: A qualitative study was conducted in 2 large Midwest primary care practices, involving in-depth semistructured interviews with 35 adult patients with prediabetes., Results: This ethnically diverse (77% nonwhite) sample of middle-aged primary care patients exhibited multiple diabetes risk factors. Knowledge gaps about prediabetes and its medical management were pervasive. Most patients overestimated the risk of developing diabetes and were not familiar with evidence-based treatment options for prediabetes. They suggested that receiving brief, yet specific information about these topics during the study interview motivated them to act. The majority of participants considered both intensive lifestyle intervention and metformin acceptable treatment options. Many preferred initial treatment with intensive lifestyle intervention but would take metformin if their efforts at lifestyle change failed and their primary care physician recommended it. Some participants expressed wanting to combine both treatments., Conclusions: This qualitative study highlights potential opportunities to promote patient-centered dialogue about prediabetes in primary care settings. Providing patients specific information about the risk of developing diabetes and evidence-based treatment options to prevent or delay its onset may encourage action. Physicians' prediabetes counseling efforts should be informed by the finding that most patients consider both intensive lifestyle intervention and metformin acceptable treatment options., Competing Interests: Dr Kandula received salary support from the American Medical Association that was not related to her participation in this study. The other authors have no potential conflicts of interest., (© 2016 The Author(s).)

Introduction There are few examples of effective cardiovascular disease prevention interventions for South Asians (SAs). We describe the results of a process evaluation of the South Asian Heart Lifestyle Intervention for medically underserved SAs implemented at a community-based organization (CBO) using community-based participatory research methods and a randomized control design (n = 63). Method Interviews were conducted with 23 intervention participants and 5 study staff using a semistructured interview guide focused on participant and staff perceptions about the intervention's feasibility and efficacy. Data were thematically analyzed. Results Intervention success was attributed to trusted CBO setting, culturally concordant study staff, and culturally tailored experiential activities. Participants said that these activities helped increase knowledge and behavior change. Some participants, especially men, found that self-monitoring with pedometers helped motivate increased physical activity. Participants said that the intervention could be strengthened by greater family involvement and by providing women-only exercise classes. Staff identified the need to reduce participant burden due to multicomponent intervention and agreed that the CBO needed greater financial resources to address participant barriers. Conclusion Community-based delivery and cultural adaptation of an evidence-based lifestyle intervention were effective and essential components for reaching and retaining medically underserved SAs in a cardiovascular disease prevention intervention study., (© 2016 Society for Public Health Education.)

Competing Interests: Compliance with ethical standards Conflicts of interest The author has no conflicts of interest with this article.

The South Asian (SA) population has been underrepresented in research linking discrimination with health indicators; studies that focus on the unique cultural and psychosocial experiences of different SA subgroups are needed. The purpose of this study was to examine associations between self-reported discrimination and mental health among Asian Indians (AIs), and whether traditional cultural beliefs (believing that South Asian cultural traditions should be practiced in the US), coping style, and social support moderated these relationships. Asian Indians ( N = 733) had been recruited from community-based sampling frames for the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study were included in this analysis. Multiple linear regression analyses were employed to evaluate relationships between discrimination and depressive symptoms, anger, and anxiety. Participants (men = 54%) were on average 55 years of age and had high levels of English proficiency, education, and income. Higher reports of discrimination were significantly associated with higher depressive symptoms, B = .27 (.05) p < .001, anger, B = .08 (.01), p < .001, and anxiety, B = .10 (.01), p < .001. Associations between discrimination and anger, B = -.005 (.002), p = .02, were weakest among those with stronger cultural beliefs. The link between discrimination and anxiety was attenuated by an active coping style, B = -.05 (.03), p = .04. In sum, self-reported discrimination appeared to adversely impact the mental health of AIs. Discrimination may be better coped with by having strong traditional cultural beliefs and actively managing experiences of discrimination.

Purpose: South Asians (Indians, Pakistanis, Bangladeshis, Sri Lankans, Nepalis, and Bhutanese) in the United States have a very high prevalence of type 2 diabetes mellitus (DM). This pilot study evaluated a culturally-tailored exercise intervention among South Asian immigrant mothers with DM risk factors., Methods: Through an academic-community partnership, South Asian women with risk factors for DM and who had at least one child between 6-14 years were enrolled into this single-arm study. The intervention for the mothers included 16-weeks of twice weekly exercise classes, self-monitoring with activity trackers, goal-setting, and classes on healthy eating. Based on prior community-based participatory research, children were offered exercise classes during the mothers' classes. The primary efficacy outcomes were change in mothers' moderate/vigorous physical activity and body weight pre- and post-intervention (16-weeks). Program adherence, clinical, and psychosocial outcomes were measured. A qualitative process evaluation was conducted to understand participant perspectives., Results: Participants' (n=30) average age was 40 (SD=5) years., 57% had a high school education or less, and all were overweight/obese.. At baseline, women were not meeting recommended physical activity guidelines. Overall, participants attended 75% of exercise classes. Compared to baseline, participants' weight decreased by 3.2 lbs. (95% CI: -5.5, -1.0) post-intervention. Among women who attended at least 80% of classes (n=17), weight change was -4.8 lbs, (95% CI: -7.7, -1.9). Change in accelerometer-measured physical activity was not significant; however exercise-related confidence increased from baseline (p-value <0.01). Women described multiple physical and psychosocial benefits from the intervention., Conclusion: This pilot study suggests that a culturally-tailored exercise intervention that included exercise classes for children was feasible and had physical and psychosocial benefits in South Asian mothers with risk factors for DM.

Background: A key challenge for longitudinal cohort studies is follow-up and retention of study participants. Participant follow-up in longitudinal cohort studies is costly and time-consuming for research staff and participants., Objective: This study determined the feasibility and costs of using Web-based technologies for follow-up and collection of patient-reported outcomes in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study., Methods: The MASALA study is a community-based cohort of 906 South Asians in the United States. Since the baseline in-person visits (2010-2013), a yearly telephone follow-up survey was used to assess participants' health status and incidence of cardiovascular disease. A Web-based version of the follow-up survey was developed using the REDCap (Research Electronic Data Capture) Web app. Participants from the Chicago field center who were due for their annual follow-up and who had a valid email address were sent an email link to a secure online portal where they could complete the survey. Telephone follow-up was used with nonresponders., Results: A link to the Web survey was emailed to 285 participants (February to October 2014) and the overall completion rate was 47.7% (136/285). One-third of participants who were unresponsive (n=36) to annual telephone follow-up completed the Web survey. Web responders were younger, more likely to be married, and to have higher education and income compared (P<.05) to telephone-only responders. Web survey development involved 240 hours of research staff time. Since launching, the Web-based survey has required 3 hours per week of staff time., Conclusions: Although electronic follow-up will not be a panacea for cohort operations, it will serve as an adjunctive strategy to telephonic follow-up for maximizing cohort retention with lower costs.

Type 2 diabetes is a major public health problem in the USA, affecting over 12 % of American adults and imposing considerable health and economic burden on individuals and society. There is a strong evidence base demonstrating that lifestyle behavioral changes and some medications can prevent or delay the onset of type 2 diabetes in high risk adults, and several policy and healthcare system changes motivated by the Patient Protection and Affordable Care Act (ACA) have the potential to accelerate diabetes prevention. In this narrative review, we (1) offer a conceptual framework for organizing how the ACA may influence diabetes prevention efforts at the level of individuals, healthcare providers, and health systems; (2) highlight ACA provisions at each of these levels that could accelerate type 2 diabetes prevention nationwide; and (3) explore possible policy gaps and opportunity areas for future research and action., Competing Interests: Compliance with Ethics Guidelines Conflict of Interest Namratha Kandula discloses that she receives salary support from the American Medical Association and honoraria from Patient-Centered Outcomes Research Institute for serving as a grant reviewer. Juleigh Nowinski Konchak, Margaret Moran, Matthew O’Brien, and Ronald Ackermann declare that they have nothing to disclose. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

Background: The neighborhood built environment can have a strong influence on physical activity levels, particularly walking for transport. In examining racial/ethnic differences in physical activity, one important and understudied group is South Asians. This study aims to describe the association between neighborhood walkability and walking for transport among South Asian men and women in the United States in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study., Methods: A cross-sectional study was conducted in 2014 using the baseline dataset of the MASALA study (N = 906). Mean age was 55 years old and 54% of the sample was male. Weekly minutes spent walking for transport was assessed using a questionnaire adapted from the Cross-Cultural Activity Participation Study. Neighborhood walkability was measured using Walk Score, a composite index of walkability., Results: After adjusting for covariates, with each 10-point increase in Walk Score, South Asian American men engaged in 13 additional minutes per week of walking for transport (P = .008). No association was observed between walkability and walking for transport in South Asian American women., Conclusions: Results provide new evidence for how the effects of environmental influences on walking for transport may vary between South Asian men and women.

Background: Small studies have shown that South Asians (SAs) have more total body, subcutaneous, visceral and hepatic fat and abnormal adipokine levels compared with Whites. However, comprehensive studies of body composition and adipokines in SAs compared with other ethnic groups are lacking., Methods: Using harmonized data, we performed a cross-sectional analysis of two community-based cohorts: Mediators of Atherosclerosis of South Asians Living in America (MASALA, n=906) and Multi-Ethnic Study of Atherosclerosis (MESA which included 2622 Whites, 803 Chinese Americans, 1893 African Americans and 1496 Latinos). General linear models were developed to assess the ethnic differences in ectopic fat (visceral, intermuscular and pericardial fat; and hepatic attenuation), lean muscle mass and adipokines (adiponectin and resistin). Models were adjusted for age, sex, site, alcohol use, smoking, exercise, education, household income and body mass index. Ectopic fat models were additionally adjusted for hypertension, diabetes, high-density lipoprotein and triglycerides. Adipokine models were adjusted for subcutaneous, visceral, intermuscular and pericardial fat; and hepatic attenuation., Results: Compared with all ethnic groups in MESA (Whites, Chinese Americans, African Americans and Latinos), SAs had greater intermuscular fat (pairwise comparisons with each MESA group, P<0.01), lower hepatic attenuation (P<0.001) and less lean mass (P<0.001). SAs had greater visceral fat compared with Chinese Americans, African Americans and Latinos (P<0.05) and greater pericardial fat compared with African Americans (P<0.001). SAs had lower adiponectin levels compared with other ethnic groups (P<0.01; except Chinese Americans) and higher resistin levels than all groups (P<0.001), even after adjusting for differences in body composition., Conclusion: There are significant ethnic differences in ectopic fat, lean mass and adipokines. A less favorable body composition and adipokine profile in SAs may partially explain the increased predisposition to cardiometabolic disease. The mechanisms that underlie these differences warrant further investigation.

Objective: To examine whether nutrient and food intakes among South Asian adult immigrants differ by length of residence in the USA., Design: Cross-sectional analysis to examine differences in nutrient and food intakes by length of residence in the USA. Dietary data were collected using an interviewer-administered, culturally appropriate FFQ, while self-reported length of residence was assessed using a questionnaire and modelled as tertiles., Setting: The Mediators of Atherosclerosis in South Asians Living in America (MASALA) study., Subjects: Eight hundred and seventy-four South Asians (mean age=55 (sd 9) years; 47 % women; range of length of residence in the USA=2-58 years), part of the baseline examination of the MASALA study., Results: Intakes of fat, including saturated and trans fats, dietary cholesterol and n-6 fatty acids, were directly associated with length of residence, while intakes of energy, carbohydrate, glycaemic index and load, protein, dietary fibre, folate and K were inversely associated with length of residence (P trend <0·05). A longer length of residence in the USA was also associated with higher intakes of alcoholic beverages, mixed dishes including pizza and pasta, fats and oils, and lower intakes of beans and lentils, breads, grains and flour products, milk and dairy products, rice, starchy vegetables and sugar, candy and jam (P for differences across groups <0·05)., Conclusions: Length of residence in the USA influences diet and nutrient intakes among South Asian adult immigrants and should be considered when investigating and planning dietary interventions to mitigate chronic disease risk.

Background: Many eligible primary cardiovascular disease prevention candidates are not treated with statins. Electronic health record data can identify patients with increased cardiovascular disease risk., Methods and Results: We performed a pragmatic randomized controlled trial at community health centers in 2 states. Participants were men aged ≥35 years and women ≥45 years, without cardiovascular disease or diabetes mellitus, and with a 10-year risk of coronary heart disease of at least 10%. The intervention group received telephone and mailed outreach, individualized based on patients' cardiovascular disease risk and uncontrolled risk factors, provided by lay health workers. Main outcomes included: documented discussion of medication treatment for cholesterol with a primary care clinician, receipt of statin prescription within 6 months, and low-density lipoprotein (LDL)-cholesterol repeated and at least 30 mg/dL lower than baseline within 1 year. Six hundred forty-six participants (328 and 318 in the intervention and control groups, respectively) were included. At 6 months, 26.8% of intervention and 11.6% of control patients had discussed cholesterol treatment with a primary care clinician (odds ratio, 2.79; [95% confidence interval, 2.25-3.46]). Statin prescribing occurred for 10.1% in the intervention group and 6.0% in the control group (odds ratio, 1.76; [95% confidence interval, 0.90-3.45]). The cholesterol outcome did not differ, and the majority of patients did not repeat lipid levels during follow-up., Conclusions: Risk communication and lay outreach increased cholesterol treatment discussions with primary care clinicians. However, most discussions did not result in statin prescribing. For outreach to be successful, it should be combined with interventions to encourage clinicians to follow contemporary risk-based cholesterol treatment guidelines., Clinical Trial Registration: URL: http://www.clincialtrials.gov. Unique identifier: NCT01610609., (© 2015 American Heart Association, Inc.)

Background: South Asians (Asian Indians and Pakistanis) are the second fastest growing ethnic group in the United States (U.S.) and have an increased risk of atherosclerotic cardiovascular disease (ASCVD). This pilot study evaluated a culturally-salient, community-based healthy lifestyle intervention to reduce ASCVD risk among South Asians., Methods: Through an academic-community partnership, medically underserved South Asian immigrants at risk for ASCVD were randomized into the South Asian Heart Lifestyle Intervention (SAHELI) study. The intervention group attended 6 interactive group classes focused on increasing physical activity, healthful diet, weight, and stress management. They also received follow-up telephone support calls. The control group received translated print education materials about ASCVD and healthy behaviors. Primary outcomes were feasibility and initial efficacy, measured as change in moderate/vigorous physical activity and dietary saturated fat intake at 3- and 6-months. Secondary clinical and psychosocial outcomes were also measured., Results: Participants' (n = 63) average age was 50 (SD = 8) years, 63 % were female, 27 % had less than or equal to a high school education, one-third were limited English proficient, and mean BMI was 30 kg/m2 (SD ± 5). There were no significant differences in change in physical activity or saturated fat intake between the intervention and control group. Compared to the control group, the intervention group showed significant weight loss (-1.5 kg, p-value = 0.04) and had a greater sex-adjusted decrease in hemoglobin A1C (-0.43 %, p-value <0.01) at 6 months. Study retention was 100 %., Conclusions: This pilot study suggests that a culturally-salient, community-based lifestyle intervention was feasible for engaging medically underserved South Asian immigrants and more effective at addressing ASCVD risk factors than print health education materials., Trial Registration: NCT01647438, Date of Trial Registration: July 19, 2012.

Purpose: We examined whether living in neighborhoods supportive of healthier diets and more active lifestyles may buffer immigrants against the unhealthy weight gain that is purported to occur with longer length of US residence., Methods: Neighborhood data referring to a 1-mile buffer around participants' baseline home addresses were linked to longitudinal data from 877 Hispanic and 684 Chinese immigrants aged 45 to 84 years in the Multi-Ethnic Study of Atherosclerosis. We used ethnicity-stratified linear mixed models to examine whether food and activity-based neighborhood measures (healthy food stores, walkability, and recreational facilities) were associated with change in waist circumference (WC) over a 9-year follow-up., Results: Among Hispanics, living in neighborhoods with more resources for healthy food and recreational activity was related to lower baseline WC. However, there was no association with change in WC over time. Among Chinese, living in more walkable neighborhoods was associated with lower baseline WC and with slower increases in WC over time, especially among the most recent immigrant arrivals., Conclusions: Where immigrants reside may have implications for health patterns that emerge with longer time in the United States., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To assess the prevalence of diabetes and prediabetes and the associated risk factors in two Asian Indian populations living in different environments., Research Design and Methods: We performed cross-sectional analyses, using representative samples of 2,305 Asian Indians aged 40-84 years living in Chennai, India, from the Centre for cArdiometabolic Risk Reduction in South-Asia study (CARRS) (2010-2011), and 757 Asian Indians aged 40-84 years living in the greater San Francisco and Chicago areas from the U.S. Mediators of Atherosclerosis in South Asians Living in America (MASALA) study (2010-2013). Diabetes was defined as self-reported use of glucose-lowering medication, fasting glucose ≥126 mg/dL, or 2-h glucose ≥200 mg/dL. Prediabetes was defined as fasting glucose 100-125 mg/dL and/or 2-h glucose 140-199 mg/dL., Results: Age-adjusted diabetes prevalence was higher in India (38% [95% CI 36-40]) than in the U.S. (24% [95% CI 21-27]). Age-adjusted prediabetes prevalence was lower in India (24% [95% CI 22-26]) than in the U.S. (33% [95% CI 30-36]). After adjustment for age, sex, waist circumference, and systolic blood pressure, living in the U.S. was associated with an increased odds for prediabetes (odds ratio 1.2 [95% CI 0.9-1.5]) and a decreased odds for diabetes (odds ratio 0.5 [95% CI 0.4-0.6])., Conclusions: These findings indicate possible changes in the relationship between migration and diabetes risk and highlight the growing burden of disease in urban India. Additionally, these results call for longitudinal studies to better identify the gene-environment-lifestyle exposures that underlie the elevated risk for type 2 diabetes development in Asian Indians., (© 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Background: South Asians are at high risk of metabolic syndrome, and dietary patterns may influence this risk., Objectives: We aimed to determine prevalent dietary patterns for South Asians in the United States and their associations with risk factors for metabolic syndrome., Methods: South Asians aged 40-84 y without known cardiovascular disease were enrolled in a community-based cohort called Mediators of Atherosclerosis in South Asians Living in America. A validated food frequency questionnaire and serum samples for fasting and 2-h glucose, insulin, glycated hemoglobin, triglycerides, and total and HDL cholesterol were collected cross-sectionally. We used principal component analysis with varimax rotation to determine dietary patterns, and sequential linear and logistic regression models for associations with metabolic factors., Results: A total of 892 participants were included (47% women). We identified 3 major dietary patterns: animal protein; fried snacks, sweets, and high-fat dairy; and fruits, vegetables, nuts, and legumes. These were analyzed by tertile of factor score. The highest vs. the lowest tertile of the fried snacks, sweets, and high-fat dairy pattern was associated with higher homeostasis model assessment of insulin resistance (HOMA-IR) (β: 1.88 mmol/L ⋅ uIU/L) and lower HDL cholesterol (β: -4.48 mg/dL) in a model adjusted for age, sex, study site, and caloric intake (P < 0.05). The animal protein pattern was associated with higher body mass index (β: 0.73 m/kg(2)), waist circumference (β: 0.84 cm), total cholesterol (β: 8.16 mg/dL), and LDL cholesterol (β: 5.69 mg/dL) (all P < 0.05). The fruits, vegetables, nuts, and legumes pattern was associated with lower odds of hypertension (OR: 0.63) and metabolic syndrome (OR: 0.53), and lower HOMA-IR (β: 1.95 mmol/L ⋅ uIU/L) (P < 0.05)., Conclusions: The animal protein and the fried snacks, sweets, and high-fat dairy patterns were associated with adverse metabolic risk factors in South Asians in the United States, whereas the fruits, vegetables, nuts, and legumes pattern was linked with a decreased prevalence of hypertension and metabolic syndrome., (© 2015 American Society for Nutrition.)

South Asians, the second fastest growing racial/ethnic minority in the United States, have high rates of coronary heart disease. Few coronary heart disease prevention efforts target this population. The authors developed and tested a culture-specific, multimedia coronary heart disease prevention education program in English and Hindi for South Asians. Participants were recruited from community organizations in Chicago, Illinois, between June and October of 2011. Bilingual interviewers used questionnaires to assess participants' knowledge and perceptions before and after the patient education program. The change from pretest score to posttest score was calculated using a paired t test. Linear regression was used to determine the association between posttest scores and education and language. Participants' (N = 112) average age was 41 years, 67% had more than a high school education, and 50% spoke Hindi. Participants' mean pretest score was 15 (SD = 4). After the patient education program, posttest scores increased significantly among all participants (posttest score = 24, SD = 4), including those with limited English proficiency. Lower education was associated with a lower posttest score (β = -2.2, 95% CI [-0.68, -3.83]) in adjusted regression. A culture-specific, multimedia patient education program significantly improved knowledge and perceptions about coronary heart disease prevention among South Asian immigrants. Culturally salient multimedia education may be an effective and engaging way to deliver health information to diverse patient populations.

Purpose: South Asian (SA) women in the United States report extremely low rates of leisure time physical activity (PA) compared with women in other ethnic minority groups. This study explored SA women's perspectives on PA during different life stages., Design: This is a community-based participatory research study that used focus groups., Setting: The study setting was a community-based organization that provides social services to SA immigrants in Chicago, Illinois., Participants: The study team conducted six focus groups (in English and Hindi) with 42 SA women, ages 18 to 71 years., Method: A semistructured interview guide was used to foster discussion about perceptions of, barriers to/facilitators of, and suggestions for PA programs. Discussions were transcribed and independently coded by two reviewers using thematic content analysis and guided by a coding scheme that was developed a priori., Results: Participants said that different life stages strongly influenced their PA. PA decreased after marriage and having children. Chronic diseases constrained older women from more vigorous PA. Barriers to PA among younger women were family disapproval and perceptions that PA is unnecessary if you are "skinny." Women agreed that PA is not a priority within the culture, and that interventions must take into account cultural, religious, and family context., Conclusion: Sociocultural norms, family constraints, and lack of awareness about the benefits of PA strongly influenced PA among SA women. Culturally salient intervention strategies might include programs in trusted community settings where women can exercise in women-only classes with their children, and targeted education campaigns to increase awareness about the benefits of PA across life stages.

Background: Ten-year and lifetime cardiovascular risk assessment algorithms have been adopted into atherosclerotic cardiovascular disease (ASCVD) prevention guidelines, but these prediction models are not based on South Asian populations and may underestimate the risk in Indians, Pakistanis, Bangladeshis, Nepali, and Sri Lankans in the United States. Little is known about ASCVD risk prediction and intermediate endpoints such as subclinical atherosclerosis in US individuals of South Asian ancestry., Methods and Results: South Asians (n=893) from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study who were 40 to 79 years and free of ASCVD were included. Ten-year ASCVD predicted risk was calculated using the 2013 Pooled Cohort Equations. Lifetime predicted risk was based on risk factor burden. Baseline levels of subclinical atherosclerosis (coronary artery calcium [CAC] and carotid intima media thickness [CIMT]) were compared across 10-year and lifetime risk strata: (1) high (≥7.5%) 10-year and low (<7.5%) 10-year risk; (2) high (≥39%) lifetime and low (<39%) lifetime risk. South Asian men and women with high 10-year predicted risk had a significantly greater CAC burden than those with low 10-year risk. South Asians with high lifetime predicted risk had a significantly increased odds for CAC higher than 0 (odds ratio: men 1.97; 95% CI, 1.2 to 3.2; women 3.14; 95% CI, 1.5, 6.6). Associations between risk strata and CIMT were also present., Conclusion: This study is the first to provide evidence that contemporary ASCVD risk assessment algorithms derived from non-Hispanic white and African-American samples can successfully identify substantial differences in atherosclerotic burden in US South Asians., (© 2014 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Objective: Longer duration of residence among immigrants to the United States, a proxy measure of acculturation, has been associated with higher subclinical atherosclerosis. South Asian immigrants are the second fastest growing immigrant group in the U.S. but little is known about the effects of acculturation with atherosclerosis in this high cardiovascular risk population., Methods: We conducted a cross-sectional analysis using data from a community-based cohort called the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Participants (n=900) were between ages of 40-84 years and had no existing cardiovascular disease. We developed a multi-dimensional measure of acculturation in South Asians, called traditional cultural beliefs, and measured other proxy measures of acculturation to determine whether they were associated with higher levels of subclinical atherosclerosis after controlling for socioeconomic, behavior/lifestyle, and cardiovascular risk factors., Results: Mean duration of residence in the U.S. was 27±11 years and tertiles of strength of traditional cultural beliefs were examined. Longer duration of U.S. residence was associated with higher levels of coronary artery calcium even after adjustment for covariates and lifestyle mediators. The novel measure of strength of traditional cultural beliefs was associated with lower common carotid intima media thickness among those with moderate traditional beliefs only., Conclusions: These findings support the need for better conceptualization and measurement of how migration influences cultural beliefs and practices, and their subsequent influence on health behaviors and cardiovascular disease risk.

Objective: We compared South Asians with four other racial/ethnic groups in the U.S. to determine whether sociodemographic, lifestyle, or metabolic factors could explain the higher diabetes prevalence and whether insulin resistance and β-cell dysfunction occurred at younger ages and/or lower adiposity levels compared with other groups., Research Design and Methods: We performed a cross-sectional analysis of two community-based cohorts, the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study and the Multi-Ethnic Study of Atherosclerosis (MESA); all participants had no known cardiovascular disease and were between 44 and 84 years of age. We compared 799 South Asians with 2,611 whites, 1,879 African Americans, 1,493 Latinos, and 801 Chinese Americans. Type 2 diabetes was classified by fasting plasma glucose ≥126 mg/dL or use of a diabetes medication. Insulin resistance was estimated by the homeostasis model assessment (HOMA) and β-cell function was measured by the HOMA-β model., Results: South Asians had significantly higher age-adjusted prevalence of diabetes (23%) than the MESA ethnic groups (6% in whites, 18% in African Americans, 17% in Latinos, and 13% in Chinese Americans). This difference increased further after adjustment for potential confounders. HOMA of insulin resistance (HOMA-IR) levels were significantly higher and HOMA-β levels were lower among South Asians compared with all other racial/ethnic groups after adjustment for age and adiposity., Conclusions: The higher prevalence of diabetes in South Asians is not explained by traditionally measured risk factors. South Asians may have lower β-cell function and an inability to compensate adequately for higher glucose levels from insulin resistance., (© 2014 by the American Diabetes Association.)

Objectives: South Asians (individuals from India, Pakistan, Bangladesh, Nepal, and Sri Lanka) have high rates of cardiovascular disease which cannot be explained by traditional risk factors. Few studies have examined coronary artery calcium (CAC) in South Asians., Methods: We created a community-based cohort of South Asians in the United States and compared the prevalence and distribution of CAC to four racial/ethnic groups in the Multi-Ethnic Study of Atherosclerosis (MESA). We compared 803 asymptomatic South Asians free of cardiovascular disease to the four MESA racial/ethnic groups (2622 Whites, 1893 African Americans, 1496 Latinos and 803 Chinese Americans)., Results: The age-adjusted prevalence of any CAC was similar between White and South Asian men, but was lower in South Asian women compared to White women. After adjusting for all covariates associated with CAC, South Asian men were similar to White men and had higher CAC scores compared to African Americans, Latinos and Chinese Americans. In fully adjusted models, CAC scores were similar for South Asian women compared to all women enrolled in MESA. However, South Asian women ≥70 years had a higher prevalence of any CAC than most other racial/ethnic groups., Conclusions: South Asian men have similarly high CAC burden as White men, but higher CAC than other racial/ethnic groups. South Asian women appear to have similar CAC burden compared to other women, but have somewhat higher CAC burden in older age. The high burden of subclinical coronary atherosclerosis in South Asians may partly explain higher rates of cardiovascular disease in South Asians., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Dietary patterns contribute to cardiovascular disease (CVD) risk. Asian Indians have earlier onset, more severe, and more prevalent CVD than many other racial/ethnic groups. We aimed to characterize dietary patterns in Asian Indians living in the United States and examine associations with cardiometabolic risk factors. One hundred fifty Asian Indians, aged 45 to 84 years, without known CVD, living in the San Francisco Bay, CA, area between August 2006 and October 2007 were enrolled into the Metabolic syndrome and Atherosclerosis in South Asians Living in America study. A food frequency questionnaire validated in Asian Indians, fasting blood samples, and computed tomography scans were obtained for all participants. Principal component analysis with varimax rotation was used to determine prevalent dietary patterns. Linear regression analyses were performed for associations between dietary patterns and metabolic factors, adjusting initially for age and sex, then additionally for BMI, income, education, metabolic equivalent of task-minutes of exercise, alcohol consumption, and smoking. Two distinct dietary patterns were identified that we termed "Western," and "Vegetarian." Compared with the Western diet, the Vegetarian diet was associated with lower homeostasis model of assessment-insulin resistance (-1.12 mmol/L × mU/L; P=0.05) and lower high-density lipoprotein cholesterol (-4.77 mg/dL; P=0.09). Given that the Western and Vegetarian dietary patterns were each associated with adverse metabolic changes, healthful diet choices may help Asian Indians improve risk factors for CVD., (Copyright © 2014 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Disseminating and implementing evidence-based, cardiovascular disease (CVD) prevention lifestyle interventions in community settings and in ethnic minority populations is a challenge. We describe the design and methods for the South Asian Heart Lifestyle Intervention (SAHELI) study, a pilot study designed to determine the feasibility and initial efficacy of a culturally-targeted, community-based lifestyle intervention to improve physical activity and diet behaviors among medically underserved South Asians (SAs). Participants with at least one CVD risk factor will be randomized to either a lifestyle intervention or a control group. Participants in both groups will be screened in a community setting and receive a primary care referral after randomization. Intervention participants will receive 6weeks of group classes, followed by 12weeks of individual telephone support where they will be encouraged to initiate and maintain a healthy lifestyle goal. Control participants will receive their screening results and monthly mailings on CVD prevention. Primary outcomes will be changes in moderate/vigorous physical activity and saturated fat intake between baseline, 3-, and 6-month follow-up. Secondary outcomes will be changes in weight, clinical risk factors, primary care visits, self-efficacy, and social support. This study will be one of the first to pilot-test a lifestyle intervention for SAs, one of the fastest growing racial/ethnic groups in the U.S. and one with disparate CVD risk. Results of this pilot study will provide preliminary data about the efficacy of a lifestyle intervention on CVD risk in SAs and inform community-engaged CVD prevention efforts in an increasingly diverse U.S. population., (© 2013.)

Objective: US birth and longer length of US residence among the foreign-born have been linked to higher anthropometric measures. However, previous studies have been cross sectional and few have examined heterogeneity by ethnic group. Cross-sectional findings that show immigrant weight converging to US-born levels with longer time in the United States imply that immigrants' weight is increasing at a faster rate relative to US-born individuals. Prospective studies are necessary to confirm this pattern., Design and Methods: Using longitudinal data from 1,486 Hispanic and 802 Chinese adults aged 45-84 years in the Multi-ethnic Study of Atherosclerosis, we examined whether foreign-born participants experienced greater increases in BMI and waist circumference (WC) than the US-born over a median follow-up of 5 years. We also investigated heterogeneity in these associations by Hispanic subgroup., Results: Among Hispanics and Chinese, the foreign-born had a lower adjusted mean BMI and WC at baseline than the US-born, but there were no significant differences in BMI or WC change over time. There was heterogeneity by Hispanic subgroup: despite small baseline nativity differences in WC, foreign-born Mexican Hispanics had a greater annual mean increase in WC over time compared to US-born Mexican Hispanics (mean difference in annual change = 0.28 cm, P = 0.03). There were no nativity differences in the rate of WC increase over time among non-Mexican Hispanics. Foreign-born Mexican Hispanics also experienced a faster rate of WC increase compared to foreign-born non-Mexican Hispanics (mean difference in annual change = 0.24 cm, P = 0.01)., Conclusions: Longer time in the United States, examined prospectively, may only be linked to adverse anthropometric changes in some immigrant groups., (Copyright © 2013 The Obesity Society.)

Objective: This study investigated South Asians' explanatory models (EM) of CHD and compared them to the biomedical model as part of an effort to inform the development of culturally targeted CHD prevention messages., Methods: We conducted in-depth, semi-structured interviews in English, Hindi and Urdu with 75 respondents from a federally qualified health center and at a community center for South Asian immigrants in Chicago, Illinois., Results: While EMs of CHD included risk factors from the biomedical model, they also included psychosocial and spiritual risk factors. Respondents emphasized that stress causes CHD and suggested that CHD was caused by sudden or inexplicable factors. Few respondents discussed cholesterol, blood pressure, or diabetes as part of CHD prevention. Women and those with lower education had low perceptions of being at-risk for CHD., Conclusion: South Asians' EMs of CHD encompassed the biomedical model; however, EMs also included psychosocial and spiritual factors., Practice Implications: Clinicians and health educators should be aware that South Asian individual's EM of CHD may include psychosocial and spiritual factors which can affect CHD prevention behaviors., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

To identify concepts of health and disease as part of a study on designing culturally-targeted heart disease prevention messages for South Asians. We conducted qualitative, semi-structured interviews in English, Hindi and Urdu with 75 respondents from a federally qualified health center and at a community center for South Asian immigrants in Chicago, Illinois. Age ranged from 20 to 70 years; 60% were women; 60% held advanced degrees; 70% migrated to the US in the last 10 years; and 60% of the interviews were in Hindi or Urdu. Concepts of health and disease fell into four domains: behavioral, physical, psycho-social and spiritual. Muslim participants consistently evoked spiritual factors such as faith and prayer. Women more frequently included performing home duties and positive affect in their concept of health. Men more frequently cited behavioral factors such as smoking and drinking as the cause of disease. Many South Asians have a holistic conceptualization of health and disease, incorporating spiritual, physical and psycho-social factors. Health promotion strategies aimed at South Asians in the US should take into account this holistic model of health and disease, while also recognizing that variations exist within South Asians, by gender and religion.

Few studies have examined the effectiveness of teaching strategies to improve patients' recall and retention of information. As a next step in implementing a literacy-appropriate, multimedia diabetes education program (MDEP), the present study reports the results of two experiments designed to answer (a) how much knowledge is retained 2 weeks after viewing the MDEP, (b) does knowledge retention differ across literacy levels, and (c) does adding a teach-back protocol after the MDEP improve knowledge retention at 2-weeks' follow-up? In Experiment 1, adult primary care patients (n = 113) watched the MDEP and answered knowledge-based questions about diabetes before and after viewing the MDEP. Two weeks later, participants completed the knowledge assessment a third time. Methods and procedures for Experiment 2 (n = 58) were exactly the same, except that if participants answered a question incorrectly after watching the MDEP, they received teach-back, wherein the information was reviewed and the question was asked again, up to two times. Two weeks later, Experiment 2 participants completed the knowledge assessment again. Literacy was measured using the S-TOFHLA. After 2 weeks, all participants, regardless of their literacy levels, forgot approximately half the new information they had learned from the MDEP. In regression models, adding a teach-back protocol did not improve knowledge retention among participants and literacy was not associated with knowledge retention at 2 weeks. Health education interventions must incorporate strategies that can improve retention of health information and actively engage patients in long-term learning.

Background: Although South Asians are at higher risk for coronary heart disease (CHD) than most other U.S. racial/ethnic groups, very little research has addressed this disparity., Purpose: As a first step in developing culturally targeted CHD prevention messages for this rapidly growing community, this study examined South Asians' knowledge and beliefs about CHD., Methods: Analyses, conducted in 2009, were based on data collected from January to July 2008 in a cross-sectional study population of 270 South Asian adults in Illinois. Interviews were conducted in English, Hindi, or Urdu using a standardized questionnaire. Multivariate regression models were used to examine the associations between sociodemographics and CHD knowledge and attitudes about preventability., Results: Eighty-one percent of respondents had one or more CHD risk factors. Most participants (89%) said they knew little or nothing about CHD. Stress was the most frequently mentioned risk factor (44%). Few mentioned controlling blood pressure (11%); cholesterol (10%); and diabetes (5%) for prevention. Fifty-three percent said that heart attacks are not preventable. Low education level, being interviewed in Urdu or Hindi, and low level of acculturation were associated with less knowledge and believing that CHD is not preventable., Conclusions: A majority of South Asians in this study believed that CHD is not preventable and had low awareness of modifiable risk factors. As a first step, CHD education should target the knowledge gaps that may affect risk factor control and behavior change. Educational messages may need to be somewhat different for subgroups (e.g., by education and language) to be maximally effective., (2010 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

The growing size and changing composition of the foreign-born population in the USA highlights the importance of examining the health consequences of living in neighborhoods with higher proportions of immigrants. Using data from the Multi-ethnic Study of Atherosclerosis in four US cities, we examined whether neighborhood immigrant composition was associated with health behaviors (diet, physical activity) among Hispanic and Chinese Americans (n=1902). Secondarily we tested whether neighborhoods with high proportions of immigrants exhibited better or worse neighborhood quality, and whether these dimensions of neighborhood quality were associated with healthy behaviors. Neighborhood immigrant composition was defined based on the Census 2000 tract percent of foreign-born from Latin-America, and separately, percent foreign-born from China. After adjustment for age, gender, income, education, neighborhood poverty, and acculturation, living in a tract with a higher proportion of immigrants was associated with lower consumption of high-fat foods among Hispanics and Chinese, but with being less physically active among Hispanics. Residents in neighborhoods with higher proportions of immigrants reported better healthy food availability, but also worse walkability, fewer recreational exercise resources, worse safety, lower social cohesion, and lower neighborhood-based civic engagement. Associations of neighborhood immigrant composition with diet persisted after adjustment for reported neighborhood characteristics, and associations with physical activity were attenuated. Respondent-reported neighborhood healthy food availability, walkability, availability of exercise facilities and civic participation remained associated with behaviors after adjusting for immigrant composition and other covariates. Results show that living in an immigrant enclave is not monolithically beneficial and may have different associations with different health behaviors.

Background: Previously, we reported a high level of comfort among Californians for collecting race/ethnicity information by health care providers (HCPs). However, minorities were less comfortable providing race/ethnicity information and were more worried than non-Hispanic whites about the potential misuse of this information., Objective: To determine if perceived experiences of discrimination (both in general and in medical care) were associated with comfort providing race/ethnicity information, and conversely, to worry about providing the information., Design and Participants: Telephone survey of 480 Californians, including 101 whites, 98 Asians, 173 Hispanics, 82 blacks, and 26 multiracial individuals., Measurements: Comfort level giving HCPs information about race/ethnicity (measured on a 1-10 scale, with text anchors of "very uncomfortable" at 1 and "very comfortable" at 10), worry that the information could be used to discriminate against patients, and worry that the information could be used to find undocumented immigrants. Worry was measured using a four-point Likert scale- not worried at all, a little worried, somewhat worried, and very worried. Respondents were also asked about perceived discrimination in general and perceived discrimination in medical care., Results: Compared to whites, Hispanics (Beta-coefficient (BC) = -1.16, SE = 0.51) and Mandarin/Cantonese-speaking Asians (BC = -1.40, SE = 0.65) reported significantly less comfort giving HCPs information about their race/ethnicity, while blacks (BC = 0.70, SE = 0.16), Hispanics (BC = 0.91, SE = 0.18), and multiracial individuals (BC = 0.63, SE = 0.24) were significantly more worried that race/ethnicity information could be used to discriminate against them. Adjusting for perceived experiences of discrimination in general and in medical care partially explained the higher discomfort and worry among minorities., Conclusions: Perceived experiences of discrimination are associated with greater discomfort and worry about providing race/ethnicity data. Health care institutions should consider how they can address the public's concerns about possible misuses of data.

Objectives: To study neighborhood-level determinants of smoking among Asian Americans, we examined 3 neighborhood factors (ethnic enclave, socioeconomics, and perceived social cohesion) and smoking prevalence in a population-based sample., Methods: We linked data from the 2003 California Health Interview Survey to tract-level data from the 2000 Census. We used multivariate logistic regression models to estimate the associations between smoking and neighborhood-level factors, independent of individual factors., Results: Twenty-two percent of 1693 Asian men and 6% of 2174 Asian women reported current smoking. Women living in an Asian enclave were less likely to smoke (adjusted odds ratio [AOR] = 0.27; 95% confidence interval [CI] = 0.08, 0.88). Among men, higher levels of perceived neighborhood social cohesion were associated with lower odds of smoking (AOR = 0.74; 95% CI = 0.61, 0.91)., Conclusions: The association between contextual factors and smoking differed for men and women. For women, living in an Asian enclave may represent cultural behavioral norms. For men, neighborhood trust and cohesiveness may buffer stress. Smoking prevention and cessation interventions among Asian Americans may be more effective if they address contextual factors.

Background: The association of acculturation and cardiovascular risk factor control among populations with high proportions of immigrants has not been well studied., Methods: We studied 1,492 Hispanic participants in the Multi-Ethnic Study of Atherosclerosis (MESA) with hypertension, hypercholesterolemia, and/or diabetes. We used linear regression to examine the cross-sectional relationships between acculturation measures and cardiovascular risk factor levels. Outcome measures included systolic blood pressure (mm Hg), fasting low-density lipoprotein (LDL) cholesterol (mg/dL), and fasting blood glucose (mg/dL). Covariates included education, income, health insurance, physical activity, dietary factors, risk factor-specific medication use, duration of medication use, smoking, and body mass index., Results: There were 580 Hispanics with hypertension, 539 with hypercholesterolemia, and 248 with diabetes. After adjustment for age and gender, Spanish-speaking Hispanics with cardiovascular risk factors had higher systolic blood pressure, fasting LDL cholesterol, and fasting blood glucose compared to English-speaking Hispanics. Differences in systolic blood pressure were accounted for mainly by education, whereas differences in LDL cholesterol were almost entirely accounted for by cholesterol-lowering medication use. Differences in fasting glucose were partly accounted for by socioeconomic variables but were augmented after adjustment for dietary factors. Similar associations were observed between proportion of life in the United States and risk factor levels., Conclusions: Among those with cardiovascular risk factors, Hispanics who spoke Spanish at home and lived less time in the United States had worse control of cardiovascular risk factors. Treatment strategies that focus on Hispanics with low levels of acculturation may improve cardiovascular risk factor control.

Background: Patients are often advised to initiate a physical activity program by walking for transportation or leisure. This study explored whether neighborhood factors beyond the individual might affect compliance., Objective: We examined the associations between total walking and neighborhood factors in a multi-ethnic population-based sample in California and the roles race/ethnicity plays in these associations., Design: Cross-sectional study, Participants: Individual-level data were obtained from the 2003 California Health Interview Survey. Participants' census tracts were linked to Census 2000 data to capture neighborhood SES., Measurements and Main Results: The dependent variable was self-reported walking at recommended levels. Neighborhood SES was measured by a scale of 4 Census-based variables (alpha = 0.83). Social cohesion was measured by a scale tapping the extent of perceived social connectedness, trust, and solidarity among neighbors (alpha = 0.70). Neighborhood access to a park, playground, or open space was measured by a single item. Safety was measured by a scale of three items (alpha = 0.66). We performed a series of multiple logit models with robust variance estimates while taking complex survey design into account. Neighborhood social cohesion (odds ratio [OR] = 1.09, 95% CI = 1.04, 1.14) and access to a park, playground, or open space (OR = 1.26, 95% CI = 1.16, 1.36) were significant environmental correlates of walking at recommended levels, independent of individual socio-demographics. Subgroup analysis showed that neighborhood effects were different by race/ethnicity., Conclusions: Neighborhood physical and social environmental factors are significantly associated with walking at recommended levels. Being aware of the ways that the environment could affect a patient's compliance with PA recommendations may help physicians tailor recommendations to circumstances.

Purpose: Self-reported overall health (SROH) is often used to compare the health status of multi-ethnic populations in the United States. SROH may not be comparable across cultural groups. We assessed if differences in SROH between non-Hispanic whites (NHW), Latinos, and Asians were explained primarily by differences in socioeconomic status (SES) or language and nativity., Methods: We used cross-sectional data on 36,660 NHW, 9399 Latinos, 1298 Chinese, 944 Filipinos, 803 Koreans, 857 Vietnamese, and 1036 "other Asians" from the 2001 California Health Interview Survey., Results: Compared with NHW, all ethnic groups were less likely to report "excellent" or "very good" health. Latinos, Chinese, Filipinos, Koreans, and Vietnamese were also more likely to report "fair" or "poor" health. Adjusting for SES attenuated these differences for Latinos but did not explain the effect of being Asian on SROH. Among all ethnicities, individuals with limited English proficiency had worse SROH than individuals who were English-proficient., Conclusions: Differences in SROH between Asians and NHW do not appear to be mediated by SES and may be due to different perceptions of health that are rooted in culture and language. There remains a need for health status measures less susceptible to cultural bias in Asian and Latino populations.

Background: Asian Americans have lower cancer screening rates compared with non-Hispanic whites (NHWs). Little is known about mechanisms that underlie disparities in cancer screening. The objectives of the current study were 1) to determine the relation between nativity, years in the United States, language, and cancer screening in NHWs and Asian Americans, independent of access to care and 2) to determine whether Asians reported different reasons than NHWs for not obtaining cancer screening., Methods: This population-based study included 36,660 NHWs, 1298 Chinese, 944 Filipinos, 803 Koreans, 857 Vietnamese, and 1036 Other Asians from the 2001 California Health Interview Survey. The main study outcomes were 1) self-reported colorectal, cervical, and breast cancer screening and 2) reasons for not obtaining cancer screening., Results: After adjusting for access to care, several Asian subgroups still had significantly lower rates of all types of cancer screening compared with NHWs. Adjusting for nativity, years in the United States, and English language attenuated the relation between Asian ethnicity and lower rates of colorectal and breast cancer screening. When they were asked what the most important reason was for not having each screening test, foreign-born Asians were significantly more likely than United States-born NHWs to report that they "didn't have problems/symptoms" (P < .01)., Conclusions: Nativity, years in the United States, and English language may be markers of cultural differences that are mediating cancer screening disparities. Foreign-born Asians may believe that cancer screening is in response to symptoms rather than tests that are used prior to the development of symptoms. Health education messages must consider how to communicate effectively that "cancer screening is valuable, because it finds cancer before it is advanced enough to cause symptoms.", (Copyright 2006 American Cancer Society.)

Purpose: Asian American immigrants' risk of heart disease, diabetes, and obesity increase with duration of residence in the United States (US). Regular physical activity reduces the risk of these diseases, yet little is known about physical activity in Asian Americans and how it changes after immigration., Methods: Data from the 2001 California Health Interview Survey, which oversampled Asian Americans, were analyzed to investigate the effects of ethnicity, nativity, and years in the US on leisure time physical activity (LTPA), non-leisure time physical activity (NLTPA), and occupational physical activity. A total of 4226 Asian Americans and 29,473 US-born non-Asians were included., Results: Asian Americans were much less likely to meet recommended levels of LTPA than US-born non-Asians (odds ratio [OR], men=0.51, 95% confidence interval [CI], 0.42, 0.61, OR, women = 0.48, 95% CI, 0.40, 0.57). Foreign-born Asians were least likely to participate in LTPA; LTPA increased as years in the US increased. After accounting for NLTPA, Asian Americans had significantly lower estimated weekly energy expenditure than US-born non-Asians., Conclusions: Asian Americans, especially immigrants, are at risk for low levels of LTPA and high levels of physical inactivity. NLTPA does not offset these lower levels of LTPA. Increasing physical activity is key to protecting the health of this rapidly growing population.

Background: During welfare reform, Congress passed legislation barring legal immigrants who entered the United States after August 1996 from Medicaid for five years after immigration. This legislation intended to bar only new immigrants (post-1996 immigrants) from Medicaid. However it may have also deterred the enrollment of legal immigrants who immigrated before 1996 (pre-1996 immigrants) and who should have remained Medicaid eligible., Objectives: To compare the Medicaid enrollment of U.S.-born citizens to pre-1996 immigrants, before and after welfare reform, and to determine if variation in state Medicaid policies toward post-1996 immigrants modified the effects of welfare reform on pre-1996 immigrants., Data Source/study Design: Secondary database analysis of cross-sectional data from 1994-2001 of the U.S. Census Bureau, Annual Demographic Survey of March Supplement of the Current Population Survey., Subjects: Low-income, U.S.-born adults (N=116,307) and low-income pre-1996 immigrants (N=24,367) before and after welfare reform., Measures: Self-reported Medicaid enrollment., Results: Before welfare reform, pre-1996 immigrants were less likely to enroll in Medicaid than the U.S.-born (OR=0.55; 95 percent CI, 0.51-0.59). After welfare reform, pre-1996 immigrants were even less likely to enroll in Medicaid. The proportion of immigrants in Medicaid dropped 3 percentage points after 1996; for the U.S.-born it dropped 1.6 percentage points (p=0.012). Except for California, state variation in Medicaid policy toward post-1996 immigrants did modify the effect of welfare reform on pre-1996 immigrants., Conclusions: Federal laws limiting the Medicaid eligibility of specific subgroups of immigrants appear to have had unintended consequences on Medicaid enrollment in the larger, still eligible immigrant community. Inclusive state policies may overcome this effect.

Background: Two months of rifampin and pyrazinamide (RIF/PZA) for tuberculosis prevention has been advocated as a way to improve adherence in mobile populations, such as recent immigrants. However, RIF/PZA requires intensive patient and laboratory monitoring for hepatotoxicity., Objectives: To describe the feasibility and outcomes of using RIF/PZA for TB prevention during a tuberculosis outbreak in a Mexican immigrant community, where 23 adults and 11 children were treated with RIF/PZA between August 2001 and October 2001., Methods: Retrospective chart review and interviews with health department employees were conducted to assess completion rates, hepatotoxicity, cost, and feasibility of monitoring., Results: Ten (91%) children and 13 (57%) adults completed RIF/PZA. One child (9%) and four adults (17%) developed drug-induced hepatitis. Cultural barriers affected care. The adults resisted the biweekly blood draw, believing it would "drain them of energy." RIF/PZA, plus monitoring, was twice as costly as 4 months of rifampin., Conclusions: RIF/PZA was associated with significant hepatotoxicity, poor completion, and cultural barriers to monitoring, and was more costly than standard therapy. Tuberculosis prevention must address potential clinical, cultural, and economic barriers to completion and monitoring of short-course therapy in immigrants.

Over the past 20 years, the United States has experienced one of the largest waves of immigration in its history. Understanding the health status and needs of immigrants is important because of their growing numbers and their contribution to the health of the nation, but it is challenging because of gaps in national databases, the heterogeneity of immigrant populations, and uncertainty about how migration affects health. Healthy People 2010 outlines the nation's public health objectives for the current decade. It includes ten leading health indicators (LHIs) chosen because of their importance as public health issues, their ability to motivate action, and the availability of data to measure their progress. In this paper, we discuss the health of immigrants from the perspective of these LHIs, as they provide a framework for anticipating some of the future health needs of immigrants and help define priority areas for research and action.