STRONG HEART STUDY I NVESTIGATING C ARDIOVASCULAR D ISEASE IN A MERICAN I NDIANS

Volume 16, Number 2 October 2004 Newlly llaunched Okllahoma Natiive Ameriican EXPORT Center partners wiith SHS

he Center for American Indian within the state and across the T Health Research (CAIHR) in the nation as a resource for health College of Public Health at the promotion, prevention, and University Health Sciences health science education. This Com- Center (OUHSC), which houses the munity Outreach Core is partnering Strong Heart Study (SHS), received a with SHS by helping with the new National Institutes of Health (NIH) dissemination (making generally grant through the National Center on known, "spreading the word") of SHS Minority Health and Health Disparities research findings so that this to establish an EXPORT Center. The research may be translated into Oklahoma Native American EXPORT health improvements. This Core has Center, launched earlier this year, also helped the Stop Atherosclerosis works closely with the Indian community to in Native Diabetics Study (SANDS) successfully improve health and reduce health disparities in recruit participants for their research and will do the the areas of and obesity. EXPORT same for the SHS for future research. stands for Excellence in Partnerships for Com- munity Outreach, and Research on Disparities in The Oklahoma Native American EXPORT Center Health and Training. The EXPORT Center has encourages SHS members and all Native partnered primarily with the Indian Health Americans in southwest Oklahoma to take part Services Lawton Service Unit and the Seven in EXPORT’s various programs. For example, Tribes of Southwest Oklahoma, but a new EXPORT funds the Headlands Indian Health partnership with the Strong Heart Study is being Careers Summer Program, which is an intense formed. academic enrichment program designed to encourage Native American youth to pursue In addition to the Administrative Core that health/science careers. The Community Outreach oversees the Center, the Oklahoma Native Core of the EXPORT Center welcomes everyone American EXPORT Center has 4 more (all ages) to its very successful monthly health cores/components: the Research Core, which is promotion programs on diabetes and obesity, currently managing 3 projects designed to providing expert speakers and curriculum along prevent obesity and diabetes; the Training with diabetes support group sessions. These public Component, which focuses on providing science educational meetings continue being held at and health educational and career opportunities different tribal facilities along with new topics each to Native American students; the Shared month and require no appointment. For dates and Resources Core, which provides technical times of meetings, or if you would like to learn more resources, such as study design and statistical about the Oklahoma Native American EXPORT analysis to all of the other Core areas; and the Center, please call (405) 271-3090 or toll free Community Outreach and Information Dissem- 1-888-231-4671, or log onto their website at ination Core, which integrates the Oklahoma http://export.ouhsc.edu. EXPORT Center into the Indian communities SHS 1 Success of the Strong Heart Study lleads to “spiin-off” studiies

The Strong Heart Study (SHS) was funded by heart disease. Participants were hooked up to a the National Heart Lung sleep monitor, which recorded several important and Blood Institute factors about their sleep habits. One important (NHLBI) in 1988 as the measurement was the exchange of oxygen during first large epidemiologic sleep. If a person’s oxygen level drops, this can be study of cardiovascular very harmful. This drop may be caused by apnea disease (CVD) in Amer- (when someone stops breathing in their sleep), ican Indians. Strong which often occurs with snoring. All participants Heart has been collabor- with apnea were referred for further care, since ating with communities in , Oklahoma, apnea can lead to heart disease over time. The and the Dakotas and values these successful SHHS repeated these sleep studies with the same participants approximately five years later. The working relationships. Nationally, the Strong information gained from this study is useful in Heart Study has the largest group of people understanding the changes in our bodies over time with diabetes who are followed on a regular in relation to sleep changes. More data will be basis in regard to CVD and its occurrences, coming out on sleep studies, as it is an area of and this is due to the unflagging support of the great interest. participants, the communities, and the NHLBI. http://www.jhucct.com/shhs/default.html http://strongheart.ouhsc.edu Insulin Resistance Study: Some of the Strong The success of Strong Heart has led to and Heart Study participants in the Dakotas and resulted in “spin-off” studies to address other Arizona volunteered for a study called “Frequently health problems. Some of these studies Sampled Intravenous Glucose Tolerance Test”. In include: this study, insulin and glucose are injected into one arm vein and over a three-hour period, blood Asthma Study: In cooperation with the Uni- samples are taken from the other arm. Blood versity of Arizona we were able to study sugar and insulin are measured. Then, by using a of the lung, including asthma. Spirometry tests computer model, the degree of insulin resistance is were used to determine if participants had any measured. This is the most reliable way to problems with breathing. These tests provided measure insulin resistance, which is important in information relating to lung conditions such as understanding why insulin no longer “works” as it is asthma, damage from heart failure, and chronic supposed to, and eventually leads to diabetes. All (long term or always present) obstructive pul- of this information will lead to better strategies for monary disease (from smoking). Skin tests were treating and preventing diabetes. also conducted, looking for allergies that may http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&d cause people to have wheezing or asthma. The b=PubMed&list_uids=12477138&dopt=Abstract results of this study help scientists, health care professionals, and tribal leaders provide more Infectious Diseases: Some of the Strong Heart sound, relevant care and treatment for people investigators conducted a study to see if there is a with breathing problems. relationship between having had an infectious disease and the chance of having heart disease or Sleep Heart Health Study (SHHS): A selection a later in life. To check this, blood samples of Strong Heart were drawn from SHS volunteers, and were tested Study partici- for signs of infection. Early results suggest that ants was part of some chronic or re-occurring infections may a multicenter increase one’s chances of developing CVD. This study conducted across the country looking at study may help in the development of new and the relationship between sleep disturbances and better ways to prevent CVD. Continued on page 3… 2 S trong Heart S tudy Newsletter October 2004

SHS “spin-off” studies…continued from page 2

PATHWAYS Study: When the Strong Heart study successfully examined over 1,200 Study found high levels of participants, including the same components as obesity in American Indians, the SHS, and is now looking at the data to the NHLBI funded a primary understand the findings. This information is vital prevention study. PATHWAYS, to these communities as they try to develop conducted in school children, prevention programs before disease rates had four components: physi- accelerate. cal activity, healthy diet, school https://www.sfbr.org/gocadan.secure/aboutgocadan.html curriculum, and a home com- (Wall hanging by Theresa Kayakavik, Arviat, Nunavut. Courtesy of w ww.drumdancer.com ponent. The home component reinforced the Photograph by J. Mackenzie-Hirasawa) teaching in school and incorporated healthful diet and increased activity into the home lifestyle. The Education and Research Towards Health children learned the importance of a balanced diet (EARTH): Several SHS investigators received for good health, but the study also showed the funding from need for much more intense, long-term efforts to the National reduce overweight and obesity in the communities. Insti- http://www.cscc.unc.edu/path/index.html tute (NCI) to examine risk Stop Atherosclerosis in Native Diabetics Study factors for cancer and other chronic illnesses (SANDS): Strong Heart found that heart disease is among a large group of Alaska Natives and rapidly increasing among American Indians, and American Indians. The main goal of EARTH is to that diabetes is the biggest risk factor. The SANDS examine how diet, lifestyle, and cultural factors Study is our attempt to address this major finding. may be associated with both health and illness, SANDS includes only American Indians with type 2 with a focus on cancer. This study is being diabetes, 40 and older, and focuses on two other conducted in several SHS communities in the risk factors, high blood pressure and high Dakotas and Arizona, in addition to sites on the . SANDS participants are being followed Navajo Nation and in three Alaska Native over three years to see if lowering blood pressure regions. If this first pilot project is successful, the and cholesterol to levels lower than currently NIH may fund a very large expansion of this recommended will stop or reverse cholesterol study, making possible a variety of intervention buildup (atherosclerosis, or "plaque") in our blood projects to promote health and prevent illness. vessels. This prevention project is currently in http://www.southcentralfoundation.com/index.cfm?pg=47 progress in four sites and recruitment goals were reached in June 2004 (see article on page 4). In about three years we will look to see if we have an answer to our question. Findings from SANDS may Excellence in Partnerships for Community be very important in order to better learn how to Outreach, Research on Health Disparities, prevent heart disease among people with diabetes and Training (EXPORT): in our communities. http://www.clinicaltrials.gov/ct/show/NCT00047424?order=47 Again, a Strong Heart investigator is a Co- Principal Investigator on this project, which is Genetics of Coronary Artery Disease in Alaska being conducted with the Hawaiian people of Natives (GOCADAN): This project is also funded Moloka’i. This is sponsored by the National Cen- by the NHLBI and is modeled after ter on Minority Health and Health Disparities. This the Strong Heart Study. It is being study is looking for heart disease and risk factors conducted in several Eskimo villages and is designed following procedures used in in the Norton Sound region of Alaska, SHS. By merging some of the results of both looking at the risk factors for heart studies, we hope to have a clearer understanding disease in these communities. This of heart disease in these communities. http://www.hawaiiexportcenter.hawaii.edu SHS 3 STRONG HEART STUDY COORDINATING CENTER Non-Profit Organization University of Oklahoma Health Sciences Center U.S. Postage

Center for American Indian Health Research PAID College of Public Health P.O. Box 26901 Oklahoma City, Oklahoma Permit No. 220 Oklahoma City, OK 73190-3040

S trong Heart S tudy Newsletter October 2004

Stop Atheroscllerosiis iin Natiive Diiabetiics Study

reaches a miillestone!

Rapid City, SD Lawton, OK Chinle, AZ Phoenix, AZ

An offspring of the Strong Heart some areas, making shipping of Study, the Stop Atherosclero- frozen blood specimens problem- sis in Native Diabetics Study atic. Yet all of these challenges were (SANDS) is investigating wheth- overcome by hard work and dedi- er lowering cholesterol and cation resulting in SANDS staff blood pressure to levels lower than what is currently reaching their recruitment goal ahead of schedule. recommended will help to prevent heart disease in American Indians with diabetes. SANDS has The study was presented to Tribal Elders and Leaders reached a milestone in that the enrollment period has many months before the trial started. From there the ended. In just 14 months of recruiting participants for information was passed down to members of the tribes this study, 547 people were entered into the study. as well as local physicians. Much effort was spent to This is quite a feat. Oftentimes in medical research it educate the communities about the short and long term is difficult to enroll appropriate, motivated participants benefits of participating in this research project.

in the time allotted. This was not the case with Many of the participants were recruited by word of SANDS. mouth. Study staff presented SANDS at local pow- The SANDS sites, located in Phoenix and Chinle, AZ., wows. Signs were posted in the communities. Most Lawton, OK, and Rapid City, SD, overcame many centers sent out letters. Many hours were spent on the obstacles in reaching their goal. All of these sites are phone and in clinics explaining the study in order to either located in, or treat participants from remote enroll people who fit the strict entry criteria, and who areas. A trailer was purchased in Chinle to house the also would be willing to invest the time and energy in nurse practitioner who treats the study patients. the project.

Some sites purchased All Terrain Vehicles to The success of the SANDS enrollment period has been transport participants to and from clinic visits. Many of due to staff and community members who are the participants in Chinle do not speak English as a dedicated to improving health care in this very first language; a Navajo translator is present at every deserving population. Without patients who are willing study visit to ensure that language and cultural to regularly take their medications, live a healthy life barriers are minimized. Communication cables are style and attend clinic visits, SANDS would not be lacking in some areas, making the transmission of possible. The SANDS family will continue to support data very difficult. In these cases, measurements each other during the treatment phase; the results of such as blood pressure and cholesterol have to be the study will help to prevent heart disease in all mailed to another location so that they can be entered diabetic patients. into a computer. Overnight mailing is sporadic in SHS 4