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12. Minority Activities
Throughout its history, the NHLBI has been a leader in
conducting and supporting research to eliminate health disparities that exist
between various segments of the U.S. population. The Institute has not only
initiated research projects with significant minority participation in order to
compare health status between various populations, but also given high priority
to programs that focus exclusively on minority health issues.
Since FY 1991, the Institute has had procedures in
place to ensure full compliance with the NIH Policy on Inclusion of Women and
Minorities as Subjects in Clinical Research. As a result, all NHLBI-supported
research that involves human subjects includes minorities, with the exception
of a very few projects for which a compelling justification for limited
diversity in the study population exists. Thus, all segments of the population,
both minority and non-minority, stand to benefit from the Institute's research
programs.
It has long been a goal of the NHLBI to increase the
number of individuals from underrepresented groups in biomedical and behavioral
research. Selected FY 2007 activities addressing this goal include the
following:
- Minority K–12 Initiative for Teachers and
Students (MKITS): Supports research, development, and evaluation of innovative
science training programs to provide minority students in grades K–12
with the exposure, skills, and knowledge that will encourage them to pursue
advanced studies in biomedical and behavioral sciences.
- Historically Black College and University (HBCU)
Research Scientist Award: Supports efforts by HBCUs to recruit an established
research scientist in cardiovascular, lung, or blood health and disease;
transfusion medicine; or sleep disorders.
- Sickle Cell Scholars Program: Supports career
development of young or new investigators in SCD research.
- Summer for Sickle Cell Science Program: Supports
research training and mentoring of individuals at the high school level as part
of the Comprehensive Sickle Cell Centers program.
- Clinical Research Education and Career Development
in Minority Institutions: Encourages the development and implementation of
curriculum-dependent programs in minority institutions to train selected
doctoral and postdoctoral candidates in clinical research leading to a Master
of Science Degree in Clinical Research or Master of Public Health Degree in a
clinically relevant area.
- Research Scientist Award for Minority Institutions:
Strengthens the biomedical and behavioral research capabilities and resources
of minority institutions by recruiting an established scientist with expertise
in areas related to cardiovascular, lung, or blood health and disease;
transfusion medicine; or sleep disorders.
- Minority Undergraduate Biomedical Education
Program: Encourages development of pilot demonstration programs at minority
undergraduate educational institutions to recruit and retain talented
undergraduate students in the biomedical sciences.
- Summer Institute Program To Increase Diversity in
Health-Related Research: Enables faculty and scientists from underrepresented
racial and ethnic groups or with disabilities to advance their research skills
and knowledge in basic and applied sciences relevant to heart, lung, and blood
diseases and sleep disorders, so that they can compete for funding for
scientific research in the biomedical and behavioral sciences.
The Office of Research Training and Minority Health
(ORTMH) within the Office of the Director provides oversight for, and
coordinates, supports, and evaluates Institute programs related to minority
health outcomes, including research, research training and career development,
public outreach, and translation of research findings. The ORTMH also
coordinates activities to foster greater participation of underrepresented
minorities in NHLBI research and research training and career development
programs. Selected FY 2007 activities include the following:
- Issuing four training and career development RFAs
to increase the number of highly trained minorities conducting biomedical and
behavioral research. Additional targeted groups include individuals from
disadvantaged backgrounds and individuals with disabilities.
- Participating in HHS-Endorsed Minority Organization
Internship Programs by supporting positions in NHLBI extramural and intramural
divisions for students from the National Association for Equal Opportunity in
Higher Education, the Hispanic Association of Colleges and Universities, the
Washington Internships for Native Students programs, and the Directors of
Health Promotion and Education Internship Program/CDC.
- Cosponsoring with the NIH, the Cherokee Elementary
School Project: Out of the Box, which is designed to create awareness and
interest in the importance of science, medicine, and health; eliminate gaps in
quality of health among minorities by encouraging health-related careers; and
encourage children to take responsibility for their own health.
- Supporting the African American, Hispanic, and
Native American Youth Initiatives to bring minority students to the NIH campus
for scientific presentations, an introduction to NHLBI research training and
career development programs, and a tour of NHLBI laboratories.
- Providing undergraduate students from the Tougaloo
College Scholars program an opportunity to learn about the NIH, biomedical
research, and research training opportunities at the NHLBI during a 3-day tour
of the NIH.
- Serving as a Web site resource for recruitment of
minority individuals into the Ruth L. Kirschstein Institutional National
Research Service Award (T32).
- Increasing recruitment of individuals for the NHLBI
intramural and extramural training programs by representing the Institute at
five minority-focused research meetings to raise awareness of research and
research training and career development opportunities available from the
NHLBI.
- Coordinating the Biomedical Research Training
Program for Individuals From Underrepresented Groups, which offers
opportunities for underrepresented undergraduate, postbaccalaureate, and
graduate students to receive training in fundamental biomedical sciences and
clinical research as it relates to the etiology and treatment of heart, blood
vessel, lung, and blood diseases and sleep disorders.
- Serving as the NHLBI contact for guidance to
candidates applying for the NIH Pathway to Independence (PI) Award (K99/R00)
and the NHLBI Career Transition Award (K22) for extramural programmatic
issues.
See Chapter 13 for
additional NHLBI-supported minority research training and career development
programs.
The following text describes selected current projects
that focus on minority populations and reflect the Institute's research
portfolio related to minority health. Additional information can be found in
Chapters 9 through 11.
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Heart and Vascular Diseases
Risk Factors
Epidemiology
Long-term epidemiologic studies are critical to
uncovering risk factors that lead to disease. The Institute has initiated
several major studies of heart disease focused significantly or completely on
minority populations.
- CARDIA (see Chapter
10): To determine the evolution of CHD risk factors and lifestyle
characteristics in young adults that may influence development of risk factors
prior to middle age; 50 percent of the participants are black.
- ARIC (see Chapter 10):
To investigate the association of CHD risk factors with development of
atherosclerosis and CVD in an adult population; 30 percent of the participants
are black.
- CHS (see Chapter 10):
To examine risk factors for CHD and stroke in the elderly; 16 percent of the
participants are black.
- Strong Heart Study (see Chapter 9 ): To compare risk factor levels and
morbidity and mortality from CVD among American Indians from three different
geographic locations.
- JHS (see Chapter 10):
To identify environmental and genetic factors influencing evolution and
progression of CVD in blacks.
- MESA (see Chapter 10):
To examine the characteristics of subclinical CVD that predict progression to
clinically overt CVD and related risk factors that predict subclinical disease
in blacks, whites, Hispanics, and Asians; 62 percent of the participants are
minorities.
- GOCADAN (see Chapter
9): To document CVD risk factors and measures of subclinical disease and to
identify and characterize genes that contribute to CVD in approximately 40
extended Alaska Native families.
- HCHS (see Chapter 10):
To identify risk factors for cardiovascular and lung disease in Hispanic
populations in the United States and determine the role of acculturation in
their prevalence and development.
The Institute supports components of the NHANES that
track the prevalence of disease and risk factors for cardiovascular and lung
diseases in the U.S. population, including Hispanics and blacks
(non-Hispanic).
Several investigator-initiated epidemiologic studies
are examining gene–environment interactions that increase CVD risk
factors among various racial groups. Included among them are studies that
compare gene–environment interactions in black populations in Africa, the
Caribbean, and selected areas of the United States; determine the genes
responsible for the metabolic syndrome, a risk factor for CVD, in 10,000
Chinese sibling pairs; determine the genes responsible for CVD risk factor
response to dietary fat changes in blacks; investigate genes influencing
changes in blood pressure in response to high- and low-salt diets in a rural
Chinese population; and identify and map specific genes that contribute to CVD
risk in Mexican Americans.
Scientific evidence is emerging that implicates
cellular and inflammatory processes in the development and characteristics of
atherosclerotic plaque and the clinical course of CVD. One study seeks to
identify cellular, metabolic, and genomic correlates of atherosclerotic plaque
characteristics and early changes in the vascular wall in a subset of the ARIC
cohort; one-third of participants are black. Another study is elucidating the
links between socioeconomic factors, stress, inflammation and hemostasis, and
cardiovascular risk in a large and diverse population.
Several drugs in four widely used classes of
noncardiovascular medications (fluoroquinolone and macrolide antibiotics,
antipsychotics, and antidepresants) have been shown to be proarrhythmic and
thus increase the risk of sudden cardiac death. Investigators are conducting a
study, using a large and comprehensive dataset of about 800,000 persons, 40
percent of whom are black, to understand the role of these medications on the
risk of sudden cardiac death. Research findings are expected to provide
information that will enable clinicians to prescribe these widely used
medications in a way that minimizes the risk of sudden cardiac death.
Ancillary studies to MESA are investigating
subclinical CVD in ethnic minority groups. They include investigations of
regional left ventricular function, progression of calcification in the aorta,
abnormalities in the small vessels of the retina, association of air pollution
and subclinical CVD, lung function in relation to endothelial dysfunction and
biomarkers, identification of genes for subclinical CVD, and relationships of
sociodemographic factors and other factors to subclinical CVD.
The Institute is supporting additional epidemiologic
investigations that include a study of Chagas' disease— leading cause of
heart disease throughout Latin America—to identify genetic determinants
of susceptibility to infection and differential disease pathogenesis in a black
population residing in rural Brazil; a project to use pooled data from nine
existing U.S. studies to compare between blacks and whites, CHD incidence and
mortality rates, exposure–outcome relationship, patterns of comorbidity,
and population attributable risk; and a study to evaluate and compare the
extent of atherosclerosis and risk factors for CHD in three different
populations: U.S. (75 percent white and 25 percent black), Japanese Americans
in Hawaii, and Japanese in Japan.
Treatment and Prevention
Low–dose aspirin is cost effective and
efficacious for the prevention and treatment of CHD. However, some individuals,
perhaps because of individual genetic variations, do not respond to the
treatment. A genetic study in high-risk siblings of patients with premature
CHD, along with their adult offspring, is seeking to determine whether
low–dose aspirin responsiveness is heritable and whether it is associated
with specific variations in candidate genes or defined haplotypes; 50 percent
of the participants are black.
Many evidence–based guidelines for treatment of
risk factors or disease have been developed, but they are often not adhered to
by patients—especially minority populations—or adopted in routine
clinical practice. The Institute has initiated the following activities to
address this important problem:
- Trials Assessing Innovative Strategies To Improve
Clinical Practice Through Guidelines in Heart, Lung, and Blood Diseases: To
identify obstacles to implementing national evidence–based guidelines and
test interventions to promote their use in clinical practice. One project is a
collaborative effort between a major academic center and minority-serving
county medical center to test the efficacy and cost–effectiveness of a
case-management program relative to usual care in coronary risk reduction in
socioeconomically disadvantaged patients at increased risk of cardiovascular
events; 63 percent of participants are Hispanics, many with low fluency in
English.
- Overcoming Barriers to Treatment Adherence in
Minorities and Persons Living in Poverty: To overcome barriers to treatment
adherence for lifestyle changes and pharmacologic therapy in minorities and
persons living in poverty.
Although great progress has been achieved in reducing
CVD morbidity and mortality in the United States over the past 40 years,
minorities have not shared fully in the progress and continue to have higher
CVD morbidity. To address this problem, the Institute has initiated programs
directed at reducing cardiovascular health disparities:
- Partnership Programs To Reduce Cardiovascular
Disparities: To expand the capacity of research institutions to reduce health
disparities, encourage more researchers to focus on minority health, and
improve minority acceptance and community willingness to participate in
research by pairing research-intensive medical centers that have a track record
of NIH–supported research and patient care with minority health care
serving institutions that lack a strong research program. Researchers are
examining the complex biological, behavioral, and societal factors that result
in cardiovascular health disparities in their target populations (e.g., blacks,
Hispanics, Native Hawaiians, and Pacific Islanders).
- Cultural Competence and Health Disparities Academic
Award: To enhance the ability of select physicians and other health care
professionals to address, in a culturally sensitive manner, disparities in the
occurrence, management, and outcomes of cardiovascular, pulmonary,
hematological, and sleep disorders among various populations in the United
States. The award addresses ethnic, cultural, religious, socioeconomic,
linguistic, and other factors that contribute to health disparities and seeks
culturally competent approaches to mitigating them.
- Community–Responsive Interventions To Reduce
Cardiovascular Risk in American Indians and Alaska Natives: To test the
effectiveness of culturally appropriate behavioral interventions that promote
adoption of healthy lifestyles related to heart disease and stroke risk,
including healthy diet, regular physical activity, smoking cessation, and
stress management in American Indians and Alaska Natives.
Education
The NHLBI, through its education programs,
disseminates health information to physicians, health care professionals,
patients, and the public on ways to prevent or treat diseases within the
Institute's mandate. It has developed the following community-based programs to
combat cardiovascular health disparities among four major cultural/ethnic
groups: blacks, Hispanics, American Indians and Alaska Natives, and Asian
Americans and Pacific Islanders.
- Public Health in Public Housing: Improving Health,
Changing Lives: To disseminate information about improving cardiovascular
health by adopting heart healthy lifestyles to populations residing in public
housing.
- NHLBI-Health Resources and Services Administration
Bureau of Primary Care Partnership: To integrate clinical care management teams
and trained community health educators to implement pilot programs for blacks,
Latinos, and Asian and Pacific Islanders who are at high risk for CVD.
- Salud para su Corazón: To disseminate
information on CVD prevention, intervention, and treatment and promote heart
healthy behaviors in Hispanic communities through lay health educators
(promotores model).
- NHLBI-Pan American Health Organization/WHO
Partnership to Promote
Cardiovascular Health in the Americas: To develop and
evaluate community-based interventions to prevent and control CVD risk factors
among low-resource communities in Argentina, Chile, and Guatemala using lay
health workers (promotores de salud). Research results will be shared with
country health authorities and the members of the CARMEN network: an Initiative
for Integrated Prevention of Noncommunicable Diseases in the Americas.
- Honoring the Gift of Heart Health: To develop and
evaluate community-based interventions to prevent and control CVD risk factors
through education and outreach using tribal community health workers and
community health educators.
- NHLBI Asian American and Pacific Islanders Heart
Health Outreach Project: To develop culturally and linguistically appropriate
outreach activities and information to increase community awareness of heart
disease and its associated risk factors and to promote heart healthy lifestyles
among a diverse Asian American and Pacific Islander population.
In addition to the activities mentioned above, the
Institute has prepared publications on CVD prevention for minority populations.
They include the following:
- On the Move to Better Heart Health for African
Americans
- Heart is Golden: Heart Health Promotion
Activities for Vietnamese Communities
- Healthy Homes, Healthy Hearts SeriesSix
easy-to-read English and Spanish booklets on heart healthy living.
- Bringing Heart Health to Latinos: A Guide for
Building Community Programs
- Your Heart, Your Life: A Health Educator's
Manual for the Latino Community
- Filipinos Aspire for Healthy Hearts in Tagalog
and English
- Filipinos Take It to Heart: A How-To Guide for
Bringing Heart Health to Your Community
- Vietnamese Aspire for Healthy Hearts in
Vietnamese and English
- Honoring the Gift of Heart Health: A Heart
Health Educator's Manual directed to American Indians and Alaska
Natives.
The educational materials listed throughout this
chapter can be obtained from the NHLBI public Web site or through the NHLBI
online catalog.
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Arrhythmias
The NHLBI is supporting basic and genetic research on
the mechanisms that underlie cardiac arrhythmias to improve diagnosis,
treatment, and prevention of arrhythmias in all ethnic and racial groups in the
United States. In one study examining common genetic variants that underlie
variability in heart rate and rhythm, researchers have found significant ethnic
and racial differences in the occurrence of sudden infant death syndrome (SIDS)
associated with mutations in the same ion channel genes that cause inherited
and acquired long QT syndrome (a rhythm disturbance that can be lethal). This
finding, which helps to explain why SIDS occurs among blacks and Native
Americans at three times its rate among whites and six times its rate among
Hispanics and Asians, may lead to prospective genetic testing for SIDS and
permit counseling for at-risk families.
Another study identified an association between
variations in certain receptors that are activated during sympathetic nervous
system stimulation and an increased risk of sudden cardiac death, most often
due to ventricular arrhythmia. Although no significant differences were found
between blacks and whites in associated risk of sudden cardiac death, continued
research in this area is expected to advance understanding of differences in
genetic predisposition for cardiac arrhythmias among ethnic and racial groups
and ultimately lead to improved therapy.
Heart Failure
Heart failure (heart muscle dysfunction) affects about
5 million Americans of all ethnicities and is a growing public health concern.
It is frequently the end result of other conditions, such as hypertension,
diabetes, and prior heart attacks.
The NHLBI is supporting basic and clinical research
associated with heart failure that will benefit Americans of all ethnicities.
One project focuses on Native Hawaiians and the other has a minority
component:
- Heart Failure Disparities in Native Hawaiians: To
characterize ethnic differences in patients hospitalized for heart failure,
determine whether a culturally competent educational program can reduce
hospitalizations, and compare the effectiveness of early diagnosis in high-risk
patients by using community-based portable echocardiography to hospital-based
echocardiography performed by professional sonographers. The project is within
the Partnership Programs To Reduce Cardiovascular Disparities Initiative (see
page 138).
- Heart Failure Clinical Research Network (see
Chapter 9): To develop, coordinate, and conduct
multiple collaborative proof-of-concept clinical protocols to improve heart
failure outcomes. In 2007, the Institute expanded the Network to include a
historically black medical center with minority investigators and access to a
high-risk, underserved population.
Other research targeting minority populations
includes an investigation of genetic variations (especially those common in
blacks) that affect individual responses to the beta blocker drugs used to
treat heart failure and identification of underlying genetic variations that
result in familial dilated cardiomyopathy, an inherited form of heart
dysfunction; five black families are participating. Another study is focusing
on angioedema or severe allergic reaction, a life-threatening side effect of
ACE-inhibitor drugs that is more common in blacks than in whites. Investigators
are determining the mechanisms that cause the side effect and studying the
genetic profile of affected individuals and their families to determine who
should avoid taking the drugs.
High Blood Pressure
Etiology and Pathophysiology
High blood pressure is a serious health problem that
is especially prevalent and severe among minorities. An Institute-initiated
study is seeking to determine the etiology and pathophysiology of high blood
pressure:
- Family Blood Pressure Program (see
Chapter 9): To use a network of investigators to
identify genes associated with high blood pressure and to examine interactions
between genetic and environmental determinants of hypertension in specific
minority populations: Asians, blacks, and Mexican Americans.
The NHLBI supports a number of investigator-initiated
studies to identify genes linked to hypertension in blacks, Mexican Americans,
and whites to determine if part of the disparity in prevalence can be
attributed to genetic differences among the groups. Genes under investigation
include those associated with the renin-angiotensin system, the autonomic
nervous system, and sodium transport.
The Institute supports a number of projects to examine
antecedents of hypertension in children to determine racial differences in
blood pressure regulation. One study is determining relationships between
cardiovascular reactivity in adolescent normotensive blacks and development of
pathobiologic markers of hypertension risk (i.e., increased resting blood
pressure, left ventricular mass, and relative wall thickness) later in life.
Another is investigating the genetics of cardiovascular reactivity following
stress in black youth.
Researchers also are examining the influence of SES
and ethnic discrimination on stress reactivity to determine if it provides a
pathophysiologic link to CVD in blacks. One group is examining the combined
influence of low SES and ethnicity on development of behavioral risk factors
(i.e., hostility, anxiety, and heightened cardiovascular reactivity to stress)
in a group of adolescents; 50 percent of them are black. Another group is
assessing the relationship between early life exposure to socioeconomic
stressors—such as adverse socioeconomic conditions, low levels of social
integration, and racial discrimination—and development of hypertension in
blacks.
Investigators have observed that blacks have an
exaggerated blood pressure response to salt. A study to improve understanding
of the genetic basis and phenotypic characterization of salt-sensitive
hypertension in blacks has located a specific region of the kidney where sodium
is reabsorbed more extensively in blacks than in whites. New data from the
study show genetic evidence for a more active reabsorption of sodium in this
region.
Impaired sodium regulation also appears to be linked
to the development of hypertension. In a twin study consisting of 41 percent
blacks, scientists are investigating sodium retention as a mechanism augmenting
systemic vascular resistance and changes in vascular function, ventricular
structure, and blood pressure. In another study, scientists are investigating
the effects of stress on salt retention and measuring hormonal variables known
to influence sodium regulation.
A third study is seeking to determine whether the
mechanisms regulating sodium retention differ between blacks and whites.
Researchers found that black youths have a slower salt excretion rate in
response to stress than white youths. New data suggest that obesity may
contribute to the racial differences in response to stress. A study among
blacks living in three different environments ( Nigeria, Jamaica, and Chicago)
is examining the role of sodium and obesity in hypertension development.
The role of dietary factors, particularly
macronutrients, in the etiology of high blood pressure is another area of
investigation. Scientists are conducting epidemiologic studies among
participants with diverse ethnicity, SES, and dietary habits in four countries
to determine the impact of selected dietary components (proteins, lipids,
carbohydrates, amino acids, calcium, magnesium, sodium, potassium,
antioxidants, fiber, and caffeine) on blood pressure. Another study is seeking
to identify the link between healthy diet, genetic factors, and their
underlying biological mechanisms.
Treatment and Prevention
Identifying effective treatment strategies for various
populations requires large scale studies with representative populations in
sufficient numbers.
- Ancillary Pharmacogenetic Studies in Heart, Lung,
and Blood Diseases and Sleep Disorders: To conduct pharmacogenetic studies in
ongoing or completed clinical trials/studies related to heart, lung, and blood
diseases and sleep disorders to examine genetic influences on interindividual
differences in prescription drug response. Understanding the genetic influences
may permit improved medication choice and dosing in individuals and help avoid
either serious adverse response or poor response to therapy. Three of the
studies focus on antihypertensive drugs and include 50 to 58 percent
blacks.
An investigator-initiated ancillary study to ALLHAT,
the largest hypertension clinical trial conducted by the NHLBI, is evaluating
the pharmacogenetic response to antihypertensive treatment and long-term
clinical complications in blacks, whites, and Hispanics. Scientists are seeking
to determine whether pharmacogenetics is a feasible approach to personalized
therapy for hypertension.
Although it is well known that reducing hypertension
will reduce CVD rates, the implementation of evidence-based guidelines for
hypertension treatment in clinical practice is disappointing. To address this
issue, the NHLBI initiated a program to improve hypertension control rates in
blacks, a group with the highest prevalence and earliest onset of hypertension
and with disparately high premature cardiovascular mortality and morbidity:
- Interventions To Improve Hypertension Control Rates
in African Americans: To evaluate the feasibility of clinical interventions
directed at the medical care delivery system to increase the proportion of
blacks who have their blood pressure controlled to levels specified by the JNC
VII guidelines. Nearly 3,900 black patients are being enrolled in
community-based projects to evaluate interventions such as pharmacy- and
visiting nurses association-based approaches, telemanagement, and patient and
physician education.
The Institute also supports a number of
investigator-initiated studies to prevent hypertension and improve blood
pressure control in ethnic and racial minorities. Interventions target both lay
and medical communities. Strategies being tested include communication skill
enhancement, organizational change, educational programs, lifestyle and
nutritional counseling, use of technology, case management, pharmacy-based
interventions, and provision of care by community health workers and other
non-traditional providers.
Anger and hostility have been demonstrated as risk
factors for hypertension. Scientists are evaluating an anger management
intervention in a hospital setting to determine whether it will improve blood
pressure and alleviate psychosocial risk factors (e.g., reduce depression); 46
percent of the participants are black.
Understanding racial differences in blood pressure
control is an area of major interest for the Institute. Scientists are
examining whether variations in genes of the renin-angiotensin-aldosterone
system predict differences in blood pressure response to diuretic therapy among
hypertensive blacks and whites. Research also is being focused on variations in
the ACE gene between blacks and whites to explain racial differences in the
antihypertensive responsiveness to ACE inhibitors.
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Education
The NHLBI has developed a number of outreach
activities to inform minority populations of the importance of blood pressure
control. Included among them are a toll-free number that provides materials on
hypertension in English or Spanish; mini telenovelas (Más vale prevenir
que lamentar), “health moments” to reinforce CVD prevention for
local Spanish-language television stations; a Spanish version of the High Blood
Pressure Education Month Kit; and several publications for health
professionals, patients, and the public. Below are some examples:
- Plan de Alimentación Saludable Contra
la Hipertensión: Prevenir y Controlar la Presión Arterial Alta
Siguiendo el Plan de Alimentación Conocida Como DASH (DASH to the
Diet: Prevent and Control High Blood Pressure Following the DASH Eating
Plan)
- Sí se Puede: Prevenir y Controlar la
Presión Arterial Alta: Lo Que Usted Debe Saber Sobre la
Preventión y Control de la Presión Arterial Alta (Prevent
and Control High Blood Pressure: What You Should Know)
- Sí se Puede: Prevenir y Controlar la
Presión Arterial Alta. Lo Que los Médicos Deben Saber
(Prevent and Control High Blood Pressure. What Every Physician Should
Know)
- Keep the Beat: Control Your High Blood
Pressure in English and Spanish
- Churches as an Avenue to High Blood Pressure
Control
- Working With Religious Congregations: A Guide
for Health Professionals
- Keep Your Heart in Check—Know Your Blood
Pressure Number in Tagalog and English and in Vietnamese and English
- Prevent and Control High Blood Pressure:
Mission Possible.
NHBPEP Coordinating Committee Activities
Member organizations of the NHBPEP coordinating
committee have continuing education programs on the prevention and treatment of
hypertension that are focused on their minority members. They are also involved
with outside activities that include designing public health interventions to
address excessive stroke mortality in the Southeastern United States;
publishing reports about best treatment practices to control hypertension;
conducting demonstration projects at the work site and in urban and rural
settings; developing reports and intervention programs regarding hypertension
among special populations or situations (e.g., blacks, hypertensive patients
with renal disease or diabetes, children, and older Americans); and promoting
population strategies for the primary prevention of hypertension.
High Serum Cholesterol
Etiology
The Institute supports a number of
investigator-initiated projects to identify genes that influence the
lipoprotein profile within various racial and ethnic groups. Research findings
could offer an explanation for differences in susceptibility to CHD found among
various racial and ethnic groups.
Variation in hepatic lipase activity is associated
with differences in plasma concentrations of HDL and LDL synthesis and
catabolism. Researchers are investigating whether ethnic differences in hepatic
lipase activity are responsible for the well-known differences in plasma HDL
concentrations found in blacks and whites. Genetic studies are being conducted
on a population that is 39 percent black.
Prevention
The NHLBI is supporting an investigator-initiated
study among minority preschool children to track the long-term effectiveness of
nutrition interventions on diet and blood cholesterol levels. Additional
potential risk factors such as increased blood pressure, obesity, and intention
to smoke, will also be monitored.
Education
The Institute has prepared the following publications
on blood cholesterol for minority audiences.
- Do You Know Your Cholesterol Levels?in
English and Spanish
- Heart-Healthy Home Cooking African American
Style
- Delicious Heart-Healthy Latino
Recipes
- American Indian and Alaska Native People: Treat
Your Heart to a Healthy Celebration!
- Serve Up a Healthy Life—Give the Gift of
Good Nutrition in Tagalog and English and in Vietnamese and English.
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Obesity
Etiology
Recent NHANES data show a continued rise in the
proportion of Americans who are overweight; black women are especially at risk.
Results from the NHLBI Growth and Health Study (NGHS) that examined the
development of obesity and CVD risk factors in a biracial cohort of young girls
found black girls consumed more calories and a higher percentage of calories
from fat and watched more television than white girls. An
investigator-initiated study using the NGHS cohort, starting at ages 18 to 19
years, is examining the changes in cardiac output and total peripheral
resistance, which occur with developing obesity, and their influence on ethnic
difference in blood pressure regulation. Another project, using data from the
NGHS, is examining CHD risk factors in black and white girls to identify genes
involved in black–white differences in lipid metabolism and obesity.
Black women have been shown to manifest lower resting
energy expenditure than white women. Scientists seeking to improve our
understanding of ethnicity, genetics, energy metabolism, and obesity
development will examine the relationship between two genes implicated in
energy metabolism and resting energy expenditure in high-risk blacks.
Menopauserelated coronary risk was previously
believed to be associated with a gain in total body fat. Research, however,
suggests that the location of the fat, not the total fat per se, is the key
risk factor. An investigator-initiated study is seeking to determine if indices
of central adiposity, particularly intra-abdominal fat, predict coronary events
better than indices of total fat. The study is also examining the role of
central adiposity with altered glucose and lipid metabolism and elevated blood
pressure; 48 percent of the participants are black.
Treatment and Prevention
The NHLBI has initiated several programs to test
approaches for treating or preventing obesity.
- GEMS (see Chapter 9): To
test the effectiveness of weight-control interventions (diet, physical
activity, and psychosocial and familial influences) administered during the
critical transitions from prepuberty to puberty in black girls at high risk for
obesity.
- Overweight and Obesity Control at Worksites: To
test innovative interventions that emphasize environmental approaches or the
combination of environmental and individual approaches at worksites to prevent
or treat obesity in adults. Environmental strategies include programs,
policies, or organizational practices (e.g., increasing the availability of,
and providing access to, healthful food choices and facilities for physical
activity, and creating a socially supportive climate to influence healthy
behaviors). Targeted groups for some projects include individuals from
underrepresented racial and ethnic groups.
- POUNDS LOST (see Chapter
9): To evaluate the effectiveness of four diets differing in macronutrient
composition to promote and sustain weight loss in overweight and obese
individuals; approximately 25 percent of the participants will be black.
- WLM (see Chapter 9): To
determine the effectiveness of continuous patient contact on weight loss
maintenance in adults who recently lost weight; 40 percent of the patients are
black.
The Institute supports a number of
investigator-initiated studies on the effectiveness of obesity prevention and
control interventions among diverse populations. One study is testing the
effectiveness of weight-control interventions (involving diet, physical
activity, and psychosocial and familial influences) administered during the
critical transition period from prepuberty to puberty in black girls at high
risk for obesity. Two studies are evaluating the effectiveness of weight
control programs to prevent weight gain in a predominately black population
that has recently completed a smoking cessation program. The blood pressure
status of the participants, who are prehypertensive or hypertensive at the
beginning of the studies, are being monitored.
Hispanic parents and children are participating in a
program that targets physical activity and dietary behaviors in a
microenvironment (i.e., home environment) and in a macroenvironment (i.e.,
apartment complex, schools, grocery stores, parks, and restaurants). Community
health workers (promotoras) are working with the families and the community to
increase awareness and promote environmental change. Preadolescent black girls
are the subject of a study to test the efficacy of an after-school dance
program and a family-based intervention involving reduced use of television,
videotapes, and video games to reduce weight gain.
Obesity is one of the major health challenges facing
Native American children and has serious implications for the development of
type 2 diabetes. A school-based intervention, augmented with a family
intervention, is focusing on reducing excess weight gain by increasing physical
activity and healthy dietary practices in kindergarten and first-grade Native
American children. A project with a subject population consisting of Asians,
Hispanics, and whites is testing an integrated school- and community-based
intervention involving physical activity and diet to reduce the prevalence of
obesity.
Blacks at high risk of CVD often have limited success
in weight loss and lifestyle change programs. A study was initiated to examine
the role of social support, particularly from family members and friends, to
facilitate weight loss and related dietary and physical activity changes in
blacks.
Education
The NHLBI has prepared health information on losing
excess weight for minorities.
- Do You Need To Lose Weight? in English
and Spanish
- Embrace Your Health! Lose Weight if You Are
Overweight.
Physical Inactivity
The Institute has initiated research on the
effectiveness of an intervention program to encourage greater physical activity
among adolescent girls.
- TAAG (see Chapter 11):
To test the effectiveness of school–community-linked interventions to
reduce the decline in physical activity among adolescent girls, from grades 6
to 8. An estimated 5,000 girls, approximately 50 percent minority, from 36
schools are participating.
An ancillary study to TAAG is investigating the
influence of community characteristics (e.g., street design, access to public
transportation and facilities for physical activity, population mix, and
socioeconomic mix of the neighborhood) on physical activity levels and body
mass index; approximately 50 percent of the girls are minority. A school-based
study is evaluating the effects of vigorous exercise programs on decreasing the
accretion of general and visceral adiposity in black girls. Two other studies
are seeking to determine the factors that lead to decline in physical activity
in adolescent girls. They include the effects of previous exposure to physical
activity intervention, race and ethnicity, weight, psychosocial influences, and
the environment.
Physical inactivity among children is often attributed
to the lack of open space, lack of recreational equipment, and fear by parents
for the safety of children playing outdoors. A study is being conducted to
determine if an intervention that changes these neighborhood features in a
low-income, inner-city neighborhood will increase physical activity in
children.
Scientists have observed an age-related decline in
aerobic capacity, but have not been able to discern the effects of physical
activity, body fat, and genetic variation on its rate of change. They also have
little understanding about how the rate of change in aerobic capacity during
early and middle adulthood affects the development of CVD. An ancillary,
investigator-initiated study being conducted in conjunction with the Year 20
CARDIA examination is addressing these issues. Data from this study should
increase understanding of the interrelationships of cardiorespiratory fitness,
body composition, and CVD-related risk factors and endpoints, and may provide
the basis for more extensive evidence-based recommendations on the role of
fitness in cardiovascular health; 45 percent of the participants are black.
Education
The Institute has prepared the following publications
for minorities on the importance of physical activity and ways to become more
physically active.
- Energize Yourself! Stay Physically Active
- Sí se Puede: Prevenir y Controlar la
Presión Arterial Alta con Actividad Física (Move To Prevent and
Control High Blood Pressure With Physical Activity)
- American Indian and Alaska Native People: Be Active
for Your Heart!
- Be Active for a Healthy Heart in Tagalog and
English
- Be Active for a Healthier Heart in Vietnamese and
English.
The Institute also has developed a Web-based
application on physical activity for lay health educators in English and
Spanish, which can be found at
http://hin.nhlbi.nih.gov/salud/pa/index.htm.
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Smoking
Smoking among minorities has increased significantly
compared with whites. To determine the causes of the increase, the Institute is
supporting an investigator-initiated study in a predominately minority
population to examine factors that prompt them to initiate smoking. In
addition, the study seeks to identify predictors of cessation.
The Institute is also supporting a number of studies
of smoking intervention and follow-up cessation maintenance that specifically
target minorities. Two studies are evaluating the effectiveness of smoking
cessation programs for smokers who seek treatment at the hospital emergency
department. One study involves patients who suffer from acute respiratory
illness; approximately 35 percent of the participants are minorities. The other
targets Chinese American patients hospitalized with CVD, pulmonary disease, or
diabetes mellitus. A third study is seeking to determine if the addition of a
physical activity intervention improves smoking cessation; 45 percent of the
participants are black. Two types of pharmacologic therapies (nicotine
replacement therapy and sustained-release bupropion) have been approved by the
U.S. Food and Drug Administration for smoking cessation. Scientists are
comparing the ability of each drug alone or in combination to increase initial
and long-term smoking cessation rates in young low-income and minority smokers.
Another study is evaluating the efficacy of a weight loss drug intervention to
prevent weight gain in obese individuals participating in a smoking cessation
program; 44 percent of the participants are black.
Education
The Institute has prepared the following publications
on smoking cessation for minorities.
- Enjoy Living Smoke Free in English and
Spanish
- Refresh Yourself! Stop Smoking
- American Indian and Alaska Native People: Help
Your Heart
- Don't Burn Your Life Away—Be Good to Your
Heart in Tagalog and English and in Vietnamese and English.
Psychosocial Factors
Major depression is a risk factor in the development
of ischemic heart disease and for death after an acute MI.
Investigator-initiated research is seeking to determine the pathways that link
depression to physiological mechanisms in post-MI patients. One study is
examining the link between the severity of depressive symptoms to the
inflammatory process implicated in atherogenesis by focusing on the basal
expression of cytokines and cell adhesion molecules on blood monocytes. Another
is focused on the autonomic nervous system and its link to depression. A third
study is investigating the role of platelets, platelet aggregation, and
adhesion in patients with major depression. Approximately 30 percent of the
participants in the studies are black.
The NHLBI is interested in the effect of depression,
anxiety, and lack of social support on prognosis after a CHD event. An
investigator-initiated study is examining the efficacy of individual and group
therapy in post-MI patients who are socially isolated or clinically depressed.
Scientists will be measuring biological risk factors (e.g., lipids, adiposity,
coagulation factors) and possible subclinical markers of disease (e.g., carotid
intimal-medial thickness, coronary calcification); 34 percent of the
participants are black.
The Institute supports investigator-initiated research
on the role of race and ethnicity, psychosocial and environmental factors, and
low SES in the development of CHD. Scientists are investigating the
contribution of biobehavioral factors (hostility, anxiety, and heightened
cardiovascular reactivity to stress) in the etiology, pathogenesis, and course
of CHD. Racial differences in stress-induced physiologic responses also are
being examined. Other investigators are focused on the relationships of
psychosocial stress, sleep disordered breathing, and nocturnal physiological
measures with emerging risk factors and subclinical CVD; 50 percent of the
participants are black.
Investigators are interested in the effects of race
and psychosocial factors, such as hostility, on glucose metabolism. A study was
initiated to determine how hostility is differentially related to glucose
metabolism in blacks and whites. Research findings may increase understanding
of the differences in the etiology of diabetes in the two groups.
Additional areas of interest include the genetic basis
of aggression and the relationships between risk-promoting variables
(psychosocial stress, smoking, poor diet, physical inactivity), presumed
mediating variables (sympathetic nervous system activity and insulin
metabolism), and CHD risk factors; 50–60 percent of the participants are
black or Hispanic.
Diabetes
Diabetes mellitus is a strong risk factor for CVD. Its
prevalence is increasing due to the significant increase of obesity and
physical inactivity in the population, especially among blacks, Hispanics, and
American Indians. To address this growing problem, the Institute is supporting
an investigator-initiated study on defining the relationship between the
overall dose of endurance exercise training and the corresponding response of
metabolic risk factors in an overweight and obese biracial female population.
Another study will determine if adolescents with type 2 diabetes have a high
risk of developing clinical CVD in their late 20s or 30s. Scientists are using
noninvasive imaging techniques for detecting subclinical atherosclerosis to
measure CVD development in a predominantly black population.
Hypertension and diabetes are major contributors to
CVD and occur disproportionately in blacks. In particular, black women seem to
have earlier disease onset and poorer outcomes. Scientists are investigating
the link between hypertension and type 2 diabetes and the relative excess of
androgen found in black women to determine whether insulin resistance, excess
androgen, and endothelial dysfunction contribute to accelerated vascular injury
in blacks.
Treatment
The NHLBI supports clinical trials to determine the
benefits of various strategies to reduce CVD among patients with diabetes or
treat patients with coronary artery disease and diabetes.
- ACCORD (see Chapter
11): To evaluate the benefits of different therapies to reduce CVD in type
2 diabetes; more than 33 percent of the participants are minorities.
- BARI 2D (see Chapter
9): To evaluate whether urgent revascularization offers an advantage over
medical therapy in patients with coronary artery disease and diabetes. In
addition, for a given level of glycemic control, to determine whether
insulin-providing drugs offer advantages or risks compared to insulin
sensitizers (drugs that enhance insulin action); 33 percent of the participants
are from minority populations.
- SANDS (see Chapter 9):
To compare intensive treatment (pharmacologic agents, such as ACE inhibitors
and simvastatin for high blood pressure and LDL cholesterol) to conventional
treatment in 488 American Indians with diabetes, ages 40 years or older. The
primary outcome measure is change in carotid intimal-medial thickness.
An investigator-initiated study will evaluate the
effectiveness of a multiple risk factor intervention (diet,exercise, stress
management, social support, and smoking cessation) targeting postmenopausal
Hispanic women with type 2 diabetes.
Education
The Institute has prepared the following publications
on diabetes for minorities:
- Protect Your Heart Against Diabetes in English and
Spanish.
Women's Health Initiative
Coronary heart disease, cancer, and osteoporosis are
the most common causes of death, disability, and impaired quality of life in
postmenopausal women. The WHI (see Chapter 11) is
addressing the benefits and risks of hormone therapy, changes in dietary
patterns, and calcium/vitamin D supplements in disease prevention. Several of
the centers have recruited primarily minority populations: American Indians,
Asians, blacks, Hispanics, and Pacific Islanders. The clinical trial recruited
12,607 minorities and the observational study recruited 15,658. Overall, of the
161,808 postmenopausal women recruited into the WHI, 17 percent were
minorities.
In 2007, the Institute awarded 12 new contracts to
help explain the postmenopausal hormone therapy and other clinical trial
findings and to investigate the effects of genetic and biological markers on
common diseases affecting postmenopausal women. Investigators will conduct
their research using blood, DNA and other biological samples and clinical data
from the WHI participants. Four contracts focus specifically on minority
women:
- Physical Activity, Obesity, Inflammation, and CHD
in a Multi-Ethnic Cohort of Women: To clarify the mechanisms underlying the
reduced risk of CHD conferred by physical activity and lower body fat, beyond
their effects on traditional risk factors. Using data from the WHI
observational study, researchers will (1) examine the association of physical
activity and inflammatory markers and determine whether the association varies
by a person's weight and (2) investigate the association between physical
activity combined with weight/obesity status and risk of CHD. They will compare
the role of inflammatory markers in mediating the associations of physical
activity combined with weight with CHD risk to the role of traditional risk
factors, such as blood pressure and cholesterol levels.
- Ancestry Association Analyses of WHI Traits: To
determine the contribution of ancestry informative markers in DNA samples to
differences in risk of CHD, stroke, breast cancer, and hip fractures in blacks
and Hispanics and analyze genetic factors related to ancestry or country of
origin affecting hip fracture and bone mineral density in whites and blacks.
- Biochemical Antecedents of Fracture in Minority
Women: To examine biochemical factors for fracture in minority and white women.
Research results could explain differences in fracture rates and contribute to
prevention strategies.
- Interaction Effects of Genes in the Inflammatory
Pathway and Dietary Supplement and Medication Exposures on General Cancer Risk:
To identify genetic variants in genes involved in inflammation and immunity
that are associated with cancer risk (breast, colon and rectum, and lung) in
whites and blacks. Scientists will test associations between the use of dietary
supplements and non-steroidal anti-inflammatory drugs (NSAID) with inflammatory
markers and risk of overall cancer. They will then study interaction effects of
genetic variants with dietary supplement and NSAID exposure on cancer
risk.
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Lung Diseases
The NHLBI supports research on a number of lung
diseases, such as asthma, sarcoidosis, and TB, which disproportionately affect
minorities. The following section provides examples of research to address
health disparities in lung diseases.
Asthma
Etiology and Pathophysiology
The NHLBI has initiated several studies to determine
the etiology and pathophysiology of asthma.
- Severe Asthma Research Program: To determine the
mechanistic basis for severe asthma and to determine how it differs from
mild-to-moderate asthma. Several of the projects have strong minority
participation.
- Asthma Exacerbation: Biology and Disease
Progression: To elucidate the biologic mechanisms of asthma exacerbation
pathobiology and resolution and to determine their effect on lung function,
physiology, and disease state; 27 to 56 percent of the study participants will
come from various minority populations.
- Genome-Wide Association Studies To Identify Genetic
Components Related to Heart, Lung, and Blood Disorders: To identify genetic
variants related to heart, lung, and blood disorders and their risk factors
using existing population, family, and clinical studies. Several of the
asthma-related projects have strong minority representation in the study
populations.
The Institute also supports investigator-initiated
projects on the etiology and pathophysiology of asthma. They include a study to
identify positional gene candidates for airway hyperresponsiveness and compare
their association with asthma between two asthmatic groups: a white population
on Tangier Island, VA, and a black population from Barbados; a study to
establish the link between specific genotypic variants and phenotypic markers,
and to elucidate the immunological pathways that contribute to asthma severity
in blacks; and a case-controlled study to identify genetic determinants of
asthma risk among populations of African ancestry by performing genome-wide
association studies and gene–gene and gene–environment interaction
studies.
Latinos carry a disproportionate burden of asthma. Yet
few investigators studying the genetics of asthma have focused on them, partly
due to the complexity of the Latino gene pool. A recently initiated study is
developing and testing new methods to correct for population stratification due
to racial admixture, a key problem confounding genetic studies in the Latino
population. The project focuses on data from the NHLBI-supported Genetics of
Asthma in Latino Americans to assess population stratification.
Other projects that focus on Hispanic populations
include one that uses genomic screening to search for the genetic basis of
asthma in a homogeneous Hispanic population in Costa Rica and another that
involves a population-based case control association study to examine the
influence of genetic and environmental factors on the development and severity
of asthma in Puerto Rican children.
Occupational and environmental factors are known to
trigger asthma symptoms. An investigator-initiated study is focusing on
understanding the mechanisms by which occupational or environmental factors
trigger the onset of asthma among low-income, urban blacks and Hispanics.
Another study is examining the association of early exposure to endotoxin
(which appears to promote the development of the immune system), nitrogen
dioxide, and aeroallergens (which trigger asthma exacerbations); obesity;
physical inactivity; and environmental tobacco smoke on the prevalence,
persistence, and incidence of asthma in black and Hispanic children enrolled in
inner-city Head Start programs.
Circadian change in airway function is an important
aspect of asthma, as more than 70 percent of deaths and 80 percent of
respiratory arrest occur during sleep. Focusing on nocturnal asthma,
researchers are investigating the mechanisms that cause the changes in airway
function that lead to exacerbation of symptoms; 36 percent of the study
population are from minority populations.
Treatment and Control
The Institute has initiated research to identify
optimal drug strategies for treatment and management of asthma. Because the
burden of asthma disproportionately affects minority children, it is important
for them to be well represented in clinical trials.
- ACRN-Phase II (see Chapter
11): To support an interactive network of asthma clinical research groups
to conduct studies of new therapies for asthma and disseminate findings to the
practicing community. Overall, 33 percent of the participants are from minority
populations.
- CARE (see Chapter 11):
To support a network of pediatric clinical care centers to determine optimal
treatment and management strategies for children with asthma. The studies
considered by the network will attempt to customize therapy based on specific
asthma phenotypes and genotypes; 30 percent of the population will be
minorities.
- Centers for Reducing Asthma Disparities (see
Chapter 9): To support partnerships between
minority-serving institutions and research-intensive institutions to conduct
studies on causes of and corrections for disparities in asthma among
racial/ethnic and low SES populations. Reciprocal training is encouraged to
ensure culturally sensitive projects and enhance research capabilities.
The Institute is also supporting
investigator-initiated studies focusing on finding effective treatment for
various populations. One study is examining the effect of steroids on enhanced
alpha-adrenergic vascular responsiveness in asthma; 77 percent of the
participants are minority. Another study is using preexisting,
well-characterized asthma patient cohorts to identify genetic variants that can
predict therapeutic response to asthma drugs. Scientists are interested in the
influence of race/ethnicity on the genetic factors associated with asthma
therapeutic responses.
Translational Activities
Ensuring full use of modern asthma treatment
strategies is an important goal of the NHLBI. The Institute is supporting an
investigator-initiated study to determine the effectiveness of an intervention
that is removing barriers to preventive care to improve asthma management and
lower asthma morbidity. Scientists are using a Breathmobile to deliver asthma
screening to black children attending Head Start programs and a special
consultation service to communicate directly with the parents about asthma
management. Another study among low-income, inner-city children with asthma
attending preschool is testing a bilingual intervention program to improve
asthma management; 60 percent of the participants are Hispanic and 40 percent
are black.
Additional studies to improve asthma management among
minority groups include a study to determine whether shared decision making in
choosing asthma therapy between patients and physicians improves adherence in a
patient population consisting of 82 percent minority and a study to test
whether individualized interventions will improve asthma management in a black
and Hispanic population. A third study seeks to improve asthma management by
teaching children with asthma to recognize symptoms of the presence of airflow
obstruction; 42 percent of the participants are black and 6 percent are
Hispanic.
Two randomized controlled trials are being conducted
among patients recruited at the time of an emergency department visit for
asthma exacerbation. One study is testing an intervention to enhance knowledge,
self-efficacy, and asthma-related social support; 40 percent of the patients
are minorities. The other focuses on young black children recruited at the time
of an emergency department visit for asthma exacerbation. Investigators are
testing the effectiveness of an intervention strategy that includes case
management, telephone contacts, and a monetary incentive to increase follow-up
visits to primary care providers.
Three studies are evaluating the benefits of working
with public school systems to improve adherence to asthma management. In
Birmingham, scientists are evaluating the impact of school-based supervised
asthma therapy on asthma exacerbations in a predominately black population with
moderate-to-severe asthma. In New York, they are testing the ability of an
intervention that includes in-school intensive asthma education to
9th- and 10th-grade students who have persistent asthma and intensive
asthma education for their community physicians to improve asthma morbidity; 90
percent of the participants are black. In Detroit, investigators are developing
and evaluating an Internet-based self-management program for black teens with
asthma.
Chronic environmental tobacco smoke exposure,
particularly from parental smoking, is associated with more severe asthma,
increased incidence of emergency department visits, life-threatening attacks,
and prolonged time to recovery from asthma exacerbation requiring
hospitalization. A study is being conducted to evaluate an intervention
tailored to parental stage of change regarding smoking practice, to reduce
asthma crisis care used by children with persistent asthma.
Education
The Institute has developed easy-to-read materials on
asthma treatment and control directed to English and Spanish audiences with low
literacy.
- Facts About Controlling Your Asthma
- El Asma: Cómo Controlar Esta
Enfermedad (Facts About Controlling Your Asthma)
Sarcoidosis
Sarcoidosis is an inflammatory disease of unknown
etiology characterized by persistent granulomas with damage to surrounding
tissue. The Institute has initiated a program to determine the
immunopathogenesis of granulomatous inflammation found in sarcoidosis,
including the role of predisposing factors, the immune components involved in
the formation of granulomas and the defective regulatory immune response.
Investigator-initiated studies on the causes of
sarcoidosis include a study to identify genes linked to sarcoidosis
susceptibility in blacks and to determine if hereditary susceptibility
predisposes blacks to sarcoidosis, and a project to elucidate the mechanisms
involved in the immunologic and inflammatory processes that ultimately lead to
end-stage fibrosis in progressive pulmonary sarcoidosis; many of the
participants are black.
Sleep Disorders
Etiology
Sleep apnea is a common disorder that
disproportionately affects blacks and is associated with an increased risk of
CVD, including hypertension and stroke; it is particularly prevalent in heart
failure patients. An Institute-initiated program is assessing the
interrelationship between sleep disorders and heart failure, and the mechanisms
leading to cardiovascular stress when the two interact.
The NHLBI supports research on the etiology,
pathophysiology, and consequences of sleep-disordered breathing (SDB), a
condition characterized by repetitive interruptions in breathing.
- Neurobiology of Sleep and Sleep Apnea (see
Chapter 9): To integrate molecular, cellular, and
genetic approaches to sleep control with clinical investigation on the etiology
and pathogenesis of sleep disorders, particularly sleep apnea. One study has 57
percent black participation and another has 37 percent Asian participation.
- Sleep Heart Health Study (see
Chapter 9): To determine the degree to which sleep
apnea is an independent or contributing risk factor for the development of
cardiovascular or cerebrovascular disease; 23 percent of the participants are
from various minority and ethnic populations.
The Institute also supports a wide spectrum of
investigator-initiated projects to elucidate cardiovascular and other health
consequences of SDB. Ongoing studies in various community settings are
assessing the health risks of SDB within specific ethnic populations, including
American Indians, Asians, blacks, and Hispanics. Characterization of how SDB
occurs within family groups is helping to identify potential genetic risk
factors that may allow early identification and treatment of high-risk
individuals. A community-based study of sleep in Hispanics is assessing the
prevalence and awareness of sleep disorders.
Treatment and Control
The NHLBI has initiated a multisite clinical trial to
find effective treatments for sleep apnea.
- APPLES (see Chapter 9):
To determine whether continuous positive airway pressure is an effective
treatment for excessive daytime sleepiness and cognitive impairment associated
with moderate-to-severe SDB; 25 percent of the participants are
minorities.
An investigator-initiated study is underway to assess
whether sleep apnea in children can be effectively treated using tonsillectomy;
50 percent of the participants will be black.
Education
The NHLBI published Your Guide to Healthy
Sleep, which provides the latest information about sleep apnea and other
sleep disorders, including insomnia, restless legs syndrome, and
narcolepsy.
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Tuberculosis
Etiology
The Institute has initiated genetic studies to
characterize genes associated with TB susceptibility and host immune responses
to infection.
- Genetic Aspects of Tuberculosis in the Lung: To
identify genes or families of genes that determine resistance and
susceptibility to mycobacterial infection, virulence, latency, reactivation of
TB, and resistance to antituberculosis drugs. A large number of the
participants being recruited are from minority populations.
Treatment and Control
The NHLBI supports a number of investigator-initiated
studies focused on understanding the relationship between the immune system and
TB. Most of the studies are being conducted among patients from minority
populations. Included among them are studies to compare susceptibility to TB in
populations in Mexico and Peru; examine the role of interferon-gamma in the
pathogenesis of TB among Hispanics with and without HIV; identify and
characterize host factors that predispose Asians to develop TB; and determine
the effectiveness of adding aerosolized interferon-gamma to the usual treatment
regimen for advanced TB in predominately minority populations in the United
States and South Africa.
The NHLBI also supports research to improve TB control
among minority populations. One project is evaluating educational strategies to
improve adherence to medication regimens and regular clinic visits among
Hispanic adolescents infected with TB. Another study, located in the Harlem
community of New York City, is testing a new strategy to promote adherence to
therapy among inner-city TB patients. Both programs are outgrowths of
behavioral research programs begun by the Institute in 1995.
A third program, directed toward public health
workers, could affect the health of minority populations, where rates for TB
are disproportionately high. Scientists are evaluating the effectiveness of a
new TB contact priority model for investigating contacts of persons with
infectious TB. An effective model could enhance contact investigations and
provide more efficient TB disease control.
Education
Building on the foundation laid by the Tuberculosis
Academic Award program, the NHLBI is supporting a consortium of five TB
curriculum centers.
- TB Curriculum Coordinating Center: To strengthen,
expand, and increase access to the best ongoing educational and training
opportunities in TB for medical, nursing, and allied health schools, especially
those that provide primary care to communities where TB is endemic and the
population is at high risk of developing TB.
Blood Diseases
The NHLBI supports basic and clinical research on SCD
and Cooley's anemia with the goal of curing the disorders and improving patient
care.
Sickle Cell Disease
Basic Research
SCD is an inherited blood disorder that produces
chronic anemia, periodic episodes of pain, and end organ damage. It affects
about 1 in 500 blacks and 1 in 1,000 Hispanics. Since 1972, the NHLBI has
supported an extensive research program to improve understanding of the
pathophysiology of SCD, identify better approaches for its diagnosis and
treatment, and prevent complications.
Basic and translational research currently focuses on
gaining an improved understanding of the expression of beta globins,
elucidating the complex mechanisms of cell adhesion and vaso-occlusion,
discovering genes that regulate fetal hemoglobin, describing the genetic
factors that are responsible for the wide spectrum of clinical severity, and
developing a prospective program for gene therapy.
Specific NHLBI initiatives include:
- Comprehensive Sickle Cell Centers Program (see
Chapter 9): To conduct basic and clinical research,
deliver state-of-the-art patient care, offer educational activities for
patients and health professionals, perform community outreach, and provide
genetic counseling services. Ongoing activities include collaborative Phase II
drug trials, neurocognitive and neuroimaging studies, a collaborative data and
clinical registry, and an epidemiology study of priapism.
- Pulmonary Complications of Sickle Cell Disease: To
stimulate collaborative translational research on the pulmonary complications
of SCD. Researchers in hematology and pulmonary science, using a combination of
basic and clinical approaches, will investigate the major known pulmonary
complications of SCD due to acute chest syndrome, pulmonary hypertension,
and oxyhemoglobin desaturation.
Two trans-NHLBI initiatives support research in
SCD:
- Genome-Wide Association Studies To Identify
Genetic Components That Relate to Heart, Lung, and Blood Diseases (see page
51): To investigate common genes involved in subphenotypes of SCD and
centenarians. Scientists are seeking to identify genetic associations with
specific clinical features in the two populations and subsequently compare the
two datasets for differences and similarities. Research results could lead to
improved treatment for SCD and increase our understanding of the genetic
components that enhance healthy aging.
- Ancillary Studies in Clinical Trials (see page
50): To identify genetic variations underlying Rh antigenic diversity in
patients with SCD. Research findings will be used to develop high throughput
microchips with which to screen for matching donors and recipients prior to
blood transfusion. Knowledge of the genetic basis for compatibility between
donors and SCD patients for transfusion could contribute to preventing
alloimmunization and improve SCD patient care.
Basic research advances reported in FY 2007
include:
- Confirmation in a sickle cell mouse model of the
link between pulmonary hypertension, hemolysis, and the nitric oxide pathway.
The model will allow for the study of pulmonary vasculature during different
stages of development, providing opportunities for testing of hypotheses
related to development of pulmonary hypertension, a common complication of SCD
associated with early mortality. It will facilitate the evaluation of future
therapies to prevent or combat pulmonary hypertension.
- Identification of genetic risk factors for
priapism in adults with SCD. Using single-nucleotide polymorphisms, researchers
found four genes important in cell adhesion, inflammation, cell signaling, or
coagulation that are highly correlated with this painful condition. Finer
analyses of these genetic factors may lead to a greater understanding of the
risk conferred by individual gene variants or groups of such variants.
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Clinical Research
The NHLBI is committed to finding improved treatments
and ultimately a cure for SCD and other hemoglobinopathies. Institute-initiated
studies have begun to yield therapies that will alleviate the symptoms of
sickle cell anemia and procedures that should ultimately provide a cure.
- BABY HUG (see Chapter
11): To assess the effectiveness of hydroxyurea in preventing onset of
chronic organ damage in young black children with sickle cell anemia. At
baseline, the trial has demonstrated that spleens and kidneys are already
damaged by 1 year of age.
- SWITCH (see Chapter 9):
To demonstrate that hydroxyurea and phlebotomy can maintain an acceptable
stroke recurrence rate and significantly reduce hepatic iron burden in
comparison to transfusion plus chelation in children who have had overt
stroke.
- Sickle Cell Disease Clinical Research Network (see
Chapter 11): To conduct Phase III randomized
controlled clinical trials to test the efficacy and effectiveness of new
therapies to treat and prevent complications of SCD and, when appropriate,
thalassemia. The interventions will be based on results from basic studies and
Phase I and Phase II clinical trials conducted in such programs as the NHLBI
Comprehensive Sickle Cell Centers Program.
- Sildenafil for Sickle Cell Disease-Associated
Pulmonary Hypertension (see Chapter 11): To test
the effects of 16 weeks of chronic sildenafil therapy on exercise endurance and
pulmonary artery pressure in patients ages 14 years or older with pulmonary
hypertension and SCD. The NHLBI Intramural Vascular Medicine Branch will
participate as one of the nine clinical centers in this trial.
The NHLBI supports several transplant-related clinical
studies that seek to reach minority populations.
- Blood and Marrow Transplant Clinical Trials Network
(see Chapter 11): In collaboration with the NCI, to
perform clinical trials to advance hematopoietic stem cell transplantation. To
reach minority populations, the Network supports bilingual transplant center
personnel and provides public Web pages and educational materials. In addition,
the Network is working with the National Marrow Donor Program to develop
strategies and implement procedures to enhance enrollment of patients from
minority groups.
The Cord Blood Stem Cell Transplantation (COBLT) Study
was completed in 2005. The COBLT bank contained more than 8,000 cord blood
units, approximately 57 percent of them from minority donors. Approximately 30
percent of the COBLT transplant patients were minorities. More than 3,500 of
the COBLT cord blood units are currently available through the National Bone
Marrow Donor Registry for clinical transplantation.
Outcomes Research
For the past several years, the NHLBI has supported
working groups and meetings to understand the health and quality-of-life
obstacles and challenges faced by adults with SCD. Activities to address the
needs of the adult SCD patient community in 2007 include:
- Sickle Cell Disease Health-Related Quality of Life
Questionnaire Project: To develop and validate an instrument to measure
health-related quality of life among adults with SCD.
- Working Group on the Neurobiology of Pain and the
Pharmacogenetics of Opioids in Sickle Cell Disease: To stimulate studies that
will investigate the nature of pain syndromes in patients with SCD and
encourage the inclusion of SCD patients in non-disease specific protocols.
- Thirty-Fifth Anniversary Meeting of the National
Sickle Cell Disease Program/Sickle Cell Disease Association of America: To
discuss the latest scientific advances by leading researchers and the effects
of SCD on patients and on their families and communities.
- A conference grant to examine best practices in
transfusion medicine for patients with SCD: To develop recommendations for the
appropriate use of red blood cells in SCD patients and to devise strategies to
facilitate awareness, acceptance, and implementation of best practices among
providers and patients.
The NHLBI has developed a number of publications on
SCD that target minorities.
- Datos Sobre La Anemia Falciforme (Facts About
Sickle Cell Anemia)
- Fact Sheet: Hydroxyurea in Pediatric Patients With
Sickle Cell Disease
- Facts About Sickle Cell Anemia
- Patient Fact Sheet: The Multicenter Study of
Hydroxyurea in Sickle Cell Anemia (MSH)
- Management and Therapy of Sickle Cell Disease.
Cooley's Anemia
Cooley's anemia is an inherited disorder of red blood
cells that affects primarily people of African, Asiatic Indian, Chinese,
Mediterranean, and Southeast Asian origin. In 2000, the Institute initiated a
program to establish a network of clinical research centers to evaluate new
therapeutic agents. Research efforts include developing oral chelators to
remove iron overload caused by repetitive transfusion therapy, testing drugs to
enhance fetal hemoglobin production, and examining hematopoetic transplantation
and gene therapy approaches to cure the disease. A registry with samples has
been established to foster genomic and proteomic studies. International
collaborations have also been established.
- Thalassemia (Cooley's Anemia) Clinical Research
Network (see Chapter 11): To establish a group of
clinical centers to accelerate research in the management of thalassemia,
standardize existing treatments, and evaluate new ones.
An important advance in the area of basic research
involves the recent identification of the processes by which oxidative stress
affects the regulation of red cell maturation and lifespan—a finding that
affects our understanding of central pathophysiologic processes in thalassemia.
When considered with the ongoing work in the Thalassemia Clinical Research
Network, which is elucidating oxidative stress responses and effects of iron
chelation therapy in patients with thalassemia, this work promises to provide
insight into possible targets for intervention.
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