Skip to main content
Top
Published in: BMC Public Health 1/2022

Open Access 01-12-2022 | Obesity | Study protocol

Pacific Islands Cohort on Cardiometabolic Health Study: rationale and design

Authors: Rachael T. Leon Guerrero, Margaret P. Hattori-Uchima, Grazyna Badowski, Tanisha F. Aflague, Kathryn Wood, Kristi Hammond, Remedios Perez

Published in: BMC Public Health | Issue 1/2022

Login to get access

Abstract

Background

Pacific Islanders, including those residing in the US Affiliated Pacific Islands (USAPI), experience some of the highest mortality rates resulting from non-communicable diseases (NCDs) worldwide. The Pacific Island Health Officers’ Association declared a Regional State of Health Emergency in 2010 due to the epidemic of NCDs in the USAPI. Obesity, a known risk factor for NCDs, has become an epidemic among both children and adults in Micronesia and other parts of the USAPI. There is some recent information about overweight and obesity (OWOB) among young children in the USAPI, but there is no data looking at the relationship between children and their biological parents. The Pacific Islands Cohort on Cardiometabolic Health (PICCAH) Study aims to collect data on NCD lifestyle factors from two generations of families (n = 600 child-parent dyads or 1,200 participants) living in Guam, Pohnpei, and Palau.

Methods

The PICCAH Study is an epidemiological study using community-based convenience sampling to recruit participants in USAPI of Guam, Palau, and Pohnpei. The goal is to recruit participant dyads consisting of 1 child plus their biological parent in Guam (500 dyads or 1,000 participants), Pohnpei (50 dyads or 100 participants), and Palau (50 dyads or 100 participants). All participants are having the following information collected: demographic, health, and lifestyle information; anthropometry; diet; physical activity; sleep; acanthosis nigricans; blood pressure; and serum levels of fasting plasma glucose, fasting insulin, glycated hemoglobin, total cholesterol, triglycerides, LDL, and HDL.

Discussion

The PICCAH Study is designed to establish the baseline of a generational epidemiologic cohort with an emphasis on cardiometabolic risk, and to better understand the extent of DM and CVD conditions and related risk factors of those living in the USAPI jurisdictions of Guam, Pohnpei, and Palau. This study also serves to further build research capacity in the underserved USAPI Region.
Appendix
Available only for authorised users
Literature
2.
go back to reference World Health Organization, Report GS, on Noncommunicable Diseases. 2014. Geneva: World Health Organization; 2014. World Health Organization, Report GS, on Noncommunicable Diseases. 2014. Geneva: World Health Organization; 2014.
3.
go back to reference World Health Organization, Monitor NDP. 2020. Geneva: World Health Organization; 2020. World Health Organization, Monitor NDP. 2020. Geneva: World Health Organization; 2020.
4.
go back to reference Banjare J, Bhalerao S. Obesity associated noncomunicable disease burden. Int J Health Allied Sci. 2016;5(2):81–7.CrossRef Banjare J, Bhalerao S. Obesity associated noncomunicable disease burden. Int J Health Allied Sci. 2016;5(2):81–7.CrossRef
5.
go back to reference Pacific Island Health Officers Association. Board Resolution #48–01: NCD Regional State of Emergency. Honolulu: PIHOA Initiatives; 2010. Pacific Island Health Officers Association. Board Resolution #48–01: NCD Regional State of Emergency. Honolulu: PIHOA Initiatives; 2010.
7.
go back to reference Underwood J. The native origins of the neo-Chamorros of the Mariana Islands. Micronesia. 1976;12:203–9. Underwood J. The native origins of the neo-Chamorros of the Mariana Islands. Micronesia. 1976;12:203–9.
8.
go back to reference Vilar MG, et al. The origins and genetic distinctiveness of the Chamorros of the Marianas Islands: an mtDNA perspective. Am J Hum Biol. 2013;25(1):116–22.PubMedCrossRef Vilar MG, et al. The origins and genetic distinctiveness of the Chamorros of the Marianas Islands: an mtDNA perspective. Am J Hum Biol. 2013;25(1):116–22.PubMedCrossRef
12.
go back to reference McElfish PA, et al. Best practices for community-engaged participatory research with Pacific Islander communities in the USA and USAPI: protocol for a scoping review. BMJ Open. 2018;8(1): e019653.PubMedPubMedCentralCrossRef McElfish PA, et al. Best practices for community-engaged participatory research with Pacific Islander communities in the USA and USAPI: protocol for a scoping review. BMJ Open. 2018;8(1): e019653.PubMedPubMedCentralCrossRef
13.
go back to reference Worldwide trends in body-mass index. underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017;390(10113):2627–42.CrossRef Worldwide trends in body-mass index. underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017;390(10113):2627–42.CrossRef
14.
go back to reference Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margano C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–81.PubMedPubMedCentralCrossRef Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margano C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–81.PubMedPubMedCentralCrossRef
16.
go back to reference Weihrauch-Blüher S, Wiegand S. Risk Factors and Implications of Childhood Obesity. Curr Obes Rep. 2018;7(4):254–9.PubMedCrossRef Weihrauch-Blüher S, Wiegand S. Risk Factors and Implications of Childhood Obesity. Curr Obes Rep. 2018;7(4):254–9.PubMedCrossRef
17.
go back to reference Singh AS, et al. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev. 2008;9(5):474–88.PubMedCrossRef Singh AS, et al. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev. 2008;9(5):474–88.PubMedCrossRef
19.
go back to reference Simmonds M, et al. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016;17(2):95–107.PubMedCrossRef Simmonds M, et al. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016;17(2):95–107.PubMedCrossRef
21.
go back to reference Ogden CL, et al. Prevalence of Obesity Among Adults and Youth: United States, 2011–2014. NCHS Data Brief. 2015;219:1–8. Ogden CL, et al. Prevalence of Obesity Among Adults and Youth: United States, 2011–2014. NCHS Data Brief. 2015;219:1–8.
22.
go back to reference Leon Guerrero RT, et al. Prevalence and Predictors of Overweight and Obesity among Young Children in the Children’s Healthy Living Study on Guam. Nutrients. 2020;12(9):2527. Leon Guerrero RT, et al. Prevalence and Predictors of Overweight and Obesity among Young Children in the Children’s Healthy Living Study on Guam. Nutrients. 2020;12(9):2527.
23.
go back to reference Afshin A, et al. Health Effects of Overweight and Obesity in 195 Countries over 25 Years. N Engl J Med. 2017;377(1):13–27.PubMedCrossRef Afshin A, et al. Health Effects of Overweight and Obesity in 195 Countries over 25 Years. N Engl J Med. 2017;377(1):13–27.PubMedCrossRef
24.
go back to reference Ogurtsova K, et al. IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract. 2017;128:40–50.PubMedCrossRef Ogurtsova K, et al. IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract. 2017;128:40–50.PubMedCrossRef
25.
go back to reference Snedecor GW, Cochran W. Statistical Methods. 8th ed. Ames, IA: Iowa State University Press.; 1989. Snedecor GW, Cochran W. Statistical Methods. 8th ed. Ames, IA: Iowa State University Press.; 1989.
26.
go back to reference Wilken LR, et al. Children’s Healthy Living (CHL) Program for remote underserved minority populations in the Pacific region: rationale and design of a community randomized trial to prevent early childhood obesity. BMC Public Health. 2013;13:944. Wilken LR, et al. Children’s Healthy Living (CHL) Program for remote underserved minority populations in the Pacific region: rationale and design of a community randomized trial to prevent early childhood obesity. BMC Public Health. 2013;13:944.
27.
go back to reference Kaholokula JK, et al. Association between perceived racism and physiological stress indices in Native Hawaiians. J Behav Med. 2012;35(1):27–37.PubMedCrossRef Kaholokula JK, et al. Association between perceived racism and physiological stress indices in Native Hawaiians. J Behav Med. 2012;35(1):27–37.PubMedCrossRef
28.
go back to reference Kaholokula JK, Iwane MK, Nacapoy AH. Effects of perceived racism and acculturation on hypertension in Native Hawaiians. Hawaii Med J. 2010;69(3):11–5.PubMedPubMedCentral Kaholokula JK, Iwane MK, Nacapoy AH. Effects of perceived racism and acculturation on hypertension in Native Hawaiians. Hawaii Med J. 2010;69(3):11–5.PubMedPubMedCentral
29.
go back to reference Kaholokula JK, et al. Association between acculturation modes and type 2 diabetes among Native Hawaiians. Diabetes Care. 2008;31(4):698–700.PubMedCrossRef Kaholokula JK, et al. Association between acculturation modes and type 2 diabetes among Native Hawaiians. Diabetes Care. 2008;31(4):698–700.PubMedCrossRef
30.
go back to reference Center for Disease Control and Prevention. National health and nutrition examination survey food security questionnaire. US Department of Health and Human Services. Hyattsville: Center for Disease Control and Prevention; 2011. Center for Disease Control and Prevention. National health and nutrition examination survey food security questionnaire. US Department of Health and Human Services. Hyattsville: Center for Disease Control and Prevention; 2011.
31.
go back to reference Centers for Disease Control and Prevention. Behavioral risk factor surveillance system questionnaire, Center for Disease Control and Prevention. Atlanta: US Department of Health and Human Services; 2011. Centers for Disease Control and Prevention. Behavioral risk factor surveillance system questionnaire, Center for Disease Control and Prevention. Atlanta: US Department of Health and Human Services; 2011.
32.
go back to reference Varni JW, et al. PROMIS® Parent Proxy Report Scales: an item response theory analysis of the parent proxy report item banks. Qual Life Res. 2012;21(7):1223–40.PubMedCrossRef Varni JW, et al. PROMIS® Parent Proxy Report Scales: an item response theory analysis of the parent proxy report item banks. Qual Life Res. 2012;21(7):1223–40.PubMedCrossRef
33.
go back to reference Lampard AM, et al. The Activity Support Scale for Multiple Groups (ACTS-MG): Child-reported Physical Activity Parenting in African American and Non-Hispanic White Families. Behav Med. 2016;42(2):112–9.PubMedCrossRef Lampard AM, et al. The Activity Support Scale for Multiple Groups (ACTS-MG): Child-reported Physical Activity Parenting in African American and Non-Hispanic White Families. Behav Med. 2016;42(2):112–9.PubMedCrossRef
34.
35.
go back to reference Buckworth J, Nigg C. Physical activity, exercise, and sedentary behavior in college students. J Am Coll Health. 2004;53(1):28–34.PubMedCrossRef Buckworth J, Nigg C. Physical activity, exercise, and sedentary behavior in college students. J Am Coll Health. 2004;53(1):28–34.PubMedCrossRef
36.
go back to reference McGreavey JA, et al. The Tayside children’s sleep questionnaire: a simple tool to evaluate sleep problems in young children. Child Care Health Dev. 2005;31(5):539–44. McGreavey JA, et al. The Tayside children’s sleep questionnaire: a simple tool to evaluate sleep problems in young children. Child Care Health Dev. 2005;31(5):539–44.
37.
go back to reference Fialkowski MK, et al. Evaluation of dietary assessment tools used to assess the diet of adults participating in the Communities Advancing the Studies of Tribal Nations Across the Lifespan cohort. J Am Diet Assoc. 2010;110(1):65–73.PubMedPubMedCentralCrossRef Fialkowski MK, et al. Evaluation of dietary assessment tools used to assess the diet of adults participating in the Communities Advancing the Studies of Tribal Nations Across the Lifespan cohort. J Am Diet Assoc. 2010;110(1):65–73.PubMedPubMedCentralCrossRef
38.
go back to reference Cook S, Auinger P, Huang TT. Growth curves for cardio metabolic risk factors in children and adolescents. J Pediatr. 2009;155(3):S6.e15-26.CrossRef Cook S, Auinger P, Huang TT. Growth curves for cardio metabolic risk factors in children and adolescents. J Pediatr. 2009;155(3):S6.e15-26.CrossRef
39.
go back to reference Burke JP, et al. A quantitative scale of acanthosis nigricans. Diabetes Care. 1999;22(10):1655–9.PubMedCrossRef Burke JP, et al. A quantitative scale of acanthosis nigricans. Diabetes Care. 1999;22(10):1655–9.PubMedCrossRef
40.
go back to reference Kolonel LN, et al. A multiethnic cohort in Hawaii and Los Angeles: baseline characteristics. Am J Epidemiol. 2000;151(4):346–57.PubMedCrossRef Kolonel LN, et al. A multiethnic cohort in Hawaii and Los Angeles: baseline characteristics. Am J Epidemiol. 2000;151(4):346–57.PubMedCrossRef
41.
go back to reference Paulino YC, et al. Abstract B15: Development and validation of an areca (betel) nut usage measurement tool for Micronesia. Cancer Epidemiol Biomark Prev. 2014;23(11 Supplement):B15.CrossRef Paulino YC, et al. Abstract B15: Development and validation of an areca (betel) nut usage measurement tool for Micronesia. Cancer Epidemiol Biomark Prev. 2014;23(11 Supplement):B15.CrossRef
42.
go back to reference Booth M. Assessment of physical activity: an international perspective. Res Q Exerc Sport. 2000;71(Suppl 2):114–20.PubMedCrossRef Booth M. Assessment of physical activity: an international perspective. Res Q Exerc Sport. 2000;71(Suppl 2):114–20.PubMedCrossRef
43.
go back to reference Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33(3):335–43.PubMedCrossRef Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33(3):335–43.PubMedCrossRef
44.
go back to reference Davison KK, et al. Measuring parental support for children’s physical activity in white and African American parents: the Activity Support Scale for Multiple Groups (ACTS-MG). Prev Med. 2011;52(1):39–43. Davison KK, et al. Measuring parental support for children’s physical activity in white and African American parents: the Activity Support Scale for Multiple Groups (ACTS-MG). Prev Med. 2011;52(1):39–43.
45.
go back to reference Leon Guerrero RT, et al. Relative validity and reliability of a quantitative food frequency questionnaire for adults in Guam. Food Nutr Res. 2015;59:26276.PubMedCrossRef Leon Guerrero RT, et al. Relative validity and reliability of a quantitative food frequency questionnaire for adults in Guam. Food Nutr Res. 2015;59:26276.PubMedCrossRef
46.
go back to reference Paulino YC, et al. Nutritional characteristics and body mass index of children in the Commonwealth of the Northern Mariana Islands. J Am Diet Assoc. 2008;108(12):2100–4.PubMedCrossRef Paulino YC, et al. Nutritional characteristics and body mass index of children in the Commonwealth of the Northern Mariana Islands. J Am Diet Assoc. 2008;108(12):2100–4.PubMedCrossRef
47.
go back to reference Lohman TG, R.A., Martorell R, Anthropometric standardization reference manual. Champaign. IL: Human Kinetics Books; 1988. Lohman TG, R.A., Martorell R, Anthropometric standardization reference manual. Champaign. IL: Human Kinetics Books; 1988.
48.
go back to reference Ikeda J, Crawford P, Guidelines for collecting heights and weights on children and adolescents in school settings. Berkeley. Berkeley, CA: Universtiy of California; 2000. Ikeda J, Crawford P, Guidelines for collecting heights and weights on children and adolescents in school settings. Berkeley. Berkeley, CA: Universtiy of California; 2000.
49.
go back to reference Center for Disease Control and Prevention, National Center for Health Statistics. Anthropometric procedures. Hyattsville, MD: CDC; 2006. Center for Disease Control and Prevention, National Center for Health Statistics. Anthropometric procedures. Hyattsville, MD: CDC; 2006.
50.
go back to reference Zerfas A, Checking continuous measures: manual for anthropometry. Los Angeles, CA: Division of Epidemiology. University of California: School of Public Health; 1986. Zerfas A, Checking continuous measures: manual for anthropometry. Los Angeles, CA: Division of Epidemiology. University of California: School of Public Health; 1986.
51.
go back to reference Li F, et al. Anthropometric measurement standardization in the US-affiliated pacific: Report from the Children’s Healthy Living Program. Am J Hum Biol. 2016;28(3):364–71. Li F, et al. Anthropometric measurement standardization in the US-affiliated pacific: Report from the Children’s Healthy Living Program. Am J Hum Biol. 2016;28(3):364–71.
52.
go back to reference Barlow S. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(Suppl 4):S164-192.PubMedCrossRef Barlow S. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(Suppl 4):S164-192.PubMedCrossRef
53.
go back to reference Cook S, A P, Huang TT. Growth curves for cardio metabolic risk factors in children and adolescents. J Pediatr. 2009;155(3):S6.e15-26.CrossRef Cook S, A P, Huang TT. Growth curves for cardio metabolic risk factors in children and adolescents. J Pediatr. 2009;155(3):S6.e15-26.CrossRef
54.
go back to reference Food and Nutrition Board. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington DC: National Academy Press; 1997. Food and Nutrition Board. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington DC: National Academy Press; 1997.
55.
go back to reference Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, vitamin B6, Folate, vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington DC: National Academy Press; 1998. Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, vitamin B6, Folate, vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington DC: National Academy Press; 1998.
56.
go back to reference Food and Nutrition Board. Board, Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington DC: National Academy Press; 2001. Food and Nutrition Board. Board, Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington DC: National Academy Press; 2001.
57.
go back to reference Food and Nutrition Board. Dietary Reference Intakes: Application in Dietary Assessment. Washington DC: National Academy Press; 2001. Food and Nutrition Board. Dietary Reference Intakes: Application in Dietary Assessment. Washington DC: National Academy Press; 2001.
58.
go back to reference Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington DC: National Academy Press; 2002. Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids. Washington DC: National Academy Press; 2002.
59.
go back to reference Food and Nutrition Board. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington DC: National Academy Press; 2000. Food and Nutrition Board. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington DC: National Academy Press; 2000.
60.
go back to reference Dixon LB, et al. Adherence to the USDA Food Guide, DASH Eating Plan, and Mediterranean dietary pattern reduces risk of colorectal adenoma. J Nutr. 2007;137(11):2443–50.PubMedCrossRef Dixon LB, et al. Adherence to the USDA Food Guide, DASH Eating Plan, and Mediterranean dietary pattern reduces risk of colorectal adenoma. J Nutr. 2007;137(11):2443–50.PubMedCrossRef
61.
go back to reference Guenther PM, D T, Ingwersen LA, Berline M. The multiple-pass approach for the 24-hour recall in the Continuing Survey of Food Intakes by Individuals (CFSII) 1994–96. Am J Clin Nutr. 1997;65:1316s. Guenther PM, D T, Ingwersen LA, Berline M. The multiple-pass approach for the 24-hour recall in the Continuing Survey of Food Intakes by Individuals (CFSII) 1994–96. Am J Clin Nutr. 1997;65:1316s.
62.
go back to reference Novotny R, N C, McGlone K, Renda G, Jung N, Matsunaga M, Karanja N. Pacific tracker 2 – expert system (PacTrac2-ES) behavioural assessment and intervention tool for the pacific kids DASH for health (PacDASH) study. Food Chem. 2013;140(3):471–7.PubMedCrossRef Novotny R, N C, McGlone K, Renda G, Jung N, Matsunaga M, Karanja N. Pacific tracker 2 – expert system (PacTrac2-ES) behavioural assessment and intervention tool for the pacific kids DASH for health (PacDASH) study. Food Chem. 2013;140(3):471–7.PubMedCrossRef
63.
go back to reference Bolland JE, Ward JY, Bolland TW. Improved accuracy of estimating food quantities up to 4 weeks after training. J Am Diet Assoc. 1990;90(10):1402–4 1407.PubMedCrossRef Bolland JE, Ward JY, Bolland TW. Improved accuracy of estimating food quantities up to 4 weeks after training. J Am Diet Assoc. 1990;90(10):1402–4 1407.PubMedCrossRef
64.
go back to reference Murphy S, B C, Novotny R. Pacific tracker (PacTrac): an interactive dietary assessment program at the CRCH website. Hawaii Med J. 2006;65(6):175–8.PubMed Murphy S, B C, Novotny R. Pacific tracker (PacTrac): an interactive dietary assessment program at the CRCH website. Hawaii Med J. 2006;65(6):175–8.PubMed
65.
go back to reference Ettienne R, et al. Validation of the Actical Accelerometer in Multiethnic Preschoolers: The Children’s Healthy Living (CHL) Program. Hawaii J Med Public Health. 2016;75(4):95–100. Ettienne R, et al. Validation of the Actical Accelerometer in Multiethnic Preschoolers: The Children’s Healthy Living (CHL) Program. Hawaii J Med Public Health. 2016;75(4):95–100.
66.
go back to reference Hardin DS. Screening for type 2 diabetes in children with acanthosis nigricans. Diabetes Educ. 2006;32(4):547–52.PubMedCrossRef Hardin DS. Screening for type 2 diabetes in children with acanthosis nigricans. Diabetes Educ. 2006;32(4):547–52.PubMedCrossRef
67.
Metadata
Title
Pacific Islands Cohort on Cardiometabolic Health Study: rationale and design
Authors
Rachael T. Leon Guerrero
Margaret P. Hattori-Uchima
Grazyna Badowski
Tanisha F. Aflague
Kathryn Wood
Kristi Hammond
Remedios Perez
Publication date
01-12-2022
Publisher
BioMed Central
Keywords
Obesity
Obesity
Published in
BMC Public Health / Issue 1/2022
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-022-13783-9

Other articles of this Issue 1/2022

BMC Public Health 1/2022 Go to the issue