Prevalence of diabetes in Mexican Americans, Cubans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey, 1982-1984

Risk Factors for Cardiovascular Disease: Knowledge Gained from the Hispanic Community Health Study/Study of Latinos

PURPOSE OF REVIEW

The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) has made important contributions on the prevalence of and factors associated with cardiovascular disease (CVD) risk factors among diverse Hispanic/Latino adults in the US. This article summarizes the knowledge gained thus far on major CVD risk factors from this landmark study.

RECENT FINDINGS

HCHS/SOL demonstrated the sizeable burdens of CVD risk in all major Hispanic/Latino groups in the US, as well as the marked variations in prevalence of hypertension, hypercholesterolemia, diabetes, obesity, and smoking by sex and background. It also identified sociodemographic, lifestyle, and sociocultural characteristics associated with risk factors. HCHS/SOL has yielded an expanding body of literature on characteristics associated with adverse CVD risk factors in this population. Long-term follow-up of this cohort will shed further light on the observed heterogeneity in CVD risk across Hispanic/Latino groups and identify specific risk/protective factors driving these variations.

Diabetes Screening and Monitoring Among Older Mexican-Origin Populations in the U.S

OBJECTIVE

The purpose of the study is to examine diabetes screening and monitoring among Latino individuals as compared with non-Latino White individuals and to better understand how we can use neighborhood data to address diabetes care inequities.

RESEARCH DESIGN AND METHODS

This is a retrospective observational study linked with neighborhood-level Latino subgroup data obtained from the American Community Survey. We used generalized estimating equation negative binomial and logistic regression models adjusted for patient-level covariates to compare annual rates of glycated hemoglobin (HbA1c) monitoring for those with diabetes and odds of HbA1c screening for those without diabetes by ethnicity and among Latinos living in neighborhoods with low (0.0-22.0%), medium (22.0-55.7%), and high (55.7-98.0%) population percent of Mexican origin.

RESULTS

Latino individuals with diabetes had 18% higher rates of HbA1c testing than non-Latino White individuals with diabetes (adjusted rate ratio [aRR] 1.18 [95% CI 1.07-1.29]), and Latinos without diabetes had 25% higher odds of screening (adjusted odds ratio 1.25 [95% CI 1.15-1.36]) than non-Latino White individuals without diabetes. In the analyses in which neighborhood-level percent Mexican population was the main independent variable, all Latinos without diabetes had higher odds of HbA1c screening compared with non-Latino White individuals, yet only those living in low percent Mexican-origin neighborhoods had increased monitoring rates (aRR 1.31 [95% CI 1.15-1.49]).

CONCLUSIONS

These findings reveal novel variation in health care utilization according to Latino subgroup neighborhood characteristics and could inform the delivery of diabetes care for a growing and increasingly diverse Latino patient population. Clinicians and researchers whose work focuses on diabetes care should take steps to improve equity in diabetes and prevent inequity in treatment.

Diabetes Incidence Among Hispanic/Latino Adults in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

OBJECTIVE

To examine diabetes incidence in a diverse cohort of U.S. Hispanic/Latinos.

RESEARCH DESIGN AND METHODS

The Hispanic Community Health Study/Study of Latinos is a prospective cohort study with participants aged 18-74 years from four U.S. metropolitan areas. Participants were assessed for diabetes at the baseline examination (2008-2011), annually via telephone interview, and at a second examination (2014-2017).

RESULTS

A total of 11,619 participants returned for the second examination. The overall age-adjusted diabetes incidence rate was 22.1 cases/1,000 person-years. The incidence was high among those with Puerto Rican and Mexican backgrounds as well as those aged ≥45 years and with a BMI ≥30 kg/m2. Significant differences in diabetes awareness, treatment, and health insurance coverage, but not glycemic control, were observed across Hispanic/Latino background groups, age groups, and BMI categories.

CONCLUSIONS

Differences in diabetes incidence by Hispanic/Latino background, age, and BMI suggest the susceptibility of these factors.

Disaggregation of Cause-Specific Cardiovascular Disease Mortality Among Hispanic Subgroups

Importance

Hispanics are the largest minority group in the United States and face a disproportionate burden of risk factors for cardiovascular disease (CVD) and low socioeconomic position. However, Hispanics paradoxically experience lower all-cause mortality rates compared with their non-Hispanic white (NHW) counterparts. This phenomenon has been largely observed in Mexicans, and whether this holds true for other Hispanic subgroups or whether these favorable trends persist over time remains unknown.

Objective

To disaggregate a decade of national CVD mortality data for the 3 largest US Hispanic subgroups.

Design, Setting, and Participants

Deaths from CVD for the 3 largest US Hispanic subgroups-Mexicans, Puerto Ricans, and Cubans-compared with NHWs were extracted from the US National Center for Health Statistics mortality records using the underlying cause of death based on coding from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (I00-II69). Mortality data were evaluated from January 1, 2003, to December 31, 2012. Population estimates were calculated using linear interpolation from the 2000 and 2010 US Census reports. Data were analyzed from November 2015 to July 2016.

Main Outcomes and Measures

Mortality due to CVD.

Results

Participants included 688 074 Mexican, 163 335 Puerto Rican, 130 397 Cuban, and 19 357 160 NHW individuals (49.0% men and 51.0% women; mean [SD] age, 75 [15] years). At the time of CVD death, Mexicans (age, 67 [18] years) and Puerto Ricans (age, 68 [17] years) were younger compared with NHWs (age, 76 [15] years). Mortality rates due to CVD decreased from a mean of 414.2 per 100 000 in 2003 to 303.3 per 100 000 in 2012. Estimated decreases in mortality rate for CVD from 2003 to 2012 ranged from 85 per 100 000 for all Hispanic women to 144 per 100 000 for Cuban men, but rate differences between groups vary substantially, with Puerto Ricans exhibiting similar mortality patterns to NHWs, and Mexicans experiencing lower mortality. Puerto Ricans experienced higher mortality rates for ischemic and hypertensive heart disease compared with other subgroups, whereas Mexicans experienced higher rates of cerebrovascular disease deaths.

Conclusions and Relevance

Significant differences in CVD mortality rates and changes over time were found among the 3 largest Hispanic subgroups in the United States. Findings suggest that the current aggregate classification of Hispanics masks heterogeneity in CVD mortality reporting, leading to an incomplete understanding of health risks and outcomes in this population.

Epithelial ovarian cancer mortality among Hispanic women: Sub-ethnic disparities and survival trend across time: An analysis of SEER 1992-2013

BACKGROUND

Over the past half century the proportion of Hispanics in the US population has been steadily increasing, and groups of Hispanic origin have diversified. Despite notable racial and ethnic disparities in ovarian cancer (OC) mortality, population-based studies on OC among Hispanic females are lacking.

OBJECTIVES

To examine sub-ethnic disparities in OC mortality and survival trends using the Surveillance, Epidemiology, and End Results Program (SEER) 18 data on Hispanic women diagnosed with epithelial OC during 1992-2013.

METHODS

The disparities in OC 5 year survival and mortality were examined using log-rank tests and Cox proportional hazards models, adjusted for sociodemographic and pathological characteristics, time of diagnosis, receipt of resection surgery and county socioeconomic status. Trends in 5-year survival rates were examined using joinpoint regression models.

RESULTS

The 5-year survival was lowest in Puerto Ricans (median survival: 33 months; survival rate: 31.07%) and was highest in the "Other" Hispanic subgroup (median survival: 59 months; survival rate: 49.14%) (log-rank test: P < 0.001). The OC-specific death hazards in Mexicans (HR_adj: 0.82, 95%CI: 0.67-1.00, P = 0.048), South or Central Americans (HR_adj: 0.77, 95%CI: 0.62-0.96, P = 0.005) and Other Hispanics (HR_adj: 0.76, 95%CI: 0.63-0.92, P = 0.038) were significantly lower than for Puerto Ricans. Mortality rates of Cubans and Puerto Ricans were not significantly different. During 1992-2008, there were non-significant increasing trends in the 5-year all-cause and OC-specific survival rates: from 43.37% to 48.94% (APC = 0.41, P = 0.40) and from 48.72% to 53.46% (APC = 0.29, P = 0.50), respectively.

CONCLUSIONS

OC mortality in Hispanic patients varied by sub-ethnicity. This heterogeneity should be considered in future cancer data collection, reports and research.

From Sea to Shining Sea and the Great Plains to Patagonia: A Review on Current Knowledge of Diabetes Mellitus in Hispanics/Latinos in the US and Latin America

The past two decades have witnessed many advances in the prevention, treatment, and control of diabetes mellitus (DM) and its complications. Increased screening has led to a greater recognition of type 2 diabetes mellitus (type 2 DM) and prediabetes; however, Hispanics/Latinos, the largest minority group in the US, have not fully benefited from these advances. The Hispanic/Latino population is highly diverse in ancestries, birth places, cultures, languages, and socioeconomic backgrounds, and it populates most of the Western Hemisphere. In the US, the prevalence of DM varies among Hispanic/Latino heritage groups, being higher among Mexicans, Puerto Ricans, and Dominicans, and lower among South Americans. The risk and prevalence of diabetes among Hispanics/Latinos are significantly higher than in non-Hispanic Whites, and nearly 40% of Hispanics/Latinos with diabetes have not been formally diagnosed. Despite these striking facts, the representation of Hispanics/Latinos in pharmacological and non-pharmacological clinical trials has been suboptimal, while the prevalence of diabetes in these populations continues to rise. This review will focus on the epidemiology, etiology and prevention of type 2 DM in populations of Latin American origin. We will set the stage by defining the terms Hispanic, Latino, and Latin American, explaining the challenges identifying Hispanics/Latinos in the scientific literature and databases, describing the epidemiology of diabetes-including type 2 DM and gestational diabetes mellitus (GDM)-and cardiovascular risk factors in Hispanics/Latinos in the US and Latin America, and discussing trends, and commonalities and differences across studies and populations, including methodology to ascertain diabetes. We will discuss studies on mechanisms of disease, and research on prevention of type 2 DM in Hispanics/Latinos, including women with GDM, youth and adults; and finalize with a discussion on lessons learned and opportunities to enhance research, and, consequently, clinical care oriented toward preventing type 2 DM in Hispanics/Latinos in the US and Latin America.

Susceptibility background for type 2 diabetes in eleven Mexican Indigenous populations: HNF4A gene analysis

The genetic risk of developing type 2 diabetes (T2D) increases in parallel with the proportion of Native American ancestry. Mestizo Mexicans have a 70% Native Amerindian genetic background. The T130I polymorphism in the HNF4A gene has been associated with early-onset T2D in mestizo Mexicans. Thus, the aim of the present study was to evaluate the frequency and relationship of the T130I variant in the HNF4A gene with risk factors for developing T2D in eleven indigenous groups from Mexico. In two groups, all exons of the HNF4A gene were directly sequenced; in the remaining the T130I polymorphism was analyzed by restriction fragment length polymorphism. Ancestry informative markers were assessed to confirm the Amerindian component. An additional analysis of EHH was carried out. Interestingly, HNF4A gene screening revealed only the presence of the T130I polymorphism. The range frequency of the risk allele (T) in the indigenous groups was from 2.7 to 16%. Genotypic frequencies (T130I/I130I) were higher and significantly different from those of all of the populations included in the HapMap Project (P < 0.005). EHH scores suggest a positive selection for T130I polymorphism. Metabolic traits indicate a relationship between the T130I/I130I genotypes with high triglyceride concentrations in the indigenous groups (P < 0.005). These results strongly suggest that the high frequency of the T130I polymorphism and its biological relationship with dysfunction in lipid metabolism in Mexican indigenous groups is a risk factor for the developing of T2D in Mexicans.

The Diabetes Disparity and Puerto Rican Identified Individuals

Purpose

The purpose of this systematic review was to describe what is known about the diabetes disparity affecting Puerto Rican identified adults living in the continental United States as well as illuminate areas that merit further investigation.

Methods

The CINAHL and PubMed databases were searched using the keywords Hispanic, Puerto Rican, and type 2 diabetes. Search limits included < 10-year-old, peer-reviewed, systematic reviews, available in the English language. The abstracts of 124 articles were reviewed, and 7 articles were reviewed in depth.

Results

The Puerto Rican identified Hispanic subgroup is disproportionately affected by diabetes—the diabetes disparity. Puerto Rican identified Hispanic adults are less affected by citizenship status, may be less affected by English proficiency, use health care services differently, and have contextually different fatalistic views of diabetes compared with other Hispanic identified people. Spiritual/religious influences, associated mental health problems, and general cultural practices related to diabetes self-care are understudied in this group.

Conclusion

Ambiguous use of the term Hispanic should be avoided when describing Hispanic subgroups. Stronger, more robust studies are needed to understand the unique cultural forces influencing the poor diabetes outcomes and individual behaviors that contribute to generally suboptimal diabetes self-care for Puerto Rican adults with type 2 diabetes.

Detecting prediabetes among Hispanics/Latinos from diverse heritage groups: Does the test matter? Findings from the Hispanic Community Health Study/Study of Latinos

The objectives of this analysis were to compare the ability of fasting plasma glucose (FPG), post oral load plasma glucose (2hPG), and hemoglobin A_1c (HbA_1c) to identify U.S. Hispanic/Latino individuals with prediabetes, and to assess its cardiovascular risk factor correlates. This is a cross-sectional analysis of baseline data from 15,507 adults without self-reported diabetes mellitus from six Hispanic/Latino heritage groups, enrolled in the Hispanic Community Health Study/Study of Latinos, which takes place in four U.S. communities. The prevalence of prediabetes was determined according to individual or combinations of ADA-defined cut points: FPG=5.6-7.0mmol/L, 2hPG=7.8-11.1mmol/L, and HbA_1c=5.7%-6.4% (39-46mmol/mol). The sensitivity of these criteria to detect prediabetes was estimated. The prevalence ratios (PRs) for selected cardiovascular risk factors were compared among alternative categories of prediabetes versus normoglycemia [FPG<5.6mmol/L and 2hPG<7.8mmol/L and HbA_1c<5.7% (39mmol/mol)]. Approximately 36% of individuals met any of the ADA prediabetes criteria. Using 2hPG as the gold standard, the sensitivity of FPG was 40.1%, HbA_1c was 45.6%, and that of HbA_1c+FPG was 62.2%. The number of significant PRs for cardiovascular risk factors was higher among individuals with isolated 2hPG=7.8-11.1mmol/L, FPG=5.6-7.0mmol/L+HbA_1c=5.7%-6.4%, or those who met the three prediabetes criteria. Assessing FPG, HbA_1c, and cardiovascular risk factors in Hispanics/Latinos at risk might enhance the early prevention of diabetes mellitus and cardiovascular complications in this young and growing population, independent of their heritage group.

The Perspectives of Six Latino Heritage Groups About Their Health Care

The Latino population in the US is projected to grow substantially in the years ahead. Although often referred to as a single group, Latinos are not homogeneous. This article, based mainly on a national telephone survey of 1,478 Latino adults, examines the perspectives of six Latino heritage groups on the health care issues they face. The six groups differ in their reported health care experiences in: the types facilities they use in getting medical care, their ratings of the quality of care they receive, their experiences with discrimination in getting quality care, the level of confidence they have in being able to pay for a major illness. One thing the heritage groups agree on is that diabetes is the biggest health problem facing their families. Community health leaders, particularly at the state level, need to focus on the specific Latino groups in their state or area and their unique situations.

Prevalence of periodontitis according to Hispanic or Latino background among study participants of the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanics and Latinos are an ethnically heterogeneous population with distinct oral health risk profiles. Few study investigators have examined potential variation in the burden of periodontitis according to Hispanic or Latino background.

METHODS

The authors used a multicenter longitudinal population-based cohort study to examine the periodontal health status at screening (2008-2011) of 14,006 Hispanic and Latino adults, aged 18 to 74 years, from four U.S. communities who self-identified as Cuban, Dominican, Mexican, Puerto Rican, Central American or South American. The authors present weighted, age-standardized prevalence estimates and corrected standard errors of probing depth (PD), attachment loss (AL) and periodontitis classified according to the case definition established by the Centers for Disease Control and Prevention and the American Academy of Periodontology (CDC-AAP). The authors used a Wald χ(2) test to compare prevalence estimates across Hispanic or Latino background, age and sex.

RESULTS

Fifty-one percent of all participants had exhibited total periodontitis (mild, moderate or severe) per the CDC-AAP classification. Cubans and Central Americans exhibited the highest prevalence of moderate periodontitis (39.9 percent and 37.2 percent, respectively). Across all ages, Mexicans had the highest prevalence of PD across severity thresholds. Among those aged 18 through 44 years, Dominicans consistently had the lowest prevalence of AL at all severity thresholds.

CONCLUSIONS

Measures of periodontitis varied significantly by age, sex and Hispanic or Latino background among the four sampled Hispanic Community Health Study/Study of Latinos communities. Further analyses are needed to account for lifestyle, behavioral, demographic and social factors, including those related to acculturation.

PRACTICAL IMPLICATIONS

Aggregating Hispanics and Latinos or using estimates from Mexicans may lead to substantial underestimation or overestimation of the burden of disease, thus leading to errors in the estimation of needed clinical and public health resources. This information will be useful in informing decisions from public health planning to patient-centered risk assessment.

A Cross-sectional Study of Depressive Symptoms and Diabetes Self-care in African Americans and Hispanics/Latinos With Diabetes: The Role of Self-efficacy

PURPOSE

The purpose of this study is to examine the relationship between depressive symptoms and diabetes self-care in African American and Hispanic/Latino patients with type 2 diabetes and whether the association, if any, is mediated by diabetes-related self-efficacy.

METHODS

The sample included self-report baseline data of African American and Hispanic/Latino patients with type 2 diabetes who were aged ≥18 years and enrolled in a diabetes self-management intervention study. Depressive symptoms were assessed with the 9-item Patient Health Questionnaire. The Summary of Diabetes Self-care Activities measured engagement in healthy eating, physical activity, blood glucose checking, foot care, and smoking. The Diabetes Empowerment Scale-Short Form assessed diabetes-related psychosocial self-efficacy. Indirect effects were examined with the Baron and Kenny regression technique and Sobel testing.

RESULTS

Sample characteristics (n = 250) were as follows: mean age of 53 years, 68% women, 54% African American, and 74% with income <$20 000. Depressive symptoms showed a significant inverse association with the self-care domains of general diet, specific diet, physical activity, and glucose monitoring in the African American group. In Hispanics/Latinos, depression was inversely associated with specific diet. Self-efficacy served a significant mediational role in the relation between depression and foot care among African Americans.

CONCLUSIONS

Self-efficacy mediated the relationship between depression and foot care in the African American group but was not found to be a mediator of any self-care areas within the Hispanic/Latino group. In clinical practice, alleviation of depressive symptoms may improve self-care behavior adherence. Diabetes education may consider inclusion of components to build self-efficacy related to diabetes self-care, especially among African American patients.

IDENTIFYING PROBABLE DIABETES MELLITUS AMONG HISPANICS/LATINOS FROM FOUR U.S. CITIES: FINDINGS FROM THE HISPANIC COMMUNITY HEALTH STUDY/STUDY OF LATINOS

OBJECTIVE

The aim of this study was to compare the ability of American Diabetes Association (ADA) diagnostic criteria to identify U.S. Hispanics/Latinos from diverse heritage groups with probable diabetes mellitus and assess cardiovascular risk factor correlates of those criteria.

METHODS

Cross-sectional analysis of data from 15,507 adults from 6 Hispanic/Latino heritage groups, enrolled in the Hispanic Community Health Study/Study of Latinos. The prevalence of probable diabetes mellitus was estimated using individual or combinations of ADA-defined cut points. The sensitivity and specificity of these criteria at identifying diabetes mellitus from ADA-defined prediabetes and normoglycemia were evaluated. Prevalence ratios of hypertension, abnormal lipids, and elevated urinary albumin-creatinine ratio for unrecognized diabetes mellitus-versus prediabetes and normoglycemia-were calculated.

RESULTS

Among Hispanics/Latinos (mean age, 43 years) with diabetes mellitus, 39.4% met laboratory test criteria for probable diabetes, and the prevalence varied by heritage group. Using the oral glucose tolerance test as the gold standard, the sensitivity of fasting plasma glucose (FPG) and hemoglobin A1c-alone or in combination-was low (18, 23, and 33%, respectively) at identifying probable diabetes mellitus. Individuals who met any criterion for probable diabetes mellitus had significantly higher (P<.05) prevalence of most cardiovascular risk factors than those with normoglycemia or prediabetes, and this association was not modified by Hispanic/Latino heritage group.

CONCLUSION

FPG and hemoglobin A1c are not sensitive (but are highly specific) at detecting probable diabetes mellitus among Hispanics/Latinos, independent of heritage group. Assessing cardiovascular risk factors at diagnosis might prompt multitarget interventions and reduce health complications in this young population.

ABBREVIATIONS

2hPG = 2-hour post-glucose load plasma glucose ADA = American Diabetes Association BMI = body mass index CV = cardiovascular FPG = fasting plasma glucose HbA1c = hemoglobin A1c HCHS/SOL = Hispanic Community Health Study/Study of Latinos HDL-C = high-density-lipoprotein cholesterol NGT = normal glucose tolerance NHANES = National Health and Nutrition Examination Survey OGTT = oral glucose tolerance test TG = triglyceride UACR = urine albumin-creatinine ratio.

Global Epidemiology of Nonalcoholic Fatty Liver Disease and Perspectives on US Minority Populations

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a clinical syndrome predicted to be the next global epidemic affecting millions of people worldwide. The natural course of this disease including its subtype, non-alcoholic steatohepatitis (NASH), is not clearly defined especially in the African-American segment of the US population.

AIMS

To conduct a review of the global epidemiology of NAFLD with emphasis on US minority populations.

METHODS

A thorough search of evidence-based literature was conducted using the Pubmed database and commercial web sources such as Medscape and Google Scholar.

RESULTS

NAFLD and its subtype NASH are becoming the principal cause of chronic liver disease across the world. In the US, Hispanics are the most disproportionately affected ethnic group with hepatic steatosis, and elevated aminotransferase levels, whereas African-Americans are the least affected. Genetic disparities involved in lipid metabolism seem to be the leading explanation for the lowest incidence and prevalence of both NAFLD and NASH in African-Americans.

CONCLUSIONS

The unprecedented rise in the prevalence of NAFLD globally requires an initiation of population cohort studies with long-term follow-up to determine the incidence and natural history of NAFLD and its underrepresentation in African-Americans. Future studies should also focus on the delineation of the interplay between genetic and environmental factors that trigger the development of NAFLD and NASH.

Diagnostic efficacy of random albumin creatinine ratio for detection of micro and macro-albuminuria in type 2 diabetes mellitus

OBJECTIVES

To compare a less cumbersome random albumin creatinine ratio (RACR) with 24-hour urinary albumin excretion (UAE) for detection of renal damage in patients with type 2 diabetes mellitus (T2DM).

METHODS

This retrospective study performed between March 2013 and June 2014 at the Department of Pathology, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia included 122 patients (mean age 54 ± 15, 104 females and 18 males) with T2DM. Urine albumin levels of less than 30 mg/g was considered normal, from 30-300 mg/g considered as micro-albuminuria, and over 300 mg/g considered as macro-albuminuria.

RESULTS

Concordance between the 2 assays was observed in 114 (93.4%) samples. The sensitivity of RACR assay was 100%, specificity was 91.3% with a positive predictive value (PPV) of 95%, and a negative predictive value (NPV) of 100% in micro-albuminuria range. For macro-albuminuria, RACR had a sensitivity of 100%, specificity of 94.1% with PPV of 94% and NPV of 100%. Receiver operating characteristic (ROC) curves analysis cut-off values of 40 mg/g-300 mg/g for micro- and greater than 300 mg/g for macro-albuminuria revealed 100% sensitivity, 97.5% specificity, 95% PPV, and 100% NPV for micro-albuminuria, and 100% sensitivity, 94% specificity, 76% PPV, and 100% NPP for macro-albuminuria. The area under the curve for micro-albuminuria was 100% and 98.2% for macro-albuminuria.

CONCLUSION

Performance of RACR was comparable to 24 hour UAE assay particularly in excluding renal damage in T2DM.

Salivary profile in diabetic patients: biochemical and immunological evaluation

BACKGROUND

The aim of this study was to evaluate the biochemical and immunological characteristics of saliva from diabetic patients compared to non-diabetic adults.

METHODS

Eighty-eight diabetic adults and 39 non-diabetic adults (control) were included in the study. Glucose, urea, calcium, total protein and amylase were determined by a colorimetric method. The levels of secretory IgA and the IgA anti-Streptococcus mutans and anti-insulin IgA antibodies were measured by enzyme-linked immunosorbent assay (ELISA). Caries status was evaluated using the DMFT index.

RESULTS

Glucose, urea, calcium, anti-S. mutans IgA, total IgA, and anti-insulin IgA were significantly higher in diabetic patients, whereas total protein and amylase levels were lower in these patients. There was no positive correlation between blood and salivary glucose levels in either group. Diabetic patients had a higher DMFT index.

CONCLUSIONS

The present study showed for the first time that IgA levels in diabetic patients'saliva, shows correlation with systemic biochemical parameters. Thus the saliva is an useful tool to follow the systemic health status in these patients.

The National Institute on Aging Health Disparities Research Framework

OBJECTIVE

Development of a new framework for the National Institute on Aging (NIA) to assess progress and opportunities toward stimulating and supporting rigorous research to address health disparities.

DESIGN

Portfolio review of NIA's health disparities research portfolio to evaluate NIA's progress in addressing priority health disparities areas.

RESULTS

The NIA Health Disparities Research Framework highlights important factors for health disparities research related to aging, provides an organizing structure for tracking progress, stimulates opportunities to better delineate causal pathways and broadens the scope for malleable targets for intervention, aiding in our efforts to address health disparities in the aging population.

CONCLUSIONS

The promise of health disparities research depends largely on scientific rigor that builds on past findings and aggressively pursues new approaches. The NIA Health Disparities Framework provides a landscape for stimulating interdisciplinary approaches, evaluating research productivity and identifying opportunities for innovative health disparities research related to aging.

The Role of Chronic Disease, Obesity, and Improved Treatment and Detection in Accounting for the Rise in Healthcare Spending Between 1987 and 2011

BACKGROUND

To curb rising healthcare expenditures in the U.S.A., the factors underlying this growth must be well understood.

OBJECTIVE

We aim to explore how chronic disease prevalence, obesity, and improved disease detection and treatment rates contributed to the growth in health spending in the U.S.A. between 1987 and 2011.

METHODS

We use spending decomposition equations to estimate the portion of spending growth attributable to prevalence increases, rising treatment costs, and population growth, respectively. We use two-part models to estimate the portion of prevalence-related spending that is potentially due to obesity. We examine changing diagnosis and treatment rates to assess how much of the growth in spending might be desirable.

RESULTS

We find that the share of total healthcare spending associated with the treatment of chronic disease has risen dramatically from 1987-2011. In particular, we estimate that 77.6% of healthcare spending growth is attributable to patients with four or more chronic conditions. We find that rising obesity levels may explain between 11.4 and 23.5% of the increase in healthcare expenditure for several specific chronic conditions. Diagnosis and treatment rates for chronic disease are improving.

CONCLUSIONS

Individuals with multiple chronic conditions are disproportionately responsible for rising healthcare expenditure. Much of spending growth associated with rising rates of chronic disease can be linked to rising obesity rates. Though much of the growth in spending is generally considered undesirable, disease detection and treatment rates are also rising, suggesting that at least some of the recent growth in healthcare expenditure may be beneficial.

Hispanic Americans living in the United States and their risk for obesity, diabetes and kidney disease: Genetic and environmental considerations

The Hispanic American, the largest minority population in the United States, is at increased risk for obesity, diabetes and end-stage renal disease. Here we review genetic and environmental factors that might account for their increased risk for these conditions. Whereas many environmental and genetic factors have important roles in driving the increased risk for obesity and kidney disease in this population, a case is made that excessive intake of sugary beverages is a contributory cause. Studies focusing on decreasing intake of sugary beverages among the Hispanic American could potentially reduce renal and cardiovascular complications in this population.

The DISTANCE model for collaborative research: distributing analytic effort using scrambled data sets

BACKGROUND

Data-sharing is encouraged to fulfill the ethical responsibility to transform research data into public health knowledge, but data sharing carries risks of improper disclosure and potential harm from release of individually identifiable data.

METHODS

The study objective was to develop and implement a novel method for scientific collaboration and data sharing which distributes the analytic burden while protecting patient privacy. A procedure was developed where in an investigator who is external to an analytic coordinating center (ACC) can conduct original research following a protocol governed by a Publications and Presentations (P&P) Committee. The collaborating investigator submits a study proposal and, if approved, develops the analytic specifications using existing data dictionaries and templates. An original data set is prepared according to the specifications and the external investigator is provided with a complete but de-identified and shuffled data set which retains all key data fields but which obfuscates individually identifiable data and patterns; this" scrambled data set" provides a "sandbox" for the external investigator to develop and test analytic code for analyses. The analytic code is then run against the original data at the ACC to generate output which is used by the external investigator in preparing a manuscript for journal submission.

RESULTS

The method has been successfully used with collaborators to produce many published papers and conference reports.

CONCLUSION

By distributing the analytic burden, this method can facilitate collaboration and expand analytic capacity, resulting in more science for less money.

Challenges in preventing heart disease in hispanics: early lessons learned from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

The challenge of preventing cardiovascular disease (CVD) in US Hispanics depends upon being able to understand and communicate about the diversity within this population in terms of environmental exposures, health behaviors, socio-cultural experiences and genetic background to CVD risk factor profiles and disease burdens. Recent publications from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) launched by the National Institutes of Health (NIH) have begun to accomplish this task. In this article we review some of the HCHS/SOL findings concerning cardiometabolic and other CVD risk factors and relate them to the need for increased access to health care and attention to lifestyle variables including nutrition. A major challenge that needs to be accomplished is to alert our lawmakers, public health officials, health care providers and the Hispanic population at large about how to lighten the CVD risk factor and disease burdens now carried by our Hispanic population.

Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association

BACKGROUND AND PURPOSE

This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA's 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.

METHODS

Writing group members were nominated by the AHA's Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.

CONCLUSIONS

Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.

Cardiovascular disease risk factors in the Hispanic/Latino population: lessons from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Cardiovascular disease (CVD) is one of the leading causes of mortality among Hispanics/Latinos residing in the United States (US), yet despite the rapid growth of this diverse population, there has been a dearth of objective, comprehensive data on prevalence of risk factors for CVD and other chronic diseases. The Hispanic Community Health Study/SOL) is the largest and most comprehensive cohort study to date/SOL) was initiated to address this gap in knowledge. This article reviews existing research on CVD risk factors among Hispanic/Latino adults of diverse background residing in the US, compares findings from HCHS/SOL with other representative samples on prevalence of major CVD risk factors in this population, and discusses the lessons learned thus far from HCHS/SOL. Baseline findings from this study demonstrate that sizeable burdens in CVD risk exist among all major Hispanic/Latino background groups in the US. At the same time, there are marked variations in rates of individual risk factors by Hispanic/Latino background groups. Comprehensive public health policies to lower CVD risk among those who have adverse levels of one or more risk factors, and to prevent development of CVD risk factors in the small proportion free of CVD risk are urgently needed to lower the future burden of CVD among the US Hispanic/Latino population.

Immigrant generation and diabetes risk among Mexican Americans: the Sacramento area Latino study on aging

OBJECTIVES

We examined whether acculturation and immigrant generation, a marker for assimilation, are associated with diabetes risk in an aging Mexican-origin population.

METHODS

We analyzed data on 1789 adults aged 60 to 101 years from the Sacramento Area Latino Study on Aging. We ascertained type 2 diabetes on the basis of diabetic medication use, self-report of physician diagnosis, or a fasting glucose of 126 milligrams/deciliter or greater. Logistic regression modeled prevalent diabetes.

RESULTS

Adjusting for age and gender, we observed significant but divergent associations between immigrant generation, acculturation, and diabetes risk. Relative to first-generation adults, second-generation adults had an odds ratio (OR) of 1.8 (95% confidence interval [CI] = 1.4, 2.4) and third-generation adults had an OR of 2.1 (95% CI = 1.4, 3.1) of having diabetes. Greater US acculturation, however, was associated with a slightly decreased diabetes rate. In the full model adjusting for socioeconomic and lifestyle factors, the association between generation (but not acculturation) and diabetes remained significant.

CONCLUSIONS

Our study lends support to the previously contested notion that assimilation is associated with an increased diabetes risk in Mexican immigrants. Researchers should examine the presence of a causal link between assimilation and health more closely.

Recent advances in the molecular genetics of type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is a complex disease in which both genetic and environmental factors interact in determining impaired β-cell insulin secretion and peripheral insulin resistance. Insulin resistance in muscle, liver and fat is a prominent feature of most patients with T2DM and obesity, resulting in a reduced response of these tissues to insulin. Considerable evidence has been accumulated to indicate that heredity is a major determinant of insulin resistance and T2DM. It is believed that, among individuals destined to develop T2DM, hyperinsulinemia is the mechanism by which the pancreatic β-cell initially compensates for deteriorating peripheral insulin sensitivity, thus ensuring normal glucose tolerance. Most of these people will develop T2DM when β-cells fail to compensate. Despite the progress achieved in this field in recent years, the genetic causes of insulin resistance and T2DM remain elusive. Candidate gene association, linkage and genome-wide association studies have highlighted the role of genetic factors in the development of T2DM. Using these strategies, a large number of variants have been identified in many of these genes, most of which may influence both hepatic and peripheral insulin resistance, adipogenesis and β-cell mass and function. Recently, a new gene has been identified by our research group, the HMGA1 gene, whose loss of function can greatly raise the risk of developing T2DM in humans and mice. Functional genetic variants of the HMGA1 gene have been associated with insulin resistance syndromes among white Europeans, Chinese individuals and Americans of Hispanic ancestry. These findings may represent new ways to improve or even prevent T2DM.

Las generaciones de inmigrantes y sus descendientes y el riesgo de diabetes en la población de los Estados Unidos de origen o ascendencia mexicana: el Estudio sobre Envejecimiento en Latinos del Área de Sacramento (estudio SALSA)

Objetivo. Se investigó si la aculturación de los inmigrantes y sus descendientes y la generación a la que pertenecen, un marcador de la asimilación, se relacionan con el riesgo de diabetes en una población de adultos mayores de ascendencia u origen mexicano.

Métodos. Se analizaron los datos sobre 1 789 adultos de 60 a 101 años de edad del Estudio sobre Envejecimiento en Latinos del Área de Sacramento (estudio SALSA). Se determinó la presencia de diabetes tipo 2 con base en el uso de medicamentos antidiabéticos, la mención por el paciente del diagnóstico de un médico, o una glucosa en ayunas de 126 mg/dL o mayor. Se aplicó un modelo de regresión logística para la prevalencia de diabetes.

Resultados. Tras ajustar por edad y sexo, se observaron asociaciones significativas pero divergentes entre las generaciones de inmigrantes y sus descendientes, la aculturación y el riesgo de diabetes. En relación con los adultos de la primera generación, los de la segunda tuvieron una razón de posibilidades (odds ratio, OR) de padecer diabetes de 1,8 (intervalo de confianza [IC] de 95% = 1,4, 2,4) y los adultos de la tercera generación tuvieron una OR de 2,1 (IC de 95% = 1,4, 3,1). Sin embargo, una mayor aculturación a los Estados Unidos se relacionó con una tasa ligeramente menor de diabetes. En el modelo completo, tras la incorporación de ajustes para tener en cuenta los factores socioeconómicos y del modo de vida, la relación entre la generación y la diabetes seguía siendo significativa, no así la relación de esta última con la aculturación.

Conclusiones. El presente estudio respalda la idea, anteriormente cuestionada, de que la asimilación se relaciona con un mayor riesgo de diabetes entre los inmigrantes de origen mexicano. Los investigadores deben analizar más detalladamente la presencia de una relación causal entre la asimilación y la salud.

Physical activity and gestational weight gain in Hispanic women

OBJECTIVE

Hispanic women have high rates of excessive and inadequate gestational weight gain (GWG) according to Institute of Medicine (IOM) guidelines. Observational studies suggest that physical activity may be associated with GWG but have been conflicting and were largely conducted in non-Hispanic white populations.

METHODS

The association between physical activity and compliance with GWG guidelines, total GWG, and rate of GWG among 1,276 Hispanic participants in Proyecto Buena Salud, a cohort study in Western Massachusetts was prospectively evaluated. The Pregnancy Physical Activity Questionnaire was used to assess pre, early, mid, and late pregnancy physical activity according to both intensity (i.e., sedentary, moderate, and vigorous) and type (i.e., housework/caregiving, occupational, and sports/exercise).

RESULTS

A total of 26.9% of women gained within IOM guidelines, 21.2% had inadequate GWG, and 51.9% experienced excessive GWG. Overall, we did not observe statistically significant associations between type or intensity of physical activity during pre, early, mid, and late pregnancy and inadequate or excessive GWG, total GWG, or rate of GWG.

CONCLUSIONS

In this prospective cohort study of Hispanic women, after controlling for important risk factors, pregnancy physical activity did not appear to be associated with GWG.

Community-based cardiovascular disease prevention to reduce cardiometabolic risk in Latina women: a pilot program

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women, yet significant health disparities exist for high-risk groups, including Latinas, and comprehensive, culturally relevant, and effective prevention intervention models are lacking. We used a systems approach to develop, assess, and pilot a community-based education program for improving outcomes for knowledge/awareness of CVD, cardiometabolic risk, and health behaviors in Latinas.

METHODS

Latinas (n=35, mean age 50) participated in a 4-month community-based bilingual preventive cardiovascular education program. Pre/post analyses were for knowledge/awareness of CVD risk factors, symptoms, calling 911; personal risk factors (smoking, physical inactivity, family history of CVD); clinical parameters (weight, body mass index [BMI], waist, blood pressure, fasting lipids, and glucose); diagnosis of metabolic syndrome (MetS); and serum inflammatory markers (tumor necrosis factor [TNF]-α, high-sensitivity C reactive protein [hsCRP], and interleukin [IL]-12).

RESULTS

Baseline knowledge/awareness was relatively low, risk factors and MetS prevalent, and serum inflammatory markers elevated. Postintervention, participants demonstrated significant (p<0.05) improvements in knowledge of symptoms, risk factors for CVD, calling 911, and knowledge/adoption of heart-healthy behaviors. Clinical health status also improved, especially for serum triglycerides (p<0.05; 21% decline), prevalence of MetS (from 43% to 37% of participants), and serum levels of the proinflammatory TNF-α (from 16.9 ± 1.11 pg/mL to 13.5 ± 0.8 pg/mL, p<0.05).

CONCLUSION

A bilingual culturally appropriate community-based CVD-prevention program based on health education, medical screenings, and empowerment is a successful, effective, adaptable, and replicable model to significantly improve cardiometabolic risk in Latinas.

Physical activity before and during pregnancy and risk of abnormal glucose tolerance among Hispanic women

AIM

Women diagnosed with abnormal glucose tolerance and gestational diabetes mellitus are at increased risk for subsequent type 2 diabetes, with higher risks in Hispanic women. Studies suggest that physical activity may be associated with a reduced risk of these disorders; however, studies in Hispanic women are sparse.

METHODS

We prospectively evaluated this association among 1241 Hispanic participants in Proyecto Buena Salud. The Pregnancy Physical Activity Questionnaire was used to assess pre, early, and mid pregnancy physical activity. Medical records were abstracted for pregnancy outcomes.

RESULTS

A total of 175 women (14.1%) were diagnosed with abnormal glucose tolerance and 57 women (4.6%) were diagnosed with gestational diabetes. Increasing age and body mass index were strongly and positively associated with risk of gestational diabetes. We did not observe statistically significant associations between total physical activity or meeting exercise guidelines and risk. However, after adjusting for age, BMI, gestational weight gain, and other important risk factors, women in the top quartile of moderate-intensity activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio=0.48, 95% Confidence Interval 0.27-0.88, Ptrend=0.03) as compared to those in the lowest quartile. Similarly, women with the highest levels of occupational activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio=0.48, 95% Confidence Interval 0.28-0.85, Ptrend=0.02) as compared to women who were unemployed.

CONCLUSION

In this Hispanic population, total physical activity and meeting exercise guidelines were not associated with risk. However, high levels of moderate-intensity and occupational activity were associated with risk reduction.

Correlates of high perceived stress among pregnant Hispanic women in Western Massachusetts

Prenatal psychosocial stress has been associated with adverse pregnancy outcomes, even after controlling for known risk factors. This paper aims to evaluate correlates of high perceived stress among Hispanic women, a group with elevated rates of stress during pregnancy. We conducted this analysis among 1,426 pregnant Hispanic women using data from Proyecto Buena Salud, a prospective cohort study conducted in Western Massachusetts. Cohen's Perceived Stress Scale (PSS-14) validated in English and Spanish was administered in early (mean = 12.4 weeks gestation), mid (mean = 21.3 weeks gestation) and late (mean = 30.8 weeks gestation) pregnancy at which time bilingual interviewers collected data on socio-demographic, acculturation, behavioral, and psychosocial factors. High perceived stress was defined as a PSS score >30. Young maternal age (odds ratio (OR) = 0.6; 95 % confidence interval (CI) 0.4-0.9 for <19 vs. 19-23 years), pre-pregnancy consumption of alcohol (OR = 2.2; 95 % CI 1.4-3.5 for >12 drinks/month vs. none) and smoking (OR = 2.2; 95 % CI 1.3-3.7 for >10 cigarettes/day vs. none) were associated with high perceived stress during early pregnancy. Furthermore, higher annual household income (OR = 0.4; 95 % CI 0.1-0.9 for >$30,000 vs. <$15,000), greater number of adults in the household (OR = 1.8; 95 % CI 1.1-3.0 for ≥3 vs. 1) and language preference (OR = 0.6; 95 % CI 0.4-0.9 for Spanish vs. English) were associated with high stress during mid-pregnancy. Likewise, annual household income was inversely associated with high stress during late pregnancy. Our results have important implications for incorporation of routine screening for psychosocial stress during prenatal visits and implementation of psychosocial counseling services for women at high risk.

Genome-wide association analysis confirms and extends the association of SLC2A9 with serum uric acid levels to Mexican Americans

Increased serum uric acid (SUA) is a risk factor for gout and renal and cardiovascular disease (CVD). The purpose of this study was to identify genetic factors that affect the variation in SUA in 632 Mexican Americans participants of the San Antonio Family Heart Study (SAFHS). A genome-wide association (GWA) analysis was performed using the Illumina Human Hap 550K single nucleotide polymorphism (SNP) microarray. We used a linear regression-based association test under an additive model of allelic effect, while accounting for non-independence among family members via a kinship variance component. All analyses were performed in the software package SOLAR. SNPs rs6832439, rs13131257, and rs737267 in solute carrier protein 2 family, member 9 (SLC2A9) were associated with SUA at genome-wide significance (p < 1.3 × 10⁻⁷). The minor alleles of these SNPs had frequencies of 36.2, 36.2, and 38.2%, respectively, and were associated with decreasing SUA levels. All of these SNPs were located in introns 3–7 of SLC2A9, the location of the previously reported associations in European populations. When analyzed for association with cardiovascular-renal disease risk factors, conditional on SLC2A9 SNPs strongly associated with SUA, significant associations were found for SLC2A9 SNPs with BMI, body weight, and waist circumference (p < 1.4 × 10⁻³) and suggestive associations with albumin-creatinine ratio and total antioxidant status (TAS). The SLC2A9 gene encodes an urate transporter that has considerable influence on variation in SUA. In addition to the primary association locus, suggestive evidence (p < 1.9 × 10⁻⁶) for joint linkage/association (JLA) was found at a previously-reported urate quantitative trait locus (Logarithm of odds score = 3.6) on 3p26.3. In summary, our GWAS extends and confirms the association of SLC2A9 with SUA for the first time in a Mexican American cohort and also shows for the first time its association with cardiovascular-renal disease risk factors.

Diabetes risk in older Mexican Americans: effects of language acculturation, generation and socioeconomic status

The effect of language acculturation, socioeconomic status (SES), and immigrant generation on development of diabetes among Mexican Americans was evaluated in the Hispanic Established Population for the Epidemiologic Study of the Elderly (HEPESE). HEPESE is a longitudinal cohort study of 3,050 non-institutionalized Mexican Americans aged 65 years at baseline (1993-1994) from 5 Southwestern states. Diabetes incidence was ascertained in 4 follow-up surveys to 2004-05 by respondent self-reported physician-diagnosis of diabetes, high blood glucose, or sugar in the urine. Language of interview, immigrant generation, gender, age, education, family history of diabetes, smoking status, alcohol use, health insurance type and self-reported height and weight were assessed. High socioeconomic status (SES) was defined by high school graduation and non-Medicaid insurance. Cox's proportional hazards models were fit to evaluate the effects of language acculturation, generation and SES on incident diabetes. 845 of 3,050 (27.7%) Mexican Americans had diabetes at baseline and were younger, more educated, and more likely to have health insurance than those without diabetes. Risk of developing diabetes increased for Spanish-speaking respondents with low SES from 1st to 3rd generation (HR = 1.76, 95% CI = 1.02-3.03) and from 2nd to 3rd generation (HR = 2.15, 95% CI = 1.20-3.84). Among English-speaking, high SES participants, generation had a protective effect on developing diabetes: HR = 0.45 (95% CI = 0.22-0.91) when comparing 3rd versus 1st generation. The effect of language acculturation and immigrant generation on incident diabetes is moderated by SES status in HEPESE participants.

Generalization of adiposity genetic loci to US Hispanic women

BACKGROUND:

Obesity is a public health concern. Yet the identification of adiposity-related genetic variants among United States (US) Hispanics, which is the largest US minority group, remains largely unknown.

OBJECTIVE:

To interrogate an a priori list of 47 (32 overall body mass and 15 central adiposity) index single-nucleotide polymorphisms (SNPs) previously studied in individuals of European descent among 3494 US Hispanic women in the Women's Health Initiative SNP Health Association Resource (WHI SHARe).

DESIGN:

Cross-sectional analysis of measured body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) were inverse normally transformed after adjusting for age, smoking, center and global ancestry. WC and WHR models were also adjusted for BMI. Genotyping was performed using the Affymetrix 6.0 array. In the absence of an a priori selected SNP, a proxy was selected (r²⩾0.8 in CEU).

RESULTS:

Six BMI loci (TMEM18, NUDT3/HMGA1, FAIM2, FTO, MC4R and KCTD15) and two WC/WHR loci (VEGFA and ITPR2-SSPN) were nominally significant (P<0.05) at the index or proxy SNP in the corresponding BMI and WC/WHR models. To account for distinct linkage disequilibrium patterns in Hispanics and further assess generalization of genetic effects at each locus, we interrogated the evidence for association at the 47 surrounding loci within 1 Mb region of the index or proxy SNP. Three additional BMI loci (FANCL, TFAP2B and ETV5) and five WC/WHR loci (DNM3-PIGC, GRB14, ADAMTS9, LY86 and MSRA) displayed Bonferroni-corrected significant associations with BMI and WC/WHR. Conditional analyses of each index SNP (or its proxy) and the most significant SNP within the 1 Mb region supported the possible presence of index-independent signals at each of these eight loci as well as at KCTD15.

CONCLUSION:

This study provides evidence for the generalization of nine BMI and seven central adiposity loci in Hispanic women. This study expands the current knowledge of common adiposity-related genetic loci to Hispanic women.

Effect of race on left ventricular ejection fraction decline after initial improvement with beta blockers in patients with non-ischemic cardiomyopathy: a retrospective analysis

Background

Although beta blockers (BBs) are established therapy in heart failure, some patients whose left ventricular ejection fraction (LVEF) initially increases on BB therapy experience a subsequent LVEF decline. This study aimed to evaluate the proportion of patients with non-ischemic cardiomyopathy (NICM) whose LVEF declines while on BB therapy and determine important predictors of LVEF decline.

Methods

A retrospective analysis of 238 patients receiving a BB (carvedilol, metoprolol succinate, or tartrate), with an ejection fraction of ≤40 % and NICM, whose LVEF initially rose ≥5 % after 1 year of BB therapy, was conducted. Post-response LVEF decline ≥5 % to a final LVEF of ≤35 % was evaluated within 4 years of BB initiation.

Results

In our study, we had 52 Caucasians (22 %), 78 Hispanics (33 %), and 108 African Americans (45 %). Overall, 32 patients (13.44 %) had post-response LVEF decline. The nadir LVEF of patients with post-response LVEF decline was 25 % (interquartile range 20–27). Compared with others, Hispanics had lower nadir LVEF (22 %, p < 0.001). Important predictors of LVEF decline were Hispanic race (odds ratio (OR) 6.094, p < 0.001), New York Heart Association (NYHA) class (OR 2.287, p < 0.05), baseline LVEF (OR 1.075, p < 0.05), and age (OR 0.933, p < 0.001).

Conclusion

A significant proportion (13.44 %) of NICM patients with LVEF increase over 1 year of BB therapy experienced subsequent LVEF decline. Race, NYHA class, baseline LVEF, and age are important predictors of this decline.

Effects of β-adrenergic blockade on left ventricular remodeling among Hispanics and African Americans with chronic heart failure

BACKGROUND

Although β-blockers (BBs) have been shown to improve cardiac function, there is individual and ethnic variation in BB clinical response. We examined the effects of BBs on left ventricular remodeling among African Americans (AAs), Hispanics, and Caucasians with systolic heart failure.

HYPOTHESIS

There is ethnic variability in the effects of BBs on cardiac remodeling.

METHODS

There were 185 AAs, 159 Hispanics, and 74 Caucasians selected with ejection fraction ≤ 40% from any etiology. Change in left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimensions (LVEDD), and degree of mitral regurgitation (MR) in response to 1 year of BBs was evaluated retrospectively.

RESULTS

Overall, there was a significant improvement in LVEF, LVEDD, and degree of MR in AAs and Caucasians after 1 year of BBs (P < 0.001 vs baseline). Compared with other races, Hispanics (%) had no significant improvement in LVEDD and degree of MR, and had fewer patients with reverse remodeling: LVEF (42.77%), LVEDD (5.03%), and MR (16.35%). In multivariable analysis, Hispanic and AA race were important predictors of LVEF and LVEDD (P < 0.01) but not MR response.

CONCLUSIONS

Although most patients demonstrated improvement of LVEF, there seems to be ethnic variability in the effects of BBs on cardiac remodeling. Degree of MR and LVEDD failed to show improvement among Hispanics.

Immigrant generation and diabetes risk among Mexican Americans: the Sacramento Area Latino Study on Aging

OBJECTIVES

We examined whether acculturation and immigrant generation, a marker for assimilation, are associated with diabetes risk in an aging Mexican-origin population.

METHODS

We analyzed data on 1789 adults aged 60 to 101 years from the Sacramento Area Latino Study on Aging. We ascertained type 2 diabetes on the basis of diabetic medication use, self-report of physician diagnosis, or a fasting glucose of 126 milligrams/deciliter or greater. Logistic regression modeled prevalent diabetes.

RESULTS

Adjusting for age and gender, we observed significant but divergent associations between immigrant generation, acculturation, and diabetes risk. Relative to first-generation adults, second-generation adults had an odds ratio (OR) of 1.8 (95% confidence interval [CI] = 1.4, 2.4) and third-generation adults had an OR of 2.1 (95% CI = 1.4, 3.1) of having diabetes. Greater US acculturation, however, was associated with a slightly decreased diabetes rate. In the full model adjusting for socioeconomic and lifestyle factors, the association between generation (but not acculturation) and diabetes remained significant.

CONCLUSIONS

Our study lends support to the previously contested notion that assimilation is associated with an increased diabetes risk in Mexican immigrants. Researchers should examine the presence of a causal link between assimilation and health more closely.

Confirming glycemic status in the Diabetes Prevention Program: implications for diagnosing diabetes in high risk adults

AIMS

To examine the ability of fasting plasma glucose (FPG) and/or 2-h glucose to confirm diabetes and to determine the proportion of participants with HbA1c ≥6.5%.

METHODS

Diabetes confirmation rates were calculated after a single elevated FPG and/or 2-h glucose on an oral glucose tolerance test (OGTT) using a confirmatory OGTT performed within 6 weeks.

RESULTS

772 (24%) participants had elevated FPG or 2-h glucose on an OGTT that triggered a confirmation visit. There were 101 triggers on FPG alone, 574 on 2-h glucose alone, and 97 on both. Only 47% of participants who triggered had confirmed diabetes. While the confirmation rate for FPG was higher than that for 2-h glucose, the larger number of 2-h glucose triggers resulted in 87% of confirmed cases triggering on 2-h glucose. Confirmation rates increased to 75% among persons with FPG ≥126 mg/dl and HbA1c ≥6.5%.

CONCLUSIONS

Only half of the persons with elevated FPG and IGT were subsequently confirmed to have diabetes. At current diagnostic levels, more persons trigger on 2-h glucose than on FPG, but fewer of these persons have their diagnoses confirmed. In individuals with FPG ≥126 mg/dl and HbA1c ≥6.5%, the confirmation rate was increased.

Elevated rates of diabetes in Pacific Islanders and Asian subgroups: The Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

We estimated the prevalence and incidence of diabetes among specific subgroups of Asians and Pacific Islanders (APIs) in a multiethnic U.S. population with uniform access to care.

RESEARCH DESIGN AND METHODS

This prospective cohort analysis included 2,123,548 adult members of Kaiser Permanente Northern California, including 1,704,363 with known race/ethnicity (white, 56.9%; Latino, 14.9%; African American, 8.0%; Filipino, 4.9%; Chinese, 4.0%; multiracial, 2.8%; Japanese, 0.9%; Native American, 0.6%; Pacific Islander, 0.5%; South Asian, 0.4%; and Southeast Asian, Korean, and Vietnamese, 0.1% each). We calculated age-standardized (to the 2010 U.S. population) and sex-adjusted diabetes prevalence at baseline and incidence (during the 2010 calendar year). Poisson models were used to estimate relative risks.

RESULTS

There were 210,632 subjects with prevalent diabetes as of 1 January 2010 and 15,357 incident cases of diabetes identified during 2010. The crude diabetes prevalence was 9.9% and the incidence was 8.0 cases per 1,000 person-years and, after standardizing by age and sex to the 2010 U.S. Census, 8.9% and 7.7 cases per 1,000 person-years. There was considerable variation among the seven largest API subgroups. Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3, 15.9, and 16.1%, respectively) and the highest incidence (19.9, 17.2, and 14.7 cases per 1,000 person-years, respectively) of diabetes among all racial/ethnic groups, including minorities traditionally considered high risk (e.g., African Americans, Latinos, and Native Americans).

CONCLUSIONS

High rates of diabetes among Pacific Islanders, South Asians, and Filipinos are obscured by much lower rates among the large population of Chinese and several smaller Asian subgroups.

Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States

CONTEXT

Major cardiovascular diseases (CVDs) are leading causes of mortality among US Hispanic and Latino individuals. Comprehensive data are limited regarding the prevalence of CVD risk factors in this population and relations of these traits to socioeconomic status (SES) and acculturation.

OBJECTIVES

To describe prevalence of major CVD risk factors and CVD (coronary heart disease [CHD] and stroke) among US Hispanic/Latino individuals of different backgrounds, examine relationships of SES and acculturation with CVD risk profiles and CVD, and assess cross-sectional associations of CVD risk factors with CVD.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, prospective, population-based Hispanic Community Health Study/Study of Latinos including individuals of Cuban (n = 2201), Dominican (n = 1400), Mexican (n = 6232), Puerto Rican (n = 2590), Central American (n = 1634), and South American backgrounds (n = 1022) aged 18 to 74 years. Analyses involved 15,079 participants with complete data enrolled between March 2008 and June 2011.

MAIN OUTCOME MEASURES

Adverse CVD risk factors defined using national guidelines for hypercholesterolemia, hypertension, obesity, diabetes, and smoking. Prevalence of CHD and stroke were ascertained from self-reported data.

RESULTS

Age-standardized prevalence of CVD risk factors varied by Hispanic/Latino background; obesity and current smoking rates were highest among Puerto Rican participants (for men, 40.9% and 34.7%; for women, 51.4% and 31.7%, respectively); hypercholesterolemia prevalence was highest among Central American men (54.9%) and Puerto Rican women (41.0%). Large proportions of participants (80% of men, 71% of women) had at least 1 risk factor. Age- and sex-adjusted prevalence of 3 or more risk factors was highest in Puerto Rican participants (25.0%) and significantly higher (P < .001) among participants with less education (16.1%), those who were US-born (18.5%), those who had lived in the United States 10 years or longer (15.7%), and those who preferred English (17.9%). Overall, self-reported CHD and stroke prevalence were low (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively). In multivariate-adjusted models, hypertension and smoking were directly associated with CHD in both sexes as were hypercholesterolemia and obesity in women and diabetes in men (odds ratios [ORs], 1.5-2.2). For stroke, associations were positive with hypertension in both sexes, diabetes in men, and smoking in women (ORs, 1.7-2.6).

CONCLUSION

Among US Hispanic/Latino adults of diverse backgrounds, a sizeable proportion of men and women had adverse major risk factors; prevalence of adverse CVD risk profiles was higher among participants with Puerto Rican background, lower SES, and higher levels of acculturation.

Diabetes control among Hispanics in the action to control cardiovascular risk in diabetes trial

BACKGROUND

Hispanics in the United States represent diverse racial, ethnic, and socioeconomic groups, and manifest heterogeneous cardiovascular risks including diabetes. It is not known if there are residual differences in the control of diabetes among Hispanic groups given uniform access to diabetes care.

OBJECTIVE

To evaluate glucose control differences among Mexicans, Puerto Ricans, and Dominicans receiving substantial diabetes care and support in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

DESIGN

Secondary analysis of data from a randomized trial comparing two treatment strategies: intensive, targeting glycated hemoglobin below 6.0 %, and standard, targeting glycated hemoglobin between 7.0 % and 7.9 %.

PARTICIPANTS

Seven hundred and sixteen Hispanic and 6066 non-Hispanic white participants were recruited from 77 clinical sites across the United States and Canada. There were 243 Mexicans, 199 Puerto Ricans, and 150 Dominicans; and 135 of these Hispanic groups were born in the United States.

MAIN MEASURE

Glycated hemoglobin

RESULTS

Compared to Puerto Ricans, Mexicans were more likely (HR=1.38, CI:0.90-2.10) and Dominicans as likely (HR=1.01, CI:0.66-1.54) to achieve glycated hemoglobin goal in the intensive arm. Participants born in the United States achieved glycated hemoglobin goal at a higher rate than those born elsewhere (HR=1.57, CI:0.99-2.51 in the intensive arm, HR=1.51, CI:0.95-2.43 in the standard arm). These differences were not statistically significant. In the intensive arm, Puerto Ricans (OR=0.47, CI:0.31-0.71), and Dominicans (OR=0.41, CI:0.26-0.66) were less likely than non-Hispanic whites to achieve glycated hemoglobin goal, whereas the difference between non-Hispanic whites and Mexicans was not statistically significant, (OR=0.66, CI:0.43-1.02).

CONCLUSIONS

Hispanic groups, given access to comprehensive diabetes care, differed from each other non-significantly and had a variable divergence from non-Hispanic whites in achieving intensive glycated hemoglobin goal. These differences, if confirmed, could be due to such factors as variable acculturation and functional health literacy levels that were not measured in the ACCORD trial, but should be further explored in future studies.

Sleep disordered breathing, insomnia symptoms, and sleep quality in a clinical cohort of U.S. Hispanics in south Florida

STUDY OBJECTIVES

There is a paucity of information on the epidemiology of sleep disorders among US Hispanics. This study describes the frequency of sleep disordered breathing (SDB) risk, insomnia complaints, poor sleep quality, and daytime somnolence in a clinical cohort of ethnically diverse US Hispanics living in South Florida.

METHODS

We explored the presence of sleep disorders in a cohort of Hispanics seen at primary care, pulmonary, and sleep clinics at the University of Miami and Miami Veterans Affair Medical Center. Participants completed validated questionnaires, evaluating risk of SDB, presence of insomnia symptoms, sleep quality, and daytime sleepiness. Polysomnography was completed on the majority of the sleep clinic participants.

RESULTS

Participants (N = 282; 62% male; mean age 54 ± 15 years; mean BMI 31 ± 6 kg/m(2)) included Hispanics of Cuban, Puerto Rican, Central/South American, and Caribbean heritage. Excessive daytime sleepiness was noted by 45% of participants. Poor sleep quality was reported by 49%; 76% screened high risk for SDB, and 68% had insomnia symptoms. Sleep disorders were more commonly reported in sleep clinic participants; however, 54% of non-sleep clinic participants were high risk for SDB, 35% had insomnia complaints, 28% had poor sleep quality, and 18% reported daytime sleepiness.

CONCLUSIONS

Sleep disorders (including SDB) are common in clinical samples of Hispanics in South Florida. These findings highlight the urgent need for linguistically relevant and culturally responsive screening, awareness and education programs in clinical sleep medicine among US Hispanics.

CITATION

Shafazand S; Wallace DM; Vargas SS; Del Toro Y; Dib S; Abreu AR; Ramos A; Nolan B; Baldwin CM; Fleming L. Sleep disordered breathing, insomnia symptoms, and sleep quality in a clinical cohort of US Hispanics in South Florida. J Clin Sleep Med 2012;8(5):507-514.

Overall health and healthcare utilization among Latino American women in the United States

PURPOSE

The purpose of this study was to examine the chronic conditions, behavioral-mental health and service utilization of Latino American women in the first epidemiologic survey in the United States.

METHODS

Using a national sample (n=1427) from the National Latino and Asian American Study, we assessed and compared the prevalence of overall health and service use in three major subgroups, Cuban, Mexican, and Puerto Rican, and in other Latino American women. Service use included general medical, mental health, and subspecialists.

RESULTS

In physical health, Puerto Rican American women reported the highest rate of asthma, whereas Mexican American women reported the highest rate of diabetes. Cuban American women reported the highest rate of hypertension and heart diseases. Body mass index (BMI) indicated that overweight (BMI 25-29.9 kg/m(2)) and obesity (BMI≥30 kg/m(2)) were prevalent in all three subgroups: two thirds of Mexicans and Puerto Ricans, respectively, and >50% of Cuban Americans. Of the sample, 11.6% rated their mental health status as fair or poor, and 10.8% reported at least one major depressive disorder (MDD) in the past 12 months. Puerto Rican American women had the highest rates on depression, substance abuse, and seeking mental health service, and Cuban American women saw specialists most frequently.

CONCLUSIONS

Patterns of overall health issues varied among Latino American subgroup women, yet they have low rates of healthcare use. It is critical to further examine factors associated with the sex-specific health issues and with their health services underuse.

Diabetic nephropathy among Mexican Americans

The incidence of diabetic nephropathy (DN) is growing rapidly worldwide as a consequence of the rising prevalence of Type 2 diabetes mellitus (T2DM). Among U.S. ethnic groups, Mexican Americans have a disproportionately high incidence and prevalence of DN and associated end-stage renal disease (ESRD). In communities bordering Mexico, as many as 90% of Mexican American patients with ESRD also suffer from T2DM compared to only 50% of non-Hispanic Whites (NHW). Both socio-economic factors and genetic predisposition appear to have a strong influence on this association. In addition, certain pathogenetic and clinical features of T2DM and DN are different in Mexican Americans compared to NHW, raising questions as to whether the diagnostic and treatment strategies that are standard practice in the NHW patient population may not be applicable in Mexican Americans. This article reviews the epidemiology of DN in Mexican Americans, describes the pathophysiology and associated risk factors, and identifies gaps in our knowledge and understanding that needs to be addressed by future investigations.

Factors associated with poor glycemic control in older Mexican American diabetics aged 75 years and older

OBJECTIVE

This study examines the prevalence and correlates of poor glycemic control in Mexican Americans aged 75 years and older with diabetes.

METHODS

Data are from the 5(th) wave (2004-05) of the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE). A total of 2,069 Mexican Americans aged 75 and over were interviewed. Six hundred eighty nine subjects (33.5%) reported having been diagnosed with diabetes and 209 (30.3%) subjects agreed to a blood test of their HbA(1)c level.

RESULTS

Of the 209 diabetic subjects with an HbA(1)c test, 73 (34.9%) had good glycemic control (HbA(1)c <7%) and 136 (65.1%) had poor glycemic control (HbA(1)c >7%). Bivariate analysis revealed that subjects with poor control had longer disease duration, had lower education, used the glucometer more frequently, and had more diabetes-complications when compared to those in the good glycemic control group. Multivariable logistic regression analysis found the following factors associated with poor glycemic control: <8 years of education, foreign-born, smoking, obesity, longer disease duration, daily glucometer use, and having macro-complications.

DISCUSSION

Prevalence of poor glycemic control is very high in this population with very high and rising prevalence of diabetes. Further studies are needed to explore the effect of these and other characteristics on glycemic control among older Mexican Americans and to develop appropriate interventions to improve diabetes outcomes and increase life-expectancy.

Gene-environment interactions in the development of type 2 diabetes: recent progress and continuing challenges

Type 2 diabetes (T2D) is thought to arise from the complex interplay of both genetic and environmental factors. Since the advent of genome-wide association studies (GWAS), we have seen considerable progress in our understanding of the role that genetics and gene-environment interactions play in the development of T2D. Recent work suggests that the adverse effect of several T2D loci may be abolished or at least attenuated by higher physical activity levels or healthy lifestyle, whereas low physical activity and dietary factors characterizing a Western dietary pattern may augment it. However, there still remain inconsistencies warranting further investigation. Lack of statistical power and measurement errors for the environmental factors continue to challenge our efforts for characterizing interactions. Although our recent focus on established T2D loci is reasonable, we may be overlooking many other potential loci not captured by recent T2D GWAS. Agnostic approaches to the discovery of gene and environment interactions may address this possibility, but their application to the field is currently limited and still faces conceptual challenges. Nonetheless, continued investment in gene-environment interaction studies through large collaborative efforts holds promise in furthering our understanding of the interplay between genetic and environmental factors.

Physical activity and dietary behaviors associated with weight gain and impaired glucose tolerance among pregnant Latinas

Pregnancy has been proposed as a critical period for the development of subsequent maternal overweight and/or obesity. Excessive gestational weight gain is, in turn, associated with maternal complications such as cesarean delivery, hypertension, preeclampsia, impaired glucose tolerance, and gestational diabetes mellitus. Although there is substantial evidence that targeting at-risk groups for type 2 diabetes prevention is effective if lifestyle changes are made, relatively little attention has been paid to the prevention of excessive gestational weight gain and impaired glucose tolerance during pregnancy. Latinos are the largest minority group in the United States, with the highest birth and immigration rates of any minority group and are disproportionately affected by overweight and obesity. However, due to cultural factors, socioeconomic factors, and language barriers, Latinos have had limited access to public health interventions that promote healthy lifestyles. Therefore, the objective of this article is to review the scientific evidence regarding the association between physical activity, dietary behaviors, and gestational weight gain and impaired glucose tolerance among Latinas. A second objective is to discuss how lifestyle interventions including weight management through diet and exercise could be successful in reducing the risk of excessive gestational weight gain and gestational diabetes mellitus. Finally, recommendations are provided for future lifestyle intervention programs in this population with a focus on translation and dissemination of research findings.

Genome-wide association studies: Where we are heading?

We have witnessed tremendous success in genome-wide association studies (GWAS) in recent years. Since the identification of variants in the complement factor H gene on the risk of age-related macular degeneration, GWAS have become ubiquitous in genetic studies and have led to the identification of genetic variants that are associated with a variety of complex human diseases and traits. These discoveries have changed our understanding of the biological architecture of common, complex diseases and have also provided new hypotheses to test. New tools, such as next-generation sequencing, will be an important part of the future of genetics research; however, GWAS studies will continue to play an important role in disease gene discovery. Many traits have yet to be explored by GWAS, especially in minority populations, and large collaborative studies are currently being conducted to maximize the return from existing GWAS data. In addition, GWAS technology continues to improve, increasing genomic coverage for major global populations and decreasing the cost of experiments. Although much of the variance attributable to genetic factors for many important traits is still unexplained, GWAS technology has been instrumental in mapping over a thousand genes to hundreds of traits. More discoveries are made each month and the scale, quality and quantity of current work has a steady trend upward. We briefly review the current key trends in GWAS, which can be summarized with three goals: increase power, increase collaborations and increase populations.