Greater Acculturation is Associated With Poorer Cardiovascular Health in the Multi-Ethnic Study of Atherosclerosis

A Latent Profile Analysis of COVID-19 and Influenza Vaccine Hesitancy among Economically Marginalized Hispanic Mothers of Children under Five Years of Age in the US

Rates of COVID-19 and influenza vaccine coverage among Hispanic young children continue to be low in comparison to other racial and ethnic groups in the United States. This study utilized a person-centered approach to understand COVID-19 and influenza vaccination hesitancy for young children under the age of five among 309 economically marginalized Hispanic mothers. Drawing on the cultural health belief model, in 2022, following FDA approval of the COVID-19 vaccine for young children, a latent profile analysis was conducted from which three profiles emerged. The Low Acculturation group (Profile 1), was notable for lower acculturation, moderate cultural medical mistrust, lower access to vaccines, and higher financial security. Compared to Profile 1, the two remaining profiles had higher acculturation and lower levels of financial security, but differed in that the High Acculturation group (Profile 2) had higher vaccine accessibility and the Moderate Acculturation group (Profile 3) had higher cultural medical mistrust. Relative to other profiles, Low Acculturation mothers were more likely to plan to vaccinate their child against current and seasonal COVID-19 and seasonal influenza, report that their child's health provider recommended the COVID-19 shot and reported lower COVID-19 and influenza vaccine mistrust. However, they also reported lower vaccine accessibility and moderate levels of cultural medical mistrust. The study highlights the importance of developing person-centered public health strategies that draw on Hispanic cultural values and consider diversity within lower income Hispanic populations to increase future pediatric COVID-19 and flu vaccination coverage among young Hispanic children.

Cardiovascular Risk Factors Among Asian Americans: Perspectives on the Role of Acculturation in Cardiovascular Diseases Health Disparities

The growing prevalence of cardiovascular diseases in the United States (US) has disproportionately affected minority populations more than their white counterparts. A population that is often overlooked is the Asian American population, particularly Southeastern Asian immigrants. Despite having relatively favorable socioeconomic indicators compared to the general US population, Asian Americans, specifically Southeast Asian individuals, face a significant burden of traditional cardiovascular risk factors and are considered a high cardiovascular disease risk group. In addition, most studies have aggregated Asian populations into one major racial group rather than analyzing the different ethnicities among the Asian categorization. While some studies suggest that the acculturation process has some degree of impact on cardiovascular health, there has not been a widely-used tool to measure or ascertain the totality of acculturation. Instead, multiple proxies have been used to measure acculturation, and prior studies have argued for more culturally-tailored acculturation proxies. This paper aims to assess the implications of different acculturation measures on cardiovascular health among Asian Americans, particularly Southeastern Asian immigrants. The following proxies were expanded on in this paper: English spoken at home, length of stay in the US, religiosity and spirituality, and admixed family structures. Previous studies showed that as the length of stay in the US increases, the burden of cardiovascular risk factors increases. However, the impact of English spoken at home, religiosity, and admixed family structure are still inconclusive given the extent of current studies. While most studies suggest that an increase in acculturation increases the risk of cardiovascular disease, it is critical to note that acculturation is a multifaceted process. Therefore, more studies are necessary to appropriately examine the implications of various acculturation processes on cardiovascular risk factors in Asians, specifically Southeastern Asian individuals in the US.

Length of Time in the United States and Cardiometabolic Outcomes Among Foreign and US-Born Black Adults

INTRODUCTION

Among certain immigrant groups, length of time spent living in the United States (LOT) is associated with poor cardiometabolic health. We aimed to evaluate the association between LOT and cardiometabolic outcomes among US Black adults.

METHODS

The National Health Interview Survey is an annual representative survey of non-institutionalized US civilians. We combined 2016-2018 data and included all Black adults (N = 10,034). LOT was defined as the number of years lived in the US, if foreign-born. Obesity, hypertension, diabetes, and high cholesterol were each self-reported. We used logistic regression models to determine whether LOT was associated with cardiometabolic health factors overall and by origin subgroups-US-born non-Hispanic, Hispanic, African-born, and Caribbean/Central American (CA)-born groups.

RESULTS

Our study population was 81% US-born non-Hispanic, 5% Hispanic (both foreign- and US-born), 6% African-born, and 6% Caribbean/CA-born groups. Among Black adults, compared with the US-born, being foreign-born with < 15 years in the US was associated with lower odds of obesity (OR: 0.31, 95%CI: 0.23-0.42) and hypertension (OR: 0.35, 95%CI: 0.24-0.49). In subgroup analyses, Caribbean/CA-born individuals with < 15 years in the US had 64% lower odds of obesity (OR: 0.36, 95%CI 0.15-0.84) and 63% lower odds of hypertension (OR: 0.37, 95%CI 0.15-0.88) compared with those with ≥ 15 years.

CONCLUSION

Shorter LOT was associated with more favorable cardiometabolic health, with differential associations among foreign-born Black adults based on origin. This heterogeneity suggests a need to examine the implications of acculturation in the context of the specific population of interest.

Strategies for Improving Enrollment of Diverse Populations with a Focus on Lipid-Lowering Clinical Trials

PURPOSE OF REVIEW

We review under-representation of key demographic groups in cardiovascular clinical trials, focusing on lipid-lowering trials. We outline multilevel strategies to recruit and retain diverse populations in cardiovascular trials.

RECENT FINDINGS

Barriers to participation in trials occur at the study, participant, health system, sponsor, and policy level, requiring a multilevel approach to effectively increase participation of under-represented groups in research. Increasing the representation of marginalized and under-represented groups in leadership positions in clinical trials can ensure that their perspectives and experiences are considered. Trial design should prioritize patient- and community-indicated needs. Women and individuals from racially/ethnically diverse populations remain under-represented in lipid-lowering and other cardiovascular clinical trials relative to their disease burden in the population. This limits the generalizability of trial results to the broader population in clinical practice. Collaboration between community stakeholders, researchers, and community members can facilitate shared learning about trials and build trust.

Trends of cardiovascular health in Asian American individuals: A national health and nutrition examination survey study

Objective

Oversampling of Asian American individuals in the National Health and Nutrition Examination Survey (NHANES) provides a unique opportunity to assess the population-level cardiovascular health (CVH) in the fastest-growing racial group in the US.

Methods

The Life's Essential 8 (LE8) score and its components were calculated in self-reported Asian American individuals ≥20 years of age and free of cardiovascular disease in the NHANES cycles from 2011-March 2020. Multivariable adjusted linear and logistic regression models were used for analysis.

Results

Among 2,059 Asian American individuals, the weighted mean LE8 score was 69.1 (0.4) with US-born [69.0 (0.8)] and foreign-born individuals [69.1 (0.4)] having similar CVH. From 2011 to March 2020, CVH in the overall population [69.7 (0.8) to 68.1 (0.8); Ptrend: 0.009] and foreign-born individuals [69.7 (0.8) to 67.7 (0.8); Ptrend: 0.005] declined. Decreasing trends were noted in the body mass index score irrespective of stratification and in the blood pressure scores in the overall population and foreign-born Asian American individuals. Compared with US-born individuals, the odds of ideal levels of smoking [ORadj:<5 years: 2.23 (95%CI: 1.45-3.44); 5-15 years: 1.97 (95%CI: 1.27-3.05); 15-30 years: 1.61 (95%CI: 1.11-2.34); ≥30 years: 1.69(95%CI:1.20-2.36)] and diet [ORadj: <5 years: 1.87 (95%CI: 1.26-2.79); 5-15 years: 2.00 (95%CI: 1.38-2.89); 15-30 years: 1.74 (95%CI: 1.14-2.68)] were higher in foreign-born individuals. Foreign-born individuals had lower odds of ideal physical activity levels [ORadj: 5-15 years: 0.55 (95%CI: 0.39-0.79); 15-30 years: 0.68 (95%CI: 0.49-0.95)] and ideal cholesterol levels [ORadj: 5-15 years: 0.59 (95%CI: 0.42-0.82); 15-30 years: 0.54 (95%CI :0.38-0.76); ≥30 years: 0.52 (95%CI: 0.38-0.76)].

Conclusion

The CVH in Asian American individuals declined from 2011 to March 2020. The odds of ideal CVH decreased with increasing duration of stay in the US, with foreign-born individuals residing in the US for ≥30 years having ∼28% lower odds of ideal CVH compared with US-born individuals.

A Longitudinal Study of Acculturation in Context and Cardiovascular Health and Their Effects on Cognition Among Older Latino Adults

Background We previously outlined the importance of considering acculturation within the context of older Latino adults' lived experience (ie, acculturation in context) to better capture contributors to cognitive aging. We now examine this conceptual framework as related to level of and change in cardiovascular health, and whether cardiovascular health modifies previously documented associations of acculturation in context with cognition. Methods and Results Acculturation in context data from 192 Latino participants without dementia at baseline (age ~70 years) were compiled into 3 separate composite scores: acculturation-related (nativity, language-, and social-based preferences), contextually related socioenvironmental (experiences of discrimination, social isolation, social networks), and familism-related (Latino-centric family ethos). A modified American Heart Association's Life's Simple 7 (mLS7; ie, smoking, physical activity, body mass index, blood pressure, total cholesterol, blood glucose) was used to measure cardiovascular health. Mixed effects regressions simultaneously tested the association of all 3 composite scores with total mLS7 adjusting for confounders. Separate models tested whether mLS7 modified associations of the 3 composite scores and cognition. The contextually related socioenvironmental composite score reflecting higher discrimination, higher social isolation, and smaller social networks (estimate=0.22, SE=0.10, P=0.02) and the familism score (estimate=0.16, SE=0.07, P=0.02) both significantly associated with change in total mLS7. The acculturation-related composite was not significantly associated with change in mLS7. No composite was significantly associated with level of mLS7. Total mLS7, however, significantly modified associations between the acculturation-related composite and change in working memory (estimate=-0.02, SE=0.01, P=0.043). Conclusions Acculturation within the context of older Latino adults' lived experience is important for maintaining cardiovascular health, relationships that also affect domain-specific cognitive decline.

COVID-19 Vaccine Hesitancy among Economically Marginalized Hispanic Parents of Children under Five Years in the United States

Hispanic children in the US have high rates of COVID-19-related hospitalizations and deaths. Following FDA emergency approval, COVID-19 vaccination rates for young children under five years have been alarmingly low, especially in border states with significant Hispanic populations. This study identified social and cultural determinants of COVID-19 vaccine hesitancy among economically marginalized Hispanic parents of children under five. In 2022, following FDA approval, 309 Hispanic female guardians in US border states responded to an online survey assessing parental intent to vaccinate their child, demographic characteristics, COVID-19 health and vaccine beliefs, trust in traditional sources of health information, physician and community support, and acculturation to Anglo American norms. The majority (45.6%) did not intend to vaccinate their child or were unsure (22.0%). Kendall’s tau-b indicated vaccine acceptance was negatively associated with COVID-19 specific and general vaccine distrust, belief the vaccine was unnecessary, time living in the U.S., and language acculturation (range tb = −0.13 to −0.44; p = 0.05–0.001) and positively related to trust in traditional resources, doctor’s recommendation, child’s age, household income and parent education (range tb = 0.11 to 0.37; p = 0.05–0.001). This research highlights the importance of COVID-19 vaccination public health strategies that draw on Hispanic cultural values, community partnerships and enhanced pediatrician communication regarding routine and COVID-19-specific vaccinations.

Heterogeneity in Cardiovascular Disease Risk Factor Prevalence Among White, African American, African Immigrant, and Afro-Caribbean Adults: Insights From the 2010-2018 National Health Interview Survey

Background In the United States, Black adults have higher rates of cardiovascular disease (CVD) risk factors than White adults. However, it is unclear how CVD risk factors compare between Black ethnic subgroups, including African Americans (AAs), African immigrants (AIs), and Afro-Caribbeans, and White people. Our objective was to examine trends in CVD risk factors among 3 Black ethnic subgroups and White adults between 2010 and 2018. Methods and Results A comparative analysis of the National Health Interview Survey was conducted among 452 997 participants, examining sociodemographic characteristics and trends in 4 self-reported CVD risk factors (hypertension, diabetes, overweight/obesity, and smoking). Generalized linear models with Poisson distribution were used to obtain predictive probabilities of the CVD risk factors. The sample included 82 635 Black (89% AAs, 5% AIs, and 6% Afro-Caribbeans) and 370 362 White adults. AIs were the youngest, most educated, and least insured group. AIs had the lowest age- and sex-adjusted prevalence of all 4 CVD risk factors. AAs had the highest prevalence of hypertension (2018: 41.9%) compared with the other groups. Overweight/obesity and diabetes prevalence increased in AAs and White adults from 2010 to 2018 (P values for trend <0.001). Smoking prevalence was highest among AAs and White adults, but decreased significantly in these groups between 2010 and 2018 (P values for trend <0.001), as compared with AIs and Afro-Caribbeans. Conclusions We observed significant heterogeneity in CVD risk factors among 3 Black ethnic subgroups compared with White adults. There were disparities (among AAs) and advantages (among AIs and Afro-Caribbeans) in CVD risk factors, suggesting that race alone does not account for disparities in CVD risk factors.

Racial and Ethnic Differences in All-Cause and Cardiovascular Disease Mortality: The MESA Study

BACKGROUND

Despite improvements in population health, marked racial and ethnic disparities in longevity and cardiovascular disease (CVD) mortality persist. This study aimed to describe risks for all-cause and CVD mortality by race and ethnicity, before and after accounting for socioeconomic status (SES) and other factors, in the MESA study (Multi-Ethnic Study of Atherosclerosis).

METHODS

MESA recruited 6814 US adults, 45 to 84 years of age, free of clinical CVD at baseline, including Black, White, Hispanic, and Chinese individuals (2000-2002). Using Cox proportional hazards modeling with time-updated covariates, we evaluated the association of self-reported race and ethnicity with all-cause and adjudicated CVD mortality, with progressive adjustments for age and sex, SES (neighborhood SES, income, education, and health insurance), lifestyle and psychosocial risk factors, clinical risk factors, and immigration history.

RESULTS

During a median of 15.8 years of follow-up, 22.8% of participants (n=1552) died, of which 5.3% (n=364) died of CVD. After adjusting for age and sex, Black participants had a 34% higher mortality hazard (hazard ratio [HR], 1.34 [95% CI, 1.19-1.51]), Chinese participants had a 21% lower mortality hazard (HR, 0.79 [95% CI, 0.66-0.95]), and there was no mortality difference in Hispanic participants (HR, 0.99 [95% CI, 0.86-1.14]) compared with White participants. After adjusting for SES, the mortality HR for Black participants compared with White participants was reduced (HR, 1.16 [95% CI, 1.01-1.34]) but still statistically significant. With adjustment for SES, the mortality hazards for Chinese and Hispanic participants also decreased in comparison with White participants. After further adjustment for additional risk factors and immigration history, Hispanic participants (HR, 0.77 [95% CI, 0.63-0.94]) had a lower mortality risk than White participants, and hazard ratios for Black participants (HR, 1.08 [95% CI, 0.92-1.26]) and Chinese participants (HR, 0.81 [95% CI, 0.60-1.08]) were not significantly different from those of White participants. Similar trends were seen for CVD mortality, although the age- and sex-adjusted HR for CVD mortality for Black participants compared with White participants was greater than all-cause mortality (HR, 1.72 [95% CI, 1.34-2.21] compared with HR, 1.34 [95% CI, 1.19-1.51]).

CONCLUSIONS

These results highlight persistent racial and ethnic differences in overall and CVD mortality, largely attributable to social determinants of health, and support the need to identify and act on systemic factors that shape differences in health across racial and ethnic groups.

Acculturation and Cardiometabolic Abnormalities Among Chinese and Korean Americans

Background

Studies generally show that higher acculturation is associated with greater cardiovascular disease (CVD) risk among immigrants in the United States (US). However, few studies have compared how proxies of acculturation are differentially associated with metabolic abnormalities measured using objective biomarkers, self-reported diagnosis, and medication use, particularly among East Asian Americans.

Methods

Survey data and biomarker measurements collected from random (non-fasting) blood samples of Chinese and Korean immigrants in the US (n = 328) were used to examine the associations between two proxies for acculturation (years living in the US and English speaking proficiency) with three cardiometabolic abnormalities (high triglyceride levels, diabetes, and hypercholesterolemia). Poisson regression models estimated prevalence ratios adjusted for demographic characteristics, socioeconomic factors, and body mass index. Gender, Asian subgroup, and household income were tested as potential effect modifiers.

Results

Living longer in the US was associated with greater likelihood of having high triglycerides. In addition, living longer in the US was associated with greater likelihood of diabetes for people with lower household income and greater likelihood of hypercholesterolemia for people with higher household income. Higher level of English proficiency was less consistently associated with higher cardiometabolic risk, although there was a significant association with greater likelihood of hypercholesterolemia.

Conclusions

Longer time lived in the US is associated with higher risk of cardiometabolic abnormalities among Chinese and Korean Americans. Future studies of acculturation and cardiometabolic risk should carefully consider potential mechanisms and what proxy measures of acculturation capture.

Trial Registration Number

NCT03481296, date of registration: 3/29/2018.

Favorable Cardiovascular Health Is Associated With Lower Prevalence, Incidence, Extent, and Progression of Extracoronary Calcification: MESA

BACKGROUND

Ideal cardiovascular health (CVH) is associated with a lower incidence of cardiovascular disease. Extracoronary calcification (ECC)-measured at the aortic valve, mitral annulus, ascending thoracic aorta, and descending thoracic aorta-is an indicator of systemic atherosclerosis. This study examined whether favorable CVH was associated with a lower risk of ECC.

METHODS

We analyzed data from MESA (Multi-Ethnic Study of Atherosclerosis) participants aged 45 to 84 years without cardiovascular disease at baseline. ECC was measured by noncontrast cardiac computed tomography scan at baseline and after an average of 2.4 years. Prevalent ECC was defined as an Agatston score >0 at the baseline scan. Incident ECC was defined as Agatston score >0 at the follow-up scan among participants with Agatston score of 0 at the baseline scan. Each CVH metric (smoking, physical activity, body mass index, diet, blood pressure, total cholesterol, and blood glucose) was scored 0 to 2 points, with 2 indicating ideal; 1, intermediate; and 0, poor. The aggregated CVH score was 0 to 14 points (0-8, inadequate; 9-10, average; 11-14, optimal). We used Poisson and linear mixed-effects regression models to examine the association between CVH and ECC adjusted for sociodemographic factors.

RESULTS

Of 6504 participants, 53% were women with a mean age (SD) of 62 (10) years. Optimal and average CVH scores were associated with lower ECC prevalence, incidence, and extent. For example, optimal CVH scores were associated with 57%, 56%, 70%, and 54% lower risk of incident aortic valve calcification, mitral annulus calcification, ascending thoracic aorta calcification, and descending thoracic aorta calcification, respectively. In addition, optimal and average CVH scores were associated with lower ECC progression at 2 years, although these associations were only significant for mitral annulus calcification and descending thoracic aorta calcification.

CONCLUSIONS

In this multiethnic cohort, favorable CVH was associated with a lower risk of extracoronary atherosclerosis. These findings emphasize the importance of primordial prevention as an intervention to reduce the burden of cardiovascular disease.

Disparities in the Outcomes Following Ischemic Stroke Between the Floating Population and Indigenous Population of Shanghai

Background and Purposes: Through this study, we hope to gain more insights into the differences in outcome following an ischemic stroke between the floating population and the indigenous population of Shanghai.

Method: In this retrospective cohort study, we analyzed patients with first-ever acute ischemic stroke who were admitted to a comprehensive stroke center in the Minhang district, Shanghai, from January 1, 2019, to December 31, 2020. All patient's demographic data and medical histories were prospectively collected and they were followed up for at least 3 months. The Indigenous population of Shanghai was defined as patients with an identification number starting with 310. All others were treated as floating population. The primary outcome was defined as an unfavorable prognosis at 3 months, with a modified Rankin Scale (mRS) score above 1. Secondary outcomes included the use of emergency medical service (EMS), 3 h arrival rate, and endovascular therapy in eligible patients. Logistic regression analysis was applied to investigate the differences.

Results: Finally, 698 patients with first-ever acute ischemic stroke were included (with mean age of 65.32 years, 74.6% men). Of these, 302 patients belonged to the floating population group. Indigenous populations with ischemic stroke were older than the floating population (68.26 years vs. 61.47 years, P &lt; 0.001). The floating population was more likely to achieve favorable outcomes at 3 months compared with the indigenous population in multivariable logistic regression analysis [Odds ratio (OR): 0.49, 95% CI: 0.32–0.75, P = 0.001]. The use of EMS, 3 h arrival rate, and the application of endovascular therapy were comparable between the floating population and indigenous population (OR: 0.89, 95% CI: 0.62–1.27, P = 0.519; OR: 0.78, 95% CI: 0.56–1.09, P = 0.14; and OR: 0.82, 95% CI: 0.54–1.26, P = 0.365, respectively).

Conclusion: Compared with the indigenous population, the floating population with the first-ever ischemic stroke was more likely to have a favorable outcome at 3 months.

Further understanding of ideal cardiovascular health score metrics and cardiovascular disease

INTRODUCTION

The American Heart Association (AHA) introduced the construct of 'cardiovascular health (CVH)', to focus on primordial prevention to reduce the burden of cardiovascular disease (CVD). The CVH score includes seven health and behavioral metrics (smoking, physical activity, body mass index, diet, total cholesterol, blood pressure, blood glucose), which are characterized as being ideal, intermediate, or poor.

AREAS COVERED

In this review, we describe the utility of the CVH score for monitoring and promoting wellness, overall and by key sociodemographic groups, and for tracking of temporal trends.

EXPERT OPINION

Notably, the seven factors are all modifiable, which differs from 10-year CVD risk scores that include non-modifiable components such as age, sex, and race. Numerous epidemiological studies have shown that achievement of a greater number of ideal CVH metrics is associated with lower incidences of CVD, cardiovascular mortality, and all-cause mortality. Longer duration of favorable CVH is associated with greater longevity and compressed morbidity. Nevertheless, the prevalence of favorable CVH is low, with <20% of U.S. adults meeting ≥5 metrics at ideal levels and significant racial/ethnic disparities persist. Many challenges must be overcome to improve CVH at individual and societal levels if the AHA Impact Goals are to be fully realized.

Greater Acculturation is Associated With Poorer Cardiovascular Health in the Multi-Ethnic Study of Atherosclerosis

Background Greater acculturation is associated with increased risk of cardiovascular disease. However, little is known about the association between acculturation and ideal cardiovascular health (CVH) as measured by the American Heart Association's 7 CVH metrics. We investigated the association between acculturation and ideal CVH among a multi-ethnic cohort of US adults free of clinical cardiovascular disease at baseline. Methods and Results This was a cross-sectional analysis of 6506 men and women aged 45 to 84 years of 4 races/ethnicities. We examined measures of acculturation(birthplace, language spoken at home, and years lived in the United States [foreign-born participants]) by CVH score. Scores of 0 to 8 indicate inadequate, 9 to 10 average and 11 to 14 optimal CVH. We used multivariable regression to examine associations between acculturation and CVH, adjusting for age, sex, race/ethnicity, education, income and health insurance. The mean (SD) age was 62 (10) years, 53% were women, 39% non-Hispanic White-, 26% non-Hispanic Black-, 12% Chinese- and 22% Hispanic-Americans. US-born participants had lower odds of optimal CVH (odds ratio [OR]: 0.63 [0.50-0.79], P<0.001) compared with foreign-born participants. Participants who spoke Chinese and other foreign languages at home had greater odds of optimal CVH compared with those who spoke English (1.91 [1.08-3.36], P=0.03; and 1.65 [1.04-2.63], P=0.03, respectively). Foreign-born participants who lived the longest in the United States had lower odds of optimal CVH (0.62 [0.43-0.91], P=0.02). Conclusions Greater US acculturation was associated with poorer CVH. This finding suggests that the promotion of ideal CVH should be encouraged among immigrant populations since more years lived in the United States was associated with poorer CVH.