Status of Cardiovascular Disease and Stroke in Hispanics/Latinos in the United States: A Science Advisory From the American Heart Association

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.  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.  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.  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.

Related papers:

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



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.



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.



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.



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).



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.

title: Effects of Diabetes and Level of Glycemia on All-Cause and Cardiovascular Mortality: The San Antonio Heart Study
abstract: Although the level of hyperglycemia is clearly a risk factor for microvascular complications in diabetic patients, its role in macrovascular complications remains controversial. We followed 4,875 subjects (65% Mexican-American) for 7–8 years to investigate the effects of diabetes and hyperglycemia on all-cause and cardiovascular disease (CVD) mortality. These end points were also analyzed according to quartiles of baseline fasting plasma glucose among diabetic participants.  The Cox proportional hazards model was used to estimate the relative risks (RRs) for all-cause and CVD mortality.  Diabetes was significantly associated with increased all-cause mortality (RR [95% CI] = 2.1 [1.3–3.5] in men; 3.2 [1.9–5.4] in women) and increased CVD mortality (3.2 [1.4–7.1] in men; 8.5 [2.8–25.2] in women). Among diabetic subjects, those in quartile 4 had a 4.2-fold greater risk of all-cause mortality (P < 0.001) and a 4.7-fold greater risk of CVD mortality (P = 0.01) than those in quartiles 1 and 2 combined. After further adjustment for other potential risk factors, subjects in quartile 4 had a 4.9-fold greater risk of all-cause mortality and a 4.9-fold greater risk of CVD mortality than those in quartiles 1 and 2. In addition, hypertension, current smoking, and cholesterol >6.2 mmol/1 were significant predictors of CVD mortality using Cox models.  We conclude that diabetes is a predictor of both all-cause and CVD mortality in the general population and that both hyperglycemia and common CVD risk factors are important predictors of all-cause and CVD mortality in diabetic subjects.

title: Effects of cigarette smoking, diabetes, high cholesterol, and hypertension on all-cause mortality and cardiovascular disease mortality in Mexican Americans. The San Antonio Heart Study.
abstract: Despite high levels of cardiovascular risk factors, Mexican Americans paradoxically have a lower prevalence of cardiovascular disease. A possible explanation is that conventional cardiovascular risk factors have a lesser impact on this ethnic group. In the present study, a 7- to 8-year follow-up of the San Antonio Heart Study cohort was used to estimate total and cardiovascular disease mortality and their association with baseline risk factors. A total of 2,629 Mexican Americans form the basis of this study, and 1,136 non-Hispanic whites from the same cohort served as the comparison group. The age- and sex-adjusted rates for total death and cardiovascular disease death were somewhat higher in Mexican Americans than non-Hispanic whites (rate ratio for total mortality = 1.4, 95% confidence interval 1.0-2.0; and rate ratio for cardiovascular mortality = 1.3, 95% confidence interval 0.7-2.4). After adjustment for sex, age, and socioeconomic status in multivariate analyses, current smoking, diabetes, high cholesterol, and hypertension were positively associated with all-cause mortality and cardiovascular disease mortality in Mexican Americans. Overall, these risk factors accounted for 45% of all-cause mortality and 55% of cardiovascular disease mortality in this ethnic group. In comparison, the risk factors accounted for 46% of all-cause mortality and 46% of cardiovascular disease mortality in non-Hispanic whites. The authors conclude that cigarette smoking, diabetes, high cholesterol, and hypertension are important predictors of both all-cause and cardiovascular disease deaths in Mexican Americans. There was no evidence for a diminished effect of these risk factors in Mexican Americans.

title: Are Latinos Becoming "White" Folk? And What That Still Says about Race in America
abstract: I use Karen Brodkin's How Jews Became White Folks as an analytic compass to consider the question: Are U.S. Latinos becoming "White"? The purpose of this paper is to meet the question head-on and to help unravel some of the complexity and contradictory issues related to the changing status of a historically marginalized and heterogeneous ethnic group within a society that operates in a Black/White racial binary. My goal is to also describe a social process that may already be under way. The essay explores several indicators that point to this process, including the growing importance of Latinos as consumers for capital accumulation in the neoliberal marketplace, the mounting significance of Latino elites to the American political scene, extant intra-Latino class differences, results of the 2000 U.S. Census, the growing xenophobia against new Latino immigrants, especially racialized indigenos coming across the southwest border, and the enduring power of the American dream, all of which must be interpreted in light of the dramatic and growing decline in the number of "Whites" in America. In this framework, I examine race as racism, and its role in reproducing a class structure where Blackness lurks in the shadows, the marker against which success can be measured and belonging determined. In an effort to anticipate the "dreadfully predictable" patterns and practices of Whiteness, I suggest that the White racial category is likely to expand to include a growing portion of Latinos, particularly those who are "aspiring," assimilated, and "English-proficient." In turn, we are likely to see their ever-growing distance from Blackness as well as from the poorer, "darker," more recent, and undocumented Hispanic indigenos.

title: First marriages in the United States: data from the 2006-2010 National Survey of Family Growth.
abstract: This report shows trends and group differences in current marital status, with a focus on first marriages among women and men aged 15-44 years in the United States. Trends and group differences in the timing and duration of first marriages are also discussed. These data are based on the 2006-2010 National Survey of Family Growth (NSFG). National estimates of probabilities of first marriage by age and probabilities of separation and divorce for women and men's first marriages are presented by a variety of demographic characteristics. Data are compared with similar measures for 1982, 1995, and 2002.



The analyses presented in this report are based on a nationally representative sample of 12,279 women and 10,403 men aged 15-44 years in the household population of the United States. The overall response rate for the 2006-2010 NSFG was 77%-78% for women and 75% for men.



The percentage of women who were currently cohabiting (living with a man in a sexual relationship) rose from 3.0% in 1982 to 11% in 2006-2010; it was higher in some groups, including Hispanic groups, and the less educated. In 2006-2010, women and men married for the first time at older ages than in previous years. The median age at first marriage was 25.8 for women and 28.3 for men. Premarital cohabitation contributed to the delay in first marriage for both women and men.

title: Socioeconomic factors and cardiovascular disease: a review of the literature.
abstract: Despite recent declines in mortality, cardiovascular diseases are the leading cause of death in the United States today. It appears that many of the major risk factors for coronary disease have been identified. Researchers are still learning about different modifiable factors that may influence cardiovascular diseases. Socioeconomic status may provide a new focus. The principal measures of SES have been education, occupation, and income or combinations of these. Education has been the most frequent measure because it does not usually change (as occupation or income might) after young adulthood, information about education can be obtained easily, and it is unlikely that poor health in adulthood influences level of education. However, other measures of SES have merit, and the most informative strategy would incorporate multiple indicators of SES. A variety of psychosocial measures--for example, certain aspects of occupational status--may be important mediators of SES and disease. The hypothesis that high job strain may adversely affect health status has a rational basis and is supported by evidence from a limited number of studies. There is a considerable body of evidence for a relation between socioeconomic factors and all-cause mortality. These findings have been replicated repeatedly for 80 years across measures of socioeconomic level and in geographically diverse populations. During 40 years of study there has been a consistent inverse relation between cardiovascular disease, primarily coronary heart disease, and many of the indicators of SES. Evidence for this relation has been derived from prevalence, prospective, and retrospective cohort studies. Of particular importance to the hypothesis that SES is a risk factor for cardiovascular disease was the finding by several investigators that the patterns of association of SES with coronary disease had changed in men during the past 30 to 40 years and that SES has been associated with the decline of coronary mortality since the mid-1960s. However, the declines in coronary mortality of the last few decades have not affected all segments of society equally. There is some evidence that areas with the poorest socioenvironmental conditions experience later onset in the decline in cardiovascular mortality. A number of studies suggest that poor living conditions in childhood and adolescence contribute to increased risk of arteriosclerosis. Some of these studies have been criticized because of their nature, and others for inadequate control of confounding factors.(ABSTRACT TRUNCATED AT 400

title: Stress-Induced Blood Pressure Reactivity and Incident Stroke in Middle-Aged Men
abstract: Exaggerated blood pressure reactivity to stress is associated with atherosclerosis and hypertension, which are known stroke risk factors, but its relation to stroke is unknown. Previous work also indicates that the association between reactivity and cardiovascular diseases may be influenced by socioeconomic status.  The impact of blood pressure reactivity and socioeconomic status on incident stroke was examined in 2303 men (mean age, 52.8±5.1 years) from a population-based, longitudinal study of risk factors for ischemic heart disease in eastern Finland. Reactivity was calculated as the difference between blood pressure measured during the anticipatory phase of an exercise tolerance test (before exercise) and resting blood pressure, measured 1 week earlier. Mean systolic reactivity was 20 mm Hg (±15.9), and mean diastolic reactivity was 8.6 mm Hg (±8.5). Socioeconomic status was assessed as years of education. One hundred thirteen incident strokes (90 ischemic) occurred in 11.2 (±1.6) years of follow-up.  Men with exaggerated systolic reactivity (≥20 mm Hg) had 72% greater risk of any stroke (relative hazard ratio [RH], 1.72; 95% CI, 1.17 to 2.54) and 87% greater risk of ischemic stroke (RH, 1.87; 95% CI, 1.20 to 2.89) relative to less reactive men. Moreover, men who were high reactors and poorly educated were nearly 3 times more likely to suffer a stroke than better educated, less reactive men (RH, 2.90; 95% CI, 1.66 to 5.08). Adjustment for stroke risk factors had little impact on these associations. Diastolic reactivity was unrelated to stroke risk.  Excessive sympathetic reactivity to stress may be etiologically important in stroke, especially ischemic strokes, and low socioeconomic status confers added risk.

title: Income, Poverty, and Health Insurance Coverage in the United States: 2004
abstract: This US Census Bureau report highlights the increasing poverty and racial inequality in America. In 2004, 45.8 million people did not have health insurance. The poverty rate increased from 12.5 percent in 2003 to 12.7 percent in 2004; 1.1 million more people - a total of 37 million - lived in poverty in 2004. This rise in poverty came despite economic growth and marks the first time on record that household incomes had failed to increase for five straight years. Black households had the lowest median income; 32.7 percent of the Hispanic population was without health insurance.

title: Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease.
abstract: Socioeconomic status (SES) is usually measured by determining education, income, occupation, or a composite of these dimensions. Although education is the most commonly used measure of SES in epidemiological studies, no investigators in the United States have conducted an empirical analysis quantifying the relative impact of each separate dimension of SES on risk factors for disease.



Using data on 2380 participants from the Stanford Five-City Project (85% White, non-Hispanic), we examined the independent contribution of education, income, and occupation to a set of cardiovascular disease risk factors (cigarette smoking, systolic and diastolic blood pressure, and total and high-density lipoprotein cholesterol).



The relationship between these SES measures and risk factors was strongest and most consistent for education, showing higher risk associated with lower levels of education. Using a forward selection model that allowed for inclusion of all three SES measures after adjustment for age and time of survey, education was the only measure that was significantly associated with the risk factors (P less than .05).



If economics or time dictate that a single parameter of SES be chosen and if the research hypothesis does not dictate otherwise, higher education may be the best SES predictor of good health.

title: Socioeconomic status, psychosocial factors, race and nocturnal blood pressure dipping in a Hispanic cohort.
abstract: Little information is available about the relationship of socioeconomic status (SES) to blunted nocturnal ambulatory blood pressure (ABP) dipping among Hispanics and whether this relationship differs by race. We sought to characterize ABP nondipping and its determinants in a sample of Hispanics.



We enrolled 180 Hispanic participants not on antihypertensive medications. SES was defined by years of educational attainment. All participants underwent 24-hour ABP monitoring. A decrease of <10% in the ratio between average awake and average asleep systolic BP was considered nondipping.



The mean age of the cohort was 67.1 ± 8.7, mean educational level was 9.4 ± 4.4 years, and 58.9% of the cohort was female. The cohort was comprised of 78.3% Caribbean Hispanics with the rest from Mexico and Central/South America; 41.4% self-identified as white Hispanic, 34.4% self-identified as black Hispanic, and 24.4% did not racially self- identify. The percentage of nondippers was 57.8%. Educational attainment (10.5 years vs. 8.6 years; P <0.01) was significantly higher among dippers than nondippers. In multivariable analyses, each 1-year increase in education was associated with a 9% reduction in the likelihood of being a nondipper (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84-0.98; P = 0.01). There were significantly greater odds of being a nondipper for black Hispanics than for white Hispanics (OR, 2.83, 95% CI, 1.29-6.23; P = 0.005). Higher SES was significantly protective of nondipping in white Hispanics but not black Hispanics.



These results document a substantial prevalence of nondipping in a cohort of predominantly normotensive Hispanics. Dipping status varied significantly by race. Lower SES is significantly associated with nondipping status, and race potentially impacts on this relation.

title: Higher Education and Children in Immigrant Families
abstract: The increasing role that immigrants and their children, especially those from Latin America, are playing in American society, Sandy Baum and Stella Flores argue, makes it essential that as many young newcomers as possible enroll and succeed in postsecondary education.Immigrant youths from some countries find the doors to the nation's colleges wide open. But other groups, such as those from Latin America, Laos, and Cambodia, often fail to get a post-secondary education. Immigration status itself is not a hindrance. The characteristics of the immigrants, such as their country of origin, race, and parental socioeconomic status, in addition to the communities, schools, and legal barriers that greet them in the United States, explain most of that variation.Postsecondary attainment rates of young people who come from low-income households and, regardless of income or immigration status, whose parents have no college experience are low across the board. Exacerbating the financial constraints is the reality that low-income students and those whose parents have little education are frequently ill prepared academically to succeed in college.The sharp rise in demand for skilled labor over the past few decades has made it more urgent than ever to provide access to postsecondary education for all. And policy solutions, say the authors, require researchers to better understand the differences among immigrant groups. Removing barriers to education and to employment opportunities for undocumented students poses political, not conceptual, problems. Providing adequate funding for postsecondary education through low tuition and grant aid is also straightforward, if not easy to accomplish. Assuring that Mexican immigrants and others who grow up in low-income communities have the opportunity to prepare themselves academically for college is more challenging. Policies to improve the elementary and secondary school experiences of all children are key to improving the postsecondary success of all.

title: Income, Poverty, and Health Insurance Coverage in the United States: 2004
abstract: This US Census Bureau report highlights the increasing poverty and racial inequality in America. In 2004, 45.8 million people did not have health insurance. The poverty rate increased from 12.5 percent in 2003 to 12.7 percent in 2004; 1.1 million more people - a total of 37 million - lived in poverty in 2004. This rise in poverty came despite economic growth and marks the first time on record that household incomes had failed to increase for five straight years. Black households had the lowest median income; 32.7 percent of the Hispanic population was without health insurance.

title: Income, Poverty, and Health Insurance Coverage in the United States: 2004
abstract: This US Census Bureau report highlights the increasing poverty and racial inequality in America. In 2004, 45.8 million people did not have health insurance. The poverty rate increased from 12.5 percent in 2003 to 12.7 percent in 2004; 1.1 million more people - a total of 37 million - lived in poverty in 2004. This rise in poverty came despite economic growth and marks the first time on record that household incomes had failed to increase for five straight years. Black households had the lowest median income; 32.7 percent of the Hispanic population was without health insurance.

title: Black Wealth, White Wealth: A New Perspective on Racial Inequality.
abstract: Black Wealth, White Wealth: A New Perspective on Racial Inequality, by Melvin L. Oliver and Thomas M. Shapiro. New York and Great Britain: Routledge, 1995. 242 pp. $22.95, cloth. Reviewed by Rodney D. Green, Department of Economics, Howard University. Black Wealth, White Wealth opens with an evocative racial comparison of income and wealth which reveals that although half of the top 10 earners in the U.S. are Black, virtually no Blacks are included among the wealthiest 400 Americans. Indeed, the wealth levels for those Blacks who have "made it" into the American middle class are shown to be only 15% of the wealth level of Whites in the same income category. These and other presented data suggest that if Blacks are disadvantaged relative to Whites in terms of income-and they are, earning on average less than 60% of White household incomethen they are completely eclipsed when it comes to wealth. This tale of two middle classes is part of an even bleaker tale of two unequal nations within America, a tale Oliver and Shapiro attribute to three historical processes: the racialization of state policy, the economic detour, and the sedimentation of racial inequality. These three concepts reflect, respectively, how government policy has systematically reduced Black capacity to accumulate wealth by historically limiting access to land, housing, and other wealth builders; how Blacks have been prevented from forming thriving businesses because of institutional barriers to their serving the entire domestic market, leaving Blacks in impoverished niche businesses; and how the cumulative effects of Black oppression have cemented Blacks to the bottom of society's economic hierarchy. The story begins in chapter one, in which the authors revisit Reconstruction's failure to provide the freedmen with elementary productive property-the proverbial 40 acres and a mule. They move next to a review of the Federal Housing Administration's role in deliberately blocking Black home ownership from the 1930s through the 1970s, followed by a contemporary account of how redlining and mortgage discrimination have deepened Black economic deprivation. They also review the ways in which macroeconomic forces such as globalization and deindustrialization have undermined Black economic wellbeing. For example, they point out that these forces have eliminated over half of the Black industrial jobs in the Great Lakes area in the last two decades. In chapter two, Oliver and Shapiro sketch a sociology of race and wealth in America, wrestling (perhaps too briefly) with the race/class debate and invoking Marx and Weber. With this backdrop, they offer additional historical and anecdotal evidence for the three historical processes noted above. Chapter three presents a discussion of the data constraints past researchers have experienced in attempting to study wealth distribution in the U.S. The authors surmount such difficulties themselves by using the relatively new Survey of Income and Program Participation (SIPP) data set to measure individual net worth (all wealth) and net financial assets (net worth minus housing equity and automobile value) as they artfully describe the trend of deepening economic inequality between the races since the 1980s. This theme is extended further in chapter four, in which two startling findings are highlighted: (a) though Black income has consistently hovered at around 60% of White income, Black wealth is only one-twelfth of White wealth; and (b) Black financial assets are, at the median, zero! Oliver and Shapiro go on to note that a large share of each race has no financial assets, and even larger shares of both races could not sustain lives even at poverty level for more than a few months if they lost their current income. The absolute wealth differences mentioned above conceal an even graver problem detailed in chapter five. Most Black wealth is shown to consist of home equity and automobile ownership while a substantial share of White wealth is shown to include financial assets, the key to wealth accumulation. …

title: Ethnic differences in circadian hemodynamic profile.
abstract: Since the introduction of 24-h ambulatory blood pressure monitoring (ABPM), some studies, although not all, have suggested the presence of a blunted nocturnal blood pressure decline in black versus white subjects, a difference that may help explain the higher incidence of target organ damage in blacks. To better define ethnic differences in diurnal hemodynamic profiles, we studied ABPM recordings from 275 black (55.6% women) and 246 white (43.1% women) previously untreated subjects, with a similar age distribution (from 20 to 79 years) and a wide range of systolic (100-230 mm Hg) and diastolic (50-130 mm Hg) blood pressures. Average clinic systolic (diastolic) blood pressures were higher in black v white men by 10.2 (7.3) mm Hg; P = .04 (P = .004), with a similar trend in women (P = NS). On ABPM, blacks had higher average values, a difference that was greater during sleep (9.4 mm Hg for systolic blood pressure) than while awake (4.7 mm Hg; P = .003). Average diurnal change in systolic blood pressure (awake minus sleep values) was 13.1 +/- 0.7 v 18.0 +/- 0.6 mm Hg for blacks v whites (P < .001). There was a strong negative correlation between baseline (ie, sleep) blood pressure and the diurnal change (r = -0.58; P < .001), but at each given level, blacks had a lower daytime increment/nocturnal fall (P = .02). Results for diastolic blood pressure and heart rate were similar. The data suggest that the smaller diurnal change in blacks may be related in part to their higher blood pressure levels, but that there is an additional, independent effect of race. This results in a greater 24-h blood pressure load in blacks than whites for each given clinic (daytime) value, and may help explain differences in target organ damage. Future studies investigating the effects of blood pressure on target organs in different populations should consider diurnal profiles in addition to clinic blood pressure.

title: Relation Between Socioeconomic Status, Race–Ethnicity, and Left Ventricular Mass: The Northern Manhattan Study
abstract: Increased left ventricular mass (LVM) and lower socioeconomic status (SES) are predictors of cardiovascular morbidity and mortality. Blacks and Hispanics are more likely to have higher LVM and lower SES. The relation between SES, race–ethnicity, and LVM has not been fully explored. Data were used from the NOMAS population-based sample of 1916 subjects living in Northern Manhattan. SES was characterized on the basis of educational attainment and divided into 4 categories. Echocardiography-defined LVM was indexed according to height at the allometric power of 2.7 and analyzed as a continuous variable. LVM varied by race in our cohort (blacks 48.9 g/m2.7, Hispanics 48.4 g/m2.7, whites 45.6 g/m2.7; P =0.004). Using ANCOVA, there was a significant inverse and graded association between mean LVM and SES for the total cohort. Mean LVM was 48.4 g/m2.7, 48.6 g/m2.7, 47.1 g/m2.7, and 45.3 g/m2.7 for the lowest to the highest educational level category (P trend=0.0004). This relationship remained among normotensives (P trend=0.0005) and was present for blacks (P trend=0.009), but not for whites (P trend=0.86) or Hispanics (P trend=0.47). The difference in mean LVM between the highest and lowest categories of education was 5.3 g/m2.7 for blacks, 0.0 g/m2.7 for whites, and 1.0 g/m2.7 for Hispanics. Lower SES is an independent predictor of increased LVM among hypertensive and normotensive blacks.

title: Perceived racism and blood pressure: A review of the literature and conceptual and methodological critique
abstract: Racial disparities in health, including elevated rates of hypertension (HT) among Blacks, are widely recognized and a matter of serious concern. Researchers have hypothesized that social stress, and in particular exposure to racism, may account for some of the between-group differences in the prevalence of HT and a portion of the within-group variations in risk for HT However, there have been surprisingly few empirical studies of the relationship between perceived racism and blood pressure (BP) or cardiovascular reactivity (CVR), a possible marker of mechanisms culminating in cardiovascular disease. This article reviews published literature investigating the relationship of perceived racismto HT-relatedvariables, including self-reported history of HT, BP level, or CVR. Strengths andweaknesses of the existing research are discussed to permit the identification of research areas that may elucidate the biopsychosocial mechanisms potentially linking racism to HT We hope to encourage investigators to invest in research on the health effects of racism because a sound and detailed knowledge base in this area is necessary to address racial disparities in health.

title: Ethnicity-Related Sources of Stress and Their Effects on Well-Being
abstract: Early research on ethnicity focused on the stereotyped thinking, prejudiced attitudes, and discriminatory actions of Euro-Americans. Minority-group members were viewed largely as passive targets of these negative reactions, with low self-esteem studied as the main psychological outcome. By contrast, recent research has increasingly made explicit use of stress theory in emphasizing the perspectives and experiences of minority-group members. Several ethnicity-related stressors have been identified, and it has been found that individuals cope with these threats in an active, purposeful manner. In this article, we focus on ethnicity-related stress stemming from discrimination, from stereotypes, and from conformity pressure arising from one's own ethnic group. We discuss theory and review research in which examination of ethnicity-related outcomes has extended beyond self-esteem to include psychological and physical well-being.

title: Understanding Racial-ethnic Disparities in Health: Sociological Contributions
abstract: This article provides an overview of the contribution of sociologists to the study of racial and ethnic inequalities in health in the United States. It argues that sociologists have made four principal contributions. First, they have challenged and problematized the biological understanding of race. Second, they have emphasized the primacy of social structure and context as determinants of racial differences in disease. Third, they have contributed to our understanding of the multiple ways in which racism affects health. Finally, sociologists have enhanced our understanding of the ways in which migration history and status can affect health. Sociological insights on racial disparities in health have important implications for the development of effective approaches to improve health and reduce health inequities.

title: Perceived discrimination, psychological distress and health.
abstract: Racism and discrimination can have significant implications for health, through complex biopsychosocial interactions. Latino groups, and particularly Puerto Ricans, are an understudied population in the United States in terms of the prevalence of discrimination and its relevance to health. Participants in our study were 45- to 75-year-old (N = 1122) Puerto Ricans. The measures were perceived discrimination, depressive symptomatology (CES-D), perceived stress (PSS), self-rated health, medical conditions, blood pressure, smoking and drinking behaviours, demographics. Our findings show that 36.9 per cent of participants had at some time experienced discrimination, with men, those with more years of education, currently employed and with higher incomes being more likely to report it. Experiences of discrimination were associated with increased levels of depressive symptoms and perceived stress. When controlling for covariates, perceived discrimination was predictive of the number of medical conditions, of ever having smoked and having been a drinker, and having higher values of diastolic pressure. Depressive symptoms are a mediator of the effect of perceived discrimination on medical conditions, confirmed by the Sobel test: z = 3.57, p < 0.001. Mediating roles of perceived stress, smoking and drinking behaviours were not confirmed. Increased depressive symptoms might be the main pathway through which perceived discrimination is associated with a greater number of medical diagnoses.

title: Genetic Ancestry, Social Classification, and Racial Inequalities in Blood Pressure in Southeastern Puerto Rico
abstract: The role of race in human genetics and biomedical research is among the most contested issues in science. Much debate centers on the relative importance of genetic versus sociocultural factors in explaining racial inequalities in health. However, few studies integrate genetic and sociocultural data to test competing explanations directly.  We draw on ethnographic, epidemiologic, and genetic data collected in southeastern Puerto Rico to isolate two distinct variables for which race is often used as a proxy: genetic ancestry versus social classification. We show that color, an aspect of social classification based on the culturally defined meaning of race in Puerto Rico, better predicts blood pressure than does a genetic-based estimate of continental ancestry. We also find that incorporating sociocultural variables reveals a new and significant association between a candidate gene polymorphism for hypertension (α2C adrenergic receptor deletion) and blood pressure.  This study addresses the recognized need to measure both genetic and sociocultural factors in research on racial inequalities in health. Our preliminary results provide the most direct evidence to date that previously reported associations between genetic ancestry and health may be attributable to sociocultural factors related to race and racism, rather than to functional genetic differences between racially defined groups. Our results also imply that including sociocultural variables in future research may improve our ability to detect significant allele-phenotype associations. Thus, measuring sociocultural factors related to race may both empower future genetic association studies and help to clarify the biological consequences of social inequalities.

title: Born in Blood and Fire: A Concise History of Latin America
abstract: Drawing on the most current scholarship, this concise text presents a direct, compelling narrative that spans six centuries and twenty countries. Carefully revised in light of recent Latin American history, the Second Edition introduces new maps, helpful chapter timelines, and a new Student Web site.

title: Population Structure of Hispanics in the United States: The Multi-Ethnic Study of Atherosclerosis
abstract: Using ∼60,000 SNPs selected for minimal linkage disequilibrium, we perform population structure analysis of 1,374 unrelated Hispanic individuals from the Multi-Ethnic Study of Atherosclerosis (MESA), with self-identification corresponding to Central America (n = 93), Cuba (n = 50), the Dominican Republic (n = 203), Mexico (n = 708), Puerto Rico (n = 192), and South America (n = 111). By projection of principal components (PCs) of ancestry to samples from the HapMap phase III and the Human Genome Diversity Panel (HGDP), we show the first two PCs quantify the Caucasian, African, and Native American origins, while the third and fourth PCs bring out an axis that aligns with known South-to-North geographic location of HGDP Native American samples and further separates MESA Mexican versus Central/South American samples along the same axis. Using k-means clustering computed from the first four PCs, we define four subgroups of the MESA Hispanic cohort that show close agreement with self-identification, labeling the clusters as primarily Dominican/Cuban, Mexican, Central/South American, and Puerto Rican. To demonstrate our recommendations for genetic analysis in the MESA Hispanic cohort, we present pooled and stratified association analysis of triglycerides for selected SNPs in the LPL and TRIB1 gene regions, previously reported in GWAS of triglycerides in Caucasians but as yet unconfirmed in Hispanic populations. We report statistically significant evidence for genetic association in both genes, and we further demonstrate the importance of considering population substructure and genetic heterogeneity in genetic association studies performed in the United States Hispanic population.

title: Admixture in the Hispanics of the San Luis Valley, Colorado, and its implications for complex trait gene mapping
abstract: Hispanic populations are a valuable resource that can and should facilitate the identification of complex trait genes by means of admixture mapping (AM). In this paper we focus on a particular Hispanic population living in the San Luis Valley (SLV) in Southern Colorado.We used a set of 22 Ancestry Informative Markers (AIMs) to describe the admixture process and dynamics in this population. AIMs are defined as genetic markers that exhibit allele frequency differences between parental populations ≥30%, and are more informative for studying admixed populations than random markers. The ancestral proportions of the SLV Hispanic population are estimated as 62.7 ± 2.1% European, 34.1 ± 1.9% Native American and 3.2 ± 1.5% West African. We also estimated the ancestral proportions of individuals using these AIMs. Population structure was demonstrated by the excess association of unlinked markers, the correlation between estimates of admixture based on unlinked marker sets, and by a highly significant correlation between individual Native American ancestry and skin pigmentation (R2= 0.082, p < 0.001). We discuss the implications of these findings in disease gene mapping efforts.

title: Ancestral proportions and their association with skin pigmentation and bone mineral density in Puerto Rican women from New York city
abstract: Hispanic and African American populations exhibit an increased risk of obesity compared with populations of European origin, a feature that may be related to inherited risk alleles from Native American and West African parental populations. However, a relationship between West African ancestry and obesity-related traits, such as body mass index (BMI), fat mass (FM), and fat-free mass (FFM), and with bone mineral density (BMD) in African American women has only recently been reported. In order to evaluate further the influence of ancestry on body composition phenotypes, we studied a Hispanic population with substantial European, West African, and Native American admixture. We ascertained a sample of Puerto Rican women living in New York (n=64), for whom we measured BMI and body composition variables, such as FM, FFM, percent body fat, and BMD. Additionally, skin pigmentation was measured as the melanin index by reflectance spectroscopy. We genotyped 35 autosomal ancestry informative markers and estimated population and individual ancestral proportions in terms of European, West African, and Native American contributions to this population. The ancestry proportions corresponding to the three parental populations are: 53.3±2.8% European, 29.1±2.3% West African, and 17.6±2.4% Native American. We detected significant genetic structure in this population with a number of different tests. A highly significant correlation was found between skin pigmentation and individual ancestry (R2=0.597, P<0.001) that was not attributable to differences in socioeconomic status. A significant association was also found between BMD and European admixture (R2=0.065, P=0.042), but no such correlation was evident with BMI or the remaining body composition measurements. We discuss the implications of our findings for the potential use of this Hispanic population for admixture mapping.

title: Latino racial choices: the effects of skin colour and discrimination on Latinos’ and Latinas’ racial self-identifications
abstract: Are predictions that Hispanics will make up 25 per cent of the US population in 2050 reliable? The authors of this paper argue that these and other predictions are problematic insofar as they do not account for the volatile nature of Latino racial and ethnic identifications. In this light, the authors propose a theoretical framework that can be used to predict Latinos’ and Latinas’ racial choices. This framework is tested using two distinct datasets – the 1989 Latino National Political Survey and the 2002 National Survey of Latinos. The results from the analyses of both of these surveys lend credence to the authors’ claims that Latinas’ and Latinos’ skin colour and experiences of discrimination affect whether people from Latin America and their descendants who live in the US will choose to identify racially as black, white or Latina/o.

title: Competing Identities? Race, Ethnicity and Panethnicity Among Dominicans in the United States
abstract: In this paper we explore the racial and ethnic self-identification of Dominican immigrants in the United States. This issue is central in understanding how immigrants experience the process of incorporation into American society. We argue that as Dominican immigrants incorporate to American life, they adopt a Hispanic or Latino identity. This identity serves both as a form of racial identification within the American racial stratification system and as a form of assertive panethnic identity. This identity, however, does not supersede national identification, which remains the anchoring identity.

title: To be or not to be (Hispanic or Latino)
abstract: I use 1990 US census data and 22 semi-structured interviews with Brazilian immigrant youth in Boston to show how Brazilians are becoming racialized into the black-white binary of American society, but how over time they manage to escape the downward mobility of Hispanic/Latino categorization by becoming ‘American’ and playing off US natives’ Spanish-centered understanding of Hispanics/Latinos (which does not include them). Successful Americanization for Brazilians means not becoming part of a stigmatized Hispanic/Latino group associated with low socioeconomic status, racial discrimination and, on the heels of massive new immigration from Latin America, disempowered immigrant status - rather than becoming ‘Hispanic/Latino’ as part and parcel of becoming ‘American’. The Brazilian case exposes some of the assumptions behind dominant US racial/ethnic categories (particularly ‘white’ and ‘black’), and it lays bare the complexities and contradictions in the Hispanic/Latino ‘panethnic’ category, pinpointing anew its racial basis and embedded immigrant analogy. That Hispanic/Latino classification continues to conflate race and immigrant status as US-bound immigration from Latin America has increased, expanded, and raised the foreign-born share of the US ‘Hispanic/Latino’ population prompts a re-evaluation of who the group includes (and why or why not), as well as a reassessment of African American/Latino positions and relations in the US ethno-racial hierarchy.

title: Trends in International Migration in Latin America and the Caribbean
abstract: The article examines international migration trends in recent decades and emphasises the distinctive features of migration processes in the Latin American subcontinent over the past 50 years. It examines the main characteristics of intraregional movements, together with the underlying trends and the nature of increasing emigration flows to the United States-the major phenomenon marking the second half of the twentieth century. Finally, a link is sought between demographic and economic growth and the development of international migration, with a look at the effects of political violence and the role of the United States in the region as prime causes of migration.

title: The new Americans : a guide to immigration since 1965
abstract: Salsa has replaced ketchup as the most popular condiment. A mosque has been erected around the corner. The local hospital is staffed by Indian doctors and Philippine nurses, and the local grocery store is owned by a Korean family. A single elementary school may include students who speak dozens of different languages at home. This is a snapshot of America at the turn of the 21st Century. The United States has always been a nation of immigrants, shaped by successive waves of new arrivals. The most recent transformation began when immigration laws and policies changed significantly in 1965, admitting migrants from around the globe in new numbers and with widely varying backgrounds and aspirations. This comprehensive guide, edited and written by an interdisciplinary group of prominent scholars, provides an authoritative account of the most recent surge of immigrants. Twenty thematic essays address such topics as immigration law and policy, refugees, unauthorised migrants, racial and ethnic identity, assimilation, nationalization, economy, politics, religion, education and family relations. These are followed by comprehensive articles on immigration from the 30 most significant nations or regions of origin. Based on the latest U.S. Census data and the most recent scholarly research, The New Americans is an essential reference for students, scholars, and anyone curious about the changing face of America.

title: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
abstract: www.mobilehealthmap.org 617‐442‐3200 New research shows that mobile health clinics improve health outcomes for hard to reach populations in cost‐effective and culturally competent ways . A Harvard Medical School study determined that for every dollar invested in a mobile health clinic, the US healthcare system saves $30 on average. Mobile health clinics, which offer a range of services from preventive screenings to asthma treatment, leverage their mobility to treat people in the convenience of their own communities. For example, a mobile health clinic in Baltimore, MD, has documented savings of $3,500 per child seen due to reduced asthma‐related hospitalizations. The estimated 2,000 mobile health clinics across the country are providing similarly cost‐effective access to healthcare for a wide range of populations. Many successful mobile health clinics cite their ability to foster trusting relationships. Qualitative research in such mobile health clinics has found that patients value the informal, familiar environment in a convenient location, with staff who “are easy to talk to,” and that the staff’s “marriage of professional and personal discourses” provides patients the space to disclose information themselves. A communications academic argued that mobile health clinics’ unique use of space is important in facilitating these relationships. Mobile health clinics park in the heart of the community in familiar spaces, like shopping centers or bus stations, which lend themselves to the local community atmosphere.

title: America's Shifting Color Line? Reexamining Determinants of Latino Racial Self-Identification
abstract: Latinos are the nation's largest minority group and will double in size by 2050. Their size coupled with the fact that Latinos do not constitute a separate race raises questions about Latinos’ incorporation into the U.S. racial hierarchy. This article explores patterns of Latino racial identity formation, examining the determinants of racial identity. 
 
 
 
Methods 
 
Using the 2006 Latino National Survey, I estimate multinomial logit and ordered probit models of identification choices. 
 
 
 
Results 
 
Latino racial identity is strongly associated with several factors, including socioeconomic status, measures of perceived discrimination and commonality, and measures of acculturation/assimilation. Most Latinos have a broader, more complex understanding of race. Furthermore, some Latinos do believe that they occupy a unique position in the racial hierarchy. 
 
 
 
The results suggest that the color line W. E. DuBois argued has long divided our nation may eventually shift.

title: Reconstructing Racial Identity
abstract: When people move across state borders, they enter not only a different labor market and political structure but also a new system of social stratification by class, race, ethnicity, and gender. Migrants bring their own cultural conceptions of their identity, which often do not coincide with the ideological constructions of the receiving societies. As a mulatto Dominican colleague told me recently, she "discovered" that she was black only when she first came to the United States; until then she had thought of herself as an india clara (literally, a light Indian) in a country whose aboriginal population was practically exterminated in the 16th century. For most Caribbean immigrants in the United States, race and color have played a crucial role in the formation of their cultural identities. Two different models of racial hegemony are juxtaposed in the process of moving from the Caribbean to the United States. On one hand, Caribbean migrantsespecially those coming from the Spanish-speaking countries of Cuba, the Dominican Republic, and Puerto Rico-tend to use three main racial categories-black, white, and mixed-based primarily on skin color and other physical characteristics such as facial features and hair texture (Seda Bonilla, 1980). On the other hand, the dominant system of racial classification in the

title: Class and ethnicity in Mexico : Somatic and racial considerations
abstract: Based on research conducted during the past twenty years on superordinate stratification in Mexico City and class system of several cities, this article has three goals. First, it establishes the historical origin of ethnic categories that began strictly as racial categories in the sixteenth century. Second, it describes the main ethnic sectors of contemporary Mexican society, their class composition, and the principles of social mobility. Third, it analyzes interclass and interethnic relations and the cultural and racial perceptions they engender. The generalization of (1) apply to the entire country, whereas those of (2) and (3) characterize central Mexico (from Oaxaca to Jalisco and from coast to coast)

title: Black-white differences in electrocardiographic left ventricular mass and its association with blood pressure (the ARIC study). Atherosclerosis Risk in Communities.
abstract: Black-white differences in the association between antihypertensive therapy, continuous measures of mean arterial and pulse pressures and left ventricular (LV) mass estimated from a multivariable electrocardiographic algorithm were examined in 6,020 men (23% black) and 7,970 women (29% black) participating in the Atherosclerosis Risk in Communities (ARIC) study. Mean arterial and pulse pressures, weight, the percentage of subjects taking antihypertensive medication, and LV mass were higher in black than in white men (98 vs 89 mm Hg, 47 vs 46 mm Hg, 188 vs 187 pounds, 30% vs 17%, and 243 vs 217 g, respectively). Results of similar direction but greater magnitude were observed in black versus white women (mean arterial pressure, 94 vs 85 mm Hg; pulse pressure, 50 vs 47 mm Hg; weight, 180 vs 153 pounds; percent treated, 42% vs 18%; and LV mass, 203 vs 169 g, respectively). In multivariable regression analyses, blacks had higher levels of LV mass, and LV mass increased more sharply with increasing mean arterial pressure in blacks than in whites after adjusting for age, pulse pressure, and weight. At equal mean arterial and pulse pressures, age, and weight, treated blacks had higher LV mass than treated whites. These data indicate that blacks have higher LV mass than whites, and a more pronounced blood pressure-LV mass relation after controlling for other risk factors and treatment status. Given the prognostic importance of LV hypertrophy,

title: Latino populations: a unique opportunity for the study of race, genetics, and social environment in epidemiological research.
abstract: Latinos are the largest minority population in the United States. Although usually classified as a single ethnic group by researchers, Latinos are heterogeneous from cultural, socioeconomic, and genetic perspectives. From a cultural and social perspective, Latinos represent a wide variety of national origins and ethnic and cultural groups, with a full spectrum of social class. From a genetic perspective, Latinos are descended from indigenous American, European, and African populations. We review the historical events that led to the formation of contemporary Latino populations and use results from recent genetic and clinical studies to illustrate the unique opportunity Latino groups offer for studying the interaction between racial, genetic, and environmental contributions to disease occurrence and drug response.

title: Culture-Bound Syndromes in Hispanic Primary Care Patients
abstract: We sought to document Hispanic primary care patients' knowledge and experience of five culture-bound syndromes (CBS), as well as the basic socio-cultural correlates of these disorders.  A convenience sample of 100 adult Hispanic patients presenting in an urban South Texas primary care clinic was recruited to complete a brief cross-sectional survey, presented in an oral format. Interviews sought information concerning five culture-bound syndromes—susto, empacho, nervios, mal de ojo, and ataques de nervios. Additional demographic, socio-economic, and acculturation data was collected. Descriptive and bivariate statistics (chi square, Fisher's) were used to assess relationships among variables and experience with each CBS. A multivariate logistic analysis was conducted to determine the possible contributions of age, gender, acculturation, and education to the personal experience of a culture-bound syndrome.  Results indicate that 77% of respondents had knowledge of all five syndromes, with 42% reporting having personally experienced at least one CBS. Nervios was the most commonly suffered disorder, being reported by 30 respondents. This was followed, in declining order of prevalence, by susto, mal de ojo, empacho, and ataques de nervios. Multivariate logistic regression analysis found that higher education beyond high school was associated with a slightly decreased likelihood of reporting having suffered from any culture-bound syndrome. While co-occurrence among these disorders occurred, the patterns of predictors suggest that the co-occurrence is not a reflection of mislabeling of one common syndrome.  Knowledge of and experience with culture-bound syndromes is common among Hispanic primary care patients in South Texas. Healthcare providers ought to consider discussing these illnesses in a non-judgmental manner with patients who present with symptoms that are consistent with these syndromes. Future studies, with larger sample sizes, are warranted to elucidate the nature of culture-bound disorders and their relationships with conventional diagnostic entities and treatment-seeking behaviors.

title: Contexts for bilingualism among US-born Latinos
abstract: This paper focuses on the contextual determinants of bilingualism among Latino adults who were born in the US or are members of the ‘1.5 generation’ of Latinos who immigrated to the US when they were 10 or younger. We model the broader contexts reflecting contemporary developments that influence change in both the real and the perceived value of bilingualism. Using US census data for metropolitan areas in 1990 and 2000, we find that the replenishment of an immigrant population is a strong predictor of higher bilingualism among US-born Latinos. We draw on ethnographic data on later-generation Mexican Americans as well as field-work in dual-language immersion schools to explain our findings. The variables measuring the size and growth of the foreign-born Latino population in the MSA/PMSAs in our models capture the factors that encourage bilingualism that we identify in our ethnographic research: institutional contact with Spanish, labour-market rewards, cosmopolitanism.

title: Family Context and Spanish-Language Use: A Study of Latino Children in the United States
abstract: This article seeks to explain why Latino children maintain some knowledge of their native language even though past research has consistently supported the view that non-English-language use rarely lasts past the third generation. I argue that family context, in addition to assimilation characteristics, plays an important role in determining their language situation.

title: Interethnic Contact, Identity, and Psychological Adjustment: The Mediating and Moderating Roles of Communication
abstract: Social psychological theories of second-language communication posit a relationship between second-language competence/usage and social identity. Identity and adaptation outcomes of intercultural contact have also been central issues for cross-cultural psychology. The studies described here are at the junction of these two research traditions. Based on a situated-identity approach, they show the mediating and moderating roles of second-language confidence for identity change and adjustment among minority- and majority-group members. Two studies involving Canadian francophone and anglophone university students illustrate the relationship between relative status and identity as well as the mediating role of communication in determining identity and adjustment. The third study, involving participants of East Indian descent, shows that incongruities among aspects of identity are related to the experience of collective discrimination and stress. Furthermore, these relations are moderated by second-language confidence. The conclusion discusses theoretical and practical implications for policy.

title: Language Maintenance versus Language of Instruction: Spanish Reading Development among Latino and Latina Bilingual Learners
abstract: Latino/a children who attend schools in the United States must learn English well for schooling success. However, bilingualism is associated with achievement in both cognition and general literacy, which are core components of academic development. We examined the growth of Spanish reading comprehension among 101 Spanish-English bilingual Latino/a children in second through fifth grade in three urban U.S. districts. The students received literacy instruction in one of three groups: English-only, Spanish-only, and bilingual. Language of instruction had a significant effect on Spanish reading, but students who received Spanish language instruction were losing Spanish literacy skills relative to the norming sample for the reading assessment. English reading and Spanish vocabulary were predictive of Spanish reading, but socioeconomic variables were not. Heritage language loss is described as paradoxical because Spanish and English reading skills are intertwined and biliteracy is associated with better economic opportunities for Latino/as in the U.S. job market.

title: Language spoken and differences in health status, access to care, and receipt of preventive services among US Hispanics.
abstract: We examined self-reported health status, health behaviors, access to care, and use of preventive services of the US Hispanic adult population to identify language-associated disparities.



We analyzed 2003 to 2005 Behavioral Risk Factor Surveillance System data from 45 076 Hispanic adults in 23 states, who represented 90% of the US Hispanic population, and compared 25 health indicators between Spanish-speaking Hispanics and English-speaking Hispanics.



Physical activity and rates of chronic disease, obesity, and smoking were significantly lower among Spanish-speaking Hispanics than among English-speaking Hispanics. Spanish-speaking Hispanics reported far worse health status and access to care than did English-speaking Hispanics (39% vs 17% in fair or poor health, 55% vs 23% uninsured, and 58% vs 29% without a personal doctor) and received less preventive care. Adjustment for demographic and socioeconomic factors did not mitigate the influence of language on these health indicators.



Spanish-language preference marks a particularly vulnerable subpopulation of US Hispanics who have less access to care and use of preventive services. Priority areas for Spanish-speaking adults include maintenance of healthy behaviors, promotion of physical activity and preventive health care, and increased access to care.

title: Linguistic disparities in health care access and health status among older adults
abstract: AbstractBACKGROUND: English proficiency may be important in explaining disparities in health and health care access among older adults.
 SUBJECTS: Population-based representative sample (N=18,659) of adults age 55 and older from the 2001 California Health Interview Survey.
 METHODS: We examined whether health care access and health status vary among older adults who have limited English proficiency (LEP), who are proficient in English but also speak another language at home (EP), and who speak English only (EO). Weighted bivariate and multivariate survey logit analyses were conducted to examine the role of language ability on 2 aspects of access to care (not having a usual source of care, delays in getting care) and 2 indicators of health status (self-rated general health and emotional health).
 RESULTS: Limited-English proficient adults were significantly worse off (1.68 to 2.49 times higher risk) than EO older adults in 3 of our 4 measures of access to care and health status. Limited-English proficient older adults had significantly worse access to care and health status than EP older adults except delays in care. English proficient adults had 52% increased risk of reporting poorer emotional health compared with EO speakers.
  Provision of language assistance services to patients and training of providers in cultural competence are 2 means by which health care systems could reduce linguistic barriers, improve access to care, and ultimately improve health status for these vulnerable populations.

title: Language preference as a predictor of access to and use of healthcare services among Hispanics in the United States.
abstract: The objective of this study was to determine if Spanish language preference was significantly associated with barriers to healthcare services among a nationally representative sample of Hispanic persons in the United States.



Cross-sectional analysis of secondary data. Differences in outcomes between those responding in Spanish and those responding in English were tested using chi-square analyses and multiple logistic regression models.



Nationally representative sample of US adults responding to the 2005 Behavioral Risk Factor Surveillance System survey.



Respondents identifying themselves as Hispanic (n = 20,400).



Four health care outcomes including health insurance coverage, having a personal health care provider, forgoing care because of cost, and having a routine check-up within the past five years.



Those responding in Spanish were less likely to have healthcare coverage, less likely to have a personal healthcare provider, and less likely to have had a routine check-up within the past five years. No difference was found for indicating that cost was a barrier to receiving care in this model.



Disparities in healthcare access exist between Hispanic persons in the United States whose language preference is Spanish and those whose language preference is English. In an effort to achieve Healthy People 2010 goals and to provide care to all persons in the United States, barriers to care, such as language preference, should be addressed more fully in our healthcare system.

title: Primary Language and Receipt of Recommended Health Care Among Hispanics in the United States
abstract: BackgroundDisparities in health care services between Hispanics and whites in the United States are well documented.ObjectiveThe objective of the study was to determine whether language spoken at home identifies Hispanics at risk for not receiving recommended health care services.DesignThe design of the study was cross-sectional, nationally representative survey of households. patients were non-Hispanic white and Hispanic adults participating in the 2003 Medical Expenditure Panel Survey.MeasurementsWe compared receipt of ten recommended health care services by ethnicity and primary language adjusting for demographic and socioeconomic characteristics, health status, and access to care.ResultsThe sample included 12,706 whites and 5,500 Hispanics. In bivariate comparisons, 57.0% of whites received all eligible health care services compared to 53.6% for Hispanics who spoke English at home, 44.9% for Hispanics who did not speak English at home but who were comfortable speaking English, and 35.0% for Hispanics who did not speak English at home and were uncomfortable speaking English (p < .001). In multivariate logistic models, compared to non-Hispanic whites, Hispanics who did not speak English at home were less likely to receive all eligible health care services, whether they were comfortable speaking English (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74–0.97) or not (RR 0.84, 95% CI 0.68–0.95).ConclusionsSpeaking a language other than English at home identified Hispanics at risk for not receiving recommended health care services, whether they were comfortable in speaking English or not. Identifying the mechanism for disparities by language usage may lead to interventions to reduce ethnic disparities.

title: Survey Language Preference as a Predictor of Meeting Fruit and Vegetable Objectives Among Hispanic Adults in the United States, Behavioral Risk Factor Surveillance System, 2009
abstract: Although Hispanics are a rapidly growing ethnic minority in the United States, the effect of acculturation on the proportion of Hispanics who meet national objectives for fruit and vegetable consumption has not been fully investigated. Our objective was to determine the extent to which ethnicity and acculturation (indicated by survey language preference) are associated with fruit and vegetable consumption among Hispanics in the United States.  Fruit and vegetable consumption among adult respondents to the 2009 Behavioral Risk Factor Surveillance System was determined from data collected from the 31 states and 2 territories that offered the fruit and vegetable screener in Spanish and English (n = 287,997). Logistic regression analyses were used to determine whether ethnicity (Hispanic vs non-Hispanic white) and survey language preference (English vs Spanish) were related to meeting objectives of consuming fruit 2 or more times per day and vegetables 3 or more times per day.  More Hispanics (37.6%) than non-Hispanic whites (32.0%) and more Spanish-speaking Hispanics (41.0%) than English-speaking Hispanics (34.7%) ate fruit 2 or more times per day. Conversely, more non-Hispanic whites (28.5%) than Hispanics (18.9%) and more English-speaking Hispanics (21.8%) than Spanish-speaking Hispanics (15.8%) ate vegetables 3 or more times per day. All associations remained significant after controlling for covariates.  Our findings have implications regarding how brief screeners can be used to determine possible dietary disparities among the Hispanic population in the United States and to monitor population goals to eliminate racial and ethnic health disparities.

title: Health literacy and outcomes among patients with heart failure.
abstract: Little is known about the effects of low health literacy among patients with heart failure, a condition that requires self-management and frequent interactions with the health care system.



To evaluate the association between low health literacy and all-cause mortality and hospitalization among outpatients with heart failure.



Retrospective cohort study conducted at Kaiser Permanente Colorado, an integrated managed care organization. Outpatients with heart failure were identified between January 2001 and May 2008, were surveyed by mail, and underwent follow-up for a median of 1.2 years. Health literacy was assessed using 3 established screening questions and categorized as adequate or low. Responders were excluded if they did not complete at least 1 health literacy question or if they did not have at least 1 year of enrollment prior to the survey date.



All-cause mortality and all-cause hospitalization.



Of the 2156 patients surveyed, 1547 responded (72% response rate). Of 1494 included responders, 262 (17.5%) had low health literacy. Patients with low health literacy were older, of lower socioeconomic status, less likely to have at least a high school education, and had higher rates of coexisting illnesses. In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted rate, 17.6% vs 6.3%; adjusted hazard ratio, 1.97 [95% confidence interval, 1.3-2.97]; P = .001) but not hospitalization (unadjusted rate, 30.5% vs 23.2%; adjusted hazard ratio, 1.05 [95% confidence interval, 0.8-1.37]; P = .73).



Among patients with heart failure in an integrated managed care organization, low health literacy was significantly associated with higher all-cause mortality.

title: Importance of adult literacy in understanding health disparities
abstract: In several recent studies, the importance of education and race in explaining health-related disparities has diminished when literacy was considered. This relationship has not been tested in a nationally representative sample of U.S. adults.
 OBJECTIVE: To understand the effect of adult literacy on the explanatory power of education and race in predicting health status among U.S. adults.
 DESIGN: Using the 1992 National Adult Literacy Survey, logistic regression models predicting health status were estimated with and without literacy to test the effect of literacy inclusion on race and education.
 SUBJECTS: A nationally representative sample of 23,889 noninstitutionalized U.S. adults.
 MEASURES: Poor health status was measured by having a work-impairing condition or a long-term illness. Literacy was measured by an extensive functional skills test.
  When literacy was not considered, African Americans were 1.54 (95% confidence interval, 1.29 to 1.84) times more likely to have a work-impairing condition than whites, and completion of an additional level of education made one 0.75 (0.69 to 0.82) times as likely to have a work-impairing condition. When literacy was considered, the effect estimates of both African-American race and education diminished 32% to the point that they were no longer significantly associated with having a work-impairing condition. Similar results were seen with long-term illness.
  The inclusion of adult literacy reduces the explanatory power of crucial variables in health disparities research. Literacy inequity may be an important factor in health disparities, and a powerful avenue for alleviation efforts, which has been mistakenly attributed to other factors.

title: Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century
abstract: Health literacy is a relatively new concept in health promotion. It is a composite term to describe a range of outcomes to health education and communication activities. From this perspective, health education is directed towards improving health literacy. This paper identifies the failings of past educational programs to address social and economic determinants of health, and traces the subsequent reduction in the role of health education in contemporary health promotion. These perceived failings may have led to significant underestimation of the potential role of health education in addressing the social determinants of health. A ‘health outcome model’ is presented. This model highlights health literacy as a key outcome from health education. Examination of the concept of health literacy identifies distinctions between functional health literacy, interactive health literacy and critical health literacy. Through this analysis, improving health literacy meant more than transmitting information, and developing skills to be able to read pamphlets and successfully make appointments. By improving people’s access to health information and their capacity to use it effectively, it is argued that improved health literacy is critical to empowerment. The implications for the content and method of contemporary health education and communication are then considered. Emphasis is given to more personal forms of communication, and community-based educational outreach, as well as the political content of health education, focussed on better equipping people to overcome structural barriers to health.

title: Understanding health literacy: an expanded model.
abstract: A long and yet unfinished history of investigating how individual capabilities and social processes explain or predict health indicates that poor education, low literacy, poor health and early death are strongly linked around the world. However, the complexity of those relationships is not fully understood. In this article, we propose an expanded model of health literacy characterized by four domains: fundamental literacy (reading, writing, speaking and numeracy), science literacy, civic literacy and cultural literacy. To explore the utility of this model, we examine selected pieces of the public discourse about terrorism and bioterrorism that dominated the mass media during the anthrax threat in the United States during 2001. We conclude that this model of health literacy is useful to analyze health communication, to aid in constructing more understandable and appropriate health communication, and ultimately can lead to the development of a new measure to assess health literacy skills in individuals.

title: Critical health literacy: a review and critical analysis.
abstract: Though there has been a considerable expansion of interest in the health literacy concept worldwide, there has also been criticism that this concept has been poorly defined, that it stretches the idea of "literacy" to an indefensible extent and more specifically, that it adds little to the existing concerns and intervention approaches of the better established discipline of health promotion. This paper takes as a starting point the expanded model of health literacy advanced by Nutbeam (2000) and addresses these concerns by interrogating the concept of "critical health literacy" in order to draw conclusions about its utility for advancing the health of individuals and communities. The constituent domains of critical health literacy are identified; namely information appraisal, understanding the social determinants of health, and collective action, and as far as possible each are clearly delineated, with links to related concepts made explicit. The paper concludes that an appreciation of work undertaken in a range of different disciplines, such as media studies, medical sociology, and evidence-based medicine can enhance our understanding of the critical health literacy construct and help us understand its usefulness as a social asset which helps individuals towards a critical engagement with health information. There is some evidence that aspects of critical health literacy have indeed been found to be a resource for better health outcomes, but more research is needed in this area, both to develop quantitative and qualitative approaches to evaluating health literacy skills, and to offer convincing evidence that investment in programmes designed to enhance critical health literacy are worthwhile.

title: Defining and measuring health literacy: what can we learn from literacy studies?
abstract: Previous contributions to this series of editorials and otherrecent papers have highlighted the growth in interest inhealth literacy, as well as continuing debate about its def-inition, measurement and importance (Kickbusch 2009;Wills 2009; Abel 2008; Nutbeam 2008; Coulter and Ellins2007). In further advancing these debates there is much tobe gained from an appraisal of the underlying concept ofliteracy.Literacy is an important but complex concept. Generallyit is acknowledged as having two distinctive elements:those that are task-based, and those that are skill-based(National Assessment of Adult Literacy 2003). Task-basedliteracy focuses on the extent to which a person can per-form key literacy tasks such as read a basic text and write asimple statement. Skill-based literacy focuses on theknowledge and skills an adult must possess in order toperform these tasks. These skills range from basic, word-level skills (such as recognising words) to higher levelskills (such as drawing appropriate inferences from con-tinuous text).It follows that literacy can be measured in absoluteterms by distinguishing between those who can read andwrite basic text and those who cannot, and in relative termsby assessing the skill differences between adults who areable to perform relatively challenging literacy tasks andthose who are not.The reason why we care so much about literacy is thateven the most basic functional literacy skills enable peopleto better develop their knowledge and improve the poten-tial to achieve personal goals, and through this toparticipate more fully in society, both economically andsocially. Given this background, it is not surprising to ﬁndthat literacy levels in a population are associated bothdirectly and indirectly with a range of health outcomes.Low literacy is often linked to poor socio-economic cir-cumstances, and in turn with adverse effects on health thatare independent of other risk factors (Jahan 2008). This isespecially the case in the relationship between female lit-eracy and maternal and child health outcomes (Schell et al.2007). People with poor literacy tend to be less responsiveto health education, less likely to use disease preventionservices, and to successfully manage chronic disease(Dewalt et al. 2004).Responding to low levels of literacy in a populationinvolves improving access to effective school education,and providing adult literacy programs for those in need.Achieving high levels of literacy in a population is not onlya vital development goal, but will also produce substantialpublic health beneﬁts.To better understand health literacy as a distinct concept,it is helpful to delve into current discourse on different‘‘literacies’’, recognising that literacy is both content andcontext speciﬁc. This is especially the case in relation to‘‘new literacies’’ emerging in response to new informationtechnologies (Coiro 2003), and context-speciﬁc literaciessuch as media literacy and ﬁnancial literacy (Primack andHobbs 2009; Kozup and Hogarth 2008). This furtherreﬁnement in the concept reﬂects the fact that individuals

title: Inadequate functional health literacy among patients at two public hospitals.
abstract: To determine the ability of patients to complete successfully basic reading and numeracy tasks required to function adequately in the health care setting.



Cross-sectional survey.



Two urban, public hospitals.



A total of 2659 predominantly indigent and minority patients, 1892 English-speaking and 767 Spanish-speaking, presenting for acute care.



Functional health literacy as measured by the Test of Functional Health Literacy in Adults (TOFHLA), an instrument that measures ability to read and understand medical instructions and health care information presented in prose passages and passages containing numerical information (eg, prescription bottle labels and appointment slips).



A high proportion of patients were unable to read and understand written basic medical instructions. Of 2659 patients, 1106 (41.6%) were unable to comprehend directions for taking medication on an empty stomach, 691 (26%) were unable to understand information regarding when a next appointment is scheduled, and 1582 (59.5%) could not understand a standard informed consent document. A total of 665 (35.1%) of 1892 English-speaking patients and 473 (61.7%) of 767 Spanish-speaking patients had inadequate or marginal functional health literacy. The prevalence of inadequate or marginal functional health literacy among the elderly (age > or = 60 years) was 81.3% (187/230) for English-speaking patients and 82.6% (57/69) for Spanish-speaking patients, and was significantly higher (P < .001) than in younger patients.



Many patients at our institutions cannot perform the basic reading tasks required to function in the health care environment. Inadequate health literacy may be an important barrier to patients' understanding of their diagnoses and treatments, and to receiving high-quality care.

title: The effects of nurse practitioner cultural competence on Latina patient satisfaction
abstract: To explore the relationship between degree of cultural competence in nurse practitioners (NPs) and measures of patient satisfaction among Latinas.  A descriptive correlational design was used to examine the degree of cultural competence in NPs and measures of patient satisfaction among Latinas. A convenience sample of 15 licensed NPs from 11 different clinics in a large southwestern city completed two self‐administered questionnaires. A convenience sample of 218 Latina patients completed three self‐administered questionnaires available in both English and Spanish. Descriptive statistics and correlations were used to analyze the data.  Latina patients reported greater satisfaction with NPs of Latina origin who were certified, had received cultural competence training, could speak Spanish, and had attended master's level programs. Latina patients were also most satisfied with decreased clinic waiting time. The two NPs with the highest levels of cultural competency scores were non‐Latinas. Noticeable differences were found in the amount of cultural competence exhibited by NPs.  The provision of culturally competent care leads to negotiation, mutual exchange of information, increased compliance, and improved patient‐provider communication. Similarly, patient satisfaction with care is associated with increased compliance and greater continuity of care. Employers seeking to meet the healthcare demands of a growing Latino population must look at extrinsic values such as NPs' certification, cultural competence training, education, and ability to speak Spanish.

title: Mexican Immigrant Mothers' Expectations for Children's Health Services
abstract: Women of Mexican descent living in the United States raise children who use health care services. What do immigrant Mexican mothers expect from children's health care services? And how do their expectations for children's health services compare to acculturated Mexican American mothers' expectations? This focused ethnographic study, based on repeated interviews with 28 mothers of varying acculturation levels, describes their expectations and experiences with children's health care services in the United States. Findings support a shared core of expectations for both Mexican immigrant and Mexican American mothers, and differences in health care access and financing, time spent in health care encounters, and cultural and linguistic expectations for care. Health care providers can use this information to approach Mexican-descent mothers and children with their expectations in mind, and craft a negotiated plan of care congruent with their expectations.

title: Listening to Rural Hispanic Immigrants in the Midwest: A Community-Based Participatory Assessment of Major Barriers to Health Care Access and Use
abstract: Hispanic immigrants are increasingly residing in rural communities, including in the midwestern United States. Limitations in the ability of rural Hispanics to access and utilize health care contribute to patterns of poor health and health disparity. A conceptual model of “vulnerability” guides this community-based participatory assessment project designed to explore rural Hispanics' perceived barriers to accessing and utilizing health care. Findings from a series of 19 focus groups with 181 participants from three communities in the upper Midwest identified perceived barriers at the individual and health care system levels. The most commonly perceived barriers were the lack of and limitations in health insurance coverage, high costs of health care services, communication issues involving patients and providers, legal status/discrimination, and transportation concerns. Findings imply that these barriers could be addressed using multiple educational and health service delivery policy-related strategies that consider the vulnerable nature of this growing population.

title: Networks of Care: How Latina Immigrants Find Their Way to and through a County Hospital
abstract: The purpose of this paper is to explore qualitatively the principal problems that Latino women face in getting health care for themselves and their families, how their experiences with the health care system affect them, and how they often overcome obstacles to get health care. Focus group and individual interviews with Latinas in a public hospital in Los Angeles County revealed that Latinas faced many challenges in getting health care for themselves and their families, and, as a result, many felt embarrassed, scolded, helpless, and discouraged from seeking care. Yet they overcame enormous obstacles to get into the system through solidarity with other Latinas, either friends or extended family, and connections with key health service personnel. These networks of care enabled Latinas to access a complicated health care system and offer lessons for providers and policy-makers concerned with improving the delivery of care to this population.

title: Strangers in a Strange Land: Health Care Experiences for Recent Latino Immigrants in Midwest Communities
abstract: Latino immigrants in recent years are moving to U.S. communities that have little experience with immigration from Latin America. Although public health initiatives have been created to expand health care services to uninsured adults and children, little is known about whether and to what extent new immigrants benefit from such resources.  We conducted 50 in-depth, semi-structured interviews with recent Latino immigrants residing in the Ann Arbor/Ypsilanti area of southeast Michigan to explore (a) these immigrants’ perceptions of access to public health resources; (b) their assessments of their own health status, social and health needs, and patterns of use of health care services; (c) barriers to health care utilization; (d) strategies they have adopted to approach these barriers; and (e) how best to address the needs of growing immigrant communities.  Latino immigrants often are not using and are unaware of local public health programs and other health resources. The principal barriers to care noted included lack of insurance, language barriers, and isolation in new communities. Many strategies, both effective and ineffective, have been adopted to overcome these barriers.  With the dynamic flux of new immigrants into many communities, outreach efforts must be continuously renewed and re-oriented to reach new arrivals.

title: Limited English proficiency is a barrier to receipt of advice about physical activity and diet among Hispanics with chronic diseases in the United States.
abstract: The prevalence of obesity, diabetes, and cardiovascular disease is reaching epidemic proportions among Hispanics in the United States. Health care providers play an important role in motivating patients to make healthful lifestyle changes to reduce the burden of such conditions. Data from the US 2000 National Health Interview Survey was analyzed to determine differences in report of physician-provided physical activity and/or dietary advice by level of English proficiency among obese Hispanics or those who reported having diabetes or cardiovascular disease and who contacted a physician during the past year (n=1,186). Only one third of the sample reported receiving advice to increase their physical activity or to improve their dietary habits; one fifth reported receipt of advice about both. English-proficient Hispanics were about 50% more likely to report receiving advice on physical activity (adjusted odd ratio [AOR]=1.5; 95% confidence interval [CI]: 1.1 to 2.1), diet (AOR=1.5; 95% CI: 1.1 to 2.2) or both (AOR=1.6; 95% CI: 1.1 to 2.3), as compared with limited English-proficient Hispanics, after controlling for health insurance coverage and number of visits to a physician during the last year. Sex, age, region of residence, level of education, annual family income, and smoking status were not significantly associated with receiving physical activity and/or dietary advice. In order to address racial health disparities, and lower the burden of chronic illness, culturally sensitive strategies must be implemented to enhance delivery of effective health-promotion messages by physicians, particularly among at-risk communities.

title: Disparities in Patient Satisfaction Among Hispanics: The Role of Language Preference
abstract: Hispanic and Spanish-speaking patients experience lower satisfaction with their health care when compared to whites and English speakers. We attempt to clarify the relationship between language preference and patient satisfaction in Hispanics. Study participants were Hispanic patients recruited from two clinics that serve an exclusively Hispanic population. We compared baseline levels of patient satisfaction among English-speaking, Spanish-speaking, and bilingual participants. Multivariate linear regression was used to model the effect of language preference on patient satisfaction. Baseline comparisons revealed that bilingual patients experienced higher satisfaction with doctor–patient communication and the office staff than Spanish-speaking patients. Multivariate analysis demonstrated that language preference was not significantly associated with patient satisfaction. Patient language preference was not a consistent predictor of satisfaction in this cohort of Hispanic patients receiving linguistically competent primary care. The analysis of local data in this study provides a crude adjustment for healthcare quality that is missing from previous research.

title: Language Preference and Perceptions of Healthcare Providers’ Communication and Autonomy Making Behaviors among Hispanics
abstract: To examine influence of language preference—English versus Spanish—on Hispanics’ perceptions of their healthcare providers’ communication behaviors.  Using the 2005 Medical Expenditure Panel Survey (MEPS), we observed non-institutionalized Hispanics (n = 5197; US population estimate = 27,070,906), aged ≥18 years, reporting visiting a healthcare provider within the past 12 months.  When compared to Spanish responders (reference group), English responders were more likely to report that their healthcare provider “always” listened to them carefully (adjusted odds ratio (OR) = 1.39, 95% confidence interval (CI) 1.09–1.78), “always” explained things so that they understood (adjusted OR 1.37, 95% CI 1.08–1.73), “always” spent enough time with them (adjusted OR = 1.62, 95% CI 1.24–2.11),”always” asked them to help make decisions (adjusted OR 1.37, 95% CI 1.03–1.82), and “always” showed respect for treatment decisions (adjusted OR = 1.66, 95% CI 1.27–2.19).  Healthcare providers should consider the complex needs of Hispanic patients whose language of choice is not English.

title: Communication and culture: Predictors of treatment adherence among Mexican immigrant patients
abstract: This study examined communication and culture in clinicians’ interactions with Mexican immigrants in Texas. Specifically, we explore the unique interplay among levels of acculturation, beliefs about culturally-based medical practices, perceptions of medical encounters, and the likelihood of adherence to medical therapy recommendations from US providers. Results suggest that: (a) acculturation predicts perceptions of out-group membership in the patient-provider interaction; (b) beliefs about complementary and alternative medicine are negatively related to medical adherence; (c) quality of care mediates the relationship between physician accommodation and medical adherence; and (d) there exists a complex relationship between out-group perceptions and adherence.

title: Mexican Americans’ Perceptions of Culturally Competent Care
abstract: Although the literature abounds with authors’discussions of the need for nurses and other health care providers to deliver safe and optimal care to patients of diverse ethnic groups, little work has focused on defining and measuring the dimensions of culturally competent care. The purpose of this research was to identify culturally competent concepts from the perspective of Mexican Americans. Focus group interviews with Mexican American registered nurses and Mexican American lay recipients of health care were used to explore the participants’subjective perceptions regarding the indicators of culturally competent care. For this group of Mexican American registered nurses, the influence of culture remained strong despite nursing professional experience and knowledge of Western biomedical system. The predominance of themes emphasizing respect, caring, understanding, and patience in health care encounters support the critical importance of personal processes of health care with Hispanics.

title: The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes.
abstract: Limited research has compared the wellbeing functioning of patients from different ethnic backgrounds with chronic medical conditions. Given that ethnic differences in attitudes, beliefs, and behavior have been reported on health-related issues such as cigarette smoking and cancer, patient reports of well-being and functioning and other outcomes also may differ by ethnicity because of cultural factors.1-4 Cultural factors may affect a patient's communication with their physician and, as a result, influence health outcomes. Kaplan et a15 found that effectiveness of information gathering by patients, more conversation by patients relative to physicians, and more affective exchange between patients and physicians were specific aspects of patient-physician communication associated with better

title: Hispanic Familism and Acculturation: What Changes and What Doesn't?
abstract: This investigation studied the effects of acculturation on attitudinal familism in 452 Hispanics compared to 227 white nonHispanics. Despite differences in the national origin of Hispanics, Mexican-, Central -and Cuban-Americans reported similar attitudes toward the family indicating that familism is a core characteristic in the Hispanic culture. Three basic dimensions of familism were found: Familial obligations, perceived support from the family and family as referents. The high level of perceived family support, invariable despite changes in acculturation, is the most essential dimension of Hispanic familism. Familial obligations and the perception of the family as referents appear to diminish with the level of acculturation, but the perception of family support doesn't change. Although these two dimensions of familism decrease concurrently with the level of acculturation, the attitudes of persons with high levels of acculturation are more familistic than those of white nonHispanics.

title: Ethnicity and nativity status as determinants of perceived social support: testing the concept of familism.
abstract: Research has demonstrated a protective effect of social support on health. Social support is most often treated as an independent variable. However, as with disease risk factors, which are not randomly distributed, health-promoting resources such as social support are also systematically patterned. For example, in the USA, family support is thought to be high among Latinos, Mexican Americans in particular. Using data from the Project on Human Development in Chicago Neighborhoods, we explored the relationships between ethnicity/nativity status, socioeconomic status (SES) and perceived social support from family and friends. We also assessed the role of retention of culture-measured as primary language spoken at home-on social support. Finally, we tested whether SES moderated the relationship between ethnicity/nativity status and social support. Foreign and US-born Latinos, most notably, foreign-born Mexicans, reported higher family support compared to non-Latino whites. Primary language spoken at home seems to account for the relationship between ethnicity/nativity and familial social support. Mexican-born and US-born Latino immigrants reported lower social support from family at higher levels of SES. Each ethnic minority group reported lower perception of friend support compared to non-Latino whites. There was a strong SES gradient in subjective support from friends with higher support reported among those with higher SES. This study provides evidence for the notion that Latinos in the USA, specifically foreign-born Mexicans, may rely on family ties for support more than do non-Latino whites. Findings also help identify ethnicity/nativity status, primary language spoken and SES as determinants of social support. Specifically, the higher familial social support found among Latino immigrants may be due to retention of culture. Effect modification by SES suggests that Latinos of lower and higher SES may differ with regard to the traditionally-held value of familism.

title: Coping and social support resources among Latinas with arthritis.
abstract: To examine the coping strategies and social support resources of Latinas (Hispanic women with arthritis.



A sample of 109 Latinas of low socioeconomic status with arthritis were interviewed. Most interviews were conducted in Spanish. In open-ended responses, participants described how they cope with their illness. Respondents also named the two individuals who help them most when they do not feel well because of their illness.



Engaging in activities was the most commonly reported coping strategy, followed by the use of religion or prayer. Respondents relied more on family members (especially daughters) than friends for support.



Coping responses to arthritis may reflect culture-based notions of "coping," as well as culturally valued norms, such as familism. The extent to which findings illustrate cultural, gender, or socioeconomic status factors requires further study.

title: Familismo: influence on Hispanic health behaviors.
abstract: This study explored the impact of hepatitis C infection among a convenience sample of adult Hispanic men and women. Data were collected through a demographic form and audiotaped responses to a vignette. Krueger's transcription-based focus group method of analysis was used to analyze the qualitative data. The major theme, familismo (importance of family), emerged from the data with individual health behavior defined by family needs and expressed by "doing right" by the family. Therefore, health promotion and disease treatment framed within a "healthy family" philosophy and health intervention message may be more culturally acceptable and effective among Hispanic populations.

title: Prenatal care experiences and birth weight among Mexican immigrant women
abstract: National studies indicate that Mexican immigrant women tend to have more positive birth outcomes than other groups, despite receiving relatively low levels of medical prenatal care. Our study-based on in-depth interviews with immigrant women who had recently given birth in Chicago-examines women's experiences seeking prenatal care. Qualitative findings contribute to understanding why many of these women received less than optimal care during pregancy. The study also offers modest evidence that, despite overall positive birth outcomes and low levels of prenatal care, adequate prenatal care may make a difference in birth outcomes in this group. Suggestions are made concerning ways to improve access to adequate care, paying particular attention to the impact of migration and communication in prenatal care.

title: Pap smear and mammogram screening in Mexican-American women: the effects of acculturation.
abstract: For Mexican Americans, acculturation is a multidimensional process of adopting attitudes, values, and behavior from the non-Hispanic White culture. This study examines the effects of different dimensions of acculturation on the cancer screening behavior of Mexican-American women.



Subjects were 450 randomly selected Mexican-American women age 40 years and older living in El Paso, Texas. Personal interviews solicited information on age, income, education, health insurance, Pap smear and mammogram use, and acculturation. Acculturation was measured with five scales that assessed English proficiency, English use, value placed on culture, traditional family attitudes, and social interaction.



The 2-year prevalence of Pap smear and mammogram screening increased with each gain in acculturation on English proficiency and use. These associations disappeared when adjusted for age, income, insurance, and education. After adjusting for sociodemographic factors and other acculturation dimensions, a strong traditional Mexican attitude toward family was positively related to mammography use.



Taking advantage of the positive influence of Hispanic familism on cancer screening behavior may increase the effectiveness of cancer control interventions in Mexican Americans.

title: Acculturation, familism, parental monitoring, and knowledge as predictors of marijuana and inhalant use in adolescents.
abstract: The authors investigated relationships between marijuana and inhalant use and several cultural and demographic factors in Anglo American and Hispanic American adolescents (N=1,094). Outcome measures assessed lifetime and 30-day marijuana and inhalant use. Predictors and covariates used in logistic regression analyses were region, grade, gender, knowledge, acculturation, familism, and parental monitoring. Hispanic Americans exhibited higher usage across all measures. In this group, high acculturation was associated with low marijuana, but high inhalant, use. Across all participants, positive family relations and parental monitoring were strongly associated with attenuated marijuana use hut only among those most knowledgeable about drugs. Familism and monitoring were not associated with diminished usage among the less knowledgeable. For inhalants, monitoring combined with high knowledge or high familism was associated with diminished usage.

title: Exploring the Complexities of Familism and Acculturation: Central Constructs for People of Mexican Origin
abstract: We examined the relationships between three dimensions of familism: importance of family, family support, and family conflict with acculturation, assessed orthogonally (Mexican and American cultural contributions assessed independently), and the relative contribution these factors make to psychological adjustment among 248 (124 women, 124 men) adults of Mexican origin. After controlling for sociodemographic characteristics, positive associations were found between importance of family and the biculturalism of Mexican and American cultural identity; family support and Mexican cultural identity; but no associations between family conflict and level of acculturation. Psychological well-being was positively associated with Mexican cultural identity and family support, whereas psychological distress was associated with greater family conflict and lower family support. The greater relative contribution of Mexican cultural identity to familism and well-being, and the importance of assessing acculturation orthogonally are discussed.

title: Social Support and Health: A Review of Physiological Processes Potentially Underlying Links to Disease Outcomes
abstract: Social support has been reliably related to lower rates of morbidity and mortality. An important issue concerns the physiological mechanisms by which support influences such health endpoints. In this review, I examine evidence linking social support to changes in cardiovascular, neuroendocrine, and immune function. Consistent with epidemiological evidence, social support appears to be related to more positive “biological profiles” across these disease-relevant systems. Recent research on immune-mediated inflammatory processes is also starting to provide data on more integrative physiological mechanisms potentially linking social support to health. The implications of these links, along with future research directions are discussed.

title: Describing Latinos Families and Their Help-Seeking Attitudes: Challenging the Family Therapy Literature
abstract: Latinos comprise a diverse ethnic group in the United States, yet central concepts describing Latinos persist. The purpose of this study was to assess the degree to which Latinos agree with the statements found in the marriage and family therapy (MFT) literature used to describe Latinos and Latino families, as well as their help-seeking attitudes and experiences. Research questions were derived from five constructs used to describe Latinos: familism, personalism, sense of hierarchy, spiritualism, and fatalism (Ho in Family therapy with ethnic minorities. Sage, Newbury, CA, 1987; Ho et al. in Family therapy with ethnic minorities, (2nd ed.). Sage, Thousand Oaks, CA, 2004). Overall, participants agreed with most of the statements pertaining to familism and personalism. However, mixed results were found for the constructs related to sense of hierarchy, spiritualism, and fatalism, as well as for participants’ help-seeking attitudes and behaviors. Latinos in this sample sought mental health professionals. However, MFTs were not sought as frequently as psychiatrists, psychologists, and clergy.

title: Incorporating the cultural value of respeto into a framework of Latino parenting.
abstract: Latino families face multiple stressors associated with adjusting to United States mainstream culture that, along with poverty and residence in inner-city communities, may further predispose their children to risk for negative developmental outcomes. Evidence-based mental health treatments may require culturally informed modifications to best address the unique needs of the Latino population, yet few empirical studies have assessed these cultural elements. The current study examined cultural values of 48 Dominican and Mexican mothers of preschoolers through focus groups in which they described their core values as related to their parenting role. Results showed that respeto, family and religion were the most important values that mothers sought to transmit to their children. Respeto is manifested in several domains, including obedience to authority, deference, decorum, and public behavior. The authors describe the socialization messages that Latina mothers use to teach their children respeto and present a culturally derived framework of how these messages may relate to child development. The authors discuss how findings may inform the cultural adaptation of evidence-based mental health treatments such as parent training programs.

title: The Hispanic Family and Male-Female Relationships: An Overview
abstract: An overview of the traditional Hispanic family and male-female relationships is presented, with an emphasis on issues relevant to providing health care to Hispanic populations. Aspects of the family presented include visitation, decision making, self-care, and emotional problems. Male-female relationships stem from traditional gender roles. Machismo and patriarchal authority characterize the male role; the roles of a traditional woman are housewife and mother. Women are expected to defer to the authority of their husbands. The negative aspects of machismo can result in heavy drinking and the pursuit of high-risk activities, leading to domestic violence and HIV/AIDS. These health risks are exacerbated by such cultural factors as male dominance, female modesty, and the practice of keeping problems within the family. The importance of personalismo in patient-provider encounters is emphasized.

title: Madres para la Salud: design of a theory-based intervention for postpartum Latinas.
abstract: Weight gain in young women suggests that childbearing may be an important contributor to the development of obesity in women. Depressive symptoms can interfere with resumption of normal activity levels following childbirth or with the initiation of or adherence to physical activity programs essential for losing pregnancy weight. Depression symptoms may function directly to promote weight gain through a physiologic mechanism. Obesity and its related insulin resistance may contribute to depressed mood physiologically. Although physical activity has well-established beneficial effects on weight management and depression, women tend to under participate in physical activity during childbearing years. Further, the mechanisms underpinning the interplay of overweight, obesity, physical activity, depression, and inflammatory processes are not clearly explained.



This report describes the theoretical rationale, design considerations, and cultural relevance for "Madres para la Salud" [Mothers for Health].



Madres para la Salud is a 12 month prospective, randomized controlled trial exploring the effectiveness of a culturally specific intervention using "bouts" of physical activity to effect changes in body fat, systemic and fat tissue inflammation, and postpartum depression symptoms in sedentary postpartum Latinas.



The significance and innovation of Madres para la Salud includes use of a theory-driven approach to intervention, specification and cultural relevance of a social support intervention, use of a Promotora model to incorporate cultural approaches, use of objective measures of physical activity in post partum Latinas women, and the examination of biomarkers indicative of cardiovascular risk related to physical activity behaviors in postpartum Latinas.

title: The myth of sameness among Latino men and their machismo.
abstract: This study examined the construct of machismo in relationship to measures of machismo, masculinity, and gender role identity. One hundred forty-eight Latino men with an average age of 36, primarily Mexican American and Puerto Rican, participated. Results indicate that machismo can be characterized as a multidimensional construct, and cluster analyses found that traditional definitions of machismo as authoritarian, emotionally restrictive, and controlling represented only about 10% of the classified Latinos. Most of the sample identified with more emotionally responsive, collaborative, and flexible masculinity styles. Five identity dimensions identified were Contemporary Masculinity, Machismo, Traditional Machismo, Conflicted/Compassionate Machismo, and Contemporary Machismo. Implications include the need to change stereotypes of machismo to be more congruent with the variation in Latino male identity.

title: Expanding the concept of acculturation in Mexican American rehabilitation psychology research and practice.
abstract: The acculturation process is increasingly being viewed as an important variable that provides a context for understanding Mexican American health disparities. Although rehabilitation psychologists have noted the importance of utilizing acculturation in research and practice, scholars continue to use out-dated conceptualizations and models of acculturation.



The authors provide a brief overview of current trends in acculturation theory and research. Limitations of current rehabilitation research and how acculturation theory can help explain Mexican American health outcomes are discussed. Finally, recommendations for rehabilitation research and practice are provided.



The authors recommend that rehabilitation scholars develop and test theoretical models that incorporate multiple dimensions of acculturation in order to understand how it influences Mexican American health outcomes. Rehabilitation professionals should incorporate acculturation theory and culturally informed interventions into rehabilitation practice with Mexican Americans.

title: Importance of race and ethnicity: an exploration of Asian, Black, Latino, and multiracial adolescent identity.
abstract: This mixed-method study used a grounded theory approach to explore the meanings underlying the importance that adolescents attach to their racial-ethnic identities. The sample consisted of 923 9th- to 12th-grade students from Black, Latino, Asian, and multiracial backgrounds. Thematic findings identified a broad range of explanations for adolescents' racial-ethnic centrality, ranging from pride and cultural connection to ambivalence and colorblind attitudes. While racial-ethnic groups differed in reported levels of racial-ethnic centrality, few group differences were identified in participants' thematic explanations, with the exception of racial-ethnic and gender differences for Positive Regard and Disengagement. These findings highlight the diversity of meanings that adolescents attribute to their racial-ethnic centrality as well as the many commonalities among adolescents across gender and racial-ethnic groups.

title: Religiosity and sexual risk behaviors among Latina adolescents: trends from 1995 to 2008.
abstract: The purpose of this study was to determine trends in the influence of religiosity on sexual activity of Latina adolescents in the United States from 1995 to 2008 and to determine if differences existed between the Mexican American and other Latina groups.



The sample comprised the subset of unmarried, 15-21-year-old (mean 17 years) Latina female respondents in the 1995 (n=267), 2002 (n=306), and 2006-2008 (n=400) National Survey of Family Growth (NSFG) datasets. Associations between religiosity (importance of religion and service attendance) and history of ever having sex, number of sex partners, and age of sexual debut were investigated.



Less than one half of Latinas in 1995 (44%) and in 2006-2008 (44%) reported that religion was very important to them, whereas in 2002, 50% reported it was important. Only in 1995 did Latinas who viewed religion as very important have a significantly lower level of sexual initiation. In 1995 and in 2006-2008, Latinas who held religion as very important had significantly fewer partners. In all three cohorts, the higher religious importance group had higher virgin survival rates. Across cohorts, approximately one third of respondents reported frequent religious attendance. In all cohorts, frequent attenders were less likely to have had sex, had fewer partners, and had older age at sexual debut. The survival rate as virgins for Mexican origin Latinas was higher in 1995 and 2002 compared to non-Mexican Latinas but was almost the same in 2006-2008.



Religiosity had a protective association with sexual activity among Latina adolescents. The association of importance of religion with sexual activity has diminished from 1995 to 2008, however, whereas the importance of service attendance has remained stable. The influence of religion was more apparent among the Latinas of Mexican origin, but this greater influence also diminished by 2006-2008.

title: Religion and Latino Partisanship in the United States
abstract: This article examines the interplay among religion, ethnicity, and the partisanship of Latinos in the U.S. Using pooled data from the 1990-2000 National Election Studies, we assess denominational affiliation and religious commitment as explanations of partisanship. We show that there is more religious diversity among Latinos than is usually acknowledged in studies of Latino politics and that the political importance of religion among Latinos has not been adequately assessed because variation beyond a Catholic/non-Catholic dichotomy has been ignored. We demonstrate that variation in Latino religious affiliation has important political implications.

title: Psychosocial and Cultural Influences on Cardiovascular Health and Quality of Life Among Hispanic Cardiac Patients in South Florida
abstract: This study examined whether psychosocial and cultural factors were related to four dimensions of cardiac-related quality of life (global, physical, emotional, and social functioning) in 120 Hispanic coronary heart disease (CHD) outpatients in south Florida. Survey data were collected on sociodemographic (age, gender, socioeconomic status), psychosocial (depression, social support), and cultural factors (acculturation, familism, fatalism), and quality of life. Medical data on CHD severity (New York Heart Association class, time since diagnosis) were obtained from patients’ clinic records. Hierarchical regression analyses revealed that women and patients with more severe CHD had poorer quality of life than men or patients with less severe CHD. Psychosocial and cultural factors were associated with poorer quality of life after controlling for sociodemographic and medical variables: Depression was associated with all four quality of life dimensions (p < .001); and fatalism (p < .05) was associated with lower social functioning in women. These findings identify Hispanic subgroups with poor cardiac-related quality of life that can benefit from special outreach.

title: Religiosity and Utilization of Complementary and Alternative Medicine Among Foreign-Born Hispanics in the United States
abstract: The purpose of this study was to test the association between religiosity and utilization of complementary and alternative medicine (CAM) in a sample of foreign-born Hispanic adults, even when excluding prayer as a form of CAM. Data were collected using a self-report Spanish-language survey. Study participants consisted of 306 respondents between the ages of 18 and 79. Most were born in Mexico (56.3%), followed by South America (24.6%), and then Central America (7.4%). Dependent variable measures included mainstream and traditional CAM utilization. Religiosity was measured using eight items representing ritual, consequential, ideological, and experimental domains. After controlling for the potentially confounding influences of age, gender, and income, respondents who reported higher levels of religiosity also reported greater utilization of mainstream and traditional CAM. Previous studies have included prayer as a form of CAM therapy, making it difficult to test the CAM—religiosity association. In this study, even when prayer was not included as a CAM therapy, religiosity was associated with CAM.

title: Religion and Substance Use among Youths of Mexican Heritage: A Social Capital Perspective.
abstract: Despite elevated levels of substance use among many Latino youths, there has been little research on protective factors against such use. In keeping with federal commitments to address health disparities, this prospective study examined the protective influence of religion on substance use among a school-based sample (N = 804) of youths of Mexican heritage in the American Southwest. Drawing from the social capital literature, the authors posited that both integration into religious networks and trust in religious values at time 1 (Tl) would predict less likelihood of using substances at time 2 (T2) but that exposure to religious norms at Tl would not predict subsequent substance use at T2. The hypotheses regarding religious networks and religious norms were largely confirmed, whereas little support emerged for the hypothesis regarding religious values. The results are discussed in light of the various pathways through which religion may exhibit a protective influence.

title: Health Issues In The Latino Community
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title: Defining and measuring acculturation: a systematic review of public health studies with Hispanic populations in the United States.
abstract: In this systematic review we sought to identify how the public health literature focusing on Hispanic populations in the United States defined and measured the concept of acculturation. A review of 134 studies found considerable variation in the definition and measurement of this construct. The ten acculturation scales used provided little theoretical orientation. It was unclear the extent to which acculturative changes in attitudes, beliefs and behaviors were captured by current measurement tools, as these primarily measure linguistic elements. We suggest future research should refine existing tools, determine their validity and usefulness across ethnic and subethnic groups, and identify which aspects of acculturation these scales and indices reliably measure. Recommendations for use of acculturation instruments in public health practice with Hispanic populations are included.

title: Association between language and risk factor levels among Hispanic adults with hypertension, hypercholesterolemia, or diabetes.
abstract: The association of acculturation and cardiovascular risk factor control among populations with high proportions of immigrants has not been well studied.



We studied 1,492 Hispanic participants in the Multi-Ethnic Study of Atherosclerosis (MESA) with hypertension, hypercholesterolemia, and/or diabetes. We used linear regression to examine the cross-sectional relationships between acculturation measures and cardiovascular risk factor levels. Outcome measures included systolic blood pressure (mm Hg), fasting low-density lipoprotein (LDL) cholesterol (mg/dL), and fasting blood glucose (mg/dL). Covariates included education, income, health insurance, physical activity, dietary factors, risk factor-specific medication use, duration of medication use, smoking, and body mass index.



There were 580 Hispanics with hypertension, 539 with hypercholesterolemia, and 248 with diabetes. After adjustment for age and gender, Spanish-speaking Hispanics with cardiovascular risk factors had higher systolic blood pressure, fasting LDL cholesterol, and fasting blood glucose compared to English-speaking Hispanics. Differences in systolic blood pressure were accounted for mainly by education, whereas differences in LDL cholesterol were almost entirely accounted for by cholesterol-lowering medication use. Differences in fasting glucose were partly accounted for by socioeconomic variables but were augmented after adjustment for dietary factors. Similar associations were observed between proportion of life in the United States and risk factor levels.



Among those with cardiovascular risk factors, Hispanics who spoke Spanish at home and lived less time in the United States had worse control of cardiovascular risk factors. Treatment strategies that focus on Hispanics with low levels of acculturation may improve cardiovascular risk factor control.

title: Integrating social epidemiology into immigrant health research: a cross-national framework.
abstract: Scholarship on immigrant health has steadily increased over the past two decades. This line of inquiry is often approached as a "specialty" topic involving a discrete de-contextualized population, rather than a topic that is central for understanding patterns of population health within and between sending and receiving countries. Frequently immigrant health research employs theoretical frameworks (e.g., acculturation) that emphasize cultural explanations, while less commonly utilized is the "social determinants of health" framework, which emphasizes social and structural explanations. Drawing upon literature in the fields of economics, sociology of immigration, and social epidemiology, we present a conceptual framework for understanding immigrant health from a cross-national perspective. We discuss the theoretical foundations of this framework; the methodological challenges for undertaking research on immigration and health using this framework; examples of emerging research in this area; and directions for future research. Progress in immigrant health research and population health improvements can be achieved through an enhanced understanding of population health patterns in sending and receiving societies. Immigrant health research needs to be better integrated into social epidemiology. Concurrently, immigrant health research offers conceptual, empirical, and analytic opportunities to advance social epidemiological research. Together, scholarship in immigrant health and social epidemiology can make significant contributions toward one of their mutual and ultimate goals: to improve knowledge about population health.

title: Beyond acculturation: immigration, discrimination, and health research among Mexicans in the United States.
abstract: Evidence suggests that, despite their lower socio-economic status, certain health outcomes are better for first-generation Mexican immigrants than their US-born counterparts. Socio-cultural explanations for this apparent epidemiological paradox propose that culture-driven health behaviors and social networks protect the health of the first generation and that, as immigrants acculturate, they lose these health-protecting factors. However, the prominence granted to acculturation within these explanations diverts attention from structural and contextual factors, such as social and economic inequalities, that could affect the health of immigrants and their descendants. The aim of this study is to offer a conceptual redirection away from individual-centered acculturation models towards a more complex understanding of immigrant adaptation in health research. To this end, 40 qualitative in-depth interviews were conducted with first- and second-generation Mexican immigrant women in Southeastern Michigan. The women's narratives highlighted a key process linked to their integration into US society, in which the second generation experienced a more pervasive and cumulative exposure to "othering" than the first generation. The findings point to "othering" and discrimination as potential pathways through which the health of immigrants and their descendants erodes. The paper concludes by proposing a conceptual model that locates "othering" processes within a structural framework, and by drawing implications for research on immigrant health and on discrimination and health.

title: More than culture: structural racism, intersectionality theory, and immigrant health.
abstract: Explanations for immigrant health outcomes often invoke culture through the use of the concept of acculturation. The over reliance on cultural explanations for immigrant health outcomes has been the topic of growing debate, with the critics' main concern being that such explanations obscure the impact of structural factors on immigrant health disparities. In this paper, we highlight the shortcomings of cultural explanations as currently employed in the health literature, and argue for a shift from individual culture-based frameworks, to perspectives that address how multiple dimensions of inequality intersect to impact health outcomes. Based on our review of the literature, we suggest specific lines of inquiry regarding immigrants' experiences with day-to-day discrimination, as well as on the roles that place and immigration policies play in shaping immigrant health outcomes. The paper concludes with suggestions for integrating intersectionality theory in future research on immigrant health.

title: Role of acculturation research in advancing science and practice in reducing health care disparities among Latinos.
abstract: An impressive body of public health knowledge on health care disparities among Latinos has been produced. However, inconclusive and conflicting results on predictors of health care disparities remain. We examined the theoretical assumptions and methodological limitations of acculturation research in understanding Latino health care disparities, the evidence for socioeconomic position as a predictor of health care disparities, and the effectiveness of cultural competency practice. Persistent use of culture-driven acculturation models decenters social determinants of health as key factors in health disparities and diminishes the effectiveness of cultural competency practice. Social and economic determinants are more important predictors than is culture in understanding health care disparities. Improvements in the material conditions of low-income Latinos can effectively reduce health care disparities.

title: Should "acculturation" be a variable in health research? A critical review of research on US Hispanics.
abstract: Acculturation has become a popular variable in research on health disparities among certain ethnic minorities, in the absence of serious reflection about its central concepts and assumptions. Key constructs such as what constitutes a culture, which traits pertain to the ethnic versus "mainstream" culture, and what cultural adaptation entails have not been carefully defined. Using examples from a systematic review of recent articles, this paper critically reviews the development and application of the concept of acculturation in US health research on Hispanics. Multiple misconceptions and errors in the central assumptions underlying the concept of acculturation are examined, and it is concluded that acculturation as a variable in health research may be based more on ethnic stereotyping than on objective representations of cultural difference.

title: Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans. The San Antonio Heart Study.
abstract: The authors hypothesized that increased socioeconomic status and acculturation of Mexican Americans to mainstream US society would be accompanied by a progressive lessening of obesity and non-insulin-dependent diabetes mellitus. This hypothesis was tested in 1979-1982 in the San Antonio Heart Study, a population-based study of 1,288 Mexican Americans and 929 non-Hispanic whites, aged 25-64 years, randomly selected from three San Antonio neighborhoods: a low-income barrio, a middle-income transitional neighborhood, and a high-income suburb. Socioeconomic status was assessed by the Duncan Socioeconomic Index, a global measure of socioeconomic status based on occupational prestige. Acculturation was assessed by three scales which measure functional integration with mainstream society, value placed on preserving Mexican cultural origin, and attitude toward traditional family structure and sex-role organization. In Mexican-American men, increased acculturation was accompanied by a statistically significant, linear decline in both obesity and diabetes, while socioeconomic status had no significant effect on either outcome. In Mexican-American women, on the other hand, increased acculturation and increased socioeconomic status were accompanied by statistically significant, linear declines in both outcomes. However, the effects of acculturation on obesity and diabetes prevalence in women were stronger than the effects of socioeconomic status. In women, obesity also appeared to be a more important mediator of the relation between socioeconomic status and diabetes than of the relation between acculturation and diabetes. The results of this study suggest that culturally mediated factors exert a more pervasive influence on obesity and diabetes in Mexican Americans than do socioeconomically mediated factors. The influence of socioeconomic status in women, however, cannot be ignored, particularly with regard to obesity.

title: Acculturation Rating Scale for Mexican Americans-II: A Revision of the Original ARSMA Scale
abstract: The Acculturation Rating Scale for Mexican Americans (ARSMA) was revised for the purpose of developing an instrument that assessed acculturation processes through an orthogonal, multidimensional approach by measuring cultural orientation toward the Mexican culture and the Anglo culture independently. Two subscales, Anglo Orientation Subcale (AOS) and Mexican Orientation Subscale (MOS), were developed from items from the original ARSMA scale. The two cultural orientation subscales were found to have good internal reliabilities (Cronbach's Alpha = .86 and .88 for the AOS and the MOS, respectively. The revised scale (ARSMA-JJ) yielded a high Pearson correlation coefficient (r = .89) with the original scale. Strong construct validity of ARSMA -II was demonstrated using a sample of 379 individuals representing generations I to 5. ARSMA-II is multifactorial and capable of generating multidimensional acculturative types, for example, integrated, separated, assimilated and marginalized.

title: Toward a theory-driven model of acculturation in public health research.
abstract: Interest in studying the impact of acculturation on immigrant health has increased in tandem with the growth of the Latino population in the United States. Linear assimilation models continue to dominate public health research despite the availability of more complex acculturation theories that propose multidimensional frameworks, reciprocal interactions between the individual and the environment, and other acculturative processes among various Latino groups. Because linear and unidimensional assessments (e.g., nativity, length of stay in the United States, and language use) provide constricted measures of acculturation, the rare use of multidimensional acculturation measures and models has inhibited a more comprehensive understanding of the association between specific components of acculturation and particular health outcomes. A public health perspective that incorporates the roles of structural and cultural forces in acculturation may help identify mechanisms underlying links between acculturation and health among Latinos.

title: Do healthy behaviors decline with greater acculturation? Implications for the Latino mortality paradox.
abstract: Relative to non-Latino whites, Latinos in the United States have a lower socioeconomic status (SES) profile, but a lower all-cause mortality rate. Because lower SES is associated with poorer overall health, a great deal of controversy surrounds the Latino mortality paradox. We employed a secondary data analysis of the 1991 National Health Interview Survey to test the health behavior and acculturation hypotheses, which have been proposed to explain this paradox. These hypotheses posit that: (1) Latinos have more favorable health behaviors and risk factor profiles than non-Latino whites, and (2) Health behaviors and risk factors become more unfavorable with greater acculturation. Specific health behaviors and risk factors studied were: smoking, alcohol use, leisure-time exercise activity, and body mass index (BMI). Consistent with the health behaviors hypothesis, Latinos relative to non-Latino whites were less likely to smoke and drink alcohol, controlling for sociodemographic factors. Latinos, however, were less likely to engage in any exercise activity, and were more likely to have a high BMI compared with non-Latino whites, after controlling for age and SES.  provided partial support for the acculturation hypothesis. After adjusting for age and SES, higher acculturation was associated with three unhealthy behaviors (a greater likelihood of high alcohol intake, current smoking, a high BMI), but improvement in a fourth (greater likelihood of recent exercise). Gender-specific analyses indicated that the observed differences between Latinos and non-Latino whites, as well as the effects of acculturation on health behaviors, varied across men and women. Results suggest that the health behaviors and acculturation hypotheses may help to at least partially explain the Latino mortality paradox. The mechanisms accounting for the relationship between acculturation and risky behaviors have yet to be identified.

title: Acculturation and healthy lifestyle habits among Hispanics in United States-Mexico border communities.
abstract: To explore the relationship between acculturation and healthy lifestyle habits in the largely Hispanic populations living in underserved communities in the United States of America along the U.S.-Mexico border.



A cross-sectional study was conducted from April 2006 to June 2008 using survey data from the Alliance for a Healthy Border, a program designed to reduce health disparities in the U.S.-Mexico border region by funding nutrition and physical activity education programs at 12 federally qualified community health centers in Arizona, California, New Mexico, and Texas. The survey included questions on acculturation, diet, exercise, and demographic factors and was completed by 2,381 Alliance program participants, of whom 95.3% were Hispanic and 45.4% were under the U.S. poverty level for 2007. Chi-square (χ2) and Student's t tests were used for bivariate comparisons between acculturation and dietary and physical activity measures. Linear regression and binary logistic regression were used to control for factors associated with nutrition and exercise.



Based on univariate tests and confirmed by regression analysis controlling for sociodemographic and health variables, less acculturated survey respondents reported a significantly higher frequency of fruit and vegetable consumption and healthier dietary habits than those who were more acculturated. Adjusted binary logistic regression confirmed that individuals with low language acculturation were less likely to engage in physical activity than those with moderate to high acculturation (odds ratio 0.75, 95% confidence interval 0.59-0.95).



Findings confirmed an association between acculturation and healthy lifestyle habits and supported the hypothesis that acculturation in border community populations tends to decrease the practice of some healthy dietary habits while increasing exposure to and awareness of the importance of other healthy behaviors.

title: Selected cultural factors associated with physical activity among Latino women.
abstract: In the United States, Latinos are the largest ethnic group after non-Hispanic whites. Latinos currently represent 15% of the U.S. population and their numbers are growing in nontraditional areas. Latino women (Latinas) disproportionately experience chronic disease risk factors and report low levels of leisure time physical activity. This study examined cultural factors associated with leisure time physical activity among Latinas living in a new Latino destination in northeastern New York.



Community-based participatory research, a collaborative approach in which community members are equitably and actively involved in the research process, was employed for this study. The Latina Health Survey was administered in Spanish and English to 289 Latina adults through snowball sampling.



Women reported that their national origin was predominantly Puerto Rican (58.7%) or Dominican (18.2%). Only 6.6% of women met American College of Sports Medicine's physical activity recommendations of exercising 5 days a week; 25% participated in physical activity two or more times per week. Acculturation and religious service attendance at least once a week was positively associated and fast food consumption one or more times a week was negatively associated with physical activity.



This study implicates the need for physical activity promotion efforts among Latinas who are culturally responsive and that address fast food consumption. In addition to acculturation, other, more specific cultural factors need to be examined to understand physical activity correlates among Latinas. Research among Latinas living in new Latino destinations is important for understanding behavior and tailoring health interventions among Latinos living in nontraditional areas.

title: Acculturation and Latino health in the United States: a review of the literature and its sociopolitical context.
abstract: This chapter provides an overview of the concept of acculturation and reviews existing evidence about the possible relationships between acculturation and selected health and behavioral outcomes among Latinos. The effect of acculturation on Latino health is complex and not well understood. In certain areas-substance abuse, dietary practices, and birth outcomes-there is evidence that acculturation has a negative effect and that it is associated with worse health outcomes, behaviors, or perceptions. In others-health care use and self-perceptions of health-the effect is mostly in the positive direction. Although the literature, to date, on acculturation lacks some breadth and methodological rigor, the public health significance of findings in areas in which there is enough evidence justifies public health action. We conclude with a set of general recommendations in two areas-public health practice and research-targeted to public health personnel in academia, community-based settings, and government agencies.

title: Risk of Cardiovascular Disease in First and Second Generation Mexican-Americans
abstract: This study examines the cardiovascular disease (CVD) risk profiles of first generation (FG) and second generation (SG) Mexican-Americans (MA) in two large national studies––the Hispanic Health and Nutrition Examination Study (HHANES) (1982–1984) and the National Health and Examination Study (NHANES) (1999–2004). The main outcome measures were five individual risk indicators of CVD (total cholesterol, HDL cholesterol, hypertension, diabetes, and smoking) and a composite measure (the Framingham Risk Score [FRS]). The analyses included cross-survey (pseudocohort) and within-survey (cross-sectional) comparisons. In multivariate analyses, SG men had higher rates of hypertension and lower rates of smoking than FG men; and SG women had lower total cholesterol levels, higher rates of hypertension, and lower rates of smoking than FG women. There was no generational difference in the FRS in men or women. The cross-survey comparisons detected generational differences in CVD risk factors not detected in within-survey comparisons, particularly among MA women. Future studies of generational differences in risk should consider using pseudocohort comparisons when possible.

title: Acculturation is associated with hypertension in a multiethnic sample.
abstract: Hypertension varies in prevalence among race/ethnic groups in the United States. Within-ethnic group differences associated with acculturation have been less frequently examined. We studied the association of three measures of acculturation (language spoken at home, place of birth, and years living in the US) with hypertension in a population sample of 2619 white, 1898 African American, 1,494 Hispanic, and 803 Chinese participants in the Multiethnic Study of Atherosclerosis.



Multivariate Poisson regression was used to estimate the association between the acculturation variables and hypertension.



Birthplace outside the US and speaking a non-English language at home were each associated with a lower prevalence of hypertension after adjustment for age, gender, and socioeconomic status (prevalence ratio [95% confidence intervals] 0.82 (0.77-0.87) for non-US born versus US born and 0.80 (0.74-0.85) for those not speaking English at home versus speakers of English at home, both P < .001). For participants born outside of the US, each 10-year increment of years in the US was associated with a higher prevalence of hypertension after adjustment for age, gender, and socioeconomic status (P for trend < .01). The associations between acculturation variables and hypertension were weakened after adjustment for race/ethnic category and risk factors for hypertension. Compared to US-born Hispanics, those born in Mexico or South America had lower prevalence of hypertension, but those born in the Caribbean and Central America had higher prevalence of hypertension.



Acculturation and place of birth are associated with hypertension in a multiethnic sample.

title: The relation of acculturation to latinas’ perceived neighborhood safety and physical activity: A structural equation analysis
abstract: Physical activity rates are low for adult Latinas. In the United States, only 7.8% of adult Latinas met Centers for Disease Control and Prevention recommendations for weekly vigorous leisure-time physical activity. The purpose of this study is to test a theoretical model examining the direct and indirect influence of individual factors (demographic factors and acculturation) and the direct influence of built environmental variables (perceived neighborhood safety/aesthetics) on Latinas’ physical activity in a U.S. border region. Acculturation, perceived neighborhood safety/aesthetics, sociodemographic variables, and minutes of physical activity a week were collected from 526 Latinas using standardized survey measures. Only 30% of the Latinas reported meeting International Physical Activity Questionnaire’s vigorous physical activity criteria, 8.6% met moderate, and 46.4% met walking. Findings from the structural equation modeling indicated that acculturation was positively associated with Latinas’ vigorous and moderate physical activity, with no significant relation to walking. There were no direct associations of perceived neighborhood safety/aesthetics on any of the three measures of physical activity. Data suggest that acculturating to the U.S. mainstream culture may have positive effects on Latinas’ reported physical activity. Contrary to studies of other populations, the perceived neighborhood environment was not related to Latinas’ physical activity. Culturally appropriate interventions are needed for Latinas who are less acculturated into the United States.

title: Acculturation and Metabolic Syndrome Risk Factors in Young Mexican and Mexican–American Women
abstract: Little is known about effects of acculturation on disease risk in young Mexican and Mexican–American women living in a border community. The purpose of this study was to examine relationships between acculturation and features of metabolic syndrome (MetS) in Mexican and Mexican–American women (n = 60) living in the largest US-Mexico border community. Acculturation was measured by the short acculturation scale for Hispanics and birthplace. Body composition was measured by Bod Pod and daily physical activity was measured by questionnaire and accelerometer. Increased acculturation was related to individual features of MetS and increased risk of MetS. These relationships were mediated by fat mass rather than inactivity. Fat mass mediates the relationships between acculturation and individual features of MetS in young Mexican and Mexican–American women. These findings suggest that fat mass, rather than inactivity, is an important contributor to disease risk in young Mexican and Mexican–American women living in a large US/Mexico border community.

title: Obesity and Immigration Among Latina Women
abstract: Several studies have shown a positive association between acculturation and obesity in Hispanics. We sought to examine the association in a sample of urban Hispanic women. Using data collected in the Chicago Breast Health Project, we used logistic regression to examine the association of obesity (BMI ≥ 30 kg/m2) with language acculturation and years in the US in a sample of 388 Hispanic women. Women self-reported the number of years they had lived in the US (mean 17.6) as well as their preferred language across several domains, which was used to calculate a language acculturation score. Nearly all the women (98%) were born outside the US with the majority (65%) born in Mexico and the majority of women (69%) had low language acculturation, i.e., answered “only Spanish” in every domain. Over half of the women were obese (56%). In multivariable analysis, odds of obesity was twice as high among women living in the US for greater than 20 years compared to those in the US for 10 years or less (OR/year = 2.07, 95% CI 1.25–3.42). In contrast, low language acculturation was not associated with odds of obesity (OR = 1.14, 95% CI 0.70–1.86). While greater years in the US increased odds of obesity among Hispanic women, no association of obesity with language acculturation was found. These results suggest that mechanisms other than language contribute to the immigration effect.

title: Association Between Length of Residence and Cardiovascular Disease Risk Factors Among an Ethnically Diverse Group of United States Immigrants
abstract: BACKGROUNDAlthough differences in cardiovascular disease (CVD) risk factors between immigrants and nonimmigrants have been examined previously, the effect of acculturation on CVD risk factors in immigrants has been less well studied.OBJECTIVETo determine the association between length of U.S. residence (proxy for acculturation) and major CVD risk factors.METHODSData on 5,230 immigrant adults from the 2002 National Health Interview Survey (NHIS) was analyzed. Primary independent variable was length of U.S. residence <10, 10 to <15, and ≥15 years. Main outcome measures included obesity, hypertension, diabetes, hyperlipidemia, smoking, and physical inactivity. Multiple logistic regression was used to assess the association between length of residence and odds of multiple CVD risk factors adjusting for confounders. SAS-callable SUDAAN was used for statistical analysis.RESULTSAmong the patients, 55.4% were obese, 17.3% had hypertension, 15.9% had hyperlipidemia, 6.6% had diabetes, 79.3% were physically inactive, and 14.3% were smokers. Using <10 years as reference, those with length of residence ≥15 years were more likely to be obese (OR 1.31, 95% CI 1.03–1.65), have hyperlipidemia (OR 1.59, 95% CI 1.14–2.22), and be smokers (OR 1.39, 95% CI 1.04–1.85). Length of residence ≥15 years was associated with decreased odds of sedentary lifestyle (OR 0.63, 95% CI 0.47–0.84). Length of residence ≥15 years was not associated with odds of having diabetes (OR 1.40, 95% CI 0.78–2.51) or hypertension (OR 1.21, 95% CI 0.86–1.71).CONCLUSIONSAmong immigrants from diverse ethnic backgrounds, longer length of residence in the United States is associated with increased odds of obesity, hyperlipidemia, and cigarette smoking even after adjusting for relevant confounding factors.

title: Looking Beyond “Affordable” Health Care: Cultural Understanding and Sensitivity—Necessities in Addressing the Health Care Disparities of the U.S. Hispanic Population
abstract: Health disparities are pervasive in the United States; but among Hispanics, access to health care is encumbered by poverty, lack of insurance, legal status, and racial or minority status. Research has identified certain aspects of Hispanic culture, values, and traditions contributing to the nature of the Hispanic patient-doctor relationship and the quality of the health care service. Current educational efforts by nonprofit organizations, government, health professionals, and pharmaceutical manufacturers fail to address the needs for accessible and appropriately culture-sensitive information when approaching the diverse Hispanic community. Understanding Hispanics’ consumptive practices and expectations surrounding medications is critical to the success of many treatment regimens. Recommendations are presented to address this health care issue.

title: Household Food Security in the United States in 2012
abstract: An estimated 85.5 percent of American households were food secure throughout the entire year in 2012, meaning that they had access at all times to enough food for an active, healthy life for all household members. The remaining households (14.5 percent) were food insecure at least some time during the year, including 5.7 percent with very low food security—meaning that the food intake of one or more household members was reduced and their eating patterns were disrupted at times during the year because the household lacked money and other resources for food. The change in food insecurity overall (from 14.9 percent in 2011) was not statistically significant. The prevalence rate of very low food security was unchanged from 5.7 percent in 2011. Children were food-insecure in 10.0 percent of households with children in 2012, unchanged from 2011. In 2012, the typical food-secure household spent 26 percent more on food than the typical food-insecure household of the same size and household composition. Fifty-nine percent of all food- insecure households participated in one or more of the three largest Federal food and nutrition assistance programs during the month prior to the 2012 survey.

title: Food insecurity is associated with acculturation and social networks in Puerto Rican households.
abstract: To examine whether acculturation and social networks influence household food insecurity in an inner-city Puerto Rican community.



A survey was administered to 200 low-income female Puerto Rican caregivers with at least 1 child 12-72 months old living in Hartford, CT. Food insecurity was measured with the Radimer/Cornell Hunger Scale. Multivariate logistic regression analyses were used to identify food insecurity risk factors.



Significant food insecurity risk factors included: being unemployed (odds ratio: 2.69), being single (2.34), being born in the United States (2.68), speaking only Spanish (3.15), planning to return to Puerto Rico (4.58), almost never/never attending Hispanic cultural events (6.85), and food stamps lasting less than a month (7.74).



Low levels of acculturation, lack of social networks, and poor food stamps management skills may influence household food insecurity.

title: Dietary patterns of Hispanic elders are associated with acculturation and obesity.
abstract: The association of dietary patterns and obesity, particularly in Hispanics, is relatively poorly understood. This large U.S. population subgroup has a high prevalence of obesity and associated chronic conditions, and Hispanics are changing their dietary practices as they acculturate. Our objectives were 1) to identify dietary patterns among elderly Hispanics in Massachusetts, compared with those of non-Hispanic whites; 2) to associate dietary patterns with acculturation; and 3) to associate dietary patterns with total and central obesity. We used a representative sample of 449 Puerto Rican and 133 Dominican elders and a neighborhood-based sample of 243 non-Hispanic white elders, aged 60 to 92 y, from the cross-sectional Massachusetts Hispanic Elders Study. Obesity and central obesity were assessed with BMI (kg/m2) and waist circumference measurement, respectively. Acculturation was assessed by evaluating language use. Usual diet was assessed with a food frequency questionnaire specifically designed for use with this population. Dietary patterns were defined by cluster analysis of food group variables. We identified five clusters of individuals by dietary pattern, with proportionately greater energy intake from 1) fruit and breakfast cereal, 2) starchy vegetables, 3) rice, 4) whole milk and 5) sweets, respectively. Hispanics were less likely to follow the fruit and cereal or sweets patterns, and more likely to follow the starchy vegetables or milk patterns, than were non-Hispanic whites. Only Hispanics followed the rice pattern. Among Hispanics, acculturation was positively associated with the fruit and cereal pattern, and negatively with the rice pattern. Total and central obesity were positively associated with the rice pattern. Longitudinal studies are needed to clarify the causal nature of these associations.

title: Acculturation and Healthy Lifestyle Among Latinos With Diabetes
abstract: Latinos have a high prevalence of diabetes and disproportionately experience diabetic complications. We sought to examine the association of acculturation on healthy lifestyle habits among the Latino population in the United States with diabetes.  We studied Latino adults (aged ≥20 years) with previously diagnosed diabetes in the 1999–2004 National Health and Nutrition Examination Survey (unweighted N = 467; weighted N = 1,957,778). Healthy lifestyle habits were those consistent with recommendations of the American Diabetes Association (ADA) regarding exercise, smoking, obesity, and diet. Acculturation was measured with the Short Acculturation Scale, a validated 5-item scale assessing use of the Spanish language. Logistic regression analyses of acculturation and healthy behaviors were computed controlling for access to care, demographics, and disease characteristics.  In bivariate analyses, compared with their less-acculturated counterparts, individuals who were more-acculturated to any extent were less likely to have a higher fiber intake (9.4% vs 35.4%, P = .001) and lower saturated fat intake (17.2% vs 46.5%, P = .03). More-acculturated individuals were more likely to report leisure time exercise (59.2% vs 19.3%, P <.001), whereas the proportion of individuals who smoked did not differ. In logistic regression analyses using the 1994 ADA dietary guidelines, more-acculturated individuals were less likely than their less-acculturated counterparts to meet dietary criteria for saturated fat consumption (odds ratio, 0.13; 95% confidence interval [CI], 0.04–0.41). When using the stricter 2006 ADA dietary guidelines, more-acculturated individuals were less likely to have recommended consumption of both saturated fat (odds ratio, 0.06; 95% CI, 0.02–0.20) and fiber (odds ratio, 0.19; 95% CI, 0.08–0.48). Acculturation did not significantly influence exercise and smoking status in logistic regression analyses.  These results suggest that acculturation among diabetic Latinos to the general US culture is associated with adoption of some less desirable dietary habits.

title: Maintenance and Change in the Diet of Hispanic Immigrants in Eastern North Carolina
abstract: The objectives of this descriptive, exploratory study were to assess maintenance and change in the food consumption, preparation, and purchasing practices of Hispanic immigrants currently residing in eastern North Carolina who had lived in the United States for no more than 10 years, and to identify underlying ecological factors and perceptions about food quality that shape their postmigrational food habits. The participants were 33 Hispanic immigrants: 8 males and 25 females. Qualitative data were collected using individual interviews and a focus group session. Findings suggest that these Hispanic immigrants struggle to retain their cultural food traditions and are consuming more high-fat, high-sugar foods than they did in their home countries. Improved economic status and school food service offerings are examples of factors that promote dietary change among children and families. These influences and identified misconceptions about food safety and freshness are important topics for culturally sensitive nutrition education for this population.

title: Intake and food sources of macronutrients among older Hispanic adults: association with ethnicity, acculturation, and length of residence in the United States.
abstract: To describe the food intake and food sources of macronutrients in diets of older Hispanic adults in the Northeastern United States and to explore relationships between acculturation, years in the United States, and macronutrient intake.



Cross-sectional study using a representative sample of older Hispanic adults and a comparison group of non-Hispanic whites.



Hispanic (n = 711) and non-Hispanic white (n = 226) persons, aged 60 years and older, residing in Massachusetts.



Macronutrient intakes, collected by 24-hour dietary recall, were compared across ethnic groups by means of the general linear models procedure (with Bonferroni adjustments). Associations between macronutrient intake and predictor variables were tested with Pearson correlations and linear regression. The contribution of foods to total intake of macronutrients was determined by use of a rank procedure.



Hispanic elderly subjects consumed significantly less saturated fat and simple sugars and more complex carbohydrates than did non-Hispanic whites. Hispanics residing in the United States for a longer time tended to have macronutrient profiles more similar to those of the non-Hispanic whites. Rice for Hispanic and bread for non-Hispanics were the major contributors of energy. More acculturated Hispanic elders consumed fewer ethnic foods and more foods related to the non-Hispanic-white eating patterns than those less acculturated.



Efforts to promote better diets among Hispanic elders need to emphasize maintenance or adoption of healthful dietary patterns based on ethnic and modern foods that will satisfy their biological, emotional, and social needs. Dietitians and other dietetics practitioners can use the information presented here in studying nutrition-related chronic diseases, in public health planning, and in nutrition education and promotion efforts directed to ethnic-specific, elderly Hispanic groups.

title: Differences in energy, nutrient, and food intakes in a US sample of Mexican-American women and men: findings from the Third National Health and Nutrition Examination Survey, 1988-1994.
abstract: As Mexican-American women and men migrate to the United States and/or become more acculturated, their diets may become less healthy, increasing their risk of cardiovascular disease. Data from the Third National Health and Nutrition Examination Survey (1988-1994) were used to compare whether energy, nutrient, and food intakes differed among three groups of Mexican-American women (n = 1,449) and men (n = 1,404) aged 25-64 years: those born in Mexico, those born in the United States whose primary language was Spanish, and those born in the United States whose primary language was English. Percentages of persons who met the national dietary guidelines for fat, fiber, and potassium and the recommended intakes of vitamins and minerals associated with cardiovascular disease were also compared. In general, Mexican Americans born in Mexico consumed significantly less fat and significantly more fiber; vitamins A, C, E, and B6; and folate, calcium, potassium, and magnesium than did those born in the United States, regardless of language spoken. More women and men born in Mexico met the dietary guidelines or recommended nutrient intakes than those born in the United States. The heart-healthy diets of women and men born in Mexico should be encouraged among all Mexican Americans living in the United States, especially given the increasing levels of obesity and diabetes among this rapidly growing group of Americans.

title: Dietary intake among Mexican-American women: generational differences and a comparison with white non-Hispanic women.
abstract: Although Mexican Americans consume diets that may protect them against adverse health, dietary advantages may disappear with increased acculturation. This study examined whether the nutrient intake of second-generation Mexican-American women of childbearing age deteriorates compared with that of first-generation Mexican-American women and approximates that of White non-Hispanic women.



Data on the absolute and relative intake of eight nutrients were obtained from a 24-hour recall and compared among 475 first-generation and 898 second-generation Mexican-American women, and among 2326 White non-Hispanic women.



Although first-generation Mexican-American women were of lower socioeconomic status than were second-generation or White non-Hispanic women, they had a higher average intake of protein; vitamins A, C, and folic acid; and calcium than the other two groups. Whereas the mean adequacy ratio of the eight nutrients studied was highest in first-generation Mexican women, it was lowest in their second-generation counterparts.



First-generation Mexican women stand a markedly lower risk of eating a poor diet than second-generation Mexican women, whose nutrient intake resembles that of White non-Hispanic women.

title: Higher fat intake and lower fruit and vegetables intakes are associated with greater acculturation among Mexicans living in Washington State.
abstract: To examine associations of diet with acculturation among Hispanic immigrants from Mexico to Washington state and to compare dietary patterns of Hispanic with non-Hispanic white residents.



Data are part of the baseline assessment for a community-randomized cancer prevention trial. The Fat-Related Diet Habits questionnaire and the National 5-A-Day for Better Health program dietary assessment instruments were used to collect data on fat and fruit and vegetable intake, respectively. Data were also collected on demographic characteristics and acculturation status.



A total of 1,689 adult Hispanic and non-Hispanic white residents of 20 communities in the Yakima Valley, WA, completed in-person interviews.


STATISTICAL ANALYSES PERFORMED
Mixed model regression analyses tested associations of acculturation with diet. These models compared the fat and the fruit and vegetable intake of Hispanics vs non-Hispanic white residents. Additional analyses compared the diets of highly acculturated Hispanics with low-acculturated Hispanics. All models included age, sex, income, and education and were also adjusted for the random effect of community.



Dietary patterns varied by ethnicity and acculturation status. On average, compared with non-Hispanic white residents, Hispanics consumed one more serving of fruits and vegetables per day (P<.001). Dietary habits changed as Hispanics acculturated to the United States. Highly acculturated Hispanics ate fewer servings of fruits and vegetables per day compared with those not highly acculturated (P<.05). Highly acculturated Hispanics had slightly higher, but not statistically significant, scores on the Fat-Related Diet Habits questionnaire, which corresponds to a higher fat intake, compared with low-acculturated Hispanics. The early dietary changes made on acculturation included adding fat at the table to breads and potatoes.



Nutrition professionals should encourage their Hispanic clients to maintain their traditional dietary practices, such as a high intake of fruits and vegetables and eating bread and potatoes without added fat.

title: Acculturation, nutrition, and health disparities in Latinos.
abstract: Latinos have become the largest minority group in the United States and will represent 25% of the US population by 2050. Latinos experience a disproportionate burden of poverty and poor health outcomes.



We critically examined the evidence for a link between acculturation and health disparities in Latinos with a focus on type 2 diabetes (T2D) and nutrition-related risk factors and illustrated how acculturation principles can help design a culturally appropriate T2D self-management intervention in Latinos.



Evidence presented in this article was drawn from 1) systematic reviews identified through PubMed searches, 2) backward searches that were based on articles cited, 3) experts in the field, and 4) the author's personal files.



The preponderance of the evidence supported an association of acculturation with poor dietary quality and obesity. These associations appeared to be modified by several socioeconomic and demographic factors and were not always linear. The association between acculturation and T2D is unclear.



Longitudinal studies and more sophisticated analytic approaches are needed to better understand if and how acculturation affects health-disparity outcomes in Latinos. Tailoring interventions to the acculturation level of individuals is likely to help reduce health disparities in Latinos.

title: A systematic review of the relationship between acculturation and diet among Latinos in the United States: implications for future research.
abstract: Dietary intake is an important determinant of obesity and numerous chronic health conditions. A healthful diet is an essential component of chronic disease self-management. Researchers have indicated that the healthfulness of the Latino diet deteriorates during the acculturation process. However, given the many operationalizations of acculturation, conclusive evidence regarding this relationship is still lacking. This comprehensive and systematic literature review examines the relationship between acculturation and diet by examining national, quantitative, and qualitative studies involving Latinos living in the United States. Studies of diet included those that examined dietary intake using one of several validated measures (eg, food frequency questionnaire, 24-hour dietary recall, or dietary screener) and/or dietary behaviors (eg, away-from-home-eating and fat avoidance). Articles were identified through two independent searches yielding a final sample of 34 articles. Articles were abstracted by two independent reviewers and inter-rater reliability was assessed. Analyses examined the extent to which various measures of acculturation (ie, acculturation score, years in the United States, birthplace, generational status, and language use) were associated with macronutrient intake, micronutrient intake, and dietary behaviors. Several relationships were consistent irrespective of how acculturation was measured: no relationship with intake of dietary fat and percent energy from fat; the less vs more acculturated consumed more fruit, rice, beans, and less sugar and sugar-sweetened beverages. Additional observed relationships depended on the measure of acculturation used in the study. These findings suggest a differential influence of acculturation on diet, requiring greater specificity in our dietary interventions by acculturation status.

title: Using Qualitative Methods for Revising Items in the Hispanic Stress Inventory
abstract: Despite progress in the development of measures to assess psychosocial stress experiences in the general population, a lack of culturally informed assessment instruments exist to enable clinicians and researchers to detect and accurately diagnosis mental health concerns among Hispanics. The Hispanic Stress Inventory (HSI) was developed specifically for Hispanic adults, however, significant social and geopolitical changes over the past two decades have affected the types and intensity of stress experienced by Hispanics. Immigration related policy changes, for example, affect stress experiences among newer immigrants from Mexico and other Latin American countries in ways that items in the original HSI may no longer capture the full range of today’s stressors. Using expert interviews from Hispanic mental health experts and data gathered in 16 community-based focus groups at two distinct study sites, the goal of the current study was to identify new item content to include in a revised HSI. Using content analysis of all interview data, a total of 155 new stressor items and seven unique stress domains were generated. Content validity analysis using Kappa coefficient reveal high interrater validity for new HSI item content. Findings are described in depth, and recommendations for future research are identified.

title: Do Socioeconomic Gradients in Subclinical Atherosclerosis Vary According to Acculturation Level? Analyses of Mexican-Americans in the Multi-Ethnic Study of Atherosclerosis
abstract: To examine whether the association between socioeconomic position (SEP) and subclinical atherosclerosis in Mexican-Americans would be moderated by acculturation. Although SEP shows a consistent, inverse relationship with cardiovascular disease (CVD) risk in westernized non-Hispanic white populations, the relationship in ethnic minorities, including Hispanics, is often weak or even reversed (i.e., worse health with higher SEP).  Participants were 801 Hispanics of Mexican origin (49.6% = female; average age = 60.47 years) from the Multi-Ethnic Study of Atherosclerosis cohort who underwent computed tomography of the chest for coronary artery calcium (CAC) and thoracic aortic calcium (TAC). SEP was represented by a composite of self-reported education and income. Acculturation was a composite score, including language spoken at home, generation, and years of “exposure” to U.S. culture.  Small but statistically significant SEP by acculturation interaction effects were identified in relation to prevalent CAC, prevalent TAC, and extent of TAC (all p < .05). Follow-up analyses revealed that the direction of the SEP gradient on detectable CAC changed as individuals progressed from low to high acculturation. Specifically, the association between SEP and calcification was positive at low levels of acculturation (i.e., a “reversed” gradient), and negative in circumstances of high acculturation (i.e., the expected, protective effect of higher SEP).  The findings support the utility of examining SEP and acculturation simultaneously, and of disaggregating large ethnic groupings (e.g., “Hispanic”) into meaningful subgroups to better understand health risks. SEP = socioeconomic position; CAC = coronary artery calcium; TAC = thoracic aortic calcium; MESA = Multi-Ethnic Study of Atherosclerosis.

title: Latina Self-Reported Mental Health and Delay in Health Care in a New Latino Destination
abstract: Understanding how depression and/or anxiety affects use of health care among Latinas in rapidly growing new Latino destinations, population where the growth rate of the Latino population exceeds the national average, may enhance community engagement efforts. Using community-based participatory research, a questionnaire assessing health care use was administered to 289 Latinas. Most (70%) reported delaying healthcare, and self-reported depression/anxiety was associated with a 3.1 fold (95% CI: 1.6–5.9) increase in delay, after adjusting for current health status, acculturation, age, education, and place of birth. Mental health disparities exist among Latinas, which are related to delays in use of health care. A gap exists regarding health education interventions for Latinas. More research is needed to identify successful models, especially in new Latino destinations as they may be particularly vulnerable to delay care.

title: Health disparities in the Latino population.
abstract: In this review, the authors provide an approach to the study of health disparities in the US Latino population and evaluate the evidence, using mortality rates for discrete medical conditions and the total US population as a standard for comparison. They examine the demographic structure of the Latino population and how nativity, age, income, and education are related to observed patterns of health and mortality. A key issue discussed is how to interpret the superior mortality indices of Latino immigrants and the subsequent declining health status of later generations. Explanations for differences in mortality include selection, reverse selection, death record inconsistencies, inequalities in health status, transnational migration, social marginality, and adaptation to environmental conditions in the United States. The utility of the public health social inequality framework and the status syndrome for explaining Latino disparities is discussed. The authors examine excess mortality from 8 causes: diabetes, stomach cancer, liver cancer, cervical cancer, human immunodeficiency virus/acquired immunodeficiency syndrome, liver disease, homicide, and work-related injuries. The impact of intergenerational changes in health behavior within the Latino population and the contributory role of suboptimal health care are interpreted in the context of implications for future research, public health programs, and policies.

title: The Influence of Immigrant Status and Acculturation on the Development of Overweight in Latino Families: A Qualitative Study
abstract: Exposure to obesogenic environments in the U.S. may foster development of overweight in immigrants with greater acculturation. Few studies document mechanisms of the acculturation process from immigrants’ own perspectives or describe implications on the children of immigrants. Focus groups and in-depth interviews were conducted with immigrant Latina mothers (N = 51) examining mothers’ beliefs, attitudes and practices related to early child feeding and weight. Focus group participants completing the Marin Acculturation Scale more closely identified with Latino culture, although the mean score (2.04, SD = 0.59) was close to “bicultural”. Analysis revealed seven themes when mothers compared lifestyles between their native countries and the U.S., related to changes in (1) diet, perceived food quality and availability, (2) food and eating practices, (3) breastfeeding practices, (4) beliefs about food, child feeding and weight status, (5) weight status of mothers and children, (6) physical activity and sedentary lifestyles, and (7) social isolation and support.

title: Immigration and Weight Gain: Mexican-American Women’s Perspectives
abstract: There is an urgent need for effective and accessible culturally-sensitive weight-loss interventions for the Mexican-American population. It is imperative that cultural factors be taken into account when designing weight-loss interventions targeting this population. As a first step in this direction, this study examined the experiences, concerns, and beliefs regarding diet, weight and weight loss of Mexican-American immigrant women. Focus groups were conducted with Mexican-American women (n = 25) between the ages of 20 and 63, from the Portland, Oregon metropolitan area. Major themes identified in the discussions included important lifestyle changes brought about by immigration, the challenges of adopting “American ways,” lack of nutritional information, and the difficulties in making food choices given the complexities of the family context. Behavioral interventions must provide culturally-centered behavioral strategies addressing some of the difficulties identified in this study. Specific suggestions are provided for the development of weight-loss interventions for this population.

title: “I Don't Make the Soups Anymore”: Pre- to Post-Migration Dietary and Lifestyle Changes Among Latinos Living in West-Central Florida
abstract: Eighteen Latino adults living in the U.S. for less than 2.5 years were surveyed and interviewed about their pre- and post-migration diets and lifestyles. While this mostly female sample reported that their primary language was Spanish, many had some limited skills in written and spoken English. Two thirds were from Colombia, married, and had between 1 and 4 children, and more than half had post-secondary education. Percent change in diet, food habits, and activities associated with lifestyle, regardless of the direction, ranged from a low of 27.8% of the sample for alcohol consumption to a high of 100% for both physical activity and sedentary behavior. In most cases, post-immigration food types and behaviors represented unhealthy changes, including weight gain, a lack of physical activity, and a corresponding increase in television viewing time and in the consumption of fast food, processed food, soda, and, to a lesser extent, artificial juices. Ten participants were interviewed about daily life in their native countries (pre-migration) and since coming to the U.S. (post-migration). Six primary themes emerged with regard to post-migration lifestyle changes: pace of life, family interaction, social integration, socioeconomic status, physical security, and control over children's eating patterns. All of these themes were related to decision-making regarding food choices and food habits, and in many cases such decisions were detrimental to health.

title: ‘We eat meat every day’: ecology and economy of dietary change among Oaxacan migrants from Mexico to New Jersey
abstract: In the late twentieth and early twenty-first centuries, the USA has experienced large-scale and continuing immigration from around the world, especially Latin America and, within Latin America, from Mexico. One dimension of these transnational processes is dietary change. In this paper, we qualitatively assess the effects of migration from Oaxaca, Mexico to central New Jersey on the ecology and economy of dietary patterns. We explore multiple factors at the micro and macro levels. Data come from focus groups held among Mexican migrants in New Jersey, and in Oaxaca among people from their sending communities. Economic constraints and lack of culturally appropriate foods are larger barriers to healthy eating than lack of knowledge about appropriate diets. We end with recommendations for nutrition education and interventions.

title: Breast and Cervical Cancer Screening: Impact of Health Insurance Status, Ethnicity, and Nativity of Latinas
abstract: Although rates of cancer screening for Latinas are lower than for non-Latina whites, little is known about how insurance status, ethnicity, and nativity interact to influence these disparities. Using a large statewide database, our study examined the relationship between breast and cervical cancer screening rates and socioeconomic and health insurance status among foreign-born Latinas, US-born Latinas, and non-Latina whites in California.  Data from the1998 California Women’s Health Survey (CWHS) were analyzed (n = 3,340) using multiple logistic regression models. Utilization rates of mammography, clinical breast examinations, and Papanicolaou (Pap) smear screening among foreign-born Latinas, US-born Latinas, and non-Latina whites were the outcome measures.  Foreign-born Latinas had the highest rates of never receiving mammography, clinical breast examinations, and Pap smears (21%, 24%, 9%, respectively) compared with US-born Latinas (12%, 11%, 7%, respectively) and non-Latina whites (9%, 5%, 2%, respectively). After controlling for socioeconomic factors, foreign-born Latinas were more likely to report mammography use in the previous 2 years and Pap smear in the previous 3 years than non-Latina whites. Lack of health insurance coverage was the strongest independent predictor of low utilization rates for mammography (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.53–2.76), clinical breast examinations (OR = 2.29; 95% CI, 1.80–2.90) and Pap smears (OR = 2.89; 95% CI, 2.17–3.85. Breast and cervical cancer screening rates vary by ethnicity and nativity, with foreign-born Latinas experiencing the highest rates of never being screened. After accounting for socioeconomic factors, differences by ethnicity and nativity are reversed or eliminated. Lack of health insurance coverage remains the strongest predictor of cancer screening underutilization.

title: Acculturation and Cardiovascular Risk Factor Control among Hispanic Adults in the United States
abstract: We sought to determine whether low acculturation, based on language measures, leads to disparities in cardiovascular risk factor control in U.S. Hispanic adults.  We studied 4,729 Hispanic adults aged 18 to 85 years from the National Health and Nutrition Examination Survey, 1999–2004. We examined the association between acculturation and control of low-density lipoprotein (LDL) cholesterol, blood pressure, and hemoglobin A1c based on national guidelines among participants with hypercholesterolemia, hypertension, and diabetes, respectively. We used weighted logistic regression adjusting for age, gender, and education. We then examined health insurance, having a usual source of care, body mass index, fat intake, and leisure-time physical activity as potential mediators.  Among participants with hypercholesterolemia, Hispanic adults with low acculturation were significantly more likely to have poorly controlled LDL cholesterol than Hispanic adults with high acculturation after multivariable adjustment (odds ratio [OR] = 3.4, 95% confidence interval [CI] 1.2, 9.5). Insurance status mildly attenuated the difference in LDL cholesterol control. After adjusting for diet and physical activity, the magnitude of the association increased. Other covariates had little influence on the observed relationship. Among those with diabetes and hypertension, we did not observe statistically significant associations between low acculturation and control of hemoglobin A1c (OR=0.5, 95% CI 0.2, 1.2), and blood pressure (OR=1.1, 95% CI 0.6, 1.7), respectively.  Low levels of acculturation may be associated with increased risk of inadequate LDL cholesterol control among Hispanic adults with hypercholesterolemia. Further studies should examine the mechanisms by which low acculturation might adversely impact lipid control among Hispanic adults in the U.S.

title: Discrimination and racial disparities in health: evidence and needed research
abstract: This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.

title: Dimensions of Perceived Racism and Self-Reported Health: Examination of Racial/Ethnic Differences and Potential Mediators
abstract: BackgroundMany details of the negative relationship between perceived racial/ethnic discrimination and health are poorly understood.PurposeThe purpose of this study was to examine racial/ethnic differences in the relationship between perceived discrimination and self-reported health, identify dimensions of discrimination that drive this relationship, and explore psychological mediators.MethodsAsian, Black, and Latino(a) adults (N = 734) completed measures of perceived racial/ethnic discrimination, self-reported health, depression, anxiety, and cynical hostility.ResultsThe association between perceived discrimination and poor self-reported health was significant and did not differ across racial/ethnic subgroups. Race-related social exclusion and threat/harassment uniquely contributed to poor health for all groups. Depression, anxiety, and cynical hostility fully mediated the effect of social exclusion on health, but did not fully explain the effect of threat.ConclusionsOur results suggest that noxious effects of race-related exclusion and threat transcend between-group differences in discriminatory experiences. The effects of race-related exclusion and threat on health, however, may operate through different mechanisms.

title: Development and psychometric testing of a multidimensional instrument of perceived discrimination among African Americans in the Jackson Heart Study.
abstract: Assessing the discrimination-health disparities hypothesis requires psychometrically sound, multidimensional measures of discrimination. Among the available discrimination measures, few are multidimensional and none have adequate psychometric testing in a large, African American sample. We report the development and psychometric testing of the multidimensional Jackson Heart Study Discrimination (JHSDIS) Instrument.



A multidimensional measure assessing the occurrence, frequency, attribution, and coping responses to perceived everyday and lifetime discrimination; lifetime burden of discrimination; and effect of skin color was developed and tested in the 5302-member cohort of the Jackson Heart Study. Internal consistency was calculated by using Cronbach alpha coefficient. Confirmatory factor analysis established the dimensions, and intercorrelation coefficients assessed the discriminant validity of the instrument.



Tri-county area of the Jackson, MS metropolitan statistical area.



The JHSDIS was psychometrically sound (overall alpha = .78, .84 and .77, respectively, for the everyday and lifetime subscales). Confirmatory factor analysis yielded 11 factors, which confirmed the a priori dimensions represented.



The JHSDIS combined three scales into a single multidimensional instrument with good psychometric properties in a large sample of African Americans. This analysis lays the foundation for using this instrument in research that will examine the association between perceived discrimination and CVD among African Americans.

title: Perceived discrimination and hypertension among African Americans in the Jackson Heart Study.
abstract: Using Jackson Heart Study data, we examined whether perceived discrimination was associated with prevalent hypertension in African Americans.



Everyday discrimination, lifetime discrimination, burden of discrimination, and stress from discrimination were examined among 4939 participants aged 35 to 84 years (women = 3123; men = 1816). We estimated prevalence ratios of hypertension by discrimination, and adjusted for age, gender, socioeconomic status, and risk factors.



The prevalence of hypertension was 64.0% in women and 59.7% in men. After adjustment for age, gender, and socioeconomic status, lifetime discrimination and burden of discrimination were associated with greater hypertension prevalence (prevalence ratios for highest vs lowest quartile were 1.08 [95% confidence interval (CI) = 1.02, 1.15] and 1.09 [95% CI = 1.02,1.16] for lifetime discrimination and burden of discrimination, respectively). Associations were slightly weakened after adjustment for body mass index and behavioral factors. No associations were observed for everyday discrimination.



Further understanding the role of perceived discrimination in the etiology of hypertension may be beneficial in eliminating hypertension disparities.

title: Chronic Exposure to Everyday Discrimination and Coronary Artery Calcification in African-American Women: The SWAN Heart Study
abstract: Emerging evidence suggests that exposure to discrimination may be associated with atherosclerosis in African-American women, although research in this area focused on short-term rather than chronic exposure to discriminatory events.  We examined the relationship between chronic exposure to multiple types of discrimination (self-reported and averaged over 5 years) and coronary artery calcification (CAC) in a sample of 181 middle-aged African-American women. Discrimination was assessed at each time point, and the presence/absence of CAC was assessed at the fifth annual follow-up examination by electron beam tomography. We hypothesized that chronic discrimination would be more strongly associated with CAC than recent discrimination and that racial/ethnic discrimination would be more strongly associated with CAC than other types of discrimination.  Chronic exposure to discrimination was significantly associated with the presence of CAC in unadjusted logistic regression analyses (p = .007) and after adjustment for demographics (p = .01), standard cardiovascular risk factors (p = .02), and Body Mass Index (BMI) (p = .05). In contrast, recent discrimination was only marginally associated with the presence of CAC in both unadjusted (p = .06) and fully adjusted logistic regression models (p = .08). Persistent exposure to racial/ethnic discrimination was not more strongly associated with CAC compared with other types of discrimination in either unadjusted or adjusted models.  Chronic exposure to discrimination may be an important risk factor for early coronary calcification in African-American women. This association appears to be driven by exposure to discrimination from multiple sources, rather than exposure to racial/ethnic discrimination alone. CVD = cardiovascular disease; CAC = coronary artery calcification; SWAN = Study of Women’s Health Across the Nation; EBT = electron beam tomographic; CES-D = Center for Epidemiological Studies Depression; BMI = body mass index; FRS = Framingham Risk score; HDL-c = high density lipoprotein cholesterol; CRP = C-reactive protein; OR = odds ratio; CI = confidence interval; IMT = intima-media thickness.

title: Racism and Cardiovascular Disease in African Americans
abstract: &NA; This article provides an overview of the evidence on the ways racism can affect the disproportionate rates of cardiovascular disease (CVD) in African Americans. It describes the significant health disparities in CVD for blacks and whites and suggests that racial disparities should be understood within the context of persistent inequities in societal institutions and relations. Evidence and potential pathways for exploring effects of 3 levels of racism on cardiovascular health risk factors and outcomes are reviewed. First, institutional racism can lead to limited opportunities for socioeconomic mobility, differential access to goods and resources, and poor living conditions that can adversely affect cardiovascular health. Second, perceived/personally mediated racism acts as a stressor and can induce psychophysiological reactions that negatively affect cardiovascular health. Third, in race‐conscious societies, such as the United States, the negative self‐evaluations of accepting negative cultural stereotypes as true (internalized racism) can have deleterious effects on cardiovascular health. Few population‐based studies have examined the relationship between racism and CVD. The findings, though suggestive of a positive association, are neither consistent nor clear. The research agenda of the Jackson Heart Study in addressing the role of racism in CVD is presented.

title: Perceived discrimination and depression among Mexican-origin adults in California.
abstract: We contend that perceived discrimination has an independent effect on depression outcomes among adults of Mexican origin. Using a sample of 3,012 Mexican-origin respondents in Fresno, California in 1995/96 (ages 18-59) we investigate the direct and moderating connections between perceived discrimination, acculturative stress, and mental health (CES-D). We also investigate the social patterning of perceived discrimination. While more highly acculturated immigrant respondents were more likely to experience discrimination than their less acculturated counterparts, more highly acculturated U.S. born respondents were less likely to experience discrimination. Discrimination was directly related to depression, but this effect was moderated through nativity/country of residence, English-language acculturation, sex, and country of education variables. Moderate levels of legal status acculturative stress were especially depressive for native-born U.S. residents.

title: Status inequalities, perceived discrimination, and eudaimonic well-being: do the challenges of minority life hone purpose and growth?
abstract: Considerable prior research has investigated links between racial/ethnic status and diverse aspects of mental functioning (e.g. psychological disorders, quality of life, self-esteem), but little work has probed the connections between minority status and eudaimonic well-being. Derived from existential and humanistic perspectives, eudaimonia describes engagement in life challenges and is operationalized with assessments of purpose in life, personal growth, autonomy, environmental mastery, self-acceptance, and positive relations with others. Using Midlife in the United States (MIDUS), a national survey of Americans aged 25-74, plus city-specific samples of African Americans in New York City and Mexican Americans in Chicago, minority status was found to be a positive predictor of eudaimonic well-being, underscoring themes of psychological strength in the face of race-related adversity. Perceived discrimination was found to be a negative predictor of eudaimonic well-being, although such effects were gender-specific: it was women, both majority and minority, with high levels of discrimination in their daily lives whose sense of growth, mastery, autonomy, and self-acceptance was compromised.

title: Perceived racial/ethnic discrimination, smoking and alcohol consumption in the Multi-Ethnic Study of Atherosclerosis (MESA).
abstract: To examine the association of perceived racial/ethnic discrimination with smoking and alcohol consumption in adults participating in the Multi-Ethnic Study of Atherosclerosis.



Data on 6680 black, Chinese, Hispanic and white adults aged 45 to 84 years of age recruited from Illinois, New York, Maryland, North Carolina, Minnesota and California during 2000 and 2002 were used for this analysis. Logistic regression was used to estimate the association of perceived racial/ethnic discrimination with smoking status and alcohol consumption for each racial/ethnic group separately.



Blacks were more likely to experience racial/ethnic discrimination (43%) than Hispanics (19%), Chinese participants (10%) or whites (4%, P<0.0001). In the fully-adjusted model, blacks reporting racial/ethnic discrimination had 34% and 51% greater odds of reporting smoking and drinking, respectively, than blacks who did not report racial/ethnic discrimination. Hispanics reporting racial/ethnic discrimination had 62% greater odds of heavy drinking. Whites reporting racial/ethnic discrimination had 88% greater odds of reporting being current smokers than whites who did not report racial/ethnic discrimination.



Our findings suggest that the experience of discrimination is associated with greater prevalence of unhealthy behaviors. Specifically, the use of smoking and alcohol may be patterned by experience of discrimination.

title: Racism and Ambulatory Blood Pressure in a Community Sample
abstract: Racism has been identified as a psychosocial stressor that may contribute to disparities in the prevalence of cardiovascular disease. The goal of the present article was to investigate the relationship of perceived racism to ambulatory blood pressure (ABP) in a sample of American-born Blacks and Latinos.  Participants included English-speaking Black or Latino(a) adults between the ages of 24 and 65. They completed daily mood diaries and measures of perceived racism, socioeconomic status, and hostility. Participants were outfitted with ABP monitors; 357 provided data on waking hours only, and 245 provided data on both waking and nocturnal ABP.  Perceived racism was positively associated with nocturnal ABP even when controlling for personality factors and socioeconomic status.  The results suggest that racism may influence cardiovascular disease risk through its effects on nocturnal BP recovery. ABP = ambulatory blood pressure; SBP = systolic blood pressure; DBP = diastolic blood pressure; CVD = cardiovascular disease; SES = socioeconomic status; HTN = hypertension; AHA = American Heart Association; GHI = gross household income; BMI = body mass index; PEDQ-CV = Perceived Ethnic Discrimination Questionnaire-Community Version.

title: Prevalence and Correlates of Everyday Discrimination among U.S. Latinos.
abstract: This study reports on the prevalence and correlates of perceived discrimination among a national sample of Latinos in the U.S. Understanding the prevalence and correlates of discrimination can help us better address disparities in the healthcare system. We define perceived discrimination as self-reported everyday experiences of unfair treatment.  Logistic regression analyses were used to assess rates of perceived discrimination among Latinos and identify correlates of discrimination. Data came from the National Latino and Asian American Study (NLAAS).  The prevalence of perceived discrimination among Latinos was 30%. Cubans and Latinos with high ethnic identity were less likely to perceive discrimination compared to other Latino subgroups or Latinos with low ethnic identity. U.S.-born Latinos and Latinos arriving to the U.S. at younger ages were more likely to perceive discrimination compared to immigrants arriving at older ages.  Perceived discrimination among Latinos is less prevalent than what has been reported for other minorities. Variations in perceived discrimination are related to sociodemographic and cultural differences across ethnic subgroups.

title: Perceived discrimination and health among Puerto Rican and Mexican Americans: buffering effect of the Lazo matrimonial?
abstract: An emerging body of research shows that perceived discrimination adversely influences the mental health of minority populations, but is it also deleterious to physical health? If yes, can marriage buffer the effect of perceived discrimination on physical health? We address these questions with data from Puerto Rican and Mexican American residents of Chicago. Multivariate regression analyses reveal that perceived discrimination is associated with more physical health problems for both Puerto Rican and Mexican Americans. In addition, an interaction effect between marital status and perceived discrimination was observed: married Mexican Americans with higher perceived discrimination had fewer physical health problems than their unmarried counterparts even after adjusting for differential effects of marriage by nativity. The findings reveal that perceived discrimination is detrimental to the physical health of both Puerto Rican and Mexican Americans, but that the stress-buffering effect of marriage on physical health exists for Mexican Americans only.

title: Social Support Research in Community Psychology
abstract: Social support is a central concept in community psychology. It is a concept that attempts to capture helping transactions that occur between people who share the same households, schools, neighborhoods, workplaces, organizations, and other community settings. From our own experiences, we are all aware of the benefits that can occur, both tangible and intangible, when neighbors help neighbors in both everyday tasks and emergencies. We are aware that in response to disasters, entire communities can become mobilized in rendering help to family, friends, neighbors, and complete strangers. Intuitively, we understand how the degree of caring expressed between community members can contribute to our psychological sense of community and the perceived safety of the places in which we live. In some of the most challenging moments of our lives, when we are faced with profound loss, serious threats to health, or personal adversity, we often seek out others for information, reassurance, advice, or concrete aid. Because our experience of social support is common and at times dramatic, it is easy to comprehend that as social scientists we became fascinated with trying to measure these natural resources, understanding their relation to adapting to adversity, and harnessing their power in planned interventions

title: Peer support telephone dyads for elderly women: Was this the wrong intervention?
abstract: Tested a preventive intervention in which peer telephone dyads were developed for low-income, community-living, elderly women with low perceived social support. After an initial assessment, respondents were randomly assigned to either an assessment-only control or received 10 weeks of friendly staff telephone contact. After a second assessment, participants receiving the staff contact were randomly assigned to continue that contact or were paired in dyads to continue phone contact with one another. Dependent variables were measures of perceived social support, morale, depression, and loneliness. All groups, particularly the staff contact group, showed some improvement in mental health scores over time, but there were no significant differences between intervention groups, or between intervention and assessment-only control groups. The results suggest that participation in the study and in personal assessment interviews at home were probably morale enhancing, and that additional telephone contact did not significantly add to that effect. Evidence also indicates that, in this sample, low perceived family support was significantly related to poor mental health, so it is possible that a program designed to increase friend support may have been the wrong intervention.

title: Social Support and Coronary Heart Disease: Epidemiologic Evidence and Implications for Treatment
abstract: The present paper reviews theories of social support and evidence for the role of social support in the development and progression of coronary heart disease (CHD).  Articles for the primary review of social support as a risk factor were identified with MEDLINE (1966–2004) and PsychINFO (1872–2004). Reviews of bibliographies also were used to identify relevant articles.  In general, evidence suggests that low social support confers a risk of 1.5 to 2.0 in both healthy populations and in patients with established CHD. However, there is substantial variability in the manner in which social support is conceptualized and measured. In addition, few studies have simultaneously compared differing types of support.  Although low levels of support are associated with increased risk for CHD events, it is not clear what types of support are most associated with clinical outcomes in healthy persons and CHD patients. The development of a consensus in the conceptualization and measurement of social support is needed to examine which types of support are most likely to be associated with adverse CHD outcomes. There also is little evidence that improving low social support reduces CHD events. AMI = acute myocardial infarction; ANS = autonomic nervous system; CHD = coronary heart disease; ENRICHD = Enhancing Recovery in Coronary Heart Disease; HPA = hypothalamic pituitary adrenal; SES = socioeconomic status; SNS = sympathetic nervous system.

title: Progression of CKD in Hispanics: potential roles of health literacy, acculturation, and social support.
abstract: Hispanics are the fastest growing minority group in the United States, and compared with non-Hispanic whites, they have a higher incidence of end-stage renal disease. Examining novel factors that may explain this disparity in progression of chronic kidney disease (CKD) in Hispanics is urgently needed. Interpersonal and patient-centered characteristics, including health literacy, acculturation, and social support, have been shown to affect health outcomes in patients with other chronic diseases. However, these characteristics have not been well studied in the context of CKD, particularly in relation to disease knowledge, attitudes, and behaviors. In this report, we examine the potential roles of these factors for CKD progression in Hispanics and propose targeted therapeutic interventions.

title: The Availability of Social Support Reduces Cardiovascular Reactivity to Acute Psychological Stress
abstract: The influence of the availability of social support on cardiovascular reactivity to acute psychological stress was examined. Twenty-eight men and twenty-one women performed a speech task either in a support availability or no support availability condition while measures of systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were assessed. Consistent with past research, the speech stressor was associated with significant increases in SBP, DBP, and HR. More important, the availability of social support moderated cardiovascular reactivity to the acute stressor: individuals in the support availability condition were characterized by lower SBP and DBP reactivity to the acute stressor compared to individuals in the no support availability condition. These data suggest that simply having potential access to support is sufficient to foster adaptation to stress in the absence of enacted support.

title: Self-reported racism and social support predict blood pressure reactivity in blacks
abstract: This study explored the effects of perceived racism and social support (quantity and quality) on blood pressure reactivity. In a college sample of 64 Blacks (M age = 22.69 years, SD = 6.60), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were assessed before and during a standardized serial subtraction task. Perceptions of racism and the quantity and quality of social support were measured by self- report. Separate multiple regression analyses revealed that perceived racism and social support (neither quantity nor quality) were not independent predictors of SBP or DBP changes (ps > .05). These analyses did indicate that perceived racism interacted with the quantity of social support (p < .002, partial R2 = .175) and with the quality of social support (p < .0007, partial R2 = .195) to predict DBP changes. Perceived racism also interacted with the quantity of social support to predict changes in SBP (p < .02, partial R2 = .11). In general, whereas high social support was related to less marked blood pressure changes under conditions of low perceived racism, high social support was associated with exaggerated blood pressure changes under conditions of high perceived racism. These significant interaction effects persisted after statistically controlling for potential confounders. The findings highlight the importance of examining the joint contribution of real- world experiences and coping resources to blood pressure reactivity in Blacks.

title: Physical Activity and Minority Women: A Qualitative Study
abstract: Few physical activity research studies have been conducted with minority women. The purpose of this study was to explore patterns of physical activity among minority women. Focus groups were conducted with volunteers older than age 40. Each group was led by a trained moderator familiar with the ethnic community targeted. The sessions were audiotaped and professionally transcribed. Constructs were researched and codes were developed. Data were analyzed using NUD*IST® qualitative analysis program. While participants did not identify themselves as "exercisers," they indicated they got enough physical activity from caregiving, housekeeping, and workday activities. The most common environmental barriers to becoming more physically active included safety, availability, and cost. Personal barriers included lack of time, health concerns, and lack of motivation. Results indicate the importance of terminology and assessment when conducting physical activity research in these populations. Also, results suggest many barriers are changeable with policies and interventions.

title: Identification of correlates of physical activity among Latino adults
abstract: Abstract127 Latino adults responded to a survey concerning physical activity. Respondents over-represented well educated and middle class Latinos. Subjects reported a mean of 48 minutes/week of walking for exercise. This sample reported less than two episodes per week of vigorous physical activity, again below the recommended 3/wk needed to insure cardiovascular fitness. We expect more representative samples to engage in less physical activity. Stepwise multiple regression analyses were conducted using 24 variables based on Social Learning Theory. A multiple R of 0.66 accounted for over 27% of the variance in walking for exercise (p<0.001). Older adults, those with a history of childhood injury, and those who reported friend support were more likely to walk for exercise. Respondents who participated in physical activity during childhood and adolescence (including formal physical education in school) and, paradoxically, those who had models for exercise in childhood were less likely to walk for exercise. A multiple R of 0.75 accounted for 43% of the variance in vigorous physical activity and reached significance (p<0.001). Self-efficacy, friends' support, childhood physical activity, and eating a heart healthy diet were positively related to vigorous activity. These results suggest that different correlates influence walking versus vigorous activity, and that correlates of physical activity are different for Latinos compared to Anglos. The findings emphasize the need for larger scale investigations of the determinants of activity within the Latino population.

title: Factors Related to Physical Activity in Hispanic Women
abstract: Hispanic women are more likely to be sedentary than the general population. Increasing physical activity in this at-risk group is an important challenge in the prevention and management of coronary heart disease. This article reviews research conducted with Hispanic women in whom physical activity was the primary focus of study or the primary outcome of interest. Computer and manual searches were performed to identify articles published from 1990 to 2005. Factors that influence physical activity in Hispanic women include self-efficacy, having a concern for own and family health, social support and norms for physical activity, serving as a role model to others, and perceived neighborhood resources. Despite significant efforts to understand and promote physical activity among Hispanic women, much work remains to be done in this area. Future research should include attention to cultural, social, and contextual resources in understanding and promoting physical activity.

title: Social Support and Social-ecological Resources as Mediators of Lifestyle Intervention Effects for Type 2 Diabetes
abstract: A study was conducted to determine if an intervention could change social support and social-ecological resources of post-menopausal women diagnosed with type 2 diabetes, and if those changes mediated the intervention’s effects on health behaviors and outcomes. Women (N = 279) were randomly assigned to receive a comprehensive 6-month Mediterranean Lifestyle Program (MLP) or usual care from their physicians (UC). MLP was successful in changing social embeddedness and social-ecological resources, but not a measure of perceived support. Changes in social-ecological resources mediated intervention effects on fat consumption, exercise and glycemic control. The experimental manipulation of mediators and the demonstrated mediation effects support the conclusion that social-ecological resources can contribute to improvements in healthful lifestyles for women with type 2 diabetes.

title: Psychosocial Correlates and Outcomes of Physical Activity Among Latinos: A Review
abstract: Despite the many physical and psychological benefits of physical activity, it is well documented that the general population does not engage in sufficient leisure time physical activity to accrue such benefits. In the Latino population the situation is even more dire. This review focuses on studies of the relationship between physical activity and psychosocial correlates and outcomes in Latino men and women. It was demonstrated that the majority of studies with Latino participants examined constructs similar to those studied in the general population, namely, self-efficacy, social support, and perceived barriers. The existing literature is discussed in terms of (a) the lack of information on the psychological/psychosocial constructs of physical activity for Latinos, (b) the lack of intervention research, (c) reporting results of studies as “minority correlates,” (d) the importance of Latino subcultures and the heterogeneity of Latinos, and (e) the measurement of physical activity.

title: Weight, Diet, and Physical Activity-Related Beliefs and Practices Among Pregnant and Postpartum Latino Women: The Role of Social Support
abstract: Eating and physical activity patterns may contribute to excessive pregnancy weight gain and postpartum retention that increase the risks of obesity and diabetes for both Latino mothers and their children. Social support is an important health determinant and may affect health-related beliefs and behaviors. The objective of this study was to investigate the influence of social support on weight, diet, and physical activity-related beliefs and behaviors among pregnant and postpartum Latinas.  A community-based participatory project, Promoting Healthy Lifestyles among Women, was conducted in southwest Detroit to plan interventions aimed at reducing risks of obesity and type 2 diabetes. Qualitative analyses of in-depth semistructured interviews with dyads of 10 pregnant and postpartum Latinas, and 10 people who influenced them were conducted.  Husbands and some female relatives were primary sources of emotional, instrumental, and informational support for weight, diet, and physical activity-related beliefs and behaviors for Latina participants. Holistic health beliefs and the opinions of others consistently influenced Latinas' motivation and beliefs about the need to remain healthy and the links between behavior and health. Absence of mothers, other female relatives, and friends to provide childcare, companionship for exercise, and advice about food were prominent barriers that limited women's ability to maintain healthy practices during and after pregnancy.  The findings support evidence that low-income, recently immigrated pregnant and postpartum Latinas could benefit from community-based, family-oriented interventions that provide social support necessary to promote and sustain healthy lifestyles.

title: Women's reasons for complementary and alternative medicine use: racial/ethnic differences.
abstract: Although racial/ethnic differences in the prevalence of complementary and alternative medicine (CAM) utilization have been documented, differences in the reasons for using CAM have not been empirically assessed. In an increasingly diverse society, understanding differences in rates of and reasons for CAM use could elucidate cultural and social factors of health behaviors and inform health care improvements. The current study examines reasons for CAM use among women in four racial/ethnic groups.



A national telephone survey of 3172 women aged 18 years and older was conducted in four languages. Respondents were asked about their use of remedies or treatments not typically prescribed by a medical doctor. This study focuses on those women who used CAM in the previous year and their reasons for using CAM.



Non-Hispanic white women were most likely to cite personal beliefs for CAM use. Cost of conventional medicine was most prevalent among Mexican-American women CAM users. Physician referral, family and friends, and media sources were all equally likely to lead to CAM use in non-Hispanic white women. In contrast, informal networks of family and friends were the most important social influences of CAM use among African-, Mexican-, and Chinese-American women.



Racial/ethnic differences in reasons for CAM use highlight cultural and social factors that are important to consider in public evaluation of the risks and benefits of CAM remedies and treatments.

title: Investigating Complementary and Alternative Medicine Use in a Spanish-Speaking Hispanic Community in South Carolina
abstract: This study investigated the use of complementary and alternative medicine (CAM) by Spanish-speaking Hispanics in the Charleston, South Carolina, area.  We administered Spanish-language questionnaires regarding use of CAM to Spanish-speaking Hispanics seeking care at either a community-based residency practice or a rural community health center.  Overall, 69% of the 70 respondents indicated that they used some type of CAM. The most common reason for using CAM was being taught to do so by family members (33%); other common reasons included a failure by their medical professionals to diagnose their problem (29%), a lack of conventional medical treatment for their problem (29%), and being unhappy with previous medical advice (21%). The main medical conditions being treated with CAM were infections (65%) and constipation and diarrhea (54%), but pregnancy-related issues were also cited (27%).  These findings improve our understanding of alternative health care practices of Spanish-speaking Hispanics visiting primary care clinics in South Carolina. Addressing patients’ reasons for CAM use may help health care professionals develop patient-centered treatment plans.

title: Use of complementary and alternative medical therapies among racial and ethnic minority adults: results from the 2002 National Health Interview Survey.
abstract: Complementary and alternative medicine (CAM) use among ethnic minority populations is poorly understood. We sought to examine CAM use in Hispanics, non-Hispanic blacks and non-Hispanic whites.



We analyzed data from the Alternative Health Supplement to the 2002 National Health Interview Survey (NHIS), including information on 19 different CAM therapies used in the past 12 months.



An estimated 34% of Hispanic, non-Hispanic black and non-Hispanic white adults in the United States used at least one CAM therapy (excluding prayer) during the prior 12 months (2002). CAM use was highest for non-Hispanic whites (36%), followed by Hispanics (27%) and non-Hispanic blacks (26%). Non-Hispanic whites were more likely to use herbal medicine, relaxation techniques and chiropractic more frequently than Hispanics and non-Hispanic blacks. After controlling for other sociodemographic factors, Hispanic and non-Hispanic black races/ethnicities were associated with less CAM use, with adjusted odds ratios (95% confidence intervals) of 0.78 (0.70, 0.87) and 0.71 (0.65, 0.78), respectively. Hispanics cited using CAM because conventional medical treatments were too expensive more frequently than non-Hispanic blacks or whites. Hispanics had the highest provider nondisclosure rates (68.5%), followed by non-Hispanic blacks (65.1%) and non-Hispanic whites (58.1%).



Excluding prayer, Hispanics and non-Hispanic blacks used CAM less frequently than non-Hispanic whites and were less likely to disclose their use to their healthcare provider. Further research is needed to improve our understanding of the disparities in CAM use.

title: ’They Don’t Ask Me So I Don’t Tell Them’: Patient-Clinician Communication About Traditional, Complementary, and Alternative Medicine
abstract: Although high rates of traditional medicine and complementary and alternative medicine (TM/CAM) use have been well documented, there has been less attention to the factors influencing communication between patients and their primary care clinicians about TM/CAM. Such communication can be important in anticipating possible drug-herb interactions and in assuring agreement about therapeutic plans.  We used sequential, multistage, qualitative methods, including focus groups, in-depth interviews, and a video vignette, to explore communication about TM/CAM between patients and their primary care clinicians. The study was conducted in RIOS Net (Research Involved in Outpatient Settings Network), a Southwestern US practice-based research network, situated largely in Hispanic and American Indian communities where TM/CAM is an important part of self-care.  One hundred fourteen patients, 41 clinic staff members, and 19 primary care clinicians in 8 clinic sites participated. The degree and nature of TM/ CAM communication is based on certain conditions in the clinical encounter. We categorized these findings into 3 themes: acceptance/nonjudgment, initiation of communication, and safety/efficacy. Perceived clinician receptivity to and initiation of discussion about TM/CAM strongly influenced patients’ decisions to communicate; perceived clinician expertise in TM/CAM was less important. Clinicians’ comfort with patients’ self-care approaches and their level of concern about lack of scientific evidence of effectiveness and safety of TM/CAM influenced their communication about TM/CAM with patients.  Specific communication barriers limit patient-clinician communication about TM/CAM. Clinicians who wish to communicate more effectively with their patients about these topics and better integrate the types of care their patients use can change the communication dynamic with simple strategies designed to overcome these barriers.

title: Factors associated with herbal use among urban multiethnic primary care patients: a cross-sectional survey
abstract: BackgroundThe use of herbal supplements in the United States has become increasingly popular. The prevalence of herbal use among primary care patients varies in previous studies; the pattern of herbal use among urban racially/ethnically diverse primary care patients has not been widely studied. The primary objectives of this study were to describe the use of herbs by ethnically diverse primary care patients in a large metropolitan area and to examine factors associated with such use. The secondary objective was to investigate perceptions about and patterns of herbal use.MethodsData for a cross-sectional survey were collected at primary care practices affiliated with the Southern Primary-care Urban Research Network (SPUR-Net) in Houston, Texas, from September 2002 to March 2003. To participate in the study, patients had to be at least 18 years of age and visiting one of the SPUR-Net clinics for routine, nonacute care. Survey questions were available in both English and Spanish. total of 322 patients who had complete information on race/ethnicity were included in the analysis. Overall, 36% of the surveyed patients (n = 322) indicated use of herbs, with wide variability among ethnic groups: 50% of Hispanics, 50% of Asians, 41% of Whites, and 22% of African-Americans. Significant factors associated with an individual's herbal use were ethnicity other than African-American, having an immigrant family history, and reporting herbal use by other family members. About 40% of survey respondents believed that taking prescription medications and herbal medicines together was more effective than taking either alone. One-third of herbal users reported using herbs on a daily basis. More Whites (67%) disclosed their herbal use to their health-care providers than did African-Americans (45%), Hispanics (31%), or Asians (31%).ConclusionsRacial/ethnic differences in herbal use were apparent among this sample of urban multiethnic adult primary care patients. Associated factors of herbal use were non-African-American ethnicity, immigrant family history, and herbal use among family members. Whereas Hispanics and Asians reported the highest rates of herbal use, they were the least likely to disclose their use to health-care professionals. These findings are important for ensuring medication safety in primary care practices.

title: Use of herbal remedies by Hispanic patients: do they inform their physician?
abstract: This study measured the knowledge and use of herbs among Hispanics and assessed their experiences when discussing herb use with their physician.



Self-administered questionnaires were collected from 620 Hispanic patients seeking treatment in urban health centers.



Most (80.3%) reported using herbs. Herb users were more comfortable speaking Spanish (91.9% vs 80.2%) and had been in the United States less than 5 years (47.0% vs 29.4%). More users considered herbs as drugs (60.5% vs 39.6%). Users were more aware that herbs could harm a baby if taken during pregnancy (56.4% vs 36.0%). The majority did not know the English name for 23 of the 25 herbs. A majority indicated their physician was unaware of their herb use. Few (17.4%) responded that their physicians asked about herb use. Only 41.6% thought their physician would understand their herb use, and 1.8% believed their physician would encourage continued use. There were no significant differences between herb users and nonusers in their perception of patient-physician communication levels.



Primary care physicians need to be aware that most Hispanic patients are likely to use herbs. It is important to initiate and encourage discussion of their patient's interest in and use of these therapies.

title: Folk Beliefs about High Blood Pressure in Hispanic Immigrants
abstract: High blood pressure (HBP) is a major public health problem in the United States and affects nearly 60 million people. Among Hispanics the prevalence rate for HBP is about 18% (Ailinger, 1984; Leonard, Igra, & Hawthorne, 1981). Hispanics are the fastest growing minority in the United States, and it is estimated that by the next decade they will be the largest minority (Giachello, Bell, Aday, & Anderson, 1983). There are several reasons that it is imperative that nurses learn about HBP and other health threats to this minority. First, folk beliefs about HBP are important, because the beliefs may determine when the individual client defines something as an illness. Second, folk beliefs about contributing factors in HBP may determine when the client goes for treatment. Third, folk beliefs may suggest who the client goes to for HBP therapy. Finally, folk beliefs may determine which preventive measures are perceived as appropriate. According to Tripp-Reimer, Brink, and Saunders (1984), nurses need to identify beliefs that influence a health problem. The purpose of this study was to describe the folk beliefs about HBP found in a community study of over 300 Hispanic immigrants. During the last 10 years there have been a number of articles in the health literature on general folk beliefs of Hispanic patient populations in the United States. Hispanics is the broad term that includes MexicanAmericans, Puerto Ricans, Cubans, Central Americans, and South Americans. Most of these studies focused on Mexican-Americans (Anthony-Tkach, 1981; Chesney, Thompson, Guevara, Vela, & Schottstaedt, 1980; Gonzales-Swafford & Gutierrez, 1983; Kay, 1977; ; Murillo-Rhode, 1980; Sandler & Chan, 1978; Trotter, 1981), Puerto Ricans (Delgado, 1979), or Central Americans and South Americans (Cohen, 1979). While all of these investigators studied folk beliefs, none focused on a particular health problem such as HBP.

title: Beliefs about AIDS, health, and illness among low-income Latina women.
abstract: The purposes of this study were to describe (a) the health beliefs of Latina women about acquired immunodeficiency syndrome (AIDS); and (b) the relationship of these beliefs to the subjects' traditional beliefs about illness and its treatment. The sample consisted of 59 low-income Latina women attending nutrition programs in Los Angeles. A qualitative approach was used to gather the data in semi-structured focus group interviews. Content analysis was used to classify data according to causes of AIDS and prevention and treatment of AIDS. Causes of AIDS included all of the current biomedical and public health explanations of transmission, current popular beliefs and misconceptions about transmission, and long-standing traditional beliefs about the causes of illness. Prevention and treatment of AIDS reflected these same three perspectives. The women's beliefs consisted of accurate, inaccurate, and incomplete information about AIDS. Implications were drawn from the findings for AIDS education and prevention programs which are congruent with the participants' cultural beliefs, values, attitudes, and expectations.

title: Hispanic Cultural Health Beliefs and Folk Remedies
abstract: Cultural awareness of health care practices and beliefs is increasing, but knowledge regarding Hispanic folk remedies and health care practices and beliefs is limited. This study used a focus group interview format for an open discussion of folk remedies and the health and illness practices of the participants. Eleven Hispanic women participated in a group interview that addressed the question, How do Hispanic health beliefs affect health care practices? Specifically, what actions are taken to treat symptoms of illness or injury? Qualitative data analysis of the 75 symptom and treatment statements was completed, and data were grouped according to symptom and complexity of treatments. This resulted in a rich compilation of remedies that Hispanics use in home treatments, with the emergence of a pattern comparable to the nursing process. This information adds to the current knowledge base of cultural health practices and provides a basis for continued research.

title: Complementary and Alternative Medicine Use Among Hispanics in the United States
abstract: To review the use of complementary and alternative medicine (CAM) in Hispanics in the US and highlight the modalities most likely to be unfamiliar to healthcare practitioners.  A search of the literature published in English and a subsequent bibliographic search were conducted using MEDLINE, International Pharmaceutical Abstracts, EMBASE, Cumulative Index of Nursing and Allied Health Literature, and Manual Alternative and Natural Therapy Index System (1980– March 2007). Primary search terms included, but were not limited to, Hispanic, Latino, complementary and alternative medicine, and dietary supplements. Studies that assessed or evaluated the use of CAM in the Hispanic population were reviewed. Articles that included both Hispanics and non-Hispanics were also included.  The literature search yielded 42 articles focused on the use of CAM by Hispanics. Survey was the most common method used in these studies, although some hybrid interviews were also conducted.  Hispanics were identified homogenously in some studies and more correctly as a heterogeneous population in others. Some trials examined overall CAM use, whereas others looked at specific dietary supplements and herbs. Most reports found a higher than expected rate of CAM use in Hispanics (50–90%). A number of products potentially unfamiliar to healthcare practitioners, such as linden, sapodilla, and star anise, were reported as commonly used in several studies. Many studies were limited by the sample size or use of only one Hispanic subgroup.  Hispanics use a wide range of CAM therapies, including several that may be unfamiliar to healthcare practitioners. Understanding the rationale, motivations, and history of Hispanics' use of CAM will enhance the cultural competence of healthcare professionals and help address these patients' medical needs.  El uso de terapias de medicina complementaria y alternativa (CAM) es común entre los pacientes y se cree que la etnicidad influye en la frecuencia y extensión de su uso. Los pacientes de origen Hispano son una sub-población en rápido crecimiento. Con el fin de proveer efectivamente cuidado a este grupo de pacientes, es importante entender el papel de las terapias CAM en los tratamientos de esta población.

title: Interactions between herbal medicines and prescribed drugs: a systematic review.
abstract: Despite the widespread use of herbal medicines, documented herb-drug interactions are sparse. We have reviewed the literature to determine the possible interactions between the seven top-selling herbal medicines (ginkgo, St John's wort, ginseng, garlic, echinacea, saw palmetto and kava) and prescribed drugs. Literature searches were performed using the following databases: Medline (via Pubmed), Cochrane Library, Embase and phytobase (all from their inception to July 2000). All data relating to herb-drug interactions were included regardless of whether they were based on case reports, case series, clinical trials or other types of investigation in humans. In vitro experiments were excluded. Data were extracted by the first author and validated by the second author. 41 case reports or case series and 17 clinical trials were identified. The results indicate that St John's wort (Hypericum perforatum) lowers blood concentrations of cyclosporin, amitriptyline, digoxin, indinavir, warfarin, phenprocoumon and theophylline; furthermore it causes intermenstrual bleeding, delirium or mild serotonin syndrome, respectively, when used concomitantly with oral contraceptives (ethinylestradiol/desogestrel), loperamide or selective serotonin-reuptake inhibitors (sertaline, paroxetine, nefazodone). Ginkgo (Ginkgo biloba) interactions include bleeding when combined with warfarin, raised blood pressure when combined with a thiazide diuretic and coma when combined with trazodone. Ginseng (Panax ginseng) lowers blood concentrations of alcohol and warfarin, and induces mania if used concomitantly with phenelzine. Garlic (Allium sativum) changes pharmacokinetic variables of paracetamol, decreases blood concentrations of warfarin and produces hypoglycaemia when taken with chlorpropamide. Kava (Piper methysticum) increases 'off' periods in Parkinson patients taking levodopa and can cause a semicomatose state when given concomitantly with alprazolam. No interactions were found for echinacea (Echinacea angustifolia, E. purpurea, E. pallida) and saw palmetto (Serenoa repens). In conclusion, interactions between herbal medicines and synthetic drugs exist and can have serious clinical consequences. Healthcare professionals should ask their patients about the use of herbal products and consider the possibility of herb-drug interactions.

title: Clinical implications of a folk illness: empacho in mainland Puerto Ricans.
abstract: The study of folk illnesses provides insight into client health beliefs and behaviors. This paper describes the expression of empacho in children living in a mainland Puerto Rican community. Etiology, symptom presentation, and treatment options in various health care sectors, as well as an investigation of overlapping folk/biomedical symptom domains are described. Implications regarding health and health care in the multicultural setting are discussed.

title: Use of complementary and alternative medicine among women in New York City: a pilot study.
abstract: This study documents the use of complementary and alternative medicine (CAM), among White, African American, and Hispanic/Latina women living in New York City. A pilot to a national survey of CAM use among American women, this study explores women's use of categories of CAM and various CAM practitioners, racial and ethnic differences in CAM use, and women's perceptions regarding the effectiveness of CAM.  Data were collected from women residing in New York City using random digit dialing/computer-assisted telephone interviewing (CATI). The sample of 300 had equal numbers of women (n = 100) who self-identified as White, Hispanic/Latina, and African American, equally stratified by age (below and above age 40).



Eligibility requirements included self-identification as Anglo/white, African American, or Hispanic/Latina and between ages 18 and 80.



Three distinct categories of CAM were explored: (1) medicinal teas, homeopathic remedies, herbs, vitamins; (2) yoga, meditation, spiritual practices; and (3) manual therapies including chiropractic, massage, acupressure. Health concerns of interest were those frequently described in prior focus groups, and included reproductive health issues (e.g., pregnancy, menstruation, menopause) as well as other common women's health problems (e.g., heart disease, high blood pressure, headaches).



More than half the sample has used a CAM treatment or remedy, and 40% have visited a CAM practitioner. Among users, half have used only one of the CAM categories, approximately one third have used two, and 16% used all three. The category of CAM used most often was medicinal tea/herbs/vitamins; the practitioners visited most frequently were chiropractors (18%) and nutritionists (17%). Racial and ethnic differences in CAM use were minimal, and approximately one third of all treatments used were rated "very effective" by users.



Substantial utilization of CAM remedies and treatments for a variety of women's health concerns is observed. Further inquiry with larger samples of women is recommended.

title: Ethnic differences in complementary and alternative medicine use among patients with diabetes.
abstract: To evaluate the effect of ethnicity as a predictor of the use of complementary and alternative medicine (CAM) among patients with diabetes.



A 16-item questionnaire investigating CAM use was distributed among patients attending the Taking Control of Your Diabetes (TCOYD) educational conferences during 2004-2006. Six TCOYD were held across the United States. Information of diabetes status and sociodemographic data was collected. CAM use was identified as pharmacologic (herbs and vitamins) and nonpharmacologic CAMs (e.g., prayer, yoga, and acupuncture).



The prevalence of pharmacologic and non-pharmacologic CAMs among 806 participants with diabetes patients was 81.9% and 80.3%, respectively. Overall, CAM prevalence was similar for Caucasians (94.2%), African Americans (95.5%), Hispanics (95.6%) and Native Americans (95.2%) and lower in Pacific Islanders/others (83.9%) and Asians (87.8%). Pharmacologic CAM prevalence was positively associated with education (p=0.001). The presence of diabetes was a powerful predictor of CAM use. Several significant ethnic differences were observed in specific forms of CAM use. Hispanics reported using frequently prickly pear (nopal) to complement their diabetes treatment while Caucasians more commonly used multivitamins.



Treatment with CAM widely used in persons with diabetes. Ethnic group differences determine a variety of practices, reflecting groups' cultural preferences. Future research is needed to clarify the perceived reasons for CAM use among patients with diabetes in clinical practice and the health belief system associated with diabetes by ethnic group.

title: Use of complementary and alternative medicine among American women.
abstract: Although women are increasingly using complementary and alternative (CAM) therapies, a national profile characterizing women who use CAM has yet to be described. The purpose of this study is to provide prevalence estimates of recent CAM use among American women and to examine sociodemographic and other characteristics associated with use.



Data from the 1999 National Health Interview Survey are used for the analysis. Three operational definitions of recent CAM use are employed (any CAM, type-specific, and domain-specific use). All proportions and prevalence estimates are weighted and standard errors are adjusted to account for complex sample design; weighted logistic regression (with coefficient variance adjustment) is also used.



Overall, 33.5% of American women used CAM in the past 12 months. Spiritual healing/prayer and herbal medicine are the most commonly used, and hypnosis, biofeedback, and energy healing are the least common. Multivariate results show that women who are older, have more education, poorer health, or live in the west or midwest (versus south) are more likely to use CAM. Compared to whites, blacks, Hispanics, and Asians are less likely to use CAM. Foreign-born women, those with lower income, or who live in the Northeast are also less likely to use CAM. Insurance status is not independently associated with CAM use.



This study provides one of the first comprehensive investigations of CAM use among American women. Future research examining the determinants of CAM use, incorporating attitudinal and health conditions, as well as clinical efficacy, effectiveness, and health outcome studies of specific CAM therapies are warranted.

title: Impact of Immigration on Complementary and Alternative Medicine Use in Hispanic Patients
abstract: Although previous research has demonstrated frequent complementary and alternative medicine (CAM) use by Hispanic patients, it remains unclear whether the status of immigration plays a role in the frequency and reasons for use.  A survey of 164 patients from a federally qualified health center in South Central Los Angeles was used; the health center serves a predominantly Latino immigrant patient population. The study included the following variables: patient age; sex; place of birth; number of years living in the United States; CAM use within the last year; and, if positive CAM use, what type(s) and for what condition(s).  Sixty-six percent of patients had used a CAM substance within the past year. Ninety-seven percent of the patients were immigrants (primarily from Mexico, El Salvador, and Guatemala). Differences in CAM use between recently arrived (≤9 years) and long-term immigrants (≥10 years) were not significant. Ninety-four percent of patients using CAM reported using herbal/tea/plant-based substances, with the most frequent reason for CAM use being digestive problems. Although most CAM substances were obtained from a market (64%), a not insignificant number of CAM substances were grown at home (23%).  Time since immigration does not seem to impact the frequency of CAM use by Hispanic immigrant patients. Herbal/tea/plant-based substances are frequently used in the Hispanic patient population, often for digestive complaints.

title: Race/ethnicity and women's use of complementary and alternative medicine in the United States: results of a national survey.
abstract: We studied the use of complementary and alternative medicine (CAM) among women in 4 racial/ethnic groups: non-Hispanic Whites, African Americans, Mexican Americans, and Chinese Americans.



We obtained a nationally representative sample of women aged 18 years and older living in the United States in 2001. Oversampling obtained 800 interviews in each group, resulting in a sample of 3068 women.



Between one third and one half of the members of all groups reported using at least 1 CAM modality in the year preceding the survey. In bivariate analyses, overall CAM use among Whites surpassed that of other groups; however, when CAM use was adjusted for socioeconomic factors, use by Whites and Mexican Americans were equivalent. Despite the socioeconomic disadvantage of African American women, socioeconomic factors did not account for differences in CAM use between Whites and African Americans.



CAM use among racial/ethnic groups is complex and nuanced. Patterns of CAM use domains differ among groups, and multivariate models of CAM use indicate that ethnicity plays an independent role in the use of CAM modalities, the use of CAM practitioners, and the health problems for which CAM is used.

title: Predictors of complementary and alternative medicine use among older Mexican Americans.
abstract: To determine predictors of complementary and alternative medicine (CAM) use, we used a cohort of 1445 non-institutionalized Mexican Americans aged 65 and older from the first wave (1993-1994) of the Hispanic Established Population for the Epidemiologic Study of the Elderly, followed until 2000-2001. The main outcome was use of any CAM (herbal medicine, chiropractic, acupuncture, massage therapy, relaxation techniques or spiritual healing) in the past 12 months and was assessed at 7 years of follow-up. Potential predictors of CAM use at baseline included sociodemographics, acculturation factors, and medical conditions. The overall rate of CAM use among older Mexican Americans was 31.6%. Independent predictors of higher CAM use were female gender, being on Medicaid, frequent church attendance and higher number of medical conditions. In contrast, subjects who were born in US and spoke either Spanish or English at interview had lower CAM use compared with subjects who were born in Mexico.

title: Toxic Mexican folk remedies for the treatment of empacho: the case of azarcon, greta, and albayalde.
abstract: This article discusses the availability of three lead-based salts which are being used as folk remedies in Mexico. Distribution systems and geographic availability were determined, and purchased samples were found to be very high in lead content. The findings suggest the need for further research to understand the reasons why such remedies are chosen, and the development of an educational program to discourage their use.

title: Empacho in four Latino groups: a study of intra- and inter-cultural variation in beliefs.
abstract: It is usually impossible to know if reported differences between cultures are due to cultural differences or due to a difference in the methods used to study the cultures. This paper describes a collaborative, multisite study using a shared methodology to study intra- and inter-cultural variation in beliefs. A series of standard interview schedules were used to study Latin American beliefs about empacho in Guatemala, Mexico, and in the United States (Mexican-Americans and Puerto Ricans). Results showed consistency in beliefs about empacho both within and between the four samples.

title: Tracking Women’s Awareness of Heart Disease: An American Heart Association National Study
abstract: Cardiovascular disease (CVD) is the leading cause of mortality in men and women in the United States, yet prior research has shown a lack of awareness of risk among women. The purpose of this study was to assess the contemporary awareness, knowledge, and perceptions related to CVD risk among American women and to evaluate trends since 1997, when the American Heart Association initiated a national campaign to improve awareness of CVD among women. A telephone survey of a nationally representative random sample of women was conducted in June and July 2003, with an oversampling of black and Hispanic women; results were compared with those of similar surveys in 2000 and 1997. The present survey included 1024 respondents age ≥25 years; 68% were white, 12% black, 12% Hispanic, and 8% other ethnicities. Awareness, knowledge, and perceptions about heart disease were evaluated by use of a standard interviewer-assisted questionnaire. A shift in awareness of heart disease as the leading killer of women has occurred since 1997. In 2003, 46% of respondents spontaneously identified heart disease as the leading cause of death in women, up from 30% in 1997 (P <0.05) and 34% in 2000 (P <0.05). In contrast, the percentage of women citing cancer as leading cause of death has significantly decreased. Black, Hispanic, and younger women (<45 years old) had lower awareness of heart disease as their leading cause of death than did white and older women. Nearly all women reported comfort in discussing prevention with healthcare providers, but only 38% of women reported that their doctors had ever discussed heart disease with them. Awareness of CVD has increased, although a significant gap between perceived and actual risk of CVD remains. Educational interventions to improve awareness and knowledge are needed, particularly for minority and younger women.

title: Hypertension and other cardiovascular disease risk factors among Mexican Americans, Cuban Americans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey.
abstract: DESPITE THEIR HIGHER PREVALENCE of obesity and diabetes, Hispanics have lower or equal rates of hypertension than non-Hispanic whites (1-4). Healthy People 2000 objectives call for increasing the proportion of hypertensive men whose blood pressure is under control to at least 40%. In addition, the objectives recommend reducing the prevalence of overweight to 41% among hypertensive women, and to 35% among hypertensive men (5). The Hispanic Health and Nutrition Examination Survey (HHANES) collected data on Mexican Americans (MA), Cuban Americans (CA), and Puerto Ricans (PR) living in the continental United States. A trained physician measured systolic (SBP) and diastolic (DBP) blood pressure twice in one visit. Our findings provide data to assess baseline estimates for several Healthy People 2000 objectives among Hispanics. Based on criteria from The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V), we found Hispanic women to have higher rates of awareness, treatment, and control of hypertension than men. Only 8% of MA and PR men and 9% of CA men who were hypertensive had their high blood pressure under control. The prevalence of overweight among hypertensive men ranged from 39% to 60%; and among hypertensive women, from 44% to 74%. Hispanic women with six or fewer years of education had higher prevalence of hypertension and other cardiovascular disease (CVD) risk factors. Future research should investigate the socioeconomic factors associated with the presence of these risk factors.

title: Cardiovascular risk factor variation within a Hispanic cohort: SWAN, the Study of Women's Health Across the Nation.
abstract: Hispanics have less favorable cardiovascular risk profiles relative to other groups, although little is known regarding variability in risk profiles according to country of origin. Our goal was to examine the association of cardiovascular risk factors with country of origin and acculturation in a cohort of middle-aged Hispanic women.



Baseline data for participants at the New Jersey Site of the Study of Women's Health Across the Nation (SWAN).



419 women, aged 42-52 years, comprising 142 non-Hispanic Whites and 277 Hispanic: Central American (n = 29), South American (n = 106), Puerto Rican (n = 56), Dominican (n = 42) and Cuban (n = 44).



BMI, smoking, blood pressure, lipid profiles, and presence of hypertension, hyperlipidemia, diabetes and metabolic syndrome were compared using univariate and multivariable models.



LDL and HDL varied significantly across Hispanic subgroups (overall P < or = .05). Prevalence of metabolic syndrome was greatest in Puerto Rican women (48.2% vs 40.0%, 35.0%, 13.9% and 29.3% in Central American, South American, Dominican and Cuban women, respectively, P = .016).  American women were least likely to smoke (P < .05 vs Puerto Rican, Cuban and South American). Prevalence of hypertension and diabetes were similar across groups. Differences in lipids and metabolic syndrome were not explained by acculturation, financial strain, education, physical activity, smoking or dietary fat intake.



There is significant heterogeneity in cardiovascular risk status among middle-aged Puerto Rican, Cuban, Dominican, Central American and South American women, not explained by acculturation or socioeconomic indicators. These differences may be important for targeting screening and preventive interventions.

title: Prevalence of and risk factors for subclinical cardiovascular disease in selected US Hispanic ethnic groups: the Multi-Ethnic Study of Atherosclerosis.
abstract: In this study, the authors determined the prevalence and extent of cardiovascular disease (CVD) risk factors and subclinical CVD in four US Hispanic subgroups, as well as associations between the CVD risk factors and subclinical CVD in these groups. Participants were 1,437 Hispanic men and women enrolled in the Multi-Ethnic Study of Atherosclerosis in 2000-2002. Fifty-six percent were Mexican-American, 12% were Dominican-American, 14% were Puerto Rican-American, and 18% were Other Hispanic-American. All participants underwent clinical examinations for coronary artery calcium, thoracic aortic calcium, carotid intimal-medial thickness, ankle-brachial index, left ventricular mass, and left ventricular size. Mexican Americans had the highest levels of coronary artery calcium, thoracic aortic calcium, and carotid intimal-medial thickness, while Puerto Rican Americans had the highest prevalence of an ankle-brachial index less than 1.0 and levels of left ventricular mass. The magnitudes of the associations between coronary artery calcium and age, sex, and body mass index were similar across all Hispanic subgroups. However, there were differences in the magnitude and significance of the associations between coronary artery calcium and hypertension, hypercholesterolemia, and cigarette smoking among the different Hispanic subgroups. This finding was also present for the other subclinical CVD measures. These results suggest a differential relationship between risk factors and either prevalence or extent of subclinical disease by Hispanic subgroup.

title: Avoiding the looming Latino/Hispanic cardiovascular health crisis: a call to action.
abstract: Cardiovascular disease (CVD) is the leading cause of death among the largest and fastest growing ethnic minority in the United States, Latinos/Hispanics. To review recent findings on the prevalence of CVD, CVD risk factors, and related illnesses in the US Latino/Hispanic population, an extensive PubMed and Internet literature search for studies published from January 1995 to July 2005 was conducted, using a combination of search terms. Data validity was assessed based on the quality of the source and a consensus of the authors on perceived validity. The review found limitations in current research as well as treatment methods and options for Latino/Hispanic persons at risk for developing CVD and related illnesses. Because of these limitations and the large public health concern, additional research is required to fully determine the best predictors of CVD and diabetes in Latino/Hispanic patients. A combined effort of health-influencing and health-governing bodies is needed on all levels to address the CVD problem in the Latino/Hispanic population.

title: Trends in hypercholesterolemia, treatment and control among United States adults.
abstract: Control of hypercholesterolemia is an important clinical and public health objective, yet it is generally poor. The objective of this study was to examine trends in the prevalence of hypercholesterolemia, having a cholesterol check, awareness, treatment, and control among United States adults.



We examined data for 18053 participants aged > or =20 years of the National Health and Nutrition Examination Surveys from 1999 to 2006.



The unadjusted prevalence of hypercholesterolemia ranged from 53.2% to 56.1% and changed little over the study period. Significant increases were evident in the percentage of United States adults who had their concentration of cholesterol checked (from 68.6% to 74.8%), who reported being told that they had high hypercholesterolemia (from 42.0% to 50.4%), who reported using cholesterol-lowering medications (from 39.1% to 54.4%), and who had their hypercholesterolemia controlled (from 47.0 to 64.3%). Among all participants with hypercholesterolemia control of hypercholesterolemia increased from 7.2% to 17.1%. Disparities related to gender and race or ethnicity existed, notably a lower rate of control among women than men and lower rates of having a cholesterol check and reporting being told about hypercholesterolemia among African Americans and Mexican Americans than whites.



Encouraging increases in awareness, treatment, and control of hypercholesterolemia occurred from 1999 through 2006. Nevertheless, control of hypercholesterolemia remains poor.

title: Disparities in the diagnosis and pharmacologic treatment of high serum cholesterol by race and ethnicity: data from the Third National Health and Nutrition Examination Survey.
abstract: Serum cholesterol is one of the most important modifiable risk factors for coronary artery disease. There are conflicting data on racial and ethnic variation in the treatment of high cholesterol.



We analyzed data from the Third National Health and Nutrition Examination Survey, a nationally representative cross-sectional survey conducted between 1988 and 1994. Participants included 7679 white, 4467 African American, and 4113 Mexican American adults older than 25 years who completed the household adult questionnaire. The adjusted odds of serum cholesterol screening and of taking a prescription medication to lower serum cholesterol among African Americans and Mexican Americans were compared with those of whites, controlling for differences in age, sex, income, educational level, insurance status, comorbid illness, and having a regular source of health care.



African Americans and Mexican Americans were significantly less likely than whites to report ever having had their blood cholesterol checked (odds ratio, 0.7 for both; P<.001). Among individuals with high cholesterol who were told to take a medication, African Americans (P<.001) and Mexican Americans (P =.05) were less likely than whites to be taking a cholesterol-lowering agent (odds ratios, 0.3 and 0.5, respectively). Individuals who reported being told they had high cholesterol had significantly higher serum cholesterol measurements (from the laboratory examination) than those who reported being told their cholesterol was not high (234 vs 198 mg/dL [6.05 vs 5.12 mmol/L]; P<.001).



African Americans and Mexican Americans were less likely to report serum cholesterol screening than whites. Even when identified as having high cholesterol that required medication, African Americans and Mexican Americans were less likely than whites to be taking cholesterol-lowering agents.

title: LDL size in African Americans, Hispanics, and non-Hispanic whites : the insulin resistance atherosclerosis study.
abstract: The prevalence of cardiovascular disease (CVD) and atherosclerosis varies among several minority ethnic groups in the United States. Recently, small, dense low density lipoprotein (LDL) particle size has been recognized as a risk factor for CVD. We examined LDL size as a possible explanation for differences in CVD rates in 1571 subjects from the Insulin Resistance Atherosclerosis Study (IRAS), a multiethnic study of insulin resistance and cardiovascular risk factors. LDL size (A) was significantly different by ethnic group (African Americans 262.1+/-0.6, Hispanics 257.6+/-0.6, and non-Hispanic whites 259.2+/-0.4, P<0.001). Ethnic differences in LDL size continued to be statistically significant after adjustment for upper body adiposity, insulin resistance, and glucose tolerance status. However, after further adjustment for other cardiovascular risk factors, especially ethnic differences in triglyceride and high density lipoprotein (HDL) cholesterol levels, the ethnic differences in LDL size were markedly attenuated and in general no longer statistically significant. The relation of triglyceride, HDL cholesterol, insulin resistance, and adiposity to LDL size in each ethnic group was similar. LDL size differs by ethnic group, which is independent of obesity or insulin resistance. These ethnic differences appear to be due to ethnic variations in dyslipidemia (especially differences in triglyceride levels); ethnic differences in LDL size are not consistent with previously reported ethnic dissimilarities in CVD or atherosclerosis.

title: Trends in Prevalence, Awareness, Treatment, and Control of Hypertension in the United States, 1988-2000
abstract: ContextPrior analyses of National Health and Nutrition Examination Survey (NHANES)
data through 1991 have suggested that hypertension prevalence is declining,
but more recent self-reported rates of hypertension suggest that the rate
is increasing.ObjectiveTo describe trends in the prevalence, awareness, treatment, and control
of hypertension in the United States using NHANES data.
noninstitutionalized population. The most recent NHANES survey, conducted
in 1999-2000 (n = 5448), was compared with the 2 phases of NHANES III conducted
in 1988-1991 (n = 9901) and 1991-1994 (n = 9717). Individuals aged 18 years
or older were included in this analysis. MeasuresHypertension, defined as a measured blood pressure of 140/90 mm Hg or
greater or reported use of antihypertensive medications. Hypertension awareness
and treatment were assessed with standardized questions. Hypertension control
was defined as treatment with antihypertensive medication and a measured blood
pressure of less than 140/90 mm Hg.ResultsIn 1999-2000, 28.7% of NHANES participants had hypertension, an increase
of 3.7% (95% confidence interval [CI], 0%-8.3%) from 1988-1991. 
prevalence was highest in non-Hispanic blacks (33.5%), increased with age
(65.4% among those aged ≥60 years), and tended to be higher in women (30.1%).
In a multiple regression analysis, increasing age, increasing body mass index,
and non-Hispanic black race/ethnicity were independently associated with increased
rates of hypertension. Overall, in 1999-2000, 68.9% were aware of their hypertension
(nonsignificant decline of −0.3%; 95% CI, −4.2% to 3.6%), 58.4%
were treated (increase of 6.0%; 95% CI, 1.2%-10.8%), and hypertension was
controlled in 31.0% (increase of 6.4%; 95% CI, 1.6%-11.2%). Women, Mexican
Americans, and those aged 60 years or older had significantly lower rates
of control compared with men, younger individuals, and non-Hispanic whites.ConclusionsContrary to earlier reports, hypertension prevalence is increasing in
the United States. Hypertension control rates, although improving, continue
to be low. Programs targeting hypertension prevention and treatment are of
utmost importance.

title: Disparities in self-reported hypertension in Hispanic subgroups, non-Hispanic black and non-Hispanic white adults: the national health interview survey.
abstract: To investigate the prevalence of self-reported hypertension in Hispanic subgroups and non-Hispanic adults in the National Health Interview Survey for years 1997 to 2005, we examined 279,387 records, including 48,630 records for Hispanic adults.



Self-reported hypertension was ascertained through the question, "Have you ever been told by a doctor or health professional that you have hypertension, also called high blood pressure?" Logistic regression was used to assess the strength of the association between race/ethnicity (Puerto Rican, Mexican, Mexican American, Cuban, Dominican, Central and South American, other Hispanic, and non-Hispanic black versus non-Hispanic white adults) and self-reported hypertension before and after adjusting for selected characteristics.



After adjusting for selected sociodemographic and health-related characteristics, Dominican and non-Hispanic black adults had 67% (95% confidence interval [CI], 1.23-2.27) and 48% (95% CI, 1.41-1.56) greater odds of reporting hypertension than non-Hispanic white adults. In contrast, Mexican (odds ratio [OR], 0.73; 95% CI, 0.65-0.82), Mexican-American (OR, 0.80; 95% CI, 0.72-0.88), and Central and South American adults (OR, 0.80; 95% CI, 0.69-0.93) had lower odds of reporting hypertension than non-Hispanic white adults. The association between race/ethnicity and self-reported hypertension differs with sex, nativity status/length of stay in the United States, and education.



This study underscores the need for data disaggregation beyond the existing racial/ethnic categories in the United States to reflect the heterogeneity and health disparities masked not only for the population under the Hispanic category but also for populations under other categories considered homogenous.

title: Hypertension and Diabetes Prevalence Among U.S. Hispanics by Country of Origin: The National Health Interview Survey 2000-2005
abstract: BackgroundDespite their diverse cultural origins, Hispanics in the US are generally studied as a single ethnic group.Objectives1) Assess demographic and disease-related differences among U.S. Hispanics by country of origin, and 2) Examine the mediating roles of socioeconomic status and acculturation on disease prevalence in these subgroups.Design and ParticipantsUsing data from the 2000-2005 National Health Interview Survey (NHIS), we compared characteristics of Mexican-Americans with Hispanics originally from: Mexico, Puerto Rico, Central/South America, Cuba, and Dominican Republic (n = 31,240). We stratified the analysis by foreign versus US-born Hispanic subgroups and modeled hypertension and diabetes prevalence, adjusting for demographic and acculturation differences.Main resultsThe six Hispanic subgroups were significantly diverse in all measured variables. Prevalence of hypertension (32%) and diabetes (15%) was highest in foreign-born Puerto Ricans. After adjusting for age, BMI, smoking, socioeconomic status and acculturation in foreign-born Hispanics, Puerto Ricans (OR = 1.76 [95% CI: 1.23, 2.50], p = 0.002) and Dominicans (OR = 1.93 [1.24, 3.00], p = 0.004), had higher prevalence of hypertension relative to Mexican-Americans. Adjusted diabetes prevalence among foreign-born Hispanics was half or less in Cubans (OR = 0.42 [0.25, 0.68] p < 0.001), Dominicans (OR = 0.48 [0.26, 0.91], p = 0.02) and Central/South Americans (OR = 0.51 [0.33, 0.78], p = 0.002) relative to Mexican-Americans. Among US-born Hispanic subgroups, Cubans had lower hypertension (OR = 0.53, [0.33, 0.83], p = 0.006) and Mexicans (OR = 0.76 [0.60, 0.98], p = 0.03) had lower diabetes prevalence compared to Mexican-Americans in adjusted models.ConclusionsThe prevalence of hypertension and diabetes varies significantly among Hispanics by country of origin. Health disparities research should include representation from all Hispanic subgroups.

title: Prevalence of hypertension, awareness, treatment, and control in the Hispanic Community Health Study/Study of Latinos.
abstract: The prevention and control of hypertension is an essential component for reducing the burden of cardiovascular diseases. Here we describe the prevalence of hypertension in diverse Hispanic/Latino background groups and describe the proportion who are aware of their diagnosis, receiving treatment, and having their hypertension under control.



The Hispanic Community Health Study/Study of Latinos is a longitudinal cohort study of 16,415 Hispanics/Latinos, aged 18-74 years from 4 US communities (Bronx, NY; Chicago, IL; Miami, FL; and San Diego, CA). At baseline (2008-2011) the study collected extensive measurements and completed questionnaires related to research on cardiovascular diseases. Hypertension was defined as measured blood pressure ≥140/90mm Hg or use of antihypertensive medication.



The total age-adjusted prevalence of hypertension in this study was 25.5% as compared with 27.4% in non-Hispanic whites in the National Health and Nutrition Examination Survey. Prevalence of hypertension increased with increasing age groups and was highest in Cuban, Puerto Rican, and Dominican background groups. The percent with hypertension who were aware, being treated with medication, or had their hypertension controlled was lower compared with US non-Hispanic whites with hypertension and it was lowest in those without health insurance.



These findings indicate a significant deficit in treatment and control of hypertension among Hispanics/Latinos residing in the United States, particularly those without health insurance. Given the relative ease of identification of hypertension and the availability of low-cost medications, enabling better access to diagnostic and treatment services should reduce the burden of hypertension in Hispanic populations.

title: Hispanic paradox in biological risk profiles.
abstract: We examined biological risk profiles by race, ethnicity, and nativity to evaluate evidence for a Hispanic paradox in measured health indicators.



We used data on adults aged 40 years and older (n = 4206) from the National Health and Nutrition Examination Surveys (1999-2002) to compare blood pressure, metabolic, and inflammatory risk profiles for Whites, Blacks, US-born and foreign-born Hispanics, and Hispanics of Mexican origin. We controlled for age, gender, and socioeconomic status.



Hispanics have more risk factors above clinical risk levels than do Whites but fewer than Blacks. Differences between Hispanics and Whites disappeared after we controlled for socioeconomic status, but results differed by nativity. After we controlled for socioeconomic status, the differences between foreign-born Hispanics and Whites were eliminated, but US-born Mexican Americans still had higher biological risk scores than did both Whites and foreign-born Mexican Americans.



There is no Hispanic paradox in biological risk profiles. However, our finding that foreign-born Hispanics and Whites had similar biological risk profiles, but US-born Mexican Americans had higher risk, was consistent with hypothesized effects of migrant health selectivity (healthy people in-migrating and unhealthy people out-migrating) as well as some differences in health behaviors between US-born and foreign-born Hispanics.

title: Type 2 diabetes in the Hispanic or Latino population: challenges and opportunities
abstract: describe how type 2 diabetes affects the Latino or Hispanic population in the United States, and identify the multiple challenges and opportunities to improve diabetes care in this rapidly growing group. Recent findingsThree compelling reasons justify the work in this area. First, this group has become the largest minority in the country, representing 13.7% of the total population. Based on current growth rates, one in four individuals will be of Hispanic origin by the year 2050. Second, this population suffers from very high rates of type 2 diabetes, obesity, the metabolic syndrome and their multiple vascular complications. A genetic tendency to develop insulin resistance and abdominal obesity, along with multiple nutritional, lifestyle, socio-economic and cultural factors, influence the development and course of type 2 diabetes among Latinos. Third, Hispanics have lagged behind in their diabetes care when compared with the predominant non-Hispanic White population. SummaryUnderstanding the challenges and opportunities in Latinos with diabetes is necessary to develop and implement comprehensive culturally oriented diabetes care, education, outreach and research programs. Some of these strategies may also be beneficial for other groups and can contribute to better integrate our societies.

title: Lifetime risk for diabetes mellitus in the United States.
abstract: Although diabetes mellitus is one of the most prevalent and costly chronic diseases in the United States, no estimates have been published of individuals' average lifetime risk of developing diabetes.



To estimate age-, sex-, and race/ethnicity-specific lifetime risk of diabetes in the cohort born in 2000 in the United States.



Data from the National Health Interview Survey (1984-2000) were used to estimate age-, sex-, and race/ethnicity-specific prevalence and incidence in 2000. US Census Bureau data and data from a previous study of diabetes as a cause of death were used to estimate age-, sex-, and race/ethnicity-specific mortality rates for diabetic and nondiabetic populations.



Residual (remaining) lifetime risk of diabetes (from birth to 80 years in 1-year intervals), duration with diabetes, and life-years and quality-adjusted life-years lost from diabetes.



The estimated lifetime risk of developing diabetes for individuals born in 2000 is 32.8% for males and 38.5% for females. Females have higher residual lifetime risks at all ages. The highest estimated lifetime risk for diabetes is among Hispanics (males, 45.4% and females, 52.5%). Individuals diagnosed as having diabetes have large reductions in life expectancy. For example, we estimate that if an individual is diagnosed at age 40 years, men will lose 11.6 life-years and 18.6 quality-adjusted life-years and women will lose 14.3 life-years and 22.0 quality-adjusted life-years.



For individuals born in the United States in 2000, the lifetime probability of being diagnosed with diabetes mellitus is substantial. Primary prevention of diabetes and its complications are important public health priorities.

title: Prevalence of Diabetes in Mexican Americans, Cubans, and Puerto Ricans From the Hispanic Health and Nutrition Examination Survey, 1982–1984
abstract: The purpose of this study was to estimate the prevalence of diagnosed and undiagnosed diabetes among Mexican Americans, Cubans, and Puerto Ricans in the United States and compare these estimates to data from prior surveys for U.S. non-Hispanic whites and blacks. Data for this study are from the Hispanic Health and Nutrition Examination Survey, a multipurpose cross-sectional survey of three U.S. Hispanic populations conducted in 1982–1984. The interviewed sample of people aged 20–74 yr included 3935 Mexican Americans in the southwest, 1134 Cubans in Florida, and 1519 Puerto Ricans in the New York City area. The diabetes component consisted of interview questions on diabetes diagnosis and treatment and an oral glucose tolerance test administered to a subsample. The prevalence of diabetes was two to three times greater for Mexican Americans and Puerto Ricans than for non-Hispanic whites surveyed in 1976–1980. In Cubans, the prevalence was similar to that for non-Hispanic whites. In men and women 45–74 yr of age, the prevalence of diabetes was extremely high for both Mexican Americans (23.9%) and Puerto Ricans (26.1%) compared with Cubans (15.8%) or non-Hispanic whites (12%). The total prevalence of diabetes was not significantly different for Mexican Americans and Puerto Ricans but was significantly lower for Cubans. The relatively lower prevalence of diabetes among Cubans and the high prevalence in both Mexican Americans and Puerto Ricans may be related to socioeconomic, genetic, behavioral, or environmental factors.

title: Hemoglobin A1c levels in diagnosed and undiagnosed black, Hispanic, and white persons with diabetes: results from NHANES 1999-2000.
abstract: Although the prevalence of diabetes among various racial/ethnic groups has been well studied, little is known about the racial/ ethnic differences in Hemoglobin A1c (HbA1c) in diagnosed and undiagnosed diabetes. HbA1c correlates with morbidity and mortality in diabetes. Knowledge of the racial/ethnic differences in HbA1c would impact screening and intervention in primary care settings. This study describes racial/ethnic differences in HbA1c among US Black, Hispanic, and White diagnosed and undiagnosed persons with diabetes.



This study included participants in the 1999-2000 National Health and Nutrition Examination Survey who were > or =20 years old with a HbA1c measurement. The association between HbA1c and race in diagnosed and undiagnosed persons with diabetes (with body mass index [BMI] and age as covariates) was determined. The distribution of HbA1c and mean HbA1c in diagnosed and undiagnosed diabetes and the rates of diagnosed and undiagnosed diabetes with their corresponding HbA1c levels are described by race/ethnicity.



Estimated diabetes prevalence in US persons > or =20 years is 8.2%, with 2.3% having undiagnosed diabetes. Whites with diabetes had lower mean HbA1c levels (7.6%, standard error [SEI 0.2) than Blacks (8.1%, SE 0.3) or Hispanics (8.2%, SE .3). Whites with diagnosed diabetes were less likely to have HbA1c> or =11% (1.7%) than Blacks (11.1%) or Hispanics (10.4%). Hispanics with undiagnosed diabetes were more likely to have HbA1c-7% (60.5%) than Blacks (39.3%) or Whites (37.8%).



Significant numbers of persons with diabetes are undiagnosed. There are significant racial/ethnic differences in HbA1c levels, which are significantly higher in Blacks and Hispanics. Comprehensive risk-based screening and intervention for diabetes is needed in order to address racial and ethnic disparities, especially in minorities.

title: Self-Reported Diabetes in Hispanic Subgroup, Non-Hispanic Black, and Non-Hispanic White Populations: National Health Interview Survey, 1997–2005
abstract: We estimated the prevalence of self-reported diabetes in Hispanic subgroup (Puerto Rican, Mexican, Mexican American, Cuban, Dominican, Central and South American, and other Hispanic), non-Hispanic black, and non-Hispanic white populations aged 20 years and older.  Using the National Health Interview Survey 1997–2005, we limited these analyses to 272,041 records of adults aged 20 years and older, including 46,749 records for Hispanic respondents. We used logistic regression to assess the strength of the association between race/ethnicity and self-reported diabetes before and after adjusting for selected characteristics.  Compared with non-Hispanic white respondents, Mexican American (odds ratio [OR] = 2.02; 95% confidence interval [CI] 1.75, 2.34), Mexican (OR=1.52; 95% CI 1.31, 1.91), Puerto Rican (OR=1.53; 95% CI 1.23, 1.91), other Hispanic (OR=2.08; 95% CI 1.68, 2.58), and non-Hispanic black (OR=1.47; 95% CI 1.35, 1.61) respondents had greater odds of reporting diabetes. When compared with non-Hispanic white respondents, Mexican American respondents with less than a high school diploma had the lowest odds of reporting diabetes, while those with at least a college degree had greater odds of reporting diabetes. However, Puerto Rican respondents with less than a high school education, Mexican respondents with at least some college education, and other Hispanic respondents with at least a high school diploma/general equivalency diploma had greater odds of reporting diabetes.  Although Hispanic respondents bear a greater burden of diabetes than non-Hispanic white respondents, this burden is unevenly distributed across subgroups. These findings call attention to data disaggregation whenever possible for U.S. racial/ethnic populations classified under categories considered homogeneous.

title: Diabetes mellitus: a "thrifty" genotype rendered detrimental by "progress"?
abstract: FOR THE POPULATION GENETICIST, diabetes mellitus has long presented an enigma. Here is a relatively frequent disease, often interfering with reproduction by virtue of an onset during the reproductive or even pre-reproductive years, with a well-defined genetic basis, perhaps as simple in many families as a single recessive or incompletely recessive gene (cf. Allan, 1933; Pincus and White, 1933, 1934; Harris, 1950; Steinberg and Wilder, 1952; Lamy, Frezal and de Grouchy, 1957; Steinberg, 1959; Post, 1962a). If the considerable frequency of the disease is of relatively long duration in the history of our species, how can this be accounted for in the face of the obvious and strong genetic selection against the condition? If, on the other hand, this frequency is a relatively recent phenomenon, what changes in the environment are responsible for the increase? Current developments in the study of this disease suggest an explanation with important biological ramifications.

title: Increased Insulin Resistance and Insulin Secretion in Nondiabetic African-Americans and Hispanics Compared With Non-Hispanic Whites: The Insulin Resistance Atherosclerosis Study
abstract: The etiology of NIDDM is still controversial, with both insulin resistance and decreased insulin secretion postulated as potential important factors. African-Americans and Hispanics have a two- to threefold excess risk of developing NIDDM compared with non-Hispanic whites. Yet little is known concerning the prevalence of insulin resistance and secretion defects in minorities, especially in African-Americans in population-based studies. Fasting and 2-h post–glucose load glucose and insulin levels, insulin-mediated glucose disposal (insulin sensitivity index) (SI), glucose effectiveness (SG), and first-phase insulin response (acute insulin response [AIR]) were determined in nondiabetic African-Americans (n = 288), Hispanics (n = 363), and non-Hispanic whites (n = 435) as part of the Insulin Resistance Atherosclerosis Study. Subjects received a standard 2-h oral glucose tolerance test on the first day and an insulin-modified frequently sampled intravenous glucose tolerance test on the second day. African-Americans and Hispanics were more obese than non-Hispanic whites. Both African-Americans and Hispanics had higher fasting and 2-h insulin concentrations and AIR but lower SI than non-Hispanic whites. No ethnic difference was observed in SG. After further adjustments for obesity, body fat distribution, and behavioral factors, African-Americans continued to have higher fasting and 2-h insulin levels and AIR, but lower SI, than non-Hispanic whites. In contrast, after adjustment for these covariates, no significant ethnic differences in SI or fasting insulin levels were observed between Hispanics and non-Hispanic whites. Hispanics continued to havehigher 2-h insulin levels and AIRs than those in non-Hispanic whites. In this report, the association between SI and upper body adiposity (waist-to-hip ratio) was similar in each ethnic group. Both nondiabetic African-Americans and Hispanics have increased insulin resistance and higher AIR than nondiabetic non-Hispanic whites, suggesting that greater insulin resistance may be in large part responsible for the higher prevalence of NIDDM in these minority groups. However, in Hispanics, the greater insulin resistance may be due to greater adiposity and other behavioral factors.

title: Insulin sensitivity differs among ethnic groups with a compensatory response in beta-cell function.
abstract: A drastic difference is evident in the prevalence of type 2 diabetes among ethnic groups. We examined the role of beta-cell function and insulin sensitivity in this disparity among 4 ethnic groups.



beta-Cell function and insulin sensitivity were assessed in 77 healthy glucose-tolerant subjects using a hyperglycemic clamp (18 Asian-Americans, 9 African-Americans, 34 Caucasians, and 16 Mexican-Americans).



A wide range of variation was evident in clinical features of the studied subjects. Insulin sensitivity index and the second-phase insulin response differed among the 4 groups (P = 0.0023 and P = 0.0082, respectively), whereas the first-phase insulin response was marginally different (P = 0.1090). Stepwise regression analysis revealed that ethnicity was an independent determinant for the insulin sensitivity index (P = 0.0014) after adjusting for sex, age, diastolic blood pressure, waist-to-hip ratio, and BMI. Also, a compensatory response of beta-cell function was observed among the ethnic groups.



In this study, we observed a drastic difference in insulin sensitivity among the different ethnic groups and observed that their beta-cell function compensates for the prevailing insulin sensitivity. The difference in the prevalence of abnormal glucose tolerance in different ethnic groups could be a result of differences in insulin sensitivity

title: Insulin resistance and associated compensatory responses in african-american and Hispanic children.
abstract: The objective of this study was to compare insulin resistance relative to body fat and the associated compensatory responses in 57 healthy children living in Los Angeles, California (14 Caucasians, 15 African-Americans, and 28 .



Insulin sensitivity and acute insulin response were determined by intravenous glucose tolerance test. Insulin secretion, hepatic insulin extraction, and insulin clearance were estimated by C-peptide and insulin modeling.



Insulin sensitivity was significantly lower in Hispanics and African-Americans compared with Caucasian children, and acute insulin response was significantly higher in African-American children. No ethnic differences were noted in the first-phase secretion, but second-phase insulin secretion was significantly higher in Hispanic children than in African-American children (200 +/- 53 vs. 289 +/- 41 nmol/min; P = 0.03). The greater acute insulin response in African-Americans, despite lower secretion, was explained by a lower hepatic insulin extraction in African-Americans compared with Hispanics (36.6 +/- 2.9 vs. 47.3 +/- 2.2%; P = 0.0006).



In conclusion, Hispanic and African-American children are more insulin resistant than Caucasian children, but the associated compensatory responses are different across ethnic groups.

title: Cardiovascular disease prevention and care in Latino and Hispanic subjects.
abstract: To determine the scope, impact, and health care limitations relative to cardiovascular disease (CVD) in the Latino-Hispanic population.



We reviewed MEDLINE and PubMed for studies published from January 1995 to June 2005 using a combination of search terms (epidemiology, Hispanic, CVD) and chose articles for review on the basis of direct informational relevance to the current status of preventive treatment and barriers to health care for CVD among the Latino-Hispanic community. Additional information was gathered through a general Internet search by using Google with the aforementioned search terms and a review of the US Bureau of the Census and governmental statistics related to these terms found through governmental Web sites.



For proactive reduction of rates of CVD among the Latino-Hispanic population in the United States, preventive interventions should be targeted. Several barriers exist to providing effective preventive care to the Latino-Hispanic community. Medical research involving the Latino-Hispanic population is sparse, many Latino and Hispanic subjects do not have health insurance or a regular source of health care, and poor English-language ability and low education and literacy levels limit awareness and inhibit communications between Latino and Hispanic persons and the health care system.



The prevalence and growth of CVD in the US Latino-Hispanic community provide a clear warning that the public health problem presented by CVD in the Latino-Hispanic population is already substantial and will become much more severe in the coming decades. Actions to manage and minimize this problem are urgently needed.

title: A genomewide single-nucleotide-polymorphism panel for Mexican American admixture mapping.
abstract: For admixture mapping studies in Mexican Americans (MAM), we define a genomewide single-nucleotide-polymorphism (SNP) panel that can distinguish between chromosomal segments of Amerindian (AMI) or European (EUR) ancestry. These studies used genotypes for >400,000 SNPs, defined in EUR and both Pima and Mayan AMI, to define a set of ancestry-informative markers (AIMs). The use of two AMI populations was necessary to remove a subset of SNPs that distinguished genotypes of only one AMI subgroup from EUR genotypes. The AIMs set contained 8,144 SNPs separated by a minimum of 50 kb with only three intermarker intervals >1 Mb and had EUR/AMI FST values >0.30 (mean FST = 0.48) and Mayan/Pima FST values <0.05 (mean FST < 0.01). Analysis of a subset of these SNP AIMs suggested that this panel may also distinguish ancestry between EUR and other disparate AMI groups, including Quechuan from South America. We show, using realistic simulation parameters that are based on our analyses of MAM genotyping results, that this panel of SNP AIMs provides good power for detecting disease-associated chromosomal segments for genes with modest ethnicity risk ratios. A reduced set of 5,287 SNP AIMs captured almost the same admixture mapping information, but smaller SNP sets showed substantial drop-off in admixture mapping information and power. The results will enable studies of type 2 diabetes, rheumatoid arthritis, and other diseases among which epidemiological studies suggest differences in the distribution of ancestry-associated susceptibility.

title: Bienestar: a diabetes risk-factor prevention program.
abstract: The Bienester Health Program, a diabetes risk-factor prevention pilot program, targeted fourth grade Mexican American children. The primary goals are to decrease the two established risk factors for diabetes--overweight and dietary fats. Since the health program is based on Social Cognitive Theory, on social systems structure, and on culturally relevant material, it considers the child's social systems on both its health program and process evaluation. Learning activities were developed for four social systems that potentially influence children's health behaviors (parent, classroom, school cafeteria, and after-school care). Preliminary results show that the Bienestar Health Program significantly decreased dietary fat, increased fruit and vegetable servings, and increased diabetes health knowledge.

title: Celebremos La Salud! A Community Randomized Trial of Cancer Prevention (United States)
abstract: BackgroundCompared to non-Hispanic whites, Hispanics in the United States are at higher risk for certain types of cancer.MethodsIn a randomized controlled trial of 20 communities, we examined whether a comprehensive intervention influenced cancer screening behaviors and lifestyle practices in rural communities in Eastern Washington State. Cross-sectional surveys at baseline and post-intervention included interviews with a random sample of approximately 100 households per community. The interview included questions on ever use and recent use of Pap test, mammogram, and fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy, fruit and vegetable consumption and smoking practices.ResultsWe found few significant changes in use of screening services for cervical (Pap test), breast (mammogram) or colorectal cancer (fecal occult blood test (FOBT) or sigmoidoscopy/colonoscopy) between intervention and control communities. We found no significant differences in fruit and vegetable consumption nor in smoking prevalence between the two groups. We found more awareness of and participation in intervention activities in the treatment communities than the control communities.ConclusionsOur null findings might be attributable to the low dose of the intervention, a cohort effect, or contamination of the effect in non-intervention communities. Further research to identify effective strategies to improve cancer prevention lifestyle behaviors and screening practices are needed.

title: Diabetes self-management among low-income spanish-speaking patients: A pilot study
abstract: The prevalence of type 2 diabetes and diabetesrelated morbidity and mortality is higher among low-income Hispanics when compared to that of Whites. However, little is known about how to effectively promote self-management in this population. The objectives were first to determine the feasibility of conducting a randomized clinical trial of an innovative self-management intervention to improve metabolic control in low-income Spanish-speaking individuals with type 2 diabetes and second to obtain preliminary data of possible intervention effects. Participants for this pilot study were recruited from a community health center, an elder program, and a community-wide database developed by the community health center, in collaboration with other agencies serving the community, by surveying households in the entire community. Participants were randomly assigned to an intervention (n = 15) or a control (n = 10) condition. Assessments were conducted at baseline and at 3 months and 6 months postrandomization. The intervention consisted of 10 group sessions that targeted diabetes knowledge, attitudes, and self-management skills through culturally specific and literacysensitive strategies. The intervention used a cognitivebehavioral theoretical framework. Recruitment rates at the community health center, elder program, and community registry were 48%, 69%, and 8%, respectively. Completion rates for baseline, 3-month, and 6-month assessments were 100%, 92%, and 92%, respectively. Each intervention participant attended an average of 7.8 out of 10 sessions, and as a group the participants showed high adherence to intervention activities (93% turned in daily logs, and 80% self-monitored glucose levels at least daily). There was an overall Group × Time interaction (p = .02) indicating group differences in glycosylated hemoglobin over time. The estimated glycosylated hemoglobin decrease at 3 months for the intervention group was −0.8% (95% confidence intervals = −1.1%, −0.5%) compared with the change in the control group (p = .02). At 6 months, the decrease in the intervention group remained significant, −0.85% (95% confidence intervals = −1.2, −0.5), and the decrease was still significantly different from that of the controls (p = .005). There was a trend toward increased physical activity in the intervention group as compared to that of the control group (p = .11) and some evidence (nonsignificant) of an increase in blood glucose self-monitoring in the intervention participants but not the control participants. Adjusting for baseline depressive scores, we oberved a significant difference in depressive symptoms between intervention participants and control participants at the 3-month assessment (p = .02).Conclusions: Low-income Spanish-speaking Hispanics are receptive to participate in diabetes-related research. This study shows that the pilot-tested diabetes self-management program is promising and warrants the conduct of a randomized clinical trial.

title: Resources for health: a primary-care-based diet and physical activity intervention targeting urban Latinos with multiple chronic conditions.
abstract: The Resources for Health trial evaluates a social-ecologically based lifestyle (physical activity and diet) intervention targeting low-income, largely Spanish-speaking patients with multiple chronic conditions.



A randomized controlled trial was conducted with 200 patients recruited from an urban community health center and assigned to intervention and usual care conditions. Intervention involved 2 face-to-face, self-management support and community linkage sessions with a health educator, 3 follow-up phone calls, and 3 tailored newsletters.



Primary outcomes measured at 6-months were changes in dietary behavior and physical activity. Changes in multilevel support for healthy living were evaluated as a secondary outcome.



After adjustment for age, sex, language, and number of chronic conditions, significant intervention effects were observed for dietary behavior and multilevel support for healthy lifestyles but not for physical activity.



The Resources for Health intervention provides an effective and practical model for improving health behavior among low-income, Spanish-speaking patients with multiple chronic conditions.

title: Secretos de la Buena Vida: processes of dietary change via a tailored nutrition communication intervention for Latinas.
abstract: Secretos de la Buena Vida was a successful tailored nutrition communication intervention delivered to Latinas living along the US-Mexico border in California. The intervention was delivered over a 14-week period and consisted of three intervention conditions: weekly home visits with promotoras + weekly tailored mailed newsletters in the first condition, weekly tailored mailed newsletters in the second condition and targeted materials in the attention control condition. The current study examined what elements of the promotora + tailored newsletter and tailored newsletter-only conditions were most effective for behavioral adoption and maintenance in a sample of 238 Latina women. Process evaluation measures assessed the implementation, fidelity and dose of these two intervention conditions. Results indicate that there was high fidelity to program implementation and delivery. Perceived effort, perceived support and intervention length predicted adoption of a lower fat diet at the 15-month follow-up. In the promotora + tailored newsletter condition, married women were four times more likely to be adopters of dietary fat changes than single women. These findings highlight the importance of process evaluation measures and help us understand the mechanism by which tailored print materials and interpersonal health communication via promotoras can facilitate health behavior change.

title: A Weight-Loss Intervention Program Designed for Mexican–American Women: Cultural Adaptations and Results
abstract: This study assessed the feasibility of a culturally-appropriate weight-loss intervention targeting obese Spanish-speaking Mexican women. This 12-month weight-loss program was based on behavioral interventions previously used successfully with English-speaking participants. Cultural adaptations included: female interventionists, minimal written materials, emphasis on group activities, focus on Mexican traditions and beliefs, and skill-building approach to food measurement. All sessions were conducted in Spanish. The study had few exclusionary criteria, which allowed participation of women with a wide range of literacy levels. Recruitment exceeded expectations, with 47 participants enrolling in the program. Not counting participants who became pregnant during the study, attendance at 6 and 12 months was 62 and 50 % respectively. Mean weight loss at 6 and 12 months was 5.3 and 7.2 kg, respectively, with a mean reduction in BMI of 4.0 and 5.5 kg/m2 from baseline to 6 and 12 months, respectively. This pilot study shows that it is feasible to develop and implement culturally-appropriate behavioral lifestyle interventions for obesity treatment in Mexican–American women.

title: Cigarette smoking among adults and trends in smoking cessation - United States, 2008.
abstract: Cigarette smoking continues to be the leading cause of preventable morbidity and mortality in the United States. Full implementation of population-based strategies and clinical interventions can educate adult smokers about the dangers of tobacco use and assist them in quitting. To assess progress toward the Healthy People 2010 objective of reducing the prevalence of cigarette smoking among adults to <12% (objective 27-1a), CDC analyzed data from the 2008 National Health Interview Survey (NHIS). This report summarizes the results of that analysis, which indicated that during 1998-2008, the proportion of U.S. adults who were current cigarette smokers declined 3.5% (from 24.1% to 20.6%). However, the proportion did not change significantly from 2007 (19.8%) to 2008 (20.6%). In 2008, adults aged >or=25 years with low educational attainment had the highest prevalence of smoking (41.3% among persons with a General Educational Development certificate [GED] and 27.5% among persons with less than a high school diploma, compared with 5.7% among those with a graduate degree). Adults with education levels at or below the equivalent of a high school diploma, who comprise approximately half of current smokers, had the lowest quit ratios (2008 range: 39.9% to 48.8%). Evidence-based programs known to be effective at reducing smoking should be intensified among groups with lower education, and health-care providers should take education level into account when communicating about smoking hazards and cessation to these patients.

title: Cigarette smoking behavior among US Latino men and women from different countries of origin.
abstract: This study sought to compare smoking behavior among Latino men and women from different countries of origin.



A telephone-administered survey was conducted in 8 cities with Latino men and women of different national origin living in census tracts with at least 70% Latino individuals.



A total of 8882 participants completed the survey; 53% were women. The average age of respondents was 44 years; 63% were foreign-born, and 59% preferred Spanish for the interview. Current smoking was more prevalent among men (25.0%, 95% confidence interval [CI] = 23.7, 26.3) than among women (12.1%, 95% CI = 11.1, 13.0). Smoking rates were not significantly different by national origin among men, but Puerto Rican women had higher rates of smoking than other women. Central American men and women had the lowest smoking rates. Foreign-born respondents were less likely to be smokers (odds ratio [OR] = 0.77, 95% CI = 0.66, 0.90) than US-born respondents, and respondents with 12 years or less of education had an increased odds of smoking (OR = 1.17, 95% CI = 1.01, 1.35). High ac culturation was associated with more smoking in women (OR = 1.12, 95% CI = 1.00-1.25) and less smoking in men (OR = 0.86, 95% CI = 0.78-0.95). Puerto Rican and Cuban respondents were more likely to be current smokers and to smoke more than 20 cigarettes per day.



Older, US-born, and more-educated respondents were less likely to be current smokers. Respondents of Puerto Rican and Cuban origin were more likely to smoke. Acculturation has divergent effects on smoking behavior by sex.

title: Health risk behaviors of Hispanics in the United States: findings from HHANES, 1982-84.
abstract: With data from the Hispanic Health and Nutrition Examination Survey (HHANES), we examined several health risk behaviors (cigarette smoking, alcohol use, dietary practices, and recency of health screening) of Mexican American, Cuban American, and Puerto Rican adults (ages 20-74). For each sample, a greater percentage of men than women smoked cigarettes and used alcohol. Heavy smoking (20+ cigarettes per day) was most prevalent for Cuban American males, and heavy drinking (1.00+ oz ethanol per day) was most prevalent for Mexican American and Puerto Rican men. Acculturation correlated positively with alcohol use (particularly for females) and negatively with dietary balance (for Mexican American men and women). The Puerto Ricans' diet was less balanced than that of the other two groups. For each sample, more men than women had not had a routine physical or dental examination within the past five years; the recency of screening was lowest for Mexican American men. Screening (including Pap smear for the women) was lower for those who smoked cigarettes and for those with poor dietary practices, indicating that many Hispanics at special risk of disease underutilize preventive health services, increasing the likelihood of diagnosis at a later stage of illness.

title: Acculturation and smoking patterns among Hispanics: a review.
abstract: To conduct a systematic review of published studies investigating the association of acculturation and smoking patterns among Hispanic men and women in the United States.



Online bibliographic databases were searched from 1985 to 2003 using three key search terms. The methodology and findings of all retrieved articles were critically evaluated. Data were extracted from each article regarding study population, study methods, exposure assessment, outcomes measured, acculturation measures used, and results.



The literature search identified 78 articles from MEDLINE, PubMed, and PsychINFO databases; of these, 11 studies met the inclusion criteria. Seven regional studies based in the western United States and four nationwide studies were included in the review. Seven studies used formal acculturation scales, three used language spoken, and one used language spoken and country of birth to indicate acculturation status. Nine studies showed a positive association between acculturation and smoking among women, and one study involving men showed a negative association.



The findings suggest that the association of acculturation and smoking is gender-specific. In this instance, increased smoking prevalence with increased acculturation is consistently observed among Hispanic women but not among men. As Hispanic women acculturate, their cigarette smoking may increase because their behavior becomes more strongly influenced by the norms and practices of the dominant group than among men. Immigrant- and gender-specific public health interventions need to be designed to combat the increase in smoking rates among Hispanics in the United States.

title: Apparent underreporting of cigarette consumption among Mexican American smokers.
abstract: To determine the accuracy of self-report of cigarette consumption among Mexican American smokers, we compared self-reported cigarette use and serum cotinine concentrations in a sample of 547 participants in the Hispanic Health and Nutrition Examination Survey (HHANES). We defined underreporting of cigarette use as a cotinine to cigarette-per-day ratio of greater than 0.142 microM/l which represented a substantial discrepancy between self-reported consumption and serum cotinine. Of the 98 men and 97 women who reported smoking one to nine cigarettes/day, 20.4 percent and 24.7 percent, respectively, underreported their cigarette consumption. Underreporting was less common among men and women smoking 10 to 19 cigarettes/day (8.3 percent and 10.8 percent, respectively) and 20 or more cigarettes/day (2.2 percent and 2.9 percent, respectively). Comparison of underreporters to other smokers by demographic characteristics within sex and cigarettes/day categories showed no differences. Differences in cotinine metabolism and extremely efficient smoking are alternative explanations that can not be ruled out with these data. We believe, however, that a proportion of Mexican American light smokers may underreport the quantity of cigarettes smoked per day, and may truly be moderate or heavy smokers.

title: Leisure-time physical activity among US adults. Results from the Third National Health and Nutrition Examination Survey.
abstract: The prevalence of no leisure-time physical activity (LTPA) among US adults is estimated to be between 24% and 30%. Such information, however, usually does not include prevalence estimates for non-Hispanic blacks, Mexican Americans, and the elderly.



To assess the prevalence of participation in leisure-time physical activity among US adults.



Between 1988 and 1991, 9488 adults aged 20 years and older were interviewed in their home as part of the third National Health and Nutrition Examination Survey. A clinic examination in a mobile center was also included. Mexican Americans, non-Hispanic blacks, and the elderly were oversampled to produce reliable estimates for these groups. Questions were asked about the type and frequency of physically active hobbies, sports, and exercises.



The prevalence of no LTPA for US adults aged 20 years or older from 1988 through 1991 was 22%. The rate was higher in women (27%) than in men (17%). Mexican-American men (33%) and women (46%) and non-Hispanic black women (40%) had the highest rates of no LTPA. Participation in moderate to vigorous LTPA five or more times per week decreased with age, with the largest decreases observed among non-Hispanic black men and women. In almost all subpopulations, gardening and/or yard work and walking were stated as the two top LTPAs of choice.



Many Americans are inactive or irregularly active during their leisure time. Rates of inactivity are greater for women, older persons, non-Hispanic blacks, and Mexican Americans. Intervention strategies meant to promote lifetime physical activities among all Americans represents a major health priority.

title: Prevalence of Physical Activity in the United States: Behavioral Risk Factor Surveillance System, 2001
abstract: The health benefits of regular cardiovascular exercise are well-known. Such exercise, however, has traditionally been defined as vigorous physical activity, such as jogging, swimming, or aerobic dance. Exercise of moderate intensity also promotes health, and many U.S. adults may be experiencing the health benefits of exercise through lifestyle activities of moderate intensity, such as yard work, housework, or walking for transportation. Until recently, public health surveillance systems have not included assessments of this type of physical activity, focusing on exercise of vigorous intensity. We used an enhanced surveillance tool to describe the prevalence and amount of both moderate-intensity and vigorous-intensity physical activity among U.S. adults.  We analyzed data from the 2001 Behavioral Risk Factor Surveillance System, a state-based, random-digit–dialed telephone survey administered to U.S. adults aged 18 years and older (n = 82,834 men and 120,286 women). Physical activity behavior was assessed using questions designed to quantify the frequency of participation in moderate- or vigorous-intensity physical activities performed during leisure time or for household chores and transportation.  Overall, 45% of adults (48% of men and 43% of women) were active at recommended levels during nonworking hours (at least 30 minutes five or more days per week in moderate-intensity activities, equivalent to brisk walking, or at least 20 minutes three or more days per week in vigorous activities, equivalent to running, heavy yard work, or aerobic dance). Less than 16% of adults (15% of men and 17% of women) reported no moderate or vigorous activity in a usual week.  Integrating surveillance of lifestyle activities into national systems is possible, and doing so may provide a more accurate representation of the prevalence of recommended levels of physical activity. These results, however, suggest that the majority of U.S. adults are not active at levels associated with the promotion and maintenance of health.

title: Leisure-time physical activity disparities among Hispanic subgroups in the United States.
abstract: Studies of leisure-time physical activity disparities for Hispanic individuals have not adjusted for sociodemographic confounds or accounted for variation by country of origin. We used the National Health Interview Survey to compare leisure-time physical activity among Hispanic and non-Hispanic White persons. All Hispanic subgroups were less active than were non-Hispanic White people, yet significant heterogeneity existed among Hispanic persons. Sociodemographic factors partly accounted for disparities among men; disparities among women persisted despite multivariate adjustments. Interventions must attend to these under-served yet varied sub-communities.

title: Physical Activity Patterns Among Latinos in the United States: Putting the Pieces Together
abstract: Estimates of participation in physical activity among Latinos are inconsistent across studies. To obtain better estimates and examine possible reasons for inconsistencies, we assessed 1) patterns of participation in various categories of physical activity among Latino adults, 2) changes in their activity patterns with acculturation, and 3) variations in their activity patterns by region of origin.  Using data from four national surveillance systems (the National Health and Nutrition Examination Survey, 1999–2002; the Behavioral Risk Factor Surveillance System, 2003; the National Household Travel Survey, 2001; and the National Health Interview Survey Cancer Supplement, 2000), we estimated the percentage of Latinos who participated at least once per week in leisure-time, household, occupational, or transportation-related physical activity, as well as in an active pattern of usual daily activity. We reported prevalences by acculturation measures and region of origin.  The percentage of Latinos who participated in the various types of physical activity ranged from 28.7% for having an active level of usual daily activity (usually walking most of the day and usually carrying or lifting objects) to 42.8% for participating in leisure-time physical activity at least once per week. The percentage who participated in leisure-time and household activities increased with acculturation, whereas the percentage who participated in occupational and transportation-related activities decreased with acculturation. Participation in an active level of usual daily activity did not change significantly. The prevalence of participation in transportation-related physical activity and of an active level of usual daily activity among Latino immigrants varied by region of origin.  Physical activity patterns among Latinos vary with acculturation and region of origin. To assess physical activity levels in Latino communities, researchers should measure all types of physical activity and the effects of acculturation on each type of activity.

title: Patterns and correlates of physical activity among US women 40 years and older.
abstract: This study describes the patterns of physical activity among minority women by using a variety of definitions and determines sociodemographic and behavioral correlates of physical activity in this population.



A cross-sectional study was conducted in 1996 and 1997 among US women 40 years and older (n = 2912) of the following racial/ethnic groups: African American, American Indian/Alaskan Native, Hispanic, and White.



Physical activity was lowest among African Americans and American Indians/Alaskan Natives (adjusted odds ratios [ORs] for no leisure-time activity were 1.35 [95% confidence interval (CI) = 1.08, 1.68] and 1.65 [95% CI = 1.33, 2.06], respectively). A much higher proportion of women were classified as being physically active when occupational activity rather than more traditional assessments of leisure activity were used to determine level of physical activity. On the basis of a composite definition of physical activity, 72% of respondents reported being physically active. Women living in rural regions (OR = 1.33; 95% CI = 1.12, 1.58) were more likely than urban inhabitants to be completely inactive during leisure time.



Minority women are among the least active subgroups in American society, although not all groups are less active than White women when all domains of physical activity are taken into account.

title: Potential Mediators of Ethnic Differences in Physical Activity in Older Mexican Americans and European Americans: Results from the San Antonio Longitudinal Study of Aging
abstract: Factors were examined that might explain reported ethnic differences in leisure time physical activity (LTPA) between Mexican Americans (MAs) and European Americans (EAs). Data were from a random sample of 749 community‐dwelling MAs and EAs, aged 65 and older, who participated in the San Antonio Longitudinal Study of Aging (SALSA) baseline examination. Variables examined included LTPA measured as kilocalories of energy expended per week, contextual variables (age, sex, socioeconomic status (SES), acculturation/structural assimilation), psychosocial measures (self‐esteem, mastery, perceived health control), lifestyle variables (fat avoidance, current alcohol drinker, years smoking, body mass index (BMI)), and presence of chronic diseases (diabetes mellitus, angina pectoris, myocardial infarction, stroke, hypertension, arthritis, chronic obstructive pulmonary disease, depression, mild cognitive impairment). Hierarchical multiple regression was used to examine potential mediators of the ethnic group–LTPA association. EAs expended almost 300 kcal/wk more energy than did MAs (1,287 kcal/wk vs 1,001 kcal/wk). SES and psychosocial (self‐esteem), lifestyle (fat avoidance, smoking, BMI), and disease (depression) factors that vary by SES explained this ethnic difference. In MAs, structural assimilation, but not acculturation, was significantly associated with LTPA independent of SES. Self‐esteem, BMI, and depression explained this association. Psychosocial resources, lifestyle behaviors, and depression explain differences in LTPA between older MAs and EAs. Interventions to increase LTPA in both ethnic groups should be targeted especially at women and persons who have low self‐esteem, smoke, and are obese or depressed. In MAs, additional emphasis should be focused on those who are less structurally assimilated into the broader American society.

title: Contribution of occupational physical activity toward meeting recommended physical activity guidelines: United States, 2007.
abstract: Regular physical activity helps maintain healthy weight and reduces the likelihood of developing chronic diseases. The 2008 Physical Activity Guidelines for Americans (1) are derived from the most recent scientific review of physical activity health benefits and do not differentiate among physical activity for leisure, transportation, work, or other purposes. To examine the potential influence of occupational physical activity on meeting minimum weekly aerobic physical activity guidelines, the Washington State Department of Health (WADOH) analyzed demographic patterns in physical activity levels with and without consideration of occupational physical activity using 2007 Behavioral Risk Factor Surveillance System (BRFSS) data. This report describes the results of that analysis, which indicated that, approximately two thirds (64.3%) of U.S. adults met minimum physical activity guidelines through nonoccupational physical activity. When occupational physical activity (defined as reported work activity of mostly walking or heavy labor) was considered, an additional 6.5% of adults likely met the guidelines. The increase was greatest for Hispanic men (14.4%) and men with less than a high school education (15.9%). Public health agencies conducting surveillance of population physical activity levels also should consider including occupational physical activity, which will help to identify demographic groups for targeted programs that increase physical activity.

title: Trends in the Prevalence of Low Risk Factor Burden for Cardiovascular Disease Among United States Adults
abstract: Cohorts consistently show that individuals with low levels of cardiovascular risk factors experience low rates of subsequent cardiovascular events. Our objective was to examine the prevalence and trends in low risk factor burden for cardiovascular disease among adults in the US population.  We used data from adults 25 to 74 years of age who participated in 4 national surveys. We created an index of low risk from the following variables: not currently smoking, total cholesterol <5.17 mmol/L (<200 mg/dL) and not using cholesterol-lowering medications, systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg and not using antihypertensive medications, body mass index <25 kg/m2, and not having been previously diagnosed with diabetes mellitus. The age-adjusted prevalence of low risk factor burden increased from 4.4% during 1971 to 1975 to 10.5% during 1988 to 1994 before decreasing to 7.5% during 1999 to 2004 (P for nonlinear trend <0.001). The patterns were similar for men and women, although the prevalence among women exceeded that among men in each survey (P<0.001 for each survey). In addition, whites had a significantly higher prevalence of low risk factor burden than blacks during each survey except during 1976 to 1980 (1971 to 1975, 1988 to 1994, 1999 to 2004: P<0.001; . Furthermore, a larger percentage of whites had a low risk factor burden than Mexican Americans during 1988 to 1994 (P<0.001) and 1999 to 2004 (P=0.001).  The prevalence of low risk factor burden for cardiovascular disease is low. The progress that had been made during the 1970s and 1980s reversed in recent decades.

title: Ideal Cardiovascular Health Predicts Lower Risks of Myocardial Infarction, Stroke, and Vascular Death Across Whites, Blacks, and Hispanics: The Northern Manhattan Study
abstract: Evidence of the relationship of cardiovascular health (CVH), defined by the American Heart Association, and specific cardiovascular outcomes is lacking, particularly among Hispanics. This study sought to evaluate the relationship between the number of ideal CVH metrics and cardiovascular risk, overall and by event subtype, in a multiethnic community-based prospective cohort.  A total of 2981 subjects (mean age, 69±10 years; 54% Caribbean Hispanic, 25% black, 21% white) free of myocardial infarction and stroke at baseline in the Northern Manhattan Study were prospectively followed up (median follow-up, 11 years). The relationship between the number of ideal CVH metrics and the risk of cardiovascular disease, including myocardial infarction, stroke, and vascular death, was investigated. Overall, a strong gradient relationship was observed between the adjusted hazard ratios for cardiovascular disease and the number of ideal CVH metrics: 0.73 (95% confidence interval, 0.60–0.89), 0.61 (95% confidence interval, 0.50–0.76), 0.49 (95% confidence interval, 0.38–0.63), and 0.41 (95% confidence interval, 0.26–0.63) for those having 2, 3, 4, and 5 to 6 ideal CVH metrics, respectively, compared with those having 0 to 1 ideal CVH metrics (P for trend <0.0001). Similar graded relationships were found between the number of ideal CVH metrics and the adjusted incidence rate for each specific outcome and among whites, blacks, and Caribbean Hispanics.  Our findings demonstrated a steep gradient relationship between ideal CVH and individual cardiovascular disease end points, including stroke, that was similar for whites, blacks, and Caribbean Hispanics. This evidence supports the application of the AHA ideal cardiovascular health metrics for cardiovascular disease risk assessment and health promotion for all Americans regardless of race-ethnic background.

title: Disparities in ideal cardiovascular health: a challenge or an opportunity?
abstract: In 2010, the American Heart Association (AHA) declared 2020 health strategy goals to reduce deaths from cardiovascular disease and stroke by 20% and to improve the cardiovascular health (CVH) of all Americans by 20%.1 The latter goal is aimed at helping everyone living in the United States to achieve, or at least move toward, ideal CVH by focusing on 7 key health behaviors and risk factors—smoking, body mass-index, diet (based on the healthy diet score), participation in physical activity, and levels of blood pressure (<120/80 mm Hg), blood glucose (<100 mg/dL), and total cholesterol (<200 mg/dL).2 What must not be forgotten is that this 2020 AHA strategy was instituted against the background of health disparities identified by the Institute of Medicine3 in 2003 that are still present in our society today. In this issue of Circulation , Dong et al4 describe a strong graded relationship between the number of ideal CVH metrics and cardiovascular disease (CVD) risk (stroke, myocardial infarction, and vascular death) among whites, blacks, and Hispanics living in the same community. Furthermore, the authors assessed stroke as a separate outcome event whereas previous studies5–8 on ideal CVH either did not include stroke or treated stroke only as a component of a composite outcome.

Article see p 2975

There are several other key observations reported by Dong et al.4 First, the study highlights the observation that ideal CVH is rare. A glaring finding of the study is the dismally low prevalence of ideal CVH in the urban setting, in which no participants had all 7 ideal CVH metrics (0%) and few participants had 5 to 6 metrics (4.4%). Thus, considerable work needs to be done to achieve ideal CVH for all Americans, and these findings point to a particular …

title: Acculturation and Socioeconomic Position as Predictors of Coronary Calcification in a Multiethnic Sample
abstract: Coronary calcium has recently emerged as a marker of subclinical coronary heart disease. Although there has been much interest in race differences in calcification, heterogeneity within race or ethnic groups has not been investigated. Data from the Multi-Ethnic Study of Atherosclerosis (MESA), a population-based study of coronary calcification, were used to investigate acculturation and socioeconomic position as predictors of coronary calcification within 2553 non-Hispanic whites, 1734 non-Hispanic blacks, 1457 Hispanics, and 797 Chinese residing in the United States. Coronary calcium was assessed by chest CT. Relative risk regression and linear regression were used to estimate adjusted associations of sociodemographic variables with the presence and amount of calcium. Not being born in the United States was associated with a lower prevalence of calcification in blacks (relative prevalence [RP], 0.75; 95% confidence limit [CL], 0.61 to 0.94) and Hispanics (RP, 0.89; 95% CL, 0.81 to 0.98) after adjustment for age, sex, income, and education. Years in the United States was positively associated with prevalence of calcification in non–US-born Chinese (adjusted RP per 10 years in United States, 1.06; 95% CL, 1.01 to 1.11) and non–US-born blacks (RP, 1.59; 95% CL, 1.22 to 2.06). Low education was associated with a higher prevalence of calcification in whites (adjusted RP for no high school versus complete college, 1.17; 95% CL, 1.05 to 1.32) but with lower prevalence of calcification in Hispanics (RP, 0.91; 95% CL, 0.77 to 1.09) (P for interaction=0.02). US birth and time in the United States were also positively associated with the extent of calcification in persons with detectable calcium. These differences did not appear to be accounted for by smoking, body mass index, LDL and HDL cholesterol, hypertension, and diabetes. Acculturation and socioeconomic factors are associated with differences in the prevalence and amount of coronary calcification within whites, Chinese, blacks, and Hispanics. The presence of this heterogeneity needs to be acknowledged in the quantification and investigation of race/ethnic differences.

title: Ethnic differences in the relationship of carotid atherosclerosis to coronary calcification: the Multi-Ethnic Study of Atherosclerosis.
abstract: Ethnic differences in non-invasive measures of atherosclerosis are increasingly being reported, but the relationship of these measures to each other has not been widely explored. Carotid ultrasonographic and computed cardiac tomographic findings were compared in 6814 participants of White, Black, Hispanic, and Chinese ethnicities free of overt cardiovascular disease. Coronary calcium and carotid atherosclerosis were strongly related to each other in all ethnic groups. Associations of coronary calcium prevalence and common carotid intimal-medial thickness (IMT) differed by ethnicity in women, being weakest among Black women (0.07 mm IMT difference between those with and without coronary calcium) compared to the other three groups (0.10-0.12 mm difference, p=0.007). Estimated percent increments in internal carotid IMT per 10% increment in coronary calcium score were highest in Hispanics (18.5%) and lowest in Blacks (6.1%, p<0.01). Coronary calcium may be less strongly associated with carotid atherosclerosis in Blacks, particularly Black women, than in other ethnic groups. These differences should be pursued for relationships to coronary events to determine whether coronary calcium carries the same risk information in other ethnic groups as it does in Whites.

title: Carotid artery intima-media thickness in college students: race/ethnicity matters.
abstract: Racial/ethnic differences in common carotid artery intima-media thickness (CIMT) and in risk factors associated with CIMT have been predominantly observed in middle-aged and older individuals. We aimed to characterize racial/ethnic differences CIMT and other cardiovascular risk factors in a healthy, young-adult population.



College students were recruited as part of a study to characterize determinants of atherogenesis. Students were eligible if they were lifetime non-smokers, lived in the United States since six months of age, and attended high school in the United States. Blood pressure, heart rate, height, and weight were measured, B-mode carotid ultrasound was performed, questionnaires were administered and a 12-h fasting blood sample was collected. Associations between CIMT and other variables were assessed in 768 students aged 18-25 years using linear regression analysis.



In models adjusted for common cardiovascular risk factors, sex exhibited the strongest influence on CIMT, with men having 15.4 μm larger CIMT compared to women (95%CI 6.6, 24.2). Race/ethnicity was also strongly associated with CIMT. African Americans had 17.3 μm greater CIMT (95%CI -0.3, 34.8) compared to non Hispanic Whites, whereas Asians and Hispanic Whites had 14.3 (95%CI -24.3, -4.4) and 15.4 (95%CI -26.2, -4.7) μm smaller CIMT, respectively. BMI and systolic blood pressure were positively associated with CIMT.



The risk factors associated with atherogenesis later in life are already present and observable in college-aged young adults, so targeted campaigns to reduce life-long cardiovascular disease burden should be initiated earlier in life to improve public health.

title: Left ventricular hypertrophy and cardiovascular mortality by race and ethnicity.
abstract: Left ventricular hypertrophy is a major independent risk factor for cardiovascular mortality. The contribution of left ventricular hypertrophy to racial and ethnic differences in cardiovascular mortality is poorly understood.



We used data from the Third National Health and Nutrition Examination Survey and from the National Death Index to compare mortality for those with an electrocardiographic (ECG) diagnosis of left ventricular hypertrophy to those without left ventricular hypertrophy separately for whites, African Americans, and Latinos. We used Cox proportional hazards regression to control for other known prognostic factors.



ECG left ventricular hypertrophy was significantly associated with 10-year cardiovascular mortality in all 3 racial/ethnic groups, both unadjusted and adjusted for other known prognostic factors. The hazard ratio for this association was significantly greater for African Americans (2.31; 95% confidence interval [CI], 1.55-3.42) than for whites and Latinos (1.32; 95% CI, 1.14-1.76 and 2.11; 95% CI, 1.35-3.30, respectively), independent of systolic blood pressure.



ECG left ventricular hypertrophy contributes more to the risk of cardiovascular mortality in African Americans than it does in whites. Using regression of ECG left ventricular hypertrophy as a goal of therapy might be a means to reduce racial differences in cardiovascular mortality; prospective validation is required.

title: Diagnostic and prognostic utility of electrocardiography for left ventricular hypertrophy defined by magnetic resonance imaging in relationship to ethnicity: the Multi-Ethnic Study of Atherosclerosis (MESA).
abstract: Left ventricular mass is a strong predictor of cardiovascular disease (CVD), and magnetic resonance imaging (MRI) of the heart is a standard of reference for left ventricular mass measurement. Ethnicity is believed to affect electrocardiographic (ECG) performance. We evaluated the diagnostic and prognostic performance of ECG for left ventricular hypertrophy (LVH) as defined by MRI in relationship to ethnicity.



Data were analyzed from 4,967 participants (48% men, mean age 62 +/- 10 years; 39% white, 13% Chinese, 26% African American, 22% Hispanic) enrolled in the Multi-Ethic Study of Atherosclerosis (MESA) who were followed for a median of 4.8 years for incident CVD.



Thirteen traditional ECG-LVH criteria were assessed, and showed overall and ethnicity-specific low sensitivity (10%-26%) and high specificity (88%-99%) in diagnosing MRI-defined LVH. Ten of 13 ECG-LVH criteria showed superior sensitivity and diagnostic performance in African Americans as compared with whites (P = .02-.001). The sum of amplitudes of S wave in V(1), S wave in V(2), and R wave in V(5) (a MESA-specific ECG-LVH criterion) offered higher sensitivity (40.4%) compared with prior ECG-LVH criteria while maintaining good specificity (90%) and diagnostic performance (receiver operating characteristic area = 0.65). In fully adjusted models, only the MESA-specific ECG-LVH criterion, Romhilt-Estes score, Framingham score, Cornell voltage, Cornell duration product, and Framingham-adjusted Cornell voltage predicted increased CVD risk (P < .05).



Electrocardiography has low sensitivity but high specificity for detecting MRI-defined LVH. The performance of ECG for LVH detection varies by ethnicity, with African Americans showing higher sensitivity and overall performance compared with other ethnic groups.

title: Do differences in subclinical cardiovascular disease in mexican americans versus European americans help explain the Hispanic paradox?
abstract: Mexican Americans have exhibited increases in various coronary heart disease risk factors compared to European Americans but have also had reportedly lower coronary heart disease mortality from vital statistics studies. We hypothesized this apparent paradox might relate to lower levels of subclinical disease in Mexican Americans. A total of 105 adult Mexican Americans (42 men and 63 women, age 46 +/- 14 years) and 100 European Americans (59 men and 41 women, age 50 +/- 11 years) were studied using blood tests, transthoracic echocardiography, and computed tomography coronary artery calcium (CAC) scans. Despite a greater body mass index and triglycerides in Mexican Americans (p <0.001), the Mexican Americans demonstrated less subclinical disease than did the European Americans (14.4% vs 25.7% with CAC scores >0, p <0.05 and mean left ventricular mass [LV] of 146 vs 160 g, p <0.05). Also, the LV mass was significantly greater in Mexican Americans with than in those without CAC (mean 172 vs 140 g, p <0.05). On logistic regression analysis, age and diastolic blood pressure were associated with an increased likelihood of CAC (p <0.001 and p <0.01, respectively), and Mexican-American ethnicity was associated with a decreased likelihood of CAC (odds ratio 0.33, 95% confidence interval 0.12 to 0.87, p <0.05). On multiple regression analysis, male gender, body surface area, and systolic blood pressure were independently associated with an increased LV mass (all p <0.001). The body mass index was less strongly related to the LV mass than was the body surface area and was not related to CAC. In conclusion, Mexican-American ethnicity is associated with both a lower LV mass and a lower prevalence of CAC, although the differences in LV mass did not remain after adjustment for other factors. Although systolic blood pressure, body surface area, and male gender were most strongly associated with the LV mass, age and diastolic blood pressure, in addition to Mexican-American ethnicity, were the most important indicators of CAC.

title: Essential hypertension predicted by tracking of elevated blood pressure from childhood to adulthood: the Bogalusa Heart Study.
abstract: It is well known that blood pressure (BP) levels persist over time. The present investigation examines tracking of elevated BP from childhood to adulthood and its progression to essential hypertension. In a community study of early natural history of arteriosclerosis and essential hypertension, a longitudinal cohort was constructed from two cross-sectional surveys > 15 years apart: 1505 individuals (56% female subjects, 35% black), aged 5 to 14 years at initial study. Persistence of BP was shown by significant correlations between childhood and adulthood levels (r = 0.36 to 0.50 for systolic BP and r = 0.20 to 0.42 for diastolic BP), varying by race, sex, and age. These correlations remained the same after controlling for body mass index (BMI). Twice the expected number of subjects (40% for systolic BP and 37% for diastolic BP), whose levels were in the highest quintile at childhood, remained there 15 years later. Furthermore, of the childhood characteristics, baseline BP level was most predictive of the follow-up level, followed by change in BMI. Subsequently, even at ages 20 to 31 years, prevalence of clinically diagnosed hypertension was much higher in subjects whose childhood BP was in the top quintile: 3.6 times (18% v 5%) as high in systolic BP and 2.6 times (15% v 5.8%) as high in diastolic BP, compared to subjects in every other quintile. Of the 116 subjects who developed hypertension, 48% and 41% had elevated childhood systolic and diastolic BP, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

title: The contribution of childhood obesity to adult carotid intima-media thickness: the Bogalusa Heart Study
abstract: Although obese children are at increased risk for coronary heart disease in later life, it is not clear if the association results from the persistence of childhood obesity into adulthood. We examined the relation of both childhood and adult levels of body mass index (BMI, kg m−2) to carotid intima-media thickness (IMT) measured at the (mean) age of 36 years.Prior to the determination of adult IMT, the 1142 participants had been examined 7 (mean) times in the Bogalusa Heart Study.In addition to BMI, levels of lipids, lipoproteins and blood pressure were measured at each examination. Cumulative levels of each risk factor were based on the areas under the individual growth curves calculated using multilevel models for repeated (BMI) measurements. We then examined the relation of these cumulative levels to adult IMT.Results:Carotid IMT was associated with cumulative levels of BMI in both childhood and adulthood (P<0.001 for each association). Furthermore, the association between childhood BMI and adult IMT persisted, but was reduced, after controlling for adult BMI. Although childhood levels of lipids, lipoproteins and blood pressure were also associated with adult IMT, these associations were not independent of adult levels of these risk factors.These results emphasize the adverse effects of elevated childhood BMI levels. In addition to the strong tracking of BMI levels from childhood to adulthood, there appears to be a modest, independent effect of childhood BMI on adult IMT. The prevention of childhood obesity should be emphasized.

title: Pediatric Metabolic Syndrome Predicts Adulthood Metabolic Syndrome, Subclinical Atherosclerosis, and Type 2 Diabetes Mellitus but Is No Better Than Body Mass Index Alone: The Bogalusa Heart Study and the Cardiovascular Risk in Young Finns Study
abstract: The clinical utility of identifying pediatric metabolic syndrome (MetS) is controversial. This study sought to determine the status of pediatric MetS as a risk factor for adult subclinical atherosclerosis (carotid intima-media thickness [cIMT]) and type 2 diabetes mellitus (T2DM) and compare and contrast this prediction with its individual components.  Using data from the population-based, prospective, observational Bogalusa Heart and Cardiovascular Risk in Young Finns studies, we examined the utility of 4 categorical definitions of youth MetS and their components in predicting adult high cIMT and T2DM among 1781 participants aged 9 to 18 years at baseline (1984 to 1988) who were then examined 14 to 27 years later (2001–2007) when aged 24 to 41 years. Youth with MetS were at 2 to 3 times the risk of having high cIMT and T2DM as adults compared with those free of MetS at youth. Risk estimates with the use of high body mass index were similar to those of MetS phenotypes in predicting adult outcomes. Comparisons of area under the receiver operating characteristic curve and net reclassification index suggested that prediction of adult MetS, high cIMT, and T2DM in adulthood with the use of youth MetS was either equivalent or inferior to classification based on high body mass index or overweight and obesity.  Youth with MetS are at increased risk of meaningful adult outcomes; however, the simplicity of screening for high BMI or overweight and obesity in the pediatric setting offers a simpler, equally accurate alternative to identifying youth at risk of developing adult MetS, high cIMT, or T2DM.

title: Cardiometabolic Risk Factors Among US Adolescents and Young Adults and Risk of Early Mortality
abstract: To determine the risk of mortality associated with cardiometabolic risk factors in a national sample of adolescents and young adults.  Prospective study of participants in the third NHANES (1988–1994), aged 12 to 39 years at the time of the survey (n = 9245). Risk factors included 3 measures of adiposity, glycated hemoglobin (HbA1c) level, cholesterol levels, blood pressure, self-reported smoking status, and cotinine level. Death before age 55 (n = 298) was determined by linkage to the National Death Index through 2006. Proportional hazards models, with age as the time scale, were used to determine the risk of death before age 55 years after adjusting for gender, race/ethnicity, and presence of comorbid conditions.  After adjusting for age, gender, and race/ethnicity, results of categorical analyses showed that current smokers were at 86% greater risk for early death than those classified as never smokers; that those with a waist-to-height ratio >0.65 were at 139% greater risk than those with a WHR <0.5; and that those with an HbA1c level >6.5% were at 281% greater risk than those with an HbA1c level <5.7%. Neither high-density lipoprotein nor non–high-density lipoprotein cholesterol measures were associated with risk for early death.  Our finding that risk for death before age 55 among US adolescents and young adults was associated with central obesity, smoking, and hyperglycemia supports reducing the prevalence of these risk factors among younger US residents.

title: Longitudinal trajectories of BMI and cardiovascular disease risk: The National Longitudinal Study of Adolescent Health
abstract: In adulthood, excess BMI is associated with cardiovascular disease (CVD); it is unknown whether risk differs by BMI trajectories from adolescence to adulthood.

title: Ethnic Disparities in Cardiovascular Risk Factors in Children and Adolescents
abstract: The pathogenesis of coronary atherosclerosis originates as early as childhood, and disparities in rates of cardiovascular disease (CVD) risk factors among children have been previously documented. This review of recently published studies on race/ethnicity-specific burden of risk factors among US children/adolescents highlights the persistent racial/ethnic variations in prevalence of CVD risk factors, with sizeable burdens of CVD risk among all race/ethnic groups. Non-Hispanic Black children had the highest rates of high blood pressure and obesity, while Mexican American children had higher diabetes rates and lowest rates of ideal fasting glucose levels. Non-Hispanic White children had lower rates of high blood pressure and higher rates of physical activity, but they experienced higher burdens of adverse lipid levels and cigarette smoking than others. Comprehensive public health policies addressing CVD risk in childhood are needed to lower the future burden of CVD.

title: Monitoring the Future Survey Methodology and Definitions of Terms Note: the following Information Was Excerpt- Ed From
abstract: Note: The following information was excerpted from Jerald G. Bachman, Lloyd D. Johnston, and Patrick M. O'Malley, Monitoring the Future 2000 ), pp. 2-11, 13, 14; Lloyd D. Johnston et al., Monitoring the Future National Survey Results on Drug Use, 1975-2003, Volumes I and II (Bethesda, MD: U.S. Department of Health and Human Services, 2004); and information provided by the Monitoring the Future Project. Non-substantive editorial adaptations have been made.

title: Overweight in Latino/Hispanic adolescents: scope of the problem and nursing implications.
abstract: Latino/Hispanic adolescents have the highest prevalence of overweight in this country. Causes of ethnic variation may include differences in the level of acculturation, ethnic beliefs, differences in ideal body images, lack of appreciation of weight management, questionable literacy levels, and/or socioeconomic status. Improved knowledge of behavioral, social-cultural, and environmental determinants of overweight individuals among adolescent Latino/Hispanics will increase the effectiveness and direction of these interventions to prevent and treat this epidemic. Research is needed to determine which interventions may specifically be most effective for preventing this overweight status. This article summarizes variables that have an impact on Latino/Hispanic youth and identifies potential strategies for pediatric nurses to use in addressing this health matter most efficaciously.

title: Latina mothers' beliefs and practices related to weight status, feeding, and the development of child overweight.
abstract: To examine maternal beliefs and practices related to weight status, child feeding, and child overweight in the Latino culture that may contribute to the rising rates of overweight among preschool Latino children in the United States.



This 2-phase qualitative study relies on data obtained in 6 focus groups with a total of 31 primarily Spanish-speaking, low-income mothers, followed by 20 individual, in-depth interviews with women participating in a health promotion educational program.



Child-feeding beliefs, practices, and weight status perceptions were elicited.



The findings indicated that most respondents reported personal struggles with weight gain, particularly during and after pregnancy, and were concerned that their children would become obese. Although subjects understood the health and social consequences related to overweight, many discussed the pressures of familial and cultural influences endorsing a "chubby child."



Education and interventions that incorporate "culturally mediated" pathways to address mothers' feeding practices are essential for the prevention and control of childhood overweight among low-income Latinos. Nurses should be aware of the social and cultural influences on Latina mothers' beliefs and practices related to weight status and feeding practices and address these in their education approaches to prevent childhood overweight and obesity with this population group.

title: Maternal feeding practices and childhood obesity: a focus group study of low-income mothers.
abstract: To identify maternal beliefs and practices about child feeding that are associated with the development of childhood obesity.



Four focus groups. One group of dietitians from the Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the Northern Kentucky Health District and 3 groups of mothers with children enrolled in WIC.



The WIC program in the Northern Kentucky Health District.



Fifteen WIC dietitians and 14 mothers (14 to 34 years of age) with young children (12 to 36 months of age) enrolled in WIC.



The mothers in this study (1) believed that it was better to have a heavy infant because infant weight was the best marker of child health and successful parenting, (2) feared that their infants were not getting enough to eat, which led them to introduce rice cereal and other solid food to the diets before the recommended ages, and (3) used food to shape their children's behaviors (eg, to reward good behavior or to calm fussiness). The mothers acknowledged that some of their child-feeding practices went against the advice of their WIC nutritionists and physicians. Instead, the participants relied on their mothers as their main source of information about child feeding.



Physicians and allied health professionals discussing childhood growth with mothers should avoid implying that infant weight is necessarily a measure of child health or parental competence. Parents who use food to satisfy their children's emotional needs or to promote good behavior in their children may promote obesity by interfering with their children's ability to regulate their own food intake. Interventions to alter child-feeding practices should include education of grandmothers.

title: Delay in presentation and evaluation for acute stroke : Stroke time registry for outcomes knowledge and epidemiology (S. T. R. O. K. E.)
abstract: Early treatment is a critical determinant of successful intervention in acute stroke. The study was designed to find current patterns of stroke care by determining delays in time from onset of signs or symptoms to arrival at the emergency department and to initial evaluation by physicians and by identifying factors associated with these delays. Data were prospectively collected by nurses and physicians from patients, patients’ family members, and medical records from 10 hospitals of the Robert Wood Johnson Health System in New Jersey. A total of 553 patients who presented with signs or symptoms of acute stroke were studied. Thirty-two percent of patients arrived at the emergency department within 1.5 hours of stroke onset. Forty-six percent of patients arrived within 3 hours and 61% within 6 hours. Delays in arrival time were significantly associated with sex, race, transportation mode, and history of cardiovascular disease. Patients arriving by ambulance were more l...

title: Ethnic Group Differences in Cardiometabolic Disease Risk Factors Independent of Body Mass Index among American Youth
abstract: The purpose of this analysis was to identify any ethnic group differences in the prevalence of cardiometabolic disease risk factors independent of BMI in United States youth.

title: Persistence of the metabolic syndrome and its influence on carotid artery intima media thickness in overweight Latino children.
abstract: The objective of this study was to examine the influence of persistence of the metabolic syndrome (Mets) and its individual components over a 3-year period on carotid intima media thickness (CIMT) in overweight Latino children.



Ninety-seven healthy male and female overweight Latino children (mean age at baseline: 11.0+/-1.8 years) were assessed for MetS on four annual evaluations and classified according to the persistence of MetS: NEVER (0 annual visits with the MetS, n=53), INTERMITTENT (1 or 2 visits with the MetS, n=28), and PERSISTENT (3 or 4 visits with the MetS, n=16). CIMT was measured with high-resolution B-mode ultrasound (7.9+/-0.7 months after the most recent MetS assessment; mean age: 14.6+/-1.8 years).



PERSISTENT MetS was associated with significantly higher CIMT (0.647+/-0.018mm compared to 0.600+/-0.007mm in those who NEVER had MetS, p<0.01). This difference remained significant after controlling for gender, baseline age, total fat mass, total lean tissue mass and insulin sensitivity. PERSISTENT high waist circumference and PERSISTENT high blood pressure were also significantly associated with higher mean CIMT, but these differences were no longer significant after controlling for total fat and lean tissue mass. Baseline systolic blood pressure and 2-h glucose were significantly related to CIMT independent of all other MetS components (p<0.05).



Persistence of the MetS over a 3-year period was uniquely associated with increased CIMT during childhood. Children with hypertension, persistent abdominal adiposity or impaired glucose tolerance may also be at higher risk for elevated CIMT.

title: Association of Race/Ethnicity, Socioeconomic Status, Acculturation, and Environmental Factors with Risk of Overweight Among Adolescents in California, 2003
abstract: Little has been published about racial/ethnic differences in the prevalence of overweight among adolescents that accounts in detail for socioeconomic status, acculturation, and behavioral and environmental factors. Increased understanding of factors associated with overweight can provide a rational basis for developing interventions to address the obesity epidemic in the United States.  Using a cross-sectional analysis of data from adolescents who participated in the California Health Interview Survey 2003, we estimated the prevalence of overweight and at risk of overweight, combined as a single measure (AROW, body mass index ≥85th percentile). We used logistic regression models to examine associations between AROW and risk factors.  Twenty-nine percent of California adolescents were AROW. The prevalence of AROW differed significantly by sex and race. Boys were more likely than girls to be AROW (33% vs 25%). American Indians/Pacific Islanders/others (39%) were at highest risk, followed by Hispanics (37%), blacks (35%), whites (23%), and Asians (15%). For boys, older age, Hispanic or American Indian/Pacific Islander/other race/ethnicity, lower education of parents, and longer residence in the United States were significantly associated with AROW. For girls, Hispanic or black race/ethnicity, lower education of parents, and poor dietary habits were significantly associated with AROW.  The high prevalence of AROW among California adolescents in most racial/ethnic groups indicates the need for culturally specific and appropriate interventions to prevent and treat overweight.

title: Acculturation and overweight-related behaviors among Hispanic immigrants to the US: the National Longitudinal Study of Adolescent Health.
abstract: Little is known about the factors underlying the striking increase in overweight occurring between first and second generation US immigrants. Using data from the National Longitudinal Study of Adolescent Health, this study addressed two goals. First, we determined which measures of acculturation (defined as the acquisition of dominant cultural norms by members of a non-dominant group) were important. Second, we determined how the acculturation process affected differences in overweight and its proximate determinants (e.g., physical activity, diet, and smoking) as immigrants acculturated to American society. In addition, we sought to elucidate the role of underlying structural factors (e.g., family income and crime) and acculturation factors (e.g., language spoken at home and proportion of foreign-born neighbors) in generation differences in overweight. Results showed clear structural and acculturation differences between foreign and US-born immigrants to the US. Foreign-born immigrants were more likely to have lower family income and maternal education, and to live in areas of higher immigrant density and greater linguistic isolation. In addition, results suggested rapid acculturation of overweight-related behaviors, such as diet, smoking, and inactivity, in US-born relative to foreign-born immigrants. Multivariate analysis indicated that longer US residence was associated with increased overweight among Puerto Ricans and Cubans. Predicted probabilities showed that controlling for acculturation and proximate factors increased overweight among foreign-born adolescents, but had minimal impact for US-born adolescents. Thus, without the beneficial pattern of: acculturation factors, diet, and physical activity, first generation Hispanic adolescents would have higher overweight prevalence. We found important generation differences in structural, acculturation, and proximate overweight determinants. These lifestyle differences between foreign- and US-born Hispanic adolescent immigrants are likely to underlie the striking increase in overweight prevalence between first and subsequent generation of US residence.

title: Adolescent obesity increases significantly in second and third generation U.S. immigrants: the National Longitudinal Study of Adolescent Health.
abstract: Little is known concerning obesity patterns of ethnic subpopulations in the U.S. and the effects of acculturation on these patterns. Adolescent obesity, a major public health problem, has important health, social and economic consequences for the adolescent. The National Longitudinal Study of Adolescent Health survey is unique in the size of the adolescent sample and in its ability to provide large representative samples of Anglo, African-American, Hispanic and Asian-American adolescents. A nationally representative sample of 13,783 adolescents was studied. Measurements of weight and height collected in the second wave of the survey were used to study adolescent obesity. Multivariate logit techniques were used to provide an understanding of the ethnic, age, gender and intergenerational patterns of adolescent obesity. Comparisons are presented between the NHANES III results and those from the Adolescent Health Survey. The smoothed version of the NHANES I 85th percentile cut-off was used for the measure of obesity in this paper. For the total sample, 26.5% were obese. The rates were as follows: white non-Hispanics, 24.2%; black non-Hispanics, 30.9%; all Hispanics, 30.4%; and all Asian-Americans, 20.6%. Important variations within the Hispanic and Asian-American subpopulations are presented. The Chinese (15.3%) and Filipino (18.5%) samples showed substantially lower obesity than non-Hispanic whites. All groups showed more obesity among males than among females, except for blacks (27.4% for males and 34.0% for females). Asian-American and Hispanic adolescents born in the U.S. are more than twice as likely to be obese as are first generation residents of the 50 states.

title: Generation and acculturation status are associated with dietary intake and body weight in Mexican American adolescents.
abstract: Mexican American children are disproportionately affected by obesity. Data on how the acculturation process influences diet and body weight among adolescents are limited. We used the data from the 1999-2004 NHANES, restricting to 2286 Mexican American children between 12 and 19 y old. Acculturation was measured by generation status and language preference. Diet was assessed using 24-h diet recall. Multiple linear, Tobit, logistic, and quantile regression models were used. We found, after adjusting for socio-demographic factors, health, dietary intake, physical activity, and sedentary behaviors compared to the first generation, second and third generations had greater odds of overweight and obesity. Adolescents in the second generation had higher BMI Z-scores than adolescents in the first and third generations. Both second and third generation adolescents consumed less fruit, whole fruit, vegetables, grains, and meats but more sweetened beverages, whole grains, saturated fat, sodium, oil, and energy from discretionary foods. Higher language acculturation was associated with poorer diet and greater body weight. Our findings suggest that Mexican American adolescents face challenges in terms of poorer diet and excessive weight gain associated with their immigration experience.

title: The rising cost of low-energy-density foods.
abstract: Consuming lower-energy-density foods is one recommended strategy for management of body weight. This cross-sectional study used retail food prices to test the hypothesis that low-energy-density foods are not only more costly per kilocalorie, but have increased disproportionately in price as compared to high-energy-density foods.



For a list of 372 foods and beverages belonging to a food frequency questionnaire database, retail prices were obtained from major supermarket chains in the Seattle, WA, metropolitan area in 2004 and 2006. Energy density of all items was calculated and prices were expressed as $/100 g edible portion and as $/1,000 kcal. Foods were stratified by quintiles of energy density and the differences in energy cost and in percent price change were tested using analyses of variance.



High-energy-density foods provided the most dietary energy at least cost. Energy cost of foods in the bottom quintile of energy density, beverages excluded, was $18.16/1,000 kcal as compared to only $1.76/1,000 kcal for foods in the top quintile. The 2-year price change for the least energy-dense foods was +19.5%, whereas the price change for the most energy-dense foods was -1.8%.



The finding that energy-dense foods are not only the least expensive, but also most resistant to inflation, may help explain why the highest rates of obesity continue to be observed among groups of limited economic means. The sharp price increase for the low-energy-density foods suggests that economic factors may pose a barrier to the adoption of more healthful diets and so limit the impact of dietary guidance.

title: Theoretical foundations of the Study of Latino (SOL) Youth: implications for obesity and cardiometabolic risk.
abstract: This article describes the conceptual model developed for the Hispanic Community Health Study/Study of Latino Youth, a multisite epidemiologic study of obesity and cardiometabolic risk among U.S. Hispanic/Latino children.



Public health, psychology, and sociology research were examined for relevant theories and paradigms. This research, in turn, led us to consider several study design features to best represent both risk and protective factors from multiple levels of influence, as well as the identification of culturally relevant scales to capture identified constructs.



The Socio-Ecological Framework, Social Cognitive Theory, family systems theory, and acculturation research informed the specification of our conceptual model. Data are being collected from both children and parents in the household to examine the bidirectional influence of children and their parents, including the potential contribution of intergenerational differences in acculturation as a risk factor. Children and parents are reporting on individual, interpersonal, and perceived organizational and community influences on children's risk for obesity consistent with Socio-Ecological Framework.



Much research has been conducted on obesity, yet conceptual models examining risk and protective factors lack specificity in several areas. Study of Latino Youth is designed to fill a gap in this research and inform future efforts.

title: Social Inequalities in Biomarkers of Cardiovascular Risk in Adolescence
abstract: Cardiovascular disease, which begins early in life but often is not manifest until adulthood, is the nation’s leading cause of mortality. Social inequalities in cardiovascular disease are pervasive, yet the process by which they accrue is poorly understood. The objective of this study was to explore the associations between socioeconomic status, a range of biomarkers reflective of cardiovascular risks, and a cumulative physiological risk score among adolescents.  Non-Hispanic black and white high school students (N = 758) in a suburban Midwestern public school district had a physical examination to measure height, weight, and waist circumference and a fasting morning blood sample drawn to assess cortisol, insulin, glucose, glycosylated hemoglobin, fibrinogen, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, and triglycerides. A cumulative risk score was created from these physiological measures and waist circumference. Information on parent education and household income was obtained from a parent in a separate survey. Generalized estimating equation models were used to assess the association of parent education to the risks and the cumulative risk score adjusting for age, gender, and race.  Lower parent education was associated with higher insulin, higher glucose, greater insulin resistance, higher LDL cholesterol, lower HDL cholesterol, higher waist circumference, and higher body mass index (p <.05 for all), but not cortisol, fibrinogen, glycosylated hemoglobin, or triglycerides in adjusted analyses. Cumulative risk scores ranged from 0 to 7 and were highly skewed; the median risk score was 1. A total of 7.4% had risk scores of 4 or more. Lower parent education was also associated with higher cumulative risk score (p <.001) and this association was maintained after adjustment for body mass index. Risk scores were highest, on average, among those with insulin levels greater than 1 standard deviation above the mean (mean risk score = 3.2, standard error = 0.18, median = 3).  Lower parent education is associated with multiple metabolic risks and cumulative risk in adolescents, suggesting that there is a strong intergenerational transfer of education’s influence on cardiovascular health. Our data imply that regulation of insulin may be a key factor underlying the influence of lower parent education on cardiovascular health early in the life course. BMI = body mass index; C = cholesterol; LDL = low-density lipoprotein; HDL = high-density lipoprotein; trig = triglycerides; fibrin = fibrinogen; HgbA1c = glycosylated hemoglobin; HOMA = homeostasis model assessment; SES = socioeconomic status; IQ = interquartile; CVD = cardiovascular disease; CV = coefficient of variation; educ = education.

title: Comparison of three lifecourse models of poverty in predicting cardiovascular disease risk in youth.
abstract: Childhood poverty heightens the risk of adulthood cardiovascular disease (CVD), but the underlying pathways are poorly understood. Three lifecourse models have been proposed but have never been tested among youth. We assessed the longitudinal association of childhood poverty with CVD risk factors in 10-year-old youth according to the timing, accumulation, and mobility models.



The Québec Longitudinal Study of Child Development birth cohort was established in 1998 (n = 2120). Poverty was defined as annual income below the low-income thresholds defined by Statistics Canada. Multiple imputation was used for missing data. Multivariable linear regression models adjusted for gender, pubertal stage, parental education, maternal age, whether the household was a single parent household, whether the child was overweight or obese, the child's physical activity in the past week, and family history.



Approximately 40% experienced poverty at least once, 16% throughout childhood, and 25% intermittently. Poverty was associated with significantly elevated triglycerides and insulin according to the timing and accumulation models, although the timing model was superior for predicting insulin and the accumulation model was superior for predicting triglycerides.



Early and prolonged exposure to poverty significantly increases CVD risk among 10-year-old youth.

title: Patient-physician Language Concordance and Primary Care Screening Among Spanish-speaking Patients
abstract: BackgroundLanguage discordance between patient and physician is associated with worse patient self-reported healthcare quality. As Hispanic patients have low rates of cardiovascular and cancer screening, we sought to determine whether patient-physician language concordance was associated with differences in rates of screening. MethodsWe performed a retrospective medical record review of 101 Spanish-speaking patients cared for by 6 Spanish-speaking PCPs (language-concordant group) and 205 Spanish-speaking patients cared for by 44 non-Spanish-speaking PCPs (language-discordant group). Patients were included in the study if they were of age 35 to 75 years and had used interpreter services 2001 to 2006 in 2 Boston-based primary care clinics. Our outcomes included screening for hyperlipidemia, diabetes, cervical cancer, breast cancer, and colorectal cancer with age-appropriate and sex-appropriate subgroups. Our main predictor of interest was patient-physician language concordance. In multivariable modeling, we adjusted for age, sex, insurance status, number of primary care visits, and comorbidities. We adjusted for clustering of patients within individual physicians and clinic sites using generalized estimating equations. ResultsPatients in the language-discordant group tended to be female compared with patients in the language-concordant group. There were no significant differences in age, insurance status, number of primary care visits, or Charlson comorbidity index between the 2 groups. Rates of screening for hyperlipidemia, diabetes, cervical cancer, and breast cancer were similar for both language-concordant and language-discordant groups. However, patients in the language-concordant group were less likely to be screened for colorectal cancer compared with the language-discordant group risk ratio 0.78 (95% confidence interval, 0.61-0.99) after multivariable adjustment. ConclusionsThis study finds that Spanish-speaking patients cared for by language-concordant PCPs were not more likely to receive recommended screening for cardiovascular risk factors and cancer. Furthermore, language concordance was associated with lower likelihood colorectal cancer screening. Further research is needed to examine which conditions are optimal to improve cardiovascular and cancer screening for Spanish-speaking patients, particularly for colorectal cancer, which has a low rate of screening.

title: Myocardial infarction in Mexican-Americans and non-Hispanic whites. The San Antonio Heart Study.
abstract: Mexican-American men experience reduced cardiovascular mortality compared with non-Hispanic white men. There is no corresponding ethnic difference in cardiovascular mortality in women. The difference in men could result either from a lower incidence of cardiovascular disease or a lower case fatality rate among Mexican-Americans. Although the incidence of cardiovascular disease in Mexican-Americans is unknown, we have collected data on prevalence of myocardial infarction in 5,148 individuals examined in the San Antonio Heart Study, a population-based survey of cardiovascular disease conducted between 1979 and 1988 in Mexican-Americans and non-Hispanic whites aged 25-64 years. Myocardial infarction was assessed by Minnesota-coded electrocardiograms and by a self-reported history of a physician-diagnosed heart attack. For both end points, the age-adjusted prevalence of myocardial infarction was lower in Mexican-American men than in non-Hispanic white men. After adjustment for age and diabetes status (present/absent), the odds of a myocardial infarction, as defined by either criterion, was approximately one third lower in Mexican-American men than in non-Hispanic white men (p = 0.06). In women, the prevalence of both myocardial infarction end points was slightly higher in Mexican-Americans than in non-Hispanic whites, although neither of these differences was significant. Although the ethnic differences in prevalence in this study were not statistically significant, their pattern parallels the pattern in the mortality due to cardiovascular diseases. Therefore, the results support the hypothesis that the reduced cardiovascular mortality rate observed in Mexican-American men reflects a lower incidence of myocardial infarction rather than a reduced case fatality rate because the latter would result in a higher prevalence.

title: Effect of metabolic syndrome on heart attack and mortality in Mexican-American elderly persons: findings of 7-year follow-up from the Hispanic established population for the epidemiological study of the elderly.
abstract: We aim to examine the effect of Metabolic syndrome (MetS) on heart attack and overall mortality in Mexican-American elderly persons over 7-year follow-up.



We studied 3050 Mexican Americans aged 65 or older from the Hispanic Established Population for the Epidemiological Study of the Elderly conducted in five Southwestern states of the United States. Participants were categorized into two groups: those with or without MetS. A total of 333 (11%) respondents at baseline had met the criteria of MetS (at least three of five characteristics--hyperinsulinemia or fasting plasma glucose > or =110 mg/dl, abdominal obesity, and hypertension--as defined by the World Health Organization).



Of 333 participants with MetS, the mean age was 71.1 years and 68% were females (compared with 73.2 years and 56% in those without MetS). Eighty percent of participants with MetS rated their health as fair or poor, compared to 55% of those participants without MetS. Fifty-four percent and 65% of patients with MetS had arthritis and at least one impairment in instrumental activities of daily living (IADL), compared to 39% and 55% of those participants without MetS. MetS was significantly associated with increased incidence of heart attack (odds ratio: 2.75, 95% confidence interval: 1.67-4.54) and was a significant predictor for overall mortality (hazard ratio: 1.46, 95% confidence interval: 1.16-1.84) over a 7-year period after adjusting for other demographic and clinical variables.



Among Mexican-American elderly participants, those with MetS had poorer self-rated health. MetS was significantly associated with increased incidence of heart attack and higher mortality over a 7-year period.

title: The effect of ethnicity on the relationship between premature coronary artery disease and traditional cardiac risk factors among uninsured young adults.
abstract: Prior studies of premature coronary artery disease (CAD) in young adults did not address the association of race/ethnicity and risk factors. Therefore, the authors conducted a study of 400 patients 40 years and older undergoing coronary angiography at a large, urban public hospital that serves predominantly minority, uninsured populations. The prevalence of risk factors and their association with premature CAD varied markedly by ethnic group. Among blacks, dyslipidemia, diabetes, and smoking were independently associated with premature CAD. Among Hispanics, dyslipidemia, male sex, and family history of CAD were independently associated with premature CAD. Smoking was the only risk factor in whites, and no independent risk factor was identified in Asian Indians. Whites and Asian Indians had a higher prevalence of disease than blacks or Hispanics--before and after adjusting for risk factor imbalances across ethnic groups. In this ethnically diverse population, the authors' findings underscore the importance of identifying distinctive risk factors in various ethnic groups.

title: Access to Care, Acculturation, and Risk Factors for Stroke in Mexican Americans: The Brain Attack Surveillance in Corpus Christi (BASIC) Project
abstract: Mexican Americans are the largest subgroup of Hispanic Americans, now the most numerous US minority population. We compared access to care, acculturation, and biological risk factors among Mexican American and non-Hispanic white stroke patients and the general population.  The Brain Attack Surveillance in Corpus Christi project is a population-based stroke surveillance study conducted in southeast Texas. All stroke cases were ascertained through active and passive surveillance from January 2000 through April 2002 and compared with population estimates from a random-digit telephone survey.  Compared with non-Hispanic white stroke patients (n=405), Mexican American stroke patients (n=403) were less likely to have graduated from high school (odds ratio [OR], 15.4; 95% confidence interval [CI], 10.6 to 22.4) and more likely to earn less than $20 000 per year (OR, 6.5; 95% CI, 4.5 to 9.4). Mexican American stroke patients were more likely to have diabetes (OR, 2.7; 95% CI, 2.0 to 3.7) and less likely to have atrial fibrillation (OR, 0.5; 95% CI, 0.4 to 0.8). Compared with population estimates (n=719), stroke was associated with diabetes (Mexican Americans: OR, 3.6; 95% CI, 2.2 to 5.8; non-Hispanic whites: OR, 3.0; 95% CI, 1.7 to 5.5), hypertension (Mexican Americans: OR, 2.8; 95% CI, 1.8 to 4.3; non-Hispanic whites: OR, 3.3; 95% CI, 2.2 to 5.0), lower incomes (Mexican Americans: OR, 3.4; 95% CI, 2.1 to 5.4; non-Hispanic whites: OR, 3.0; 95% CI, 1.7 to 5.2), and lower educational attainment (Mexican Americans: OR, 5.1; 95% CI, 3.2 to 8.1; non-Hispanic whites: OR, 4.5; 95% CI, 2.2 to 9.3).  Biological and social variables are associated with stroke to a similar extent in both Mexican Americans and non-Hispanic whites. Health behavior interventions for both populations may follow from this work. Stroke disparities between these populations may be explained only partially by differences in the prevalence of currently identified biological and social factors.

title: Ischemic Stroke Subtype Incidence Among Whites, Blacks, and Hispanics: The Northern Manhattan Study
abstract: Stroke incidence is greater in blacks than in whites; data on Hispanics are limited. Comparing subtype-specific ischemic stroke incidence rates may help to explain race-ethnic differences in stroke risk. The aim of this population-based study was to determine ischemic stroke subtype incidence rates for whites, blacks, and Hispanics living in one community. A comprehensive stroke surveillance system incorporating multiple overlapping strategies was used to identify all cases of first ischemic stroke occurring between July 1, 1993, and June 30, 1997, in northern Manhattan. Ischemic stroke subtypes were determined according to a modified NINDS scheme, and age-adjusted, race-specific incidence rates calculated. The annual age-adjusted incidence of first ischemic stroke per 100 000 was 88 (95% CI, 75 to 101) in whites, 149 (95% CI, 132 to 165) in Hispanics, and 191 (95% CI, 160 to 221) in blacks. Among blacks compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.85 (95% CI, 1.82 to 18.73); extracranial atherosclerotic stroke, 3.18 (95% CI, 1.42 to 7.13); lacunar stroke, 3.09 (95% CI, 1.86 to 5.11); and cardioembolic stroke, 1.58 (95% CI, 0.99 to 2.52). Among Hispanics compared with whites, the relative rate of intracranial atherosclerotic stroke was 5.00 (95% CI, 1.69 to 14.76); extracranial atherosclerotic stroke, 1.71 (95% CI, 0.80 to 3.63); lacunar stroke, 2.32 (95% CI, 1.48 to 3.63); and cardioembolic stroke, 1.42 (95% CI, 0.97 to 2.09). The high ischemic stroke incidence among blacks and Hispanics compared with whites is due to higher rates of all ischemic stroke subtypes.

title: Heart failure in Hispanics.
abstract: Although large-scale heart failure (HF) studies in Hispanic Americans are lacking, some compelling data indicate that they are a particularly vulnerable population and underscore the need for further research. Hispanics comprise the largest and fastest-growing ethnic group in the U.S., in whom the impact of this burgeoning public health problem may be magnified. Current data show that Hispanics with HF are more likely to be younger and underinsured than non-Hispanic whites. They have higher rates of readmissions but have lower in-hospital and short-term mortality rates. Epidemiologic studies demonstrate that Hispanics have excessive rates of diabetes, obesity, dyslipidemia, and metabolic syndrome. Although hypertension and ischemic heart disease are established risk factors in this ethnic group, it may be considered that insulin resistance plays a significant role in the pathogenesis of HF in Hispanics, accounting for their inordinate cardiometabolic risk burden and the growing evidence of novel metabolic risk factors for HF. Hispanics encounter multiple barriers to health care influenced by socioeconomic, linguistic, and cultural factors that, in turn, have an adverse impact on disease prognosis. Recognition of predominant risk factors and health care disparities in this population is crucial to tailoring appropriate management strategies. This review summarizes epidemiologic and clinical data on Hispanics with HF, details risk factors and health care impediments, and presents an agenda for future investigation.

title: Comparison of incidences of congestive heart failure in older African-Americans, Hispanics, and whites.
abstract: In a prospective study of 2,893 African-Americans, Hispanics, and whites, mean age 81 years, at 43-month follow-up, congestive heart failure (CHF) developed in 194 of 686 African-Americans (28%), in 67 of 257 Hispanics (26%), and in 533 of 1,950 whites (27%) (p = NS). The Cox regression model showed that significant independent risk factors for CHF were male gender (risk ratio = 1.4, p = 0.0001); hypertension (risk ratio = 2.5, p = 0.0001); coronary artery disease (risk ratio = 4.0, p = 0.0001); diabetes mellitus (risk ratio = 1.6, p = 0.0001); and age (risk ratio = 1.05, p = 0.0001).

title: Disparities in the treatment and outcomes of vascular disease in Hispanic patients.
abstract: The Hispanic population represents the fastest growing minority in the United States. As the population grows and ages, the vascular surgery community will be providing increasing amounts of care to this diverse group. To appropriately administer preventive and therapeutic care, it is important to understand the incidence, risk factors, and natural history of vascular disease in Hispanic patients.



We analyzed hospital discharge databases from New York and Florida to determine the rate of lower extremity revascularization (LER), carotid revascularization (CR), and abdominal aortic aneurysm (AAA) repair in Hispanics relative to the general population. The rates of common comorbidities, the indications for the procedures, and outcomes during the same hospitalization as the index procedure were determined. Multivariate logistic regression analysis was used to determine the differences between Hispanics and white non-Hispanics with respect to rate of procedure, symptoms at presentation, and outcome after procedure. Demographic variables and length of stay were also analyzed.



The rate of LER, CR, and AAA repair was significantly lower in Hispanic patients than in white non-Hispanics. Despite this lower rate of intervention, Hispanics were significantly more likely than whites to present with limb-threatening lower extremity ischemia (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.91 to 2.29), symptomatic carotid artery disease (OR, 1.57; 95% CI, 1.4 to 1.75), and ruptured AAA (OR, 1.26; 95% CI, 1.04-1.52) than white non-Hispanics These differences were maintained after controlling for the presence of diabetes mellitus and other comorbidities. Hispanic patients had higher rates of amputation during the same hospitalization after LER (6.2% vs 3.4%, P < .0001) and higher mortality after elective AAA repair (5% vs 3.4%, P = .0032). Length of stay after LER, CR, and AAA repair was longer for Hispanic patients than white non-Hispanics.



Significant disparities in the rate of utilization of three common vascular surgical procedures exist between Hispanic patients and the general population. In addition, Hispanics appear to present with more advanced disease and have worse outcomes in some cases. Reasons for these disparities must be determined to improve these results in the fastest growing segment of our society.

title: Variation in the Incidence and Proportion of Diabetes-Related Amputations in Minorities
abstract: To identify the age-adjusted and level-specific incidence of amputations associated with diabetes in Hispanics, African-Americans, and non-Hispanic whites.  We used a database from the Office of Statewide Planning and Development in California that identified all hospitalizations for lower-extremity amputations in the state in 1991. Amputation level was defined by ICD-9-CM codes 84.11–84.18 and were categorized as toe, foot, leg, and thigh amputations.  The age-adjusted incidence of diabetes-related amputation per 10,000 persons with diabetes in 1991 was 95.25 in African-Americans, 55.98 in non-Hispanic whites, and 44.43 in Hispanics. Hispanics had a higher proportion of amputations (82.7%) associated with diabetes than did African-Americans (61.6%) or non-Hispanic whites (56.8%) (P < 0.001). African-Americans had the highest age-adjusted incidence rate for each level in people with and without diabetes. African-Americans underwent more proximal amputations compared with non-Hispanic whites and Hispanics (P < 0.001). Diabetes-related amputations were 1.72 and 2.17 times more likely in African-Americans compared with non-Hispanic whites and Hispanics, respectively.  Hispanics had proportionally more amputations associated with diabetes than did African-Americans or non-Hispanic whites. A significant excess incidence of both diabetes- and non-diabetes-related amputations and proportionally more proximal amputations were identified in African-Americans compared with Hispanics and non-Hispanic whites. A possible explanation could be the higher prevalence of peripheral vascular disease in African-Americans. Public health initiatives, which have been demonstrated to reduce the incidence of diabetes-related lower-extremity amputations, should be implemented, and additional work should focus on minority groups.

title: The effect of novel cardiovascular risk factors on the ethnic-specific odds for peripheral arterial disease in the Multi-Ethnic Study of Atherosclerosis (MESA).
abstract: The purpose of this study was to: 1) determine the significance and magnitude of associations between novel cardiovascular disease (CVD) risk factors and peripheral arterial disease (PAD) after adjustment for traditional risk factors; and 2) ascertain the extent to which novel risk factors explain the excess or lower risk for PAD in different ethnic groups.



Previous reports have found a significant difference in the risk of PAD by ethnic group, with some of the risk difference attributed to different levels of traditional CVD risk factors.



A total of 6,814 individuals free of clinically apparent CVD were enrolled in the MESA (Multiethnic Study of Atherosclerosis) and underwent standardized testing for the presence of PAD by the ankle-brachial index. These subjects also had fasting blood drawn for serum cholesterol, glucose, and a number of novel biomarkers for CVD. Non-Hispanic whites were the largest ethnic group (38%), followed by African Americans (28%), Hispanics (22%), and Chinese (12%).



In this cross-sectional analysis, 6,653 subjects with an ankle brachial index <1.40 were analyzed. The mean (SD) age was 62.2 (10.2) years, and 52.9% were women. Interleukin-6, fibrinogen, D-dimer, and homocysteine were significantly associated with PAD after adjustment for traditional CVD risk factors. Compared with non-Hispanic whites and after adjustment for traditional and "novel" risk factors, the odds for PAD were 1.47 (95% confidence interval [CI]: 1.07 to 2.02) times higher in African Americans, while being 0.45 (95% CI: 0.29 to 0.70) and 0.44 (95% CI: 0.24 to 0.78) in Hispanics and Chinese, respectively.



Ethnic associations with PAD remained significant even after adjustment for traditional and novel risk factors. This suggests that unknown factors may account for the residual ethnic differences in PAD.

title: Prevalence of Coronary Artery Disease, Atherothrombotic Brain Infarction, and Peripheral Arterial Disease: Associated Risk Factors in Older Hispanics in an Academic Hospital‐Based Geriatrics Practice
abstract: To investigate the prevalence of coronary artery disease (CAD), atherothrombotic brain infarction (ABI), and peripheral arterial disease (PAD) in older Hispanics and the association with risk factors in this population.

title: Sudden cardiac death in Hispanic Americans and African Americans.
abstract: The goal of this study was to estimate rates of sudden cardiac death in US Hispanics and African Americans.



Data on coronary deaths occurring outside of the hospital or in emergency rooms were examined for 1992.



In 1992, 53% (8194) of coronary heart disease deaths among Hispanic Americans 25 years of age and older occurred outside of the hospital or in emergency rooms. The percentage was lower among Hispanics than among non-Hispanic Whites and Blacks. Age-adjusted rates per 100,000 were lower in Hispanics than in non-Hispanic Whites or Blacks (Hispanic men, 75; White men, 166; Black men, 209; Hispanic women, 35; White women, 74; Black women, 108). The percentages dying outside of the hospital or in emergency rooms were higher in young persons, those living in nonurban areas, and those who were single.



The percentage and rate of coronary deaths occurring outside of the hospital or in emergency rooms were lower in Hispanics than in non-Hispanics; African Americans had the highest rates. Further research is needed on sudden coronary death in Hispanic Americans and African Americans.

title: Epidemiology and genetics of sudden cardiac death.
abstract: Sudden cardiac death (SCD) generally refers to an unexpected death from a cardiovascular cause in a person with or without preexisting heart disease. The specificity of this definition varies depending on whether the event was witnessed; however, most studies include cases that are associated with a witnessed collapse, death occurring within 1 hour of an acute change in clinical status, or an unexpected death that occurred within the previous 24 hours.1–3 Further, sudden cardiac arrest describes SCD cases with resuscitation records or aborted SCD cases in which the individual survived the cardiac arrest.

The incidence of SCD in the United States ranges between 180 000 and 450 000 cases annually.4 These estimates vary owing to differences in SCD definitions and surveillance methods for case ascertainment.4,5 In recent prospective studies using multiple sources in the United States,6,7 Netherlands,8 Ireland,9 and China,10 SCD rates range from 50 to 100 per 100 000 in the general population.3 Despite the need for multiple sources of surveillance to provide a more accurate estimate of SCD incidence, it is clear that the overall burden in the population remains high. Although improvements in primary and secondary prevention have resulted in substantial declines in overall coronary heart disease (CHD) mortality over the past 30 years,11,12 SCD rates specifically have declined to a lesser extent.13–16 SCD still accounts for >50% of all CHD deaths and 15% to 20% of all deaths.17,18 For some segments of the population, rates are not decreasing19 and may actually be increasing.14,19 As a result, SCD prevention represents a major opportunity to further reduce mortality from CHD.

Despite major advances in cardiopulmonary resuscitation20 and postresuscitation care, survival …

title: Deaths: preliminary data for 2011.
abstract: This report presents preliminary U.S. data on deaths, death rates, life expectancy, leading causes of death, and infant mortality for 2011 by selected characteristics such as age, sex, race, and Hispanic origin.



Data in this report are based on death records comprising more than 98 percent of the demographic and medical files for all deaths in the United States in 2011. The records are weighted to independent control counts for 2011. Comparisons are made with 2010 final data.



The age-adjusted death rate decreased from 747.0 deaths per 100,000 population in 2010 to 740.6 deaths per 100,000 population in 2011. From 2010 to 2011, age-adjusted death rates decreased significantly for 5 of the 15 leading causes of death: Diseases of heart, Malignant neoplasms, Cerebrovascular diseases, Alzheimer's disease, and Nephritis, nephrotic syndrome and nephrosis. The age-adjusted death rate increased for six leading causes of death: Chronic lower respiratory diseases, Diabetes mellitus, Influenza and pneumonia, Chronic liver disease and cirrhosis, Parkinson's disease, and Pneumonitis due to solids and liquids. Life expectancy remained the same in 2011 as it had been in 2010 at 78.7 years.

title: Mortality among minority populations: a review of recent patterns and trends.
abstract: The mortality experiences of blacks, Native Americans, and Hispanics are reviewed. Evidence recently made available shows the Hispanic experience to be only slightly less favorable than the Anglo (other white) experience, suggesting remarkable progress in recent years. Native Americans have also made remarkable progress in recent years, especially in reducing infant mortality. Blacks have shown less improvement than the other two groups. Reasons for these trends, for differences among the groups in mortality rates and life expectancy, and for patterns of mortality by cause are discussed.

title: Mortality by Hispanic status in the United States.
abstract: To compare all-cause and cause-specific mortality rates between Hispanic and non-Hispanic groups and estimate the effect of family income, place of birth, and place of residence on these rates.



Cohort study using national survey data matched to the National Death Index, with a mortality follow-up period of 9 years.



The noninstitutionalized population of the United States.



Approximately 700,000 respondents (aged 25 years or older), including 40,000 Hispanics, to national surveys conducted by the US Bureau of the Census (Current Population Surveys).



All causes and underlying cause of death, coded from the death certificate, occurring between 1979 and 1987.



Adjusting for age, Hispanics were shown to have lower mortality from all causes compared with non-Hispanics (standardized rate ratio [SRR], 0.74 for men, 0.82 for women), lower mortality from cancer (SRR, 0.69 for men, 0.61 for women), lower mortality from cardiovascular disease (SRR, 0.65 for men, 0.80 for women), higher mortality from diabetes (SRR, 1.86 for men, 2.38 for women), and higher mortality from homicide (SRR, 3.60 for men). After adjusting for differences in annual family income, the relative mortality ratios were even lower for Hispanics than non-Hispanics.



These data describe, in a large national cohort study, a lower mortality in Hispanics than in non-Hispanics. This mortality is particularly low after adjustment for differences in family income.

title: Race/ethnicity and all-cause mortality in US adults: revisiting the Hispanic paradox.
abstract: We examined the association between race/ethnicity and all-cause mortality risk in US adults and whether this association differs by nativity status.



We used Cox proportional hazards regression to estimate all-cause mortality rates in 1997 through 2004 National Health Interview Survey respondents, relating the risk for Hispanic subgroup, non-Hispanic Black, and other non-Hispanic to non-Hispanic White adults before and after controlling for selected characteristics stratified by age and gender.



We observed a Hispanic mortality advantage over non-Hispanic Whites among women that depended on nativity status: US-born Mexican Americans aged 25 to 44 years had a 90% (95% confidence interval [CI] = 0.03, 0.31) lower death rate; island- or foreign-born Cubans and other Hispanics aged 45 to 64 years were more than two times less likely to die than were their non-Hispanic White counterparts. Island- or foreign-born Puerto Rican and US-born Mexican American women aged 65 years and older exhibited at least a 25% lower rate of dying than did their non-Hispanics White counterparts.



The "Hispanic paradox" may not be a static process and may change with this population growth and its increasing diversity over time.

title: Mortality among Hispanics.
abstract: Hispanic Americans remain an understudied population, an issue that has surfaced in JAMA and other journals. The US Department of Health and Human Services Healthy People 2000 , which declared increasing life expectancy and decreasing inequality among subpopulations as the top health objectives for the nation, reports a higher life expectancy for Hispanics (75 years) than non-Hispanic blacks (68 years) and whites (74.4 years). 1 Sorlie et al 2 confirmed the lower mortality of Latino adults in the United States. These statistics seem paradoxical, however, given the lower income, education, and health access, and the risk factor profile of Hispanics. 3 The possibility of genetic or cultural factors accounting for a survival advantage is exciting, and the policy implications of these estimates are significant, yet readers and decision makers should keep in mind that conceptual and operational problems plague research on race and ethnicity. 4 Two methodologic issues

title: LESSONS FROM THE STUDY OF IMMIGRANT MORTALITY
abstract: This paper reports the results of a systematic review of mortality among immigrant groups in England and Wales. Mortality rates in 1970-72 were compared with rates both in the countries of origin and in England and Wales. All-cause male mortality was lower in immigrants from italy, the Caribbean, and Poland than in the countries of origin, suggesting a selection effect among migrants. The opposite patttern was noted for imigrants from Ireland, however, indicating social and health disadvantages may be a stimulus to migration. The high mortality from tuberculosis in immigrants from the indian subcontinent and Ireland, low mortality from ischemic heart disease and high mortality from cerebrovascular disease in Caribbean men, and low mortality from cancer of the lung and intestine in all but Irish men reflect the influence of the migrants' original country. A possible influence of the host country on determining disease rates is seen in adaptation of immigrant mortality ratios toward the England and Wales average. For example, immigrants from several countries analyzed had ischemic heart disease mortalty ratios intermediate between those for the original country and for England and Wales. In addition, British people born in the Indian subcontinent showed a mortality pattern intermediate between that of the Indians and the England and Wales average, supporting the argument that environmental rather than genetic determinants may be involved in the principal chronic diseases. Particularly high mortality from complications of pregnancy and childbirthwas noted in indian and Caribbean immigrants, indicating that there may be social and cultural barriers to the receipt of adequate medical care. Finally, social class differences did not account for mortality differences among immigrant groups. Mortality was higher for the Irish than the English or Welsh in each social class group, which suggests there are cultural influences on mortality that act independently of social class influences.

title: The Latino mortality paradox: a test of the "salmon bias" and healthy migrant hypotheses.
abstract: Relative to non-Latino Whites, Latinos have a worse socioeconomic profile but a lower mortality rate, a finding that presents an epidemiologic paradox. This study tested the salmon bias hypothesis that Latinos engage in return migration to their country of origin and are thereby rendered "statistically immortal" and the alternative hypothesis that selection of healthier migrants to the United States accounts for the paradox.



National Longitudinal Mortality Study data were used to examine mortality rates of the following groups for whom the salmon hypothesis is not feasible: Cubans, who face barriers against return migration; Puerto Ricans, whose deaths in Puerto Rico are recorded in US national statistics; and US-born individuals, who are not subject to either salmon or healthy migrant effects.



The sample included 301,718 non-Latino Whites and 17,375 Latino Whites 25 years or older. Cubans and Puerto Ricans had lower mortality than non-Latino Whites. Moreover, US-born Latinos had lower mortality than US-born non-Latino Whites.



Neither the salmon nor the healthy migrant hypothesis explains the pattern of findings. Other factors must be operating to produce the lower mortality.

title: All-cause and cardiovascular mortality among Mexican-American and non-Hispanic White older participants in the San Antonio Heart Study- evidence against the "Hispanic paradox".
abstract: The observation that Hispanics have lower all-cause and cardiovascular mortality rates despite increased rates of diabetes and obesity and lower socioeconomic status has been termed the "Hispanic paradox." The authors therefore examined the relation between ethnicity and mortality in 1,438 Mexican-American and 921 non-Hispanic White San Antonio Heart Study participants, aged 45-64 years when they enrolled between 1979 and 1988. Over an average of 14.5 years, 466 deaths occurred: 238 attributed to cardiovascular disease (death certificate International Classification of Diseases, Ninth Revision, codes 401-414 or codes 420-447 with the exception of code 427.5) and 117 attributed to coronary heart disease (codes 410-414). Age- and gender-adjusted hazard ratios for all-cause, cardiovascular, and coronary heart disease mortality comparing Mexican Americans with non-Hispanic Whites were 1.50 (95% confidence interval (CI): 1.23, 1.81), 1.70 (95% CI: 1.30, 2.24), and 1.60 (95% CI: 1.09, 2.36), respectively. After adjusting for possible confounders, among diabetic individuals not using insulin, the authors found excess risk of all-cause, cardiovascular, and coronary heart disease mortality associated with being Mexican American; however, in nondiabetic individuals and insulin-using diabetic individuals, Mexican Americans and non-Hispanic Whites appeared to be at similar risk of mortality. Contrary to the prediction of the "Hispanic paradox," in the San Antonio Heart Study, Mexican Americans were at greater risk of all-cause, cardiovascular, and coronary heart disease mortality than were non-Hispanic Whites.

title: Community-wide coronary heart disease mortality in Mexican Americans equals or exceeds that in non-Hispanic whites: the Corpus Christi Heart Project.
abstract: Previous comparisons of coronary heart disease mortality between Mexican Americans and non-Hispanic whites have given paradoxic results: despite their adverse cardiovascular risk profiles, especially a greater prevalence of diabetes, Mexican Americans are reported to have lower rates of mortality from coronary heart disease.



We performed a community-based surveillance among all residents of Nueces County, Texas, aged 25 to 74 years, from 1990 to 1994. All death certificates were obtained and coded, and deaths potentially related to coronary heart disease were selected and validated by standardized methods blinded to ethnicity. Validated in-hospital and out-of-hospital coronary heart disease mortality was compared between 785 Mexican Americans and 862 non-Hispanic white women and men.



Validated coronary heart disease mortality in Mexican Americans exceeded that for non-Hispanic whites in the same community. Among women, definite coronary heart disease mortality was 40% greater among Mexican Americans (rate ratio [RR] 1.43, 95% confidence interval [CI]: 1.12 to 1.82), as was all coronary heart disease mortality (RR, 1.32, 95% CI: 1.08 to 1.63). Among men, Mexican Americans had greater rates of all (RR, 1.11; 95% CI: 0.96 to 1.28) and definite coronary heart disease mortality (RR, 1.16; 95% CI: 0.91 to 1.47), but the associations were not statistically significant.



When community-wide mortality rates from coronary heart disease are properly validated, Mexican Americans have rates equal to or higher than those of non-Hispanic whites. Community-based surveillance with validation of coronary heart disease as the cause of death is necessary to avoid the errors that occur with the use of death certificates alone.

title: Obesity among US immigrant subgroups by duration of residence.
abstract: The prevalence of obesity has increased substantially since the 1980s. While immigrants are the fastest growing segment of the US population, little is known about obesity or clinician counseling about diet and exercise in this group.



To estimate the prevalence of obesity among immigrant subgroups and quantify the magnitude of the association with duration of US residence, and to describe reported diet and exercise counseling by birthplace, race, and ethnicity.



Cross-sectional study using data from the 2000 National Health Interview Survey.



Body mass index (BMI, measured as weight in kilograms divided by the square of height in meters) based on self-reported height and weight measurements, and self-reported rates of diet and exercise counseling.



Of 32,374 respondents, 14% were immigrants. The prevalence of obesity was 16% among immigrants and 22% among US-born individuals. The age- and sex-adjusted prevalence of obesity was 8% among immigrants living in the United States for less than 1 year, but 19% among those living in the United States for at least 15 years. After adjusting for age, sociodemographic, and lifestyle factors, living in the United States for 10 to 15 and at least 15 years was associated with BMI increases of 0.88 and 1.39, respectively. The association for 15 years or more was significant for all immigrant subgroups except foreign-born blacks. Additionally, immigrants were less likely than US-born individuals to report discussing diet and exercise with clinicians (18% vs 24%, P<.001; 19% vs 23%, P<.001, respectively). These differences were not accounted for by sociodemographic characteristics, illness burden, BMI, or access to care among some subgroups of immigrants.



Among different immigrant subgroups, number of years of residence in the United States is associated with higher BMI beginning after 10 years. The prevalence of obesity among immigrants living in the United States for at least 15 years approached that of US-born adults. Early intervention with diet and physical activity may represent an opportunity to prevent weight gain, obesity, and obesity-related chronic illnesses.

title: Smoking, acculturation, and pregnancy outcome among Mexican Americans.
abstract: The authors present an evaluation of the role of acculturation in smoking practices and pregnancy outcome (N = 767 births) in a national sample of Mexican American women. Data employed are from the 1982-1984 Hispanic Health and Nutrition Examination Survey. The prevalence rates of smoking during pregnancy, low birth weight (< or = 2500 g), and preterm delivery (> or = 3 weeks prior to the expected date) are higher among more acculturated women compared with less acculturated women. Among the more acculturated women, the prevalence of smoking and poor birth outcomes did not increase linearly with increasing American orientation. Rather, women in the third quartile of acculturation scores, i.e., those with a moderate American orientation, experienced significantly poorer birth outcomes than women with either a stronger American orientation or a Mexican orientation. Women at this moderate level of acculturation appear to have the greatest need for public health services rather than women with the lowest level of acculturation (non-English speaking, lowest income) as a means of improving their pregnancy outcomes.