Cardiovascular DiseaseHispanic Perspective

Max Solano M.D.St. Vincent’s Family Medicine Center – Coordinator of

Healthy LifeStyle Initiatives Project

This is part 5 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of

Duval County Health Department. For more information or register for the seminars, please call 620-1289.

Goals

• Definition of Cardiovascular Problems• Background on Hispanic Issues• Risk Factors Definition• Outcomes Definition• Risk Factors among the Hispanic

Community• Barriers• Programs

Cardiovascular Diseases

• Coronary Artery Disease (CAD)

• Coronary Heart Disease (CHD)

• Carotid Disease

• Cerebrovascular Disease (CVA)

• Peripheral Vascular Disease (PVD)

• Dyslipidemia

• Hypertension

U.S. Population by Race and Ethnicity

12%

4%

2%

14%

68%

Black

Asian

Other

Hispanic

White

Hispanic Population

55%

45%Native - born

Foreign - born

Adapted from GM Bell Institute Hispanic Heart Health Presentation

U.S. Demographics of Hispanics

Total US Populatio

n

Puerto Rican 9% Cuban 4%

Central & South American 14%

Other Latino/Hispanic 7%

13.8%(2003)

Mexican 66.9%

US Census Bureau 2003

Statistical Biases

• Clustering of multiple cultures, racial/ethnic, and genetic backgrounds in one group: Latino or Hispanic

• Most of the studies under-represent the Hispanic population

• The impact of undocumented Hispanics is unknown, but felt to be significant

Projected Growth by Race and Ethnicity

Hispanic White Black AsianActual Increase

1980-00

Projected Increase

00-20

20.7%

25.1%

14.3%

13.3%

7.5%

9.7%

7.0%

11.4%

10States hold 80% of the U.S. Latino Population

80%Of the Electoral votes needed to win the presidency are concentrated in those states

$ 13 MillionAmount spent in 2004 by both parties on Spanish-language television ads

A new major in L.A. A decisive showing in ’04.Latinos are making their mark on politics as never before. Get used to it.

Arian Campo-Flores May 30, 2005 Newsweek

Si TV

“Speak English. Live Latin”English Tongue with Latin Flavor

• $636 billion – plus market• Young spenders between the ages of 14 and

34, want to be spoken to in English, even as they stay true to their Latino identity.

• “They’re doing it their way”

• Coor’s “Turn it losse” campaign translated into “Sueltalo” or “Let it loose”, as in diarrhea changed to “Won’t slow you down”

• Kmart:Thalia• Pulaski Furniture: Casa

Cristina a furniture with “bold carvings”

• Sears: Latina Life Tropical colors, faux-fur prints, lots of spangles and sizes befitting “curve conscious” chicas with an “active lifestyle and a unique sense of self”

• Latino shoppers “don’t want to be segregated”

• Men’s Warehouse Eddie Rodriguez stores at the end of this year all the 6 stores will be closed.

Interest on Hispanics

• Politics

• Commerce

• Public Health– If unattended, health disparities create a

significant social and economic burden for the whole country

Leading Causes of Death in the United States in 2000

Cause of Death No of Deaths Rate/100,000

Heart Disease 710760 258.2

Malignant Neoplasm 553091 200.9

Cerebrovascular disease 167661 60.9

Chronic lower respiratory tract disease 12209 44.3

Unintentional injuries 97900 35.6

Diabetes mellitus 69301 25.2

Influenza and pneumonia 65313 23.7

Alzheimer disease 49558 18

Nephritis, nephrotic syndrome, neprhosis

37251 13.5

Septicemia 31224 11.3

Other 499283 181.4

TOTAL 2403351 873.1

Actual Causes of Death in the U.S. in 1990 and 2000

Actual Cause No(%)1990 No(%) 2000

Tobacco 400 000(19) 435 000(18.1)

Poor diet and physical inactivity 300 000(14) 400 000(16.6)

Alcohol consumption 100 000(5) 85 000(3.5)

Microbial agents 90 000(4) 75 000(3.1)

Toxic agents 60 000(3) 55 000(2.3)

Motor vehicle 25 000(1) 43 000(1.8)

Firearms 35 000(2) 29 000(1.2)

Sexual behavior 30 000(1) 20 000(0.8)

Illicit drug use 20 000(<1) 17 000(0.7)

Total 1 060 000(50) 1159 000(48.2)

Mokdad A.; Marks J.; Stroup D.; Gerberding J. Actual Causes of Death in the United States, 2000. JAMA, March 10,2004-Vol 291, No 10 1238-1245

Selected Death Rates by Race/Ethnicity, Duval County

0

20

40

60

80

100

120

140

160

180

Heart Disease Cancer Injury

Hispanic

White, Non-Hispanic

Source: FDOH, Office of Vital Statistics, 2001-2003

Source Hispanic Population Estimates: Claritas 2003

Source Duval County Population Estimates: Demographic Estimating Conference Database, 4/2004 (R.Remo DCHD)

Cardiovascular Disease Spectrum

RISK FACTORS

CAD

Outcomes:Heart Failure

Death

Risk Factors

• Influenced by– Behavior– Culture– Social factors: Migration and acculturation

• Low social support• Lack of educational or occupational opportunities• Low access to medical care• Discrimination and injustice• Other structural inequalities

Risk Factors

• Risk factors:– Physical inactivity– Unfavorable fat distribution– Obesity– Type 2 DM

• Higher among Mexican-Americans than among Whites.

Risk Factors

• Black Participants were at the greatest risk of CVD, and Hispanic and Alaska Native participants were healthier in terms of CVD risk than white participants

Finkelstein EA et al. Racial/ethnic disparities in CHD risk factors among Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) J Womens Health 2004 Jun; Vol 13 (5) pp 503-18

Risk Factors• Increased CVD risk factor clustering exists

among Americans with low Socio-economical Status (SES), particularly among non-Hispanic Blacks. Among persons with high SES, Mexican Americans and non-Hispanic Blacks have a higher risk of CVD than non-Hispanic Whites

Sharma S et al. Racial, ethnic and socioeconomic disparities in the clustering of CVD risk factors. Ethnicity & Disease 2004 Winter; Vol 14(1), pp 43-8

0 20 40 60 80 100

Poor Near Poor

Hispanic

Black only

Asian only

White only, not Hispanic

Under 18 years

HispanicBlack only

Asian only

White only, not Hispanic

HispanicBlack only

Asian only

White only, not Hispanic

18-64 years

65 years and over

Figure 5. Low income population by age, race, and Hispanic origin: United States, 2002

NOTES: Poor is defined as family income less than 100 percent of the poverty level and near poor as 100-199 percent of the poverty level. Persons of Hispanic origin may be of any race. Black and Asian races include persons of Hispanic and non-Hispanic origin. See Data Table for data points graphed and additional notes.

SOURCE: U.S. Census Bureau, Current Population Survey.

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

Percent

Risk Factors

Awareness: First Step to Action

Lopez-Candales A. (Univ Pittsburg) Cardiovascular Diseases: a review of the Hispanic perspective. Awareness is the first step to action. J Med 2002; 33(1-4): 227-45

Risk FactorsEstimated 10-year coronary heart disease

mortality risk per 1000 persons, adjusted for age and education, was– Highest for US-born Spanish-speaking men and

women (27.5 and 11.4, respectively)– Intermediate for US-born English-speaking men and

women (22.5 and 7.0)– Lowest for Mexican-born men and women (20.0 and

6.6). • A similar pattern of higher risk among US-born

Spanish-speaking men and women was demonstrated for each of the 5 cardiovascular disease risk factors.

CARDIOVASCULAR RISK FACTORS IN MEXICAN AMERICAN ADULTS: A TRANSCULTURAL ANALYSIS OF NHANES III, 1988-1994 ,  By: Sundquist, Jan, Winkieb, Marilyn A., American Journal of Public Health, 0090-0036, May 1, 1999, Vol. 89, Issue 5

Risk Factors

• Lipid Factors: Dyslipidemia– High LDL– Low HDL– High Triglycerides– Metabolic Syndrome

• Non Lipid Risk Factors

Risk Factors

• Mexican-Americans compared with Whites have:– Higher prevalence of hyperinsulinemia– Abnormalities in plasma lipoprotein lipids

• Especially higher levels of LDL and apolipoprotein B, and lower levels of HDL

Dyslipidemia

MMWR Feb 11 2005 /54(05); 117-119

Nonlipid Risk Factors for CAD

Modifiable Nonmodifiable

Hypertension

Cigarette Smoking

Thrombogenic/ Hemostatic State

Diabetes

Obesity

Physical Inactivity

Atherogenic Diet

Age

Male Sex

Family History of Premature CAD

Hypertension• Mexican Americans and Native Americans have• lower control rates than non-Hispanic Whites

and• African Americans. • The pathogenesis of hypertension in different

racial subgroups may differ with respect to the contributions of such factors as – salt, potassium, stress, cardiovascular– reactivity, body weight, nephron number, sodium– handling, or hormonal systems,

• but in all subgroups, the etiology is multifactorial.• JNC 7

Hypertension

• Blood pressure findings are somewhat inconsistent Mexican Americans have higher levels of uncontrolled and untreated hypertension than do Whites.

Hypertension

• Hispanic Americans of Caribbean descent has a prevalence of hypertension similar to that in the black community.

Kountz DS. Hypertension in ethnic populations: tailoring treatments. Clin Cornerstone 2004; vol 6 (3), pp 39-46

04/08/23 Healthy People 2010 40

Obesity

• Latinos: higher prevalence than the general population

• Obesity is prevalent among Hispanics, especially women

• (Dairy Council Digest, Jan/Feb 2001; www.nationaldairycouncil.org)

Mokdad, AH et al JAMA, Oct/99 v282 i16 p1519

Obesity

Among U.S. Groups: Hispanics had the

most growth in prevalence of obesity

Hispanic ethnicity

11.6% to 20.8% 1991-1999

0 10 20 30 40 50 60 70

Women

White only, not Hispanic

Men

All races

Mexican

Men

Men

Figure 17. Obesity among adults 20-74 years of age by sex, race, and Hispanic origin: United States, 1999-2002

NOTES: Percents are age-adjusted. Obese is defined as a body mass index (BMI) greater than or equal to 30. Persons of Mexican origin may be of any race. See Data Table for data points graphed, standard errors, and additional notes.

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey.

Percent

Black only, not Hispanic

Men

Women

Women

Women

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

Obesity

• Remarkable ethnic differences in the relationship between SES and obesity.

• Lower SES inequality in obesity within minority groups.

Zhang Q; Wang Y. Socioeconomic inequality of obesity in the US: do gender, age and ethnicity matter?. Soc Sci Med 2004 Mar; Vol 58(6), pp 1171-80

Obesity

• Waist circumference difference between Mexican American and European American at higher percentiles of the distribution, and, in some cases exceeded the adult cutoff value for obesity-related disease risk at as early as 13 years of age.

Fernandez JR et al. Waist Circumference percentiles in nationally representative samples of African American, European-American, and Mexican American children and adolescents. J Pediatr 2004 Oct; vol 145(4), pp 439-44

Obesity

• Mexican-American children ages 6-11 were more likely to be overweight (22 percent) than non-Hispanic black children (20 percent) and non-Hispanic white children (14 percent).

http://www.cdc.gov/nchs/pressroom/04facts/obesity.htm

Obesity

• Most of the sample were in the 97th percentile, many perceived themselves to be as healthy as or healthier than others.

Tyler DO. Overweight and perceived health in Mexican American children: a pilot study in a central Texas community. J Sch Nurs 2004 Oct; vol 20(5) pp 285-92

Tobacco Smoking

• Young adults and adults of Mexican or Mexican-American origin smoke cigarettes less frequently than non-Hispanic Whites. However, this lower rate is due mainly to the lower use of cigarettes among Mexican American and Mexican women (combined)

Caraballo RS; Lee CW. Tobacco use among Mexicans and their descendants in the United States. Salud Publica Mex 2004 May-Jun; Vol 46(3), pp 241-50

• About one third of total diabetes among Hispanic Americans is undiagnosed (NHANES III; www.niddk.nih.gov)

Diabetes

Outcomes

• Myocardial Infarction• Heart Failure• Mortality

Myocardial Infarction

• On discharge from hospital after MI, Mexican Americans received fewer medications than whites, even after adjusting for clinical, socioeconomic, and demographic characteristics.

• Mexican Americans were less likely to receive all major medications, especially antiarrythmics, anticoagulants, and lipid-lowering therapy.

Carolina Reyes. Genes, Culture and Medicines: Bridging Gaps in Treatment for Hispanic Americans.

Heart Failure

• Race not a significant risk factor for the development of CHF1

• After 6 months of hospitalization for CHF: Improvement on both groups but significantly more so in the Hispanics when compared to the non-Hispanics21. Aronow W. et al. Comparison of incidents of CHF in older African-Americans, Hispanics, and

Whites The Am J Cardiol vol 84(5) 611-612

2. Riegel B. et al. Changes over 6-months in health-related quality of life in a matched sample of Hispanics and non-Hispanics with heart failure. Qual Life Res. 2003 Sep; 12(6): 689-98

Mortality

• CVD mortality is ~ 20% lower among adult Hispanics than among whites in the US.

• Latino mortality paradox– “salmon bias”– Health migrant hypothesis

Liao Y. et al. Mortality from CHD and CVD among Adult U.S. Hispanics: Findings from the National Health Interview Survey (1986-1994) J Amer Coll Cardiol vol 30(5) 1200-1205

Latino Mortality Paradox

• Cubans and Puerto Ricans had lower mortality that non-Latino Whites. Moreover, US-born Latinos had lower mortality than US born non-Latino Whites

Abraido-Lanza et al. The Latino mortality paradox: a test of the “salmon bias” and healthy migrant hypothesis. Am J Public Health 2000 Nov 90(11): 1798-9

Barriers

• Hispanic men were much less likely to receive colorectal cancer screening, cardiovascular risk factor screening and management and vaccinations

Felix-Aaron K. et al. Variation in quality of men’s health care by race/ethnicity and social class. Med Care 2005 Mar; vol 43(3 suppl) 172-81

0 10 20 30 40

18-24 years25-34 years

45-54 years

Under 18 years

100-149 percent150-199 percent

200 percent or more

White only, not Hispanic

Hispanic (total)

Black only, not HispanicAsian only

Mexican

Below 100 percent

Figure 7. No Health insurance coverage among persons under 65 years of age by selected characteristics: United States, 2002

NOTES: Percents by poverty level, Hispanic origin, and race are age adjusted. Persons of Hispanic origin may be of any race. Asian and American Indian and Alaska Native races include persons of Hispanic and non-Hispanic origin. See Data Table for data points graphed, standard errors, and additional notes.

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey.

Percent

Age

55-64 years

Percent of poverty level

Other HispanicCuban

Puerto Rican

Race and Hispanic origin

American Indian and Alaska Native only

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

35-44 years

Barriers

• Are genetic differences?

Attitudes

• Sociocultural advantages conferred on Mexican Americans by living in high-density Mexican American neighborhoods outweigh the disadvantages conferred by the high poverty of those neighborhoods. Am J Public Health 2004; 94: 1807-1812

Attitudes

• Experiencing strong emotions such as fright (susto), intense anger (coraje) or sadness and depression (tristeza) was thought to precipitate diabetes

• In addition to follow medical treatments, many cite herbal treatments such as pear cactus (nopal) and aloe vera (savilla) as effective treatments

Coronado GD et al. Attitudes and beliefs among Mexican Americans about type 2 diabetes. J Health Care Poor Underserved 2004 Nov; vol 15(4) 576-88

Attitudes

• Higher levels of perceived family support and greater self-efficacy were associated with higher reported levels of diet and exercise self-care.

Wen LK et al. Family support, diet, and exercise among older Mexican Americans with type 2 diabetes. Diabetes Educ 2004 Nov-Dec vol 30(6) 980-93

0 5 10 15 20 25

45-54 years

Sex

55-64 years

Age

Hispanic

200 percent or more

Below 100 percent

Figure 19. Limitation of activity caused by 1 or more chronic health conditions among working-age adults by selected characteristics: United States, 2000-2002

NOTES: Data are for the civilian noninstitutionalized population and are age adjusted. Persons of Hispanic origin may be of any race. See Data Table for data points graphed, standard errors, and additional notes.

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey.

Percent

Female

18-44 years

Male

100-199 percent

White only, not Hispanic

Percent of poverty level

Black only, not Hispanic

Race and Hispanic origin

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

0 5 10 15 20

1999-2000

White, not Hispanic

1988-94

All ages

1988-94

Figure 31. Percent of adults 18 years of age and over reporting antidepressant drug use in the past month by race and ethnicity: United States, 1988-94 and 1999-2000

NOTES: Data are age age-adjusted. All races includes persons of all races and Hispanic origins, not just those shown separately. Data for adults of Mexican origin and non-Hispanic black adults have been combined due to the small sample size in each of those categories. See Data Table for data points graphed, standard errors, and additional notes.

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey.

Percent of population

Mexican or Black, not Hispanic

1988-94

1999-2000

1999-2000

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

SSRI antidepressants

Non-SSRI antidepressants

Acculturation

• Young Latino women and women living in the US for a longer period more closely identify with the Anglo culture.

Ayala GX. Et al. Restaurant and food shopping selections among Latino women in Southern California. J Am Diet Assoc 2005 Jan vol 105 38-45

Salud para su Corazón (For the Health of Your Heart) is an exciting new and comprehensive community-based heart-health promotion initiative from the

National Heart, Lung, and Blood Institute. It targets Latinos living in the United States. The project raises awareness of the risk factors and promotes lifestyle

changes to reduce the chances of developing heart disease.Why was Salud para su Corazón established?

The Latino population is a very young and rapidly growing segment of our society. However, despite this younger age, the leading cause of death among Latinos is heart disease. Latinos are also generally unaware of important lifestyle changes that could help prevent heart disease. This

knowledge gap transcends socioeconomic status. The initiative began in the Washington, D.C. metropolitan area. Community

leaders, through the Community Alliance Working for Heart Health, carried out the activities using culturally sensitive strategies and educational materials.Salud para su Corazón offers many educational materials in English and

Spanish for the general public and community health planners

Healthy People 2010 Goals

• 12-Heart Disease and Stroke– 12-1 Reduce coronary heart disease deaths– Baseline- 208 deaths per 100,000– Hispanics-145 deaths per 100,000

• 12-11 Increase the proportion of adults with high blood pressure who are taking action to help control their blood pressure– Baseline- 82% of adults aged 18+– Hispanics- 74% of adults aged 18+

• 12-15 Increase the proportion of adults who have had their blood cholesterol checked within the preceding 5 years– Baseline- 67% of adults aged 18+– Hispanics- 59% of adults aged 18+Healthy People 2010; www.health.gov/healthlypeople/

St Vincent’s Medical Center

• Woman to Woman Heart to Heart

• Mujer a Mujer Corazon a Corazon