Morbidity: Cardiovascular (Atherosclerotic) Risk Factors

Overview

The prevalences of a number of cardiovascular risk factors were compared among older Mexican-American and non-Hispanic white women and men during the NHANES III study (1988-1994) (Sundquist, Winkleby, Pudaric, 2001). Mexican-American women had more diabetes, sedentary life style, and hypertension, but comparable rates of abdominal obesity, current smoking, and high non-HDL cholesterol. Mexican-American men had more diabetes and sedentary life style, less abdominal obesity and current smoking, and comparable rates of hypertension and high non-HDL cholesterol. In a California study there was an alarmingly high prevalence of obesity, sedentary life style, and diabetes in Hispanics compared to NHW, with comparable rates of hypertension and smoking in the two ethnicities (Karter, et., al., 1998).

Changes in cardiovascular risk factors over a 10-year period were examined by comparing data from the Hispanic Health and Nutrition Survey (HHANES) (1982-84) with Hispanic EPESE (1993-94) (Stroup-Benham, Markides, Espino, & Goodwin, 1999). The prevalence of obesity and severe obesity increased significantly, as did the prevalence of diagnosed diabetes (20% to 30%) among older Mexican Americans. The percentage of current smokers fell from 28% to 14%.

In the New Mexico Elder Health Survey Lindeman et al. (1999) found the NHW men drink alcohol more frequently than Hispanic men, and very few Hispanic women drink daily, which could increase the risk for CHD in Hispanics.

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Dyslipidemias

Hispanics of both genders in the New Mexico Elder Health Survey had higher serum triglyceride and lower HDL cholesterol levels than non-Hispanic whites (Lindeman, Romero, Hundley, 1998). Because these changes are characteristic of diabetes, most of these differences could be attributed to the higher prevalence of diabetes in Hispanics. After adjustments for the effects of diabetes, Hispanic men still had significantly higher serum triglyceride levels and Hispanic women had lower HDL cholesterol levels than NHW.

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Smoking

An analysis of population-based, cross-sectional surveys conducted in California between 1979 and 1990 paired Hispanic men and women with NHW counterparts (Winkleby, Schooler, Kraemer, Lin, Fortmann, 1995). There were large differences in smoking prevalence rates between Hispanic and NHW pairs with low educational attainment (less than high school education) with NHW more likely to be smokers than Hispanics (46% vs. 21% for women; 53% vs. 30% for men). With higher levels of educational attainment, these differences by ethnicity tended to disappear. Changes in smoking habits over a decade (HHANES data from the early 1980s compared to Hispanic EPESE data from the early 1990s) have shown significant declines in the cigarette smoking rates in the over age 65 years Mexican Americans from the Southwestern United States (Markides, et al., 1999).

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Cerebrovascular Disease and Stroke

A study from a neurological institute in Arizona comparing 242 Hispanic stroke and TIA patients with 1290 NHW patients found that hemorrhagic stroke was more common in Hispanics than NHW (48% vs. 37%), and cardioembolic stroke was less prevalent (9% vs. 16%) (Frey, et al., 1998). Hypertension and diabetes were more often risk factor in Hispanics, who also had a lower mean age of stroke onset (61 vs. 69 years).

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Hypertension

Data from the Hispanic HANES database indicate mean systolic and diastolic blood pressures and the prevalence of hypertension are lower in Mexican Americans compared to non-Hispanic whites. This is despite a higher prevalence of diabetes and obesity, two recognized risk factors for hypertension (Espino, Burge, & Moreno, 1991; Sorel, Ragland, & Syme, 1991). A lower prevalence of both systolic and diastolic hypertension after adjustments for age, body mass index, and type 2 diabetes mellitus also was found in the San Antonio Heart Study in Mexican-Americans when compared to non-Hispanic whites (Haffner, Mitchell, & Stern, 1990).

Data from the NHANES III study showed Mexican American women over age 65 years had a higher prevalence of hypertension than NHW women, whereas there was no difference in men of the two ethnicities (Sundquist, et al., 2001). Other studies have failed to show statistical differences in the ethnic prevalences of hypertension when elderly men and women with and without diabetes are examined separately (Lindeman, et al, 1998; Rewers, Shetterly, & Hamman, 1996). Another analysis of the NHANES III data showed the prevalence of hypertension almost identical between MA and NHW (22.6 vs. 23.3%) (Burt, Whelton, Roccella, Brown, Cutler, Higgins, Horan, & Labarthe, 1995). However, only 35% of MA were being treated and 14% had achieved control, percentages much lower than for NHW.

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Type 2 Diabetes Mellitus

The prevalence of type 2 diabetes occurs disproportionately with Hispanics—1.5 times greater compared to non-Hispanic whites and are more likely to experience complications as a result of the disease (CDC, 2003; American Diabetes Association, 2003). Based on a sample of 3.2050 Hispanics living in the Data from the Hispanic Health and Nutrition Examination Survey (HHANES 1982-84) showed an increased prevalence of diabetes in all Hispanic populations compared to non-Hispanic whites (Flegal, Ezzati, Harris, Haynes, Juarez, Knowler, Perez-Stabler, & Stern, 1991). In men and women, age 45-74 years, diabetes was found in 23.9% of Mexican-Americans, 26.1% of Puerto Ricans, and 15.8% of Cubans compared to 12% of non-Hispanic whites. A subsequent report showed the age-standardized prevalence of diabetes (diagnosed plus previously undiagnosed cases) was 13.4% in Puerto Ricans, 13% in Mexican-Americans, 9.3% in Cubans, and 6.2% in non-Hispanic whites (Harris, 1991). The age-standardized rates of impaired glucose tolerances, interestingly, were very comparable in the 4 populations. Increasing age, obesity, and family history of diabetes were associated with higher rates of diabetes, but gender, physical activity, education, income, and acculturation were not.

There has been a significant increasing trend in the incidence of Type 2 diabetes in Mexican-Americans and a borderline significant trend in NHW in the San Antonio Heart study (Burke, Williams, Gaskill, Hazuda, Haffner, & Stern, 1999). Unlike other cardiovascular risk factors, (e.g. lipid levels, smoking, and blood pressure) which are either declining or under progressively better medical management and control, and unlike cardiovascular mortality, which also is declining, obesity and type 2 diabetes show increasing trends.

Carter, Pugh, Monterrosa, (1996) published a comprehensive review of the prevalence and incidence data on diabetes in minority populations including a comparison between Hispanics and non-Hispanic whites. They compared diabetes complication rates and found that Hispanics had more end-stage renal disease (ESRD), albuminuria, and proteinuria, slightly more retinopathy, but comparable rates of lower extremity amputations and coronary artery disease when compared against NHW.

Findings from a study comparing rural Hispanic and non-Hispanic white elderly reported that highly acculturated Hispanics were more likely to have diabetes (Coronado, Thompson, Tejeda, Godina & Chen, 2007). Other findings of note in this study were a lower proportion of Hispanics who reported exercising regularly and less likely to use diet to manage their diabetes. An important qualitative study yielded findings that are critical for diabetes self-management. Two key factors that emerged in diabetes self-management included family support and religious faith (Carbone, Rosal, Torres, Goins & Bermudez, 2007).

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Malignancies

Cancer incidence rates have been monitored in Hispanic populations using cancer registries and compared to those in NHW whites in Florida, Texas, New Mexico, Illinois, California, Connecticut, and New York City. All have shown remarkably lower incidences of most cancers in Hispanics with the notable exception of cervical cancers in women. In New Mexico Hispanics were found to have lower rates for all cancers except those in the gall bladder, stomach, and cervix.
According to the American Cancer Society the median age at any cancer diagnoses was the youngest among Latinos at age 62 years (2006). Latino cancer incidence was the lowest within all age categories from 20 years to over 75, although prostate cancer in Latino men age 75 was higher than non-Hispanic whites of this same age group (American Cancer Society, 2006).

Studies in Florida compared the incidence of cancer between White Hispanic women and Black Hispanic women and their non-Hispanic counterparts in both races. Both white Hispanic and Black Hispanic women had lower cancer incidence rates than their non-Hispanic counterparts with the following exception: White Hispanic women had higher rates of cancer of the liver, gallbladder, and uterine cervix, when compared to NHW women (Trapido, Chen, Davis, Lewis, MacKinnon, & Strait, 1994).

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End-Stage Renal Disease (ESRD)

Male Hispanics had substantially higher proportions of ESRD attributed to diabetes than did Blacks or Whites, with notable regional differences. Based on the Medicare ESRD registry, between 1980 and 1990, the incidence of treated renal failure increased more in Hispanics than in Blacks or whites (Chiapella & Feldman, 1995). Once entered onto treatment (dialysis), Mexican Americans appear to have a survival advantage over NHW in most age, disease, and treatment groups (Pugh, Tuley, & Basu 1994). This survival advantage persisted for all disease etiologies combined, and for diabetic and hypertensive renal disease. The combination of an increased incidence of ESRD in Mexican-Americans and survival advantage means the cost for renal replacement therapy for Hispanics is disproportionately high.

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Hispanic/Latino Elders and End-of-Life Care

Hispanic/Latinos die at home more frequently as compared to other ethnic groups (Enguidanos, 2005). Generally they often underutilize hospice; however, the reasons remain unclear (Colon, 2005). Some reasons have been attributed to lack of insurance, lack of information, and living in a minority community (Haas, 2007). However, no studies have been conducted specifically in the elderly population. Those Hispanic/Latino patients that do receive hospice services are likely to prefer to speak Spanish with their providers. As expected, families were more involved in the care of Hispanic family members under the care of Hospice as compared with non-Hispanic white populations; but non-Hispanic elders do seem to make greater use of volunteer services from hospice program (Adams, 2006).

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