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Body Mass Index, Sex, and Cardiovascular Disease Risk Factors Among Hispanic/Latino Adults: Hispanic Community Health Study/Study of Latinos

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Background: All major Hispanic/Latino groups in the United States have a high prevalence of obesity, which is often severe. Little is known about cardiovascular disease (CVD) risk factors among those at very high levels of body mass index (BMI). Methods and results: Among US Hispanic men (N=6547) and women (N=9797), we described gradients across the range of BMI and age in CVD risk factors including hypertension, serum lipids, diabetes, and C-reactive protein. Sex differences in CVD risk factor prevalences were determined at each level of BMI, after adjustment for age and other demographic and socioeconomic variables. Among those with class II or III obesity (BMI ≥35 kg/m(2), 18% women and 12% men), prevalences of hypertension, diabetes, low high-density lipoprotein cholesterol level, and high C-reactive protein level approached or exceeded 40% during the fourth decade of life. While women had a higher prevalence of class III obesity (BMI ≥40 kg/m(2)) than did men (7% and 4%, respectively), within this highest BMI category there was a >50% greater relative prevalence of diabetes, hypertension, and hyperlipidemia in men versus women, while sex differences in prevalence of these CVD risk factors were ≈20% or less at other BMI levels. Conclusions: Elevated BMI is common in Hispanic/Latino adults and is associated with a considerable excess of CVD risk factors. At the highest BMI levels, CVD risk factors often emerge in the earliest decades of adulthood and they affect men more often than women.
Prevalence by age and body mass index category of cardiovascular disease risk factors: hypertension (upper left); diabetes (upper middle); high low‐density lipoprotein cholesterol (LDL‐C) level (upper right); low high‐density lipoprotein cholesterol (HDL‐C) level (lower left); hypertriglyceridemia (lower middle); high C‐reactive protein (CRP) level (lower right). Smoothed curves display the age‐ and sex‐specific prevalence of each CVD risk factor within groups defined by normal weight, BMI ≥18.5 and <25 kg/m2; overweight, BMI ≥25 and <30 kg/m2; class I obesity, BMI ≥30 and <35 kg/m2; and class II to III obesity, BMI ≥35 kg/m2. Black curves represent males and red curves represent females. Hypertension was defined as systolic blood pressure of ≥140 mm Hg, diastolic blood pressure of ≥90 mm Hg, or use of antihypertensive medication. Diabetes was defined as fasting plasma glucose of ≥126 mg/dL, 2‐hour postload glucose levels of ≥200 mg/dL, hemoglobin A1c level of ≥6.5%, or use of antidiabetic medication. High LDL‐C level was defined as (calculated) LDL‐C of ≥160 mg/dL or statin use. Low HDL‐C level was defined as <40 mg/dL in men and <50 mg/dL in women. Hypertriglyceridemia was defined as ≥200 mg/dL. High CRP was defined as 3 to 10 mg/L (individuals with CRP levels >10 mg/L were excluded from analyses). Smoothed curves were drawn by using local polynomials estimation using the svysmooth procedure with a bandwidth of 20 in the R statistical program. BMI indicates body mass index; CVD, cardiovascular disease.
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Body Mass Index, Sex, and Cardiovascular Disease Risk Factors
Among Hispanic/Latino Adults: Hispanic Community Health
Study/Study of Latinos
Robert C. Kaplan, PhD; M. Larissa Avil!
es-Santa, MD, PhD; Christina M. Parrinello, MPH; David B. Hanna, PhD; Molly Jung, MPH; Sheila F.
Casta~
neda, PhD; Arlene L. Hankinson, MD, MS; Carmen R. Isasi, MD, PhD; Orit Birnbaum-Weitzman, PhD; Ryung S. Kim, PhD; Martha L.
Daviglus, MD, PhD; Gregory A. Talavera, MD, MPH; Neil Schneiderman, PhD; Jianwen Cai, PhD
Background-All major Hispanic/Latino groups in the United States have a high prevalence of obesity, which is often
severe. Little is known about cardiovascular disease (CVD) risk factors among those at very high levels of body mass index
(BMI).
Methods and Results-Among US Hispanic men (N=6547) and women (N=9797), we described gradients across the range of BMI
and age in CVD risk factors including hypertension, serum lipids, diabetes, and C-reactive protein. Sex differences in CVD risk
factor prevalences were determined at each level of BMI, after adjustment for age and other demographic and socioeconomic
variables. Among those with class II or III obesity (BMI 35 kg/m
2
, 18% women and 12% men), prevalences of hypertension,
diabetes, low high-density lipoprotein cholesterol level, and high C-reactive protein level approached or exceeded 40% during the
fourth decade of life. While women had a higher prevalence of class III obesity (BMI 40 kg/m
2
) than did men (7% and 4%,
respectively), within this highest BMI category there was a >50% greater relative prevalence of diabetes, hypertension, and
hyperlipidemia in men versus women, while sex differences in prevalence of these CVD risk factors were !20% or less at other BMI
levels.
Conclusions-Elevated BMI is common in Hispanic/Latino adults and is associated with a considerable excess of CVD risk factors.
At the highest BMI levels, CVD risk factors often emerge in the earliest decades of adulthood and they affect men more often than
women. (J Am Heart Assoc. 2014;3:e000923 doi: 10.1161/JAHA.114.000923)
Key Words: BMI CVD risk factor Hispanic/Latino sex
Obesity has risen in prevalence in the United States over
time and has become increasingly severe, particularly in
Hispanics/Latinos, who make up a large share of the US
population.
13
All of the largest Hispanic/Latino groups in
the United States, including those of Mexican, Puerto Rican,
and Cuban background, have a high prevalence of obesity.
14
Risks of diabetes, hypertension, cardiovascular disease (CVD),
and mortality increase progressively at levels of body mass
index (BMI) far beyond the commonly used clinical thresholds
used to dene overweight and obesity (BMI 25 kg/m
2
and
30 kg/m
2
, respectively).
5
There may be sex differences in
the relationship between BMI and risk of CVD, which would
have clinical implications for the use of BMI cut points to
dene the level of CVD risk. For instance, among 221 934
persons in the Emerging Risk Factors Collaboration, the
hazard ratio (HR) for ischemic stroke associated with BMI was
signicantly larger in men (HR per 1 SD higher BMI=1.33)
than in women (HR per 1 SD higher BMI=1.20, Pfor
interaction by sex=0.030), whereas the association between
From the Department of Epidemiology and Population Health, Albert Einstein,
College of Medicine, Bronx, NY (R.C.K., C.M.P., D.B.H., M.J., C.R.I., R.S.K.);
Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute,
National Institutes of Health, Bethesda, MD (M.L.A.-S.); Department of
Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical
Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
(C.M.P.); Department of Preventive Medicine, Feinberg School of Medicine,
Northwestern University, Chicago, IL (A.L.H.); Institute for Minority Health
Research, University of Illinois-Chicago (M.L.D); Department of Psychology,
University of Miami, Miami, FL (N.S., O.B.-W.); Graduate School of Public
Health, San Diego State University, San Diego, CA (S.F.C., G.A.T.); and
Collaborative Studies Coordinating Center, Department of Biostatistics, Gillings
School of Global Public Health, University of North Carolina, Chapel Hill,
NC (J.C.).
Correspondence to: Robert C. Kaplan, PhD, Department of Epidemiology and
Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave,
Room 1315, Bronx, NY 10461. E-mail: robert.kaplan@einstein.yu.edu
Received March 5, 2014; accepted May 24, 2014.
ª2014 The Authors. Published on behalf of the American Heart Association,
Inc., by Wiley Blackwell. This is an open access article under the terms of the
Creative Commons Attribution-NonCommercial License, which permits use,
distribution and reproduction in any medium, provided the original work is
properly cited and is not used for commercial purposes.
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BMI and incident coronary heart disease events did not differ
by sex (Pfor interaction=0.643).
6
To date, obesity-related risk factors for CVD have not been
well studied in Hispanic/Latino adults, who, as a group, have
not only a high prevalence of obesity but also a predisposition
to obesity-related disorders such as diabetes and low high-
density lipoprotein cholesterol (HDL-C). We used the Hispanic
Community Health Study/Study of Latinos (HCHS/SOL)
cohort of >16 000 persons 18 to 74 years old to make
comparisons between men and women in the prevalence of
high BMI and in the BMI-specic prevalence of CVD risk
factors. Unusual features of the study include a diverse
population-based sample of Hispanic/Latino individuals,
inclusion of persons across a wide spectrum of age, and
large sample size with nearly 1000 individuals who met
World Health Organization criteria for severe obesity (BMI
40 kg/m
2
, also known as class III obesity).
Methods
Participants
HCHS/SOL is a study of 16 415 men and women recruited
during 20082011 in Bronx, NY, Chicago, IL, Miami, FL, and
San Diego, CA.
7,8
Within recruitment areas delineated in each
community, participants were identied and recruited by
sampling census block groups, households, and household
residents using a stratied multistage area probability sam-
pling approach. Eligible persons were community-dwelling
adults who were 18 to 74 years old at the time of screening,
who self-identied as Hispanic or Latino, who were not
pregnant or on active military duty, and who did not plan to
move from the study area in the near future. Sampling
methods were designed to yield a study-wide cohort of
!6000 participants aged 18 to 44 years and !10 000
participants aged 45 to 74 years. Of screened individuals who
were eligible, 41.7% were enrolled. This study was approved
by eld center institutional review boards, and subjects gave
informed consent.
Data Collection
Study examinations included clinical measurements, ques-
tionnaires, and venous blood specimens collected at fasting
and again after a 75-g glucose load. Measurements of lipids,
glucose, C-reactive protein (CRP), and hemoglobin A1c had
laboratory coefcients of variation between 0.8% and 4.7%.
Variable Denition
Self-report was used to dene smoking, alcohol use, place of
birth and family national background, medical history, and
socioeconomic status by using standardized instruments. Total
physical activity at work, travel, and leisure was measured
using the Global Physical Activity Questionnaire (GPAQ)
developed by the World Health Organization. GPAQ scores
for exercise intensity and type was created following the World
Health Organization guidelines (http://www.who.int/chp/
steps/en/). Medication use was ascertained by conducting
an inventory of all currently used medications. BMI was
calculated as measured weight in kilograms (Tanita Body
Composition Analyzer, TBF 300A) divided by the square of
measured height in meters (SECA 222; Perspective Enter-
prises, Inc). BMI categories were underweight, <18.5 kg/m
2
;
normal-weight, 18.5 kg/m
2
and <25 kg/m
2
; overweight,
25 kg/m
2
and <30 kg/m
2
; class I obesity, 30 kg/m
2
and
<35 kg/m
2
; class II obesity, 35 kg/m
2
and <40 kg/m
2
; and
class III obesity, 40 kg/m
2
. Blood pressures were dened as
the average of the second and third of 3 repeat seated
measurements obtained after a 5-minute rest (Omron
HEM-907 XL). Hypertension was dened as systolic blood
pressure of 140 mm Hg, diastolic blood pressure of
90 mm Hg, or use of antihypertensive medication. Diabetes
was dened as fasting plasma glucose of 126 mg/dL, 2-hour
postload glucose levels of 200 mg/dL, hemoglobin A1c level
of 6.5%, or use of antidiabetic medication. High low-density
lipoprotein cholesterol (LDL-C) was dened as (calculated)
LDL-C of 160 mg/dL or statin use. We used cut points of
<40 mg/dL to dene low HDL-C and 200 mg/dL to dene
hypertriglyceridemia. Additional analyses were conducted with
a cut point of 50 mg/dL used to dene low HDL-C level in
women. High CRP level was dened as 3 to 10 mg/L, with
levels >10 mg/L excluded from analyses.
9
Statistical Analyses
To obtain accurate population estimates of the prevalences of
BMI and CVD risk factors, we calculated nonresponse-
adjusted, trimmed, and calibrated sampling weights. The
sampling weights were calibrated to local age, sex, and
Hispanic/Latino background distributions in the 2010 US
Census and were normalized to the overall study cohort.
Individuals with missing BMI values (n=71) were excluded. We
examined the prevalence of BMI categories by age group and
sex, as well as the distribution of CVD risk factors across sex-
specic BMI categories. The CochranArmitage test was used
to test for trend in cross-tabulations between BMI category
and age group. The age-adjusted distribution of CVD risk
factors by BMI categories was estimated using survey logistic
regression with predicted marginals, adjusting each BMI level
to the age distribution of the target population of Hispanics/
Latinos in the 4 HCHS/SOL communities. After assigning
to each individual within a given BMI category the median
within-category BMI value, we tested for linear trend in
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prevalence of risk factors across BMI categories using survey
logistic regression procedures in SUDAAN. We used additional
models using squared terms to test for nonlinear associations
between BMI category and risk factor prevalence. In further
analyses, we plotted smoothed curves displaying the
age-specic prevalence of CVD risk factors within the
normal-weight, overweight, class I obese, and class II or III
(combined) obese groups by using local polynomials estima-
tion using the svysmooth procedure with a bandwidth of 20 in
the R statistical program. At each level of BMI, we estimated
the prevalence ratio (PR) for major CVD risk factors
(hypertension, diabetes, unfavorable lipid levels, and high
CRP level) comparing men versus women, again using survey
logistic regression with predicted marginals. These analyses
were adjusted for age, education, health insurance status,
eld center, national background (Mexican, Cuban, etc.),
nativity, smoking, alcohol use, and physical activity. In
sensitivity analyses, we found that differences in CVD risk
factor prevalence between men and women within the highest
BMI category (40 kg/m
2
) were similar when we excluded
individuals with BMI >45 kg/m
2
. Results were also similar
when we adjusted for residual differences within BMI category
in distribution of BMI levels between men and women. We
tested for evidence of effect modication by major national
background group for the sex differences described in Table 3.
This was done through inclusion of sex9background interac-
tion terms, and the test for the interaction terms was
conducted at a 0.05 signicance level. All statistical analyses
took into account the survey design and survey weights.
Analyses used SUDAAN version 11 (RTI International), SAS
version 9.3 (SAS Institute), and R version 2.14.2 (R Founda-
tion for Statistical Computing).
Results
BMI measures were available from 6547 Hispanic/Latino men
(mean age 40.2 years, SD 14.8 years) and 9797 Hispanic/
Latino women (mean age 41.8 years, SD 15.1 years)
(Figure 1). The largest group was of Mexican background
(37%), followed by persons of Cuban (20%), Puerto Rican
(16%), Dominican (10%), and Central or South American,
other, or multiple backgrounds (combined prevalence 17%).
Approximately one-third (34%) had less than a high school
education, 39% reported at least some college education, 46%
reported an annual household income of $20 000, and 20%
reported income >$40 000.
Prevalence and Correlates of Elevated BMI
Figure 1 shows the distribution of BMI levels. Among both
men and women, 22% had BMI in the normal range of 18.5 to
25 kg/m
2
. The proportion in the overweight range (BMI
25 kg/m
2
and <30 kg/m
2
) was 41% among men and 34%
among women. Men were less likely than women to have BMI
in the obesity range (BMI 30 kg/m
2
, 37% among men and
42% among women). Men were also less likely to meet criteria
for class II obesity (BMI 35 kg/m
2
and <40 kg/m
2
, 8%
among men and 11% among women) and class III obesity (BMI
40 kg/m
2
, 4% among men and 7% among women).
The distribution of subjects across BMI categories within
age groups differed between men and women (Table 1).
Among both men and women, the 18- to 24-year-old age
group had the highest prevalence of normal weight. Among
men, the 35- to 44-year-old age group had the lowest
prevalence of normal weight (12%), while among women the
prevalence of normal weight decreased progressively across
all age groups, reaching the lowest prevalence among the
oldest group of 65- to 74-year-old women (12% normal
weight). The highest BMI category, class III obesity, was more
common among men aged between 18 and 54 years with 4%
to 5% prevalence, compared with 2% among men aged
55 years. Among women, the 25- to 34-year-old age group
had the highest prevalence of BMI in the class III obesity
Figure 1. Distribution of body mass index among men and
women among participants in the Hispanic Community Health
Study/Study of Latinos (HCHS/SOL). Light gray bars represent
N=6547 men. Dark gray bars represent N=9797 women. Among
men, N (%) with normal weight N=1326 (22%), overweight
N=2739 (41%), class I obesity N=1667 (25%), class II obesity
N=516 (8%), and class III obesity N=248 (4%). Among women, N
(%) with normal weight N=1865 (22%), overweight N=3377 (34%),
class I obesity N=2552 (24%), class II obesity N=1192 (11%), and
class III obesity N=732 (7%). Minimum and maximum body mass
index values were 14.9 and 62.2 among women and 13.8 and
70.3 among men.
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range (9%). Average levels of all CVD risk factors tended to
worsen with higher level of BMI (Table 2).
Cardiovascular Disease Risk Factors Across the
Spectrum of BMI
Hypertension
The prevalence of hypertension increased consistently across
categories of BMI (Figure 2). After adjustment for age,
education, health insurance status, eld center, national
background, nativity, smoking, alcohol use, and physical
activity, the prevalence of hypertension was signicantly
higher among men than women (Table 3). Among those with
class III obesity, men had a 58% higher adjusted prevalence of
hypertension compared with women (adjusted PR, men versus
women=1.58, 95% CI=1.30 to 1.92), while the differences
between men and women in hypertension prevalence were
relatively modest within other BMI groups (range of adjusted
PRs, men versus women=1.17 to 1.30). The sex difference in
hypertension prevalence within the class III obesity group was
similar across national background groups (Pfor interac-
tion=0.73).
Diabetes mellitus
Diabetes mellitus rose in prevalence with increasing BMI
category in both men and women (Figure 2).Among persons
in the class III obese group, men were signicantly more likely
to have diabetes mellitus than women (adjusted PR=1.50,
95% CI=1.16 to 1.94) (Table 3). The sex difference in diabetes
mellitus prevalence within the class III obesity group was
similar across national background groups (Pfor interac-
tion=0.60). Within the other BMI categories, adjusted prev-
alence of diabetes was not signicantly different between
men and women.
Unfavorable serum lipid levels
Among men, high LDL-C level was less prevalent in the
normal-weight group as compared with the groups with
elevated BMI. However, the prevalence of high LDL-C level
among men did not increase across overweight and obese
groups (Figure 2). Among women, high LDL-C levels had a less
apparent association with BMI with neither a linear or quadratic
statistically signicant trend across categories. We observed
no signicant difference by sex in the adjusted prevalence of
high LDL-C levels, except in the group with class III obesity,
among whom high LDL-C levels was of 82% greater prevalence
in men than in women (Table 3). The prevalence ratios of high
LDL-C by sex were similar across national background groups
(P=0.76 for interaction by national background).
Compared with the normal-weight group, those with
progressively higher BMI tended to have greater prevalence
of low HDL-C levels (Figure 2). Women were signicantly
more likely than men to have low HDL-C levels when
sex-specic cut points were used to dene low HDL-C level
in women (Table 3). When the same cut point of <40 mg/dL
Table 1. Prevalence of Body Mass Index Categories Within Age Group Among Participants in the Hispanic Community Health
Study/Study of Latinos (HCHS/SOL)
Age Group, y, n (%)
18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 P
trend
Men (n=6547)
Underweight 25 (3) 1 (0) 6 (1) 5 (0) 13 (1) 1 (0) <0.0001
Normal weight 314 (39) 223 (24) 150 (12) 299 (17) 242 (18) 98 (20) <0.0001
Overweight 218 (28) 377 (41) 501 (43) 838 (46) 576 (44) 229 (46) <0.0001
Obese class I 140 (20) 221 (22) 337 (30) 490 (26) 352 (29) 127 (25) <0.0001
Obese class II 54 (6) 79 (8) 118 (10) 149 (7) 87 (6) 29 (7) 0.9846
Obese class III 34 (4) 39 (5) 51 (4) 85 (4) 27 (2) 12 (2) 0.0046
Women (n=9797)
Underweight 37 (5) 12 (1) 8 (0) 10 (0) 7 (1) 5 (0) <0.0001
Normal weight 362 (43) 280 (26) 350 (19) 469 (16) 305 (14) 99 (12) <0.0001
Overweight 218 (25) 374 (33) 631 (37) 1075 (35) 758 (37) 321 (40) <0.0001
Obese class I 146 (15) 246 (21) 435 (25) 840 (28) 627 (27) 258 (31) <0.0001
Obese class II 64 (7) 109 (10) 196 (11) 434 (14) 287 (14) 102 (11) <0.0001
Obese class III 49 (5) 108 (9) 158 (8) 218 (7) 158 (8) 41 (6) 0.4778
P
trend
calculated using CochranArmitage test. Body mass index categories were underweight, <18.5 kg/m
2
; normal weight, 18.5 kg/m
2
and <25 kg/m
2
; overweight, 25 kg/m
2
and <30 kg/m
2
; class I obesity, 30 kg/m
2
and <35 kg/m
2
; class II obesity, 35 kg/m
2
and <40 kg/m
2
; and class III obesity, 40 kg/m
2
.
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Table 2. Age-Adjusted Cardiovascular Disease Risk Factors by Body Mass Index Category, Among Men and Women in the
Hispanic Community Health Study/Study of Latinos (HCHS/SOL)
BMI class
Normal Weight,
n=1326 (22%)
Overweight,
n=2739 (41%)
Class I Obese,
n=1667 (25%)
Class II Obese,
n=516 (8%)
Class III Obese,
n=248 (4%)
Mean* (95% CI)
Men
Age, y
36 (35 to 37) 42 (41 to 43) 42 (41 to 43) 40 (39 to 42) 37 (35 to 39)
Systolic BP, mm Hg 121 (120 to 122) 123 (123 to 124) 125 (124 to 126) 127 (126 to 129) 127 (125 to 130)
Diastolic BP, mm Hg 69 (69 to 70) 73 (72 to 73) 76 (75 to 77) 78 (77 to 80) 82 (79 to 84)
LDL-C, mg/dL 114 (111 to 117) 124 (122 to 125) 125 (122 to 128) 121 (118 to 125) 116 (111 to 121)
HDL-C, mg/dL 50 (49 to 51) 45 (44 to 46) 42 (41 to 42) 40 (39 to 42) 40 (39 to 42)
Total cholesterol, mg/dL 186 (183 to 189) 197 (195 to 199) 200 (197 to 203) 193 (189 to 197) 188 (182 to 194)
Triglycerides, mg/dL 115 (108 to 122) 146 (140 to 151) 177 (165 to 189) 162 (152 to 172) 160 (149 to 172)
Fasting glucose, mg/dL 101 (99 to 102) 103 (102 to 105) 106 (104 to 108) 110 (106 to 114) 122 (114 to 131)
2-hour glucose, mg/dL 104 (101 to 106) 111 (109 to 113) 120 (118 to 122) 128 (123 to 133) 128 (120 to 135)
Hemoglobin A1c, % 5.6 (5.6 to 5.7) 5.7 (5.6 to 5.8) 5.8 (5.7 to 5.9) 6.1 (5.9 to 6.2) 6.5 (6.3 to 6.7)
C-reactive protein, g/L 1.4 (1.3 to 1.5) 1.8 (1.7 to 1.9) 2.6 (2.5 to 2.8) 3.5 (3.3 to 3.8) 4.4 (4.0 to 4.9)
No. (%)
Nativity
Within 50 states 296 (23) 393 (22) 294 (26) 143 (33) 110 (48)
Outside of 50 states 1025 (77) 2340 (78) 1366 (74) 372 (67) 137 (52)
Less than high school
education
482 (33) 1053 (32) 614 (31) 177 (33) 68 (25)
Income
$40 000 930 (43) 2024 (41) 1224 (39) 362 (40) 167 (37)
$40 001 to $75 000 180 (50) 419 (50) 248 (53) 89 (52) 48 (56)
>$75 000 70 (7) 141 (8) 99 (8) 35 (8) 18 (7)
Normal Weight,
n=1865 (22%)
Overweight,
n=3377 (34%)
Class I Obese,
n=2552 (24%)
Class II Obese,
n=1192 (11%)
Class III Obese,
n=732 (7%)
Mean* (95% CI)
Women
Age, y
36 (35 to 37) 43 (43 to 44) 45 (44 to 46) 44 (43 to 46) 42 (39 to 44)
Systolic BP, mm Hg 114 (113 to 115) 117 (116 to 118) 118 (117 to 119) 119 (118 to 121) 118 (116 to 119)
Diastolic BP, mm Hg 67 (66 to 67) 70 (70 to 71) 73 (72 to 73) 76 (75 to 77) 76 (75 to 77)
LDL-C, mg/dL 114 (112 to 116) 121 (119 to 123) 120 (118 to 122) 117 (114 to 119) 119 (115 to 123)
HDL-C, mg/dL 58 (57 to 59) 52 (51 to 53) 49 (49 to 50) 48 (47 to 49) 46 (46 to 47)
Total cholesterol, mg/dL 191 (189 to 194) 197 (195 to 199) 196 (193 to 198) 192 (189 to 195) 191 (186 to 195)
Triglycerides, mg/dL 97 (94 to 100) 121 (118 to 125) 131 (126 to 135) 138 (130 to 145) 125 (119 to 131)
Fasting glucose, mg/dL 95 (94 to 97) 97 (96 to 99) 103 (101 to 105) 105 (101 to 108) 109 (105 to 113)
2-hour glucose, mg/dL 112 (110 to 113) 119 (117 to 121) 128 (125 to 131) 133 (130 to 137) 133 (128 to 138)
Hemoglobin A1c, % 5.5 (5.5 to 5.6) 5.6 (5.6 to 5.7) 5.9 (5.8 to 5.9) 5.9 (5.8 to 6.0) 6.1 (6.0 to 6.3)
C-reactive protein, g/L 1.6 (1.5 to 1.7) 2.6 (2.4 to 2.7) 3.6 (3.4 to 3.7) 4.5 (4.3 to 4.8) 5.1 (4.8 to 5.4)
Continued
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was used in both men and women, men were signicantly
more likely than women to have low HDL-C levels at all levels
of BMI.
Among men and women, the prevalence of hypertrigly-
ceridemia was lower among normal-weight persons than
among those with BMI 25 kg/m
2
(Figure 2). However, the
prevalence of hypertriglyceridemia did not have increasing
frequency across overweight and obese groups. The
adjusted prevalence of hypertriglyceridemia was !2-fold
higher among men than women at any given level of BMI
(Table 3).
High CRP levels
The prevalence of high CRP level increased markedly with
each progressively higher BMI category (Figure 2). At a given
level of BMI, prevalence of high CRP level was signicantly
higher among women than among men (Table 3).
Age-Specic Association Between Elevated BMI
and Prevalent CVD Risk Factors
Analyses relating BMI with CVD risk factors at different ages
(Figure 3) recapitulated the overall (age-adjusted) associa-
tions between BMI and cardiovascular risk factors that appear
in Figure 2. The increase in prevalences of hypertension and
diabetes at higher levels of BMI was relatively consistent
across the observed age range of 18 to 74 years. For other
risk factors including low HDL-C level and high CRP level, the
differences in prevalence comparing overweight or obese
individuals versus normal-weight individuals were larger
among younger age groups than among older age groups.
Among those with class II or class III obesity, by the
fourth decade of life, individual CVD risk factors including
hypertension, diabetes, low HDL-C level, and high CRP level
were present among 40% of individuals.
Discussion
BMI is an easily obtained measure to estimate adiposity that
is widely used for identifying individuals at increased risk of
adiposity-related health outcomes and for setting body weight
targets for patients attempting to lose weight.
10,11
In a study
of >16 000 Hispanic/Latino adults aged 18 to 74 years old,
our analyses characterizing the joint prevalences of high BMI
levels and CVD risk factors suggest several conclusions. First,
obesity was not only prevalent but also tended to be severe as
dened by BMI level, particularly among young Latino adults.
Second, women were more likely than men to have class III
obesity (BMI 40 kg/m
2
). Yet, at these very high levels of
BMI, relative to women, men were disproportionately affected
by unfavorable metabolic CVD risk factors. Third, high BMI
had a more pronounced association with prevalence of CVD
risk factors among individuals at younger ages. For several
CVD risk factors, including low HDL-C level and high CRP
level, we observed an especially steep gradient in these risk
factors across the spectrum of BMI among younger as
opposed to older adults. Moreover, among individuals with
class II or class III obesity (BMI 35 kg/m
2
), prevalence of
hypertension, diabetes, low HDL-C levels, and high CRP levels
approached or exceeded 40% in the fourth decade of life.
Our ndings are yet another indicator of the vast morbidity,
health care needs, and costs to society that are attributed not
only to the presence but also the severity of obesity in the
United States.
1214
One in 5 women and 1 in 10 men had BMI
of 35 kg/m
2
, which denes class II or III obesity. The most
severe form of obesity, class III, disproportionately affected
Table 2. Continued
Normal Weight,
n=1865 (22%)
Overweight,
n=3377 (34%)
Class I Obese,
n=2552 (24%)
Class II Obese,
n=1192 (11%)
Class III Obese,
n=732 (7%)
No. (%)
Nativity
Within 50 states 358 (19) 424 (18) 370 (20) 217 (25) 199 (36)
Outside of 50 states 1500 (81) 2943 (82) 2173 (80) 970 (75) 529 (64)
Less than high school education 564 (27) 1269 (33) 1077 (37) 478 (36) 283 (36)
Income
$40 000 1355 (46) 2605 (52) 1949 (53) 920 (55) 583 (53)
$40 001 to $75 000 221 (48) 328 (44) 269 (43) 132 (43) 65 (44)
>$75 000 71 (6) 91 (4) 69 (3) 27 (2) 22 (3)
Body mass index categories were normal weight, 18.5 kg/m
2
and <25 kg/m
2
; overweight, 25 kg/m
2
and <30 kg/m
2
; class I obesity, 30 kg/m
2
and <35 kg/m
2
; class II obesity,
35 kg/m
2
and <40 kg/m
2
; and class III obesity, 40 kg/m
2
. BP indicates blood pressure; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol. Values
presented in table are unweighted counts of participants. Other gures are weighted to reect the sampling design.
*Adjusted for age.
Not adjusted for age.
DOI: 10.1161/JAHA.114.000923 Journal of the American Heart Association 6
BMI, Sex, and CVRFs Among Hispanic/Latino Adults Kaplan et al
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AB
CD
EF
Figure 2. Age-adjusted prevalence by sex and body mass index category of cardiovascular disease risk
factors: hypertension (A), diabetes (B), high low-density lipoprotein cholesterol (LDL-C) level (C), low high-density
lipoprotein cholesterol (HDL-C) level (D), hypertriglyceridemia (E), and high C-reactive protein (CRP) level (F).
Sex-specic age-adjusted prevalence of each CVD risk factor within groups dened by normal weight, BMI 18.5
and <25 kg/m
2
; overweight, BMI 25 and <30 kg/m
2
; class I obesity, BMI 30 and <35 kg/m
2
; and class II to
III obesity, BMI 35 kg/m
2
. Hypertension was dened as systolic blood pressure of 140 mm Hg, diastolic
blood pressure of 90 mm Hg, or use of antihypertensive medication. Diabetes was dened as fasting plasma
glucose of 126 mg/dL, 2-hour postload glucose levels of 200 mg/dL, hemoglobin A1c level of 6.5%, or use
of antidiabetic medication. High LDL-C level was dened as (calculated) LDL-C of 160 mg/dL or statin use.
Low HDL-C level was dened as <40 mg/dL in men and <50 mg/dL in women. Hypertriglyceridemia was
dened as 200 mg/dL. High CRP was dened as 3 mg/L to 10 mg/L (individuals with CRP levels >10 mg/L
were excluded from analyses). Test for linear trend across BMI categories was P<0.001 for all analyses except
for LDL-C in women, which suggested neither linear (P=0.381) nor quadratic (P=0.644) trends across BMI
category. BMI indicates body mass index.
DOI: 10.1161/JAHA.114.000923 Journal of the American Heart Association 7
BMI, Sex, and CVRFs Among Hispanic/Latino Adults Kaplan et al
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younger Hispanic/Latino adults. This was especially the case
among women, who had peak prevalence of BMI 40 kg/m
2
in the 25- to 34-year-old age group (9% prevalence).
Individuals with high BMI had a high prevalence both of
traditional CVD risk factors (diabetes, hypertension, high LDL-
C level, and low HDL-C level), as well as emerging risk factors
such as hypertriglyceridemia and high CRP level, which may
confer additional risk of CVD in the extremely obese beyond
that captured by standard clinical disease risk scores.
15
It has previously been shown that the magnitude of the
association between elevated BMI and coronary heart disease
mortality is nearly identical in men and in women. Relative
risks of stroke associated with high BMI, however, are larger
in men than in women.
6
Data from population samples have
not characterized in detail the sex-specic CVD risk proles of
individuals at the highest levels of BMI. Our data raise
questions about whether traditional BMI cut points to dene
classes of obesity stratify total CVD risks equally well in men
and women, particularly at the extreme upper ranges.
Diabetes mellitus and high LDL-C level had comparable
prevalence in men and women at BMI levels <40 kg/m
2
, but
in the most severely obese group (class III obesity) men had
50% greater prevalence of diabetes and 75% greater preva-
lence of hypercholesterolemia than did women. Gender
differences in blood pressure also became more dramatic
with severe obesity, with men having 60% greater hyperten-
sion prevalence than women among the class III obesity group
compared with <20% higher prevalence in the other BMI
categories. Thus, we hypothesize that when patients reach
the upper range of BMI, sex differences emerge that pose an
especially important relative hazard of CVD, and therefore a
greater need for intervention, among men than among
women.
This large contemporary study examined CVD risk factors
in >16 000 Latino adults, including 980 who met criteria for
class III obesity. Few population-based samples of any race or
ethnic description have had sufcient numbers of individuals
in the upper range of BMI to shed light on population CVD risk
associated with class III obesity.
5
While we did not address
race/ethnicity comparisons directly in our study, prior data
suggest that Hispanics and other minority groups may have
increased cardiometabolic risk both because of, and inde-
pendent of, their increased risk of suffering from obesity. In
the San Antonio Heart Study, Mexican American individuals
had higher prevalence of diabetes than non-Hispanic whites at
all levels of skinfold thickness.
16
The San Antonio Heart Study
data among US Hispanics mirror other ndings suggesting
increased obesity-independent risk of diabetes among popu-
lations that have immigrated from low- and middle-income
countries to Western societies. For instance, in Ontario,
Canada, black and Asian adults, most of whom were
immigrants, had increased diabetes risk compared with
Table 3. Adjusted Sex Prevalence Ratio (Men Versus Reference Group of Women) for Presence of Cardiovascular Disease Risk Factors, Within Categories of Body Mass
Index, Among Participants in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)
BMI Class
Hypertension Diabetes High LDL-C Level Low HDL-C Level* Low HDL-C Level
High Triglyceride Level
High C-Reactive
Protein Level
PR 95% CI PR 95% CI PR 95% CI PR 95% CI PR 95% CI PR 95% CI PR 95% CI
Normal weight 1.17 0.96 to 1.43 1.28 0.90 to 1.80 0.92 0.72 to 1.18 2.51 1.94 to 3.26 0.61 0.51 to 0.72 1.82 1.18 to 2.80 0.66 0.48 to 0.92
Overweight 1.21 1.07 to 1.36 1.23 1.03 to 1.48 1.10 0.97 to 1.25 2.72 2.29 to 3.23 0.74 0.67 to 0.82 2.03 1.69 to 2.44 0.53 0.46 to 0.60
Obese I 1.18 1.04 to 1.34 0.92 0.78 to 1.07 1.19 1.00 to 1.43 2.17 1.83 to 2.58 0.86 0.77 to 0.95 2.14 1.79 to 2.57 0.64 0.56 to 0.73
Obese II 1.30 1.09 to 1.55 1.23 1.00 to 1.52 1.18 0.92 to 1.51 2.31 1.84 to 2.89 0.79 0.68 to 0.91 1.75 1.26 to 2.42 0.68 0.58 to 0.79
Obese III 1.58 1.30 to 1.92 1.50 1.16 to 1.94 1.82 1.29 to 2.56 2.05 1.58 to 2.66 0.72 0.60 to 0.86 2.15 1.41 to 3.27 0.85 0.73 to 0.99
Body mass index categories were normal weight, 18.5 kg/m
2
and <25 kg/m
2
; overweight, 25 kg/m
2
and <30 kg/m
2
; class I obesity, 30 kg/m
2
and <35 kg/m
2
; class II obesity, 35 kg/m
2
and <40 kg/m
2
; and class III obesity,
40 kg/m
2
. Hypertension was dened as systolic blood pressure of greater than or equal to 140 mm Hg, diastolic blood pressure was greater than or equal to 90 mm Hg or use of antihypertensive medication. Diabetes was dened as
fasting plasma glucose of 126 mg/dL or higher, 2-hour cholesterol level was dened as 160 mg/dL or higher, or statin use. Low high-density lipoprotein level was dened a >40 mg/dL in both men and women, or alternatively as <40 mg/
dL in men and <50 mg/dL in women (sex-specic threshold). Hypertriglyceridemia was dened as 200 mg/dL. High C-reactive protein level was dened as 3 to 10 mg/dL, with exclusion of individuals with C-reactive protein levels above
10 mg/L. Prevalence ratio was adjusted for age, level of education, current health insurance status, eld center, national background, nativity, smoking, alcohol use, and physical activity. Women represent the reference group for PR
estimates. BMI indicates body mass index; HDL-C, High-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; PR, prevalence ratio.
*Uniform threshold in men and women.
Sex-specic threshold.
DOI: 10.1161/JAHA.114.000923 Journal of the American Heart Association 8
BMI, Sex, and CVRFs Among Hispanic/Latino Adults Kaplan et al
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whites at all levels across the BMI spectrum.
17
Analyses of
our HCHS/SOL Hispanic cohort reveal an overall diabetes
prevalence of 16.9%, which is intermediate between contem-
poraneous published prevalences of 10.2% among non-
Hispanic whites and 18.7% among non-Hispanic blacks in
the US National Health and Nutrition Examination Survey.
18
On the other hand, the SAHS found similar or lower
prevalence of hypertension in Mexican Americans compared
with non-Hispanic whites.
19
This is also consistent with
comparisons among specic racial/ethnic groups within the
US National Health and Nutrition Examination Survey and our
own HCHS/SOL population.
20,21
Limitations of our study included a lack of data on
incident CVD events, leading us to rely instead on risk
factors that predict future CVD risk. However, traditional
CVD risk factors such as those studied here appear largely
AB C
DE F
Figure 3. Prevalence by age and body mass index category of cardiovascular disease risk factors: hypertension (upper left); diabetes (upper
middle); high low-density lipoprotein cholesterol (LDL-C) level (upper right); low high-density lipoprotein cholesterol (HDL-C) level (lower left);
hypertriglyceridemia (lower middle); high C-reactive protein (CRP) level (lower right). Smoothed curves display the age- and sex-specic
prevalence of each CVD risk factor within groups dened by normal weight, BMI 18.5 and <25 kg/m
2
; overweight, BMI 25 and <30 kg/m
2
;
class I obesity, BMI 30 and <35 kg/m
2
; and class II to III obesity, BMI 35 kg/m
2
. Black curves represent males and red curves represent
females. Hypertension was dened as systolic blood pressure of 140 mm Hg, diastolic blood pressure of 90 mm Hg, or use of
antihypertensive medication. Diabetes was dened as fasting plasma glucose of 126 mg/dL, 2-hour postload glucose levels of 200 mg/dL,
hemoglobin A1c level of 6.5%, or use of antidiabetic medication. High LDL-C level was dened as (calculated) LDL-C of 160 mg/dL or statin
use. Low HDL-C level was dened as <40 mg/dL in men and <50 mg/dL in women. Hypertriglyceridemia was dened as 200 mg/dL. High
CRP was dened as 3 to 10 mg/L (individuals with CRP levels >10 mg/L were excluded from analyses). Smoothed curves were drawn by using
local polynomials estimation using the svysmooth procedure with a bandwidth of 20 in the R statistical program. BMI indicates body mass index;
CVD, cardiovascular disease.
DOI: 10.1161/JAHA.114.000923 Journal of the American Heart Association 9
BMI, Sex, and CVRFs Among Hispanic/Latino Adults Kaplan et al
ORIGINAL RESEARCH
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to explain the excess obesity-related mortality and coronary
heart disease risks.
5
Our observational, cross-sectional study
data do not address what might be the benets of weight
reduction in the obese population.
22
Comparisons of CVD
risk factors across BMI categories were potentially con-
founded by unmeasured factors or differences in response
rates by BMI. However, patterns of variation in risk factor
prevalences by BMI, age, and sex were generally as
expected, and a variety of confounding variables were
considered. The present study was limited to a population-
based sample of Hispanics and Latinos recruited from 4
urban centers with an imperfect response rate. However, our
observed BMI distribution was similar to that among
Hispanic/Latino adults in the contemporaneous 2009
2010 US National Health and Nutrition Examination Survey.
1
Moreover, the centers represented in HCHS/SOL reect the
majority of the US Hispanic/Latino population, which is
largely concentrated within a small number of urban centers
in the United States.
23
Conclusions
We provide some of the rst large-scale data on BMI and CVD
risk factors in the Hispanic/Latino adult population, among
whom the obesity epidemic is markedly severe, especially in
the youngest generations.
24
While it is recognized that CVD
risk factor proles in general worsen with higher BMI, our data
suggest that severe obesity may be associated with a
considerable excess in CVD risk mediated by known CVD
risk factors. Class III obesity (BMI 40 kg/m
2
) was more
common among women than among men in the Hispanic
population sampled for the HCHS/SOL cohort. At the same
time, we nd that the tendency for men to have more
unfavorable CVD risk factor status as compared with women
is most pronounced at very high levels of BMI. Finally,
individuals with severe obesity have a very high prevalence of
known CVD risk factors even in the earliest decades of
adulthood, auguring an extremely high lifetime risk of
morbidity and mortality.
Acknowledgments
The Helen Riaboff Whiteley Center at University of Washington Friday
Harbor Laboratories is gratefully acknowledged for facilitating the
completion of this work.
The Hispanic Community Health Study/Study
of Latinos Investigators
Program Ofce: National Heart, Lung, and Blood Institute, Bethesda,
MD: Larissa Avil!
es-Santa, Paul Sorlie, Lorraine Silsbee. Field Centers:
Bronx Field Center, Albert Einstein School of Medicine, Bronx, NY:
Robert Kaplan, Sylvia Wassertheil-Smoller. Chicago Field Center,
Northwestern University Feinberg School of Medicine and University
of Illinois at Chicago: Martha L. Daviglus, Aida L. Giachello, Kiang Liu.
Miami Field Center, University of Miami, Miami, FL: Neil Schneider-
man, David Lee, Leopoldo Raij. San Diego Field Center, San Diego
State University and University of California, San Diego: Greg
Talavera, John Elder, Matthew Allison, Michael Criqui. Coordinating
Center: University of North Carolina, Chapel Hill: Jianwen Cai,
Gerardo Heiss, Lisa LaVange, Marston Youngblood. Central Labora-
tory: University of Minnesota, Minneapolis: Bharat Thyagarajan, John
H. Eckfeldt. Central Reading Centers: Audiometry Center: University
of Wisconsin: Karen J. Cruickshanks. ECG Reading Center: Wake
Forest University: Elsayed Soliman. Neurocognitive Reading Center:
University of Mississippi Medical Center: Hector Gonzales, Thomas
Mosley. Nutrition Reading Center. University of Minnesota: John H.
Himes. Pulmonary Reading Center: Columbia University: R. Graham
Barr, Paul Enright. Sleep Center: Case Western Reserve University:
Susan Redline.
Sources of Funding
The Hispanic Community Health Study/Study of Latinos was
supported by contracts from the National Heart, Lung, and
Blood Institute (NHLBI) to the University of North Carolina
(N01-HC65233), University of Miami (N01-HC65234), Albert
Einstein College of Medicine (N01-HC65235), Northwestern
University (N01-HC65236), and San Diego State University
(N01-HC65237). The following institutes/ofces contribute to
the HCHS/SOL baseline examination through a transfer of
funds to the NHLBI: National Institute on Minority Health and
Health Disparities, the National Institute of Deafness and
Other Communications Disorders, the National Institute of
Dental and Craniofacial Research, the National Institute of
Diabetes and Digestive and Kidney Diseases, the National
Institute of Neurological Disorders and Stroke, and the Ofce
of Dietary Supplements.
Disclosures
None.
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DOI: 10.1161/JAHA.114.000923 Journal of the American Heart Association 11
BMI, Sex, and CVRFs Among Hispanic/Latino Adults Kaplan et al
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Kim, Martha L. Daviglus, Gregory A. Talavera, Neil Schneiderman and Jianwen Cai
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Adults: Hispanic Community Health Study/Study of Latinos
Body Mass Index, Sex, and Cardiovascular Disease Risk Factors Among Hispanic/Latino
Online ISSN: 2047-9980
Dallas, TX 75231
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Objective: To explore biochemical and lipid parameters in the serum of type 2 diabetes mellitus (T2DM) patients with obesity having cardiovascular disease from Northern India. Methods: We enrolled 450 subjects out of which 167 type 2 diabetes mellitus patients were obese having cardiovascular disease, 166 were obese with type 2 diabetes mellitus and 117 were type 2 diabetes mellitus patients without any complication. The circulating serum biomarker such as low-density lipoprotein, high-density lipoprotein, very low density lipoprotein, Triglyceride, Creatinine, Fasting blood sugar etc were analysed by biochemical methods and enzyme linked immunosorbent assay (ELISA). Results: The low density lipoprotein was significantly higher whereas reduced high density lipoprotein was observed in obese type 2 diabetes mellitus patients with cardiovascular disease as compared to T2DM and T2DM with obese patients. Conclusions: Significant differentiation in lipid profile and biochemical markers between all three groups shows that North Indian patients having T2DM and obesity are at higher risk of developing cardiovascular complications.
... Although limited prospective data exist on the etiology of weight gain in this understudied population, it is thought that such within group differences may reflect differential exposures to either demographic or sociocultural risk factors (e.g. nativity, age at immigration, acculturative stress, etc.) for weight gain, or differential experiences with obesity-related health conditions later in adulthood [6][7][8]. ...
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Background United States (US) Hispanic/Latinos experience a disproportionate burden of obesity, which may in part be related to demographic or sociocultural factors, including acculturation to an US diet or inactive lifestyle. Therefore, we sought to describe the association between adulthood weight histories and demographic and sociocultural factors in a large diverse community-based cohort of US Hispanic/Latinos. Methods We estimated the effect of several factors on weight gain across adulthood, using multivariable linear mixed models to leverage 38,759 self-reported current body weights and weight histories recalled for 21, 45 and 65 years of age, from 15,203 adults at least 21 years of age at the baseline visit of the Hispanic Community Health Study/Study of Latinos (2008–2011). Results The average rate of weight gain was nearly 10 kg per decade in early adulthood, but slowed to < 5 kg a decade among individuals 60+ years of age. Birth cohort, gender, nativity or age at immigration, Hispanic/Latino background, and study site each significantly modified the form of the predicted adulthood weight trajectory. Among immigrants, weight gain during the 5 years post-migration was on average 0.88 kg (95% CI: 0.04, 1.72) greater than the weight gain during the 5 years prior. The rate of weight gain appeared to slow after 15 years post-migration. Conclusions Using self-reported and weight history data in a diverse sample of US Hispanic/Latinos, we revealed that both demographic and sociocultural factors were associated with the patterning of adulthood weight gain in this sample. Given the steep rate of weight gain in this population and the fact that many Hispanic/Latinos living in the US immigrated as adults, efforts to promote weight maintenance across the life course, including after immigration, should be a top priority for promoting Hispanic/Latino health and addressing US health disparities more broadly.
... Metabolic disease conditions are a major health concern for Latina immigrants. Findings from the Hispanic Community Health Study/Study of Latinos (N=16,415) indicate that 45% of first-generation Latina immigrants (ie, Latinas born outside of the United States) are obese [1] and 17% have type 2 diabetes [2]. In comparison, national surveys estimate the prevalence of these conditions as 38% and 7%, respectively, among non-Latina White women and 40% and 9% among the US population as a whole [3,4]. ...
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Background Metabolic diseases, including obesity and type 2 diabetes, are a major health concern for Latina immigrants. Performing regular aerobic physical activity (PA) is a lifestyle behavior associated with the prevention and control of these conditions. However, PA levels of most Latina immigrants are below national guidelines. Neighborhood environmental factors may influence the PA levels of adults, but limited research has explored associations between the neighborhood environment and PA levels among Latina immigrants. Objective The objective of this study was to explore the PA patterns of first-generation US Latina immigrants and how neighborhood environmental factors are related to those PA patterns. Methods Using a cross-sectional study design, 50 first-generation Latina immigrants completed the International Physical Activity Questionnaire (IPAQ) and the Neighborhood Scales Questionnaire, which assessed 6 perceived neighborhood factors: (1) walking environment, (2) aesthetic quality, (3) safety, (4) violence, (5) social cohesion, and (6) activities with neighbors. Median self-reported metabolic equivalent (MET)-minutes/week of PA were used to summarize domain-specific (ie, work, domestic/household, leisure, and transportation) and intensity-specific (ie, walking, moderate, vigorous, moderate to vigorous) PA patterns. Logistic regression examined associations between neighborhood factors and engaging in leisure-time PA (ie, dichotomous outcome of some versus no leisure-time PA), transportation PA (ie, dichotomous outcome of some versus no transportation PA), and meeting national PA guidelines (ie, dichotomous outcome of meeting versus not meeting guidelines). ResultsPreliminary analyses showed that 10 participants reported excessively high PA levels and 1 participant had incomplete PA data; these women were excluded from analyses based on IPAQ scoring guidelines. The remaining 39 participants (mean age 40.5 years; mean length of US residency 4.6 years) reported a median of 4512 MET-minutes/week of total PA. The majority of PA was acquired through domestic activities (median 2160 MET-minutes/week), followed by leisure-time PA (median 396 MET-minutes/week), transportation PA (median 198 MET-minutes/week), and work PA (0 MET-minutes/week). Intensity-specific PA patterns showed a median of 594 MET-minutes/week of walking activity and 3500 MET-minutes/week of moderate-to-vigorous PA. Logistic regression models indicated that the neighborhood factors of walking environment, aesthetic quality, and safety were positively associated with engaging in leisure-time PA (odds ratios of 5.95, 95% CI 1.49-23.74; 2.45, 95% CI 1.01-5.93; and 3.30, 95% CI 1.26-8.67, respectively) and meeting national PA guidelines (odds ratios of 4.15, 95% CI 1.13-15.18; 6.43, 95% CI 1.45-28.39; and 2.53, 95% CI 1.00-6.36, respectively). The neighborhood factors of violence, social cohesion, and activities with neighbors were not significantly associated with PA outcomes. Conclusions Although most participants met national PA guidelines (ie, ≥500 MET-minutes/week of moderate-to-vigorous PA), the majority of their PA was achieved through domestic activities, with limited leisure, transportation, and work PA. Given that leisure-time PA in particular plays a significant role in improving health outcomes, findings suggest that many Latina immigrants could benefit from a leisure-time PA intervention. Such interventions should consider neighborhood environmental influences, as these factors may serve as determinants of PA.
... In this study adults with lesser volume of MVPA had increases in all the cardiometabolic biomarkers over time except for LDL cholesterol; these increases were not statistically significantly different from adults meeting MVPA guidelines except for fasting glucose in the overall group and in fasting glucose and HOMA-IR in the healthiest group (normoglycemic without cardiovascular disease.) These data suggest that an active lifestyle may blunt the association of advancing age with worsening cardiometabolic risk factors [34]. ...
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Background Whether physical activity can reduce cardiometabolic risk particularly in understudied populations such as US Hispanics/Latinos is of public health interest. We prospectively examined the association of physical activity and cardiometabolic biomarkers in n = 8049 participants of the Hispanic Community Health Study/Study of Latinos, a community-based cohort study of 16,415 adults aged 18–74 yr who self-identified as Hispanic/Latino from four US urban centers. Methods We assessed physical activity using accelerometry in 2008–2011 at visit 1. We assessed cardiometabolic biomarkers twice: once at visit 1 and collected a second measure in 2014–2017 at visit 2. We used survey linear regression models with changes in cardiometabolic markers as the dependent variables and quartiles of sedentary behavior or whether adults met guidelines for moderate-to-vigorous physical activity as the independent variables. Results In normoglycemic adults without cardiovascular disease, but not in adults with evidence of cardiometabolic disease, those who were in the lowest quartile for sedentary behavior (< 10.08 h/day) had a significant decline in mean LDL-cholesterol of − 3.94 mg/dL (95% CI: − 6.37, − 1.52) compared to adults in the highest quartile (≥13.0 h/day) who exhibited a significant increase in LDL-cholesterol of 0.14 mg/dL (95% CI, − 2.15,2.42) over the six year period ( P < 0.02 in fully adjusted models.) There was also a trend toward lower mean increase in HbA1c comparing the lowest with the highest quartile of sedentary behavior. Overall regardless of glycemic level or evidence of cardiometabolic disease, adults who met guidelines for moderate-to-vigorous physical activity at visit 1, had significantly lower mean increases in level of fasting glucose compared to adults not meeting guidelines in fully adjusted models. Conclusions In this cohort of Hispanics/Latinos, being free of cardiometabolic disease and having low levels of sedentary behavior were associated with health benefits. Among all adults regardless of cardiometabolic disease, meeting guidelines for moderate-to-vigorous physical activity was associated with health benefits. Overall these data suggest that an active lifestyle may blunt the association of advancing age with worsening cardiometabolic risk factors.
Article
Objective: To investigate whether the association of chronic stress with obesity is independent of genetic risk and test whether it varies by the underlying genetic risk. Methods: The analysis included data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a community-based study of Hispanic/Latinos living in four US communities (Bronx, NY, Chicago, IL, Miami, FL, San Diego, CA). The sample consisted of 5336 women and 3231 men who attended the HCHS/SOL second in-person examination and had measures of obesity, chronic stress and were genotyped. Chronic stress burden was assessed by an 8-item scale. An overall polygenic risk score (PRS) was calculated based on the summary statistics from GIANT and UK BioBank meta-analysis of BMI GWAS. Mixed effect models were used to account for genetic relatedness and sampling design, as well as to adjust for potential confounders. Results: A higher number of chronic stressors was associated with both BMI [β (log odds) = 0.31(95% Confidence Interval 0.23,0.38)] and obesity [β (log odds) = 0.10 (95% Confidence Interval 0.07,0.13)], after adjustment for covariates and genetic risk. No interactions were found between chronic stress and the genetic risk score for BMI or obesity. Conclusions: We did not find evidence for an interaction between chronic stress and PRS, which was not consistent with other publications that showed greater BMI or obesity in the groups with high stressors and elevated genetic risk.
Chapter
Hispanics constitute the largest growing ethnic group in the United States (US). They are disproportionately affected by cardiovascular (CV) risk factors and despite accounting for a large sector of the population, as the largest ethnic minority in the US, until recently they were unaccounted for in clinical guidelines and public health policies. Hispanics are a heterogeneous group whose members come from different countries of mixed racial backgrounds (with some generalizations, Caucasian in South America, Amerindian in Central America and Mexico, and African in the Caribbean); they carry different histories, societal structures, and geography. In spite of a high degree of first-generation migrants, Hispanics hold a common identity in the U.S. that somehow blurs the race vs. ethnic divide.
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Background Existing studies show that consuming food consistent with one’s culture reduces cardiometabolic risk. However, few studies have assessed whether these dietary choices influence sleep health. Accordingly, this study assessed how Mexican food consumption by individuals of Mexican descent residing at the US-Mexico border, was associated with various measures of sleep, after accounting for acculturation. Methods Data were provided by 100 adults between the ages of 18–60, in the city of Nogales, AZ. Questionnaires were provided in either Spanish or English. Acculturation was assessed with the Acculturation Scale for Mexican-Americans (ARSMA-II), with an additional question, asking how often “my family cooks Mexican foods.” Frequency of cooking Mexican food was coded as either “yes” or “no.” Sleep was assessed, using validated measures that include the Insomnia Severity Index (ISI), the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), and sleep duration with the item “how many hours of actual sleep did you get at night?” Regression models estimated the associations between sleep health variables as outcomes and consumption of Mexican food as the independent variable. Covariates included age, sex, and acculturation scores. Parental education level was also included, as an indicator of childhood socioeconomic status and since food culture likely involves parents. Result We found that among individuals who identified as Mexican-Americans who consumed culturally-consistent foods, was associated with, on average, 1.41 more hours of sleep (95% CI 0.19, 2.62; p = 0.024) and were less likely to report snoring (OR: 0.25; 95% CI 0.07, 0.93; p = 0.039). Consuming Mexican food was not associated with sleep quality, insomnia severity or sleepiness. Conclusion Individuals of Mexican descent residing at the US-Mexico border who regularly consumed Mexican food, reported more sleep and less snoring. Mexican acculturation has been shown previously to improve sleep health. This is likely due to consumption of a culturally- consistent diet. Future studies should examine the role of acculturation in sleep health, dietary choices, and subsequent cardiometabolic risk.
Article
Objective To assess the relationship between adverse childhood experiences (ACEs) and cardiometabolic risk among Hispanic adolescents. Study design This cross-sectional study was conducted at an academic research center in Gainesville, Florida. Participants were locally recruited, and data were collected from 06/2016-07/2018. Participants (n=133, 60.2% female) were healthy adolescents ages 15-21 who self-identified as Hispanic, born in the United States, and had a body mass index (BMI) ≥18.5 and ≤40 kg/m². Primary outcomes were BMI, body fat percentage, waist circumference, and resting blood pressure. Associations between ACEs and cardiometabolic measures were assessed by multivariable logistic regression models, which controlled for sex, age, parental education, and food insecurity. Results were sex-stratified to assess potential variations. Results Reporting ≥4 ACEs (28.6%) was significantly associated with a higher BMI (P = .004), body fat percentage (p=0.02), and diastolic blood pressure (p=0.05) compared with reporting <4 ACEs. Females reporting ≥4 ACEs were significantly more likely to have a higher BMI (p=0.04) and body fat percentage (p=0.03) whereas males reporting ≥4 ACEs were significantly more likely to have a higher BMI (p=0.04), systolic blood pressure (p=0.03), and diastolic blood pressure (p=0.03). Conclusions Hispanic adolescent participants who experienced ≥4 ACEs were more likely to have elevated risk markers of obesity and cardiometabolic disease. Further research is needed to elucidate the physiological mechanisms driving these relationships.
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Introduction: Cardiovascular disease (CVD) is a major cause of death and disability worldwide. The most stringent primary CVD screening guidelines in developed countries use absolute CVD risk scores or coronary heart disease, such as Framingham or SCORE (Systematic Coronary Risk Evaluation) there are two types of CVD risk factors namely modif iable risk factors and unmodified risk factors. The aim of the current study is to determine the profil of potentially modif iable and unmodif ied cardiovascular risk factors. Method: This research consists of 41 elderly people which aged ≥ 60 years in Guguak, Kabupaten 50 Kota, West Sumatera, Indonesia. The data taken is modif iable risk factors consisting of diseases related risk factors including blood pressure categories, lipid profile, central obesity, body mass index and lifestyle related risk factors such as smoking habit. We also take data of unmodified risk factors such as age and gender. The result: this study consists of 41 elderly people which aged ≥ 60 years in Guguak, Kabupaten 50 Kota, West Sumatera, Indonesia. The mean age of elderly were 687.64861 years old that consisting of 29.3% men and 70.7% women, 34% of elderly with hypertension, the elderly with hypercholesterolemia 71%, hypertriglyceridemia 41%, and the elderly women with low HDL-C levels were 53%, the elderly men with low HDL-C levels were 92%. Conclusion: There are two types of risk factors CVD, modif iable risk factors and nonmodif iable risk factors. The modif iable risk factors consisting of diseases related risk factors including blood pressure categories, lipid profile, central obesity, body mass index and lifestyle related risk factors such as smoking habit. Keywords: Cardiovascular diseases, elderly, guguak 50 Kota, West Sumatera
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Objective: We examine differences in prevalence of diabetes and rates of awareness and control among adults from diverse Hispanic/Latino backgrounds in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Research design and methods: The HCHS/SOL, a prospective, multicenter, population-based study, enrolled from four U.S. metropolitan areas from 2008 to 2011 16,415 18-74-year-old people of Hispanic/Latino descent. Diabetes was defined by either fasting plasma glucose, impaired glucose tolerance 2 h after a glucose load, glycosylated hemoglobin (A1C), or documented use of hypoglycemic agents (scanned medications). Results: Diabetes prevalence varied from 10.2% in South Americans and 13.4% in Cubans to 17.7% in Central Americans, 18.0% in Dominicans and Puerto Ricans, and 18.3% in Mexicans (P < 0.0001). Prevalence related positively to age (P < 0.0001), BMI (P < 0.0001), and years living in the U.S. (P = 0.0010) but was negatively related to education (P = 0.0005) and household income (P = 0.0043). Rate of diabetes awareness was 58.7%, adequate glycemic control (A1C <7%, 53 mmol/mol) was 48.0%, and having health insurance among those with diabetes was 52.4%. Conclusions: Present findings indicate a high prevalence of diabetes but considerable diversity as a function of Hispanic background. The low rates of diabetes awareness, diabetes control, and health insurance in conjunction with the negative associations between diabetes prevalence and both household income and education among Hispanics/Latinos in the U.S. have important implications for public health policies.
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Myocardial ischemia is commonly associated with coronary artery disease as well as many congenital and acquired heart diseases without obstructed coronary arteries. With brief ischemia ventricular function is impaired but myocytes recover, whereas prolonged ischemia causes necrosis and associated
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Context Major cardiovascular diseases (CVDs) are leading causes of mortality among US Hispanic and Latino individuals. Comprehensive data are limited regarding the prevalence of CVD risk factors in this population and relations of these traits to socioeconomic status (SES) and acculturation. Objectives To describe prevalence of major CVD risk factors and CVD (coronary heart disease [CHD] and stroke) among US Hispanic/Latino individuals of different backgrounds, examine relationships of SES and acculturation with CVD risk profiles and CVD, and assess cross-sectional associations of CVD risk factors with CVD. Design, Setting, and Participants Multicenter, prospective, population-based Hispanic Community Health Study/Study of Latinos including individuals of Cuban (n = 2201), Dominican (n = 1400), Mexican (n = 6232), Puerto Rican (n = 2590), Central American (n = 1634), and South American backgrounds (n = 1022) aged 18 to 74 years. Analyses involved 15 079 participants with complete data enrolled between March 2008 and June 2011. Main Outcome Measures Adverse CVD risk factors defined using national guidelines for hypercholesterolemia, hypertension, obesity, diabetes, and smoking. Prevalence of CHD and stroke were ascertained from self-reported data. Results Age-standardized prevalence of CVD risk factors varied by Hispanic/Latino background; obesity and current smoking rates were highest among Puerto Rican participants (for men, 40.9% and 34.7%; for women, 51.4% and 31.7%, respectively); hypercholesterolemia prevalence was highest among Central American men (54.9%) and Puerto Rican women (41.0%). Large proportions of participants (80% of men, 71% of women) had at least 1 risk factor. Age- and sex-adjusted prevalence of 3 or more risk factors was highest in Puerto Rican participants (25.0%) and significantly higher (P < .001) among participants with less education (16.1%), those who were US-born (18.5%), those who had lived in the United States 10 years or longer (15.7%), and those who preferred English (17.9%). Overall, self-reported CHD and stroke prevalence were low (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively). In multivariate-adjusted models, hypertension and smoking were directly associated with CHD in both sexes as were hypercholesterolemia and obesity in women and diabetes in men (odds ratios [ORs], 1.5-2.2). For stroke, associations were positive with hypertension in both sexes, diabetes in men, and smoking in women (ORs, 1.7-2.6). Conclusion Among US Hispanic/Latino adults of diverse backgrounds, a sizeable proportion of men and women had adverse major risk factors; prevalence of adverse CVD risk profiles was higher among participants with Puerto Rican background, lower SES, and higher levels of acculturation.
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Previous studies have identified an obese phenotype without the burden of adiposity-associated cardiometabolic risk factors, although the health effects remain unclear. We examined the association between metabolically healthy obesity and risk of cardiovascular disease (CVD) and all-cause mortality. This was an observational study with prospective linkage to mortality records in community-dwelling adults from the general population in Scotland and England. A total of 22,203 men and women [aged 54.1 (SD 12.7 yr), 45.2% men] without known history of CVD at baseline. Based on blood pressure, high-density lipoprotein-cholesterol, diabetes diagnosis, waist circumference, and low-grade inflammation (C-reactive protein ≥ 3 mg/liter), participants were classified as metabolically healthy (0 or 1 metabolic abnormality) or unhealthy (two or more metabolic abnormalities). Obesity was defined as a body mass index of 30 kg/m(2) or greater. Study members were followed up, on average, more than 7.0 ± 3.0 yr for cause-specific mortality. Cox proportional hazards models were used to examine the association of metabolic health/obesity categories with mortality. There were 604 CVD and 1868 all-cause deaths, respectively. Compared with the metabolically healthy nonobese participants, their obese counterparts were not at elevated risk of CVD [hazard ratio (HR) 1.26, 95% confidence interval (CI) 0.74-2.13], although both nonobese (HR 1.59, 95% CI 1.30-1.94) and obese (HR 1.64, 95% CI 1.17-2.30) participants with two or more metabolic abnormalities were at elevated risk. Metabolically unhealthy obese participants were at elevated risk of all-cause mortality compared with their metabolically healthy obese counterparts (HR 1.72, 95% CI 1.23-2.41). Metabolically healthy obese participants were not at increased risk of CVD and all-cause mortality over 7 yr.
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The definition of obesity (BMI ≥ 30 kg/m(2)), a key risk factor of diabetes, is widely used in white populations; however, its appropriateness in nonwhite populations has been questioned. We compared the incidence rates of diabetes across white, South Asian, Chinese, and black populations and identified equivalent ethnic-specific BMI cutoff values for assessing diabetes risk. We conducted a multiethnic cohort study of 59,824 nondiabetic adults aged ≥ 30 years living in Ontario, Canada. Subjects were identified from Statistics Canada's population health surveys and followed for up to 12.8 years for diabetes incidence using record linkages to multiple health administrative databases. The median duration of follow-up was 6 years. After adjusting for age, sex, sociodemographic characteristics, and BMI, the risk of diabetes was significantly higher among South Asian (hazard ratio 3.40, P < 0.001), black (1.99, P < 0.001), and Chinese (1.87, P = 0.002) subjects than among white subjects. The median age at diagnosis was lowest among South Asian (aged 49 years) subjects, followed by Chinese (aged 55 years), black (aged 57 years), and white (aged 58 years) subjects. For the equivalent incidence rate of diabetes at a BMI of 30 kg/m(2) in white subjects, the BMI cutoff value was 24 kg/m(2) in South Asian, 25 kg/m(2) in Chinese, and 26 kg/m(2) in black subjects. South Asian, Chinese, and black subjects developed diabetes at a higher rate, at an earlier age, and at lower ranges of BMI than their white counterparts. Our findings highlight the need for designing ethnically tailored prevention strategies and for lowering current targets for ideal body weight for nonwhite populations.
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Corresponding Author: Cynthia L. Ogden, PhD, National Center for Health Statistics, 3311 Toledo Rd, Room 4414, Hyattsville, MD 20782 (cogden@cdc.gov). ... Context The prevalence of high body mass index ( BMI ) among children and adolescents in the United States appeared to ...
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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.
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Few studies have examined both the relative magnitude of association and the discriminative capability of multiple indicators of obesity with cardiovascular disease (CVD) mortality risk. We conducted an individual-participant meta-analysis of nine cohort studies of men and women drawn from the British general population resulting in sample of 82 864 individuals. Body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) were measured directly. There were 6641 deaths (1998 CVD) during a mean of 8.1 years of follow-up. After adjustment, a one SD higher in WHR and WC was related to a higher risk of CVD mortality (hazard ratio [95% CI]): 1.15 (1.05-1.25) and 1.15 (1.04-1.27), respectively. The risk of CVD mortality also increased linearly across quintiles of both these abdominal obesity markers with a 66% increased risk in the highest quintile of WHR. In age- and sex-adjusted models only, BMI was related to CVD mortality but not in any other analyses. No major differences were revealed in the discrimination capabilities of models with BMI, WC or WHR for cardiovascular or total mortality outcomes. In conclusion, measures of abdominal adiposity, but not BMI, were related to an increased risk of CVD mortality. No difference was observed in discrimination capacities between adiposity markers.