Cardiovascular risk factors among Asian Americans living in northern California

Application of national screening criteria for blood pressure and cholesterol to perimenopausal women: prevalence of hypertension and hypercholesterolemia in the Study of Women's Health Across the Nation

National screening guidelines for hypertension and cholesterol were applied to the multiethnic sample of perimenopausal women (N = 1349) in the Study of Women's Health Across the Nation (SWAN). To reduce low-density lipoprotein, lifestyle modification was indicated in 9.5% of patients and drug therapy in 5%. Chinese and Japanese women were least likely and African Americans were most likely to require interventions. Among all women, 27% were prehypertensive, 23% were hypertensive (blood pressure >140/90 mm Hg or treated), and 9.1% were untreated hypertensive. Untreated hypertension was lowest among Japanese and Chinese and highest among Hispanic and African-American women. Among all hypertensives, 60.5% were treated and only 58.5% of those treated were controlled. Control rates were lowest among African Americans and Hispanics. In this relatively low-risk population, a significant proportion of women with hypertension or hypercholesterolemia were either not treated, not treated adequately, or had borderline risk factors that would benefit from lifestyle interventions to prevent the need for future drug treatment.

The conundrum of increased burden of end-stage renal disease in Asians

BACKGROUND

Few cohort studies have examined the risk of end-stage renal disease (ESRD) among Asians compared with whites and blacks.

METHODS

To compare the incidence of ESRD in Asians, whites, and blacks in Northern California, we examined sociodemographic and clinical data on 299,168 adults who underwent a screening health checkup at Kaiser Permanente between 1964 and 1985. Incident cases of ESRD were ascertained by matching patient identifiers with the nationally comprehensive United States Renal Data System ESRD registry.

RESULTS

Overall, 1346 cases of ESRD occurred during 7,837,310 person-years of follow-up. The age-adjusted rate of ESRD (per 100,000 person-years) was 14.0 [95% confidence interval (CI) 10.5-18.5] among Asians, 7.9 (95% CI 6.5-9.5) among whites, and 43.4 (95% CI 36.6-51.4)] among blacks. Controlling for age, gender, educational attainment, diabetes, prior myocardial infarction, serum creatinine, systolic and diastolic blood pressure, proteinuria, hematuria, cigarette smoking, serum total cholesterol, and body mass index increased the risk of ESRD in Asians relative to whites from 1.69 to 2.08 (95% CI 1.61-2.67). By contrast, adjustment for the same covariates decreased the risk of ESRD in blacks relative to whites from 5.30 to 3.28 (95% CI 2.91-3.69).

CONCLUSION

Factors contributing to the excess ESRD risk in Asians relative to whites extend beyond usually considered sociodemographic and comorbidity disparities. Strategies aimed at examining novel risk factors for kidney disease and efforts to increase awareness of kidney disease among Asians may reduce ESRD incidence in this high-risk group.

Perceptions of Asian American men about tobacco cigarette consumption: a social learning theory framework

Little information exists regarding the perceptions that ethnic-specific groups of Asian American men have about tobacco cigarette smoking. Thirty Asian American men of immigrant status living in Seattle, Washington, were stratified by ethnicity (Chinese and Vietnamese), language (Mandarin, Cantonese, Vietnamese) and age to comprise six focus groups (two Mandarin speaking men aged 20-40 years and 10 aged 41-65+ years; three Cantonese men aged 20-40 years and another six aged 41-65+ years; four Vietnamese men aged 20-40 years and another five aged 41-65+ years). All group interviews were audio-taped and six separate hard-copy transcripts were produced, independently theme-coded by three investigators to ensure inter-rater reliability, and analyzed with QRS NUD*IST ethnographic software. Bandura (1969, 1986) categorized emergent contextual themes within the constructs of "predisposing, enabling, and reinforcing" behavioral determinants from Social Learning Theory. Smoking to be sociable emerged as the most salient theme. Awareness of tobacco-related diseases other than lung cancer was less evident, as was a self-perceived lack of will-power to quit. Concerns about side-stream smoking affecting family members, along with smoking to alleviate stress, were key findings. Further tobacco-related research is needed that incorporates considerations for cultural dynamics.

Ethnic differences in cardiovascular risk factor burden among middle-aged women: Study of Women's Health Across the Nation (SWAN)

BACKGROUND

We evaluated ethnic differences in the 10-year risk of myocardial infarction or coronary death derived from Framingham risk equation and in a composite measure of emerging cardiovascular disease risk factors in women and whether statistical adjustments for educational attainment, geographic location, and lifestyle attenuated the magnitude of the ethnic differences in risk.

METHODS

Two thousand eight hundred thirty-four premenopausal women free of stroke, heart disease, or diabetes and aged of 42 to 52 years (1400 whites, 729 African American, 226 Hispanic, 231 Chinese, and 248 Japanese) had measurements of blood pressure, lipids and lipoproteins, waist circumference, glucose, insulin, lipoprotein(a), fibrinogen, factor VII, plasminogen activator inhibitor, tissue-type plasminogen activator antigen, and high-sensitivity C-reactive protein. Framingham risk score and number of risk factors in the top quartile of the distribution of risk factors not included in the Framingham score (called composite burden) were calculated.

RESULTS

The unadjusted mean values for the two summary scores were higher among African Americans and Hispanics than other groups. Statistical adjustments for education and geographical site accounted for a majority of the ethnic differences, with an additional small effect of lifestyle for the composite burden score. Largest ethnic differences were apparent for waist circumference, lipoprotein(a), high-sensitivity C-reactive protein, and untreated blood pressure.

CONCLUSIONS

A substantial part of the risk associated with ethnicity can be attributed to socioeconomic status and geographical location. As the ethnic composition of the United States population becomes more diverse, it is important to appreciate the cardiovascular disease risk factor burden present in some minority groups.

Risk of hemorrhagic stroke in Asian American ethnic groups

The sparseness of prospective data about hemorrhagic stroke (HS) risk among Asian American ethnic groups led to the investigation of 128,934 persons with self-classified ethnicity at health examinations in 1978-1985. Subsequently, 431 persons were hospitalized for HS; 31% for subarachnoid hemorrhage (SAH) and 69% for intracerebral hemorrhage (ICH). Ethnic predictors of HS were studied by Cox proportional hazard models with 7 covariates. With whites as reference, the adjusted relative risk (95% CI) of all Asians for HS was 1.6 (1.1-2.3, p = 0.01), due substantially to increased risks of SAH in Japanese people and ICH in Filipinos. These data mandate emphasis upon preventive measures in these groups.

Subclinical Coronary Atherosclerosis in Asymptomatic Filipino and White Women

Background— Coronary heart disease (CHD) is the leading cause of morbidity and mortality in persons with type 2 diabetes mellitus (T2DM). Electron-beam computed tomography (EBCT) detects coronary artery calcium (CAC), a marker of atherosclerotic plaque. Few studies have described EBCT-defined CHD among ethnic minorities with elevated T2DM prevalence. The objective of this study was to compare EBCT-defined CAC in Filipino and white women without known cardiovascular disease.

Methods and Results— Subjects were participants aged 55 to 78 years in the Rancho Bernardo Study (n=196) and the University of California at San Diego’s Filipino Women’s Health Study (n=181). Glucose, blood pressure, lipids, anthropometric measurements, and lifestyle factors were measured from 1995 to 1999. EBCT-defined CAC scores, visceral and subcutaneous fat, and statin use were assessed in 2001 to 2002. Compared with whites, Filipinas had a significantly higher prevalence of T2DM (32.6% versus 6.1%, P <0.001) and the metabolic syndrome (32.6% versus 13.8, P <0.001). Filipinas were younger (64.4 versus 66.7 years), had higher triglyceride levels (155 versus 135 mg/dL), had a higher ratio of total cholesterol to HDL cholesterol (4.3 versus 3.5), more frequently used statins (31% versus 19%), and had more visceral fat (69.4 versus 62.1 cm 3 ) and lower HDL cholesterol levels (54 versus 66 mg/dL) than whites. Exercise frequency, body mass index, and waist girth did not differ by ethnicity. Nevertheless, extensive (CAC score ≥400; 9% versus 9%) and moderate (CAC score 150 to 399; 13% versus 11%) atherosclerotic plaque did not differ by ethnicity, even after adjustment for age, T2DM, hypertension, estrogen use, statin use, smoking, lipids, and visceral fat.

Conclusions— Filipinas had no excess of subclinical atherosclerosis despite their significantly higher prevalence of T2DM, the metabolic syndrome, hypertension, and visceral adiposity.

Immigration and acculturation in relation to health and health-related risk factors among specific Asian subgroups in a health maintenance organization

OBJECTIVES

We sought to determine how risk factors for disease vary among Asian subgroups.

METHODS

Using data from a case-control study conducted at Northern California Kaiser Medical Centers (from 1996 to 2001), we compared prevalence of selected risk factors among Asian subgroups and evaluated the associations of these risk factors with sociodemographic factors.

RESULTS

Chinese and Japanese patients had a lower body mass index (kg/m(2)) than did other Asians. In all subgroups, being born in the United States was associated with having a body mass index greater than 25 kg/m(2). Compared with other Asians, more Japanese and multiple-race Asians smoked, and more Filipino and multiple-race Asian smokers started smoking at 18 years or younger. Filipinos and multiple-race Asians also were more likely to report diabetes.

CONCLUSIONS

These data support the importance of efforts to distinguish among Asian subgroups in public health practice and research.

Prevalence and correlates of alcohol use: a population-based study in Hong Kong

OBJECTIVE

To estimate the prevalence and pattern of alcohol use and to analyse the socio-demographic and biological correlates of alcohol drinking in Hong Kong Chinese.

DESIGN

A population-based cross-sectional study conducted from December 1994 to October 1996.

SETTING AND PARTICIPANTS

2900 randomly selected subjects age 25-74 years who participated in the Cardiovascular Risk Factor Prevalence Study in Hong Kong.

RESULTS

Alcohol consumers comprised 55.4% (95% CI: 52.8-58.0) of men and 19.4% (95% CI: 17.4-21.4) of women. The median weekly ethanol consumed by male and female drinkers were 9.6 g and 3.6 g, respectively. Beer was the main source of alcohol; 61.5% of drinkers consumed beer as their main drink. In stepwise multiple regression among drinkers, male sex, smoking, high density lipoprotein cholesterol, primary or below education, diastolic blood pressure and separated or widowed marital status were associated positively with weekly ethanol consumption.

CONCLUSION

In this representative sample of Hong Kong adults, the majority were either non-drinkers or very light drinkers, which can be used as a benchmark to measure changes in drinking pattern in the future. The putative protective effect of alcohol on heart disease could be due to the higher level of HDL in moderate drinkers.

The impact of ethnicity on type 2 diabetes

The rapid increase of diabetes prevalence in the US population and across all westernized world has been associated with environmental changes that promote obesity. Although dietary factors, such as total caloric intake, relative excess of dietary saturated fats content and lack of fibers, together with reduced level of physical activity clearly determine the main features of the "obesogenic" environment typical of "western" societies, the impact of lifestyle factors on obesity and diabetes appears to differ in various ethnic groups. Although ethnic-related differences in lifestyle factors may account for some of the predisposition to obesity and diabetes of various ethnic groups, genetic factors may play a more determinant role. These observations pose important public health questions in regard to strategies for treatment and prevention of diabetes both within the multiethnic US population and in the population of origin of various ethnicities. The elucidation of the pathophysiologic mechanisms responsible for the heterogeneous relationship between obesity and type 2 diabetes in various ethnicities may give important contributions to better understand the complex mechanisms involved in the development of this disease. This review examines epidemiological and pathophysiological aspects of the interaction between environment and ethnic predisposition to type 2 diabetes.

Type 2 diabetes and metabolic syndrome in Filipina-American women : a high-risk nonobese population

OBJECTIVE

To compare the prevalence of type 2 diabetes and features of the metabolic syndrome among Filipina and Caucasian women in San Diego County, California.

RESEARCH DESIGN AND METHODS

Data on several chronic diseases were collected between 1992 and 1999 from community-dwelling Filipina (n=294) and Caucasian (n=379) women aged 50-69 years.

RESULTS

Filipina and Caucasian women did not differ in mean age (59.7 vs. 60 years, respectively), BMI (25.6 vs. 25.4 kg/m(2)), percentage of body fat (33.5 vs. 34.2%), or waist-to-hip ratio (0.84 vs. 0.83), although Filipinas had larger waist circumferences and higher percentages of truncal fat. Compared with Caucasians, Filipinas were less likely to be obese (BMI > or = 30 kg/m(2), 8.8 vs. 14%, P=0.04) and less likely to smoke, consume alcohol, or take postmenopausal estrogen; Filipinas also had lower levels of HDL cholesterol. Compared with Caucasians, Filipinas had higher prevalence of type 2 diabetes by oral glucose tolerance test criteria (36 vs. 9%) and the metabolic syndrome (34 vs. 13%). These differences persisted after adjusting for age, body size, fat distribution, percentage of body fat, smoking, alcohol consumption, exercise, and estrogen therapy.

CONCLUSIONS

A total of 10% of Filipinas with diabetes were obese, compared with one third of Caucasians with diabetes. The finding of a high prevalence of diabetes in an unstudied nonobese ethnic group reinforces the importance of expanding the study of diabetes to diverse populations. The high prevalence of diabetes in populations who are not of Northern European ancestry may be missed when they are not obese by Western standards.

Do patient assessments of primary care differ by patient ethnicity?

OBJECTIVE

To determine if patient assessments (reports and ratings) of primary care differ by patient ethnicity.

DATA SOURCES/STUDY DESIGN

A self-administered patient survey of 6,092 Massachusetts employees measured seven defining characteristics of primary care: (1) access (financial, organizational); (2) continuity (longitudinal, visit based); (3) comprehensiveness (knowledge of patient, preventive counseling); (4) integration; (5) clinical interaction (communication, thoroughness of physical examinations); (6) interpersonal treatment; and (7) trust. The study employed a cross-sectional observational design.

PRINCIPAL FINDINGS

Asians had the lowest primary care performance assessments of any ethnic group after adjustment for socioeconomic and other factors. For example, compared to whites, Asians had lower scores for communication (69 vs. 79, p = .001) and comprehensive knowledge of patient (56 vs. 48, p = .002), African Americans and Latinos had less access to care, and African Americans had less longitudinal continuity than whites.

CONCLUSIONS

We do not know what accounts for the observed differences in patient assessments of primary care. The fact that patient reports as well as the more subjective ratings of care differed by ethnicity suggests that quality differences might exist that need to be addressed.

Usefulness of psychosocial theory variables in explaining fat-related dietary behavior in Chinese Americans: association with degree of acculturation

OBJECTIVE

To determine the usefulness of variables from psychosocial models of health behavior in explaining fat-related dietary behavior among a sample of Chinese Americans.

DESIGN

A survey questionnaire was administered to a convenience sample of Chinese Americans and analyzed for descriptive statistics and relationships among variables.

SUBJECTS/SETTINGS

Participants were 600 healthy individuals, ranging from 25 to 70 years of age, living in New York City.

VARIABLES MEASURED

Demographic factors, degree of acculturation, food preferences, and 13 social psychological scales derived from the Theory of Planned Behavior, the Healthy Belief Model, and Social Cognitive Theory. Dependent measures assessed were intention to reduce dietary fat and behaviors related to the selection of reduced-fat diets.

STATISTICAL ANALYSES

Descriptive statistics, Pearsons' correlation coefficients, t-tests, one-way analyses of variance, and multiple regression analyses were used.

RESULTS

Attitude, overall health concern, and self-efficacy accounted for 58% of the variance in behavioral intention for the entire sample. Attitude, perceived barriers, and self-efficacy accounted for 19% of the variance in the prediction of dietary fat reduction behaviors. In general, a gradient was seen in the increased predictiveness of each regression model by degree of acculturation of the immigrants to American culture: predictiveness (R2) for behavior ranged from 15% for the least to 34% for the most acculturated. Acculturation was significantly related to declines in the influence of habit and of social norms. These effects were not seen by length of residency.

IMPLICATIONS

Nutrition educators should assess the degree of acculturation of groups with whom they work and recognize that the degree of acculturation impacts the relative importance of various psychosocial variables in fat reduction behaviors.

Ethnic issues in the epidemiology of childhood obesity

Childhood obesity may be seen as a marker for high-risk dietary and physical inactivity practices. Recent increases in the prevalence of overweight and obesity among American children are not limited to one age, gender, or ethnic group, which suggests that unique behaviors of the members of various racial or ethnic subgroups of the population are unlikely to be the major contributing factors. Rather, it seems that environmental changes promoting increased energy intake and decreased energy output are occurring and have widespread impact on children from various backgrounds. Although no ethnic group is immune from the current shift in energy balance, differential rates of overweight seem to exist among ethnic groups. National probability samples of African-American, Hispanic, and white children in the United States provide clear evidence that white children are at lower risk for childhood overweight than are African-American or Hispanic children. Of concern is the lack of national data on the prevalence of overweight and obesity for Native-American and Asian-American groups. Also of concern is the aggregation of racial and ethnic subgroups, which may render prevalence rates meaningless. This possibility is clearly true with some surveys of weight status that combine diverse populations, such as Asians and Pacific Islanders, into one group. The high rates of obesity in African-American, Hispanic, and Native-American children are of concern. Although parental SES is associated inversely with childhood obesity among whites, higher SES does not seem to protect African-American and Hispanic children against obesity. In these groups, childhood obesity does not seem to be associated significantly with parental income and education. Health consequences of childhood obesity include a higher prevalence of type 2 diabetes and an increased risk for adverse levels of lipids, lipoproteins, and blood pressure. The effects of recently reported unprecedented levels of childhood overweight on subsequent risk for obesity in middle age are not known until future longitudinal data can be collected. It seems likely, however, that future health consequences of current early and severe childhood obesity will be staggering. Funding for adult follow-up of longitudinal studies of high-risk African American, Hispanic, and Native-American children is needed urgently to provide information on the long-term effects of childhood obesity. Halting the obesity epidemic is a formidable task, but the success in recent decades of drastically reducing childhood undernutrition offers hope and should spur similar action and leadership efforts. Promotion of efforts to reduce excess caloric intake with efforts to increase energy expenditure should receive paramount attention in the design of health programs. Given the relatively few published obesity-prevention and treatment studies that are designed to address specific cultural issues, it is important to promote the development of culturally appropriate intervention strategies that are shown to be effective among youth of diverse backgrounds. Although the dietary and activity goals will be similar, parental, family, and community messages and techniques grounded in cultural traditions and norms will be different for each ethnic group. This approach is crucial in the United States, a country with an increasingly diverse population.

Standard definitions of overweight and central adiposity for determining diabetes risk in Japanese Americans

BACKGROUND

Despite having lower average body mass indexes (BMIs) than do whites, Asians are at high risk of type 2 diabetes, possibly because of their greater central adiposity. The criteria for identifying individuals at risk of obesity-related conditions are usually not population specific.

OBJECTIVE

Our goal was to determine whether the National Heart, Lung, and Blood Institute (NHLBI) overweight and obesity guidelines are useful for identifying diabetes risk in Japanese Americans.

DESIGN

This was a prospective, cohort study of 466 nondiabetic Japanese Americans [age: 52.2 +/- 0.6 y; BMI (in kg/m(2)): 24.1 +/- 0.2; +/- SEM]. Diabetes status at a 5-y follow-up visit was assessed with an oral-glucose-tolerance test.

RESULTS

Among 240 subjects aged < or = 55 y, incident diabetes was strongly associated with overweight (BMI > or = 25) at baseline [relative risk (RR): 22.4; 95% CI: 2.7, 183; adjusted for age, sex, smoking, and family history] and weight gain of > 10 kg since the age of 20 y (adjusted RR: 4.5; 95% CI: 1.4, 14.5). NHLBI definitions of central obesity (waist circumference > or = 88 cm for women and > or = 102 cm for men) were unsuitable for this population because only 15 of 240 subjects met these criteria. A waist circumference greater than or equal to the third tertile was associated with diabetes (adjusted RR: 5.4; 95% CI: 1.7, 17.0). Among 226 subjects aged >55 y, incident diabetes was not associated with BMI, weight gain, or waist circumference.

CONCLUSIONS

NHLBI definitions are useful for identifying overweight Japanese Americans aged < 55 y who are at high risk of diabetes. Although central adiposity is an important risk factor, the guidelines for waist circumference are insensitive predictors of diabetes risk in this population.

Negative consequences of acculturation on health behaviour, social support and stress among pregnant Southeast Asian immigrant women in Montreal: an exploratory study

It is frequently assumed that migrant status constitutes a health risk because migration is inevitably associated with a period of significant adjustment and stress. This paper describes the role of acculturation in understanding the relationship between migration and low birthweight (LBW). Psychosocial and behavioural risk factors for LBW were explored using semi-structured interviews with 17 pregnant Southeast Asian women who represented different levels of acculturation. Findings suggested that acculturation had negative consequences for immigrant women. Higher levels of acculturation were associated with dieting during pregnancy, inadequate social support and stressful life experiences.

Differences in body fat and central adiposity between Swedes and European immigrants: the Malmö Diet and Cancer Study

OBJECTIVE

Comparative data on ecological differences in body fatness and fat distribution within Europe are sparse. Migration studies may provide information on the impact of environmental factors on body size in different populations. The objective was to investigate differences in adiposity between European immigrants and native Swedes, specifically to examine gender differences and the effect of time since immigration, and to compare two selected immigrant groups with their native countrymen.

RESEARCH METHODS AND PROCEDURES

A cross-sectional analysis of 27,808 adults aged 45 to 73 years participating in the Malmö Diet and Cancer prospective cohort study in Sweden was performed. Percentage body fat (impedance analysis) and waist-hip ratio (WHR) were compared between Swedish-born and foreign-born participants.

RESULTS

Obesity was 40% more prevalent in non-Swedish Europeans compared with Swedes. Controlling for age, height, smoking, physical activity, and occupation, it was found that women born in the former Yugoslavia, southern Europe, Hungary, and Finland had a significantly higher percentage of body fat, and those from Hungary, Poland, and Germany had more centralized adiposity compared with Swedish women. Men born in the former Yugoslavia, Hungary, and Denmark had a significantly higher mean percentage of body fat compared with Swedish-born men, whereas Yugoslavian, Finnish, and German men differed significantly in mean WHR. Length of residence in Sweden was inversely associated with central adiposity in immigrants. A comparison between German and Danish immigrants, their respective native populations, and Swedes indicated an intermediate positioning of German immigrants with regard to body mass index and WHR.

DISCUSSION

Differences in general and central adiposity by country of origin appear to remain after migration. Central adiposity seems to be more influenced than fatness per se by time of residency in Sweden.

Body mass index in a US national sample of Asian Americans: effects of nativity, years since immigration and socioeconomic status

OBJECTIVE

To examine body mass index (BMI) and the proportion overweight and obese among adults age 18-59 in the six largest Asian American ethnic groups (Chinese, Filipino, Asian Indian, Japanese, Korean, Vietnamese), and investigate whether BMI varies by nativity (foreign-vs native-born), years in US, or socioeconomic status.

DESIGN

Cross-sectional interview data were pooled from the 1992-1995 National Health Interview Survey (NHIS).

SUBJECTS

254,153 persons aged 18-59 included in the 1992-1995 NHIS. Sample sizes range from 816 to 1940 for each of six Asian American ethnic groups.

MEASUREMENTS

Self-reported height and weight used to calculate BMI and classify individuals as overweight (BMI > or = 25 kg/m2) or obese (BMI > or = 30 kg/m2), age, sex, years in the US, household income and household size.

RESULTS

For men, the percentage overweight ranges from 17% of Vietnamese to 42% of Japanese, while the total male population is 57% overweight. For women, the percentage overweight ranges from 9% of Vietnamese and Chinese to 25% of Asian Indians, while the total female population is 38% overweight. The percentage of Asian Americans classified as obese is very low. Adjusted for age and ethnicity, the odds ratio for obese is 3.5 for women and 4.0 for men for US-vs foreign-born. Among the foreign-born, more years in the US is associated with higher risk of being overweight or obese. The association between household income for women is similar for US-born Asian Americans and Whites and Blacks, but is much weaker for foreign-born Asian Americans.

CONCLUSIONS

While these data find low proportions of Asian Americans overweight at present, they also imply the proportion will increase with more US-born Asian Americans and longer duration in the US.

Negative consequences of acculturation on health behaviour, social support and stress among pregnant Southeast Asian immigrant women in Montreal: an exploratory study

It is frequently assumed that migrant status constitutes a health risk because migration is inevitably associated with a period of significant adjustment and stress. This paper describes the role of acculturation in understanding the relationship between migration and low birthweight (LBW). Psychosocial and behavioural risk factors for LBW were explored using semi-structured interviews with 17 pregnant Southeast Asian women who represented different levels of acculturation. Findings suggested that acculturation had negative consequences for immigrant women. Higher levels of acculturation were associated with dieting during pregnancy, inadequate social support and stressful life experiences.

Smoking among ethnic Chinese patients and their recall of quit advice by Chinese-speaking general practitioners in Sydney

OBJECTIVES

To collect smoking-related data from Chinese patients attending Chinese-speaking general practitioners (CSGPs), including self-reported smoking status, recall of a question about smoking status during the previous six months by their GP and, for smokers, their recall of quit advice in their most recent consultation.

DESIGN

Descriptive research first involving self-administered waiting-room questionnaires and, afterwards, a second self-administered questionnaire to examine behaviour in that most recent consultation.

SETTING

Surgeries of 24 CSGPs in Central Sydney.

SUBJECTS

1084 Chinese patients aged 18-70 years.

RESULTS

Self-reported smoking prevalence was 25% (95% CI: 21%-29%) for men and 4% (95% CI: 2%-5%) for women. Of 103 smokers who had visited their regular GP during the previous 6 months, 42% recalled a question about smoking status and 38% quit advice. As elicited at follow-up, 72% recalled any discussion in their most recent consultation about smoking although effective techniques were rarely recalled. Patient's sex (OR: 1.78; 95% CI: 1.28-2.47) and smoking status (OR: 1.39; 2.38; 95% CI: 0.85-2.25, 1.49-3.81) independently predicted a question about smoking status. Among smokers, marital status was the only independent predictor of quit advice. As assessed by a stage-of-change scale, significantly more Chinese smokers were not ready to contemplate cessation, compared with Angio-Celtic community survey results.

CONCLUSIONS

Our study provides unique information about smoking among ethnic Chinese patients attending CSGPs. Findings also suggest CSGPs need greater support to maximize their clinical opportunities to advise Chinese smokers to quit.

Access to medical care reported by Asians and Pacific Islanders in a West Coast physician group association

This study examines access to medical care for Asians and Pacific Islanders in the United States, using a survey of patients receiving care provided by a physician group practice association concentrated on the West Coast. Asians and Pacific Islanders who had used their health plan in the past year had worse access to health care than whites, blacks, Hispanics, and Native American or other ethnicities. The odds that Asians reported that they had adequate access ranged from about one quarter to three quarters that of whites, depending on the measure. Cultural differences and associated communication problems may explain the access problems experienced by Asians. Interventions need to be developed to address the problems with access to services, and better translation services may play an important role in improving access to care for Asians. Future studies need to clarify why Asians were more vulnerable to the access problems examined than other ethnic groups that might experience similar barriers.

Blood pressure responses to acute static and dynamic exercise in three racial groups

PURPOSE

African Americans have a higher incidence of hypertension than other racial groups. Furthermore, some research suggests that normotensive individuals who exhibit exaggerated blood pressure (BP) responses to exercise may be at risk for future hypertension. This study sought to determine whether normotensive African Americans exhibited exaggerated BP responses to static exercise or dynamic exercise relative to Caucasian Americans and Asian Americans.

METHODS

Thirty normotensive subjects participated from each of the three racial groups (15 men and 15 women). Subjects held 30% of maximal voluntary contraction (right knee extension) for 3 min, and BP was recorded during the 3rd min. On a separate occasion, subjects cycled for six min at a power equivalent to 70% of VO2 reserve, and BP was recorded during the 6th min.

RESULTS

Static exercise produced large, significant increases in both systolic and diastolic BP (35 +/- 1.5 and 29 +/- 1.3 mm Hg, respectively). Dynamic exercise produced large, significant increases in systolic BP (51 +/- 1.6 mm Hg) and moderate, yet significant, increases in diastolic BP (8 +/- 1.0 mm Hg). There were no significant differences between racial groups in BP response to either static exercise or dynamic exercise. However, during dynamic exercise, men had a higher systolic BP response than did women.

CONCLUSIONS

African Americans who are normotensive at rest do not exhibit a greater BP response to static exercise or dynamic exercise than do Caucasian Americans or Asian Americans.

Congestive heart failure hospitalizations and survival in California: patterns according to race/ethnicity

BACKGROUND

Congestive heart failure (CHF) disproportionately affects African Americans, but data are limited concerning CHF hospitalization patterns among Hispanic and Asian populations, the 2 fastest growing ethnic groups in the United States, and race/ethnic patterns of rehospitalization and survival among patients with CHF are unknown. We conducted a study to assess rates of CHF hospitalization, readmission, and survival among diverse populations in California.

METHODS AND RESULTS

We used 2 study designs. First, we calculated the population-based incidence of CHF hospitalization in California in 1991. Next we conducted a retrospective cohort study that identified patients initially hospitalized for CHF in 1991 or 1992 and followed these patients for 12 months after their index hospitalization to determine their likelihood of rehospitalization or death. Data were analyzed with Cox proportional hazards models. African Americans had the highest rate of CHF hospitalization. Age-adjusted hospitalization rates were comparable among whites, Latinos, and Asian women and all lower than those in African American, whereas Asian men had the lowest rates. On adjusted analyses, African Americans were more likely than whites and Asians to be rehospitalized (relative risk 1.07; 95% confidence interval 1.04 to 1.10). However, they were less likely to die within the 12-month follow-up period (relative risk 0.86; 95% confidence interval 0.82 to 0.90). Whites, conversely, had the highest posthospitalization mortality rates.

CONCLUSIONS

These findings demonstrate important racial-ethnic differences in CHF morbidity and mortality rates. The disparate findings of higher hospitalization and rehospitalization rates and lower mortality rates among African Americans than whites may represent differences in the underlying pathophysiology of CHF in these groups or differences in access to quality care. Further studies are needed to explain these seemingly paradoxical outcomes.

Cigarette smoking among native and foreign-born African Americans

PURPOSE

To examine differences in current smoking status and the number of cigarettes consumed daily between foreign and native-born African Americans, and the impact of demographic and socioeconomic status (SES) factors on smoking behavior.

METHODS

Data were obtained from combining the 1990-1994 National Health Interview Surveys and consisted of 16,738 U.S. born and foreign-born African Americans between 18 and 64 years of age. The statistical analysis included cross-tabulations and weighted multiple logistic regression (MLR) using the Statistical Packages for the Social Sciences (SPSS) and the Survey Data Analysis (SUDAAN) computer programs.

RESULTS

Adjusted MLR analysis revealed that native-born African Americans were more likely (odds ratio (OR) = 2.7, p < 0.001) to be current smokers than foreign-born blacks. Within the native-born group, smoking prevalence decreased with increasing education and income, but these associations were not found for foreign-born blacks. Women in both groups were less likely than men to be current smokers. Statistically significant differences were not found between the two groups in the number of cigarettes smoked per day.

CONCLUSIONS

This analysis of nativity and smoking behavior further demonstrates the social diversity among African Americans and suggests the differential impact of social and cultural factors on smoking behavior within racially classified social groups. In areas where there are substantial numbers of foreign-born blacks, researchers should consider differentiating smoking status by nativity. Though differences in smoking prevalence were apparent for native and foreign-born American Americans, prevention and cessation programs are needed for both groups.

The health status and characteristics of hypertensives in Guam

Studies of Asian Pacific American populations are often flawed because while the population is quite heterogeneous, researchers usually collapse them into a single category, making it impossible to assess the health status or needs of individual Asian Pacific American ethnic groups. Using a probability sample of Guam residents, the analysis reported here addresses the problem by documenting the health status and characteristics of Chamorro and Filipino hypertensives. In contrast to predictions from the literature, Chamorros have a higher prevalence of hypertension than Filipinos. Additional results show that hypertensive Chamorro men and women are from lower socioeconomic status levels than their Filipino counterparts, while hypertensive men and women of both ethnic groups appear equally likely to be overweight and to suffer diabetes. Male hypertensives are at greater risk for psychological distress than normotensives, and have a greater chance of heart failure. Compared to Filipinos, hypertensive Chamorros are more likely to evaluate their overall physical health as poor.

The perimenopausal transition of Filipino American midlife women: biopsychosociocultural dimensions

OBJECTIVES

To describe the biologic, psychological, social, and cultural (biopsychosociocultural) dimensions of the perimenopausal transition of Filipino American midlife women.

METHODS

A community-based sample of 165 women (a) self-identified as Filipino American, (b) ages 35 to 56 years, and (c) English language proficient was recruited from churches and social groups.

RESULTS

Women in the study were born in the Philippines (93.3%), had lived in the United States an average of 18.4 +/- 8.7 years, were married or partnered (74.6%), had completed college (62.8%) or a graduate degree (15.9%), worked (full-time, 77.9%; part-time, 12.9%), had household incomes greater than $50,000 (>58%). Menopause ages were calculated from reports of last menstrual periods (natural, 48.9 +/- 4.9 years; surgical, 42.2 +/- 5.7 years). Neither the age at menarche nor the number of pregnancies and children born was significantly related to age at menopause. Calcium from food sources was generally low, and the Center for Epidemiological Studies Depression Scale (CES-D) revealed a 24.8% depression rate. The low prevalence of physical health problems confirms previous research that foreign-born individuals have better health than those born in the United States.

CONCLUSIONS

The profile of this understudied group identified calcium intake, osteoporosis morbidity, and prevalence of depression as key areas for future study.

Minority women and tobacco: implications for smoking cessation interventions

Quitting smoking is the single most important preventive health behavior a woman can perform to significantly reduce her chances of morbidity and premature mortality. Minority women are an extremely important population to target for smoking cessation intervention. Rates and risk factors for cardiovascular diseases and cancer are markedly higher among women of certain minority groups. In addition, smoking prevalence rates in women of some ethnic groups are elevated relative to the majority population of women, and specific groups have displayed slower rates of decline in smoking. Furthermore, minority women tend to have less access and appear to be less responsive to smoking cessation programs aimed at the majority culture. Thus, consideration of the practical and cultural needs of ethnic minority women is imperative when designing smoking intervention programs. This article describes the smoking behaviors of African-American, American Indian and Native Alaskan, Asian and Pacific Islander, and Hispanic women smokers, in order to gain a greater understanding of the treatment needs of these women. Information on prevalence rates and smoking patterns, barriers to quitting, and findings from intervention studies within each population are reviewed as well as recommendations for smoking cessation treatment.

Evaluating health status of elderly Chinese in Boston

There is increasing demand for measurement tools to assess health related quality of life among the Chinese elderly population in the United States. Health services questionnaires, developed largely in English, often under-represent Chinese Americans. Based on conventional mortality statistics, the public mistakenly views Chinese Americans as a "model" minority with no health problems. This general perception has masked the serious health problems among the elderly Chinese Americans. Using the newly developed Chinese version of the MOS SF-36, we aim to explore how elderly Chinese perceive their own health. Based on 219 elderly Chinese recruited in Boston, the study provided mixed results with regard to the perception of a healthy minority model. While the study subjects perceived similar or better physical health to the U.S. norm, they reported worse mental health than the U.S. norm. We explored possible explanations for this discrepancy and discussed the implications as well as directions for future research.

Epidemiology and prevention of hypertension

At least 43 million (24%) adults in the general population of the United States have hypertension. The prevalence of hypertension increases with age and is higher among African-Americans compared to other ethnic groups. During the past several decades, the prevalence of hypertension in the general population of the United States has declined and the proportion of hypertensives who are aware of their high blood pressure, as well as the portion who are being treated and controlled has improved. Hypertension is the most important modifiable risk factor for coronary heart disease, stroke, congestive heart failure, and end-stage renal disease. To achieve the final goal of eliminating all blood pressure-related disease in the community, detection and treatment of hypertension must be complemented by equally energetic approaches directed at primary prevention of hypertension. A small downward shift in the entire distribution of blood pressure in the general population will not only reduce the incidence of hypertension, but substantially diminish the burden of blood pressure in the general population.

Racial and ethnic disparities in the use of cardiovascular procedures: associations with type of health insurance

OBJECTIVES

This study examined whether disparities in the use of cardiovascular procedures exist among African Americans, Latinos, and Asians relative to White patients, within health insurance categories.

METHODS

Hospital discharge records (n = 104,952) of Los Angeles Country, California, residents with possible coronary artery disease were analyzed.

RESULTS

After adjustment for confounders, lower odds of procedure use were found for African American and Latino patients for most types of insurance. Asians and Pacific Islanders had odds of procedure use similar to those of White patients. Disparities were absent among the privately insured.

CONCLUSIONS

Racial and ethnic disparities in procedure rates were evident in all types of insurance except private insurance.

Perceived weight of other persons

On the basis of photographs, students (N = 258) evaluated the weights of 77 male executives or 50 businesswomen. Women students were expected to be less likely than men, and non-American students (mostly ethnic Chinese) to be less likely than Americans, to assign thin ratings to the people in the photographs. No differences in ratings were found between the responses of male and female students, but some significant differences in ratings were found between the American and non-American students. The results suggest that studies of other persons, body images may yield limited insights into the eating disorders that can accompany body self-image distortions.

The impact of ethnicity on response to antihypertensive therapy

The aim of this review is to assess the prevalence of complications and responses to various antihypertensive drug therapies in ethnic minority groups in the United States. In some instances, these comments are extended to responses of citizens in their countries of origin. The incidence of hypertension, mortality from hypertensive heart disease, stroke, and hypertensive renal disease are higher in African Americans. Although some Hispanic Americans have a lesser risk for hypertension, they have a greater risk for other risk factors such as diabetes and dyslipidemia. There is a similar association between income and mortality for both African Americans and Hispanic Americans. When compared to European Americans and other ethnic minorities, African Americans respond less favorably to beta blockers and angiotensin-converting enzyme (ACE) inhibitors. Nevertheless, the observed response in African Americans to ACE inhibitors and beta blockers is clinically significant. The available literature indicates that Asian American responses to calcium antagonists seem to be more favorable than responses to ACE inhibitors and equivalent to their responses to diuretic and beta blocker therapy. Although there are few published studies of drug efficacy in Hispanic Americans, there appears to be no hierarchy in response to the various antihypertensive drug classes. Ethnicity is not an accurate criterion for predicting poor response to any class of antihypertensive therapy. Thus, there is little justification to use racial profiling as a criterion for the avoidance of selected drug classes because of presumed lack of efficacy. Observed differences in the incidence of hypertension and its poor outcomes have led some investigators to postulate that the etiology of hypertension in ethnic minority groups is intrinsically different from whites. Awareness of racial differences in hypertension outcomes evolved in the United States within a historical context that does not fully appreciate that race is often a surrogate for many social and economic factors that influence health status and healthcare delivery. Poor outcomes in ethnic minority groups occur in many diseases, not only hypertension. The goal of ethnicity-related research should be to describe the diversity of disease expression in humans and to target at-risk groups for prevention and early intervention. The use of racial descriptors to explain genetic differences in ethnic groups should take a lesser priority.

Cardiovascular risk factors among Asian Americans

MANY ASIANS HAVE RECENTLY IMMIGRATED to the United States, but there have been few studies of cardiovascular risk factors in these groups. Researchers analyzed data from 13,031 people who described themselves as Chinese, Filipino, Japanese, and other Asians, and used regression analyses controlled for age, alcohol use, education, and marital status. Adjusted mean body mass index and smoking prevalence were lowest in Chinese men and women. Adjusted total cholesterol levels were highest in Japanese men and women. Hypertension prevalence was highest in Filipino men and women. Comparisons of Asians born outside the United States with those U.S.-born showed 1) no major cholesterol differences; 2) higher body mass index in U.S.-born men, but not in women of most races; 3) more hypertension only in U.S.-born Chinese men; and 4) a lower smoking prevalence in U.S.-born men but generally higher smoking prevalence in U.S.-born women. These data show important ethnic differences in cardiovascular risk factors among Asian Americans and have implications for targeting public health efforts.

A debunking of the myth of healthy Asian Americans and Pacific Islanders

PURPOSE

To present evidence that the model of healthy Asian Americans and Pacific Islanders (AAPIs) stereotype is a myth.

SEARCH METHOD

The authors retrieved literature from the National Library of Medicine's compact disk databases (Cancerlit, CINAHL, Health, and MEDLINE), and examined pertinent federal government publications supplemented by the authors' knowledge of other published materials.

IMPORTANT FINDINGS

This review paper presents three reasons why AAPIs are underserved: (1) the population growth rate has been unusually rapid and recent; (2) data regarding the health status of AAPIs are inadequate; and (3) the myth that AAPIs are model minority populations in terms of their health status was promulgated.

MAJOR CONCLUSIONS

The conclusions are as follows: (1) AAPIs are heterogenous with respect to demographic factors and health risk factors; (2) because the current databases on the health status of AAPIs include small sample sizes, both the quantity and quality of these data need to be improved with respect to appropriate gender and ethnic group representation; (3) Risk factor and mortality data for AAPIs suggest that the burden of certain preventable diseases, namely, tuberculosis, hepatitis-B, liver cancer, and lung cancer may be higher than those of any other racial and ethnic population. The model healthy AAPI stereotype is a myth.

The risk of hospitalization for ischemic heart disease among Asian Americans in northern California

To supplement sparse data about ischemic heart disease in Asian Americans, hospitalization risk was prospectively examined in a group of Asian Americans living in Northern California. Analyses used Cox models with ischemic heart disease risk traits as covariables. With Whites as the referent category, relative risks by ethnic group were as follows: Chinese, 0.6 (P = .001); Japanese, 1.0 (P = .97); Filipinos, 1.0 (P = .95); South Asians, 3.7 (P < .001); other Asian Americans, 0.8 (P = .55). Thus, unexplained differences in ischemic heart disease risk exist among Asian-American ethnic groups, with Chinese Americans at lowest risk and persons of South Asian origin at highest risk.

Heart disease risk factors in the Vietnamese community of southwestern Sydney

Despite low mortality from heart disease in the New South Wales Vietnamese community, the prevalence of risk factors for heart disease has been increasing. This study sought to identify the prevalence of heart disease risk factors in the Vietnamese community in southwestern Sydney. In 1991, 389 randomly selected Vietnamese-born residents of southwestern Sydney (79.2 per cent response rate) were interviewed by telephone about their risk status. Sixty-one per cent of this sample agreed to a second interview in their homes where physical measurements were taken. Smoking prevalence was high in males (53 per cent), whereas raised blood pressure (5.1 per cent), high blood cholesterol (21.1 per cent) and overweight (14.0 per cent) had a low prevalence compared to National Heart Foundation data for the general population. Interventions targeting males about smoking should be a health promotion priority, and the maintenance of the traditional Vietnamese diet should be encouraged.

Cardiovascular health among Asian Americans/Pacific Islanders: an examination of health status and intervention approaches

PURPOSE OF THE REVIEW. The purpose of this review is to examine the cardiovascular health status of Asian Americans/Pacific Islanders by primary risk factor and review current intervention approaches targeting this population. Asian Americans/Pacific Islanders in the United States have experienced triple digit percentage increases in population for every decade since 1970. Despite their rapidly increasing numbers, little is known about their cardiovascular health status. SEARCH METHODS USED. This article reviews the literature on the demographics, mortality, and prevalence of major cardiovascular risk factors among Asian Americans/Pacific Islanders. Selected intervention programs are also described. SUMMARY OF IMPORTANT FINDINGS. Data on cardiovascular disease mortality for Asian Americans/Pacific Islanders are relatively limited because few states collect ethnically specific mortality statistics. Data on cardiovascular risk factors, particularly smoking and hypertension, for certain Asian American/Pacific Islander groups portend excessive cardiovascular disease burdens. MAJOR CONCLUSIONS. Data specific to ethnic groups comprising Asian Americans and Pacific Islanders need to be called. Also, scientifically valid and linguistically appropriate interventions approved by ethnic community leaders are needed to address Asian Americans/Pacific Islanders.

US National Health Data on Asian Americans and Pacific Islanders: a research agenda for the 1990s

OBJECTIVES

In spite of over 30 years of periodic nationwide surveys, we have thus far only the most rudimentary estimates of the determinants of the health of Asian Americans and Pacific Islanders. This paper explores ways to improve the capability of the National Center for Health Statistics (NCHS) to collect national health data on these populations.

METHODS

The NCHS "race" coding practices are reviewed, their limitations stated, ways to improve the numerator and denominator data discussed, and a research agenda presented.

RESULTS

Resources can be intensified to produce better denominator data, and to improve the collection of detailed ethnicity information for the numerators, in at least the three states (California, New York, and Hawaii) where the majority of Asian/Pacific Islanders lived in 1990. Subsequently, these efforts should be extended to the 10 states where 79% of these individuals reside or to the top 15 metropolitan areas where they are concentrated.

CONCLUSIONS

If the recommendations are implemented, several coordinated multisite, multiwave epidemiologic surveys can be conducted using standardized interview instruments and data collection procedures that will capitalize on the geographic distribution of Asian/Pacific Islanders.