Impact of Length of Residence in the United States on Risk of Diabetes and Hypertension in Resettled Refugees

Increases in Psychological Stress Are Associated With Higher Fasting Glucose in US Chinese Immigrants

BACKGROUND

The majority of Chinese Americans is foreign-born, and it is well-documented that immigration to the United States (US) leads to increased risk for chronic diseases including type 2 diabetes. Increased disease risk has been attributed to changes in lifestyle behaviors following immigration, but few studies have considered the psychosocial impact of immigration upon biomarkers of disease risk.

PURPOSE

To examine associations of psychological stress and social isolation with markers of type 2 diabetes risk over time among US Chinese immigrants.

METHODS

In this longitudinal study of 614 Chinese immigrants, participants completed assessments of perceived stress, acculturative stress, negative life events, and social isolation annually at three time points. Fasting blood samples were obtained at each time point to measure blood glucose, glycated hemoglobin, and insulin resistance. Mean duration between baseline and follow-up assessments was approximately 2 years.

RESULTS

Increases in migration-related stress, perceived stress and social isolation were associated with significant increases in fasting glucose at follow-up independent of age, body mass index, length of US residence, and other potential covariates. Moreover, increases in glucose varied depending on perceived stress levels at baseline, such that those with higher baseline stress had a steeper increase in glucose over time.

CONCLUSIONS

Psychological stress and social isolation are associated with increases in fasting glucose in a sample of US Chinese immigrants. Findings suggest that the unique experiences of immigration may be involved in the risk of developing type 2 diabetes, a condition that is prevalent among US Chinese despite relatively low rates of obesity.

Stroke Characteristics in a Cohort of Hmong American Patients

Background Prior studies have indicated high rates of vascular risk factors, but little is known about stroke in Hmong. Methods and Results The institutional Get With The Guidelines (GWTG) database was used to identify patients discharged with acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage between 2010 and 2019. Hmong patients were identified using clan names and primary language. Univariate analysis was used to compare Hmong and White patients. A subarachnoid hemorrhage comparison was not conducted because of the small sample size. We identified 128 Hmong patients and 3084 White patients. Hmong patients had more prevalent hemorrhagic stroke (31% versus 15%; P<0.0016). In the acute ischemic stroke cohort, compared with White patients, Hmong patients were younger (60±13 versus 71±15 years; P<0.0001), presented to the emergency department almost 4 hours later; and had a lower thrombolysis usage rate (6% versus 14%; P=0.03496), worse lipid profile, higher hemoglobin A1C, similar stroke severity, and less frequent discharge to rehabilitation facilities. The most common ischemic stroke mechanism for Hmong patients was small-vessel disease. In the intracerebral hemorrhage cohort, Hmong patients were younger (55±13 versus 70±15 years; P<0.0001), had higher blood pressure, and had a lower rate of independent ambulation on discharge (9% versus 30%; P=0.0041). Conclusions Hmong patients with stroke were younger and had poorer risk factor control compared with White patients. There was a significant delay in emergency department arrival and low use of acute therapies among the Hmong acute ischemic stroke cohort. Larger studies are needed to confirm these observations, but action is urgently needed to close gaps in primary care and stroke health literacy.

Cardiovascular health and risk factors in African refugees and immigrants in the United States: a narrative review

OBJECTIVES

Refugees and immigrants often experience challenges pre- and post-settlement that expose them to risk factors of cardiovascular disease (CVD). Literature on CVD among the growing population of African refugees and immigrants in the United States (US) is scant. This narrative review aimed to evaluate existing studies reporting on CVD and its risk factors among African refugees and immigrants in the US, and to recognize limitations in the current research, policy, and healthcare for adequate CVD-related care for African refugees and immigrants.

DESIGN

Articles on African refugee and/or immigrant health were searched on PubMed using multiple key search terms. Studies conducted between 1995 and 2020 and reporting on CVD-related measures in individuals from African countries of origin were included. Six articles were found discussing refugee health only and seven articles discussed refugee and immigrant health together.

RESULTS

Overall, the studies showed the varying prevalence of CVD risk factors, mostly depending on the country of origin. Worsening cardiometabolic health with longer residency in the US was generally reported. Refugee-only studies relied mostly on medical records data, while refugee and immigrant studies used both medical records and primary data collection. Limitations in data pertain to the geographical representation of both African countries (predominantly from Somalia despite migrants arriving from diverse African countries) and of regions of settling in the US (predominantly the north/northeast), scarce longitudinal studies, and lack of distinction between refugees and immigrants. Multiple social and structural barriers to cardiovascular health were identified, mostly related to cultural and linguistic challenges and to inadequate or complex health insurance and healthcare systems.

CONCLUSION

The cardiovascular health of African refugees and immigrants remains understudied and underserved. Further research and interventions to alleviate barriers and improve cardiovascular health in African refugees and immigrants in the US should be developed using culturally appropriate, accessible, flexible, and multifaceted strategies.

‘Swallow medicine, eat rice, pray about health’: health, health care and health-seeking experiences of South-East Asian older refugees

South-East Asian refugees have lived in the United States of America for nearly four decades, with early refugee immigrants experiencing ageing and later life within the refugee context. As refugees age, health concerns of this older population grow, highlighting the need for ongoing assessment of refugee health and health-seeking behaviours. This study builds on previous literature that assessed the health and health-seeking patterns of South-East Asian refugees in the early years following resettlement, exploring how health and health-seeking is understood among older refugees 40 years after immigration. This paper includes a subset of 37 older refugees from a larger, community-based participatory, mixed-methods intergenerational study of Cambodian and Laotian refugee families conducted over four years (quantitative N = 433; qualitative N = 183). Thematic analysis of 34 semi-structured interviews with these older refugees in coastal Alabama revealed trends in health and health-seeking practices. Older refugees reported high rates of diabetes and hypertension within their generational cohort, and indicated a shift in health-seeking behaviours, whereby Western biomedicine is sought first for such chronic concerns, followed by traditional medicines for mild ailments such as headaches or colds. Older refugees underscored barriers of language, finances and transportation as limiting access to Western health care. Implications for engaging in community health practices and incorporating services to specifically meet the needs of the ageing refugee population are discussed.

Recognizing and Breaking the Cycle of Trauma and Violence Among Resettled Refugees

Purpose of Review

The number of refugees across the globe continues to grow, leaving a large proportion of the global population in a vulnerable state of health. However, the number of robust clinical interventions has not kept apace. This paper provides a general review of literature on the trauma and violence that refugees face, the impact on health outcomes, and some of the promising models for clinical intervention.

Recent Findings

Refugees experience a cycle of trauma, violence, and distress that begins before migration and continues during migration and after resettlement. It has been challenging to develop robust clinical interventions due to the cumulative and cyclic effects of trauma, as well as the unique experiences of trauma that each refugee community and each refugee individual faces.

Summary

Trauma-informed care is a critical component of health care. Developing stronger guidelines for trauma-informed care will help clinicians better provide inclusive and equitable care for refugee patients.

Long-Term Physical Health Outcomes of Resettled Refugee Populations in the United States: A Scoping Review

Several studies describe the health of recently resettled refugee populations in the US beyond the first 8 months after arrival. This review summarizes the results of these studies. Scientific articles from five databases published from January 2008 to March 2019 were reviewed. Articles were included if study subjects included any of the top five US resettlement populations during 2008-2018 and if data described long-term physical health outcomes beyond the first 8 months after arrival in the US. Thirty-three studies met the inclusion criteria (1.5%). Refugee adults had higher odds of having a chronic disease compared with non-refugee immigrant adults, and an increased risk for diabetes compared with US-born controls. The most commonly reported chronic diseases among Iraqi, Somali, and Bhutanese refugee adults included diabetes and hypertension. Clinicians should consider screening and evaluating for chronic conditions in the early resettlement period. Further evaluations can build a more comprehensive, long-term health profile of resettled refugees to inform public health practice.

Prevalence of Overweight and Obesity in US-Bound Refugees: 2009-2017

Refugees are an often understudied population and vulnerable to poor health outcomes. No large-scale analyses have evaluated the prevalence of overweight and obesity in US-bound refugees. Using data obtained from the Centers for Disease Control (CDC) Electronic Disease Notification system, we quantified the prevalence of overweight and obesity in adult US-bound refugees by nationality from 2009 through 2017. This repeated cross-sectional analysis used CDC data to quantify and examine body mass index (BMI) trends in US-bound adult refugees during 2009-2017. Utilizing data from an overseas medical exam required for all US-bound refugees, we determined BMI for 334,746 refugees ≥ 18 years old who arrived in the United States during January 1, 2009-December 31, 2017. We calculated and compared the prevalence of overweight and obesity as well as changes in demographic characteristics (age, sex, and nationality) by year. Adjusted prevalence and prevalence ratios (APR) for yearly trends were assessed using a modified Poisson regression model with robust error variances. After adjusting for age, sex, and nationality, we observed a significant linear trend in the prevalence of overweight/obesity with an average annual relative percent increase of 3% for refugees entering the United States from 2009 through 2017 (APR = 1.031; 95% CI 1.029-1.033). The adjusted prevalence of overweight/obesity increased from 35.7% in 2009 to 44.7% in 2017. The prevalence of overweight and obesity in US-bound refugees increased steadily over the analysis period. Investigation into pre-migration and post-resettlement interventions is warranted.

Blood pressure and fasting glucose changes in male migrants waiting for an asylum decision in Italy. A pilot study

BACKGROUND

The Central Mediterranean route from Libya to Italy has been for years the major port of entry from Africa to Europe. However, information on the early effects of permanence in Italy on cardiovascular risk factors is limited. Therefore, the association between length of stay in Italy and blood pressure or blood glucose was explored in young asylum seekers.

METHODS

Cross-sectional study performed on male asylum seekers (aged 18-40 years), hosted for 0-30 months in Prato, Italy. Blood pressure and blood glucose, measured with validated instruments, were classified according to European Society of Hypertension and American Diabetes Association guidelines respectively. The relationship of quartiles of months of stay in Italy (independent variable) with blood pressure and fasting glucose was investigated with multivariate linear regression adjusted for years of age, world area of origin, education level, travel duration in months, smoking habit, alcohol use, body mass index, triglycerides.

RESULTS

On average, the 217 asylum seekers lived in Italy for 8.4 months (95% CI 7.5-9.3; range 0-30 months). At multivariate adjusted linear regression analysis, quartiles of months in Italy were associated with a forward shift in the blood pressure categories of the European Society of Hypertension (B = 0.396; 95% CI 0.190 to 0.602) and in the categories fasting glucose levels of the American Diabetes Association (B = 0.450; 95% CI 0.023 to 0.876).

CONCLUSIONS

When considering the importance of high blood pressure and type 2 diabetes for ethnic minorities living in Europe, changes of cardiovascular risk factors in the new environment probably need more attention.