Citizenship Status and the Prevalence, Treatment, and Control of Cardiovascular Disease Risk Factors Among Adults in the United States, 2011-2016

LifeCourse Socioeconomic Position and Ideal Cardiovascular Health in Hispanic/Latino Adults of the Hispanic Community Health Study/Study of Latinos

BACKGROUND

The Hispanic/Latino population experiences socioeconomic disadvantages across the lifespan. Yet, little is known about the role of these disadvantages in cardiovascular health (CVH). We assessed the association of lifecourse socioeconomic position (SEP) with ideal CVH and change in Hispanic/Latino adults.

METHODS AND RESULTS

We used longitudinal data from the HCHS/SOL (Hispanic Community Health Study/Study of Latinos). Childhood SEP was determined using parental educational attainment. Adult SEP was determined through an index combining participants' education, occupation, income, and assets at baseline. We classified participants into 4 socioeconomic mobility categories (eg, stable low or high SEP, upward or downward mobility). Using the 4 health factors of the American Heart Association "Life's Essential 8," we built a score of ideal CVH at baseline and the 6-year follow-up. Linear mixed-effects models using inverse probability weighting were fitted to assess the main associations. Higher childhood SEP was associated with higher ideal CVH at baseline (β for high school versus high school versus

CONCLUSIONS

Although high childhood and adult SEP and socioeconomic mobility were associated with higher levels of ideal CVH, they were not associated with change in ideal-CVH.

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Key Words

• Hispanic
• Latino
• cardiovascular health
• childhood
• life‐course
• social mobility
• socioeconomic position

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MESH Headings

• Humans
• Male
• Female
• Hispanic or Latino/statistics & numerical data
• Adult
• Middle Aged
• United States/epidemiology
• Cardiovascular Diseases/ethnology
• Cardiovascular Diseases/epidemiology
• Longitudinal Studies
• Socioeconomic Factors
• Health Status
• Social Determinants of Health/ethnology
• Educational Status
• Social Class
• Risk Factors
• Aged
• Health Status Disparities
• Young Adult

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Affiliation(s)

Paola Filigrana Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA
Jee-Young Moon Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA
Linda C Gallo Department of Psychology San Diego State University San Diego CA USA
Lindsay Fernández-Rhodes Department of Biobehavioral Health, College of Health and Human Development Pennsylvania State University University Park PA USA
Krista M Perreira Department of Social Medicine, School of Medicine University of North Carolina at Chapel Hill Chapel Hill NC USA
Martha L Daviglus Institute for Minority Health Research, College of Medicine University of Illinois at Chicago Chicago IL USA
Bharat Thyagarajan Department of Laboratory Medicine and Pathology University of Minnesota Medical School Minneapolis MN USA
Olga L Garcia-Bedoya Division of Academic Internal Medicine and Geriatrics, College of Medicine University of Illinois at Chicago Chicago IL USA
Jianwen Cai Department of Biostatistics University of North Carolina at Chapel Hill Chapel Hill NC USA
Xiaonan Xue Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA
Robert C Kaplan Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA Public Health Sciences Division Fred Hutchinson Cancer Center Seattle WA USA
Shakira Suglia Department of Epidemiology, Rollins School of Public Health Emory University Atlanta GA USA
Carmen R Isasi Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA

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Integrating NHANES and toxicity forecaster data to compare pesticide exposure and bioactivity by farmwork history and US citizenship

BACKGROUND

Farmworkers in the United States, especially migrant workers, face unique barriers to healthcare and have documented disparities in health outcomes. Exposure to pesticides, especially those persistent in the environment, may contribute to these health disparities.

OBJECTIVE

Quantify differences in pesticide exposure bioactivity by farmworker category and US citizenship status.

METHODS

We queried the National Health and Nutrition Examination Study (NHANES) from 1999-2014 for pesticide exposure biomarker concentrations among farmworkers and non-farmworkers by citizenship status. We combined this with toxicity assay data from the US Environmental Protection Agency's (EPA's) Toxicity Forecaster (ToxCast). We estimated adverse biological effects that occur across a range of human population-relevant pesticide doses.

RESULTS

In total, there were 844 people with any farmwork history and 23,592 non-farmworkers. Of 12 commonly detectable pesticide biomarkers in NHANES, 2,4-dichlorophenoxyacetic acid (OR = 3.76, p = 1.33 × 10-6) was significantly higher in farmworkers than non-farmworkers. Farmworkers were 1.15 times more likely to have a bioactive pesticide biomarker measurement in comparison to non-farmworkers (adjusted OR = 1.15, 95% CI: 0.87, 1.51). Non-U.S. citizens were 1.39 times more likely to have bioactive pesticide biomarker concentrations compared to people with U.S. citizenship (adjusted OR 1.39, 95% CI: 1.17, 1.64). Additionally, non-citizens were significantly more exposed to bioactive levels of β-hexachlorocyclohexane (BHC) (OR = 8.10, p = 1.33 × 10-6), p,p-DDE (OR = 2.60, p = 0.02), and p,p'-DDT (OR = 7.75, p = 0.01).

IMPACT STATEMENT

Farmworkers are a vulnerable population due to social determinants of health and occupational exposures. Here, we integrate US population chemical biomonitoring data and toxicity outcome data to assess pesticide exposure by farmwork history and citizenship. We find that farmworkers and those without US citizenship are significantly more likely to be exposed to concentrations of pesticides which are bioactive in toxicological assays. Thus, farmworkers employed in the US but who are not citizens could be at increased risk of harm to their health due to pesticides. These findings are important to shape evidence-based policies in regulatory science to promote worker safety.

Social Determinants of Health and Multimorbidity Among Adults 50 Years and Older in the United States

BACKGROUND

Living with two or more chronic conditions simultaneously-known as multimorbidity-has become increasingly prevalent as the aging population continues to grow. However, the factors that influence the development of multimorbidity are still not fully understood.

OBJECTIVES

The purpose of this study was to investigate the prevalence of multimorbidity among U.S. adults 50 years and older and identify associated factors with multimorbidity.

METHODS

We used data from four cycles from the National Health and Nutrition Examination Survey (2011-2018) to examine the associations between social determinants of health and multimorbidity among American adults aged 50 years and older. A set of variables on socioeconomic status and health behaviors was chosen based on the social determinants of health conceptual framework developed by the World Health Organization. In our study, 4,552 participants were included. All analyses were accounted for a complex survey design and the use of survey weights. Multiple logistic regression analyses were performed to examine the associated factors with multimorbidity.

RESULTS

The average age was 63.1 years, and 52.9% were female. The average number of chronic conditions was 2.27. The prevalence of multimorbidity was 63.8%, with high cholesterol and hypertension being the most prevalent conditions. In the adjusted model, age, gender, household income, citizenship status, health insurance, healthcare access, body mass index, and smoking status were found to be associated with living with multimorbidity.

DISCUSSION

Our results indicate that continued efforts aimed at promoting smoking cessation and maintaining a healthy weight will be beneficial in preventing the onset of chronic conditions. Additional research is warranted to gain a deeper understanding of the interrelationships between gender, race/ethnicity, household income, citizenship status, health insurance, and healthcare access as social determinants of health in the context of multimorbidity. Further research will help us develop targeted interventions and policies to address disparities and improve health outcomes for individuals with multimorbidity.

Challenges for the prevention of hypertension among international migrants in Latin America: prioritizing the health of migrants in healthcare systems

Among the health priorities of international migrants, non-communicable diseases such as hypertension are of major interest due to their increasing prevalence, mainly in low- and middle-income countries. Previous evidence has reported a significant risk of hypertension in international migrants derived from multiple exposures during the migration process and at the destination, such as living conditions, health literacy and access to preventive services. Also, poorer disease control has been found compared to the local population. Considering existing deficiencies in access and use of healthcare services related to hypertension prevention and continuity of care of migrants globally, we aimed to offer a Latin American perspective of the challenges faced by international migrants residing in Latin America in accessing hypertension preventive care from a human rights, equity, and universal primary healthcare approaches. From a health systems perspective, we conducted a scoping review of scientific literature on hypertension prevention and control among international migrants in Latin America and the Caribbean. Based on the findings, we discuss the potential influence of migration and health policies on healthcare systems and individual and structural barriers to healthcare access, including lack of insurance, linguistic barriers, limited intercultural competence, and geographical and financial barriers. From existing evidence related to hypertension, we highlight the particular healthcare needs of migrants and their implications for regional public health goals. This aligns with promoting culturally tailored interventions considering the migration process, lifestyle patterns, structural vulnerabilities, and gender particularities in hypertension prevention, diagnosis, and treatment. We advocate for developing universal, voluntary, and systemic regional screening and disease control initiatives in Latin America for hypertension and other chronic conditions.

Associations of depression with hypertension and citizenship among U.S. adults: A cross-sectional study of the interactions of hypertension and citizenship

With the increasing prevalence of hypertension-related cardiovascular deaths and depression, this study examined the associations of depression with hypertension, citizenship status, and interaction of hypertension and citizenship status among U.S. adults. Data from the 2015-2018 National Health Interview Survey (NHIS), including 63,985 individuals, were analyzed. Depression status was the outcome, with hypertension and U.S. citizenship status as the main independent variables. Using odds ratio (OR) estimates, we evaluated the associations between hypertension and depression, and citizenship status. The result indicates that a higher proportion of U.S. adults with hypertension reported depression compared to those who did not have hypertension (42.9 % vs. 37.5 %). In terms of U.S. citizenship status, a higher proportion of U.S. citizens reported depression than non-citizens (39.6 % vs. 31.6 %). However, non-citizens with hypertension were more likely to report depression compared to U.S. citizens without hypertension (OR = 1.46; 95 % CI = 1.15, 1.86). While hypertension marginally increased the odds of depression among the general U.S. population, being a non-U.S. citizen with hypertension significantly increased the risk of depression by 46 %. The findings imply that the healthy immigrant paradox, in the context of hypertension-depression prevention and control, may not apply to non-citizens with hypertension. We therefore recommend community-based screenings and more tailored interventions to address these health disparities while taking into consideration the unique cultural norms, behaviors and healthcare barriers encountered by specific immigrant communities.

Perceived Racial/Ethnic Discrimination, Citizenship Status, and Self-Rated Health Among Immigrant Young Adults

Both racial/ethnic discrimination and citizenship status are manifestations of racism. Few empirical studies have examined the role of multiple stressors and how both stressors are interlinked to influence health among immigrant young adults. Informed by the theory of stress proliferation, the current study seeks to examine the interplay between perceived racial/ethnic discrimination and citizenship status on health. We used the third wave of the Children of Immigrants Longitudinal Study (CILS) to examine the influence of perceived racial/ethnic discrimination and citizenship status on self-rated health (SRH) among immigrant young adults (N = 3344). Perceived racial/ethnic discrimination was initially associated with SRH. After adjusting for both predictors, those experiencing perceived racial/ethnic discrimination and non-citizen youth were less likely to report better health than youth who did not report perceived racial/ethnic discrimination or citizen youth. In fully adjusted multivariate regression models, racial/ethnic discrimination remained significant, while citizenship status was no longer associated with SRH. To test stress proliferation, an interaction term was included to assess whether the relationship between perceived racial/ethnic discrimination and SRH varied by citizenship status. The interaction term was significant; non-citizen young adults who experienced racial/ethnic discrimination were less likely to report better health in comparison to citizen young adults and those who did not report perceived racial/ethnic discrimination. Results suggest that the interplay between perceived racial/ethnic discrimination and citizenship status may be influential for health among immigrant young adults. These findings underscore the need for further assessment of the role of stress proliferation on immigrant young adults' health.

Inequity in care delivery in cardio-oncology: dissecting disparities in underrepresented populations

It is well known that patients with cancer have a significantly higher cardiovascular mortality risk than the general population. Cardio-oncology has emerged to focus on these issues including risk reduction, detection, monitoring, and treatment of cardiovascular disease or complications in patients with cancer. The rapid advances in early detection and drug development in oncology, along with socioeconomic differences, racial inequities, lack of support, and barriers to accessing quality medical care, have created disparities in various marginalized populations. In this review, we will discuss the factors contributing to disparities in cardio-oncologic care in distinct populations, including Hispanic/Latinx, Black, Asian and Pacific Islander, indigenous populations, sex and gender minorities, and immigrants. Some factors that contribute to differences in outcomes in cardio-oncology include the prevalence of cancer screening rates, genetic cardiac/oncologic risk factors, cultural stressors, tobacco exposure rates, and physical inactivity. We will also discuss the barriers to cardio-oncologic care in these communities from the racial and socioeconomic context. Appropriate and timely cardiovascular and cancer care in minority groups is a critical component in addressing these disparities, and there need to be urgent efforts to address this widening gap.

Integrating NHANES and Toxicity Forecaster Data to Compare Pesticide Exposure and Bioactivity by Farmwork History and US Citizenship

Introduction

Farmworkers in the United States, especially migrant workers, face unique barriers to healthcare and have documented disparities in health outcomes. Exposure to pesticides, especially those persistent in the environment, may contribute to these health disparities.

Methods

We queried the National Health and Nutrition Examination Study (NHANES) from 1999-2014 for pesticide exposure biomarker concentrations among farmworkers and non-farmworkers by citizenship status. We combined this with toxicity assay data from the US Environmental Protection Agency's (EPA's) Toxicity Forecast Dashboard (ToxCast). We estimated adverse biological effects that occur across a range of human population-relevant pesticide doses.

Results

In total, there were 1,137 people with any farmwork history and 20,205 non-farmworkers. Of the 14 commonly detectable pesticide biomarkers in NHANES, 2,4-dichlorophenol (OR= 4.32, p= 2.01×10 -7 ) was significantly higher in farmworkers than non-farmworkers. Farmworkers were 1.37 times more likely to have a bioactive pesticide biomarker measurement in comparison to non-farmworkers (adjusted OR=1.37, 95% CI: 1.10, 1.71). Within farmworkers only, those without U.S. citizenships were 1.31 times more likely to have bioactive pesticide biomarker concentrations compared those with U.S. citizenship (adjusted OR 1.31, 95% CI: 0.75, 2.30). Additionally, non-citizen farmworkers were significantly more exposed to bioactive levels of β -hexachlorocyclohexane (BHC) (OR= 8.50, p= 1.23×10 -9 ), p,p-DDE (OR= 2.98, p= 3.11×10 -3 ), and p,p'-DDT (OR= 10.78, p= 8.70×10 -4 ).

Discussion

These results highlight pesticide exposure disparities in farmworkers, particularly those without U.S. citizenship. Many of these exposures are occurring at doses which are bioactive in toxicological assays.

Were US Asian Indian decedents with atherosclerosis more likely to have concurrent diabetes mellitus? Analysis of national multiple cause of mortality data (2012-2019)

BACKGROUND

Asian Indians (AI) are at high risk for both atherosclerotic diseases (ATH) and diabetes mellitus (DM). We analyze the clustering of these two comorbidities as contributing causes of death in AI versus Non-AI populations in the US.

METHODS

Using Mortality Multiple Cause-of-Death Files (2012-2019) from the National Center for Health Statistics, we included deaths at age ≥ 45 years among US residents where AI versus Non-AI status could be ascertained (n = 55,461 AI; n = 20,090,038 Non-AI) and identsified ATH (ICD10: I20-I25, I63, I70) and DM (ICD10: E10-E14) as contributing causes of death. We calculated the tetrachoric correlation (Rho) between these contributing causes and the difference in the fraction of deaths involving DM in those with versus without ATH.

RESULTS

Among AI decedents, 29.9% of deaths included ATH as a contributing cause, 16.4% included DM as a contributing cause with 8.3% deaths being included in the overlap (Rho = 0.36, SE = 0.007) whereas, among Non-AI, 22.4% of deaths included ATH as a contributing cause, 10.0% included DM as a contributing cause with 4.1% deaths being included in the overlap (Rho = 0.31, SE = 0.001). Thus, DM and ATH as co-occurring causes correlated more strongly in AI versus Non-AI (p < 0.001). Further, this difference in clustering of DM with ATH was highest for younger AI women (age < 60 years) compared to comparable Non-AI women.

CONCLUSIONS

The more frequent co-occurrence of DM and ATH as causes of death among AI compared to Non-AI suggest that the increased burden of these diseases among AI during life has vicious synergistic consequences in terms of mortality. Public health strategies targeted to AI should focus on prevention and clinical treatment of both conditions jointly, in all adults, and especially in women < 60 years.

Male Infertility Increases the Risk of Cardiovascular Diseases: A Nationwide Population-Based Cohort Study in Taiwan

PURPOSE

Some evidence suggests that male infertility increases the risk of cardiovascular diseases (CVDs). However, the evidence in Asian populations is relatively scarce. The aim of this study is to determine whether male infertility increases the risk of CVDs.

MATERIALS AND METHODS

We used inpatient and outpatient data for the years 2000 to 2015 from the Taiwanese Longitudinal Health Insurance Database. We enrolled 7,016 males over 18 years old and diagnosed with male infertility. Of these, 2,326 matched our inclusion criteria and were assigned to the study group. For each infertility patient, four comparison patients were frequency-matched by age and index date to form a control cohort comprising 9,304 patients. Cox proportional hazards analysis was used to estimate the association between male infertility and CVDs.

RESULTS

After a 15-year follow-up, the incidence rate of CVDs was higher in the infertility group than the control group (1,460.23 and 1,073.70 per 100,000 person-years, respectively). The Cox proportional hazards regression analysis revealed that the adjusted HR for CVDs was 1.472 for the infertility group (95% CI, 1.288-1.683; p<0.001) relative to the control group. The Kaplan-Meier analysis of the cumulative incidence of CVDs in the two groups showed that the cumulative risk curve for CVDs was significantly higher for the infertility group than the control group.

CONCLUSIONS

This study shows that men with infertility have a higher risk of developing incident CVDs. In the future, healthcare providers should pay attention to these patients because of their higher health risks.

Citizenship Status and Mortality Among Young Latino Adults in the U.S., 1998‒2015

INTRODUCTION

Although Latino immigrants, especially noncitizens, endure structural factors that may increase their risk of death at younger ages, little is known about their risk of death in young adulthood. This study evaluates mortality differences across citizenship status among young Latino adults (aged 18-44 years) in the U.S.

METHODS

This study used the National Health Interview Survey (1998-2014) with mortality follow-up through 2015. Cox regression models adjusted for age and sex were used to determine baseline differences in mortality. Models adjusted for socioeconomic factors (i.e., English proficiency, education, poverty, and health insurance) were used to determine whether socioeconomic conditions attenuate mortality differences.

RESULTS

Participants included noncitizens (n=48,388), naturalized citizens (n=16,241), and U.S.-born citizens (n=63,388). Noncitizens (hazard ratio [HR]=1.40, 95% CI=1.31, 1.51), but not naturalized citizens (HR=1.04, 95% CI=0.94, 1.16), were at greater risk of all-cause death than U.S.-born citizens. Both noncitizens (HR=2.46, 95% CI=2.07, 2.92) and naturalized citizens (HR=1.76, 95% CI=1.40, 2.21) were more likely to die of cancer. Noncitizens were also at a greater risk of death because of cardiometabolic diseases (HR=1.46, 95% CI=1.20, 1.78) and accidents (HR=1.33, 95% CI=1.14, 1.55). Socioeconomic factors attenuated differences in all-cause, cardiometabolic, and accidental deaths, but not differences in cancer mortality.

CONCLUSIONS

Contrary to the long-held notion of the healthy migrant, young Latino immigrants, especially noncitizens, are at increased risk of death than their U.S.-born counterparts. Efforts to reduce these disparities should focus on improving their socioeconomic conditions and healthcare access early in adulthood.

Understanding Immigration as a Social Determinant of Health: Cardiovascular Disease in Hispanics/Latinos and South Asians in the United States

PURPOSE OF REVIEW

The main purpose of this review is to summarize the epidemiology of cardiovascular disease and its risk factors among two of the largest and most diverse immigrant groups in the United States (Hispanics/Latinos and South Asians).

RECENT FINDINGS

While the migration process generates unique challenges for individuals, there is a wide heterogeneity in the characteristics of immigrant populations, both between and within regions of origin. Hispanic/Latino immigrants to the United States have lower levels of cardiovascular risk factors, prevalence, and mortality, but this assessment is limited by issues related to the "salmon bias." South Asian immigrants to the United States generally have higher levels of risk factors and higher mortality. In both cases, levels of risk factors and mortality generally increase with time of living in the United States (US). While immigration acts as a social determinant of health, associations between immigration and cardiovascular disease and its risk factors are complex and vary across subpopulations.

Statin nonadherence in Latino and noncitizen neighborhoods in New York City, Los Angeles, and Chicago, 2012-2016

BACKGROUND

Latino adults, especially immigrants without citizenship (i.e., noncitizens), experience considerable barriers to health care, including medications. Inequitable access to medications, especially statins, may exacerbate disparities in cardiovascular disease. Despite this, little is known about medication nonadherence in Latino neighborhoods, especially those with large noncitizen populations.

OBJECTIVES

To estimate nonadherence to statins in Latino neighborhoods and evaluate differences on the basis of their noncitizen population.

METHODS

We conducted a retrospective cohort study among 48,161 adults who lived in predominately Latino neighborhoods in New York City, Los Angeles, and Chicago and who initiated statin therapy from January 2012 to December 2015 using IQVIA LifeLink. Statin nonadherence was defined as a proportion of days covered amounting to less than 80% over 12 months. We focused on differences between neighborhoods with high noncitizen concentrations (areas where noncitizens are at least 35% of the adult population) and other Latino neighborhoods. We examined associations using logistic regressions adjusted for individual (e.g., payment method) and neighborhood characteristics (e.g., poverty).

RESULTS

Individuals living in neighborhoods with high noncitizen concentrations were more nonadherent to statins than those in Latino neighborhoods with fewer noncitizens (75.0% vs. 70.0%, adjusted odds ratio [aOR] 1.18, [95% CI 1.06-1.33]). These disparities were worse in New York City (77.7% vs. 69.1%, aOR 1.37, [95% CI 1.23-1.53]) and Chicago (76.1% vs. 68.8%, aOR 1.38, [95% CI 1.14-1.67]) than in Los Angeles (73.8% vs. 71.3%, aOR 1.10, [95% CI 1.01-1.20]).

CONCLUSION

Neighborhoods with large noncitizen populations have much higher rates of statin nonadherence than Latino neighborhoods with fewer noncitizens. These disparities were least pronounced in Los Angeles, where the county provides health care to all uninsured residents, including noncitizens without documentation to reside in the United States. Efforts to improve medication access in Latino neighborhoods should be multifocal and start by implementing state and local health care options for low-income residents, regardless of citizenship status.

Immigration Status and Disparities in the Treatment of Cardiovascular Disease Risk Factors in the Hispanic Community Health Study/Study of Latinos (Visit 2, 2014-2017)

Objectives. To estimate treatment rates of high cholesterol, hypertension, and diabetes among Hispanic/Latino immigrants by immigration status (i.e., naturalized citizens, documented immigrants, or undocumented immigrants).Methods. We performed a cross-sectional analyses of the Hispanic Community Health Study/Study of Latinos (visit 2, 2014-2017). We restricted our analysis to Hispanic/Latino immigrants with high cholesterol (n = 3974), hypertension (n = 3353), or diabetes (n = 2406); treatment was defined as use of statins, antihypertensives, and antidiabetics, respectively.Results. When compared with naturalized citizens, undocumented and documented immigrants were less likely to receive treatment for high cholesterol (38.4% vs 14.1%; prevalence ratio [PR] = 0.37 [95% confidence interval [CI] = 0.27, 0.51] and 25.7%; PR = 0.67 [95% CI = 0.58, 0.76]), hypertension (77.7% vs 57.7%; PR = 0.74 [95% CI = 0.62, 0.89] and 68.1%; PR = 0.88 [95% CI = 0.82, 0.94]), and diabetes (60.3% vs. 50.4%; PR = 0.84 [95% CI = 0.68, 1.02] and 55.8%; PR = 0.93 [95% CI = 0.83, 1.03]); the latter did not reach statistical significance. Undocumented and documented immigrants had less access to health care, including insurance coverage or a usual health care provider, than naturalized citizens. Therefore, adjusting for health care access largely explained treatment disparities across immigration status.Conclusions. Preventing cardiovascular disease among Hispanic/Latino immigrants should focus on undertreatment of high cholesterol, hypertension, and diabetes by increasing health care access, especially among undocumented immigrants.