Health conditions and lifestyle risk factors of adults living in Puerto Rico: a cross-sectional study

Lifestyle factors, physical health, and life satisfaction under different changes in depressive symptoms among Chinese community-dwelling older adults: A longitudinal analysis

BACKGROUND

The study aims to investigate the long-term impact of lifestyle-related factors and physical health on life satisfaction and depressive symptoms among Chinese community-dwelling older adults.

METHODS

Using data from the China Health and Retirement Longitudinal Study (CHARLS), the analytic sample of this study included 1,068 older adults who had participated in the surveys in both 2011 and 2018. Multivariate regression was employed to analyze both cross-sectional and longitudinal relationships between lifestyle-related factors, physical health, and subjective well-being - specifically depressive symptoms and life satisfaction. Additionally, the model tested how these factors correlate with life satisfaction across different groups of depressive symptom changes among older adults, categorized as not at risk of depression, intermittent depression, and chronic depression.

RESULTS

Multimorbidity was significantly related to baseline and follow-up depressive risk in older adults. Shorter sleep duration was associated with baseline depression risk. Current alcohol drinkers reported significantly more severe depressive symptoms than non-drinkers. At baseline, current smokers were more likely to have a lower degree of life satisfaction than nonsmokers. Among older adults with chronic depression at the 7-year follow-up, former smokers tended to have lower life satisfaction than nonsmokers.

CONCLUSIONS

Our findings identified drinking alcohol and having a shorter sleep duration as modifiable lifestyle-related risk factors for late-life depression and smoking as a detrimental factor for life satisfaction in older Chinese adults. Multimorbidity was a significant predictor of more depressive symptoms. Our findings have implications for future psychosocial interventions that target the alleviation of depressive symptoms and the promotion of life satisfaction in older Chinese people based on their different long-term mental and physical health conditions.

Empowering Underserved Communities in Southern Puerto Rico: A Formal Training Program in Community Health Promotion

Community health promotion offers a potential solution to persistent healthcare challenges, with community health workers playing a pivotal role. The Community Training Institute for Health Disparities (CTIHD) implemented a problem-solving curriculum in Community Health Promotion, integrating a competency-based learning model through two courses: Introduction to Community Health Promotion and Design of an Action Plan for the Promotion of Community Health. Each course comprised ten three-hour sessions, featuring pre/post-tests, evaluations, and a cognitive debriefing. Knowledge change was assessed using pre/post-test scores among 27 community leaders from southern Puerto Rico. Cohort 1 and Cohort 2 demonstrated an overall retention rate of 62.6% and 96.7%, respectively. Although differences in knowledge gained between cohorts and courses weren't statistically significant, a trend toward increased knowledge was noted. Cohort 1 experienced a 22% knowledge increase in Course 1 and a 24% increase in Course 2. Cohort 2 demonstrated a 41% knowledge increase in Course 1 and a 25% increase in Course 2. The CTIHD's Community Health Promotion Program has made significant strides in elevating awareness and knowledge, marking a positive step toward reducing health disparities and fostering healthier, empowered communities in southern Puerto Rico.

Prevalence of cardiometabolic risk and health factors among Puerto Rican young adults in the Boricua Youth Study - Health Assessment

We describe and compare the prevalence of cardiometabolic risk factors and ideal cardiovascular health (CVH) among Puerto Rican young adults in the San Juan metro area in Puerto Rico and the South Bronx, NY. As part of the Boricua Youth Study - Health Assessment, (mean age 23 ± 0.1 years) objective anthropometric, blood pressure and blood samples were collected. Information on diet, physical activity and sleep were collected via surveys. Life's Essential 8 metrics were characterized as continuous with higher scores indicating more optimal CVH and categorically (80-100 scores for ideal CVH). Mean CVH score among NY participants was lower (61.9) than in PR (68.9). No participant had all ideal health metrics, 36% of participants in PR had 5 or more ideal CVH; while only 16% in NY met this criterion. The prevalence of cardiometabolic risk factors was high for obesity (35% in NY, 19% in PR) and diabetes (17% NY, 20% PR). In this ethnically homogenous population, we found low levels of ideal CVH that varied across study site, suggesting differences by sociocultural context. Interventions to maintain and improve CVH across the life course, tailored to sociocultural environments, are necessary for the prevention of cardiovascular disease.

Sociodemographic and health risk factors associated with health-related quality of life among adults living in Puerto Rico in 2019: a cross-sectional study

BACKGROUND

Puerto Rico, a US territory, faces numerous challenges adversely affecting public health, including poverty, a fragile healthcare system, inadequate infrastructure, a debt crisis, and vulnerability to climate change-related natural disasters. The impact of these factors on the Health-Related Quality of Life (HRQoL) measure has not been comprehensively evaluated. Only two studies have assessed HRQoL, with the latest conducted in 2011, prior to recent events that could affect public health. This study aimed to assess the HRQoL and associated sociodemographic and health risk factors among adults living in Puerto Rico in 2019.

METHODS

Prevalence and 95% confidence intervals were used to describe HRQoL and its associations with sociodemographic and health-related variables among adults living in Puerto Rico who answered the Behavioral Risk Factor Surveillance System (BRFSS) survey (n = 4,944) in 2019. Multivariable logistic regression models were developed to identify which of these variables were more likely to be associated with each of the four core HRQoL questions (HRQoL-4), expressed as prevalence odds ratios with 95% confidence intervals adjusted for potential confounders.

RESULTS

Through a comprehensive multivariable analysis, we uncovered significant risk factors - increasing number of chronic conditions, advanced age, and low income - associated with poor HRQoL among adults living in Puerto Rico. Specifically, our findings suggest that individuals with an increasing number of chronic conditions were more likely to report poor HRQoL across all 4 domains. As the number of reported chronic conditions increases by one, the odds of reporting having: fair/poor general health increased by a factor of 2.24 (POR: 2.24, 95% CI: 2.08-2.41), physical health impairment increased by a factor of 1.93 (POR: 1.93, 95% CI: 1.78-2.08), mental health impairment increased by a factor of 1.90 (POR: 1.90, 95% CI: 1.78-2.02) and activity limitation increased by a factor of 1.27 ( POR: 1.27, 95% CI: 1.13-1.42). Advancing age was associated with all domains of poor HRQoL, except for the mental health domain for which we observed higher rates of poor HRQoL among the younger population (POR: 4.76, 95% CI: 2.4-9.1).

CONCLUSION

This paper shows that the prevalence of poor HRQoL has not improved compared to the only previous study of HRQoL of Puerto Rico in the last decade. We also found that poor HRQoL is associated with having multiple chronic conditions in adults living in Puerto Rico. This may be a consequence of a decline in health services after natural disasters and socioeconomic downturns on the island. The study emphasizes the need for targeted interventions and ongoing monitoring of the population's HRQoL over time to reach vulnerable subgroups, especially those with chronic conditions, advanced age, and low income, in order to reduce health disparities in Puerto Rico.

Self-Rated Health and Medically Diagnosed Chronic Disease Association among Adults in Puerto Rico

Introduction

Latinos report lower self-rated health (SRH) than non-Hispanic White persons. However, the association between SRH and medically diagnosed chronic diseases (MDCDs) remains understudied in Latino populations. This study assessed the relationship between a single-item SRH indicator and MDCD status among predominantly Latino adults in Puerto Rico.

Methods

Participants (30-75 years; n=965) of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) reported SRH (excellent/very good, good, or fair/poor) and MDCD (ever vs never). We performed multivariate logistic regressions to evaluate the association between SRH and MDCD, which adjusted for key socioeconomic, demographic, and behavioral confounders.

Results

Twenty-seven percent of participants reported excellent/very good SRH, 39% good, and 34% fair/poor. Participants with fair/poor SRH (vs excellent/very good) were more likely to report MDCD for painful inflammation (odds ratio [OR]=4.95 [95% CI, 3.27-7.48]), kidney disease (4.64 [2.16-9.97]), sleep disorder (4.47 [2.83-7.05]), migraine headaches (4.07 [2.52-6.58]), overweight/obesity (3.84 [2.51-5.88]), depression (3.61 [2.28-5.74]), hypertension (3.59 [2.43-5.32]), high blood sugar (3.43 [2.00-5.89]), cardiovascular disease (3.13 [2.01-4.87]), anxiety (2.87 [1.85-4.44]), arthritis (2.80 [1.83-4.30]), diabetes (2.46 [1.57-3.83]), respiratory problems (2.45 [1.59-3.79]), stomach problems (2.44 [1.57-3.81]), eye disease (2.42 [1.44-4.06]), gallbladder disease (2.34 [1.35-4.05]), liver disease (2.26 [1.38-3.70]), heartburn (2.25 [1.55-3.26]), hyperlipidemia (2.10 [1.44-3.06]), and thyroid conditions (2.04 [1.30-3.21]).

Conclusions

SRH may reflect MDCD burden and serve as a valid screener to efficiently identify Latino individuals in high need of clinical services. This is relevant in Puerto Rico, where chronic disease rates remain high amid limited, disparate access to health care.

ietanti-flamatoria or DAIN: A Crohn's disease management strategy tailored for Puerto Ricans

Diet has been increasingly shown to be of therapeutic benefit for patients with inflammatory bowel diseases (IBD), especially Crohn's disease (CD). Yet dietary guidelines are nonexistent. Moreover, diets tailored to Puerto Ricans with IBD living on the island, have not been developed and tested. The rising prevalence of IBD in Puerto Rico warrants exploring the use of diet as part of the treatment strategies for these patients [1]. Here, we describe the study design of "Dieta Anti-Inflamatoria" or DAIN, a parallel two-arm randomized pilot trial aiming at testing the efficacy of IBD-Anti-inflammatory diet (IBD-AID) adapted for adults with CD living in Puerto Rico (clinical trial registration number: NCT05627128). We tailored the IBD-AID to the local cuisine preferences and food availability by creating and adapting recipes consistent with the IBD-AID principles [2,3]. In focus groups with a Community Research Advisory Panel and one-on-one consultations with implementation experts, we identified several aspects of the intervention to adapt before the implementation. The objectives of the stakeholder/expert-informed adaptation were to improve feasibility and compliance while developing the culturally tailored dietary intervention. DAIN was designed for adults living in Puerto Rico with CD and geared to be affordable, appropriate, and acceptable for patients with mild-to-moderate CD. The significance of this work is the validation of culturally appropriate nutritional guidelines to help manage CD symptoms. DAIN provides a blueprint for a comprehensive nutritional program that can be adapted to regional preferences and local food availability allowing wider implementation of diet as an adjunct treatment in diverse clinical settings.

The co-management of HIV and chronic non-communicable diseases in the Dominican Republic: A qualitative study

People living with HIV and a non-communicable disease (NCD) experience multi-level barriers when co-managing multiple conditions. We explored the factors affecting living with multiple chronic conditions in the Dominican Republic. We conducted 21 in-depth interviews from October 2019-February 2020 with Dominican adults who participated in a food security intervention and managed HIV and at least one chronic NCD. Using thematic analysis, we explored participant lived experiences co-managing multiple chronic conditions. All participants (mean age = 45.5 years) were linked to HIV care, but only three were linked to NCD-specific care. Individual-level barriers to managing NCDs included limited education and limited self-efficacy for self-management. Interpersonally, barriers included limited rapport building with an NCD-specific specialist. Structural barriers to managing NCDs were no health insurance, poor referral systems, and limited financial assistance. Health system adaptation requires equitably considering the needs of individuals managing multiple chronic conditions. Key factors to address include patient-provider relationships, improved referral systems, accessibility and availability of specialists, and financial assistance.

Epidemiological intelligence community network intervention: a community response for COVID-19 community transmission

BACKGROUND

Expanding and providing access to early detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through testing community-based strategies among socially vulnerable communities (SVC) are critical to reducing health disparities. The Epidemiological Intelligence Community Network (EpI-Net) community-based intervention sought to increase coronavirus 2019 (COVID-19) testing uptake and prevention practices among SVC in Puerto Rico (PR). We evaluated EpI-Net's community leaders' capacity-building component by assessing pre-post COVID-19 public health workshops' tests' score changes and satisfaction among trained community leaders.

METHODS

A total of 24 community leaders from SVC in PR have completed four community workshops. Pre- and post-assessments were completed as part of the health promotors training program to evaluate participants' tests score changes and satisfaction outcomes.

RESULTS

Preliminary results showed: (1) high intervention retention levels of community leaders (85.7% acceptance rate); (2) change in post-test scores for community engagement strategies (p = 0.012); (3) change in post-test educational scores in COVID-19 prevention practices (p = 0.014); and (4) a change in scores in public health emergency management strategies (p < 0.001).

CONCLUSIONS

The overall workshop satisfaction was 99.6%. Community leaders have shown the importance of community capacity building as a key component for intervention feasibility and impact.

TRIAL REGISTRATION

Our study was retrospectively registered under the ClinicalTrial.gov ID NCT04910542.

A Qualitative Approach to Explore Perceptions, Opinions and Beliefs of Communities who Experienced Health Disparities towards Chronic Health Conditions

The prevalence of chronic medical conditions is associated with biological, behavioral, and social factors. In Puerto Rico (PR), events such as budget cuts to essential services in recent years have contributed to deepening health disparities. This study aimed to explore community perceptions, opinions, and beliefs about chronic health conditions in the southern region of Puerto Rico. Framed by a Community-Based Participatory Research (CBPR) approach, this qualitative study developed eight focus groups (n = 59) with adults (age of 21 or older) from southern Puerto Rico, in person and remotely, during 2020 and 2021. Eight open-ended questions were used for discussions, which were recorded, transcribed, and analyzed via computer analysis. Content analysis revealed four main dimensions: knowledge, vulnerabilities, barriers, and identified resources. Relevant topics included: concerns about mental health-depression, anxiety, substance use, and suicide; individual vulnerabilities-risk behaviors, and unhealthy habits; economic factors-health access and commercialization of health. Resource identification was also explored, and participants discussed the importance of alliances between public and private sectors. These topics were addressed across all focus groups, with various recommendations. The results highlight the importance of prioritizing identified community needs, evaluating available resources, and promoting tailored-made interventions to reduce risk factors for chronic health conditions.

The neighborhood context and all-cause mortality among older adults in Puerto Rico

Background

Recent efforts have been made to collect data on neighborhood-level attributes and link them to longitudinal population-based surveys. These linked data have allowed researchers to assess the influence of neighborhood characteristics on the health of older adults in the US. However, these data exclude Puerto Rico. Because of significantly differing historical and political contexts, and widely ranging structural factors between the island and the mainland, it may not be appropriate to apply current knowledge on neighborhood health effects based on studies conducted in the US to Puerto Rico. Thus, we aim to (1) examine the types of neighborhood environments older Puerto Rican adults reside in and (2) explore the association between neighborhood environments and all-cause mortality.

Methods

We linked data from the 2000 US Census to the longitudinal Puerto Rican Elderly Health Conditions Project (PREHCO) with mortality follow-up through 2021 to examine the effects of the baseline neighborhood environment on all-cause mortality among 3,469 participants. Latent profile analysis, a model-based clustering technique, classified Puerto Rican neighborhoods based on 19 census block group indicators related to the neighborhood constructs of socioeconomic status, household composition, minority status, and housing and transportation. The associations between the latent classes and all-cause mortality were assessed using multilevel mixed-effects parametric survival models with a Weibull distribution.

Results

A five-class model was fit on 2,477 census block groups in Puerto Rico with varying patterns of social (dis)advantage. Our results show that older adults residing in neighborhoods classified as Urban High Deprivation and Urban High-Moderate Deprivation in Puerto Rico were at higher risk of death over the 19-year study period relative to the Urban Low Deprivation cluster, controlling for individual-level covariates.

Conclusions

Considering Puerto Rico's socio-structural reality, we recommend that policymakers, healthcare providers, and leaders across industries to (1) understand how individual health and mortality is embedded within larger social, cultural, structural, and historical contexts, and (2) make concerted efforts to reach out to residents living in disadvantaged community contexts to understand better what they need to successfully age in place in Puerto Rico.

Consumption of Foods Away from Home Is Associated with Lower Diet Quality Among Adults Living in Puerto Rico

BACKGROUND

Consuming foods away from home (FAFH) is ubiquitous, yet, it is unclear how it influences diet in diverse populations.

OBJECTIVE

The study aimed to evaluate the association between frequency and type of consumption of FAFH and diet quality.

DESIGN

The study had a cross-sectional design. Participants self-reported the frequency of consuming FAFH as "rarely" (≤1 time per week) vs "frequently" (≥2 times per week) at various commercial establishments or noncommercial FAFH (ie, friends' or relatives' homes).

PARTICIPANTS/SETTING

Participants were adults (aged 30 through 75 years) from the PRADLAD (Puerto Rico Assessment of Diet, Lifestyle, and Diseases) study conducted in San Juan, Puerto Rico metro area (n = 239) in 2015.

MAIN OUTCOME MEASURES

A validated food frequency questionnaire captured dietary intake. The Alternate Healthy Eating Index-2010 defined diet quality. Secondary outcomes included whether participants met 2015-2020 Dietary Guidelines for Americans recommendations for sodium, added sugars, saturated fat, dietary fiber, total energy, and alcohol.

STATISTICAL ANALYSES PERFORMED

Linear or logistic regression models adjusted for age, sex, employment, income, education, and food insufficiency tested differences in mean Alternate Healthy Eating Index-2010 scores or odds of meeting (vs not meeting) intake recommendations by FAFH type and frequency.

RESULTS

Overall, 54.4% and 37.2% of participants reported consuming commercial FAFH and noncommercial FAFH "frequently," respectively. Consuming FAFH "frequently" (vs "rarely") was associated with lower mean Alternate Healthy Eating Index-2010 scores for both commercial FAFH (57.92 vs 63.58; P = .001) and noncommercial FAFH (56.22 vs 62.32; P < .001). Consuming commercial FAFH "frequently" (vs "rarely") at any type of food establishment was associated with lower odds of meeting the dietary fiber Dietary Reference Intakes (odds ratio 0.43; 95% CI 0.23 to 0.81). Consuming noncommercial FAFH "frequently" was associated with lower odds of meeting recommendations for sodium (odds ratio 0.30; 95% CI 0.11 to 0.79) and added sugars (odds ratio 0.41; 95% CI 0.18 to 0.93).

CONCLUSIONS

Frequent consumption of FAFH is associated with lower diet quality and lower adherence to dietary recommendations in Puerto Rico. Future studies should explore whether diet quality can be improved by prioritizing healthy at-home meals and reformulating the quality of commercial FAFH.

Design and Implementation of a Culturally-Tailored Randomized Pilot Trial: Puerto Rican Optimized Mediterranean-Like Diet

Background

Adhering to a Mediterranean Diet (MedDiet) is associated with a healthier cardiometabolic profile. However, there are limited studies on the MedDiet benefits for non-Mediterranean racial/ethnic minorities, for whom this diet may be unfamiliar and inaccessible and who have a high risk of chronic diseases.

Objectives

To describe the study design of a pilot trial testing the efficacy of a MedDiet-like tailored to adults in Puerto Rico (PR).

Methods

The Puerto Rican Optimized Mediterranean-like Diet (PROMED) was a single-site 4-mo parallel two-arm randomized pilot trial among a projected 50 free-living adults (25-65 y) living in PR with at least two cardiometabolic risk factors (clinicaltrials.gov registration #NCT03975556). The intervention group received 1 individual nutritional counseling session on a portion-control culturally-tailored MedDiet. Daily text messages reinforced the counseling content for 2 mo, and we supplied legumes and vegetable oils. Participants in the control group received cooking utensils and one standard portion-control nutritional counseling session that was reinforced with daily texts for 2 mo. Text messages for each group were repeated for two more months. Outcome measures were assessed at baseline, 2 and 4 m. The primary outcome was a composite cardiometabolic improvement score; secondary outcomes included individual cardiometabolic factors; dietary intake, behaviors, and satisfaction; psychosocial factors; and the gut microbiome.

Results

PROMED was designed to be culturally appropriate, acceptable, accessible, and feasible for adults in PR. Strengths of the study include applying deep-structure cultural components, easing structural barriers, and representing a real-life setting. Limitations include difficulty with blinding and with monitoring adherence, and reduced timing and sample size. The COVID-19 pandemic influenced implementation, warranting replication.

Conclusions

If PROMED is proven efficacious in improving cardiometabolic health and diet quality, the findings would strengthen the evidence on the healthfulness of a culturally-appropriate MedDiet and support its wider implementation in clinical and population-wide disease-prevention programs.

How Social Determinants of Health of Individuals Living or Working in U.S. Department of Veterans Affairs Home-Based Long-Term Care Programs in Puerto Rico Influenced Recovery after Hurricane Maria

In September 2017, Hurricane Maria devastated Puerto Rico, causing extensive infrastructure damage and a significant number of deaths. In the months and years since, recovery from Maria has been slow, hampered by delayed delivery of fiscal aid, corruption, economic hardships, and Puerto Rico's colonial status. Simultaneously, Puerto Rico's population is rapidly aging and hundreds of thousands of mostly younger Puerto Ricans are migrating out of Puerto Rico for more opportunities. Many Puerto Ricans who are older or disabled and need long-term care receive this care in home-based environments, as Puerto Rico has minimal institutionalized long-term care infrastructure and limited funding to expand it. The Department of Veterans Affairs (VA) offers several home-based long-term care options for Veterans in Puerto Rico. In this qualitative case study, veterans, VA staff, veterans' caregivers, caregivers' family members, and veterans' family members receiving or involved with providing this care were interviewed regarding their experiences during and after Hurricane Maria. Specifically, this study highlights how social determinants of health of those residing in or involved with VA home-based long-term care programs influenced recovery from Hurricane Maria, and how findings can inform disaster recovery and provision of home-based long-term care going forward.

Treatment Patterns Among Patients with Rheumatoid Arthritis in Puerto Rico

Introduction

Racial and ethnic disparities in rheumatoid arthritis (RA) have been identified in the United States, with higher levels of disease activity and worse functional status reported in Hispanic patients compared with their white counterparts. Although RA is one of the most prevalent health conditions in Puerto Rico, few studies have previously examined the characteristics or treatment patterns of patients receiving biological and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) in this population.

Methods

This was a retrospective cohort study using data extracted from the Advanced Business Management Organization database, which represents around 70% of pharmacy claims in Puerto Rico. Patients with RA were included if they had ≥ 1 prescription for any approved b/tsDMARD during the index period (January 2016 to July 2018), and ≥ 2 years of follow-up. The objective was to describe and compare the demographic and clinical characteristics of patients with RA being treated with b/tsDMARD therapy in Puerto Rico, and to evaluate the treatment patterns among these patients.

Results

Most patients (74%) received tumor necrosis factor inhibitors (TNFis) as index therapy, followed by abatacept (17%), Janus kinase inhibitors (JAKis; 5%), and other non-TNFis (4%). Similar trends were observed in subsequent lines of therapy, although abatacept was more frequently used in these later lines versus index therapy. At 2 years, 62% of patients had discontinued their index therapy and 17% had switched to an alternative b/tsDMARD; only 21% persisted with index therapy. The percentage of patients who were persistent with their index therapy at the end of year 2 was 28% for JAKis, 36% for abatacept, 41% for TNFis, and 45% for other non-TNFis.

Conclusions

These findings demonstrate that despite the availability of several b/tsDMARDs, patients with RA in Puerto Rico still experience substantial treatment disruption, with almost two-thirds of patients discontinuing their index therapy within 2 years.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00408-7.

Chronic Diseases and Associated Risk Factors Among Adults in Puerto Rico After Hurricane Maria

IMPORTANCE

As public health emergencies become more prevalent, it is crucial to identify adverse physical and mental health conditions that may be triggered by natural disasters. There is a lack of data on whether Hurricane Maria in 2017 influenced the disease burden of adults in Puerto Rico.

OBJECTIVE

To estimate the prevalence of chronic diseases and their associated risk factors among adults living in Puerto Rico before and after Hurricane Maria in 2017.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from 2 previous cross-sectional studies, including the pre-Hurricane Maria Puerto Rico Assessment on Diet, Lifestyles and Disease (PRADLAD) study, conducted in 2015, and the post-Hurricane Maria Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT), conducted in 2019. Participants included adults aged 30 to 75 years residing in Puerto Rico. Data were analyzed from April to October 2020.

EXPOSURES

Self-reported data were obtained on sociodemographic, lifestyle, and psychosocial factors and medically diagnosed conditions using validated questionnaires. Anthropometrics were measured in triplicate.

MAIN OUTCOMES AND MEASURES

Data were obtained using similar protocols in both studies. Characteristics were contrasted for all participants across studies and for 87 PRADLAD participants who returned to PROSPECT.

RESULTS

A total of 825 participants from both cohorts were included, with 380 PRADLAD participants and 532 PROSPECT participants. In the 2019 PROSPECT study, the mean (SD) age was 53.7 (10.8) years, and 363 participants (68.2%) were assigned female at birth and 169 participants (31.8%) were assigned male at birth. In the 2019 cohort, 360 participants (67.7%) had college education or higher, 205 participants (38.5%) reported annual income greater than $20 001, and 263 participants (49.5%) were employed. Most sociodemographic variables were similar between studies, except for higher income and employment after the hurricane. In the main analysis, participants in 2019, compared with participants in 2015, had higher abdominal obesity (389 participants [73.2%] vs 233 participants [61.3%]), sedentarism (236 participants [44.4%] vs 136 participants [35.8%]), binge drinking (95 participants [17.9%] vs 46 participants [12.1%]), and social support (mean [SD] score, 26.9 [7.2] vs 24.7 [7.1]) but lower depressive symptoms (169 participants [31.7%] vs 200 participants [52.6%]) and perceived stress (mean [SD] score, 19.3 [9.5] vs 21.7 [7.7]). In 2019, compared with 2015, there were higher rates of hypertension (252 participants [47.3%] vs 149 participants [39.2%]), arthritis (172 participants [32.3%] vs 97 participants [25.6%]), high cholesterol (194 participants [36.4%] vs 90 participants [23.8%]), high triglycerides (123 participants [23.1%] vs 56 participants [14.7%]), eye disease (94 participants [17.6%] vs 48 participants [12.7%]), fatty liver disease (68 participants [12.8%] vs 29 participants [7.5%]), and osteoporosis (74 participants [13.9%] vs 20 participants [5.2%]). Secondary analysis for the 87 returning participants showed similar results.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, a higher prevalence of unhealthy behaviors and chronic conditions was noted among adults in Puerto Rico after Hurricane Maria, warranting long-term studies. Psychosocial factors were better, but still need attention. As natural disasters intensify, efforts should focus on continuous surveillance of health outcomes and promoting healthy behaviors, positive emotional health, and disease control, particularly in populations with higher risk for poor health.

Influence of Health Beliefs on COVID-19 Vaccination among Individuals with Cancer and Other Comorbidities in Puerto Rico

Ethnic minority populations are more likely to suffer from chronic comorbidities, making them more susceptible to the poor health outcomes associated with COVID-19 infection. Therefore, ensuring COVID-19 vaccination among vulnerable populations is of utmost importance. We aimed to investigate health behaviors and perceptions of COVID-19 vaccination among adults self-reporting diagnosis of cancer and of other chronic comorbidities in Puerto Rico (PR). This secondary analysis used data from 1911 participants who completed an online survey from December 2020 to February 2021. The Health Belief Model was used to measure perceptions surrounding COVID-19 vaccination among individuals self-reporting diagnosis of cancer and of other chronic comorbidities, and healthy adults. Among study participants, 76% were female, 34% were 50 years or older, 5% self-reported cancer diagnosis, and 70% had other chronic comorbidities. Participants self-reporting a cancer diagnosis had two times higher odds of getting vaccinated than healthy individuals (95% CI: 1.00-4.30). Compared to healthy participants, those self-reporting being diagnosed with cancer and those with chronic conditions other than cancer had significantly higher perceived COVID-19 susceptibility and severity. Our findings elucidate the effect of disease status on health-related decision-making and highlights information needed to be included in education campaigns to increase vaccine uptake among ethnic minority populations.

Colorism and Health Disparities in Home Countries: The Case of Puerto Rico

This study reveals the association of skin color with health disparities in Puerto Rico, a US territory that is home to the second largest Latino population in the US. Aware of the inadequacy of standard OMB ethno-racial categories in capturing racial differences among Latinos, we incorporated skin color scales into the Puerto Rico BRFSS. We apply both logistic regressions and propensity score matching techniques. We found that colorism plays a significant role in health outcomes of dark-skinned Puerto Ricans in Puerto Rico and that skin color is a better health predictor than the OMB ethno-racial categories. Our results indicate that Puerto Ricans of the lightest skin tone have better general health than Puerto Ricans who self-described as being of the darkest skin tones. Findings underscore the importance of considering how racial discrimination manifested through colorism affects the health of Latino populations in the US and its territories.

Lifestyle Behavioral Factors and Integrative Successful Aging Among Puerto Ricans Living in the Mainland United States

BACKGROUND

Few studies have assessed multidimensional models for predicting successful aging that incorporate both physical and cognitive-psychosocial elements among minority populations. This study aimed to establish a comprehensive lifestyle behavioral factors (cLBF) score and an integrative successful aging (ISA) score and explore their associations among older Puerto Rican adults.

METHODS

Data were assessed from 889 adults (45-75 years) participating in the longitudinal (baseline and 2-year follow-up) Boston Puerto Rican Health Study. Higher cLBF score (range 0-10) indicates healthier behaviors (nonsmoking, lack of sedentarism, physical activity, high diet quality, and adequate sleep). The physical domain score of ISA included 8 components (functional impairment, hypertension, diabetes, cancer, cardiovascular disease, respiratory disease, arthritis, osteoporosis) and ranged 0-11. The cognitive-psychosocial domain of ISA included 5 components (cognitive impairment, depressive symptoms, social support, perceived stress, and self-rated health) and ranged 0-10. The sum of both domains comprised the ISA score, ranging 0-21. Higher scores of ISA and its domains indicate more successful aging.

RESULTS

At 2 years, the mean ± SD of cLBF score was 4.9 ± 1.8, and ISA was 10.1 ± 3.3. In multivariable-adjusted models, cLBF score was significantly and positively associated with 2-year change in overall ISA (β [95% CI]: 0.15 [0.07, 0.24] points), in physical domain (0.09 [0.04, 0.13] points), and in cognitive-psychosocial domain (0.08 [0.02, 0.14] points).

CONCLUSIONS

Maintaining healthier lifestyle behaviors may contribute to successful aging through both physical and cognitive-psychosocial domains. The results support using a multidimensional definition of successful aging in Puerto Ricans and evaluating it in other populations.

Design and Implementation of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT)

The Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) is a prospective cohort study in Puerto Rico (PR) aiming to identify trends and longitudinal associations in risk factors for cardiovascular disease (CVD). In 2019, PROSPECT investigators started recruiting a sample of 2,000 adults aged 30-75 years in PR using multistage probabilistic sampling of households and community approaches. Culturally sensitive trained research assistants assess participants, at baseline and at 2-year follow-up, in private rooms at a network of partner clinics. The study collects comprehensive data on demographic factors, socioeconomic and environmental factors, medical history, health conditions, lifestyle behaviors, psychosocial status, and biomarkers of CVD and stress. PROSPECT will estimate the prevalence and incidence of psychosocial, lifestyle, and biological CVD risk factors, describe variations in risk factors by urbanicity (urban areas vs. rural areas) and exposure (before and after) to natural disasters, and determine predictors of longitudinal changes in CVD risk factors. The study has 4 coordinated operational strategies: 1) research productivity (including synergy with existing epidemiologic cohorts of Hispanics/Latinos for comparison); 2) research infrastructure (biorepository, ancillary studies, and clinical research network); 3) capacity-building, education, and training; and 4) community outreach, dissemination, and policy. PROSPECT will inform public health priorities to help reduce CVD in PR.

Sex differences in mortality: results from a population-based study of 12 longitudinal cohorts

BACKGROUND

Women generally have longer life expectancy than men but have higher levels of disability and morbidity. Few studies have identified factors that explain higher mortality in men. The aim of this study was to identify potential factors contributing to sex differences in mortality at older age and to investigate variation across countries.

METHODS

This study included participants age ≥ 50 yr from 28 countries in 12 cohort studies of the Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) consortium. Using a 2-step individual participant data meta-analysis framework, we applied Cox proportional hazards modelling to investigate the association between sex and mortality across different countries. We included socioeconomic (education, wealth), lifestyle (smoking, alcohol consumption), social (marital status, living alone) and health factors (cardiovascular disease, diabetes, mental disorders) as covariates or interaction terms with sex to test whether these factors contributed to the mortality gap between men and women.

RESULTS

The study included 179 044 individuals. Men had 60% higher mortality risk than women after adjustment for age (pooled hazard ratio [HR] 1.6; 95% confidence interval 1.5-1.7), yet the effect sizes varied across countries (I 2 = 71.5%, HR range 1.1-2.4). Only smoking and cardiovascular diseases substantially attenuated the effect size (by about 22%).

INTERPRETATION

Lifestyle and health factors may partially account for excess mortality in men compared with women, but residual variation remains unaccounted for. Variation in the effect sizes across countries may indicate contextual factors contributing to gender inequality in specific settings.

Dietary intake and cardiometabolic risk factors among Venezuelan adults: a nationally representative analysis

BACKGROUND

Increasing trends in global obesity have been attributed to a nutrition transition where healthy foods are replaced by ultra-processed foods. It remains unknown if this nutrition transition has occurred in Venezuela, a country undergoing a socio-political crisis with widespread food shortages.

METHODS

We described dietary intake of Venezuelans from a nationally representative study conducted between 2014 and 2017. We conducted a cross-sectional analysis of dietary, sociodemographic, and clinical data from Venezuelans ≥20 years of age (n = 3420). Dietary intake was assessed using a semi-quantitative food frequency questionnaire. Standardized clinical and anthropometric measurements estimated obesity, type 2 diabetes, and hypertension. A Dietary Diversity Score (DDS) was calculated using an amended Minimum Dietary Diversity for Women score where the range was 0 to 8 food groups, with 8 being the most diverse. Analyses accounted for complex survey design by estimating weighted frequencies of dietary intake and DDS across sociodemographic and cardiometabolic risk-based subgroups.

RESULTS

The prevalence of obesity was 24.6% (95% CI: 21.6-27.7), type 2 diabetes was 13.3% (11.2-15.7), and hypertension was 30.8% (27.7-34.0). Western foods were consumed infrequently. Most frequently consumed foods included coffee, arepas (a salted corn flour cake), and cheese. Mean DDS was 2.3 food groups (Range: 0-8, Standard Error: 0.07) and this score did not vary among subgroups. Men, younger individuals, and those with higher socioeconomic status were more likely to consume red meat and soft drinks once or more weekly. Women and those with higher socioeconomic status were more likely to consume vegetables and cheese once or more daily. Participants with obesity, type 2 diabetes, and hypertension had lower daily intake of red meat and arepas compared to participants without these risk factors.

CONCLUSIONS

Despite high prevalence of cardiometabolic risk factors, adults in Venezuela have not gone through a nutrition transition similar to that observed elsewhere in Latin America. Dietary diversity is low and widely consumed food groups that are considered unhealthy are part of the traditional diet. Future studies are needed in Venezuela using more comprehensive measurements of dietary intake to understand the effect of the socio-political crisis on dietary patterns and cardiometabolic risk factors.

Puerto Rico Health System Resilience After Hurricane Maria: Implications for Disaster Preparedness in the COVID-19 Era

BACKGROUND

Every year, Puerto Rico faces a hurricane season fraught with potentially catastrophic structural, emotional and health consequences. In 2017, Puerto Rico was hit by Hurricane Maria, the largest natural disaster to ever affect the island. Several studies have estimated the excess morbidity and mortality following Hurricane Maria in Puerto Rico, yet no study has comprehensively examined the underlying health system weaknesses contributing to the deleterious health outcomes.

METHODS

A qualitative case study was conducted to assess the ability of the UPR health system to provide patient care in response to Hurricane Maria. An established five key resilience framework and inductive analysis was used to identify factors that affected health system resilience. Thirteen Emergency Medicine Physicians, Family Medicine Physicians, and Hospital Administrators in a University of Puerto Rico (UPR) Community Hospital were interviewed as part of our study.

RESULTS

Of the five key resiliency components, three domains were notably weak with respect to UPR resiliency. Prior to the Hurricane, key personnel at the UPR hospital were unaware of the limited capacity of back-up generators at hospitals and were ill-prepared to transfer ICU patients to appropriate hospitals. Post Hurricane, the hospital faced self-regulation challenges when triaging the provision of Hurricane-related emergency services with delivering core health services, in particular for patients with chronic conditions. Finally, during and after the Hurricane, integration of patient care coordination between the UPR hospital ambulances, neighboring hospitals, and national and state government was suboptimal. The two remaining resiliency factors, addressing diverse needs and system adaptiveness in a time of crisis, were seen as strengths.

CONCLUSIONS

Hurricane Maria exposed weaknesses in the Puerto Rican health system, notably the lack of awareness about the limited capacity of backup generators, poor patient care coordination, and interruption of medical care for patients with chronic conditions. As in other countries, the current COVID epidemic is taxing the capacity of the Puerto Rico health system, which could increase the likelihood of another health system collapse should another hurricane hit the island. Therefore, a resilience framework is a useful tool to help health systems identify areas of improvement in preparation for possible natural disasters.

Strategies for Healthy Eating Promotion and Behavioral Change Perceived as Effective by Nutrition Professionals: A Mixed-Methods Study

Nutrition professionals may recognize ways to improve diet among their clients/patients. This study aimed to survey strategies and foods that nutrition professionals in Puerto Rico perceive as most effective for healthy eating promotion and behavioral change. The study was a cross-sectional online mixed-methods survey conducted among registered members of the College of Nutritionists and Dietitians of Puerto Rico. Using close-ended questions, nutrition professionals identified foods that they considered as easy to include or difficult to control in the diet of their clients/patients, and strategies that may work best for healthy eating. Frequencies of responses were analyzed. Open-ended questions were qualitatively analyzed in NVivo v11. The response rate was 33.2% (n = 414). The foods deemed as easy to include in the diet were root vegetables (66%), fruit (66%), legumes (57%), water (38%), and yogurt/dairy (37%). The foods deemed as more difficult to control were sugary beverages (63%), sweets and desserts (57%), fats and fried foods (56%), salt (50%), and white rice (44%). The strategies for healthy eating deemed effective were personalized orientation (79%), setting short-term goals (61%), making gradual dietary changes (53%), and setting health-oriented (41%), and personal (37%) goals. Emerging themes from qualitative analysis included the intuited key role of nutrition professionals, the need for policy changes, emphasizing prevention, cultural sensitivity, and practical issues. Respondents suggested potential strategies across levels of the socioecological model. In conclusion, healthy eating strategies and foods perceived by nutrition professionals as effective may shape optimal nutritional counseling and population-wide approaches to improve healthy eating in Puerto Rico.

Lifestyle patterns and their nutritional, socio-demographic and psychological determinants in a community-based study: A mixed approach of latent class and factor analyses

Background

Lifestyle risk factors, such as unhealthy diet, physical inactivity or tobacco smoking can have detrimental effects on health and well-being. Therefore, it is important to examine multiple lifestyle risk factors instead of single ones. Cluster analysis allows the combination of single health behaviors in order to recognize distinguished behavior patterns. This study aimed to evaluate lifestyle patterns of general adult population in northwest of Iran with particular focus on dietary patterns, physical activity, and smoking status.

Methods

The current cross-sectional study consists of 525 adults aged 18–64 years from East-Azarbaijan Iran. Latent class analysis (LCA) was applied to recognize patterns of lifestyle behaviors with ingredients of diet, physical activity, and smoking status. Dietary intake was assessed using a validated food frequency questionnaire and dietary patterns were derived using factor analysis. Biochemical parameters including fasting blood sugar (FBS), serum lipids, liver enzyme and serum 25(OH)-D3 were measured with commercial ELIZA kits.

Results

Mean ages of participants were 42.90 ± 11.89 years. Using principal component analysis (PCA) three major dietary patterns were extracted including traditional dietary pattern (e.g. nuts and dry fruits), unhealthy dietary pattern (e.g. fast foods, refined grains) and the healthy dietary patterns (e.g. fruits, vegetables). Using LCA, three classes of lifestyles pattern were identified: 1^st class was characterized by a healthy dietary pattern, moderate physical activity, and low probability of smoking. 2^nd class was characterized by a traditional dietary pattern, low level of physical activity and low probability of smoking and 3^rd class was characterized by a unhealthy dietary pattern, low level of physical activity and low probability of smoking and further analysis found that there were significant differences in body mass index (BMI), Waist-to-hip ratio (WHR), FBS, Hemoglobin (Hb), education levels and anxiety status between classes (P <0.05).

Conclusion

This study attempts to classify Iranian adults by their own health behavior. Healthcare professionals should be aware of associations between different lifestyle risk factors and health promotion strategies should further focus on multiple behaviors at the same time. In our country, more studies about the adult population are needed to support the observed findings of our study and therefore allow for a certain generalization of the observations.

Decolonial visual resistance as a public health strategy in post-María Puerto Rico

In this article, we explore the use of the image as a strategy to understand how natural disasters and coloniality impact the health of marginalized communities. We focus on the aftermath of Hurricane María in Puerto Rico and aim to describe how local people used the image as a strategy to challenge the invisibility fostered by coloniality and advocate for a more humane, equitable and effective public health response. We implemented a mixed methods research design including: (1) ethnographic observations, (2) qualitative in-depth interviews with 67 representatives of the health care system, (3) photographs they had taken as part of their experiences during and after the hurricane and (4) images from local newspapers and social media. In light of the findings we argue that Puerto Ricans engaged in decolonial visual resistance to manage the aftermath of the hurricane. Thus, while surviving the natural disaster, they challenged the traditional use of the image in public health endeavours.

Incident Chronic Kidney Disease Risk among Hispanics/Latinos in the United States: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

BACKGROUND

Although Hispanics/Latinos in the United States are often considered a single ethnic group, they represent a heterogenous mixture of ancestries who can self-identify as any race defined by the U.S. Census. They have higher ESKD incidence compared with non-Hispanics, but little is known about the CKD incidence in this population.

METHODS

We examined rates and risk factors of new-onset CKD using data from 8774 adults in the Hispanic Community Health Study/Study of Latinos. Incident CKD was defined as eGFR <60 ml/min per 1.73 m² with eGFR decline ≥1 ml/min per 1.73 m² per year, or urine albumin/creatinine ratio ≥30 mg/g. Rates and incidence rate ratios were estimated using Poisson regression with robust variance while accounting for the study's complex design.

RESULTS

Mean age was 40.3 years at baseline and 51.6% were women. In 5.9 years of follow-up, 648 participants developed CKD (10.6 per 1000 person-years). The age- and sex-adjusted incidence rates ranged from 6.6 (other Hispanic/mixed background) to 15.0 (Puerto Ricans) per 1000 person-years. Compared with Mexican background, Puerto Rican background was associated with 79% increased risk for incident CKD (incidence rate ratios, 1.79; 95% confidence interval, 1.33 to 2.40), which was accounted for by differences in sociodemographics, acculturation, and clinical characteristics. In multivariable regression analysis, predictors of incident CKD included BP >140/90 mm Hg, higher glycated hemoglobin, lower baseline eGFR, and higher baseline urine albumin/creatinine ratio.

CONCLUSIONS

CKD incidence varies by Hispanic/Latino heritage and this disparity may be in part attributed to differences in sociodemographic characteristics. Culturally tailored public heath interventions focusing on the prevention and control of risk factors might ameliorate the CKD burden in this population.

Relationships between psychosocial factors during pregnancy and preterm birth in Puerto Rico

Psychosocial stress during pregnancy has been associated with adverse pregnancy outcomes including preterm birth (PTB). This has not been studied in Puerto Rico, an area with high PTB rates. Our objective was to develop a conceptual model describing the interrelationships between measures of psychosocial stress and depression, a result of stress, among pregnant women in Puerto Rico and to examine their associations with PTB. We used data from the Puerto Rico Testsite for Exploring Contamination Threats pregnancy cohort (PROTECT, N = 1,047) to examine associations among depression and different continuous measures of psychosocial stress using path analysis. Psychosocial stress during pregnancy was assessed using validated measures of perceived stress, negative life experiences, neighborhood perceptions and social support. Logistic regression was used to examine associations between psychosocial stress measures in tertiles and PTB. Perceived stress, negative life experiences, and neighborhood perceptions influenced depression through multiple pathways. Our model indicated that perceived stress had the strongest direct effect on depression, where one standard deviation (SD) increase in perceived stress was associated with a 57% SD increase in depression. Negative life experiences were directly but also indirectly, through perceived stress, associated with depression. Finally, neighborhood perceptions directly influenced negative life experiences and perceived stress and consequently had an indirect effect on depression. Psychosocial stress was not associated with PTB across any of the measures examined. Our study examined interrelationships between multiple measures of psychosocial stress and depression among a pregnant Puerto Rican population and identified negative neighborhood perceptions as important upstream factors leading to depression. Our findings highlight the complex relationship between psychosocial stress measures and indicate that psychosocial stress and depression, assessed using 5 different scales, were not associated with PTB. Future research should investigate other environmental and behavioral risk factors contributing to higher rates of PTB in this population.

Higher eating frequency, but not skipping breakfast, is associated with higher odds of abdominal obesity in adults living in Puerto Rico

Puerto Ricans have a high prevalence of obesity, yet little information is available regarding its association with eating patterns in this population. We hypothesized that higher eating frequency and skipping breakfast would be associated with increased odds of abdominal obesity among adults living in Puerto Rico (PR). In a cross-sectional study of adults living in PR aged 30-75 years (N = 310), participants reported their frequency of eating meals per day including snacks and breakfast. Trained interviewers measured waist (WC) and hip circumferences. We calculated the waist-to-hip ratio (WHR) dividing the waist by the hip measurement. Abdominal obesity was defined as either high WC (men ≥94 cm; women ≥80 cm) or high WHR (men ≥0.90; women ≥0.85). We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) to assess the association of eating frequency (≤1.5; 1.5-3; ≥3 times/day) and breakfast consumption (vs none) with abdominal obesity. Models were adjusted for age, sex, income, smoking, physical activity, TV watching, energy intake, diet quality, and eating frequency (only for breakfast consumption). Most participants consumed breakfast (70%), ate 1.5-3 times/d (47%), and had high WC (75%) and WHR (77%). Participants who ate 1.5-3 (OR: 2.75, 95% CI: 1.23-6.15) and ≥3 times/day (OR: 2.88; 95% CI: 1.14-7.31) were more likely to have high WC compared with participants who ate ≤1.5 times/d (P trend = .04). Breakfast consumption was not associated with abdominal obesity. In conclusion, higher eating frequency, but not skipping breakfast, is associated with abdominal obesity among adults in PR. Consuming less frequent meals may help prevent abdominal obesity in this population.

Associations between socioeconomic status, psychosocial stress, and urinary levels of 8-iso-prostaglandin-F2α during pregnancy in Puerto Rico

BACKGROUND

Lower socioeconomic status (SES) and psychosocial stress during pregnancy have been associated with adverse birth outcomes. While hypothalamic-pituitary-axis activation is thought to be the primary driver, oxidative stress may also be involved mechanistically. We used data from the Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) cohort (N=476) to examine associations between self-reported psychosocial stress measures, SES indicators, and urinary oxidative stress biomarker concentrations, hypothesizing that women with lower SES and increased psychosocial stress would have elevated oxidative stress biomarkers.

METHODS

Maternal age, education, marital status, insurance status, alcohol use and smoking status were obtained via self-reported questionnaires and were used as indicators of SES. Perceived stress, depression, negative life experiences, neighborhood perceptions, and social support were self-reported in questionnaires administered during pregnancy. Responses were grouped into tertiles for analysis, where the highest tertile corresponded to highest level of psychosocial stress. Urinary concentrations of 8-iso-prostaglandin F2α (8-iso-PGF2α) and its primary metabolite were measured at three study visits (median 18, 24, 28 weeks gestation) and averaged to reflect oxidative stress across pregnancy. Linear models were used to examine associations between SES indicators, tertiles of psychosocial stress and oxidative stress biomarkers.

RESULTS

Average levels of 8-iso-PGF2α and the 8-iso-PGF2α metabolite were higher among pregnant women who were younger, who had public compared to private insurance, and who were unemployed compared to employed. However, no associations were observed between psychosocial stress measures and biomarker concentrations in adjusted analyses.

CONCLUSIONS

Psychosocial stress during pregnancy, as indicated by self-reported questionnaire measures, was not associated with biomarkers of oxidative stress in the PROTECT study. However, results suggest that these biomarkers are elevated among women of lower SES, which is typically associated with stress. Notably, compared to other populations, self-reported psychosocial stress measures were lower in PROTECT compared to other populations.

Impact of delayed treatment on exacerbations of multiple sclerosis among Puerto Rican patients

BACKGROUND

There are limited data on multiple sclerosis (MS) patients in underserved groups, including Puerto Rico. In this study, we analyzed the characteristic of MS symptoms and number of relapses in Puerto Rican patients. We then compare these characteristics with MS patients from the US. The number of MS relapses is highly correlated with the treatment onset and adherence. Patients in Puerto Rico have been experiencing lengthy treatment delay. We will discuss the possible causes of such delay and its impact on MS prognosis.

METHODS

This retrospective cohort study consisted of the evaluation of 325 medical records from MS patients attending the Caribbean Neurological Center from 2014 to 2019. We gathered symptoms and comorbidities data as binary objects. The treatment delay was calculated based on the mean value of days between diagnosis and treatment onset for these groups of patients.

RESULTS

We found that on average, the treatment delay for MS patients in Puerto Rico (PR) to receive their medication was 120 days. The most common MS subtype was relapsing-remitting 72.8%, with a mean of 1.684 relapses per year. Initial symptoms were sensory 54%, visual 33.1%, motor 28.8%, coordination 23.2%, fatigue 9.7%, memory 7.3%, depression 6.5%, urinary 4.9%, gastrointestinal 2.4%, and sexual dysfunction 1.6%. The most common comorbidities were hypertension 18.4%, asthma 13.6%, and thyroid disease 12.8%. When we compared the comorbidities between the two populations, immune thrombocytopenia had the highest percent change with the value of almost 200% (0.001% of US patient vs. 0.8% of Puerto Rican MS patients).

CONCLUSION

Patients from Puerto Rico had a 33% higher relapse rate compared to the one reported for MS patients in the US. This higher rate may be related to the long delay in receiving their medications. They also had a higher rate of complex comorbidities such as immune thrombocytopenia or thyroid disease. Our findings provide a proof of concept that delay in receiving medications can increase the number of relapses and complex comorbidities among MS patients.

Promoting Integrated Mental Health Care Services in Disaster Response Programs: Lessons Learned After the Impact of Hurricane María in Puerto Rico

Meteorological and even human-made disasters are increasing every year in frequency and magnitude. The passage of a disaster affects a society without distinction, but groups with social vulnerability (low socioeconomic status, chronic medical, or psychological conditions, limited access to resources) face the most significant impact. As a result, psychological and behavioral symptoms (eg, depression and anxiety) can ensue, making the immediate response of mental health services crucial. Secondary data from a database of a temporary healthcare unit were analyzed. A total of 54 records were reviewed to collect information; univariate and bivariate analyses were done. The purpose of this article is to present our experience regarding the incorporation of a mental health services model, with its respective benefits and challenges, into a temporary healthcare unit, after Hurricane Maria in 2017.

Dietary Intake and Its Determinants Among Adults Living in the Metropolitan Area of Puerto Rico

There is scarce information regarding the dietary intake of adults living in Puerto Rico (PR). We aimed to assess intake of nutrients and foods, adherence to recommended intake of nutrients and diet quality, and sociodemographic and lifestyle factors correlated with diet quality among adults in the San Juan metropolitan area of PR. Data were obtained from participants of the cross-sectional convenience-sample Puerto Rico Assessment of Diet, Lifestyle, and Diseases (n = 248; ages 30-75 years). Diet quality was defined using the Alternate Healthy Eating Index 2010 (AHEI; range 0-110 indicating lower-higher quality). Linear regression models were used to relate AHEI to sociodemographic and lifestyle factors. Most participants met the Estimated Average Requirement (EAR) for iron, folate, and vitamins B12 and B6; 61% met the EAR for magnesium and 56% for calcium. Only 4% met the EAR for vitamin D, and 7% met the adequate intake for potassium. The main contributors to total energy intake were sugary beverages (11.8%), sweets/desserts (10.2%), dairy (8.5%), mixed dishes (7.6%), starches (6.3%), fast foods (5.5%), and rice (4.9%). The mean (SD) AHEI score was 59.8 (11.0). The lowest AHEI components for which recommended servings were met were red/processed meats, fruit, sodium, sugary beverages, and polyunsaturated fats, and the highest were nuts/legumes, omega-3 fats, and whole grains. Significantly higher AHEI scores were noted for older adults, other ethnicities (vs. Puerto Rican), being single, having some college or higher education, and never/formerly smoking. Adults living in PR report healthy and unhealthy dietary intakes, providing an opportunity to improve diet at the population level.

What the Puerto Rican hurricanes make visible: Chronicle of a public health disaster foretold

García Márquez's novel, "Chronicle of a Death Foretold", narrates the multiple strands of a story leading up to a murder in a small Caribbean village. The novel shows both the incredulity of those who do not believe it possible that this tragic death could occur, and the impotence of those who see it coming but can do nothing to prevent it. Something akin to this double incapacity seems to be occurring today in Puerto Rico. In September 2017, the passage of Hurricanes Irma and María caused a public health disaster with large-scale death and destruction. Paradoxically, this catastrophe has made visible the need to evaluate the critical socio-environmental situation of this country, and to analyse the underlying social factors contributing to the problems caused by the hurricanes. Why did neither the US nor the Puerto Rican government react as expected when faced with such a serious situation? For decades, this country has been suppressed by colonial domination, exploitation of the workforce, and health discrimination. It has been a "laboratory", where colonial practices have institutionalized social control, racism, and inequality, with profound negative effects on society, quality of life and health equality. Poverty and unemployment have always been very high, and thousands of families live in precarious housing situations. Additionally, current labour reforms imposed as part of a neoliberal agenda, are eroding the job security and protections of the working population, while education, health, housing, pensions, energy, and land are being progressively privatized. What are the root causes of this situation? What future does the country await? To answer these questions, critical and comprehensive scrutiny of history showing what the hurricanes have helped to make visible is required. This shows that neoliberal colonialism has shaped the social features behind the principle health and inequality problems of the Puerto-Rican population.

Trends in cause of death among patients with multiple myeloma in Puerto Rico and the United States SEER population, 1987-2013

Multiple myeloma (MM) survival has improved due to recent developments in MM treatment. As a result, other co-morbid conditions may be of increasing importance to MM patients' long-term survival. This study examines trends in common causes of death among patients with MM in Puerto Rico, and in the US Surveillance, Epidemiology, and End Results (SEER) population. We analyzed the primary cause of death among incident MM cases recorded in the Puerto Rico Central Cancer Registry (n = 3,018) and the US SEER Program (n = 67,733) between 1987 and 2013. We calculated the cumulative incidence of death due to the eight most common causes and analyzed temporal trends in mortality rates using joinpoint regression. Analyses of SEER were also stratified by Hispanic ethnicity. MM accounted for approximately 72% of all reported deaths among persons diagnosed with MM in Puerto Rico and in SEER. In both populations, the proportion of patients who died from MM decreased with increasing time since diagnosis. Age-standardized temporal trends showed a decreased MM-specific mortality rate among US SEER (annual percent change [APC] = -5.0) and Puerto Rican (APC = -1.8) patients during the study period, and particularly after 2003 in non-Hispanic SEER patients. Temporal decline in non-MM causes of death was also observed among US SEER (APC = -2.1) and Puerto Rican (APC = -0.1) populations. MM-specific mortality decreased, yet remained the predominant cause of death for individuals diagnosed with MM over a 26-year period. The most pronounced decreases in MM-specific death occurred after 2003, which suggests a possible influence of more recently developed MM therapies.

Dietary Acculturation among Puerto Rican Adults Varies by Acculturation Construct and Dietary Measure

Background

The role of acculturation in dietary behaviors among Hispanics/Latinos in the United States remains unclear. Discrepancies may be explained by variations in acculturation constructs or ethnicity-specific dynamics.

Objective

We aimed to compare relations between 3 different acculturation constructs with dietary quality and patterns among Puerto Ricans in the mainland United States.

Methods

We analyzed cross-sectional data with 1194-1380 Puerto Ricans, aged 45-75 y. Acculturation was measured with the use of a language-based scale (0-100; higher score denotes more English use), a psychological-based scale (0-50; higher score denotes stronger US orientation), and years living in the mainland United States. Diet quality scores (higher scores denote healthier diet) were defined with the use of the Alternate Healthy Eating Index-2010 (AHEI) and the Mediterranean Diet Score (MeDS). Three dietary patterns were previously derived with the use of principal components analysis. Adjusted multivariable regression models tested the association of each acculturation construct with diet quality score or pattern. Interaction terms were included for income or education status.

Results

Psychological-based acculturation, but not the other constructs, was positively associated with AHEI (β ± SE: 0.013 ± 0.004; P = 0.002) and MeDS (0.009 ± 0.005; P = 0.041). Income, but not education, moderated this association (P = 0.03), with higher diet quality observed with higher income (>$25,000) and stronger US orientation. All constructs were inversely associated with a traditional dietary pattern, with the language-based scale being stronger (z score β ± SE: -0.160 ± 0.032; P < 0.0001) than the psychological-based scale (-0.097 ± 0.028; P = 0.001) or years living in the mainland United States (-0.058 ± 0.028; P = 0.041). No associations were observed for the Western or sweets/desserts patterns.

Conclusions

In Puerto Rican adults, stronger psychological US orientation was associated with higher diet quality, particularly with higher income. More Spanish use, stronger psychological Puerto Rican orientation, and shorter length of mainland-US residency were associated with traditional dietary patterns. Appropriate diet-related acculturation constructs should be carefully considered among Hispanics/Latinos. This trial was registered at clinicaltrials.gov as NCT01231958.