NEWS & VIEWS PUBLIC HEALTH
An agenda to promote Hispanic cardiovascular health Robert C. Kaplan
The Hispanic population will grow to represent nearly one-third of residents in the USA by mid-century. A new AHA Science Advisory paper provides an overview of current evidence on cardiovascular disease in this population, including prevailing risk factors and specific clinical approaches for treatment, and predicts what insights future research might reveal. Kaplan, R. C. Nat. Rev. Cardiol. 11, 560–562 (2014); published online 2 September 2014; doi:10.1038/nrcardio.2014.126
By 2060, Hispanic individuals will comprise 31% of all residents in the USA. A Science Advisory paper from the AHA published in July 2014 contains a comprehensive overview of the literature, and outlines 44 priorities for improving cardiovascular health in the Hispanic population. The report offers culturally-appropriate suggestions to assist health-care providers who work with Hispanic patients.1 The AHA report provides a brief background on the socioeconomic and psycho social factors, cultural beliefs, and other information specific to the Hispanic population that are important for health-care providers to recognize. Hispanic individuals in the USA are heterogeneous with regard to birthplace, duration of residence, and acculturation to existing social norms and behaviours. Hispanic individuals of Mexican origin are the largest and beststudied Hispanic group; those from other backgrounds represent 36% of all Hispanic individuals in the USA. When compared with other ethnic groups in the USA, Hispanic individuals are disproportionately affected by cardiovascular disease risk factors such as diabetes mellitus, but often have a lower burden of coronary heart disease and other cardiovascular conditions. Discrepancies in access to health care exist between Hispanic individuals and non-Hispanic white individuals, owing to language barriers and socioeconomic variables. Nearly half of the 40 million immigrants living in the USA originate from Spanish-speaking countries in Latin America and the Caribbean. Among this group of
foreign-born Hispanic individuals, only one-third report being able to speak English “very well” and average educational attainment is low.1 Hispanic individuals have high workforce participation, but tend to hold low-wage positions, which contributes to a high number of uninsured people in this group. Hispanic individuals comprise 30% of the uninsured citizens in the USA, despite making up only 17% of the population. They are three times more likely than a nonHispanic white individual and twice as likely as an African American individual to not have a regular health-care provider. Spanish speaking residents in the USA have lower average health literacy and higher risk of not receiving recommended health-care services compared with non-Hispanic white individuals. With the fastest growing Hispanic communities now in regions outside traditional Hispanic population centres in the USA, the language mismatch between those patients with limited English and non-Spanish speaking health-care providers is likely to worsen. One influence on health not mentioned in the report is the pernicious effects of government policies that have generated suspicion and fear among the community, which include a record number of deportations, involvement of police departments in immigration enforcement, and harsh local and state laws. These policies are likely to have contributed to difficulties in increasing Hispanic individuals’ participation in health and social service programmes, and might discourage them from actively seeking out health care.2 The AHA report also highlights common aspects of Hispanic culture in the family
NATURE REVIEWS | CARDIOLOGY
and wider community that can influence behaviours related to accessing health care. Hispanic individuals tend to rely heavily on extended family networks for financial or emotional support, and family members are often involved in health-care encounters and decision-making. The better-than-expected health outcomes in Hispanic individuals might be attributable to their strong values of familism or familismo. Strong family obligations, however, can also generate stress, and Hispanic women, in particular, might prioritize family responsibilities over self-care to fulfil cultural sex-specific norms (marianismo). Understanding these cultural factors can assist health-care providers who care for Hispanic patients. For example, patients might be more motivated by having communal rather than individual benefits emphasized (‘do the right thing for the family’ rather than ‘do it for yourself ’). Importantly, the most detailed studies on health care in Hispanic patients in the USA often describe concentrated regional populations, and might not be relevant to other Hispanic individuals, particularly those who are born in the USA and have integrated socially, culturally, and geographically with others of non-Hispanic background. The authors of the AHA report make several important points. First, the differences among Hispanic groups in health indices are often obscured by the catchall label ‘Hispanic’. Early reports from the Framingham Heart Study hinted at variation in the incidence of coronary heart disease among the white non-Hispanic population according to country of birth and European ancestry.3 Second, the report emphasizes family and community level influences on cardiovascular health, departing from the usual tendency to focus explanations and clinical strategies on the individual. Third, the AHA makes the important recommendation that health-care providers should be trained in cultural literacy and competency. Patient beliefs and customs should frame health-care encounters, and these will vary among ethnic groups in sp ecific Hispanic communities. The AHA Science Advisory report provides clinicians with an insight into the sociocultural characteristics of Hispanic individuals living in the USA, which is often VOLUME 11 | OCTOBER 2014
© 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS lacking in the literature and unaccounted for in clinical guidelines. For example, health-care providers are unable to recommend a weight-loss diet that respects the dietary preferences and cooking styles of the Hispanic individual if they are unaware of aspects of Hispanic cuisine. To follow current lipid treatment guidelines, physicians must use the Atherosclerotic Cardio vascular Disease Risk Estimator 4 to guide therapy based upon a patient’s estimated future risk of atherosclerosis. This estimator, however, is not suited for all groups in that it can underestimate the risk of athero sclerosis for some Hispanics individuals (such as those from Puerto Rico) and overestimate the risk for other Hispanic individuals (including those from Mexico). Patients of Hispanic origin might, therefore, be either undertreated or overtreated for hypercholesterolaemia. The lack of up-todate, long-term studies on Hispanic patients precludes the accurate assessment of risk predictions for atherosclerosis. To generate accurate data on cardiovascular disease incidence and risk factors among individuals of Cuban, Mexican, Puerto Rican, and other Hispanic backgrounds, a multicentre, prospective, population-based study of 16,415 Hispanic patients was funded in 2006 by the National Heart, Lung and Blood Institute.5 Only in the past decade have Hispanic patients begun to be represented in major US epidemiological follow-up studies, as shown in Figure 1 (Timeline).
Reading the AHA Scientific Advisory reminded me of why I chose to pursue my scientific endeavours through epidemiological research in the Hispanic population. Epidemiology thrives upon disease-related characteristics that have high variability within the population. 6 Owing to their heterogeneity, studying Hispanic groups can offer unique biological insights. Dietary patterns,7 fetal and earlylife nutritional and microbial exposure, and genetics, which received only cursory attention in the AHA report, are examples of characteristics that vary across groups that make up the Hispanic population and that differ from non-Hispanic white individuals in the USA. Latin American populations have a unique mixture of African, American Indian, and European genes, which allows identification of novel disease loci.8 In this era of personalized care and medicine, Hispanic individuals are underrepresented in genomic studies, have low community awareness of genomics, lack available genetic counselling services, and face other related ethical, legal, regulatory, and social issues.9 Achieving the goals and recommendations set out by the AHA Scientific Advisory will be essential if the Hispanic population in the USA is to benefit equitably from future advances in cardiovascular disease prevention and treatment. David Sackett and colleagues noted that evidence-based medicine is “about integrating individual
Cardiovascular Health Study [E, A]
Framingham Heart Study [E]
Strong Heart Study [I] 1948
1985
1987
Coronary Artery Risk Development in Young Adults (CARDIA) [E, A]
1989
Atherosclerotic Risk in Communities (ARIC) [E, A]
Jackson Heart Study [A] Multiethnic Study of Atherosclerosis (MESA) [E, A, H, C] 2000
2008
Hispanic Community Health Study [H]
Figure 1 | Timeline of the major US epidemiological heart studies that involve different ethnic groups. In the decades since the establishment of the seminal Framingham Heart Study in 1948, a series of large prospective epidemiological cohort studies funded by the National Heart, Lung and Blood Institute have assessed cardiovascular disease incidence and risk factors among several ethnic groups living in the USA. The Hispanic Community Health Study, which began recruitment in 2008, is the largest such study that has focused on Hispanic individuals (n = 16,415). Abbreviations: A, African American/Black; C, Chinese/Chinese American; E, European American/White; H, Hispanic; I, American Indian/Indigenous.
OCTOBER 2014 | VOLUME 11
clinical expertise and the best external evidence”, and pointed out that the evidence base must include not only randomized trials, but also studies on disease prevalence, incidence, and prognosis that accurately describe the patient cohort being treated.10 The AHA report will hopefully reach a wide audience in the clinical and research community, propelling the field forwards with efforts to both enhance clinical expertise and understanding of Hispanic culture, and to increase the amount and quality of population-specific epidemiological data. Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, 1300 Morris Park Avenue, Bronx, NY 10461, USA. [email protected] Competing interests The author declares no competing interests. 1.
Rodriguez, C. J. et al. Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States. Circulation http://dx.doi.org/ 10.1161/CIR.0000000000000071. 2. Easley, J. Obama to Hispanics: we won’t deport relatives because you enroll in ObamaCare. The Hill (Washington DC) (18 Mar 2014). 3. Dawber, T. R. et al. Some factors associated with the development of coronary heart disease: six years’ follow-up experience in the Framingham study. Am. J. Public Health Nations Health 49, 1349–1356 (1959). 4. Stone, N. J. et al. 2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/ American Heart Association task force on practice guidelines. J. Am. Coll. Cardiol. 63, 2889–2934 (2014). 5. Daviglus, M. L. et al. Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States. JAMA 308, 1775–1784 (2012). 6. Rose, G. Sick individuals and sick populations. Int. J. Epidemiol. 30, 427–432 (2001). 7. US Department of Agriculture Economic Research Service. The U.S. grain consumption landscape: who eats grain, in what form, where and how much [online], http://www.ers.usda.gov/ (2007). 8. The SIGMA Type 2 Diabetes Consortium. Sequence variants in SLC16A11 are a common risk factor for type 2 diabetes in Mexico. Nature 506, 97–101 (2014). 9. Kahn, J. Mandating race: how the USPTO is forcing race into biotech patents. Nat. Biotechnol. 29, 401 (2011). 10. Sackett, D. L., Rosenberg, W. M. C., Gray, J. A., Haynes, R. B. & Richardson, W. S. Evidence based medicine: what it is and what it isn’t. BMJ 312, 71 (1996).
www.nature.com/nrcardio © 2014 Macmillan Publishers Limited. All rights reserved
An agenda to promote Hispanic cardiovascular health Robert C. Kaplan
The Hispanic population will grow to represent nearly one-third of residents in the USA by mid-century. A new AHA Science Advisory paper provides an overview of current evidence on cardiovascular disease in this population, including prevailing risk factors and specific clinical approaches for treatment, and predicts what insights future research might reveal. Kaplan, R. C. Nat. Rev. Cardiol. 11, 560–562 (2014); published online 2 September 2014; doi:10.1038/nrcardio.2014.126
By 2060, Hispanic individuals will comprise 31% of all residents in the USA. A Science Advisory paper from the AHA published in July 2014 contains a comprehensive overview of the literature, and outlines 44 priorities for improving cardiovascular health in the Hispanic population. The report offers culturally-appropriate suggestions to assist health-care providers who work with Hispanic patients.1 The AHA report provides a brief background on the socioeconomic and psycho social factors, cultural beliefs, and other information specific to the Hispanic population that are important for health-care providers to recognize. Hispanic individuals in the USA are heterogeneous with regard to birthplace, duration of residence, and acculturation to existing social norms and behaviours. Hispanic individuals of Mexican origin are the largest and beststudied Hispanic group; those from other backgrounds represent 36% of all Hispanic individuals in the USA. When compared with other ethnic groups in the USA, Hispanic individuals are disproportionately affected by cardiovascular disease risk factors such as diabetes mellitus, but often have a lower burden of coronary heart disease and other cardiovascular conditions. Discrepancies in access to health care exist between Hispanic individuals and non-Hispanic white individuals, owing to language barriers and socioeconomic variables. Nearly half of the 40 million immigrants living in the USA originate from Spanish-speaking countries in Latin America and the Caribbean. Among this group of
foreign-born Hispanic individuals, only one-third report being able to speak English “very well” and average educational attainment is low.1 Hispanic individuals have high workforce participation, but tend to hold low-wage positions, which contributes to a high number of uninsured people in this group. Hispanic individuals comprise 30% of the uninsured citizens in the USA, despite making up only 17% of the population. They are three times more likely than a nonHispanic white individual and twice as likely as an African American individual to not have a regular health-care provider. Spanish speaking residents in the USA have lower average health literacy and higher risk of not receiving recommended health-care services compared with non-Hispanic white individuals. With the fastest growing Hispanic communities now in regions outside traditional Hispanic population centres in the USA, the language mismatch between those patients with limited English and non-Spanish speaking health-care providers is likely to worsen. One influence on health not mentioned in the report is the pernicious effects of government policies that have generated suspicion and fear among the community, which include a record number of deportations, involvement of police departments in immigration enforcement, and harsh local and state laws. These policies are likely to have contributed to difficulties in increasing Hispanic individuals’ participation in health and social service programmes, and might discourage them from actively seeking out health care.2 The AHA report also highlights common aspects of Hispanic culture in the family
NATURE REVIEWS | CARDIOLOGY
and wider community that can influence behaviours related to accessing health care. Hispanic individuals tend to rely heavily on extended family networks for financial or emotional support, and family members are often involved in health-care encounters and decision-making. The better-than-expected health outcomes in Hispanic individuals might be attributable to their strong values of familism or familismo. Strong family obligations, however, can also generate stress, and Hispanic women, in particular, might prioritize family responsibilities over self-care to fulfil cultural sex-specific norms (marianismo). Understanding these cultural factors can assist health-care providers who care for Hispanic patients. For example, patients might be more motivated by having communal rather than individual benefits emphasized (‘do the right thing for the family’ rather than ‘do it for yourself ’). Importantly, the most detailed studies on health care in Hispanic patients in the USA often describe concentrated regional populations, and might not be relevant to other Hispanic individuals, particularly those who are born in the USA and have integrated socially, culturally, and geographically with others of non-Hispanic background. The authors of the AHA report make several important points. First, the differences among Hispanic groups in health indices are often obscured by the catchall label ‘Hispanic’. Early reports from the Framingham Heart Study hinted at variation in the incidence of coronary heart disease among the white non-Hispanic population according to country of birth and European ancestry.3 Second, the report emphasizes family and community level influences on cardiovascular health, departing from the usual tendency to focus explanations and clinical strategies on the individual. Third, the AHA makes the important recommendation that health-care providers should be trained in cultural literacy and competency. Patient beliefs and customs should frame health-care encounters, and these will vary among ethnic groups in sp ecific Hispanic communities. The AHA Science Advisory report provides clinicians with an insight into the sociocultural characteristics of Hispanic individuals living in the USA, which is often VOLUME 11 | OCTOBER 2014
© 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS lacking in the literature and unaccounted for in clinical guidelines. For example, health-care providers are unable to recommend a weight-loss diet that respects the dietary preferences and cooking styles of the Hispanic individual if they are unaware of aspects of Hispanic cuisine. To follow current lipid treatment guidelines, physicians must use the Atherosclerotic Cardio vascular Disease Risk Estimator 4 to guide therapy based upon a patient’s estimated future risk of atherosclerosis. This estimator, however, is not suited for all groups in that it can underestimate the risk of athero sclerosis for some Hispanics individuals (such as those from Puerto Rico) and overestimate the risk for other Hispanic individuals (including those from Mexico). Patients of Hispanic origin might, therefore, be either undertreated or overtreated for hypercholesterolaemia. The lack of up-todate, long-term studies on Hispanic patients precludes the accurate assessment of risk predictions for atherosclerosis. To generate accurate data on cardiovascular disease incidence and risk factors among individuals of Cuban, Mexican, Puerto Rican, and other Hispanic backgrounds, a multicentre, prospective, population-based study of 16,415 Hispanic patients was funded in 2006 by the National Heart, Lung and Blood Institute.5 Only in the past decade have Hispanic patients begun to be represented in major US epidemiological follow-up studies, as shown in Figure 1 (Timeline).
Reading the AHA Scientific Advisory reminded me of why I chose to pursue my scientific endeavours through epidemiological research in the Hispanic population. Epidemiology thrives upon disease-related characteristics that have high variability within the population. 6 Owing to their heterogeneity, studying Hispanic groups can offer unique biological insights. Dietary patterns,7 fetal and earlylife nutritional and microbial exposure, and genetics, which received only cursory attention in the AHA report, are examples of characteristics that vary across groups that make up the Hispanic population and that differ from non-Hispanic white individuals in the USA. Latin American populations have a unique mixture of African, American Indian, and European genes, which allows identification of novel disease loci.8 In this era of personalized care and medicine, Hispanic individuals are underrepresented in genomic studies, have low community awareness of genomics, lack available genetic counselling services, and face other related ethical, legal, regulatory, and social issues.9 Achieving the goals and recommendations set out by the AHA Scientific Advisory will be essential if the Hispanic population in the USA is to benefit equitably from future advances in cardiovascular disease prevention and treatment. David Sackett and colleagues noted that evidence-based medicine is “about integrating individual
Cardiovascular Health Study [E, A]
Framingham Heart Study [E]
Strong Heart Study [I] 1948
1985
1987
Coronary Artery Risk Development in Young Adults (CARDIA) [E, A]
1989
Atherosclerotic Risk in Communities (ARIC) [E, A]
Jackson Heart Study [A] Multiethnic Study of Atherosclerosis (MESA) [E, A, H, C] 2000
2008
Hispanic Community Health Study [H]
Figure 1 | Timeline of the major US epidemiological heart studies that involve different ethnic groups. In the decades since the establishment of the seminal Framingham Heart Study in 1948, a series of large prospective epidemiological cohort studies funded by the National Heart, Lung and Blood Institute have assessed cardiovascular disease incidence and risk factors among several ethnic groups living in the USA. The Hispanic Community Health Study, which began recruitment in 2008, is the largest such study that has focused on Hispanic individuals (n = 16,415). Abbreviations: A, African American/Black; C, Chinese/Chinese American; E, European American/White; H, Hispanic; I, American Indian/Indigenous.
OCTOBER 2014 | VOLUME 11
clinical expertise and the best external evidence”, and pointed out that the evidence base must include not only randomized trials, but also studies on disease prevalence, incidence, and prognosis that accurately describe the patient cohort being treated.10 The AHA report will hopefully reach a wide audience in the clinical and research community, propelling the field forwards with efforts to both enhance clinical expertise and understanding of Hispanic culture, and to increase the amount and quality of population-specific epidemiological data. Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, 1300 Morris Park Avenue, Bronx, NY 10461, USA. [email protected] Competing interests The author declares no competing interests. 1.
Rodriguez, C. J. et al. Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States. Circulation http://dx.doi.org/ 10.1161/CIR.0000000000000071. 2. Easley, J. Obama to Hispanics: we won’t deport relatives because you enroll in ObamaCare. The Hill (Washington DC) (18 Mar 2014). 3. Dawber, T. R. et al. Some factors associated with the development of coronary heart disease: six years’ follow-up experience in the Framingham study. Am. J. Public Health Nations Health 49, 1349–1356 (1959). 4. Stone, N. J. et al. 2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/ American Heart Association task force on practice guidelines. J. Am. Coll. Cardiol. 63, 2889–2934 (2014). 5. Daviglus, M. L. et al. Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States. JAMA 308, 1775–1784 (2012). 6. Rose, G. Sick individuals and sick populations. Int. J. Epidemiol. 30, 427–432 (2001). 7. US Department of Agriculture Economic Research Service. The U.S. grain consumption landscape: who eats grain, in what form, where and how much [online], http://www.ers.usda.gov/ (2007). 8. The SIGMA Type 2 Diabetes Consortium. Sequence variants in SLC16A11 are a common risk factor for type 2 diabetes in Mexico. Nature 506, 97–101 (2014). 9. Kahn, J. Mandating race: how the USPTO is forcing race into biotech patents. Nat. Biotechnol. 29, 401 (2011). 10. Sackett, D. L., Rosenberg, W. M. C., Gray, J. A., Haynes, R. B. & Richardson, W. S. Evidence based medicine: what it is and what it isn’t. BMJ 312, 71 (1996).
www.nature.com/nrcardio © 2014 Macmillan Publishers Limited. All rights reserved
