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Risk and Preventive Factors for Type 2 Diabetes and Heart Disease Among Foreign-Born Older Vietnamese Americans a

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Thanh Tran PhD , Nancy A. Allen PhD ANP-BC , Thuc-Nhi Nguyen a

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MA MSW , Hae Nim Lee MSW & Keith TSZ-KIT Chan MSW PhD

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Graduate School of Social Work, Boston College , Chestnut Hill , Massachusetts , USA b

William F. Connell School of Nursing, Boston College , Chestnut Hill , Massachusetts , USA c

School of Social Welfare, University at Albany SUNY , Albany , New York , USA Published online: 31 Jan 2014.

To cite this article: Thanh Tran PhD , Nancy A. Allen PhD ANP-BC , Thuc-Nhi Nguyen MA MSW , Hae Nim Lee MSW & Keith TSZ-KIT Chan MSW PhD (2014) Risk and Preventive Factors for Type 2 Diabetes and Heart Disease Among Foreign-Born Older Vietnamese Americans, Social Work in Health Care, 53:2, 96-114, DOI: 10.1080/00981389.2013.844220 To link to this article: http://dx.doi.org/10.1080/00981389.2013.844220

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Social Work in Health Care, 53:96–114, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2013.844220

Risk and Preventive Factors for Type 2 Diabetes and Heart Disease Among Foreign-Born Older Vietnamese Americans THANH TRAN, PhD Downloaded by [University of Iowa Libraries] at 09:25 05 October 2014

Graduate School of Social Work, Boston College, Chestnut Hill, Massachusetts, USA

NANCY A. ALLEN, PhD, ANP-BC William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA

THUC-NHI NGUYEN, MA, MSW and HAE NIM LEE, MSW Graduate School of Social Work, Boston College, Chestnut Hill, Massachusetts, USA

KEITH TSZ-KIT CHAN, MSW, PhD School of Social Welfare, University at Albany SUNY, Albany, New York, USA

The 2009 California Health Interview Survey (CHIS) data was used to examine associations of bodyweight, lifestyles, and demographic variables with type 2 diabetes (T2DM) and heart disease among foreign-born older Vietnamese adults. CHIS consisted of 709 Vietnamese Americans aged 50 to 85. Thirteen percent reported T2DM and 11% had heart disease. Using logistic regression, body mass index ≥ 24, age ≥ 65, and female were significantly associated with T2DM. There was significant interaction effect of alcohol consumption and psychological distress with T2DM. The interaction of vegetable consumption, poverty, and length of living in the U.S. was significantly associated with heart disease. KEYWORDS chronic illness, geriatrics, health care, older adult, prevention

Received February 8, 2013; accepted September 10, 2013. Address correspondence to Thanh Tran, PhD, Boston College, Graduate School of Social Work, 140 Commonwealth Avenue, McGuinn 205, Chestnut Hill, MA 02467. E-mail: [email protected] 96

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Diabetes has reached epidemic proportions worldwide. In 2011, 346 million people worldwide had diabetes (World Health Organization [WHO], 2011) and it is projected it will be the seventh leading cause of death in 2030 (WHO, 2011). It is estimated that more than 60% of the world population diagnosed with diabetes will be from Asian countries (Chan et al., 2009). Of these cases, more than 228 million will come from developing countries such as Vietnam. In Vietnam, it was found that the prevalence of diabetes in Ho Chi Minh City, the country’s most developed city, diabetes increased from 2.5% in 1994 to 6.9% in 2002 following similar trends in urban areas worldwide (DucSon et al., 2004). In the United States, Vietnamese is one of the fastest growing ethnic groups with a projected population growth in 2030 to be nearly 4 million people. It is the second largest Asian Pacific Islander (API) ethnic group in the United States after the Filipino (McPhee, 2002). Diabetes rates have increased more than threefold for native born Asian Americans in just 10 years (Singh & Hiatt, 2006). And according to the National Diabetes Information Clearinghouse (2011), the estimated incidence of Asian Americans developing diabetes was 8.4% after adjusting for population age differences, a much higher percentage than the U.S. general population (7.1%). Diabetes is a serious, chronic medical condition that is linked to many disabling conditions. Type 2 diabetes is the most common form of diabetes, accounting for 9–95% of cases (Centers for Disease Control and Prevention [CDC], 2011). Physiologically, type 2 diabetes is characterized by insufficient production of insulin and/or an abnormal cellular response to endogenously produced insulin (insulin resistance). The resulting hyperglycemia and coexisting hypertension and dyslipidemia promote a range of serious problems, including heart disease, stroke, peripheral vascular disease, blindness, and chronic kidney disease (CDC, 2011).

VIETNAMESE AND HEALTH RISKS Cardiovascular diseases including myocardial infarction, stroke, heart failure, and hypertension have ranked among the leading causes of death in Vietnam (CDC, 2013). There is a lack of data on causes of Vietnamese deaths in the United States. However, health data from a 2001–2002 survey (CDC, 2004) revealed that in the United States, Vietnamese have a varying degree of selfreported risk factors for heart disease when compared to a national aggregate of Asians and the general U.S. population: smoking prevalence in Vietnamese men 30.4% (± 27.1–34.0) versus Asian men 14.7% (± 11.8–18.1) versus U.S. men 24.9 (± 24.4–25.4), smoking prevalence in Vietnamese women 0.9% (± 0.5–1.8) versus Asian women 7.3% (± 5.5–9.6) versus U.S. women 20.4%

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(± 20.1–20.8), hypertension in Vietnamese 18.9% (± 17.3–20.6 ) versus Asians 20.9 (± 15.5–27.7) versus U.S. general population 26.5 (± 25.9–27.1), high blood cholesterol in Vietnamese 24.8% (± 22.4–27.4) versus Asians 28.5 (± 22.5–35.2), versus U.S. general population 29.7 (± 29.0–30.4), meeting physical activity recommendations in Vietnamese 14.3% (± 12.6–16.2) versus Asians 28.1% (± 25.2–31.2) versus U.S. general population 33.3% (± 32.9–33.8%) and eating five or more fruits and vegetables daily in Vietnamese 11.1% (9.6–12.7) versus Asians 32.1% (28.9–35.5%) versus U.S. general population 24.4% (± 24.1–24.7). This present study will examine current risk factors for diabetes and cardiovascular disease. Furthermore, clinical depression, depressive symptoms, and diabetesspecific emotional distress are common co-morbidities found among patients with diabetes. Statistics show that people with diabetes are twice as likely to be depressed and those with depression can have a 60% increased risk of developing type 2 diabetes (CDC, 2011). Depression and posttraumatic stress disorder (PTSD) is common among Vietnamese refugees (McPhee, 2002) having been detected between 8.2% and 9.8% of Vietnamese men in California and Texas, and in 2.3% of women in California. It is possible that these findings of depression and PTSD are associated with poorer diabetes self-care behaviors and an increase in diabetes rates (CDC, 2011). Vietnamese immigrating to the United States increase their risk of diabetes and overall health-related complications. In one study, when compared to non-Hispanic Whites, Vietnamese Americans were found to be less likely to eat the recommended servings of fruits and vegetables and less likely to engage in moderate or vigorous physical activity (Nguyen et al., 2008; Tran, Vatcher, Lee, Phan, Nguyen, 2013). Results were further compared between those Vietnamese Americans who responded to the survey in the Vietnamese language and those who responded in English. It was found that those who responded in Vietnamese had an even higher incidence of diabetes, were even more likely to eat less than the recommended servings of vegetables and fruit, and even more likely to be sedentary (Nguyen et al., 2008). Vietnamese Americans, and especially Vietnamese speakers, have been shown to eat less than the recommended servings for fruits and vegetables and to have decreased levels of physical activity (Nguyen et al., 2008). In California, Vietnamese and Chinese-Vietnamese have reported higher alcohol consumption levels compared to Japanese, Chinese, Koreans, and Filipinos (Caetano, Clark, & Tam, 1998). The differing health patterns among foreign-born Vietnamese Americans are likely shaped by numerous factors that include culture and historic experiences. Vietnamese immigrants’ traditional lifestyle involving higher levels of physical labor for both men and women, moderate body weight, and a lower-calorie, lower-fat diet is usually replaced by a more sedentary, Western lifestyle with its higher-calorie, higher fat diet (Chan et al., 2009). Curiously, even with a low body mass index (BMI)

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some Asian countries have similar or even higher prevalence of diabetes than Western countries (Chan et al., 2009). It is possible that the rapid increase in the availability of inexpensive, ready-to-eat street foods and fast foods, along with a shift to consumer-oriented industrialization, has resulted in significant changes in lifestyle. Vietnamese Americans face many health care barriers that increase the risk for diabetes and heart disease. In the United States, approximately 3 out of 10 Vietnamese Americans are living in poor socioeconomic circumstances and more than 1 out of 5 do not have health insurance (Terrazas & Batog, 2010). In 2008, 21.4% of Vietnamese immigrants did not have health insurance and although this is alarming, it is a lower percentage than that of all immigrant groups combined (32.9%) (Terrazas & Batog, 2010). In addition, 2 out of 3 of Vietnamese immigrants have limited English proficiency (Terrazas & Batog, 2010). This inability to communicate contributes significantly to the low utilization of health care services in the Vietnamese community resulting in a low level of awareness of medical problems such as undiagnosed diabetes on the part of the health care community (Pham, Rosenthal, & Diamond, 1999; McPhee, 2002). Information on foreign-born Vietnamese immigrants in the United States is limited for a couple of reasons. Previous research has focused on other Asian ethnic groups such as Japanese Americans, Chinese Americans, and Korean Americans because they have a long history in the United States. Research that has included the Vietnamese population tends to categorize them with other Asian ethnicities. What is known is that Vietnamese Americans differ from other Asian Americans in that they have their own language, history, traditions, and largely immigrated as refugees. The majority of Vietnamese arrived in the United States as middle age or older adults starting in 1975. Thus, those who are 65 or older in 2000 arrived in the United States at the age of 40 or older (U.S. Census, 2011). Older Vietnamese Americans who arrived in the United States experienced some form of traumatic life events due to war, life in refugee camps, re-education or prison camps following the Vietnam war or economic hardships (Hauff & Vaglum, 1995; Steel, Silove, Phan, & Bauman, 2002). Compared to other Asian American groups with different migration histories to the United States, Vietnamese Americans have a poorer health status (Cho & Hummer, 2001; Frisbie, Cho, & Hummer, 2001). Therefore, older Vietnamese Americans have a greater risk for stressrelated conditions and chronic diseases such as heart disease and this risk is compounded when combined with the Western lifestyle. Therefore, because diabetes is such a great risk factor for cardiovascular disease and because little is known about foreign-born Vietnamese immigrants in the United States, the purpose of this article is to examine sociodemographic and lifestyle factors associated with reported type 2 diabetes and heart disease in a sample of foreign born older adults Vietnamese Americans, aged 50 to 85.

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ACCULTURATION AND HEALTH FOR VIETNAMESE AMERICANS Acculturation refers to the process that occurs when two distinctly different cultures merge (Guiterrez, Franco, Gilmore Powell, Peterson, & Reid, 2009). This process can initiate social, attitudinal, psychological, and health changes within individuals (Guiterrez et al., 2009). The “Acculturation hypothesis” implies that acculturation is the key mechanism in linking migration with health status (Abraido-Lanza, Chao, & Florez, 2005; Dey & Lucas, 2006; Goel, McCarthy, Phillips, & Wee, 2004; Kaplan, Huguet, Newsom, & McFarland, 2004; Coronado, Woodall, Do, Li, Yasui, & Taylor, 2008). The longer an individual resides within the host environment the more likely the immigrants are to adopt the lifestyle of the local inhabitants with regard to lifestyle, social norms, and health practices. The resulting hypothesis is that increased acculturation results in an increased similarity of health and disease risk profiles between local inhabitants and immigrants that can be associated with social, attitudinal, and psychological variables. For example, the traditional Western diet is higher in fat content than the traditional Vietnamese diet and there is an abundance of meat, processed food, and snacks higher in fat. Moreover, fruits and vegetables, a mainstay of the Vietnamese diet are less affordable in the United States, making it harder to eat a healthy diet (U.S. Department of Health and Human Services, 2003).

STUDY’S PURPOSE AND HYPOTHESES The purpose of this study is to examine the association of lifestyle factors including bodyweight, vegetable consumption, alcohol consumption, cigarette smoking, physical activities, and psychological distress with type 2 diabetes and heart disease among older Vietnamese immigrants in the United States controlling for sociodemographic variables including age, gender, education, poverty, English language ability, health insurance, and length of residence in the United States. It’s important to examine the interaction effect of alcohol consumption and psychological distress on type 2 diabetes as the literature has revealed that moderate alcohol consumption is a protective factor of type 2 diabetes, but psychological distress is a risk of type 2 diabetes (Golden et al., 2007; Koppes, Dekker, Hendriks, Bouter, & Heine, 2005). We also examined the interaction effect among vegetable consumption, poverty and length of residence in the United States with heart disease due to the fact that vegetable consumption is a significantly preventive factor of heart disease, but Asian immigrants with higher family income tend to consume less vegetables. In addition the length of residence in the United States also associates with economic well-being and changes

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in lifestyle behaviors (Tran, Vatcher, Lee, Phan, Nguyen, 2013; Rosenmoller, Gasevic, Seidell, & Lear, 2011). H1 : We hypothesize that controlling for sociodemographic variables; bodyweight, cigarette smoking, and psychological distress would increase the odds of developing type 2 diabetes, while vegetable consumption, moderate alcohol consumption, and physical activities would decrease the odds of developing type 2 diabetes. However, the association between moderate alcohol consumption and the likelihood of type 2 diabetes depends on the levels of psychological distress. H2 : We hypothesize that controlling for sociodemographic variables; type 2 diabetes, bodyweight, cigarette smoking, psychological distress would increase the likelihood of heart disease, while vegetable consumption, moderate alcohol consumption, and physical activities would decrease the likelihood of heart disease. However, the association between vegetable consumption and heart disease depends on poverty levels, and length of living in the United States.

METHODS Data Sources The California Health Interview Survey (CHIS) from 2009 was used in this study (CHIS, 2011). This is the fifth CHIS data collection cycle, which has been conducted every other year since 2001. This is one of the largest population-based telephone health surveys conducted in any state and in the nation. CHIS used Random Digit Dial (RDD) telephone survey to select and interview one adult aged 18 years old or older in each randomly sampled household. In households that have children under age 12 or adolescents age from 12 to 17, one child and one adolescent were selected. Thus only three interviews could be conducted in each sampled household. The 2009 CHIS data consisted of 47,617 interviews conducted among adults aged 18 or older between September 2009 and April 2010. CHIS is also unique in that it is one of the largest health surveys that captures a rich and diverse sample of individuals from different races, ethnicities, and language backgrounds. Interviews were conducted in five languages: English, Spanish, Chinese (Mandarin and Cantonese dialects), Vietnamese, and Korean. Interviews in all languages were administered using Westat’s computer-assisted telephone interviewing (CATI) system. The average length of an adult interview was 35 minutes. CHIS used both landline and cell-phone lists to select sampled households. In order to increase representatives of race ethnic subgroups, CHIS employed both disproportional stratified sampling and multiple frame sampling methods. Detailed description and discussion of CHIS sampling methods can be found online posted on CHIS (CHIS, 2011).

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The original data has 1,354 Vietnamese Americans aged 18 and older who were born outside the United States. We selected 709 older adults aged 50 and older as our study sample The rationale for this selection is based on previous research that has confirmed that older adults from 50 years and older are more likely to develop type 2 diabetes and heart disease (Alexander, Landsman, Teutsch, & Haffner, 2003).

Measures

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DEPENDENT

VARIABLES

Self-reported type 2 diabetes and self-reported heart disease are two dependent variables coded 1 for yes and 0 for no. These two variables were based on the question regarding whether a doctor had ever told you that you had type 2 diabetes or heart disease. LIFESTYLE

VARIABLES

Body mass index (BMI) was coded as 1 for equal to or greater than 24 which indicates overweight or obesity. We coded obesity and overweight as one category based on the data from the Harvard Joslin Diabetes Center’s Asian American Diabetes Initiatives (http://aadi.joslin.org/content/bmi-calculator), and our own data screening also indicated that there is no difference between obesity and overweight in predicting the likelihood of type 2 diabetes and heart disease. Vegetable consumption was coded as 1 for eating any vegetable in the last 5 days and 0 for no. Alcohol consumption in the past 12 months coded 1 for yes and 0 for no. Smoking at least 100 or more cigarettes in entire life time was coded 1 for yes and 0 for no. With respect to smoking, we used the definition provided by the CDC that defines “Current smoker as an adult who has smoked 100 cigarettes in his or her lifetime and who currently smokes cigarettes.” Beginning in 1991 this group was divided into “everyday” smokers or “somedays” smokers, and never smoker as an adult who has never smoked, or who has smoked less than 100 cigarettes in his or her life (CDC, 2009). Physical activity was coded as 1 for engaged in vigorous physical activity or moderate physical activity and 0 for no. Psychological distress was measured by the K6 short screening for psychological distress (Kessler et al., 2002). The scale’s scores ranged from 0 to 22 in this study and it had a Cronbach’s alpha index of internal consistency reliability at 0.82. The scale was further coded in three categories low stress for the total score of 0 on the scale, medium stress for scores ranged from 1 to 5, and high stress for scores ranged from 6 to 22. There are two reasons that psychological distress was coded as a categorical variable in this study. First, it is much clearer and easier to handle interaction effect with categorical variables

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than continuous variables (Long & Freese, 2006); second, it’s also easier for clinicians/practitioners to be able to group clients into different levels or categories of psychological distress for diagnosis and treatment or service delivery.

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SOCIODEMOGRAPHIC

VARIABLES

Age was measured by the self-reported chronological age ranging from 50 to 85 years and coded 1 for ≥ 65 years old and 0 for < 65 years old. Sex was coded 1 for women and 0 for men. Marital status was coded as 1 for currently married or lived with partner and 0 for other groups. Education was coded as 1 for college and 0 for high school or less. Poverty level was coded 1 for being 200% above the federal poverty level and 0 for under 200% of federal level of poverty. English was coded as 1 for speaking English only or very well and 0 for speaking English poorly or no English. Length of residence was coded as 1 for 15 or more years and 0 for less than 15 years. Health insurance was coded 1 for having health insurance and 0 for having no health insurance.

Statistical Analysis Among 709 older foreign-born Vietnamese Americans aged 50 and older. Forty-seven percent (47%) aged 65 and older and 47.70% were female. The effective sample size in logistic regression models was 672 due to random missing data in some variables. The missing data accounted for 5% of random missing data, which are not a problem for the data analysis, especially with the estimation of prevalence. We used Listwise deletion procedure in our Logistic Regression analyses to provide accurate estimates of prevalence of type 2 diabetes and heart disease. In Table 1, we added the sample size for each variable used in our analyses (Long & Freese, 2006).

RESULTS The prevalence of self-reported type 2 diabetes and heart disease are reported in Table 1. Of older Vietnamese Americans, 12% reported their doctor had told them they had type 2 diabetes and 11% were told they had heart disease. In addition, Table 1 shows a significantly high percent (47%) of respondents had a BMI level 24 and higher, which is considered as overweight and obese for Asian Americans according the guideline of the Asian American Diabetes Initiative at Joslin Diabetes Center (2012). Sixtyeight percent of respondents answered that they consumed vegetables at least once during the last 5 days. Forty-seven percent of respondents reported that they consumed alcohol in the last 12 months at a rate of consumption of six or more drinks in the

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TABLE 1 Descriptive Statistics of Variables Used in the Study (N = 709)

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Variables Type 2 Diabetes Heart Disease Overweight & Obese Eating Vegetables (Yes) Drinking Alcohol Smoking Cigarettes Physical Activity Psychological Distress Low Medium High Age 65> Female Married College ≥200% FPL Poverty Speak English Well ≥15 Years in U.S. Health Insurance

Percent

n

12.78 11.28 47.10 69.00 47.00 32.29 10.43

673 709 709 709 709 709 709 708

47.00 39.00 14.00 36.81 47.67 73.62 40.90 34.83 28.63 85.19 90.00

709 709 709 709 709 709 709 709

last 12 months. About 32% of older Vietnamese adults smoked cigarettes at least 100 cigarettes or more in their life time. Only 10% of older Vietnamese engaged in either vigorous or moderate physical activity in the past 7 days. For psychological distress, 14% rated their stress as high, 39% as medium, and 47% as low. With respect to demographic characteristics of the sample, 37% aged 65 and older, 48% were female, 74% were currently married or living with a partner, 41% had some college or higher education, 35% lived above 200% of Federal Poverty Level (FPL), 29% spoke English well, 85% had lived in the United States at least 15 years, and 90% had health insurance. Table 2 presents two logistic regression models. In Model 1, we examined the direct associations of lifestyle variables and sociodemographic variables with type 2 diabetes. The results indicate that BMI greater than 24, high psychological distress, and age greater than 65 were more likely to be associated with type 2 diabetes. However, respondents who had consumed some alcohol during the prior 12 months were less likely to have type 2 diabetes. In order to provide a clearer explanation of the association between alcohol and type 2 diabetes, we examined the associations of the lifestyle variables and the sociodemographic variables with alcohol consumption and found that psychological distress exerted a significant association with alcohol consumption. In Model 2, we examined the interaction effect of alcohol consumption and psychological distress with type 2 diabetes. Only variables that were significant in Model 1 were analyzed in Model 2. The results in Table 2 show that BMI greater than 24 (Odds = 2.37, 95% CI = 1.45, 3.88), age greater than 65 (2.74, 95% CI = 1.70, 4.44), and sex (Odds = 0.62, 95% CI = 0.37, 1.00) remained statistically significant. More importantly,

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0.29, 0.85 0.33, 1.15 0.15, 1.33

0.50∗∗ 0.61 0.44

1.56, 4.66 0.21, 0.80 0.40, 1.21 0.57, 1.90 0.40, 1.40 0.89, 3.24 0.27, 1.47 0.86, 4.12

2.70∗∗∗ 0.41∗∗∗ 0.70 1.04 0.75 1.70 0.63 1.88

.0.92, 2.73 1.49, 6.00

0.71, –2.10

1.22

1.59+ 3.00∗∗∗

1.51, 4.15

95% C.I.

2.50∗∗∗

Odds Ratio

Note. Model 1’s LR Chi 2 (15 DF) = 62.13, P = 0.001; Model 2’s LR Chi 2 (8 DF) = 49.32, P = 0.001. a Overweight/Obese = BMI ≥ 24 based on Joslin Diabetes Center’s Guideline. b Only statistically significant interaction effects are reported in the table. +p = .06, ∗ p = .05, ∗∗ p = .01, ∗∗∗ p = .001.

Drinking Alcohol (Yes, No) Smoking Cigarettes (Yes, No) Physical Activity (Yes, No) Psychological Distress Ref: Low Medium High Sociodemographic variables Age 65> Ref: 50–64 Female Currently Married & Partner College Ref: High School or less ≥200% FPL Poverty Ref: Ref: 50–64 Female Currently Married & Partner College Ref: High School or less ≥200% FPL Poverty Ref:

Risk and preventive factors for type 2 diabetes and heart disease among foreign-born older Vietnamese Americans.

The 2009 California Health Interview Survey (CHIS) data was used to examine associations of bodyweight, lifestyles, and demographic variables with typ...
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