Myths, Heart Disease and the Latino Population. Maria T. Vivaldi MD MGH Women s Heart Health Program. Hispanics constitute 16.3 % of US population!

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1 Myths, Heart Disease and the Latino Population Maria T. Vivaldi MD MGH Women s Heart Health Program Hispanics constitute 16.3 % of US population! 1

2 LEADING CAUSES OF DEATH IN LATINOS Heart disease is the number 1 killer! Myth or Fact Latinos have the highest prevalence of CAD! 2

3 Blacks Whites Blacks Latinos Whites Latinos Coronary Heart Disease 3

4 Coronary Heart Disease Framingham Heart Study: Risk prediction score Step 1 Age Step 2 Cholesterol (LDL) Step 3 HDL Step 4 Blood pressure Step 5 Diabetes Step 6 Smoking 4

5 Myth or Fact Latino men have the highest prevalence of elevated total cholesterol. Blood Cholesterol 5

6 Cholesterol 6

7 DISLIPIDEMIAS IN LATINOS Disparitiy: multifactorial lifestyle diet culture gender suboptimal healthcare genetics? Current Atheroscler Rep 2006 Jan;8(1):32-40 Framingham Heart Study: Risk prediction score Step 1 Age Step 2 Cholesterol (LDL) Step 3 HDL Step 4 Blood Pressure Step 5 Diabetes Step 6 Smoking 7

8 Myth or Fact Latino men have the highest prevalence of Hypertension 8

9 High Blood Pressure High Blood Pressure 9

10 According to NHIS surveys of 2000 to 2002, black Hispanics were at slightly greater risk of HBP than white Hispanics. Arch Intern Med. 2002;162: According to a CDC analysis of death certificate t data from 1995 to 2002, among Hispanics, Puerto Rican Americans had the highest hypertension-related death rate (154.0) and Cuban Americans had the lowest (82.5). MMWR Morb Mortal Wkly Rep.2006;55:

11 Uncontrolled HTN in Hispanics exceeds rates in non Hispanics. Proposed explanations : lack of access, low SES, language barrier, degree of acculturation, poor doctor-patient communication and genetic factors. PostGrad Med 2011Nov;123(6):46-57 Analysis of NHANES/NCHS data from through revealed substantial increases in awareness and treatment of hypertension. Control rates increased in both sexes, non-hispanic blacks and Mexican Americans. NCHS. Hypertension Awareness,Treatment and Control: Continued Disparities in Adults, United States, NCHS Data Brief No. 3,

12 Framingham Heart Study: Risk prediction score Step 1 Age Step 2 Cholesterol (LDL) Step 3 HDL Step 4 Blood pressure Step 5 Diabetes Step 6 Smoking 12

13 Myth or Fact Diabetes is a more important cardiac risk factor in the latino population than in the general population. About 186,000 people under age 20 have diabetes. Each year, about 15,000 people under 20 are diagnosed with type 1 diabetes. Healthcare providers are finding more and more children with type 2 diabetes, a disease usually diagnosed in adults age 40 and older. 13

14 Children who develop type 2 diabetes are typically overweight or obese and have a family history of diabetes. Most are American Indian, black, Asian or Hispanic/Latino. CDC. National Diabetes Fact Sheet, 2007; CDCFact2008.pdf Among adolescents ages diagnosed with diabetes type 2: JAMA. 2007;297:

15 Diabetes Mellitus Diabetes Mellitus 15

16 Diabetes in the Latino population 1. Prevalence of Adults who are overweight or obese is higher in Hispanics compared to non Hispanics. 2. CDC reported Type 2 DM is almost twice higher in Hispanics. 3. Explanations include genetics, high incidence of obesity, under treatment, SES, language age barriers. 4. Type 2 DM: increases risk of CVD by 2-4 fold. AmJMed 2011Oct;124(Sup)S2-9 Diabetes in the Latino population Prevention is the key: goal is to prevent obesity in children and teenagers. Targeting enviromental factors including: Diet and promoting physical activity at an early age. 16

17 Diabetes in the Latino population 17

18 In 2006, an estimated 145,000,000 U.S. adults (age 20 and older) were overweight or obese (76,900,000 males; 68,1000,000 females.) Thi 66 f h d l This represents 66.7 percent of the adult population. 18

19 Overweight and Obesity Overweight and Obesity 19

20 OBESITY in association with DM, HTN and HL contributes to racial/ethnic disparities in CVD risk. Lifestyle modification and weight reduction is the key. PREVENTION: 1. Community level changes and policies at local, state and national level. 2. Individually oriented approaches. Circulation, 2005, 111:e134-e139 Data from the CDC s YRBS 2007 survey showed that the prevalence of being overweight among students t was: non-hispanic black (19.0%) Hispanic (18.1 %) non-hispanic white (14.3 %) CDC. YRBS Survey

21 non-hispanic i black female (21.4%) Hispanic female (17.9%) non-hispanic white female (12.8 %) non-hispanic black male (16.66 %) Hispanic male (18.3%) non-hispanic white male (15.7 %) A recent study of the decrease in U.S. deaths from CHD from1980 to 2000 found that about 47 % of the decrease was attributable to evidence-based medical therapies and 44 % to changes in risk factors. Nevertheless, these improvements have been offset by increases in body mass index and diabetes prevalence. N Engl J Med. 2007;356:

22 According to the 2007 YRBS survey of students in grades 9 12, 31.8 % of females and 18 % of males did not engage in 60 minutes of moderate-to-vigorous physical activity even once in the previous seven days. (despite recommendations that children do so five or more days per week). MMWR Surveill Summ. 2008;57:

23 61.5 % of children ages 9 13 don t participate in any organized physical activity it during their nonschool hours, and 22.6 % don t engage in any free-time physical activity. Non-Hispanic black and Hispanic children are significantly less likely than non-hispanic white children to report involvement in organized activities, iti as are children with parents who have lower incomes and education levels. MMWR Morb Mortal Wkly Rep. 2003;52: Rates of inactivity it were highest among black (42.1 %) and Hispanic (35.2 %) females, compared with white females (28.2 %). 23

24 Women were more likely to add physical activity to their children s lives, and Hispanic women were more likely to do so than blacks or whites (90% vs 75% vs 78%). However, women did not increase their own activity. it Circulation, 2006;113: Physical inactivity is responsible for 12.2 percent of the global burden of heart attack. Lancet. 2004;364:

25 Lifestyle Interventions Physical Activity Minimum of 30 minutes of moderate-intensity physical activity (biking, walking, etc) on most and preferably all, days of the week For weight loss, minutes of moderate-intensity physical activity on most if not all days American Heart Association website: Metabolic Syndrome Definition Any three of the following: 1) Abdominal obesity (>35 in) 2) Triglycerides > 150 or on treatment 3) HDL < 50 in women or on treatment 4) Blood pressure > 130/85 or tx for hypertension 5) Elevated fasting glucose > 110 or on treatment 25

26 METABOLIC SYNDROME IN LATINOS AJM , Based on NHANES data, the prevalence of Metabolic Syndrome in adolescents ages was 9.4 %, representing about 2.9 million persons. The prevalence was 13.2 % in males and 5.3% in females 10.7 % in whites, 5.2 % in blacks and 11.1 % in Mexican Americans. J Pediatr. 2008;152:

27 Among overweight eight or obese adolescents (based on NHANES data) 44 percent had Metabolic Syndrome! J Pediatr. 2008;152: Framingham Heart Study: Risk prediction score Step 1 Age Step 2 Cholesterol (LDL) Step 3 HDL Step 4 Blood pressure Step 5 Diabetes Step 6 Smoking 27

28 Myth or Fact? Latino Population has the highest rate of smoking. Tobacco 28

29 Tobacco Smoking cessation in Latinos Latinos who smoke are less likely to use pharmacological aids such as nicotine replacement. Or to receive Physician advice to stop smoking Social influence is a strong motivator Increase awareness is the key 29

30 In 2005, the prevalence for smoking (age 18+) was 47,100,000 (26,200,000 males; 20,900,000 females). This represents 20.8 % of the adult population. (NCHS) From 1965 to 2006, smoking in the United States has declined by 50.4 percent among people age 18 and older. (NCHS) Use of any tobacco product in 2005 was : 31.2 % for non-hispanic whites 28.4 % for non-hispanic blacks 41.7 % for non-hispanic American Indians 14.6 % for non-hispanic Asians 24.5 % for Hispanics or Latinos of any race. Health, United States,

31 STROK E MYTH or FACT Latinos have a high prevalence of stroke 31

32 Age adjusted Death rates for stoke by sex/ethnic groups NCHS/NHLBI 2007 Stroke 32

33 Stroke Atrial fibrillation is less prevalent in hispanics (3.0% vs 5.7% in whites). White males have the highest incidence of Afib even after adjustment for risk factors. Whites have a higher incidence of CAD while hispanics a highest incidence of diabetes mellitus. J Natl Med Assoc 2008;100(2)

34 Peripheral arterial disease affects about 8 million Americans and is associated with significant ifi morbidity and mortality. JAMA. 2001;286: PAD prevalence increases dramatically with age and disproportionately affects blacks. Circulation2004;110: The prevalence of PAD in persons of Hispanic origin is similar to or slightly higher than in Caucasians, according to available evidence. Circulation. 2005;112: ; Am J Prev Med.2007;32: In a telephone survey of more than 2,500 adults age 50 and older, 26 % of respondents said they were familiar with PAD. Of these respondents, half were not aware that diabetes and smoking increase the risk of PAD. One in four knew that PAD is associated with increased risk of heart attack and stroke. Awareness levels were lower in respondents with lower income and education levels. Circulation. 2007;116:

35 Heart Failure Heart Failure 35

36 Chronic Stress and Depression in Latinos Chronic Stress has the greatest neg impact on health. Translating into a chronic state of activation with increase wear and tear of biological systems, increasing cardiovascular reactivity, leading to increased incidence of HTN, CVD, DM and obesity in Latinos. C. M. Arthur / Californian Journal of Health Promotion 2007, Volume 5, Special Issue (Health Disparities & Social Justice),

37 Depression in the Latino population 1. Severity of Depression is associated with CVD 2. Depression was associated with increased BMI, DM, serum cholesterol and serum TG. 3. Diabetics on antidepressants presented with increased BMI, increased TG and high cholesterol. Psychol Health Med 2010 Heart Disease in Latinos 8.5 % have heart disease 5.8 % have CHD 21.5 % have hypertension 2.0 % have had a stroke. 37

38 Social and economic determinants are more important predictors than is culture in understanding health care disparities. Improvements in the material conditions of low-income Latinos can effectively reduce health care disparities. Am J Public Health. 2010;100:18-23 SELF REPORTED BARRIERS TO CVH IN LATINOS 1.- Confusion in the media 2.- Higher power determines health 3.- Caretaker responsibilities Am J Public Health. 2010;100:

39 In summary 1. Diabetes Mellitus and Prediabetes 2. Obesity and physical inactivity 3. Metabolic syndrome 4.- Dislipidemia specifically, low HDL 5.-Uncontrolled Hypertension A looming Latino cardiovascular health crisis? Latinos have the highest prevalence of prediabetes and diabetes of any ethnic group in America Latinos have the highest prevalence of metabolic syndrome Latinos have the highest prevalence of overweight and physical inactivity Latino paradox? Are we underestimating the prevalence of CAD? The salmon hypothesis at play? 39

40 Myths, Heart Disease and the Latino Population American Heart Association The MGH Heart Center Women s Heart Health Program THANK YOU 40