Biopsychosocial Determinants of Stress and Cardiovascular Disease Risk Factors in Foreign- and US-Born Adults

Background: Immigrants make up over 14% of the United States’ (U.S.) populace. Despite the growing number of U.S. immigrants, disparities exist in health and health outcomes between foreign- and US-born persons. Studies comparing biopsychosocial determinants of these disparities in foreign- and US-born persons are limited. Objective: This dissertation research reports the results of three studies from three independent and diverse datasets. The objective of the first study was to examine differences in chronic stress (allostatic load) between foreign- and US-born adults. The objective of the second study was to examine differences in social determinants of health between foreign- and US-born persons. The objective of the third study was to examine discrimination and elevated cardiovascular risk and cardiovascular disease risk factors in African immigrants. Methods: All three studies employed a cross-sectional design. The first study examined allostatic load in foreign- and US-born persons in the National Health and Nutrition Examination Survey (NHANES). Allostatic load was defined by a composite score of a count of the number of high-risk classifications for 10 cardiovascular, metabolic, and immune system biomarkers (where high allostatic load score was ≥ 4). Logistic regression was used to examine differences in high allostatic load scores between the two groups. The second study examined differences in social determinants of health (SDoH) between foreign- and US-born persons in the Multi- Ethnic Study of Atherosclerosis (MESA). Multivariable linear, logistic, and ordered logistic regressions as appropriate were used to examine psychosocial factors (wealth, depression, discrimination, and social support), environmental factors (social cohesion, safe environment, and neighborhood problems) and behaviors (physical activity and dietary patterns) in foreign- and US-born persons. In the third study, logistic regression was used to examine the association between high CVD risk scores and discrimination and examine resilience as a moderator of the relationship between discrimination and high CVD risk scores in African immigrants in the African immigrant Health Study (AIHS). Results: In NHANES, foreign-born persons had lower odds of high allostatic load than US-born persons in the multivariable analyses (adjusted Odds Ratio: 0.63; 95% Confidence Interval [CI]: 0.50–0.78). In MESA, in the fully adjusted model, we observed disparities in that foreign-born had lower mean wealth-income indices (6.41 vs. 7.57; P<0.01), were more likely to report lower social cohesion, (adjusted Odds Ratio [aOR]: 0.81; 95%CI: 0.70–0.94) and have fewer experiences of everyday (aOR: 0.57; 95%CI: 0.49–0.67), major (aOR: 0.57; 95%CI: 0.49– 0.65), and racial (aOR: 0.52; 95%CI: 0.43–0.64) discrimination than their US-born counterparts. This model was adjusted for age, gender, race/ethnicity, education, and wealth-index. However, foreign-born persons lived in safer environments (aOR: 1.26; 95%CI:1.07–1.49) and were less likely to engage in recommended amounts of physical activity (aOR: 0.82; 95%CI: 0.70–0.96) than US-born persons. However, foreign-born persons had better dietary habits than US-born persons as they consumed more vegetables and fish (aOR: 1.52; 95%CI: 1.31– 1.76) and less fats and processed meats (aOR: 0.48; 95%CI: 0.41–0.56). In the AIHS, increased CVD risk was associated with frequent experiences of discrimination (aOR: 1.87; 95%CI: 1.15–3.05). Conclusion: We observed differences in allostatic load and social determinants of health between foreign- and US-born persons and high CVD risk in African immigrants. Allostatic load was lower in foreign-born persons. Foreign-born persons had lower wealth- income indices, lower social cohesion, and fewer experiences of discrimination, but had healthier dietary patterns and lived in safer neighborhoods. Increased experiences of discrimination was associated with increased CVD risk in African immigrants. Despite having many psychosocial stressors including lower social support, immigrants may have unique protective factors insulating them against the manifestations and effects of chronic stress. Implications: There is a need to increase policies and funding for research targeting immigrant health as well as community-based interventions involving immigrants. Healthcare providers should screen and address SDoH in their encounters with patients. Researchers should examine the impact of nativity status as a determinant of health outcomes when examining multiethnic populations and incorporate the assessment of nativity status in their work

The Associations between Depression, Acculturation, and Cardiovascular Health among African Immigrants in the United States

Cardiovascular disease (CVD) is the leading cause of death both globally and in the United States (U.S.). Racial health disparities in cardiovascular health (CVH) persist with non-Hispanic Black adults having a higher burden of CVD morbidity and mortality compared to other racial groups. African immigrants represent an increasingly growing sub-population of the overall U.S. non-Hispanic Black adult population, however little is known about how specific psychological and social factors (i.e., depression and acculturation) influence the CVH of U.S. African immigrants. We sought to examine the association between severity of depression symptomology and CVH among African immigrants, and whether acculturation moderated the relationship between severity of depression symptoms and CVH. Study participants were those in the African Immigrant Health Study conducted in the Baltimore-Washington D.C. area. Severity of depression symptoms were assessed using the Patient Health Questionnaire-8 (PHQ-8). CVH was assessed using the American Heart Association Life&rsquo;s Simple 7 metrics and categorized as poor, intermediate, and ideal CVH. Acculturation measured as length of stay and acculturation strategy was examined as a moderator variable. Multivariable logistic regression was used to examine the association between depression and CVH and the moderating effect of acculturation adjusting for known confounders. In total 317 African immigrants participated in the study. The mean (&plusmn;SD) age of study participants was 46.9 (&plusmn;11.1) and a majority (60%) identified as female. Overall, 8.8% of study participants endorsed moderate-to-severe symptoms of depression. African immigrants endorsing moderate-to-severe levels of depression were less likely to have ideal CVH compared to those with minimal-to-mild symptoms of depression (Adjusted Odds Ratio [AOR]: 0.42, 95% CI: 0.17&ndash;0.99). Acculturation measured either as length of stay or acculturation strategy did not moderate the relationship between depression and CVH among study participants. Study participants exhibited elevated levels of symptoms of depression. Greater severity of depression symptoms was associated with worse CVH. Efforts to treat and prevent CVD among African immigrants should also include a focus on addressing symptoms of depression within this population

Financial strain is associated with poorer cardiovascular health: The multi-ethnic study of atherosclerosis

Objective: Psychosocial stress is associated with increased cardiovascular disease (CVD) risk. The relationship between financial strain, a toxic form of psychosocial stress, and ideal cardiovascular health (CVH) is not well established. We examined whether financial strain was associated with poorer CVH in a multi-ethnic cohort free of CVD at baseline. Methods: This was a cross-sectional analysis of 6,453 adults aged 45–84 years from the Multi-Ethnic Study of Atherosclerosis. Financial strain was assessed by questionnaire and responses were categorized as yes or no. CVH was measured from 7 metrics (smoking, body mass index, physical activity, diet, total cholesterol, blood glucose and blood pressure). A CVH score of 14 was calculated by assigning points to the categories of each metric (poor = 0 points, intermediate = 1 point, ideal = 2 points). Multinomial logistic regression was used to examine the association of financial strain with the CVH score (inadequate 0–8, average 9–10, and optimal 11–14 points) adjusting for sociodemographic factors, depression and anxiety. Results: The mean age (SD) was 62 (10) and 53 % were women. Financial strain was reported by 25 % of participants. Participants who reported financial strain had lower odds of average (OR, 0.82 [95 % CI, 0.71, 0.94]) and optimal (0.73 [0.62, 0.87]) CVH scores. However, in the fully adjusted model, the association was only significant for optimal CVH scores (0.81, [0.68, 0.97]). Conclusion: Financial strain was associated with poorer CVH. More research is needed to understand this relationship so the burden of CVD can be decreased, particularly among people experiencing financial hardship

Effects of the DASH diet and losartan on serum urate among adults with hypertension: Results of a randomized trial

Abstract Serum urate is a risk factor for hypertension and gout. The DASH diet and losartan independently lower blood pressure (BP); however, their effects on serum urate are understudied. We performed a post‐hoc analysis of the DASH‐losartan trial, which randomized participants with hypertension in parallel fashion to the DASH diet or a standard American diet (control) and in crossover fashion to 4‐week losartan or placebo. Serum urate was measured at baseline and after each 4‐week period. Diets were designed to maintain weight constant. We examined the effects of DASH (vs control) and/or losartan (vs placebo) on serum urate, overall and among those with baseline serum urate ≥6 mg/dL, using generalized estimating equations. Of 55 participants (mean age 52 years, 58% women, 64% Black), mean (±SD) baseline ambulatory SBP/DBP was 146±12/91±9 and mean (±SD) serum urate was 5.2±1.2 mg/dL. The DASH diet did not significantly reduce urate levels overall (mean difference −0.05 mg/dL; 95%CI: −0.39, 0.28), but did decrease levels among participants with baseline hyperuricemia (−0.33 mg/dL; 95%CI: −0.87, 0.21; P‐interaction=0.007 across hyperuricemia groups). Losartan significantly decreased serum urate (−0.23 mg/dL; 95%CI: −0.40, −0.05) with greater effects on serum urate among adults <60 years old versus adults ≥60 years old (−0.33 mg/dL vs 0.16 mg/dL, P interaction = 0.003). In summary, the DASH diet significantly decreased serum urate among participants with higher urate at baseline, while losartan significantly reduced serum urate, especially among younger adults. Future research should examine the effects of these interventions in patients with hyperuricemia or gout

Hypertension, overweight/obesity, and diabetes among immigrants in the United States: an analysis of the 2010–2016 National Health Interview Survey

Abstract Background Ethnic minority populations in the United States (US) are disproportionately affected by cardiovascular disease (CVD) risk factors, including hypertension, overweight/obesity, and diabetes. The size and diversity of ethnic minority immigrant populations in the US have increased substantially over the past three decades. However, most studies on immigrants in the US are limited to Asians and Hispanics; only a few have examined the prevalence of CVD risk factors across diverse immigrant populations. The prevalence of diagnosed hypertension, overweight/obesity, and diagnosed diabetes was examined and contrasted among a socioeconomically diverse sample of immigrants. It was hypothesized that considerable variability would exist in the prevalence of hypertension, overweight and diabetes. Methods A cross-sectional analysis of the 2010–2016 National Health Interview Survey (NHIS) was conducted among 41,717 immigrants born in Europe, South America, Mexico/Central America/Caribbean, Russia, Africa, Middle East, Indian subcontinent, Asia and Southeast Asia. The outcomes were the prevalence of diagnosed hypertension, overweight/obesity, and diagnosed diabetes. Results The highest multivariable adjusted prevalence of diagnosed hypertension was observed in Russian (24.2%) and Southeast Asian immigrants (23.5%). Immigrants from Mexico/Central America/Caribbean and the Indian subcontinent had the highest prevalence of overweight/obesity (71.5 and 73.4%, respectively) and diagnosed diabetes (9.6 and 10.1%, respectively). Compared to European immigrants, immigrants from Mexico/Central America/Caribbean and the Indian subcontinent respectively had higher prevalence of overweight/obesity (Prevalence Ratio (PR): 1.19[95% CI, 1.13–1.24]) and (PR: 1.22[95% CI, 1.14–1.29]), and diabetes (PR: 1.70[95% CI, 1.42–2.03]) and (PR: 1.78[95% CI, 1.36–2.32]). African immigrants and Middle Eastern immigrants had a higher prevalence of diabetes (PR: 1.41[95% CI, 1.01–1.96]) and PR: 1.57(95% CI: 1.09–2.25), respectively, than European immigrants —without a corresponding higher prevalence of overweight/obesity. Conclusions Immigrants from Mexico/Central America/Caribbean and the Indian subcontinent bore the highest burden of overweight/obesity and diabetes while those from Southeast Asia and Russia bore the highest burden of hypertension

Heterogeneity in Cardiovascular Disease Risk Factor Prevalence Among White, African American, African Immigrant, and Afro‐Caribbean Adults: Insights From the 2010–2018 National Health Interview Survey

Background In the United States, Black adults have higher rates of cardiovascular disease (CVD) risk factors than White adults. However, it is unclear how CVD risk factors compare between Black ethnic subgroups, including African Americans (AAs), African immigrants (AIs), and Afro‐Caribbeans, and White people. Our objective was to examine trends in CVD risk factors among 3 Black ethnic subgroups and White adults between 2010 and 2018. Methods and Results A comparative analysis of the National Health Interview Survey was conducted among 452 997 participants, examining sociodemographic characteristics and trends in 4 self‐reported CVD risk factors (hypertension, diabetes, overweight/obesity, and smoking). Generalized linear models with Poisson distribution were used to obtain predictive probabilities of the CVD risk factors. The sample included 82 635 Black (89% AAs, 5% AIs, and 6% Afro‐Caribbeans) and 370 362 White adults. AIs were the youngest, most educated, and least insured group. AIs had the lowest age‐ and sex‐adjusted prevalence of all 4 CVD risk factors. AAs had the highest prevalence of hypertension (2018: 41.9%) compared with the other groups. Overweight/obesity and diabetes prevalence increased in AAs and White adults from 2010 to 2018 (P values for trend <0.001). Smoking prevalence was highest among AAs and White adults, but decreased significantly in these groups between 2010 and 2018 (P values for trend <0.001), as compared with AIs and Afro‐Caribbeans. Conclusions We observed significant heterogeneity in CVD risk factors among 3 Black ethnic subgroups compared with White adults. There were disparities (among AAs) and advantages (among AIs and Afro‐Caribbeans) in CVD risk factors, suggesting that race alone does not account for disparities in CVD risk factors

Heterogeneity in the Prevalence of Cardiovascular Risk Factors by Ethnicity and Birthplace Among Asian Subgroups: Evidence From the 2010 to 2018 National Health Interview Survey

Background Asian people in the United States have different sociodemographic and health‐related characteristics that might affect cardiovascular disease (CVD) risk by ethnicity and birthplace. However, they are often studied as a monolithic group in health care research. This study aimed to examine heterogeneity in CVD risk factors on the basis of birthplace among the 3 largest Asian subgroups (Chinese, Asian Indian, and Filipino) compared with US‐born non‐Hispanic White (NHW) adults. Methods and Results A cross‐sectional analysis was conducted using the 2010 to 2018 National Health Interview Survey data from 125 008 US‐born and foreign‐born Chinese, Asian Indian, Filipino, and US‐born NHW adults. Generalized linear models with Poisson distribution were used to examine the prevalence and prevalence ratios of self‐reported hypertension, diabetes, high cholesterol, physical inactivity, smoking, and overweight/obesity among Asian subgroups compared with US‐born NHW adults. The study included 118 979 US‐born NHW and 6029 Asian adults who self‐identified as Chinese (29%), Asian Indian (33%), and Filipino (38%). Participants' mean (±SD) age was 49±0.1 years, and 53% were females. In an adjusted analysis, foreign‐born Asian Indians had significantly higher prevalence of diabetes, physical inactivity, and overweight/obesity; foreign‐born Chinese had higher prevalence of physical inactivity, and foreign‐born Filipinos had higher prevalence of all 5 CVD risk factors except smoking compared with NHW adults. Conclusions This study revealed significant heterogeneity in the prevalence of CVD risk factors among Asian subgroups by ethnicity and birthplace, stressing the necessity of disaggregating Asian subgroup data. Providers should consider this heterogeneity in CVD risk factors and establish tailored CVD prevention plans for Asian subgroups

The Cardiometabolic Health of African Immigrants in High-Income Countries: A Systematic Review

In recent decades, the number of African immigrants in high-income countries (HICs) has increased significantly. However, the cardiometabolic health of this population remains poorly examined. Thus, we conducted a systematic review to examine the prevalence of cardiometabolic risk factors among sub-Saharan African immigrants residing in HICs. Studies were identified through searches in electronic databases including PubMed, Embase, CINAHL, Cochrane, Scopus, and Web of Science up to July 2021. Data on the prevalence of cardiometabolic risk factors were extracted and synthesized in a narrative format, and a meta-analysis of pooled proportions was also conducted. Of 8655 unique records, 35 articles that reported data on the specific African countries of origin of African immigrants were included in the review. We observed heterogeneity in the burden of cardiometabolic risk factors by African country of origin and HIC. The most prevalent risk factors were hypertension (27%, range: 6&ndash;55%), overweight/obesity (59%, range: 13&ndash;91%), and dyslipidemia (29%, range: 11&ndash;77.2%). The pooled prevalence of diabetes was 11% (range: 5&ndash;17%), and 7% (range: 0.7&ndash;14.8%) for smoking. Few studies examined kidney disease, hyperlipidemia, and diagnosed cardiometabolic disease. Policy changes and effective interventions are needed to improve the cardiometabolic health of African immigrants, improve care access and utilization, and advance health equity

Advancing Cardiovascular Health Equity Globally Through Digital Technologies

Cardiovascular diseases (CVDs) remain the leading cause of death and disability worldwide. Digital health technologies are important public health interventions for addressing the burden of cardiovascular disease. In this article, we discuss the importance of translating digital innovations in research‐funded projects to low‐resource settings globally to advance global cardiovascular health equity. We also discuss current global cardiovascular health inequities and the digital health divide within and between countries. We present various considerations for translating digital innovations across different settings across the globe, including reciprocal innovation, a “bidirectional, co‐constituted, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings.” In this case, afferent reciprocal innovations may flow from high‐income countries toward low‐ and middle‐income countries, and efferent reciprocal innovations may be exported to high‐income countries from low‐ and middle‐income countries with adaptation. Finally, we discuss opportunities for bidirectional learning between local and global institutions and highlight examples of projects funded through the American Heart Association Health and Innovation Strategically Funded Research Network that have been adapted to lower‐resource settings or have the potential to be adapted to lower‐resource settings

Migration-Related Weight Changes among African Immigrants in the United States

(1) Background: people who migrate from low-to high-income countries are at an increased risk of weight gain, and excess weight is a risk factor for cardiovascular disease. Few studies have quantified the changes in body mass index (BMI) pre- and post-migration among African immigrants. We assessed changes in BMI pre- and post-migration from Africa to the United States (US) and its associated risk factors. (2) Methods: we performed a cross-sectional analysis of the African Immigrant Health Study, which included African immigrants in the Baltimore-Washington District of the Columbia metropolitan area. BMI category change was the outcome of interest, categorized as healthy BMI change or maintenance, unhealthy BMI maintenance, and unhealthy BMI change. We explored the following potential factors of BMI change: sex, age at migration, percentage of life in the US, perceived stress, and reasons for migration. We performed multinomial logistic regression adjusting for employment, education, income, and marital status. (3) Results: we included 300 participants with a mean (±SD) current age of 47 (±11.4) years, and 56% were female. Overall, 14% of the participants had a healthy BMI change or maintenance, 22% had an unhealthy BMI maintenance, and 64% had an unhealthy BMI change. Each year of age at immigration was associated with a 7% higher relative risk of maintaining an unhealthy BMI (relative risk ratio [RRR]: 1.07; 95% CI 1.01, 1.14), and compared to men, females had two times the relative risk of unhealthy BMI maintenance (RRR: 2.67; 95% CI 1.02, 7.02). Spending 25% or more of life in the US was associated with a 3-fold higher risk of unhealthy BMI change (RRR: 2.78; 95% CI 1.1, 6.97). (4) Conclusions: the age at immigration, the reason for migration, and length of residence in the US could inform health promotion interventions that are targeted at preventing unhealthy weight gain among African immigrants