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author:("isass, Carmen")
1.  Perceived Discrimination and Cancer Screening Behaviors in US Hispanics: the Hispanic Community Health Study/Study of Latinos Socio-cultural Ancillary Study 
Cancer causes & control : CCC  2016;27(1):27-37.
Perceived discrimination has been associated with lower adherence to cancer screening guidelines. We examined whether perceived discrimination was associated with adherence to breast, cervical, colorectal, and prostate cancer screening guidelines in US Hispanic/Latino adults.
Data were obtained from the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study, including 5,313 Hispanic adults ages 18–74 from Bronx NY, Chicago IL, Miami FL, and San Diego CA who were within appropriate age ranges for specific screening tests were included in the analysis. Cancer screening behaviors were assessed via self-report. Perceived discrimination was measured using the Perceived Ethnic Discrimination Questionnaire. Confounder-adjusted multivariable polytomous logistic regression models assessed the association between perceived discrimination and adherence to cancer screening guidelines.
Among women eligible for screening, 72.1% were adherent to cervical cancer screening guidelines and 71.3% were adherent to breast cancer screening guidelines. In participants aged 50–74, 24.6% of women and 27.0% of men were adherent to fecal occult blood test guidelines; 43.5% of women and 34.8% of men were adherent to colonscopy/sigmoidoscopy guidelines; 41.0% of men were adherent to prostate specific antigen screening guidelines. Health insurance coverage, rather than perceived ethnic discrimination, was the variable most associated with receiving breast, cervical, colorectal, or prostate cancer screening.
The influence of discrimination as a barrier to cancer screening may be modest among Hispanics/Latinos in urban US regions. Having health insurance facilitates cancer screening in this population. Efforts to increase cancer screening in Hispanics/Latinos should focus on increasing access to these services, especially among the uninsured.
PMCID: PMC4842160  PMID: 26498194
Perceived discrimination; cancer screening; cancer disparities; epidemiology; prevention; Cancer screening; cohort studies; epidemiology; public health
2.  Family Environment and the Metabolic Syndrome: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study (SCAS) 
Metabolic syndrome (MetS) is a risk factor for cardiovascular disease. Very limited work has evaluated associations of sociocultural processes with prevalence of the MetS.
The purpose of the present study was to evaluate associations between family environment (cohesion/conflict) and the MetS, in a multi-site sample of US Hispanics/Latinos.
A total of 3278 participants from the Hispanic Community Health Study/Study of Latinos underwent a clinical exam and completed psychosocial measures including family environment (cohesion and conflict) as part of the Sociocultural Ancillary Study.
The association between family environment and the MetS was moderated by sex. Among all women, higher family conflict was associated with MetS prevalence. Results by ancestry group showed that only among Cuban women, higher conflict was associated with the MetS, whereas only among Dominican men, greater cohesion was associated with the MetS.
The family context may be a sociocultural protective or risk factor among Hispanics/Latinos in terms of MetS risk, but these associations may vary by sex and Hispanic background.
PMCID: PMC4636468  PMID: 26068057
Family environment; Cohesion; Conflict; Sex; Metabolic syndrome; Hispanics-Latinos
3.  Anxious-Depression among Hispanic/Latinos from different backgrounds: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) 
Anxious-depression is a constellation of symptoms, frequently encountered among patients in primary care centers. There is a need to study how anxious-depression presents among Hispanic/Latinos of different backgrounds.
To study the construct of anxious-depression among 16,064 Hispanic/Latinos of different backgrounds participating in the Hispanic Community Health Study/ Study of Latinos (HCHS/SOL). We hypothesized that Hispanic/Latinos will cluster in 3 classes: low anxiety/high depression, high anxiety/low depression and a combined anxious-depression construct.
Using latent profile analysis, symptoms of depression and anxiety measured by the 10-item Center for Epidemiologic Studies Depression Scale (CES-D) and 10-item State-Trait Anxiety Inventory (STAI) were evaluated to determine if an anxious-depression typology would result. A multinomial logistic regression analysis explored the association of the 3-class solution with different Hispanic/Latino backgrounds controlling for age, gender, language, education and income.
A 3-class mixed anxious-depression structure emerged with 10% of Hispanic/Latinos in the high, 30% in the moderate and 60% in the low anxious-depression category. After adjusting for age, gender, language preference, income and education, individuals of Puerto-Rican background were more likely to experience high (OR=1.79,p<0.05) and moderate (OR=1.36,p<0.05) (vs.low) anxious-depression symptomatology compared to those of Mexican background. Individuals of Central-American and South-American background were less likely to experience high (OR=0.68,p<0.05) and moderate (OR=0.8,p<0.05) (vs.low) anxious-depression compared to those of Mexican background.
Anxious-depression symptomatology varied among this sample of Hispanic/Latino groups. These classes should be investigated as to their relationship with different health outcomes relevant to the Hispanic/Latino of different backgrounds.
PMCID: PMC4618171  PMID: 26363900
4.  Clinical Utility of Magnetic Resonance Imaging (MRI) and Ultrasonography (US) for Diagnosis of Polycystic Ovary Syndrome (PCOS) in Adolescent Girls 
Fertility and sterility  2015;104(5):1302-1309.e4.
Evaluate ovarian morphology using 3-dimensional MRI in adolescent girls with and without PCOS. Compare the utility of MRI versus ultrasonography (US) for diagnosis of PCOS
Urban academic tertiary-care children’s hospital
Thirty-nine adolescent girls with untreated PCOS and 22 age/BMI-matched controls.
MRI and/or transvaginal/transabdominal US
Main Outcome Measure
Ovarian volume (OV); follicle number per section (FNPS); correlation between OV on MRI and US; proportion of subjects with features of polycystic ovaries on MRI and US.
MRI demonstrated larger OV and higher FNPS in subjects with PCOS compared to controls. Within the PCOS group, median OV was 11.9 (7.7) cm3 by MRI, compared with 8.8 (7.8) cm3 by US. Correlation coefficient between OV by MRI and US was 0.701. Due to poor resolution, FNPS could not be determined by US or compared with MRI. ROC curve analysis for MRI demonstrated that increasing volume cut-offs for polycystic ovaries from 10cm3 to 14cm3, increased specificity from 77% to 95%. For FNPS on MRI, specificity increased from 82% to 98% by increasing cut-offs from ≥12 to ≥17. Using Rotterdam cut-offs, 91% of subjects with PCOS met polycystic ovary criteria on MRI, while only 52% met criteria by US.
US measures smaller OV than MRI, cannot accurately detect follicle number, and is a poor imaging modality for characterizing polycystic ovaries in adolescents with suspected PCOS. For adolescents in whom diagnosis of PCOS remains uncertain after clinical and laboratory evaluation, MRI should be considered as a diagnostic imaging modality.
PMCID: PMC4630153  PMID: 26354095
PCOS; Ovarian Imaging; MRI; Adolescent
5.  Objectively-Measured Sedentary Time and Cardiometabolic Biomarkers in U.S. Hispanic/Latino Adults: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) 
Circulation  2015;132(16):1560-1569.
Sedentary behavior is recognized as a distinct construct from lack of moderate-vigorous physical activity and is associated with deleterious health outcomes. Previous studies have primarily relied on self-reported data, while data on the relationship between objectively-measured sedentary time and cardiometabolic biomarkers are sparse, especially among U.S. Hispanics/Latinos.
Methods and Results
We examined associations of objectively-measured sedentary time (via Actical accelerometers for 7 days) and multiple cardiometabolic biomarkers among 12,083 participants, aged 18–74 years, from the Hispanic Community Health Study/Study of Latinos. Hispanics/Latinos of diverse backgrounds (Central American, Cuban, Dominican, Mexican, Puerto Rican, and South American) were recruited from 4 U.S. cities between 2008 and 2011. Sedentary time (<100 counts/minute) was standardized to 16-hour/day of wear time. The mean sedentary time was 11.9 hours/day (74% of accelerometer wear time). After adjustment for moderate-vigorous physical activity and confounding variables, prolonged sedentary time was associated with decreased high-density lipoprotein (HDL)-cholesterol (P=0.04), and increased triglycerides, 2-hour glucose, fasting insulin and HOMA-IR (all P<0.0001). These associations were generally consistent across age, sex, Hispanic/Latino backgrounds, and physical activity levels. Even among individuals meeting physical activity guidelines, sedentary time was detrimentally associated with several cardiometabolic biomarkers (diastolic blood pressure, HDL-cholesterol, fasting and 2-hour glucose, fasting insulin and HOMA-IR; all P<0.05).
Our large population-based, objectively-derived data showed deleterious associations between sedentary time and cardiometabolic biomarkers, independent of physical activity, in U.S. Hispanics/Latinos. Our findings emphasize the importance of reducing sedentary behavior for the prevention of cardiometabolic diseases, even in those who meet physical activity recommendations.
PMCID: PMC4618246  PMID: 26416808
sedentary behavior; Hispanic; epidemiology; physical exercise; cardiovascular disease risk factors
6.  Mental Health and Exposure to the United States: Key Correlates from the Hispanic Community Health Study of Latinos 
We examined the association between exposure to the U.S. and symptoms of poor mental health among adult Hispanic/Latinos (N=15,004) overall and by Hispanic/Latino background. Using data from the Hispanic Community Health Study of Latinos (HCHS/SOL), we estimated logistic regressions to model the risk of moderate to severe symptoms of psychological distress, depression, and anxiety as a function of years in the U.S. and 6 key psychosocial risk and protective factors. In unadjusted models, increased time in the U.S. was associated with higher risk of poor mental health. After adjustment for just 3 key factors – perceived discrimination, perceived U.S. social standing, and the size of close social networks, differences in the odds of poor mental health by years in the U.S became insignificant for Hispanics/Latinos overall. However, analyses by Hispanic/Latino background revealed different patterns of association with exposure to the U.S. that could not be fully explained.
PMCID: PMC4552578  PMID: 26237134
Latino; Hispanic; Immigrant; depression; anxiety; acculturation
7.  The Role of Stress in Understanding Differences in Sedentary Behavior in Hispanic/Latino Adults: Results From the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study 
Chronic stress and/or lifetime traumatic stress can create a self-reinforcing cycle of unhealthy behaviors, such as overeating and sedentary behavior, that can lead to further increases in stress. This study examined the relationship between stress and sedentary behavior in a sample of Hispanic/Latino adults (N = 4244) from the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study.
Stress was measured as the number of ongoing difficulties lasting 6 months or more and as lifetime exposure to traumatic events. Sedentary behavior was measured by self-report and with accelerometer. Multivariable regression models examined associations of stress measures with time spent in sedentary behaviors adjusting by potential confounders.
Those who reported more than one chronic stressor spent, on average, 8 to 10 additional minutes per day in objectively measured sedentary activities (P < .05), whereas those with more than one lifetime traumatic stressor spent (after we adjusted for confounders) 10 to 14 additional minutes in sedentary activities (P < .01) compared with those who did not report any stressors. Statistical interactions between the 2 stress measures and age or sex were not significant.
Interventions aimed at reducing sedentary behaviors might consider incorporating stress reduction into their approaches.
PMCID: PMC4985239  PMID: 26181079
accelerometer; chronic stress; gender
8.  The Role of Parenting Practices in the Home Environment among Underserved Youth 
Childhood Obesity  2015;11(4):394-405.
Background: The home environment, which includes parenting practices, is an important setting in which children develop their health behaviors. We examined the role of parenting practices in the home environment among underserved youth.
Methods: We examined baseline data of a family-focused pediatric obesity intervention. Parenting practices (monitoring, discipline, limit setting of soda/snacks [SS] and screen media [SM], pressure to eat, and reinforcement) and availability of fruits/vegetables (FV) and sugar-sweetened beverages (SSBs), family meals, television (TV) watching during meals, TVs in the home, owning active video games/sports equipment, and household food security were assessed in 301 parent/caregivers of overweight/obese children (ages 7–12 years; BMI≥85th percentile). Associations were evaluated using Spearman's rank correlation coefficients and logistic regression models adjusted for potential confounders.
Results: Parents/caregivers (ages 22–67 years) were largely Hispanic/Latino (74.1%), female (92.4%), and reported high levels of limit setting SS and low levels of pressure to eat. Parent age, gender, country of birth, and years living in the United States accounted for differences among several parenting practices. Adjusted logistic regression models identified several statistically significant associations, including: Monitoring was positively associated with availability FV (odds ratio [OR]=2.19; 95% confidence interval [CI], 1.25, 3.82); limit setting SS was inversely associated with availability of SSBs (OR=0.40; 95% CI, 0.21, 0.75); and limit setting SM was inversely associated with TV viewing during family meals (OR=0.51; 95% CI, 0.31, 0.85). Nearly 40% of our population was food insecure, and food insecurity was positively associated with pressure to eat (OR=1.77; 95% CI, 1.01, 3.15).
Conclusions: Parenting practices play an important role in the home environment, and longitudinal studies are needed to examine these associations in the context of family-focused pediatric obesity interventions.
PMCID: PMC4528989  PMID: 26258561
9.  Chronic Stress, Inflammation, and Glucose Regulation in U.S. Hispanics from the HCHS/SOL Sociocultural Ancillary Study 
Psychophysiology  2015;52(8):1071-1079.
Diabetes prevalence is rising rapidly, and diabetes disproportionately affects Hispanics and other underserved groups. Chronic stress may contribute to diabetes risk, but few studies have examined this relationship in U.S. Hispanics. We examined associations of chronic stress with fasting glucose, glucose tolerance, and glycosylated hemoglobin (HbA1c) in Hispanics without diabetes, and also assessed indirect effects of stress through inflammation (CRP). Participants were 3923 men and women, aged 18-74, without diabetes, from the four U.S. field centers (Bronx, NY; Chicago, IL; Miami, FL; San Diego, CA) of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)-Sociocultural Ancillary study. Participants completed a measure of chronic life stress and a physical exam with oral glucose tolerance test. In a multivariate regression analysis with adjustment for demographic and health covariates, higher chronic stress was related to higher fasting glucose (standardized regression coefficient: β=.09, p<0.01), post load glucose (β=.07, p<0.05), and HbA1c levels (β=.08, p<0.01). However, there was no indirect effect of stress through inflammation. Findings suggest that higher chronic stress is associated with poorer glucose regulation in Hispanics, prior to the onset of a clinical diabetes diagnosis.
PMCID: PMC4640890  PMID: 25898909
Stress; glucose; insulin; Hispanic; inflammation
10.  Dietary Intake, FTO Genetic Variants, and Adiposity: A Combined Analysis of Over 16,000 Children and Adolescents 
Diabetes  2015;64(7):2467-2476.
The FTO gene harbors variation with the strongest effect on adiposity and obesity risk. Previous data support a role for FTO variation in influencing food intake. We conducted a combined analysis of 16,094 boys and girls aged 1–18 years from 14 studies to examine the following: 1) the association between the FTO rs9939609 variant (or a proxy) and total energy and macronutrient intake; and 2) the interaction between the FTO variant and dietary intake, and the effect on BMI. We found that the BMI-increasing allele (minor allele) of the FTO variant was associated with increased total energy intake (effect per allele = 14.3 kcal/day [95% CI 5.9, 22.7 kcal/day], P = 6.5 × 10−4), but not with protein, carbohydrate, or fat intake. We also found that protein intake modified the association between the FTO variant and BMI (interactive effect per allele = 0.08 SD [0.03, 0.12 SD], P for interaction = 7.2 × 10−4): the association between FTO genotype and BMI was much stronger in individuals with high protein intake (effect per allele = 0.10 SD [0.07, 0.13 SD], P = 8.2 × 10−10) than in those with low intake (effect per allele = 0.04 SD [0.01, 0.07 SD], P = 0.02). Our results suggest that the FTO variant that confers a predisposition to higher BMI is associated with higher total energy intake, and that lower dietary protein intake attenuates the association between FTO genotype and adiposity in children and adolescents.
PMCID: PMC4876751  PMID: 25720386
11.  Differences in Cardiometabolic Risk between Insulin-Sensitive and Insulin-Resistant Overweight and Obese Children 
Childhood Obesity  2015;11(3):289-296.
Background: It is known that 15–30% overweight/obese adults do not suffer cardiometabolic consequences. There is limited literature examining factors that can be used to assess cardiometabolic health in overweight/obese children. If such factors can be identified, they would aid in differentiating those most in need for aggressive management.
Methods: Baseline data from 7- to 12-year-old, overweight, and obese children enrolled in a weight management program at an urban hospital were analyzed. Homeostatic model assessment for insulin resistance (HOMA-IR) <2.6 was used to define insulin-sensitive and HOMA-IR ≥2.6 was used to defined insulin-resistant participants. Demographics, physical activity measures, and cardiometabolic risk factors were compared between the two phenotypes. Odds ratios (ORs) examining the association between intermediate endpoints (metabolic syndrome [MetS], nonalcoholic fatty liver disease [NAFLD], systemic inflammation, and microalbuminuria) and the two metabolic phenotypes were evaluated.
Results: Of the 362 overweight/obese participants, 157 (43.5%) were insulin sensitive and 204 (56.5%) were insulin resistant. Compared to the insulin-sensitive group, the insulin-resistant group was older (8.6±1.6 vs. 9.9±1.7; p<0.001) and had a higher BMI z-score (1.89±0.42 vs. 2.04±0.42; p=0.001). After multivariable adjustment, compared to the insulin-sensitive group, the insulin-resistant group had higher odds of having MetS (OR, 5.47; 95% confidence interval [CI]: 1.72, 17.35; p=0.004) and NAFLD (OR, 8.66; 95% CI, 2.48, 30.31; p=0.001), but not systemic inflammation (OR, 1.06; 95% CI: 0.56, 2.03; p=0.86) or microalbuminuria (OR, 1.71; 95% CI, 0.49, 6.04; p=0.403).
Conclusions: Using a HOMA-IR value of ≥2.6, clinical providers can identify prepubertal and early pubertal children most at risk. Focusing limited resources on aggressive weight interventions may lead to improvement in cardiometabolic health.
PMCID: PMC4485365  PMID: 25774664
12.  Accelerometer Adherence and Performance in a Cohort Study of US Hispanic Adults 
This study described participant adherence to wearing the accelerometer and accelerometer performance in a cohort study of adults.
From 2008-2011, 16,415 United States (US) Hispanic/Latino adults age 18-74 years enrolled in the Hispanic Community Health Study/Study of Latinos. Immediately following the baseline visit, participants wore an Actical accelerometer for one week. This study explored correlates of accelerometer participation and adherence, defined as wearing it for at least 3 of a possible days for >=10 hours/day. Accelerometer performance was assessed by exploring the number of different values of accelerometer counts/minute for each participant.
Overall, 92.3% (n=15,153) had at least one day with accelerometer data and 77.7% (n=12,750) were adherent. Both accelerometer participation and adherence were higher among participants who were married or partnered, reported a higher household income, were first generation immigrants, or reported lower sitting time. Participation was also higher among those with no stair limitations. Adherence was higher among participants who were male, older, employed or retired, not US born, preferred Spanish over English, reported higher work activity or lower recreational activity, and those with a lower body mass index. Among the sample that met the adherence definition, the maximum recorded count/minute was 12,000, and there were a total of 5,846 different counts/minute. On average, participants had 112.5 different counts/minute over 6 days (median 106, interquartile range 91-122). The number of different counts/minute were higher among men, younger ages, normal weight, and those with higher accelerometer assessed physical activity.
Several correlates differed between accelerometer participation and adherence. These characteristics could be targeted in future studies to improve accelerometer wear. The performance of the accelerometer provided insight into creating a more accurate non-wear algorithm.
PMCID: PMC4333140  PMID: 25137369
Actical; missingness; non-wear; physical activity; sample weights; surveillance
13.  Association of Childhood Economic Hardship with Adult Height and Adult Adiposity among Hispanics/Latinos. The HCHS/SOL Socio-Cultural Ancillary Study 
PLoS ONE  2016;11(2):e0149923.
The study examined the association of childhood and current economic hardship with anthropometric indices in Hispanic/Latino adults, using data from the HCHS/SOL Socio-cultural ancillary study (N = 5,084), a community-based study of Hispanic/Latinos living in four urban areas (Bronx, NY, Chicago, IL, Miami, FL, and San Diego, CA). Childhood economic hardship was defined as having experienced a period of time when one’s family had trouble paying for basic needs (e.g., food, housing), and when this economic hardship occurred: between 0–12, 13–18 years old, or throughout both of those times. Current economic hardship was defined as experiencing trouble paying for basic needs during the past 12 months. Anthropometry included height, body mass index (BMI), waist circumference (WC), and percentage body fat (%BF). Complex survey linear regression models were used to test the associations of childhood economic hardship with adult anthropometric indices, adjusting for potential confounders (e.g., age, sex, Hispanic background). Childhood economic hardship varied by Hispanic background, place of birth, and adult socio-economic status. Childhood economic hardship during both periods, childhood and adolescence, was associated with shorter height. Childhood economic hardship was associated with greater adiposity among US born individuals only. Current economic hardship was significantly associated with all three measures of adiposity (BMI, WC, %BF). These findings suggest that previous periods of childhood economic hardship appear to influence adult height more than adiposity, whereas current economic hardship may be a better determinant of adult adiposity in Hispanics.
PMCID: PMC4769180  PMID: 26919283
14.  Glycemic Control among U.S. Hispanics/Latinos with Diabetes from the HCHS/SOL Sociocultural Ancillary Study: Do Structural and Functional Social Support Play a Role? 
Journal of behavioral medicine  2014;38(1):153-159.
Social support is one potential source of health-related resiliency in Hispanics with diabetes.
This study examined relationships of structural (i.e., social integration) and functional (i.e., perceived) social support with glycemic control (glycosylated hemoglobin; HbA1c) in the Hispanic Community Health Study/Study of Hispanics (HCHS/SOL) Sociocultural Ancillary Study.
This study included 766 men and women representing multiple Hispanic ethnic backgrounds, aged 18-74 years, with diagnosed diabetes who completed fasting blood draw, medication review, and measures of sociodemographic factors, medical history, structural support (Cohen Social Network Index), and functional support (Interpersonal Support Evaluation List-12).
After adjusting for sociodemographic covariates and medication, a one standard deviation increase in functional support was related to an 0.18 % higher HbA1c (p = 0.04). A similar trend was observed for structural support; however, this effect was non-significant in adjusted models.
Greater functional support was associated with poorer glycemic control in Hispanics.
PMCID: PMC4302022  PMID: 25107503
Hispanic; Latino; Diabetes; Glycemic Control; Social Support
15.  Psychosocial stress is associated with obesity and diet quality in Hispanic/Latino adults 
Annals of epidemiology  2014;25(2):84-89.
To examine the association of psychosocial stress with obesity, adiposity, and dietary intake in a diverse sample of Hispanic/Latino adults.
Participants were 5077 men and women, 18–74 years old, from diverse Hispanic/Latino ethnic backgrounds. Linear regression models were used to assess the association of ongoing chronic stressors and recent perceived stress with measures of adiposity (waist circumference and percentage body fat) and dietary intake (total energy, saturated fat, alternative healthy eating index [AHEI-2010]). Multinomial logistic models were used to describe the odds of obesity or overweight relative to normal weight.
Greater number of chronic stressors and greater perceived stress were associated with higher total energy intake. Greater recent perceived stress was associated with lower diet quality as indicated by AHEI-2010 scores. Compared to no stressors, reporting ≥ 3 chronic stressors was associated with higher odds of being obese (OR = 1.5, 95%CI 1.01–2.1), greater waist circumference (β = 3.3, 95%CI 1.0–5.5) and percentage body fat (β = 1.5, 95%CI 0.4, 2.6).
The study found an association between stress and obesity and adiposity measures, suggesting that stress management techniques may be useful in obesity prevention and treatment programs that target Hispanic/Latino populations.
PMCID: PMC4306634  PMID: 25487969
16.  Associations of Structural and Functional Social Support with Diabetes Prevalence in U.S. Hispanics/Latinos: Results from the HCHS/SOL Sociocultural Ancillary Study 
Journal of behavioral medicine  2014;38(1):160-170.
Little research has examined associations of social support with diabetes (or other physical health outcomes) in Hispanics, who are at elevated risk.
We examined associations between social support and diabetes prevalence in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study.
Participants were 5181 adults, 18–74 years old, representing diverse Hispanic backgrounds, who underwent baseline exam with fasting blood draw, oral glucose tolerance test, medication review, sociodemographic assessment, and sociocultural exam with functional and structural social support measures.
In adjusted analyses, one standard deviation higher structural and functional social support related to 16% and 15% lower odds, respectively, of having diabetes. Structural and functional support were related to both previously diagnosed diabetes (OR = .84 and .88, respectively) and newly recognized diabetes prevalence (OR = .84 and .83, respectively).
Higher functional and structural social support are associated with lower diabetes prevalence in Hispanics/Latinos.
PMCID: PMC4349398  PMID: 25107504
Diabetes; Hispanic; Latino; Prevalence; Risk Factor; Social Support
17.  Prevalence and Correlates of Perceived Ethnic Discrimination in the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study 
Journal of Latina/o psychology  2015;3(3):160-176.
Empirical studies examining perceived ethnic discrimination in Latinos of diverse background groups are limited. This study examined prevalence and correlates of discrimination in a diverse sample of U.S. Latinos (N=5,291) from the multi-site Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and HCHS/SOL Sociocultural Ancillary Study. The sample permitted an examination of differences across seven groups (Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, and Other/Multiple Background). Most participants (79.5%) reported lifetime discrimination exposure and prevalence rates ranged from 64.9% to 98% across groups. Structural Equation Models (SEM) indicated that after adjusting for sociodemographic covariates most group differences in reports of discrimination were eliminated. However, Cubans reported the lowest levels of discrimination, overall among all groups. Furthermore, regional effects were more important than group effects. Participants from Chicago reported the highest levels of discrimination in comparison to other regions. Group differences among Latinos appear to be primarily a function of sociodemographic differences in education, income, and acculturation. In addition, differences in exposure to discrimination may be tied to variables associated with both immigration patterns and integration to U.S. culture. Results highlight the importance of considering historical context and the intersection of discrimination and immigration when evaluating the mental health of Latinos.
PMCID: PMC4610197  PMID: 26491624
Latinos; ethnic discrimination; acculturation; within group differences; regional differences
18.  Depressive Symptoms Are Associated with Excess Weight and Unhealthier Lifestyle Behaviors in Urban Adolescents 
Childhood Obesity  2014;10(5):400-407.
Background: Adolescence is a critical period for the development of depressive symptoms and obesity. This study examined the association of depressive symptoms with standardized BMI (BMI z-score), lifestyle behaviors, and self-efficacy measures in a sample of urban adolescents.
Methods: A school-based study was conducted among adolescents (N=1508) enrolled from 11 public schools. Depressive symptoms were assessed with Kandel's depressive symptoms scale for adolescents. Fruit and vegetable intake and intake of energy-dense foods were assessed by a short food frequency questionnaire. Sedentary behavior and physical activity (PA) were obtained by self-report. Height and weight were measured directly and BMI z-scores were calculated. Mixed-effects models were used to examine the association of depressive symptoms with BMI z-score and lifestyle behaviors, accounting for clustering at school level and adjusting for confounders. Self-efficacy measures were evaluated as potential mediators.
Results: The sample was 53% female, 75% Hispanic, and 82% US born, with a mean age of 13.9 years. Higher depressive symptoms were associated with higher BMI z-score (β=0.02; p=0.02), intake of energy-dense foods (β=0.42; p<0.001), and sedentary behavior (β=0.48; p<0.001), but lower PA (β=−0.03; p=0.01). There was an interaction by gender in the association of depressive symptoms and PA. Self-efficacy mediated the association of depressive symptoms and PA.
Conclusions: Obesity prevention and treatment programs should consider addressing the role of negative emotions as part of their preventive strategies.
PMCID: PMC4195427  PMID: 25181530
19.  Status of Cardiovascular Disease and Stroke in Hispanics/Latinos in the United States 
Circulation  2014;130(7):593-625.
Background and Purpose
This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA’s 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.
Writing group members were nominated by the AHA’s Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.
This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.
Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.
PMCID: PMC4577282  PMID: 25098323
AHA Scientific Statements; cardiovascular disease; Hispanic; Latino; stroke
20.  Chocolate-candy consumption and three-year weight gain among postmenopausal U.S. women 
Obesity (Silver Spring, Md.)  2015;23(3):677-683.
To test the hypothesis that greater chocolate-candy intake is associated with more weight gain in postmenopausal women.
Prospective cohort study involving 107,243 post-menopausal American women aged 50–79 years (mean=60.7) at enrolment in the Women’s Health Initiative (WHI), with three-year follow up. Chocolate-candy consumption was assessed by food frequency questionnaire and body weight was measured. Linear mixed models, adjusted for demographic, socio-economic, anthropomorphic and behavioral variables, were used to test our main hypotheses.
Compared to women who ate a 1 oz (~28 g) serving of chocolate candy <1 per month, those who ate this amount 1 per month to <1 per week, 1 per week to < 3 per week and ≥3 per week showed greater three-year prospective weight gains (kg) of 0.76 (95% CI: 0.66, 0.85), 0.95 (0.84, 1.06) and 1.40 (1.27, 1.53), respectively, (p for linear trend<0.0001). Each additional 1 oz/day was associated with a greater three-year weight gain (kg) of 0.92 (0.80, 1.05). The weight gain in each chocolate-candy intake level increased as BMI increased above the normal range (18.5–25 kg/m2), and as age decreased.
Greater chocolate-candy intake was associated with greater prospective weight gain in this cohort of post-menopausal women.
PMCID: PMC4351742  PMID: 25644711
Nutrition; chocolate; weight gain; body weight; weight management; women's Health
21.  Computational Fluid Dynamics Endpoints for Assessment of Adenotonsillectomy Outcome in Obese Children with Obstructive Sleep Apnea Syndrome 
Journal of biomechanics  2014;47(10):2498-2503.
Improvements in obstructive sleep apnea syndrome (OSAS) severity may be associated with improved pharyngeal fluid mechanics following adenotonsillectomy (AT). The study objective is to use image-based computational fluid dynamics (CFD) to model changes in pharyngeal pressures after AT, in obese children with OSAS and adenotonsillar hypertrophy.
Three-dimensional models of the upper airway from nares to trachea, before and after AT, were derived from magnetic resonance images obtained during wakefulness, in a cohort of 10 obese children with OSAS. Velocity, pressure, and turbulence fields during peak tidal inspiratory flow were computed using commercial software. CFD endpoints were correlated with polysomnography endpoints before and after AT using Spearman’s rank correlation (rs).
Apnea hypopnea index (AHI) decrease after AT was strongly correlated with reduction in maximum pressure drop (dPTAmax) in the region where tonsils and adenoid constrict the pharynx (rs=0.78, P = 0.011), and with decrease of the ratio of dPTAmax to flow rate (rs = 0.82, P = 0.006). Correlations of AHI decrease to anatomy, negative pressure in the overlap region (including nasal flow resistance), or pressure drop through the entire pharynx, were not significant. In a subgroup of subjects with more than 10% improvement in AHI, correlations between flow variables and AHI decrease were stronger than in all subjects.
The correlation between change in dPTAmax and improved AHI suggests that dPTAmax may be a useful index for internal airway loading due to anatomical narrowing, and may be better correlated to AHI than direct airway anatomic measurements.
PMCID: PMC4057952  PMID: 24840295
Magnetic Resonance Imaging; Humans; Computer Simulation; Airway Resistance; Pediatrics
22.  Associations of chronic stress burden, perceived stress, and traumatic stress with cardiovascular disease prevalence and risk factors in the HCHS/SOL Sociocultural Ancillary Study 
Psychosomatic medicine  2014;76(6):468-475.
The current study examined multiple stress indicators (chronic, perceived, traumatic) in relation to prevalent coronary heart disease (CHD), stroke, and major cardiovascular disease (CVD) risk factors (i.e., diabetes, dyslipidemia, hypertension, current smoking) in the multi-site Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study (2010–2011).
Participants were 5313 men and women, 18–74 years old, representing diverse Hispanic/Latino ethnic backgrounds, who underwent a comprehensive baseline clinical exam and sociocultural exam with measures of stress.
Chronic stress burden was related to a higher prevalence of CHD after adjusting for sociodemographic, behavioral and biological risk factors [OR (95% CI) = 1.22, (1.10–1.36)] and related to stroke prevalence in the model adjusted for demographic and behavioral factors [OR (95% CI) = 1.26, (1.03–1.55∂)]. Chronic stress was also related to a higher prevalence of diabetes [OR=1.20, (1.11–1.31)] and hypertension [OR=1.10 (1.02–1.19)] in individuals free from CVD (N=4926). Perceived stress [OR=1.03 (1.01–1.05)] and traumatic stress [OR=1.15 (1.05–1.26)] were associated with a higher prevalence of smoking. Participants who reported a greater number of lifetime traumatic events also unexpectedly showed a lower prevalence of diabetes [OR=.89 (.83–.97)] and hypertension [OR=.88 (.82–.93)]. Effects were largely consistent across age and sex groups.
The study underscores the utility of examining multiple indicators of stress in relation to health, since the direction and consistency of associations may vary across distinct stress conceptualizations. In addition, the study suggests that chronic stress is related to higher CVD risk and prevalence in Hispanics/Latinos, the largest U.S. ethnic minority group.
PMCID: PMC4349387  PMID: 24979579
Cardiovascular Disease; Coronary Heart Disease; Hispanic; Latino; Stress
23.  Association of Pulmonary Function with Adiposity and Metabolic Abnormalities in Urban Minority Adolescents 
Rationale: Childhood obesity is a known risk factor for pulmonary diseases, likely due to obesity-mediated alteration of pulmonary function. Inflammation and mechanical fat load are two proposed causative mechanisms for altered pulmonary function among obese children; however, the association of metabolic abnormalities with pulmonary function among children is poorly understood.
Objectives: We investigated the independent association of truncal and general adiposity and metabolic abnormalities with pulmonary function in a sample of urban minority adolescents.
Methods: Spirometry and lung volume indices were compared between adolescents with general (body mass index [BMI] > 95th percentile) or truncal adiposity (waist circumference > 90th percentile) and normal-weight (BMI < 85th percentile or waist circumference ≤ 90th percentile) and between those with metabolic abnormalities (homeostatic model assessment of insulin resistance [HOMA-IR] in the top quartile or high-density lipoprotein [HDL] < 40 mg/dl) and those with a normal metabolic profile.
Measurements and Main Results: Obese adolescents had lower lung volumes, including residual volume (RV), RV/TLC ratio, expiratory reserve volume (ERV), and FRC, and higher inspiratory capacity (IC) than normal-weight adolescents, but did not differ in measures of lower airway obstruction, FEV1/FVC ratio, and mid-expiratory flow rate. Adolescents with high HOMA-IR had lower FEV1/FVC ratio, RV, RV/TLC ratio, ERV, and FRC and higher IC, whereas those with low HDL had lower FEV1/FVC and RV/TLC ratios. After adjusting for adiposity, HOMA-IR remained a predictor of ERV (β = −1.4; P = 0.02) and FEV1/FVC ratio (β = −0.5; P = 0.03), and HDL remained a predictor of FEV1/FVC ratio (β = 0.1; P = 0.01). General adiposity was a predictor of FRC (β = −0.5; P < 0.001), IC (β = 0.3; P < 0.001), RV (β = −0.8; P < 0.0001), and RV/TLC ratio (β = −0.2; P < 0.0001), and truncal adiposity was a predictor of RV (β = −20.3; P = 0.03) and FRC (β = −13.8; P = 0.004). Thus, adiposity and metabolic abnormalities were independent predictors of ERV, but only metabolic abnormalities independently predicted FEV1/FVC ratio. Although general adiposity predicted RV and RV/TLC ratio, truncal adiposity was predictive of RV and FRC, conferring additional risk above general adiposity.
Conclusions: These results suggest that metabolic abnormalities and adiposity are independently associated with pulmonary function deficits among urban adolescents. Metabolic assessment of obese adolescents may identify those at risk of developing obesity-associated pulmonary morbidity.
PMCID: PMC4225805  PMID: 24785169
obesity; metabolic abnormalities; pulmonary function; children
24.  Is Acculturation Related to Obesity in Hispanic/Latino Adults? Results from the Hispanic Community Health Study/Study of Latinos 
Journal of Obesity  2015;2015:186276.
Background. The study examined the association of obesity with acculturation in a large and diverse sample of US Hispanic/Latino adults. Methods. The Hispanic Community Health Study (HCHS)/Study of Latinos (SOL) is a community-based cohort study of Hispanic/Latino adults aged 18–74 years (N = 16,415) from four urban areas. Height and weight were directly measured using a standardized protocol. Acculturation was assessed by the Short Acculturation Scale for Hispanics (SASH). Other immigration related variables included place of birth, length of residency in the US, and age at immigration. Odds ratios were calculated to assess the association of overweight, moderate obesity, and extreme obesity (≥40 kg/m2) with acculturation and sociodemographic variables. Results. The prevalence of obesity was 42.4% for women and 36.5% for men and varied by field center and Hispanic/Latino background. The strongest predictor of moderate and extreme obesity was length of residency in mainland US. This association was consistent across Hispanic/Latino backgrounds. Acculturation was not significantly associated with obesity. Discussion. The burden of obesity is high among Hispanic/Latino adults. The study findings suggest that prolonged exposure to the environments in these communities, rather than acculturation, is an important risk factor for obesity in this population.
PMCID: PMC4393894  PMID: 25893114
25.  Theoretical foundations of the Study of Latino (SOL) Youth: implications for obesity and cardiometabolic risk 
Annals of epidemiology  2013;24(1):10.1016/j.annepidem.2013.10.011.
This article describes the conceptual model developed for the Hispanic Community Health Study/Study of Latino Youth, a multisite epidemiologic study of obesity and cardiometabolic risk among U.S. Hispanic/Latino children.
Public health, psychology, and sociology research were examined for relevant theories and paradigms. This research, in turn, led us to consider several study design features to best represent both risk and protective factors from multiple levels of influence, as well as the identification of culturally relevant scales to capture identified constructs.
The Socio-Ecological Framework, Social Cognitive Theory, family systems theory, and acculturation research informed the specification of our conceptual model. Data are being collected from both children and parents in the household to examine the bidirectional influence of children and their parents, including the potential contribution of intergenerational differences in acculturation as a risk factor. Children and parents are reporting on individual, interpersonal, and perceived organizational and community influences on children's risk for obesity consistent with Socio-Ecological Framework.
Much research has been conducted on obesity, yet conceptual models examining risk and protective factors lack specificity in several areas. Study of Latino Youth is designed to fill a gap in this research and inform future efforts.
PMCID: PMC3879411  PMID: 24246265
Hispanic/Latino; Children; Obesity; Acculturation; Socio-Ecological Framework; Theory

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