Obesity Disparities Among Adult Single-Race and Multiracial Asian and Pacific Islander Populations.

Importance: Despite increasing numbers of multiracial individuals, they are often excluded in studies or aggregated within larger race and ethnicity groups due to small sample sizes. Objective: To examine disparities in the prevalence of obesity among single-race and multiracial Asian and Pacific Islander individuals compared with non-Hispanic White (hereafter, White) individuals. Design, Setting, and Participants: This cross-sectional study used electronic health record (EHR) data linked to social determinants of health and health behavior data for adult (age ≥18 years) members of 2 large health care systems in California and Hawai'i who had at least 1 ambulatory visit to a primary care practitioner between January 1, 2006, and December 31, 2018. Data were analyzed from October 31, 2022, to July 31, 2023. Exposure: Self-identified race and ethnicity provided in the EHR as a single-race category (Asian Indian, Chinese, Filipino, Japanese, Native Hawaiian only, Other Pacific Islander, or White) or a multiracial category (Asian and Pacific Islander; Asian, Pacific Islander, and White; Asian and White; or Pacific Islander and White). Main Outcomes and Measures: The main outcome was obesity (body mass index [BMI] ≥30.0), based on last measured height and weight from the EHR. Logistic regression was used to examine the association between race and ethnicity and odds of obesity. Results: A total of 5229 individuals (3055 [58.4%] male; mean [SD] age, 70.73 [11.51] years) were examined, of whom 444 (8.5%) were Asian Indian; 1091 (20.9%), Chinese; 483 (9.2%), Filipino; 666 (12.7%), Japanese; 91 (1.7%), Native Hawaiian; 95 (1.8%), Other Pacific Islander; and 888 (17.0%), White. The percentages of individuals who identified as multiracial were as follows: 417 (8.0%) were Asian and Pacific Islander; 392 (7.5%), Asian, Pacific Islander, and White; 248 (4.7%), Asian and White; and 414 (7.9%), Pacific Islander and White. A total of 1333 participants (25.5%) were classified as having obesity based on standard BMI criteria. Obesity was highest among people who identified as Asian, Pacific Islander, and White (204 of 392 [52.0%]) followed by those who identified as Other Pacific Islander (47 of 95 [49.5%]), Native Hawaiian (44 of 91 [48.4%]), and Pacific Islander and White (186 of 414 [44.9%]). After accounting for demographic, socioeconomic, and health behavior factors, people who identified as Asian, Pacific Islander, and White (odds ratio [OR], 1.80; 95% CI, 1.37-2.38) or Pacific Islander and White (OR, 1.55; 95% CI, 1.18-2.04) had increased odds of obesity compared with White individuals. All single-race Asian groups had lower odds of obesity compared with White individuals: Asian Indian (OR, 0.29; 95% CI, 0.20-0.40), Chinese (OR, 0.22; 95% CI, 0.17-0.29), Filipino (OR, 0.46; 95% CI, 0.35-0.62), and Japanese (OR, 0.38, 95% CI, 0.29-0.50). Conclusions and Relevance: In this study, multiracial Asian and Pacific Islander individuals had an increased prevalence of obesity compared with many of their single-race counterparts. As the number of multiracial individuals increases, it will be important for clinical and public health systems to track disparities in these populations.

Diabetes-Related Cardiovascular and All-Cause Mortality in Asian American Subgroups.

Background: Asian Americans experience heterogeneity in cardiovascular risk factors and cardiovascular disease, with a particularly high burden of diabetes in several Asian subgroups. Objectives: The objectives of this study were to quantify diabetes-related mortality in Asian American subgroups and compare this with Hispanic, non-Hispanic Black, and non-Hispanic White individuals. Methods: Using national-level vital statistics data and concurrent population estimates, age-standardized mortality rates and proportional mortality from diabetes-related mortality were calculated for non-Hispanic Asian (and subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese), Hispanic, non-Hispanic Black, and non-Hispanic White populations in the United States, 2018-2021. Results: Diabetes-related deaths numbered 45,249 in non-Hispanic Asian, 159,279 in Hispanic, 209,281 in non-Hispanic Black, and 904,067 in non-Hispanic White individuals. Among Asian Americans, age-standardized mortality rates of diabetes-related mortality with cardiovascular disease as underlying cause ranged from 10.8 (95% CI: 9.9-11.6) per 100,000 in Japanese females to 19.9 (95% CI: 18.9-20.9) per 100,000 in Filipina females, and from 15.3 (95% CI: 13.9-16.8) per 100,000 in Korean males to 37.8 (95% CI: 36.1-39.5) per 100,000 in Filipino males. The proportion of all deaths related to diabetes was higher in all Asian subgroups (9.7%-16.4% for females; 11.8%-19.2% for males) compared with non-Hispanic Whites (8.5% for females; 10.7% for males). The highest proportion of diabetes-related deaths occurred in Filipino adults. Conclusions: There was an approximately 2-fold variation in diabetes-related mortality among Asian American subgroups, with Filipino adults experiencing the greatest burden. All Asian subgroups experienced higher proportional mortality for diabetes-related mortality compared with non-Hispanic White individuals.

Assessing and Addressing Social Determinants of Cardiovascular Health: JACC State-of-the-Art Review.

Social determinants of health (SDOH) are the social conditions in which people are born, live, and work. SDOH offers a more inclusive view of how environment, geographic location, neighborhoods, access to health care, nutrition, socioeconomics, and so on are critical in cardiovascular morbidity and mortality. SDOH will continue to increase in relevance and integration of patient management, thus, applying the information herein to clinical and health systems will become increasingly commonplace. This state-of-the-art review covers the 5 domains of SDOH, including economic stability, education, health care access and quality, social and community context, and neighborhood and built environment. Recognizing and addressing SDOH is an important step toward achieving equity in cardiovascular care. We discuss each SDOH within the context of cardiovascular disease, how they can be assessed by clinicians and within health care systems, and key strategies for clinicians and health care systems to address these SDOH. Summaries of these tools and key strategies are provided.

Racial Discrimination, Social Disadvantage, and Racial-Ethnic Disparities in COVID-19 Vaccine Uptake.

Introduction: Racial-ethnic disparities in COVID-19 vaccination are well documented. The extent to which racism, manifested at the individual and ZIP code levels, explains disparities in early vaccination uptake remains unclear. Methods: Data from a statewide poll of California registered voters (N=10,256), conducted between April 29 and May 5, 2021, linked to area-level resource data, were analyzed. Weighted multivariable logistic regression models examined racial disparities in COVID-19 vaccination. Decomposition analyses quantified how much of the observed racial disparities in vaccination were explained by racial discrimination and social disadvantage (i.e., educational attainment, 2019 household income, and ZIP code social vulnerability). Results: Latinx (64.6%) and Black (66.7%) adults were less likely to have at least 1 COVID-19 vaccine dose by April or May 2021 than White adults (74.7%). In adjusted analyses, Latinx (AOR=0.69, 95% CI=0.57, 0.84) and Black (AOR=0.51, 95% CI=0.37, 0.70) adults had a lower likelihood of being vaccinated than Whites. Social disadvantage accounted for 77.4% (p<0.05) and 35.8% (p<0.05) of the explainable variation in Latinx-White and Black-White disparities, respectively. Self-reported racial discrimination was not associated with COVID-19 vaccination in adjusted analyses. Conclusions: Social disadvantage but not self-reported racial discrimination explained racial-ethnic disparities in COVID-19 vaccination in California. Removing resource-related barriers may help to increase the relatively low COVID-19 vaccination rates among Black and Latinx populations.

Visa type and financial strain on depressive symptoms among Filipino migrants to the United States.

Migrants have been theorized to be healthier than their non-migrant counterparts; however, there is limited examination of health selection using binational data and how selection occurs, particularly for mental health outcomes. This study examines the role of visa status and financial strain as critical factors for mental health selection among Filipino migrants to the U.S. and non-migrants who remain in the Philippines. We used the baseline data from the Health of Philippine Emigrants Study (HoPES; n = 1631) to compare depressive symptoms between non-migrants and migrants who were both surveyed prior to their departure to the U.S. We assessed depressive symptoms using linear regression by migration status, financial strain, and by visa categories including fiancée/marriage, unlimited family reunification, limited family reunification, and employment. Overall, all migrants reported lower depressive symptoms than non-migrants; however, depressive symptoms varied by visa type. Fiancée/marriage migrants had lower depressive symptoms than compared to limited family reunification migrants. Additionally, those who reported financial strain had higher depressive symptoms than those without any financial strain. We find that migrants were positively selected for mental health using a unique sample of Filipino migrants before they left for the U.S.

Learning to love ourselves again: Organizing Filipinx/a/o scholar-activists as antiracist public health praxis.

A critical component for health equity lies in the inclusion of structurally excluded voices, such as Filipina/x/o Americans (FilAms). Because filam invisibility is normalized, denaturalizing these conditions requires reimagining power relations regarding whose experiences are documented, whose perspectives are legitimized, and whose strategies are supported. in this community case study, we describe our efforts to organize a multidisciplinary, multigenerational, community-driven collaboration for FilAm community wellness. Catalyzed by the disproportionate burden of deaths among FilAm healthcare workers at the onset of the COVID-19 pandemic and the accompanying silence from mainstream public health leaders, we formed the Filipinx/a/o Community Health Association (FilCHA). FilCHA is a counterspace where students, faculty, clinicians, and community leaders across the nation could collectively organize to resist our erasure. By building a virtual, intellectual community that centers our voices, FilCHA shifts power through partnerships in which people who directly experience the conditions that cause inequities have leadership roles and avenues to share their perspectives. We used Pinayism to guide our study of FilCHA, not just for the current crisis State-side, but through a multigenerational, transnational understanding of what knowledges have been taken from us and our ancestors. By naming our collective pain, building a counterspace for love of the community, and generating reflections for our communities, we work toward shared liberation. Harnessing the collective power of researchers as truth seekers and organizers as community builders in affirming spaces for holistic community wellbeing is love in action. This moment demands that we explicitly name love as essential to antiracist public health praxis.

Prevalence and risk factors of food insecurity among Californians during the COVID-19 pandemic: Disparities by immigration status and ethnicity.

The COVID-19 pandemic exacerbated socioeconomic disparities in food insecurity. Non-citizens, who do not qualify for most publicly-funded food assistance programs, may be most vulnerable to food insecurity during the pandemic. However, no study has examined heterogeneity in food insecurity by immigration status and ethnicity in the context of the pandemic. We analyzed the 2020 non-restricted California Health Interview Survey to examine disparities in food insecurity by ethnicity and immigration status (i.e., US-born, naturalized, non-citizen) among Asians and Latinxs (N = 19,514) compared to US-born Whites. Weighted multivariable logistic regression analyses assessed the association of immigration status and ethnicity with food insecurity. Decomposition analyses assessed the extent to which pandemic-related economic stressors, including experiencing reduced work hours or losing a job versus pre-pandemic socioeconomic position (SEP), accounted for disparities in food insecurity by ethnicity and immigration status. Regardless of immigration status, Latinxs were more likely to experience food insecurity than Whites. Based on the adjusted analyses, non-citizen, naturalized, and US-born Latinxs had a predicted probability of 12%, 11.4%, and 11.9% of experiencing food insecurity, respectively. In contrast, non-citizen Asians, but not US-born or naturalized Asians, reported greater food insecurity than Whites (12.5% vs. 8.2%). SEP accounted for 43% to 66% of the relationship between immigration status-ethnicity and food insecurity. The pandemic exacerbated economic hardship, but food insecurity was largely explained by long-standing SEP-related factors among Latinxs, regardless of immigration status, and non-citizen Asians. To address disparities in food insecurity, social assistance programs and COVID-19 economic relief should be extended to non-citizens.

Immigration and the Life Course: Contextualizing and Understanding Healthcare Access and Health of Older Adult Immigrants.

OBJECTIVE: Immigrant health discussions often focus on acculturation and omit discussions on historical events that may underlie health differences among immigrant older adults. This paper provides a historical overview of immigration policy and flows to the U.S. and examines insurance access and health difficulties by sending country. METHODS: We analyzed the "Immigrants Admitted to the United States, Fiscal Years 1972-2000" and 2015-2019 American Community Survey datasets to examine the number of admitted immigrants, sociodemographic profiles for current immigrant older adults, and the predicted probabilities of health insurance access and health difficulties. RESULTS: Our results highlight alignment of immigration flows with immigration legislation and vast heterogeneity in migration, health, and healthcare access of immigrants by sending country. DISCUSSION/IMPLICATIONS: Public health practitioners must consider how historical events and social factors contribute to the healthcare access and health of immigrant populations, as demographic shifts will require interventions that promote equitable healthy aging.

Considerations of Racism and Data Equity Among Asian Americans, Native Hawaiians, And Pacific Islanders in the Context of COVID-19.

Purpose of Review: The COVID-19 pandemic has revealed the importance of considering social determinants of health, including factors such as structural racism. This review discusses some of the evidence that triangulates on this issue, including data from hate crime statistics, social media analysis, and survey-based research. It also examines the data needs for Asian Americans, Native Hawaiian, and Pacific Islander (NHPI) communities. Recent Findings: The available data provides evidence that the pandemic has contributed to an increase in anti-Asian sentiment and discriminatory incidents. Many reports have surfaced showing a surge in anti-Chinese discrimination, which has "spilled over" into other Asian communities. Research is beginning to emerge to show that such discrimination may also impact health issues such as psychological distress. Given prior research, we would expect many more studies to emerge in the future. Also, the pandemic has illustrated the major gaps in data available to disentangle the health and social concerns facing Asian Americans and NHPI communities. Significant issues include the lack of systematic reporting of data for these communities both across states, and even among agencies within a state; erroneous aggregation of Asians with NHPIs; and censoring of data. These gaps and issues contribute to bias that obscures objective data and amplifies health inequalities. Summary: The COVID-19 pandemic has had a negative impact on the well-being of Asian American and NHPI communities. It is critical to provide disaggregated data, not only so that we can have accurate reporting, but also to ensure data and health equity.

Addressing The Interlocking Impact Of Colonialism And Racism On Filipinx/a/o American Health Inequities.

Within the monolithic racial category of "Asian American," health determinants are often hidden within each subgroup's complex histories of indigeneity, colonialism, migration, culture, and socio-political systems. Although racism is typically framed to underscore the ways in which various institutions (for example, employment and education) disproportionately disadvantage Black/Latinx communities over White people, what does structural racism look like among Filipinx/a/o Americans (FilAms), the third-largest Asian American group in the US? We argue that racism defines who is visible. We discuss pathways through which colonialism and racism preserve inequities for FilAms, a large and overlooked Asian American subgroup. We bring to light historical and modern practices inhibiting progress toward dismantling systemic racial barriers that impinge on FilAm health. We encourage multilevel strategies that focus on and invest in FilAms, such as robust accounting of demographic data in heterogeneous populations, explicitly naming neocolonial forces that devalue and neglect FilAms, and structurally supporting community approaches to promote better self- and community care.

Epidemiologists Count: The Role of Diversity and Inclusion in the Field of Epidemiology.

We present interpretations of the idea that "epidemiologists count" in response to the current status of membership and diversity and inclusion efforts within the Society for Epidemiological Research (SER). We review whom epidemiologists count to describe the (mis)representation of SER membership and how categorizations of people reflect social constructions of identity and biases that exist in broader society. We argue that what epidemiologists count-how diversity and inclusion are operationalized-has real-world implications on institutional norms and how inclusive/non-inclusive environments are. Finally, we examine which epidemiologists count within the field and argue that inclusion can only be achieved when we address how resources and opportunities are distributed among epidemiologists. To improve diversity and inclusion within SER and beyond, we recommend that SER strengthen its commitment to diversity, inclusion, and equity by: 1) integrating this priority on all agendas; 2) enhancing efforts to improve self-awareness among members and accountability within the organization; 3) supporting the growth of a diversifying workforce in epidemiology; and 4) increasing the visibility of health disparities research and researchers in epidemiology.

Healthcare Decision-Making Among Dual-Eligible Immigrants: Implications from a Study of an Integrated Medicare-Medicaid Demonstration Program in California.

To improve the coordination of long-term services and supports for dual-eligibles (those with both Medicare and Medicaid), California created Cal MediConnect (CMC), an Affordable Care Act-authorized managed care demonstration program. Beneficiaries were "passively enrolled" into CMC, meaning they were automatically enrolled unless they actively opted out. The aim of this study was to examine differences in factors influencing the enrollment decisions of U.S. born and immigrant dual-eligible beneficiaries. To explore differences in decision-making processes, we conducted in-depth interviews with dual-eligible consumers (39 native and 14 immigrant) in Los Angeles County. Interviews were analyzed using a constructivist grounded theory approach. Our findings illustrate a heightened sense of vulnerability and disempowerment experienced by immigrant participants. Immigrant participants also faced greater challenges in accessing healthcare and eliciting healthcare information compared to U.S.-born participants. Understanding the diverse perspectives of dual-eligible immigrant healthcare decision-making has implications for health care reform strategies aimed at ameliorating disparities for vulnerable immigrant populations.