A comparison of statistical methods for modeling count data with an application to hospital length of stay.

BACKGROUND: Hospital length of stay (LOS) is a key indicator of hospital care management efficiency, cost of care, and hospital planning. Hospital LOS is often used as a measure of a post-medical procedure outcome, as a guide to the benefit of a treatment of interest, or as an important risk factor for adverse events. Therefore, understanding hospital LOS variability is always an important healthcare focus. Hospital LOS data can be treated as count data, with discrete and non-negative values, typically right skewed, and often exhibiting excessive zeros. In this study, we compared the performance of the Poisson, negative binomial (NB), zero-inflated Poisson (ZIP), and zero-inflated negative binomial (ZINB) regression models using simulated and empirical data. METHODS: Data were generated under different simulation scenarios with varying sample sizes, proportions of zeros, and levels of overdispersion. Analysis of hospital LOS was conducted using empirical data from the Medical Information Mart for Intensive Care database. RESULTS: Results showed that Poisson and ZIP models performed poorly in overdispersed data. ZIP outperformed the rest of the regression models when the overdispersion is due to zero-inflation only. NB and ZINB regression models faced substantial convergence issues when incorrectly used to model equidispersed data. NB model provided the best fit in overdispersed data and outperformed the ZINB model in many simulation scenarios with combinations of zero-inflation and overdispersion, regardless of the sample size. In the empirical data analysis, we demonstrated that fitting incorrect models to overdispersed data leaded to incorrect regression coefficients estimates and overstated significance of some of the predictors. CONCLUSIONS: Based on this study, we recommend to the researchers that they consider the ZIP models for count data with zero-inflation only and NB models for overdispersed data or data with combinations of zero-inflation and overdispersion. If the researcher believes there are two different data generating mechanisms producing zeros, then the ZINB regression model may provide greater flexibility when modeling the zero-inflation and overdispersion.

Understanding the Intention to Use Telehealth Services in Underserved Hispanic Border Communities: Cross-Sectional Study.

BACKGROUND: Despite the United States having one of the leading health care systems in the world, underserved minority communities face significant access challenges. These communities can benefit from telehealth innovations that promise to improve health care access and, consequently, health outcomes. However, little is known about the attitudes toward telehealth in these communities, an essential first step toward effective adoption and use. OBJECTIVE: The purpose of this study is to assess the factors that shape behavioral intention to use telehealth services in underserved Hispanic communities along the Texas-Mexico border and examine the role of electronic health (eHealth) literacy in telehealth use intention. METHODS: We used cross-sectional design to collect data at a community health event along the Texas-Mexico border. The area is characterized by high poverty rates, low educational attainment, and health care access challenges. Trained bilingual students conducted 322 in-person interviews over a 1-week period. The survey instrument assessed sociodemographic information and telehealth-related variables. Attitudes toward telehealth were measured by asking participants to indicate their level of agreement with 9 statements reflecting different aspects of telehealth use. For eHealth literacy, we used the eHealth Literacy Scale (eHEALS), an 8-item scale designed to measure consumer confidence in finding, evaluating, and acting upon eHealth information. To assess the intention to use telehealth, we asked participants about the likelihood that they would use telehealth services if offered by a health care provider. We analyzed data using univariate, multivariate, and mediation statistical models. RESULTS: Participants were primarily Hispanic (310/319, 97.2%) and female (261/322, 81.1%), with an average age of 43 years. Almost three-quarters (219/298) reported annual household incomes below $20,000. Health-wise, 42.2% (136/322) self-rated their health as fair or poor, and 79.7% (255/320) were uninsured. The overwhelming majority (289/319, 90.6%) had never heard of telehealth. Once we defined the term, participants exhibited positive attitudes toward telehealth, and 78.9% (254/322) reported being somewhat likely or very likely to use telehealth services if offered by a health care provider. Based on multivariate proportional odds regression analysis, a 1-point increase in telehealth attitudes reduced the odds of lower versus higher response in the intention to use telehealth services by 23% (OR 0.77, 95% CI 0.73-0.81). Mediation analysis revealed that telehealth attitudes fully mediated the association between eHealth literacy and intention to use telehealth services. For a 1-point increase in eHEALS, the odds of lower telehealth use decreased by a factor of 0.95 (5%; OR 0.95, 95% CI 0.93-0.98; P<.001) via the increase in the score of telehealth attitudes. CONCLUSIONS: Telehealth promises to address many of the access challenges facing ethnic and racial minorities, rural communities, and low-income populations. Findings underscore the importance of raising awareness of telehealth and promoting eHealth literacy as a key step in fostering positive attitudes toward telehealth and furthering interest in its use.

The Precarious Health of Young Mexican American Men in South Texas, Cameron County Hispanic Cohort, 2004-2015.

INTRODUCTION: Hispanic men have higher rates of illness and death from various chronic conditions than do non-Hispanic men. We aimed to characterize the health of Mexican American men living on the US-Mexico border in South Texas and elucidate indications of chronic disease in young men. METHODS: We sampled all male participants from the Cameron County Hispanic Cohort, an ongoing population-based cohort of Mexican Americans in Brownsville, Texas. We calculated descriptive statistics and stratified the sample into 3 age groups to estimate the prevalence of sociodemographic, behavioral, and clinical factors by age group and evaluated differences between age groups. RESULTS: Obesity prevalence was approximately 50% across all age groups (P = .83). Diabetes prevalence was high overall (26.8%), and 16.9% (95% confidence interval [CI], 10.1%-23.8%) of men younger than 35 had diabetes. More than 70% of these young men had elevated liver enzymes, and mean values of aspartate aminotransferase were significantly higher in younger men (45.0 u/L; 95% CI, 39.5-50.6 u/L) than in both older age groups. Less than 20% of young men had any form of health insurance. Current smoking was higher in young men than in men in the other groups, and the rate was higher than the national prevalence of current smoking among Hispanic men. CONCLUSIONS: We suggest a need for obesity and diabetes prevention programs and smoking cessation programs for men in this region. Opportunities exist to expand current intervention programs and tailor them to better reach this vulnerable population of young Hispanic men. Elevated liver enzymes in men younger than 35 suggest a substantial burden of liver abnormalities, a finding that warrants further study.

Anxiety, depression and smoking status among adults of Mexican heritage on the Texas-Mexico Border.

The goal of the current analysis is to examine relationships between smoking status and anxiety and depression among adults of Mexican heritage to inform the development of culturally relevant smoking cessations efforts. Mexican heritage residents (N=1,791) of the city of Brownsville, TX, aged 18 years or older, enrolled in the Cameron County Hispanic Cohort, were selected through two stage cluster sampling of randomly selected census tracts from the first and third quartile of SES using Census 2000. Among current smokers, anxiety and depression scores were highest among women who had not completed high school (p<0.05). Former smoking women, but not men, with at least a high school education and former smoking women born in the United States reported higher levels of anxiety and depression than never smoking women. Negative affective states may represent a greater barrier to smoking cessation among women than men.

Association of Variability and Hypertensive Loads in 24-h Blood Pressure With Mortality and Cardiovascular Risk.

BACKGROUND: Evidence shows that high 24-h blood pressure (BP) variability increases cardiovascular risk. We investigated whether 24-h BP variability relates to mortality and cardiovascular risk due to inherent variability and/or hypertensive loads in 24-h BP. METHODS: A total of 1,050 participants from the Maracaibo Aging Study (mean age, 66 years; women, 67.2%) underwent 24-h ambulatory BP monitoring and were followed between 2001 and 2016. To evaluate inherent BP variability, we used average real variability (ARV) as it captures variability among consecutive BP readings. 24-h systolic BP load was the proportion (%) of systolic BP readings ≥130 mm Hg during the daytime and ≥110 during the nighttime. Our primary endpoint was total mortality and major adverse cardiovascular endpoints (MACE). Statistics included Cox proportional models. RESULTS: During a median follow-up of 8.3 years, 299 participants died and 210 experienced MACE. Each +2 mm Hg (corresponding to 1-standard deviation) higher 24-h systolic ARV (mean value, 9.0 ±â€…2.0 mm Hg) was associated with higher hazard ratios (HRs) for mortality by 1.28-fold (95% confidence interval [CI], 1.14-1.43) and for MACE by 1.24-fold (95% CI, 1.08-1.42). Each 30% higher 24-h systolic BP load (median value, 63%) was associated with mortality and MACE with HRs of 1.29 (95% CI, 1.15-1.46) and 1.28 (95% CI, 1.10-1.48); respectively. After models were additionally adjusted by BP level, only ARV was associated with mortality (HR, 1.17; 95% CI, 1.04-1.33) and MACE (HR, 1.16; 95% CI, 1.00-1.34). CONCLUSIONS: High ARV and hypertensive loads in 24-h systolic BP were associated with mortality and cardiovascular risk, however, only ARV is associated independently of the BP level.

High prevalence of subclinical atherosclerosis by carotid ultrasound among Mexican Americans: discordance with 10-year risk assessment using the Framingham risk score.

BACKGROUND: Framingham risk scores (FRS) were validated in a mostly Caucasian population. Evaluation of subclinical atherosclerosis by carotid ultrasound may improve ascertainment of risk in nonwhite populations. This study aimed to evaluate carotid intima-media thickness (cIMT) and carotid plaquing among Mexican Americans, and to correlate these markers with coronary risk factors and the FRS. METHODS/RESULTS: Participants (n = 141) were drawn from the Cameron County Hispanic Cohort. Carotid artery ultrasound was performed and cIMT measured. Carotid plaque was defined as areas of thickening >50% of the thickness of the surrounding walls. Mean age was 53.1 ± 11.7 years (73.8% female). Most were overweight or obese (88.7%) and more than half (53.2%) had the metabolic syndrome. One third (34.8%) had abnormal carotid ultrasound findings (either cIMT ≥75th percentile for gender and age or presence of plaque). Among those with abnormal carotid ultrasound, the majority were classified as being at low 10-year risk for cardiovascular events. Carotid ultrasound reclassified nearly a third of the cohort as being at high risk. This discordance between 10-year FRS and carotid ultrasound was noted whether risk was assessed for hard coronary events or global risk. Concordance between FRS and carotid ultrasound findings was best when long-term (30-year) risk was assessed and no subject with an abnormal carotid ultrasound was categorized as low risk by the 30-year FRS algorithm. CONCLUSIONS: Integration of carotid ultrasound findings to coronary risk assessments and use of longer term prediction models may provide better risk assessment in this minority population, with earlier initiation of appropriate therapies.

Missed opportunities for diagnosis and treatment of diabetes, hypertension, and hypercholesterolemia in a Mexican American population, Cameron County Hispanic Cohort, 2003-2008.

INTRODUCTION: Diabetes, hypertension, and hypercholesterolemia are common chronic diseases among Hispanics, a group projected to comprise 30% of the US population by 2050. Mexican Americans are the largest ethnically distinct subgroup among Hispanics. We assessed the prevalence of and risk factors for undiagnosed and untreated diabetes, hypertension, and hypercholesterolemia among Mexican Americans in Cameron County, Texas. METHODS: We analyzed cross-sectional baseline data collected from 2003 to 2008 in the Cameron County Hispanic Cohort, a randomly selected, community-recruited cohort of 2,000 Mexican American adults aged 18 or older, to assess prevalence of diabetes, hypertension, and hypercholesterolemia; to assess the extent to which these diseases had been previously diagnosed based on self-report; and to determine whether participants who self-reported having these diseases were receiving treatment. We also assessed social and economic factors associated with prevalence, diagnosis, and treatment. RESULTS: Approximately 70% of participants had 1 or more of the 3 chronic diseases studied. Of these, at least half had had 1 of these 3 diagnosed, and at least half of those who had had a disease diagnosed were not being treated. Having insurance coverage was positively associated with having the 3 diseases diagnosed and treated, as were higher income and education level. CONCLUSIONS: Although having insurance coverage is associated with receiving treatment, important social and cultural barriers remain. Failure to provide widespread preventive medicine at the primary care level will have costly consequences.

Social distancing and testing as optimal strategies against the spread of COVID-19 in the Rio Grande Valley of Texas.

At the beginning of August 2020, the Rio Grande Valley (RGV) of Texas experienced a rapid increase of coronavirus disease 2019 (abbreviated as COVID-19) cases and deaths. This study aims to determine the optimal levels of effective social distancing and testing to slow the virus spread at the outset of the pandemic. We use an age-stratified eight compartment epidemiological model to depict COVID-19 transmission in the community and within households. With a simulated 120-day outbreak period data we obtain a post 180-days period optimal control strategy solution. Our results show that easing social distancing between adults by the end of the 180-day period requires very strict testing a month later and then daily testing rates of 5% followed by isolation of positive cases. Relaxing social distancing rates in adults from 50% to 25% requires both children and seniors to maintain social distancing rates of 50% for nearly the entire period while maintaining maximum testing rates of children and seniors for 150 of the 180 days considered in this model. Children have higher contact rates which leads to transmission based on our model, emphasizing the need for caution when considering school reopenings.

Sex and age differences in prevalence and risk factors for prediabetes in Mexican-Americans.

AIMS: Over 1/3 of Americans have prediabetes, while 9.4% have type 2 diabetes. The aim of our study was to estimate the prevalence of prediabetes in Mexican Americans, with known 28.2% prevalence of type 2 diabetes, by age and sex and to identify critical socio-demographic and clinical factors associated with prediabetes. METHODS: Data were collected between 2004 and 2017 from the Cameron County Hispanic Cohort in Texas. Weighted crude and sex- and age- stratified prevalences were calculated. Survey weighted logistic regression analyses were conducted to identify risk factors for prediabetes. RESULTS: The prevalence of prediabetes (32%) was slightly higher than the alarmingly high rate of type 2 diabetes (28.2%). Hispanic men had the highest overall (37.8%) and highest age stratified prevalence of prediabetes. Males had higher odds of prediabetes than females 1.56 (1.19, 2.06), controlling for the effect of family history of diabetes, age, BMI, and high-density lipoprotein. Family history of diabetes was a strong independent risk factor for prediabetes in all men, and in men and women in the age group 40-64 years. Elevated triglycerides (p = 0.003) was an independent risk factor for men and women in the age group 18-39 years. CONCLUSIONS: Despite the very high prevalence of type 2 diabetes, prediabetes prevalence among Mexican Americans is only marginally less than national prediabetes rates. This suggests that progression to type 2 diabetes is more rapid and occurs earlier than nationally. Earlier screening and interventions for prediabetes, especially for men, are necessary to slow the transition to diabetes.

Association of Visceral Adipose Tissue and Subclinical Atherosclerosis in US-Born Mexican Americans but not First Generation Immigrants.

Background Excess visceral adipose tissue (VAT) is a primary driver for the cardiometabolic complications of obesity; VAT-associated cardiovascular disease risk varies by race, but most studies have been done on Non-Hispanics. This study aimed to evaluate the clinical and metabolic correlates of VAT, its association with subclinical atherosclerosis, and the factors affecting this association in Mexican Americans. Methods and Results Participants (n=527) were drawn from the Cameron County Hispanic Cohort (CCHC), on whom a carotid ultrasound to assess carotid intima media thickness and a dual-energy X-ray absorptiometry scan to assess for VAT were obtained. Those in the highest quartiles of VAT were more likely to have hypertension, hypertriglyceridemia, low high-density lipoprotein, diabetes mellitus, and metabolic syndrome. Increased carotid intima media thickness was more prevalent in those in the highest quartile for VAT (57.4% versus 15.4% for the lowest quartile; P<0.001). There was a graded increase in mean carotid intima media thickness with increasing VAT, after adjusting for covariates; for every 10 cm2 increase in VAT, there was an increase of 0.004 mm (SE=0.002; P=0.0299) in mean carotid intima media thickness. However, this association was only seen among second or higher generation US-born Mexican Americans but not among first generation immigrants (P=0.024). Conclusions Excess VAT is associated with indicators of metabolic disorders and subclinical atherosclerosis in Mexican Americans regardless of body mass index. However, acculturation appears to be an important modulator of this association. Longitudinal follow-up with targeted interventions among second or higher generation Hispanics to lower VAT and improve cardiometabolic risk may help prevent premature cardiovascular disease in this cohort.

Statin Prescription for Patients With Atherosclerotic Cardiovascular Disease from National Survey Data.

Despite strong evidence for the use of statins for patients with atherosclerotic cardiovascular disease (ASCVD), statin prescription is still suboptimal. We aimed to determine the rates and factors that influence statin prescription using national survey data. This is a cross-sectional retrospective study on 8,468 patients with clinical ASCVD who were drawn from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from years 2011 to 2015. Survey-weighted analysis was conducted to estimate weighted prevalence and odds ratios for statin prescription. There was a significant increase in statin prescription from the years 2011 to 2015. Nevertheless, only 52% of ASCVD patients (55.4% in coronary heart disease and 37.7% in noncoronary heart disease) were prescribed a statin. Based on multivariable regression analysis, after adjusting for covariates, males had 1.28 (1.06, 1.55) higher odds of statin prescription, in coronary heart disease patients only. In the overall study population, Black n on-Hispanics had 31% lower odds of statin prescription compared with White non-Hispanics, and patients seen only by a healthcare provider other than a physician were 80% less likely to have a statin prescribed to them. In conclusion, the disparity in statin prescription in patients with ASCVD exists across minority groups, and our findings underscore existing variations in healthcare delivery.

Frequency of Nonalcoholic Fatty Liver Disease and Subclinical Atherosclerosis Among Young Mexican Americans.

Nonalcoholic fatty liver disease (NAFLD) is considered as the hepatic manifestation of the metabolic syndrome, whose criteria are risk factors for atherosclerotic cardiovascular disease. We aimed to evaluate the prevalence of NAFLD, its association with subclinical atherosclerosis, and factors that may account for this association in Mexican Americans. In a population-based cross-sectional sample drawn from the Cameron County Hispanic Cohort in Texas, carotid intima media thickness (cIMT), an indicator of subclinical atherosclerosis, was measured. Abnormal carotid ultrasound study was defined as mean cIMT >75th percentile for age and gender and/or plaque presence. NAFLD was defined as steatosis by ultrasound in the absence of other causes of liver disease. Multivariable weighted regression analyses were performed to evaluate associations between NAFLD and cIMT. Mean age was 50.4 ± 1.2 years with 58.3% women. Mean body mass index was 31.0 ± 0.4 kg/m2, and 54.0% had the metabolic syndrome. NAFLD was highly prevalent (48.80%); subjects with NAFLD had greater body mass index, central obesity, fasting glucose levels, and dyslipidemia and were more likely to have the metabolic syndrome. Nearly 1/3 of subjects with NAFLD also had evidence of subclinical atherosclerosis (31.2%). After adjusting for covariates, there was an independent association between NAFLD and increased cIMT only in younger subjects <45 years (p = 0.0328). Subjects with both abnormal liver and carotid ultrasound studies tended to be obese, diabetic and have the metabolic syndrome. In conclusion, NAFLD is highly prevalent in this Mexican American cohort, with an independent association between NAFLD and subclinical atherosclerosis among younger subjects; clustering of diabetes, obesity, and metabolic syndrome in this health disparity cohort increases the risk of both liver disease and early atherosclerosis in young adults.

Multicollinearity in Regression Analyses Conducted in Epidemiologic Studies.

The adverse impact of ignoring multicollinearity on findings and data interpretation in regression analysis is very well documented in the statistical literature. The failure to identify and report multicollinearity could result in misleading interpretations of the results. A review of epidemiological literature in PubMed from January 2004 to December 2013, illustrated the need for a greater attention to identifying and minimizing the effect of multicollinearity in analysis of data from epidemiologic studies. We used simulated datasets and real life data from the Cameron County Hispanic Cohort to demonstrate the adverse effects of multicollinearity in the regression analysis and encourage researchers to consider the diagnostic for multicollinearity as one of the steps in regression analysis.

Liver and Other Gastrointestinal Cancers Are Frequent in Mexican Americans.

BACKGROUND: Disease patterns in Mexican American health-disparity populations differ from larger US populations. AIMS: This study is aimed to determine frequency of gastrointestinal cancers in Mexican Americans. METHODS: We analyzed self-reported data from the Cameron County Hispanic Cohort where we find high rates of risk factors for cancer: obesity (48.5 %) and diabetes (30.7 %). Participants provided cancer histories about themselves and first- and second-degree relatives. Logistic regression models assessed risk factors. Frequencies of cancer sites were ranked and validated using concurrent age local cancer registry data. RESULTS: Among 9,249 individuals (participants and their relatives), there were 1,184 individuals with reports of cancer. Among cohort participants under 70 years of age, the most significant risk factor for all-cause cancers was diabetes (OR 3.57, 95 % CI 1.32, 9.62). Participants with metabolic syndrome were significantly more likely to report cancer in relatives [1.73 (95 % CI 1.26, 2.37]. Among cancers in fathers, liver cancer was ranked third, stomach fourth, colorectal sixth, and pancreas tenth. In mothers, stomach was third, liver fourth, colorectal seventh, and pancreas eleventh. The unusual prominence of these cancers in Mexican Americans, including liver cancer, was supported by age-adjusted incidence in local registry data. CONCLUSIONS: Gastrointestinal system cancers, particularly, liver cancer, in a Mexican American health disparity cohort and their relatives rank higher than in other ethnicities and are associated with high rates of diabetes and metabolic syndrome. Effective prevention of diabetes and low-tech, high-quality screening strategies for gastrointestinal cancers are needed in health disparity communities.

Cirrhosis and Advanced Fibrosis in Hispanics in Texas: The Dominant Contribution of Central Obesity.

Liver cirrhosis is a leading cause of death in Hispanics and Hispanics who live in South Texas have the highest incidence of liver cancer in the United States. We aimed at determining the prevalence and associated risk factors of cirrhosis in this population. Clinical and demographic variables were extracted for 2466 participants in the community-based Cameron County Hispanic Cohort in South Texas. Aspartate transaminase to Platelet Ratio Index (APRI) was used to predict cirrhosis in Cameron County Hispanic Cohort. The prevalence of cirrhosis using APRI≥2 was 0.94%, which is nearly 4-fold higher than the national prevalence. Using APRI≥1, the overall prevalence of cirrhosis/advanced fibrosis was 3.54%. In both analyses, highest prevalence was observed in males, specifically in the 25-34 age group. Risk factors independently associated with APRI≥2 and APRI≥1 included hepatitis C, diabetes and central obesity with a remarkable population attributable fraction of 52.5% and 65.3% from central obesity, respectively. Excess alcohol consumption was also independently associated with APRI≥2. The presence of patatin-like phospholipase domain-containing-3 gene variants was independently associated with APRI≥1 in participants >50 years old. Males with both central obesity and excess alcohol consumption presented with cirrhosis/advanced fibrosis at a young age. Alarmingly high prevalence of cirrhosis and advanced fibrosis was identified in Hispanics in South Texas, affecting young males in particular. Central obesity was identified as the major risk factor. Public health efforts are urgently needed to increase awareness and diagnosis of advanced liver fibrosis in Hispanics.

Depression, obesity, and metabolic syndrome: prevalence and risks of comorbidity in a population-based representative sample of Mexican Americans.

INTRODUCTION: We examined the prevalence of depression, obesity, and metabolic syndrome and associations between them in a population-based representative cohort of Mexican Americans living on the United States-Mexico border. METHOD: The sample in this cross-sectional analysis consisted of 1,768 Mexican American adults (≥ 18 years of age) assessed between the years 2004 and 2010, with whom we tested our central hypothesis of a significant relationship between obesity and depression. Depression was measured using the Center for Epidemiologic Studies-Depression scale (CES-D) with a cutoff score of ≥ 16 for depression and a cutoff score of ≥ 27 for severe depression. We categorized body mass index (BMI) values as obese (≥ 30kg/m(2)) and later subdivided the obese subjects into obese (30-39 kg/m(2)[inclusive]) and morbidly obese (≥ 40 kg/m(2)). Metabolic syndrome was defined using the American Heart Association definition requiring at least 3 of the following: increased waist circumference, elevated triglycerides, reduced high-density lipoprotein (HDL) cholesterol, elevated blood pressure, and elevated fasting glucose. Weighted data were analyzed to establish prevalence of depression, obesity, and metabolic syndrome. Univariate and multivariable weighted regression models were used to test potential associations between these disorders. RESULTS: Using weighted prevalence, we observed high rates of depression (30%), obesity (52%), and metabolic syndrome (45%). Univariate models revealed female gender (P = .0004), low education (P = .003), low HDL level (P = .009), and increased waist circumference (P = .03) were associated with depression. Female gender (P = .01), low education (P = .003), and morbid obesity (P = .002) were risk factors for severe depression and remained significant in multivariable models. CONCLUSIONS: In this large cohort of Mexican Americans, obesity, female gender, and low education were identified risk factors for depression. These indicators may serve as targets for early detection, prevention, and intervention in this population.

Undiagnosed Diabetes and Pre-Diabetes in Health Disparities.

Globally half of all diabetes mellitus is undiagnosed. We sought to determine the extent and characteristics of undiagnosed type 2 diabetes mellitus and pre-diabetes in Mexican Americans residing in the United States. This disadvantaged population with 50% lifetime risk of diabetes is a microcosm of the current pandemic. We accessed baseline data between 2004 and 2014 from 2,838 adults recruited to our Cameron County Hispanic Cohort (CCHC); a two-stage randomly selected 'Framingham-like' cohort of Mexican Americans on the US Mexico border with severe health disparities. We examined prevalence, risk factors and metabolic health in diagnosed and undiagnosed diabetes and pre-diabetes. Two thirds of this Mexican American population has diabetes or pre-diabetes. Diabetes prevalence was 28.0%, nearly half undiagnosed, and pre-diabetes 31.6%. Mean BMI among those with diabetes was 33.5 kg/m2 compared with 29.0 kg/m2 for those without diabetes. Significant risk factors were low income and educational levels. Most with diabetes had increased waist/hip ratio. Lack of insurance and access to health services played a decisive role in failure to have diabetes diagnosed. Participants with undiagnosed diabetes and pre-diabetes had similar measures of poor metabolic health similar but generally not as severe as those with diagnosed diabetes. More than 50% of a minority Mexican American population in South Texas has diabetes or pre-diabetes and is metabolically unhealthy. Only a third of diabetes cases were diagnosed. Sustained efforts are imperative to identify, diagnose and treat individuals in underserved communities.

ASSOCIATION OF TOTAL AND DIFFERENTIAL WHITE BLOOD CELL COUNTS TO DEVELOPMENT OF TYPE 2 DIABETES IN MEXICAN AMERICANS IN CAMERON COUNTY HISPANIC COHORT.

OBJECTIVE: To evaluate the relationship between total and differential White Blood Cell (WBC) counts with time to transition to type 2 diabetes in Mexican Americans using prospective data from the Cameron County Hispanic Cohort (CCHC). RESULTS: Multivariable Cox proportional hazards regression models revealed that obese Mexican-American cohort participants whose total WBC or granulocyte count increased over time had 1.39 and 1.35 times higher risk respectively of transition to type 2 diabetes when compared to overweight participants. The granulocyte or total WBC count in participants with BMI≥35 were significant risk factors for transition to type 2 diabetes. CONCLUSIONS: Increased total WBC and WBC differential counts, particularly lymphocytes and granulocytes, are associated with risk of transition to type 2 diabetes in obese Mexican Americans, after adjusting for other potential confounders. Screening and monitoring the WBC counts, including lymphocytes and granulocytes can help with monitoring potential transition to type 2 diabetes.

Subclinical atherosclerosis and obesity phenotypes among Mexican Americans.

BACKGROUND: Data on the influence of obesity on atherosclerosis in Hispanics are inconsistent, possibly related to varying cardiometabolic risk among obese individuals. We aimed to determine the association of obesity and cardiometabolic risk with subclinical atherosclerosis in Mexican-Americans. METHODS AND RESULTS: Participants (n=503) were drawn from the Cameron County Hispanic Cohort. Metabolic health was defined as <2 of the following: blood pressure ≥130/85; triglyceride ≥150 mg/dL; high-density lipoprotein cholesterol <40 mg/dL (men) or <50 mg/dL (women); fasting glucose ≥100 mg/dL; homeostasis model assessment of insulin resistance value >5.13; or high-sensitivity C-reactive protein >3 mg/L. Carotid intima media thickness (cIMT) was measured. A high proportion of participants (77.8%) were metabolically unhealthy; they were more likely to be male, older, with fewer years of education, and less likely to meet daily recommendations regarding fruit and vegetable servings. One-third (31.8%) had abnormal carotid ultrasound findings. After adjusting for covariates, mean cIMT varied across the obesity phenotypes (P=0.0001); there was no difference among the metabolically unhealthy regardless of whether they were obese or not. In multivariable analysis, after adjusting for covariates, cardiometabolic risk (P=0.0159), but not obesity (P=0.1446), was significantly associated with subclinical atherosclerosis. CONCLUSIONS: In Mexican-Americans, cardiometabolic risk has a greater effect on early atherosclerosis development than body mass index. Non-obese but metabolically unhealthy participants had similar development of subclinical atherosclerosis as their obese counterparts. Interventions to maintain metabolic health among obese and non-obese patients may be a more important goal than weight loss alone.

ELECTROCARDIOGRAPHIC ABNORMALITIES AMONG MEXICAN AMERICANS: CORRELATIONS WITH DIABETES, OBESITY, AND THE METABOLIC SYNDROME.

BACKGROUND: Resting ischemic electrocardiographic abnormalities have been associated with cardiovascular mortality. Simple markers of abnormal autonomic tone have also been associated with diabetes, obesity, and the metabolic syndrome in some populations. Data on these electrocardiographic abnormalities and correlations with coronary risk factors are lacking among Mexican Americans wherein these conditions are prevalent. OBJECTIVE: This study aimed to evaluate the prevalent resting electrocardiographic abnormalities among community-dwelling Mexican Americans, and correlate these findings with coronary risk factors, particularly diabetes, obesity, and the metabolic syndrome. METHODS: Study subjects (n=1280) were drawn from the Cameron County Hispanic Cohort comprised of community-dwelling Mexican Americans living in Brownsville, Texas at the United States-Mexico border. Ischemic electrocardiographic abnormalities were defined as presence of ST/T wave abnormalities suggestive of ischemia, abnormal Q waves, and left bundle branch block. Parameters that reflect autonomic tone, such as heart rate-corrected QT interval and resting heart rate, were also measured. RESULTS: Ischemic electrocardiographic abnormalities were more prevalent among older persons and those with hypertension, diabetes, obesity, and the metabolic syndrome. Subjects in the highest quartiles of QTc interval and resting heart rate were also more likely to be diabetic, hypertensive, obese, or have the metabolic syndrome. CONCLUSIONS: Among Mexican Americans, persons with diabetes, obesity, and the metabolic syndrome were more likely to have ischemic electrocardiographic abnormalities, longer QTc intervals, and higher resting heart rates. A resting electrocardiogram can play a complementary role in the comprehensive evaluation of cardiovascular risk in this minority population.