Ana P. Ortiz

Major Cardiovascular Risk Factors in Latin America: A Comparison with the United States. The Latin American Consortium of Studies in Obesity (LASO)

Background Limited knowledge on the prevalence and distribution of risk factors impairs the planning and implementation of cardiovascular prevention programs in the Latin American and Caribbean (LAC) region. Methods and Findings Prevalence of hypertension, diabetes mellitus, abnormal lipoprotein levels, obesity, and smoking were estimated from individual-level patient data pooled from population-based surveys (1998–2007, n = 31,009) from eight LAC countries and from a national survey of the United States (US) population (1999–2004) Age and gender specific prevalence were estimated and age-gender adjusted comparisons between both populations were conducted. Prevalence of diabetes mellitus, hypertension, and low high-density lipoprotein (HDL)-cholesterol in LAC were 5% (95% confidence interval [95% CI]: 3.4, 7.9), 20.2% (95% CI: 12.5, 31), and 53.3% (95% CI: 47, 63.4), respectively. Compared to LAC region’s average, the prevalence of each risk factor tended to be lower in Peru and higher in Chile. LAC women had higher prevalence of obesity and low HDL-cholesterol than men. Obesity, hypercholesterolemia, and hypertriglyceridemia were more prevalent in the US population than in LAC population (31 vs. 16.1%, 16.8 vs. 8.9%, and 36.2 vs. 26.5%, respectively). However, the prevalence of low HDL-cholesterol was higher in LAC than in the US (53.3 vs. 33.7%). Conclusions Major cardiovascular risk factors are highly prevalent in LAC region, in particular low HDL-cholesterol. In addition, marked differences do exist in this prevalence profile between LAC and the US. The observed patterns of obesity-related risk factors and their current and future impact on the burden of cardiovascular diseases remain to be explained.

Interethnic differences in the accuracy of anthropometric indicators of obesity in screening for high risk of coronary heart disease

Background:Cut points for defining obesity have been derived from mortality data among Whites from Europe and the United States and their accuracy to screen for high risk of coronary heart disease (CHD) in other ethnic groups has been questioned.Objective:To compare the accuracy and to define ethnic and gender-specific optimal cut points for body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) when they are used in screening for high risk of CHD in the Latin-American and the US populations.Methods:We estimated the accuracy and optimal cut points for BMI, WC and WHR to screen for CHD risk in Latin Americans (n=18 976), non-Hispanic Whites (Whites; n=8956), non-Hispanic Blacks (Blacks; n=5205) and Hispanics (n=5803). High risk of CHD was defined as a 10-year risk ⩾20% (Framingham equation). The area under the receiver operator characteristic curve (AUC) and the misclassification-cost term were used to assess accuracy and to identify optimal cut points.Results:WHR had the highest AUC in all ethnic groups (from 0.75 to 0.82) and BMI had the lowest (from 0.50 to 0.59). Optimal cut point for BMI was similar across ethnic/gender groups (27 kg/m2). In women, cut points for WC (94 cm) and WHR (0.91) were consistent by ethnicity. In men, cut points for WC and WHR varied significantly with ethnicity: from 91 cm in Latin Americans to 102 cm in Whites, and from 0.94 in Latin Americans to 0.99 in Hispanics, respectively.Conclusion:WHR is the most accurate anthropometric indicator to screen for high risk of CHD, whereas BMI is almost uninformative. The same BMI cut point should be used in all men and women. Unique cut points for WC and WHR should be used in all women, but ethnic-specific cut points seem warranted among men.

Cesarean Delivery as a Barrier for Breastfeeding Initiation: The Puerto Rican Experience

The studys objective was to examine the relationship between cesarean section delivery and the initiation of breastfeeding in a representative sample of 1695 Puerto Rican women aged 15 to 49 years, who delivered their last healthy singleton child in Puerto Rico between 1990 and 1996. Secondary analysis of data collected in the population-based cross-sectional study Puerto Rico Reproductive Health Survey was performed. Bivariate and multivariate logistic regression analyses were used to examine the crude and covariate adjusted association between type of childbirth and initiation of breastfeeding. Overall, 36% of all births were performed by cesarean section, while initiation of breastfeeding was achieved by 61.5% of the women. Cesarean section was negatively related to breastfeeding initiation in multivariable logistic regression models (odds ratio = .64; 95% CI = 0.51-0.81) after controlling for confounding variables. Intervention programs that aim to promote breastfeeding and that provide special assistance to women undergoing this procedure should be developed. El objetivo de este estudio fue evaluar la relación entre el parto por cesárea y la iniciación de la lactancia materna en una muestra representativa de 1,695 mujeres puertorriqueñas entre las edades de 15-49 años, quienes tuvieron su último parto de hijo único en Puerto Rico entre 1990-1996. Se hizo un análisis secundario de los datos coleccionados en la población basada en un estudio seccional cruzado de la Encuesta de Salud Reproductiva de Puerto Rico. Se hizo análisis de regresión logística multivariada y bivariada para evaluar la asociación del crudo y covariable ajustado entre el tipo de parto y la iniciación de la lactancia materna. En general, 36% de los partos fueron por cesárea, mientras que la iniciación de la lactancia materna fue de 61.5%. La cesárea se relacionó negativamente con la iniciación de la lactancia materna en los módulos de regresión logística multivariable (Odds ratio = .64; 95% CI = 0.51-0.81) después de controlar variables atribuibles. Se deben desarrollar programas de intervención que se dirijan a la promoción de la lactancia materna que provee asistencia especial a mujeres que vayan a tener este procedimiento.

Incidence and mortality rates for colorectal cancer in Puerto Rico and among Hispanics, Non-Hispanic Whites, and Non-Hispanic Blacks in the United States, 1998–2002

Colorectal cancer (CRC) is the second most commonly diagnosed cancer in Puerto Rico (PR). In the United States, the incidence and mortality rates of CRC have great variation by sex and race/ethnicity. Age‐standardized incidence and mortality rates of CRC in PR were assessed and compared with the rates among US Hispanics (USH), non‐Hispanic whites (NHW), and non‐Hispanic blacks (NHB) in the United States for the period from 1998 through 2002. Incidence and mortality trends and relative differences among racial/ethnic groups by sex and age were determined.

The Latin American Consortium of Studies in Obesity (LASO).

Current, high‐quality data are needed to evaluate the health impact of the epidemic of obesity in Latin America. The Latin American Consortium of Studies of Obesity (LASO) has been established, with the objectives of (i) Accurately estimating the prevalence of obesity and its distribution by sociodemographic characteristics; (ii) Identifying ethnic, socioeconomic and behavioural determinants of obesity; (iii) Estimating the association between various anthropometric indicators or obesity and major cardiovascular risk factors and (iv) Quantifying the validity of standard definitions of the various indexes of obesity in Latin American population. To achieve these objectives, LASO makes use of individual data from existing studies. To date, the LASO consortium includes data from 11 studies from eight countries (Argentina, Chile, Colombia, Costa Rica, Dominican Republic, Peru, Puerto Rico and Venezuela), including a total of 32 462 subjects. This article describes the overall organization of LASO, the individual studies involved and the overall strategy for data analysis. LASO will foster the development of collaborative obesity research among Latin American investigators. More important, results from LASO will be instrumental to inform health policies aiming to curtail the epidemic of obesity in the region.

Insulin resistance, central obesity, and risk of colorectal adenomas.

Increasing evidence supports insulin resistance (IR) as the underpinning of the obesity‐colorectal neoplasia link. The homeostasis model assessment‐IR (HOMA‐IR) is a widely accepted index of evolving hyperinsulinemia and early IR. Studies of the relation between HOMA‐IR and colorectal adenomas are limited. Therefore, the authors sought to determine the associations of HOMA‐IR and central obesity (waist to hip ratio [WHR]) with risk of colorectal adenomas in a screening colonoscopy‐based study.

Age-standardized incidence and mortality rates of oral and pharyngeal cancer in Puerto Rico and among Non-Hispanics Whites, Non-Hispanic Blacks, and Hispanics in the USA

BackgroundIn the American region, Puerto Rico (PR) has the highest incidence of oral and pharyngeal cancer (OPC), but racial/ethnic differences have never been assessed and compared with other groups in the United States of America (USA). We compared the age-adjusted incidence and mortality rates of OPC between PR and among USA Hispanics (USH), Non-Hispanic Whites (NHW), and Non-Hispanic Blacks (NHB) to assess the burden of this cancer in PR.MethodsAnalysis of the age-standardized rates (per 100,000) was performed using the direct method with the world standard population (ASR(World)) from 1998–2002. Annual percent change (APC) and Relative Risks (RR) were calculated using the Poisson regression model.ResultsThe incidence ASR(World) for men in PR was constant (APC ≈ 0.0%), in contrast, a decrease was observed among NHW, NHB, and USH men, although only USH showed statistical significance (APC = -4.9%, p < 0.05). In women, the highest increase in incidence (APC = 5.3%) and the lowest decrease in mortality (APC = -1.4%) was observed in PR. The ratio of the ASR(World) showed that in all racial/ethnic groups, men had approximately 2–4 fold increased incidence and mortality risk of OPC than women (p < 0.05). Men in PR had a higher mortality risk (p < 0.05) of OPC as compared to USH, NHW, and NHB; but among women, PR showed a significant excess of mortality only as compared to USH (est. SRR = 1.82, 95% CI = 1.41, 2.33).ConclusionThe overall higher incidence of OPC in men in PR as compared to USH, NHB, and NHW could be explained by the effect of gene-environment interactions. Meanwhile, the higher mortality from OPC in PR suggests limitations in the health-care access within this population. Further research is warranted to elucidate these findings.

Association between adiposity indices and cardiometabolic risk factors among adults living in Puerto Rico

OBJECTIVE To compare the general adiposity index (BMI) with abdominal obesity indices (waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR)) in order to examine the best predictor of cardiometabolic risk factors among Hispanics living in Puerto Rico. DESIGN Secondary analysis of measurements taken from a representative sample of adults. Logistic regression models (prevalence odds ratios (POR)), partial Pearsons correlations (controlling for age and sex) and receiver-operating characteristic (ROC) curves were calculated between indices of obesity (BMI, WC, WHR and WHtR) and blood pressure, HDL cholesterol (HDL-C), LDL cholesterol (LDL-C), total cholesterol (TC):HDL-C, TAG, fasting blood glucose, glycosylated Hb, high-sensitivity C-reactive protein (hs-CRP), fibrinogen, plasminogen activator inhibitor-1 (PAI-1) and an aggregated measure of cardiometabolic risk. SETTING Household study conducted between 2005 and 2007 in the San Juan Metropolitan Area in Puerto Rico. SUBJECTS A representative sample of 858 non-institutionalized adults. RESULTS All four obesity indices significantly correlated with the cardiometabolic risk factors. WHtR had the highest POR for high TC:HDL-C, blood pressure, hs-CRP, fibrinogen and PAI-1; WC had the highest POR for low HDL-C and high LDL-C and fasting blood glucose; WHR had the highest POR for overall cardiometabolic risk, TAG and glycosylated Hb. BMI had the lowest POR for most risk factors and smallest ROC curve for overall cardiometabolic risk. CONCLUSIONS The findings of the study suggest that general adiposity and abdominal adiposity are both associated with cardiometabolic risk in this population, although WC, WHR and WHtR appear to be slightly better predictors than BMI.

Health and cancer information seeking practices and preferences in Puerto Rico: creating an evidence base for cancer communication efforts.

Effective communication around cancer control requires understanding of population information seeking practices and their cancer-relevant risk behaviors, attitudes, and knowledge. The Health Information National Trends Survey (HINTS) developed by the U.S. National Cancer Institute (NCI) provides surveillance of the nations investment in cancer communication tracking the effects of the changing communication environment on cancer-related knowledge, attitudes, and behaviors. The University of Puerto Rico Comprehensive Cancer Center (UPRCCC), the Puerto Rico Behavioral Risk Factors Surveillance System (PRBRFSS), and the NCI implemented HINTS in Puerto Rico in 2009. In this article we describe the health and cancer information seeking behaviors, sources of information, trust in information sources, and experiences seeking information among the population of Puerto Rico. A total of 639 (603 complete and 36 partially complete) interviews were conducted. Nearly one-third of respondents had ever looked for information about health (32.9%) or about cancer (28.1%). The Internet was the most frequently reported source of information. College educated (odds ratio [OR] = 7.6) and females (OR = 2.8) were more likely to seek health information. Similarly, college educated (OR = 5.4) and females (OR = 2.0) were more likely to seek cancer information. Only 32.7% of respondents had ever accessed the Internet, and college educated were more likely to use it (OR = 12.2). Results provide insights into the health and cancer information seeking behaviors and experiences of the population in Puerto Rico and contribute to the evidence base for cancer control planning on the island.

Age at natural menopause and factors associated with menopause state among Puerto Rican women aged 40-59 years, living in Puerto Rico.

Objective:The timing of menopause is associated with multiple health outcomes in female populations including all-cause mortality, heart disease, breast cancer, and osteoporosis. Although research suggests that age at menopause varies in different ethnic groups, data on age at menopause among Hispanic women are limited. Design:The present cross-sectional study estimates age at natural menopause among a sample of 1,272 Puerto Rican women aged 40 to 59 years who participated in health fairs held in 22 municipalities of Puerto Rico between May 2000 and November 2001. Cox proportional hazard regression analysis was used to characterize age at natural menopause and its association with relevant covariates. Results:The overall adjusted median age at natural menopause was 51.3 years. Current employment (hazard ratio = 0.75, 95% CI: 0.59-0.95) and parity of two or three children as compared with having no children or one child (hazard ratio = 0.73, 95% CI: 0.54-0.98) were associated with a later menopause. Conclusions:This study provides a robust estimate of age at menopause for Puerto Rican women, which is similar to overall estimates previously reported for US populations, but higher than estimates for other Hispanic populations. Our results confirm attributes associated with age at menopause and provide information relevant to understanding the potential chronic disease burden of Puerto Rican women as they age.