Luis M. Falcón

The Boston Puerto Rican Health Study, a longitudinal cohort study on health disparities in Puerto Rican adults: challenges and opportunities.

BackgroundThe Boston Puerto Rican Health Study is an ongoing longitudinal cohort study designed to examine the role of psychosocial stress on presence and development of allostatic load and health outcomes in Puerto Ricans, and potential modification by nutritional status, genetic variation, and social support.MethodsSelf-identified Puerto Ricans, aged 45-75 years and residing in the Boston, MA metro area, were recruited through door-to-door enumeration and community approaches. Participants completed a comprehensive set of questionnaires and tests. Blood, urine and salivary samples were extracted for biomarker and genetic analysis. Measurements are repeated at a two-year follow-up.ResultsA total of 1500 eligible participants completed baseline measurements, with nearly 80% two-year follow-up retention. The majority of the cohort is female (70%), and many have less than 8th grade education (48%), and fall below the poverty level (59%). Baseline prevalence of health conditions is high for this age range: considerable physical (26%) and cognitive (7%) impairment, obesity (57%), type 2 diabetes (40%), hypertension (69%), arthritis (50%) and depressive symptomatology (60%).ConclusionsThe enrollment of minority groups presents unique challenges. This report highlights approaches to working with difficult to reach populations, and describes some of the health issues and needs of Puerto Rican older adults. These results may inform future studies and interventions aiming to improve the health of this and similar communities.

Allostatic load is associated with chronic conditions in the Boston Puerto Rican Health Study.

Puerto Ricans living in the United States mainland present multiple disparities in prevalence of chronic diseases, relative to other racial and ethnic groups. Allostatic load (AL), or the cumulative wear and tear of physiological responses to stressors such as major life events, social and environmental burden, has been proposed as a possible mechanism for the inequalities observed in minority groups, but has not been studied in Puerto Ricans. The aim of this study was to determine the association of AL to six chronic diseases (abdominal obesity, hypertension, diabetes, and self-reported cardiovascular disease (CVD), arthritis and cancer) in Puerto Ricans, and to contrast AL to metabolic syndrome (MetS). Participants of the Boston Puerto Rican Health Study (n=1116, ages 45-75 years) underwent a home-based interview, where questionnaires were completed and biological samples collected. A summary definition of AL was constructed using clinically-defined cutoffs and medication use for 10 physiological parameters in different body systems. Logistic regression models were run to determine associations between AL score and disease status, controlling for age, sex, smoking, alcohol use, physical activity, total fat intake and energy intake. Parallel models were also run with MetS score replacing AL. We found that increasing categories of AL score were significantly associated with abdominal obesity, hypertension, diabetes and self-reported cardiovascular disease (CVD) and arthritis, but not with self-reported cancer. The strength of associations of AL with all conditions, except diabetes and cancer, was similar to or larger than those of MetS score. In conclusion, Puerto Rican older adults experienced physiological dysregulation that was associated with increased odds of chronic conditions. AL was more strongly associated with most conditions, compared to MetS, suggesting that this cumulative measure may be a better predictor of disease. These results have prospective research implications for Puerto Ricans and other ethnic groups.

Perceived discrimination, psychological distress and health

Racism and discrimination can have significant implications for health, through complex biopsychosocial interactions. Latino groups, and particularly Puerto Ricans, are an understudied population in the United States in terms of the prevalence of discrimination and its relevance to health. Participants in our study were 45- to 75-year-old (N = 1122) Puerto Ricans. The measures were perceived discrimination, depressive symptomatology (CES-D), perceived stress (PSS), self-rated health, medical conditions, blood pressure, smoking and drinking behaviours, demographics. Our findings show that 36.9 per cent of participants had at some time experienced discrimination, with men, those with more years of education, currently employed and with higher incomes being more likely to report it. Experiences of discrimination were associated with increased levels of depressive symptoms and perceived stress. When controlling for covariates, perceived discrimination was predictive of the number of medical conditions, of ever having smoked and having been a drinker, and having higher values of diastolic pressure. Depressive symptoms are a mediator of the effect of perceived discrimination on medical conditions, confirmed by the Sobel test: z = 3.57, p < 0.001. Mediating roles of perceived stress, smoking and drinking behaviours were not confirmed. Increased depressive symptoms might be the main pathway through which perceived discrimination is associated with a greater number of medical diagnoses.

Relationship between perceived stress and dietary and activity patterns in older adults participating in the Boston Puerto Rican Health Study.

Previous research supports a relationship between psychological stress and chronic disease in Puerto Rican adults living in the Boston, Massachusetts area. Stress may affect health by influencing dietary and physical activity patterns. Therefore, perceived stress and two hypothesized mediators of stress-related food intake, insulin and cortisol, were examined for possible associations with dietary and activity patterns in >1300 Puerto Ricans (aged 45-75 years; 70% women) living in the Boston, Massachusetts area. Data were analyzed using multiple linear regression and ANCOVA. Greater perceived stress was associated with lower fruit, vegetable, and protein intake, greater consumption of salty snacks, and lower participation in physical activity. Stress was associated with higher intake of sweets, particularly in those with type 2 diabetes. Cortisol and stress were positively associated in those without diabetes. Cortisol was associated with higher intake of saturated fat and, in those with diabetes, sweet foods. Independent of diabetes, perceived stress was associated with higher circulating insulin and BMI. Our findings support a link between stress, cortisol, and dietary and activity patterns in this population. For high-sugar foods, this relationship may be particularly important in those with type 2 diabetes. Longitudinal research to determine causal pathways for these identified associations is warranted.

Vitamin B6 Is Associated with Depressive Symptomatology in Massachusetts Elders

Objective: We examined the cross-sectional relationship between dietary vitamin B6 and plasma pyridoxyl-5′-phosphate concentrations (PLP) with depressive symptomatology among a representative sample of 618 elderly Caribbean Hispanics, and a neighborhood based comparison group of 251 non-Hispanic white (NHW) older adults in Massachusetts. Methods: Depressive symptomatology was assessed with the Center for Epidemiologic Studies Depression Scale (CES-D). 41% of Hispanics and 22.6% of NHWs had CES-D scores greater than 16, indicating depressive caseness. Dietary intake was calculated from a semi-quantitative food frequency questionnaire (FFQ) designed for this population. Results: PLP was significantly associated with CES-D score and depressive caseness in the total sample and in non-supplement users. Deficient levels of plasma PLP (plasma PLP < 20 nmol/L) approximately doubled the likelihood of depressive caseness. Total intake (diet + supplement) of vitamin B6 was not associated with these outcomes. However, dietary vitamin B6 was significantly associated with CES-D score and depressive caseness. Conclusion: Longitudinal studies are needed to clarify the direction of causality between vitamin B6 and depressive symptoms.

Social support, life events, and psychological distress among the Puerto Rican population in the Boston area of the United States

Objectives: The aim of this article is to investigate the role of social network support in ameliorating the psychological impact of life stressors that are prevalent for the older Puerto Rican population. Method: Social support was measured through the Norbeck Social Support Questionnaire, and psychological distress through the Center for Epidemiological Studies Depression Scale and the Perceived Stress Scale. We describe the life stressors (Norbeck Life Events) faced by Puerto Ricans and their implications for psychological distress. We present associations between depression, perceived stress, social support, and socio-demographic indicators. The role of social network support–emotional and instrumental–in buffering the effect of negative events is examined. Attention is given to the interacting effect of gender and the type of support. Results: The analysis shows that dimensions of social support, particularly emotional support, are generally protective of psychological health. However, when delineating the moderating effects of gender, social support is beneficial for men, but manifestly less so for women. Emotional, tangible support and duration of social contacts show a moderate effect on the impact of life stressors on psychological distress which, however, is in a direction opposite to that proposed by the buffering hypothesis. Discussion: Social ties are generally protective, but may also be contributing, particularly for women, to increased psychological distress in the face of stressful life events.

Food insecurity and cognitive function in Puerto Rican adults

BACKGROUND Food insecurity is associated with nutrient inadequacy and a variety of unfavorable health outcomes. However, little is known about whether food security is associated with lower cognitive function in the elderly. OBJECTIVE We investigated the prevalence of food insecurity in a representative sample of 1358 Puerto Ricans aged 45-75 y living in Massachusetts in relation to cognitive function performances. DESIGN Food security was assessed with the US Household Food Security Scale. Cognitive function was measured to capture general cognition with a battery of 7 tests: Mini-Mental State Examination (MMSE), word list learning (verbal memory), digit span (attention), clock drawing and figure copying (visual-spatial ability), and Stroop and verbal fluency tests (fluency executive functioning). RESULTS The overall prevalence of food insecurity during the past 12 mo was 12.1%; 6.1% of the subjects reported very low food security. Food insecurity was inversely associated with global cognitive performance, as assessed by the MMSE score. The adjusted difference in the MMSE score was -0.90 (95% CI: -1.6, -0.19; P for trend = 0.003) for a comparison of participants with very low food security with those who were food secure, after adjustment for age, smoking, education, poverty status, income, acculturation, plasma homocysteine, alcohol, diabetes, and hypertension. Food insecurity was significantly associated with lower scores for word-list learning, percentage retention, letter fluency, and digit span backward tests. CONCLUSIONS Very low food security was prevalent among the study subjects and was associated with lower cognitive performance. Further studies, both observational and experimental, are warranted to clarify the direction of causality in this association.

Acculturation and sociocultural influences on dietary intake and health status among Puerto Rican adults in Massachusetts.

BACKGROUND Previous studies have shown negative consequences of acculturation on lifestyle factors, health status, and dietary intake of Hispanic immigrants in the US. Despite prevalent type 2 diabetes and low socioeconomic status (SES) among Puerto Rican adults living on the US mainland, little is known about acculturation in this group. OBJECTIVE We investigated associations among acculturation, lifestyle characteristics, health status, and carbohydrate nutrition in Puerto Rican adults. A secondary objective was to investigate possible confounding and/or effect modification on these associations by SES. DESIGN Cross-sectional data from the Boston Puerto Rican Health Study, which included 1219 Puerto Ricans in the Boston area, aged 45-75 years. STATISTICAL ANALYSES Characteristics were compared using ANCOVA, linear trend and Pearsons chi-square tests across quartiles of acculturation. Tests for interaction by poverty status were conducted. Proportional contributions of foods to intake of total carbohydrate and fiber were assessed using SAS RANK. RESULTS Levels of acculturation were low, despite young age at first arrival to the US mainland (25.4 ± 12.3 y) and long length of stay (34.2 ± 12.2 y). Greater English language use was associated with higher SES, alcohol consumption, physical activity, better perceived health, and less central obesity. Acculturation was associated with lower legume fiber and greater cereal fiber intake. Among those above the poverty threshold, acculturation was associated with lower dietary glycemic index and starch intake, and greater fruit and non-starchy vegetable intake. CONCLUSIONS In contrast to studies with Mexican Americans, the association of acculturation with dietary quality in these Puerto Rican adults was mixed, but tended toward better carbohydrate quality. Dietary recommendations should include maintenance of traditional, healthful dietary practices including consumption of legumes, but also reduction in refined grains, and greater inclusion of fruit, non-starchy vegetables, and whole grains. Interventions to improve access to better quality carbohydrate sources are necessary for this group disproportionately affected by diabetes.

Physical function and health status in aging Puerto Rican adults: the Boston Puerto Rican Health Study.

Objectives: This article describes physical function in Puerto Rican older adults and examines associations between health status and physical function. It also assesses relationships between physical function and disability. Method: This study uses a cross-sectional study of Puerto Ricans 45 to 75 years in Boston (N = 1,357). Measures included performance-based physical function (handgrip strength, walking speed, balance, chair stands, foot tapping), health conditions (obesity, diabetes, depressive symptomatology, history of heart disease, heart attack, stroke, and arthritis), and self-reported disability (activities of daily living, instrumental activities of daily living). Results: Older women (60-75 years) had the poorest physical function. Poor physical function was associated with obesity, diabetes, depression, history of heart attack, stroke, and arthritis, after adjusting for age, sex, education, income, and lifestyle (p < .05). Physical function and disability were correlated (p < .01). Discussion: Health status among Puerto Ricans appears to contribute to poor physical function. Targeted interventions to improve strength, endurance, and balance are needed to combat physical frailty and its consequences in this population.

Perceived problems with access to medical care and depression among older Puerto Ricans, Dominicans, other Hispanics, and a comparison group of non-Hispanic Whites.

The relationship between problems accessing medical care and depression is examined in a sample of older Hispanics (Puerto Rican, Dominican, and Other Hispanic) in Massachusetts and a comparison group of same-neighborhood non-Hispanic Whites. The research questions are: Do older Hispanics experience more problems with access to medical care than do older non-Hispanic Whites? What types of access problems do Hispanics encounter, and how do these relate to depression symptoms? The data come from the Massachusetts Hispanic Elders Study; descriptive and multivariate regression analysis procedures are used. Older Hispanics report more problems obtaining medical care than do older non-Hispanic Whites. Puerto Ricans report significantly more transportation problems to access medical care. For Dominicans and Puerto Ricans, being female, living alone, and lower education attainment are associated with depression. For Puerto Ricans, health problems, disability, and access problems are also significant.