Debunking Paradoxes: Integrating Complexity in Cardiovascular Disease Research Among Latino Populations

C onsistent with the migration history of the United States, immigrants today represent a large and important segment of the population and the nation’s health. Latino/ Hispanic (herein Latino) individuals represented more than half of the growth of the US population from 2000 to 2010 and are projected to represent 30% of the population by 2060. The growth of the Latino population in the United States is a function of both migration and US-born descendants, as nearly 1 in 4 young people enrolled in school today are of Latino origin. Although research on the health of Latino communities has not kept pace with this fast-growing population, several key findings have emerged over the past few decades. First, all-cause mortality rates tend to be lower among Latinos than their non-Latino white counterparts, with some evidence suggesting that methodological issues may explain this health advantage in part but not fully. Second, abundant evidence indicates that Latino groups have a disproportionate burden of cardiovascular disease (CVD) risk factors. The Hispanic Community Health Study/Study of Latinos is the largest epidemiological study of Latino people living in the United States and showed a high prevalence of obesity, diabetes mellitus, hypertension, and physical inactivity, the latter a particularly modifiable health behavior consistently associated with better health. Nonetheless, age-adjusted CVD mortality rates remain lower among Latinos than non-Latino whites. This apparent health advantage is often referred to as the Latino health paradox, given that Latino people are more likely to live in poverty, have lower educational attainment, and often lack health insurance access. Third, and finally, studies indicate that the health of Latinos varies by ethnic group, migration, and “acculturation”-related factors such as nativity, generational status, age at migration, length of time in the United States, and English language proficiency. For example, although all Latino populations have lower CVD mortality than non-Latino white populations, there are striking differences in the prevalence of cardiovascular risk factors and CVD mortality across Latino subgroups and by nativity status. Puerto Ricans have the highest smoking prevalence and Mexicans have one of the lowest, whereas US-born Latino people overall and regardless of country of origin experience lower CVD mortality relative to their foreign-born counterparts. Similarly, research suggests that the relationship between any of these acculturation proxies and health may differ depending on the outcome examined. Increased English language proficiency may exert a detrimental effect on health if it is a proxy for adoption of health-damaging behaviors such as smoking, physical inactivity, and poor diet, all of which are prevalent problems in the United States. Conversely, increased English language proficiency has been associated with improved health outcomes among those diagnosed with CVD or associated risk factors, such as diabetes mellitus, where language proficiency is essential for proper disease care and management. In this issue of the Journal of the American Heart Association (JAHA), Rodriguez and colleagues build on this prior research to consider how broader social environments influence CVD mortality among Latino communities. The authors characterized counties where CVD deaths occurred according to the proportion of the population of the county that was of Latino origin. This measure of the social environment is based on theories of “ethnic enclaves,” which suggest that living in an area with a high concentration of immigrants or coethnic peers can provide cultural, emotional, and material resources that can support health. Of the counties included in the study sample, nearly 35% had a Latino ethnic concentration that ranged from 20% to as high as 96%. However, as Latino density increased, so did poverty, unemployment, lack of English language proficiency, and limited health insurance or access to primary care physicians. Contrary to their hypothesis, the authors found that increased Latino ethnic density was positively associated with CVD The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the UNC Greensboro, Greensboro, NC. Correspondence to: Sandra E. Echeverria, PhD, MPH, Department of Public Health Education, UNC Greensboro, 1408 Walker Avenue, 437-F Coleman, Greensboro, NC 27412. E-mail: seecheve@uncg.edu J Am Heart Assoc. 2018:7:e010434. DOI: 10.1161/JAHA.118.010434. a 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.