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Suboptimal Management of Cardiovascular Risk Factors Among Non-US-Citizen Immigrants

2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 3 Linguagem: Inglês

10.1161/circoutcomes.120.006498

1941-7705

Miguel Cainzos‐Achirica, Khurram Nasir,

Global Health Workforce Issues

HomeCirculation: Cardiovascular Quality and OutcomesVol. 13, No. 3Suboptimal Management of Cardiovascular Risk Factors Among Non-US-Citizen Immigrants Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBSuboptimal Management of Cardiovascular Risk Factors Among Non-US-Citizen ImmigrantsTime to Build a Healthier Immigrant Workforce in the United States Miguel Cainzos-Achirica, , MD, MPH, PhD and Khurram Nasir, MD, MPH, MSc Miguel Cainzos-AchiricaMiguel Cainzos-Achirica Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (M.C.-A., K.N.). and Khurram NasirKhurram Nasir Khurram Nasir, MD, MPH, MSc, Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin St, Suite 1801, Houston, TX 77030. Email E-mail Address: [email protected] Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD (M.C.-A., K.N.). Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX (K.N.). Center for Outcomes Research, Houston Methodist, TX (K.N.). Originally published10 Mar 2020https://doi.org/10.1161/CIRCOUTCOMES.120.006498Circulation: Cardiovascular Quality and Outcomes. 2020;13:e006498This article is a commentary on the followingCitizenship Status and the Prevalence, Treatment, and Control of Cardiovascular Disease Risk Factors Among Adults in the United States, 2011–2016See Article by Guadamuz et alThe history of the United States is a history of immigration. According to the Colonial and Pre-Federal Statistics, <5000 non-native people lived in the American colonies in 1630, the majority of whom were European-born.1 After almost 4 centuries of massive immigration from all over the world, the United States now comprises a multiracial, multiethnic population of 328 million men and women including whites, African Americans, Asians, American Indians, Alaska Natives, Native Hawaiians, other Pacific Islanders, and persons of Hispanic ethnicity.2As of 2020, immigration remains a major, growing demographic phenomenon in the United States and is one of the fuels that sustain the economic growth of the country.3 According to the Migration Policy Institute, 44.5 million foreign-born persons lived in the United States as of 2017, as compared with 31.1 million in 2000, representing a 43% increase. Of them, half had non-US-citizen legal status, and Hispanics represented the largest racial/ethnic group (44%).4Voluntary (ie, nonforced) migration to a foreign country is an enthralling experience. Specifically, persons who move to the United States leave their homes and families in the pursue of a better life and more fulfilling professional opportunities. However, this fascinating journey comes with a number of challenges, one of the most prominent being access to health care. The barriers are multiple, from obvious ones such as language or limited understanding of how to navigate the system—which can be particularly intricate for persons coming from countries with universal coverage and strong public healthcare systems—to more complex hurdles such as limited availability of healthcare services in certain areas, insufficient healthcare coverage, and cost of care. These obstacles are typically greater among immigrants with low education and/or income, features which typically cluster among noncitizens.5Altogether, these barriers can have negative implications for the health of these individuals; and this may be particularly true regarding their ability to prevent cardiovascular disease (CVD), which is a major killer in the United States.6 Metabolic cardiovascular risk factors, such as high blood cholesterol levels, insulin resistance, and high blood pressure are latent, chronic processes, and their potential long-term consequences may not be perceived as immediate health priorities worth devoting a share of some already limited resources. This may result in the under- and late detection of these risk factors, and in their suboptimal lifestyle and pharmacological management once identified. Although many immigrant groups living in the United States traditionally have had lower CVD rates than the local population7 (a phenomenon also observed in Canada8), suboptimal control of risk factors over time may eventually remove any healthy immigrant protection and increase the risk of developing CVD in these very large demographic groups.9In this issue of Circulation: Cardiovascular Quality and Outcomes, Guadamuz et al5 illustrate some of these issues. The authors described the prevalence, management, and metabolic control of 3 major cardiovascular risk factors among persons living in the United States, by US citizenship status. Compared with US-born citizens, immigrants had a markedly lower use of treatments for hypercholesterolemia, hypertension, and diabetes mellitus, as well as a worse metabolic control of these risk factors. Differences between immigrants and nonimmigrants were mostly driven by noncitizens and were particularly salient for the metabolic control of diabetes mellitus. Of note, noncitizens were more frequently poor, 35% had no usual source of health care and a staggering 52% were uninsured. The vast majority of these persons (60%) were of Hispanic ethnicity.5The results of the study by Guadamuz and colleagues are consistent with prior research conducted in the United States.10,11 But, is immigration a "social determinant of health"12 only in the US? Not really. In Catalonia, a Spanish region with universal healthcare coverage including for all legal immigrants, women above age 65 born in Latin America and sub-Saharan Africa use antidiabetic medications less frequently than local Spanish women despite a similar or even higher prevalence of diabetes mellitus; and South Asian immigrants have a much lower use of statins than the Spanish population despite an up to 7-fold higher prevalence of diabetes mellitus.13 Also, the metabolic control of diabetes mellitus among many immigrants living in Spain is far from optimal.14 Suboptimal management of cardiovascular risk factors among first-generation immigrants from low-income areas has been reported in other European countries with strong public healthcare systems,15 highlighting the fact that while healthcare coverage is key, it is not a panacea. Effectively caring for the health of immigrants coming from low-income areas requires more complex approaches.There are several examples of success stories. In Canada, a multiethnic society with strong policies that protect immigrants and minority groups and facilitate their access to care, the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) Immigrant Study not only confirmed low baseline CVD event rates in the majority of immigrant geographic groups living in Ontario but also demonstrated that longer duration of stay was not associated with increasing age-adjusted event rates for most of those groups.8 In the United Kingdom, persons of South Asian origin with diabetes mellitus now have less excess mortality risk associated with diabetes mellitus than local white Europeans, and this is believed to be the consequence of early detection and optimal management.16Socioeconomic factors are strong determinants of the prevalence and incidence of CVD at the population level, and interventions aimed at improving the socioeconomic conditions of vulnerable groups can lead to powerful, large health benefits.17 In the study by Guadamuz et al,5 lack of usual source of care and lack of health insurance were important independent predictors of poor risk factor treatment. Although the association between noncitizen status and risk factor management was attenuated after accounting for those factors, immigrants who had US citizenship (the largest racial/ethnic group also being persons of Hispanic ethnicity) had almost identical risk factor prevalence, treatment, and control than those of US-born citizens. These findings together with prior local and international research highlight the need to improve the social protection, health literacy, and insurance coverage of foreign persons working in the United States who are not granted US-citizen status18 and remove barriers preventing them from accessing care. This is particularly warranted among those developing the humblest jobs, most of whom are poor and of Hispanic origin. Should these "privileges" be intrinsically tied to US citizenship, then access to such status should be facilitated to build a healthier US immigrant workforce.DisclosuresDr Nasir and Dr Cainzos-Achirica declare that they are both non-US-born immigrants. Dr Nasir is supported by the Jerold B. Katz Academy of Translational Research.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Khurram Nasir, MD, MPH, MSc, Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin St, Suite 1801, Houston, TX 77030. Email [email protected]orgReferences1. United States Census Bureau. Colonial and Pre-Federal Statistics.2004. https://www2.census.gov/prod2/statcomp/documents/CT1970p2-13.pdf. Accessed 18 January 2020.Google Scholar2. United States Census Bureau. Quick Facts. Table.https://www.census.gov/quickfacts/fact/table/US/PST045219#. Accessed 18 January 2020.Google Scholar3. La Monica PR. America needs more immigrants to keep economy growing. CNN Business. https://www.cnn.com/2019/08/27/investing/david-kelly-markets-now-preview/index.html. Published August 27, 2019. Accessed 18 January 2020.Google Scholar4. Migration Policy Institute. State Immigration Data Profiles. United States; https://www.migrationpolicy.org/data/state-profiles/state/demographics/US. Accessed 18 January 2020.Google Scholar5. Guadamuz JS, Durazo-Arvizu RA, Daviglus ML, Calip GS, Nutescu EA, Qato DM. Citizenship status and the prevalence, treatment, and control of cardiovascular disease risk factors among adults in the United States, 2011-2016.Circ Cardiovasc Qual Outcomes. 2020; 13:e006215. doi: 10.1161/CIRCOUTCOMES.119.006215LinkGoogle Scholar6. 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Association of birthplace and coronary heart disease and stroke among US adults: national health interview survey, 2006 to 2014.J Am Heart Assoc. 2018; 7:e008153. doi: 10.1161/JAHA.117.008153LinkGoogle Scholar8. Tu JV, Chu A, Rezai MR, Guo H, Maclagan LC, Austin PC, Booth GL, Manuel DG, Chiu M, Ko DT, Lee DS, Shah BR, Donovan LR, Sohail QZ, Alter DA. The incidence of major cardiovascular events in immigrants to Ontario, Canada: the CANHEART Immigrant Study.Circulation. 2015; 132:1549–1559. doi: 10.1161/CIRCULATIONAHA.115.015345LinkGoogle Scholar9. Rodriguez F, Hastings KG, Hu J, Lopez L, Cullen M, Harrington RA, Palaniappan LP. Nativity status and cardiovascular disease mortality among Hispanic adults.J Am Heart Assoc. 2017; 6:e007207. doi: 10.1161/JAHA.117.007207LinkGoogle Scholar10. Ku L, Matani S. Left out: immigrants' access to health care and insurance.Health Aff (Millwood). 2001; 20:247–256. doi: 10.1377/hlthaff.20.1.247CrossrefMedlineGoogle Scholar11. 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Contributions of the IDIME study.Rev Esp Cardiol (Engl Ed). 2013; 66:39–46. doi: 10.1016/j.recesp.2012.07.016CrossrefMedlineGoogle Scholar15. Sanchez-Ramirez DC, Krasnik A, Kildemoes HW. Do immigrants from Turkey, Pakistan and Ex-Yugoslavia with newly diagnosed type 2 diabetes initiate recommended statin therapy to the same extent as danish-born residents? A nationwide register study.Eur J Clin Pharmacol. 2013; 69:87–95. doi: 10.1007/s00228-012-1306-6CrossrefMedlineGoogle Scholar16. Johns E, Sattar N. Cardiovascular and mortality risks in migrant south asians with type 2 diabetes: are we winning the battle?Curr Diab Rep. 2017; 17:100. doi: 10.1007/s11892-017-0929-5CrossrefMedlineGoogle Scholar17. Rose G. The Strategy of Preventive Medicine. Oxford University Press, Oxford; 1992.Google Scholar18. Stimpson JP, Wilson FA. Medicaid expansion improved health insurance coverage for immigrants, but disparities persist.Health Aff (Millwood). 2018; 37:1656–1662. doi: 10.1377/hlthaff.2018.0181CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Guadamuz J, Kapoor K, Lazo M, Eleazar A, Yahya T, Kanaya A, Cainzos-Achirica M and Bilal U (2021) Understanding Immigration as a Social Determinant of Health: Cardiovascular Disease in Hispanics/Latinos and South Asians in the United States, Current Atherosclerosis Reports, 10.1007/s11883-021-00920-9, 23:6, Online publication date: 1-Jun-2021. Satish P, Sadaf M, Valero-Elizondo J, Grandhi G, Yahya T, Zawahir H, Javed Z, Mszar R, Hanif B, Kalra A, Virani S, Cainzos-Achirica M and Nasir K (2021) Heterogeneity in cardio-metabolic risk factors and atherosclerotic cardiovascular disease among Asian groups in the United States, American Journal of Preventive Cardiology, 10.1016/j.ajpc.2021.100219, 7, (100219), Online publication date: 1-Sep-2021. Related articlesCitizenship Status and the Prevalence, Treatment, and Control of Cardiovascular Disease Risk Factors Among Adults in the United States, 2011–2016Jenny S. Guadamuz, et al. Circulation: Cardiovascular Quality and Outcomes. 2020;13 March 2020Vol 13, Issue 3 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.120.006498PMID: 32151147 Originally publishedMarch 10, 2020 Keywordslifestyleimmigrationdiabetes mellituscardiovascular diseaseEditorialsPDF download Advertisement SubjectsPrimary PreventionQuality and OutcomesRace and Ethnicity