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As part of the Boricua Youth Study – Health Assessment study, which examines the cardiovascular health of Puerto Rican young adults in the San Juan metro area in Puerto Rico and the South Bronx, NY, we recently published on the prevalence of cardiometabolic risk factors and ideal cardiovascular health (CVH) among this population.

The BYS-HA study conducted home visits to collect objective anthropometric, blood pressure and blood samples when participants were on average 23 years of age. Information on diet, physical activity and sleep were collected via surveys. In addition to calculating measures of obesity, diabetes and hypertension we also calculated a measure of ideal cardiovascular Health (CVH). We utilized the American Heart Association, Life’s Essential 8 metric which includes 8 markers of cardiovascular health: adequate sleep, healthy diet, physical activity, no tobacco exposure, blood pressure, weight status, diabetes and lipids. We characterized CVH scores as continuous with higher scores indicating more optimal CVH and categorically (80-100 scores for ideal CVH). We examined different prevalence of cardiometabolic risk factors and CVH by site (NY vs PR) and by sex.

In this sample of 759 participants, 413 of the participants lived in Puerto Rico with 346 in the South Bronx NY. The mean age of participants was 22.6 years and 50% were female. Twenty-seven percent of the sample received public assistance in young adulthood. Overall, there was a high prevalence of obesity and high HBA1C (≥5.7, a measure of diabetes risk) with noted differences across study site. Participants in NY had a higher prevalence of obesity (35% in NY and 19% in PR) and hypertension (8% in NY and 2% in PR). Across both sites, men had a higher prevalence of hypertension, but women had a higher prevalence of obesity and low total cholesterol compared to men. In both NY and PR, women had better blood pressure and lipids but lower physical activity compared to men. In PR, women also had better diet and nicotine exposure scores compared to men.

Mean CVH score among NY participants was lower (61.9) than in PR (68.9). No participant had all ideal health metrics, 36% of participants in PR had 5 or more ideal CVH; while only 16% in NY met this criterion.

Our findings suggest sociocultural factors can influence cardiometabolic health measures. Overall, 4 of the 7 metrics examined were worse in the NY population compared to PR. In PR, measures of diet and PA were worse compared to the NY site. While study participants are ethnically homogenous, Puerto Ricans living in NY are considered and ethnic minority while those living in Puerto Rico are the ethnic majority, experiences of discrimination and racism may differ across groups. Furthermore, BYS participants live in distinct social, political, cultural and built environments. Differences between sites based on access to food, recreational facilities and walkability of neighborhoods could explain noted cardiometabolic differences. Similarly social, political, and cultural factors, including economic and political instability, structural racism, adequate health care access and educational and occupational opportunities differ across sites. Interventions to maintain and improve CVH across the life course, tailored to sociocultural environments, are necessary for the prevention of cardiovascular disease.

https://www.sciencedirect.com/science/article/abs/pii/S1047279723002144

In the United States (U.S.), roughly one in three adults has hypertension, and the burden of hypertension is particularly high among African American populations (African American: 40.3%; White: 27.8%). Existing literature has demonstrated that experiencing stress is positively associated with hypertension. Coping strategies, or how individuals respond to stress, have been hypothesized to explain disparate associations between stress and hypertension.

Whether directly stated or implied, public health has historically tended to focus on behavioral and individual- level explanations for understanding patterns in racial/ethnic or class health inequities. Past research has demonstrated that attributing health disparities to poorer health behaviors (e.g., not following recommended guidelines) and individual-level factors without accounting for the broader social context in which they arise is insufficient and inaccurate in seeking to understand and address disparities.

This research examined the association between avoidant coping (often perceived to be maladaptive, individual-level behavior) and hypertension while assessing potential differences by race. Additionally, we assessed this relationship both with regard to coping responses to discrimination and stress more generally.

We found that avoidant coping in response to the general stress and discrimination was associated with increased hypertension among White respondents and no associations among African American respondents. This research suggests that racial disparities in hypertension may not be attributable to individual-level coping behaviors.

As this paper examined coping in relation to hypertension, we are not suggesting that general stress and discrimination do not impact the cardiovascular health of African Americans. The impacts of stress and discrimination on cardiovascular health are well supported by the literature, which we suggest be a continued area of research.

We recommend further research build on examinations of stress and social context as determinants of hypertension. Our findings call for a nuanced analytic approach that situates findings within broader social contexts that shape both stressors and coping responses when studying relationships between coping and health. To mitigate the impacts of stress on hypertension, we recommend health interventions not only address individual-level behavior change but also address policies that reinforce health disparities at the structural level.

Read the full paper: Batayeh, B., Shelton, R., Factor-Litvak, P. et al. Racial Disparities in Avoidant Coping and Hypertension Among Midlife Adults. J. Racial and Ethnic Health Disparities (2022). https://doi.org/10.1007/s40615-022-01232-7
https://link.springer.com/article/10.1007%2Fs40615-022-01232-7

Accountability groups and writing groups are fairly common, particularly in academic settings, where students and faculty may have a variety of roles and shifting demands. A quick Google search yields posts from people seeking groups to join, and institution-specific groups for students or faculty to join. A Pub-Med search even identified a study examining differences in “scholarly production” from participants of a faculty research/writing group compared to a matched group of faculty not participating in the group. The results indicated that participation in the group provided junior faculty with the support system needed to feel confident, and that over time, faculty in the group increased their productivity. (https://www-sciencedirect-com.proxy.library.emory.edu/science/article/pii/S1877129716301459)

I joined the SDOH-LIFE research group in the spring of 2019 to begin a project examining cumulative social stress and childhood obesity using data from the Early Childhood Longitudinal Study – Kindergarten Class 2010-11 (ECLS-K:2011). In the fall of 2019, four fellow PhD students and I started an accountability group to motivate ourselves and try to remain productive in the amorphous post-coursework days of our PhD program. We are all completing our PhDs in Epidemiology, though in a variety of different topic areas, and the group has since become integral to our productivity and progress. Our accountability not only serves as a place for goal-setting and planning, but a sounding board for advice, and navigating imposter syndrome and mentor relationships.

Through that first semester we learned what worked and what did not work for our group, and tried to make progress on various projects and dissertations. Probably most importantly, we learned more about each other and how to support each other in the PhD program. Ultimately, the accountability group has seen its members through successful grant submissions, PhD milestones, and of course the pandemic and transition to working from home. During the pandemic we continue to meet via zoom, though those first months were mostly spent figuring out how to make our new reality work for us.

Since its inception, our AG has settled on some best practices and lessons learned for our group that could be adapted for others:

• Block off the time on your calendar, and treat it like you would any other meeting
• Have some kind of tracking document for short and long term goal setting
• Keep track of accomplishments!
• Check in at regular intervals for wrap-up and next set of long term goals (semesters, quarterly, etc.)
• Be ready to talk about both what you did and how you did it – we have had a lot of success with helping each other identify processes that work!

Since joining the SDOH-Life Research group, I have also worked on other projects examining bullying and school connectedness in relation to adolescent adiposity in the Fragile Families Child and Wellbeing Study, completed my dissertation proposal and moved into candidacy, submitted pre-doctoral grants, and worked on other projects outside of the research group – and I did most of this while working from home! While it is possible I could have done all these things without an accountability group, the group provided structure and community to help me navigate the challenges of academic life while keeping my sanity intact.

We are excited to announce we have received a new R01 award (R01MD015204) from NIMHD to examine the association between social stressors, in relation to DNA methylation, mitochondrial DNA (mtDNA) damage and cardiometabolic health, among children participating in the Hispanic Community Health Study /Study of Latinos (HCHS/SOL) Youth Study. The HCHS/SOL Youth study is a study of US Latinos, representing varied countries of origin, conducted in the US. Existing blood samples will be assayed for DNA methylation age, genome-wide methylation and a mtDNA damage marker.  Cardiometabolic health markers (obesity, diabetes, hypertension, inflammation and lipids) have also been assessed. Existing data also includes assessments of current family environment as well as socio-cultural factors among children. Specifically, we will examine 1) whethersocial and economic stressors are associated with DNA methylation age, mtDNA damage and genome-wide methylation; 2) whether DNA methylation age, genome-wide methylation and mtDNA damage is associated with cardiometabolic health among children and 3) whether socio-cultural factors (i.e, ethnic identity, parental closeness, place of birth) modify the association between social and economic stress and DNA methylation and mtDNA damage association. This project is in collaboration with Dr. Carmen Isasi at Albert Einstein College of Medicine and compliments our ongoing Social stress and epigenetics study among HCHS/SOL adult participants (R01MD013320).

There are more than 44 million immigrants in the U.S. who make up approximately 14 percent of the U.S. population. For these immigrants, a complex system of federal, state, and local policies determines their rights and their eligibility for resources and services based on their immigration status and length of residence in the U.S. In doing so, these policies influence immigrants’ ability to incorporate socially and economically into U.S. society and can have implications for their health and for the health of their families. For example, in the U.S., having health insurance is associated with better health care usage, better quality of care, and better health outcomes. Current federal policies restrict unlawfully present immigrants (undocumented immigrants) from receiving Medicaid and from purchasing insurance coverage through the Health Insurance Marketplace®, even though many undocumented immigrants pay taxes and provide economic and social contributions to U.S. society, including working as frontline essential workers. Restrictions are sometimes not limited to undocumented immigrants. Some lawfully present immigrants face a five-year waiting period before they are eligible for Medicaid, a practice which began in 1996 under the Personal Responsibility and Work Opportunity Act. Using state-level funds, some states opted to offer coverage to pregnant women and/or children up who had not met the five-year eligibility and in 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) allowed states to opt to use federal funding to provide coverage for these special groups. In January 2020, 11 states still do not provide this coverage. 

Non-healthcare policies also affect health through access to employment, driver’s licenses and other resources, and increased policing. For example, states that restrict undocumented immigrants from obtaining state driver’s licenses, limit the mobility of these immigrants, which can limit access to employment opportunities and threaten their family’s financial wellbeing, can limit access to clinics and force a delay care seeking when needed, and can increase experiences of policing, identification and apprehension through strategically placed police license, insurance, and registration checkpoints. When policies limit the health care access, employment opportunities, and mobility of caregivers, the policies limit the family resources needed for children to thrive. 

Understanding that policies that affect adult immigrants may also affect the children in their families, we conducted a systematic review of quantitative studies published between 1986 and 2020 that examined the relationship between immigrant-related policies in the U.S. and the mental and physical health of infants, children, and adolescents living in immigrant families. After screening more than 7,000 studies, we identified only 17 studies that specifically examined the effect of a policy on the health of these youth. Among the 12 policies examined in these studies were the Personal Responsibility and Work Opportunity Act, Arizona Senate Bill 1070 (the infamous “Show me your papers” omnibus law), and the Deferred Action for Childhood Arrivals (DACA) program. Most studies (58%) examined birth outcomes and the remaining studies examined additional outcomes in childhood and adolescence such as self-rated health, food insecurity, and school days missed. While there were studies that did not observe an association between policies and the health of these youth, especially for birth outcomes, among those studies that did find an association, restrictive policies were generally associated with worse health outcomes and inclusive policies were associated with better health outcomes.

Our review highlights that immigrant-related policies can be structural drivers of health not just for adults targeted by these laws, but also for the children living in immigrant families. These findings support a rich body of qualitative research that has found that immigrant-related policies affect the health and wellbeing of immigrant families, especially undocumented and mixed status families. Our review also highlights that even though our search spanned a 30-year period during which several immigrant-related policies were passed at all levels of government, there are very few quantitative studies that have examined the effects of these policies on the health of youth living in immigrant families. Further, while we made no restrictions on the race/ethnicity of the study populations, nearly all of the studies focused on or included immigrants from Latin America, highlighting the burden that these laws place on Latinx immigrants and their families. With growing support for the study of structural drivers of health, it is time to push forward the study of immigrant-related policies, which are forms of structural racism and xenophobia. 

Read the full paper: Crookes, D. M., Stanhope, K. K., Kim, Y. J., Lummus, E., & Suglia, S. F. (2021). Federal, State, and Local Immigrant-Related Policies and Child Health Outcomes: a Systematic Review. Journal of racial and ethnic health disparities, 1-11. https://link.springer.com/article/10.1007/s40615-021-00978-w