Appendix 1a Daviglus et al Prevalence of CVD risk Factors

ORIGINAL CONTRIBUTION

Prevalence of Major Cardiovascular
Risk Factors and Cardiovascular Diseases
Among Hispanic/Latino Individuals
of Diverse Backgrounds in the United States
Martha L. Daviglus, MD, PhD
Gregory A. Talavera, MD, MPH
M. Larissa Avile´s-Santa, MD, MPH
Matthew Allison, MD, MPH
Jianwen Cai, PhD
Michael H. Criqui, MD, MPH
Marc Gellman, PhD
Aida L. Giachello, PhD
Natalia Gouskova, MS
Robert C. Kaplan, PhD
Lisa LaVange, PhD
Frank Penedo, PhD
Krista Perreira, PhD
Amber Pirzada, MD
Neil Schneiderman, PhD
Sylvia Wassertheil-Smoller, PhD
Paul D. Sorlie, PhD
Jeremiah Stamler, MD

I

N THE LAST DECADES, THE US HISpanic and Latino population has
increased dramatically, now comprising the nation’s largest minority group.1 Cardiovascular diseases
(CVDs) are leading causes of mortality
among Hispanic/Latino individuals in
the United States,2 and this relatively
young ethnic group is at high risk of
future CVD morbidity and mortality
as it ages. Evidence also suggests that
CVD risk factors and disease rates may
vary considerably among Hispanic/
Latino groups. Risk for CVDs among

See also pp 1768 and 1804.

Context Major cardiovascular diseases (CVDs) are leading causes of mortality among
US Hispanic and Latino individuals. Comprehensive data are limited regarding the prevalence of CVD risk factors in this population and relations of these traits to socioeconomic status (SES) and acculturation.
Objectives To describe prevalence of major CVD risk factors and CVD (coronary
heart disease [CHD] and stroke) among US Hispanic/Latino individuals of different
backgrounds, examine relationships of SES and acculturation with CVD risk profiles
and CVD, and assess cross-sectional associations of CVD risk factors with CVD.
Design, Setting, and Participants Multicenter, prospective, population-based Hispanic Community Health Study/Study of Latinos including individuals of Cuban (n=2201),
Dominican (n=1400), Mexican (n=6232), Puerto Rican (n=2590), Central American
(n=1634),andSouthAmericanbackgrounds(n=1022)aged18to74years.Analysesinvolved
15 079 participants with complete data enrolled between March 2008 and June 2011.
Main Outcome Measures Adverse CVD risk factors defined using national guidelines for hypercholesterolemia, hypertension, obesity, diabetes, and smoking. Prevalence of CHD and stroke were ascertained from self-reported data.
Results Age-standardized prevalence of CVD risk factors varied by Hispanic/Latino
background; obesity and current smoking rates were highest among Puerto Rican participants (for men, 40.9% and 34.7%; for women, 51.4% and 31.7%, respectively);
hypercholesterolemia prevalence was highest among Central American men (54.9%)
and Puerto Rican women (41.0%). Large proportions of participants (80% of men,
71% of women) had at least 1 risk factor. Age- and sex-adjusted prevalence of 3 or
more risk factors was highest in Puerto Rican participants (25.0%) and significantly
higher (P⬍.001) among participants with less education (16.1%), those who were
US-born (18.5%), those who had lived in the United States 10 years or longer (15.7%),
and those who preferred English (17.9%). Overall, self-reported CHD and stroke prevalence were low (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively). In
multivariate-adjusted models, hypertension and smoking were directly associated with
CHD in both sexes as were hypercholesterolemia and obesity in women and diabetes
in men (odds ratios [ORs], 1.5-2.2). For stroke, associations were positive with hypertension in both sexes, diabetes in men, and smoking in women (ORs, 1.7-2.6).
Conclusion Among US Hispanic/Latino adults of diverse backgrounds, a sizeable
proportion of men and women had adverse major risk factors; prevalence of adverse
CVD risk profiles was higher among participants with Puerto Rican background, lower
SES, and higher levels of acculturation.
JAMA. 2012;308(17):1775-1784

Hispanic/Latino individuals has been
reported to differ by degree of acculturation and duration of residence in
the United States.3-7

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www.jama.com
Author Affiliations are Iisted at the end of this article.
Corresponding Author: Martha L. Daviglus, MD, PhD,
Institute for Minority Health Research, University
of Illinois at Chicago, 1819 W Polk St, Ste 246,
Chicago, IL 60612 ([email protected], daviglus
@northwestern.edu).
JAMA, November 7, 2012—Vol 308, No. 17 1775

CARDIOVASCULAR DISEASES AND HISPANICS/LATINOS IN THE UNITED STATES

Existing research on CVD risk factors among Hispanic/Latino groups in the
United States has largely involved Mexican-American individuals.2,8-10 The few
studies that have attempted to examine
differences in CVD risk factors within
this heterogeneous population have been
limited to a few Hispanic/Latino
groups11,12 or small sample sizes.13,14
This report expands the literature on
Hispanic/Latino health by describing the
prevalence of 5 major, readily measured biomedical CVD risk factors (high
serum cholesterol and blood pressure
levels, obesity, hyperglycemia/diabetes,
cigarette smoking), adverse CVD risk
profiles (combinations of CVD risk factors; ie, any 1 only, any 2 only, or ⱖ3 risk
factors), and CVD (coronary heart disease [CHD] and stroke) among US Hispanic/Latino adults of diverse backgrounds. Relationships of socioeconomic
status (SES), acculturation, and lifestyle factors with adverse CVD risk factor profiles and CVD were examined, and
cross-sectional associations of CVD risk
factors with self-reported CVD were assessed using data from the landmark Hispanic Community Health Study/Study of
Latinos (HCHS/SOL).
METHODS
The HCHS/SOL is a population-based
cohort study designed to examine risk
and protective factors for chronic diseases and to quantify morbidity and
mortality prospectively. Details of the
sampling methods and design have
been published.15,16 Briefly, between
March 2008 and June 2011, the HCHS/
SOL examined 16 415 self-identified
Hispanic/Latino persons aged 18 to 74
years recruited from randomly selected households in 4 US communities (Bronx, New York; Chicago, Illinois; Miami, Florida; San Diego,
California). Households were selected
using a stratified 2-stage area probability sample design. 15 Census block
groups were randomly selected in the
defined community areas of each field
center, and households were randomly selected in each sampled block
group. Households were screened for
eligibility, and Hispanic/Latino per1776

JAMA, November 7, 2012—Vol 308, No. 17

sons aged 18 to 74 years were selected
in each household agreeing to participate. Oversampling occurred at each
stage, with block groups in areas of Hispanic/Latino concentration, households associated with a Hispanic/
Latino surname, and persons aged 45
to 74 years selected at higher rates than
their counterparts. Sampling weights
were generated to reflect the probabilities of selection at each stage. The
HCHS/SOL included participants from
Cuban, Dominican, Mexican, Puerto Rican, Central American, and South
American backgrounds. The study was
approved by institutional review boards
at each participating institution; written informed consent was obtained
from all participants.

United States, generational status, and
language preference), cigarette smoking, physical activity (moderate/heavy
intensity work and leisure activities in
a typical week), and medical history.
Participants were instructed to bring all
prescription and nonprescription medications taken in the past month. Dietary intake was ascertained by two 24hour dietary recalls administered 6
weeks apart. A diet score was calculated by assigning participants a score
of 1 to 5 according to sex-specific quintile of daily intake of saturated fatty acids, potassium, calcium, and fiber (with
5 the most favorable quintile). The 4
scores were summed and the highest 40
percentile considered a healthier diet.18
Risk Factors, CHD, and Stroke

Examination Methods

Participants were asked to fast and refrain from smoking for 12 hours prior
to the examination and to avoid vigorous physical activity the morning of the
visit. Height was measured to the nearest centimeter and body weight to the
nearest 0.1 kg. Body mass index (BMI)
was calculated as weight in kilograms divided by height in meters squared. After a 5-minute rest period, 3 seated blood
pressure measurements were obtained
with an automatic sphygmomanometer; the second and third readings were
averaged. Blood samples, including
plasma glucose (fasting and after a
2-hour oral glucose load) were collected according to standardized protocols. Total serum cholesterol was measured using a cholesterol oxidase
enzymatic method and high-density lipoprotein (HDL) cholesterol with a direct magnesium/dextran sulfate method.
Plasma glucose was measured using a
hexokinase enzymatic method (Roche
Diagnostics). Low-density lipoprotein
(LDL) cholesterol was calculated using
the Friedewald equation.17 Hemoglobin A1c (HbA1c) was measured using a
Tosoh G7 Automated HPLC Analyzer
(Tosoh Bioscience).
Information was obtained by questionnaires on demographic factors, SES
(education and income), acculturation (including years of residence in the

Major CVD risk factors were defined
based on current national guidelines. Hypercholesterolemia and dyslipidemia
were defined as total cholesterol 240
mg/dL or greater, LDL cholesterol 160
mg/dL or greater, or HDL cholesterol less
than 40 mg/dL (for persons with and
without diabetes) or receiving cholesterol-lowering medication.19 Hypertension was a systolic blood pressure 140
mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or receiving
antihypertensive medication.20 Obesity
was defined as a BMI of 30.0 or greater.21
Diabetes mellitus was a fasting plasma
glucose 126 mg/dL or greater, 2-hourpostload plasma glucose 200 mg/dL or
greater, an HbA1c 6.5% or greater, or use
of antihyperglycemic medications.22
Smoking was defined as currently smoking cigarettes. (To convert total, LDL, and
HDL cholesterol to mmol/L, multiply by
0.0259; to convert glucose to mmol/L,
multiply by 0.0555.)
Prevalent CHD was defined as selfreported history of myocardial infarction, coronary bypass surgery, balloon angioplasty, or stent placement in
coronary arteries. Prevalence of stroke
was ascertained from self-reported history of stroke.
Statistical Analyses

All reported values (means, prevalence, and odds ratios [ORs]) were

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CARDIOVASCULAR DISEASES AND HISPANICS/LATINOS IN THE UNITED STATES

weighted to adjust for sampling probability and nonresponse.15,16 Descriptive characteristics, age-standardized to
the year 2010 US population, were computed by sex and for all participants by
Hispanic/Latino background. Additional analyses age-standardized to the
year 2000 US population were also conducted. Mean levels and prevalence of
individual risk factors, adverse CVD risk
profiles (ie, presence of 0, any 1 only,
any 2 only, any ⱖ3 risk factors), and
self-reported CVD were computed by
sex and by Hispanic/Latino group.
Prevalence was also assessed of various combinations of risk factors, and
self-reported CHD and stroke stratified by age and sex. Survey-specific procedures were used to compute 95% confidence intervals to account for the
2-stage sampling design, stratification, and clustering. Comparisons
across Hispanic/Latino groups were performed using the overall Wald test.
Age- and sex-adjusted prevalence of
adverse CVD risk profiles and selfreported CHD and stroke were calculated for the total cohort by age group
(sex-adjusted only), sex (age-adjusted
only), SES, acculturation, and lifestyle
factors. Similar analyses were done for
individual risk factors.
Logistic regression analyses were used
to examine associations of CVD risk factors with CHD and stroke prevalence for
men and women separately. Models were
adjusted for age only (model 1); age plus
all other major CVD risk factors (model
2); and all variables in model 2 plus education, annual family income, Hispanic/
Latino background, language preference,
nativity (US-born), Short Acculturation Scale for Hispanics (SASH) score,
physical activity, diet (model 3). Age,
years of education, years resided in the
United States, and SASH score were continuous variables, and the remaining variables were categorical. Odds ratios with
95% CIs were computed. All statistical
tests were 2-sided at a significance level
of .05. No adjustments were made for
multiple comparisons. All analyses
were performed using SAS version 9.2
(SAS Institute) and SUDAAN release
10.0.0 (RTI).

RESULTS
Household-level response rate was
33.5%. Of 39 384 individuals who were
screened and selected and who met eligibility criteria, 41.7% were enrolled,
representing 16 415 persons from 9872
households.
Of the 16 415 HCHS/SOL participants, 772 were excluded from analyses here because of missing data on total
cholesterol (n=16), BMI (n=48), cigarette smoking (n = 39), self-reported
CHD (n = 19), stroke (n = 9), or other
covariates (n=641). In addition, 9 participants 75 years and older and 555
participants who did not self-identify
as any of the 6 aforementioned Hispanic/Latino groups were excluded.
Thus, these analyses are based on data
from 15 079 participants (5979 men;
9100 women).
Participant Characteristics

Mean baseline ages standardized to year
2010 US population were similar in all
Hispanic/Latino groups (range 43 to
~44 years) (TABLE 1). About 15% of the
sample had a college degree, and 37%
had annual family income between
$20 000 and $50 000. Approximately
51% were married or living with a partner. Seventy percent had lived in the
United States for 10 or more years.
Spanish was the preferred language for
the majority (78%). These demographic characteristics varied across
Hispanic/Latino groups. Sex-specific
and other characteristics are described in eTable 1 and eTable 2 (available at http://www.jama.com).
Prevalence of Major CVD Risk
Factors

The overall prevalence of hypercholesterolemia was 52% among men and
ranged from 48% (Dominican and
Puerto Rican men) to 55% (Central
American men). In women, prevalence of hypercholesterolemia was 37%
and ranged from 31% (South American women) to 41% (Puerto Rican
women) (TABLE 2).
Overall, 25% of men had hypertension; hypertension prevalence was highest among Dominican men. Hyperten-

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sion prevalence overall among women
was 24%. The prevalence of hypertension ranged from 16% (South American women) to 29% (Puerto Rican
women) (Table 2).
About 37% of men were obese; prevalence of obesity ranged from 27%
(South American men) to 41% (Puerto
Rican men). Among women, overall
prevalence of obesity was 43%. Prevalence of obesity was highest among
Puerto Rican women (Table 2).
Overall, 17% of men and women
had diabetes. Prevalence ranged from
10% in South American men and
women to 19% in Mexican men and
women and Puerto Rican women
(Table 2).
About 26% of men were current
smokers, with highest prevalence of
smoking among Puerto Rican men.
Overall, current smoking prevalence in
women was low (15%). However, 32%
of Puerto Rican women and 21% of Cuban women were current smokers
(Table 2).
Mean levels of individual risk factors varied by Hispanic/Latino group
(eTable 3 and eTable 4). For example,
among men, those of Central American background had the highest mean
level of total cholesterol, and those of
Central and South American backgrounds had higher mean levels of LDL
cholesterol compared with others.
Among women, those of Cuban and
Central American background had
higher mean total cholesterol levels than
other groups; Cuban women also had
the highest average level of LDL
cholesterol.
About 15% of men and women
were currently using an antihypertensive medication. Use of antihypertensive medications was highest
among Dominican men; in women,
antihypertensive medication use was
higher among those of Puerto Rican
and Dominican backgrounds.
Dominican and Mexican men and
Puerto Rican women had the highest
rate of antihyperglycemic medication
use (eTable 3 and eTable 4).
When analyses were repeated on the
whole sample without exclusions other
JAMA, November 7, 2012—Vol 308, No. 17 1777

CARDIOVASCULAR DISEASES AND HISPANICS/LATINOS IN THE UNITED STATES

Table 1. Descriptive Characteristics for All Participants and by Hispanic/Latino Group (Age Standardized) a
% (95% CI)

Characteristic
Women, No.

All
(N = 15 079)

Cuban
(n = 2201)

Dominican
(n = 1400)

Mexican
(n = 6232)

Puerto Rican
(n = 2590)

Central
American
(n = 1634)

South American
(n = 1022)

9100

1167

920

3895

1523

986

609

Age, mean, y b

43.2 (43.1-43.3)

43.5 (43.3-43.7)

43.1 (42.9-43.3)

43.0 (42.9-43.2)

43.2 (43.0-43.4)

43.4 (43.2-43.6)

43.2 (42.9-43.4)

Education b
⬍High school

24.0 (20.4-28.0)

35.3 (33.8-36.8)

21.2 (19.2-23.4)

40.2 (36.9-43.6)

41.5 (38.9-44.2)

35.7 (32.8-38.8)

40.1 (36.9-43.5)

High school graduate

27.4 (26.4-28.5)

30.9 (28.2-33.7)

22.3 (19.0-25.9)

26.9 (25.4-28.5)

28.0 (25.8-30.4)

24.4 (21.7-27.2)

26.8 (23.5-30.4)

Some college

22.0 (20.9-23.1)

27.7 (25.1-30.5)

21.9 (19.2-24.9)

19.2 (17.7-20.9)

21.7 (19.1-24.5)

20.6 (17.8-23.8)

26.8 (23.4-30.4)

College degree

15.3 (14.0-16.6)

20.2 (17.5-23.2)

15.6 (13.4-18.1)

12.4 (10.2-14.9)

14.5 (12.6-16.7)

14.8 (12.6-17.4)

22.4 (19.3-25.9)
40.3 (36.1-44.6)

Annual family income, $ b
⬍20 000

42.6 (40.9-44.3)

45.1 (42.3-48.0)

50.9 (47.0-54.7)

38.0 (35.2-40.9)

44.0 (40.6-47.5)

47.3 (43.4-51.2)

20 000-50 000

37.3 (36.1-38.5)

31.4 (28.6-34.4)

32.4 (29.2-35.8)

42.2 (40.4-44.0)

33.6 (30.4-36.9)

34.6 (31.2-38.2)

40.0 (36.3-43.9)

⬎50 000

11.4 (10.1-12.9)

8.2 (6.3-10.7)

7.2 (5.3-9.5)

14.0 (11.7-16.6)

14.0 (11.9-16.4)

7.2 (5.6-9.3)

11.6 (9.3-14.4)

8.7 (8.0-9.4)

15.3 (13.2-17.5)

9.5 (7.8-11.6)

5.9 (5.1-6.7)

8.4 (7.1-9.9)

10.9 (9.1-12.9)

8.0 (6.0-10.7)

Not reported
Marital status b
Single

31.0 (29.9-32.1)

30.0 (27.6-32.4)

41.1 (37.9-44.4)

23.3 (21.9-24.8)

45.6 (42.5-48.8)

34.2 (31.4-37.1)

29.5 (26.5-32.7)

Married or living with a
partner

51.1 (49.6-52.5)

50.3 (47.3-53.2)

39.8 (36.2-43.5)

61.3 (59.2-63.3)

34.9 (31.9-38.1)

47.8 (44.6-51.1)

50.4 (46.5-54.3)

Separated, divorced, or
widowed

18.0 (17.0-18.9)

19.8 (17.9-21.7)

19.1 (16.5-22.0)

15.4 (14.1-16.9)

19.5 (17.2-21.9)

18.0 (15.8-20.4)

20.1 (17.4-23.1)

US residence ⬎10 y b

69.5 (67.6-71.4)

45.1 (41.1-49.1)

73.6 (70.0-76.9)

73.2 (71.1-75.3)

92.7 (90.9-94.2)

62.6 (58.8-66.3)

53.9 (49.4-58.3)

Immigrant generational status b
First

78.5 (77.1-79.8)

90.9 (88.4-93.0)

86.9 (83.8-89.5)

77.8 (75.9-79.6)

49.6 (47.1-52.2)

93.4 (91.1-95.1)

94.1 (91.8-95.8)

21.5 (20.2-22.9)

9.1 (7.0-11.6)

13.1 (10.5-16.2)

22.2 (20.4-24.1)

50.4 (47.8-52.9)

6.6 (4.9-8.9)

5.9 (4.2-8.2)

77.5 (75.9-79.0)

91.9 (88.9-92.9)

80.4 (76.8-83.7)

81.4 (79.6-83.1)

42.7 (39.4-46.2)

89.0 (86.0-91.4)

89.9 (87.1-92.1)

22.5 (21.0-24.1)

8.9 (7.1-11.1)

19.6 (16.3-23.2)

18.6 (16.9-20.4)

57.3 (53.8-60.6)

11.0 (8.6-14.0)

10.1 (7.9-12.9)

Health insurance b

50.9 (49.2-52.5)

40.0 (37.1-43.0)

72.3 (68.4-75.9)

44.7 (42.4-46.9)

77.3 (74.5-79.9)

34.4 (30.8-38.2)

41.9 (37.6-46.3)

Physical activity, higher 40% b,c

39.1 (37.9-40.2)

29.7 (27.3-32.3)

37.1 (33.1-41.2)

42.1 (40.3-43.8)

41.1 (38.3-44.0)

43.2 (40.1-46.2)

37.0 (33.1-41.1)

Diet score, higher 40% b,d

46.1 (44.2-48.0)

36.2 (33.6-38.9)

19.6 (17.0-22.5)

69.2 (67.3-71.0)

18.9 (16.6-21.3)

39.5 (36.2-43.0)

40.7 (36.8-44.7)

Second or higher
Language preference b
Spanish
English

a Values (except No. of women) are weighted for study design and nonresponse and age standardized to Census 2010 US population.
b P⬍.001.
c Higher sex-specific 40% of mean total physical activity.
d Diet score was calculated by assigning participants a score of 1-5 according to their sex-specific quintile of daily intake of saturated fatty acids, potassium, calcium, and fiber, with

5 representing the most favorable quintile (ie, lowest quintile of intake for saturated fatty acids and highest quintile of intake for potassium, calcium, and fiber). The 4 scores were
summed and the higher 40 percentile considered a healthier diet.

Table 2. Prevalence of Cardiovascular Disease Risk Factors for All Participants and by Hispanic/Latino Group and Sex (Age Standardized) a
% (95% CI)
Characteristic b
Men, No.
Hypertension c
Hypercholesterolemia
Obesity c
Diabetes mellitus c
Smoking c
Women, No.
Hypertension c
Hypercholesterolemia d
Obesity c
Diabetes mellitus c
Smoking c

All
5979
25.4 (24.1-26.7)
51.7 (50.1-53.3)
36.5 (34.7-38.3)
16.7 (15.5-17.9)
25.7 (24.1-27.4)
9100
23.5 (22.4-24.5)
36.9 (35.6-38.3)
42.6 (41.0-44.2)
17.2 (16.3-18.3)
15.2 (14.1-16.5)

Cuban
1034
28.9 (26.6-31.4)
53.7 (50.3-57.1)
33.6 (30.2-37.3)
13.2 (11.3-15.3)
31.1 (27.6-34.8)
1167
26.4 (24.5-28.3)
37.5 (33.8-41.4)
38.9 (35.3-42.7)
13.9 (12.0-16.0)
21.2 (18.6-24.0)

Dominican
480
32.6 (28.2-37.4)
47.6 (42.3-52.9)
38.6 (33.1-44.5)
18.2 (15.0-21.9)
11.1 (7.7-15.7)
920
26.1 (23.2-29.3)
33.1 (29.7-36.6)
42.5 (37.8-47.2)
18.0 (15.4-21.0)
11.7 (8.3-16.4)

Mexican
2337
21.4 (19.1-24.0)
53.9 (51.4-56.3)
36.8 (33.9-39.8)
19.3 (17.0-21.8)
23.1 (20.8-25.7)
3895
19.5 (17.8-21.3)
36.2 (30.4-38.4)
41.5 (38.8-44.2)
18.5 (16.8-20.2)
10.0 (8.3-11.9)

Puerto Rican
1067
27.4 (24.5-30.5)
48.2 (43.8-52.6)
40.9 (36.8-45.1)
16.2 (14.0-18.7)
34.7 (30.7-38.9)
1523
29.1 (26.4-31.9)
41.0 (36.9-45.1)
51.4 (47.6-55.1)
19.4 (17.0-22.1)
31.7 (28.3-35.2)

Central
American
South American
648
413
25.0 (21.8-28.5) 19.9 (16.0-24.4)
54.9 (50.5-59.1) 52.2 (45.3-58.9)
32.7 (28.7-36.9) 26.8 (22.4-31.9)
16.3 (13.1-20.1) 10.1 (7.2-14.1)
19.9 (16.4-24.0) 15.1 (11.0-20.4)
986
609
25.6 (22.9-28.4) 15.9 (13.2-19.0)
39.4 (35.4-43.5) 31.4 (27.3-35.8)
41.6 (37.9-45.4) 30.8 (26.0-36.0)
17.9 (15.0-21.3)
9.8 (7.8-12.3)
8.7 (6.7-11.2)
11.3 (8.6-14.8)

a Values (except No.) weighted for survey design and nonresponse and age standardized to Census 2010 US population.
b Hypertension was defined as systolic blood pressure ⱖ140 mm Hg, diastolic blood pressure ⱖ90 mm Hg, or receiving treatment. Hypercholesterolemia was defined as total

cholesterol ⱖ240 mg/dL, high-density lipoprotein cholesterol ⬍40 mg/dL, low-density lipoprotein cholesterol ⱖ160 mg/dL, or receiving treatment. Obesity was defined as a body
mass index ⱖ30, calculated as weight in kilograms divided by height in meters squared. Diabetes mellitus was defined as fasting glucose ⱖ126 mg/dL, 2-hour-postload plasma
glucose ⱖ200 mg/dL, hemoglobin A1c ⱖ6.5%, or use of diabetes medications. Smoking was defined as currently smoking cigarettes. (To convert total, LDL, and HDL cholesterol
to mmol/L, multiply by 0.0259; to convert glucose to mmol/L, multiply by 0.0555.)
c P⬍.001.
d P⬍.01.

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CARDIOVASCULAR DISEASES AND HISPANICS/LATINOS IN THE UNITED STATES

risk factors was significantly higher
(P⬍.001) with lower education or income. In general, participants with
lower income or education had higher
rates of smoking, diabetes, obesity, and
hypercholesterolemia (eTable 8). Compared with those who were less acculturated (ie, were foreign-born or firstgeneration immigrants, had lived in the
United States ⬍10 years, or for whom
Spanish was the preferred language),
more acculturated participants had
higher prevalence of 3 or more risk factors. In sensitivity analyses excluding
Puerto Rican participants (the most acculturated group who also had the highest prevalence of multiple risk factors), the magnitude of difference in
prevalence of 3 or more risk factors by
acculturation level was slightly lower;

17% had any 2 or 3 or more risk factors (Figure 1). Prevalence of 3 or more
risk factors was highest among Puerto
Rican women and lowest among South
American women. Specific combinations of individual risk factors by sex
are shown in eTable 5 and eTable 6.
The overall prevalence of CHD and
stroke was, respectively, 4% and 2% for
men and 2% and 1% for women. Prevalence of CHD was highest among Puerto
Rican men and women and Cuban and
Dominicanmen(5%);self-reportedstroke
was highest for Dominican men (4%) and
Puerto Rican women (2%) (eTable 7).
A significantly higher proportion of
men than women, and those aged 65
to 74 years compared with younger persons had 3 or more risk factors
(TABLE 3). Prevalence of 3 or more

than missing data for the major CVD
risk factors, prevalences were almost
identical to those in Table 2.
Prevalence rates age-standardized to
year 2000 US population were slightly
lower (~1 percentage point) than rates
reported earlier in this section.
CVD Risk Profiles
and Self-reported CVD

Overall, 31% of men had an adverse level
of any 1 major risk factor only (most
commonly hypercholesterolemia); 28%
and 21% had any 2 only or 3 or more
risk factors (FIGURE 1). Prevalence of
3 or more risk factors was highest
among Puerto Rican men and lowest
among South American men. Among
women, 30% had 1 risk factor only
(most commonly obesity); 23% and

Figure 1. Prevalence of Adverse Cardiovascular Disease Risk Profiles for All Participants and by Hispanic/Latino Group and Sex
Men

Women

No risk factors
All
Cuban
Dominican
Mexican
Puerto Rican
Central American
South American

No risk factors
All
Cuban
Dominican
Mexican
Puerto Rican
Central American
South American

1 Risk factor
All
Cuban
Dominican
Mexican
Puerto Rican
Central American
South American

1 Risk factor
All
Cuban
Dominican
Mexican
Puerto Rican
Central American
South American

2 Risk factors
All
Cuban
Dominican
Mexican
Puerto Rican
Central American
South American

2 Risk factors
All
Cuban
Dominican
Mexican
Puerto Rican
Central American
South American

≥3 Risk factors
All
Cuban
Dominican
Mexican
Puerto Rican
Central American
South American

≥3 Risk factors
All
Cuban
Dominican
Mexican
Puerto Rican
Central American
South American
0

10

20

30

40

50

Prevalence, % (95% CI)

0

10

20

30

40

50

Prevalence, % (95% CI)

Risk factors were hypercholesterolemia (serum total cholesterol ⱖ240 mg/dL or taking cholesterol-lowering medication), hypertension (systolic blood pressure
ⱖ140 mm Hg or diastolic blood pressure ⱖ90 mm Hg or taking antihypertensive medication), obesity (body mass index ⱖ30, calculated as weight in kilograms
divided by height in meters squared), diabetes mellitus (use of diabetes medication, fasting glucose ⱖ126 mg/dL, 2-hour-postload plasma glucose ⱖ200 mg/dL, or
hemoglobin A1c ⱖ6.5%), and smoking (current cigarette smoker). Values were weighted for survey design and nonresponse and adjusted for age. Error bars indicate 95% CI.

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Table 3. Number of Adverse CVD Risk Factors and Prevalence of Self-reported CVD (CHD and Stroke) by Age, Education, Income,
Acculturation, and Lifestyle Factors Among Hispanic/Latino Participants (Age and Sex Adjusted) a
% (95% CI)
Characteristic
Age group a
18-44

No Risk Factors b

1 Risk Factor b

2 Risk Factors b

35.8 (34.0-37.7) c

33.8 (32.2-35.5)

21.5 (20.1-22.9) c

ⱖ3 Risk Factors b
8.9 (8.0-9.8) c

CHD

Stroke

0.7 (0.5-1.2) c

0.6 (0.4-0.9) d

45-64

14.0 (12.9-15.3)

30.1 (28.6-31.7)

29.0 (27.5-30.6)

26.8 (25.2-28.5)

4.5 (3.9-5.2)

2.0 (1.6-2.5)

65-74

6.5 (4.7-8.8)

18.0 (15.2-21.1)

32.5 (28.7-36.5)

43.1 (39.4-46.8)

9.0 (7.2-11.3)

4.3 (3.2-5.8)

Sex a
Male
Female
Education
⬍High school

19.4 (17.8-21.1) c

34.1 (32.3-36.0)

29.2 (27.5-31.0) c

17.2 (15.8-18.8) c

2.0 (1.5-2.6) c

1.2 (0.8-1.7) d

30.4 (28.9-32.0)

33.5 (31.9-35.1)

23.7 (22.3-25.2)

12.4 (11.5-13.4)

1.1 (0.8-1.5)

0.7 (0.5-1.0)
0.9 (0.6-1.2)

21.2 (19.3-23.2) c

34.8 (32.9-36.7)

27.1 (25.5-28.9) d

16.9 (15.5-18.4) c

1.6 (1.1-2.4)

High school graduate

23.6 (21.8-25.5)

32.9 (30.7-35.1)

28.7 (26.5-31.1)

14.8 (13.3-16.4)

1.3 (1.0-1.7)

1.0 (0.6-1.5)

Some college

26.0 (23.9-28.3)

34.8 (32.2-37.6)

25.9 (23.6-28.3)

13.3 (11.8-14.9)

1.5 (1.0-2.1)

1.0 (0.6-1.5)

College degree

32.5 (29.0-36.3)

33.9 (30.8-37.2)

21.7 (19.4-24.2)

11.8 (9.9-14.1)

1.4 (0.9-2.0)

0.8 (0.4-1.3)

Annual family income, $
⬍20 000

21.1 (19.6-22.7) c

34.9 (32.9-36.8)

27.9 (26.2-29.7)

16.2 (14.8-17.6) d

1.8 (1.3-2.5)

1.3 (1.0-1.7) d

20 000-50 000

26.4 (24.5-28.3)

33.4 (31.5-35.3)

25.7 (24.1-27.3)

14.6 (13.3-15.9)

1.2 (1.0-1.6)

0.7 (0.5-1.1)

⬎50 000

31.7 (27.0-36.7)

35.0 (31.5-38.7)

23.1 (20.0-26.4)

10.3 (8.2-12.8)

1.2 (0.7-2.0)

0.3 (0.1-1.1)

Not reported

26.0 (22.6-29.8)

32.3 (28.8-36.0)

27.6 (24.2-31.3)

14.1 (12.0-16.5)

1.4 (0.9-2.2)

1.0 (0.5-1.8)

Country of birth
Foreign

26.4 (25.1-27.8) c

34.7 (33.3-36.0)

25.4 (24.2-26.7) d

13.5 (12.5-14.4) c

1.3 (1.0-1.8) e

0.7 (0.5-0.9) c

18.5 (16.2-21.0)

32.1 (29.4-34.9)

30.1 (27.4-33.0)

19.3 (17.0-21.8)

2.1 (1.4-3.1)

1.8 (1.2-2.8)

29.2 (27.1-31.4) c

34.7 (32.7-36.8)

24.8 (23.1-26.6)

11.2 (9.9-12.7) c

0.8 (0.5-1.1) c

0.7 (0.4-1.1)

22.7 (21.3-24.1)

33.8 (32.3-35.3)

27.2 (25.9-28.6)

16.3 (15.2-17.5)

1.8 (1.3-2.4)

1.0 (0.8-1.4)

26.3 (24.8-27.9) c

34.4 (32.9-35.8)

25.8 (24.6-27.1)

13.5 (12.6-14.5) c

1.3 (1.0-1.8) e

0.8 (0.6-1.1) d

19.6 (17.5-21.8)

33.2 (30.7-35.9)

28.5 (26.1-31.1)

18.7 (16.6-20.9)

2.0 (1.4-2.8)

1.4 (1.0-2.0)

26.5 (25.1-27.9) c

34.6 (33.3-36.1)

25.5 (24.3-26.8) e

13.3 (12.4-14.3) c

1.3 (0.9-1.8) e

0.7 (0.5-1.0) c

18.8 (16.6-21.2)

32.2 (29.6-34.8)

29.6 (27.0-32.3)

19.4 (17.2-21.8)

2.1 (1.5-3.1)

1.7 (1.1-2.5)

17.6 (15.4-20.0) c

32.6 (29.9-35.4)

30.4 (27.6-33.2) e

19.5 (17.2-22.0) c

2.1 (1.4-3.1) c

1.8 (1.2-2.8) c

ⱕ10 y

21.5 (18.2-25.2)

36.2 (31.4-41.3)

25.1 (21.0-29.7)

17.3 (13.6-21.7)

1.5 (1.0-2.3)

1.2 (0.6-2.3)

11-24 y

24.5 (22.7-26.4)

35.5 (33.6-37.5)

25.9 (24.1-27.9)

14.0 (12.7-15.4)

1.7 (1.1-2.5)

0.5 (0.3-0.8)

ⱖ25 y

29.4 (27.2-31.7)

33.3 (31.4-35.3)

25.0 (23.3-26.7)

12.3 (11.2-13.6)

1.0 (0.8-1.3)

0.7 (0.5-1.0)

25.8 (24.4-27.2) c

34.6 (33.2-36.0)

25.9 (24.7-27.2)

13.8 (12.8-14.8) c

1.3 (1.0-1.8)

0.7 (0.5-1.0) c

20.7 (18.3-23.2)

32.2 (29.6-35.0)

28.7 (26.0-31.5)

18.4 (16.1-20.9)

2.0 (1.3-2.9)

1.7 (1.2-2.5)

25.9 (24.1-27.8)

35.3 (33.5-37.1)

26.4 (24.7-28.2)

12.5 (11.4-13.6) c

1.4 (1.0-2.0)

0.9 (0.6-1.4)

24.0 (22.4-25.6)

33.3 (31.8-34.8)

26.5 (25.1-28.0)

16.2 (15.0-17.5)

1.5 (1.1-1.9)

0.9 (0.7-1.2)

28.1 (26.0-30.2) c

33.9 (32.1-35.7)

25.1 (23.5-26.7)

12.9 (11.7-14.2) c

1.1 (0.8-1.4) c

0.7 (0.5-0.9) d

21.9 (20.5-23.3)

34.3 (32.6-35.9)

27.6 (26.2-29.1)

16.2 (15.1-17.4)

1.8 (1.3-2.4)

1.1 (0.8-1.5)

US
US residence ⬎10 y
No
Yes
Language preference
Spanish
English
Immigrant generational status
First
Second or higher
Age at immigration
US born

Acculturation, SASH score f
Low, 1-⬍3
High, ⱖ3
Physical activity, higher 40% g
Yes
No
Diet score, higher 40% h
Yes
No

Abbreviations: CHD, coronary heart disease; CVD, cardiovascular disease; SASH, Short Acculturation Scale for Hispanics.
a Prevalence by age group was adjusted for sex. Prevalence by sex was adjusted for age. The average age used for the computation was 41.02 years (overall weighted mean age).
Values (except No.) were weighted for survey design and nonresponse. Model-adjusted prevalence was obtained based on multinomial logistic regression for risk factor profiles
and logistic regression for CHD and stroke.
b Adverse CVD risk factors were defined as follows. Hypercholesterolemia was total cholesterol ⱖ240 mg/dL, high-density lipoprotein cholesterol ⬍40 mg/dL, low-density lipoprotein cholesterol ⱖ160 mg/dL, or receiving treatment. Hypertension was defined as systolic blood pressure ⱖ140 mm Hg, diastolic blood pressure ⱖ90 mm Hg, or receiving
treatment. Obesity was defined as a body mass index ⱖ30, calculated as weight in kilograms divided by height in meters squared. Diabetes mellitus was defined as use of
diabetes medications, fasting glucose ⱖ126 mg/dL, 2-hour-postload plasma glucose ⱖ200 mg/dL, or hemoglobin A1c ⱖ6.5%. Smoking was defined as currently smoking cigarettes.
(To convert total, LDL, and HDL cholesterol to mmol/L, multiply by 0.0259; to convert glucose to mmol/L, multiply by 0.0555.)
c P⬍.001.
d P⬍.01.
e P⬍.05.
f An abbreviated 10-question SASH was used; the range of scores was 1-5. Average scores ⬍3 indicate lower acculturation and scores ⱖ3 indicate higher acculturation.
g Higher sex-specific 40% of mean total physical activity.
h Diet score was calculated by assigning participants a score of 1-5 according to their sex-specific quintile of daily intake of saturated fatty acids, potassium, calcium, and fiber, with
5 representing the most favorable quintile (ie, lowest quintile of intake for saturated fatty acids and highest quintile of intake for potassium, calcium, and fiber). The 4 scores were
summed and the higher 40 percentile considered a healthy diet.

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findings remained significant although level of significance was diminished. In general, more acculturated
participants had markedly higher rates
of current smoking and obesity compared with others. Additionally, participants with lower physical activity
levels and less healthy diets had higher
prevalence of 3 or more CVD risk
factors.
Age- and sex-adjusted prevalence of
CHD and stroke were significantly
higher among men, older participants
(aged 65-74 years compared with
younger), those who were second- or
third-generation immigrants, and those
who preferred English (Table 3). Ad-

pecially strong for hypertension and
diabetes. Associations of CVD risk factors with self-reported CHD were attenuated and in some cases lost statistical significance, with additional
adjustment for other CVD risk factors
(model 2) or for variables in model 3.
Associations of risk factors with
prevalent stroke were less consistent
(Figure 2). In age-adjusted analyses
(model 1), hypertension and diabetes
mellitus were strongly associated with
prevalent stroke in both sexes; high
cholesterol and obesity were significantly associated and cigarette smoking was borderline significantly associated with prevalent stroke among

ditionally, CHD prevalence was significantly higher among participants who
had resided in the United States 10 or
more years, and stroke prevalence was
significantly higher among participants with lower family income and
those born in the United States. Unweighted cell counts corresponding to
weighted prevalences in eTables 1-8 are
presented in eTables 9-16.
Association of CVD Risk Factors
With CHD and Stroke

In age-adjusted analyses (model 1), all
individual CVD risk factors were associated with higher odds of prevalent
CHD (FIGURE 2); associations were es-

Figure 2. Association of Cardiovascular Disease Risk Factors With Cardiovascular Disease Prevalence Among Hispanic/Latino Participants by Sex
Risk Factor
High cholesterol
Men

Women

High blood pressure
Men

Women

Obesity
Men

Women

Diabetes mellitus
Men

Women

Smoking
Men

Women

Coronary Heart Disease
Model

Stroke
Risk Factor

Model

High cholesterol
Men

1
2
3
1
2
3

1
2
3
1
2
3

Women

High blood pressure
Men

1
2
3
1
2
3

Women

Obesity
Men

1
2
3
1
2
3

Women

Diabetes mellitus
Men

1
2
3
1
2
3

Women

Smoking
Men

1
2
3
1
2
3

Women

0.7

1.0

7.0

OR (95% CI)

1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
0.7

1.0

7.0

OR (95% CI)

High cholesterol was defined as serum total cholesterol level ⱖ240 mg/dL or taking cholesterol-lowering medication. High blood pressure was defined as systolic blood
pressure ⱖ140 mm Hg or diastolic blood pressure ⱖ90 mm Hg or taking antihypertensive medication. Obesity was defined as a body mass index ⱖ30 (calculated as
weight in kilograms divided by height in meters squared). Diabetes mellitus was defined as use of diabetes medication, fasting glucose ⱖ126 mg/dL, 2-hour-postload
plasma glucose ⱖ200 mg/dL, or hemoglobin A1c ⱖ6.5%. Smoking was defined as current cigarette smoker. Model 1 was adjusted for age. Model 2 was adjusted for
age and all other major biomedical cardiovascular disease risk factors. Model 3 was adjusted for all variables in model 2 plus education, annual family income, Hispanic/
Latino background, language preference, nativity (US born), Short Acculturation Scale for Hispanics score, physical activity, and diet. Error bars indicate 95% CI.

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CARDIOVASCULAR DISEASES AND HISPANICS/LATINOS IN THE UNITED STATES

women only. With further adjustment
for other CVD risk factors (model 2),
the association of hypertension with
prevalent stroke was attenuated but remained significant in women and borderline significant in men, diabetes remained significantly associated with
stroke in men, and smoking was borderline significantly associated with
stroke in women only. With additional adjustment for variables in model
3, diabetes and hypertension remained positively associated with stroke
among men and women, respectively.
COMMENT
The HCHS/SOL baseline examination
has yielded several insights about CVD
risk factors among adult Hispanic/
Latino men and women living in the
United States. Prevalence of individual major CVD risk factors varied
markedly across Hispanic background groups. Moreover, as compared with first-generation participants (born outside of the United
States), participants who were USborn were more likely to report a history of CHD and stroke and to have
multiple CVD risk factors. Additionally, higher prevalence of CVD was associated with longer duration of residence in the United States and greater
acculturation. Thus, although numerous US studies have demonstrated racial/ethnic variations in CVD and its risk
factors, our findings demonstrate a great
deal of diversity within a population
that would typically be classified as a
single “Hispanic/Latino” group in biomedical research.
Previous studies of US Hispanic/
Latino individuals have primarily involved Mexican American participants
or have considered Hispanics/Latinos as
a single group.2,8-10,23-26 The limited available data on Hispanic/Latino people from
diverse ethnic, geographic, cultural, and
socioeconomic backgrounds suggest that
CVD risk factor burden may vary by Hispanic/Latino origin and sociocultural
characteristics. However, findings on intergroup variation in individual CVD risk
factor prevalence have been inconsistent.11-14,27
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JAMA, November 7, 2012—Vol 308, No. 17

The HCHS/SOL aimed to address the
gap in current knowledge on prevalence of CVD risk factors and adverse
CVD risk profiles within the diverse
Hispanic/Latino population and relationships of sociocultural factors and
acculturation to risk factors. Baseline
HCHS/SOL findings demonstrate the
sizeable burden of CVD risk factors
among all Hispanic/Latino groups with
prevalence of risk factors comparable
or higher than those reported for nonHispanic white individuals.28,29 The
HCHS/SOL data show marked variation in CVD risk factor prevalence
within the Hispanic/Latino population with some groups, particularly
those of Puerto Rican background, experiencing strikingly high rates of individual adverse CVD risk factors or
overall risk factor burden compared
with others. For example, women of
Puerto Rican background had the highest prevalence of each of the major CVD
risk factors, and Mexican men and
women both had high rates of diabetes. Thus, results from the HCHS/SOL
suggest that previous prevalence estimates based on data primarily from
Mexican American participants may
have underestimated the CVD risk factor burden and diversity among US Hispanics/Latinos.
Studies in diverse Latin American
countries have demonstrated similar
variations in prevalence of CVD risk
factors. The cross-sectional population-based Cardiovascular Risk
Factor Multiple Evaluation in Latin
America (CARMELA) study30 examined participants from Mexico and 6
South American countries; Mexican
participants had higher prevalence of
obesity and diabetes compared with
South American participants, consistent with findings reported here.
Rates of hypertension and cigarette
smoking were higher in CARMELA
participants from some South American countries, in contrast to generally
lower risk factor burden among South
American participants in the HCHS/
SOL; these differences are likely due
to differential patterns of immigration
to the United States.

Among HCHS/SOL participants, major CVD risk factors were strongly associated with prevalent self-reported
CVD. These findings are consistent with
those reported by studies in Latin
American populations such as the
INTERHEART Study, ie, strong associations of CVD risk factors with risk
of acute myocardial infarction.31,32
In other racial/ethnic groups with
little or no CVD originally, migration
and adoption of Western lifestyles have
been associated with development of
unfavorable risk factor profiles and
CVD.33-35 In the HCHS/SOL, higher degrees of acculturation by multiple proxy
measures were associated with higher
prevalence of multiple adverse CVD risk
factors. Moreover, more acculturated
participants—particularly those born in
the United States—were significantly
more likely to have prevalent CHD and
stroke. Mexican background participants from the HCHS/SOL had higher
rates of hypertension and obesity compared with those from the CARMELA
study (based on similar definitions for
these risk factors).30 Thus, findings from
the HCHS/SOL suggest that CVD risk
status of Hispanic/Latino individuals is
likely to worsen over time with increasing adoption of US lifestyles.
Findings here are limited to selfreported information on prevalent CHD
and stroke (possibly biased by access
to health care) and the cross-sectional
nature of the data. However, the
planned long-term follow-up of HCHS/
SOL participants will produce objective information on incident CVD and
non-CVD outcomes. A further limitation is that the HCHS/SOL did not include any other US racial/ethnic groups
for comparison. However, the data
were age-standardized to the year 2000
US population to allow for comparisons with observations from national
surveys, and protocols used were similar to those of other epidemiological
studies.
In conclusion, findings from the
HCHS/SOL demonstrate the pervasive
burden of CVD risk factors in all Hispanic/Latino groups in the United States
and identify specific groups by origin,

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CARDIOVASCULAR DISEASES AND HISPANICS/LATINOS IN THE UNITED STATES

sociodemographic characteristics, and
sociocultural backgrounds at particularly high risk of CVD. These data may
enhance the impetus to implement interventions to lower the burden of CVD
risk factors among Hispanic/Latino
people overall and targeted at-risk
groups, as well as develop strategies to
prevent future development of adverse CVD risk factors starting at the
youngest ages.
Author Affiliations: Institute for Minority Health Research, Section of General Internal Medicine, Department of Medicine, University of Illinois at Chicago (Dr
Daviglus); Graduate School of Public Health, San Diego State University, San Diego, California (Dr
Talavera); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland (Drs Avile´sSanta and Sorlie); Department of Family and Preventive
Medicine, University of California, San Diego, La Jolla
(Drs Allison and Criqui); Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill (Drs Cai, LaVange, and Perreira and Ms
Gouskova); Behavioral Medicine Research Center, Department of Psychology, University of Miami, Miami, Florida (Drs Gellman and Schneiderman); Departments of Preventive Medicine (Drs Daviglus,
Giachello, Pirzada, and Stamler) and Medical Social
Sciences (Dr Penedo), Northwestern University Feinberg School of Medicine, Chicago; and Department
of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York (Drs Kaplan
and Wassertheil-Smoller).
Author Contributions: Drs Daviglus and Talavera had
full access to all of the data in the study and take responsibility for the integrity of the data and the
accuracy of the data analysis. Drs Daviglus and
Talavera, as co–first authors, contributed equally to
this article.
Study concept and design: Daviglus, Talavera, Gellman,
Kaplan, LaVange, Penedo, Perreira, Schneiderman,
Wassertheil-Smoller, Sorlie.
Acquisition of data: Daviglus, Talavera, Avile´s-Santa,
Allison, Criqui, Gellman, Kaplan, Penedo, Perreira,
Schneiderman, Wassertheil-Smoller, Stamler.
Analysis and interpretation of data: Daviglus, Talavera,
Avile´ s-Santa, Cai, Criqui, Giachello, Gouskova,
Kaplan, LaVange, Penedo, Pirzada, Schneiderman,
Wassertheil-Smoller, Sorlie, Stamler.
Drafting of the manuscript: Daviglus, Talavera, Cai,
Kaplan, Pirzada.
Critical revision of the manuscript for important intellectual content: Daviglus, Talavera, Avile´s-Santa,
Allison, Cai, Criqui, Gouskova, Kaplan, LaVange,
Penedo, Perreira, Pirzada, Schneiderman,
Wassertheil-Smoller, Sorlie, Stamler.
Statistical analysis: Cai, Gouskova, LaVange,
Perreira.
Obtained funding: Daviglus, Talavera, Avile´s-Santa,
Criqui, Kaplan, Penedo, Perreira, Schneiderman,
Wassertheil-Smoller, Sorlie, Stamler.
Administrative, technical, or material support:
Daviglus, Talavera, Cai, Gellman, Kaplan, Perreira,
Pirzada, Schneiderman, Wassertheil-Smoller.
Study supervision: Daviglus, Talavera, Allison, Cai,
Criqui, Gellman, Kaplan, Schneiderman, Stamler.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest. Dr Cai reported having consulted for Outcomes Research Solutions. Dr
Gellman reported receiving book royalties from
Springer. No other disclosures were reported.

Funding/Support: The Hispanic Community Health
Study/Study of Latinos was carried out as a collaborative study supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) to the
University of North Carolina (N01-HC65233), University of Miami (N01-HC65234), Albert Einstein College of Medicine (N01-HC65235), Northwestern University (N01-HC65236), and San Diego State University
(N01-HC65237). The following institutes, centers, or
offices contribute to the HCHS/SOL through a transfer of funds to the NHLBI: National Center on Minority Health and Health Disparities, the National Institute on Deafness and Other Communications
Disorders, the National Institute of Dental and Craniofacial Research, the National Institute of Diabetes
and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the
Office of Dietary Supplements.
Role of the Sponsor: The funding agency had a role
in the design and conduct of the study; in the collection, analysis, and interpretation of the data; and in
the review and approval of the manuscript.
The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Investigators: Program Office: National Heart, Lung, and Blood Institute, Bethesda,
Maryland: Larissa Avile´s-Santa, Paul Sorlie, Lorraine
Silsbee. Field Centers: Bronx Field Center, Albert Einstein School of Medicine, Bronx, New York: Robert
Kaplan, Sylvia Wassertheil-Smoller. Chicago Field Center, Northwestern University Feinberg School of Medicine and University of Illinois at Chicago: Martha L.
Daviglus, Aida L. Giachello, Kiang Liu. Miami Field
Center, University of Miami, Miami, Florida: Neil
Schneiderman, David Lee, Leopoldo Raij. San Diego
Field Center, San Diego State University and University of California, San Diego: Greg Talavera, John Elder,
Matthew Allison, Michael Criqui. Coordinating Center: University of North Carolina, Chapel Hill: Jianwen
Cai, Gerardo Heiss, Lisa LaVange, Marston Youngblood.
Central Laboratory: University of Minnesota, Minneapolis: Bharat Thyagarajan, John H. Eckfeldt. Central
Reading Centers: Audiometry Center: University of
Wisconsin: Karen J. Cruickshanks. ECG Reading Center: Wake Forest University: Elsayed Soliman. Neurocognitive Reading Center: University of Mississippi
Medical Center: Hector Gonza´les, Thomas Mosley. Nutrition Reading Center. University of Minnesota: John
H. Himes. Pulmonary Reading Center: Columbia University: R. Graham Barr, Paul Enright. Sleep Center:
Case Western Reserve University: Susan Redline.
Online-Only Material: The eTables are available at
http://www.jama.com.
Additional Contributions: We thank the staff and participants of HCHS/SOL for their important contributions. A complete list of staff and investigators was
published in Ann Epidemiol. 2010;20:642-649 and is
also available on the study website, http://www.cscc
.unc.edu/hchs/.

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It is one of the paradoxes of the human race and possibly its last paradox, that the people who control the
fortunes of our community should at the same time be
wildly radical in matters that concern our own change
of our environment, and rigidly conservative in the social matters that determine our adaptation to it.
—Norbert Wiener (1894-1964)

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©2012 American Medical Association. All rights reserved.

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