Is Cardiovascular Disease Part of Hispanic Heritage?
Thank you to Brenda Olmos, MSN, APRN, FNP-C and Emily Jones, PhD, RNC-OB, FAHA, FPCNA for this article on cardiovascular disease and Hispanic heritage.
During Hispanic Heritage Month, many organizations are recognizing the contributions of Latinos/Hispanics/Latinx populations to American society. (For the purpose of this article, these terms will be used interchangeably to preserve the original usage of cited authors.) It’s a great opportunity to also shine the light on Latinx cardiovascular health since social and structural factors greatly influence cardiovascular health outcomes in this population. According to the Centers for Disease Control and Prevention (CDC).1Hispanics often face challenges in getting the care needed to protect their health. Socio-demographic factors that may impact individuals’ relationship to the healthcare system and access to care include the following:
• “About one in three Hispanics have limited English proficiency;
• About one in four Hispanics live below the poverty line, compared with whites; and
• About one in three has not completed high school.”1
These social determinants of health interact in complex ways with risk factors and contribute to the current reality that four out of ten Hispanics will die of cardiovascular disease (CVD) or cancer.1 Also, Mexicans and Puerto Ricans are about twice as likely to die from diabetes as whites.1 As of 2015, one in six people living in the US is Hispanic1, so these collective statistics of disproportionate illness and death also represent a costly healthcare burden.
The most recent CDC Diabetes Statistics Report2 from 2020 reports an increase of diabetes diagnoses from 4.9 million to 6.4 million diabetes cases in the United States among Latinx individuals. Metabolic syndrome contributes to the development of both diabetes and CVD, and it has become increasingly challenging to optimize Latinx cardiometabolic health during the current COVID-19 pandemic.3 In an American Heart Association survey conducted in 20204 (before vaccine availability), “more than half of Hispanics (55%) would be scared to go to the hospital if they thought they were having a heart attack or stroke because they might get infected with COVID-19, and 41% would stay home if they thought they were experiencing a heart attack or stroke rather than risk getting infected at the hospital.”
As we celebrate the rich culture that Latinx groups contribute, cardiovascular nurses and care teams can take the opportunity to consider cardiometabolic risk factors unique to this population and how appropriate cardiovascular care may be challenged during the era of COVID-19.
Metabolic Syndrome, Discrimination, and Distress in Latinx Groups
Culturally sensitive care has been identified as an effective way to reduce the burden of metabolic syndrome in Latinxs.5 Yet, the realities of weight management and glucose regulation remain challenging in this minoritized group. When referring to Latinxs, we must consider that there are 57 million people who identify in this way, and that includes people of Mexican, Puerto Rican, Central American, Caribbean, and South American descent as well as the distinction between US-born and foreign-born.1 Despite the heterogeneity of the group and the subsequent inability to identify it as a monolith, the issues associated with metabolic syndrome (suboptimal glucose control, vascular and organ complications, diabetes-related distress, CVD, and mortality) apply to all the subgroups within the larger ethnic population.5
The inequalities in metabolic syndrome and other chronic conditions that impact Hispanics5 in the US collide with the social determinants of health that are known to affect health outcomes. Hispanics in the US, much like African Americans, have disproportionately higher rates of chronic stress and illness than White people.6 Though Latinxs do not experience everyday discrimination at rates as high as those of Black Americans, the health-related effects of discrimination among Latinxs are still significant and manifest in higher rates of diabetes-related distress and depressive symptoms.7 Type 2 diabetes affects almost 15% of Hispanic people,2 and the mental burden of this chronic illness can lead to depressive symptoms. In terms of policy, Hispanics in the US are less likely to be insured than non-Hispanic Whites, and lack of access to health services can lead to worse health outcomes.8 The policies that limit insurance coverage exacerbate the challenges of caring for Latinx patients, and higher morbidity and mortality are associated with low social class and poverty.9
Diabetes, CVD, and the Added Burden of COVID-19
Hypertension is a major risk factor for CVD in the Latinx population and often overlaps with diabetes as a common comorbidity.10 A key feature of prediabetes, insulin resistance, is also a feature of prehypertension, and it is more pronounced in individuals who gain weight over time.11 A diagnosis of hypertension can predict diabetes in the future and the reverse is also true; incidence of diabetes is significantly and positively associated with a diagnosis of hypertension.11
Adding to the complexity, research over the last 18 months has highlighted that metabolic syndrome is a significant risk factor for COVID-19.12 Studies show that risk of death is higher in those with uncontrolled blood glucose compared to controlled blood glucose.10 Additionally, those with hypertension are more likely to have worse outcomes from pneumonia or acute respiratory distress syndrome (ARDS).10
COVID-19 has widened the health disparities for Latinx groups. Studies12 show that individuals who were older (65+) and Hispanic or Latino, were more likely to have moderate/ severe COVID-19. The Annals of Internal Medicine13 highlight that “Age-standardized excess deaths per 100 000 persons among Black, American Indian/Alaska Native (AI/AN), and Latino males and females were more than double those in White and Asian males and females.” Structural disparities, such as racism and under-resourced communities and healthcare systems, that contributed to these outcomes already existed before COVID-19, but the pandemic has exacerbated them for communities of color. Social determinants of health like limited English proficiency and living in poverty are potential targets for future research and policies that aim to advance health equity.
Key Takeaways for Cardiovascular Nurses
As we observe Hispanic Heritage Month, nurses can reaffirm their commitment to practicing cultural humility and patient-centered care. They can also affirm a new commitment, perhaps, to learning about social and structural root causes of health inequities that impact Latinx populations. Cardiovascular care needs for Latinx populations in the era of COVID-19 are unique, and nurses can take actionable steps to close the gaps in healthcare-related disparities. Cardiovascular nurses can:
- Consider the common comorbidities of diabetes and hypertension in this population and ensure all screenings are completed for each chronic disease.
- Assess if antidiabetic drugs that reduce blood pressure (such as SGLT2 inhibitors or GLP-1 receptor agonists) are being used in patients at high risk for the development of or a diagnosis of hypertension.4
- Ensure there are adequate interpretation services for Spanish-speaking patients.
- Educate patients and their family members on heart attack, stroke, and the symptoms of hypo/hyperglycemic events, and encourage them to call 9-1-1, if needed.
- Educate patients and communities on the safety precautions taken in hospitals to prevent the spread of COVID-19 and reassure them that the benefits of going to the hospital in an emergency outweigh the risks.4
- Support the contributions of local community health workers, or promotoras,15 in providing culturally-safe and sensitive care to optimize cardiovascular health.
- Centers for Disease Control and Prevention (2015). Hispanics Health in the United States.
- Centers for Disease Control and Prevention. (2020). https://www.cdc.gov/diabetes/data/statistics-report/index.html
- Auriemma RS, Pirchio R, Liccardi A, et al. Metabolic syndrome in the era of COVID-19 outbreak: impact of lockdown on cardiometabolic health. J Endocrinol Invest. 2021;1-3.
- American Heart Association. (2021). Fueled by COVID-19 Fears, Approximately Half of Hispanics and Black Americans Would Fear Going to the Hospital if Experiencing Symptoms of a Heart Attack or Stroke.
- Bambra C, Riordan R, Ford J, Matthews F. The COVID-19 pandemic and health inequalities. Journal of Epidemiology and Community Health. 2020:jech-2020-21440. .
- Alvidrez J, Tabor DC. Now Is the Time to Incorporate the Construct of Structural Racism and Discrimination into Health Research. Ethn Dis. 2021;31(Suppl 1):283-284. Published 2021 May 20.
- LeBron AM, Valerio MA, Kieffer E, et al. Everyday discrimination, diabetes-related distress, and depressive symptoms among African Americans and Latinos with diabetes. J Immigr Minor Health. 2014;16(6):1208-1216.
- Artiga, S., K. Orgera, & A. Damico. Changes in health coverage by race and ethnicity since the ACA, 2010-2018. (PDF) (2020). Kaiser Family Foundation.
- Angel,J.L. Challenges of Caring for Hispanic Elders, Public Policy & Aging Report, Volume 11, Issue 2, Winter 2001, Pages 11–16.
- Mccurley JL, Gutierrez AP, Gallo LC. Diabetes Prevention in U.S. Hispanic Adults: A Systematic Review of Culturally Tailored Interventions. American Journal of Preventive Medicine. 2017;52(4):519-529.
- Tsimihodimos V, Gonzalez-Villalpando C, Meigs JB, Ferrannini E. Hypertension and Diabetes Mellitus. Hypertension. 2018;71(3):422-428.
- Bansal R, Gubbi S, Muniyappa R. Metabolic Syndrome and COVID 19: Endocrine-Immune-Vascular Interactions Shapes Clinical Course. Endocrinology. 2020;161(10).
- Shields, MS., Haque, AT., Haozous, EA., Albert, PS., Alemida, J.S., Garcia-Closas, M., Napoles, AM., Perez-Stable, EJ., Freedman, ND., de Gonzales, AB. Racial and Ethnic Disparities in Excess Deaths During the COVID-19 Pandemic, March to December 2020. The Annals of Internal Medicine.
- Yang X, Zhang J, Chen S, et al.. Demographic Disparities in Clinical Outcomes of COVID-19: Data From a Statewide Cohort in South Carolina. Open Forum Infectious Diseases. 2021;8(9). .
- Centers for Disease Control and Prevention. (2019). Promotores de Salud/Community Health Workers.