Social Factors and Obesity in Puerto Rican Women

Since I am no longer doing this particular research project, I thought I would post the background/introduction part of my old proposal to show part of what interested me in Puerto Rico in the first place. A large part of my project will still involve preventive care, obesity, and women's health, don't worry. But those of you in the health care field might find some of the information interesting, especially if you have Puerto Rican patients. What you might also find interesting is the evidence that socioeconomic status more strongly affects women's obesity rates than men's. Might have some implications for public health preventative care measures, that's all I'm saying.
For those of you who think this stuff is boring/are just looking for travel blog info, just skip this entry! (Yes, friends and family, I am saying you don't have to read it, I won't phone quiz you like I usually do!)

Title

Social Factors and Obesity in Puerto Rican Women
Renee Robinson, MS1

Background and Goals:

Recent focus on health disparities among various ethnic and cultural minority groups in the United States has sparked interest in understanding the socioeconomic determinants of good health. Obesity, an important risk factor for cancer, diabetes, cardiovascular diseases, and other chronic medical problems, has become a growing epidemic in the United States and in other developed countries. Among Hispanic minority groups, the fast-growing Puerto Rican population, with 3.8 million people living on the island itself and an additional 3.4 million in the mainland United States,^1,2 has drawn attention recently for its steadily rising rates of obesity, with the governor of Puerto Rico recently calling the childhood obesity problem a “state of emergency” on the island.³. A study of U.S. Hispanic populations indicates that 40.7% of Puerto Ricans are classified as overweight (BMI in excess of 85^th percentile of US reference standards) and an additional 15.0% classified as obese (BMI in excess of 95^th percent).⁴ Puerto Ricans living on the mainland have a similar obesity prevalence as island Puerto Ricans (21% versus 22%, respectively), but island Puerto Ricans have significantly lower access to primary preventive health care, placing them at greater risk for complications of chronic obesity.⁵ One of the most important chronic conditions associated with obesity is type 2 diabetes. A study in 1999 indicated that 9.6% of island Puerto Ricans suffer from type 2 diabetes, higher than the U.S. national average.¹² Residents of Puerto Rico are 1.8 times more likely to develop type 2 diabetes than U.S. non-Hispanic whites,⁹ and the diabetes in elder Puerto Rican populations living in the mainland is generally more poorly controlled than the diabetes of non-Hispanic whites.¹⁰ Obesity’s role in coronary heart disease is also especially important in Latin American populations, including Puerto Rico. One study investigated worldwide risk factors for coronary heart disease, including abnormal lipid levels, smoking, hypertension, diabetes, abdominal obesity, psychosocial stress, lack of physical activity, and diet, and found that the population attributable risk for abdominal obesity is more important for Latin American populations than for other populations.¹¹

Much of the research assessing cardiovascular and chronic disease risk in Puerto Ricans has centered on men and children. A large study known as the Puerto Rico Heart Health Program (PRHHP) followed almost 10,000 men with the objective of investigating “morbidity and mortality from CHD [coronary heart disease] in Puerto Rican urban and rural men.” ⁶ No such large scale investigation of Puerto Rican women has been undertaken to date. Additionally, studies of the childhood obesity epidemic rarely include information about maternal obesity. This is a significant oversight given that women in Puerto Rico tend to be the primary caregivers and that parental obesity is directly related to child obesity. In a small study of 53 Puerto Rican children in Hartford, Connecticut, increased maternal body mass index (BMI) was associated with increased obesity levels in children, suggesting that, due to a shared environment, targeting risk factors for maternal obesity may have an impact on childhood obesity as well.⁷ This association has also been shown in a study on Mexican Americans, with obese mothers being twice as likely to have an overweight or at-risk-for-overweight child compared with normal-weight mothers.⁸

There are several important reasons to investigate predictive factors of obesity in Puerto Rican women. First, there are gender discrepancies in obesity-related disease status, notably type 2 diabetes, between Puerto Rican men and women. A 1999 study in Puerto Rico found that rates of diabetes were highest among women, older individuals, the unemployed, and individuals with high blood pressure, high cholesterol, and high BMI. The same study found that after age 65, the only significant characteristic associated with diabetes was the female sex.¹² Studies also show an inverse relationship between BMI and pre-menopausal breast cancer risk for Hispanic women, including Puerto Ricans, living in the United States.¹³ Second, it appears that socioeconomic factors, such as income and educational level, play a very important role in obesity risk in Puerto Rican women, offering a potential basis for the implementation of socially appropriate preventive health programs. Among various populations in the mainland United States, it has been shown that while men are about as likely to be obese in any socioeconomic group, women of lower socioeconomic status are fifty percent more likely to be obese than those of a higher economic status.¹⁴ Another study shows that socioeconomic factors, especially lower levels of education, are associated with metabolic syndrome in a diverse population of women in the United States, but does not show the same association for men.¹⁵ Metabolic syndrome is a group of risk factors including abdominal obesity, dyslipidemia, high blood pressure, resistance to insulin, and proinflammatory and prothrombotic states that increases risk for type 2 diabetes.¹⁶ The San Antonio Heart study found that among Mexican Americans, there is a higher prevalence of diabetes among women of a low socioeconomic status, but again, this relationship did not hold true for men.¹⁷

While obesity prevalence rates and health disparities have been documented for Puerto Rican women, there have been few studies on the socioeconomic and cultural factors underlying obesity risk. The few studies that have tackled the predictive factors illness have focused primarily on Puerto Rican populations living in the mainland United States. A study of Puerto Rican women in a Connecticut population showed that obesity is correlated with higher levels of acculturation and lower socioeconomic status. It also found that women who do not own a car consume less meat, eggs, and fish, and that smokers are more likely to have an unhealthy pattern of food intake than nonsmokers.¹⁸ Another study also found acculturation to be a significant factor in obesity among Puerto Rican women living in the United States, with women who speak more English or who have lived in the mainland United States for a longer period being more likely to be obese than women who speak primarily Spanish or who had just recently moved to he mainland.¹⁹ A study of nutritional intake of Puerto Rican women living in both Puerto Rico and in the South Bronx indicate that these women tend to over-consume protein, sugar, and carbonated beverages, and that factors influencing a woman’s food acquisition included nutrition education programs, availability of foods and the food preference of children in the household.²⁰

1. U.S. Census Bureau. Census 2000 Data for Puerto Rico. April 1, 2000. Retrieved April 1, 2008 from http://www.census.gov/census2000/states/pr.html

2. U.S. Census Bureau. We the people: Hispanics in the United States: Census 2000 special reports. April 1, 2000. Retrieved April 1, 2008 from http://www.census.gov/prod/2004pubs/censr-18.pdf

3. Big trouble in little Puerto Rico: Obese kids. Associated Press. Retrieved March 31, 2008 from http://www.msnbc.msn.com/id/18768818/

4. Pawson I, Martorell R, Mendoza F. Prevalence of overweight and obesity in US Hispanic populations. Am J Clin Nutr. 1991; 53: 1522S-1528S.

5. Ho G, Qian H, Kim M, Melnik T, Tucker K, Jimenez-Velazquez I, Kaplan R, Lee-Rey E, Stein D, Rivera W, Rohan T. Health disparities between island and mainland Puerto Ricans. Rev Panam Salud Publica. 2006; 19: 331-339.

6. Puerto Rico Heart Health Program (PRHHP). National heart, lung, and bloodinstitute. Retrieved April 1, 2008 from http://www.nhlbi.nih.gov/resources/deca/descriptions/prhhp.htm

7. Tanasescu M, Ferris A, Himmelgreen D, Rodriguez N, Perez-Escamilla R. Biobehavioral factors associated with obesity in Puerto Rican children. The Journal of Nutrition. 2000; 130: 1734-1742.

8. Hernández-Valero MA, Wilkinson AV, Forman MR, Etzel CJ, Cao Y, Bárcenas CH, Strom SS, Spitz MR, Bondy ML. Maternal BMI and country of birth as indicators of childhood obesity in children of Mexican origin. Obesity. 2007; 15: 2512-2519.

9. National diabetes statistics. National Diabetes Information Clearinghouse. Retrieved March 30, 2008 from http://diabetes.niddk.nih.gov/dm/pubs/statistics/

10. Tucker KL, Bermudez OI, Castaneda C. Type 2 diabetes is prevalent and poorly controlled among Hispanic elders of Caribbean origin. American Journal of Public Health. 2000; 90: 1288-1293.

11. Lanas F, Avezum A, Bautista LE, Diaz R, Luna M, Islam S, Yusuf S; INTERHEART investigators in Latin America. Risk factors for acute myocardial infarction in Latin America: the INTERHEART Latin American study. Circulation. 2007; 115: 1067-1074.

12. Pérez-Cardona C, Pérez-Perdomo R. Prevalence and associated factors of diabetes mellitus in Puerto Rican adults: behavioral risk factor surveillance system, 1999. P R Health Sci J. 2001; 20: 147-155.

13. Slattery ML, Sweeney C, Edwards S, Herrick J, Baumgartner K, Wolff R, Murtaugh M, Baumgartner R, Giuliano A, Byers T. Body size, weight change, fat distribution and breast cancer risk in Hispanic and non-Hispanic white women. Breast Cancer Res Treat. 2007; 102: 85-101.

14. HHS. Healthy People 2010, 2nd ed. Understanding and improving health and objectives for improving health. 2 vol. Washington (DC): GPO; 2000. p. 19-12.

15. Loucks E, Rehkopf D, Thurston R, Kawachi I. Socioeconomic Disparities in Metabolic Syndrome Differ by Gender: Evidence from NHANES III. Annals of Epidemiology. 2007; 17: 19-26.

16. Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome: Time for a critical appraisal: Joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2005; 28: 2289-2304.

17. Hazuda HP, Haffner, SM, Stern, MP, Eifler CW. Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans: The San Antonio Heart Study. Am J Epidemiol 1988;128:1289–1301.

18. Fitzgerald N, Himmelgreen D, Damio G, Segura-Perez S, Peng Y, Perez-Escamilla R. Acculturation, socioeconomic status, obesity and lifestyle factors among low-income Puerto Rican women in Connecticut, U.S., 1998-1999. Rev Panam Salud Publica. 2006; 19: 306-313.

19. Himmelgreen DA, Perez-Escamilla R, Martinez D, Bretnall A, Eells B, Peng Y, Bermudez A. The longer you stay, the bigger you get: Length of time and language use in the U.S. are associated with obesity in Puerto Rican women. American Journal of Physical Anthropology. 2004; 125: 90-96.

20. Sanjur D, Immink M, Colon M, Bentz L, Burgos M, Alicea-Santana S. Trends and differentials in dietary patterns and nutrient intake among migrant Puerto Rican families. Arch Latinoam Nutr. 1986; 36: 625-641.