In 2005, Einstein’s Robert C. Kaplan, Ph.D., professor of epidemiology & population health (epidemiology), heard about a proposed national Hispanic Community Health Study/Study of Latinos (HCHS/SOL). The Bronx was a perfect site—its Hispanic/Latino population is large—and “we jumped at the opportunity,” he said.

Today, with 4,000 Bronx participants and 12,000 more in San Diego, Chicago, and Miami, HCHS/SOL is the largest, most comprehensive study of cardiovascular and lung disease in Hispanic/Latino people ever undertaken in the United States. Data had been grievously lacking because studies rarely included Hispanic/Latino populations or focused only on those who identify as Mexican American or combined diverse Hispanic/Latino populations into one. Now thanks to continuous funding from the National Heart, Lung, and Blood Institute, HCHS/SOL investigators are creating a high-definition picture of Hispanic/Latino health.

Closer Cultural Focus

Early on, the study revealed that 80 percent of Hispanic/Latino men and 71 percent of women had at least one major risk factor (high blood pressure, high cholesterol, obesity, diabetes, or smoking) for cardiovascular disease. That is roughly in line with Americans as a whole at 75 percent. But HCHS looked deeper and compared people of varying Hispanic backgrounds, “the single most important design feature of our study,” said Dr. Kaplan, principal investigator of the Bronx field center. Puerto Rican individuals were most likely to have an alarming three or more adverse CVD risk factors, and those from South America were least likely. Asthma prevalence was highest in Puerto Rican people and lowest in the Mexican population. Diabetes was highest in Mexican people and lowest in the South American population. Cuban persons exercised the least, those who were Puerto Rican the most.

American Health

A second major finding of HCHS/SOL is that families who come to America may pay for economic opportunity with their health. The prevalence of three or more CVD risk factors was significantly higher among those who were U.S.-born, had lived in the United States 10 years or longer, and whose language preference was English. Diabetes and asthma followed similar patterns.

This plunge in health may trace to risk factors such as poor diet, smoking, and the sedentary American lifestyle compounded by the immigrant experience. Carmen Isasi, M.D., Ph.D., co-PI of HCHS/SOL and professor of epidemiology & population health (health behavior research & implementation science), is seeking to pinpoint the reasons for the drop-off in health. Through years of cultural and psychosocial research, she and colleagues identified stress, adverse childhood experiences, and economic disadvantage as important drivers of cardiovascular and brain health. Dr. Kaplan and colleagues found that when income and education were low, so were rates of diabetes awareness, diabetes control, and health insurance.

The study’s evolving view of life in America may explain the “Hispanic paradox”: Though Hispanic/Latino persons have many risk factors for heart disease, past studies found that compared with non-Hispanic white people, they were 10 percent less likely to have coronary heart disease and 30 percent less likely to die from it. “We’re just now getting to where we can answer that question,” said Dr. Kaplan. It may be, he explained, that the benefit applies to older Hispanic groups, not younger ones.

Still, the picture is not always clear. “When we look at foods that we think are healthy, like fruits, vegetables, and beans, we see that no single conclusion can be drawn in some groups,” said Dr. Kaplan. “The more acculturated people often eat fewer of those foods—for example, the Mexican population—but in other groups, such as Puerto Rican people, we seem to find that individuals who are here longer have a healthy diet. So, it depends on where you come from and what part of the country you’re living in.”

Attention and Intervention

The good news is that “low-tech solutions are underused,” said Dr. Kaplan. “People are not being treated adequately for high blood pressure even though we have inexpensive and well-tolerated medicines. We have opportunities to use strategies for better medication adherence, better smoking cessation results, and dietary advice that works with foods people like, can cook, and can afford. This may be different for a recent immigrant from the Dominican Republic compared to Puerto Rican people born in the Bronx.”

Health can begin in the doctor’s office. Carlos J. Rodriguez, M.D., M.P.H., professor of medicine (cardiology), was born in the Dominican Republic and came to Einstein in 2019. He was a natural fit because of the large Hispanic/Latino population in the Bronx that receives its health care at Einstein and also because he has been an HCHS/SOL ancillary study PI since 2010. His Hispanic/Latino patients appreciate that he understands their language and culture, which are “important to health and relationships,” he said. “These patients bring behavioral and clinical risk factors on top of some poor social determinants of health, so when you put it all together, it’s a high-risk population. It’s a good moment when a patient’s cholesterol or blood pressure are better controlled,” he said. Dr. Rodriguez recently led a study within HCHS/SOL that found that young Puerto Rican males were especially likely to use e-cigarettes, and that Dominican individuals have the highest levels of lipoprotein (a), signaling a need for screening and counseling in these respective groups. Likewise, Dr. Isasi, also a professor of pediatrics (adolescent medicine) and PI of HCHS/SOL’s ancillary Study of Latino Youth, found a high burden of obesity, diabetes, and dyslipidemia among Hispanic/Latino children, especially boys, an indication that directing resources to these young people could make for a healthier future. 

Adding to the Picture

HCHS/SOL is broad and deep and expands in multiple directions.

Heart abnormalities. Compared with non-Hispanic white people, Hispanic/Latino persons have a higher incidence of heart failure and tend to develop it earlier. Dr. Rodriguez, who is also director of clinical cardiovascular research and director of cardiovascular epidemiology at Einstein and Montefiore, recently completed the first population-based echocardiographic study of the low-flow state (LFS) in Hispanics/Latinos. In LFS, the heart’s stroke volume (pumping action) is low and is a silent risk factor for heart disease. The research, which he led as PI of the ECHO-SOL, an ancillary study within HCHS/SOL, found a high prevalence of LFS in U.S. Hispanics/Latinos. In a related research direction, a new $5.2 million grant from the NHLBI will allow Dr. Rodriguez to explore the aorta’s role in heart’s pumping function and heart failure risk in Hispanics/Latinos.

Bacterial signatures. HCHS/SOL recently showed that “the area of the world where you’re born, even if you’ve lived in New York City for decades, can leave evidence in the gut microbiome of where you came from,” said Dr. Kaplan. “These bacteria can have lifelong impacts on how our immune system functions, how we metabolize our food, and how we respond to medicines.”

Genetic studies. Dr. Kaplan is searching the genes for personalized medicine approaches, which can be anything from a patient’s response to a medication to the risk of high blood cholesterol. But multi-ethnic studies, and therefore genetic reference points, are lacking for Hispanics/Latinos. “Addressing that was one of our reasons for studying the genetics of this population,” said Dr. Kaplan.

To Learn More

For more detail on HCHS/SOL, see “Evolving Science on Cardiovascular Disease Among Hispanic/Latino Adults” in the Journal of the American College of Cardiology, April 2023. Drs. Kaplan, Isasi, and Rodriguez all contributed to the article.