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Nutritional Epidemiology

Dietary Intake and Risk of Coronary Heart Disease Differ among Ethnic Subgroups of Black Americans

Department of Nutrition, Food Studies and Public Health, New York University, New York, NY 10012

¹ To whom correspondence should be addressed. E-mail: kjl1{at}nyu.edu.

	ABSTRACT

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
Coronary heart disease (CHD) morbidity and mortality are more prevalent in Blacks than Whites in the United States. Most studies evaluate the dietary intake and health of Black Americans as one group and do not consider possible differences among ethnic subgroups within the U.S. Black population. We used data from NHANES III to assess whether dietary intake, CHD risk factors, and predicted 10-y risk of CHD differed between non-Hispanic Black adults born in the United States (NHB-US), and non-Hispanic and Hispanic Black adults born outside of the United States (NHB-nonUS, HB-nonUS). Data were provided from single 24-h dietary recalls, biochemical measures, the medical examination, and self-reported responses to survey questions. NHB-US had higher intakes of energy, fat, protein, meat, added sugars, and sodium, and lower intakes of fruits, fiber, and most micronutrients. NHB-US also had higher predicted 10-y risk of developing CHD (5.8%) than NHB-nonUS (3.7%, P < 0.001) or HB-nonUS (4.7%, P = 0.017). Both immigrant groups had better CHD risk profiles and lower proportions of persons with metabolic syndrome and other CHD-related conditions. Our findings show differences in dietary intake and risk of CHD and related health conditions among ethnic subgroups of Blacks living in the United States. Future studies of diet and health should consider cultural differences within the Black population to better understand and reduce overall health disparities in the United States.

KEY WORDS: • Black Americans • coronary heart disease • dietary intake • health disparities • acculturation

An overarching goal of Healthy People 2010 is to eliminate health disparities among different segments of the population (1). Although overall mortality from coronary heart disease (CHD)² is decreasing in the United States, Black Americans still have higher CHD mortality than Whites (2). Blacks also have greater morbidity from CHD and related conditions including metabolic syndrome, hypertension, diabetes, stroke, and obesity (3–6). Diet is a key component in the prevention and treatment of CHD and related conditions (7). Therefore, differences in dietary intake may contribute to the health disparities between Blacks and other ethnic groups in the United States.

Traditionally, research studies treat Black Americans as a homogeneous group, grouping all Blacks into one category for analysis despite cultural differences within this population. However, it is well documented that dietary patterns often differ within racial groups by ethnicity and measures of acculturation such as place of birth. For example, persons born outside of the United States often have more healthful diets than their U.S.-born counterparts (8–10). Additionally, other risk factors and health conditions related to CHD, including obesity and diabetes, differ by acculturation (11–14). According to U.S. Census data from 2000, 8% of the U.S. Black population were born outside of the United States, 2% were of Hispanic heritage, and these numbers continue to rise (15). Thus, it is likely that dietary intake and other risk factors and health conditions related to CHD differ within the U.S. Black population. In this study, we used data from the Third National Health and Nutrition Examination Survey (NHANES III) to determine whether dietary intake, CHD risk factors, and predicted 10-y risk of CHD differ among Black Americans according to their place of birth and Hispanic heritage.

	SUBJECTS AND METHODS

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
NHANES III is a cross-sectional survey with health and nutrition information from a stratified probability sample of the noninstitutionalized U.S. population. From October 1988 through October 1994, health professionals administered an extensive standardized questionnaire that gathered sociodemographic, health, and dietary data from participants in their homes. After completion of the questionnaire, participants underwent a medical examination conducted at mobile examination centers (MEC) at 89 sites nationwide. Blacks were oversampled to ensure reliable health estimates for Blacks in the United States. Further detail of the survey design is available (16).

    Study sample. The study sample included all NHANES III participants 20–79 y old who had reliable interviews, were examined at the MEC, and reported being Black. Participants who were pregnant at the time of the interview were excluded to avoid potential confounding from gestational hypertension and diabetes. We also excluded participants with 24-h dietary recall data coded as either unreliable or incomplete as described in NHANES III documentation (17). Data on country of birth (United States vs. other) and heritage (Hispanic vs. non-Hispanic) were used to determine the comparison groups. The final sample included 4062 African Americans [non-Hispanic Blacks born in the United States (NHB-US)], 241 non-Hispanic Blacks born outside the United States (NHB-nonUS), 104 Hispanic Blacks born outside the United States (HB-nonUS), and 21 Hispanic Blacks born in the United States (HB-US).

To describe the sample, we examined demographic characteristics including sex, age, years of education, and the poverty income ratio (PIR), a calculation of the midpoint of the family income category divided by the poverty threshold for the year the survey was administered, and the age of the family reference person. We also examined Census region, urban residence, primary language spoken, and the number of years in the United States.

    Dietary intake. A single 24-h dietary recall was administered at the MEC; interviewers used 3-dimensional food models, measurement aids, and food-specific units to estimate amounts consumed. Intake of food groups and nutrients recommended by the AHA Dietary Guidelines (7), or that were shown in the literature to be associated with markers and outcomes of CHD and related diseases (18–23), were estimated from the recall data. Estimates of energy, fat, saturated fat, polyunsaturated fat, cholesterol, fiber, protein, carbohydrates, carotenes, vitamins C, E, folate, vitamin B-6 and vitamin B-12, calcium, magnesium, sodium, and potassium did not include amounts in nutritional supplements, condiments added at the table, or medications.

We linked the data from the 24-h dietary recalls with the Pyramid Servings Database, a tool developed for NHANES III by investigators at the National Cancer Institute (24), to determine the number of servings from 5 major food groups and 22 subgroups and the amounts of added sugars and discretionary fats in every 100 g of the foods. Added sugars included those added to food at the table, eaten separately, or used as ingredients in prepared or processed foods. Discretionary fat included fats added to foods either at the table or during preparation, and fat in foods in the major food groups that was greater than the amount of fat in the lowest fat version of the food (25).

    Diet-related and other CHD risk factors. Certified phlebotomists drew blood from participants during the MEC visit using standardized protocols. All laboratory staff received comprehensive training, and unscheduled quality assurance evaluations were conducted periodically to ensure uniform procedures throughout the study. Concentrations of serum lipids and lipoproteins, serum nutrients including ß-carotene, vitamins C, E, and folate, and other serum markers including C-reactive protein (CRP), homocysteine, serum glucose, and glycosylated hemoglobin (HbA1c) were estimated from the biochemical data. All participants 12 y old were instructed to fast for at least 10–12 h before the morning examination, or at least 6 h before the afternoon or evening examination. As recommended (26), LDL cholesterol and triacylglycerol (TG) concentrations included only participants who reported fasting for at least 9 h. Sample size for serum homocysteine was also reduced because it was measured only during the second wave of NHANES III (1991–1994). Detailed information about the laboratory procedures and quality control protocols used for the measurement of these serum nutrients is provided in the Laboratory Procedures Used for NHANES III (27).

Physicians took 3 sets of blood pressure (BP) measurements as part of the physical examination conducted at the MEC. Blood pressure was measured on the right arm of participants who had been seated quietly for at least 5 min using a mercury sphygmomanometer; physicians followed the standardized BP measurement protocols recommended by the AHA (28). We used the mean of the 3 BP readings taken by a health professional in the MEC to determine the systolic and diastolic BP in this analysis.

Trained technicians in the MEC measured weight, height, and waist circumference. Data on weight and height were used to calculate BMI (kg/m²). The household questionnaire also asked participants about their smoking behavior.

    Predicted 10-y risk of CHD, metabolic syndrome, and CHD-related conditions. Predicted 10-y risk for developing CHD was based on the Framingham risk scoring described in the Adult Treatment Panel III or ATP III (29). As part of the Framingham Heart study, 5345 participants who were free of CHD at the time of their examination in 1971–1974 were followed for 12 y. CHD outcomes, including angina pectoris, recognized and unrecognized myocardial infarction, coronary insufficiency, and coronary heart disease death, were used to develop prediction models of 10-y CHD incidence estimates. Framingham scoring assigns points based on age, total and HDL cholesterol concentrations, systolic BP, treatment for hypertension, and cigarette smoking for each sex. The point total is then used to estimate 10-y risk for myocardial infarction and coronary death. Goals for lowering LDL cholesterol and cutpoints for therapeutic lifestyle changes and drug therapy are determined by the degree of risk for CHD: >20% risk, 10–20% risk, or <10% risk.

Using ATP III criteria (29), we determined the prevalence of metabolic syndrome as having at least 3 of the following risk factors: waist circumference >102 cm for men and 88 cm for women; serum TG 150 mg/dL (1.70 mmol/L); HDL cholesterol <40 mg/dL (1.04 mmol/L) for men and 50 mg/dL (1.30 mmol/L) for women; BP 130 mm Hg systolic or 85 mm Hg diastolic; and fasting glucose 110 mg/dL (6.10 mmol/L). Participants with a history of CHD-related conditions including hypertension, diabetes, high serum cholesterol, heart attack, and stroke were determined from their responses to these items on the household questionnaire.

    Statistical analysis. We calculated descriptive statistics of sociodemographic characteristics for the 4 ethnic groups of Black Americans: NHB-US, NHB-nonUS, HB-non US, and HB-US. Multivariate linear regression models, adjusted for sex, age, BMI, and years of education (a marker of socioeconomic status), were created to compare mean values of dietary intake, diet-related, and other CHD risk factors, 10-y CHD risk, and prevalence of CHD-related conditions including metabolic syndrome among NHB-US, NHB-nonUS, and HB-nonUS. HB-US were not included in the regression analyses because of the small sample (n = 21).

To determine whether overall differences in energy intake explained differences in the intake of nutrients or food groups, energy intake was added to those multivariate linear regression models as a covariate. We also analyzed differences in nutrient intake per 1000 kcal (4.187 MJ). To assess possible underreporting of energy intake, we calculated the ratio of energy intake to estimated basal metabolic rate from age- and sex-specific formulas derived for adults (30). Participants with a ratio of energy intake to estimated basal metabolic rate <0.9, a cutpoint that is appropriate for data from single 24-h dietary recalls (31), were considered underreporters. To clarify whether underreporting of energy may explain differences in nutrient and food intakes among the ethnic subgroups, we compared results from multivariate regression models with and without those participants.

SAS-callable SUDAAN, version 8.2 (Research Triangle Institute) was used to account for the complex sample design. All analyses incorporated sampling weights and strata that adjusted for unequal probabilities of selection. Two-tailed P-values <0.05 were considered significant.

	RESULTS

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
All groups of Black Americans, except HB-US, had similar proportions of men and women with a mean age of 40 y (Table 1). NHB, regardless of country of birth, had more years of education and higher incomes, and were more likely to speak English as their primary language compared with HB-nonUS. HB-US had more years of education and somewhat higher PIR compared with the other 3 groups, and most spoke English as their primary language. More than 50% of Blacks in all groups lived in urban areas mainly in the Northeast and South. HB-US also lived in the West. Both immigrant groups had lived in the United States a mean of 12 y.

	DISCUSSION

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

Studies of other ethnic groups also showed less favorable dietary patterns among adults born in the United States compared with foreign-born adults (32). For example, Dixon et al (9). found that Mexican American adults who were born in the United States and whose primary language was English (i.e., those most acculturated) ate more fat and desserts, and less fiber, fruits, vegetables, and whole grains than Mexican American adults who were born in Mexico. Similar to our findings, Mexican American adults born in the United States had higher predicted 10-y risk of CHD compared with Mexican American adults born in Mexico (33).

Very few studies have examined the dietary and health practices of immigrant Blacks who live in the United States According to U.S. Census data, the majority of immigrant Blacks were born in the Caribbean (15). One study found that Caribbean Blacks living in New York City had more healthful diets than U.S.-born Blacks (34). Another study found that Caribbean Blacks living in New York City also had lower mortality from CHD, hypertension, and stroke than U.S.-born Blacks (35). In other studies, adults who migrated to the United States and Britain had higher BMI, larger waist circumferences, and higher rates of CAD, hypertension, and diabetes compared with adults living in the Caribbean or West Africa (36–38).

Unfortunately, the diets and health of immigrants may worsen with length of residence in the United States. Several studies showed that older or more acculturated immigrants have dietary patterns that more closely resemble the typical U.S. diet, i.e., high in energy, fat, and added sugars, compared with the dietary patterns of younger or less acculturated immigrants (8,10,14,39,40). Recent studies also showed that rates of CHD and obesity were highest among immigrants living in the United States for 10 y compared with more recent immigrants (11,12,41). In our study, both immigrant groups of Black Americans had lived in the United States an average of 12 y. Interestingly, the more healthful dietary intake of HB-nonUS suggests that Hispanic Blacks are more likely to maintain their traditional eating habits than non-Hispanic Black immigrants. However, NHB-nonUS had lower predicted 10-y risk of CHD. Although not measured in this study, it is possible that HB-nonUS had reduced access to care, especially because English was not their primary language (42), or experienced more stress from racial discrimination compared with NHB-nonUS (43).

It is important to acknowledge a few limitations of this study. More healthful dietary intakes and lower risk of CHD in immigrant Blacks may be due in part to the "healthy migrant" effect whereby persons who migrate to the United States have more healthful lifestyles than persons who remain in the native countries (44). Country of birth is commonly used to characterize members of different ethnic groups but does not capture the complex process of acculturation (45). Even within an ethnic group, culture may differ as it relates to diet and health (41,46,47). To maintain confidentiality, NHANES III data do not include participants' country of birth, other than the United States and Mexico; thus, we used Hispanic ethnicity to further characterize foreign-born Blacks in the United States. Also, due to small sample sizes in some of the groups, we did not differentiate U.S.-born Blacks by generational status or foreign-born Blacks by length of time in the United States. U.S.-born Blacks who are first generation (i.e., with parents who were foreign-born) may have intermediate dietary patterns and CHD risk profiles among Blacks not born in the United States and second or later generation U.S.-born Blacks. Similarly, foreign-born Blacks who have lived in the United States for longer periods of time may have dietary patterns and CHD risk profiles that are more similar to U.S.-born Blacks than newly arrived foreign-born Blacks.

Measurement of dietary intake also has limitations. Although 24-h dietary recalls are commonly used to assess dietary intake of groups of individuals, a single day of dietary data does not capture the usual intake of an individual and is prone to measurement error (48). In NHANES III, nutrients obtained from dietary supplements, condiments added at the table, or medications were not included in the estimates from the 24-h recalls. Exact nutrient data for some of the foods and mixed dishes reported by Blacks born outside of the United States may not have been available, despite substantial efforts by nutritionists to add hundreds of ethnic foods, especially Hispanic foods, to the food databases for NHANES III (49). Participants with metabolic syndrome and other CHD-related conditions may have recalled their intake from the previous day differently than participants without these health conditions.

For the risk of CHD, Framingham risk scoring was derived from a homogeneous sample of White Americans (50). However, Framingham risk scoring was found to be a reasonably good estimation of predicted 5-y risk of CHD for Black Americans (51). In addition to potential measurement error associated with the serum and physiological measures, some of the CHD-related conditions relied on self-report. Finally, these analyses required use of NHANES III data because more recent national data do not have adequate sample sizes or the necessary variables to compare dietary intake, CHD risk factors, and predicted 10-y risk of CHD among the 4 ethnic groups of Black Americans. It is our opinion that the inherent strengths of NHANES III, most notably the oversampling of Blacks nationwide and the wealth of nutrition and health data carefully collected from this sample, merit the use of these data, especially given the paucity of data on dietary intake and risk for CHD among ethnic subgroups in the U.S. Black population and the recognized health disparities between Black and White Americans.

In conclusion, Blacks born in the United States have less favorable dietary intake and higher CHD risk than other groups of Blacks living in the United States, highlighting the cultural differences among Black Americans. Our findings support the need for culturally appropriate interventions designed to improve the dietary intake of Blacks born in the United States and to encourage immigrant Blacks to maintain the healthful dietary intake of their native country. Dietary intakes more in accordance with national dietary guidance will likely reduce the risk of CHD in all Black Americans, and thus overall health disparities among Blacks, Whites, and other ethnic populations. We strongly encourage future studies of diet and health to consider cultural differences within the U.S. Black population.

	FOOTNOTES

 
² Abbreviations used: ATP III, Adult Treatment Panel III; BP, blood pressure; CHD, coronary heart disease; CRP, C-reactive protein; HbA1c, hemoglobin A1c; HB-nonUS, Hispanic Black born outside of the United States; HB-US, Hispanic Black born in the United States; MEC, mobile examination center; NHANES III, the Third National Health and Nutrition Examination Survey; NHB-nonUS, non-Hispanic Black born outside of the United States; NHB-US, non-Hispanic Black born in the United States; TG, triacylglycerol.

Manuscript received 25 May 2005. Initial review completed 28 June 2005. Revision accepted 22 November 2005.

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TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 

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