Prevalence of Blood Pressure, Blood Glucose and Serum
Lipids Abnormalities Among Ethiopian Immigrants:
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Prevalence of blood pressure, glucose and lipid abnomalities among eth

Published on: Mar 4, 2016

Transcripts - Prevalence of blood pressure, glucose and lipid abnomalities among eth

  • 1. ORIGINAL PAPER Prevalence of Blood Pressure, Blood Glucose and Serum Lipids Abnormalities Among Ethiopian Immigrants: A Community-Based Cross-Sectional Study Maryam Ghobadzadeh • Ellen W. Demerath • Yisehak Tura Ó Springer Science+Business Media New York 2014 Abstract The main objective of this study was to investigate the prevalence of hypertension, glucose and blood lipid abnormalities among a community of Ethiopian immigrants in Minnesota. This cross-sectional study used data from the parish nursing program 2007–2012. A total of 673 encounters were included in this study. Various dependent variables including systolic blood pressure (SBP), diastolic blood pressure (DBP), blood glucose (BG), and serum lipids were examined. High blood pressure was defined as a mean SBP equal to or higher than 140 mm/Hg and/or DBP equal to or higher than 90 mmHg. Elevated fasting glucose defined as levels equal to or higher than 126 mg/dL. High level of total cholesterol (TC), total tri- glyceride (TG), low-density lipoprotein (LDL) cholesterol, and low high-density lipoprotein (HDL) cholesterol were defined as C240, C200, C160 and B40 mg/dL, respec- tively. General linear regression models were used to investigate the relationship of participants’ age and gender, to the continuously distributed response variables, which included systolic and DBP, BG, TC, TG, LDL cholesterol and HDL cholesterol. This is a nonrandom sample of adult Ethiopian church members who were invited to participate in a parish nurse cardiovascular disease (CVD) risk factor screening program. Participants in this sample were 43 % male and 57 % female. The overall prevalence of hyper- tension was 30.1 % with a cut off mark of 140/90 mm/Hg. The prevalence of hypertension was 33 and 24 % among men than among women, respectively (p 0.01). Of all participants, 12 % had BG level of equal to or higher than 126 mg/dL. Low levels of HDL were reported in 30 % of the participants (40 mg/dL). A higher prevalence of high LDL level (20 %) was observed among women compared to those found in men (16 %). High TC levels ([240 mg/ dL) were observed in 15 % of the women and 10 % of the men (p = 0.2). Higher SBP and DBP were significantly higher in male participants than their female counterparts (p 0.05) and in contrast, women showed a significantly higher TC (p 0.01) and LDL (0.05) and HDL (p 0.001). Female participants also had higher BG than male participants but the difference was not statistically significant (p [ 0.05). This opportunity sample suggests high prevalence of CVD risk factors in a community of Ethiopian-American adults, and a pressing need for more comprehensive and systematic assessment of chronic dis- ease health needs in this growing community. Keywords Blood pressure Á Prevalence Á Cardiovascular risk factors Á Ethnic groups Background Immigrants of African ethnicity represent one of the fastest-growing immigrant groups in the United States. According to Bureau of the Census [18] data, 13 % of the general population of central Minnesota was from Africa. Demographic trends indicate the number of Ethiopian M. Ghobadzadeh (&) School of Nursing, University of Minnesota, 5-140 Weaver- Densford Hall, 308 Harvard Street SE, Minneapolis, MN 55455, USA e-mail: ghoba001@umn.edu E. W. Demerath Division of Epidemiology & Community Health, University of Minnesota, 1300 2nd Street S, Suite 300, Minneapolis, MN 55455, USA Y. Tura School of Nursing, Minnesota State University, Mankato, MN, USA 123 J Immigrant Minority Health DOI 10.1007/s10903-014-0051-6
  • 2. immigrants will increase over time throughout the US and Minnesota. Minneapolis-St. Paul happens to be home to one of the largest populations of Ethiopian immigrants in the US. According to the US Census American Community Survey, 14,070 Ethiopians live in Minnesota [18, 19]. However, the health status of this diverse group remains relatively understudied compared with many other immi- grant populations. As immigrants become long-term resi- dents, a particular focus on screening, prevention of non- communicable chronic diseases, and treatment of these conditions will become a public health priority and adopting and implementing necessary interventions are recommended to meet needs of this diverse group of people [20, 21]. This study is the description of recent trends in the prev- alence of selected cardiovascular disease (CVD) risk factors in a vulnerable understudied population with potentially high rates of undiagnosed disease due to their recent immigration to the US, lack of health insurance, and exposure to high physical and emotional stress during their childhood and adulthood period secondary to their immigration status. Cardiovascular disease is a combination of hyperten- sion, heart disease, and stroke and is the leading cause of mortality and morbidity in the USA. [12]. Hypertension is one of the most significant health problems for people of African origin and has been shown to be strongly associ- ated with other diseases such as diabetes mellitus and hyperlipidemia [1, 14]. When left uncontrolled, hyperten- sion causes serious conditions such as CVD and kidney failure. Patients with hypertension tend not to seek medical care until complications are already apparent and affect their quality of life. One major emphasis of the primary prevention of CVD since the early 1970s has focused on early detection and treatment of hypertensive patients. The literature indicates that timely screening of high blood pressure is beneficial in terms of reducing the occurrence of these outcomes and helps to reduce the chance of the aforementioned complications [6]. Although nation-wide programs for timely screening of hypertension have been carried out in many places, community-based data regarding the prevalence of hypertension and hypertension subtypes among Ethiopian populations are scarce. In Ethiopia, incomplete and irregular reporting of routine health care has made it impossible to understand the risk factor of non-communicable diseases. The prevalence of high blood pressure in urban areas of Ethiopia was reported to be comparable to the situation in the developed countries and the risk of CVD morbidity and mortality associated with elevated blood pressure may even be higher in Afri- cans. A study carried out among residents of Addis Ababa found prevalence of 31.5 and 28.9 % for hypertension among men and women, respectively [16]. Although hypertension and diabetes are two indepen- dent risk factors for developing coronary heart disease (CHD), they often coexist and diabetic patients are twice as likely to develop hypertension as general population [22]. Diabetes also leads to pathological changes including ath- erosclerosis and subsequent chronic diseases. It was esti- mated that 10.8 million Africans in Sub-Saharan Africa had diabetes in 2006 and this figure is estimated to increase to 18.7 million by 2025 [9]. Some information on chronic disease risk factors among Ethiopians has been made available from studies conducted in Israel on Ethiopian immigrants. The studies in Israel found a higher prevalence of diabetes among the Ethiopian immigrants compared to the other Israelis. They also reported a higher risk for development of diabetes and its complications among population of Ethiopian immigrants in comparison to the general population [5]. Elevated serum lipids are also a major, potentially risk factor for cardiovascular chronic diseases in adults. How- ever, elevated blood lipids are modifiable and can be reduced by healthy lifestyle and timely medical interven- tion. Thus, screening procedures that detect elevated lipid levels appear justifiable as a public health care measure. Furthermore, there is a myriad of evidence to support screening for hypertension, blood sugar and lipid abnor- malities in women. More women die each year due to CVDs than from all types of cancers combined [10]. However, of those sudden cardiac deaths among women, approximately two-thirds (64 %) have no previous symp- toms [13]. To our knowledge, few studies have evaluated the prevalence of serum lipids, blood sugar and blood pressure abnormalities among African immigrants in the United States. This work sets the foundation for future efforts of prevention and control of chronic diseases among African immigrants in the Twin Cities region. Objective results from this study may also be used to identify the health needs of the community members and suggest possible intervention strategies to reduce risk fac- tors for developing CHD. The main objective of this analysis was to study the prevalence of hypertension, glucose and blood lipid abnormalities as well as mean levels of blood pressure, serum glucose, and blood lipids among adults in an Ethi- opian community using recently available data from a Parish Nursing Program conducted 2007–2012 in Minne- apolis, MN. Particular attention is given to sex and age differences in the prevalence and levels of these risk fac- tors, and to the extent of risk factor clustering. Methods The current study was based entirely on an existing com- munity-based CVD risk factor screening and referral J Immigrant Minority Health 123
  • 3. program completed in three Ethiopian Orthodox Christian Churches whose members are approximately 100 % Amharic-speakers, and thus are likely to be fairly homo- geneous in terms of cultural background and dietary habits. The church attendees came from different regions of Ethiopia, however. Individual-level information on region of origin was not collected in the Parish Nurse risk factor survey. The target population is Ethiopian immigrants living in the Twin Cities metro area. Hundreds of Ethio- pians are parishioners or attendees of the DSMA church and other Ethiopian churches in the Twin Cities. At a given Sunday service, over one hundred children, thirty to forty teenagers, young parents, middle age and elderly Ethiopi- ans attend the church. This allows the program to have access to a wide range of Ethiopian families. Most mem- bers of the community are first generation immigrants, and they lack access to health care, face linguistic barriers, and generally have limited knowledge in the critical areas of health and wellness. As first generation immigrant com- munity, members are often engaged in entry level jobs or attend higher education for career development. Some are considered middle income families. The gathering of the community in one place allowed the program to easily reach the community after services. The program has also expanded its health screening services to two other Ethio- pian churches in St. Paul, Minnesota that have the same demographic, socio economic status and understanding of health and wellness. A series of annual cross-sectional surveys were con- ducted in St. Paul and Minneapolis between 2007 and 2012. The screening events were advertised in the church bulletin, local Ethiopian radio (KFAI, Voices of Ethiopia) and flyers which included information announced after services about the direction for fasting prior to the tests. Participation in the disease prevention programs was also encouraged by the church’s leaders and priests. The parish nurse coordinator organized screenings and health fairs, as well as provided literature and health information to volunteers. The screen- ing programs were carried out right after worship services. Upon completion of the screening events, participants were provided necessary education tailored to their risk status as well as referral services for screening findings needing immediate attention. Information on how to access low cost health care services and clinics was also provided to the participants. Survey Data (2007–2012) As stated above, study data came from a parish nursing screening program for hypertension, hyperlipidemia, and high blood sugar among people aged 18 or over supported by the Minnesota Department of Health, Refugee Health Program. Registered nurses working as volunteers collected the clinical data. The data collection form included age, gender, Systolic blood pressure (SBP), Diastolic blood pressure (DBP), blood glucose (BG), total cholesterol (TC), Triglyceride (TG), low density lipoprotein (LDL) and high density lipoprotein (HDL). A database was developed for quantitative analysis. To increase anonymity of the partici- pants (a concern for the community), age was recorded in three categories: 18–37, 38–57, and C58 year. Blood Pressure Measurement Sitting blood pressure was measured by nurses after wor- ship services. Clients rested for 5–10 min before mea- surement, one blood pressure reading was taken in right arm. A second measurement was made in the opposite arm if the first blood pressure reading was 10 mm/Hg higher or 20 mm/Hg lower than normal range (120/80 mmHg) [3]. All reading measurements were recorded on the data collection sheets. The average of all readings recorded for each participant was calculated and used in the analysis. Individuals were classified as hypertensive if their SBPs were equal to or higher than 140 mmHg and/or DBPs equal to orhigherthan90 mmHg.Ifaperson’sSBPrangesfrom120to 139 mmHg or DBP rises to a level of 80–89 mmHg, the person is considered ‘‘pre-hypertensive’’. We further classi- fied the severity of hypertension as pre-hypertension (SBP C 120 mmHg and DBP C 80 mmHg), hypertensive stage 1 (SBP 140-159 mmHg or DBP 90-99 mmHg), stage 2 (SBP C 160 or BP C 100 mmHg for DBP) according to the blood pressure classifications set by the Seventh Report of the Joint National Committee on Prevention, Detection, Evalua- tion, and Treatment of High Blood Pressure (JNC 7) [3]. Blood Glucose Measurement The level of blood sugar was measured in the fasting state. Before the test, the participants fasted for 12–15 h. The tests were performed with participants in a sitting position at a constant temperature room. BG measurements were measured from finger blood sample using FreeStyle LiteÒ (Abbott Diabetes Care Inc), Accu-check or True track. The participants were classified into three subgroups according to the level of fasting BG: (1) B100 mg/dL, (2) 101–125 mg/dL, (3) 126–199 mg/dL, and (4) C200 mg/dL, as rec- ommended by the American Diabetes Association (ADA), with 100 mg/dL defined as the upper limit of normality for fasting BG levels. Serum Lipids Measurement A handheld Professional Blood Testing Device (Cardi- oChekÒ PA POC cholesterol testing system) was used to measure the blood lipid levels. A drop of fresh capillary J Immigrant Minority Health 123
  • 4. blood (35-40 lL for Lipid Panel tests) was applied directly to the test strip. The results were available within 2 min for LDL, HDL, TG, and TC. Samples were collected after a 12-hour overnight fasting. Blood lipid levels were classi- fied according to the Third Report of the National Cho- lesterol Education Program Expert Panel [11]. TC concentrations are classified into 3 categories: Desirable (200 mg/dL), borderline (200–239 mg/dL), and high (Above 240 mg/dL). It has been suggested that HDL cho- lesterol concentrations defined as ‘‘desirable’’ (40–59 mg/dL), ‘‘low’’ (40 mg/dL), and ‘‘optimal ([60 mg/dL). LDL cho- lesterol levels were classified as ‘‘optimal’’ (100 mg/dL), ‘‘desirable’’ (100–129 mg/dL), ‘‘borderline’’ (130–159 mg/ dL), ‘‘high (160–189) and ‘‘very high’’ ([189 mg/dL). Ele- vated TG levels were defined as ‘‘desirable’’ (150 mg/dL), borderline (150–199 mg/dL), high (200–499 mg/dL) and very high ([500 mg/dL). Risk Score Determination The participants were classified into four groups as 0, 1, 2 and 3 based on the number of risk factors they had for CHD: SBP C 140 mmHg or DBP C 90, glucose [ 100, dyslipidemia: TC [ 200 or LDL [ 130 or HDL 40 or TG [ 150. The participants with none of these above cutoff points were coded as 0, and so forth, with maximum being 3 (hypertension?, high BG?, high serum lipids?). Statistical Analysis Chi-square tests were used to assess sex differences in the distribution of categorical variables (e.g., the prevalence of different blood lipid, glucose, and blood pressure catego- ries). General linear regression models were constructed to examine the relationship of participants’ age and gender, to the continuously distributed response variables, which included systolic and DBP, BG, TC, TG, LDL cholesterol and HDL cholesterol. In order to account for differences in measurement conditions over repeated survey years, a covariate term for year of data collection was also included in the models. Gender is a dichotomous variable with males coded as 0 and females as 1. We implemented SAS Proc MI to impute the missing value based on gender and age. We then used Proc MIANALYZE to provide param- eter estimates, standard errors of the estimates, and p val- ues for the association of gender and age group with the cardiovascular risk factors using the imputed datasets. Participants were divided into three age groups: 18–37, 38–57, and C58 years and age was entered as a categorical variable in the regression models. In all analyses, statistical significance was set at a = 0.05. Values are expressed as mean ± SE and frequency ± [95 % confidence interval (CI)]. The analyses were performed using SAS software, version 9.3. Results Nurses recorded services provided for a total of 718 indi- viduals from 2007 to 2012. A total 673 encounters were included in the analyses, following the exclusion of 35 incomplete forms. We examined the association of outcome variables by survey year and found that prevalence and mean values for the outcomes were relatively consistent across survey years (data not shown). For this reason, and because the program included some of the same individuals across multiple survey years (but did not assign individual-level identifiers) we chose to use only the 2012 data for the subsequent analysis to avoid non-independence of the observations. According to US Census Bureau, 51 % of all Ethiopian living in Twin Cities was male and 49 % was female and the mean age reported 30.2 for the males and 29.3 for the females [18]. In 2012, the sample comprised 197 partici- pants, 83 (43 %) men and 111(57 %) women. Over 80 % of the study participants were older than 38 years of age and more than 18 % were 58 years or older. The partici- pants’ age were entered as a categorical variable in the regression models. Overall, only 31.6 % of the participants had blood pres- sure values within normal ranges. A large number of those surveyed had blood pressures that were within the pre- hypertensive (SBP[ 130 mm Hg or DBP [ 80 mm Hg) (38.3 %). Overall, prevalence of hypertension with a cut off mark of 140/90 mm Hg was 30.1 %. The prevalence of hypertension was significantly higher among men than among women (33 and 24 % of all men and women respectively, p = 0.01) (Table 1). The gender- and age- specific mean BP, BG and serum lipids among participants are shown in Table 2. Overall, the mean SBP was 127.7 ± 1.6 mmHg (124.4 ± 6.2 and 130.57 ± 4.8 for women and men respectively) and the mean DBP was 78.36 ± 0.82 mmHg (80.8 mmHg ± 3.6 for men and 75.78 mm/ Hg ± 3.4 for women) (Table 2). SBP and DBP increased with age in both men and women throughout the age groups (p = 0.001). There was also a significant relationship between gender and SBP (F = 5.07, p = 0.001), and the association remained significant after age groups included as a covariate (F = 15.5, p = 0.001). The overall mean value for blood sugar was 109.4 ± 2.5 mg/100 ml. The fasting BG mean was higher in women (113.7 ± 3.7 mg/100 ml vs. 104.7 ± 3 mg/100 ml). Of all participants, 45 % had normal BG levels; 41.2 % were considered as pre-diabetic (101–125 mg/dL) and 12 % had BG level of equal to or higher than 126 mg/dL-199 (9 and J Immigrant Minority Health 123
  • 5. 12 % of all men and women respectively, p = 0.7) and only 1.8 % participants had BG level of equal to or higher than 200 mg/dL. Neither the prevalence of elevated BG nor mean fasting BG levels rose with age (p [ 0.05). A linear regression was also performed and BG dependence on gender and age was tested. Significant differences were not observed between average fasting BG values and gender after adjusting for age (F = 1.48, p = 0.2). The mean serum cholesterol concentration was 168.5 ± 2.7 mg/dL. The mean TC was higher for women (171.9 ± 3.6 mg/dL) compared to male participants (162.39 ± 4.03 mg/dL). We found significant differences between male and female participants in cholesterol levels (p = 0.03) after adjusting for age. The mean LDL cho- lesterol and TG concentration was 95 ± 5 and 130 ± 5.7 mg/dL, respectively. Elevated TC and LDL were observed in 13.5 and 18.3 % of the sample, respectively. There were no differ- ences in the prevalence of elevated TG between men (22 %) and women (18 %) (p = 0.3). High TC levels were observed in 15 % of the women and 10 % of the men (p = 0.2). TC concentration was significantly associated with gender and age as a cofactor (F = 5.78, p = 0.03). Elevated levels of LDL were also marginally associated with gender (F = 1.73, p = 0.05). Women showed a higher prevalence of high LDL levels (20 %) when compared with those found in men (16 %) (Table 1). The overall mean for HDL concentration was 48.93 ± 2.3 mg/dL. Reduced levels of HDL were observed in 30 % of the participants (40 mg/dL), and this percentage was higher in men (37.4 %) than in women (20 %) (p 0.05). A linear regression model that adjusted for age showed an association between HDL and gender (F = 5.2, p = 0.006). Table 3 shows the age-stratified prevalence of 0, 1, 2, and 3 risk factor groups among men and women. Of all female participants, 42 % had at least one risk factor for CHD while the figure was 39 % for their male counter- parts. Using the study criteria, 15 % of women and 22.5 % of men had two risk factors. The criteria also showed that a Table 1 Prevalence of elevated blood pressure, blood glucose and serum lipids among participants by sex Gender BPa BGb TCc TGd LDLe HDLf Female 24 % 12 % 15 % 18 % 20 % 20 % Male 33 % 9 % 10 % 22 % 16 % 37.4 % P value 0.01 0.7 0.2 0.3 0.2 0.001 a Blood pressure cutoff point C140/80 b Blood glucose cutoff point C126 mg/dL c Total cholesterol cutoff point C240 mg/dL d Total glyceride cutoff point C200 mg/dL e Low-density lipoprotein cutoff point C160 mg/dL f High-density lipoprotein cutoff point B40 mg/dL Table 2 Mean (SD) of blood pressure, blood glucose and serum lipids among participants by sex and age Age SBP DBP BG TC TG LDL HDL Mean SE Mean SE Mean SE Mean SE Mean SE Mean SE Mean SE Women (n = 111) 18–37 110 1.5 72 0.7 103 2.4 152 2.7 120 1.9 89 2.9 51.3 1.1 38–57 124.8 1.2 77 1.1 119 4.6 173 2.6 125 2.1 97 2.2 50 1.6 C58 126 1.1 74 1.7 106 2.5 183 1.3 139 2.9 128 2.3 43 1.2 Overall mean 124 6.2 75.78 3.4 113.7 3.7 171.9 3.6 128 2.3 98.22 3.4 52.87 1.5 Men (n = 80) 18–37 122 1.6 73 1.5 97.6 1.8 154 2.3 121 1.8 79 3 41 2.2 38–57 130 2.1 83 1.4 107 1.3 162 1.4 137.6 2.5 90 3.3 43 1.2 C58 135.5 6.5 82.5 2.6 104 3.2 171 1.5 131.5 1.2 94 1.4 50 2.1 Overall mean 130.57 4.8 80.8 3.6 104.7 3 162.39 4.03 135.47 7.8 90.54 3.01 44.27 2.1 p* 0.001 0.001 0.1 0.04 0.01 0.1 0.3 p** 0.02 0.002 0.2 0.01 0.04 0.05 0.001 p*** 0.001 0.001 0.2 0.03 0.07 0.3 0.006 p**** 0.1 0.001 0.1 0.1 0.7 0.2 0.001 SBP systolic blood pressure, DNP diastolic blood pressure, BP blood glucose, TC total cholesterol, TG total glyceride, LDL low-density lipoprotein, HDL high-density lipoprotein p * age effect p ** sex effect p *** sex effect after adjustment for age p ****sex age interaction J Immigrant Minority Health 123
  • 6. higher of number of men who had three risk factors com- pared to women (13 vs. 7 %) but this difference was not statistically significant (See Fig. 1). As expected, the number of risk factors increased strikingly with age in both sexes (p 0.001). Discussion The impact of hypertension on cardiac function and its economic consequences makes it a major public health concern both in the US and in the world [4]. This study was the first to-investigate the prevalence of blood pressure, BG and serum lipid abnormalities in a group of adult Ethiopian immigrants in the US. Overall, the prevalence rate of hypertension in the study population was 30 %. Of all men 33 % were hypertensive while the figure was 24 % for their female participants (p = 0.01). Higher SBP and DBP were more common in male participants than their female counterparts and in contrast, women tended to have higher BG, TC and LDL, although the difference was marginally significant for LDL and not significant for BG levels. In the current study the overall prevalence of high blood pressure was high among both male and female partici- pants and indicates hypertension is a major public health problem in this community. Awoke et al. [1] found similar results in a study in Northwest Ethiopia on the prevalence of hypertension in which the overall prevalence of hyper- tension was reported as 28.3 % (n = 679). However, the finding that higher blood pressure is more prevalent in men than women in this study appears to be not in agreement with [1] study in which the prevalence of hypertension was slightly higher in women (30.3 %) than men (26.0 %). Worldwide prevalence of hypertension also showed that males had a slightly higher prevalence of hypertension than females, but the statistical difference was not significant except for the region of America and European countries [7, 23]. Kinzie et al. [8] found a high prevalence of blood pressure among Vietnamese, Cambodian, Somali, and Bosnian refugees which was higher than US norms (45 %). In all participants combined, 41.2 % had BG level of higher than 101 mgdL but less than 126 mg/dL, a condi- tion that is known as pre-diabetes. The overall diabetes prevalence of 12 % in this group of (n = 197) Ethiopian adults is higher than that found in other communities. In the study by Kinzie et al. [8] the prevalence of diabetes (fasting BG greater than 126 mg/dL) reported as to be 15.5 % which was also higher than the prevalence esti- mated from most previous epidemiologic surveys of the US population. Identification of those people who are pre- diabetic and at risk of developing diabetes mellitus might lead us to select an appropriate target group for interven- tions targeted at preventing Type 2 diabetes [15]. The high prevalence of hypertension and high BG may be explained by the fact that the participants are mostly immigrants. Longitudinal studies on immigrants in Israel found that African immigrants had more hypertension and a higher prevalence of diabetes compared to the general population [2]. Furthermore, the rates of diabetes and hypertension are dramatically increasing in African coun- tries including Ethiopia [1, 14]. Therefore this increase in prevalence may merely reflect alterations in rates of diabetes and hypertensive disorders in the country of origin [8]. Table 3 Frequency of risk factors by age and gender F frequency, P percent p value for sex [0.05, p value for age 0.001 Female Male Age groups Age groups Risk 1 (18–37) 2 (38–57) 3 C 58 Total Risk 1 (18–37) 2 (38–57) 3 (C58) Total F P F P F P F P F P F P F P F P 0 20 71 12 21 7 26 39 35 0 7 37 10 20 3 19 20 25 1 8 29 27 49 12 44 47 42 1 8 42 17 35 6 33 31 39 2 0 0 13 23 4 15 17 15 2 1 5 13 27 4 22 18 22 3 0 0 4 7 4 15 8 7 3 0 0 8 18 3 16 11 14 25 39 22 14 35 43 15 7 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 0 1 2 3 Percent Number of Risk Factors Male Female Fig. 1 Number of selected CVD risk factors by sex. p value for gender effect [0.05, p value for age effect 0.001 J Immigrant Minority Health 123
  • 7. We found that the overall prevalence of high TC and LDL was 13.5 and 18.3 % among the participants and the higher prevalence of both factors were observed among women compared to those found in men. Little information exists concerning the prevalence of serum lipid abnor- malities among Ethiopian population. However, a study conducted in 1993 by Swai et al. [14] in Tanzania, also found that female participants had significantly higher mean TC levels than male participants. CVD events are commonly perceived as less serious threats to women than men. Normally, premenopausal women are somewhat protected from heart disease by estrogen. However, pre- vious studies indicated that the female advantage is decreased in women when other risk factors including high blood sugar and hyperlipidemia presented. According to the World Health Organization’s Global Burden Disease, CVD is the leading cause of death among women and accounted for approximately 32 % of death among women in 2004 [24]. A study conducted by Tran [17] in Ethiopia reported a high number of participants with one (40 and 35.4 % for women and men respectively) or two (20.4 % of women and 18.6 % of men) metabolic syndrome components. The number of risk for CHD also increased significantly with age in this study which used the same cutoff values. The estimates are higher in the current study which may be due to a smaller sample size. Tran [17] also used different definitions to evaluate the risk prevalence among the par- ticipants including Adult Treatment Panel III (ATP III) and International Diabetes Federation (IDF) criteria. It is worth mentioning that in the current study the evaluation of risk prevalence based on the above mentioned standard criteria was not possible due to the available data. Although most of CVD risk factors are amenable to change, not enough attention has been paid to identifica- tion, screening and prevention of them in many under- served communities. Health disparities, including inadequate access to care, linguistic barriers and lack of health insurance, certainly impact the availability of health services for Ethiopian community. Consequently, despite their risks and high rates of medical problems, they tend not to seek professional help as much as they need. This is concerning and necessitates interventions at the community level that improve identification of problems and early access to health services. Several limitations should be considered when inter- preting results of the present survey. The first limitation is the non-random sampling design of the survey, which suggests caution in interpretation of prevalence estimates and the generalizability of the findings to all Ethiopian immigrants. Further, due to the data deficiencies this study could not investigate the impact of lifestyle and socio- economic variables on the associations with blood pressure, BG and serum lipid abnormalities. Body mass index (BMI) and physical activity levels would be of par- ticular importance to address in future surveys, as obesity and sedentary behavior are upstream determinants of all of the risk factors examined here. Therefore, larger studies with more detailed information on demographic as well as lifestyle characteristics including smoking status, BMI, dietary habits and years living in the US will be needed to help develop effective interventions and health promotion programs among African immigrants. In the future, we also hope to track individuals over time so that longitudinal changes across all survey years can be assessed. Acknowledgments We thank all the volunteers of the parish nurs- ing program at the DSMA Parish Nursing Program (Debre Selam Medhane Alem Ethiopian Orthodox Tewahedo Church) for their excellent participation in collecting data and their incredibly valuable role in educating and serving their community. References 1. Awoke A, Awoke T, Alemu S, Megabiaw B. Prevalence and asso- ciated factors of hypertension among adults in Gondar, Northwest Ethiopia: a community based cross-sectional study. BMC Cardio- vasc Disord. 2012;12:113. doi:10.1186/1471-2261-12-113. 2. Bursztyn M, Raz I. Blood pressure and insulin in Ethiopian immigrants: longitudinal study. J Hum Hypertens. 1995;9(4): 245–8. 3. Chobanian AV, Barkis GL, Black HR, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42: 1206–52. 4. Collins R, MacMahon S. Blood pressure, antihypertensive drug treatment and the risks of stroke and of coronary heart disease. Br Med Bull. 1994;50:272–98. 5. Green S, Etzion T, Jucha E. Blood pressure and serum cholesterol among male Ethiopian immigrants compared to other Israelis. J Epidemiol Commun Health. 1995;45:281–6. 6. Greenland P, Abrams J, Aurigemma GP, et al. 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