All-Cause and Cardiovascular Mortality Among Diabetic Participants in the San Antonio Heart Study: Evidence against the “Hispanic Paradox”

Kelly J. Hunt; Ken Williams; Roy G. Resendez; Helen P. Hazuda; Steve M. Haffner; Michael P. Stern

doi:10.2337/diacare.25.9.1557

Epidemiology/Health Services/Psychosocial Research

All-Cause and Cardiovascular Mortality Among Diabetic Participants in the San Antonio Heart Study

Evidence against the “Hispanic Paradox”

Kelly J. Hunt, PHD,
Ken Williams, MS,
Roy G. Resendez, MA,
Helen P. Hazuda, PHD,
Steve M. Haffner, MD and
Michael P. Stern, MD

From the Division of Clinical Epidemiology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas

Diabetes Care 2002 Sep; 25(9): 1557-1563. https://doi.org/10.2337/diacare.25.9.1557

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Figure 1—
A: Kaplan-Meier all-cause and cardiovascular survival estimates for the three ethnicity/birthplace stratum (unadjusted). B: All-cause and cardiovascular mortality rates (rates/1,000 person-years and 95% confidence intervals) adjusted for age and sex.

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Table 1—

Characteristics of the study population stratified by ethnicity and birthplace

	U.S.-born NHWs (n = 178)	U.S.-born MAs (n = 554)	Mexico-born MAs (n = 95)
Unadjusted
Age (years)	55.0	53.2	51.6
Male [% (n)]	47.8 (85)	39.4 (218)	39.0 (37)
Decreased before 1 January 1999 [% (n)]	20.8 (37)	24.4 (135)	16.8 (16)
Cardiovascular mortality [% (n)]	12.9 (23)	15.2 (84)	8.4 (8)
Adjusted for age and sex
Diabetic medication
Using any medication (%)	22.1 (16.6–28.9)	33.7 (29.9–37.8)	27.3 (19.2–37.3)
Insulin use (%)	10.5 (6.7–16.0)	10.6 (8.3–13.5)	3.1 (1.0–9.2)
Hypertension (%)	39.1 (32.0–46.8)	39.9 (35.8–44.3)	30.4 (21.6–40.9)
Current smoker (%)	22.6 (16.9–29.5)	28.1 (24.4–32.2)	22.3 (15.0–31.9)
Poor health (%)	34.2 (27.2–42.0)	36.1 (32.0–40.5)	24.5 (16.6–34.6)
Heart attack (%)	7.2 (4.1–12.5)	7.2 (5.0–10.2)	2.4 (0.6–9.5)
Stroke (%)	4.7 (2.4–9.2)	3.7 (2.3–5.8)	3.6 (1.2–10.8)
Rose angina (%)	5.6 (3.0–10.1)	9.6 (7.4–12.4)	7.6 (3.7–15.2)
Cancer (%)	13.4 (8.5–20.5)	2.8 (1.7–4.8)	3.3 (1.0–10.1)
Gallbladder disease (%)	12.4 (7.9–19.0)	22.6 (18.3–27.7)	14.8 (8.5–24.9)
CVD history (%)	15.3 (10.7–21.5)	17.1 (14.9–20.7)	13.5 (7.8–22.4)
Duncan SEI (scale: 0 to 100)	57.9 (54.8–60.9)	39.0 (37.2–40.7)	34.4 (30.1–38.6)
BMI (kg/m²)	30.4 (29.5–31.3)	31.6 (31.1–32.1)	30.7 (29.5–31.9)
Fasting glucose (mg/dl)	145 (136–154)	163 (158–169)	156 (144–168)
2-h glucose (mg/dl)	260 (245–275)	300 (292–308)	291 (271–312)
Duration of diabetes (years)	2.46 (1.51–3.40)	3.62 (3.09–4.15)	2.73 (1.45–4.00)
Systolic BP (mmHg)	127 (124–129)	130 (128–131)	129 (126–132)
Diastolic BP (mmHg)	74.3 (72.8–75.7)	75.0 (74.2–75.8)	75.4 (73.4–77.4)
Total cholesterol (mg/dl)	220 (212–228)	217 (213–222)	223 (213–234)
HDL cholesterol (mg/dl)	46.3 (44.2–48.4)	43.1 (41.9–44.3)	43.9 (41.0–46.7)
Triglycerides (mg/dl)	237 (208–266)	230 (214–247)	211 (171–250)

Data are means or proportions (95% CI) unless otherwise indicated. Poor health was defined as having had CVD, cancer, or gall bladder disease; a history of CVD was defined as having had a heart attack, stroke, or Rose angina; Variables for which >1% of the population was missing information follow (number missing): history of cancer (9), history of a heart attack (12), Duncan SEI (18), fasting glucose (9), 2-h glucose (79), total cholesterol (12), HDL cholesterol (23), and triglycerides (12).

Table 2—

Adjusted hazard rate ratios (and 95% CIs) from multivariate Cox models for a given difference in risk factor level for all-cause and cardiovascular mortality

All-cause mortality	Model 1a (n = 827)			Model 2a (n = 799)			Model 3a (n = 795)
All-cause mortality		HR	95% CI	HR	95% CI	HR	95% CI
Age (1-year increase)	1.08	(1.06–1.10)	1.08	(1.05–1.10)	1.08	(1.05–1.10)
Sex (M vs. F)	1.43	(1.07–1.90)	1.45	(1.07–1.97)	1.44	(1.06–1.96)
Ethnicity and birthplace
U.S.-born MAs vs. NHWs	1.66	(1.15–2.40)	1.52	(1.02–2.27)	1.35	(0.90–2.03)
Mexico-born MAs vs. NHWs	1.14	(0.63–2.06)	1.08	(0.58–2.01)	0.97	(0.52–1.81)
Diabetic medication
Insulin vs. none	—	—	2.63	(1.76–3.94)	1.69	(1.05–2.73)
Oral antidiabetic agents alone versus none	—	—	1.26	(0.88–1.81)	1.04	(0.71–1.52)
Current smoker versus others	—	—	1.53	(1.11–2.11)	1.43	(1.04–1.98)
Total cholesterol (high vs. low)*	—	—	1.45	(1.05–2.00)	1.36	(0.98–1.88)
HDL cholesterol (low vs. high)†	—	—	1.39	(1.02–1.89)	1.22	(0.89–1.68)
Systolic blood pressure (an increase of 10 mmHg)	—	—	1.05	(0.96–1.16)	1.09	(0.99–1.19)
Duration of diabetes (an increase of 1 year)	—	—	—	—	1.03	(1.01–1.05)
Fasting glucose (an increase of 10 mg/dl)	—	—	—	—	1.05	(1.03–1.08)

Cardiovascular mortality	Model 1b (n = 825)			Model 2b (n = 797)			Model 3b (n = 793)
Cardiovascular mortality		HR	95% CI	HR	95% CI	HR	95% CI
Age (1-year increase)	1.07	(1.04–1.09)	1.06	(1.03–1.09)	1.06	(1.03–1.09)
Sex (M vs. F)	1.45	(1.01–2.10)	1.64	(1.11–2.42)	1.67	(1.12–2.47)
Ethnicity and birthplace
U.S.-born MAs vs. NHWs	1.66	(1.04–2.65)	1.47	(0.87–2.47)	1.29	(0.76–2.17)
Mexico-born MAs vs. NHWs	0.89	(0.40–2.01)	0.90	(0.39–2.09)	0.83	(0.36–1.91)
Diabetic medication
Insulin vs. none	—	—	3.31	(2.02–5.40)	1.83	(1.01–3.32)
Oral antidiabetic agents alone versus none	—	—	1.27	(0.78–2.04)	0.97	(0.58–1.60)
History of CVD at index visit (yes versus no)	—	—	1.65	(1.07–2.54)	1.93	(1.25–2.99)
Current smoker versus others	—	—	1.44	(0.95–2.17)	1.30	(0.86–1.98)
Total cholesterol (high vs. low)*	—	—	1.81	(1.21–2.71)	1.72	(1.15–2.58)
HDL cholesterol (low vs. high)†	—	—	1.61	(1.09–2.40)	1.40	(0.94–2.10)
Systolic blood pressure (an increase of 10 mmHg)	—	—	1.13	(1.00–1.27)	1.17	(1.04–1.31)
Duration of diabetes (an increase of 1 year)	—	—	—	—	1.04	(1.01–1.06)
Fasting glucose (an increase of 10 mg/dl)	—	—	—	—	1.06	(1.03–1.09)

*
↵* High total cholesterol was defined as ≥240 mg/dl (6.22 mmol/l);
†
↵† low HDL cholesterol was defined as 35 mg/dl (0.91 mmol/l) or less in men and 45 mg/dl (1.17 mmol/l) or less in women.