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(Circulation. 1997;96:418-423.)
© 1997 American Heart Association, Inc.

Articles

Cardiovascular Risk Factors in Mexican-American and Non-Hispanic White Children

The Corpus Christi Child Heart Study

Susan R. Tortolero, PhD; David C. Goff, Jr, MD, PhD; Milton Z. Nichaman, MD, ScD; Darwin R. Labarthe, MD, PhD; Jo Anne Grunbaum, EdD; ; Craig L. Hanis, PhD

From the Southwest Center for Prevention Research, School of Public Health, University of Texas–Houston Health Science Center.

Correspondence to Susan R. Tortolero, PhD, Assistant Professor of Epidemiology, Southwest Center for Prevention Research, School of Public Health, University of Texas–Houston Health Science Center, PO Box 20186, Houston, TX 77225. E-mail stortolero{at}utsph.sph.uth.tmc.edu

	Abstract

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Background Information concerning differences in cardiovascular disease risk factors between Mexican-American and non-Hispanic white children is limited. We conducted a study to determine if there were ethnic differences in cardiovascular disease risk factors in children and whether such differences were explained by differences in body mass index.

Methods and Results Fasting glucose, insulin, and blood lipid concentrations, blood pressure, weight, and height were measured in a cross-sectional survey among 403 third-grade children in Corpus Christi, Tex. We found significantly higher fasting insulin and glucose concentrations among Mexican-American than among non-Hispanic white children. Mexican-American boys had slightly lower levels of HDL cholesterol and higher systolic blood pressure than non-Hispanic white boys. Ethnic differences in insulin and glucose were not explained by body mass index.

Conclusions These results provide preliminary evidence that ethnic differences in insulin, glucose, body mass index, and other risk factors occur as early as age 8 to 10 years. Additional research is warranted on differences in risk factors in Mexican-American and non-Hispanic white children and the potential importance of insulin in influencing the natural history of these characteristics.

Key Words: cardiovascular diseases • insulin • glucose • blood pressure • cholesterol

	Introduction

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Hypertension, hyperlipidemia, smoking, and obesity have been recognized as important precursors of CVD in adults and begin to develop in childhood.^{1 2 3} Levels of blood pressure, blood cholesterol, and BMI in childhood and adolescence have been shown to predict levels in adulthood.^{4 5 6 7 8 9 10} In autopsy studies, fatty streaks and raised lesions have been found in the aortas and coronary arteries of teenagers and young adults.^{11 12} Risk factors for development of these lesions include serum lipoproteins, cigarette smoking (serum thiocyanate), diabetes (glycohemoglobin), obesity (thickness of panniculus adiposus), and hypertension (changes in the small renal arteries).¹² In adults, hyperinsulinemia has also been suggested to be an important risk factor for CVD^{13 14 15} ; however, much less is understood about insulin concentrations and their changes during childhood and the role insulin may play in the development of CVD risk.

Ethnic differences in the distributions of CVD risk factors in children have been reported extensively.^{16 17 18 19 20 21 22 23 24 25} Comparisons of blood pressure across ethnic groups are conflicting, although several studies have reported that black children have significantly higher blood pressure levels than white children.^{24 26 27} Differences among Hispanic and NHW children are less clear. Whereas some investigations found no differences in blood pressure among Hispanic, black, and NHW children,^{16 28} others found that Mexican-American children had significantly higher DPB4 measurements than NHW or black children²⁰ and significantly higher SBP than black or NHW boys.²⁷

Several studies of ethnic differences in blood lipids among preschool and school children have reported black children to have higher TC levels than NHW children.^{18 29 30 31 32 33} Again, however, differences between Hispanics and other ethnic groups are less clear. Several investigations have reported Hispanic children to have TC levels similar to NHW children.^{18 25} Others have reported that Hispanics have higher levels of LDL-C and TGs than NHW children.¹⁶

Epidemiological evidence suggests that Mexican-American adults have higher coronary heart disease mortality rates^{34 35} and a two to three times higher prevalence of NIDDM than NHWs.³⁶ Among the Mexican-American population, data indicate an earlier age of onset of NIDDM³⁷ and an increased risk of NIDDM and hyperinsulinemia after controlling for obesity.^{38 39} Very little information exists on ethnic differences in serum insulin and glucose levels among children,^{23 40 41} and no information has been published¹⁷ regarding the comparison of serum insulin and glucose levels in Hispanic and NHW children. Because Mexican-American adults have greater frequencies of obesity, diabetes, hypercholesterolemia, and hypertriglyceridemia than NHWs,^{36 37 38 39 42 43 44 45 46} it is especially important to gain an understanding of how these potential risk factors evolve in childhood for this ethnic group. Therefore, we undertook a study of third-grade Mexican-American and NHW children to determine if there were ethnic differences in the distributions of fasting glucose, insulin, and blood lipid concentrations, blood pressure, and BMI and whether any such differences were found consistently in both girls and boys. Because adiposity has been found to account in part for risk factor differences between ethnic groups in some studies,^{24 26 41} we also tested for such a role of BMI.

	Methods

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Study Population
The target population consisted of 785 third-grade students from eight public schools in Nueces County, Texas. According to the 1990 census, Nueces County had an estimated population of 291 145. Of this population, 43% were NHWs, 52% were Hispanic (92% Mexican Americans), and the remainder were blacks or other ethnic groups.

All third-grade students in these eight schools were eligible to participate. Before the screening examination, both parental consent and child assent were obtained, and a demographic questionnaire including family history information was sent to parents. Of the 785 third-grade students, 615 (78%) returned the questionnaire, and 529 (67%) participated in the screening examination, resulting in a population of 446 children with a completed questionnaire and examination. In addition, data from 31 children (7%) ineligible by ethnicity were excluded from the present study, and 12 children (3%) were excluded because they did not fast before venipuncture. The resulting study population of 403 participants with complete information on all measures was included in the analysis. Participation rates did not significantly vary by ethnicity (P=.17), sex (P=.15), or school lunch subsidy eligibility status (P=.52), a surrogate measure of socioeconomic status.

Measurement Procedures
The parent questionnaire was developed in Spanish and English to ascertain ethnicity and family history for each student's biological parents and grandparents. The questionnaire and a return envelope were sent home with the child. Assistance was provided to parents who needed help in completing the survey by providing a telephone number and by scheduling meetings at the school. Ethnicity was classified in accordance with that reported by the parent who responded.

Blood was obtained by venipuncture after an overnight fast. Blood samples were centrifuged, and the separated serum was frozen at -70°C and shipped on dry ice to the University of Texas Health Science Center at Houston. Laboratory analyses for insulin, TC, HDL-C, and TG were conducted. LDL-C was calculated as TC-[HDL-C+1/5 TG].

Height was measured to the nearest 0.1 cm by a portable stadiometer, and weight was measured on a beam balance scale to the nearest 0.1 kg. BMI was calculated as weight in kilograms divided by height in meters squared.

All blood pressure observers were trained and certified under a standardized protocol that used mercury sphygmomanometers. After children had rested in a sitting position for 5 minutes, two complete blood pressure measurements were recorded, and the average of these two values was used in all analyses. SBP was reported as the first Korotkoff phase, and diastolic blood pressure (DBP4) was reported as the fourth Korotkoff phase.

Statistical Analysis
Measures of central tendency and dispersion of the distributions of blood pressure, glucose, insulin, BMI, and blood lipid levels were determined. Mean values were compared by ethnicity and gender subgroups, and differences were evaluated by ANOVA.

To determine whether ethnic differences in insulin, glucose, HDL-C, and SBP levels remained after controlling for BMI, we conducted multiple linear regression analysis for each gender group. We assessed model assumptions using a variety of plots and regression diagnostic procedures. In the regression analyses, insulin values were log transformed because of their skewed distributions. For each risk factor (insulin, glucose, SBP, and HDL-C), we examined two models: the first with ethnicity alone and the second adjusting for BMI. We considered age and participation in the school lunch program (a surrogate for socioeconomic status), but these variables neither predicted outcome nor acted as confounders, and therefore we omitted them.

	Results

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Complete data were obtained on 403 children. Selected demographic characteristics of the study population are presented in Table 1. Slightly more than half of the sample were classified as Mexican Americans. The gender distributions of the two samples were approximately equal. The majority of children were either 8 or 9 years of age. Although slightly more Mexican-American boys fell into the 9-to-10-year-old category, the age distributions of Mexican-American and NHW boys were very similar: median age for Mexican-American boys was 9.2 years compared with 9.1 years for NHW boys. Eligibility for the school lunch subsidy program, a surrogate for socioeconomic status, was significantly more frequent among Mexican Americans than among NHW children (61% versus 36%; P<.01) for whom this information was included.

View this table: [in this window] [in a new window]   Table 1. Study Population by Age, Sex, and Ethnicity: Corpus Christi Child Heart Study, 1994

Ethnic and sex differences in the distributions of selected characteristics are presented in Table 2. Mexican-American participants had higher mean values of fasting insulin (P<.01) and glucose levels (P<.01) than NHW participants. TG levels were higher among Mexican-American than among NHW boys and girls; however; the differences in these distributions were not statistically significant (P=.11 and P=.28 for boys and girls, respectively). Negligible or insignificant differences by ethnicity were found for TC and DBP4. Mexican-American boys had higher SBP (P=.01) and BMI (P<.01) than NHW boys, whereas no ethnic differences were observed for these variables among girls. Furthermore, Mexican-American boys had lower HDL levels than NHW boys (P=.03).

View this table: [in this window] [in a new window]   Table 2. Mean Values for Selected Characteristics by Sex and Ethnicity: Corpus Christi Child Heart Study, 1994

Selected Pearson correlation coefficients by ethnic-gender groups are displayed in Table 3. Fasting insulin correlated to BMI and glucose in all four ethnic-gender groups and to TGs and SBP in all groups except NHW boys. BMI correlated to SBP in all four ethnic-gender groups and to TGs in all groups except NHW boys. The inverse direction of associations of HDL-C with both insulin and BMI was expected; however, the correlation was weak.

View this table: [in this window] [in a new window]   Table 3. Pearson Correlation Coefficients of Selected Variables With Insulin Concentration and BMI by Ethnicity and Sex: Corpus Christi Child Heart Study, 1994

To further assess whether ethnic differences in insulin, glucose, SBP, and HDL-C might be associated with differences in BMI, multiple linear regression analyses were performed separately for boys and girls with ethnicity and BMI in the model. Table 4 shows the unadjusted and adjusted regression coefficients for ethnicity associated with each risk factor for which an ethnic difference was observed in either girls or boys. Ethnicity remained an important predictor of log insulin and glucose levels among boys and girls after adjustment for BMI, although among boys, adding BMI to the model decreased the strength of the association between ethnicity and insulin and glucose levels. Adding BMI to the model did not alter these associations among girls. Among both sexes, ethnicity was not an important predictor of HDL-C or SBP after controlling for BMI.

View this table: [in this window] [in a new window]   Table 4. Multiple Linear Regression of Selected Risk Factors by Ethnicity for Each Sex: Corpus Christi Child Heart Study, 1994

	Discussion

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Glucose and Insulin Concentrations
Results from this study suggest significant differences in CVD risk among third-grade Mexican-American and NHW children. We found significantly higher fasting insulin and glucose levels among Mexican-American children of both sexes than among NHW children. Differences in glucose and insulin levels between Hispanic and NHW children have not been reported previously. Mexican-American adults have decreased insulin sensitivity^{42 47} compared with NHWs, and decreased insulin sensitivity has been demonstrated among young, lean, normoglycemic Mexican-American adults.³⁹ In the present study, ethnic differences in insulin levels were still significant even after controlling for BMI. Others²³ have reported ethnic differences in insulin distributions between black children and adolescents compared with NHWs and have reported that these differences were not explained by differences in adiposity. The reasons for these ethnic differences in insulin levels have yet to be elucidated.

Blood Pressure
Other important ethnic differences observed in the present study include higher SBP levels among Mexican-American third-grade children than among NHW children. Inconsistent results have been reported previously regarding ethnic differences in blood pressure levels.^{16 20 48 49} However, several studies demonstrated an association between blood pressure and adiposity,^{41 50} which may explain why Mexican-American boys in the present study had higher levels of SBP. Gutin and colleagues⁵⁰ reported that among inner-city Hispanic children aged 5 and 6 years, significant proportions of the variance in blood pressure are accounted for by aerobic fitness and adiposity. We observed significant positive correlations between BMI and SBP ranging from .31 to .46 in all ethnic-gender groups. Furthermore, ethnic differences in SBP were not apparent after controlling for BMI.

Blood Lipids
Very few data exist on differences in blood lipid levels between Hispanic and NHW children. In this study, we found lower levels of HDL-C among Mexican-American boys than among NHW boys. Similarly, Belcher et al¹⁷ reported that Hispanic schoolchildren had the lowest levels of HDL-C compared with black and NHW children. Moreover, they found Hispanic children tended to have greater indices of body fatness and more adverse lipoprotein profiles. Several other investigations indicated that HDL-C was associated with various indicators of fatness in both children and adults. Folsom et al⁴¹ reported that abdominal adiposity was negatively associated with HDL among young black adults.

Concurrence of Insulin Concentrations With Risk Factors
We observed significant positive correlations between insulin and other CVD risk factors. We observed significant associations of DBP4 and insulin among NHW girls in particular and associations between SBP and insulin among all ethnic-gender groups except NHW boys. In several epidemiological studies,^{15 51 52} it has been shown that fasting insulin concentrations are closely related to blood pressure levels in obese and diabetic adults. Among children, Jiang et al⁴⁰ reported strong positive correlations between insulin and both diastolic and systolic blood pressures in preadolescent children but not among adolescent children. In Finnish boys and girls aged 9 to 18 years, Ronnemaa and colleagues⁵³ reported a positive association between SBP levels and insulin levels, whereas less consistent associations were observed between diastolic blood pressure and insulin, particularly among boys. These results may be indicative that insulin is positively associated with blood pressure early in life and may influence the natural history of hypertension and CVD.

The association between plasma insulin and lipid levels has also been described in population-based studies in healthy, normal-weight adults.^{15 54 55} In healthy adults, a positive association between TGs and insulin, an inverse relationship between insulin and HDL-C concentrations, and weak, inconsistent associations between TC and insulin have been reported.^{15 55 56} Consistent with the adult data, the present study and others^{41 53} report strong positive associations between insulin and TGs among children; however, this association was weaker for NHW boys than for other ethnic-gender groups, perhaps because they were the leanest group in the study. Among children, the association between HDL-C and insulin has been fairly consistent. Ronnemaa and colleagues⁵³ found strong inverse associations in all gender and age groups except among 15-year-old and 24-year-old females, and Folsom et al⁴¹ reported strong inverse associations among young adults. In the current study, we found no association between HDL-C and insulin among NHWs and a modest and statistically nonsignificant association among Mexican Americans. Whereas little or no association between TC and insulin in children has been reported in most studies, we observed a strong positive association among Mexican-American boys.

The present study had several potential limitations. A cross-sectional approach does not allow for the investigation of the potential pathways of insulin regulation and use among children. A birth cohort study is needed to better elucidate both the environmental and genetic factors and the mechanisms for these factors in establishing the observed patterns. Participation rates were 78% for the survey and 67% for the examination, leaving open the possibility of selection bias; however, we found no differences in participation rates by ethnicity, sex, or school lunch status. Although we found that socioeconomic status did not explain ethnic differences in risk factors, school lunch status is a crude measure of socioeconomic status and may be subject to misclassification. More complete ascertainment of socioeconomic status and the role this plays in the association of ethnicity and CVD risk factors is needed.

These results provide preliminary evidence that ethnic differences in insulin, glucose, BMI, and other CVD risk factors may occur as early as age 8 to 10 years. It has been suggested that obesity, hypertension, hyperinsulinemia, and hyperlipidemia that coexist in the adult may share a common pathogenesis. These results and others suggest that this constellation of risk factors may begin to develop in early childhood. Some researchers have suggested that insulin levels play an important role in the pathophysiology of atherosclerosis in diabetic patients.⁵⁷ Our results support the contention that insulin may play a role in the development of hypertension and atherosclerosis and that this influence may begin early in life. Additional research is warranted to better understand the reasons for ethnic differences in CVD risk factors in children and the importance of insulin in influencing the natural history of CVD.

	Selected Abbreviations and Acronyms

 

BMI = body mass index CVD = cardiovascular disease DBP4 = fourth phase of diastolic blood pressure HDL-C = HDL cholesterol LDL-C = LDL cholesterol NHW = non-Hispanic white NIDDM = non–insulin-dependent diabetes mellitus SBP = systolic blood pressure TC = total cholesterol TG = triglyceride

	Acknowledgments

 
This research was supported by Public Health Service grant U48/CCU609653 from the Centers for Disease Control and Prevention.

	Footnotes

 
Guest editor for this article was Charles H. Hennekens, MD, Brigham and Women's Hospital, Boston, Mass.

Received July 25, 1996; revision received December 4, 1996; accepted February 10, 1997.

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