Running head: THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

The Prevalence of Diabetes in the Hispanic Community

Mariah Delaire
National University

October 4, 2015

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

The Prevalence of Diabetes in the Hispanic Community

Introduction
Diabetes in the United States is an increasing public health concern due to the large
number of individuals being diagnosed with it annually. It has been reported by the CDC that
10.2% of non-Hispanic whites and 18.7% of non-Hispanic blacks 20 years and older in the
United States have diabetes (Schneiderman, 2014). Among this population are about 30 percent
of undiagnosed individuals with the rest being racial/ethnic minority populations. It is even more
of a public health concern to have insufficient data on different populations, such as the Hispanic
population. The Hispanic population has a higher prevalence of diabetes along with higher rates
of mobility and mortality in relation to diabetes, making it even more important to understand
populations susceptibility to certain diseases (Hatcher, 2007). The need for data on the
prevalence of certain diseases, such as diabetes, helps to plan for healthcare needs. The future of
disease control is prevention, which can be made possible by understanding the population along
with associated risk factors that contribute to the emergence of a disease.

Research question/objective
The objective of this proposal is to understand the prevalence of diabetes in the Hispanic
population by identifying common risk factors that contribute to the susceptibility of this disease.
The key to this study is to discover associated risk factors that can be well understood to allow
for proper prevention, lowering the overall prevalence in the population. The variables that will
be analyzed are body mass index, diet, exercise, stress, insurance coverage, and how proactive an
individual is about their health/wellness.

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

Secondary data analysis will be conducted using the Hispanic Community Health Study/
Study of Latinos (HCHS/SOL) and the National Health and Nutrition Examination Survey
(NHANES). These resources will supplement the study to help reach the objective of
understanding the prevalence of diabetes in the Hispanic population.

Null Hypothesis: There is no relationship between the independent variables (body mass index,
exercise, stress, insurance coverage, proactivity in health, and education)
and the prevalence of diabetes.

Alternative hypothesis: There is a relationship between the independent variables and the
prevalence of diabetes.

Literature review
Diabetes is a major public health concern, where 9.3% of the overall population in the
United States have diabetes along with it being the 7th leading cause of death (National Center for
Chronic Disease Control and Prevention , 2014). However, there are gaps in information in
regards to minority populations. Due to the lack of data, the CDC is unable to estimate the
prevalence of diabetes among different minority populations (Schneiderman, 2014). Some major
barriers to gathering data include poor patient-physician communication, language barriers, lack
of education, diabetes awareness and lack of health insurance (Aranda, 2004). Currently, there
are various methods for assessing the risk of having undiagnosed diabetes, but there is a shortage
in methods for assessing the risk of developing diabetes. This could be a major indicator as to
why there is a gap in knowledge, especially concerning minority populations. If risk factors can

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

be determined for individuals who are susceptible to the disease, then prevention can take place
to stop the emergence of diabetes. With the Hispanic population in the United States growing
rapidly, it is vital to focus on their healthcare needs.
In the United States, Mexican-Americans have a two to three fold higher chance of
developing diabetes than do non-Hispanic whites, and it is suggested that the prevalence is
rapidly increasing (Hunt, 2011). A study that tested how lethal diabetes is in the Mexican
American population showed that factors associated with diabetes mortality included biological
differences in the severity of diabetes, differences in health care access, treatment practices and
major differences in on-going prevention efforts (Hunt, 2011). Although Hispanics have a higher
prevalence of diabetes with a greater risk of complications, there was also a lower chance that
they have a regular place of care or health insurance.
It is extremely important for health care providers to understand diabetes, it symptoms,
and treatments along with conveying this information to the patient. Lack of comprehension in
regards to health is more common among individuals with low education which has been shown
to be associated with worse glycemic control (Hunt, 2011). It was found that individuals in a
lower socioeconomic class along with less education had a higher chance of getting diabetes
(Schneiderman, 2014). Many individuals who were unware that they had diabetes had poor
glycemic control and lack of health insurance, creating even more negative effects on their health
(Schneiderman, 2014). The difference in glycemic control between Hispanics and non-Hispanic
whites could be greatly influenced by lack of health insurance between the two groups, creating
the major differences in diabetes cases (Schneiderman, 2014). It is important to understand the
diversity between different populations to allow for proper prevention and treatment of certain
diseases.

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

Sample
The research will be conducted using the Hispanic Community Health Study/ Study of
Latinos (HCHS/SOL) and the National Health and Nutrition Examination Survey (NHANES).
The survey population for HCHS/SOL consists of 16,000 people of Hispanic origin that were
recruited in four field centers located at San Diego State University, Northwestern University in
Chicago, Albert Einstein College of Medicine in the Bronx and University of Miami. The
participants ranged in age from 18-74 years old and underwent an extensive clinical exam and
assessments to determine baseline and then were followed over time to assess changes (National
Heart, 2011). The NHANES survey consisted of about 12,000 people every two year cycle where
an average of 10,500 people agreed to complete an interview (U.S. Department of Health and
Human Services, 2013). The individuals of this study were located in different counties all over
the United States who ranged in ages 12 years old to over 70 years old. To produce statistics that
are reliable, NHANES over samples individuals 60 years and older, African-Americans, and
Hispanics (U.S. Department of Health and Human Services, 2013).
The Hispanic Community Health Study is planned to last six and a half years which will
collect baseline comprehensive health data from 16,000 Hispanics and have annual follow ups to
allow information on changes in health (National Heart, 2011). This is the largest longitudinal
epidemiological study in the Latino population in the U.S. for health and disease. This study will
provide much insight for prevalence of diabetes in the Hispanic community along with
associated risk factors. NHANES is a program designed to gain information about nutritional
status and health in adults and children. It is extremely informational in that it combines both
interviews and physical examinations to produce vital health statistics for the U.S.

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

The HCHS/SOL participants were selected randomly from households recruited during
2008-2011 in New York, Chicago, Miami, and San Diego. The cohort was selected through a
stratified multistage area probability sample from these four different communities
(Schneiderman, 2014). These four areas have the largest number of Hispanics/Latinos which
consists of high concentrations of specific Latino background. Population based sampling
allowed for recruitment of participants and rosters of eligible participants were compiled
followed by screening through telephone calls or in person interviews (Schneiderman, 2014).
Participants were eligible if they were community dwelling and identified as Hispanic/Latino,
were able to travel to sites for examinations, not on active military or pregnant, and did not plan
on moving for three years (Schneiderman, 2014). The eligible individuals were again sampled by
age which resulted in 9,714 participants between the ages of 45-74 years old and 6,701
participants between the ages of 18-44 years old. After screening and eligibility was determined,
42% of the eligible participants enrolled in the study (Schneiderman, 2014).
NHANES sampling was done by a multistage probability sample design which selected a
sample representative of a civilian population in the United States (U.S. Department of Health
and Human Services, 2013). The sample selection process consisted of four stages. The first
stage focused on selection of primary sampling units that consisted of counties or small groups.
The second selection created segments within the primary sampling units that resulted in a block
or group containing a sum of households. The third stage involved selection of specific
households within each segment. Lastly, the fourth stage selected specific individuals (U.S.
Department of Health and Human Services, 2013). 12,000 people every 2 years were asked to
participate. The number of participants who responded averaged around 10,500 people. These

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

individuals agreed to take part in a household interview who are located in counties all over the
United States (U.S. Department of Health and Human Services, 2013).

Data Collection
Data from the HCHS/SOL study was collected through clinical examinations, interviews,
and questionnaires which included measurements of height and weight. Standardized instruments
were used to collect information about health behaviors, medical history, and demographics
(Schneiderman, 2014). A two hour glucose tolerance test was performed for participants who did
not have fasting plasma glucose >150 mg/dL and those who already reported having diabetes.
After participants fasted for eight hours before the physical examination, blood was collected,
processed and frozen on site. Information from the self-report interview was used to determine
personal and family medical history, awareness of diabetes, age, sex, Hispanic background,
income, education, and length of Residence in the United States.
The NHANES data was collected in a variety of different ways. The household interview
consisted of four parts which included screener questionnaire, relationship questionnaire, sample
participant questionnaire and a family questionnaire (U.S. Department of Health and Human
Services, 2013). The questionnaires were administered in the participants homes with rare cases
being done in a field office or public location. A computer-assisted personal interview system
and Blaise software was utilized to help conduct the interviews (U.S. Department of Health and
Human Services, 2013). Another component of the data collection was a physical examination
that took place in a mobile examination center (MEC). The eligibility for certain components of
the exam were determined from age and gender along with interviews and laboratory tests. The
physical exam measured a variety of things from hearing, body measurements, balance, to blood

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

pressure, muscle strength, respiratory health, heart health and vision. Blood specimens were also
taken to measure a variety of different components. One last component was the post MEC data
collection questionnaire which consisted of phone interviews regarding current health status and
examination results. NHANES used automated systems that integrated biomedical equipment
and questionnaire items to provide efficient data capture.

Data Analysis
The data for this study will be analyzed used SAS studio. Variables taken from the
HCHS/SOL and NHANES study will be analyzed and organized to properly fit the objective of
this study. The table below shows what types of variables are going to be measured along with
their names for the purpose of SAS. Since this project focuses on disease occurrence in the
Hispanic community, only individuals who answer Hispanic/Latino will be eligible to continue
forward with the study.
Questions

Please Describe your

race/ethnicity.

Have you ever been

diagnosed with type I or type
II diabetes?
In a typical week, how many
days do you exercise?

Possible Answers

White
African American
Hispanic/Latino
Asian
Pacific Islander
Native American
I dont know
Refused
Yes
No
I dont know
Refused
5 to 7 days a week
2 to 4 days a week
Once a week
I do not regularly

SAS Variable Name

RACE2

AB51

EXERCISE2

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

exercise

How many meals a week

consist of fruits and
vegetables?

In the last 12 months, did you

make any appointments for a
check-up or routine care with
your health care provider?
How many times a
week do you feel
stressed on a scale of
0-7? (7 being stressed
every day)

Do you currently have

health insurance
coverage?
What is your height and
weight?

15 to 20+
meals
9 to 14 meals
5 to 8 meals
1 to 4 meals
0 meals
I dont know
Yes
No
I dont know
Refused
7
6
5
4
3
2
1
0
Yes
No
I dont know
Refused
Refused

DIET2

PROACTIVE2

STRESS2

HLTHCOV2

BMI_P

Descriptive Statistics
To analyze each variable, descriptive statistics will be used which will help describe,
show and summarize data in a way to visually examine it. PROC UNIVARIATE procedures will
be used to measure mean, median, mode, and standard deviation for BMI_P and DIET2. To
understand distributions, PROC FREQ will be used for the categorical/ordinal variables which

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include HLTHCOV2, STRESS2, PROACTIVE2, EXERCISE2, AB51, and HISPANIC2. Gender

and age will also be determined to allow for proper stratifying of data.

Inferential Statistics
In order to analyze relationships between the independent and dependent variables,
inferential statistics needs to take place. Bivariate analysis will be used to identify relationships
between the dependent and all the independent variables with age, gender, and ethnicity used as a
control. ANOVA testing (PROC GLM) will be used to analyze differences between BMI
(independent variable) and type I or type II diabetes (dependent variable) as well as diet and
diabetes. One way ANOVA works is by analyzing differences among group means and their
variation. Generally ANOVA works by testing the differences between multiple groups, in this
case it was used to test the difference between two variables. The Chi-squared procedure (PROC
FREQ) will also be used to understand the relationships between diabetes and health coverage,
stress, how proactive individuals are, and exercise, with the test only being ran with the
dependent and one independent variable at a time. To fully understand if the relationship between
extraneous variables influences the dependent variable, PROC CORR will be used to identify the
correlations between BMI and diet.
It is critical to understand the relationships between all the variables in order to fully
discern if they impact one another. Multivariate analysis is used to study three or more variables
at once. Multi-regression using PROC REG will be used to explore the independent effects on
one dependent variable (diabetes). As previously discussed, the control variables will remain the
same, and multivariate regression will be used to see how body mass index, diet, exercise, stress,

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insurance coverage, and how proactive an individual is about their health/wellness affects
diabetes status. Univariate, bivariate and multivariate analysis used together will help understand
the relationship between diabetes prevalence and the extraneous variables.

Ethical considerations
To help protect the confidentiality of individuals, the NHANES protocol was developed
to be in compliance with the HHS Policy for Protection of Human Research Subjects (U.S.
Department of Health and Human Services, 2013). The Privacy Act of 1974, Section 308(d) of
the Public Health Service Act and Confidential Information Protection and Statistical Efficiency
Act were three federal laws that protected all the data (U.S. Department of Health and Human
Services, 2013). To ensure protection of information and prevent disclosing information to
unauthorized persons, all staff affiliated with NHANES read and signed a nondisclosure affidavit
(U.S. Department of Health and Human Services, 2013). Ethics Review Board also protects the
rights and welfare of individuals enrolled in the study including vulnerable populations such as
children, pregnant women, and the elderly. These same actions will be taken to ensure protection
of any additional information gained outside of the NHANES survey and the HCHS/SOL study.

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References
Aranda, J. V. (2004). Awareness of Hypertenstion and Diabetes in the Hispanic Community.
Clinical Cornerstone, 7-15.
Hatcher, E. W. (2007). Hispanic adults' beliefs about type 2 diabetes: clinical implications.
American Academy of Nurse Practioners, 536-545.
Hunt, K. G. (2011). Diabetes is more lethal in Mexicans and Mexican Americans compared to
non-Hispanic Whites. Ann Epidemiol, 899-906.
Mainous, A. B. (2007). Impact of the population at risk of diabetes on projections. Diabetologia,
934-940.
Mainous, A. M. (2006). Acculturation and Diabetes Among Hispanics: Evidence from the 1999
2002 National Health and Nutrition Examination Survey. Public Health Reports, 60-66.
National Center for Chronic Disease Control and Prevention . (2014). National Diabetes Statistic
Report. Atlanta: Center for Disease Control .
National Heart, L. a. (2011). The Hispanic Community Health Study . Department of Health and
Human Services.
Schneiderman, N. L.-C.-S. (2014). Prevalence of Diabetes Among Hispanics/Latinos From
Diverse Backgrounds: The Hispanic Community Health Study/Study of Latinos .
Diabetes Care, 2233-2239.

THE PREVALENCE OF DIABETES IN THE HISPANIC COMMUNITY

U.S. Department of Health and Human Services. (2013). National Health and Nutrition
Examination Survey. Vital and Health Statistics , 1-37.

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