EDITORIALS
Cardiovascular Disease Among
Mexican Americans
Russell V. Luepker, MD
T
he burden of cardiovascular disease, particularly
coronary heart disease (CHD), among Mexican
Americans has been a matter of considerable de-
bate. Mexican Americans have higher levels of traditional
risk factors than their non-Hispanic white counterparts
but appear to have lower rates of CHD diagnoses and
mortality from cardiovascular disease (1,2). High levels
of obesity, low socioeconomic status, and increased prev-
alence of adult onset diabetes added to this paradox (3).
Some suggested that Mexican Americans had genetic
protection against these common risk factors (2,3).
Other authors question these observations, suggesting
misdiagnoses and misclassification of cause of death in
minority populations, a documented phenomena (4).
Among the errors is misrecording of ethnic group on hos-
pital records and death certificates with Mexican Ameri-
cans categorized as non-Hispanic whites. Also of concern
is the excess use of nonspecific causes of death for ethnic
minorities in cases in which cardiovascular disease is ac-
tually the cause. Finally, Mexican Americans are more
likely to have diabetes mellitus listed as the underlying
cause of death rather than CHD, resulting in a shift away
from this category. These sources of error could result in
an underestimate of cardiovascular disease prevalence
and mortality among Mexican Americans.
The article by Pandey and colleagues (5) in this issue of
The American Journal of Medicine addresses these prob-
lems with a rigorous study of mortality in Nueces County,
Texas. Using multiple sources of data, Pandey et al vali-
date death certificate classifications for Mexican Ameri-
cans and non-Hispanic whites. Recognizing that a major-
ity of cardiovascular disease deaths are outside of hospi-
tals, they carefully studied this group as well. They found
that along with higher rates of dyslipidemia, obesity, dia-
betes mellitus, and untreated hypertension, Mexican
Americans living in Nueces County have higher levels of
CHD mortality than their non-Hispanic white neighbors.
These findings are concordant with previous publications
of this University of Texas group, who observed higher
Am J Med. 2001;110:147–148.
From the Division of Epidemiology, University of Minnesota School of
Public Health, Minneapolis, Minnesota.
Requests for reprints should be addressed to Russell V. Luepker, MD,
Division of Epidemiology, University of Minnesota School of Public
Health, 1300 South Second Street, Suite 300, Minneapolis Minnesota
55454-1015.
䉷2001 by Excerpta Medica, Inc.
All rights reserved.
rates of hospitalization and poor prognosis after acute
myocardial infarction for Mexican Americans (6).
While these results may not surprise epidemiologists,
who are familiar with misclassification on death certifi-
cates, it is new and important news to many clinicians.
Similar to the “Yentl syndrome” suggesting women are
underdiagnosed and undertreated for coronary heart dis-
ease, Mexican Americans may suffer from the belief by
clinicians that they are “protected” from cardiovascular
diseases (7). Additional cultural and language barriers
may add to this perception. The resulting underdiagnosis
and undertreatment does not serve this group of patients
well.
The origin of this epidemic among Mexican Americans
deserves further consideration. Rates of cardiovascular
disease in Mexico are lower than those in the United
States (8). Some suggest that these differences are the re-
sult of different genetic characteristics. Others suggest
that lifestyle differences underly these contrasts. The lat-
ter is supported by numerous migration studies that have
found that individuals migrating from low to high CHD
risk cultures assume the disease patterns of their new
home. Perhaps the most famous of these studies is the
Ni-Hon-San study, which compared Japanese living in
Japan (a low CHD risk country) to Japanese Americans
living in Hawaii and San Francisco (9). Those living in
San Francisco experienced disease rates similar to non-
Hispanic whites, whereas those living in Honolulu had
disease rates intermediate between Japan and the United
States. Those in Honolulu were more likely to follow a
traditional Japanese lifestyle and diet.
There is evidence of a similar migration phenomenon
among Mexican Americans. Data from San Antonio,
Texas, find that US-born Mexican Americans have the
highest mortality rates, whereas recent migrants from
Mexico have rates lower than non-Hispanic whites (10).
These differences are postulated to be the result of several
factors, including a “healthy migrant effect” that is anal-
ogous to the “healthy worker effect.” Here, persons who
are most healthy are prepared for the additional stress of
migration to a new and foreign country. The current
study of Nueces County finds that 92% of the Mexican
Americans were born in the United States and are life-
long residents (5). There is also the question of time of
exposure to risk. Coronary heart disease is the result of
many years of exposure to well-known risk characteristics
0002-9343/01/$–see front matter 147
PII S0002-9343(00)00731-2
 Cardiovascular Disease among Mexican Americans/Luepker
such as smoking, hyperlipidemia, hypertension, obesity,
and diabetes. These factors rise on migration to a new
country, but migrants have had years of low-risk status
with presumed protection from disease. Differences in
risk factors between Mexicans and US whites were ob-
served in comparisons of Wisconsin schoolchildren and
Mexico City children in which blood cholesterol levels
were substantially higher among the US children (11).
There are also other factors likely to put Mexican
Americans at higher risk of mortal disease. Among these
is the lower socioeconomic status that characterizes this
group. Socioeconomic status is well recognized to be in-
versely associated with cardiovascular disease risk and
mortality in the United States and other industrialized
countries (12). CHD is more common among the less
educated and less affluent than among those with higher
socioeconomic status. This is partly due to classic risk
factors, which are greater in low socioeconomic status
groups, but also may result from more stressful life cir-
cumstances. These circumstances characterize migrant
populations exposed to a new culture and language (13).
Finally, cultural differences in presentation and re-
porting of symptoms can lead to differences in medical
care. This is confirmed by lower rates of hypertension
treatment among Mexican Americans (5) and the likely
lower rates of using other life-saving cardiovascular pro-
cedures.
It is increasingly apparent that Mexican Americans are
not protected from cardiovascular disease. In fact, they
have higher rates than their white counterparts in the
United States where CHD remains at epidemic propor-
tions. As clinicians listen to, diagnose, and treat their
Mexican-American patients, the observations by Pandey
and others should influence thinking as they seek to pro-
vide optimal care.
148 February 1, 2001 THE AMERICAN JOURNAL OF MEDICINE威
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