Predicting the development of the metabolically healthy obese phenotype.

OBJECTIVE: The metabolically healthy (MHO) and unhealthy obese (MUHO) differ in terms of cardiovascular risk. However, little is known about predicting the development of these phenotypes and the future stability of the MHO phenotype. Therefore, we examined these two issues in the San Antonio Heart Study. DESIGN: Longitudinal, population-based study of cardiometabolic risk factors among Mexican Americans and non-Hispanic whites in San Antonio. SUBJECTS: The study sample included 2368 participants with neither MUHO nor diabetes at baseline. Median follow-up was 7.8 years. MHO was defined as obesity with ⩽1 metabolic abnormality; MUHO, as obesity with ⩾2 abnormalities. RESULTS: At baseline, 1595 and 498 individuals were non-obese with ⩽1 and ⩾2 metabolic abnormalities, respectively, and 275 were MHO. Among non-obese individuals, independent predictors of incident MHO (odds ratio (OR) for 1 s.d. change (95% confidence interval)) included body mass index (8.12 (5.66-11.7)), triglycerides (0.52 (0.39-0.68)) and high-density lipoprotein cholesterol (HDL-C) (1.41 (1.11-1.81)), whereas independent predictors of incident MUHO included body mass index (5.97 (4.58-7.77)) and triglycerides (1.26 (1.05-1.51)). Among participants with ⩽1 metabolic abnormality, obesity was associated with greater odds of developing multiple metabolic abnormalities (OR 2.26 (1.74-2.95)). CONCLUSIONS: Triglycerides and HDL-C may be useful for predicting progression to MHO. MHO may not be a stable condition, because it confers an increased risk of developing multiple metabolic abnormalities.

Was the historic contribution of Spain to the Mexican gene pool partially responsible for the higher prevalence of type 2 diabetes in mexican-origin populations? The Spanish Insulin Resistance Study Group, the San Antonio Heart Study, and the Mexico City Diabetes Study.

OBJECTIVE: Mexican-American populations in San Antonio, Texas (SA-MA) and Mexico have a higher prevalence of type 2 diabetes than non-Hispanic whites in San Antonio (SA-NHW). However, the higher prevalence of type 2 diabetes in Mexican-origin populations might be related, in part, not to Native American genetic admixture but to Spanish genetic admixture. RESEARCH DESIGN AND METHODS: Four population-based epidemiological surveys conducted with Mexican-origin and European-origin samples provided data relevant to this question. In all four surveys, type 2 diabetes was defined as fasting plasma glucose > or =7.0 mmol/l or 2-h glucose > or =11.1 mmol/l or use of antidiabetic agents. RESULTS: A comparison of the two Mexican-origin populations showed that the age- and sex-adjusted prevalence of type 2 diabetes was lower in Mexico than in SA-MA (15.1 vs. 17.9%, P = 0.032). Between the two European-origin populations, the prevalence of type 2 diabetes was lower in SA-NHW than in Spain (6.2 vs. 9.1%, P < 0.0001), but differences were attenuated by adjustment for BMI or after stratification by education. In logistic regression analyses, type 2 diabetes was associated with Mexican ethnic origin after adjusting for age, education, BMI, and waist-to-hip ratio. CONCLUSIONS: The prevalence of type 2 diabetes in Spain was intermediate between that in Mexican-origin populations and SA-NHW. Although the higher degree of Native American admixture is a major contributor to the higher rates of type 2 diabetes, we cannot completely rule out a partial contribution of Spanish admixture to diabetes susceptibility among Mexican- origin populations.

Hopelessness predicts mortality in older Mexican and European Americans.

OBJECTIVE: The purpose of this study was to evaluate the relationship between hopelessness and mortality in a biethnic cohort of older community-dwelling Mexican Americans, the most rapidly growing segment of the elderly, and European Americans. METHODS: A total of 795 persons aged 64 to 79 years completed an English or Spanish version of the 30-item Geriatric Depression Scale on entering the San Antonio Longitudinal Study of Aging, an epidemiologic survey, between 1992 and 1996. Women constituted 58% and Mexican Americans 54% of this randomly selected sample. Subjects who answered "no" to the item "Are you hopeful about the future?" were classified as hopeless. RESULTS: As of August 1999, 29% of the 73 hopeless subjects had died, compared with 11% of the hopeful, a highly significant difference. The mortality rates for cardiovascular disease and cancer were significantly greater among the hopeless subjects (7%) than among the hopeful (3%). Hopelessness predicted all-cause mortality in a Cox proportional hazards model adjusted for age, ethnic background, current smoking status, number of comorbid medical conditions, self-rated health, and frequency of social contacts (risk ratio = 2.23, 95% confidence interval = 1.33 to 3.76, p = .0026). Neither sex nor probable depression was a significant predictor of mortality in this model. CONCLUSION: These findings, together with those of others, suggest that hopelessness is a significant predictor of mortality in older and middle-aged adults of various ethnic backgrounds. Further research is needed to evaluate the mechanisms that underlie this phenomenon and the effects of treating hopelessness on the quality and duration of subjects' lives.

Walking velocity in aged persons: its association with lower extremity joint range of motion.

OBJECTIVE: To measure the association between walking velocity and hip and knee flexion range, ethnic background, anthropometrics, comorbid pathologies, and coimpairments, in a sample of community-dwelling aged persons. METHODS: To reach our objective, we used data from the San Antonio Longitudinal Study of Aging (SALSA), a population-based cohort of Mexican American and European American persons aged 64 to 79. By fitting hierarchical regression models, we measured the variance in the walking velocity over 50 feet explained by hip and knee flexion range, adjusting for the combined influence of demographic and anthropometric variables, coexistent pathologic conditions, impairments, and the examiners who conducted the assessments. RESULTS: The average walking velocity among the 702 subjects for whom data were available was 73.6 meters per minute (range 20 to 121). Bivariate analyses revealed significant associations between walking velocity and age, sex, ethnic background, height, weight, presence of arthritis, diabetes mellitus, stroke, upper leg pain, peripheral vascular disease, left ventricular hypertrophy, and forced expiratory volume at 1 second. The correlation (r) between walking velocity and flexion range of the hip and knee were 0.40 and 0.35, respectively (P < or = 0.001 for each). Multivariate hierarchical models adjusting for demographic and anthropometric characteristics of the subjects, and examiner variation, revealed that hip and knee flexion range explained 6% of the variance in walking velocity. Adjusting for the presence of comorbid conditions and coimpairments reduced the variance attributable to hip and knee flexion range only slightly, to 5%. CONCLUSION: Hip and knee flexion range contribute significantly to walking velocity in the SALSA cohort of community-dwelling aged persons.

Ethnic differences in mini-mental state examination (MMSE) scores: where you live makes a difference.

OBJECTIVES: To examine differences in correlates of the Mini-Mental State Examination (MMSE) in a population-based sample of older Mexican Americans and European Americans and to provide empirical validation of the MMSE as an indicator of cognitive impairment in survey research in older Mexican Americans by comparing MMSE classification against performance on timed tasks with varying levels of cognitive demand. DESIGN: A population-based cross-sectional study. SETTING: Trained bilingual staff administered the MMSE as part of the San Antonio Longitudinal Study of Aging (SALSA) home-based assessment battery. PARTICIPANTS: 827 community-dwelling Mexican Americans and European Americans, 65 and older, residing in three socioeconomically and culturally distinct neighborhoods (barrio, transitional, suburban). MEASUREMENTS: The MMSE was compared against a variety of demographic, biomedical, and sociocultural variables ascertained by self-report and against performance-based measures of functional tasks representing varying levels of cognitive demand (Structured Assessment of Independent Living Skills (SAILS) subscales for food manipulation and money management). RESULTS: Mexican Americans were 2.2 times more likely than European Americans to have MMSE scores <24. Multiple logistic regression analysis revealed that neighborhood was an independent predictor of low MMSE scores in Mexican Americans, with the relationship between ethnic group and MMSE explained by neighborhood. After adjusting for neighborhood type, no differences were noted between Mexican Americans and European Americans. Independent of other factors examined, low education was associated with low MMSE scores in both Mexican Americans and European Americans. Mexican Americans with MMSE scores <24 took significantly longer to complete four out of five performance-based food manipulation tasks and all three money management tasks. CONCLUSIONS: Neighborhood type was a predictor of cognitive impairment. Education affected MMSE scores similarly in both ethnic groups. MMSE scores <24, indicative of cognitive impairment, were uniformly associated with functional impairment in both the Mexican Americans and European Americans. Among older Mexican Americans, MMSE-classified cognitive impairment was significantly associated with poorer performance on timed tasks with varying levels of cognitive demand independent of other correlates. A similar pattern of association was observed in European Americans. Thus, the MMSE appears to be a valid indicator of cognitive impairment in survey research in both older Mexican Americans and European Americans.

Rising trend in obesity in Mexican Americans and non-Hispanic whites: is it due to cigarette smoking cessation?

OBJECTIVE: Several studies have examined the influence of smoking cessation on weight gain. However, to date no study has examined this association in Mexican Americans (MA). DESIGN: Using data collected from the San Antonio Heart Study, a population-based study of diabetes and cardiovascular disease, we examined the association between smoking cessation and weight gain in 1930 Mexican Americans and 1126 non-Hispanic whites (NHW). Smoking cessation was defined as self-reported smoking at baseline but not at follow-up. RESULTS: Although there was no significant ethnic difference in the prevalence of smoking at baseline (27.2% in MA and 25.4% in NHW, P = 0.309), a greater proportion of MA smoked at follow-up compared to NHW (19.7% vs 16.5%, P = 0.037). However, there was no significant ethnic difference in the percentage of individuals who stopped smoking during the follow-up period. A two-fold greater percentage of MA quitters than NHW quitters became overweight or obese, defined as a body mass index greater than or equal to 25 kg/m2 (7.4% vs 3.1%). However, this difference did not quite reach statistical significance (P = 0.072). Using linear regression to predict change in weight or body mass index from baseline to follow-up, smoking cessation was predictive of either weight gain or BMI gain in both ethnic groups. However, smoking status accounted for only 1.0% of the variance in these outcomes, and the estimated risk of becoming overweight or obese attributable to smoking cessation was only 7.4% in MA and 3.1% in NHW. CONCLUSION: We conclude that there is an ethnic difference in the influence of smoking cessation on weight gain in MA and NHW. However, in both ethnic groups this effect is quite small and makes only a slight contribution to the overall increase in prevalence of obesity in this population.

Modeling impairment: using the disablement process as a framework to evaluate determinants of hip and knee flexion.

Elders often present to health care providers with multiple inter-related conditions that determine an individual's ability to function. The disablement process provides a generalized sociomedical framework for investigating the complex pathways from chronic disease to disability. At each stage of the main pathway, associations may exist among primary physical factors and modifying variables that ultimately have downstream effects on the progression toward disability. The purpose of the present analysis is to examine the inter-relationships between a cohesive set of variables primarily at the level of impairment that may affect hip and knee flexion range of motion (ROM). The San Antonio Longitudinal Study of Aging enrolled 833 community dwelling Mexican (MA) and European American (EA) elders aged 64-78 years between 1992 and 1996. Of these, 647 had complete data from both a home-based and performance-based battery of assessments for these analyses. Concerning impairments, hip ROM was measured using an inclinometer, and knee ROM using a goniometer. Pain location and intensity were assessed using the McGill Pain Questionnaire. Peripheral vascular disease was assessed using doppler brachial and ankle systolic blood pressures. Ankle and knee reflexes, and vibratory sensation were assessed by a standardized neurological examination. As to diseases, diabetes was assessed using a combination of blood glucose levels and self-report, and arthritis by self-report. Concerning modifying variables, height and weight were directly measured and used to calculate BMI. Activity level was assessed with the Minnesota Leisure Time Questionnaire. Analgesic use was assessed by direct observation of medications taken within the past two weeks. We used structural equation modeling to test associations between the variables that were specified a priori. These analyses demonstrate the central role of BMI as a determinant of hip and knee flexion ROM. For an increase in level of BMI, the coefficients [SEM] for changes in levels of hip and knee ROM were -0.38 [0.05] and -0.26 [0.05], respectively. A higher BMI resulted in lower hip and knee ROM. BMI was also directly associated with prevalent diabetes (0.10 [0.05]) and arthritis (0.17 [0.05]). However, after adjustment for BMI, diabetes and arthritis did not have direct independent associations with either hip or knee ROM. BMI was also indirectly associated with knee, but not hip, ROM through paths including lower-leg pain, pain intensity, and neurosensory impairments. Diabetes had an indirect association with hip, but not knee ROM, through a path including peripheral vascular disease. In conclusion, BMI is a primary direct determinant of hip and knee ROM. The paths by which diabetes and arthritis lead to physical disability may be mediated, in part, at the level of impairment by BMI's association with joint range of motion. Interventions designed to decrease the impact of diabetes and arthritis on disability should track changes in BMI and joint ROM to measure the paths that account for the intervention's success. The observed associations suggest that interventions targeted to decrease BMI itself may lead to improved function in part through improved joint ROM.

Challenges in teaching ethics in medical schools.

Modern medical ethics has effected dramatic changes in medicine. Yet teaching medical ethics still presents many challenges. The main teaching methods used--inpatient ethics consultations, courses, and case conferences--have notable weaknesses. In addition, the attitudes and knowledge gaps of some learners may hamper these methods further. To encourage open discussion of the challenges, we outline our current approach to teaching medical ethics. We teach with the conviction that ethics instruction gives physicians vital knowledge not available from science. Our teaching addresses ethical issues directly relevant to residents and students, emphasizes a few important concepts, and nurtures learners' critical reasoning skills. Our teaching also tries to use scarce faculty time efficiently. However, we believe successful medical ethics teaching requires medical schools to commit significant material and moral support. We hope the discussion here encourages medical ethics teachers everywhere to describe the challenges they face and to collaborate on finding solutions.

A cross-cultural consumer-based decision aid for screening mammography.

BACKGROUND: "Women should have mammograms" is the usual perspective of educational interventions about screening. The perspective that "women should be informed" about potential risks and benefits so they can make value- and evidence-integrated personal decisions has recently been advocated. However, this perspective has not previously been operationalized. We developed an evidence-based cross-cultural mammography decision aid (MDA), for European American and Mexican American women who are 50-70 years old, at average risk of breast cancer, of varying educational levels, and English- or Spanish-speaking. METHODS: MDA development included: (1) content development by a multidisciplinary team and lay women and (2) testing for validity and reliability. Four parts include: (1) introduction; (2) information about logistics (cost, time, discomfort) and risks (sequelae of false-positive or negative results; (3) probability of developing breast cancer; and (4) benefit of mammography regarding breast cancer outcomes (e.g., death and recurrence). We assessed reliability (stability of decisions with the same information) after 1-2 weeks. We assessed validity (comprehension of information) quantitatively (probabilities were changed to see whether preferences changed predictably) and qualitatively (focus groups, standardized probes for comprehension). Subjects were a convenience sample of 49 European American (50-81 years old) and 54 Mexican American (49-89 years old) women from administrative staff at a medical school, the waiting room of an indigent primary care clinic, and a community center. RESULTS: Reliability was 100%. In quantitative validity testing, 22 of 28 women (89%) changed preference as predicted with changed probabilities. Comprehension was confirmed qualitatively in all phases of testing with both Spanish and English versions. CONCLUSION: The decision aid is valid and reliable in English and Spanish for southwestern Mexican American and European American women at average risk of breast cancer, including those of low educational levels.

The influence of noncognitive factors on the Mini-Mental State Examination in older Mexican-Americans: findings from the Hispanic EPESE. Established Population for the Epidemiologic Study of the Elderly.

Mini-Mental State Examination data from the Hispanic Established Population for the Epidemiologic Study of the Elderly baseline survey, a population-based study of community-dwelling Mexican Americans aged 65 and older, were used to examine the relationship between cognitive impairment, sociodemographics, and health-related characteristics. The rate of cognitive impairment found in this group of older Mexican Americans, using the conventional cut point of 23/24 on the MMSE, was 36.7%. Using a more conservative cut point of 17/18 indicated an overall rate of severe cognitive impairment of 6.7%. Rates of impairment varied significantly with age, education, literacy, marital status, language of interview, and immigrant status and were associated with high and moderate levels of depressive symptoms, and history of stroke. Importantly, although education was strongly related to poor cognitive performance, it was not a significant predictor of severe cognitive impairment. Multivariate analyses further indicated that as a screen for cognitive impairment in older Mexican Americans, the MMSE is strongly influenced by these noncognitive factors. Scores may reflect test bias, secondary to cultural differences or the level of education in this population.

Determinants of hip and knee flexion range: results from the San Antonio Longitudinal Study of Aging.

OBJECTIVE: We analyzed data from the San Antonio Longitudinal Study of Aging, a neighborhood-based study of community-dwelling elderly people, to identify factors that determine the flexion range (FR) of hips and knees. METHODS: The FR of hips and knees was measured in a cohort of 687 subjects aged 65 to 79 years. We used multivariate models to examine the associations among the FR of hips and knees, and between these and age, gender, ethnicity, body mass index (BMI), pain and its location, self-reported arthritis, and diabetes mellitus. The functional relevance of hip and knee FR was tested by measuring its association with 50-foot walking velocity. RESULTS: More than 90 degrees of flexion in both hips and both knees was observed in 619 subjects (90.1%). Correlations among the FR of hips and knees ranged from 0.54 to 0.80 (P < 0.001 for Spearman r values). Multivariate analysis revealed a pattern of significant associations between each of the joints and its contralateral mate and ipsilateral partner joints that was consistent for both hips and both knees. Using each individual joint as the unit of analysis, the following variables were independently associated with hip or knee FR in multivariate models: rising BMI and female sex with reduced FR of both hips and knees, a Mexican American ethnic background with decreased hip FR, and knee pain with decreased knee FR. The functional importance of the FR of these two important joints was supported by its significant association with walking velocity in a model that adjusted for age, gender, ethnic background, BMI, and hip or knee pain. CONCLUSIONS: Most community-dwelling elderly people have a FR of hips and knees that can be considered functional. The ipsilateral and contralateral hip or knee are significant independent determinants of the FR of each of these joints. Obesity, a health problem potentially amenable to preventive and therapeutic interventions, is a factor significantly associated with decreased FR of hips and knees.

A quantitative scale of acanthosis nigricans.

OBJECTIVE: To develop and validate a scale for acanthosis nigricans (AN). RESEARCH DESIGN AND METHODS: Subjects were participants from the San Antonio Family Diabetes Study and the San Antonio Family Heart Study. A total of 406 subjects were independently examined for AN by at least two observers. Five locations were examined: the neck, axilla, elbows, knuckles, and knees. Interobserver concordance and kappa statistics were calculated to determine replicability of the scale. Comparisons of diabetes-related risk factors by AN score were also calculated. RESULTS: Only the neck had consistently high kappa statistics, and thus, other locations were excluded from further analyses. Elevated AN was strongly associated with elevated fasting insulin and BMI in both diabetic and nondiabetic subjects. Elevated AN was also strongly associated with elevated fasting glucose, systolic blood pressure, and diastolic blood pressure, and with decreased HDL in nondiabetic subjects. In diabetic subjects, elevated AN was associated with elevated total cholesterol. CONCLUSIONS: We have developed a scale for AN that is easy to use, has high interobserver reliability in Mexican Americans, and correlates well with fasting insulin and BMI. This scale will permit longitudinal and cross-sectional evaluation of AN and will permit the evaluation of AN as a trait in genetic studies.

Rapid rise in the incidence of type 2 diabetes from 1987 to 1996: results from the San Antonio Heart Study.

BACKGROUND: The prevalence of type 2 diabetes has increased in the early part of the 20th century, particularly in developing countries. There is now evidence that the prevalence also continues to increase in developed countries, including the United States. However, it is unknown whether this increase is due to a rise in the incidence of diabetes or to decreasing diabetic mortality or both. METHODS: Participants in the San Antonio Heart Study, who were nondiabetic at baseline and who returned for a 7- to 8-year follow-up examination, were examined for secular trends in the incidence of type 2 diabetes. Risk factors for diabetes, such as obesity, were also examined. Patients were enrolled in the San Antonio Heart Study from 1979 to 1988 and 7- to 8-year incidence of diabetes was determined from 1987 to 1996. RESULTS: A significant secular trend in the 7- to 8-year incidence of type 2 diabetes was observed in Mexican Americans (5.7% for participants enrolled in 1979 to 15.7% for participants enrolled in 1988). In non-Hispanic whites, the incidence increased from 2.6% for participants enrolled in 1980 to 9.4% for participants enrolled in 1988 (P = .07) . After adjusting for age and sex, the secular trend remained significant in Mexican Americans and borderline significant in non-Hispanic whites. This indicates that between 1987 and 1996 the 7- to 8-year incidence of type 2 diabetes approximately tripled in both ethnic groups. The overall secular trend also remained significant after adjusting for additional risk factors for diabetes, such as obesity. A rising secular trend in obesity was also observed. CONCLUSIONS: There has been a significant increasing secular trend in the incidence of type 2 diabetes in Mexican Americans and a borderline significant trend in non-Hispanic whites participating in the San Antonio Heart Study. Unlike other cardiovascular risk factors such as lipid levels, cigarette smoking, and blood pressure, which are either declining or under progressively better medical management and control, and unlike cardiovascular mortality, which is also declining, obesity and type 2 diabetes are exhibiting increasing trends. Thus, obesity and diabetes could easily become the preeminent US public health problem.

Determinants of shoulder and elbow flexion range: results from the San Antonio Longitudinal Study of Aging.

OBJECTIVE: To gain a knowledge of factors associated with impaired upper extremity range of motion (ROM) in order to understand pathways that lead to disability. METHODS: Shoulder and elbow flexion range was measured in a cohort of 695 community-dwelling subjects aged 65 to 74 years. Associations between subjects' shoulder and elbow flexion ranges and their demographic and anthropometric characteristics, as well as the presence of diabetes mellitus or self-reported physician-diagnosed arthritis, were examined using multivariate regression models. The relationship between shoulder or elbow flexion range and subjects' functional reach was examined to explore the functional significance of ROM in these joints. RESULTS: The flexion range for the 4 joints studied was at least 120 degrees in nearly all subjects (> or = 99% of the subjects for each of the 4 joints). Multivariate models revealed significant associations between male sex, Mexican American ethnic background, the use of oral hypoglycemic drugs or insulin to treat diabetes mellitus, and a lower shoulder flexion range. A lower elbow flexion range was associated with male sex, increasing body mass index, and the use of oral hypoglycemic drugs or insulin. A higher shoulder or elbow flexion range was associated with a lower likelihood of having a short functional reach. CONCLUSIONS: The great majority of community-dwelling elderly have a flexion range of shoulder and elbow joints that can be considered functional. Diabetes mellitus and obesity are two potentially treatable factors associated with reduced flexion range of these two functionally important joints.

Disaggregating pain and its effect on physical functional limitations.

BACKGROUND: Pain is a common impairment that limits the abilities of older persons. The purposes of this article are to: (i) describe the distribution of pain location using the McGill Pain Map (MPM) in a community-based cohort of aged subjects; (ii) investigate whether individual areas of pain could be sensibly grouped into regions of pain; (iii) determine whether intensity, frequency, and location constitute independent dimensions of pain; and (iv) determine whether these three pain dimensions make differential contributions to the presence of self-reported physical functional limitations. METHODS: A total of 833 Mexican American and European American subjects, aged 65-79 years, were enrolled in the San Antonio Longitudinal Study of Aging and were interviewed in their homes between 1992 and 1996. A total of 373 (46%) of the subjects reported having pain in the past week. Physical functional limitations were ascertained using the nine items from the Nagi scale. Three composite scales were created: upper extremity, lower extremity, and total. Pain intensity and frequency were ascertained using the McGill Pain Questionnaire. Pain location was ascertained by using the MPM. RESULTS: Pain was reported in every area of the MPM. Using multiple groups confirmatory factor analysis, the 36 areas were grouped into 7 regions of pain: head, arms, hands and wrists, trunk, back, upper leg, and lower leg. Among persons with pain, pain frequency, intensity, and location were weakly associated with each other. Pain regions were primarily independent of each other, yet weak associations existed between 6 of the 21 pair-wise correlations between regions. Pain regions were differentially associated with individual physical functional limitations. Pain in the upper leg was associated with 8 of the 9 physical tasks. In multivariate analyses, age, gender, and ethnic group accounted for only 2-3% of the variance in physical tasks. In multivariate analyses, age, gender, and ethnic group accounted for only 2-3% of the variance in physical functional limitations. Pain intensity accounted for 5-6% of the variance in the composite scores of functional limitation. Pain frequency accounted for 4-5% of the variance in upper extremity limitations but did not contribute to the modeling of lower extremity limitations. In contrast, pain location accounted for 9-14% of the variance in physical functional limitations. CONCLUSIONS: We tested a method for ascertaining pain location and clearly demonstrated that pain location is an important determinant of self-reported physical functional limitations. The MPM methodology may be used in population-based studies or in clinical samples that focus on specific impairments and seek to control for pain frequency and intensity. Future studies can link specific diseases with the common impairment of pain and tease out the pathways that lead to other impairments (e.g., weakness), functional limitations, and disability.

Correlates of prescription and over-the-counter medication usage among older Mexican Americans: the Hispanic EPESE study. Established Population for the Epidemiologic Study of the Elderly.

OBJECTIVES: To determine the prevalence rates of prescription and over-the-counter (OTC) medication usage among community-dwelling older Mexican Americans. DESIGN: Cross-sectional survey of a regional probability sample of older Mexican Americans. SETTING: The 1992-1997 Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE), a probability sample of noninstitutionalized Mexican Americans, age 65 and over, living in the five Southwestern states of Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: 2899 persons, age 65 and over, considered Mexican American, using appropriate weighting procedures to produce regional estimates. OUTCOME MEASURES: Use of prescription and OTC medication within the last 2 weeks before the survey confirmed by in-home review of medication containers. RESULTS: Medication users consumed a mean of 2.9 prescription and 1.3 OTC medications. Over half (58.9%, n = 1,798) of the participants used at least one prescribed medication, and 31.3% (n = 847) used at least one OTC medication within the 2 weeks before their participation in the study. Factors associated with both prescription and OTC medication usage were self-perceived health and number of co-morbid conditions. Factors associated only with prescription medication usage included female gender, alcohol usage, ADL dependency, and presence of additional insurance. Structural assimilation was associated only with OTC medication usage. CONCLUSIONS: These data show lower prevalence rates of prescription medication usage among Mexican American older men and lower rates of OTC medication usage in older Mexican Americans of both genders than previously reported in other ethnic groups. This may reflect differences in time and geographic location of the Hispanic EPESE relative to other EPESE studies, ethnic differences in access to care as reflected by insurance in addition to Medicare, ethnic differences in survival, especially among males, or ethnic differences in medication preferences.

Cultural differences among health professionals: a case illustration.

This study illustrates that cultural differences arise among similarly trained health professionals. Health professionals must learn to communicate sensitively with colleagues from other cultures, to respect their values, and to recognize and resolve cultural differences that affect patient care. In this shrinking, multicultural world, health professionals cannot afford the comfortable illusion that all similarly trained practitioners share the same values about the care of patients and professional conduct.

Cross-cultural adaptation of the hearing handicap inventory for the Elderly-Screening Version (HHIE-S) for use with Spanish-speaking Mexican Americans.

OBJECTIVE: To cross-culturally adapt the Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S) for use with older Spanish-speaking Mexican Americans. SUBJECTS AND SETTING: Two different samples were used. First, a convenience sample of 100 older community-dwelling Mexican American men and women in San Antonio, Texas, was used to test technical equivalence of the Spanish and English language versions of the HHIE-S. Second, a neighborhood-based sample of older Mexican Americans was used to establish conceptual (n = 433) and criterion equivalence (n = 381) of the two HHIE-S language versions. METHODS: Independent forward and back translations were done to create a Spanish language version of the HHIE-S. In the convenience sample, subjects were administered the English and Spanish HHIE-S in random order on separate days. In the neighborhood sample, the HHIE-S was given on one occasion in the language of the subject's preference. Depressive symptoms were assessed using the Geriatric Depression scale to see if the two language versions of the HHIE-S were similarly associated with depression (conceptual equivalence). Hearing impairment was assessed using the Welch-Allyn Audioscope to see if the two language versions were similarly associated with an audiometric measure for hearing loss (criterion equivalence). RESULTS: In the convenience sample, the overall mean (SD) Spanish and English HHIE-S scores were 6.2 (8.7) and 6.2 (9.3), respectively (P = 1.00). Total scores of the English and Spanish versions were highly correlated (r = .89), and regression analysis indicated that the two language versions gave nearly identical results. In the neighborhood-based sample, men had higher HHIE-S scores than women (OR 2.0, 95% CI = 1.3-3.5). Having depressive symptoms (OR 3.2, 95% CI = 1.9-5.5) or hearing impairment (OR 6.1, 95% CI = 3.5-10.5) was associated with higher HHIE-S scores. After adjustment for gender, depressive symptoms, and/or hearing impairment, the language of interview was not associated with HHIE-S score. CONCLUSION: We have developed and tested a Spanish translation of the HHIE-S that yields equivalent results to those obtained with the English version in bilingual Mexican Americans. The Spanish HHIE-S presented here is suitable for clinical use and research studies involving older Mexican Americans.