Arterial hypertension (HTN) is a major public health problem with more than 1 billion affected individuals worldwide, a number that is expected to climb to 1.5 billions in 2025 1. Hypertension is a major cardiovascular risk factor and overwhelming observational data demonstrate a linear relationship between blood pressure levels and the risk of cardiovascular events 2. Elevated blood pressure levels affect the heart (myocardial infarction, heart failure, vascular dementia), the kidneys (chronic kidney disease) and the eyes (hypertensive nephropathy). More importantly, hypertension is a major public health problem in the United States, and its prevalence is estimated to surpass 50% of the US adult population when the new 2017 updated guidelines are applied, as per the American Heart Association 3. The total cost associated with HTN in 2011 in the US was $46 billion in health care services, medications, and missed days of work 4. Tackling this issue from a public policy perspective will be quite challenging and require a multidisciplinary effort across the various spectrums of society. In order to do so, one has to go straight to the origin of the problem: salt. An excessive dietary salt intake remains the main driver of hypertension, and the role of sodium in the pathogenesis of high blood pressure has been demonstrated in animal studies, ecologic studies, longitudinal observational studies, clinical trials, and genetic studies 5. Reducing sodium content in foods that are widely used by the public is a very important policy issue, and restricting dietary sodium intake to less than 2,300 mg daily will help decrease the risk of adverse cardiovascular events that include myocardial infarctions, heart failures and strokes, in society as a whole 6. However the issue has received a significant backlash from the food industry and the fast food gurus, obviously for financial reasons. Fast food sells because it tastes good, and it tastes good because it is filled with salt. Processed foods are the main culprits of sodium in our diets, but even bread can contain anywhere between 220 and 671 mg per 100 grams. Americans eat on average 3,400 mg of sodium daily, far exceeding the recommended daily intake of 2,300 mg as per the Federal Drug Administration’s estimates. Prior vigorous efforts to tackle this issue have not been successful, and the public health initiative lead by President Obama in 2016 was met with fierce resistance from the food industry and the discussion quickly abated in the ensuing months after strong lobbying from the big chains and the broader food industry. Immigration has also been thrust into the spotlight over the past year in the current political climate. Despite this emerging interest in the topic, there is little data on the epidemiology of hypertension and other cardiovascular disease risk factors among US immigrants. Acculturation is defined by the Merriam–Webster dictionary as the “cultural modification of an individual by adapting to or borrowing traits from another culture”.  It is the process by which a newcomer to a certain culture integrates himself or herself within its social environment, acquiring its habits, customs and lifestyle. How well acculturation goes will have a significant impact on a person’s well being and health, and suboptimal acculturation has been associated with poorer health outcomes in US immigrants 7. Length of residence in the US is a validated proxy for acculturation in population–based studies  8. A longer length of residence was found to be associated with heightened odds of obesity, hyperlipidemia and smoking among a diverse pool of US immigrants based on the 2002 National Health Interview Survey (NHiS)  9. Given the increasing size of immigrants in the US and the economic burden associated with managing hypertension in society as a whole, our aim in this study is to examine the association between the length of stay in the US and the prevalence of hypertension. We hypothesize that an increased length of stay in the United States would be correlated with a greater odds of hypertension. If this proves to be true, then this would be another way to confirm the impact of sodium in the American diet on the prevalence of hypertension. We’d like to particularly take a closer look at individuals who are specifically coming from societies with known low dietary sodium consumption, and assess the effect of acculturation on their risk of hypertension.   We will be utilizing data from the 2016 NHiS for this study. The NHiS is a cross–sectional nationally representative survey of adults living in the US, aged 18 years or older, administered yearly by the US Bureau of the Census for the National Center for Health Statistics.  The survey design incorporates complex sampling techniques that include stratification, clustering and differential sampling, including more than 110,000 participants. We will restrict our analysis to the immigrants, defined as individuals living in the US, but who were born abroad (variable USBORN in the dataset, which specifies if individual was born in the US or not). The NHiS does have the predictor variable of interest, YRSINUS (number of years spent in US), along with the outcome variable of interest, hypertension (HYP2TIME: ever been told you had hypertension on two visits), and a proxy variable that can be used for validation, HYPMEDNOW (now taking prescribed blood pressure medications). The dataset also contains the other variables that act as confounders, that we’ll need to adjust for in our analysis, such as age, gender, diabetes mellitus, high cholesterol, obesity etc. Hence the concepts we are interested in researching are appropriately operationalized into variables in the NHiS dataset. We will use logistic regression with multivariate analyses in order to obtain the desired inferences, estimating the odds of hypertension per every additional year spent in the United States, after adjusting for other relevant covariates.


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