Original Report:

Health Risks and Chronic Health

Public Health
Conditions among Arab American
and White Adults
in Northern California

Nadia N. Abuelezam, ScD1;

Abdulrahman M. El-Sayed, MD, PhD2;
Sandro Galea, MD, MPH, DrPH 3; Nancy P. Gordon, ScD4

Objectives: To characterize the prevalence

of chronic cardiovascular conditions and
Introduction complicated by a lack of racial and
risk factors among Arab American adults ethnic identifiers on many standard-
stratified by sex and compare these with Arab Americans are a minor- ized forms used by the federal gov-
non-Hispanic Whites.
ity group in the United States (US) ernment, health insurers, health care
Design: Cross-sectional study using with ethnic origins in Arabic speak- providers, and public service agen-
electronic health record data from visits be- ing countries in the Middle East and cies.3 Decennial Census and National
tween January 2015 and December 2016.
Age-adjusted prevalence estimates were cal- North Africa. California has become Health Interview Survey forms rely
culated for men and women and compared home to one of the largest groups of on country of birth to capture Arab
using generalized linear models. Arab Americans since early immigra- Americans born outside of the United
Setting: Kaiser Permanente health plan in tion waves in the 1880s. It is estimat- States (first generation immigrants)
Northern California. ed that 820,000 Arab Americans live but often miss those who are born in
in California, representing 2% of the the United States to Arab immigrants
Participants: Non-Hispanic White
(N=969,566) and Arab American adult population of the state.1 Recent (second generation immigrants) or
(N=18,072) adult members. evidence from the California Health US-born Arab Americans with Arab
Interview Survey suggests that Arab ancestry (third generation immi-
Main Outcome Measures: Sex-stratified
prevalence and prevalence ratios of diabe- Americans in California have a higher grants). Further, much of our under-
tes, pre-diabetes, hypertension, and hyper- risk of some chronic health conditions standing of Arab American health
lipidemia diagnosed by December 2016 than non-Hispanic Whites and that relies on convenience sample surveys
and of obesity, ever smoking, and current
smoking status. patterns previously observed in the that identify Arab Americans in eth-
health of other minority groups do nic enclaves or in areas where Arab
Results: Arab American men had a not seem to hold for Arab Americans.2 Americans are known to reside. In
significantly higher prevalence of ever
smoking (41.8 vs 40.8%), diabetes (17.3 Understanding and quantify- one of the first studies of its kind, a re-
vs 12.5%), and hyperlipidemia (40.8 vs ing Arab American health needs is cent analysis using data from a Mich-
34.7%) than White men, but a significantly
lower prevalence of obesity (34.4 vs 37.8%)
and hypertension (30.5 vs 33.3%). Arab reduce the disparities this minority group 3
Boston University School of Public Health,
American women had a significantly higher faces. Ethn Dis. 2021;31(2):235-242; Boston, MA
prevalence of diabetes (11.1 vs 8.7%) and doi:10.18865/ed.31.2.235 4
Kaiser Permanente Division of Research,
hyperlipidemia (31.5 vs 28.3%) than White Oakland, CA
women but significantly lower prevalence Keywords: Health Disparities; Chronic
of obesity (31.0 vs 34.2%), ever smoking Disease; Arab Americans; Risk Factors; Address correspondence to Nadia N.
(24.8 vs 34.5%), and hypertension (25.8 vs California Abuelezam, ScD; Boston College William
28.4%). F. Connell School of Nursing, 140
1
Boston College William F. Connell School Commonwealth Avenue, Chestnut Hill, MA
Conclusions: Hospital and health systems of Nursing, Chestnut Hill, MA 02467; [email protected]
should intentionally collect data on Middle 2
College of Literature, Science, & the Arts &
Eastern and North African ethnicity in Department of Internal Medicine, University
electronic health records to identify and of Michigan, MI

Ethnicity & Disease, Volume 31, Number 2, Spring 2021 235

Chronic Disease Prevalence in Arab Americans in California - Abuelezam et al

igan-based hospital identified Arab panic Whites. Health plan-based ethnicity was characterized as Arab
Americans and compared their health samples provide a comprehensive pic- or originating from one of 22 Arab
indicators with those for Whites in ture of health in a particular region League countries, or preferred writ-
the same hospital.4 This study found and are a low-cost means of access- ten or spoken language was Arabic,
that Arab American men and women ing rich data on large populations.6 those individuals (excluding Arme-
had a higher prevalence of diabetes nians, Iranian/Persians, and Turks)
and hypertension than Whites. The were classified as Arab American.
study also found significant differ- Methods Second, we used an Arab surname
ences between Arab American men algorithm previously validated using
and women on chronic disease preva- a cancer registry in California10 to
lence4 as has a study examining men- Setting identify potential Arab Americans in
tal health outcomes using EHR data.5 Kaiser Permanente Northern Cali- the cohort, with subsequent review
Aiming to contribute to our fornia (KPNC) is an integrated health of first name and other REL data for
care delivery system that provides each individual to eliminate those
outpatient, inpatient, and ancillary with questionable Arab ethnicity.
health care services to more than 3.2 Overall, 25,603 adults were clas-
We used electronic health million adults in the San Francisco and sified as Arab American in the study
Greater Bay Area of California. The sample. Due to the focus of our study
record (EHR) data for sociodemographic and health charac- on chronic health outcomes, which
teristics of the KPNC adult member- are more likely to develop with older
adult members of a large ship are similar to those of the insured age, we restricted our sample to the
Northern California population of Northern California.7 18,072 Arab Americans aged 35-84
years. Of these, 26.6% (n=4,815)
health plan to characterize Study Population were identified from EHR ethnic-
Data for Arab American and non- ity data, 1.6% (n=287) from Ara-
the prevalence of chronic Hispanic White adults used for this bic language, 1.5% (n=268) from
cardiovascular conditions study came from a larger adult race/ self-reported patient survey data,
ethnicity cohort described in de- and 70.3% (n=12,702) from sur-
and risk factors in Arab tail elsewhere.8 First and last names, name. The non-Hispanic Whites
race/ethnicity, and preferred writ- in our study sample (n=969,566)
American adult men and ten and spoken language (REL) data had been identified previously
were available for the entire cohort. based on race and ethnicity data
women… However, because KPNC primar- from the EHR and research sources.
ily uses the Office of Management
and Budget (OMB) minimum cat- EHR-Derived Variables
egories to capture race/ethnicity9 for Sex at birth, age, smoking status,
understanding of Arab American the EHR in the outpatient setting, obesity, and chronic condition vari-
health, we used electronic health members of Arab American/North ables were created from EHR and
record (EHR) data for adult mem- African ethnicity are coded using registry data. Individuals were classi-
bers of a large Northern Califor- the White and Other race categories. fied as having diabetes mellitus (DM)
nia health plan to characterize the We used two methods to iden- if they were in the KPNC Diabetes
prevalence of chronic cardiovascular tify Arab Americans in the cohort. Registry, which identifies people us-
conditions and risk factors in Arab First, we used individual member’s ing inpatient and outpatient diagnosis
American adult men and women ethnicity reported in the EHR or codes, lab test results, and pharmacy
and compared these with non-His- available from previous studies. If data (see Karter et al for specifica-

236 Ethnicity & Disease, Volume 31, Number 2, Spring 2021

 Chronic Disease Prevalence in Arab Americans in California - Abuelezam et al

Table 1. Prevalence of risk factors and chronic health conditions among Arab American and White men and women aged 35-
84 years, 2016.
All Men Women
Arab Americans Whites Arab Americans Whites Arab Americans Whites
% (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Ages 35-84/All
Risk Factors
Obesity (BMI ≥30) 32.8 (32.0, 33.6) 35.9 (35.8, 36.0) 34.4 (33.2, 35.5) 37.8 (37.6, 37.9) 31.0 (29.9, 32.2) 34.2 (34.0, 34.4)
Current smoking 10.0 (9.5, 10.4) 8.9 (8.9, 9.0) 13.3 (12.6, 14.0) 10.4 (10.3, 10.5) 6.5 (5.9, 7.0) 7.6 (7.5, 7.7)
Ever smoking 33.4 (32.7, 34.1) 37.4 (37.4, 37.5) 41.8 (40.7, 42.8) 40.8 (40.7, 41.0) 24.8 (23.9, 25.7) 34.5 (34.3, 34.6)
Chronic conditions
Diabetes 14.3 (13.7, 14.8) 10.5 (10.4, 10.5) 17.3 (16.6, 18.1) 12.5 (12.4, 12.6) 11.1 (10.4, 11.7) 8.7 (8.7, 8.8)
Prediabetes 10.1 (9.6, 10.5) 8.8 (8.8, 8.9) 11.4 (10.8, 12.1) 10.1 (10.1, 10.2) 8.6 (8.0, 9.2) 7.7 (7.6, 7.7)
Hypertension 28.2 (27.6, 28.8) 30.7 (30.6, 30.8) 30.5 (29.6, 31.3) 33.3 (33.2, 33.5) 25.8 (25.0, 26.7) 28.4 (28.3, 28.5)
Hyperlipidemia 36.3 (35.7, 37.0) 31.3 (31.3, 31.4) 40.8 (39.8, 41.7) 34.7 (34.6, 34.8) 31.5 (30.6, 32.4) 28.3 (28.1, 28.4)

tions).11 The specific ICD-9 and ICD- aged 35-64 years and 24% of adults (“younger” group), 45-64 (“middle-
10 outpatient visit and problem list aged 65-84 years did not have usable aged” group), and 65-84 years (“old-
codes appearing in the EHR between BMI data, with no significant dif- er” group). We used Proc Genmod12
January 2015 and December 2016 ference between Arabs and Whites. to calculate sex-specific age-adjust-
that were used to classify individuals Heart disease was examined as an out- ed prevalence ratios (PR) for Arab
as having pre-diabetes, hypertension, come in the 65-84 age group due to Americans compared with Whites.
and hyperlipidemia can be found in low incidence in younger age groups. All differences mentioned in the text
Gordon et al.8 BMI was calculated are statistically significant at P<.05.
using the valid 2016 EHR-entered Analysis
weight closest to December 1, 2016, Study data were analyzed us- Ethical Review
and valid EHR-entered height clos- ing SAS version 9.4 (SAS Institute, All procedures were in accor-
est to the date closest to the weight. Cary, IN, 2013). We used Proc Sur- dance with the ethical standards of
Individuals were considered obese if veyreg, with a log-binomial model the responsible committee on hu-
they had a BMI ≥30 kg/m2. Smok- for dichotomous outcomes, to pro- man experimentation (institutional
ing status (current or ever smoker) duce prevalence estimates with 95% and national) and with the Helsin-
was based on EHR tobacco use data confidence intervals for smoking, ki Declaration of 1975, as revised
on the visit date closest to December obesity, and the health conditions in 2000. This study was approved
1, 2016. Those who did not have us- for Arab American and White men by KPNC’s institutional review
able smoking status data from 2015 and women age-standardized to the board. The IRB waived the require-
or 2016 but who had information in 2016 US Census. Estimates for Arab ment to obtain informed consent.
their EHR during the three previous American and White men and wom-
years or first three months of 2017 en aged 35-84 years (Overall preva-
that indicated they had never smoked lence) were age-standardized using R esults
were coded as never smokers. Ap- five age groups (35-44 years, 45-54
proximately 3.9% of Arab American years, 55-64 years, 65-74 years, and Sample Characteristics
men aged 35-64 years, 1% of men 75-84 years). Prevalence estimates Our sample consisted of 18,072
aged 65-84 years, and 1% of women for smoking, obesity, and health Arab Americans and 969,566
in both groups were missing smoking conditions were additionally calcu- non-Hispanic Whites aged 35-84
status. Approximately 30% of adults lated for men and women ages 35-44 years. The Arab American group

Ethnicity & Disease, Volume 31, Number 2, Spring 2021 237

Chronic Disease Prevalence in Arab Americans in California - Abuelezam et al

Table 2. Prevalence of risk factors and chronic health conditions among Arab American and White men and women stratified
by age groups (35-44, 45-64, and 65-84), 2016
All Men Women
Arab Americans Whites Arab Americans Whites Arab Americans Whites
% (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Ages 35-44/Younger group
Risk Factors
Obesity (BMI ≥30) 30.8 (29.2, 32.3) 34.8 (34.5, 35.0) 34.7 (32.5, 37.0) 36.8 (36.4, 37.2) 26.7 (24.6, 28.7) 33 (32.6, 33.4)
Current smoking 11.8 (10.9, 12.7) 10.1 (10.0, 10.2) 17.0 (15.6, 18.5) 13.0 (12.8, 13.2) 6.4 (5.5, 7.4) 7.3 (7.2, 7.5)
Ever smoking 27.3 (26.0, 28.5) 31.5 (31.3, 31.7) 36.7 (34.8, 38.5) 35.6 (35.3, 36.0) 17.5 (16.0, 19.0) 27.6 (27.3, 27.9)
Chronic conditions
Diabetes 3.6 (3.1, 4.2) 2.9 (2.8, 3.0) 4.7 (3.9, 5.5) 3.2 (3.1, 3.4) 2.5 (1.9, 3.1) 2.6 (2.5, 2.7)
Prediabetes 4.5 (3.9, 5.0) 2.7 (2.6, 2.8) 5.3 (4.5, 6.1) 3.1 (3.0, 3.2) 3.6 (2.8, 4.3) 2.3 (2.2, 2.4)
Hypertension 5.8 (5.2, 6.5) 8.2 (8.1, 8.4) 7.0 (6.0, 7.9) 9.8 (9.6, 10.0) 4.5 (3.7, 5.4) 6.8 (6.6, 7.0)
Hyperlipidemia 10.6 (9.8, 11.5) 7.3 (7.2, 7.4) 15.1 (13.8, 16.5) 9.9 (9.7, 10.1) 6.4 (5.5, 7.4) 4.9 (4.8, 5.1)
Ages 45-64/Middle-aged group
Risk Factors
Obesity (BMI ≥30) 34.5 (33.3, 35.6) 38.4 (38.2, 38.5) 36.7 (35.1, 38.3) 40.7 (40.5, 41.0) 32.1 (30.5, 33.7) 36.2 (36.0, 36.4)
Current smoking 11.0 (10.4, 11.7) 9.9 (9.8, 10.0) 14.1 (13.1, 15.2) 11.3 (11.1, 11.4) 7.6 (6.8, 8.4) 8.6 (8.5, 8.7)
Ever smoking 32.4 (31.4, 33.4) 35 (34.9, 35.2) 39.3 (37.9, 40.7) 36.9 (36.7, 37.1) 24.9 (23.6, 26.2) 33.3 (33.1, 33.5)
Chronic conditions
Diabetes 12.7 (12.0, 13.4) 9.6 (9.5, 9.6) 15.8 (14.7, 16.8) 11.4 (11.3, 11.6) 9.3 (8.5, 10.2) 7.9 (7.7, 8.0)
Prediabetes 10.2 (9.6, 10.8) 8.3 (8.2, 8.4) 11.9 (11.0, 12.8) 9.8 (9.7, 9.9) 8.3 (7.5, 9.1) 6.9 (6.8, 7.0)
Hypertension 23.4 (22.5, 24.2) 26.7 (26.6, 26.8) 25.8 (24.6, 27.0) 29.8 (29.7, 30.0) 20.6 (19.4, 21.7) 23.8 (23.6, 23.9)
Hyperlipidemia 33.6 (32.4, 34.5) 27.1 (27.0, 27.3) 39.3 (37.9, 40.6) 31.4 (31.3, 31.6) 27.3 (26.0, 28.6) 23.1 (23.0, 23.3)
Ages 65-84/Older group
Risk factors
Obesity (BMI ≥30) 31.3 (29.6, 33.1) 32.1 (31.9, 32.3) 29.5 (27.1, 31.9) 33 (32.7, 33.2) 33.1 (30.7, 35.6) 31.4 (31.2, 31.7)
Current smoking 6.1 (5.4, 6.9) 6.0 (5.9, 6.1) 8.1 (6.8, 9.4) 6.2 (6.1, 6.4) 4.3 (3.3, 5.2) 5.8 (5.7, 5.9)
Ever smoking 41.2 (39.6, 42.8) 47.8 (47.7, 48.0) 51.4 (49.1, 53.8) 53.4 (53.2, 53.7) 31.7 (29.5, 33.8) 43.2 (43.0, 43.5)
Chronic conditions
Diabetes 27.3 (25.9, 28.8) 19.5 (19.4, 19.6) 32.4 (30.2, 34.6) 23.3 (23.1, 23.6) 22.6 (20.7, 24.5) 16.3 (16.2, 16.5)
Prediabetes 15.2 (14.0, 16.3) 15.7 (15.6, 15.9) 16.3 (14.6, 18.0) 17.5 (17.3, 17.7) 14.1 (12.5, 15.7) 14.2 (14.1, 14.4)
Hypertension 58.9 (57.4, 60.5) 59.9 (59.8, 60.1) 61.7 (59.5, 64.0) 62.5 (62.2, 62.7) 56.3 (54.1, 58.5) 57.8 (57.6, 58.0)
Hyperlipidemia 65.9 (64.4, 67.4) 62.3 (62.2, 62.5) 67.9 (65.8, 70.1) 64.7 (64.4, 64.9) 64.0 (61.9, 66.2) 60.4 (60.2, 60.6)
Coronary artery disease 7.6 (6.8, 8.5) 6.0 (5.9, 6.1) 11.2 (9.8, 12.7) 8.5 (8.4, 8.7) 4.2 (3.3, 5.2) 3.7 (3.6, 3.8)
Heart failure 6.5 (5.7, 7.4) 6.3 (6.2, 6.4) 7.6 (6.3, 8.8) 7.5 (7.4, 7.6) 5.6 (4.6, 6.7) 5.0 (4.9, 5.1)

was younger than the White spoken language, with 4.2% of sity prevalence than Arab American
group, with 29.0% vs 18.3% in Arab Americans preferring Arabic. women in the same age groups, but
the younger age group, 51.0% vs in the older age group, Arab wom-
49.3% in the middle-aged group, Risk Factors en had higher obesity prevalence
and 20.0% vs 32.5% in the older than Arab American men (Tables
age group. Approximately half of Obesity 1, 2). Arab American men (34.4%
both groups (51.8% of Arab Ameri- Overall obesity prevalence was vs 37.8%) and women (31.0% vs
cans and 47.2% of Whites) were 32.8% (95% CI: 32.0%, 33.6%) for 34.2%) had a lower prevalence of
male. Nearly all adults in both Arab Americans and 35.9% (95% obesity than Whites overall (Table 1)
groups (95.8% of Arab Americans CI: 35.8%, 36.0%) for Whites (Ta- but not among women in the older
and 98.9% of Whites) had Eng- ble 1). Younger and middle-aged age group (Table 2). The age-adjusted
lish indicated as their preferred Arab American men had higher obe- obesity prevalence ratio comparing

238 Ethnicity & Disease, Volume 31, Number 2, Spring 2021

 Chronic Disease Prevalence in Arab Americans in California - Abuelezam et al

Arab Americans to Whites were sig- both Arab American and Whites was nosed heart failure (Table 2). Among
nificantly lower for Arab American higher in men than women (Table 2). both Arab Americans and Whites,
men (PR: .92, 95% CI: .88, .94) and prevalence of these conditions was
women (PR: .90, 95% CI: .87, .93). Hypertension higher among men than women.
Overall prevalence of diag-
Smoking nosed hypertension among both
Prevalence of current smoking was men (30.5% vs 33.3%) and women Discussion
significantly higher in Arab American (25.8% vs 28.4%) was significantly
men than White men overall (13.3% lower in Arab Americans than in Using EHR-derived data for a
vs 10.4%) (Table 1) and in all three Whites (Table 1), but the disparity cohort of Arab American and White
age groups (Table 2). Overall age- was largest in the middle-aged group adult members of a large Northern
adjusted prevalence of ever smok- (Table 2). The age-adjusted preva- California health plan we aimed to
ing was significantly higher for Arab lence ratio for hypertension compar- quantify sex-specific differences in the
American than White men (41.8% ing Arab American men with White prevalence of risk factors and chronic
vs 40.8%, PR: 1.02, 95% CI: 1.00, men (PR: .93, 95% CI: .90, .95) conditions between these groups. We
1.05), but further analysis showed was similar to that for the compari- found that Arab American men had
that this difference was only signifi- son among women (PR: .93, 95% a higher prevalence of ever smoking,
cant in the younger and middle-aged CI: .90, .96). Across all age groups
groups. Among women, prevalence of in both Arab Americans and Whites,
current smoking (6.5% vs 7.6%) and the prevalence of hypertension was
ever smoking (24.8% vs 34.5%) was higher in men than women (Table 2). Overall, Arab American
significantly lower in Arab Ameri-
men had a higher
cans than Whites, respectively, overall Hyperlipidemia
and in all three age groups (Table 2). Overall prevalence of diagnosed prevalence of risk factors
hyperlipidemia was significantly
Chronic Conditions higher for Arab Americans than for and chronic conditions
Whites among both men (40.8%
Diabetes and Pre-Diabetes vs 34.7%) and women (31.5% vs
than Arab American
Prevalence of diagnosed diabe- 28.3%) (Table 1). The prevalence women across all age
tes was significantly higher in Arab ratio for hyperlipidemia comparing
American men (17.3% vs 12.5%, Arab Americans and Whites was larg- groups.
PR: 1.39, 95% CI: 1.33, 1.45) and er among men (PR: 1.14, 95% CI:
women (11.1% vs 8.7%, PR: 1.26, 1.11, 1.16) than among women (PR:
95% CI: 1.18, 1.34) compared with 1.09, 95% CI: 1.06, 1.12). Across all
Whites overall (Table 1) and in all age groups, Arab American and White currently smoking, diabetes, pre-dia-
three age groups (Table 2). Similarly, men had a higher prevalence of hy- betes, and hyperlipidemia than White
prevalence of pre-diabetes was higher perlipidemia than women (Table 2). men, but a lower prevalence of obesi-
for Arab Americans than non-His- ty and hypertension. Arab American
panic Whites overall (10.1% vs 8.8%) Heart Disease women had a higher prevalence of
(Table 1) and in the younger and Among adults aged 65-84 years, diabetes, pre-diabetes, and hyperlip-
middle-aged groups. The disparity in Arab American men and women idemia than White women but lower
prevalence of diabetes between Arab had a significantly higher prevalence prevalence of obesity, ever smoking,
Americans and Whites increased with of diagnosed coronary artery dis- currently smoking, and hypertension.
age. Across all age groups, the preva- ease than Whites (7.6% vs 6.0%), Overall, Arab American men had a
lence of diabetes and pre-diabetes in but no difference was seen for diag- higher prevalence of risk factors and

Ethnicity & Disease, Volume 31, Number 2, Spring 2021 239

Chronic Disease Prevalence in Arab Americans in California - Abuelezam et al

chronic conditions than Arab Ameri- and women had higher prevalence of and White adults who resided in a
can women across all age groups. diabetes when compared with Whites,4 defined geographic area and received
Differences in risk factors and as we found in our study. Unlike the health care from the same health
chronic health conditions between Michigan study, our study found that plan. The large size of the study co-
Arab Americans and Whites could hypertension prevalence was lower in hort enabled precise age-standardized
occur for a number of underlying Arab Americans than in Whites. Our sex-specific estimates of the preva-
reasons. First, differences in health previous work with the California lence of the risk factors and chronic
behaviors may exist between the Health Interview Survey, a population- conditions for Arab Americans in
two groups that could be related to based phone interview survey, also three age groups. It also provided suf-
sociodemographic and accultura- found higher odds of self-reported dia- ficient power to test for differences
tion factors. Data from the Ameri- betes and lower odds of hypertension in prevalence between Arab Ameri-
can Community Survey showed that for Arab Americans vs Whites based on can and White men and women and
sociodemographic characteristics self-reported data.17 Differences in the between Arab American men and
of Arab Americans differ substan- prevalence of chronic health outcomes women within the three age groups.
tially from non-Hispanic Whites between Arab Americans in Michigan We also acknowledge some
with regard to the proportion of and California may be due to regional limitations. First, most of the Arab
individuals living in poverty, who differences in health behaviors such as Americans in our study cohort were
are unemployed, who live in large smoking, diet, and physical activity identified using a vetted surname al-
households, and have public insur- and sociodemographic characteristics gorithm. We subsequently used other
ance.13 These factors could influence such as educational attainment and in- ethnicity, language preference, and
health behaviors that impact chronic come or acculturation that have been first name data in the EHR to iden-
health conditions in this population. observed in national health surveys. tify and exclude adults with question-
Second, Arab Americans may be Additionally, the hospital administra- able Arab ethnicity, but we cannot
experiencing discrimination in their tive database examined in the Dallo assume that our review caught every-
daily lives that may be influencing study was smaller than KPNC, which one who should have been excluded.
their chronic health risks. Recent may lead to differences in representa- Second, acculturation variables
evidence suggests that experiences of tion of the individuals examined. Fur- like length of time and generation
discrimination and racism can in- ther, Michigan has the highest density in the United States were not avail-
crease health risks in minority popu- of Arab Americans of any state in the able from the EHR data and thus
lations.14,15 Arab Americans have been United States with a large number of could not be controlled for in the
found to be experiencing increasing Arab ethnic enclaves. Arab Americans analysis. Preferred language could
discrimination and hate crimes due living in ethnic enclaves may experi- not be used as a measure of accul-
to the changes to the sociopolitical ence benefits that Arab Americans turation because only a very small
climate over the past few decades in living in less dense areas, like North- percentage of Arab Americans had
the United States.16 The nature of ern California, may not experience. a preferred spoken language other
the available data in the EHR does Further work needs to be done to than English indicated in their EHR.
not allow us to explore which of understand the potential reasons for Third, at the time of this study,
these mechanisms is responsible for geographic differences in chronic dis- less than 3% of KPNC adult health
the differences we have observed. ease risk for this minority population. plan members aged 35-84 years
Two other studies have used data were covered by Medicaid, the US
from a hospital EHR to compare Arab Study Strengths and government insurance program for
American health with the health of Limitations very low income adults. Analysis of
White Americans in Michigan.4,5 In Our study had several strengths. California Health Interview Survey
the study examining chronic health It utilized EHR data for a contempo- data showed that compared with
conditions, both Arab American men rary cohort of insured Arab American other insured adults, and the general

240 Ethnicity & Disease, Volume 31, Number 2, Spring 2021

 Chronic Disease Prevalence in Arab Americans in California - Abuelezam et al

6. Casey JA, Schwartz BS, Stewart WF, Adler

population in the same geographic captured in an easily usable way, if NE. Using electronic health records for popu-
area, a lower percentage of adults at all, in EHRs, precluding their use lation health research: a review of methods
and applications. Annu Rev Public Health.
covered by KPNC had a house- for large scale EHR-based studies; 2016;37(1):61-81. https://doi.org/10.1146/
hold income of <$35,000.18 Thus, research has shown that Census-de- annurev-publhealth-032315-021353
PMID:26667605
the results of our study may not be rived education and income variables
7. Gordon NP. Similarity of the Adult Kaiser Per-
generalizable to “safety net” and can add context but do not replace manente Membership in Northern California to
lower-income populations, as well individual level data.19-21 We sug- the Insured and General Population in Northern
California: Statistics from the 2011 California
as to Arab American populations in gest that in areas where large groups Health Interview Survey. Oakland, CA: Kaiser
other regions of the United States. of Arab Americans live, hospital and Permanente Division of Research; 2012. Last
accessed March 15, 2021 from https://divi-
Fourth, Arab Americans in our health systems should intentionally
sionofresearch.kaiserpermanente.org/projects/
study cohort have a diversity of nation- collect data on Middle Eastern and memberhealthsurvey/SiteCollectionDocu-
al origins and cultural backgrounds, North African ethnicity to charac- ments/chis_non_kp_2011.pdf
8. Gordon NP, Lin TY, Rau J, Lo JC. Aggrega-
which may have resulted in masking terize Arab American health and to tion of Asian-American subgroups masks
of differences in risks and chronic identify and reduce the health dis- meaningful differences in health and health
risks among Asian ethnicities: an electronic
disease prevalence. Because less than parities this minority group faces.
health record based cohort study. BMC
one-fifth of our Arab American study Public Health. 2019;19(1):1551. https://
Conflict of Interest
group was identified using race/eth- doi.org/10.1186/s12889-019-7683-3
No conflicts of interest to report. PMID:31760942
nicity data, we could not examine 9. Office of Management and Budget. Executive
differences in health risks and chronic Author Contributions Office of the President, Office of Management
Research concept and design: Abuelezam, and Budget (OMB), Office of Information
conditions in specific Arab American
El-Sayed, Gordon; Acquisition of data: and Regulatory Affairs. Standard for the Clas-
ethnic subgroups. Further research is sification of Federal Data on Race and Ethnic-
Gordon; Data analysis and interpretation:
needed to characterize health-related Abuelezam, Galea, Gordon; Manuscript draft:
ity. 1995. Last accessed March 15, 2021 from
https://obamawhitehouse.archives.gov/omb/
differences in specific Arab American Abuelezam, El-Sayed, Galea, Gordon; Statisti- fedreg_race-ethnicity
ethnic subgroups and to compare the cal expertise: Abuelezam; Administrative: 10. Nasseri K. Construction and valida-
Abuelezam, Gordon; Supervision: Galea tion of a list of common Middle Eastern
health of Arab Americans in these
surnames for epidemiological research.
ethnic subgroups with the health of References Cancer Detect Prev. 2007;31(5):424-429.
Arabs in relevant countries of origin. 1. Arab American Institute Foundation. Arab https://doi.org/10.1016/j.cdp.2007.10.006
American Demographics. 2014. Last accessed PMID:18023539
March 15, 2021 from https://yallacountmein. 11. Karter AJ, Schillinger D, Adams AS, et al.
org/materials/arab-amreican-demographics. Elevated rates of diabetes in Pacific Islanders
Conclusions 2. Abuelezam NN, El-Sayed AM, Galea S. Rel- and Asian subgroups: The Diabetes Study of
evance of the “immigrant health paradox” for Northern California (DISTANCE). Diabetes
the health of Arab Americans in California. Care. 2013;36(3):574-579. https://doi.
Future research is needed to en- Am J Public Health. 2019;109(12):1733-1738. org/10.2337/dc12-0722 PMID:23069837
https://doi.org/10.2105/AJPH.2019.305308 12. Spiegelman D, Hertzmark E. Easy SAS
able more comprehensive and rig- PMID:31622140 calculations for risk or prevalence ratios and
orous comparisons of the health 3. Abuelezam NN, El-Sayed AM, Galea S. Arab differences. Am J Epidemiol. 2005;162(3):199-
American health in a racially charged US. Am 200. https://doi.org/10.1093/aje/kwi188
characteristics of Arab Americans in
J Prev Med. 2017;52(6):810-812. https:// PMID:15987728
different regions in the United States doi.org/10.1016/j.amepre.2017.02.021 13. Raed Jn, Ajrouch K, West J. Arab Ameri-
that also control for sociodemograph- PMID:28413143 cans: A Community Portrait. Last accessed
4. Dallo FJ, Ruterbusch JJ, Kirma JD, Schwartz February 4, 2021 from https://insight.
ic factors. This effort will require K, Fakhouri M. A health profile of Arab livestories.com/s/v2/arab-american-heritage-
more widespread inclusion of racial Americans in Michigan: a novel approach to v2/0adb9ffd-937c-4f57-9dca-80b81ee46b9f/.
using a hospital administrative database. J 14. Cuevas AG, Ho T, Rodgers J, et al. Develop-
and ethnic identifiers for Arab Amer-
Immigr Minor Health. 2016;18(6):1449-1454. mental timing of initial racial discrimination
icans in state and national health https://doi.org/10.1007/s10903-015-0296-8 exposure is associated with cardiovascu-
surveys and hospital and health plan PMID:26472547 lar health conditions in adulthood. Ethn
5. Dallo FJ, Prabhakar D, Ruterbusch J, et Health. Online 07 May 2019 at https://
EHRs. Additionally, while education al. Screening and follow-up for depres- doi.org/10.1080/13557858.2019.1613517
and income are usually captured in sion among Arab Americans. Depress PMID:31064206
Anxiety. 2018;35(12):1198-1206. https://doi. 15. Williams DR, Lawrence JA, Davis BA. Rac-
health surveys, these data are seldom
org/10.1002/da.22817 PMID:30099819 ism and health: evidence and needed research.

Ethnicity & Disease, Volume 31, Number 2, Spring 2021 241

Chronic Disease Prevalence in Arab Americans in California - Abuelezam et al

Annu Rev Public Health. 2019;40(1):105-125.

https://doi.org/10.1146/annurev-publ-
health-040218-043750 PMID:30601726
16. Arab American Institute Foundation. Under-
reported, Under Threat: Hate crime in the
United States and the targeting of Arab Amer-
icans 1991-2016. 2018. Last accessed March
15, 2021 from https://www.decodehate.com/
reporthate
17. Abuelezam NN, El-Sayed AM, Galea S.
Differences in health behaviors and health
outcomes among non-Hispanic Whites
and Arab Americans in a population-based
survey in California. BMC Public Health.
2019;19(1):892. https://doi.org/10.1186/
s12889-019-7233-z PMID:31286920
18. Gordon NP. Similarity of Adult Kaiser Per-
manente Members to the Adult Population in
Kaiser Permanente’s Northern California Service
Area: Comparisons Based on the 2017/2018
Cycle of the California Health Interview Survey.
Oakland, CA: Kaiser Permanente Division of
Research; November 8 2020. Last accessed
March 15, 2021 from https://divisionofre-
search.kaiserpermanente.org/projects/mem-
berhealthsurvey/SiteCollectionDocuments/
compare_kp_ncal_chis2017-18.pdf
19. Pardo-Crespo MR, Narla NP, Williams
AR, et al. Comparison of individual-level
versus area-level socioeconomic measures
in assessing health outcomes of children in
Olmsted County, Minnesota. J Epidemiol
Community Health. 2013;67(4):305-310.
https://doi.org/10.1136/jech-2012-201742
PMID:23322850
20. Kwok RK, Yankaskas BC. The use of census
data for determining race and education
as SES indicators: a validation study. Ann
Epidemiol. 2001;11(3):171-177. https://
doi.org/10.1016/S1047-2797(00)00205-2
PMID:11293403
21. Geronimus AT, Bound J. Use of census-based
aggregate variables to proxy for socioeconomic
group: evidence from national samples. Am
J Epidemiol. 1998;148(5):475-486. https://
doi.org/10.1093/oxfordjournals.aje.a009673
PMID:9737560

242 Ethnicity & Disease, Volume 31, Number 2, Spring 2021