**4. Discussion**

We examined the prevalence and clustering of three common health behaviors among Mexican and Puerto Rican men. Our results revealed a high prevalence of smoking (38%), engaging in low levels of physical activity (47%), and particularly low consumption of fruits and vegetables (93%) among all participants. Among all participants, almost half (47%) engaged in two health risk behaviors while 30% engaged in one health risk behavior and 18% in all three health risk behaviors; only 5% did not engage in any health risk behavior. We also found differences based on Latino background. Specifically, fewer Puerto Rican (43%) relative to Mexican (52%) men engaged in low physical activity, although this difference was not significant. Lastly, more Puerto Ricans (51%) reported engaging in two health risk behaviors than Mexicans (43%); this difference, however, was not statistically significant.

These results align with the findings of previous studies. For example, the results of the HCHS/SOL revealed that the smoking rates were the highest (35.0%) among men of Puerto Rican descent compared to men of other Hispanic/Latino backgrounds [18]. Similarly, data from the Centers for Disease Control and Prevention demonstrated that between the periods of 2002–2005 and 2010–2013, the prevalence rates of smoking were the highest among Puerto Rican men (33.9%) compared to men of other Hispanic/Latino subgroups (22.5–27.6%), non-Hispanic White men (28.1%), and non-Hispanic Black men (31.7%) [42]. In addition, data from the HCHS/SOL showed that almost 50% of the men in the study engaged in less than 150 min per week of moderate to vigorous physical activity, with men of Puerto Rican descent having more minutes per day of moderate to vigorous physical activity, as assessed by an accelerometer, than men of other Hispanic/Latino backgrounds [29]. The previous studies have shown that Hispanics/Latinos do not meet the national recommendation for the consumption of fruits and vegetables [40,43,44], and the results of the HCHS/SOL revealed that individuals of Puerto Rican descent tend to eat less fruit and vegetables than other Hispanics/Latinos [45]. Overall, our findings provide further evidence of the high prevalence of smoking, physical inactivity, and low fruit and vegetable consumption among Mexican and Puerto Rican men.

Few studies have examined the prevalence of multiple risk behaviors among Latinxs; however, the few that have done so indicate that Hispanics/Latinos tend to engage in at least two risk health behaviors simultaneously [1,7]. In our study, almost half of all participants—and half of all Puerto Ricans—engaged in two health risk behaviors. These findings are somewhat similar to those of Daviglus et al. [1], which found that about

half of all Hispanic/Latino men had at least two cardiovascular disease risk factors. Although Berrigan et al. [7] assessed adherence to recommendations rather than health risk factors, they found that the most common pattern among all participants, including non-Hispanic Blacks, non-Hispanic Whites, and Mexican Americans, involved non-adherence to health behavior recommendations regarding physical activity, fat intake, or fruit and vegetable consumption.

We also identified specific clusters of health risk behaviors. For instance, Latino men, in general, who did not engage in "regular" physical activity (i.e., 30 min or more of physical activity per day for at least four days per week) were more likely to consume <5 fruits and vegetables per day. The most common health risk behavior cluster in Puerto Rican men was engaging in smoking cigarettes and consuming <5 servings/day of fruits and vegetables (28%), whereas the most common health risk behavior cluster among Mexican men was engaging in low physical activity and consuming <5 servings/day of fruits and vegetables (33%). Furthermore, in Puerto Rican men, smoking was associated with less fruit and vegetables intake per day. These risk clusters were also verified through multivariate modelling.

To our knowledge, no study to date has examined health behavior clustering exclusively among Latinxs. The only study that included Latinxs in their sample—albeit only Mexican Americans—produced similar findings to ours, with clusters of adherence to recommendations for alcohol and tobacco but non-adherence to recommendations for physical activity, dietary fat intake, and fruit and vegetable consumption [7]. In the HCHS/SOL, the most common patterns of any two cardiovascular disease risk factors were hypercholesterolemia and obesity followed by hypercholesterolemia and smoking among Hispanics/Latinos of a Puerto Rican background; and hypercholesterolemia and obesity followed by hypercholesterolemia and hypertension among Hispanics/Latinos of Mexican descent [1]. Those patterns are roughly consistent with the patterns found in the current study, wherein smoking was more prevalent among Puerto Ricans and physical inactivity among Mexicans. Daviglus et al. [1], however, did not examine the clustering of health behaviors.

The awareness of health risk behaviors among Latino men has implications for health and health promotion. The low levels of physical activity and high prevalence of smoking coupled with low intake of fruits and vegetables are major risk factors for morbidity and mortality [3,46]. Conversely, higher consumption of fruits and vegetables along with nuts and whole grains has been associated with lower cardiovascular disease-related morbidity and mortality in men [47]. Hence, our findings underscore the need for interventions that target multiple health risk behaviors simultaneously. Although interventions that target multiple co-existing health risk behaviors are needed and are believed to have the potential for a greater public health impact [48], they are scant among Latinxs. Their scarcity may be due to lack of research on behavior clusters in this population. Our findings may provide a starting point for such interventions. The differences in behavior clusters between Mexican and Puerto Rican men identified in this study, for instance, may aid in tailoring interventions to the specific needs of these groups, thereby increasing their effectiveness.

A few limitations must be borne in mind. First, in this secondary data analyses, measures for physical activity, smoking, and fruit and vegetable intake were cross-sectional and self-reported. Indeed, past studies on physical activity have yielded conflicting results when using self-reported versus accelerometer data (e.g., [20,22]). In addition, twenty four hour food recalls and food diaries are more effective methods to obtain accurate measurements of fruit and vegetable intake [49]. Second, our study was limited to Mexican and Puerto Rican men from the Chicagoland area, which limits the generalizability to other Latinx subgroups and Mexicans and Puerto Ricans in other cities. At least one study has found differences in health risk behaviors between Mexicans and Puerto Ricans and their counterparts in different cities across the U.S. [18]. Future studies should address these limitations by using objective methods across multiple time points.

These limitations notwithstanding, our study had a number of strengths. The most important strength of this study is its focus on a greatly underserved and understudied group, namely Latino men, and particularly Mexican and Puerto Rican men—the two largest Hispanic/Latino ethnic groups in the U.S. [11]. This is important not only because of the scant research on this group and its large population size, but also because of the high rates of engagement in health risk behaviors and high prevalence of overweight and obesity. A second strength is the focus of the current study on the differences between Latino subgroups. Few studies outside of the HCHS/SOL have examined differences between Latinx subgroups, despite the glaring variations in health behaviors and disparities in health outcomes.
