August 26, 2005 University of Iowa

1
August 26, 2005University of Iowa

• The Health of Hispanics in the United States
  with Special Focus on Older People
• Kyriakos S. Markides, Ph.D.
• University of Texas Medical Branch
• Galveston, Texas, USA

2
U.S. Hispanic Population Growth, 19402003
Millions
Source U.S. Bureau of the Census
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Hispanics as of U.S. Population
Source U.S. Bureau of the Census
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FIGURE 1.
Hispanics by Origin 2002
(In percent)
Mexican American 66.9
Central and
South American 14.3
Puerto Rican 8.6
Cuban 3.7
Other Hispanic 6.5
Source U.S. Census Bureau, Annual Demographic
Supplement to the March 2002 Current Population
Survey.
(Adapted from U.S. Bureau of the Census, 2003)
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POPULATION PROJECTIONS TO 2050

• Non-Hispanic Whites 210 million
• Hispanics 103 million (25)
• African Americans (Blacks) 61 million
• Asian Origin 33 million

Source U.S. Bureau of the Census (2004)
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An Epidemiologic Paradox

• Risk factor profiles
• High rates of DIABETES
• High rates of obesity
• Similar rates of hypertension, cholesterol
• High SMOKING rates among men, lower among women
  (fewer cigarettes). Cuban American males smoke
  the most
• High ALCOHOL (binge) drinking rates among men,
  low among women. Alcohol consumption in women
  increases with acculturation
• Low rates of physical ACTIVITY
• Strong families
• Migration selection

• Hispanics (except Cuban Americans) are
  socioeconomically disadvantaged, but have
  favorable overall mortality
• Markides and Coreil (1986)

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Aging, Migration and Mortality Current Status of
Research on the Hispanic Mortality Paradox

• Data based on Vital Statistics show the greatest
  mortality advantage compared to Non-Hispanic
  Whites for all Hispanics combined. The advantage
  is greatest among older people.
• National Community Surveys linked to the National
  Death Index show a narrowing of the advantage and
  one study suggests that the Mexican origin
  mortality advantage (Palloni Arias, 2004) can
  be attributed to selective return migration of
  less healthy immigrants to Mexico.
• The Medicare NUDIMENT data show a much lower
  advantage of Hispanic elders than the Vital
  Statistics Method.
• Markides Eschbach, J. Geront Social Sciences
  (in press)

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A LONGITUDINAL STUDY OF THE HEALTH OF MEXICAN
AMERICAN ELDERLY 1992-2008 FUNDED BY
NIA(HISPANIC EPESE)

• UTMB, GALVESTON, TX
• PI, Kyriakos S. Markides,Ph.D.
• CO-INVESTIGATORS
• James S. Goodwin, MD.
• Kenneth Ottenbacher, Ph.D.
• M. Kristen Peek, Ph.D.
• Glenn V. Ostir, Ph.D.
• Mukaila Raji, MD.
• Laura Rudkin, Ph.D.
• Karl Eschbach, Ph.D.
• Daniel H. Freeman, Jr., Ph.D -Biostatistician.
• Laura A. Ray, M.P.A. -Project Director
• Soham Al Snih, MD., PhD Research Associate
• Max Otiniano, MD., MPH Research Associate

• NIA STAFF
• Sidney Stahl, Ph.D.
• FIELD STAFF
• Harris Interactive, Inc. (formerly Louis Harris
  and Associates)
• OUTSIDE CONSULTANTS
• Carlos Mendes de Leon, Ph.D.
• Laurence Branch, Ph.D.
• Robert Wallace, MD.
• Dan Blazer, Ph.D.
• Denis Evans, MD.
• Sandra A. Black, Ph.D.
• David Chiriboga, Ph.D.
• Mary Haan, Dr.PH

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Investigators - continued

• UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER,
• SAN ANTONIO, TX
• PI, David V. Espino, MD.
• CO-INVESTIGATORS
• Ray Palmer, Ph.D., Biostatistician
• Donald Royall, MD
• UNIVERSITY OF TEXAS,
• AUSTIN, TX
• PI, Ronald J. Angel, Ph.D.
• CO-INVESTIGATOR
• Jacqueline Angel, Ph.D.

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SAMPLING PROCEDURES
Area probability multi-stage sample of Mexican
Americans aged 65 and over residing in the five
Southwestern states (Texas, New Mexico, Colorado,
Arizona, and California) (Non-institutionalized
population). Data collected during 1993-1994. N
3,050
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Hispanic EPESE Summary Baseline, Wave 2, Wave 3,
Wave 4 and Projected Waves 5 6
Total Proxy Deceased Refused Not Located Age
1993-4 3050 177 65 1995-6
2438 143 236 105 270
67 1998-9 1980 145 424 120
289 70 2000-1 1683 101
280 131 297 72 2004-5
1158 91 392 86
155 75 Added Sample 2005 758(of 1000)
45 0 0 na 75
Both samples combined 2006 1500
300 ? ? ? 77
Cumulative deceased940 at end of 4th wave
Included in Total Currently in the field.
Status as 10/06/05
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SELECTED SAMPLE CHARACTERISTICSN3,050 (1993-94)
AGE RANGE 65-99 MEAN 73.0 yrs.
MARITAL STATUS MARRIED 55.3
DIV/SEP 7.9 WIDOWED
31.6 NEVER MARRIED 5.3
GENDER MALE 43.3 FEMALE 56.7
LIVING ARRANGEMENTS ALONE 20.9
2 PERSONS 41.0 3 PERSONS 15.3
4 PERSONS 22.8
YEARS of SCHOOL MEAN 5.1 yrs.
PLACE OF BIRTH MEXICO 46.8 U.S.A.
53.2
Continued on next slide
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SELECTED SAMPLE CHARACTERISTICS
CONTINUED
HOUSEHOLD INCOME 0- 4,999 13.2
5,000- 9,999 37.7 10,000-14,999
25.8 15,000-19,999 11.7 20,000-29,999
6.2 30,000 5.4
SPEAKS ENGLISH NOT AT ALL 30.1
NOT TOO WELL 27.0 PRETTY WELL
17.0 VERY WELL 24.6
SOURCES OF INCOME SOCIAL SECURITY 96.1
PRIVATE PENSION 17.1 SSI
25.4 CHILDREN
7.0 RENT/STOCKS/ BONDS, ETC.
4.4
HEALTH INSURANCE MEDICARE 87.4 (92)
MEDICAID 34.1 PRIVATE 23.5
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PERCENT REPORTING SELECTED CHRONIC CONDITIONS by
AGE and GENDER
65-74 75 (n 863) (n 431) 34.5
31.4 28.4 28.2 25.0 17.6 19.2 22.9
5.9 6.7 4.4 6.7 1.6 3.5
MALES
HYPERTENSION ARTHRITIS DIABETES HEART
DISEASE STROKE CANCER HIP FRACTURE
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PERCENT REPORTING SELECTED CHRONIC CONDITIONS by
AGE and GENDER
continued
65-74 75 (n1139) (n 615) 45.6
49.3 47.3 50.5 24.6 19.5 21.9 23.2
3.5 9.8 4.7 6.7 2.4 7.5
FEMALES
HYPERTENSION ARTHRITIS DIABETES HEART
DISEASE STROKE CANCER HIP FRACTURE
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Percent of Persons 65 and Over Who Report
Difficulty Performing Selected Activities of
Daily Living by Ethnicity
Whites (n24,753)
Non-Whites (n2,784)
Mexican Americans (n3,050)
Note Data on Whites and Non-Whites are from the
1986 National Health Survey (NCHS, 1993). Data
on Mexican Americans are from the 1993-94
Hispanic EPESE.
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Changes in Blood Pressure and Risk Factors for
Cardiovascular Disease among Older Mexican
Americans from 1982-1984 to 1993-1994
Stroup-Benham, C.A., Markides, K.S., Espino, D.V.
Goodwin, J. S.

• Prevalence of obesity and diabetes rose
  significantly
• Mean diastolic pressure increased significantly

Journal of the American Geriatric Society, 1999
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Depression Predicts Increased Incidence of
Adverse Health Outcomes in Older Mexican
Americans with Type 2 DiabetesBlack, S.A.,
Markides, K.S, Ray, L.A.

• Depression exacerbates effect of diabetes on
  complications, disability, mortality over seven
  years
• Diabetes Care, 2003

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Lower Body Functioning as a Predictor of
Subsequent Disability among Older Mexican
AmericansOstir, G.V., Markides, K.S., Black,
S.A. and Goodwin, J.S.

• Eight foot walk, repeated chair stands, and
  standing balance are strong predictors of the
  development of disability among initially
  non-disabled persons

J. of Gerontology Medical Sciences, 1998
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Lower Body Function and Mortality in Mexican
American Elderly PeopleMarkides, K.S., Black,
S.A., Ostir, G.V., Angel, R.J., Angel, J.A.,
Guralnik, J.M., and Lichtenstein, M.

• Physical performance tests are strong independent
  predictors of mortality over a two-year period
• J. of Gerontology Medical Sciences, 2001

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Handgrip Strength and Mortality in Older Mexican
AmericansAl Snih, S.A., Markides, K.S., Ray,
L.A., Ostir, G.V., and Goodwin, J.S.

• Handgrip strength is an independent predictor of
  mortality over a five year period

Journal of the American Geriatrics Society, 2002
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Emotional Well-Being Predicts Subsequent
Functional Independence and SurvivalOstir,
G.V., Markides, K.S., Black, S.A. and Goodwin,
J.S.

• Independently of depressive symptoms, positive
  affect predicts independence and survival over a
  two-year period

Journal of the American Geriatrics Society, 2000
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Baseline Prevalence of 6 Medical Conditions,
Disability, and 7-Year Mortality by Mexican
Americans Population Share in Local Environments
(Hispanic EPESE)Eschbach, K., Markides, K.S.,
Patel, K., Goodwin, J.S.

• Neighborhood Percentage Mexican American is
  associated with lower prevalence of stroke,
  cancer, hip fracture, and seven-year mortality.

American Journal of Public Health, 2004
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Neighborhood Composition and the Incidence of
Cancer among Hispanics in the United States
Eschbach et al.

• Using SEER and Census data Eschbach et al (2005)
  found that the incidence of breast, colorectal,
  and lung carcinoma among Hispanics increased as
  the percentage of Hispanics in the census tract
  decreased.
• The lower cancer rates among Hispanics relative
  to non-Hispanic Whites may dissipate as Hispanics
  become more assimilated into the mainstream
  society.

Cancer, 2005
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Stage I
Stage II
Stage III
Stage IV
Cognitive
Stressors/Strains
Community
Major Life Events Financial Strain
Function
Context
Physical
Function
Sociodemographic
Mortality
Variables
Social Support
Age, Gender,
Emotional
Social Class,
Function
Acculturation,
Migration History
Medical Conditions
Institutionalization/
Changes in Living
Arrangements
Impairments/Limitations
Sensory, Physical, etc.
Health Service Use/
Access
Figure 1. Conceptual Model
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COLLABORATIONS

• Mexican Health and Aging Study (MHAS)
• Puerto Rican Health Conditions Study (PREHCO)
• SABE Studies (Chile, Mexico, Uruguay, Brazil,
  Cuba, Argentina, Barbados)

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Census Disability Rates among Older People by
Race/Ethnicity and Type of Hispanic Origin

• Kyriakos S. Markides
• Karl Eschbach
• Laura A. Ray
• M. Kristen Peek

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Hypotheses

• Older Hispanics as a group will have greater
  disability rates than older Non-Hispanic Whites,
  rates that are only slightly lower than those for
  African Americans.
• Older Asian and Pacific Islanders will have
  disability rates that are somewhat lower than
  those of older Non-Hispanic Whites.
• Older Native Americans (American Indians and
  Alaska Natives) will have high disability rates
  possibly higher than any other population.

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Hypotheses (continued)

• Among the Hispanic populations, older Puerto
  Ricans will have the highest disability rates
  with older Cubans having the lowest and Mexican
  Americans having intermediate rates.
• It is not clear what rates for older Central
  Americans and older South Americans would be like
  given absence of guidance from existing
  literature. We might hypothesize that since these
  groups are overwhelmingly immigrants, that their
  rates might be somewhat lower than rates for
  Mexican Americans if indeed they are selected
  through migration. Given that men are more likely
  to be selected than women, men will have lower
  disability rates.

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Hypotheses (continued)

• It is also not clear what the rates for Other
  Hispanics might be like. Other Hispanics are a
  heterogeneous mix of Spaniards, Dominicans,
  perhaps some Filipinos, as well as more than a
  few Mexican Americans, Puerto Ricans, and Cubans
  and persons of mixed ancestry who fail to
  identify with a specific Hispanic origin in their
  responses to the Census. Given this mix, we might
  expect them to exhibit average disability rates
  perhaps similar to those for Mexican Americans.
• Among older persons of Mexican origin the
  foreign-born will have lower disability rates
  than the native-born. This is more likely to be
  the case for men than for women.

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Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90.
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Table 1 Age-standardized census disability rates
(percent) by race/ethnicity
for persons 65 over United States Census, 2000
Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90.
33
Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90. Note Hispanic origin persons are recorded
based on ancestry or country of birth, if they
report general Hispanic. All Other includes
U.S. born Hispanics, who report non-specific
identity, and who live in a Southwestern state.
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Table 2. Age-standardized census disability
rates (percent) for persons 65 and over by type
of Hispanic origin United
States Census, 2000
35
Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90.
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Table 3. Age-standardized census disability
rates (percent) for U.S. born and
foreign born men 65 and over by race/ethnicity
United States Census, 2000
Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90.
37
Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90.
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Table 4. Age-standardized census disability
rates (percent) for U.S. born and foreign- born
females 65 and over by race/ethnicity United
States Census, 2000
Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90.
39
Note Hispanic origin persons are recoded to a
specific group based on ancestry or country of
birth, if they report general Hispanic.
Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90.
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Table 5. Age-standardized census disability
rates (percent) for U.S. born and
foreign-born males 65 and over by type of
Hispanic origin United States
Census, 2000.
Note Hispanic origin persons are recoded to a
specific group based on ancestry or country of
birth, if they report general Hispanic. Note
Directly standardized to age 65 population, U.S.
all racial/ethnic groups in 2000, for ages 65-69,
70-74, 75-79, 80-84, 85-89, 90.
41
Note Hispanic origin persons are recoded to a
specific group based on ancestry or country of
birth, if they report general Hispanic.
Note Directly standardized to age 65
population, U.S. all racial/ethnic groups in
2000, for ages 65-69, 70-74, 75-79, 80-84, 85-89,
90.
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Table 6. Age-standardized census disability
rates (percent) for U.S. born and
foreign-born females 65 and over by type of
Hispanic origin United States
Census, 2000.
Note Hispanic origin persons are recoded to a
specific group based on ancestry or country of
birth, if they report general Hispanic. Note
Directly standardized to age 65 population, U.S.
all racial/ethnic groups in 2000, for ages 65-69,
70-74, 75-79, 80-84, 85-89, 90.
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Appendix Table. Unweighted frequency counts for
race and Hispanic origin subjects 65 years-old or
older in the Census 2000 5 percent public-use
micro data file, by gender and immigrant status
For Puerto Ricans, immigrant refers to
persons born in Puerto Rico or abroad.