Latino Health Disparities: A Cultural Paradox?

1. Latino Health Disparities: A Cultural Paradox? Eliseo J. Pérez-Stable, M.D. Professor of Medicine Division of General Internal Medicine Department of Medicine, UCSF October 27, 2005

2. Disparities and Differences • Disparities implies a difference that demonstrates a disadvantage for a group that has been traditionally disenfranchised • Some differences may not be classified as disparities–White men have more CAD • Disadvantaged groups may have better outcomes for leading causes of death–Latinos and Asians

3. Race or Ethnicity? • Racial categories fit geographic origins of humans • Ethnicity refers to self-identity with a national origin or cultural group • Admixture may confound categories • Census uses racial categories and subgroups and Hispanic ethnicity • Self identification = gold standard

4. Social Class and Race/Ethnicity • Race has been a substitute for defining social class in the U.S. • Gradient of health outcomes at all SES levels comparing Blacks and Whites • Education and income are insufficient measuresof social class • Measures of wealth • Generation of social class • Community measures for segregation, safety, inequality, acculturation…

5. TB Rate Ratio by EthnicityDemographics and SES

6. Demographic Changes • 35% of persons in the US did not identify as White in the 2000 census • Immigrant tsunami of the the 20th century may be waning, but… • Spanish is an important language • Birth rates are highest for non-Whites––population growth • California is a minority majority state

7. Chaos

8. Latino Ethnicity • Admixture of major racial categories in Latino America for 500 years– European, Indigenous, and African • Ethnicity refers to self-identity with a group––diversity in US • National background, cultural identity • Genetic component

11. Our History • Americas had 75 million inhabitants in 1500 • By 1600, over 50% were dead • Victims of disease, forced labor, war, …. • The greatest genocide known in history

12. Race and Genetics • More genetic variance within than between racial groups–no genetic basis for race • Race/ethnicity identifies group more likely to share specific alleles • Random coupling will eliminate race––ever? • Interaction with environment–gene expression • Ancestral Informative Markers

13. 21% of SNPs are racially specific 25% of SNPs are Pan Racial 3,899 SNPs in 313 genes in 4 U.S. racial groups Common to: # SNPs Stephens, et al Science 2001

14. 100% 3.0% 90% 15% 80% 70% 52% 24% African 60% Native American 50% European 40% 30% 61% 45% 20% 10% 0% Mexican Puerto Rican American Genetic Origins of Latinos Percent Ancestral Contribution Admixture

15. Latinos in the U.S. • More similarities than differences • Central role of Spanish language • Cultural themes unify • Racial admixture–500 years • Common cultural heritage: • Catholics, Spain, Indigenous

16. Definition of Epidemiologic Paradox • Outcomes are better than expected based on the known or standard predictive risk factors • Low SES does not always translate to worse outcomes

17. % LBW Rates by Ethnicity Fuentes-Afflick E and Lurie P, Arch Pediatr Adolesc Med 1997

18. Death Rate by Ethnicity, US 2000 W B L A/PI Heart Disease 130 191 89 72 Stroke 25 44 20 24 Diabetes 12 29 19 9 • Age-adjusted per 100,000 NCHS

19. Latinos % Heart Disease 23.9 Cancer 19.7 Injury 8.4 Stroke 5.7 Diabetes 5.0 Homicide 2.9 Liver Disease 2.9 Whites % Heart Disease 29.7 Cancer 23.3 Stroke 6.8 COPD+ 5.6 Injury 3.9 Flu/pneumonia 2.6 Diabetes 2.6 Causes of Death, US 2001

20. NHANES Self-Reported Rates of CV Outcomes 1999-2000

21. Average Annual Rates per Million 50 40.9 40.75 40 30 15 20 11.3 10 0 Mexican White African Puerto Rican American U.S. Asthma Mortality 1990-1995 Homa et al. 2000

22. Adverse Demographic Profile for Latinos • Less household income on average • About 30% live in poverty and have less wealth at every level of income • Fewer average years of education and proportion of college graduates • Fewer than half of Latinos 25 years or older completed high school compared with 77% of Whites • More single-parent households

23. Proportions (Premature Mortality) Determinants of Health Social15% • Genetic • Behavioral • Environmental • Social Setting • Health care Genetic 30% Environment5% Health care 10% Behavior 40% Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.

24. Adverse Social and Access Factors • Lower functional health literacy • Limited English proficiency–25% • Lowest health insurance coverage– 40% between 18-64 y are uninsured • Mexicans have the lowest insurance coverage of any national origin group • Less access to primary care MD • Twice as likely to report using ER as primary source of care

25. Access to Markets with Healthy Foods for Diabetics in New York • Food targets: Fruit, vegetables, 1% fat milk, diet drinks, high fiber bread • 173 stores in East Harlem and 152 stores in Upper East Side • Had all 5 categories: 9% vs. 48% • More likely to live on a block with no store selling foods in E Harlem–50% vs. 24% • Example of disparities in environmental justice issues complicating behavior AJPH 2004; 94: 1549-54

26. Diabetes, Hypertension and Cigarette Smoking Do these risk factors or conditions explain the paradox?

27. Diabetes Prevalence in Latinos • NHANES III: 20% Mexican Americans vs. 11% Whites have DM • Increase of 20% to 35% in 15 years • Undiagnosed diabetes 4% • Up to half of Latinos unaware of DM • 95% of diabetes is type 2 • Prevalence in Puerto Ricans similar

28. Disparities in Diabetes Treatment and Outcomes • CDC report--compared to Whites, Latinos were less likely to have: • Dilated eye exam(56% vs. 60%) • Foot exam (47% vs. 56%) • A1C test (18% vs. 27%) • Latinos have more LE amputations • Mexican Am have more retinopathy • More proteinuria and ESRD

29. Hispanic HANES, 1982-1984:Hypertension Prevalence Men Women Mexican Am 23% 20% Puerto Rican 20% 18% Cuban American 21% 14% =

30. NHANES III Hypertension Rate Men Women Total Mexican Am 23% 22% 23% African Am 34% 31% 32% White 25% 21% 23% Burt Hypertension 1995; 25:305

31. NHANES Hypertension Rate Men Women Total Mex Am 88-94 23% 22% 23% 99-00 27% 30% 29% White 88-94 25% 21% 23% 99-00 28% 29% 29%

32. Hypertension Control in Latinos - Have We Made Any Progress? • HHANES 1982-84 20% controlled at <140/90 • HHANES 1988-1992 24% controlled • San Antonio and Laredo Fewer aware, treated and controlled • South Bronx 23% Puerto Ricans controlled • Less knowledge about CAD prevention

33. Hypertension Awareness and Control, 1999-2000 • Awareness: 58% Mex Am vs. 68% Whites • Only 50% of Mex Am men were aware • Similar awareness among women • Treatment rates lower: 39% vs. 59% • Control among those treated: 40% vs. 54% • Only 33% of Mex Am men at goal • +60 y more aware, treated, less control • Slow improvements in 1990s

34. Behavioral Factors • Less cigarette smoking • More alcohol consumed - men • Nutritional habits less healthy • Less physical activity - women • More violence - DV plus • Less adherence to medications

35. Cigarette Smoking in the U.S. – 2002National Health Interview Survey

36. Biochemical Smokers in Mexican American Latinos • Underreporting occurred in up to 25% of Mexican American smokers • Former smokers misclassified - 11% • Never smokers misclassified in 4% • 12.1% of smokers had non-smoker cotinine levels • Cotinine measure may be better

37. Ethnic Differences in Serum Cotinine Levels: NHANES 3 > 1 5 ng /ml ≤ 1 5 ng /ml p e r c e n t p e r c e n t A f r ic an A ms s m o k e r 9 6 4 non - s m o k e r 2 9 8 W hi t e s s m o k e r 9 4 6 non - s m o k e r 2 9 8 M e x ic an A ms s m o k e r 7 2 2 8 non - s m o k e r 1 9 9 J A MA 19 9 8;28 0 :13 5 -13 9

38. Nicotine Metabolism in Blacks, Whites, Chinese and Latinos • Metabolic clearance of nicotine & cotinine in Latinos was similar to Whites, higher among Blacks and lower among Chinese • Intake of nicotine(mg) per cigarette: • Chinese: 0.73 • Latinos: 1.05 • Whites 1.10 • Blacks 1.41 • Nicotine intake = tobacco smoke

39. Latino Paradox in CV Disease? • Prevalence of smoking is lower • Hypertension and lipids similar • Obesity more common • Physical inactivity more common • Less BP & DM awareness and control • Diabetes rate is 2-4 times • Lower SES by income, education • Fewer heart attacks • Fewer procedures to treat CAD

40. CHD Prediction Scores By EthnicityColor in Framingham? • Applied sex specific CHD functions to 6 ethnically diverse cohorts • White and Black men and women prediction of CHD events works well • Japanese & Latino men and American Indian men & women–risk is overestimated • Adjust for different rates of risk factors and underlying rate of CHD • JAMA 2001; 286:180-7

41. Is culture a protective factor? • Lower heart disease mortality rates despite higher or similar prevalence of cardiovascular risk • Unidentified factors that are protective against chronic diseases • More social support through community or social networks? • Genetic factors?

42. Proposed Explanations of Paradox • Healthy immigrant effect • Salmon hypothesis–return to die at home and deaths not recorded • Misclassification of ethnicity in diagnosis and deaths––Latinos misclassified as Whites • Census undercounts (increase)

43. What About Acculturation?

44. Role of Acculturation? • NHANES III: Mexican Americans born in the US and speaking Spanish have higher adjusted SBP than English speaking counter parts - 123.9 vs. 121.5 mm Hg • US born Spanish speaking was significant in logistic regression models for men and women for SBP, BMI and current smoking • Bicultural Latinos at highest risk? Sundquist, AJPH 1999; 89:723

45. Are Latina Women at Higher Risk? • Women 25 to 64 years showed adjusted SBP higher for Mexican Americans in HANES III • SBP was intermediate between Whites and African Americans • Not observed for women 18 to 24 years of any ethnic group

46. Sacramento Area Latino Study on Aging: Cohort Study Study Population • 1,789 Latinos aged 60+, Mexican ancestry (85%) • Mean age at baseline: 71 (60-101); 58% women • 51% born in Mexico or another Latin American country and were Spanish speaking • Baseline: 1998-99 & 4 –year follow up In home clinical evaluations and interview • Cultural orientation assessed by the Cuellar scale • language, contact with own ethnic group vs. others, celebration of traditions (0-30 pts) higher score higher Anglo orientation • Cognition (3MS) Haan, M, SCAIA (2005)

47. Anglo cultural orientation Protective of Cognitive Decline Incidence of Alzheimer’s Disease was 15.4% in Mexican born and 12.4% in US born • Hazard of cognitive decline per point on cultural scale HR=0.98 95% CI (0.96-0.99) • 1 point increase means higher Anglo cultural orientation • Adjusted for age and gender, baseline diabetes and stroke

48. Risk of dementia associated with combined income and education in study participants Adjusted for age, type 2 diabetes, stroke, gender, cultural orientation

49. Cancer

50. Cancer Incidence by Site and Ethnicity in Men, U.S. 2000(per 100,000 age-adjusted)