Hypertension among Hispanics Carlos J. Crespo, DrPH, FACSM

Portland State University

School of Community Health

Hypertension among Hispanics Carlos J. Crespo, FACSM

Portland State University

Major Points:

1. Heterogeneity of Blood Pressure Control in Hispanic Population.

2. Lifestyle and Environmental determinants of high blood pressure control among Hispanics.

3. Recommendations to eliminate disparities and improve hypertension control rates.

Population and Clinical Approaches

to Health

Problem Response

Surveillance: What is the

problem?

Risk Factor Identification: What is the

cause?

Intervention Evaluation:

What works?

Implementation: How do you

do it?

Race/Ethnicity in the US, per OMB

•  Ethnicity: –  Hispanics-can be of any race

•  Race: –  Whites –  Blacks –  Asian/Pacific Islanders –  American Indians or Native

Alaskans

Who are Hispanics

•  Mexican Americans •  Puerto Ricans – mainland and island •  Cuban Americans •  Other Caribbean – e.g., Dominican Rep, •  Central Americans •  South Americans •  Spain

Percent Distribution of Hispanics Subgroups

Mexican66%

Puerto Rican

9%

Cuban4%

Central and South American

15%

Other6%

Distribution of Hispanic Subgroups, 2006

Type of origin Number Percent Total 44,252,278 100.0 Mexican 28,339,354 64.0 Puerto Rican* 3,987,947 9.0 Cuban 1,520,276 3.4 Dominican 1,217,225 2.8 Central American 3,372,090 7.6 South American 2,421,297 5.5 Other Hispanic 3,394,089 7.7

Population growth of Hispanics in US

9.6 14.622.4

35.347.8

59.773

87.6102.6

0

20

40

60

80

100

120

1970 1980 1990 2000 2010* 2020* 2030* 2040* 2050*

Hispanics as Percent of US Population

4.7 6.49

12.515.5

17.820.1

22.324.4

0

5

10

15

20

25

30

1970 1980 1990 2000 2010* 2020* 2030* 2040* 2050*

15 10 5 0 5 10 15

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

15 10 5 0 5 10 15

Male Female Female Male

Hispanic Non-Hispanic

White

Source: Current Population Survey, March 2000, PGP-4

age

Top Five States by Hispanic Population Size: 2006

Rank State Population

Size 1 California 13,074,156

2 Texas 8,385,139

3 Florida 3,646,499 4 New York 3,139,456

5 Illinois 1,886,933

Top Five County by Hispanic Population, 2006

Rank County Population Size

1 Los Angeles County, CA 4,706,994

2 Harris County, TX 1,484,311

3 Miami-Dade County, FL 1,471,709

4 Cook County, IL 1,200,957

5 Maricopa County, AZ 1,129,556

The Latino Paradox in Los Angeles

Source: Glenn Braunstein, MD Cedars-Sinai Medical Center Accessed at www.Huffingtonpost.com on , Oct 4, 2010

•  Los Angeles is the healthiest it's been since the late 1990s. The county's death rate dropped 22 percent from 1998 to 2007.

•  Latinos had fewer deaths than blacks - despite comparable levels of income and access to health insurance. They also enjoyed lower mortality rates than non-Hispanic whites.

•  Life expectancy among Latinos is 84.4 years - four years longer than the county average.

Leading Causes of Death among Hispanics, 2004

Homicide

Heart Disease

NeoplasmAccidents

Stroke

Diabetes mellitus

Liver and Cirrhosis

Lower Respiratory

Influenza

Perinatal

0 5 10 15 20 25

Figure 1. Heart disease death rates, 1996-2000. Hispanic ages 35 years and older by county.

Death Rate due to Heart Disease by Race/Ethnicity, 2006

250.0

160.9175.2

118.9

320.6

212.5

136.3

87.3

170.2

113.2

Men Women

White, Non-

Hispanic

Hispanic African American

Asian and Pacific

Islander

American Indian/ Alaska Native

White, Non-

Hispanic

Hispanic African American

Asian and Pacific

Islander

American Indian/ Alaska Native

NOTES: Rates are age-adjusted. DATA: Centers for Disease Control and Prevention/National Center for Health Statistics, National Vital Statistics System. SOURCE: Health US, 2009 Table 32.

Deaths per 100,000 population:

Disparities, Inequalities or Inequities

•  Health Disparities= as differences in the occurrence, frequency, death, and burden of diseases and other unfavorable health conditions that exist among specific population groups, including racial and ethnic minority groups.

Determinants of Health Disparities •  Natural, biological variation; •  Freely chosen health damaging

behavior; •  Transient health advantage of one over

another (first adopters of health promoting behavior);

•  Health damaging behavior where the degree of lifestyle choices is severely restricted;

•  Exposure to unhealthy, stressful living and working conditions;

•  Inadequate access to essential health and other basic services;

•  Natural selection (health related mobility) Sick people have less social advancement

Inequalities

Inequities

CHD mortality among Hispanic subgroups in the US, 1994

0

50

100

150

200

Total Men Women

All races Hispanics Mexican AmericansPuerto Ricans Cuban Americans

Source: CDC/NCHS, Healthy People 2000 Hispanic Progress Review, 1997 (all States except Oklahoma).

Stroke mortality among Hispanic subgroups in the US, 1994

0

10

20

30

40

Total Men Women

All races Hispanics Mexican AmericansPuerto Ricans Cuban Americans

Diabetes-related mortality among Hispanic subgroups in the US, 1994

0

20

40

60

80

Total Men Women

All races Hispanics Mexican AmericansPuerto Ricans Cuban Americans

Age adjusted (per 100,000 pop) hypertension-related mortality and percent change among US adults aged 25+ yrs, 1995-2002

Source: CDC, MMWR, 2006; 55(07):177-80

020406080100120140160180

Mexican-American

MainlandPuerto Rican

Cuban-American

OtherHispanics

White, non-Hispanic

1995 2002

+30.7

-5.2

+46.1

+26.5

-3.7

Hispanic, Race and Hypertension

•  Dark-skinned Puerto Rican men: Higher prevalence of left ventricular hypertrophy & higher systolic blood pressure than their light skinned counterparts

•  Wide Pulse Pressure as an independent risk factor for CVD mortality in Puerto Rican Men.

Sorlie P, Garcia Palmieri MR, et al.,1988, Am Heart J, 116:777-83 Garcia Palmieri MR, Crespo et al., 2005, Nutr Met CVD, 15: 71-8

Risk Factors for

Coronary Heart Disease

Modifiable •  High Blood Pressure •  Dyslipidemia •  Tobacco smoke •  Physical Inactivity •  Diabetes •  Obesity and overweight •  GFR<60mL/min •  Microalbuminuria

Non-modifiable •  Age •  Family history •  Sex

Source: JNC VII

Hypertension

Blood Pressure Classification, JNC VII

Blood Pressure Classification

SBP, mmHg

DBP, mmHg

Normal < 120 <80 Pre-hypertension 120-139 80-89 Stage 1 Hypertension 140-159 90-99 Stage 2 Hypertension 160+ 100+

Definitions

•  Hypertension >=140/90 or currently taking medication to lower high blood pressure

•  Undiagnosed hypertension: A finding of HBP but never told by health care provider that blood pressure was high

•  Treatment: Taking Rx to lower blood pressure •  Controlled: BP<=140/90 •  Treated-uncontrolled: Taking Rx but BP>=140/90 •  Resistant hypertension: failure to achieve goal BP after

full doses of 3-drug regimen, including diuretic •  Pulse Pressure = SBP-DBP

Source: JNC VII

0

5

10

15

20

25

30

35

40

45

Age-adjusted Prevalence of Hypertension among US Adults 20+ yrs, NHANES 1999-2000

Total

Black, Not Hispanic

Mexican American

White, Not Hispanic

Age

-adj

uste

d pe

rcen

t

Age Adjusted Prevalence of Hypertension in US, NHANES 1999-2006

30.5 29.1

42.5

26.1

0

10

20

30

40

50

Total Non-HispanicWhite

Non-HispanicBlack

MexicanAmerican

Prevalence, %

Source: NCHS Data Brief, No. 26, April, 2010

0

20

40

60

Age Adjusted Prevalence of Controlled Hypertension in US Adults 18+ yrs, NHANES, 1999-2000

Total

Age

-adj

uste

d pe

rcen

t

Black, Not Hispanic

Mexican American

White, Not Hispanic

Age Adjusted Prevalence of Taking Action to Help Control Hypertension in US Adults 18+ yrs, NHIS, 1998

0

20

40

60

80

100

Total

Black, Not Hispanic

Hispanic

Asian or Pacific Islander White, Not

Hispanic

Age

-adj

uste

d pe

rcen

t

Percent of Adults 18+ yrs who Know if Blood Pressure is High or Low, NHIS, 1998

0

20

40

60

80

100

Total

Age

-adj

uste

d pe

rcen

t

Environmental Determinants of High Blood Pressure

Lifestyle Approaches to Control Blood Pressure

Source: JNC VII

Lifestyle Modification Recommendation

Range mmHg

Weight reduction BMI=18.5-24.9 5-10/10kg

Physical Activity 30 min/d 4-9

DASH eating plan F/V/low fat dairy 8-14

Sodium reduction <=2.4 g Na 2-8

Moderate alcohol 1-2 d/day (F/M) 2-4

Inadequate Blood Pressure Control

Source: JNC VII

•  Failure to prescribe lifestyle modification

•  Inadequate antihypertensive drug doses

•  Inappropriate drug combination

Triple Aims of Health Reform

Improve Population Health

Quality Patient Care Contain Cost

Environmental Determinants of High Blood Pressure

Source: JNC VII

Lifestyle Modification Determinants

Impact on Hispanics

Weight reduction Positive energy balance ✔

Physical Activity Built environment ✔

DASH eating plan Access to quality foods ✔

Sodium reduction Market forces ✔

Moderate alcohol Market forces ✔

Health=the science of human adaptation

The Economist, 2004

Our Evolution... America, as a whole,

has successfully achieved a high level of productivity, producing abundant food, effective medical treatment, and labor saving technology...

Our Problem ...Yet, this success has

produced unintended consequences that make it difficult for many individuals to maintain a healthy lifestyle

Leading Health Indicators for US

•  Physical Activity •  Overweight/Obesity •  Tobacco use •  Substance abuse •  Responsible sexual

behavior

•  Mental health •  Injury and violence •  Environmental quality •  Immunization •  Access to health care

Source: Healthy People 2010 (467 objectives in 28 focus areas)

Our advancing environment 14

Leading Health Indicators for US

•  Physical Activity •  Overweight/Obesity •  Tobacco use •  Substance abuse •  Responsible sexual

behavior

•  Mental health •  Injury and violence •  Environmental quality •  Immunization •  Access to health care

Source: Healthy People 2010 (467 objectives in 28 focus areas)

Palatable, low-cost,

easily available foods

EIn EOut

Body Fat

Mass ↓ Work-related physical activity

↓ Activity of daily living

↑ Sedendary behavior

High Fat, energy dense

foods

Large Portion Sizes

Age-specific prevalence of obesity among boys in the US, 1999-2000

0

5

10

15

20

25

30

2-5 yrs 6-11 yrs 12-19 yrs

Whites Blacks Mexican Americans

Source: Ogden et al., JAMA, 288;1728-32. NHANES, 1999-2000

Age-specific prevalence of obesity among girls in the US, 1999-2000

0

5

10

15

20

25

30

2-5 yrs 6-11 yrs 12-19 yrs

Whites Blacks Mexican Americans

Source: Ogden et al., JAMA, 288;1732 NHANES 1999-2000,

Percent of 17-20 year old not eligible for military services due to excess body weight

0

10

20

30

40

50

60

Army Navy AirForce

Marines Army Navy AirForce

Marines

Non-Hispanic White Mexican American

Source: Nolte, Franckowiak, Crespo et al., Am J Med. 2002;114:486-90

Men Women

Spending in fast-food restaurants per person $0 $100 $200 $300 $400 $500 $600

US

Japan

Britain

Italy

Germany

France

Spain

1995 1999

Change Isn’t Easy

Childhood poverty

Educational achievement

Family function

cognitive and emotional

development

Access to health care

employment

Exposure to toxins, allergens, & infections

Cognitive stimulation

Access to social networks stress

Health

behavior

Intrauterine effects

Peer effects

• Adult poverty

Racism segregation

Community decline

Marriage

Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2003, 2005, 2007), NCCDPHP, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.

24.2 24.4 24.1 24.4 23.6 24.3 24.7

0

5

10

15

20

25

30

35

1994 1996 1998 2000 2003 2005 2007

Year

Pre

vale

nce

(%)

Trends in Consumption of Five or More Servings of Vegetable and Fruit among US Adults 18+ yr 1994-2007

Surgeon General’s Report on Physical Activity and Heath, 1996

•  Major findings: – People who are usually inactive can improve

their health by becoming moderately active on a regular basis

– Physical activity need not be strenuous to achieve health benefits

– Greater health benefits can be achieved by increasing amount (duration, intensity or frequency) of physical activity

Physical Activity is today’s best buy in public health •  Reduces risk of dying prematurely •  Reduces risk of dying from heart disease (and stroke) •  Reduces risk of developing diabetes •  Reduces the risk of developing and lowering high blood

pressure •  Reduces risk of developing certain cancers (colon,

breast) •  Reduces feeling of depression and anxiety •  Helps control weight •  Helps build and maintain healthy bones, muscles and

joints •  Help older adults become stronger and better able to

move about without falling •  Promotes psychological well-being