Familias in accion presentation
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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