9
The Health Status and Health Behaviors of Hispanics

José J. Escarce, Leo S. Morales, and Rubén G. Rumbaut

The rapid growth in the Hispanic population, and especially in the number of Hispanic youth, represents one of the most dramatic and important demographic trends affecting the United States. Contemporary working-age Hispanic adults will age to become the first sizable wave of Hispanic seniors. More consequential, the large number of contemporary Hispanic children and adolescents will age to swell the ranks of Hispanic young and middle-aged adults within a decade or two. The health status and health behaviors of today’s Hispanic youth will play a central role in shaping the long-term health and health care needs not only of Hispanics in the United States but also of all Americans.

Efforts to provide a detailed and comprehensive description of the health and health behaviors of Hispanics are complicated by a variety of factors. Hispanics living in the United States represent an increasing diversity of national-origin groups. Relatively new groups, including Dominicans, Salvadorans, Guatemalans, and Colombians, have grown rapidly, adding their numbers to well-established populations of Mexican, Puerto Rican, and Cuban origin. The available information suggests that health status differs across national-origin groups. In addition, the health of U.S. Hispanics differs by generational status. On numerous dimensions, foreign-born Hispanics—i.e., immigrants to the United States—have better health indicators than their U.S.-born counterparts. Among the foreign-born, moreover, health status and health behaviors may differ by degree of acculturation to American culture.

In this context, the gaps in the available data on the health and health



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Hispanics and the Future of America 9 The Health Status and Health Behaviors of Hispanics José J. Escarce, Leo S. Morales, and Rubén G. Rumbaut The rapid growth in the Hispanic population, and especially in the number of Hispanic youth, represents one of the most dramatic and important demographic trends affecting the United States. Contemporary working-age Hispanic adults will age to become the first sizable wave of Hispanic seniors. More consequential, the large number of contemporary Hispanic children and adolescents will age to swell the ranks of Hispanic young and middle-aged adults within a decade or two. The health status and health behaviors of today’s Hispanic youth will play a central role in shaping the long-term health and health care needs not only of Hispanics in the United States but also of all Americans. Efforts to provide a detailed and comprehensive description of the health and health behaviors of Hispanics are complicated by a variety of factors. Hispanics living in the United States represent an increasing diversity of national-origin groups. Relatively new groups, including Dominicans, Salvadorans, Guatemalans, and Colombians, have grown rapidly, adding their numbers to well-established populations of Mexican, Puerto Rican, and Cuban origin. The available information suggests that health status differs across national-origin groups. In addition, the health of U.S. Hispanics differs by generational status. On numerous dimensions, foreign-born Hispanics—i.e., immigrants to the United States—have better health indicators than their U.S.-born counterparts. Among the foreign-born, moreover, health status and health behaviors may differ by degree of acculturation to American culture. In this context, the gaps in the available data on the health and health

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Hispanics and the Future of America behaviors of Hispanics impose serious limitations. One frequent and noteworthy problem is the lack of detailed data for subgroups of Hispanics defined by national origin and generation in the United States. Most studies group Hispanics into a single category or focus on Hispanics of Mexican origin, who are by far the most numerous. Another problem is the relative lack of detailed epidemiological data on the incidence and prevalence of common and important diseases, such as cardiovascular disease. Moreover, for many conditions, data are unavailable to assess incidence or prevalence according to immigrant status or, among the foreign-born, by length of residence in the United States and degree of acculturation. Despite these limitations, researchers have learned a great deal about the health status and health behaviors of Hispanics over the past 25 years. The story that has emerged is a complex one, with some findings that warrant optimism and others that merit serious concern. The picture of both advantage and disadvantage that has surfaced must be appreciated and understood in order to develop interventions and design policies to improve Hispanic health. In this chapter, we provide an overview of the health status and health behaviors of Hispanics in the United States. The chapter is divided into sections, as follows. The next section discusses mortality rates among Hispanics and compares them with rates for non-Hispanic whites and non-Hispanic blacks. This section also illustrates the variation in mortality across Hispanic national-origin groups. The three sections that follow cover, in order, the health status and health behaviors of Hispanic adults, the health status and health behaviors of Hispanic children and adolescents, and birth outcomes. The sixth section discusses the so-called epidemiological paradox, one of the most fascinating findings regarding the health of Hispanics and a source of controversy since it was first described. Finally, we conclude with a summary of our findings and what they mean for the health and health care needs of future generations of Hispanics in the United States. Our objective is not to be comprehensive. Rather, our goal is to summarize research findings that have an especially strong bearing on future trends in Hispanic health. Accordingly, a major portion of the chapter is devoted to reviewing selected aspects of the health and health behaviors of Hispanic children and adolescents. We have chosen today’s Hispanic youth as a major focus because their health has enormous implications for the future health and health care needs of all Americans. MORTALITY As Table 9-1 shows, Hispanics in the United States have lower age-adjusted mortality rates than both non-Hispanic whites and non-Hispanic

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Hispanics and the Future of America TABLE 9-1 Mortality Rates per 100,000 Persons for Non-Hispanic Whites, Non-Hispanic Blacks, and Hispanics, and for Hispanic National-Origin Groups, by Age and Gender, 2001 Males Non-Hispanic Whites Non-Hispanic Blacks All Hispanics Mexicans Puerto Ricans Cubans Other Hispanics All ages, age adjusted 1012.8 1393.7 802.5 779.0 1029.1 — 747.6 Under 1 year 611.6 1484.2 624.4 50.0 — — 865.5 1–4 years 33.8 55.1 33.8 33.7 — — 35.3 5–14 years 18.6 28.6 16.6 16.5 20.3 — 5.8 15–24 years 105.1 186.2 111.5 115.2 127.0 58.6 99.0 25–34 years 131.5 267.9 118.0 111.4 183.4 94.7 122.9 35–44 years 241.6 456.3 208.5 189.0 373.2 199.7 202.2 45–54 years 502.6 1014.6 443.9 396.6 767.3 428.0 440.4 55–64 years 1136.3 2055.4 923.9 882.1 1424.5 1010.4 763.4 65–74 years 2869.4 4218.9 2242.6 2228.9 2671.7 1849.0 2333.0 75–84 years 6851.5 8426.8 5258.0 5262.6 — — — 85 years and over 17055.3 16576.2 12888.3 — — — — Females All ages, age adjusted 713.5 925.5 544.2 536.2 667.6 450.6 649.6 Under 1 year 496.4 1217.8 518.9 490.5 — — 584.0 1–4 years 26.3 43.6 27.2 27.6 — — 27.6 5–14 years 13.9 19.3 12.7 13.4 12.4 — 10.6 15–24 years 41.9 56.8 33.7 32.2 40.7 — 36.1 25–34 years 60.9 122.4 45.2 39.0 80.7 — 49.9 35–44 years 134.9 285.7 97.0 88.9 170.0 100.3 87.2 45–54 years 291.0 591.5 226.7 214.2 317.0 08.7 216.2 55–64 years 723.5 1238.2 543.0 538.3 45.9 427.3 494.4 65–74 years 1864.1 2653.0 1408.0 1550.1 1345.2 1140.9 1274.3 75–84 years 4777.3 5645.1 3589.8 3759.9 — 3047.2 3112.5 85 years and over 14670.6 13951.4 11300.5 9989.8 — — — SOURCE: Arias et al. (2003). blacks (Arias, Anderson, Hsiang-Ching, Murphy, and Kochanek, 2003). In 2001, the age-adjusted death rate for Hispanic men was 802.5 per 100,000 persons, compared with 1012.8 for white men and 1393.7 for black men. The age-adjusted death rate for Hispanic women was 544.2 per 100,000, compared with 713.5 for white women and 925.5 for black women. The mortality advantage of Hispanics in comparison with whites is present

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Hispanics and the Future of America throughout most of the age range, although the advantage grows at older ages. However, Hispanic infants and men ages 15 to 24 have slightly higher death rates than their white counterparts. It is worth noting that vital statistics data may understate mortality for Hispanics due to underidentification of Hispanic ethnicity on death certificates (Rosenberg et al., 1999). We discuss this in greater detail later in the chapter. Mortality rates differ among Hispanic groups defined by national origin (Table 9-1). Men of Mexican origin and other Hispanic men have lower death rates than men of Puerto Rican origin. (An age-adjusted death rate was unavailable for Cuban men.) Women of Cuban origin have the lowest death rates, followed by Puerto Rican and other Hispanic women; women of Mexican origin have the highest death rates. Notably, all Hispanic groups except Puerto Rican men have lower age-adjusted death rates than non-Hispanic whites. For certain national-origin groups, death rates also differ by nativity, with the foreign-born having lower rates than the U.S.-born. The two leading causes of death are heart disease and cancer among Hispanics, non-Hispanic whites, and non-Hispanic blacks (Table 9-2). Beyond the top two causes, however, the leading causes of death differ. In particular, homicide, chronic liver disease and cirrhosis, and conditions originating in the perinatal period are among the 10 leading causes of death for Hispanics, but not for whites. The age-adjusted death rate from homicide among Hispanic men was 11.8 per 100,000 persons in 2000, more than three times the rate of 3.6 for non-Hispanic white men (National Center for Health Statistics, 2003). In fact, homicide is responsible for the higher death rate among Hispanic men ages 15 to 24. Both alcohol use and chronic hepatitis infection contribute to the high death rates from chronic liver disease and cirrhosis among Hispanics (Caetano and Galvan, 2001; Vong and Bell, 2004). The finding that age-adjusted mortality is lower for Hispanics than for non-Hispanic whites, despite the fact that Hispanics have lower socioeconomic status, is at the core of the “epidemiological paradox.” This phenomenon, and its relationship to the finding of a mortality advantage for Hispanic immigrants from certain countries relative to their U.S.-born peers, is discussed in detail later in the chapter. THE HEALTH AND HEALTH BEHAVIORS OF HISPANIC ADULTS We begin with a discussion of the health status and health behaviors of Hispanic adults. We review data on common chronic conditions, including diabetes, hypertension, cardiovascular disease, and cancer; on activity limitations caused by chronic conditions; and on biological risk factors for chronic disease, including lipid levels and obesity. We also summarize the available information concerning mental health as well as relevant research

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Hispanics and the Future of America TABLE 9-2 Leading Causes of Death for Non-Hispanic Whites, Non-Hispanic Blacks, and Hispanics, by Sex, 2000 Racial or Ethnic Groups/Sex/Cause of Death Number of Deaths Non-Hispanic whites Men All causes 1,007,191 Diseases of heart 301,551 Malignant neoplasms 247,403 Cerebrovascular diseases 54,938 Chronic lower respiratory diseases 54,816 Unintentional injuries 53,329 Diabetes mellitus 26,009 Influenza and pneumonia 25,002 Suicide 21,293 Chronic liver disease and cirrhosis 15,002 Nephritis, nephrotic syndrome and nephrosis 14,385 Women All causes 1,064,096 Diseases of heart 320,168 Malignant neoplasms 232,608 Cerebrovascular diseases 89,642 Chronic lower respiratory diseases 58,024 Alzheimer’s disease 32,936 Influenza and pneumonia 32,912 Diabetes mellitus 29,552 Unintentional injuries 29,263 Nephritis, nephrotic syndrome and nephrosis 15,213 Septicemia 14,088 Non-Hispanic blacks Men All causes 145,184 Diseases of heart 36,740 Malignant neoplasms 32,817 Unintentional injuries 8,531 Cerebrovascular diseases 8,026 Homicide 6,482 Human immunodeficiency virus (HIV) disease 5,400 Diabetes mellitus 4,771 Chronic lower respiratory diseases 4,238 Nephritis, nephrotic syndrome and nephrosis 3,074 Influenza and pneumonia 2,915 Women All causes 140,642 Diseases of heart 40,783 Malignant neoplasms 29,128 Cerebrovascular diseases 11,195 Diabetes mellitus 7,250

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Hispanics and the Future of America Racial or Ethnic Groups/Sex/Cause of Death Number of Deaths Nephritis, nephrotic syndrome and nephrosis 3,837 Unintentional injuries 3,746 Chronic lower respiratory diseases 3,369 Septicemia 3,341 Influenza and pneumonia 3,075 HIV disease 2,448 Hispanics Men All causes 60,172 Diseases of heart 13,566 Malignant neoplasms 11,138 Unintentional injuries 6,696 Cerebrovascular diseases 2,865 Diabetes mellitus 2,507 Homicide 2,431 Chronic liver disease and cirrhosis 2,312 Suicide 1,525 HIV disease 1,493 Chronic lower respiratory diseases 1,451 Women All causes 47,082 Diseases of heart 12,253 Malignant neoplasms 10,022 Cerebrovascular diseases 3,322 Diabetes mellitus 2,821 Unintentional injuries 2,134 Influenza and pneumonia 1,322 Chronic lower respiratory diseases 1,238 Certain conditions originating in the perinatal period 951 Chronic liver disease and cirrhosis 875 Nephritis, nephrotic syndrome and nephrosis 841 SOURCE: National Center for Health Statistics (2003). findings on health behaviors, including diet, cigarette smoking, alcohol consumption, and illicit drug use. Our focus on chronic conditions and biological and behavioral risk factors for chronic disease stems from our goal of assessing the dimensions of health status and health behaviors that have the greatest implications for the long-term health of Hispanics in the United States. For comparative purposes, the available data on Hispanics is contrasted principally with non-Hispanic whites and whenever possible among the major Hispanic national-origin groups and between foreign-born and U.S.-born Hispanics. We will also highlight the role of acculturation when the data allow.

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Hispanics and the Future of America Chronic Conditions Diabetes Mellitus The term “diabetes” refers to a group of diseases characterized by abnormal metabolism of glucose (sugar) and elevated blood glucose levels. Diabetes is one of the most common chronic conditions in the United States, and its prevalence is increasing (Harris, 1998). There are two types of diabetes. Type 1 diabetes is caused by an absolute deficiency of insulin and usually begins in childhood or early adulthood. Type 2 diabetes is caused by either reduced or increased insulin secretion coupled with insulin resistance and accounts for 90 to 95 percent of all cases of diabetes. Compared with non-Hispanic whites, Hispanics have higher rates of Type 2 diabetes and other manifestations of abnormal glucose metabolism. For example, using data from the Hispanic Health and Nutrition Examination Survey (HHANES, 1982–1984), Flegal et al. (1991) found that 3.8 percent of Hispanics of Mexican origin who were 20 to 44 years old and 23.9 percent of Hispanics of Mexican origin who were 45 to 74 years old had diabetes, compared with 2.4 percent and 15.8 percent of Hispanics of Cuban origin and 4.1 percent and 26.1 percent of Puerto Ricans, respectively. The prevalence of diabetes for non-Hispanic whites was 1.6 percent for 20- to 44-year-olds and 12.0 percent for 45- to 74-year-olds. Using more recent data from the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994), Harris et al. (1998a) found that the age-adjusted rate of diabetes was 13.8 percent for adults of Mexican origin and 7.3 percent for non-Hispanic white adults. Diabetes prevalence was higher for Mexicans than for non-Hispanic whites throughout the age range. Hispanics of Mexican origin also had higher rates than whites of impaired fasting glucose and impaired glucose tolerance, both of which indicate abnormal glucose metabolism and are frequent precursors of diabetes (Harris et al., 1998a). Complications of diabetes include heart disease, blindness, kidney disease, and peripheral nervous system damage. Studies to assess the risk of developing diabetes complications among Hispanics have yielded conflicting results. For example, Harris et al. (1998b) found that people of Mexican origin with diabetes were more likely than non-Hispanic whites to develop diabetic retinopathy, which can lead to blindness, whereas other investigators have concluded that Hispanics are no different from other ethnic groups with regard to their risk of diabetic complications (Luchsinger, 2001). Notably, Harris et al. (1999) found worse glycemic control (i.e., control of blood sugar levels) among Hispanic adults with Type 2 diabetes compared with non-Hispanic whites. Due to the higher prevalence of diabetes in Hispanics, the burden of

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Hispanics and the Future of America complications attributable to diabetes is greater for Hispanics than for other groups. The health consequences of diabetes for Hispanics are also reflected in data on cause-specific mortality. Thus, in 2000 the age-adjusted rate of death from diabetes for Hispanics was 36.9 per 100,000 people, compared with 21.8 for non-Hispanic whites (National Center for Health Statistics, 2003). The number of years of potential life lost before age 75 per 100,000 people was 215.6 for Hispanics and 150.2 for non-Hispanic whites (National Center for Health Statistics, 2003). (The number of years of potential life lost is calculated by assuming that everyone would live to age 75.) Hypertension Hypertension, or chronic elevation of arterial blood pressure, is a major risk factor for heart disease and stroke. Previous reviews have concluded that the prevalence of hypertension in Hispanics is no greater than among non-Hispanic whites and may be lower (Pérez-Stable, Juarbe, and Moreno, 2001; Ramírez, 1996). However, data from the National Health and Nutrition Examination Surveys suggest that, while rates of hypertension were once lower among Hispanics than among non-Hispanic whites, these rates are now similar. Using the HHANES (1982–1984) and NHANES II (1976–1980), Pappas, Gergen, and Carroll (1990) found lower age-adjusted rates of hypertension among Hispanic adults who were younger than 75 years old than among non-Hispanic whites. Specifically, age-adjusted rates of hypertension were 22.9 percent, 19.7 percent, and 20.5 percent for men of Mexican, Puerto Rican, and Cuban origin, respectively, compared with 32.6 percent for non-Hispanic white men. Similarly, age-adjusted rates of hypertension were 19.7 percent, 18.0 percent, and 13.8 percent for Mexican, Puerto Rican, and Cuban women compared with 25.3 percent for non-Hispanic white women. By contrast, NHANES III (1988–1994) and NHANES IV (1999–2000) found similar rates of hypertension among people of Mexican origin and non-Hispanic whites. The most recent data from NHANES IV found age-adjusted rates of hypertension of 30.6 percent and 25.0 percent, respectively, for adult men and women of Mexican origin who were less than 75 years old. The corresponding rates for non-Hispanic white men and women were 28.8 percent and 24.5 percent, respectively (National Center for Health Statistics, 2003). Hypertension is also common among elderly Hispanics. For example, analyses of the 1994 Hispanic Established Populations for the Epidemiologic Study of the Elderly investigation found that 61 percent seniors of Mexican origin had hypertension (Stroup-Benham, Markides, Espino, and Goodwin, 1999). The growing prevalence of hypertension in Hispanics—especially Hispan-

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Hispanics and the Future of America ics of Mexican origin—could be due to the obesity epidemic that disproportionately affects this population, as we discuss later in the chapter. Several studies have documented undertreatment of hypertension and poor blood pressure control in hypertensive Hispanics compared with non-Hispanic whites (Pappas et al., 1990; Satish, Stroup-Benham, Espino, Markides, Goodwin, 1998; Sudano and Baker, 2001). Adequate control of hypertension reduces the risk of stroke, coronary artery disease, congestive heart failure, and cardiovascular death. Cardiovascular Disease Cardiovascular disease, including ischemic heart disease and cerebrovascular disease, is the leading cause of death for all ethnic groups in the United States. The main risk factors include diabetes, hypertension, obesity, elevated low-density lipoprotein (LDL) cholesterol, low levels of high-density lipoprotein (HDL) cholesterol, and smoking. As discussed in earlier sections of this chapter, Hispanics have higher rates of diabetes and obesity than non-Hispanic whites. However, Hispanics have similar rates of hypertension and similar cholesterol profiles when compared with non-Hispanic whites, although Hispanics are less likely than whites to have their blood pressure controlled. Hispanics also have lower rates of smoking than non-Hispanic whites, as we discuss later on. Few data are available on the epidemiology of ischemic heart disease among Hispanics. Studies have found both higher and lower prevalence and incidence of acute myocardial infarction among Hispanics of Mexican origin compared with non-Hispanic whites (Goff et al., 1997; Mitchell, Hazuda, Haffner, Patterson, and Stern, 1991; Rewers et al., 1993). Analyses of death certificate data suggest that mortality rates from heart disease are lower for Hispanics than for non-Hispanic whites (e.g., Liao et al., 1997; Sorlie, Backlund, Johnson, and Rogot, 1993). For example, vital statistics data for 2000 indicate that the age-adjusted death rate from heart disease among Hispanics was 196.0 per 100,000 people, compared with 255.5 per 100,000 people among non-Hispanic whites, while the age-adjusted death rate from ischemic heart disease among Hispanics was 153.2 per 100,000 people, compared with 186.6 per 100,000 people among non-Hispanic whites (National Center for Health Statistics, 2003). However, mortality rates based on vital statistics data have several limitations, including incomplete ascertainment of deaths and misclassification of cause of death or ethnicity (Pandey, Labarthe, Goff, Chan, and Nichaman, 2001). Studies that have validated the cause of death have yielded conflicting findings. Analyses of data from the Corpus Christi Heart Project found higher ischemic heart disease mortality in Hispanics of Mexican origin than in whites, especially among women (Pandy et al., 2001). A study based on

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Hispanics and the Future of America data from the San Luis Valley Diabetics Study found similar ischemic heart disease mortality in both ethnic groups (Swenson et al., 2002). The controversy about how heart disease mortality in Hispanics compares with that in whites remains unsettled, and data from regional studies may not be generalizable. Data on the incidence and prevalence of stroke in Hispanics also are scarce. In the Northern Manhattan Stroke Study, a population-based incidence study in the New York City area, the rates of stroke for Hispanics of all ages were twice as high as the rates for non-Hispanic whites (Jacobs, Boden-Albala, Lin, and Sacco, 2002; Sacco et al. 1998). (In this study, most of the Hispanics were presumably Puerto Ricans and Dominicans.) Several studies have found that Hispanics, including Hispanics in New York and in New Mexico, have a higher incidence than non-Hispanic whites of intracerebral hemorrhage (Bruno, Carter, Qualls, and Nolte, 1996; Frey, Jahnke, and Bulfinch, 1998; Sacco et al., 1998), suggesting an important role for uncontrolled hypertension. However, Hispanics and non-Hispanic whites have similar death rates after both ischemic and hemorrhagic stroke (Ayala et al., 2001). In 2000, the age-adjusted death rates from strokes was 46.4 per 100,000 people for Hispanics and 59.0 per 100,000 people for non-Hispanic whites (National Center for Health Statistics, 2003). Interestingly, relative mortality rates from cerebrovascular disease vary by age. For people under age 65, Hispanics have higher mortality than non-Hispanic whites, whereas Hispanics older than age 65 have lower mortality than non-Hispanic whites in the same age group (Gillum, 1995; National Center for Health Statistics, 2003). Hispanics lost 207.8 potential years of life before age 75 from stroke, compared with 183.0 years for non-Hispanic whites. Cancer Cancer is a leading cause of death in all racial and ethnic groups. Registry data indicate that Hispanics experience overall lower cancer incidence rates than do non-Hispanic whites. Incidence rates are also lower among Hispanics for several major cancers, including cancer of the breast, lung, prostate, and colon and rectum. However, Hispanics have higher rates than non-Hispanic whites of certain cancers, including cervical and stomach cancer (Ramírez and Suárez, 2001). Cancer mortality reflects differences in cancer incidence rates. In 2000, the age-adjusted death rate from cancer was 134.9 per 100,000 people among Hispanics, compared with 200.6 per 100,000 people among non-Hispanic whites. Hispanics also had lower mortality rates than non-Hispanic whites from cancers of the lung, breast, prostate, and colon and rectum. In addition, Hispanics lost fewer potential years of life before age

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Hispanics and the Future of America 75 from cancer than non-Hispanic whites (1,098.2 versus 1,668.4 years of life lost per 100,000 people) (National Center for Health Statistics, 2003). Activity Limitations from Chronic Conditions Hispanics in general are less likely than non-Hispanic whites and non-Hispanic blacks to report activity limitations caused by chronic conditions. In 2001, the age-adjusted proportion of Hispanics reporting an activity limitation was 10.6 percent, compared with 12.1 percent for whites and 15.5 percent for blacks (National Center for Health Statistics, 2003). However, Hispanic seniors age 65 or older have higher rates of activity limitations and disability than their white counterparts (e.g., Markides and Rudkin, 1995). Biological Risk Factors for Chronic Disease Cholesterol Levels Cholesterol levels are associated with the development of cardiovascular disease. Regional data from the 1980s indicate that Hispanics of Mexican origin had less favorable lipid profiles than non-Hispanic whites (e.g., Haffner, Stern, Hazuda, Rosenthal, and Knapp, 1986; Mitchell, Stern, Haffner, Hazuda, and Patterson, 1990). However, more recent data suggest that cholesterol levels for Hispanics are generally similar to those for non-Hispanic whites. Pérez-Stable et al. (2001) summarized several studies based on the HHANES data. These studies found that total cholesterol levels were similar for men and women of Mexican, Puerto Rican, and Cuban origin, and that the levels for Hispanics compared favorably with those for non-Hispanic whites. More recent data from NHANES III and NHANES IV show similar or more favorable total cholesterol levels for men and women of Mexican origin compared with non-Hispanic whites. For instance, in NHANES IV the age-adjusted total cholesterol level for adult Mexican men less than 75 years old was 207 mg/dl, compared with 204 mg/dl for non-Hispanic white men. The age-adjusted total cholesterol level for Mexican women was 198 mg/dl, compared with 206 mg/dl for non-Hispanic white women (National Center for Health Statistics, 2003). Lipoprotein fractions are generally similar for Hispanics of Mexican origin and non-Hispanic whites, although there are a few differences. Using NHANES III, Sundquist, Winkleby, and Pudaric (2001) found that the prevalence of high non-DL cholesterol (> 155 mg/dl) was 69 percent in Mexican-origin Hispanics age 65 or older, identical to the prevalence of 70

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Hispanics and the Future of America cular disease and other manifestations of atherosclerosis as today’s Hispanic youth moves into adulthood. Unhealthy diets combined with low levels of physical activity are important underlying causes of the rising rates of overweight in Hispanic children and adolescents. In this context, our review has raised serious concerns about the future dietary habits of Hispanics. The available evidence suggests that acculturation is associated with less healthy diets among Hispanics of all ages, and that second-generation Hispanic youth have worse dietary habits than immigrant youth. The process of acculturation is likely to lead today’s immigrant youth to adopt less healthy diets that put them at higher risk of overweight. The second-generation offspring of today’s immigrant adults are likely to be at high risk for unhealthy diets and excessive weight as well. The other data we have reviewed on the health and health behaviors of Hispanic youth are less worrisome than the data on obesity and its complications. Nonetheless, we uncovered several findings of concern with regard to the well-being of Hispanic youth and especially to their educational performance. Health conditions and behaviors that affect educational performance are noteworthy, because the educational outcomes and attainment of today’s Hispanic youth have important implications for the future economic trajectory of Hispanics in the United States. Hispanic children and adolescents have considerably worse oral health than their non-Hispanic white peers. Poor oral health is associated with a variety of adverse outcomes among youth, including lower quality of life and worse educational outcomes. Hispanic children also have higher blood lead levels than white children and, consequently, are at much higher risk for the adverse effects of lead poisoning on cognitive development. The Centers for Disease Control and Prevention are currently considering lowering the threshold blood lead level for intervention from 10 μg/dL to 5 μg/dL. More than one-fourth of preschool-age children and one-fifth of elementary schoolchildren of Mexican origin have blood lead levels that would meet the revised threshold. Other threats to the well-being and educational performance of Hispanic youth, and in particular, of adolescent girls, include relatively high rates of depression and teenage childbearing. Finally, the available evidence suggests that the process of acculturation is associated with higher rates of smoking and illicit drug use among Hispanic youth, implying that these may become more salient problems among the second-generation offspring of today’s immigrant adults. Our review suggests that addressing the rising prevalence of overweight and obesity among Hispanics must be a priority for public health. Hispanic youth, in particular, should be targeted by public health and community-based efforts to prevent overweight before it has a chance to develop. The available data on the relationship between acculturation and both over-

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Hispanics and the Future of America weight and diet suggest that interventions to help Hispanic families preserve the dietary habits that they bring with them from their countries of origin could have an important role to play. However, although Hispanics have been disproportionately affected by the epidemic of overweight and obesity in the United States, no racial or ethnic group is unscathed. Hispanics must be included in broader societal initiatives to address this epidemic. Other health problems that disproportionately affect Hispanic youth and that may be amenable to public health and community-based interventions include poor oral health, high blood lead levels, and teenage childbearing. Interventions designed to preserve and build on salutary elements of Hispanic culture may be helpful in dealing with smoking, drug use, and teenage childbearing among Hispanic youth and in promoting favorable birth outcomes among Hispanic women. More research is needed on how acculturation to American culture affects the health and health behaviors of Hispanics and on how interventions that exploit the beneficial elements of Hispanic culture can be designed. Finally, if present trends continue, the U.S. health care system of the future will be faced with much larger numbers of Hispanic patients suffering from such chronic conditions as diabetes, hypertension, and cardiovascular disease as well as from the consequences of these conditions. Hispanics currently face numerous barriers to receiving timely, appropriate, and high quality health care. These barriers, and what must be done to address them, are discussed in detail in the next chapter. REFERENCES Abraido-Lanza, A.F., Dohrenwend, B.P., Ng-Mak, D.S., and Turner, J.B. (1999). The Latino mortality paradox: A test of the “salmon bias” and healthy migrant hypotheses. American Journal of Public Health, 89(10), 1748–1751. Adler, N.E., and Ostrove, J.M. (1999). Socioeconomic status and health: What we know and what we don’t. In N.E. Adler, M. Marmot, B.S. McEwen, and J. Stewart (Eds.), Socioeconomic status and health in industrial nations: Social, psychological and biological pathways (pp. 3–16). New York: New York Academy of Sciences. Alderete, E., Vega, W.A., Kolody, B., and Aguilar-Gaxiola, S. (2000). Lifetime prevalence of and risk factors for psychiatric disorders among Mexican farm workers in California. American Journal of Public Health, 90(4), 608–614. Amaro, H., Whitaker, R., Coffman, J., and Heeren, T. (1990). Acculturation and marijuana and cocaine use: Findings from HHANES 1982–84. American Journal of Public Health, 80(suppl.), 54–60. Arias, E., Anderson, R.N., Hsiang-Ching, K., Murphy, S.L., and Kochanek, K.D. (2003). Deaths: Final data for 2001. (National Vital Statistics Reports; Vol. 52, No. 3.) Hyattsville, MD: National Center for Health Statistics. Ayala, C., Greenlund, K., Croft, J.B., Keenan, N.L., Donehoo, R.S., Giles, W.H., Kittner, S.J., and Marks, J.S. (2001). Racial/ethnic disparities in mortality by stroke subtype in the United States, 1995–1998. American Journal of Epidemiology, 154(11), 1057–1063.

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