CHAPTER 4
The Health and Nutritional Status of Immigrant Hispanic Children: Analyses of the Hispanic Health and Nutrition Examination Survey

Fernando S. Mendoza and Lori Beth Dixon

The Hispanic population will soon be the largest ethnic minority group in the United States. Its growth is being fueled by both a high fertility rate and immigration (Lewit et al., 1994). Indeed, over the past decade half of the increase in its population has been from immigration. As a result, federal and state public policies have focused more intently on immigrant Hispanics and their children. Although there has always been a flow of Hispanic immigrants to the United States, the recent upsurge in immigration has led to a debate about the use of public resources by immigrants, particularly their children, and concerns about the strain they cause on programs for other needy children. In reaction, federal and state governments have begun to enact changes in immigration and social welfare policies aimed at limiting public resources to immigrants, including children (e.g., congressional reform of immigration policy, Proposition 187 in California). However, two questions arise: What do we know about the nutritional and health status of immigrant Hispanic children? Are they disproportionately in need of nutrition-related and health care services? At present there is limited knowledge about their actual health and nutritional needs. If informed public policy is to be developed to deal with immigrant Hispanic children in the United States, accurate information about their health and nutritional needs is required.



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Children of Immigrants: Health, Adjustment, and Public Assistance CHAPTER 4 The Health and Nutritional Status of Immigrant Hispanic Children: Analyses of the Hispanic Health and Nutrition Examination Survey Fernando S. Mendoza and Lori Beth Dixon The Hispanic population will soon be the largest ethnic minority group in the United States. Its growth is being fueled by both a high fertility rate and immigration (Lewit et al., 1994). Indeed, over the past decade half of the increase in its population has been from immigration. As a result, federal and state public policies have focused more intently on immigrant Hispanics and their children. Although there has always been a flow of Hispanic immigrants to the United States, the recent upsurge in immigration has led to a debate about the use of public resources by immigrants, particularly their children, and concerns about the strain they cause on programs for other needy children. In reaction, federal and state governments have begun to enact changes in immigration and social welfare policies aimed at limiting public resources to immigrants, including children (e.g., congressional reform of immigration policy, Proposition 187 in California). However, two questions arise: What do we know about the nutritional and health status of immigrant Hispanic children? Are they disproportionately in need of nutrition-related and health care services? At present there is limited knowledge about their actual health and nutritional needs. If informed public policy is to be developed to deal with immigrant Hispanic children in the United States, accurate information about their health and nutritional needs is required.

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Children of Immigrants: Health, Adjustment, and Public Assistance Currently, about 60 percent of immigrant children are from Latin America, primarily Mexico, Cuba, and Central America (Bureau of the Census, 1994). Although immigrant children come from other countries too, such as those in Asia and Eastern Europe, for the most part Hispanics are now and will continue to be the major ethnic group of immigrant children in the United States. Furthermore, the problematic issues of poverty, low parental education, and difficulty in accessing health care encountered by many immigrant families and their children are common to Hispanics. Therefore, immigrant Hispanic children can be seen as instructive examples of immigrant children in general in the United States. To evaluate the nutritional and health status of immigrant versus nonimmigrant Hispanic children, we examined the Hispanic Health and Nutrition Examination Survey, a health survey conducted by the National Center for Health Statistics (NCHS) in 1984 on the three major Hispanic subgroups in the United States (NCHS, 1985). This paper presents data on the growth patterns, dietary intakes, and prevalences of chronic medical conditions and the perceived health status of Mexican American, Puerto Rican, and Cuban American children and adolescents. We differentiate these findings by the birthplaces of the children and adolescents. Thus, this study provides one of the first large-scale nutritional and health status comparisons of immigrant and non-immigrant Hispanic children in the United States. METHODS Sample The study subjects were children, ages 6 months to 18 years, who participated in the Hispanic Health and Nutrition Examination Survey (HHANES) in 1984 (National Center for Health Statistics, 1985). This survey sampled Mexican American children from the five Southwestern states (California, Arizona, Colorado, New Mexico, and Texas), mainland Puerto Rican children from the New York City area, and Cuban American children from Dade County, Florida. These geographic regions contain the majority of children from these three Hispanic subgroups. Therefore, al-

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Children of Immigrants: Health, Adjustment, and Public Assistance though not encompassing all children in the United States who are in these Hispanic subgroups, HHANES surveyed 73 percent of Mexican Americans, 53 percent of mainland Puerto Ricans, and 55 percent of Cuban Americans living in the United States at the time of the survey. Among those children and adolescents who were missed by the HHANES sampling were the homeless; those who were migrants; and, in general, those more difficult to contact, usually the poor. The survey obtained health and nutritional data from subjects through questionnaires, biochemical tests, and physical examinations. Unlike most other national health surveys, HHANES contains information from physicians' examinations of surveyed subjects. Therefore, this survey differentiates itself from other household health surveys by utilizing more than questionnaire data to determine health and nutritional status. The survey also contains information about children's birthplaces and for adolescents assesses generational status by determining their birthplace and their parents' birthplaces. No other documentation was available to determine citizenship status of a family or its child. As a result, for this study Mexican American children and adolescents were identified as being born either in Mexico or the United States; similarly, Cuban Americans were identified as being born in Cuba or the United States. Puerto Rican children were classified as being born either on the mainland or on the island of Puerto Rico. Variables All subjects had assessed demographic data, including age, sex, poverty status as measured by a poverty index,1 parental education, and birthplace (United States, Mexico, Cuba, or Puerto Rico). Adolescent subjects also had generational status determined.2 Subjects were assessed for their nutritional health by 1   The poverty index is a proportion determined by the family's income divided by the cost of food and shelter for a family of similar size. A poverty index of 1.0 is the poverty line, while a poverty index of 2.0 is a family income of 200 percent of poverty. 2   Generation status was determined as follows: first, foreign-born adolescent; second, U.S.-born adolescent with one or both parents foreign born; and third or greater, U.S.-born adolescent with both parents U.S. born.

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Children of Immigrants: Health, Adjustment, and Public Assistance using measures of anthropometry (height, weight, body mass index (weight/height2)); daily dietary intake (as assessed by a food frequency questionnaire); and for children under age 12 a parental report of anemia. The physical health of children and adolescents was assessed by the presence of chronic medical conditions and parental reports of specific conditions. The assessment of chronic medical conditions was done by survey physicians through questionnaires and a standardized physical examination. A chronic medical condition was any medical condition that impaired the child's or adolescent's function for at least the three previous months. For children under age 12 a medical condition questionnaire was administered to parents that assessed whether the children had any of several listed medical conditions. Lastly, an overall subjective assessment of health status was determined for each subject by the survey physician. Survey physicians were asked to assess each adolescent's health as excellent, very good, good, fair, or poor. A rating of fair or poor was labeled as reporting poor health, while those reporting excellent, very good, or good health were labeled as reporting good health. In addition to physicians, adolescent subjects were asked to assess their health status using the same categories. If an adolescent was unable to answer, a parent (usually the mother) responded to the question. Analyses The HHANES is a complex, multistage, stratified, clustered survey that requires the use of sample weights and a complex sample design effect for population estimates and comparisons. Our analyses used sample weights for population estimates (i.e., percentages, means, and medians) and an average sample design effect of 1.5 as recommended by Delgaldo et al. (1990). Chi-square analyses had critical values divided by 1.5 to account for the design effect. Regression analysis utilized sample weight and a complex sample design effect of 1.0 since regression parameters included age, sex, and measures of socioeconomic status (SES). Accurate prevalence estimates require samples of 45 or greater. Those estimates with smaller samples are not reliable as population estimates but instead reflect values for only the sampled population.

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Children of Immigrants: Health, Adjustment, and Public Assistance Nutritional Status Assessment The medians for weight and height of sampled children and adolescents were assessed by age, sex, ethnic group, and birthplace. Age was determined by prior birthday. For example, all children in the age 2 category ranged from 2.00 to 2.99 years old. The HHANES data on height and weight were compared to the NCHS midyear-age 50th percentile standard for 1983 for height and weight (i.e., all children age 2 were compared to NCHS median values of 2.5 years). Calculated body mass index (BMI) values for surveyed children and adolescents were compared to standardized values of BMI from the NHANES I (1971-1974) developed by Hammer et al. (1991). To compare HHANES groups with NCHS and BMI standards, children from two-year age groups (e.g., 2 to 2.9 years plus 3 to 3.9 years) were combined because of the small immigrant sample sizes in each individual age group. Regression analyses of anthropometric measures were done by age cohort (2 to 5 years, preschoolers; 6 to 11 years, school age; 12 to 18 years, adolescents), with age, sex, poverty, parental education, and whether the child or adolescent was foreign born as independent variables. The latter variable for Mexican American adolescents includes three groupings: foreign born, U.S. born with one or both parents foreign born, and U.S. born with U.S.-born parents. The diets of children and adolescents were assessed by determining daily intakes of the four basic food groups. This was done by utilizing the same methodology developed by Murphy et al. (1990) to analyze food frequency data from the HHANES. This method estimates the completeness of the diet with respect to the four basic food groups by comparing the daily servings of each food compared to the recommendations for age by the U.S. Department of Agriculture's (USDA) Daily Food Guide. Maximum servings ranged from 12.5 to 14 per day of the four food groups. Statistical differences in dietary intake scores between U.S.- and foreign-born children were assessed by t test. A maternal report of anemia in a child, either current or past (ever having been treated for anemia), was examined for U.S.- and foreign-born children by chi-square analyses.

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Children of Immigrants: Health, Adjustment, and Public Assistance Health Status Assessment The prevalence of chronic medical conditions was assessed for U.S.- and foreign-born children in each of the Hispanic subgroups and compared by chi-square analyses. Parental reports of selected medical conditions were compared by chi-square analyses for U.S.- and foreign-born children age 6 months to 11 years. The prevalence of perceived poor health status among adolescents as assessed by survey physicians and adolescents was compared by chi-square analyses for differences between U.S.- and foreign-born subjects. RESULTS The size and characteristics of each sample are presented in Table 4-1. For children 6 months to 11 years old, the three Hispanic groups differed demographically among themselves and within groups by birthplace. Compared to U.S.-born Mexican American children, foreign-born ones tended to have families that were poorer, less educated, predominantly Spanish speaking, and less likely to have a female-headed household. Puerto Rican chil- TABLE 4-1 Demographics Profile of U.S. and Foreign-Born Hispanic Children and Adolescents   Mexican American   U.S. Mexico 6 mos.-11 yrs. sample (N) 2,493 272 % with female head of household 18 10 % in poverty 34 60 % parental education less than grade 9 36 77 % Spanish-speaking only 28 78 12-18 yrs. sample (N) 1,088 259 % female head of household 26 17 % in poverty 36 50 % parental education less than grade 9 41 81 % Spanish-speaking only 6 20 (N) Second generation 374   (N) Third generation 705  

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Children of Immigrants: Health, Adjustment, and Public Assistance dren more frequently lived in female-headed households and in poverty than Mexican Americans or Cuban Americans. Puerto Rican children born on the island were similar to those born in the United States, except they were more likely to speak only Spanish. Cuban children born outside the United States were poorer and less well educated than U.S.-born Cuban children. The characteristics of the adolescent samples were similar to those of the younger age group. However, fewer foreign-born adolescents spoke only Spanish. Although the generational status of adolescents was available, only Mexican Americans had a significant number of subjects who were third-generation children or higher. In general, foreign-born children came from families that were poorer and less well educated than their U.S. counterparts. The data for height and weight medians by age, sex, and birthplace for Mexican American, Puerto Rican, and Cuban American children are shown in Appendix 4A, Tables 4A-1 through 4A-6. The medians for U.S.- and foreign-born subjects (Puerto Ricans were divided into mainland and island born) were examined against the NCHS 50th percentile for age. Figures 4-1 through 4-4 plot the median values for height and weight of Mexican Ameri-   Puerto Rican Cuban American   U.S. Puerto Rico U.S. Cuba 6 mos.-11 yrs. sample (N) 723 171 227 53 % with female head of household 50 51 16 17 % in poverty 58 60 25 44 % parental education less than grade 9 24 32 28 48 % Spanish-speaking only 27 61 53 61 12-18 yrs. sample (N) 55 163 105 114 % female head of household 58 63 19 22 % in poverty 57 70 20 45 % parental education less than grade 9 33 43 34 53 % Spanish speaking only 5 12 2 9 (N) Second generation 405   105   (N) Third generation 44   0  

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Children of Immigrants: Health, Adjustment, and Public Assistance can males and females compared to the NCHS median or 50th percentile for age and sex. Values below the zero line indicate medians lower than the NCHS median, while values above the line are above the median. Because data were unstable owing to small sample sizes by age and sex, two-year averages are presented. Compared to the NCHS height standard for 1983, foreign-born Mexican American males had median heights that were greater than the 50th percentile for ages 2 to 3 but were generally less than the 50th percentile for ages 4 to 17 years (Figure 4-1). The differences between the median heights of foreign-born Mexican American males and the NCHS age-appropriate median were as much as -4cm during childhood and early adolescence and then increased to about -8 cm in late adolescence. This suggests mild-to-moderate stunting of foreign-born males. Accordingly, the median heights of foreign-born Mexican American males in FIGURE 4-1 Median heights of Mexican American males by two-year intervals.

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Children of Immigrants: Health, Adjustment, and Public Assistance FIGURE 4-2 Median heights of Mexican American females by two-year intervals. FIGURE 4-3 Median weights of Mexican American males by two-year intervals.

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Children of Immigrants: Health, Adjustment, and Public Assistance FIGURE 4-4 Median weights of Mexican American females by two-year intervals. late adolescence were between the NCHS 5th and 10th percentiles for age. Although U.S.-born Mexican American males under age 12 were taller than their foreign-born counterparts, this decreased during adolescence, with medians averaging 5.7 cm below the 50th percentile or between the NCHS 10th and 25th percentiles at ages 16 to 18. Similarly, foreign-born Mexican American females had average median heights greater than the NCHS 50th percentile from ages 2 to 4 but then were generally below the 50th percentile from ages 5 to 17 (Figure 4-2). Specifically, the median heights of foreign-born Mexican American females were 1 to 2 cm less than their age-appropriate NCHS standard during childhood and early adolescence and then averaged 7 cm below the NCHS 50th percentile in late adolescence. In late adolescence the median heights of foreign-born females ranged between the NCHS 5th and 25th percentiles, indicating stunting among girls as well. Median heights for U.S.-born Mexican

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Children of Immigrants: Health, Adjustment, and Public Assistance American females compared to foreign-born females were improved, but like males they had less of a height advantage at the end of adolescence, with median heights ranging from the NCHS 10th to 25th percentiles. Linear regressions were conducted on the heights of Mexican American children by age cohorts: 2 to 5 years, 6 to 11 years, and 12 to 18 years. Table 4-2 shows results from linear regressions on height with betas for variable levels compared to control levels (e.g., for children ages 2 to 5, male is a control variable with a beta of 0.0, while female is the variable of interest with a beta of -0.88). For children ages 2 to 5, main predictors were age, sex, and parental education (R2 = .739). Those who were older and male and whose parents were more educated are taller. For school-age children, age and parental education were the main determinants (R2 = .724). A stepwise regression indicated that the poverty score rather than parental education was a major determinant of height for school-age children. Adolescents were taller if they were older and male, had higher parental education, and were wealthier (R2= .358). (Stepwise regression selected the poverty index as a better predictor variable than parental education.) None of the regression analyses showed being foreign born as a significant determinant of height. However, in all three age groups a measure of SES predicted height. The median weights of Mexican American children were less variant than their heights from the NCHS median or 50th percentile. Foreign-born boys through age 12 showed median weights that varied around the NCHS 50th percentile, from +1.3 kg above the 50th percentile to -2.9 kg below (Figure 4-3). During early adolescence, foreign-born boys' median weights were above the NCHS median and then fell below it after age 15, resulting in median weights around the NCHS 25th percentile. U.S.-born boys tended to be slightly heavier (-0.5 to +2.7 kg from the NCHS median) but likewise showed median weights below the NCHS 50th percentile after age 15. Their weight percentiles were also at the 25th percentile. Foreign and U.S.-born girls ages 2 to 15 had median weights above the NCHS median, with foreign-born girls usually heavier than U.S.-born girls (Figure 4-4). After age 15 both groups weighed below the NCHS median for age, with foreign-born adolescent girls having lower weights (NCHS 25th per-

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Children of Immigrants: Health, Adjustment, and Public Assistance   Median Weights (kg)   NCHS U.S.-Born Foreign-Born Mexican American males, ages 2-11   2 13.5 14.1 14.2 3 15.7 15.3 17.0 4 17.7 17.2 15.9 5 19.7 19.4 19.2 6 21.7 21.6 19.3 7 24.0 24.4 22.7 8 26.7 27.4 26.4 9 29.7 30.0 28.5 10 33.3 33.9 34.6 11 37.5 40.2 40.4 Mexican American females, ages 2-11   2 13.0 12.8 13.6 3 15.1 14.8 16.4 4 16.8 16.6 17.8 5 18.6 18.8 18.2 6 20.6 20.7 21.5 7 23.3 23.8 25.7 8 26.6 27.2 25.5 9 30.4 32.4 36.4 10 34.7 35.5 37.7 11 39.2 39.4 38.4

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Children of Immigrants: Health, Adjustment, and Public Assistance TABLE 4A-2 Median Heights and Weights for Mexican American Adolescents   Median Heights (cm) Age NCHS USB&USPa USB&FBP Foreign-Born Mexican American males, ages 12-18 12 153.0 151.3 150.6 154.8 13 159.9 161.1 159.7 151.3 14 166.2 163.7 167.4 174.4 15 171.5 169.7 167.1 163.4 16 175.2 171.1 170.4 171.7 17 176.7 169.0 175.4 167.5 18   169.8 167.8 165.1 Mexican American females, ages 12-18 12 154.6 152.7 153.2 155.5 13 159.0 157.3 157.4 157.1 14 161.2 156.4 157.9 154.8 15 162.1 159.8 161.0 159.6 16 162.7 159.0 156.0 158.4 17 163.4 158.9 159.4 157.1 18   158.4 158.8 152.4 a First-generation children are all subjects who are foreign born; second-generation children are U.S. born and have one or both parents who are foreign born (USB&FBP); third-generation children are U.S. born and have parents who are both U.S. born (USB&USP).

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Children of Immigrants: Health, Adjustment, and Public Assistance   Median Weights (kg)   NCHS USB&USP USB&FBP Foreign-Born Mexican American males, ages 12-18 12 42.3 44.6 42.8 46.0 13 47.8 53.2 49.2 41.2 14 53.8 54.2 57.5 64.5 15 59.5 57.6 56.9 74.1 16 64.4 63.2 61.2 61.4 17 67.8 60.6 63.2 60.4 18 68.9 65.8 67.3 68.1 Mexican American females, ages 12-18 12 43.8 46.0 47.3 52.0 13 48.3 51.8 50.5 50.0 14 52.1 52.4 53.1 57.4 15 55.0 54.3 55.3 58.0 16 56.4 53.6 53.4 51.3 17 56.7 54.2 54.4 49.8 18 56.6 56.3 59.3 53.7

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Children of Immigrants: Health, Adjustment, and Public Assistance TABLE 4A-3 Median Heights and Weights for Puerto Rican Males, Ages 2-18   Median Heights (cm) Age NCHS U S-Born Foreign-Born 2 90.4 92.3 90.8 3 99.1 99.2 97.4 4 106.6 107.3 104.6 5 113.1 112.5 112.6 6 119.0 118.6 115.6 7 124.4 124.5 123.0 8 129.6 130.2 128.2 9 134.8 135.9 137.3 10 140.3 140.9 138.7 11 146.4 146.5 146.6 12 153.0 155.6 154.7 13 159.9 159.2 158.4 14 166.2 165.0 163.0 15 171.5 169.7 167.2 16 175.2 170.8 168.8 17 176.7 173.0 169.3 18 176.8 172.0 172.7 TABLE 4A-4 Median Heights and Weights for Puerto Rican Females, Ages 2-18   Median Heights (cm) Age NCHS U.S.-Born Foreign-Born 2 90.0 87.9 89.5 3 97.9 97.2 97.4 4 105.0 105.6 105.4 5 111.6 114.1 111.4 6 117.6 119.5 119.3 7 123.5 123.7 117.6 8 129.3 132.7 127.2 9 135.2 136.7 130.6 10 141.5 143.5 140.7 11 148.2 151.7 146.6 12 154.6 155.6 153.4 13 159.0 157.8 158.0 14 161.2 157.0 156.9 15 162.1 157.8 159.6 16 162.7 160.8 162.1 17 163.4 159.9 160.4 18 163.7 160.6 157.8

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Children of Immigrants: Health, Adjustment, and Public Assistance   Median Weights (kg) Age NCHS U.S.-Born Foreign-Born 2 13.5 14.2 14.0 3 15.7 15.5 16.2 4 17.7 18.3 16.0 5 19.7 19.9 19.8 6 21.7 22.4 21.7 7 24.0 24.2 23.3 8 26.7 27.3 25.2 9 29.7 31.4 31.5 10 33.3 33.4 33.0 11 37.5 40.7 35.1 12 42.3 50.9 41.6 13 47.8 48.4 45.8 14 53.8 55.8 57.3 15 59.5 57.1 59.2 16 64.4 65.4 64.2 17 67.8 66.8 59.8 18 68.9 67.3 67.8   Median Weights (kg) Age NCHS U.S.-Born Foreign-Born 2 13.0 12.7 12.9 3 15.1 16.0 14.8 4 16.8 16.8 18.4 5 18.6 21.8 20.0 6 20.6 23.0 29.7 7 23.3 23.4 25.3 8 26.6 30.5 25.6 9 30.4 32.4 25.4 10 34.7 37.4 40.0 11 39.2 40.1 38.1 12 43.8 47.4 45.5 13 48.3 51.4 49.4 14 52.1 51.4 52.6 15 55.0 52.7 58.3 16 56.4 56.9 61.4 17 56.7 55.8 57.4 18 56.6 56.4 56.1

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Children of Immigrants: Health, Adjustment, and Public Assistance TABLE 4A-5 Median Heights and Weights for Cuban Males, Ages 2-18   Median Heights (cm) Age NCHS U.S.-Born Foreign-Born 2 90.4 91.4   3 99.1 101.4 97.6 4 106.6 108.6 107.2 5 113.1 113.0 112.5 6 119.0 124.1 116.0 7 124.4 127.2 129.3 8 129.6 134.2 134.0 9 134.8 134.9 140.7 10 140.3 143.4 130.7 11 146.4 147.1 144.2 12 153.0 149.8 153.7 13 159.9 162.8 152.8 14 166.2 165.6 162.8 15 171.5 172.8 171.2 16 175.2 174.2 174.7 17 176.7 175.7 170.3 18 176.8 184.5 171.7 TABLE 4A-6 Median Heights and Weights for Cuban Females, Ages 2-18   Median Heights (cm) Age NCHS U.S.-Born Foreign-Born 2 90.0 89.9   3 97.9 98.7   4 105.0 106.2 109.1 5 111.6 114.1 111.7 6 117.6 120.8 117.6 7 123.5 127.2 126.7 8 129.3 131.1 123.7 9 135.2 139.4 129.0 10 141.5 142.8 131.3 11 148.2 147.0 148.5 12 154.6 157.6 153.5 13 159.0 155.8 157.8 14 161.2 163.3 155.3 15 162.1 158.6 164.2 16 162.7 155.5 159.1 17 163.4 160.8 160 5 18 163.7 160.5 158.5

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Children of Immigrants: Health, Adjustment, and Public Assistance   Median Weights (kg) Age NCHS U.S.-Born Foreign-Born 2 13.5 13.7   3 15.7 16.6 16.3 4 17.7 19.5 17.2 5 19.7 20.0 23.3 6 21.7 27.6 18.7 7 24.0 28.2 31.8 8 26.7 35.8 33.0 9 29.7 32.2 40.1 10 33.3 41.2 29.3 11 37.5 52.8 40.6 12 42.3 39.5 35.8 13 47.8 51.4 47.6 14 53.8 52.6 52.4 15 59.5 58.6 65.4 16 64.4 58.3 65.4 17 67.8 65.6 65.3 18 68.9 84.2 64.4   Median Weights (kg) Age NCHS U.S.-Born Foreign-Born 2 13.0 12.4   3 15.1 16.5   4 16.8 17.6 20.6 5 18.6 20.6 16.2 6 20.6 26.3 22.1 7 23.3 25.4 25.2 8 26.6 34.4 24.4 9 30.4 36.2 28.6 10 34.7 41.0 27.0 11 39.2 45.6 38.5 12 43.8 49.4 49.9 13 48.3 44.4 42.6 14 52.1 55.6 49.3 15 55.0 55.2 56.6 16 56.4 49.9 48.7 17 56,7 51.0 54.8 18 56.6 52.1 57.8

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Children of Immigrants: Health, Adjustment, and Public Assistance TABLE 4A-7 Body Mass Index and Percentage of BMI Above the 90th Percentile for Mexican American Children and Adolescents     U.S Born with U.S.-Born Parents Age (years) BMI Reference Average Median Median BMI (N) % > Reference 90th Percentile Mexican American males 2-5 16 — — 6-11 16.1 — — 12-18 19,8 20.2 (320) 13.9 Mexican American females 2-5 15.6 — — 6-11 16.4 — — 12-18 19.8 21.3 (336) 16.2

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Children of Immigrants: Health, Adjustment, and Public Assistance   U.S Born with Foreign-Born Parents Foreign-Born Age (Years) Median BMI (N) % > Reference 90th Percentile Median BMI (N) % > Reference 90th Percentile Mexican American males 2-5 15.9 (428) 5.1 16.0(39) 3.4 6-11 16.7 (539) 12.4 16.8(85) 13.1 12-18 20.4 (215) 11.0 20.8(32) 3.1 Mexican American females 2-5 15.7 (384) 4.9 15.8 (22) 1.6 6-11 16.7 (541) 9.5 17.2 (108) 15.5 12-18 21.2 (227) 10.4 21.8 (27) 11.1

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Children of Immigrants: Health, Adjustment, and Public Assistance TABLE 4A-8 Median Body Mass Index and Percentage of BMI Above 90th Percentile for Puerto Rican Children and Adolescents Age (years) BMI Reference Average Median Puerto Rican Males   2-5 16 6-11 16.1 12-18 19.8 Puerto Rican Females   2-5 15.6 6-11 16.4 12-18 19.8 TABLE 4A-9 Median Body Mass Index and Percentage of BMI Above the 90th Percentile for Cuban Children and Adolescents Age (years) BMI Reference Average Median Cuban Males   2-5 16 6-11 16.1 12-18 19.8 Cuban Females   2-5 15.6 6-11 16.4 12-18 19.8

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Children of Immigrants: Health, Adjustment, and Public Assistance   U.S. Mainland Born Puerto Rico Born Age (Years) Median BMI (N) % > Reference 90th Percentile Median BMI (N) % > Reference 90th Percentile Puerto Rican Males 2-5 16.0(110) 6.1 16.0(20) 7.1 6-11 16.8(153) 15.1 16.3(51) 16.7 12-18 20.8(191) 18.3 20.8(72) 17.3 Puerto Rican Females 2-5 16.1 (94) 5.7 15.8(32) 8.1 6-11 16.8 (171) 15.4 17.0(35) 8.9 12-18 21.1 (195) 19.8 22.2(74) 16.4   U.S. Born Foreign Born Age (years) Median BMI (N) % > Reference 90th Percentile Median BMI (N) % > Reference 90th Percentile Cuban Males 2-5 16.2(27) 6.9 16.0(5) 3.4 6-11 18.4(42) 28.3 18.4(19) 27.5 12-18 20.1(39) 16.4 21.0(55) 8.1 Cuban Females 2-5 15.9(26) 10.1 15.2(2) 0 6-11 18.9(44) 25.5 16.4(15) 11.8 12-18 20.6(45) 7.5 20.6(35) 7.2