familias in accion presentation
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Hypertension among Hispanics Carlos J. Crespo, DrPH, FACSM
Portland State University
School of Community Health
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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.
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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?
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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
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Who are Hispanics
• Mexican Americans • Puerto Ricans – mainland and island • Cuban Americans • Other Caribbean – e.g., Dominican Rep, • Central Americans • South Americans • Spain
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Percent Distribution of Hispanics Subgroups
Mexican66%
Puerto Rican
9%
Cuban4%
Central and South American
15%
Other6%
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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
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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*
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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*
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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
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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
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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
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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.
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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
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Figure 1. Heart disease death rates, 1996-2000. Hispanic ages 35 years and older by county.
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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:
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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.
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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
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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).
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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
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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
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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
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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
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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
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Hypertension
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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+
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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
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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
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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
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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
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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
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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
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Environmental Determinants of High Blood Pressure
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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
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Inadequate Blood Pressure Control
Source: JNC VII
• Failure to prescribe lifestyle modification
• Inadequate antihypertensive drug doses
• Inappropriate drug combination
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Triple Aims of Health Reform
Improve Population Health
Quality Patient Care Contain Cost
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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 ✔
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Health=the science of human adaptation
The Economist, 2004
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Our Evolution... America, as a whole,
has successfully achieved a high level of productivity, producing abundant food, effective medical treatment, and labor saving technology...
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Our Problem ...Yet, this success has
produced unintended consequences that make it difficult for many individuals to maintain a healthy lifestyle
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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)
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Our advancing environment 14
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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)
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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
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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
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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,
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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
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Spending in fast-food restaurants per person $0 $100 $200 $300 $400 $500 $600
US
Japan
Britain
Italy
Germany
France
Spain
1995 1999
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Change Isn’t Easy
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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
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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
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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
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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