Judy Monroe, MDDeputy Director

Centers for Disease Control and Prevention

Hispanic Health in the United States

March 18, 2011

Edward Roybal1822–1995

CDC is better aligned to address public health priorities…

• Excellence in surveillance, epidemiology, and laboratory services

• Strengthen support for state, tribal, local, and territorial public health

• Increase global health impact• Use scientific and program expertise to advance

policies that promote health• Better prevent illness, injury, disability, and death

Winnable battles

• Each area is a leading cause of illness, injury, disability, and death

• Evidence-based, scalable interventions• Our efforts are likely to make a difference• We can get results within 1 to 4 years―

but none are easy

Key winnable public health battles for the United States

Nutrition, Physical Activity, Obesity and Food Safety

Healthcare- Associated

Infections

HIV

Motor Vehicle Injuries

Tobacco

Teen Pregnancy

Tobacco • Tobacco is the leading preventable cause of death

• After 40 years of progress, the decrease in adult smoking rates has stalled in the past 6 years

• But most people who have ever smoked have already quit, and most of today’s smokers want to quit

Progress stalls starting in 2004

Prevalence of current smoking among adults, US, 1997–2009

Nutrition, physical activity, obesity, and food safety

1960

/62

1966

/70

1971

/74

1976

/80

1988

/94

1999

/2000

2001

/02

2003

/04

2005

/06

2007

/080%

10%

20%

30%

40%

Obe

sity

pre

vale

nce

Adult

Child 12–19

• Since the 1960s, obesity rates doubled for adults and tripled for children

• >36% of adults (>72 million) and 17% of children are obese

• Each year, foodborne diseases sicken 1 out of 6 Americans and cause >$9 billion in health care-related costs

Obesity rates, 1960–2008

Healthcare-associated infections

• Inpatient hospital setting• 1 out of 20 patients contracts an HAI • 100,000 patients die/year from an HAI• HAIs costs range between $26–$33

billion/year

• Outpatient settings (eg, dialysis, laboratory, long-term care)• Patients can acquire bloodstream

infections in these settings

At least 1/3 of HAIs are preventable with simple, existing tools

Motor vehicle injuries

• Motor vehicle crashes are leading cause of death among Americans ages 5–34

• Despite progress, U.S. rates of death from car crashes are twice rates of other countries and could be reduced by simple, low-cost methods

22%

12%12

%11%

43%

MV crashes HomicideSuicide PoisoningAll other

Causes of death among people ages 5–34, U.S., 2007

U.S. Norway France Denmark Switzerland Sweden0

10

20

30

40

50

60

70

80 1970 2006

39%

80%

68% 81%

80%

82%

Rates are far lower and are decreasing much faster in other countries

Teen pregnancy

HIV HIV continues to spread despite being preventable

Source: Hall Irene et al. Estimation of HIV Incidence in the US. JAMA 2008 Aug 6; 300(5): 520-529

Estimated number of new HIV infections by transmission category, U.S.,1977–2006

The excess medical cost of diseases

• Diabetes: +$6,600 • Obesity: +1,430• Tobacco: +$1,400 is

increment of current vs former smoker; $2,400 is increment of current vs never smoker

Factors that affect health

Socioeconomic Factors

Changing the ContextTo make individuals’ default

decisions healthier

Long-lasting Protective Interventions

ClinicalInterventions

Counseling & Education

LargestImpact

SmallestImpact

Examples

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopy

Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Rx for high blood pressure, high cholesterol, diabetes

Eat healthy, be physically active

Hispanic population in U.S. increased 29% from 2000 to 2009

Source: U.S. Census Bureau

1970 1980 1990 2000 20100

10

20

30

40

50

60

1015

22

35

48P

opul

atio

n in

mill

ions

Hispanics represent 16% of U.S. population

The majority of Hispanics living in the U.S. are from Mexico

65%9%

8%

6%6%

4%

3%

1%

MexicanPuerto RicanCentral AmericanOther HispanicSouth AmericanCubanDominicanSpaniard

Numbers are rounded up

Source: U.S. life tables by Hispanic origin, CDC, October 2010

Hispanics experience lower health status

Hispanics have disproportionate health needs compared with other racial or ethnic groups in the U.S.

Inequalities in health status in the U.S. are large, persistent, and increasing…poverty, income and wealth inequality, poor quality of life, racism, sex discrimination, and low socioeconomic conditions are the major risk factors for ill health and health inequalities

National Association of County and City Health Officials Health and Social Justice Committee

Hispanics have higher life expectancy than whites or blacks

Source: CDC/NCHS, National Vital Statistics System, 2006

Hisp. female White female Hisp. Male Black female White male Black male0

10

20

30

40

50

60

70

80

90 83 80 78 76 7669

Age

in y

ears

Life expectancy at birth, U.S. 2006

Yet they face many health disparitiesDisproportionate disease burden linked to• Low education • Language and cultural barriers• Poor access to preventive care and health

insurance• High poverty• Unsteady/poor/unsafe working conditions• Precarious social status• Use of unconventional medicine• Cultural views on health

More than twice as many Hispanics as whites live below poverty level

White Black Asian/Pacific Islander

AI/AN Hispanic0%

5%

10%

15%

20%

25%

8%

21%

10%

23%

18%

8%

21%

11%

20% 19%

20052009

Adults ≥18 years who live below federal poverty level

Source: CDC Health Disparities and Inequalities Report 2011, MMWR, Vo. 60

Four times as many Hispanics as whites do not complete high school

White Black Asian/Pacific Islander

AI/AN Hispanic0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

11%

21%

14%

27%

43%

9%

18%

13%

21%

39%

20052009

Adults ≥18 years who did not complete high school

Source: CDC Health Disparities and Inequalities Report 2011, MMWR, Vo. 60

Hispanics adults have the highest rate of uninsured of any group

White Black Asian/Pacific Islander

AI/AN Hispanic0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

15%

22%

34%

14%

42%Adults 18–64 without health insurance, U.S., 2008

Source: CDC Health Disparities and Inequalities Report 2011, MMWR, Vo. 60

Lower-income Hispanic children are twice as likely as whites to be uninsured

Source: 1998–2001 National Health Interview Surveys

Percentage of children without health insurance, U.S., 1998–2001

Influenza & pneumonia

Conditions origin. in perinatal period

Homicide

Chronic lower respiratory diseases

Chronic liver disease & cirrhosis

Diabetes

Stroke

Unintentional injuries

Cancer

Heart disease

0 10,000 20,000 30,000 40,000

2,735

2,946

3,466

3,531

3,913

6,417

7,078

11,723

27,660

29,021

Age-adjusted death rates are greater for Hispanics than for whites in 3/10 leading causes of death

Top 10 leading causes of death for Hispanics, 2007

Source: Health, US, 2009

1.5

1.6

2.5

Puerto Ricans have highest rates of asthma and Mexicans have lowest

Adults 18–64 without health insurance, U.S., 2008

Source: National Health Statistics Report, Nr 32, January 12, 2011

White

Total Hispanic

Puerto Rican

Mexican

0 2 4 6 8 10 12 14 16 18

8

6

17

5 Asthma prevalence, U.S., 2009

Hispanic teens engage in high-risk behavior more

frequently than whites or blacks• 34% rode in car driven by someone who drank• 15% seriously considered attempting suicide• 8% attempted suicide• 19% smoke• 14% used inhalants• 9% used cocaine in past and 4% use now• 8% used ecstacy in past• 6% used methamphetamines

Source: 2009 Youth Risk Behavior Surveillance System

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

20

40

60

80

100

120

140

Rat

e pe

r 1,0

00 g

irls

in s

peci

fied

age

grou

p

Source: National Center for Health Statistics

HispanicBlackAI/ANWhiteAsian/Pacific Islander

U.S. birth trends by race/ethnicity girls 15–19, 1991–2009

Since 1995, Hispanic girls have hadthe highest birth rate of any group

Source: Health, US, 2010

Teenage childbearing varies widely among Hispanic groups

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 200620070.0

2.0

4.0

6.0

8.0

10.0

12.0 Puerto RicanMexicanCubanCentral & S. American

6%

2%

Birth by race and Hispanic origin for girls < 18, 1980–2007

Per

cent

of l

ive

birth

s

CDC is working in communities with high teen birth rates

• Enhancing community partnerships and improving access to family planning

• Promoting evidence-based prevention programs and policies

• Working with diverse communities—especially Hispanic and black youth

Grantees are funded, in part, through a collaboration with the HHS Office of Adolescent Health, President’s Teen Pregnancy Prevention Initiative and the Office of Population Affairs, Title X Program.

CDC teen pregnancy prevention grantee activities

Hartford, CT, Health and Human Services• Collaborate with CBOs and clinic partners that serve

Hispanics in area Population is 41% Hispanic; 38% black

• Implement ¡Cuidate! in English and Spanish Evidence-based intervention to reduce sexual risk behavior related to HIV

infection among Hispanic youth

• Increase bilingual communications efforts with targeted teen pregnancy prevention public awareness campaigns

• Sponsor parent education

CDC teen pregnancy prevention grantee activities

Fund for Public Health in New York• Work in South Bronx, Community District 2 and 3

• Population of 15−19 year old Hispanic youth is 65%

• Implement Reducing the Risk in 9th grade through school system

South Carolina Campaign to Prevent Teen Pregnancy • Provide training and technical assistance to partner

organizations on the ¡Cuidate! curriculum

Massachusetts Alliance on Teen Pregnancy• Collaborate with CBOs and clinical partners that serve

Hispanic populations in Springfield/Holyoke• Predominantly minority population (65% black and/or Hispanic) female ages

15−19

• Partner with the YEAH Network • Focus on reducing racial and ethnic health disparities and improving

reproductive health for Hispanic youth

• Implement ¡Cuidate!

CDC teen pregnancy prevention grantee activities

University of Texas Health Science Center,San Antonio• Work in south and southwest portion of Bexar

County (San Antonio) Population is >90% Hispanic

• Work with 15 Hispanic youth serving CBOs to implement evidence-based programs

• Translate all curricula and information into Spanish

CDC teen pregnancy prevention grantee activities

Estimated percentage of new HIV infections by race/ethnicity, 2006

Blacks45%

Whites35%

Hispanics17%

Asian/Pac. Isl.2%

American Indians/Alaska Natives

1%

Source: CDC surveillance data; Hall JAMA 2008

N = 56,300

HIV among Hispanics

• Diagnoses of HIV infection among Hispanics decreased from 2006−2009

• In 2009, the rate was 23 in Hispanic population• Hispanics are 3 times more likely to be living with

HIV than whites*• Hispanics account for 17% of new infections and

18% of people living with HIV

Source: CDC, HIV Surveillance Report,2009 (ww.cdc.gov/hiv/surveillance/resources/reports); Purcell National STD Prevention Conference 2010; National HIV Behavioral Surveillance System, Denning IAS 2010; *40 states with mature HIV reporting, year-end 2008;

CDC HIV prevention activities for Hispanics

• Work with local communities and health care providers to increase HIV testing, early diagnosis, and access to care for Hispanics

• Implement routine testing recommendations and expand testing in non-medical settings

• Provide training for researchers of minority ethnicities via the Minority HIV/AIDS Research Initiative

• Expand access to effective prevention programs to reach a broad spectrum of Hispanic populations

State-specific prevalence of obesity among Hispanic adults, 2006−2008

Source: CDC Behavioral Risk Factor Surveillance System

20−24 25−29 30−34 35+

More than 75% of Hispanic adults have unhealthy weight (38% are overweight and 39% are obese)

Source: Flegal K et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010; 303(3): 235-241

Hispanics have high rates of overweight and obesity

• Ranged from 21% (Maryland) to 37% (Tennessee) • Adult obesity rates for Hispanics are higher than those for

Whites in most states* • Adult obesity rates for Hispanics are ≥30% in 11 states*• Obesity rates for Hispanics high school students are 10%

higher than for white students*• 40% of Hispanic mothers and 38% of Hispanic toddlers are

overweight or obese**

Source: *F as in fat: How obesity threatens America’s future, 2010** Racial and ethnic differentials in overweight and obesity Among 3-year-old children, Am J Public Health, Feb 2007;97:298-305

Control prevalence and treatment for hypertension and cholesterol

are low for Mexican Americans

Source: Vital Signs, February 2011. www.cdc.gov/VitalSigns/CardiovascularDisease/index.html

Hypertension Cholesterol0

10

20

30

40

50

60PrevalenceTreatmentControl

Per

cent

age

38% of Hispanic children are overweight or obese

Cultural food intake factors • Equating overweight

with healthiness in children

• Use of food treats by parents as token of love and caring

Gorditos y colorados

• Taking a bottle to bed (14% do vs. 4% for blacks and 6% for whites)

Data for children between 2 and 19 years of age

Hispanics have the highest risk of developing diabetes of any group

Total population White Black Hispanic0

15

30

45

60

75

3327

4045

3931

4953

MenWomen

Perc

enta

ge

Source: Narayan KMV, JAMA, 2003

Estimated lifetime risk of developing diabetes for individuals born in the U.S., 2000

Mexican dishes are high in sodium

• Hispanics aged 2 and older consume 3,097 mg of sodium per day

• Mexican mixed dishes contribute • 7% of sodium intake in the diet of the general

population

• 11% of sodium intake in the diet of the Mexican-American population

Beef burritoCalories: 830Saturated fat: 10.5 gCholesterol: 95 mgSodium: 1,570 mgSugar: 1 g

Americanized Mexican food is high in calories, fat, and salt

• Rubio's Fresh Mexican Grill Carne Asada Taco with rice and beans: 710 calories and 22 g of fat

• Taco Bell Nachos Bell Grande: 770 calories and 39 g of fat

• Baja Fresh Steak quesadilla: 1,450 and 86 g of fat

Source: F as in fat: How obesity threatens America’s future, 2010

Age-adjusted prevalence of diabetes and percentage at high risk for diabetes (IFG), by country

of residence: 2001−2002

Mexico side U.S. side, Hispanics U.S. side, Whites0

5

10

15

20

25

1715

9

14 14 14

Diabetes IFG

Perc

enta

ge

IFG = Fasting Plasma Glucose ≥ 126 mg/dLSource: Diaz-Apodaca BA, Rev Panam Salud Publica, 2010

Prevalence of type 1 (T1) and type 2 (T2) diabetes among US youth, 2006

0−9 years 10−19 years

T1 T20

0.2

0.4

0.6

0.8

1

1.2

Prev

alen

ce (%

)

T1 T20

0.5

1

1.5

2

2.5

3

3.5

Prev

alen

ce (%

)

Source: SEARCH Study Group, Pediatrics, 2006

WhiteBlackAsian/Pac. Isl.Am. Ind./Al. N.Hispanic

Mexican Other Hispanic Black White0

2

4

6

8

10

8

5

6

5

7

5

4 4

Outside U.S.U.S.

Age

-Adj

. Pre

vale

nce

(%)

Age-adjusted prevalence of gestational diabetes, by race/ethnicity and country of birth: Kaiser-Permanente, Northern

CA, 1995-2004

Mexicans have a 60% higher prevalence of gestational diabetes than whites

CDC diabetes prevention activities for Hispanics

• Mobilize Communities to Reduce Diabetes: 5-year cooperative agreement with National Alliance for Hispanic Health (the Alliance)• Focus on Phoenix, AZ; Rio Rancho, NM, Watsonville, CA

• National Diabetes Education Program• Focus on Hispanics and other at-risk groups

Affordable Care Act (ACA)• Funds prevention at sustainable level• Lowers barriers to preventive care by eliminating

cost-sharing for critical services• HHS is working with state and local partners and

dispersing grant assistance to ensure that Americans get needed care

• ACA investments in public health workforce will benefit our communities for decades

ACA reduces health disparities by improving access to health care

• Preventive care:  Medicare and some insurance plans cover recommended preventive services

• Coordinated care:  Make investments in community health teams to manage chronic diseases

• Diversity and cultural competency: Increase racial and ethnic diversity in health care professions

ACA reduces health disparities by improving access to health care

• Health care providers for underserved communities: Expand health care workforce and increase funding for community health centers

• End insurance discrimination: People who have been sick can’t be excluded from coverage or charged higher premiums

• Affordable insurance coverage: Health insurance exchanges will offer one-stop shopping for individuals in the market for insurance

ACA national prevention strategy framework

• Goal (draft): Increase the number of Americans who live to 85 in good health

• Strategy focus (draft)• Healthy communities

• Preventive clinical and community efforts

• Empowered individuals

• Eliminating health disparities

CDC investment in ACA in Prevention of Public Health Funds:

$752M

National Prevention Strategyrecommendations (draft)

• Standardize and collect health data for diverse groups to identify and address disparities

• Expand community collaboration to plan and implement prevention policies and programs

• Ensure that prevention strategies are culturally, linguistically, and age appropriate

• Reduce community and cultural barriers to accessing clinical preventive services, especially among populations at greatest risk

Prevention and Public Health Fund• $145M to community transformation grants in 2011

to implement, evaluate, and disseminate evidence-based community preventive health activities to • Reduce chronic disease rates

• Prevent development of secondary conditions,

• Address health disparities

• Develop a stronger evidence-base of effective prevention programming

• $25M to Racial and Ethnic Approaches to Community Health (REACH)

REACH

• CDC effort to eliminate racial and ethnic health disparities in U.S.

• Hispanics targeted through 6 grantees: • University of Illinois at Chicago

• Hidalgo Medical Services, Silver City, NM

• Greater Lawrence Family Health Center, Lawrence, MA

• ABOR University of Arizona, Tucson, AZ

• YMCA of Santa Clara Valley, San Jose, CA

• Health Visions Midwest, Hammond, IN

Our goal

• Improve health of all populations and eliminate health disparities

• Ensure that Hispanic communities receive public health services that keep them safe and healthy