U.S. Latino Population: 1970 to 2010 (Population in Millions)

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1 60 50 U.S. Latino Population: 1970 to 2010 (Population in Millions) Average growth rate from 1970 to 2010 ~52%

2 Percent Latino in the U.S. Population 18% 16% 14% Latinos Mexican All Latinos = 12.5% All Latinos = 16.3% 12% 10% All Latinos = 9.0% 8% 6.4% 6% 4.7% 10.3% 4% 2% 6.1% 7.3% 0%

3 Data Source: U.S. Census Bureau, 2010 SF1 Percent Distribution of the Latino Population by Type of Origin: % 10.9% 9.2% 5.5% 63.0% 8.0% Mexican South American Cuban Non-Mexican Central American Puerto Rican Other Latinos

4 POPULATION PROJECTIONS TO 2050 Non-Hispanic Whites 210 million Hispanics 120 million (30%) African Americans (Blacks) 61 million Asian Origin 33 million Source: U.S. Bureau of the Census (2004)

5 AN EPIDEMIOLOGIC PARADOX Hispanics (except Cuban Americans) are socioeconomically disadvantaged, but have favorable overall mortality Markides and Coreil (1986) Risk factor profiles High rates of DIABETES High rates of OBESITY Similar rates of hypertension, cholesterol High SMOKING rates among men, lower among women (fewer cigarettes). Cuban American males smoke the most High ALCOHOL (binge) drinking rates among men, low among women. Alcohol consumption in women increases with acculturation Low rates of physical ACTIVITY Strong families Migration selection

6 AGING, MIGRATION AND MORTALITY: CURRENT STATUS OF RESEARCH ON THE HISPANIC MORTALITY PARADOX Data based on Vital Statistics show the greatest mortality advantage compared to Non-Hispanic Whites for all Hispanics combined. The advantage is greatest among older people. National Community Surveys linked to the National Death Index show a narrowing of the advantage and one study suggests that the Mexican origin mortality advantage (Palloni & Arias, 2004) can be attributed to selective return migration of less healthy immigrants to Mexico. The Medicare NUDIMENT data show a much lower advantage of Hispanic elders than the Vital Statistics Method. Markides & Eschbach, J. Gerontology: Social Sciences (2005)

7 CONCLUSION (Markides & Eschbach, 2005) The majority of the evidence continued to support a mortality advantage at a minimum for Mexican Americans. Greatest advantage is in old age. Self-reports of health status in old age do not support an advantage. Suggested that older Mexican Americans live longer with more disability. Data not yet available on trends in disability. Greatest challenge was Palloni & Arias (2004) suggestion of a salmon bias.

8 RECENT EVIDENCE OF A SALMON BIAS Turra & Elo (2008) used the Medicare- NUDIMENT data to examine the existence of a salmon bias. Data supported a salmon bias: foreign-born social security beneficiaries living abroad had higher mortality rates than foreign-born beneficiaries living in the U.S. Too small to explain mortality advantage. Effect of salmon bias on death rates is partially offset by the high mortality of Hispanic emigrants returning to the U.S.

9 A DIFFERENT TEST OF THE SALMON BIAS Hummer and colleagues examined infant mortality rates among Hispanics by nativity and in comparison to non-hispanic whites. They found that first hour, first day and first week mortality rates among infants born in the U.SA. to Mexican immigrant women are about 10% lower than those of infants of U.S. born non-hispanic white women. It is unlikely that such favorable rates are the result of out-migration of Mexican origin women and infants

10 EVIDENCE FROM MHAS (Wong and Colleagues) While there is considerable return migration back to Mexico, MHAS data show that the vast majority of return migrants are younger Very few older people return to Mexico because their children live in the U.S.

11 THE SES GRADIENT Turra & Goldman (2007) National Health Interview (NIH) linked the National Death Index (NDI) through Differences in mortality by education were smaller for Hispanic groups than for non-hispanic whites. Mortality advantage was greater among foreignborn than the native-born especially in old age. The Hispanic mortality advantage pertains primarily to persons of lower SES

12 MORTALITY AT YOUNGER AGES (Eschbach and Colleagues, 2007) Study used Texas and California vital registration data from linked to 2000 census population data. Focus on ages 15 to 44 where little attention had been paid and where consistent advantages have not always been found. Mortality advantage confined to foreign-born Hispanics. Advantages primarily attributed to social and behavioral causes (substance abuse, HIV, suicide)

13 OVERALL IMMIGRANT ADVANTAGE (Singh & Hyatt, 2006) Immigrant mortality advantage not confined to Hispanics. There appears to be an overall immigrant advantage which may have increased in recent years. Immigrant advantage was evident for cardiovascular diseases, major cancers, diabetes, respiratory diseases, suicide, and unintentional injuries. These trends due to growing heterogeneity of immigrant population, continuing advantages in behavioral characteristics, and migration selectivity. Asian/Pacific Islanders had the highest life expectancy followed by Hispanics and non-hispanic Whites. For each ethnic origin, there was an immigrant advantage except for Asian/Pacific Islanders which likely reflects compositional differences between the native-born and immigrants (Markides & Colleagues, 2007)

14 IMMIGRANT ENCLAVES Osypuk, Diez Roux, Hadley & Kandula (2009) used data from the Multi-Ethnic Study of Atherosclerosis in four U.S. cities (New York, Los Angeles, St Paul and Chicago). They found that high neighborhood immigrant concentration was associated with lower consumption of high fat foods among Hispanics and Chinese but also less walk ability, fewer recreational exercise resources, worse safety, and other negative characteristics.

15 HISPANIC PARADOX IN BIOLOGICAL PROFILES (Crimmins & Colleagues, 2007) Use NHANES ( ) to compare blood pressure, metabolic, and inflammatory risk profiles. After controls for SES differences U.S. born Mexican Americans had higher biological risk scores than did non-hispanic Whites and foreign-born Mexican Americans. There were no differences between foreign-born Mexican Americans and non-hispanic Whites leading some to the notion of migration selectivity and superior health behaviors of immigrants.

16 A TEST OF THE HEALTHY MIGRANT EFFECT USING DATA FROM THE MEXICAN FAMILY LIFE SURVEY (Rubalcava, Teruel, Thomas et al, 2008) 6446 respondents aged in Some moved to the U.S. during the next three years. Health significantly predicted migration among females and rural males. However associations were weak with considerable variation in the estimates between males and females and between urban and rural dwellers. Note: Small numbers of migrants might be a problem: 113 rural men; 87 urban men; 90 rural women, and 52 urban women

17 UNITED STATES LIFE TABLES BY HISPANIC ORIGIN (2006) E. Arias, NCHS, 2010 Life Expectancy at Birth Total Male Female Hispanic: Non-Hispanic White Non-Hispanic Black Adjusted for misclassification of race and Hispanic origin on death certificates. 80+ rates for Hispanics based on Non-Hispanic White rates.

18 Immigrant Health in Australia Australia Institute of Health and Welfare, (2002) Almost all immigrants demonstrate good, if not better health on arrival and for some years following than does the Australian population (exceptions for breast cancer among U.K. and Irish-born) Biddle et al, (2007) Health of Australian immigrants is better than the Australian-born population but the longer immigrants spend in Australia the closer their health approximates that of the Australian-born population (especially from non-english or non-european countries)

19 Immigrant Health in Australia, cont. Jetrana et al, (2014) Immigrants from both English-speaking and non- English speaking countries, reported fewer chronic conditions than the native-born. There was a convergence to native levels after about 20 years. Chriswik et al, (2008) immigrant health is poorest for refugees and best for independent (economic) migrants. Declines over time

20 Immigrant Health in Canada Chen et al, (1996) Immigrants, especially those from non-eurpoean countries, had a longer life expectancy and more years of life free of disability and dependency than did the Canadian-born McDonald & Kennedy, (2004) Evidence of a healthy immigrant effect in the incidence of chronic conditions. Slow convergence to native levels, over about 20 years. Immigrant advantage is real and not the result of screening levels.

21 Immigrant Health in Canada cont. Gee et al, (2007) Recent immigrants (< 10 yrs) aged were advantaged. Not those aged 65 and over. Gushulak et al, (2011) in general, newly arriving immigrants are healthier than the Canadian population but over time there is a decline in this health immigrant effects

22 CONCLUSIONS/NEXT STEPS Migration selection still most viable explanation A Healthy migrant effect is found in most immigrant groups to the U.S., but also to Canada and Australia. Salmon bias exists but has minor effects. Immigrant communities. Need search for mechanisms. Low class has different meanings for Mexican Immigrants than for non-hispanic Whites and African Americans. Increasing rates of obesity and diabetes including in old age. Hispanic EPESE data suggest increases in the prevalence of diabetes, disability, and cognitive impairment in very old Mexican Americans. Need closer examination of changes with time in the U.S. in health behaviors, diet, and obesity.

23 A LONGITUDINAL STUDY OF THE HEALTH OF MEXICAN AMERICAN ELDERLY (HISPANIC EPESE) FUNDED BY NIA UTMB, GALVESTON, TX PI, Kyriakos S. Markides,Ph.D. CO-INVESTIGATORS: Soham Al Snih, MD., PhD Karl Eschbach, Ph.D. James S. Goodwin, MD. Yong-Fang Kuo, Ph.D. Biostatistician. Kenneth Ottenbacher, Ph.D. M. Kristen Peek, Ph.D. Mukaila Raji, MD.. Laura A. Ray, M.P.A. -Project Director Nai-Wei Chen, PhD Project Director, Rebeca Wong, Ph.D. NIA STAFF: Georgeanne Patmios FIELD STAFF: Harris Interactive, Inc. OUTSIDE CONSULTANTS: Carlos Mendes de Leon, Ph.D. Robert Wallace, MD. Maria Aranda, Ph.D. Richard Schulz, Ph.D.

24 Investigators - continued UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER, SAN ANTONIO, TX CO-INVESTIGATORS: PI Ray Palmer, Ph.D., Biostatistician Co-Investigator, Donald Royall, MD UNIVERSITY OF TEXAS, AUSTIN, TX PI, Ronald J. Angel, Ph.D. CO-INVESTIGATOR: Jacqueline Angel, Ph.D.

25 SAMPLING PROCEDURES Area probability multi-stage sample of Mexican Americans aged 65 and over residing in the five Southwestern states (Texas, New Mexico, Colorado, Arizona, and California) (Non-institutionalized population). Baseline data collected during N = 3,050 (Additional 902 aged 65+ added at 5 th wave).

26 Hispanic EPESE Summary: Baseline, Wave 2, Wave 3, Wave 4, Wave 5 and Wave 6 Total Proxy + Deceased Refused Not Located Age Added Sample Combined (925 Informants) Cumulative deceased=2259 at end Wave 7 Updated 2/27/2012

27 Hispanic EPESE Summary: Baseline, Wave 2, Wave 3, Wave 4, Wave 5 and Wave 6

28 Table 5: Trends in the health of older Mexican Americans aged 75 + Men Women Health Conditions ADL Disability ( 1) (20.2) (29.7) (26.8) (41.2) Diabetes mellitus (21.3) (31.3) (21.5) (34.8) Hypertension (49.8) (61.7) (60.5) (69.6) Stroke (9.6) (14.9) (10.0) (12.9) Obesity (BMI 30) (18.0) (22.8) (26.7) (31.5) Cognitive impairment (MMSE < 21) 96 (23.2) 310 (41.3) 157 (26.0) 477 (40.3) Total N

29 Odds Ratios from Logistic Regression of Predictors of Surviving to Age 85 Hispanic EPSESE (1993/ /2011) Survived to Age 85 Demographics Education 0.98 ( ) Female 1.42** ( ) Born outside U.S. 1.23* ( ) Health Status No Diabetes 1.97*** ( ) No Hypertension 1.25* ( ) No Heart Attack 1.29 ( ) No Stroke 1.01 ( ) No Cancer 1.35 ( ) No Depression 1.26* ( ) Underweight 0.71** ( ) Overweight 0.96 ( ) Obese 0.72 ( ) Health Behavior Currently smokes 0.54*** ( )

30 Stage I Stage II Stage III Stage IV Community Context Stressors/Strains Major Life Events Financial Strain Cognitive Function Sociodemographic Variables Age, Gender, Social Class, Acculturation, Migration History Social Support Medical Conditions Impairments/Limitations Sensory, Physical, etc. Physical Function Emotional Function Institutionalization/ Changes in Living Arrangements Health Service Use/ Access Mortality Figure 1. Conceptual Model

31 COLLABORATIONS Mexican Health and Aging Study (MHAS) Puerto Rican Health Conditions Study (PREHCO) SABE Studies (Chile, Mexico, Uruguay, Brazil, Cuba, Argentina, Barbados) Colombia, Frailty and Cognitive Function (Carlos Cano) Mexico, Frailty and Cognitive Function (L.M. Guiterrez)