Transcript Health Disparities in Los Angeles

Health Disparities,
in Los Angeles, the state
of California, & the US
Antronette (Toni) Yancey, MD, MPH
Professor (7/1/07), Health Services
Co-Director, Center to Eliminate Health
Disparities
Staying healthy is easier for
some than for others…
UPPER SES
LOWER SES
Education
College
GED or HS
Housing
Own / Safe
Rent / Safe?
Physical activity
Gyms /Parks, “move
Parks?, “move insecure”
secure”
Neighborhood stores
Fruit/Veg, food secure
Drugs/Alcohol, food insecure
Police
Helpful
Abusive
Healthcare
Private Doc
Sick leave
Accrued
None
Leisure priority
Exercise
Rest
Work conditions
Safe, hi decis. lat.,
+flex time
Child care
Nanny/hi-qual facil.
ER, VA
Hazardous, lo decis. lat., no
no flex time
Family/neighbor, lo-qual facil.
Elder/disabled care
HHW/hi-qual facil.
Family/neighbor, lo-qual facil.
Criminal just. sys.
Little contact
Much contact
Premature M&M
Low
High
Marketing Expenditures, CMR, 2005
(in millions)
$123.4
$43.9
$35.7
$22.8
$17.5
$10.5
$0.0
Coca Cola
Diet Coke
Odwalla
Minute Maid
Dasani
Powerade
Sprite
Years of Potential Life Lost
by Ethnicity (per 100,000)
14000
12000
10000
Afr Am
Am Ind
AsianPI
Latino
White
8000
6000
4000
2000
0
Total
Years of Potential Life Lost
by Ethnicity (per 100,000)
14000
12000
10000
Total
Cancer
Heart Disease
Unint. Injury
Homicide
Diabetes
8000
6000
4000
2000
0
African
Am
Asian Latinos Native
Am
Am
whites
Death rates by cause for persons aged 45 to 65, 1995
600
Deaths per 100,000 persons
Men
500
N-H White
Black
Asian
Am Ind
Hispanic
400
Women
300
200
100
0
Heart Disease
Cancer
Source: National Center for Health Statistics
Heart Disease
Cancer
Years of Potential Life Lost to Diabetes
YPLL before age 75 y per
100,000 population
500
N-H White
Black
Hispanic
Asian or PI
Am Ind
450
400
350
300
250
200
150
100
50
0
Men
Women
Age-adjusted, 1998 data
Source: National Center for Health Statistics, Health US 2000, table 31
Black-White Mortality Ratios:
Women in the U.S.
Cause
Black-White Ratio
Heart disease
1.63
Cancer
1.21
Diabetes
3.00
Pulmonary disease
0.68
Age-Adjusted Prevalence of
Overweight & Obese by Race –
NHANES Adults
90
80
70
60
50
40
30
20
10
0
77.3
74.7
71.9
67.4
60.7
57.3
49.7
39.7
27.3 28.128.9
30.1
Men
Whites
Blacks
Women
Hispanic
Whites
Blacks
Left bars = BMI 25.0 or higher; right bars = BMI 30.0 or higher
Hispanics
Adult Obesity: 1988-94 to 1999-2000
Race/Ethnicity
1988-94
Target
Total
White
Female
Male
Black
Female
Male
Mexican American
Female
Male
0
10
20
Percent
30
Note: Data are for ages 20 years and over, age adjusted to the 2000 standard population.
Obesity is defined as BMI >= 30.0. Black and white exclude persons of Hispanic origin. Persons
of Mexican-American origin may be any race.
Source: National Health and Nutrition Examination Survey, NCHS, CDC.
40
50
Obj. 19-2
Race / Ethnic Composition of the
Los Angeles County Population, 1990 and 2000
1990
2000
n= 8,863,164
n=9,519,338
Latino
Latino
Black
37.8%
44.6%
10.5%
9.5%
10.2%
Black
Asian/PI
40.8%
0.7%
31.1%
Other
White
12.0%
2.8%
White
Other
Asian/PI
Los Angeles County
Service Planning Areas
Antelope Valley
San Fernando
San Gabriel
West

Metro
South
UCLA
South Bay
East
Percentage of Adults (Age 18 years and older)
living below 200% of Federal Poverty Level,
by Service Planning Area, Los Angeles County, 1999
100%
90%
80%
73%
70%
60%
50%
48%
50%
40%
36%
33%
30%
Antelope
Valley
San
Fernando
LA County
40%
35%
29%
30%
20%
10%
0%
San Gabriel
Metro
West
South
East
South Bay
1999-2000 Los Angeles County Health Survey
Department of Health Services, Public Health
Percentage of Children (17 years old)
Living in Poverty by Race/Ethnicity,
Los Angeles County, 1999-2000
100%
90%
80%
70%
60%
50%
46%
37%
40%
30%
21%
20%
9%
10%
0%
Latino
White
African American
Asian/Pacific
Islander
1999-2000 Los Angeles County Health Survey
Department of Health Services, Public Health
Life Expectancy at Birth by Sex and Race/Ethnicity,
Los Angeles County, 1998
85
80.7
79.8
80
78.0
77.8
77.7
76.4
Years
75
74.3
74.3
Male
72.5
Female
70
66.4
65
60
Total
White
Latino
Black
Asian/PI
Infant Mortality Rate by Mother’s Race/Ethnicity,
Los Angeles County, 1991-2000
20
Rate per 1,000 live births
18
16
14
White
12
Latino
10
8
African
American
6
Asian/ Pacific
Islander
4
2
0
1991
1992
1993
1994
1995
1996
Year
1997
1998
1999
2000
Trends in the Leading Causes of Death,
Los Angeles County, 1991-2000
Rate (per 100,000)
Cause of death
1991
2000
Percent change
280.4
187.4
-35.5%
Stroke
64.1
48.9
-23.8%
Pneumonia/Influenza
42.9
40.6 *
-5.3%
Lung cancer
49.8
36.9
-25.8%
Chronic respiratory disease
34.1
32.7
-4.0%
Diabetes
14.6
21.7
+48.2%
Unintentional Injury
29.2
20.8
-28.6%
Chronic liver disease
15.4
12.7
-17.5%
Homicide
20.1
9.8
-51.3%
Suicide
11.5
7.6
-34.3%
HIV/AIDS
23.2
5.3
-77.1%
3.7
4.8 *
+28.3%
Coronary heart disease
Alzheimer disease
* 1998 rate
Prevalence of Obesity among LAC
Adults by Ethnicity, 1997-2002
35
30
25
20
1997
1999
2002
15
10
5
0
Afr-Am
API
Latino
White
Physical Activity Levels, %
L.A. County Adults, 1999
District
Sedentary (<10 min/wk)
County
41
+1
Compton
45
+6
South
50
+9
Inglewood
46
+6
Long Beach
37
+5
West
31
+3
Physical Inactivity Levels:
TV viewing/computer use, %
L.A. County Adults, 1999
Ethnic Group
TV/Computer Use
>3 hrs/d (95% CI)
County total
21.7
20.6-22.9
African Americans
36.5%
32.4-40.5
American Indian
34.2%
16.1-52.3
Asian/Pacific Isl.
21.1%
17.6-24.6
Latino
15.8%
14.3-17.3
White
24.3%
22.4-26.2
Physical Activity Levels:
TV viewing>2 hrs/d vs. regular PA, %
California adolescents, 2001
Group
TV Viewing Regular PA
>2 hrs/d
CDC/ACSM def.
African-American
males
67.5%
79.9%
African-American
females
62.4%
67.7%
White males
47.9%
81.4%
White females
39.2%
71.2%
Prevalence of Overweight Among
Children and Adolescents in the United States
(NHANES)
Prevalence (%)
20
15
10
5
0
1963-65
1971-74
1976-80
1988-94
1999-2000
NHANES Study Period
6-11 years of age
12-19 years of age
Prevalence of Overweight Among Children in
Grades 5, 7, and 9, Los Angeles County, 2001
(California Physical Fitness Testing Program)
40
At Risk
Overweight
Prevalence (%)
30
20
10
0
White
Latino
Black
Asian
Pacific American
Islander
Indian
Percentage of Children (Age 3 to 17 years) Whose Parents
Report Not Having a Park, Playground,
or Other Safe Place They Can Get to Easily, by Household
Income, Los Angeles County, 1999-2000
70%
60%
50%
40%
33%
27%
30%
20%
15%
11%
10%
0%
< 100% FPL*
*Federal Poverty Level
100% to < 200% FPL
200% to < 300% FPL
> 300% FPL
1999-2000 Los Angeles County Health Survey
Department of Health Services, Public Health
Major Points

Significant reductions in mortality in the county
population over the past decade.

Large disparities in health persist across
racial/ethnic and socioeconomic groups.

Chronic non-infectious diseases and injuries
comprise the predominant sources of morbidity
and mortality; need to address underlying
determinants.

Ongoing demographic shifts likely to shape
future public health and health care needs.
Current Population Status


Little change in leisure time physical activity (PA) during past
several decades of obesity increases (1 in 5), but marked
increases in sedentary entertainment, transportation, and
other ADLs (Sturm, 2004)
PA levels within increasingly sedentary, deconditioned,
overweight population are unlikely to increase primarily
through individual motivation and volition—relatively little
demand for goods & services or political will to push for
aggressive legislative policy change, e.g., radical alteration in
the built environment favoring bicycle, pedestrian, and mass
transit over private automobile transportation
Population benefit estimates of risk
factor change: PA
3-minute bouts of PA 10 times per day lowers
serum triglycerides to same extent as 1
continuous 30-minute bout of PA (Miyashita et
al., 2006)
 Type 2 DM risk was 50% lower among
individuals physically active at any level, and 66%
lower among those at least moderately active
(James et al., 1998)
 Sedentary behaviors (e.g., TV watching) as well
as sub-optimal >moderate PA levels contributed
to DM & obesity risk over 6 yrs in women (Hu
et al., 2003)

Population Obesity Control:
Early stage in development
To avoid exacerbating health risk/disease burden
disparities, push strategies (skip-stop or slowed
hydraulic elevators, proximal parking restrictions,
non-discretionary time exercise breaks, walking
meetings, mass transit & distant parking
incentives) should be prioritized over pull
strategies (building trails & parks, offering gym
membership subsidies/discounts)—make it easier
to do it than not to do it!
Lesser Effectiveness of Key Environmental
Interventions in Underserved Groups:
Example
Posting of Signs Promoting Stair Usage





(suburban Baltimore mall)
Overall, stair use increased from 4.8% to 6.9%, 7.2%,
depending upon which of 2 signs used
Among whites, increased from 5.1% to 7.5%, 7.8%
Among blacks, changed from 4.1% to 3.4%, 5.0%
Among n’l wt, inc from 5.4% to 7.2%, 6.9%
Among overwt, inc from 3.8% to 6.3%, 7.8%
Andersen, Franckowiak, Snyder et al., Ann Int Med, 1998;129:363-369.
Community “Cost-Sharing:”
Policy Change Opportunities
1.
Leveraging your managerial and fiscal roles to
mandate or incentivize healthy/fit workplace
practices for your subsidiaries, suppliers,
community-based organizations (CBOs) to which
you donate $, health plans with which you
contract, etc.
2. Changing your internal organizational culture
(social norms) to create healthy/fit organizational
practices, in your social life and in your
workplaces.
Community “Cost-Sharing”
“Healthy/fit” organizational PA promotion practices include
core & elective components, e.g., 10’ movement (or walking)
breaks in meetings/ functions & at certain time(s) of day;
walking meetings; stair prompts & improvements; leading
employee groups to stairs in moving between work activities;
restricted near parking; distant parking & mass transit
incentives; model & reward fidgeting and lifestyle PA
integration (e.g., less high heel & tie wearing, more pedometer
wearing, formal recognition/ kudos to those who
walk/jog/swim during lunchtime)
Translating Evidence-Based CDC/ACSM
Recommendation into Practice: Building on
cultural assets
Integrating 10-’ PA into organizational routine:
 Movement to music integral to African-American, Latino culture—
dancing normative for adults
 Short bouts minimize perspiration, hairstyle disturbance
 Social support & conformity desires drive participation (collectivist
vs. indiv. orientation)
 Addresses less activity conducive outdoor environments
(safety, utility, aesthetics)
 Designed for organizational settings for work, worship,
other purposes--less disposable t, $
Lift Offs Work!:
the Rapidly Growing Evidence Base





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Documented individual and organizational receptivity to
integrating PA on paid work time
Contribute meaningfully to daily accumulation of MVPA
Motivational “teachable moment” linking sedentariness to
health status for inactive folks
Improvements in clinical outcomes from as little as one 10min. break/day—BP, BMI, waist circ., mood, attention
span, cumulative trauma disorders
“Spill-over” or generalization to inc. active leisure
Favorable cost-benefit ratio, eg, L.L. Bean mfg plant
WIC Staff Wellness Training
Community “Cost-Sharing”
3. Address K-12 PE deficiencies:

Require use of evidence-based curricula focusing on
cooperation vs. competition, lifetime PA, maximizing
MVPA/session, behavioral mgt (e.g., self-monitoring, goal
set.) vs. motor skill dev. focus

Include in core curriculum, with same resources,
monitoring & accountability as reading, math

Increase mandated t to 1 hr daily instruction K-12

Require training in PE instruction in all undergraduate
education curricula

Require elementary-level PE to be taught by certified PE
specialists

Institute PE class size caps of <35
% PE class time in MVPA
by % FRPL-eligibility
& by district avg. Fitnessgram scores
50%
% class time in MVPA
39.9%
40%
33.4%
29.6%
30%
low
fitnessgram
districts,
21.2%
20%
10%
29.7%
low
fitnessgram
districts,
14.4%
0%
0-33% FRPL
34-66% FRPL
low fitnessgram districts
67-100% FRPL
high fitnessgram districts
Avg. amount of PE class time in MVPA
by class size (secondary schools only)
37.0%
% of class time PA≥3
37%
33.1%
26.5%
30%
22.4%
22%
15%
N=6
N=12
N=12
N=10
7%
0%
<=25
26-35
36-45
>45
Class Size
The amount of P.E. class time that students were
physically active was less in larger classes.
Relationship between PE Quality (%class t in MVPA)
& API Score in High & Low SES Schools
800.0
Min. PE-MVPA/wk
dichot
0-49 min/wk
50+ min/wk
Mean 3 year avg API score
750.0
700.0
650.0
750.3
600.0
702.9
n=6
n=4
617.7
550.0
584.2
n=2
n=3
500.0
<35%
>=75%
%FRPL 3yr avg
Community “Cost-Sharing”
4. Local legislative policy advocacy:
Redress inequitable distribution of free-for-use recreational
facilities favoring high-income areas and poor upkeep of
parks & playgrounds in low-income areas
--explore litigation (Public Health Law Center)
--explore limited liability protection (“Good Samaritan”
laws) for organizations making facilities available for joint
use before-/after-hours
--explore incentives for locating supermarkets & other
produce vendors in low-income areas
Community “Cost-Sharing”
“We must be the
change
we wish to see in the
world.”
--Mahatma Gandhi