health disparities, in los angeles, the state of california, & the us antronette (toni) yancey,...
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Health Disparities,Health Disparities, in Los Angeles, the in Los Angeles, the state of California, state of California,
& the US& the USAntronette (Toni) Yancey, MD, MPHAntronette (Toni) Yancey, MD, MPH
Professor (7/1/07), Health ServicesProfessor (7/1/07), Health Services
Co-Director, Center to Eliminate Co-Director, Center to Eliminate Health DisparitiesHealth Disparities
Staying healthy is easier for Staying healthy is easier for some than for others…some than for others…
UPPER SES UPPER SES LOWER SESLOWER SES
EducationEducation College College GED or HS GED or HS
HousingHousing Own / SafeOwn / Safe Rent / Safe?Rent / Safe?
Physical activityPhysical activity Gyms /Parks, “move Gyms /Parks, “move Parks?, “move Parks?, “move insecure”insecure”
secure”secure”
Neighborhood storesNeighborhood stores Fruit/Veg, food secureFruit/Veg, food secure Drugs/Alcohol, food insecure Drugs/Alcohol, food insecure
PolicePolice HelpfulHelpful AbusiveAbusive
HealthcareHealthcare Private Doc Private Doc ER, VA ER, VA
Sick leaveSick leave Accrued Accrued NoneNone
Leisure priorityLeisure priority ExerciseExercise RestRest
Work conditionsWork conditions Safe, hi decis. lat.,Safe, hi decis. lat., Hazardous, lo decis. Hazardous, lo decis. lat., no lat., no +flex time+flex time no flex timeno flex time
Child careChild care Nanny/hi-qual facil.Nanny/hi-qual facil. Family/neighbor, lo-qual facil.Family/neighbor, lo-qual facil.
Elder/disabled careElder/disabled care HHW/hi-qual facil.HHW/hi-qual facil.Family/neighbor, lo-qual facil.Family/neighbor, lo-qual facil.
Criminal just. sys.Criminal just. sys. Little contactLittle contact Much contactMuch contact
Premature M&MPremature M&M LowLow HighHigh
Marketing Expenditures, CMR, 2005(in millions)
$123.4
$22.8
$0.0
$35.7
$17.5$10.5
$43.9
Coca Cola Diet Coke Odwalla Minute Maid Dasani Powerade Sprite
Years of Potential Life LostYears of Potential Life Lostby Ethnicity (per 100,000)by Ethnicity (per 100,000)
0
2000
4000
6000
8000
10000
12000
14000
Total
Afr AmAm IndAsianPILatinoWhite
Years of Potential Life LostYears of Potential Life Lostby Ethnicity (per 100,000)by Ethnicity (per 100,000)
0
2000
4000
6000
8000
10000
12000
14000
AfricanAm
AsianAm
Latinos NativeAm
whites
Total
Cancer
Heart Disease
Unint. Injury
Homicide
Diabetes
0
100
200
300
400
500
600
Heart Disease Cancer Heart Disease Cancer
N-H White Black Hispanic
Asian Am Ind
Source: National Center for Health Statistics
Death rates by cause for persons aged 45 to 65, 1995
Men
Women
Dea
ths
per
100,
000
pers
ons
0
50
100
150
200
250
300
350
400
450
500
Men Women
N-H White Black Hispanic Asian or PI Am Ind
Age-adjusted, 1998 data
Source: National Center for Health Statistics, Health US 2000, table 31
Years of Potential Life Lost to Diabetes
YP
LL b
efo
re a
ge 7
5 y
p
er
10
0,0
00
pop
ula
tion
Black-White Mortality Black-White Mortality Ratios:Ratios:
Women in the U.S.Women in the U.S.CauseCause Black-White RatioBlack-White Ratio
Heart diseaseHeart disease 1.631.63
CancerCancer 1.211.21
DiabetesDiabetes 3.003.00
Pulmonary diseasePulmonary disease 0.680.68
Age-Adjusted Age-Adjusted Prevalence of Prevalence of
Overweight & Obese by Overweight & Obese by Race – NHANES AdultsRace – NHANES Adults
28.1
49.7
28.9
39.7
67.4
57.360.7
77.374.771.9
27.3 30.1
0102030405060708090
Men Women
Whites Blacks Hispanic Whites Blacks Hispanics
Left bars = BMI 25.0 or higher; right bars = BMI 30.0 or higher
Obj. 19-2
Total
White Female
Male
Black Female
Male
Mexican American Female
Male
Target
Adult Obesity: 1988-94 to 1999-2000
0 10 20 30 40 50
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.
Percent
1988-94Race/Ethnicity
Race / Ethnic Composition of the Race / Ethnic Composition of the Los Angeles County Population, 1990 and 2000Los Angeles County Population, 1990 and 2000
Black
Asian/PI
Other
Latino
White
Black
Asian/PI
OtherWhite
Latino
1990n= 8,863,164
2000n=9,519,338
37.8%
0.7%40.8% 31.1% 12.0%
9.5%
44.6%
10.2%
10.5%
2.8%
Los Angeles CountyLos Angeles County
Service Planning AreasService Planning Areas
Percentage of Adults (Age 18 years and older) Percentage of Adults (Age 18 years and older) living below 200% of Federal Poverty Level, living below 200% of Federal Poverty Level,
by Service Planning Area, Los Angeles County, 1999by Service Planning Area, Los Angeles County, 1999
30%
50%
29%
73%
48%
33%35%36%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AntelopeValley
SanFernando
San Gabriel Metro West South East South Bay
LA County40%
1999-2000 Los Angeles County Health Survey
Department of Health Services, Public Health
Percentage of Children (Percentage of Children (17 years old) 17 years old) Living in Poverty by Race/Ethnicity, Living in Poverty by Race/Ethnicity,
Los Angeles County, 1999-2000Los Angeles County, 1999-2000
46%
9%
37%
21%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Latino White African American Asian/PacificIslander
1999-2000 Los Angeles County Health Survey
Department of Health Services, Public Health
Life Expectancy at Birth by Sex and Race/Ethnicity, Life Expectancy at Birth by Sex and Race/Ethnicity, Los Angeles County, 1998Los Angeles County, 1998
74.3 74.3
76.4
66.4
77.878.0 77.7
79.8
72.5
80.7
60
65
70
75
80
85
Total White Latino Black Asian/PI
Yea
rs
Male
Female
Infant Mortality Rate by Mother’s Race/Ethnicity, Infant Mortality Rate by Mother’s Race/Ethnicity, Los Angeles County, 1991-2000Los Angeles County, 1991-2000
0
2
4
6
8
10
12
14
16
18
20
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Year
Rat
e p
er 1
,000
liv
e b
irth
s
White
Latino
AfricanAmerican
Asian/ PacificIslander
Trends in the Leading Causes of Death,Trends in the Leading Causes of Death,Los Angeles County, 1991-2000Los Angeles County, 1991-2000
Rate (per 100,000)
Cause of death 1991 2000 Percent change
Coronary heart disease 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%
Alzheimer disease 3.7 4.8 * +28.3%
* 1998 rate
Prevalence of Obesity Prevalence of Obesity among LAC Adults by among LAC Adults by Ethnicity, 1997-2002Ethnicity, 1997-2002
0
5
10
15
20
25
30
35
Afr-Am API Latino White
199719992002
Physical Activity Levels, Physical Activity Levels, %%
L.A. County Adults, 1999L.A. County Adults, 1999DistrictDistrict Sedentary Sedentary (<10 min/wk)(<10 min/wk)
CountyCounty 4141 ++11
ComptonCompton 4545 ++66
SouthSouth 5050 ++99
InglewoodInglewood 4646 ++66
Long BeachLong Beach 3737 ++55
WestWest 3131 ++33
Physical Inactivity Levels:Physical Inactivity Levels: TV viewing/computer use, %TV viewing/computer use, %
L.A. County Adults, 1999L.A. County Adults, 1999
Ethnic GroupEthnic Group TV/Computer Use TV/Computer Use
>3 hrs/d >3 hrs/d (95% CI)(95% CI)
County totalCounty total 21.721.7 20.6-22.920.6-22.9African African AmericansAmericans
36.5%36.5% 32.4-40.532.4-40.5
American American IndianIndian
34.2%34.2% 16.1-52.316.1-52.3
Asian/Pacific Asian/Pacific Isl.Isl.
21.1%21.1% 17.6-24.617.6-24.6
LatinoLatino 15.8%15.8% 14.3-17.314.3-17.3
WhiteWhite 24.3%24.3% 22.4-26.222.4-26.2
Physical Activity Levels:Physical Activity Levels: TV viewing>2 hrs/d vs. regular TV viewing>2 hrs/d vs. regular
PA, %PA, %California adolescents, 2001California adolescents, 2001
GroupGroup TV Viewing Regular PATV Viewing Regular PA >2 hrs/d >2 hrs/d CDC/ACSM CDC/ACSM
def.def.
African-American African-American malesmales
67.5%67.5% 79.9%79.9%
African-American African-American femalesfemales
62.4%62.4% 67.7%67.7%
White malesWhite males 47.9%47.9% 81.4%81.4%White femalesWhite females 39.2%39.2% 71.2%71.2%
Prevalence of Overweight Among Prevalence of Overweight Among Children and Adolescents in the United StatesChildren and Adolescents in the United States
(NHANES) (NHANES)
0
5
10
15
20
1963-65 1971-74 1976-80 1988-94 1999-2000
NHANES Study Period
Pre
vale
nce
(%
)
6-11 years of age 12-19 years of age
Prevalence of Overweight Among Children in Prevalence of Overweight Among Children in Grades 5, 7, and 9, Los Angeles County, 2001Grades 5, 7, and 9, Los Angeles County, 2001(California Physical Fitness Testing Program)(California Physical Fitness Testing Program)
0
10
20
30
40
White Latino Black Asian PacificIslander
AmericanIndian
Pre
va
len
ce
(%
)
At Risk
Overweight
Percentage of Children (Age 3 to 17 years) Whose Parents Report Percentage of Children (Age 3 to 17 years) Whose Parents Report Not Having a Park, Playground, Not Having a Park, Playground,
or Other Safe Place They Can Get to Easily, by Household or Other Safe Place They Can Get to Easily, by Household Income, Los Angeles County, 1999-2000Income, Los Angeles County, 1999-2000
33%
27%
15%11%
0%
10%
20%
30%
40%
50%
60%
70%
< 100% FPL* 100% to < 200% FPL 200% to < 300% FPL > 300% FPL
*Federal Poverty Level1999-2000 Los Angeles County Health Survey
Department of Health Services, Public Health
Major PointsMajor Points
Significant reductions in mortality in the county Significant reductions in mortality in the county population over the past decade.population over the past decade.
Large disparities in health persist across racial/ethnic Large disparities in health persist across racial/ethnic and socioeconomic groups.and socioeconomic groups.
Chronic non-infectious diseases and injuries comprise Chronic non-infectious diseases and injuries comprise the predominant sources of morbidity and mortality; the predominant sources of morbidity and mortality; need to address underlying determinants.need to address underlying determinants.
Ongoing demographic shifts likely to shape future Ongoing demographic shifts likely to shape future public health and health care needs.public health and health care needs.
Current Population StatusCurrent Population Status
Little change in leisure time physical activity (PA) Little change in leisure time physical activity (PA) during past several decades of obesity increases (1 during past several decades of obesity increases (1 in 5), but marked increases in sedentary in 5), but marked increases in sedentary entertainment, transportation, and other ADLs entertainment, transportation, and other ADLs (Sturm, 2004)(Sturm, 2004)
PA levels within increasingly sedentary, PA levels within increasingly sedentary, deconditioned, overweight population are unlikely deconditioned, overweight population are unlikely to increase to increase primarilyprimarily through individual motivation through individual motivation and volition—relatively little demand for goods & and volition—relatively little demand for goods & services or services or political willpolitical will to push for aggressive to push for aggressive legislative policy change, e.g., radical alteration in legislative policy change, e.g., radical alteration in the built environment favoring bicycle, pedestrian, the built environment favoring bicycle, pedestrian, and mass transit over private automobile and mass transit over private automobile transportationtransportation
Population benefit estimates of Population benefit estimates of risk factor change: PArisk factor change: PA
3-minute bouts of PA 10 times per day 3-minute bouts of PA 10 times per day lowers serum triglycerides to same extent lowers serum triglycerides to same extent as 1 continuous 30-minute bout of PA as 1 continuous 30-minute bout of PA (Miyashita et al., 2006)(Miyashita et al., 2006)
Type 2 DM risk was 50% lower among Type 2 DM risk was 50% lower among individuals physically active individuals physically active at any levelat any level, , and 66% lower among those at least and 66% lower among those at least moderately active (James et al., 1998)moderately active (James et al., 1998)
Sedentary behaviors (e.g., TV watching) Sedentary behaviors (e.g., TV watching) as well as sub-optimal as well as sub-optimal >>moderate PA moderate PA levels contributed to DM & obesity risk levels contributed to DM & obesity risk over 6 yrs in women (Hu et al., 2003)over 6 yrs in women (Hu et al., 2003)
Population Obesity Control: Population Obesity Control: Early stage in developmentEarly stage in development
To avoid exacerbating health risk/disease To avoid exacerbating health risk/disease burden disparities, burden disparities, pushpush strategies (skip- strategies (skip-stop or slowed hydraulic elevators, proximal stop or slowed hydraulic elevators, proximal parking restrictions, non-discretionary time parking restrictions, non-discretionary time exercise breaks, walking meetings, mass exercise breaks, walking meetings, mass transit & distant parking incentives) should transit & distant parking incentives) should be prioritized over be prioritized over pullpull strategies (building strategies (building trails & parks, offering gym membership trails & parks, offering gym membership subsidies/discounts)—subsidies/discounts)—make it easier to make it easier to dodo it it than than notnot to do it! to do it!
Lesser Effectiveness of Key Lesser Effectiveness of Key Environmental Interventions in Environmental Interventions in Underserved Groups: ExampleUnderserved Groups: Example
Posting of Signs Promoting Stair UsagePosting of Signs Promoting Stair Usage(suburban Baltimore mall)(suburban Baltimore mall)
Overall, stair use increased from 4.8% to 6.9%, Overall, stair use increased from 4.8% to 6.9%, 7.2%, depending upon which of 2 signs used7.2%, depending upon which of 2 signs used
Among whites, increased from 5.1% to 7.5%, Among whites, increased from 5.1% to 7.5%, 7.8%7.8%
Among blacks, changed from 4.1% to 3.4%, 5.0%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 n’l wt, inc from 5.4% to 7.2%, 6.9% Among overwt, inc from 3.8% to 6.3%, 7.8%Among overwt, inc from 3.8% to 6.3%, 7.8%
Andersen, Franckowiak, Snyder et al., Andersen, Franckowiak, Snyder et al., Ann Int Med, Ann Int Med, 1998;129:363-369.1998;129:363-369.
Community “Cost-Sharing:”Community “Cost-Sharing:”Policy Change OpportunitiesPolicy Change Opportunities
1.1. Leveraging your managerial and fiscal Leveraging your managerial and fiscal roles to mandate or incentivize roles to mandate or incentivize healthy/fit workplace practices for your healthy/fit workplace practices for your subsidiaries, suppliers, community-subsidiaries, suppliers, community-based organizations (CBOs) to which based organizations (CBOs) to which you donate $, health plans with which you donate $, health plans with which you contract, etc. you contract, etc.
2. Changing your internal organizational 2. Changing your internal organizational culture (social norms) to create culture (social norms) to create healthy/fit organizational practiceshealthy/fit organizational practices, in , in your social life and in your workplaces.your social life and in your workplaces.
Community “Cost-Sharing”Community “Cost-Sharing”
““Healthy/fit” organizational PA promotion Healthy/fit” organizational PA promotion practicespractices include include corecore & & electiveelective components, e.g., components, e.g., 10’ movement (or walking) breaks in meetings/ 10’ movement (or walking) breaks in meetings/ functions & at certain time(s) of day; walking functions & at certain time(s) of day; walking meetings; stair prompts & improvements; leading meetings; stair prompts & improvements; leading employee groups to stairs in moving between work employee groups to stairs in moving between work activities; restricted near parking; distant parking activities; restricted near parking; distant parking & mass transit incentives; model & reward & mass transit incentives; model & reward fidgeting and lifestyle PA integration (e.g., less fidgeting and lifestyle PA integration (e.g., less high heel & tie wearing, more pedometer wearing, high heel & tie wearing, more pedometer wearing, formal recognition/ kudos to those who formal recognition/ kudos to those who walk/jog/swim during lunchtime)walk/jog/swim during lunchtime)
Translating Evidence-Based Translating Evidence-Based CDC/ACSM Recommendation into CDC/ACSM Recommendation into
Practice: Building on cultural assetsPractice: Building on cultural assets Integrating 10-’ PA into organizational routine:Integrating 10-’ PA into organizational routine: Movement to music integral to African-Movement to music integral to African-
American, Latino culture—dancing normative American, Latino culture—dancing normative for adultsfor adults
Short bouts minimize perspiration, hairstyle Short bouts minimize perspiration, hairstyle disturbancedisturbance
Social support & conformity desires drive Social support & conformity desires drive participation (collectivist vs. indiv. orientation)participation (collectivist vs. indiv. orientation)
Addresses less activity conducive outdoor Addresses less activity conducive outdoor environments (safety, utility, aesthetics)environments (safety, utility, aesthetics)
Designed for organizational settings for work, Designed for organizational settings for work, worship, other purposes--less disposable t, $worship, other purposes--less disposable t, $
Lift Offs Lift Offs Work!: Work!: the Rapidly Growing Evidence Basethe Rapidly Growing Evidence Base
Documented individual and organizational Documented individual and organizational receptivity to integrating PA on paid work timereceptivity to integrating PA on paid work time
Contribute meaningfully to daily accumulation of Contribute meaningfully to daily accumulation of MVPAMVPA
Motivational “teachable moment” linking Motivational “teachable moment” linking sedentariness to health status for inactive folkssedentariness to health status for inactive folks
Improvements in clinical outcomes from as little as Improvements in clinical outcomes from as little as one 10-min. break/day—BP, BMI, waist circ., one 10-min. break/day—BP, BMI, waist circ., mood, attention span, cumulative trauma disordersmood, attention span, cumulative trauma disorders
““Spill-over” or generalization to inc. active leisureSpill-over” or generalization to inc. active leisure Favorable cost-benefit ratio, eg, L.L. Bean mfg Favorable cost-benefit ratio, eg, L.L. Bean mfg
plantplant
WIC Staff Wellness TrainingWIC Staff Wellness Training
Community “Cost-Sharing”Community “Cost-Sharing”
3. Address K-12 PE deficiencies:3. Address K-12 PE deficiencies: Require use of evidence-based curricula Require use of evidence-based curricula
focusing on cooperation vs. competition, lifetime focusing on cooperation vs. competition, lifetime PA, maximizing MVPA/session, behavioral mgt PA, maximizing MVPA/session, behavioral mgt (e.g., self-monitoring, goal set.) vs. motor skill (e.g., self-monitoring, goal set.) vs. motor skill dev. focusdev. focus
Include in core curriculum, with same resources, Include in core curriculum, with same resources, monitoring & accountability as reading, mathmonitoring & accountability as reading, math
Increase mandated t to 1 hr daily instruction K-Increase mandated t to 1 hr daily instruction K-1212
Require training in PE instruction in all Require training in PE instruction in all undergraduate education curriculaundergraduate education curricula
Require elementary-level PE to be taught by Require elementary-level PE to be taught by certified PE specialistscertified PE specialists
Institute PE class size caps of <35Institute PE class size caps of <35
% PE class time in MVPA % PE class time in MVPA by % FRPL-eligibility by % FRPL-eligibility
& by district avg. Fitnessgram scores& by district avg. Fitnessgram scores
29.6%
39.9%
low fitnessgram
districts, 21.2%
33.4%
low fitnessgram
districts, 14.4%
29.7%
0%
10%
20%
30%
40%
50%
% c
lass
tim
e in
MV
PA
0-33% FRPL 34-66% FRPL 67-100% FRPL
low fitnessgram districts high fitnessgram districts
Avg. amount of PE class time in MVPAAvg. amount of PE class time in MVPAby class size (secondary schools only)by class size (secondary schools only)
37.0%33.1%
26.5%22.4%
0%
7%
15%
22%
30%
37%
% o
f cl
ass
tim
e P
A≥
3
<=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.
N=6 N=12 N=12 N=10
Relationship between PE Quality (%class Relationship between PE Quality (%class t in MVPA) t in MVPA)
& API Score in High & Low SES Schools& API Score in High & Low SES Schools
>=75%<35%
%FRPL 3yr avg
800.0
750.0
700.0
650.0
600.0
550.0
500.0
Mea
n 3
yea
r av
g A
PI s
core
617.7
750.3
584.2
702.9
50+ min/wk
0-49 min/wk
Min. PE-MVPA/wk dichot
n=4
n=6
n=3n=2
Community “Cost-Sharing”Community “Cost-Sharing”
4. Local legislative policy advocacy:4. Local legislative policy advocacy:Redress inequitable distribution of free-for-use Redress inequitable distribution of free-for-use recreational facilities favoring high-income recreational facilities favoring high-income areas and poor upkeep of parks & playgrounds areas and poor upkeep of parks & playgrounds in low-income areasin low-income areas--explore litigation (Public Health Law Center)--explore litigation (Public Health Law Center)--explore limited liability protection (“Good --explore limited liability protection (“Good Samaritan” laws) for organizations making Samaritan” laws) for organizations making facilities available for joint use before-/after-facilities available for joint use before-/after-hourshours--explore incentives for locating supermarkets --explore incentives for locating supermarkets & other produce vendors in low-income areas& other produce vendors in low-income areas
““We must We must bebe the change the change
we wish to see we wish to see in the world.”in the world.”
--Mahatma Gandhi--Mahatma Gandhi
Community “Cost-Sharing”Community “Cost-Sharing”