Racial and Ethnic Differences in the Health of Older Americans (1997) / Chapter Skim
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3 Health and Disability Differences Among Racial and Ethnic Groups
3 Health and Disability Differences Among Racial and Ethnic Groups
Pages 43-105
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From page 43... ...
Consequently, there is often little consensus on the magnitude or age dependence of racial and ethnic differences in health or on the biological mechanisms underlying many differences. Since the scientific record on racial and ethnic health differences, especially at late ages, is incomplete, we must assemble available data into a coherent description to compare age-related health differences across racial and ethnic groups.
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From page 44... ...
SOURCE: Duke University Center for Demographic Studies.
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From page 45... ...
racial and ethnic differences in disability and mortality because African-American and Hispanic females have lower risks of hip fracture than white females.
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From page 46... ...
Since most disease-specific studies are of select populations, as a second stage we review the age relation of racial and ethnic differences in health, disability, and mortality in two sets of national data. First, we examine age patterns of total and cause-specific mortality by race to determine if they are consistent with the epidemiological data on racial and ethnic differences in the age dependence of disease processes.
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From page 47... ...
47 no o x VO a' be ¢ so ~ ,~o.
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From page 48... ...
They start to increase exponentially for white men and black women at age 75 and for black men past age 85. Since the incidence rates of hip fracture double every 5 years, this means that white men and black women have half the incidence of white women.
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From page 49... ...
study of gender differences in bone density suggests that female racial differences in bone mass that are not explained by serum estrone might be due to the greater lean body mass of African-American females in comparison with white females and to the mechanical effects of greater muscle mass on physical activity and bone metabolism. The greater bone density of AfricanAmerican females may be due to higher body mass and to greater postmenopausal production of estrone due to a higher proportion of body fat, factors that could increase the risk of hypertension and adult onset diabetes.
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From page 50... ...
A decreased sensitivity to parathyroid hormone and greater stability of skeletal mass in African-American females thus appear as important in their lower risk of osteoporosis as body mass differences and their effects on the postmenopausal production of sex hormones. Consistent with findings on the two types of osteoporosis, vitamin D and calcium supplementation, at least in white women, decreased hip fracture to advanced ages (e.g., in a group with a mean age of 84; Chapuy et al., 1994~.
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From page 51... ...
The two best known longitudinal studies of circulatory disease containing significant numbers of African Americans and whites are the Charleston Heart Study and the Evans County study. There are, however, cross-sectional studies of risk factors for circulatory disease that represent African Americans and whites; a few represent Hispanics.
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From page 52... ...
was evident for African Americans as it is for whites (Melby et al., 1994~. Total cholesterol is a general indicator of the risk of coronary heart disease.
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From page 53... ...
, these age patterns of disease risk (and mortality selection) could contribute to a convergence of mortality patterns in blacks and whites owing to a different age dependence of circulatory diseases related to atherosclerosis at late ages.
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White women had an incidence of 7.0 percent; white men, 6.9 percent. Risk factors for diabetes include body mass index (body weight in kilograms divided by height in meters squared, i.e., kg/m2)
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. The risks of coronary heart disease in diabetics could be due to central obesity associated with the failure of insulin to suppress release of nonesterified fatty acids from intra-abdominal fat cells.
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Thus, people with better physiological control of insulin, blood glucose, and body mass index have better survival to late ages (Campbell et al., 1993; Bild et al., 1993~. Body Iron Stores The role of physiological iron in disease is complex.
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From page 57... ...
Low bone density was one of the strongest risk factors for stroke in women; that is, there is a 74 percent increase in mortality per 1 standard deviation decrease in the bone density of the heel (Browner et al., 1991~. One hypothesis is that in addition to calcium release, production of parathyroid hormone is increased, which causes both smooth muscle cell absorption of calcium and hypertension (Browner et al., 1993~.
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From page 58... ...
At late ages, systolic hypertension elevates stroke, total mortality, and mortality from coronary heart disease (Rutan et al., 1988~. Diastolic hypertension is less of a risk at late ages; its decline may indicate progression of aortic atherosclerosis (Witteman et al., 1994~.
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From page 59... ...
Indeed there may be a negative correlation between cervical and breast cancer risk owing to their joint dependence on reproductive behavior. We examined racial and ethnic differences in prostate cancer because of large racial and ethnic differences in incidence and because its risk rises at late ages.
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Four risk factors for breast cancer were the same for blacks and whites (age at first birth, parity, surgical menopause, benign breast disease) , and two (family history and breast feeding)
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There were some racial differences in treatment. Blacks and whites received similar systemic therapy for node-positive breast cancer.
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From page 62... ...
Because myeloma is related to the aging of the immune system, it may be more an indicator of generalized aging processes than are many specific chronic diseases that have well-characterized risk factors. Thus, racial differences in multiple myeloma may reflect racial differences in generalized aging rates better than other diseases.
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From page 63... ...
Disease Interactions To fully explain racial and ethnic differences in disease risks and progression, we must consider interactions of multiple diseases and multifactorial syndromes. For example, the "X syndrome" in circulatory disease the clustering of insulin resistance, hyperinsulinemia, hyperglycemia, high triglycerides, and low HDL (Feskens and Kromhout, 1994)
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From page 64... ...
Racial and ethnic differences in dementia have been underresearched and require specialized longitudinal studies of risk factors in black, white, and Hispanic populations. Thus, there is a complex set of feedbacks that differ in Hispanics, blacks, and whites.
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From page 65... ...
and may be responsible for the secular changes in black-white differences in the rate of atherosclerotic progression noted between the PDAY and earlier studies. A recent anticholesterol drug trial shows significant reductions in total mortality as well as mortality from coronary heart disease.
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From page 66... ...
To see if this is a reasonable strategy, we first examined the quality of age reporting on death certificates relative to other sources in matched record studies. Table 3-2 compares ages at death reported on death certificates (grouped into 5-year age categories)
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For ages 100 and above, the number of deaths from the death certificates is overstated, but the two studies disagreed on magnitude. A difficulty in assessing mortality rates above age 100 is that the number of
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From page 69... ...
In this method, the numerator of each qx is the number of deaths recorded on death certificates for that age. The denominator is the sum of deaths reported on the death certificate at age x, plus deaths reported on death certificates for each subsequent year for each subsequent age.
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From page 70... ...
For both genders, nonwhite qx drops below that for whites at age 81 (i.e., about 5 years below the crossover age observed by Kestenbaum, 1992, in Medicare data for 1987; Figures 3-2 and 3-3 were not adjusted to reflect data in Table 3-2~. At late ages, rates are variable owing to small numbers.
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From page 71... ...
death certificate files.
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From page 72... ...
72 0.6 0.5 0.4 .` 0.3 a ~ 0.2 0.1 o 0.6 0.5 0.4 Is .` 0.3 0.2 0.1 o HEALTH AND DISA:BIL[l Y DIFFERENCES A Cohort Birth Year 1882 - - - ~ White Nonwhite You , _~ , \\ .~ ,' of, ~ .
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From page 73... ...
Having examined racial differences in cohort mortality, we then examined cross-sectional (1992) data on several causes of death to see at what ages the peak differences in mortality relative risks occur.
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SOURCE: Duke University Center for Demographic Studies, analysis of 1960-1990 U.S. death certificate files.
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From page 75... ...
a' -24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age Groups FIGURE 3-4 Ratios of black to white mortality rates, by age, cause of death, and gender. SOURCE: Data from Kochanek and Hudson, 1994:Table 8.
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From page 76... ...
. For females, both black and white Hispanic cancer risks were about 70 percent of that for black and white nonHispanics, with black Hispanic risk about 78.5 percent that of white Hispanics (Trapido et al., 1994b)
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From page 77... ...
Other explanations may involve differences in risk factors for specific diseases (e.g., while diabetes prevalence is high in Hispanics, so are HDL levels)
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From page 78... ...
In general the proportion receiving help with three or more activities of daily living is higher for nongraduates. Stratified by education, race, and age, sample sizes for some estimates are small.
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From page 79... ...
1982 Nondisabled80.62 78.10 82.86 84.33 1 or more IADLs5.80 6.61 5.10 5.32 1-2 ADLs7.11 7.08 6.31 4.01 3-4 ADLs2.79 3.41 2.67 2.83 5-6 ADLs3.68 4.79 3.06 3.51 1989 Nondisabled79.59 78.71 85.27 83.92 1 or more IADLs5.37 5.96 3.57 3.88 1-2 ADLs7.85 6.86 5.75 5.74 3-4 ADLs3.96 4.47 3.30 2.97 5-6 ADLs3.23 4.02 2.12 3.51 Sample Sizeb~c 1982 Nondisabled321 48 162 9 Disabled3,188 594 1,500 89 1989 Nondisabled465 77 373 15 Disabled1,839 411 1,124 61 aDisabled persons are defined as receiving help on any of six activities of daily living (ADLs) or nine instrumental activities of daily living (IADLs)
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From page 80... ...
80 HEALTH AND DISA:BIL[l Y DIFFERENCES TABLE 3-5 Disability Status of White and Nonwhite Community Residents, Stratified by Age and Education, for 1982 and 1989 Age 65-74 Age 75-84 Age 85+ Disabilitya Level White Nonwhite White Nonwhite White Nonwhite Percentage Distribution (weighted)
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From page 81... ...
Sample sizes for nonwhite, nondisabled graduates are small; this implies that their estimates in Tables 3-4 and 3-5 have low precision. SOURCE: Duke University Center for Demographic Studies, analysis of the 1982, 1984, and 1989 National Long Term Care Surveys.
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From page 82... ...
82 oo oo C~ oo a' a' bC o ¢ E~ o s~ s~ · ~ ~ ¢ ~ ~ ~1- ¢ s~ · ~ .~ ~ ~ ~ o ~ ~ F~ ~ ~ 4= ~ ~ ¢ ~ .
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From page 83... ...
83 ooo o oo ~o o o o ~o o o ~o o o ~ CM~ oo o o o o o o o ~ ~ ~o o ~ ~ ~o ~ oo ~ .
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From page 85... ...
3. IADL impaired with performance limitation, a group with a number of impairments in instrumental activities of daily living (but none in the activities of daily living except bathing)
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From page 86... ...
Table 3-8 shows mortality coefficients for white and nonwhite males. There are more differences in the coefficients for white and nonwhite males (e.g., 12.5 vs.
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From page 88... ...
88 Cal ·_4 C)
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From page 89... ...
MANTON AND ERIC STALLARD A ohs 0.8 0.7 0.6 lo: 0.5 .~ lo 0.4 0.3 0.2 0.1 0.5 0.4 <~ 0.3 of: ._ O 0.2 o. 89 -White Nonwhite Males ....
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From page 90... ...
were significant risk factors for incident disability in the young old, possibly because of effects on osteoarthritis. Current weight loss and past high body mass index (> 28)
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From page 91... ...
SOURCE: Duke University Demographic Studies, analysis of 1982, 1984, and 1989 National Long Term Care Surveys.
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From page 92... ...
at each age by gender. SOURCE: Duke University Demographic Studies, analysis of 1982, 1984, and 1989 National Long Term Care Surveys.
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From page 93... ...
cancers; black males have a 20 percent greater incidence of prostate cancer than whites, and white females have a 30 percent greater incidence of breast cancer (NCHS, 1994~. First, we reviewed disease mechanisms.
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From page 94... ...
] Limitations Active Age 65 White males 100,000 16.30 0.9364 0.9122 0.0242 Nonwhite males 100,000 14.28 0.8256 0.7597 0.0659 White females 100,000 20.88 0.9597 0.9487 0.0110 Nonwhite females 100,000 18.91 0.9168 0.9049 0.0119 Age 75 White males 73,339 10.28 0.6626 0.8059 0.0976 Nonwhite males 61,228 10.17 0.4909 0.6696 0.1321 White females 84,265 13.76 0.7746 0.8523 0.0670 Nonwhite females 79,089 12.49 0.6391 0.6900 0.1181 Age 85 White males 35,578 5.72 0.2785 0.6701 0.1128 Nonwhite males 27,889 6.56 0.2002 0.5678 0.1501 White females 55,967 7.95 0.4260 0.6443 0.1169 Nonwhite females 47,248 7.39 0.2782 0.4372 0.1516 Age 95 White males 5,820 3.06 0.0380 0.5197 0.1331 Nonwhite males 6,301 3.62 0.0160 0.2271 0.0276 White females 18,021 4.40 0.1034 0.4669 0.1069 Nonwhite females 13,406 4.33 0.0517 0.2737 0.1122 Age 105 White males 133 1.79 0.0009 0.5479 0.1185 Nonwhite males 331 2.68 0.0012 0.3270 0.0367 White females 1,573 2.91 0.0097 0.5125 0.1069 Nonwhite females 1,140 3.05 0.0038 0.2247 0.1049 SOURCE: Duke University Center for Demographic Studies, analysis of the 1982, 1984, and 1989 National Long Term Care Surveys.
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From page 95... ...
ondisabled, IADL fodest Impaired with 4 5 fly sic al 2 Performance IADL ADL 6 7 imitations Active Limitations Impaired Impaired Frail Institutional 9122 7597 9487 9049 8059 6696 8523 6900 Age 65 0.0242 0.0659 0.0110 0.0119 Age 75 0.0976 0.1321 0.0670 0.1181 Age 85 0.0095 0.1292 0.0101 0.0111 0.0092 0.0346 0.0125 0.0349 0.0023 0.0452 0.0040 0.0045 0.0130 0.0333 0.0102 0.0236 0.0285 0.0000 0.0099 0.0455 0.0248 0.0486 0.0214 0.0422 0.0231 0.0000 0.0076 0.0221 0.0234 0.0447 0.0142 0.0616 0.0003 0.0000 0.0086 0.0078 0.0262 0.0371 0.0224 0.0297 6701 0.1128 0.0142 0.0248 0.0402 0.0521 0.0858 5678 0.1501 0.0307 0.0504 0.0329 0.0734 0.0947 6443 0.1169 0.0201 0.0252 0.0549 0.0379 0.1008 4372 0.1516 0.0552 0.0601 0.1075 0.0886 0.0998 Age 95 5197 0.1331 0.0159 0.0327 0.0724 0.0976 0.1285 2271 0.0276 0.0635 0.1171 0.0887 0.0961 0.3798 4669 0.1069 0.0149 0.0409 0.0556 0.0676 0.2473 2737 0.1122 0.0435 0.0570 0.0661 0.2045 0.2429 Age 105 5479 0.1185 0.0048 0.0131 0.2047 0.0356 0.0753 3270 0.0367 0.1030 0.1467 0.0938 0.1456 0.1472 5125 0.1069 0.0080 0.0358 0.0438 0.0548 0.2382 2247 0.1049 0.0236 0.0883 0.0637 0.2163 0.2784 , and 1989 Third, we examined the linkage of disability with mortality at late ages. In a model describing the interaction of disability and mortality, there was a more rapid increase in mortality with age for whites than for blacks.
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From page 96... ...
to develop a picture of U.S. racial differences in the age dependence of mortality, morbidity, and disability to extreme ages.
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From page 97... ...
Johnson, and K.F. Rust 1993 Effect of multiple risk factors on differences between blacks and whites in the prevalence of non-insulin-dependent diabetes mellitus in the United States.
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From page 98... ...
Hoffman 1994 Risk factors for hip fracture in black women. New England Journal of Medicine 330(22)
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From page 99... ...
Gazes, and H.A. Tyroler 1993 Mortality rates and risk factors for coronary disease in black as compared with white men and women.
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From page 100... ...
Madans 1994 Body mass index, weight change, and risk of mobility disability in middle-aged and older women. Journal of the American Medical Association 271(14)
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From page 101... ...
Stoddard-Wright 1992 Breast cancer risk factors among black women and white women: Similarities and differences. American Journal of Epidemiology 136(12)
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From page 102... ...
Brand, and K.L. Gould 1990 Can lifestyle changes reverse coronary heart disease?
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From page 103... ...
Ross, R.K., and B.E. Henderson 1994 Do diet and androgens alter prostate cancer risk via a common etiologic pathway?
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From page 104... ...
SOLVD Investigators 1991 Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. New England Journal of Medicine 325(5)
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From page 105... ...
Havekes (for the EARS Group) 1994 ApoE polymorphism and predisposition to coronary heart disease in youths of different European populations: The EARS study.
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