Filipino American Cardiovascular Health
Presented to: NYU Post-Graduate Medical School
UP Medical Alumni Society in America
Presented by: Luceli C. Cuasay, DrPH, MPH
Summit, July 8-9, 2011
1
Largest Asian American Ethnic Groups
Census 2000 and Census 2010
Race Alone
2
Filipino Population in U.S.
U.S.
Texas
2000a
2006b
2009b
Change
2000-2009
Change
2000-2009
2,364,815
2,915,745
3,177,947
813,132
34.4%
75,226
116,773
128,870
53,644
71.3%
Rapidly increasing Filipino population has
significant implications.
a U.S.
Census 2000
b American Community Survey Estimates
Data for Filipino alone or in any race combination (97.6% one race)
3
Educational Attainment by Race/Ethnicity
ACS 2006
1 or more race(s)
4
Median Household Income by
Race/Ethnicity
ACS 2006
1 or more race(s)
5
Filipino
Occupation and Industry
Census 2000
ACS 2009
Texas
U.S.
Texas
U.S.
Management,
professional or
related occupations
50%
38%
56%
41%
Educational, health
and social services
industries
42%
29%
45%
33%
Filipinos have favorable socioeconomic profile.
Ages 16 and over
6
Unemployment Rate by Race/Ethnicity
ACS 2006
1 or more race(s)
7
Poverty Rate by Race/Ethnicity
ACS 2006
1 or more race(s)
8
Filipino Population in U.S.

47.1% Male

52.9% Female

12.4% Age 18-24

12.5% Age 65+

62.9% Married

64.1% Family size 4+

68.5% Foreign-born

72.9% ≥10 yrs in U.S.
NHIS, 2004-2006
9
FA Health Care Access & Utilization

87.4% has usual place for health care

12.2% has no usual place

Type of place for health care
•
•
•
•
82.3%
14.3%
1.8%
1.1%
Doctor’s office
Clinic or health center
Hospital ER or outpatient dept.
Not one place most often

3.4% delayed medical care due to cost

2.2% did not receive medical care due to cost
NHIS, 2004-2006
10
FA Health Issues


At high risk for hypertension, coronary artery
disease, diabetes, other metabolic disorders
Leading causes of death:
• Heart disease
• Cancer
• Stroke



2nd highest rate of hypertension of all APIs
Highest TB cases among Asian immigrants;
2nd of all immigrant groups
High prevalence of HIV
11
FA Health Status/Behaviors

33.0% Overweight

14.1% Obese

37.0% Inactive

34.7% Engaged in some activity

9.8%

50.7% Current drinker (8.7% mod/heavy)

16.6% Former smoker

13.9% Current smoker
NHIS, 2004-2006
Former drinker
12
Smoking in Asian Subgroups
NHIS 2004-2006
13
Smoking and Alcohol Consumption


FA has 2nd highest rate of former and
current smokers (31%), next to Koreans
(35%)
FA has 2nd highest rate of former and
current alcohol drinkers (61%), next to
Japanese (68%)
NHIS, 2004-2006
14
FA: Obesity, CVD & Diabetes




Most likely to be obese as compared to other
Asian groups
Obesity prevalence (14%) - more than twice as
likely to be obese as Asian Indian (6%),
Vietnamese (5%), or Chinese (4%)
Most likely to have ever been told they had
hypertension (27%)
Most likely to have ever been told they had
diabetes (9%) or heart disease (7%), next to
Asian Indians.
NHIS, 2004-2006
15
FA: CVD & Diabetes

Diabetes and CHD in Filipino-American women (Langenberg)
• Significant predictors of high prevalence (31.4%) of CHD




socioeconomic disadvantage
family history of diabetes
larger waist
San Diego Filipino Women’s Health Study (Araneta)
• CVD prevalence = 20.7%; 85.5% newly diagnosed
• Filipinas with CVD vs. without CVD





more antihypertensive medication use
more family history of MI
higher proinsulin levels
lower adiponectin levels
higher prevalence of metabolic syndrome and
microalbuminuria
16
Type 2 Diabetes among Filipino Americans
in Houston MSA
STUDY OBJECTIVES

To determine the prevalence of previously
diagnosed type 2 diabetes

To determine the major risk factors
Cuasay LC, et al, 2001
17
RESEARCH DESIGN & METHODS
Cross-sectional survey
FA in Houston MSA, September 1998 - March 2000
Sample Population
831 survey respondents:
• Of Filipino origin or ancestry
• Ages 20-74 years
• Residents of Harris, Brazoria, Fort Bend, Liberty,
Montgomery, Waller, and Galveston counties
Survey Questionnaire
• English
• Tagalog
18
Table 1. Demographic characteristics of Filipino-Americans,
ages 20-74 years. Houston MSA.
Characteristics
Age (years)
20-44
45-64
65-74
Sex
Male
Female
Birth place region (Philippines)
Metro Manila
Luzon
Visaya
Mindanao
Marital status
Married
Widowed
Divorced or separated
Never married
Highest educational level
High school or elementary
Technical or vocational
College
Graduate school
*
Total n varies due to missing values
Total
Population*
%
(n=749)
44.9
49.1
6.0
(n=787)
38.9
61.1
(n=778)
30.7
39.6
23.0
6.7
(n=805)
77.4
2.9
3.9
15.9
(n=805)
3.0
3.5
71.2
22.3
†
Diabetic
Non-diabetic
*
Respondents Respondents*
%
%
(n=118)
(n=631)
21.2
49.3
57.6
47.5
21.2
3.2
(n=124)
(n=663)
50.8
36.6
49.2
63.4
(n=121)
(n=622)
25.6
31.7
40.5
38.8
23.1
23.4
10.7
6.1
(n=118)
(n=654)
84.8
75.8
7.6
2.0
2.5
4.0
5.1
18.2
(n=117)
(n=655)
3.4
2.4
4.3
3.2
66.7
72.1
25.6
22.3
Diabetic vs. non-diabetic respondents
p-value†
0.000
0.009
0.216
0.000
0.660
19
Table 2. Medical history of Filipino-Americans,
ages 20-74 years. Houston MSA.
Characteristics
Family history parent/sibling
Hypertension
Heart attack
Stroke
Coronary artery disease
Diabetic Respondents
Total No.*
%
117
102
101
93
82.0
41.2
42.6
23.7
Sibling(s) with diabetes
1
2
3 or more
44
Heart attack
Stroke
Coronary artery disease
120
118
119
*
Non-diabetic
Respondents
Total No.*
%
633
589
590
555
89
47.7
31.8
20.4
Total n varies due to missing values
74.1
32.4
27.1
18.0
p-value†
0.070
0.080
0.002
0.200
0.340
60.7
25.8
13.5
6.7
5.9
7.6
649
656
653
†
2.0
2.0
0.8
0.004
0.010
0.000
Diabetic vs. non-diabetic
20
Table 3. Dietary practices of Filipino-Americans,
ages 20-74 years. Houston MSA.
Dietary Practices
Diabetic Non-diabetic
Respondents Respondents
(n=115)
(n=647)
%
%
Consumption of Rice (meals per day)
3 meals always or often
< 3 meals always/often or
sometimes/rarely/never
Packaged food†
Restaurant/fast food†
Fried food†
Restriction ofSugar
Salt or sodium
Fat
*
Diabetic vs. non-diabetic
p-value*
30.4
69.6
20.2
79.8
0.033
14.9
28.3
45.3
12.0
34.1
47.7
n.s.
n.s.
n.s.
66.4
65.2
64.5
34.0
38.0
42.7
0.000
0.000
0.000
†
Always or often
21
Figure 1. Family history of diabetes among diabetic and
non-diabetic Filipino-Americans, ages 20-74 years, Houston.
70
Diabetic
57.7
Non-diabetic
60
51.4
Percent
50
40
34.1
30
15.4
20
10
14.4
4.6
0
Either parent
Both parents
Any sibling
22
Figure 2. Medical history of diabetic and non-diabetic
Filipino-Americans, ages 20-74 years. Houston MSA.
80
Diabetic
70
63.6
Non-diabetic
60
50
40
33.6
26.9
27.6
27.2
30
23.5
20
15.6
12.9
10.8
10
%
4.5
2.7
5.3
0
23
Figure 3. Type 2 diabetes prevalence rates for major risk
factors, Filipino-Americans, ages 20-74 years. Houston.
3.7
Ages 20-34
Overall prevalence: 16.1
(95 CI: 13.5-18.7)
10.1
35-44
16.1
45-54
23.8
55-64
65-74
56.3
19.7
Male
13.1
Female
25.5
Diabetes family history
30
Obesity (BMI >30)
44.7
Baby > 9 lbs (women)
56.5
Gestational (women)
28.2
Low income (<$20,000)
0
10
20
30
Prevalence (%)
40
50
60
24
STUDY RESULTS
 Age- and sex-adjusted prevalence of
previously diagnosed type 2 diabetes: 16.1%
 Major risk factors identified were:
• older age [OR=5.6 - 34.2]
• male sex [OR=1.8]
• family history [OR=4.7]
• obesity [OR=3.6]
• gestational diabetes [OR=21.7]
• low income in women [OR=5.3]
• region of birth [OR 3.2]
Cuasay LC, et al, 2001
25
Figure 4. Type 2 diabetes: FA compared with U.S.
45
Parental history-diabetes
58
50
Hypertensive
64
47
Obese women
14
21
Obese men
17
20
Smoking history
34
U.S.
FA
28
Physically active women
22
Physically active men
22
42
20
Excellent/good health
33
33
Employed
64
21
College education
92
58
Female
49
0
20
40
60
80
100
Percent
26
27
Figure 6. Use of diabetes therapy by
Filipino American diabetic participants
Insulin +
pills
4%
None
10%
Insulin only
2%
Pills + insulin
+ diet
8%
Pills only
24%
Diet only
16%
Pills + diet
36%
28
STUDY CONCLUSIONS

High prevalence of type 2 diabetes was observed; supports
earlier studies that FA are at higher risk.

Both FA and US population surveys revealed: older age,
obesity, and family history of diabetes to be associated
with type 2 diabetes.

FA diabetic population was less obese, yet, had a high
frequency of hypertension.

Survey data suggest an inverse association between
acculturation and type 2 diabetes.

Effect of acculturation on diabetes risk stresses
importance of prevention and control strategies.
Cuasay LC, et al, 2001
29
STUDY CONCLUSIONS



FA diabetic population had higher % of persons with
parental history of diabetes, medical history of
hypertension, and history of smoking − compared with
U.S. diabetic population.
“Westernization”, accompanied by decreased physical
activity and changes in dietary pattern towards a less
healthy diet − likely to increase risk for obesity and type
2 diabetes.
Rapidly growing FA population, with high diabetes
prevalence, will require increased diabetes-related
health care and preventive services.
Cuasay LC, et al, 2001
30
Filipino Americans
An Invisible Minority

Large population, with very limited data on health needs

Major health issues persist in spite of:
• having a favorable socioeconomic status,
• large percentage employed in health care industry,
• being English proficient
— characteristics associated with improved
health access and health status.
31
Filipino Health Needs Assessment
(FilHNA)

Collect information on health status, health behaviors
and beliefs, health care access, and utilization of
Filipinos (≥18 years) residing in Brazoria, Fort Bend,
Galveston, and Harris counties.

Major emphasis on cancer, diabetes, circulatory and
respiratory conditions, and mental health issues.

Improve understanding of health and cancer concerns,
so that educational programs and interventions can be
developed to help meet the Filipino community’s needs.
32
FilHNA Project

Qualitative study: Conduct focus group interviews of
key community groups (ages 18-55 and >55 years).
• physicians
• nurses
• allied health professionals
• non-health professionals
• non-professionals

Quantitative study: Conduct health needs assessment
survey of representative sample of Filipinos in four target
counties.
33
References
1.
2.
3.
4.
5.
6.
7.
Cuasay LC, et al. Prevalence and determinants of Type 2 diabetes among
Filipino-Americans in the Houston, Texas Metropolitan Statistical Area.
Diabetes Care 2001:24:2054-2058.
Barnes PM, Adams PF, Powell-Griner E. Health Characteristics of the Asian
adult population: United States, 2004-2006. Adv Data 2008;394:1-22.
Klatsky AL, Tekawa I, Armstrong MA. Cardiovascular risk factors among
Asian Americans. Public Health Rep 1996;111(Suppl 2):62-4.
Ryan C, Shaw R, et al. Coronary heart disease in Filipino and Filipino
American patients: prevalence of risk factors and outcomes of treatment. J
Invasive Cardiol. 2000;12(3):134-139.
Stavig G, Igra A, Leonard A. Hypertension and related health issues
among Asians and Pacific Islanders in California. Public Health Reports.
1988;103, 28-37.
Langenberg C, Rosario M, et al. Diabetes and Coronary Heart Disease in
Filipino-American Women: Role of growth and life course socioeconomic
factors. Diabetes Care 2007;30;535-541.
Araneta MR, Wingard DL, Barrett-Connor E. Type 2 diabetes and metabolic
syndrome in Filipina-American women: A high risk non-obese population.
Diabetes Care 2002;25(3):494-499.
34
QUESTIONS?
Luceli C. Cuasay, DrPH, MPH
lucelicuasay@westat.com
5615 Kirby Drive, Suite 710
Houston, TX 77005
35
SURVEY QUESTIONNAIRE
• English, adapted from National Health and
Nutrition Examination Survey (NHANES), Hispanic
Health and Nutrition Examination Survey (HHANES)
& National Health Interview Survey (NHIS)
questionnaires
• Tagalog, produced by back-and-forth translation
36
RISK FACTORS – DEFINITIONS
Age
Sex
Family history of diabetes: Having a parent or a sibling
who had been diagnosed with diabetes.
History of gestational diabetes: A “yes” response to the
question, “Have you ever been told by a physician that you
had diabetes when you were pregnant?”
Overall obesity: Self-reported body mass index (BMI) > 30
kg/m2.
Physical activity: Person engaged in any exercise, sports, or
physically active hobbies for at least 20 minutes: physically
active,  4 times a week; moderately active, 1-3 times a
week; and sedentary, < 1 time a week or no activity.
37
RISK FACTORS – DEFINITIONS
Educational attainment and household income:
Surrogate items for socioeconomic status
Respondent’s birthplace (Philippines):
 Manila, the country’s capital
 One of 3 major regions:
• Luzon (north)
• Visayas (central)
• Mindanao (south)
38
RISK FACTORS – DEFINITIONS
Acculturation level: A six-item acculturation score equal
to the arithmetic mean of the codes of six data items.
• 1st four items represented language ability and
preference in speaking, reading, and writing
• 5th itemgeneration
• 6th itemfood preference
1=strongest Filipino orientation
5=strongest American orientation
3=equally Filipino and American
orientation
Based on scores, respondents were classified into 3
acculturation levels: high, middle, and low
39