Abstract
PURPOSE
To describe trends in hypertension prevalence, awareness, treatment, and control among older Mexican Americans living in the Southwestern United States from 1993-94 to 2004-05.
METHODS
This is a comparison between two separate cross-sectional cohorts of non-institutionalized Mexican Americans aged ≥ 75 from the Hispanic Established Population for the Epidemiological Study of the Elderly (919 subjects from the 1993–1994 cohort and 738 from the 2004–2005 cohort). Data were collected on self-reported hypertension, measured blood pressure, medications, socio-demographic, and other health-related factors.
RESULTS
Hypertension prevalence increased from 73.0% in 1993-94, to 78.4% in 2004-05. Cross-cohort multivariate analyses showed that the higher odds of hypertension in 2004-05 cohort was attenuated by adding diabetes and obesity to the model. There was a significant increase in hypertension awareness among hypertensives (63.0% to 82.6%) and in control among treated hypertensives (42.5% to 55.4%). Cross-cohort multivariate analyses showed that the higher odds of control in 2004-05 cohorts was accentuated by adding diabetes to the model. There were no significant changes in treatment rates (62.2% to 65.6%)
CONCLUSION
Hypertension prevalence in very old Mexican Americans residing in the Southwestern United States was higher in 2004-05 than in 1993-94, and was accompanied by a significant increase in awareness and control rates.
Keywords: Trends, Hypertension, Awareness, Treatment, Control, Mexican American elders
INTRODUCTION
Although hypertension is one of the most common diseases in the United States (U.S.) affecting more than 72 million Americans (1–3), it is a major modifiable risk factor for cardiovascular disease (4, 5). Advancements in hypertension diagnosis, treatment, and control have been major contributors to the decline in cardiovascular mortality in recent decades (1, 6). Despite considerable progress, hypertension treatment and control rates are still suboptimal (3, 7–9).
Mexican Americans are traditionally known for their lower rates of hypertension awareness, treatment, and control compared to other ethnic groups (8, 10–12). An analysis of pooled data from the National Health and Nutrition Examination Survey (NHANES), from 1999 to 2004, showed that only 56% of hypertensive Mexican Americans aged 25–84 in the U.S. were aware of having hypertension. Of these, just 50% were treated, and only 44% had their BP under control (11). For older Mexican Americans, a rapidly growing segment of the U.S. population (13), hypertension remains a major health burden that puts them at high risk for cardiovascular morbidity and mortality (14).
A previous report comparing hypertension prevalence between the NHANES III 1988–1994 and NHANES 1999–2004 (3), reflected a significant increase in age-adjusted hypertension prevalence among subjects aged ≥18 years accompanied by an increase in age-adjusted awareness, treatment, and control. There were ethnic differences with non-significant increases in age-adjusted prevalence, awareness, treatment and control among Mexican American men and slight increases in age-adjusted prevalence and control rates among Mexican American women as compared to other major ethnic groups.
Previous reports using the Hispanic Health and Nutrition Examination Survey (HHANES) and the Hispanic Established Population for the Epidemiological Study of the Elderly (Hispanic-EPESE) (15) found no significant change in hypertension prevalence and treatment among older Mexican Americans aged 65–74 from 1982–1984 to 1993–1994. A decrease in mean systolic BP and an increase in mean diastolic BP were found. Previous findings from the Hispanic-EPESE (10, 12) showed a 61% prevalence of hypertension among Mexican Americans aged 65 and older in 1993–1994. Sixty-three percent of the hypertensive subjects were aware of their diagnosis, and 51% were under treatment (12).
Several studies using the NHANES data have addressed trends in hypertension in recent years, but few have shed light on trends among older Mexican Americans (3, 8). The findings from these studies were limited by the relatively smaller number of older Mexican Americans in the NHANES data and targeted the population of Mexican Americans in the U.S. in general. The Hispanic-EPESE, at its fifth wave (2004–2005), added a new representative cohort of older Mexican Americans aged 75 and older living in the Southwestern U.S., providing the opportunity to examine health trends in this group. In this analysis, we aim to study trends in hypertension, awareness, treatment, and control among Mexican Americans aged 75 and older residing in the Southwestern U.S. over an 11- year period. Knowledge about trends in hypertension in this population can serve as a basis for the development of health policy to improve hypertension control rates and thus decrease the burden of hypertension.
METHODS
Data used are from the Hispanic-EPESE, a longitudinal study of 3,952 older Mexican Americans residing in Texas, New Mexico, Colorado, Arizona and California. At baseline in 1993–1994, 3,050 Mexican Americans aged 65 and older were selected. An area probability sample design was developed by listing counties in the Southwestern states by the number of Mexican Americans in descending order needed to cover 90% of all Mexican Americans. Census tracts and enumeration districts in the above counties were subsequently listed by the number of older Mexican Americans. Three hundred census tracts were selected as primary sampling units (PSU’s). The sampling procedure ensured obtaining a sample that was generalizable to approximately 500,000 older Mexican Americans living in the Southwest (16, 17). In 2004–2005, an additional sample of 902 Mexican Americans aged 75 and older from the same region was added using similar area probability and sampling procedures employed at baseline. Both cohorts received identical evaluations at their baseline. In-home interviews were conducted in Spanish or English depending on the respondent’s preference. The 1993–1994 and 2004–2005 baseline samples have been described elsewhere (16, 17, 21).
Sample
This analysis used data on Mexican American men and women aged 75 years and older from the baseline of the original cohort (1993–1994) (N=1132) and baseline of the new cohort (2004–2005) (N=902). Two hundred and thirteen subjects from the original cohort and 164 subjects from the new cohort were excluded from the analyses because of missing values in any of the three components of hypertension (Self-reported hypertension, blood pressure measurements, or treatment). The final sample consisted of 919 and 738 subjects from the original and the new cohort, respectively. Subjects excluded were more likely to be older and to be men. No significant differences were noted in characteristics of excluded subjects between the two cohorts.
Outcome variables
Self-reported hypertension was assessed by asking subjects if a doctor had ever told them that they had high BP. Blood pressure data were collected based on the Fifth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC5) recommendations available at the time of the baseline wave, 1993–94(18). The same protocol was followed in 2004-05 as no changes were made in JNC7 in this regard (19). Blood pressure readings were taken by adequately trained interviewers during in-home visits. Participants were asked to sit quietly on a chair with arms comfortably positioned over a table at the level of the heart for a period of five minutes. Blood pressure was taken using standard stethoscope (Litton Classic II), standard Mercury Column Sphygmomanometer and blood pressure cuff in different sizes (pediatric, regular, large arm) with the proper size chosen to cover at least 80% of the arm. Two sitting BP readings were taken within sixty seconds and an average systolic and diastolic BP were calculated for each subject. Participants were asked to provide the containers of the medications taken in the two weeks prior to the interview, and drugs’ names were recorded. Anti-hypertensive medications were identified and categorized into Angiotensin Converting Enzyme Inhibitors (ACE-I), Beta Blockers, Calcium Channel Blockers, vasodilators, and others. A subject was considered hypertensive if, 1) he/she had been told by a physician that he/she had hypertension, 2) had an average systolic BP of ≥ 140mmHg or an average diastolic BP of ≥ 90 mmHg (3, 12), or 3) was on anti-hypertensive medications upon review of the medications they were taking during the two weeks prior to the interview. Hypertension awareness among hypertensives was defined as responding affirmatively to the question: “Has a doctor ever told you that you have high blood pressure?” Hypertension treatment refers to finding any antihypertensive medication while reviewing the medications the subjects had taken in the two weeks prior to the interview, regardless of the indication of the medication taken. Hypertension control was defined as an average BP of < 140/90 mmHg among non-diabetics, and an average BP of < 130/80 mmHg among diabetics, based on the recommendations of the JNC 7 (19).
Covariates
Sociodemographic covariates included age, gender, country of birth, and years of education. A subject was considered diabetic if he/she had reported ever having been told by a doctor that he/she had diabetes or if insulin or oral-hypoglycemics were found among the medications taken in the two weeks prior to the interview. Physician visits were assessed by asking the subjects about the number of visits with a medical doctor in the past 12 months. Subjects were classified as having < 2, 2–4 and > 4 physician visits/year. In this classification, we considered the minimum number of BP follow-ups recommended by the JNC 7 for hypertensive subjects (19). Subjects were asked about their health insurance and were classified as uninsured, Medicare alone, Medicare plus Medicaid, and Medicare plus private insurance. Height was measured using a tape placed against the wall and weight using a Metro 9800 measuring scale. Subjects with BMI’s of 30 Kg/m2 or over were considered obese. Body Mass Index (BMI) was computed as weight in kilograms divided by height in meters squared (20).
Statistical Analysis
Means and 95% Confidence Intervals for continuous variables and proportions for categorical variables for the two cohorts were compared by t-test and Rao-Scott likelihood ratio Chi-square test. Hypertension prevalence, awareness, treatment, and control rates in both cohorts were estimated and compared for the total and for the categories of the covariates by Rao-Scott likelihood ratio Chi-square test. Differences in hypertension prevalence, awareness, treatment, and control by covariates in each of the two cohorts were tested by Rao-Scott likelihood ratio Chi-square test. Multivariate logistic regression models were conducted in each cohort separately with hypertension, prevalence, awareness, treatment, and control as dependent variables to assess the independent association of the covariates of a demographic importance and those found different between the two cohorts. To examine the effect of diabetes and obesity on hypertension trends, multivariate logistic regression models were conducted predicting HTN with all models including age, gender, and survey (2004-05 vs. 1993-94). Subsequently, obesity (BMI≥30 Kg/m2), and diabetes were added to the model separately then jointly. A similar analysis was done to examine the effect of diabetes, obesity, physician visits, and health insurance on the trends in hypertension awareness and control. Sample weights for each of the two cohorts were calculated as the inverse of the probability of selection. Sampling weights for each wave were raked to population totals. Raking variables were age, gender, state of residence, education, by immigrant status, and percentage Mexican American in census tract of residence. To account for design effects and sampling weights SAS SURVEYFREQ and SURVEYMEANS procedures were used to compare proportions for categorical variables and means for continuous variables, respectively and the SURVEYLOGISTIC procedure was used for multivariate analyses. All analyses were performed using SAS System for Windows, Version 9.2.
RESULTS
Table 1 presents the weighted descriptive characteristics of the two cohorts. The two cohorts were similar in age, ranging 75–108 years in 1993–1994 and 75–103 years in 2004-05. Both cohorts were similar in gender and marital status. Subjects in 2004–2005 were significantly more likely to be U.S.-born, to have more years of education, a higher prevalence of diabetes and obesity, and were less likely to be current smokers. There was a significant change in health insurance coverage with subjects in 2004–2005 more likely to have both Medicare plus private insurance. The mean systolic BP and the mean diastolic BP were significantly lower in the 2004-05 compared to 1993-94.
Table 1.
Descriptive Characteristics of Mexican Americans Aged 75 and Older in The Hispanic-EPESE. 1993–1994 and 2004–2005.¶
| Subjects characteristics | 1993–1994 N=919 |
2004–2005 N=738 |
P-value |
|---|---|---|---|
| Age, years, Mean (95% CI) | 80.5 (80.1 –80.9) | 81.2 (80.7–81.6) | 0.12 |
| Age | 0.641 | ||
| 75–79 | 455 (52.4) | 343 (49.0) | |
| ≥80 | 464 (51.0) | 395 (51.0) | |
| Gender | 0.859 | ||
| Female | 546 (60.6) | 440 (60.1) | |
| Male | 373 (39.4) | 298 (39.9) | |
| Marital Status | 0.673 | ||
| Married | 393 (22.5) | 331 (44.0) | |
| Unmarried | 526 (57.5) | 407 (56.0) | |
| Country of Birth | 0.042 | ||
| Mexico | 453 (54.1) | 328 (43.7) | |
| USA | 465 (45.9) | 410 (56.3) | |
| Years of Education, Mean (95% CI) | 4.4 (3.9 – 4.8) | 5.3 (4.8 – 5.9) | 0.002 |
| Smoking | 0.002 | ||
| Never | 538(55.8) | 369 (51.5) | |
| Previous | 293 (33.8 ) | 327 (43.2) | |
| Current | 86 (9.4 ) | 39 (5.3) | |
| Self-reported diabetes | <0.001 | ||
| No | 723 (79.9) | 470 (62.1) | |
| Yes | 196 (20.1) | 268 (37.9) | |
| Physician visit | 0.266 | ||
| <2 | 176 (19.7) | 100 (16.1) | |
| 2–4 | 264 (30.3) | 265 (36.2) | |
| > 4 | 440 (50.0) | 358 (47.7) | |
| Health Insurance | 0.041 | ||
| None | 55 (6.8) | 37 (5.1) | |
| Medicare only | 345 (36.7) | 206 (29.0) | |
| Medicare and Medicaid | 366 (40.3) | 316 (39.8) | |
| Medicare and private | 153 (16.2) | 179 (26.1) | |
| Obesity (BMI ≥ 30 Kg/m2) | 0.001 | ||
| Yes | 205 (19.9) | 164 (28.8) | |
| No | 677 (80.1) | 471 (71.2) | |
| BMI, Kg/m2, Mean (95% CI) | 26.7 (26.2 – 27.1) | 27.6 (26.9 – 28.2) | 0.027 |
| Systolic BP, Mean (95% CI) | 135.4 (132.9 – 137.9) | 132.3 (130.6–134.0) | 0.039 |
| Diastolic BP, Mean (95% CI) | 78.5 (77.2 – 79.7) | 74.8 (73.7 – 76.0) | <0.001 |
The frequencies presented are unweighted and the percentages are weighted.
N varies because of missing values.
BMI: Body Mass Index
BP: blood pressure
Table 2 shows weighted hypertension prevalence rates. There was a statistically significant difference in the overall hypertension prevalence in 1993-94 compared to 2004-05 (73.0% vs. 78.4%, respectively). The increase in hypertension prevalence was significant for subjects aged 75–79, for U.S.-born subjects, for subjects with diabetes, and for the obese. Table 3 presents the independent association of covariates with hypertension prevalence in each of the cohorts. Diabetics and the obese were more likely to be hypertensive in 2004-05 but not in 1993-94. Subjects with more frequent physician visits were more likely to be hypertensive in both cohorts with the odds ratio being more prominent in 2004-05. A cross-cohort multivariate logistic regression analyses examining the effect of diabetes and obesity on the trends in hypertension between 1993-94 and 2004-05 showed that the odds ratio associated with the survey (2004-05 vs. 1993-94) adjusting for age and gender was 1.44 (95%CI 1.03–2.01). Including diabetes and obesity in the model reduced the odds ratio associated with Survey to 1.29 (0.90–1.85) and 1.35 (0.96–1.895), respectively. Including both diabetes and obesity in the model further reduced the odds ratio associated with survey to 1.23 (0.85–1.78).
Table 2.
Hypertension Prevalence among Mexican Americans aged 75 Years and Older in 1993–1994 and 2004–2005.
| Independent Variables | 1993–1994 | 2004–2005 | ||||
|---|---|---|---|---|---|---|
| N | n (Weighted %)¶ | N | n (Weighted %)¶ | Difference (95%CI) | P-Value | |
| Overall prevalence | 919 | 648 (73.0) | 738 | 559 (78.4) | 5.40 (0.01 – 11.30) | 0.049 |
| Age | ||||||
| 75–79 | 455 | 304 (70.5) | 343 | 263(80.5) | 10.04 (2.48–17.59) | 0.006 |
| ≥80 | 464 | 344 (75.3) | 395 | 296 (76.3) | 1.05 (–6.00 – 8.11) | 0.767 |
| Gender | ||||||
| Women | 546 | 408 (76.3) ‡ | 440 | 344 (79.6) | 3.38 (−3.36 – 10.12) | 0.315 |
| Men | 373 | 240 (68.0) | 298 | 215 (76.5) | 8.52 (−0.27 – 17.30) | 0.051 |
| Country of birth | ||||||
| U.S. | 465 | 327 (70.6) | 410 | 319 (81.6) ‡ | 10.99 (3.41–18.57) | 0.002 |
| Mexico | 453 | 321 (75.2) | 328 | 240 (74.3) | −0.88 (−8.84 – 7.08) | 0.828 |
| Education | ||||||
| < 7 years | 714 | 512 (73.2) | 484 | 366 (78.2) | 4.96 (−11.52 – 1.61) | 0.129 |
| ≥ 7 years | 205 | 136 (72.2) | 254 | 193 (78.8) | 6.52 (−4.26 – 17.3) | 0.219 |
| Physician visits | ||||||
| <2 | 176 | 95 (59.9)† | 100 | 54 (61.2)* | 1.36 (−12.77 – 15.50) | 0.849 |
| 2–4 | 264 | 185 (74.4) | 265 | 199 (79.0) | 4.58 (−4.07 – 13.23) | 0.285 |
| > 4 | 440 | 353 (80.2) | 358 | 296 (84.4) | 4.27 (−3.50 – 12.04) | 0.267 |
| Health Insurance coverage | ||||||
| None | 55 | 32 (56.1) | 37 | 26 (69.8) | 13.7 (−39.50 – 12.09) | 0.298 |
| Medicare only | 345 | 237 (73.5) | 206 | 147 (74.7) | 1.17 (−8.90 – 11.23) | 0.819 |
| Medicare and Medicaid | 366 | 275(76.2) | 316 | 250 (81.4) | 5.19 (−2.75 – 13.13) | 0.182 |
| Medicare and private | 153 | 104 (71.0) | 179 | 136 (79.6) | 8.61 (−2.96 – 20.19) | 0.115 |
| Self-reported diabetes | ||||||
| Yes | 196 | 153 (77.6) | 268 | 236 (90.0)* | 12.35 (1.64 – 23.07) | 0.005 |
| No | 723 | 495 (71.8) | 470 | 323 (71.3) | −0.52 (−7.69 – 6.66) | 0.887 |
| Obesity (BMI ≥ 30 Kg/m2) | ||||||
| Yes | 205 | 163 (81.8)† | 164 | 144 (89.7)* | 7.89 (0.00 – 15.90) | 0.042 |
| No | 677 | 457 (70.1) | 471 | 338 (74.4) | 4.36 (−3.12 – 11.83) | 0.249 |
Unweighted frequency and weighted percentage of subjects with hypertension.
N varies because of missing values.
p value * < 0.001.† p value < 0.01. ‡ p value < 0.05, for any difference across covariates strata in each cohort.
BMI: Body Mass Index
Table 3.
Multivariate logistic regression models predicting hypertension among Mexican Americans aged 75 and older in 1993–1994 and 2004–2005
| Independent covariates. | 1993–1994 (N=835) OR (95% CI) |
2004–2005 (N=622) OR (95% CI) |
|---|---|---|
| Age (years) | 0.99 (0.94 – 1.05) | 1.02 (0.97 – 1.06) |
| Gender (Ref: men) | 1.40 (0.88 – 2.23) | 1.01 (0.66 – 1.54) |
| Birth country (Ref: Mexico) | 0.69 (0.44 – 1.08) | 1.58 (0.89 – 2.79) |
| Education (years) | 0.99 (0.92 – 1.06) | 1.00 (0.94 – 1.07) |
| Health Insurance (Ref : Medicare and private) | ||
| None | 0.61 (0.25 – 1.46) | 1.06 (0.40 – 2.84) |
| Medicare only | 0.81 (0.44 – 1.47) | 0.92 (0.46 – 1.85) |
| Medicare and Medicaid | 0.85 (0.42 – 1.71) | 1.05 (0.53 – 2.09) |
| Physician visit (Ref: <2 visits/year) | ||
| 2–4 | 1.96 (1.17 – 3.29) | 2.50 (1.39 – 4.51) |
| > 4 | 2.55 (1.48 – 4.41) | 3.70 (1.83 – 7.50) |
| Smoking (Ref: Never) | ||
| Previous | 1.09 (0.73 – 1.63) | 1.33 (0.78 – 2.27) |
| Current | 0.68 (0.33 – 1.44) | 0.41 (0.15 – 1.11) |
| Obesity (Ref: Non-obese BMI < 30 kg/m2) | 1.63 (0.96 – 2.74) | 3.32 (1.87 – 5.90) |
| Diabetes (Ref: Non-diabetic) | 0.89 (0.45 – 1.73) | 2.33 (1.25 – 4.36) |
Table 4 presents the weighted prevalence of hypertension awareness among hypertensive subjects. Overall hypertension awareness was significantly higher in 2004-05 than in 1993-94 (82.6% vs. 63.0%, respectively) with the increase being more notable in men than women. The first section in Table 5 presents the independent predictors of hypertension awareness in both cohorts. Women were more likely to be aware of hypertension than men in both cohorts. A cross-cohort multivariate analysis examining the effect of diabetes, obesity, physician visits, and health insurance on trends in hypertension awareness showed no attenuation of the association between survey (2004-05 vs. 1993-94) and higher hypertension awareness after including the aforementioned covariates in the model (data not shown.)
Table 4.
Prevalence of Hypertension Awareness among Hypertensive Older Mexican Americans aged 75 Years and Older.
| Explanatory Variables | 1993–1994 | 2004–2005 | ||||
|---|---|---|---|---|---|---|
| N | n (Weighted %)¶ | N | n (Weighted %)¶ | Difference (95%CI) | P-Value | |
| Total | 648 | 398 (63.0) | 559 | 467 (82.6) | 19.55 (12.98–26.12) | <0.001 |
| Age | ||||||
| 75–79 | 304 | 196 (69.8)† | 263 | 223 (86.1) | 16.33 (7.34 – 25.32) | 0.002 |
| ≥80 | 344 | 202 (57.3) | 296 | 244 (79.0) | 21.70 (12.02–31.38) | <0.001 |
| Gender | ||||||
| Women | 408 | 277 (71.6)* | 344 | 295 (86.8)§ | 15.24 (8.40–22.08) | <0.001 |
| Men | 240 | 121 (48.2) | 215 | 172 (75.8) | 27.67 (15.42 – 39.92) | <0.001 |
| Country of birth | ||||||
| US | 327 | 206 (68.4) | 319 | 269 (82.4) | 14.07 (4.22 – 23.93) | 0.005 |
| Mexico | 321 | 192 (58.8) | 240 | 198 (82.7) | 23.98 (15.62–32.35) | <0.001 |
| Education | ||||||
| < 7 years | 512 | 310 (61.2) | 366 | 302 (81.4) | 20.24 (12.95 – 27.53) | <0.001 |
| ≥ 7 years | 136 | 88 (69.5) | 193 | 165 (84.6) | 15.12 (2.87–27.37) | 0.008 |
| Physician visit | ||||||
| <2 | 95 | 42 (37.1)* | 54 | 33 (59.7 )* | 22.6 (1.18 – 44.01) | 0.043 |
| 2–4 | 185 | 116 (65.1) | 199 | 167 (83.1) | 17.97 (7.41–44.01) | <0.001 |
| ≥ 4 | 353 | 259 (70.2) | 296 | 259 (87.8) | 17.63 (9.48–25.77 | <0.001 |
| Health Insurance | ||||||
| None | 32 | 19 (41.6) | 26 | 22 (87.0) | 45.44 (15.27 – 76.61) | <0.001 |
| Medicare only | 237 | 143 (64.4) | 147 | 121 (81.8) | 17.42 (5.86 – 28.98) | 0.006 |
| Medicare and Medicaid | 275 | 173 (65.5) | 250 | 202 (79.6) | 14.18 (4.04 – 24.32) | 0.004 |
| Medicare and private | 104 | 63 (60.4) | 136 | 122 (87.1) | 26.74 (11.47 – 42.00) | <0.001 |
| Diabetes | ||||||
| No | 495 | 291 (61.7) | 323 | 260 (80.5) | 18.89 (11.31–26.47) | <0.001 |
| Yes | 153 | 107 (68.0) | 236 | 207 (85.2) | 17.15 (6.07–28.24) | 0.002 |
| Obesity (BMI ≥ 30 Kg/m2) | ||||||
| No | 457 | 273 (64.1) | 338 | 275 (79.4) | 18.24 (9.84–26.64) | <0.001 |
| Yes | 163 | 105 (68.8) | 144 | 123 (88.2) | 20.66 (14.50–26.82) | <0.001 |
Unweighted frequency and weighted percentage of hypertensive subjects aware of having hypertension.
N varies because of missing values in the covariates.
p value * < 0.001. † p value < 0.01. ‡ p value < 0.05, for any difference across covariates strata in each cohort.
BMI: Body Mass Index.
Table 5.
Multivariate logistic regression models predicting hypertension awareness, treatment, and control under treatment among Mexican Americans with hypertension aged 75 and older in 1993–1994 and 2004–2005
| Independent covariates | Awareness | Treatment | Control | |||
|---|---|---|---|---|---|---|
| 1993–1994 (N=597) OR (95% CI) |
2004–2005 (N=474) OR (95% CI) |
1993–1994 (N=597) OR (95% CI) |
2004–2005 (N=474) OR (95% CI) |
1993–1994 (N=377) OR (95% CI) |
2004–2005 (N=317) OR (95% CI) |
|
| Age (years) | 0.95 (0.90–1.01) | 0.96 (0.90–1.03) | 0.98 (0.93–1.04) | 0.97 (0.92–1.03) | 1.01 (0.97–1.05) | 1.00 (0.94–1.06) |
| Gender (Ref: men) | 2.75 (1.77–4.28) | 2.28 (1.08–4.84) | 1.81 (1.05–3.13) | 1.05 (0.56–1.97) | 1.22 (0.79–1.88) | 0.92 (0.58–1.45) |
| Birth country(Ref: Mexico) | 1.18 (0.73–1.90) | 0.74 (0.38–1.41) | 1.02 (0.95–1.10) | 0.99 (0.94 1.05) | 0.99 (0.93–1.06) | 1.02 (0.96–1.09) |
| Education (years) | 1.01 (0.93–1.10) | 1.04 (0.98–1.10) | 1.02 (0.63–1.66) | 0.91 (0.48–1.71) | 1.29 (0.87–1.90) | 0.68 (0.42–1.10) |
| Health Insurance | ||||||
| Ref : Medicare & private) | ||||||
| None | 0.59 (0.16–2.22) | 0.76 (0.15–3.86) | 0.85 (0.31–2.30) | 0.40 (0.10–1.56) | 1.68 (0.75–3.74) | 0.24 (0.11–0.52) |
| Medicare only | 1.01 (0.48–2.12) | 0.83 (0.27–2.58) | 1.00 (0.45–2.23) | 0.25 (0.13–0.48) | 1.09 (0.63–1.87) | 0.42 (0.24–0.74) |
| Medicare and Medicaid | 1.53 (0.68–3.45) | 0.51 (0.20–1.31) | 1.12 (0.45–2.75) | 0.31 (0.16–0.63) | 0.94 (0.52–1.72) | 0.49 (0.30–0.81) |
| Physician visit | ||||||
| (Ref: <2 visits/year) | ||||||
| 2–4 | 2.56 (1.13–5.82) | 2.59 (0.97–6.92) | 3.83 (1.81–8.09) | 1.51 (0.60–3.80) | 1.37 (0.77–2.42) | 1.18 (0.74–1.88) |
| > 4 | 2.99 (1.38–6.46) | 3.65 (1.70–7.85) | 6.76 (3.29–3.86) | 1.74 (0.75–4.02) | 0.88 (0.53–1.48) | 1.27 (0.70–2.33) |
| Smoking (Ref: Never) | ||||||
| Previous | 1.59 (0.93–2.72) | 1.05 (0.52–2.14) | 1.01 (0.54–1.91) | 0.63 (0.38–1.04) | 1.08 (0.72–1.60) | 0.89 (0.57–1.38) |
| Current | 0.67 (0.24–1.88) | 0.58 (0.09–3.91) | 0.77 (0.20–2.92) | 0.69 (0.28–1.69) | 1.24 (0.54–2.84) | 1.40 (0.66–2.98) |
| Obesity | 1.10 (0.65–1.88) | 1.91 (0.86–4.25) | 0.73 (0.43–1.24) | 0.84 (0.48–1.49) | 0.70 (0.44–1.09) | 0.68 (0.46–1.00) |
| (Ref: BMI < 30 kg/m2) | ||||||
| Diabetes | 1.20 (0.71–2.04) | 1.30 (0.59–2.84) | 1.77 (1.03–3.05) | 1.35 (0.82–2.21) | 0.42 (0.23–0.76) | 0.23 (0.15–0.36) |
| (Ref: Non-diabetic) | ||||||
BMI: Body Mass Index.
Table 6 shows the weighted prevalence of hypertension treatment among hypertensive subjects. Overall hypertension treatment was not significantly higher in 2004-05 than in 1993-94 (65.6% vs. 62.2%, respectively). These trends were similar across age and gender subgroups. However, as men had a relatively higher increase in treatment rates compared to women over this period, the significant treatment disadvantage for men found in 1993-94 was attenuated in 2004-05. There was a significant increase in hypertension treatment among subjects with < 2 physician visits, and those with Medicare plus private health insurance. The second section of Table 5 presents the independent predictors of hypertension treatment in both cohorts. Women were more likely to be treated than men in 1993-94, but not in 2004-05. Similarly, the association between number of physician visits and treatment observed in 1993-94 was not observed in 2004-05. On the other hand, subjects with Medicare only, or Medicare plus Medicaid were less likely to be treated than those with Medicare plus private health insurance in 2004-05. This was not the case in 1993-94.
Table 6.
Prevalence of Hypertension Treatment among Hypertensive Older Mexican Americans aged 75 Years and Older.
| Explanatory Variables | 1993–1994 | 2004–2005 | ||||
|---|---|---|---|---|---|---|
| N | n (Weighted %)¶ | N | n (Weighted %)¶ | Difference (95%CI) | P-Value | |
| Total | 648 | 409 (62.2) | 559 | 383 (65.6) | 3.44 (−3.92 – 10.81) | 0.359 |
| Age | ||||||
| 75–79 | 281 | 174 (61.1) | 263 | 179 (67.2) | 3.33 (−6.57 – 12.97) | 0.147 |
| ≥80 | 344 | 212 (60.6) | 296 | 204 (64.0) | 3.40 (−7.62 – 14.42 ) | 0.548 |
| Gender | ||||||
| Women | 408 | 271 (65.9)‡ | 344 | 245 (68.8) | 2.87 (−5.95 – 11.96) | 0.523 |
| Men | 240 | 138 (55.8) | 215 | 138 (60.7) | 4.93 (−6.97 – 16.84) | 0.412 |
| Country of birth | ||||||
| US | 327 | 207 (60.8) | 319 | 213 (65.8) | 4.97 (−3.91 – 13.85) | 0.261 |
| Mexico | 321 | 202 (63.2) | 240 | 170 (65.3) | 2.10 (−9.90 – 14.10) | 0.733 |
| Education | ||||||
| < 7 years | 512 | 322 (63.2) | 366 | 247 (64.0) | 0.8 (−7.74 – 9.36) | 0.852 |
| ≥ 7 years | 136 | 87 (58.6) | 193 | 136 (68.4) | 9.85 (−4.88 – 24.58) | 0.178 |
| Physician visit | ||||||
| <2 | 85 | 29 (30.6)* | 54 | 26 (50.9 ) ‡ | 20.30 (2.28 – 38.32) | 0.021 |
| 2–4 | 185 | 117 (61.4) | 199 | 138 (64.8) | 3.38 (−10.36– 17.13) | 0.628 |
| ≥ 4 | 353 | 252 (71.5) | 296 | 212 (69.7) | −1.88 (−11.26 – 7.50) | 0.694 |
| Health Insurance | ||||||
| None | 32 | 19 (49.9) | 26 | 19 (67.1)* | 17.14 (−10.54 – 44.83) | 0.214 |
| Medicare only | 237 | 142 (59.4) | 147 | 91 (56.7) | 2.73 (−14.15 – 8.69) | 0.635 |
| Medicare and Medicaid | 275 | 178 (66.8) | 250 | 166 (61.9) | −4.85 (−15.85 – 6.14) | 0.379 |
| Medicare and private | 104 | 70 (60.38) | 136 | 107 (80.4) | 20.01 (3.24 – 36.79) | 0.005 |
| Diabetes | ||||||
| No | 495 | 299 (59.0)† | 323 | 212 (61.7) | 7.3 (−1.8 – 16.3) | 0.541 |
| Yes | 153 | 110 (73.8) | 236 | 171 (70.7) | −3.07 (−15.24 – 9.11) | 0.616 |
| Obesity (BMI ≥ 30 Kg/m2 ) | ||||||
| No | 457 | 290 (62.9) | 338 | 228 (64.3) | 1.37 (−7.36 – 10.10) | 0.757 |
| Yes | 163 | 100 (61.9) | 144 | 96 (61.9) | 0.00 (−14.93 – 14.97) | 0.718 |
Unweighted frequency and weighted percentage of hypertensive subjects on antihypertensive treatment.
N varies because of missing values in the covariates.
p value * < 0.001. † p value < 0.01. ‡ p value < 0.05, for any difference across covariates strata in each cohort.
BMI: Body Mass Index.
Table 7 presents the weighted prevalence of hypertension control among treated hypertensive subjects. The overall hypertension control rate was significantly higher in 2004–2005 than 1993–1994 (55.4% vs. 42.5%). Men experienced a higher increase in hypertension control than women. The third section of Table 5 presents the independent predictors of hypertension control in both cohorts. Noninsured subjects, those with Medicare only, or Medicare plus Medicaid were less likely to be controlled than those with Medicare plus private health insurance in 2004-05 but not in 1993–1994. A cross-cohort multivariate analysis examining the effect of diabetes, obesity, physician visits, and health insurance on trends in hypertension control showed that the odds ratio associated with the survey (2004-05 vs. 1993-94) adjusted for age and gender was 1.73 (95%CI 1.06–2.73). Including diabetes in the model increased the odds ratio associated with Survey to 2.32 (1.41–3.81). Including other covariates did not result in any significant changes (data not shown).
Table 7.
Hypertension Control rates among Treated Hypertensive Older Mexican Americans aged 75 Years and Older.
| Explanatory Variables | 1993–1994 | 2004–2005 | ||||
|---|---|---|---|---|---|---|
| N | n (Weighted %)¶ | N | n (Weighted %)¶ | Difference (95%CI) | P-Value | |
| Overall | 409 | 184 (42.5) | 383 | 203 (55.4) | 12.91 (1.63–24.20) | 0.018 |
| Age | ||||||
| 75–79 | 197 | 88 (43.9) | 179 | 90 (53.2) | 9.26 (5.46 – 23.98) | 0.204 |
| ≥80 | 212 | 96 (41.2) | 204 | 113 (57.7) | 16.56 (3.65 – 29.47) | 0.007 |
| Gender | ||||||
| Women | 271 | 120 (41.8) | 245 | 121 (49.3)† | 7.48 (6.50– 21.01) | 0.266 |
| Men | 138 | 64 (43.8) | 138 | 82 (66.2) | 22.40 (7.90– 36.91) | 0.001 |
| Country of birth | ||||||
| US | 207 | 93 (41.6) | 213 | 123 (58.5) | 16.94 (1.84– 32.04) | 0.018 |
| Mexico | 202 | 91 (43.2) | 170 | 80 (51.0) | 7.78 (−5.62 – 21.19) | 0.241 |
| Education | ||||||
| < 7 years | 322 | 148 (44.2) | 247 | 121 (51.6) | 7.39 (−5.29– 20.08)§ | 0.240 |
| ≥ 7 years | 87 | 36 (36.0) | 136 | 82 (61.7) | 25.62 (8.93– 42.31) | <0.001 |
| Physician visit | ||||||
| <2 | 29 | 15 (48.2)‡ | 26 | 9 (46.7) | −0.01 (4.27 – 39.8) | 0.946 |
| 2–4 | 117 | 64 (56.4) | 138 | 79 (57.0) | 0.59 (−16.54 – 17.72) | 0.946 |
| ≥ 4 | 252 | 100 (35.4) | 212 | 112 (56.6) | 21.17 (8.90 – 33.4) | <0.001 |
| Health Insurance | ||||||
| None | 19 | 10 (57.3) | 19 | 9 (54.1)† | 3.20 (−39.00 – 32.59) | 0.867 |
| Medicare only | 142 | 60 (44.2) | 91 | 47 (54.6) | 10.43 (−9.68– 30.53) | 0.308 |
| Medicare and Medicaid | 178 | 77 (37.9) | 166 | 78 (47.2) | 9.35 (−6.09– 24.78) | 0.221 |
| Medicare and private | 70 | 37 (48.1) | 107 | 69 (66.0) | 17.92 (0.00– 35.80) | 0.028 |
| Diabetes | ||||||
| No | 299 | 159 (49.2) | 212 | 145 (70.6)* | 21.44 (8.84– 34.05) | <0.001 |
| Yes | 110 | 25 (22.7) | 171 | 58(38.1) | 15.40 (1.05 – 29.75) | 0.030 |
| Obesity (BMI ≥ 30 Kg/m2) | ||||||
| No | 290 | 135 (40.7) | 228 | 124 (58.1) | 17.31 (5.01– 29.62) | 0.003 |
| Yes | 100 | 41 (43.9) | 96 | 47 (48.6) | 4.72 (15.56 – 24.99) | 0.646 |
Unweighted frequency and weighted percentage of hypertensive subjects with controlled blood pressure.
N varies because of missing values in the covariates.
p value * < 0.001. † p value < 0.01. ‡ p value < 0.05, for any difference across covariates strata in each cohort.
BMI: Body Mass Index.
DISCUSSION
Hypertension prevalence in Mexican Americans aged 75 years and older residing in the Southwestern U.S. increased from 1993-94 to 2004-05. Hypertension awareness and control rates were significantly higher in 2004-05 compared to 1993-94, while hypertension treatment rates were not significantly higher in 2004-05 compared to 1993-94. These trends in prevalence are analogous to previous reports using NHANES data (3, 8) which showed a nonsignificant increase in hypertension prevalence among Mexican Americans aged 70 and older in the U.S. from 1988–1994 to 1999–2004 (3, 8). A recent analysis of the Hispanic-EPESE data showed an increase in diabetes prevalence between 1993-94 and 2004-05(21). Our analysis showed increased rates of diabetes and obesity and a more prominent association of diabetes and obesity with hypertension in 2004-05 compared to 1993-94.
Multivariate logistic regression models predicting hypertension showed that diabetes accounted for a part of the increase in hypertension: including diabetes in the model reduced the odds ratio associated with the survey period by 34%. The association between diabetes and hypertension is well established (22, 23). Diabetic nephropathy is an important contributing factor to the development of hypertension among diabetics (23). On the other hand, both hypertension and diabetes could be a result of the same metabolic disorder leading to a parallel increase in both entities (22). The latter proposition is supported by our findings of the similar positive association between hypertension and obesity and that adding obesity to the multivariate logistic regression model further reduced the odds ratio associated with survey period by 43%. This positive association between hypertension and obesity is consistent with previous reports (24, 25). Data from the NHANES surveys aforementioned showed that non-Hispanic black and white persons of the same age as our study population, experienced an increase in hypertension prevalence which was mainly attributed to an increase in obesity. However these trends were not observed among Mexican Americans in the United States. We think that this is mainly attributed to the small sample size of Mexican Americans in the NHANES data. These findings strongly emphasize the importance of addressing obesity and diabetes as part of hypertension prevention efforts (26, 27).
We found an increase in hypertension awareness in 2004-05 compared to 1993-94. NHANES data have shown a non-significant improvement in awareness rates in Mexican Americans aged 70 years and older from 1988–1994, to 1999–2004 (3). The small number of Mexican Americans aged 70 and older in the NHANES data likely weakened the power of these studies. Contrary to previous reports of low rates of hypertension awareness among Mexican Americans compared to other major ethnic groups (3, 8, 10), our estimates of hypertension awareness (87.8%) in 2004–2005, exceeds those shown for non-Hispanic blacks and whites of the same age (3). This increase was not explained by covariates measured in this study and is most likely a reflection of better publicity and implementation of community-based education as well as efforts targeting at-risk and disadvantaged populations (28).
Inconsistent with previous reports showing a significant increase in treatment rates in the general population and in Mexican Americans aged 60 years and older (3), we found a non-significant increase in overall hypertension treatment. It is important to consider that we measured treatment by inspecting the medications taken in the two weeks prior to the interview, which gives a more precise estimate of the actual treatment. The higher treatment rate in 2004-05 compared to 1993-94 among subjects with < 2 physician visits might indicate a better utilization of other methods of obtaining prescriptions such as telephone prescriptions when a direct doctor visit is not required or is not possible. This eliminated the treatment disadvantage among those with <2 physician visits in 1993-94. The significant differences noted in the likelihood of being treated based on the health insurance coverage in 2004-05 with those with Medicare plus private insurance being more likely to be treated suggest that improvement in coverage might be a potential way to improve treatment rates in this population. Research has shown that about 58% of physicians wouldn’t start pharmacological therapy if systolic BP was greater than 140mmHg in patients aged 85 and older (29, 30). However, recent reports from the Hypertension in the Very Elderly Trial (HYVET) (31) provide evidence of the benefits of hypertension treatment in relatively healthy subjects aged 80 and older. Providing clear guidelines for treating hypertension among the very old and a more focused education for physicians who care for Hispanic patients (32) will help improve hypertension treatment rates and therefore hypertension outcomes in this population.
We also found that hypertension control was higher in 2004-05 than in 1993-94 which is consistent with previous finding from the NHANES data (3). Subjects with Medicare plus private health insurance had significantly better control than other groups. Subjects with diabetes had lower rates of control. Although, this is a numerical result of the lower BP goals in this group, this reflects that these recommendations are not strictly followed. Multivariate logistic regression showed a negative role of diabetes on the promising trends in hypertension control demonstrated by an increase in the odds ratio of control associated with the survey (2004-05 vs. 1993-94) after adjusting for diabetes. Barriers against optimal hypertension control include the lack of clear guidelines regarding goals of blood pressure among the very old in general and among diabetics in particular, as well as a fear among physicians of adverse effects of excessive blood pressure control including postural hypotension (33) and cognitive impairment associated with low blood pressure (34).
Our study has some limitations. First, the definition of hypertension and diabetes involved a self-report of a previous diagnosis by a physician, which implies possible errors in both physician diagnosis and subject recall. Previous research, however, has reported good validity for self-reported medical conditions confirmed by physician diagnosis (29). Second, BP measurements were taken only two times 60 seconds apart during one in-home interview which might lead to overestimated prevalence of hypertension as we could not evaluate the persistency of high BP an important criterion in the definition of hypertension. The NHANES data implemented three measurements in mobile examination center in a better controlled environment (19). Third, definition of hypertension included being on any anti-hypertensive medication regardless of the indication. Thus, subjects taking antihypertensive medications for other indications would be considered hypertensive. However, this issue does not appear to be important in our data as only 1 subject in 1993-94 and 4 subjects 2004-05 were considered hypertensives only because they were on an ACE-I that could be used be used for proteinnuria and congestive heart failure. Fourth, our estimates of hypertension control could be biased by the effect of sicker subjects with uncontrolled hypertension returning to Mexico falsely leading to higher control rates. However our data showed that control rates increased among U.S.-born subjects but not among Mexico-born ones for whom a healthy immigrant effect is supposed to be more prominent suggesting this bias to be minor. Fifth, the comparison with the NHANES surveys is limited by the fact that they targeted Mexican Americans in the U.S. in general while our study targeted those in the Southwestern U.S. This would make our findings less generalizable but more regional specific which allows better tailored approaches for a major section of older Mexican Americans. Lastly, the small sample size in some of the subgroups and application of the weights lead to wide confidence intervals of estimates. At the same time, this study has several strengths including a large, well-defined community sample, the prospective design, and the examination of hypertension trends over 11-year period using two separate cohorts selected using similar procedures from the same region. To our knowledge, this is the first study to describe in detail trends in hypertension and related factors among Mexican Americans aged 75 and older.
In conclusion, there was an increase in hypertension prevalence among Mexican Americans aged 75 and older from 1993–1994, to 2004–2005 which was explained in part by the increase in diabetes and obesity. There was also an increase in hypertension awareness and control rates. However, hypertension treatment rates did not improve. More effort should be targeted to reverse trends of both obesity and diabetes as potential causes of increases in hypertension. Further investigations should be directed toward providing clear guidelines and goals for hypertension treatment and control in the very old to improve hypertension outcomes in this population.
ACKNOWLEDGMENT
M. Al Ghatrif conducted statistical analyses, was the primary writer of the article, and participated in study design, and interpretation of data. Y-F. Kuo participated in drafting of the manuscript, study design, data interpretation, and supervised statistical analyses. S. Al Snih and M. A. Raji participated in study design, drafting of the manuscript, and interpretation of data. L. A. Ray conducted data acquisition and analyses and participated in study design. K. S. Markides participated in study design, drafting of the manuscript, interpretation of data, and supervised statistical analyses. All authors contributed to and reviewed the final version of the article. The authors would like to thank Dr. James Goodwin for assisting with early drafts of the manuscript.
This study was supported by grant AG10939 from the National Institute on Aging, U.S.A. The UTMB Center for Health and Health Disparities (5P50CA105631-05), and the Robert Wood Johnson Foundation’s Network for Multicultural Research on Health and Healthcare at UCLA. Dr. Raji’s work is supported by Research Supplement to Promote Diversity in Health-Related Research Grant 1R01AG031178-01A1S1 from the National Institute on Aging, U.S.A. Dr. Al Snih is supported by a research career development award (K12HD52023: Building Interdisciplinary Research Careers in Women’s Health Program – BIRCWH) from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD); the National Institute of Allergy and Infectious Diseases (NIAID); and the Office of the Director (OD), National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of these Institutes or of the National Institutes of Health.”
Financial support: Grants AG10939, 1R01AG031178-01A1S1 from the National Institute on Aging, USA; UTMB Center for Health and Health Disparities, 5P50CA105631-05; the Robert Wood Johnson Foundation’s Network for Multicultural Research on Health and Healthcare at UCLA; K12HD52023, from Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD); the National Institute of Allergy and Infectious Diseases (NIAID); and the Office of the Director (OD), National Institutes of Health.
Footnotes
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Some of the findings of this paper were presented as an abstract at the Annual meeting of the American Geriatrics Society in Washington D.C., 2008.
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Notice of Rights
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