1. K yriakos S. Markides, PhD University of Texas Medical Branch Galveston, Texas, USA Adelaide, Australia, July 2, 2011

2. To provide an overview of the health status and health care needs of older immigrants to the United States, Canada, and Australia, the three largest traditional immigrant receiving nations.

3. Most Advanced Western societies are receiving increasing numbers of immigrants originating in non-Western or developing countries. While immigrants tend to be relatively young, their large numbers will ensure rising numbers of older immigrants of foreign-born older people who may have special concerns.

4. The United States, Canada, and Australia have been the three major immigrant nations where there have been considerable research interest in the health of immigrants. The volume and nature of immigration has changed in recent decades with most immigrants coming from non-European origins.

5. Canada 1 All immigrants vs. Canadian-born United States 2 All immigrants vs. U.S. Born Australia 3 U.K. & Ireland/Other Europe/Asia vs. Australian-born Males 0.81 Females 0.89 0.77 0.84 0.89 0.83 0.72 0.94 0.82 0.80 Sources: 1 Trovato, 2003 2 Singh & Hiatt, 2006 3 Australian Institute of Health and Welfare, 2002 Data: 1 1991 2 1999-2001 3 1997-1999

6.  Immigrants are younger, less educated, have lower incomes, and live in large families.  Hispanic immigrants were least likely to have health insurance.  Non-Hispanic black and Hispanic immigrants were less likely to be obese than their U.S.-born counterparts.  Hispanic immigrants were more likely to be obese the longer they lived in the U.S.

7.  Non-Hispanic black and Hispanic immigrants experienced fewer symptoms of psychological distress than their U.S.-born counterparts.  Foreign-born persons in all major ethic groups (Blacks, Hispanics, persons of Asian origin) have consistently lower mortality rates than native-born persons.  Foreign-born Blacks and persons of Asian-origin have the lowest odds of mortality with the native- born Blacks having the highest odds. The mortality advantage appears to be greatest in old age, especially among Hispanics.

8.  U.S. national data show that the immigrant health advantage tends to diminish with time and to disappear in the next generation.  A central mechanism of convergence is obesity. BMI levels of immigrants converge with native levels within 10 years among women, and 15 years among men.

9. Risk factor profiles: Hispanics (except Cuban Americans) are socioeconomically disadvantaged, but have favorable overall mortality.  High rates of DIABETES  High rates of OBESITY  Similar rates of hypertension/cholesterol  Rising SMOKING rates among men, lower among women (fewer cigarettes). Cuban American males smoke the most.  High ALCOHOL (binge) drinking rates among men, low among women. Alcohol consumption in women increases with acculturation.  Low rates of physical ACTIVITY  Strong families  Migration selection Markides and Coreil (1986)

10. Life Expectancy at Birth TotalMaleFemale Hispanic:80.677.983.1 Non-Hispanic White 78.175.680.4 Non-Hispanic Black72.969.276.2 Adjusted for misclassification of race and Hispanic origin on death certificates. 80+ rates for Hispanics based on Non-Hispanic White rates.

11. Trends in the health of older Mexican Americans aged 75 + MenWomen Health Conditions 1993-42004-51993-42004-5 Depressive symptoms (CESD ≥ 16) 75 (18.6%) 121 (16.1) 181 (30.3) 291 (24.1) ADL Disability (≥ 1) 93 (20.2) 237 (29.7) 176 (26.8) 524 (41.2) Diabetes mellitus100 (21.3) 248 (31.3) 142 (21.5) 442 (34.8) Hypertension233 (49.8) 435 (61.7) 399 (60.5) 780 (69.6) Stroke45 (9.6) 118 (14.9) 66 (10.0) 164 (12.9) Obesity (BMI ≥ 30) 72 (18.0) 148 (22.8) 153 (26.7) 313 (31.5) Cognitive impairment (MMSE < 21) 96 (23.2) 310 (41.3) 157 (26.0) 477 (40.3) Total N4697976621272

12.  Data clearly show an increase in ADL disability from 1993-1994 to 2004-2005 in Mexican Americans aged 75 and over, especially women.  Part of the increase can be attributed to increases in the prevalence of obesity and diabetes.  Data support the notion that the Mexican American population is at a stage of the epidemiologic transition when the general U.S. population was in the 1970’s—a period of rising life expectancy accompanied by increases in the prevalence of chronic diseases and disabilities.

13. Data from the 1994-95 National Population Health Survey* (NPHS) showed: Immigrants, especially recent immigrants, are less likely than the native-born to have chronic conditions and disabilities. This is especially so among those from non-European countries (Mostly Asian-born) *Chen, Ng, and Wilkins, 1996

14.  Immigrants were considerably less likely to have ever been smokers.  Non-European immigrants were less physically active.  European-origin immigrants were more physically active than the Canadian-born.  Health Levels of immigrants tend to converge to Canadian–born levels in about 10 years.

15. More recent analysis of multiple cross-sections of NPHS data found: There is strong evidence that the healthy immigrant effect is present in both men and women for the incidence of chronic conditions. Convergence over time to native levels reflects actual convergence in physical health rather than convergence in screening and diagnosis of existing health problems. McDonald and Kennedy, 2004

16.  Regardless of country of origin, almost all immigrants have good or better health compared to Australian-born counterparts (1).  Health advantage becomes smaller with more time in Australia.  Migrants from Asia have lowest standardized mortality ratio for all cause mortality, especially from colorectal and prostate cancers, respiratory causes and suicide 2  Those born in Asia less likely to be obese and overweight, to drink alcohol at risky levels. But, tend to have high rates of physical inactivity. 1 Australian Institute of Health and Welfare, 2002 2 Young, 1992

17. Data on immigrants to Australia aged 20-64 show*:  Immigrants have better health than the Australian-born.  Immigrants from non-English speaking Europe and from non-European countries have better health upon arrival than those from English speaking countries.  Within 10-20 years the health of immigrants approximates the health of native-born Australians.  * Biddle, Kennedy, and McDonald, 2007

18.  Immigrants have lower mortality rates compared to native born - but it does not appear that rising life expectancies will be accompanied by good health and good quality of life of many immigrants in old age.  Convergence between the health statuses of the two with time in the host country. - This reflects adoption of a Western life-style that includes higher levels of smoking and alcohol consumption, and especially higher rates of obesity.

19. Populations of Immigrants are aging rapidly and in some cases they are becoming more disabled, thus increasing the burden on families, communities and the health care system These issues are especially relevant in a time of shrinking financial resources.