Very little is known about the newest New Yorkers of Chinese heritage, the largest and fastest growing immigrant group in the city. This article compares measures of the health of immigrants to New York from Mainland China to the health of other New Yorkers of Asian heritage along with all other New Yorkers. We did so using the 1,999 subjects in the 2004 New York Health and Nutrition Examination Survey, controlling for age and gender. We found that New Yorkers born in Mainland China have a lower body mass index, a smaller waist circumference, a more sexually conservative lifestyle, highly favorable high-density lipoprotein profiles, and lower rates of herpes II infection. However, they also have higher blood levels of lead, cadmium, and mercury than either reference group. This article provides the first study of the health needs of New York's largest and most rapidly growing immigrant group

Jakubowski, Aleksandra

Muennig, Peter A.

Wang, Yue

Journal of Immigrant & Refugee Studies

English

Peter Muennig

Yue Wang

Aleksandra Jakubowski

Crossref

The Health of Immigrants to New York City From Mainland China: Evidence From the New York Health Examination and Nutrition Survey

Columbia University Academic Commons

Journal of Immigrant & Refugee Studies, 10:131–137, 2012Copyright © Taylor & Francis Group, LLCISSN: 1556-2948 print / 1556-2956 onlineDOI: 10.1080/15562948.2012.646541BRIEF NOTEThe Health of Immigrants to New York CityFrom Mainland China: Evidence From the NewYork Health Examination and Nutrition SurveyPETER MUENNIG, YUE WANG, and ALEKSANDRA JAKUBOWSKIMailman School of Public Health, Department of Health Policy and Management,Columbia University, New York, New York, USAVery little is known about the newest New Yorkers of Chinese her-itage, the largest and fastest growing immigrant group in the city.This article compares measures of the health of immigrants to NewYork from Mainland China to the health of other New Yorkers ofAsian heritage along with all other New Yorkers. We did so using the1,999 subjects in the 2004 New York Health and Nutrition Exami-nation Survey, controlling for age and gender. We found that NewYorkers born in Mainland China have a lower body mass index, asmaller waist circumference, a more sexually conservative lifestyle,highly favorable high-density lipoprotein profiles, and lower ratesof herpes II infection. However, they also have higher blood levelsof lead, cadmium, and mercury than either reference group. Thisarticle provides the first study of the health needs of New York’slargest and most rapidly growing immigrant group.KEYWORDS emigrants, immigrants, Chinese Americans, AsianAmericans, health status disparities, health statusPeople of Chinese ancestry first began to arrive in New York in the latenineteenth and early twentieth century (Kwong, 2002; Takaki, 1989; Yung,1995; Zhou, 2009). It is believed that New York served as a multiculturalrefuge, where it was possible for Chinese Americans to blend in and escapepersecution. After the Immigration and Nationality Act of 1965, Chinese NewYorkers came of their own, eventually forming large communities in Man-hattan, Queens, and Brooklyn (Logan, Zhang, & Alba, 2002; Zhou, 2009).Address correspondence to Peter Muennig, MD, MPH, Mailman School of Public Health,Department of Health Policy and Management, Columbia University, 600 W. 168th Street, 6thFl., New York, NY 10032. E-mail: pm124@columbia.edu131Downloaded by [Peter Muennig] at 05:04 07 March 2012 132 P. Muennig et al.Immigrants from China represent the largest and most rapidly growing im-migrant group in the city (U.S. Census Bureau, 2010), but almost nothing isknown about their health needs.The vast majority of recently arrived Chinese New Yorkers have theirorigins in Fujian Province of China, and many are undocumented (Kwong,2002; Zhou, 2009). In this article, we explore the social attributes, behavioralrisk factors, and overall health of these newest New Yorkers using the NewYork City Health and Nutrition Examination Survey (NYC HANES).METHODSThe 2004 NYC HANES includes a representative, weighted sample of par-ticipants residing within New York City who are age 20 and older (Thorpeet al., 2006). It was modeled after the National Health and Nutrition Ex-amination Survey, and was conducted by the Centers for Disease Controland Prevention’s National Center for Health Statistics (NCHS, 2011). Afterparticipants were selected, they were enrolled and examined at a healthcenter in New York City where they were administered a comprehensivehealth interview, they were examined, and blood and laboratory valueswere obtained. The analytic sample included 1,999 participants. All subjectsin the analytic sample were included.Our study focuses on persons born in Mainland China (n = 87). Thoseborn in Taiwan, Hong Kong, and Macau were excluded because these groupstend to be wealthier and to have lived for a longer time in New York City.Our two comparison groups include all New Yorkers not born in MainlandChina (n = 1,912) and a subgroup of those New Yorkers identifying asAsians (n = 173). All analyses were conducted using Stata 11.0 (StataCorpCollege Station, TX) and were weighted to produce representative estimatesof the New York City adult population. We examined differences in medicalexamination outcomes using linear regression models (for continuous data)or logistic models (for dichotomized data) adjusted for age and gender. Ed-ucation produced relatively little effect in the models, and was not includedas a covariate. We used two regression models to compare New Yorkersborn in Mainland China to all New Yorkers and Asian New Yorkers, as thesereference groups are not mutually exclusive. Length of time in New Yorkwas not available as a variable for foreign-born Chinese.RESULTSThere were 87 subjects who were born in China, 173 Asian New Yorkers,and 1,912 other New Yorkers available for analysis. While the majority AsianDownloaded by [Peter Muennig] at 05:04 07 March 2012 Chinese American Health 133TABLE 1 Demographic Characteristics of Study ParticipantsBorn in All other All otherParticipant demographics mainland China Asian race New YorkersDescriptive characteristics n = 87 n = 173 n = 1,912Female (%) 49.3 57.8 54.0Age (mean) 43.5 41.8 45.718−29 years (%) 19.7 19.8 19.830−49 years (%) 42.1 43.0 4350+ years (%) 38.2 37.0 37.2Socioeconomic characteristicsLess than high school education (%) 50.4 20∗∗∗ 26.2∗∗∗High school education (%) 24.5 15.4 19.1More than high school education (%) 25.1 64.6∗∗∗ 53.2∗∗∗Income above $20,000 per year (%) 46.1 70.7∗∗ 69 ∗∗∗Anyone to help with financial support (%) 74.0 73.9 77.6Access to healthcareInsured (%) 72.2 67.7 79.3Has access to routine healthcare (%) 80.5 61.1∗∗ 75.2Ever had colonoscopy/sigmoidoscopy(>50 years old) (%)25.8 43.5 51.8∗Self-reported risk factorsSedentary lifestyle (%) 27.8 25.2 22.4Drinks alcohol heavily (%) 14 25.2 31.2∗∗∗Self-reported health statusExcellent (%) 6.4 8.3 9.7Very good (%) 15.5 22.5 26.2Good (%) 46.6 48.1 39.0Fair (%) 29.8 16.8 21.8Poor (%) 1.7 4.3 3.3∗p < .05. ∗∗p < .01. ∗∗∗p < .001.New Yorkers and other New Yorkers are female, the majority of those born inChina are male (Table 1). Those born in Mainland China are also less likelyto have a high school education, tend to have a lower income, and tendto have somewhat higher access to routine health care. The one measureof social capital, self-reporting having someone who might lend financialsupport, was similar across all three groups.Relative to all other New Yorkers, New Yorkers born in Mainland Chinawere one third as likely to report having a high school education or higher(OR = 0.32; p < .001) or to have an income over $20,000 (OR = 0.36;p < .01) adjusting for age and gender (Table 2). They were also one fifthas likely to have ever taken oral contraceptives (OR = 0.22; p < .001) andwere nearly eight times as likely to have initiated intercourse after age 15(OR = 7.89; p < .01). But they were twice as likely to report having had aninfluenza vaccination (OR = 1.95; p < .01). With respect to adjusted medicalexamination data (Table 3), those born in Mainland China rated 4.5 pointsDownloaded by [Peter Muennig] at 05:04 07 March 2012 134 P. Muennig et al.TABLE 2 Odds Ratios for Self-Report Health History Data for Immigrants to New York FromMainland China Relative to Other Asian New Yorkers and Other New Yorkers in GeneralAfter Adjusting for age and Gender: 2004 New York City Health and Nutrition ExaminationSurveyAsian New Yorkers All New YorkersParticipant demographics OR (95% CI) OR (95% CI)Socioeconomic characteristicsHigh school education or higher 0.22∗∗∗ (−2.14,−0.85) 0.32∗∗∗ (−1.63,−0.67)Income above $20,000 per year 0.36∗∗ (−1.63,−0.42) 0.36∗∗∗ (−1.52,−0.52)Insureda 1.24 (−0.33, 0.77) 0.71 (−0.78, 0.098)Access to routine healthcareb 2.43∗ (0.13, 1.64) 1.22 (−0.44, 0.84)Mental health statusCurrent depression diagnosisc 0.97 (−1.85, 1.78) 0.44 (−2.32, 0.67)Lifetime depression diagnosisd 0.97 (−1.29, 1.22) 0.43 (−1.91, 0.24)Experienced confusion or memoryproblems0.69 (−1.56, 0.82) 0.87 (−1.18, 0.90)Has more than five close friends 0.85 (−0.82, 0.49) 0.75 (−0.83, 0.27)Sexual historyAge at first sexual intercourse>15 years old2.25 (−0.82, 2.45) 7.89∗∗ (0.69, 3.44)Ever had same sex partnere 1.63 (−1.91, 2.89) 1.05 (−1.92, 2.03)Ever taken birth control pill 0.55 (−1.50, 0.29) 0.22∗∗∗ (−2.27,−0.73)Vaccination historyReceived hepatitis B 3-dose series 0.77 (−0.90, 0.38) 1.02 (−0.60, 0.63)Had flu shot past 12 months 2.06∗ (0.076, 1.37) 1.95∗∗ (0.21, 1.13)OtherEver had colonoscopy (>50 years old) 0.50 (−1.94, 0.54) 0.40 (−1.95, 0.10)Sedentary lifestylef 1.15 (−0.50, 0.77) 1.21 (−0.23, 0.61)Physical limitations to working 0.77 (−1.11, 0.58) 0.87 (−0.79, 0.51)Self-reported excellent health status 0.64 (0.35, 1.17) 0.62∗ (−0.91,−0.056)aIncludes health insurance obtained through employment or purchased directly as well as governmentprograms like Medicare, Medicaid, and military health care/VA that provide medical care or help paymedical bills.bParticipant has a regular place to go for healthcare. cCurrent diagnosis established duringthe interview using World Health Organization’s Composite International Diagnostic Interview. dLifetimediagnosis based on doctor or other health care professional ever telling the participant that he/she isdepressed. eParticipant has, at any point in his or her life, had a sexual partner of the same gender.fParticipant does not stand or walk about a lot during the day, carry or lift things very often, or climbsstairs or hills often.∗p < .05. ∗∗p < .01. ∗∗∗p < .001.lower with respect to body mass index (BMI), a waist circumference thatwas 11cm smaller (p < .001), had a higher high-density lipoprotein (HDL, or“good” cholesterol) by 5mg/dl (p < .001), and were nearly one fifth as likelyto have a positive herpes II test result relative to other New Yorkers (p <.001). On the other hand, they were more likely to have elevated blood leadlevels, cadmium levels, and mercury levels.Downloaded by [Peter Muennig] at 05:04 07 March 2012 Chinese American Health 135TABLE 3 Differences in Medical Examination and Laboratory Data Between Immigrants toNew York from Mainland China Relative to Other Asian New Yorkers and Other New Yorkersin General After Adjusting for Age and Gender: 2004 New York City Health and NutritionExamination SurveyOther Asian New All New YorkersYorkers (95% CI) (95% CI)Average body mass index (kg/m2) −2.2∗∗∗ (−3.3,−1.2) −4.5∗∗∗ (−5.7,−3.2)Average waist circumference (cm) −5.7∗∗∗ (−8.3,−3.2) −11.0∗∗∗ (−13.8,−8.1)Average plasma glucose (mg/dL)a −5.7 (−14.8, 3.2) 0.6 (−6.1, 7.4)Average glycohemoglobin (%)b −0.22 (−0.48, 0.00) 0.03 (−0.17, 0.23)Total cholesterol (mg/dL)c 3.1 (−8.0, 14.3) 7 (−1.8, 15.8)High density lipoprotein cholesterol (mg/dl)c 6.5∗∗ (2.4, 10.6) 5.0∗∗ (1.4, 8.5)Low density lipoprotein cholesterol (mg/dl)c −5.6 (−17.3, 6.4) −2.5 (−11.8, 7.0)Triglycerides (mg/dl)c −7.1 (− 33.9, 18.4) 4.7 (−15.8, 25.1)Average systolic blood pressure (mm Hg) −2 (−5.5, 1.7) −2.1 (−5.2, 1.0)Average diastolic blood pressure (mm Hg) 0.56 (−2.1, 3.4) 0.62 (−1.7, 3.0)Cotinine (ng/mL)d 1.3 (−24.3, 27.2) −8 (−31.5, 16.0)Lead (ug/dL)e 0.44 (−0.02, 0.86) 0.81∗∗∗ (0.41, 1.20)Cadmium (ug/L)e 0.60∗∗∗ (0.39, 0.80) 0.69∗∗∗ (0.55, 0.83)Mercury, total (ug/L)e 5.3∗∗∗ (3.7, 6.8) 6.6∗∗∗ (5.7, 7.5)Odds ratio (reference is Born in Mainland China)Herpes I diagnosisf 5.64∗∗ (0.61, 2.85) 5.85∗∗∗ (0.80, 2.73)Herpes II diagnosisf 0.42 (−1.93, 0.19) 0.22∗∗∗ (−2.31,−0.71)aPlasma glucose concentration was measured using an enzymatic reaction. bHbA1C was measured onwhole blood with an ion-exchange high-performance liquid chromatography (HPLC) method. cFastinglevels. Serum cholesterol and triglycerides were measured enzymatically using commercial reagents.dSerum cotinine levels were measured using an isotope dilution, liquid chromatography, tandem massspectrometry method. eTested using inductively coupled plasma mass spectroscopy (ICP–MS). fSerumsamples were analyzed for antibodies to HSV-1 and HSV-2 using type-specific immunodot assays.∗p < .05. ∗∗p < .01. ∗∗∗p < .001.CONCLUSIONSNew Yorkers who were born in Mainland China have a more favorable men-tal, cardiac, and reproductive health profile than other New Yorkers, buthigher exposures to heavy metals. The diet among Chinese New Yorkers isheavy in vegetables and seafood, which may both explain the lower cardiacrisk profile and the higher exposure to mercury (Newman & Linke, 1982;Porterfield, 1951). Cadmium and lead can persist in the body for decades,and may reflect exposures within China (Centers for Disease Control andPrevention, n.d.). However, recent exposures to lead could occur via tra-ditional medicines that contain lead (Ernst, 2002). While lead tends to besequestered in the bones, on average, those with significant early life leadexposures could plausibly have higher average blood lead levels due toleeching.Relative to other New Yorkers, those born in China appear to be sexuallyconservative. They are much less likely to report an early age of intercourseDownloaded by [Peter Muennig] at 05:04 07 March 2012 136 P. Muennig et al.or to use birth control pills. This self-report data is supported by laboratorymeasures of herpes II (most often genital), with prevalence that is one fifthof the average New Yorker.These differences are not likely attributable to less access to healthcare, as those born in China had comparable or better access to health carethan other New Yorkers. This is likely attributable to the extensive outreachprovided to Chinatown communities and the presence of clinics that providefree or subsidized care, such as the Charles B. Wang Health Center.At present, there are no other medical examination studies of Chinesegroups within the United States with which to compare New York’s Chineseimmigrant population. Studies form within Mainland China suggest that ur-ban dwellers in China share more in common with native-born New Yorkerswith respect to health risks than they do to Chinese immigrants to New YorkCity (Fang, Chen, & Rizzo, 2009; Hannum, 2002; Ho et al., 2010; Liu, Hsiao,& Eggleston, 1999; Wang & Zhou, 2010; Weng et al., 2007; Wu, 2006).The primary limitation of the NYC HANES data lies in the self-reportportion of the medical interview. Cross-cultural differences in norms or per-ceived stigma can plausibly skew results in either direction. In addition,sample sizes were too small to detect anything less than a moderate effectsize for some measures. Finally, we did not have an adequate measure ofacculturation available to us. This variable would have allowed us to presentthe reader with a sense of how different levels of exposure to the UnitedStates might influence health. However, the majority of Chinese immigrantsarrived to New York City arrived within the past 10 years and reside in en-claves in Manhattan’s Chinatown, Brooklyn’s Sunset Park Chinatown, andQueen’s Elmhurst and Flushing neighborhoods (U.S. Bureau of the Census,2010).The superior health status of lower-income immigrant groups has beenhypothesized to be related to social cohesion (Franzini, Ribble, & Keddie,2001). The target population in this sample had similar numbers of friendsor people in their social network who could lend financial support, a findingcongruent with a previous report (Osypuk, Diez Roux, Hadley, & Kandula,2009). Rather, good health markers (e.g., highly favorable cholesterol pro-files) in the face of poverty and low educational attainment may well beexplained by a favorable behavioral risk profile. While there is cause forconcern regarding heavy metal exposure, the future looks bright for NewYorkers who were born in Mainland China.REFERENCESCenters for Disease Control and Prevention. (n.d.). National report on humanexposure to enviornmental chemicals. Retrieved from http://www.cdc.gov/exposurereport/Downloaded by [Peter Muennig] at 05:04 07 March 2012 Chinese American Health 137Ernst, E. (2002). Toxic heavy metals and undeclared drugs in Asian herbal medicines.Trends in pharmacological sciences, 23(3), 136–139.Fang, H., Chen, J., & Rizzo, J. A. (2009). Explaining urban−rural health disparitiesin China. Medical care, 47, 1209–1216.Franzini, L., Ribble, J. C., & Keddie, A. M. (2001). Understanding the Hispanic para-dox. Ethnicity & Disease, 11, 496–518.Hannum, E. (2002). 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The Health of Immigrants to New York City From Mainland China: Evidence From the New York Health Examination and Nutrition Survey

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