Immigrant Health

By Silvia Helena Barcellos, Dana P. Goldman, and James P. Smith

doi: 10.1377/hlthaff.2011.0973

Undiagnosed Disease, Especially

HEALTH AFFAIRS 31,
NO. 12 (2012): –
©2012 Project HOPE—
The People-to-People Health

Diabetes, Casts Doubt On Some Foundation, Inc.

Of Reported Health ‘Advantage’

Of Recent Mexican Immigrants
Silvia Helena Barcellos is an
ABSTRACT Newly arrived Mexican immigrants in the United States associate economist at RAND
in Santa Monica, California.
generally report better health than do native-born Americans, but this
health advantage erodes over time. At issue is whether the advantage is Dana P. Goldman is the
illusory—a product of disease that goes undiagnosed in Mexico but is founding director of the
Leonard D. Schaeffer Center
discovered after immigration. Using results from the National Health and for Health Policy and
Economics and the Norman
Nutrition Examination Survey, we compared clinical to self-reported Topping Chair in Medicine and
diagnosed disease prevalence and found that Mexican immigrants are not Public Policy at the University
of Southern California, in Los
as healthy as previously thought when undiagnosed disease is taken into Angeles.
account, particularly with respect to diabetes. About half of recent
James P. Smith (smith@
immigrants with diabetes were unaware that they had the disease—an rand.org) holds the
undiagnosed prevalence that was 2.3 times higher than that among Distinguished Chair in Labor
Markets and Demographic
Mexican Americans with similar characteristics. Diagnosed prevalence Studies at the RAND
was 47 percent lower among recent Mexican immigrants than among Corporation in Los Angeles,
California.
native-born Americans for both diabetes and hypertension, but
undiagnosed disease explained one-third of this recent immigrant
advantage for diabetes and one-fifth for hypertension. The remaining
health advantage might be explained in part by immigrant selectivity—the
notion that healthier people might be more likely to come to the United
States. Lack of disease awareness is clearly a serious problem among
recent Mexican immigrants. Since undiagnosed disease can have adverse
health consequences, medical practice should emphasize disease detection
among new arrivals as part of routine visits. Although we found little
evidence that health insurance plays much of a role in preventing these
diseases, we did find that having health insurance was an important
factor in promoting awareness of both hypertension and diabetes.

T
here are forty-two million foreign-
born residents in the United States,
accounting for 13 percent of the
current American population. Two-
thirds of America’s population
growth between 1995 and 2050 will directly or
indirectly stem from immigration.1 As a result,
the health status of Americans will increasingly
reflect the health status of recent immigrants
and their descendants. It is important, then, to
monitor the health of foreign-born populations
and its implications for the US health system.
Differences in the health status of Mexican
immigrants and native-born Americans have
generated substantial research in past decades.
A key stylized fact—that is, an observation that
has been made in so many contexts that it is
widely understood to be an empirical truth—
is that, compared to native-born Americans,
Mexican immigrants arriving in the United

D e c e m b e r 201 2 3 1 :1 2 Health Affairs 1

Immigrant Health
States report being in better health. However,
this health advantage disappears the longer they
stay in the United States.2–4
This phenomenon—often called the “healthy
immigrant effect”—has been studied by re-
searchers from many disciplines and has also
been shown in other major immigrant-receiving
countries. Mexican immigrants are also found to
have lower rates of mortality than native-born
Americans, of both Mexican and non-Mexican
heritage.5–7
The reasons underlying the healthy immigrant
effect have been a source of considerable debate.
One explanation is based on selective immigra-
tion and return migration: If healthy immigrants
are more likely to come to the United States or if
unhealthy immigrants are more likely to return
to their home country, we will observe that im-
migrants are generally healthier than native-
born Americans.2,8,9 Another explanation uses
assimilation: If immigrants are exposed to a
more harmful environment or adopt a more
harmful lifestyle—say, through poorer diet and
less exercise—than they had in their native coun-
try, their health status could decline over time in
the United States.3,8,10–12
One possible explanation receiving less atten-
tion stems from improved health care access as a
consequence of immigration. The hypothesis is
that immigrants from countries with poor access
to health services may come with preexisting,
undiagnosed health problems. After arriving in
the United States, they are exposed to a more
accessible health care system and become more
aware of these conditions. If so, improved care
access can explain part of the initial immigrant
health advantage as well as its subsequent ero-
sion. One important difference between this hy-
pothesis and others is that it implies immigrants
might not truly be in better physical health than
the native born—a finding with important impli-
cations for health policy.
This article focuses on the healthy immigrant
effect with respect to diabetes and hypertension,
two prevalent chronic diseases in the Mexican
American population. We used direct measures
of undiagnosed disease—through clinical and
laboratory tests—to investigate if these patterns
can be explained by disease awareness. We mea-
sured awareness as the fraction of those with the
disease (who either reported that they had been
diagnosed by a doctor or who were above the
clinical thresholds) who reported being told by
a doctor that they had the disease.
Study Data And Methods
Data This research used yearly data from the
National Health and Nutrition Examination
2 Health A ffairs D e ce m b er 2 012 3 1 :1 2
Survey (NHANES)13 from 1988 to 1994 and from
1999 to 2008. The survey examines a nationally
representative sample of about 5,000 people
each year and provides crucial information about
respondents’ immigrant status and characteris-
tics. To have sufficient sample sizes to investi-
gate patterns for different immigrant groups, we
pooled data from different years.
The key advantage of this survey is that, in
addition to self-reported data, it assesses health
status through comprehensive physical exami-
nations and laboratory tests (blood, urine, and
swabs) conducted around the same time as the
home interview by a physician in a mobile health
center. This fact allowed us to identify health
conditions that respondents didn’t know they
had but that surfaced through clinical testing.
Diabetes And Hypertension Prevalence
Measures We investigated clinical prevalence,
diagnosed prevalence, and awareness of hyper-
tension and diabetes, using the following spe-
cific measures.
▸ SELF - REPORTED DISEASE STATUS : People
have a diagnosed condition (hypertension or
diabetes) if in the NHANES survey they reported
that a doctor told them that they had the disease.
▸ CLINICAL HYPERTENSION : Following the lit-
erature,14,15 we used the mean of the second and
third reading of systolic and diastolic blood pres-
sure measured during the physical exam. Based
on standard definitions, we considered a person
to have hypertension if he or she had more than
140 mmHg systolic or more than 90 mmHg dia-
stolic pressure.16–18
▸ CLINICAL DIABETES : We followed the stan-
dard convention by using values of glycosylated
hemoglobin (HbA1c) equal to or greater than
6.5 percent.19,20 HbA1c is highly correlated with
fasting plasma glucose levels and is a frequently
used measure of clinical diabetes in academic
studies.20,21
▸ TOTAL PREVALENCE : People were consid-
ered to have either condition if they reported
that a doctor told them they had the condition
or if they had a clinical value above the diagnostic
threshold.
▸ AWARENESS : People had undiagnosed dis-
ease if they did not report being previously diag-
nosed but an examination subsequently revealed
a condition.
▸ MISSING VALUES : A nontrivial fraction of
clinical values was missing from the final pooled
data set: 9.8 percent for clinical diabetes and
8.7 percent for clinical hypertension (see
Appendix Table A).22 These missing values were
the result of refusals of laboratory or physical
exams, or of conditions that prevented the exam
from being performed. Examples of these con-
ditions are rashes, open wounds, or blood
having been drawn from a participant within the
previous week.
Self-reported prevalence of diabetes and
hypertension were not statistically different in
a comparison of those with and without clinical
values missing. Other studies using NHANES
reported similar fractions of missing values.23
Risk Factors In addition to years since im-
migration, we used as covariates the following
risk factors: age, race, years of education, in-
come, having health insurance, smoking, and
being overweight or obese. Dummy variables for
low, middle, and high income were constructed
by dividing respondents into three equal year-
specific income terciles in each NHANES. We
categorized each respondent as low, middle, or
high income relative to other respondents in the
same survey year, avoiding complications result-
ing from inflation or income increases over time.
Health insurance refers to coverage by any
insurance type (public, employer-provided, or
individual), and smoking to whether a respon-
dent currently smokes.
NHANES measures respondents’ height and
weight during the physical test so that body mass
index can be computed. With the index, an ob-
jective assessment can be made of whether the
respondent is obese (body mass index ≥30) or
overweight (body mass index ≥25 and <30).
Immigrant Status We considered Mexican
immigrants to be people born in Mexico.
Mexican Americans were people born in the
United States who defined themselves as
Mexican Americans in the ethnicity question
and were presumably the children, grand-
children, or great-grandchildren of immigrants
(so-called second-, third-, or fourth-generation
immigrants) or beyond.
Our definitions are conventional, although
there is always some imprecision in defining
ancestry because of mixed heritage in family
backgrounds and different propensities to claim
a particular heritage.1 An important variable for
analysis is tenure in the United States, derived
from a question asking the year foreign-born
respondents came to the United States “to stay.”
Analysis We estimated ordinary least squares
models—weighted to account for the NHANES
design—to explain diagnosed, undiagnosed,
and total hypertension and diabetes prevalence
as a function of individual characteristics. We
used repeated cross-sectional analysis with sev-
eral NHANES survey waves. Our main interest
was differences in total disease prevalence,
diagnosis, and awareness among native-born
Americans of non-Mexican heritage, Mexican
Americans, Mexican-born immigrants, and re-
cent versus nonrecent Mexican immigrants.
Raw comparisons of disease prevalence might
be misleading because of differences in risk fac-
tors across groups, as shown in Appendix
Table B.22 We controlled for individual character-
istics in a multivariate regression framework
(see Appendix Table C).22 Based on our esti-
mated models, we calculated predicted probabil-
ities of having hypertension or diabetes for
different subgroups, holding individual charac-
teristics constant.
For example, to compare the characteristic-
adjusted diabetes total prevalence rates of non-
Mexican native-born Americans and Mexican
immigrants, we used our ordinary least squares
estimates to predict the probability of having
hypertension or diabetes for each of the two
groups if both groups had individual character-
istics equal to the sample mean. Therefore,
differences in predicted probabilities presented
in this article cannot be attributed to measured
differences between groups (in this case non-
Mexican native-born Americans and Mexican
immigrants) in characteristics included in the
model.
Our sample was restricted to males and fe-
males ages 30–60. The prevalence of hyperten-
sion and diabetes for people over thirty is high
enough to make analyses feasible with NHANES
sample sizes. We restricted the sample to people
under sixty to avoid the possibility of negative
health selection of older immigrants, as people
who move to the United States when they are
older than sixty often do so to take advantage
of better medical treatment here.2,19 Our analysis
applies only to Mexican immigrants who come to
the United States within this age group.
Limitations There are several limitations to
this research. The primary limitation is the lack
of panel data tracking immigrants from time of
their arrival well into their stay in the United
States. Because of this, we relied on synthetic
cohort techniques to trace average experiences
of immigrants over time.
Instead of tracking the same group from one
year to the next, synthetic cohorts capture differ-
ent groups of people (for example, immigrants)
who have lived in this country for different time
intervals, simulating what might happen if a par-
ticular cohort were tracked over time. Cohort
effects in prevalence and diagnosis of disease
could affect these synthetic cohort patterns. We
tested for cohort effects in our sample of new
entrants and did not find any significant
differences, but the sample sizes were relatively
small.
Since we focused on the Mexican immigrant
experience, we were limited by the standard com-
plexities of defining Mexican heritage. Our data
for people living in Mexico were not strictly com-
parable to data for Mexicans living in the United
December 2012 3 1:12 Health Affairs 3
Immigrant Health
States because of a different test for clinical dia-
betes (fasting glucose instead of HbA1c) for a
population in Mexico that largely did not follow
instructions to fast.
Finally, because we relied on observational
data, this study can identify strong suggestive
correlations but not strict causal links.
Study Results
Socioeconomic Differences By Country
Of Origin And Time In The United States
Appendix Table B shows summary statistics
for immigrants born in Mexico and im-
migrants born elsewhere, along with native-born
Americans of Mexican descent (Mexican
Americans) and native-born Americans not of
Mexican descent.22 The data for Mexican im-
migrants are presented by length of tenure in
the United States. All differences across groups
discussed below have been found to be signifi-
cant at the 0.05 level.
Standard demographic characteristics (age
and sex) of these populations were generally
similar. However, Mexican immigrants on aver-
age had fewer years of education, lower income,
and a lower probability of having health insur-
ance than both Mexican and non-Mexican
Americans as well as immigrants from other
countries. Although Mexican immigrants were
more likely to be overweight than other im-
migrants, their smoking and obesity rates were
about the same.
Compared to all other groups, Mexican im-
migrants were significantly less likely to be
covered by health insurance. The gap was large
for Mexican immigrants who had been in the
United States for less than five years—only
23 percent had health insurance, compared to
86 percent of native-born Americans of non-
Mexican heritage and 77 percent of Mexican
Americans. These low rates of health insurance,
which do rise as the length-of-stay increases, are
largely because of the undocumented status of
many recent Mexican immigrants and their con-
sequent lack of eligibility for public health insur-
ance in the United States.24
Risk factors such as age and overweight or
obesity are related to diabetes and hypertension
prevalence. Therefore, differences between
native-born Americans and Mexican immigrants
in Appendix Table B22 emphasize the importance
of taking these factors into account when com-
paring prevalence across groups. In any year
Mexicans immigrants were younger than
native-born Americans of Mexican or non-
Mexican heritage, which should lead to lower
disease prevalence, but they were also more
likely to be uninsured.
4 Health Affairs D e ce m b e r 2 0 1 2 31:12
Diabetes And Hypertension Prevalence
Exhibit 1 displays alternative measures of
diabetes and hypertension prevalence for our
demographic groups. These figures are simple
weighted averages for each group, not adjusted
for differences in the individual characteristics
shown in Appendix Table B22 (for adjusted fig-
ures, see Exhibits 2–5). The data in Exhibit 1
provide suggestive evidence that undiagnosed
disease may partly explain the “healthy im-
migrant” effect for diabetes and hypertension
among Mexican immigrants—thus making that
effect at least in part illusory. To illustrate for
diabetes, 58.5 percent of immigrants with dia-
betes in their first four years in the United States
were undiagnosed, compared to 29.5 percent of
those who had been in the country for fifteen or
more years.
The numbers for diagnosed prevalence of both
diseases show the already documented effect—
that Mexican immigrants in the United States
for less than five years report being in much
better health on arrival than their native-born
American counterparts, but this health advan-
tage erodes as length-of-stay in the United
States increases. The fraction of recent Mexican
immigrants reporting ever having been diag-
nosed with diabetes (1.8 percent) or hyper-
tension (10.0 percent) was significantly lower
than the same fraction for Mexican and non-
Mexican Americans, but the fraction increased
for Mexican immigrants who had been in the
United States longer.
When we examined clinical diagnosis, how-
ever, the healthy immigrant effect was attenu-
ated. Although recent Mexican immigrants still
appeared to be healthier, relative differences
were not as large. Clinical diabetes prevalence
for all recent Mexican immigrants was 3.8 per-
cent (Exhibit 1)—about three-quarters of the dia-
betes prevalence for native-born Americans of
non-Mexican descent (5.2 percent). Total dis-
ease prevalence—which includes diagnosed
and undiagnosed disease—painted a picture in
which recent Mexican immigrants were not as
healthy as traditional measures (diagnosed
prevalence) suggested.
Finally, undiagnosed prevalence as a fraction
of total prevalence was substantially lower
among Mexican Americans than among im-
migrants from Mexico, a country where access
to health care among the poor is arguably much
worse than in the United States. The fraction
was particularly high among recent Mexican im-
migrants. Fifty-nine percent of recent Mexican
immigrants who had diabetes were un-
diagnosed, as were 33 percent who had hyper-
tension. Comparable rates for native-born
Americans were about one-fifth for both diabetes
 Exhibit 1

Prevalence Of Diabetes And Hypertension In US Native-Born And Immigrant Men And Women Ages 30–60
Native born Immigrants born in Mexico
Not of Immigrants
Mexican Of Mexican not born 0–4 years 5–14 years ≥15 years
Condition/ descent descent in Mexico All in US in US in US
diagnosis status (n = 14,124) (n = 2,081) (n = 2,137) (n = 2,666) (n = 365) (n = 883) (n = 1,418)
Diabetes
Diagnosed (%) 5.8 8.9*** 6.5 6.6 1.8 5.0 9.0***
Clinical (%) 5.2 9.2*** 6.5** 8.3*** 3.8 6.2 10.8***
Total (%) 7.2 11.3*** 8.8** 10.5*** 4.7 8.6 13.3***
Undiagnosed
(% of total) 21.3 22.6 24.1 33.7*** 58.5** 38.2** 29.5
Hypertension
Diagnosed (%) 26.0 25.2 18.4*** 13.7*** 10.0*** 11.8*** 15.9***
Clinical (%) 13.0 14.5 11.9 8.5*** 5.3** 6.6*** 10.5
Total (%) 31.4 30.9 24.0*** 18.6*** 14.6*** 16.0*** 21.3***
Undiagnosed
(% of total) 17.9 19.6 22.6** 28.8*** 33.3 28.2** 28.6**

SOURCE Authors’ calculations, based on data from the National Health and Nutrition Examination Survey (see Note 13 in text), 1988–94 and 1999–2008. NOTES Averages
were weighted using survey weights for the different subgroups, using pooled data from NHANES 1988–1994 and 1999–2008. Diagnosed prevalence is the percentage of
respondents who had a doctor diagnose the disease. Clinical prevalence is the percentage with readings above the clinical threshold for the disease (see the text). Total
prevalence is diagnosed plus clinical prevalence. Undiagnosed is the percentage of respondents with total (clinical or diagnosed) diabetes or hypertension who have not
been diagnosed. Significance refers to significant difference from the mean for native-born Americans not of Mexican descent. **p < 0:05 ***p < 0:01

and hypertension. Moreover, for Mexican im-
migrants, undiagnosed disease as a fraction of
total prevalence decreased steeply for diabetes
the longer the immigrants had stayed in the
United States.
The patterns shown in Exhibit 1 suggest that
lower disease awareness among Mexican im-
migrants—and increased awareness with time
in the United States—may be important when
interpreting the “healthy immigrant” effect.
Disease Prevalence Analysis We analyzed
determinants of diagnosed, total, and un-
diagnosed diabetes and hypertension prevalence
by estimating ordinary least squares models, in-
vestigating factors related to these prevalence
measures. Estimated parameters of ordinary
least squares models are presented in the online
Appendix.22
Since the main patterns of our interest con-
cern comparisons between Mexican immigrants
and native-born Americans of Mexican and non-
Mexican heritage, we restricted the sample to
respondents in these groups, dropping im-
migrants from countries other than Mexico, who
constituted 9 percent of the total sample. Native-
born Americans of non-Mexican descent were
the excluded group in these models, and we in-
cluded dummy variables for Mexican Americans
and three groups of Mexican immigrants based
on their time since immigration (0–4, 5–14, and
15 or more years).
The other covariates were age; sex (1 = male);
race (1 = black); three education and income
groups (in both cases, the left-out group was
the lowest category); dummy variables for being
a smoker, being overweight, and being obese;
and sets of dummy variables indicating the
NHANES survey year in which a respondent par-
ticipated. The first four columns of Appendix
Table C show estimated results for diagnosed
and total disease prevalence for diabetes and
hypertension.22
Results were consistent with previous research
on the importance of certain risk factors for dia-
betes and hypertension prevalence.15,19 For both
diseases, diagnosed and total prevalence de-
clined as education or income increased or as
age decreased and were higher among black
respondents and men (especially for total preva-
lence). Being overweight or obese was strongly
related to the probability of reporting being di-
agnosed or having the condition. Of particular
interest, respondents who were not covered by
health insurance were less likely to be diagnosed
for either diabetes or hypertension.
These regressions show that Mexican
Americans were more likely to have diabetes
but no more likely to have hypertension than
were native-born Americans not of Mexican
descent. Recent Mexican immigrants had a diag-
nosed diabetes prevalence 2.7 percentage points
lower than that of native-born Americans of
non-Mexican heritage. This compares to a
four-percentage-point lower rate in the raw data

December 2012 3 1:12 Health Affairs 5

Immigrant Health
in Exhibit 1, indicating that attributes in the
regressions can explain only part of the healthy
immigrant effect for diabetes among recent
Mexican immigrants.
Similarly, when we performed the same calcu-
lation for diagnosed hypertension, we found that
covariates in the model accounted for only part
of the healthy immigrant effect for recent
Mexican immigrants. Compared to the raw dif-
ference of sixteen percentage points in Exhibit 1,
our model predicted a thirteen-percentage-point
lower prevalence of diagnosed hypertension
among recent Mexican immigrants.
We looked more directly at the role of
undiagnosed diabetes and hypertension and
factors related to it by restricting the sample to
those who had diabetes or hypertension (diag-
nosed or undiagnosed) and constructing a
dummy variable for those who were un-
diagnosed. We present these ordinary least
squares analyses in the last two columns of
Appendix Table C.22
Mexican immigrants, especially those recently
arrived in the United States, who had either
diabetes or hypertension were more likely to
have been undiagnosed than both Mexican
Americans and native-born Americans of non-
Mexican heritage. The increased probability of
having undiagnosed diabetes or hypertension
declined among Mexican immigrants in the
United States for fifteen years or more, although
the probability declined more steeply for those
Exhibit 2
Predicted Diagnosed And Total Prevalence Of Diabetes, Adjusted By Individual Characteristics, In Men And Women
Ages 30–60
SOURCE Authors’ calculations, based on data from the National Health and Nutrition Examination Survey (see Note 13 in text), 1988–
94 and 1999–2008, and the 2000 Mexican National Health Survey (see Note 25 in text), for diabetes levels among Mexicans in Mexico.
6 H ea lt h A f fai r s December 2 012 31:12
with diabetes. For both diseases, having health
insurance was a strong predictor of being diag-
nosed. Previous research on factors related to
undiagnosed diabetes and hypertension found
similar results.16,20
Simulations Based on the estimated preva-
lence models in Appendix Table C,22 we com-
puted predicted probabilities of being diagnosed
and having diabetes or hypertension, adjusted
for all attributes in the models. Results are dis-
played graphically in Exhibits 2 and 3 for diabe-
tes and Exhibits 4 and 5 for hypertension.
Exhibit 2 shows predicted diagnosed and
total diabetes prevalence for our demographic
groups. Since predictions were adjusted for all
included individual characteristics in Appendix
Table C,22 differences in included characteristics
between groups cannot explain differences in
disease prevalence in Exhibit 2.
For comparative purposes, Exhibit 2 also
shows data on diagnosed and total diabetes
prevalence for a random sample of Mexicans
living in Mexico in the same age group, using
data from the 2000 Mexican National Health
Survey.25 One caution in interpreting data on
total diabetes prevalence for the Mexican sample
is that although fasting glucose was used, much
of the sample did not fast in the previous twelve
hours. A twelve-hour fast is normally required
for an accurate measure.
For those born in the United States, these
characteristic-adjusted figures closely follow
 Exhibit 3

Predicted Undiagnosed Diabetes Prevalence As Percentage Of Total Prevalence, Adjusted By Individual Characteristics, In
Men And Women Ages 30–60

SOURCE Authors’ calculations, based on data from the National Health and Nutrition Examination Survey (see Note 13 in text), 1988–
94 and 1999–2008, and the 2000 Mexican National Health Survey (see Note 25 in text), for diabetes levels among Mexicans in Mexico.
NOTES Fraction of people who were diagnosed with diabetes by a doctor or were above the clinical threshold (see the text) who were
not aware that they had diabetes.

the raw prevalences shown in Exhibit 1, which is
not surprising because the characteristics of the
groups were not that different (see Appendix
Table B).22 The major effect of these adjustments
occurred among Mexican immigrants and
among them, those who most recently came to
the United States.
Consider first the most recent Mexican im-
migrants. Their diagnosed diabetes rate in
Exhibit 1 was 1.8 percent, four percentage points
less than our comparison group of native-born
Americans not of Mexican heritage (5.8 per-
cent). Adjusting for all characteristics in the
model, we predicted a diagnosed rate for recent
Mexican immigrants of 3 percent, 2.7 percent-
age points less than the comparison group of
native-born Americans not of Mexican descent
(Exhibit 2). Attributes included in the model
explained part but not all of the low rate of
diagnosed diabetes among recent Mexican
immigrants.
We found similar but more attenuated patterns
for Mexican immigrants who had stayed longer
in the United States. The characteristic-adjusted
increase in diagnosed diabetes as time since im-
migration increased was considerably smaller.
Our raw numbers in Exhibit 1 indicated that
diagnosed diabetes increased from 1.8 percent
to 9.0 percent, while our attribute-adjusted rates
in Exhibit 2 indicated a rise from 3.0 percent to
7.9 percent. Thus, a significant part but, once
again, not all of the increases in diagnosed dia-
betes for Mexican immigrants as time passed
reflected a larger likelihood that diabetes would
be diagnosed.
Total diabetes prevalence was higher
among Mexican Americans and Mexican immi-
grants than among native-born Americans who
were not of Mexican descent, indicating that
Mexicans generally had a higher risk for diabe-
tes. Adjusted prevalence data for Mexican
immigrants also revealed a high rate of un-
diagnosed diabetes, higher than among Mexican
Americans. This view is supported by the high
prevalence of diabetes and the large fraction of
people with diabetes who were undiagnosed
in our sample of Mexicans living in Mexico
(Exhibit 2).
To calculate how much of the recent im-
migrant advantage in diabetes was explained
by undiagnosed disease, we can compare the
diagnosed and total prevalence rates for Mexican
immigrants with less than five years in the
United States and the rates for native-born
Americans not of Mexican descent in Exhibit 2.
The covariate-adjusted advantage in diagnosed
prevalence was 2.7 percentage points, as noted
above, or 47 percent of the native-born preva-
lence (2.7 percent divided by 5.7 percent).
In contrast, the advantage in total prevalence

D ec e m be r 2 0 12 3 1: 1 2 H ea lt h A f fai r s 7
Immigrant Health

Exhibit 4

Predicted Diagnosed And Total Prevalence Of Hypertension, Adjusted By Individual Characteristics, In Men And Women
Ages 30–60

SOURCE Authors’ calculations, based on data from the National Health and Nutrition Examination Survey (see Note 13 in text), 1988–
94 and 1999–2008, and the 2000 Mexican National Health Survey (see Note 25 in text), for hypertension levels among Mexicans in
Mexico.

Exhibit 5

Predicted Undiagnosed Hypertension Prevalence As Percentage Of Total Prevalence, Adjusted By Individual

Characteristics, In Men And Women Ages 30–60

SOURCE Authors’ calculations, based on data from the National Health and Nutrition Examination Survey (see Note 13 in text), 1988–
94 and 1999–2008, and the 2000 Mexican National Health Survey (see Note 25 in text), for hypertension levels among Mexicans in
Mexico. NOTES Fraction of people who were diagnosed with hypertension by a doctor or were above the clinical threshold (see the text)
who were not aware they had diabetes.

8 Health A ffairs D e ce m b er 2 012 3 1 :1 2

(taking into account undiagnosed disease) was
only 2.3 percentage points (7.2 percent minus
4.9 percent), or 32 percent (2.3 percent divided
by 7.2 percent). Therefore, undiagnosed disease
explained about one-third of the total recent
immigrant advantage.
Exhibit 3 presents graphically our character-
istic-adjusted fraction of people with diabetes
who were undiagnosed. The percentage of peo-
ple with undiagnosed diabetes was about the
same among the native-born population whether
they were of Mexican descent or not. These sim-
ilar rates have been shown to be the result of the
National Institutes of Health’s campaign to re-
duce undiagnosed disease in minority groups.19
In sharp contrast, adjusted rates of un-
diagnosed diabetes for all subsets of Mexican
immigrants were much higher, especially for re-
cent immigrants. The fraction of recent Mexican
immigrants with undiagnosed diabetes was 2.3
times higher than for Mexican Americans with
similar characteristics (Exhibit 3). These data
are consistent with the hypothesis that un-
diagnosed disease falls with time in the United
States. The data from Mexico suggest that un-
diagnosed diabetes is an even larger problem
among Mexicans who stayed in Mexico.
Exhibits 4 and 5 provide an identical analysis
for hypertension. Compared to Mexican im-
migrants living in the United States, un-
diagnosed hypertension was an even more se-
vere problem among those living in Mexico
(49 percent of Mexicans with hypertension were
undiagnosed). No matter what the duration of
immigration, total prevalence of hypertension
was lower among Mexican immigrants than
among Mexicans living in their native country.
We can use figures in Exhibit 4 for recent
Mexican immigrants and native-born Americans
not of Mexican descent to calculate how much of
the recent immigrant advantage in hypertension
is explained by differences in disease awareness.
The self-reported hypertension advantage, given
by the diagnosed rates, was 12.4 percentage
points (26.2 percent minus 13.8 percent), or
47 percent of the diagnosed prevalence among
native-born Americans (12.4 percent divided by
26.2 percent).
In contrast, the total hypertension advantage
(taking into account undiagnosed hyperten-
sion) was twelve percentage points (Exhibit 4),
or 38 percent of total prevalence for native-born
Americans not of Mexican descent (12 percent
divided by 31.5 percent). Therefore, differences
in undiagnosed hypertension explained one-
fifth of the recent immigrant advantage.
Exhibit 5 shows that for hypertension, the per-
centage undiagnosed was higher for Mexican
immigrants than for the native-born population
of either Mexican or non-Mexican heritage,
but it was much lower than for those living in
Mexico. At least for hypertension, Mexican im-
migrants were positively selected in that their
true hypertension rates were much lower than
the rates for those living in Mexico.
In addition, Mexican immigrants had
lower rates of undiagnosed hypertension than
Mexicans who remained in Mexico, although
the immigrants’ rates of undiagnosed hyperten-
sion were higher than those of native-born
Americans of either Mexican or non-Mexican
descent.
Discussion
Our diabetes and hypertension analyses suggest
that the primary “healthy immigrant” patterns
for Mexican immigrants still remain when we
use a more comprehensive measure of diabetes
and hypertension prevalence, taking into ac-
count high levels of undiagnosed disease among
Mexican immigrants. However, the magnitude
of the healthy immigrant effect is lessened once
these comprehensive measures of prevalence
are used.
Undiagnosed disease explained about one-
third of the recent immigrant advantage for dia-
betes and one-fifth for hypertension. These
trends indicate that high levels of undiagnosed
disease were a significant component of our
understanding of the health of Mexican im-
migrants in the United States.
The healthy immigrant effect that remained
after accounting for undiagnosed disease was
consistent with a large literature documenting
that Mexican immigrants in the United States
have lower mortality rates than do native-born
Americans.5–7 The remaining effect might be
explained by changing immigrant selectivity
across cohorts or immigrant assimilation to
the American lifestyle.12,14
Our analysis of undiagnosed diabetes revealed
that lack of disease awareness is a serious prob-
lem among recent Mexican immigrants. Almost
half of recent migrants with diabetes were un-
aware that they had the disease—an undiagnosed
prevalence 2.3 times higher than that among
Mexican Americans with similar characteristics.
In the case of hypertension, positive selection
was evident among Mexicans coming to the
United States, with Mexican immigrants having
significantly lower hypertension prevalence
than the Mexican population in Mexico.
This research quantifies the effects of im-
migration on disease awareness. Doing so is im-
portant, given the growth of the foreign-born
population and potential effects of immigrant
health on the US health care system. Our results
D e c em b e r 2 0 1 2 31:12 Health Affa irs 9
Immigrant Health

reveal that Mexican immigrants are not as
healthy as previously thought when undiag-
nosed disease is taken into account, particularly
with respect to diabetes. The large dif-
ferences in disease awareness point to the
importance of screening recent immigrants to
avoid late diagnosis and any potential costs of
delayed treatment. Recent research suggests that
disparities in awareness might translate into dis-
parities in health.26,27
Although we found little evidence that health
insurance plays much of a role in preventing
these diseases, we did find that having health
insurance was an important factor in promoting
awareness of both hypertension and diabetes.
Awareness is the first step toward effective treat-
ment, especially in populations with high rates
of undiagnosed disease.
Providing health insurance to undocumented
immigrants is a complex subject that begins with
rules on who should be eligible to receive bene-
fits, a subject on which this article provides no
insight. If benefits are to be provided, assistance
in disease diagnosis should surely head the list of
most cost-effective benefits. ▪

This research was supported by grants

from the National Institutes of Health.
Silvia Helena Barcellos thanks the RAND
Center for the Study of Aging and the
RAND Bing Center for Health Economics
for generous research support.

NOTES
1 Smith JP, Edmonson B, editors. The
new Americans: economic, demo-
graphic, and fiscal effects of im-
migration. Washington (DC):
National Academies Press; 1997.
2 Jasso G, Massey DS, Rosenzweig
MR, Smith JP. Immigrant health
selectivity and acculturation.
Chapter 7 in: Anderson NB, Bulatao
RA, Cohen B, editors. Critical per-
spectives on racial and ethnic
differences in health in late life.
Washington (DC): National
Academies Press; 2004. p. 227–66.
3 Stephen EH, Foote K, Hendershot
GE, Schoenborn CA. Health of the
foreign-born population: United
States, 1989–90. Adv Data. 1994;
(241):1–12.
4 Antecol H, Bedard K. Unhealthy
assimilation: why do immigrants
converge to American health status
levels? Demography. 2006;43(2):
337–60.
5 Hayes-Bautista DE. The Latino
health research agenda for the
twenty-first century. Chapter 10 in:
Suárez-Orozco MM, Páez MM, edi-
tors. Latinos: remaking America.
Berkeley (CA): University of
California Press; 2002. p. 215–35.
6 Markides KS, Eschbach K. Aging,
migration, and mortality: current
status of research on the Hispanic
paradox. J Gerontol B Psychol Sci
Soc Sci. 2005;60(Spec No 2):68–75.
7 Palloni A. Paradox lost: explaining
the Hispanic adult mortality advan-
tage? Demography. 2004;41(3):
385–415.
8 Marmot MG, Syme SL. Acculturation
and coronary heart disease in
Japanese-Americans. Am J
Epidemiol. 1976;104(3):225–47.
9 Palloni A, Arias E. A re-examination
of the Hispanic mortality paradox.
Madison (WI): University of
Wisconsin Center for Demography
and Ecology; 2003. (CDE Working
Paper No. 2003-01).
10 Kasl SV, Berkman L. Health conse-
quences of the experience of migra-
tion. Annu Rev Public Health.
1983;4:69–90.
11 Allen ML, Elliott MN, Morales LS,
Diamant AL, Hambarsoomian K,
Schuster MA. Adolescent participa-
tion in preventive health behaviors,
physical activity, and nutrition:
differences across immigrant gener-
ations for Asians and Latinos com-
pared with Whites. Am J Public
Health. 2007;97(2):337–43.
12 Pérez-Escamilla R, Putnik P. The role
of acculturation in nutrition, life-
style, and incidence of type 2 dia-
betes among Latinos. J Nutr. 2007;
137(4):860–70.
13 Centers for Disease Control and
Prevention. National Health and
Nutrition Examination Survey
[Internet]. Atlanta (GA): CDC; [last
updated 2012 Nov 14; cited 2012
Nov 19]. Available from: http://
www.cdc.gov/nchs/nhanes.htm
14 Johnston DW, Propper C, Shields
MA. Comparing subjective and ob-
jective measures of health: evidence
from hypertension for the income/
health gradient. J Health Econ.
2009;28(3):540–52.
15 Chatterji P, Joo H, Lahiri K. Beware
of unawareness: racial/ethnic dis-
parities in awareness of chronic
diseases. Cambridge (MA): National
Bureau of Economic Research; 2010.
(NBER Working Paper No. 16578).
16 Hertz RP, Unger AN, Cornell JA,
Saunders E. Racial disparities in
hypertension prevalence, awareness
and management. Arch Intern Med.
2005;165:2098–104.
17 Morenoff JD, House JS, Hansen BB,
Williams DR, Kaplan GA, Hunte HE.
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65:1853–66.
18 Angell SY, Garg RK, Gwynn RC, Bash
L, Thorpe LE, Frieden TR.
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19 Smith JP. Nature and causes of
trends in male diabetes prevalence,
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economic status health gradient.
PNAS. 2007;104(33):13225–31.
20 Goldman N, Lin IF, Weinstein M, Lin
YH. Evaluating the quality of self-
reports of hypertension and diabe-
tes. J Clin Epidemiol. 2003;56(2):
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21 Gregg E, Cheng Y, Cadwell B,
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et al. Secular trends in cardio-
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JAMA. 2005;293:1868–74.
22 To access the Appendix, click on the
Appendix link in the box to the right
of the article online.
23 Crimmins EM, Kim JK, Alley DE,
Karlamangla A, Seeman T. Hispanic
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1305–10.
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25 Sepúlveda J, Valdespino JL, Olaiz G,
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 población y utilización de servicios
de salud [Internet]. Cuernavaca
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ABOUT THE AUTHORS: SILVIA HELENA BARCELLOS, DANA P. GOLDMAN

& JAMES P. SMITH

recommend stepped-up disease Economic Research and a member

Silvia Helena
Barcellos is an
associate
economist at RAND.
In this month’s Health Affairs,
Silvia Helena Barcellos and
coauthors delve into the Mexican
immigrant health “advantage”—the
fact that newly arrived Mexican
immigrants in the United States
generally report better health than
do native-born Americans,
although this difference dissipates
over time. Using results from the
National Health and Nutrition
Examination Survey, the authors
compared clinical to self-reported
diagnosed disease prevalence and
found that about half of recent
migrants with diabetes were
unaware that they had the
condition. Thus, undiagnosed
disease explained one-third of the
reported recent immigrant
“advantage” for diabetes.
Leaving undiagnosed disease
aside, the rest of the reported
health advantage might be
explained in part by immigrant
selectivity—the notion that
healthier people might be more
likely to come to the United States.
The authors observe that lack of
disease awareness is clearly a
serious problem among recent
Mexican immigrants and
detection among new arrivals as
part of routine health care visits.
Barcellos is an associate
economist at RAND, where she
studies immigration and health and
labor economics. Her research has
focused on the economic causes
and consequences of immigration,
the effects of taxation on where
people and companies locate
themselves, and sex discrimination
in the amount of time parents
spend raising boys and girls in
India.
Barcellos received a doctorate in
economics from Princeton
University.
Dana P. Goldman is
the founding
director of the
Leonard D.
Schaeffer Center
for Health Policy
and Economics.
Dana Goldman is the founding
director of the Leonard D.
Schaeffer Center for Health Policy
and Economics and the Norman
Topping Chair in Medicine and
Public Policy at the University of
Southern California. He serves on
the editorial boards of Health
Affairs and several other journals
and is the editor-in-chief of the
Forum for Health Economics and
Policy. He is a research associate
with the National Bureau of
of the Institute of Medicine.
Goldman holds a doctorate in
economics from Stanford
University.
James P. Smith
holds the
Distinguished Chair
in Labor Markets
and Demographic
Studies at the
RAND Corporation.
James Smith holds the
Distinguished Chair in Labor
Markets and Demographic Studies
at the RAND Corporation. His
principal research interests are
immigration, global health, and
childhood health. He is a member
of the Institute of Medicine and
has twice received the National
Institutes of Health Merit Award,
which provides long-term support
to researchers with distinguished
records of scientific achievement.
Earlier this year, Smith was
awarded the Proceedings of the
National Academy of Sciences’
Cozzarelli Prize for his article on
the impact of physical and mental
problems in childhood on adult
life. Some of his articles on
immigration and on aging
populations in China and India
have appeared in Health Affairs.
Smith received a doctorate in
economics from the University of
Chicago.

D e c e m b e r 201 2 3 1 :1 2 Health Affairs 11