Wide educational disparities in young adult cardiovascular health

LifeCourse Socioeconomic Position and Ideal Cardiovascular Health in Hispanic/Latino Adults of the Hispanic Community Health Study/Study of Latinos

BACKGROUND

The Hispanic/Latino population experiences socioeconomic disadvantages across the lifespan. Yet, little is known about the role of these disadvantages in cardiovascular health (CVH). We assessed the association of lifecourse socioeconomic position (SEP) with ideal CVH and change in Hispanic/Latino adults.

METHODS AND RESULTS

We used longitudinal data from the HCHS/SOL (Hispanic Community Health Study/Study of Latinos). Childhood SEP was determined using parental educational attainment. Adult SEP was determined through an index combining participants' education, occupation, income, and assets at baseline. We classified participants into 4 socioeconomic mobility categories (eg, stable low or high SEP, upward or downward mobility). Using the 4 health factors of the American Heart Association "Life's Essential 8," we built a score of ideal CVH at baseline and the 6-year follow-up. Linear mixed-effects models using inverse probability weighting were fitted to assess the main associations. Higher childhood SEP was associated with higher ideal CVH at baseline (β for high school versus high school versus

CONCLUSIONS

Although high childhood and adult SEP and socioeconomic mobility were associated with higher levels of ideal CVH, they were not associated with change in ideal-CVH.

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Key Words

• Hispanic
• Latino
• cardiovascular health
• childhood
• life‐course
• social mobility
• socioeconomic position

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Affiliation(s)

Paola Filigrana Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA
Jee-Young Moon Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA
Linda C Gallo Department of Psychology San Diego State University San Diego CA USA
Lindsay Fernández-Rhodes Department of Biobehavioral Health, College of Health and Human Development Pennsylvania State University University Park PA USA
Krista M Perreira Department of Social Medicine, School of Medicine University of North Carolina at Chapel Hill Chapel Hill NC USA
Martha L Daviglus Institute for Minority Health Research, College of Medicine University of Illinois at Chicago Chicago IL USA
Bharat Thyagarajan Department of Laboratory Medicine and Pathology University of Minnesota Medical School Minneapolis MN USA
Olga L Garcia-Bedoya Division of Academic Internal Medicine and Geriatrics, College of Medicine University of Illinois at Chicago Chicago IL USA
Jianwen Cai Department of Biostatistics University of North Carolina at Chapel Hill Chapel Hill NC USA
Xiaonan Xue Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA
Robert C Kaplan Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA Public Health Sciences Division Fred Hutchinson Cancer Center Seattle WA USA
Shakira Suglia Department of Epidemiology, Rollins School of Public Health Emory University Atlanta GA USA
Carmen R Isasi Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY USA

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Educational Attainment and Lifetime Risk of Cardiovascular Disease

Importance

Education is a social determinant of health. Quantifying its association with lifetime cardiovascular disease (CVD) risk has public health importance.

Objective

To calculate lifetime risk estimates of incident CVD and CVD subtypes and estimate years lived with and without CVD by education.

Design, Setting, and Participants

Included community-based cohort studies with adjudicated cardiovascular events used pooled individual-level data from 1985 to 2015 of 6 prospective cohort studies. The study team assessed the association between education and lifetime CVD risk with modified Kaplan-Meier and Cox models accounting for competing risk of noncardiovascular death. The study team estimated years lived with and without CVD by education with the Irwin restricted mean and the utility of adding educational attainment to CVD risk assessment. Participants (baseline 40 to 59 years old and 60 to 79 years old) were without CVD at baseline and had complete education, cardiovascular risk factors, and prospective CVD outcomes data. Data were analyzed from January 2022 to September 2022.

Exposures

Educational attainment (less than high school, high school completion, some college, or college graduate).

Main outcome and measures

Cardiovascular events (fatal and nonfatal coronary heart disease, heart failure, and stroke; CVD-related deaths; and total CVD encompassing any of these events).

Results

There were 40 998 participants (23 305 female [56.2%]) with a mean (SD) age of 58.1 (9.7) years for males and 58.3 (9.9) years for females. Compared with college graduates, those with less than high school or high school completion had higher lifetime CVD risks. Among middle-aged men, the competing hazard ratios (HRs) for a CVD event were 1.58 (95% CI, 1.38-1.80), 1.30 (95% CI, 1.10-1.46), and 1.16 (95% CI, 1.00-1.34) in those with less than high school, high school, and some college, respectively, compared with those with college completion. Among women, these competing HRs were 1.70 (95% CI, 1.49-1.95), 1.19 (95% CI, 1.05-1.35), and 0.98 (95% CI, 0.83-1.15). Individuals with higher education had longer duration of life prior to incident CVD. Education provided limited contribution toward enhancing CVD risk prediction.

Conclusions and relevance

Lower education was associated with lifetime CVD risk across adulthood; higher education translated to healthy longevity. Educational policy initiatives may associate with long-term health benefits.

Sex Differences in Cardiac Risk Factors in Young Adults: A Secondary Analysis and Surveillance Study

BACKGROUND

Coronary artery disease (CAD) is increasing in young adults, and greater understanding of their cardiac risk factors is essential to ensure effective prevention. Given the sex differences in CAD observed in older adults, understanding sex differences in risk factors for this younger group of adults is important. Having insight of cardiac risk factors and sex differences in the young adult population is essential to creating personalized strategies for prevention in nursing care and in this age group.

OBJECTIVES

The aims of this study were to determine the differences in CAD risk factors for young adult men and women and examine which factors are related to CAD early in life, ultimately to guide approaches for CAD prevention in primary care.

METHODS

In this secondary analysis, 125 017 community-dwelling young adults were evaluated for health behaviors considered as risk factors for CAD. The 2017 Behavior Risk Factor Surveillance System database from the Center for Disease Control was utilized. This database contains questions asked of young adults that would help with risk management for chronic diseases like CAD. Young adults in this article were defined as being between 18 and 44 years of age.

RESULTS

Men reported more cardiovascular risk factors than women and developed risk factors at an earlier age. Women had greater percentages of obesity and low activity levels. In this population, those with hypertension had the highest odds ratio for developing CAD.

CONCLUSIONS

Differences between men and women in CAD risk factors included lifestyle and other chronic conditions. Greater prevention efforts should focus on these differences in young men and women to reduce risk factors and prevent the development of CAD.

Adverse Childhood Experiences and Cardiovascular Health: An Exploration of Protective Social Determinants Among Young Adult Black Women

This study sought to advance the literature on Black women's cardiovascular health (CVH) by examining maternal relationship, religion and spirituality, and social connections as potential protective social determinants that buffer the stress of adverse childhood experiences (ACEs). The outcome was the American Heart Association's ideal CVH score. Neither maternal relationship nor religion/spirituality was able to buffer the stress of ACEs on ideal CVH. Findings are discussed in terms of cultural aspects of potential protective factors that are critical for future research. Identifying protective factors that may buffer the influence of ACEs on CVH remains a priority to promote health equity.

The social determinants of ideal cardiovascular health: A global systematic review

This systematic review synthesizes research published from January 2010-July 2022 on the social determinants of ideal cardiovascular health (CVH) carried out around the world and compares trends in high-income countries (HICs) to those in low- and middle-income countries (LMICs). 41 studies met inclusion criteria (n = 28 HICs, n = 13 LMICs). Most were from the United States (n = 22) and cross-sectional (n = 33), and nearly all evaluated associations among adults. Among studies conducted in LMICs, nearly all were from middle-income countries and only one was carried out in low-income country. Education (n = 24) and income/wealth (n = 17) were the most frequently examined social determinants in both HICs and LMICs. Although most studies assessed ideal CVH using reliable and valid methods (n = 24), only 7 used criteria pre-defined by the American Heart Association to characterize ideal levels of each CVH metric. Despite heterogeneity in how outcome measures were derived and analyzed, consistent associations were evident between multiple markers of higher social status (i.e. greater education, income/wealth, socioeconomic status, racial/ethnic majority status) and greater levels of ideal CVH across both country contexts. Gaps in the literature include evidence from LMICs and HICs other than the United States, longitudinal research, and investigations of a wider array of social determinants beyond education and income/wealth.

Adverse Childhood Experiences and Cardiovascular Risk among Young Adults: Findings from the 2019 Behavioral Risk Factor Surveillance System

Background: Heart disease is the fourth leading cause of death for young adults aged 18-34 in the United States. Recent research suggests that adverse childhood experiences (ACEs) may shape cardiovascular health and its proximate antecedents. In the current study, we draw on a contemporary, national sample to examine the association between ACEs and cardiovascular health among young adults in the United States, as well as potential mediating pathways. Methods: The present study uses data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS) to examine associations between ACEs and cardiovascular risk, as well as the role of cumulative disadvantage and poor mental health in these associations. Results: Findings indicate that young adults who have experienced a greater number of ACEs have a higher likelihood of having moderate to high cardiovascular risk compared to those who have zero or few reported ACEs. Moreover, both poor mental health and cumulative disadvantage explain a significant proportion of this association. Conclusions: The present findings suggest that young adulthood is an appropriate age for deploying prevention efforts related to cardiovascular risk, particularly for young adults reporting high levels of ACEs.

Generational Shifts in Young Adult Cardiovascular Health? Millennials and Generation X in the United States and England

OBJECTIVES

To compare cardiovascular (CV) risks/conditions of Millennials (born 1981-1996) to those of Generation X (Gen X; born 1965-1980) at ages 20-34 years, across 2 countries (United States, England), by gender.

METHODS

Using data from the National Health and Nutrition Examination Survey (United States) and Health Survey for England, we estimated weighted unadjusted and adjusted gender-specific proportions of CV risk factors/conditions, separately for Millennials and Generation X in each country. We also further calculated sex-specific generational differences in CV risk factor/conditions by income tercile and for individuals with normal body weight.

RESULTS

Millennials in the United States were more obese compared to their Gen X counterparts and more likely to have diabetes risk but less likely to smoke or have high cholesterol. Millennials in England had higher diabetes risk but similar or lower rates of other CV risk/conditions compared to their Gen X counterparts. Generational changes could not be fully attributed to increases in obesity or decreases in income.

DISCUSSION

We expected that Millennial CV risk factors/conditions would be worse than those of Gen X, particularly in the United States, because Millennials came of age during the Great Recession and a period of increasing population obesity. Millennials generally fared worse than their Gen X counterparts in terms of obesity and diabetes risk, especially in the United States, but had lower rates of smoking and high cholesterol in both countries. Secular trends of increasing obesity and decreased economic opportunities did not appear to lead to uniform generational differences in CV risk factors.

Quantifying impacts of the COVID-19 pandemic through life-expectancy losses: a population-level study of 29 countries

Background

Variations in the age patterns and magnitudes of excess deaths, as well as differences in population sizes and age structures, make cross-national comparisons of the cumulative mortality impacts of the COVID-19 pandemic challenging. Life expectancy is a widely used indicator that provides a clear and cross-nationally comparable picture of the population-level impacts of the pandemic on mortality.

Methods

Life tables by sex were calculated for 29 countries, including most European countries, Chile and the USA, for 2015–2020. Life expectancy at birth and at age 60 years for 2020 were contextualized against recent trends between 2015 and 2019. Using decomposition techniques, we examined which specific age groups contributed to reductions in life expectancy in 2020 and to what extent reductions were attributable to official COVID-19 deaths.

Results

Life expectancy at birth declined from 2019 to 2020 in 27 out of 29 countries. Males in the USA and Lithuania experienced the largest losses in life expectancy at birth during 2020 (2.2 and 1.7 years, respectively), but reductions of more than an entire year were documented in 11 countries for males and 8 among females. Reductions were mostly attributable to increased mortality above age 60 years and to official COVID-19 deaths.

Conclusions

The COVID-19 pandemic triggered significant mortality increases in 2020 of a magnitude not witnessed since World War II in Western Europe or the breakup of the Soviet Union in Eastern Europe. Females from 15 countries and males from 10 ended up with lower life expectancy at birth in 2020 than in 2015.

Demographic and socioeconomic inequalities in ideal cardiovascular health: A systematic review and meta-analysis

BACKGROUND

In 2010, the American Heart Association introduced a new concept of ideal cardiovascular health (CVH) defined as the simultaneous presence of 7 favorable CVH metrics (smoking, diet, physical activity, body mass index, blood pressure, total cholesterol, and fasting blood glucose). The objective of this study was to conduct a systematic literature review and meta-analysis of studies examining the prevalence of ideal CVH, and each of the ideal CVH metrics as well as the relationship between socio-demographic determinants and ideal CVH.

METHODS

A comprehensive literature search was conducted in Medline and Scopus databases for studies published between 1 January 2010 and 30 June 2020. A total of 50 studies including 2,148,470 participants were analyzed. Associations were estimated using DerSimonian-Laird random-effect models. Heterogeneity was investigated through subgroup analyses, Q-test, and I2 statistics.

RESULTS

This study showed a low prevalence of ideal CVH defining as 6 and 7 ideal metrics (3.3%). Among seven ideal CVH metrics, smoking was the best metric (71%), while the poorest CVH metric was a healthy diet (5.8%). Gender was a statistically significant moderator of ideal smoking (81% in females and 60% in males) and ideal blood pressure (42% in females and 30% in males). Females and young adults had better CVH status compared to males and older adults. Also, more educated and better-off individuals had a greater number of ideal CVH metrics.

CONCLUSIONS

To the best of our knowledge, this is the first systematic review on the relationship between participants' socioeconomic status and ideal CVH. The results suggest that the prevalence of ideal CVH and most metrics was unsatisfactory. In order to achieve the improvement of the CVH metrics and the overall ideal CVH, nationwide prevention efforts at the population and individual levels are urgently needed.

Racial Residential Segregation and Race Differences in Ideal Cardiovascular Health among Young Men

Background: Race disparities in cardiovascular disease (CVD) related morbidity and mortality are evident among men. While previous studies show health in young adulthood and racial residential segregation (RRS) are important factors for CVD risk, these factors have not been widely studied in male populations. We sought to examine race differences in ideal cardiovascular health (CVH) among young men (ages 24–34) and whether RRS influenced this association. Methods: We used cross-sectional data from young men who participated in Wave IV (2008) of the National Longitudinal Survey of Adolescent to Adult Health (N = 5080). The dichotomous outcome, achieving ideal CVH, was defined as having ≥4 of the American Heart Association’s Life’s Simple 7 targets. Race (Black/White) and RRS (proportion of White residents in census tract) were the independent variables. Descriptive and multivariate analyses were conducted. Results: Young Black men had lower odds of achieving ideal CVH (OR = 0.67, 95% CI = 0.49, 0.92) than young White men. However, RRS did not have a significant effect on race differences in ideal CVH until the proportion of White residents was ≥55%. Conclusions: Among young Black and White men, RRS is an important factor to consider when seeking to understand CVH and reduce future cardiovascular risk.

Trajectories of Subjective Health: Testing Longitudinal Models for Self-rated Health From Adolescence to Midlife

Self-rated health (SRH) is ubiquitous in population health research. It is one of the few consistent health measures in longitudinal studies. Yet, extant research offers little guidance on its longitudinal trajectory. The literature on SRH suggests several possibilities, including SRH as (1) a more fixed, longer-term view of past, present, and anticipated health; (2) a spontaneous assessment at the time of the survey; (3) a result of lagged effects from prior responses; (4) a function of life course processes; and (5) a combination of the preceding. Different perspectives suggest different longitudinal models, but evidence is lacking about which model best captures SRH trajectory. Using data from the National Longitudinal Study of Adolescent to Adult Health and the National Longitudinal Survey of Youth, we employ structural equation modeling to correct for measurement error and identify the best-fitting, theoretically guided models describing SRH trajectories. Results support a hybrid model that combines the lagged effect of SRH with the enduring perspectives, fitted with a type of autoregressive latent trajectory (ALT) model. This model structure consistently outperforms other commonly used models and underscores the importance of accounting for lagged effects combined with time-invariant effects in longitudinal studies of SRH. Interestingly, comparisons of this latent, time-invariant autoregressive model across gender and racial/ethnic groups suggest that there are differences in starting points but less variability in SRH trajectories from early life into adulthood.

Linking Underserved Patients to Social Services Using the SScAR Tool

BACKGROUND

The need to screen for social determinants of health (SDOH) is well documented in the literature. Addressing SDOH also requires linking patients to available social service resources.

OBJECTIVE

This Social Screen Assess and Refer (SScAR) Quality Improvement (QI) project purpose was threefold: (1) develop an agency specific tool to screen for SODH; (2) implement this tool in all new patient evaluations; and (3) provide referral to patients for necessary social services.

METHODS

The SScAR tool adapted questions from published screening tools and created new questions centered on available social services. A pilot study implemented the tool. Documentation of social needs before the pilot, SScAR utilization during the pilot, number of social needs, and referrals made were measured.

RESULTS

Documentation of SDOH screening significantly improved with the tool (α .05, χ2(1) = 21.85, p < .001). Follow-through referral to specific social resources only increased by 5%.

CONCLUSIONS

The SScAR is a feasible tool for identifying SDOH needs and creates a mechanism for linking patients with social services.

IMPLICATIONS FOR NURSING

Future studies must measure social service referrals, utilization of social services, and the resulting impact on specific health outcomes such as blood pressure, hemoglobin A1c, and cholesterol.

Cardiovascular health behaviors and associations of sex, age, and education in adolescents - Results from the EVA Tyrol study

BACKGROUND AND AIMS

Ideal cardiovascular health (CVH) behaviors in adolescents are defined by body mass index (BMI), diet, physical activity and smoking, and are directly associated with better health in later life. To further improve health prevention programs we investigated the prevalence of these behaviors in a cohort of healthy adolescents and focused on the associations with sex, age, and education.

METHODS AND RESULTS

The Early Vascular Aging Tyrol study is a cross-sectional study assessing 14- to 19-year-old pupils and apprentices in Western Austria and South Tyrol. Between May 2015 and July 2018 2047 adolescents (43.6% males, mean age 16.4 years) with complete data for all 4 health behaviors were included. The prevalence of ideal body mass index (BMI) was 78.3%, of ideal physical activity 42.5%, of non-smoking 70.4% and of ideal diet 8.1%. Females showed a higher smoking prevalence and a lower physical activity, but better dietary habits than males. Older adolescents of both sexes had lower prevalence of ideal smoking and diet. Apprentices and pupils of vocational schools had a higher BMI and a less favorable diet compared to secondary academic school students. Smoking prevalence was highest in apprentices. Non-ideal BMI was independently associated with smoking.

CONCLUSION

In our cohort, only a minority showed ideal CVH behaviors which were best in adolescents younger than 16 years. We observed significant differences between males and females and a clear impact of school education with apprentices being at risk for non-ideal CVH behaviors.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03929692, clinicaltrials.gov.

Is educational attainment associated with young adult cardiometabolic health?

Educational disparities in health and mortality are well-documented and evidence suggests that they may be widening. Yet, there is much unknown about when educational disparities begin to emerge and for whom. This paper investigates the association between educational attainment and cardiometabolic health in young adults with critical attention paid to differences across racial/ethnic and sex subgroups. We focus on cardiometabolic health in young adulthood as it is particularly relevant for understanding current population health trends. We used data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) when participants were aged 12-19 years (Wave I) and aged 24-32 years (Wave IV). Using a series of logistic regression models, we first estimated the association between education and five markers of cardiometabolic health (high-risk blood pressure, high-risk waist circumference, diabetes/pre-diabetes, hyperlipidemia, and high-risk inflammation). We then examined the extent to which this association was explained by adolescent health and both adolescent and young adult socioeconomic status (SES) (including parental education, participant educational attainment, household income, and employment status). Finally, we investigated whether the association between educational attainment and cardiometabolic health differed by race/ethnicity and sex. We found evidence of an association between educational attainment and cardiometabolic health that persisted net of adolescent health, adolescent SES, and young adult SES. We also found some evidence of modest differences in this association by race/ethnicity and sex. Our findings suggest that even as early as young adulthood there are disparities in cardiometabolic health by educational attainment, which may lead to even larger disparities in late life health.

Inequalities and Deteriorations in Cardiovascular Health in Premenopausal US Women, 1990-2016

Coronary heart disease (CHD) mortality rates in the United States have declined by up to two thirds in recent decades. Closer examination of these trends reveals substantial inequities in the distribution of mortality benefits. It is worrying that the uneven distribution of CHD that exists from lowest to highest social class-the social gradient-has become more pronounced in the United States since 1990 and is most pronounced for women.Here we consider ways in which this trend disproportionately affects premenopausal women aged 35 to 54 years. We apply a social determinants of health framework focusing on intersecting axes of inequalities-notably gender, class, ethnicity, geographical location, access to wealth, and class-among other power relations to which young and middle-aged women are especially vulnerable, and we argue that increasing inequalities may be driving these unprecedented deteriorations. We conclude by discussing interventions and policies to target and alleviate inequality axes that have potential to promote greater equity in the distribution of CHD mortality and morbidity gains.The application of this framework in the context of women's cardiovascular health can help shed light regarding why we are seeing persistently poorer outcomes for premenopausal US women.

Food deserts and cardiovascular health among young adults

OBJECTIVE

This study assesses the association between living in a food desert and cardiovascular health risk among young adults in the USA, as well as evaluates whether personal and area socioeconomic status moderates this relationship.

DESIGN

A cross-sectional analysis was performed using data from Wave I (1993-1994) and Wave IV (2008) from the National Longitudinal Study of Adolescent to Adult Health. Ordinary least squares regression models assessing the association between living in a food desert and cardiovascular health were performed. Mediation and moderation analyses assessed the degree to which this association was conditioned by area and personal socioeconomic status.

SETTING

Sample of respondents living in urban census tracts in the USA in 2008.

PARTICIPANTS

Young adults (n 8896) aged 24-34 years.

RESULTS

Net of covariates living in a food desert had a statistically significant association with cardiovascular health risk (range 0-14) (β = 0·048, P < 0·01). This association was partially mediated by area and personal socioeconomic status. Further analyses demonstrate that the adverse association between living in a food desert and cardiovascular health is concentrated among low socioeconomic status respondents.

CONCLUSIONS

The findings from this study suggest a complex interplay between food deserts and economic conditions for the cardiovascular health of young adults. Developing interventions that aim to improve health behaviour among lower-income populations may yield benefits for preventing the development of cardiovascular health problems.