The Great Recession worsened blood pressure and blood glucose levels in American adults

Risk Factors for Lower Extremity Amputation in Patients with End-Stage Kidney Disease: A Nationwide Cohort Study

Individuals with end-stage kidney disease (ESKD) on dialysis are at a high risk of developing foot ulcerations and undergoing subsequent lower extremity amputation (LEA), which can exert significant impacts on their quality of life and contribute to rising healthcare costs. We aimed to identify risk factors associated with LEA in patients with ESKD to predict LEA progression and eventually prevent it. We used 18 years (2002-2019) of data from the Korean National Health Insurance Service (KNHIS). Data were collected from patients with ESKD who underwent renal replacement therapy (RRT) and had no history of amputation caused by trauma or toxins. The risk factors were compared between patients with or without LEA. We collected data from 220,838 patients newly diagnosed with ESKD, including 6348 in the LEA group and 214,490 in the non-LEA group. The total incidence of LEA was 2.9%. Older age, male gender, lower income, non-metropolitan residence, diabetes mellitus, dialysis treatment (compared to kidney transplantation), microvascular disease, peripheral vascular disease, endovascular procedure, and endovascular operation were associated with an increased risk of LEA. Thus, individuals with ESKD who are at a higher risk for LEA should be closely monitored, and kidney transplantation should be considered as a preventative measure.

From financial wealth shocks to ill-health: Allostatic load and overload

A number of studies have associated financial wealth changes with health-related outcomes arguing that the effect is due to psychological distress and is immediate. In this paper, I examine this relationship for cumulative shocks to the financial wealth of American retirees using the allostatic load model of pathways from stress to poor health. Wealth shocks are identified from Health and Retirement Study reports of stock ownership along with significant negative discontinuities in high-frequency S&P500 index data. I find that a one standard deviation increase in cumulative shocks over two years increases the probability of elevated blood pressure by 9.5%, increases waist circumference by 1.2% and the cholesterol ratio by 6.1% for those whose wealth is all in shares. My findings suggest that the combined effect of random shocks to financial wealth over time is salient for health outcomes. This is consistent with the allostatic load model in which repeated activation of stress responses leads to cumulative wear and tear on the body.

The trilateral interactions between mammalian target of rapamycin (mTOR) signaling, the circadian clock, and psychiatric disorders: an emerging model

Circadian (~24 h) rhythms in physiology and behavior are evolutionarily conserved and found in almost all living organisms. The rhythms are endogenously driven by daily oscillatory activities of so-called "clock genes/proteins", which are widely distributed throughout the mammalian brain. Mammalian (mechanistic) target of rapamycin (mTOR) signaling is a fundamental intracellular signal transduction cascade that controls important neuronal processes including neurodevelopment, synaptic plasticity, metabolism, and aging. Dysregulation of the mTOR pathway is associated with psychiatric disorders including autism spectrum disorders (ASD) and mood disorders (MD), in which patients often exhibit disrupted daily physiological rhythms and abnormal circadian gene expression in the brain. Recent work has found that the activities of mTOR signaling are temporally controlled by the circadian clock and exhibit robust circadian oscillations in multiple systems. In the meantime, mTOR signaling regulates fundamental properties of the central and peripheral circadian clocks, including period length, entrainment, and synchronization. Whereas the underlying mechanisms remain to be fully elucidated, increasing clinical and preclinical evidence support significant crosstalk between mTOR signaling, the circadian clock, and psychiatric disorders. Here, we review recent progress in understanding the trilateral interactions and propose an "interaction triangle" model between mTOR signaling, the circadian clock, and psychiatric disorders (focusing on ASD and MD).

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.

Depressive Symptoms among US Adults during the Great Recession and Economic Recovery

BACKGROUND AND AIMS

We study the trajectory of depressive symptoms among US adults before, during, and after the 2008/2009 Great Recession.

METHODS

We use repeated cross-sectional surveys of the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2018. Mental health is assessed with the Patient Health Questionnaire-9 (PHQ-9), with the following categorization for depressive symptoms: none or mild (score 0-9), moderate or severe (score 10-27). A parallel time series was calculated from the Behavioral Risk Factor Surveillance System (BRFSS) on self-reported number of days with poor mental health.

RESULTS

NHANES data show a statistically significant increase in depressive symptoms from 2005/2006 to 2007/2008 (the beginning of the Great Recession), but there were no significant or consistent changes after 2007/2008. In particular, the deterioration in the adjusted predicted PHQ-9 scores occurred prior to the large increase in unemployment rate (2009/2010). As the macroeconomic situations improved and unemployment rates recovered, mental health did not return to the previous level. In the latest wave of NHANES (2017/2018), unemployment rates were at the lowest level over the analysis period; however, the adjusted predicted PHQ-9 scores were higher than that at the beginning of the Great Recession. Trends of PHQ-9 scores were similar across income groups - all groups had an increase in depressive symptoms after 2005/2006 and PHQ-9 scores were still high in 2017/2018 after controlling for sociodemographic status. Group with the lowest income had higher levels of depressive symptoms at every time point. BRFSS data shows no consistent changes in the number of days with poor mental health that parallel economic conditions.

DISCUSSION

Depressive symptoms at the population level did not match the economic cycle before, during and after the Great Recession. Future research is needed to better understand the lack of correlation between population mental health and macroeconomic conditions.

Diet quality in the US improved during the Great Recession and deteriorated during economic recovery

BACKGROUND

Macroeconomic changes are associated with population health outcomes, such as mortality, accidents, and alcohol use. Diet quality is a risk or protective factor that could be influenced by economic conditions.

OBJECTIVE

This study examined the trajectory of diet quality measured by the Healthy ] before, during, and after the 2008/2009 Great Recession.

DESIGN

Repeated cross-sectional survey data from the National Health and Nutrition Examination Survey (NHANES) were analyzed.

PARTICIPANTS/SETTING

The analytic sample included 48,679 adults who completed at least one dietary recall from NHANES 1999-2018.

MAIN OUTCOME MEASURES

Diet quality was assessed with a 24-hour dietary recall to calculate the Healthy Eating Index (HEI)-2015 total scores, a measure of the conformance with the 2015-2020 Dietary Guidelines for Americans.

STATISTICAL ANALYSES PERFORMED

Least squares regression was used to adjust for demographic changes across waves.

RESULTS

Diet quality improved noticeably during the Great Recession and deteriorated as economic conditions improved.

CONCLUSIONS

Deteriorating economic circumstances may constrain choices, but that does not necessarily imply a worsening of dietary quality. During the Great Recession, American diets became more consistent with Dietary Guidelines for Americans recommendations, possibly because of a shift towards food prepared at home instead of prepared food bought away from home.

Unemployment, religious disintegration and suicide fluctuations in Alberta

This study looks at the relationship between unemployment, religious disintegration and suicide in Alberta during 1997-2015. Religious disintegration is operationalized as the percentage of population with no religious affiliation. Economic theory predicts suicides increase when unemployment rates are high and decline when unemployment rates are low. Sociological theory calls for suicides to vary inversely with the degree of religious integration in society. Multivariate analysis supports both economic and sociological interpretations. In Alberta, periods of rising unemployment (recessions) produce more suicides, and increased levels of religious disintegration are positively associated with the incidence of voluntary deaths.

Effects of the Great Recession on Educational Disparities in Cardiometabolic Health

BACKGROUND

Macroeconomic crises can exaggerate existing educational disparities in health. Few studies, however, have examined whether macroeconomic crises get under the skin to affect educational disparities in health-related biological processes.

PURPOSE

This study aimed to examine the effect of the economic recession of 2008 (i.e., Great Recession) on educational disparities in cardiometabolic risk and self-reported psychological distress.

METHODS

Data were drawn from two subsamples of the Midlife in the United States (MIDUS) study: the second wave of the MIDUS sample (pre-recession cohort, N = 985) and the refresher sample (post-recession cohort, N = 863). Educational attainment was categorized into high school education or less, some college, and bachelor's degree or higher. Outcomes included metabolic syndrome, C-reactive protein, and interleukin-6, as well as self-reported perceived stress, depressive symptoms, and financial distress.

RESULTS

Results showed that having a bachelor's degree or higher (compared to having a high school education or less) was more strongly associated with decreased metabolic syndrome symptoms in the post-recession cohort than the pre-recession cohort, above and beyond demographic, health, and behavioral covariates. These findings did not extend to systemic inflammation or psychological distress.

CONCLUSIONS

Our findings suggest that chronic macroeconomic stressors may widen the educational gap in physical health, particularly cardiometabolic health, by modifying biological and anthropometric risk factors implicated in metabolic syndrome.

COVID-19 economic impacts in perspective: A comparison to recent U.S. disasters

This paper places the COVID-19 pandemic into perspective by comparing it to other recent disasters in terms of impacts on the macroeconomy of the U.S. We present a short summary of advances in the state-of-the-art of economic consequence analysis, as well as estimates this approach yields on economic impacts of 9/11, a variety of natural disasters, the Great Recession, and COVID-19. The prevention of these negative impacts represents the benefits of various types of risk management tactics and strategies. In light of the enormously greater economic impact of COVID-19 as compared to natural and man-made disasters, it is reasonable to question whether adequate investments are being made to prevent future pandemics.

The Impact of the Great Recession on Diabetes Management in a High-Risk Population

This study examined the effects of the Great Recession (GR) on type 2 diabetes management using individual-level data in a historically underserved, high-risk patient population at a federally qualified health center (FQHC). Comparing three time periods (pre-recession [2004-2006], recession [2007-2009], and recession recovery [2010-2012]), we found that patients had significant increases in blood pressure and body mass index as they entered the GR. Conversely, we found a significant decrease in HbA1c across the study period likely influenced by interventions to improve HbA1c during this time at this FQHC. While previous studies on the impact of the GR have focused primarily on the middle class, our findings suggest that high-risk patients who are already struggling to maintain their health may be further hurt by economic downturns. Intensive programs to serve these patients can act as a safety net to buffer the potential health impacts of these downturns.

Implications of the COVID-19 Pandemic for Cardiovascular Disease and Risk-Factor Management

COVID-19 and our public health responses to the pandemic may have far-reaching implications for cardiovascular (CV) risk, affecting the general population and not only survivors of COVID-19. In this narrative review, we discuss how the pandemic may affect general CV risk for years to come and explore the mitigating potential of telehealth interventions. From a health care perspective, the shift away from in-person office visits may have led many to defer routine risk- factor management and may have had unforeseen effects on continuity of care and adherence. Fear of COVID-19 has led some patients to forego care for acute CV events. Curtailment of routine outpatient laboratory testing has likely delayed intensification of risk-factor–modifying medical therapy, and drug shortages and misinformation may have negative impacts on adherence to antihypertensive, glucose-lowering, and lipid-lowering agents. From a societal perspective, the unprecedented curtailment of social and economic activities has led to loss of income, unemployment, social isolation, decreased physical activity, and increased frequency of depression and anxiety, all of which are known to be associated with worse CV risk-factor control and outcomes. We must embrace and evaluate measures to mitigate these potential harms to avoid an epidemic of CV morbidity and mortality in the coming years that could dwarf the initial health effects of COVID-19.

Economic influences on population health in the United States: Toward policymaking driven by data and evidence

Atheendar S. Venkataramani and colleagues discuss economic factors and population health in the United States.

Health Care Utilization of Homeless Minors With Diabetes in New York State From 2009 to 2014

OBJECTIVE

This study aims to describe differences in health care utilization between homeless and nonhomeless minors with diabetes.

RESEARCH DESIGN AND METHODS

Data from the Healthcare Cost and Utilization Project's Statewide Inpatient Database from New York for years 2009-2014 were examined to identify pediatric patients <18 years old with diabetes. Outcomes of interest included hospitalization rate, in-hospital mortality, admission through the emergency department (ED), diabetic ketoacidosis (DKA), hospitalization cost, and length of stay (LOS). Other variables of interest included age-group, race/ethnicity, insurance type, and year. Multivariate logistic regression models were used for in-hospital mortality, admission through ED, and DKA. Log-transformed linear regression models were used for hospitalization cost, and negative binomial regression models were used for LOS.

RESULTS

A total of 643 homeless and 10,559 nonhomeless patients were identified. The hospitalization rate was higher among homeless minors, with 3.64 per 1,000 homeless population compared with 0.38 per 1,000 in the nonhomeless population. A statistically significant higher readmission rate was detected among homeless minors (20.4% among homeless and 14.1% among nonhomeless, P < 0.01). Lower rates of DKA (odds ratio 0.75, P = 0.02), lower hospitalization costs (point estimate 0.88, P < 0.01), and longer LOS (incidence rate ratio 1.20, P < 0.01) were detected among homeless minors compared with nonhomeless minors.

CONCLUSIONS

This study found that among minors with diabetes, those who are homeless experience a higher hospitalization rate than the nonhomeless. Housing instability, among other environmental factors, may be targeted for intervention to improve health outcomes.

An acceleration in hypertension-related mortality for middle-aged and older Americans, 1999-2016: An observational study

BACKGROUND

Hypertension-related mortality has been increasing in recent years; however, limited information exists concerning rate, temporal, secular, and geographic trends in the United States.

METHODS AND RESULTS

Using CDC death certificate data spanning 1999-2016, we sought to delineate trends in deaths attributable to an underlying cause of hypertension using joinpoint regression and proportion testing. From 1999-2016, the hypertension-related mortality rate increased by 36.4% with an average annual percent change (AAPC) of 1.8% for individuals ≥ 35 years of age. Interestingly, there was a notable acceleration in the AAPC of hypertension mortality between 2011 and 2016 (2.7% per year). This increase was due to a significant uptick in mortality for individuals ≥ 55 years of age with the greatest AAPC occurring in individuals 55-64 (4.5%) and 65-74 (5.1%) years of age. Increased mortality and AAPC were pervasive throughout sex, ethnicity, and White and American Indian or Alaska Native race, but not Black or African American race. From 2011-2016, there were significant increases in AAPC for hypertension-related mortality with contributing causes of atrial fibrillation, heart failure, diabetes, obesity, and vascular dementia. Elevated mortality was observed for conditions with a contributing cause of hypertension that included chronic obstructive pulmonary disease, diabetes, Alzheimer's, Parkinson's, and all types of falls. Geographically, increases in AAPCs and mortality rates were observed for 25/51 States between 2011 and 2016.

CONCLUSIONS

Our results indicate hypertension-related mortality may have accelerated since 2011 for middle-aged and older Americans, which may create new challenges in care and healthcare planning.

Economic Insecurity and Deaths of Despair in US Counties

Recent research has implicated economic insecurity in increasing midlife death rates and "deaths of despair," including suicide, chronic liver disease, and drug and alcohol poisoning. In this ecological longitudinal study, we evaluated the association between changes in economic insecurity and increases in deaths of despair and midlife all-cause mortality in US counties during 2000-2015. We extended a previously developed measure of economic insecurity using indicators from the Census and Federal Reserve Bank in US counties for the years 2000 and 2010. Linear regression models were used to estimate the association of change in economic insecurity with change in death rates through 2015. Counties experiencing elevated economic insecurity in either 2000 or 2010 had higher rates of deaths of despair and all-cause midlife mortality at baseline but similar rates of increase in deaths of despair from 2001 to 2015 compared with counties with stable low economic insecurity. Counties in the highest tertile of economic insecurity in 2000 and 2010 had 41% (95% confidence interval: 1.36, 1.47) higher midlife mortality rates at baseline and a rate of increase of 2% more per 5-year period (95% confidence interval: 1.00, 1.03) than counties with stable low economic insecurity. Economic insecurity may represent a population-level driver of US death trends.

Ideal Cardiovascular Health Among American Adults After the Economic Recession of 2008-2009: Insights from NHANES

BACKGROUND

The economic recession of 2008-2009 resulted in unprecedented employment and economic losses leading to deterioration of cardiovascular health. We examined the trends in ideal cardiovascular health as measured by the American Heart Association's (AHA's) Life's Simple 7 metric during the periods of economic recession and subsequent economic recovery.

METHODS

Data on adults ages ≥20 years from the NHANES from economic-recession (2007-2010) and post-recession (2011-2016) periods was analyzed. The AHA's Life's Simple 7 score of 10-14 was used to classify ideal cardiovascular health status. Socioeconomic status was divided into 3 categories: high, middle, and low based on education and income status. Multivariable linear and logistic regression models including demographics, insurance status, health care access, and adjustment for multiple testing were used to analyze the trends in prevalence of ideal cardiovascular health across socioeconomic strata.

RESULTS

We observed a decline in the multivariable-adjusted mean cardiovascular health score from 8.18 in 2007-2010 to 7.94 in 2015-2016 (P_linear = 0.02). This was primarily driven by the increasing prevalence of obesity (34% in 2007-2010 vs 41% in 2015-2016, P_linear = 0.005) and poor fasting glucose (8% in 2007-2010 vs 12% in 2015-2016, P_linear = 0.003). In multivariable-adjusted models, we observed the decreasing prevalence of ideal cardiovascular health with a nonlinear trend in the participants in the highest (51% in 2007-2010 vs 42% in 2015-2016, P_quadratic = 0.01) and lowest socioeconomic strata (16% in 2007-2010 vs 13% in 2015-2016, P_quadratic = 0.02). The prevalence of ideal cardiovascular health was higher in participants with high-socioeconomic status compared with other socioeconomic status participants.

CONCLUSIONS

Despite economic recovery, ideal cardiovascular health metrics have not yet recovered. Cardiovascular health appears to be further deteriorating for US adults, particularly those in high- and lower-socioeconomic strata.

How do economic downturns affect the mental health of children? Evidence from the National Health Interview Survey

Research linking economic conditions and health often does not consider children's mental health problems, which are the most common and consequential health issues for children and adolescents. We examine the effects of unemployment rates and housing prices on well-validated child and adolescent mental health outcomes and use of special education services for emotional problems in the 2001-2013 National Health Interview Survey. We find that the effects of economic conditions on children's mental health are clinically and economically meaningful; children's mental health outcomes worsen as the economy weakens. The effects of economic conditions on child and adolescent mental health are pervasive, found in almost every subgroup that we examine. The use of special education services for emotional problems also rises when economic conditions worsen. Our analyses of possible mechanisms that link economic conditions to child mental health suggest that parental unemployment cannot fully explain the relationship between economic conditions and child mental health.

Weathering, Drugs, and Whack-a-Mole: Fundamental and Proximate Causes of Widening Educational Inequity in U.S. Life Expectancy by Sex and Race, 1990-2015

Discussion of growing inequity in U.S. life expectancy increasingly focuses on the popularized narrative that it is driven by a surge of "deaths of despair." Does this narrative fit the empirical evidence? Using census and Vital Statistics data, we apply life-table methods to calculate cause-specific years of life lost between ages 25 and 84 by sex and educational rank for non-Hispanic blacks and whites in 1990 and 2015. Drug overdoses do contribute importantly to widening inequity for whites, especially men, but trivially for blacks. The contribution of suicide to growing inequity is unremarkable. Cardiovascular disease, non-lung cancers, and other internal causes are key to explaining growing life expectancy inequity. Results underline the speculative nature of attempts to attribute trends in life-expectancy inequity to an epidemic of despair. They call for continued investigation of the possible weathering effects of tenacious high-effort coping with chronic stressors on the health of marginalized populations.

Resurgence of Diabetes-Related Nontraumatic Lower-Extremity Amputation in the Young and Middle-Aged Adult U.S. Population

OBJECTIVE

To determine whether declining trends in lower-extremity amputations have continued into the current decade.

RESEARCH DESIGN AND METHODS

We calculated hospitalization rates for nontraumatic lower-extremity amputation (NLEA) for the years 2000-2015 using nationally representative, serial cross-sectional data from the Nationwide Inpatient Sample on NLEA procedures and from the National Health Interview Survey for estimates of the populations with and without diabetes.

RESULTS

Age-adjusted NLEA rates per 1,000 adults with diabetes decreased 43% between 2000 (5.38 [95% CI 4.93-5.84]) and 2009 (3.07 [95% CI 2.79-3.34]) (P < 0.001) and then rebounded by 50% between 2009 and 2015 (4.62 [95% CI 4.25-5.00]) (P < 0.001). In contrast, age-adjusted NLEA rates per 1,000 adults without diabetes decreased 22%, from 0.23 per 1,000 (95% CI 0.22-0.25) in 2000 to 0.18 per 1,000 (95% CI 0.17-0.18) in 2015 (P < 0.001). The increase in diabetes-related NLEA rates between 2009 and 2015 was driven by a 62% increase in the rate of minor amputations (from 2.03 [95% CI 1.83-2.22] to 3.29 [95% CI 3.01-3.57], P < 0.001) and a smaller, but also statistically significant, 29% increase in major NLEAs (from 1.04 [95% CI 0.94-1.13] to 1.34 [95% CI 1.22-1.45]). The increases in rates of total, major, and minor amputations were most pronounced in young (age 18-44 years) and middle-aged (age 45-64 years) adults and more pronounced in men than women.

CONCLUSIONS

After a two-decade decline in lower-extremity amputations, the U.S. may now be experiencing a reversal in the progress, particularly in young and middle-aged adults.