Decomposing Black-White Disparities in Heart Disease Mortality in the United States, 1973-2010: An Age-Period-Cohort Analysis

The impacts of exposure to risk factors during youth on the increasing global trend of early-onset pancreatic cancer

OBJECTIVES

An increasing trend of pancreatic cancer in young adults has emerged in some countries. This study aimed to investigate global trends of pancreatic cancer in young adults and explore the impact of exposure to risk factors on pancreatic cancer incidence during youth.

METHODS

Global and national data on pancreatic cancer incidence, disability-adjusted life-years, attributive mortality, and summary exposure values of risk factors were retrieved from the Global Burden of Disease 2019. The average annual percent change (AAPC) of incidence and mortality was calculated. Additionally, generalized additive models were applied to explore the non-linear associations between the levels and changes in the Human Development Index and AAPC.

RESULTS

Global pancreatic cancer incidence increased during various periods from 1990 to 2019, particularly in adults aged <45 years from 2010 to 2019, at an average annual increase rate of 0.7% (95% confidence interval: 0.4-1.0%). The AAPC of early-onset pancreatic cancer incidence from 2010 to 2019 was negatively correlated with Human Development Index levels in both 2010 and 2019 but positively correlated with Human Development Index acceleration. Significant increases in early-onset pancreatic cancer incidence were observed over this period in 32 of 88 countries, primarily in South America, North America, Oceania, and Africa. Early-onset pancreatic cancer mortality attributed to high body mass index and fasting plasma glucose increased, while that attributed to tobacco use declined.

CONCLUSIONS

An increasing trend has emerged in the global incidence and burden of early-onset pancreatic cancer over the last few decades. This rise may partly be attributed to global epidemics of high body mass index and fasting plasma glucose.

40 years of adding more fructose to high fructose corn syrup than is safe, through the lens of malabsorption and altered gut health-gateways to chronic disease

Labels do not disclose the excess-free-fructose/unpaired-fructose content in foods/beverages. Objective was to estimate excess-free-fructose intake using USDA loss-adjusted-food-availability (LAFA) data (1970-2019) for high fructose corn syrup (HFCS) and apple juice, major sources of excess-free-fructose, for comparison with malabsorption dosages (~ 5 g-children/ ~ 10 g-adults). Unlike sucrose and equimolar fructose/glucose, unpaired-fructose triggers fructose malabsorption and its health consequences. Daily intakes were calculated for HFCS that is generally-recognized-as-safe/ (55% fructose/45% glucose), and variants (65/35, 60/40) with higher fructose-to-glucose ratios (1.9:1, 1.5:1), as measured by independent laboratories. Estimations include consumer-level-loss (CLL) allowances used before (20%), and after, subjective, retroactively-applied increases (34%), as recommended by corn-refiners (~ 2012). No contributions from crystalline-fructose or agave syrup were included due to lack of LAFA data. High-excess-free-fructose-fruits (apples/pears/watermelons/mangoes) were not included. Eaten in moderation they are less likely to trigger malabsorption. Another objective was to identify potential parallel trends between excess-free-fructose intake and the "unexplained" US asthma epidemic. The fructose/gut-dysbiosis/lung axis is well documented, case-study evidence and epidemiological research link HFCS/apple juice intake with asthma, and unlike gut-dysbiosis/gut-fructosylation, childhood asthma prevalence data spans > 40 years. Results Excess-free-fructose daily intake for individuals consuming HFCS with an average 1.5:1 fructose-to-glucose ratio, ranged from 0.10 g/d in 1970, to 11.3 g/d in 1999, to 6.5 g/d in 2019, and for those consuming HFCS with an average 1.9:1 ratio, intakes ranged from 0.13 g/d to 16.9 g/d (1999), to 9.7 g/d in 2019, based upon estimates with a 20% CLL allowance. Intake exceeded dosages that trigger malabsorption (~ 5 g) around ~ 1980. By the early 1980's, tripled apple juice intake had added ~ 0.5 g to average-per-capita excess-free-fructose intake. Contributions were higher (~ 3.8 g /4-oz.) for individuals consuming apple juice consistent with a healthy eating pattern (4-oz. children, 8-oz. adults). The "unexplained" childhood asthma epidemic (1980-present) parallels increasing average-per-capita HFCS/apple juice intake trends and reflects epidemiological research findings. Conclusion Displacement of sucrose with HFCS, its ubiquitous presence in the US food-supply, the industry practice of adding more fructose to HFCS than generally-recognized-as-safe, and increased use of apple juice/crystalline fructose/agave syrup in foods/beverages has contributed to unprecedented excess-free-fructose intake levels, fructose malabsorption, gut-dysbiosis and gut-fructosylation (immunogen burden)-gateways to chronic disease.

Study on the burden of digestive diseases among Chinese residents in the 21st century

Background

The global burden of digestive diseases has increased in recent years. The study aims to comprehend the trend of incidence and death rates related to digestive diseases in China from 2000 to 2020.

Methods

The study collected data on digestive diseases and their causes, such as incidence rates, death rates, Years of Life Lost, Years Lived with Disability, Disability-Adjusted Life Years and estimated annual percentage change from the 2019 Global Burden of Disease website and the Chinese Health and Wellness Statistical Yearbook spanning. And we employed the age-period-cohort model to analyze the influence of age, period, and birth cohort on the trend of death rates associated with digestive diseases.

Results

In contrast to the global burden of digestive disease, China experienced increases in the age-standardized incidence for inflammatory bowel disease, gallbladder and biliary diseases, as well as appendicitis from 2000 to 2019. The corresponding estimated annual percentage change for these diseases were 2.06, 1.74, and 0.99. Females showed a significantly higher incidence of digestive diseases, while males experienced a higher death rate. Moreover, individuals in the age groups under 5 years and over 60 years exhibited higher death rates than those in other age groups.

Conclusion

The findings underscore the ongoing importance of digestive diseases as a substantial public health issue in China. Reducing the disease burden of IBD in China necessitates healthcare systems to enhance their infrastructure and personnel readiness, ensuring an equitable, affordable, and accessible distribution of care for IBD patients. To reduce the occurrence and mortality rates of digestive diseases in China, the government should promote the adoption of early screening policies for individuals under the 5 year and those above the 60 year. These policies should be accompanied by customized preventive measures.

Risk predictors of race disparity in patients undergoing coronary artery bypass grafting: a propensity-matched analysis

OBJECTIVES

The aim of this study was to compare long-term prognosis after isolated coronary artery bypass grafting between white and black patients and to investigate risk factors for poorer outcomes among the latest.

METHODS

All consecutive 4766 black and white patients undergoing isolated coronary artery bypass grafting between May 2005 and June 2021 at our institution were included. Primary outcomes were long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events in black versus white patients. A propensity-matched analysis was used 2 compare groups.

RESULTS

After matching, 459 patients were included in each black and white groups while groups were correctly balanced. The mean age was 70.4 vs 70.6 years old (P = 0.7) in black and white groups, respectively. Intraoperatively, mean operating room time and blood product transfusion, were higher in the black group while incidence of extubation in the operating room was higher in the white one. Postoperatively, hospital length of stay was higher in the black cohort. Thirty-day all-cause mortality was not different among groups. The median follow-up time was 4 years. Primary outcome of all-cause death was higher in the black versus the white, respectively. Major adverse cardiovascular and cerebrovascular events incidence was twice higher in the black compared to the white cohort (7.6% vs 3.7%, P = 0.013). Risk predictors for all-cause death and major adverse cardiovascular and cerebrovascular events in blacks were creatinine level, chronic obstructive pulmonary disease, ejection fraction <50% and preoperative atrial fibrillation.

CONCLUSIONS

Racial disparities persist in a high-volume centre. Despite no preoperative difference, black minority has a higher incidence of major adverse cardiovascular and cerebrovascular events.

Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level

Importance

Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program's income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries' ability to afford care.

Objective

To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care.

Design, Setting, and Participants

This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022.

Main outcome measures

Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data.

Results

This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries.

Conclusions and Relevance

This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.

State Minimum Wage Increases As a Potential Policy Lever to Reduce Black-White Disparities in Hypertension

Introduction

Black adults are disproportionately burdened by hypertension. Income inequality is associated with elevated risk of hypertension. Minimum wage increases have been explored as a potential policy lever to address the disparate impact of hypertension on this population. However, these increases may have no significant impact on health among Black adults due to structural racism and "diminished gain" of health effects from socioeconomic resources. This study assesses the relationship between state minimum wage increases and Black-White disparities in hypertension.

Methods

We merged state-level minimum wage data with survey data from the Behavioral Risk Factor Surveillance System (2001-2019). Odd survey years included questions about hypertension. Separate difference-in-difference models estimated the odds of hypertension among Black and White adults in states with and without minimum wage increases. Difference-in-difference-in-difference models estimated the impact of minimum wage increases on hypertension among Black adults relative to White adults.

Results

As state wage limits increase, the odds of hypertension significantly decreased among Black adults overall. This relationship is largely driven by the impact of these policies on Black women. However, the Black-White disparity in hypertension worsened as state minimum wage limits increased, and the magnitude of this disparity was larger among women.

Conclusion

States having a minimum wage above the federal wage limit are not sufficient to combat structural racism and reduce the disparities in hypertension among Black adults. Rather, future research should explore livable wages as a policy lever to reduce disparities in hypertension among Black adults.

Improving Older Adults' Health by Reducing Administrative Burden

Policy Points Administrative burdens, which are the onerous experiences people have when trying to access government benefits and services, reduce older adult's access to health promoting policies. Although considerable attention has been focused on threats to the old-age welfare state, ranging from long-term financing problems to attempts to roll back benefits, administrative barriers to these programs already threaten their effectiveness. Reducing administrative burden is a viable way to improve population health among older adults going forward over the next decade.

Structural racism theory, measurement, and methods: A scoping review

Introduction

Epidemiologic and public health interest in structural racism has grown dramatically, producing both increasingly sophisticated questions, methods, and findings, coupled with concerns of atheoretical and ahistorical approaches that often leave the actual production of health or disease ambiguous. This trajectory raises concerns as investigators adopt the term "structural racism" without engaging with theories and scholars with a long history in this area. This scoping review aims to build upon recent work by identifying current themes about the incorporation of structural racism into (social) epidemiologic research and practice with respect to theory, measurement, and practices and methods for trainees and public health researchers who are not already deeply grounded in this work.

Methods

This review uses methodological framework and includes peer-review articles written in English published between January 2000-August 2022.

Results

A search of Google Scholar, manual collection, and referenced lists identified a total of 235 articles; 138 met the inclusion criteria after duplicates were removed. Results were extracted by, and organized into, three broad sections: theory, construct measurement, and study practice and methods, with several themes summarized in each section.

Discussion

This review concludes with a summary of recommendations derived from our scoping review and a call to action echoing previous literature to resist an uncritical and superficial adoption of "structural racism" without attention to already existing scholarship and recommendations put forth by experts in the field.

Brain-heart connections in stress and cardiovascular disease: Implications for the cardiac patient

The influence of psychological stress on the physiology of the cardiovascular system, and on the etiology and outcomes of cardiovascular disease (CVD) has been the object of intense investigation. As a whole, current knowledge points to a "brain-heart axis" that is especially important in individuals with pre-existing CVD. The use of acute psychological stress provocation in the laboratory has been useful to clarify the effects of psychological stress on cardiovascular physiology, immune function, vascular reactivity, myocardial ischemia, neurobiology and cardiovascular outcomes. An emerging paradigm is that dynamic perturbations of physiological and molecular pathways during stress or negative emotions are important in influencing cardiovascular outcomes, and that some patient subgroups, such as women, patients with an early-onset myocardial infarction, and patients with adverse psychosocial exposures, may be at especially high risk for these effects. This review summarizes recent knowledge on mind-body connections in CVD among cardiac patients and highlights important pathways of risk which could become the object of future intervention efforts. As a whole, this research suggests that an integrated study of mind and body is necessary to fully understand the determinants and consequences of CVD.

A likelihood ratio test on temporal trends in age-period-cohort models with applications to the disparities of heart disease mortality among US populations and comparison with Japan

In this article, we introduce the recently developed intrinsic estimator method in the age-period-cohort (APC) models in examining disease incidence and mortality data, further develop a likelihood ratio (L-R) test for testing differences in temporal trends across populations, and apply the methods to examining temporal trends in the age, period or calendar time, and birth cohort of the US heart disease mortality across racial and sex groups. The temporal trends are estimated with the intrinsic estimator method to address the model identification problem, in which multiple sets of parameter estimates yield the same fitted values for a given dataset, making it difficult to conduct comparison of and hypothesis testing on the temporal trends in the age, period, and cohort across populations. We employ a penalized profile log-likelihood approach in developing the L-R test to deal with the issues of multiple estimators and the diverging number of model parameters. The identification problem also induces overparametrization of the APC model, which requires a correction of the degree of freedom of the L-R test. Monte Carlo simulation studies demonstrate that the L-R test performs well in the Type I error calculation and is powerful to detect differences in the age or period trends. The L-R test further reveals disparities of heart disease mortality among the US populations and between the US and Japanese populations.

Progress Toward Achieving National Targets for Reducing Coronary Heart Disease and Stroke Mortality: A County-Level Perspective

Background

The American Heart Association and Healthy People 2020 established objectives to reduce coronary heart disease (CHD) and stroke death rates by 20% by the year 2020, with 2007 as the baseline year. We examined county‐level achievement of the targeted reduction in CHD and stroke death rates from 2007 to 2017.

Methods and Results

Applying a hierarchical Bayesian model to National Vital Statistics data, we estimated annual age‐standardized county‐level death rates and the corresponding percentage change during 2007 to 2017 for those aged 35 to 64 and ≥65 years and by urban‐rural classification. For those aged ≥35 years, 56.1% (95% credible interval [CI], 54.1%–57.7%) and 39.8% (95% CI, 36.9%–42.7%) of counties achieved a 20% reduction in CHD and stroke death rates, respectively. For both CHD and stroke, the proportions of counties achieving a 20% reduction were lower for those aged 35 to 64 years than for those aged ≥65 years (CHD: 32.2% [95% CI, 29.4%–35.6%] and 64.1% [95% CI, 62.3%–65.7%]), respectively; stroke: 17.9% [95% CI, 13.9%–22.2%] and 45.6% [95% CI, 42.8%–48.3%]). Counties achieving a 20% reduction in death rates were more commonly urban counties (except stroke death rates for those aged ≥65 years).

Conclusions

Our analysis found substantial, but uneven, achievement of the targeted 20% reduction in CHD and stroke death rates, defined by the American Heart Association and Healthy People. The large proportion of counties not achieving the targeted reduction suggests a renewed focus on CHD and stroke prevention and treatment, especially among younger adults living outside of urban centers. These county‐level patterns provide a foundation for robust responses by clinicians, public health professionals, and communities.

High fructose corn syrup, excess-free-fructose, and risk of coronary heart disease among African Americans- the Jackson Heart Study

BACKGROUND

Researchers have sought to explain the black-white coronary heart disease (CHD) mortality disparity that increased from near parity to ~ 30% between 1980 and 2010. Contributing factors include cardiovascular disease prevention and treatment disparities attributable to disparities in insurance coverage. Recent research suggests that dietary/environmental factors may be contributors to the disparity. Unabsorbed/luminal fructose alters gut bacterial load, composition and diversity. There is evidence that such microbiome disruptions promote hypertension and atherosclerosis. The heart-gut axis may, in part, explain the black-white CHD disparity, as fructose malabsorption prevalence is higher among African Americans. Between 1980 and 2010, consumption of excess-free-fructose-the fructose type that triggers malabsorption-exceeded dosages associated with fructose malabsorption (~ 5 g-10 g), as extrapolated from food availability data before subjective, retroactively-applied loss adjustments. This occurred due to an industrial preference shift from sucrose to high-fructose-corn-syrup (HFCS) that began ~ 1980. During this period, HFCS became the main sweetener in US soda. Importantly, there has been more fructose in HFCS than thought, as the fructose-to-glucose ratio in popular sodas (1.9-to-1 and 1.5-to-1) has exceeded generally-recognized-as-safe levels (1.2-to-1). Most natural foods contain a ~ 1-to-1 ratio. In one recent study, ≥5 times/wk. consumers of HFCS sweetened soda/fruit drinks/and apple juice-high excess-free-fructose beverages-were more likely to have CHD, than seldom/never consumers.

METHODS

Jackson-Heart-Study data of African Americans was used to test the hypothesis that regular relative to low/infrequent intake of HFCS sweetened soda/fruit drinks increases CHD risk, but not orange juice-a low excess-free-fructose juice. Cox proportional hazards models were used to calculate hazard ratios using prospective data of 3407-3621 participants, aged 21-93 y (mean 55 y).

RESULTS

African Americans who consumed HFCS sweetend soda 5-6x/wk. or any combination of HFCS sweetened soda and/or fruit drinks ≥3 times/day had ~ 2 (HR 2.08, 95% CI 1.03-4.20, P = 0.041) and 2.5-3 times higher CHD risk (HR 2.98, 95% CI 1.15-7.76; P = 0.025), respectively, than never/seldom consumers, independent of confounders. There were no associations with diet-soda or 100% orange-juice, which has a similar glycemic profile as HFCS sweetened soda, but contains a ~ 1:1 fructose-to-glucose ratio.

CONCLUSION

The ubiquitous presence of HFCS in the food supply may pre-dispose African Americans to increased CHD risk.

Clarifying assumptions in age-period-cohort analyses and validating results

BACKGROUND

Age-period-cohort (APC) models are often used to decompose health trends into period- and cohort-based sources, but their use in epidemiology and population sciences remains contentious. Central to the contention are researchers' failures to 1) clearly state their analytic assumptions and/or 2) thoroughly evaluate model results. These failures often produce varying conclusions across APC studies and generate confusion about APC methods. Consequently, scholarly exchanges about APC methods usually result in strong disagreements that rarely offer practical advice to users or readers of APC methods.

METHODS

We use research guidelines to help practitioners of APC methods articulate their analytic assumptions and validate their results. To demonstrate the usefulness of the guidelines, we apply them to a 2015 American Journal of Epidemiology study about trends in black-white differences in U.S. heart disease mortality.

RESULTS

The application of the guidelines highlights two important findings. On the one hand, some APC methods produce inconsistent results that are highly sensitive to researcher manipulation. On the other hand, other APC methods estimate results that are robust to researcher manipulation and consistent across APC models.

CONCLUSIONS

The exercise shows the simplicity and effectiveness of the guidelines in resolving disagreements over APC results. The cautious use of APC models can generate results that are consistent across methods and robust to researcher manipulation. If followed, the guidelines can likely reduce the chance of publishing variable and conflicting results across APC studies.

Persistent Racial and Sex Disparities in Outcomes After Coronary Artery Bypass Surgery: A Retrospective Clinical Registry Review in the Drug-eluting Stent Era

OBJECTIVE

The purpose of this study was to assess the temporal trends in 30-day mortality by race group for patients undergoing coronary artery bypass grafting (CABG) between 2011 and 2018 and to investigate the effect of race and sex on postoperative outcomes after CABG.

SUMMARY BACKGROUND DATA

Cardiovascular diseases remain a leading cause of death in the United States with studies demonstrating increased morbidity and mortality for black and female patients undergoing surgery. In the post drug-eluting stent era, studies of racial disparities CABG are outdated.

METHODS

We performed a retrospective analysis of the Society for Thoracic Surgeons database for patients undergoing CABG between 2011 and 2018. Primary outcome was 30-day mortality. Secondary outcomes included postoperative length of stay, surgical site infection, sepsis, pneumonia, stroke, reoperation, reintervention, early extubation, and readmission.

RESULTS

The study population was comprised of 1,042,506 patients who underwent isolated CABG between 2011 and 2018. Among all races, Black patients had higher rates of preoperative comorbidities. Compared with White patients, Black patients had higher overall mortality (2.76% vs 2.19%, P < 0.001). On univariable regression, Black patients had higher rates of death, infection, pneumonia, and postoperative stroke compared to White patients. On multivariable regression, Black patients had higher odds of 30-day mortality compared to white patients [odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.05-1.18]. Similarly, female patients had higher odds of death compared to males (OR = 1.26, 95% CI 1.21-1.30).

CONCLUSIONS

In the modern era, racial and sex disparities in mortality and postoperative morbidity after coronary bypass surgery persist with Black patients and female patients consistently experiencing worse outcomes than White male patients. Although there may be unknown or underappreciated biological mechanisms at play, future research should focus on socioeconomic, cultural, and multilevel factors.

Historic and recent trends in county-level coronary heart disease death rates by race, gender, and age group, United States, 1979-2017

Given recent slowing of declines in national all-cause, heart disease, and stroke mortality, examining spatiotemporal distributions of coronary heart disease (CHD) death rates and trends can provide data critical to improving the cardiovascular health of populations. This paper documents county-level CHD death rates and trends by age group, race, and gender from 1979 through 2017. Using data from the National Vital Statistics System and a Bayesian multivariate space-time conditional autoregressive model, we estimated county-level age-standardized annual CHD death rates for 1979 through 2017 by age group (35–64 years, 65 years and older), race (white, black, other), and gender (men, women). We then estimated county-level total percent change in CHD death rates during four intervals (1979–1990, 1990–2000, 2000–2010, 2010–2017) using log-linear regression models. For all intervals, national CHD death rates declined for all groups. Prior to 2010, although most counties across age, race, and gender experienced declines, pockets of increasing CHD death rates were observed in the Mississippi Delta, Oklahoma, East Texas, and New Mexico across age groups and gender, and were more prominent among non-white populations than whites. Since 2010, across age, race, and gender, county-level declines in CHD death rates have slowed, with a marked increase in the percent of counties with increasing CHD death rates (e.g. 4.4% and 19.9% for ages 35 and older during 1979–1990 and 2010–2017, respectively). Recent increases were especially prevalent and geographically widespread among ages 35–64 years, with 40.5% of counties (95% CI: 38.4, 43.1) experiencing increases. Spatiotemporal differences in these long term, county-level results can inform responses by the public health community, medical providers, researchers, and communities to address troubling recent trends.

The disparities in gastrointestinal cancer incidence among Chinese populations in Shanghai compared to Chinese immigrants and indigenous non-Hispanic white populations in Los Angeles, USA

Gastrointestinal cancer patterns are distinct among populations. Our study aims to compare the incidence and risk of gastrointestinal cancers between Chinese American and non-Hispanic whites in Los Angeles, CA, USA, to those of people indigenous to Shanghai to elucidate the changing patterns of gastrointestinal cancers. Cancer incidence data from 1988 to 2012 were extracted from the Cancer Incidence in Five Continents plus database. The age standardized incidence and estimated annual percentage change were calculated to estimate the temporal trends of gastrointestinal cancers. Traditional Poisson regression models and three-factor constrained Poisson regression models were applied to compare the gastrointestinal cancer risk across populations. The incidences of oesophageal, stomach, liver and gall bladder cancers were higher among indigenous Chinese residents of Shanghai than among the other two populations in Los Angeles. While the incidences of colorectal and pancreatic cancer were higher among non-Hispanic whites, Chinese American immigrants were considered to be at an intermediate level for most gastrointestinal cancers. The gender-specific gastrointestinal cancer disparities across populations, especially between Shanghai Chinese and non-Hispanic US whites, were significant regardless of age, period or cohort scale. However, the regional differences in gastrointestinal cancer rates decreased over time. Most gastrointestinal cancer patterns in Chinese American immigrants were more aligned to those of their new country of residence than to those of their original country. The disparities in gastrointestinal cancers across populations indicate that environmental factors might play a key role in cancer genesis. Shift in environmental exposures may result in significant changes in gastrointestinal cancer incidence.

Trends in Cardiovascular Disease Morbidity and Mortality in American Indians Over 25 Years: The Strong Heart Study

Background American Indians experience high rates of cardiovascular disease. We evaluated whether cardiovascular disease incidence, mortality, and prevalence changed over 25 years among American Indians aged 30 to 85. Methods and Results The SHS (Strong Heart Study) and SHFS (Strong Heart Family Study) are prospective studies of cardiovascular disease in American Indians. Participants enrolled in 1989 to 1990 or 2000 to 2003 with birth years from 1915 to 1984 were followed for cardiovascular disease events through 2013. We used Poisson regression to analyze data for 5627 individuals aged 30 to 85 years during follow-up. Outcomes reflect change in age-specific cardiovascular disease incidence, mortality, and prevalence, stratified by sex. To illustrate generational change, 5-year relative risk compared most recent birth years for ages 45, 55, 65, and 75 to same-aged counterparts born 1 generation (23-25 years) earlier. At all ages, cardiovascular disease incidence was lower for people with more recent birth years. Cardiovascular disease mortality declined consistently among men, while prevalence declined among women. Generational comparisons were similar for women aged 45 to 75 (relative risk, 0.39-0.46), but among men magnitudes strengthened from age 45 to 75 (relative risk, 0.91-0.39). For cardiovascular disease mortality, risk was lower in the most recent versus the earliest birth years for women (relative risk, 0.56-0.83) and men (relative risk, 0.40-0.54), but results for women were inconclusive. Conclusions Cardiovascular disease incidence declined over a generation in an American Indian cohort. Mortality declined more for men, while prevalence declined more for women. These trends might reflect more improvement in case survival among men compared with women.

Black-White Differences in 20-year Trends in Cardiovascular Risk in the United States, 1990-2010

Objective

Improvements in the Black-White difference in life expectancy have been attributed to improved diagnosis and treatment of cardiovascular diseases and declines in cardiovascular disease mortality. However, it is unclear whether race differences in total cardiovascular risk and the prevalence of cardiovascular risk factors have improved in the United States since the 1990s.

Design

Serial cross-sectional design.

Setting

Data from the 1988-1994, 1999-2002, and 2009-2012 National Health and Nutrition Examination Survey (NHANES).

Methods

We estimated total cardiovascular risk levels, the prevalence of high-risk cardiovascular risk factors and the use of antihypertensive and lipid-lowering drugs among US Black and White men and women to determine whether differential changes occurred from 1990-2010.

Results

Total cardiovascular risk declined for all races from 1990-2010. The Black-White difference was only significant in 2000 and sex-specific analyses showed that trends seen in the total population were driven by changes among women. Black and White men did not differ in risk at any time during this period. Conversely, Black women had significantly higher risk than White women in 1990 and 2000; this difference was eliminated by 2010. Improved diagnosis and treatment of high blood pressure and high cholesterol reduced risk in the total population; improved blood pressure and lipid profiles among Black women and increasing obesity prevalence among White women specifically contributed to the narrowing of the Black-White difference in risk among women.

Conclusion

Cardiovascular risk and racial disparities in risk declined among US Whites and Blacks due to greater use and effectiveness of lipid-lowering and antihypertensive medications.

Structural Characteristics of Tree Cover and the Association with Cardiovascular and Respiratory Health in Tampa, FL

Urban tree cover can provide several ecological and public health benefits. Secondary datasets for Tampa, FL, including sociodemographic variables (e.g., race/ethnicity), health data, and interpolated values for features of tree cover (e.g., percent canopy and leaf area index) were analyzed using correlation and regression. Percent canopy cover and leaf area index were inversely correlated to respiratory and cardiovascular outcomes, yet only leaf area index displayed a significant association with respiratory conditions in the logistic regression model. Percent racial/ethnic minority residents at the block group level was significantly negatively correlated with median income and tree density. Leaf area index was also significantly lower in block groups with more African-American residents. The percentage of African Americans (p = 0.101) and Hispanics (p < 0.001) were positively associated with respiratory outcomes while population density (p < 0.001), percent canopy (p < 0.01), and leaf area index (p < 0.01) were negatively associated. In multivariate models, higher tree density, leaf area index, and median income were significantly negatively associated with respiratory cases. Block groups with a higher proportion of African Americans had a higher odds of displaying respiratory admissions above the median rate. Tree density and median income were also negatively associated with cardiovascular cases. Home ownership and tree condition were significantly positively associated with cardiovascular cases.

Help-seeking from indigenous healers among persons of African ancestry in the United States: Ethnic and racial disparities in mental and physical health

OBJECTIVE

Racial disparities in mental and physical health status are a persistent problem for people of African ancestry in the United States (U.S.). The current study seeks to determine whether indigenous help-seeking is related to ethnic and racial differences in health problems in persons of African ancestry.

METHODS/DESIGN

Complex sampling produced a nationally representative sample of 3570 African Americans, 1623 Caribbean Blacks, and 1006 non-Hispanic Whites. All 3750 African Americans, 1438 (88.6%) African Caribbeans, and 891(88.6%) European Americans had relevant data for the current study. Respondents to the National Survey of American Life (NSAL) were studied with structural equation modeling (SEM) to evaluate a model of help seeking from "faith healers," "herbalists or rootworkers," or "astrologists or psychics." Mental and physical health were predicted by this indigenous help-seeking.

RESULTS

Consistent with the hypothesis, SEM analyses indicated better model fit for African Americans with greater similarly to African Caribbean respondents (r = .901, p =  .001) than European Americans counterparts (r = -.332, p =  .382) in measurement models. These analyses also showed African Americans' indigenous help-seeking was negatively correlated with lifetime diagnoses of any DSM psychiatric disorders but positively correlated with burden of chronic diseases. The association between indigenous help-seeking and professional diagnoses of chronic diseases was negative for Caribbean Blacks.

CONCLUSION

Culturally competent psychological or medical services by Western practitioners to people in the U.S Black population require attention to indigenous healing systems.

Changing rate orders of race-gender heart disease death rates: An exploration of county-level race-gender disparities

A holistic view of racial and gender disparities that simultaneously compares multiple groups can suggest associated underlying contextual factors. Therefore, to more comprehensively understand temporal changes in combined racial and gender disparities, we examine variations in the orders of county-level race-gender specific heart disease death rates by age group from 1973-2015. We estimated county-level heart disease death rates by race, gender, and age group (35-44, 45-54, 55-64, 65-74, 75-84, ≥ 85, and ≥ 35) from the National Vital Statistics System of the National Center for Health Statistics from 1973-2015. We then ordered these rates from lowest to highest for each county and year. The predominant national rate order (i.e., white women (WW) < black women (BW) < white men (WM) < black men (BM)) was most common in younger age groups. Inverted rates for black women and white men (WW Collapse

Key Words

• BM, black men
• BW, black women
• CDC, Centers for Disease Control and Prevention
• County-level
• Gender
• Heart disease mortality
• ICD, International Classification of Diseases
• MCMC, Markov chain Monte Carlo
• NCHS, National Center for Health Statistics
• Race
• Spatiotemporal
• Temporal trends
• WM, white men
• WW, white women

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Grants

• K01 HD074726 NICHD NIH HHS

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Affiliation(s)

Adam S. Vaughan Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States
Harrison Quick Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Nesbitt Hall, 3215 Market St., Philadelphia, PA 19104, United States
Linda Schieb Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States
Michael R. Kramer Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, United States
Herman A. Taylor Cardiovascular Research Institute, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, United States
Michele Casper Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, United States

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Preventive parenting intervention during childhood and young black adults' unhealthful behaviors: a randomized controlled trial

OBJECTIVE

Lifestyle variables such as drug use and excessive weight gain contribute to adult morbidity and mortality. This study was designed to determine whether participation in a preventive intervention designed to enhance supportive parenting can reduce drug use and body mass index (BMI) in young Black adults from disadvantaged neighborhoods.

METHOD

This study was conducted in the rural southeastern United States. Black parents and their 11-year-old children (517 families) were assigned randomly to the Strong African American Families (SAAF) prevention trial or a control condition. Data assessing neighborhood socioeconomic status and supportive parenting were obtained when the youths were ages 11 and 16. When youths were ages 19-21 and 25, drug use and BMI were measured.

RESULTS

As hypothesized, significant three-way interactions were detected among neighborhood disadvantage, prevention condition, and gender for BMI (B = 3.341, p = .009, 95% CI [0.832, 5.849]) and substance use (B = -0.169, p = .049, 95% CI [-0.337, -0.001]). Living in a disadvantaged neighborhood during adolescence was associated with increased drug use among young men in the control group (simple-slope = 0.215, p < .003) but not among those in the SAAF condition (simple-slope = 0.030, p = .650). Neighborhood disadvantage was associated with elevated BMI among young women in the control group (simple-slope = 3.343, p < .001), but not in the SAAF condition (simple-slope = 0.204, p = .820).

CONCLUSIONS

The results suggest that participation during childhood in a preventive intervention to enhance supportive parenting can ameliorate the effects of life in a disadvantaged neighborhood on men's drug use and women's BMI across ages 19-25 years. These findings suggest a possible role for parenting enhancement programs in narrowing health disparities.

Before the here and now: What we can learn from variation in spatiotemporal patterns of changing heart disease mortality by age group, time period, and birth cohort

One hypothesized explanation for the recent slowing of declines in heart disease death rates is the generational shift in the timing and accumulation of risk factors. However, directly testing this hypothesis requires historical age-group-specific risk factor data that do not exist. Using national death records, we compared spatiotemporal patterns of heart disease death rates by age group, time period, and birth cohort to provide insight into possible drivers of trends. To do this, we calculated county-level percent change for five time periods (1973-1980, 1980-1990, 1990-2000, 2000-2010, 2010-2015) for four age groups (35-44, 45-54, 55-64, 65-74), resulting in eight birth cohorts for each decade from the 1900s through the 1970s. From 1973 through 1990, few counties experienced increased heart disease death rates. In 1990-2000, 49.0% of counties for ages 35-44 were increasing, while all other age groups continued to decrease. In 2000-2010, heart disease death rates for ages 45-54 increased in 30.4% of counties. In 2010-2015, all four age groups showed widespread increasing county-level heart disease death rates. Likewise, birth cohorts from the 1900s through the 1930s experienced consistently decreasing heart disease death rates in almost all counties. Similarly, with the exception of 2010-2015, most counties experienced decreases for the 1940s birth cohort. For birth cohorts in the 1950s, 1960s, and 1970s, increases were common and geographically widespread for all age groups and calendar years. This analysis revealed variation in trends across age groups and across counties. However, trends in heart disease death rates tended to be generally decreasing and increasing for early and late birth cohorts, respectively. These findings are consistent with the hypothesis that recent increases in heart disease mortality stem from the beginnings of the obesity and diabetes epidemics. However, the common geographic patterns within the earliest and latest time periods support the importance of place-based macro-level factors.

Sex and Race Differences in the Utilization and Outcomes of Coronary Artery Bypass Grafting Among Medicare Beneficiaries, 1999-2014

BACKGROUND

With over a decade of directed efforts to reduce sex and racial differences in coronary artery bypass grafting (CABG) utilization, and post-CABG outcomes, we sought to evaluate how the use of CABG and its outcomes have evolved in different sex and racial subgroups.

METHODS AND RESULTS

Using data on all fee-for-service Medicare beneficiaries undergoing CABG in the United States from 1999 to 2014, we examined differences by sex and race in calendar-year trends for CABG utilization and post-CABG outcomes (in-hospital, 30-day, and 1-year mortality and 30-day readmission). A total of 1 863 719 Medicare fee-for-service beneficiaries (33.6% women, 4.6% black) underwent CABG from 1999 to 2014, with a decrease from 611 to 245 CABG procedures per 100 000 person-years. Men compared with women and whites compared with blacks had higher CABG utilization, with declines in all subgroups. Higher post-CABG annual declines in mortality (95% confidence interval) were observed in women (in-hospital, -2.70% [-2.97, -2.44]; 30-day, -2.29% [-2.54, -2.04]; and 1-year mortality, -1.67% [-1.88, -1.46]) and blacks (in-hospital, -3.31% [-4.02, -2.60]; 30-day, -2.80% [-3.49, -2.12]; and 1-year mortality, -2.38% [-2.92, -1.84]), compared with men and whites, respectively. Mortality rates remained higher in women and blacks, but differences narrowed over time. Annual adjusted 30-day readmission rates remained unchanged for all patient groups.

CONCLUSIONS

Women and black patients had persistently higher CABG mortality than men and white patients, respectively, despite greater declines over the time period. These findings indicate progress, but also the need for further progress.

Modeling racial disparities in physical health via close relationship functioning: A life course approach

OBJECTIVE

The aim of the present study was to test a life course model in which racial disparities in physical health between Caucasian and African Americans are driven by disparities in close relationship functioning. This model also examined relative evidence for intergenerational transmission of relationship functioning and ongoing exposure to prejudice and discrimination as two pathways that might shape adult relationship functioning.

METHOD

A sample of 523 Caucasian and African American men and women were prospectively tracked from a birth cohort initiated in the 1960s. Reports of parental relationship functioning were obtained from participants and their mothers in adolescence. In midlife, participants completed measures of perceived discrimination (lifetime and everyday discrimination), close relationship functioning (relationship strain and support) and physical health (self-rated health, resting heart rate and systolic blood pressure).

RESULTS

As hypothesized, close relationship functioning was a strong predictor of physical health in adulthood. Furthermore, we observed that perceived discrimination over the life course was linked to impaired relationship functioning. Evidence for intergenerational transmission of relationship functioning was more equivocal.

CONCLUSION

Racial disparities in physical health may be maintained via social factors throughout the life course. Although such factors have sometimes been considered outside the purview of the medical field, it is vital that researchers and clinicians begin to more fully address the implications of social forces in order to remediate racial health disparities.

Heart Disease Death Rates Among Blacks and Whites Aged ≥35 Years - United States, 1968-2015

PROBLEM/CONDITION

Heart disease is the leading cause of death in the United States. In 2015, heart disease accounted for approximately 630,000 deaths, representing one in four deaths in the United States. Although heart disease death rates decreased 68% for the total population from 1968 to 2015, marked disparities in decreases exist by race and state.

PERIOD COVERED

1968-2015.

DESCRIPTION OF SYSTEM

The National Vital Statistics System (NVSS) data on deaths in the United States were abstracted for heart disease using diagnosis codes from the eighth, ninth, and tenth revisions of the International Classification of Diseases (ICD-8, ICD-9, and ICD-10) for 1968-2015. Population estimates were obtained from NVSS files. National and state-specific heart disease death rates for the total population and by race for adults aged ≥35 years were calculated for 1968-2015. National and state-specific black-white heart disease mortality ratios also were calculated. Death rates were age standardized to the 2000 U.S. standard population. Joinpoint regression was used to perform time trend analyses.

RESULTS

From 1968 to 2015, heart disease death rates decreased for the total U.S. population among adults aged ≥35 years, from 1,034.5 to 327.2 per 100,000 population, respectively, with variations in the magnitude of decreases by race and state. Rates decreased for the total population an average of 2.4% per year, with greater average decreases among whites (2.4% per year) than blacks (2.2% per year). At the national level, heart disease death rates for blacks and whites were similar at the start of the study period (1968) but began to diverge in the late 1970s, when rates for blacks plateaued while rates for whites continued to decrease. Heart disease death rates among blacks remained higher than among whites for the remainder of the study period. Nationwide, the black-white ratio of heart disease death rates increased from 1.04 in 1968 to 1.21 in 2015, with large increases occurring during the 1970s and 1980s followed by small but steady increases until approximately 2005. Since 2005, modest decreases have occurred in the black-white ratio of heart disease death rates at the national level. The majority of states had increases in black-white mortality ratios from 1968 to 2015. The number of states with black-white mortality ratios >1 increased from 16 (40%) to 27 (67.5%).

INTERPRETATION

Although heart disease death rates decreased both for blacks and whites from 1968 to 2015, substantial differences in decreases were found by race and state. At the national level and in most states, blacks experienced smaller decreases in heart disease death rates than whites for the majority of the period. Overall, the black-white disparity in heart disease death rates increased from 1968 to 2005, with a modest decrease from 2005 to 2015.

PUBLIC HEALTH ACTION

Since 1968, substantial increases have occurred in black-white disparities of heart disease death rates in the United States at the national level and in many states. These increases appear to be due to faster decreases in heart disease death rates for whites than blacks, particularly from the late 1970s until the mid-2000s. Despite modest decreases in black-white disparities at the national level since 2005, in 2015, heart disease death rates were 21% higher among blacks than among whites. This study demonstrates the use of NVSS data to conduct surveillance of heart disease death rates by race and of black-white disparities in heart disease death rates. Continued surveillance of temporal trends in heart disease death rates by race can provide valuable information to policy makers and public health practitioners working to reduce heart disease death rates both for blacks and whites and disparities between blacks and whites.

Drug-related deaths in Scotland 1979-2013: evidence of a vulnerable cohort of young men living in deprived areas

BACKGROUND

Even after accounting for deprivation, mortality rates are higher in Scotland relative to the rest of Western Europe. Higher mortality from alcohol- and drug-related deaths (DRDs), violence and suicide (particularly in young adults) contribute to this 'excess' mortality. Age-period and cohort effects help explain the trends in alcohol-related deaths and suicide, respectively. This study investigated whether age, period or cohort effects might explain recent trends in DRDs in Scotland and relate to exposure to the changing political context from the 1980s.

METHODS

We analysed data on DRDs from 1979 to 2013 by sex and deprivation using shaded contour plots and intrinsic estimator regression modelling to identify and quantify relative age, period and cohort effects.

RESULTS

The peak age for DRDs fell around 1990, especially for males as rates increased for those aged 18 to 45 years. There was evidence of a cohort effect, especially among males living in the most deprived areas; those born between 1960 and 1980 had an increased risk of DRD, highest for those born 1970 to 1975. The cohort effect started around a decade earlier in the most deprived areas compared to the rest of the population.

CONCLUSION

Age-standardised rates for DRDs among young adults rose during the 1990s in Scotland due to an increased risk of DRD for the cohort born between 1960 and 1980, especially for males living in the most deprived areas. This cohort effect is consistent with the hypothesis that exposure to the changing social, economic and political contexts of the 1980s created a delayed negative health impact.

Correlated Poisson models for age-period-cohort analysis

Age-period-cohort (APC) models are widely used to analyze population-level rates, particularly cancer incidence and mortality. These models are used for descriptive epidemiology, comparative risk analysis, and extrapolating future disease burden. Traditional APC models have 2 major limitations: (1) they lack parsimony because they require estimation of deviations from linear trends for each level of age, period, and cohort; and (2) rates observed at similar ages, periods, and cohorts are treated as independent, ignoring any correlations between them that may lead to biased parameter estimates and inefficient standard errors. We propose a novel approach to estimation of APC models using a spatially correlated Poisson model that accounts for over-dispersion and correlations in age, period, and cohort, simultaneously. We treat the outcome of interest as event rates occurring over a grid defined by values of age, period, and cohort. Rates defined in this manner lend themselves to well-established approaches from spatial statistics in which correlation among proximate observations may be modeled using a spatial random effect. Through simulations, we show that in the presence of spatial dependence and over-dispersion: (1) the correlated Poisson model attains lower AIC; (2) the traditional APC model produces biased trend parameter estimates; and (3) the correlated Poisson model corrects most of this bias. We illustrate our approach using brain and breast cancer incidence rates from the Surveillance Epidemiology and End Results Program of the United States. Our approach can be easily extended to accommodate comparative risk analyses and interpolation of cells in the Lexis with sparse data.

Neighborhood Environmental Health and Premature Death From Cardiovascular Disease

Introduction

Cardiovascular disease (CVD) is the leading cause of death in the United States and disproportionately affects racial/ethnic minority groups. Healthy neighborhood conditions are associated with increased uptake of health behaviors that reduce CVD risk, but minority neighborhoods often have poor food access and poor walkability. This study tested the community-driven hypothesis that poor access to food at the neighborhood level and poor neighborhood walkability are associated with racial disparities in premature deaths from CVD.

Methods

We examined the relationship between neighborhood-level food access and walkability on premature CVD mortality rates at the census tract level for the city of Atlanta using multivariable logistic regression models. We produced maps to illustrate premature CVD mortality, food access, and walkability by census tract for the city.

Results

We found significant racial differences in premature CVD mortality rates and geographic disparities in food access and walkability among census tracts in Atlanta. Improved food access and walkability were associated with reduced overall premature CVD mortality in unadjusted models, but this association did not persist in models adjusted for census tract population composition and poverty. Census tracts with high concentrations of minority populations had higher levels of poor food access, poor walkability, and premature CVD mortality.

Conclusion

This study highlights disparities in premature CVD mortality and neighborhood food access and walkability at the census tract level in the city of Atlanta. Improving food access may have differential effects for subpopulations living in the same area. These results can be used to calibrate neighborhood-level interventions, and they highlight the need to examine race-specific health outcomes.

Race, Preoperative Risk Factors, and Death After Surgery

BACKGROUND AND OBJECTIVES

African American children are more than twice as likely to die after surgery compared with white children. In this study, we evaluated whether risk factors for death after surgery differ for African American and white children, and we also assessed whether race-specific risk stratification models perform better than non-race-specific models.

METHODS

The National Surgical Quality Improvement Program Pediatric Participant Use Data File contains clinical data on operations performed on children at participating institutions in the United States. Variables predictive of death within 30 days of surgery were analyzed for differences in prevalence and strength of association with death for both African American and white children. Classification tree and network analysis were used.

RESULTS

Network analyses revealed that the prevalence of preoperative risk factors associated with death after surgery was significantly higher for African American than for white children. In addition, many of the risk factors associated with death after surgery carried a higher risk when they occurred in African American children. Race-specific risk models provided high accuracy, with a specificity of 94% and a sensitivity of 83% for African American children and a specificity of 96% and a sensitivity of 77% for white children, and yet these 2 models were significantly different from each other.

CONCLUSIONS

Race-specific models predict outcomes after surgery more accurately compared with non-race-specific models. Identification of race-specific modifiable risk factors may help reduce racial disparities in surgery outcome.

The Life Course, Cohort Dynamics, and International Differences in Aging Trajectories

In recent years, population health research has focused on understanding the determinants of later-life health. Two strands of that work have focused on (1) international comparisons of later-life health and (2) assessing the early-life origins of disease and disability and the importance of life course processes. However, the less frequently examined intersection of these approaches remains an important frontier. The present study contributes to the integration of these approaches. We use the Health and Retirement Study family of data sets and a cohort dynamic approach to compare functional health trajectories across 12 high-income countries and to examine the role of life course processes and cohort dynamics in contributing to variation in those trajectories. We find substantial international variation in functional health trajectories and an important role of cohort dynamics in generating that variation, with younger cohorts often less healthy at comparable ages than the older cohorts they are replacing. We further find evidence of heterogeneous effects of life course processes on health trajectories. The results have important implications for future trends in morbidity and mortality as well as public policy.

Widespread recent increases in county-level heart disease mortality across age groups

PURPOSE

Recent national trends show decelerating declines in heart disease mortality, especially among younger adults. National trends may mask variation by geography and age. We examined recent county-level trends in heart disease mortality by age group.

METHODS

Using a Bayesian statistical model and National Vital Statistics Systems data, we estimated overall rates and percent change in heart disease mortality from 2010 through 2015 for four age groups (35-44, 45-54, 55-64, and 65-74 years) in 3098 US counties.

RESULTS

Nationally, heart disease mortality declined in every age group except ages 55-64 years. County-level trends by age group showed geographically widespread increases, with 52.3%, 58.5%, 69.1%, and 42.0% of counties experiencing increases with median percent changes of 0.6%, 2.2%, 4.6%, and -1.5% for ages 35-44, 45-54, 55-64, and 65-74 years, respectively. Increases were more likely in counties with initially high heart disease mortality and outside large metropolitan areas.

CONCLUSIONS

Recent national trends have masked local increases in heart disease mortality. These increases, especially among adults younger than age 65 years, represent challenges to communities across the country. Reversing these trends may require intensification of primary and secondary prevention-focusing policies, strategies, and interventions on younger populations, especially those living in less urban counties.

The legacy of slavery and contemporary declines in heart disease mortality in the U.S. South

BACKGROUND

This study aims to characterize the role of county-specific legacy of slavery in patterning temporal (i.e., 1968-2014), and geographic (i.e., Southern counties) declines in heart disease mortality. In this context, the U.S. has witnessed dramatic declines in heart disease mortality since the 1960's, which have benefitted place and race groups unevenly, with slower declines in the South, especially for the Black population.

METHODS

Age-adjusted race- and county-specific mortality rates from 1968-2014 for all diseases of the heart were calculated for all Southern U.S. counties. Candidate confounding and mediating covariates from 1860, 1930, and 1970, were combined with mortality data in multivariable regression models to estimate the ecological association between the concentration of slavery in1860 and declines in heart disease mortality from 1968-2014.

RESULTS

Black populations, in counties with a history of highest versus lowest concentration of slavery, experienced a 17% slower decline in heart disease mortality. The association for Black populations varied by region (stronger in Deep South than Upper South states) and was partially explained by intervening socioeconomic factors. In models accounting for spatial autocorrelation, there was no association between slave concentration and heart disease mortality decline for Whites.

CONCLUSIONS

Nearly 50 years of declining heart disease mortality is a major public health success, but one marked by uneven progress by place and race. At the county level, progress in heart disease mortality reduction among Blacks is associated with place-based historical legacy of slavery. Effective and equitable public health prevention efforts should consider the historical context of place and the social and economic institutions that may play a role in facilitating or impeding diffusion of prevention efforts thereby producing heart healthy places and populations. Graphical abstract.

Metabolic Syndrome Risks Following the Great Recession in Rural Black Young Adults

Background

Some of the country's highest rates of morbidity and mortality from cardiovascular disease are found in lower‐income black communities in the rural Southeast. Research suggests these disparities originate in the early decades of life, and partly reflect the influence of broader socioeconomic forces acting on behavioral and biological processes that accelerate cardiovascular disease progression. However, this hypothesis has not been tested explicitly. Here, we examine metabolic syndrome (MetS) in rural black young adults as a function of their family's economic conditions before and after the Great Recession.

Methods and Results

In an ongoing prospective study, we followed 328 black youth from rural Georgia, who were 16 to 17 years old when the Great Recession began. When youth were 25, we assessed MetS prevalence using the International Diabetes Federation's guidelines. The sample's overall MetS prevalence was 18.6%, but rates varied depending on family economic trajectory from before to after the Great Recession. MetS prevalence was lowest (10.4%) among youth whose families maintained stable low‐income conditions across the Recession. It was intermediate (21.8%) among downwardly mobile youth (ie, those whose families were lower income before the Recession, but slipped into poverty). The highest MetS rates (27.5%) were among youth whose families began the Recession in poverty, and sank into more meager conditions afterwards. The same patterns were observed with 3 alternative MetS definitions.

Conclusions

These patterns suggest that broader economic forces shape cardiometabolic risk in young blacks, and may exacerbate disparities already present in this community.

Black-White Cardiovascular Disease Disparities After Target-Based Versus Personalized Benefit-Based Lipid and Blood Pressure Treatment

Background: Cardiovascular disease (CVD) remains the leading cause of black-white morbidity and mortality disparities in the United States. Objectives: We sought to compare black-white CVD morbidity and mortality if lipid and blood pressure treatments were prescribed to achieve targeted lipid and blood pressure levels (treat-to-target [TTT]) or personalized CVD risk and treatment benefit estimates (benefit-based tailored treatment [BTT]). Methods: We utilized a microsimulation model of statin and blood pressure treatment based on a TTT approach (Joint National Commission 7; Adult Treatment Panel III) or a BTT approach (treating those with 10-year CVD risk ≥10%, a modification and extension of recent American College of Cardiology/American Heart Association guidelines). We input data from the National Health and Nutrition Examination Survey, isolating adults 40 to 75 years of age without prior CVD events. Results: We observed that TTT would prevent fewer CVD events (17.0 events prevented per 1,000 whites, 22.2 per 1,000 blacks) than the BTT approach (25.9 events prevented per 1,000 whites, 45.4 per 1,000 blacks). TTT could lower the national black-white CVD event rate disparity from 23.1 excess events per 1,000 blacks to 17.9 excess events (-23%), while BTT could lower the disparity to 3.6 excess events (-84% overall). The inferiority of TTT to BTT remained consistent in sensitivity analyses testing alternative treatment targets and either over- or underestimation of risk by commonly used equations. Conclusions: A BTT approach to lipid and blood pressure treatment would be expected to prevent more CVD events in the overall population and more effectively reduce national black-white CVD disparities than a traditional TTT approach.

Fruit and Vegetable Consumption, and Physical Activity with Partner and Parental Status in African American Adults

OBJECTIVES

The purpose of this study was to examine the relationships between partner and parental status and self-reported weekly fruit and vegetable consumption and level of physical activity in African American adults.

METHODS

A national sample of 2,370 African Americans participated in a telephone survey. Demographic data were collected and compared with fruit and vegetable consumption and physical activity responses.

RESULTS

When controlling for age (mean age = 53.6 ± 14.8 years) and education level, having children in the household was associated with greater fruit consumption. Being partnered was associated with moderate physical activity weekly for a higher percentage of women, and yet a shorter duration of minutes of moderate physical activity weekly for both women and men. Males (38.2% of the sample) reported being more physically active and females (61.8% of the sample) reported eating more fruits and vegetables.

CONCLUSIONS

By understanding the role of partner and parental status in relation to healthy lifestyle for African Americans, family scientists and health care practitioners may be able to target the needs of this population to help prevent obesity and chronic illness.

A unified approach for assessing heterogeneity in age-period-cohort model parameters using random effects

Age-period-cohort models are a popular tool for studying population-level rates; for example, trends in cancer incidence and mortality. Age-period-cohort models decompose observed trends into age effects that correlate with natural history, period effects that reveal factors impacting all ages simultaneously (e.g. innovations in screening), and birth cohort effects that reflect differential risk exposures that vary across birth years. Methodology for the analysis of multiple population strata (e.g. ethnicity, cancer registry) within the age-period-cohort framework has not been thoroughly investigated. Here, we outline a general model for characterizing differences in age-period-cohort model parameters for a potentially large number of strata. Our model incorporates stratum-specific random effects for the intercept, the longitudinal age trend, and the model-based estimate of annual percent change (net drift), thereby enabling a comprehensive analysis of heterogeneity. We also extend the standard model to include quadratic terms for age, period, and cohort, along with the corresponding random effects, which quantify possible stratum-specific departures from global curvature. We illustrate the utility of our model with an application to metastatic prostate cancer incidence (2004-2013) in non-Hispanic white and black men, using 17 population-based cancer registries in the Surveillance, Epidemiology, and End Results Program.

Recent cohort effects in suicide in Scotland: a legacy of the 1980s?

BACKGROUND

Mortality rates are higher in Scotland relative to England and Wales, even after accounting for deprivation. This 'excess' mortality is partly due to higher mortality from alcohol-related and drug-related deaths, violence and suicide (particularly in young adults). This study investigated whether cohort effects from exposure to neoliberal politics from the 1980s might explain the recent trends in suicide in Scotland.

METHODS

We analysed suicide deaths data from 1974 to 2013 by sex and deprivation using shaded contour plots and intrinsic estimator regression modelling to identify and quantify relative age, period and cohort effects.

RESULTS

Suicide was most common in young adults (aged around 25-40 years) living in deprived areas, with a younger peak in men. The peak age for suicide fell around 1990, especially for men for whom it dropped quickly from around 50 to 30 years. There was evidence of an increased risk of suicide for the cohort born between 1960 and 1980, especially among men living in the most deprived areas (of around 30%). The cohort at highest risk occurred earlier in the most deprived areas, 1965-1969 compared with 1970-1974.

CONCLUSIONS

The risk of suicide increased in Scotland for those born between 1960 and 1980, especially for men living in the most deprived areas, which resulted in a rise in age-standardised rates for suicide among young adults during the 1990s. This is consistent with the hypothesis that exposure to neoliberal politics created a delayed negative health impact.

Changes in the Geographic Patterns of Heart Disease Mortality in the United States: 1973 to 2010

BACKGROUND

Although many studies have documented the dramatic declines in heart disease mortality in the United States at the national level, little attention has been given to the temporal changes in the geographic patterns of heart disease mortality.

METHODS AND RESULTS

Age-adjusted and spatially smoothed county-level heart disease death rates were calculated for 2-year intervals from 1973 to 1974 to 2009 to 2010 for those aged ≥35 years. Heart disease deaths were defined according to the International Classification of Diseases codes for diseases of the heart in the eighth, ninth, and tenth revisions of the International Classification of Diseases. A fully Bayesian spatiotemporal model was used to produce precise rate estimates, even in counties with small populations. A substantial shift in the concentration of high-rate counties from the Northeast to the Deep South was observed, along with a concentration of slow-decline counties in the South and a nearly 2-fold increase in the geographic inequality among counties.

CONCLUSIONS

The dramatic change in the geographic patterns of heart disease mortality during 40 years highlights the importance of small-area surveillance to reveal patterns that are hidden at the national level, gives communities the historical context for understanding their current burden of heart disease, and provides important clues for understanding the determinants of the geographic disparities in heart disease mortality.

Disparities in Temporal and Geographic Patterns of Declining Heart Disease Mortality by Race and Sex in the United States, 1973-2010

BACKGROUND

Examining small-area differences in the strength of declining heart disease mortality by race and sex provides important context for current racial and geographic disparities and identifies localities that could benefit from targeted interventions. We identified and described temporal trends in declining county-level heart disease mortality by race, sex, and geography between 1973 and 2010.

METHODS AND RESULTS

Using a Bayesian hierarchical model, we estimated age-adjusted mortality with diseases of the heart listed as the underlying cause for 3099 counties. County-level percentage declines were calculated by race and sex for 3 time periods (1973-1985, 1986-1997, 1998-2010). Strong declines were statistically faster or no different than the total national decline in that time period. We observed county-level race-sex disparities in heart disease mortality trends. Continual (from 1973 to 2010) strong declines occurred in 73.2%, 44.6%, 15.5%, and 17.3% of counties for white men, white women, black men, and black women, respectively. Delayed (1998-2010) strong declines occurred in 15.4%, 42.0%, 75.5%, and 76.6% of counties for white men, white women, black men, and black women, respectively. Counties with the weakest patterns of decline were concentrated in the South.

CONCLUSIONS

Since 1973, heart disease mortality has declined substantially for these race-sex groups. Patterns of decline differed by race and geography, reflecting potential disparities in national and local drivers of these declines. Better understanding of racial and geographic disparities in the diffusion of heart disease prevention and treatment may allow us to find clues to progress toward racial and geographic equity in heart disease mortality.

Invited Commentary: A-P-C... It's Easy as 1-2-3!

Investigations of age, period, and cohort effects are difficult because the 3 factors are linearly dependent. In a novel application, Kramer et al. (Am J Epidemiol. 2015;182(4):302-312) have used graphical analysis and statistical models to estimate the impact that age, period, and cohort effects have had on trends in black-white inequalities in heart disease mortality. Using a constrained regression approach (with the first 2 periods' effects constrained to zero), Kramer et al. find evidence that age and cohort effects figure more prominently than do period effects in contributing to relative black-white mortality differences, and they argue that early-life exposures should be given greater consideration for mitigation of racial differences in heart disease. In this invited commentary, I argue that the utility of age-period-cohort models for understanding health inequalities depends on the plausibility of the assumptions used to break the link between the 3 factors. Based on the existing age-period-cohort literature, alternative assumptions seem likely to produce substantially different results. I also argue that interpretations of the impacts of age, period, and cohort effects on racial inequalities in heart disease mortality may depend on whether inequalities are assessed on the absolute scale or the relative scale.