1
|
Fantin R, Sierra MS, Vaccarella S, Herrero R, Barboza-Solís C. Social gradient and rural-urban disparities in cancer mortality in Costa Rica. Cancer Epidemiol 2024; 91:102604. [PMID: 38941875 PMCID: PMC11246819 DOI: 10.1016/j.canep.2024.102604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 06/14/2024] [Accepted: 06/19/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION Data on social inequalities in cancer mortality are sparse, especially in low- and middle-income countries. We aimed to analyze the socioeconomic inequalities in cancer mortality in Costa Rica between 2010 and 2018. METHODS We linked 9-years of data from the National Electoral Rolls, National Birth Index and National Death Index to classify deaths due to cancer and socioeconomic characteristics of the district of residence, as measured by levels of urbanicity and wealth. We analyzed the fifteen most frequent cancer sites in Costa Rica among the 2.7 million inhabitants aged 20 years and older. We used a parametric survival model based on a Gompertz distribution. RESULTS Compared to urban areas, mixed and rural area residents had lower mortality from pancreas, lung, breast, prostate, kidney, and bladder cancers, and higher mortality from stomach cancer. Mortality from stomach, lung and cervical cancer was higher, and mortality from colorectal cancer, non-Hodgkin lymphoma and leukemia was lower in the most disadvantaged districts, compared to the wealthiest ones. CONCLUSION We observed marked disparities in cancer mortality in Costa Rica in particular from infection- and lifestyle- related cancers. There are important opportunities to reduce disparities in cancer mortality by targeting cancer prevention, early detection and opportune treatment, mainly in urban and disadvantaged districts.
Collapse
Affiliation(s)
- Romain Fantin
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica; Centro Centroamericano de Población, Universidad de Costa Rica, Costa Rica.
| | - Mónica S Sierra
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | | | - Rolando Herrero
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica
| | | |
Collapse
|
2
|
Lam A, Keenan K, Cézard G, Kulu H, Myrskylä M. Inequalities in Disability-Free and Disabling Multimorbid Life Expectancy in Costa Rica, Mexico, and the United States. J Gerontol B Psychol Sci Soc Sci 2024; 79:gbae093. [PMID: 38785331 PMCID: PMC11227002 DOI: 10.1093/geronb/gbae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVES To better understand variations in multimorbidity severity over time, we estimate disability-free and disabling multimorbid life expectancy (MMLE), comparing Costa Rica, Mexico, and the United States (US). We also assess MMLE inequalities by sex and education. METHODS Data come from the Costa Rican Study on Longevity and Healthy Aging (2005-2009), the Mexican Health and Aging Study (2012-2018), and the Health and Retirement Study (2004-2018). We apply an incidence-based multistate Markov approach to estimate disability-free and disabling MMLE and stratify models by sex and education to study within-country heterogeneity. Multimorbidity is defined as a count of 2 or more chronic diseases. Disability is defined using limitations in activities of daily living. RESULTS Costa Ricans have the lowest MMLE, followed by Mexicans, then individuals from the US. Individuals from the US spend about twice as long with disability-free multimorbidity compared with individuals from Costa Rica or Mexico. Females generally have longer MMLE than males, with particularly stark differences in disabling MMLE. In the US, higher education was associated with longer disability-free MMLE and shorter disabling MMLE. We identified evidence for cumulative disadvantage in Mexico and the US, where sex differences in MMLE were larger among the lower educated. DISCUSSION Substantial sex and educational inequalities in MMLE exist within and between these countries. Estimating disability-free and disabling MMLE reveals another layer of health inequality not captured when examining disability and multimorbidity separately. MMLE is a flexible population health measure that can be used to better understand the aging process across contexts.
Collapse
Affiliation(s)
- Anastasia Lam
- Max Planck Institute for Demographic Research, Rostock, Germany
- School of Geography and Sustainable Development, University of St Andrews, St Andrews, UK
| | - Katherine Keenan
- School of Geography and Sustainable Development, University of St Andrews, St Andrews, UK
| | - Geneviève Cézard
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Hill Kulu
- School of Geography and Sustainable Development, University of St Andrews, St Andrews, UK
| | - Mikko Myrskylä
- Max Planck Institute for Demographic Research, Rostock, Germany
- Center for Social Data Science and Population Research Unit, University of Helsinki, Helsinki, Finland
| |
Collapse
|
3
|
Aliberti SM, Donato A, Funk RHW, Capunzo M. A Narrative Review Exploring the Similarities between Cilento and the Already Defined "Blue Zones" in Terms of Environment, Nutrition, and Lifestyle: Can Cilento Be Considered an Undefined "Blue Zone"? Nutrients 2024; 16:729. [PMID: 38474857 DOI: 10.3390/nu16050729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
Longevity is rightly considered one of the greatest achievements of modern society, not only as a function of lifespan, but, more importantly, as a function of healthspan. There are Longevity Blue Zones (LBZs), regions around the world, such as in Okinawa, Japan; the Nicoya Peninsula, Costa Rica; Loma Linda, California; Icaria, Greece; and Ogliastra, Sardinia, that are characterized by a significant percentage of residents who live exceptionally long lives, often avoiding age-related disability to a significantly higher degree than in the Western way of life. Longevity is not a universal phenomenon, so if there are places in the world with characteristics similar to the LBZs, it is important to identify them in order to better understand what other factors, in addition to the known ones, might contribute to a long and healthy life. This narrative review aims to identify common factors between Cilento and the five LBZs, taking into account environmental, nutritional, and lifestyle factors. Articles from 2004 to the present, limited to studies published in English, German, and Italian, were searched in PubMed/Medline, Scopus, and Google Scholar. The co-authors agreed on 18 final reference texts. In order to evaluate the similarities between Cilento and the LBZs, a descriptive comparative approach was used. Cilento and the LBZs share several common factors, including a hilly altitude ranging from 355 to 600 m; a mild climate throughout the year, with temperatures between 17.4 and 23.5 degrees Celsius; traditional professions, such as agriculture and animal husbandry; and a predominantly Mediterranean or plant-based diet, with typical recipes based on legumes, tubers, vegetables, and extra virgin olive oil. Additionally, maintenance of strong intergenerational family relationships, religious devotion, and social relationships within the community are also prevalent. Given the similarities to Cilento, one might wonder if this is an LBZ waiting to be discovered. The lessons learned from this discovery could be applied to the general population to protect them from non-communicable chronic diseases and help slow the aging process.
Collapse
Affiliation(s)
- Silvana Mirella Aliberti
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Salerno, Italy
| | - Antonio Donato
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Salerno, Italy
| | - Richard H W Funk
- Institute of Anatomy, Technische Universität Dresden, 01307 Dresden, Germany
- Division of Preventive Medicine, Dresden International University (DIU), 01067 Dresden, Germany
| | - Mario Capunzo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Salerno, Italy
- Complex Operational Unit Health Hygiene, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", 84131 Salerno, Italy
| |
Collapse
|
4
|
Wealth and inequality gradients for the detection and control of hypertension in older individuals in middle-income economies around 2007-2015. PLoS One 2022; 17:e0269118. [PMID: 35802577 PMCID: PMC9269405 DOI: 10.1371/journal.pone.0269118] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/15/2022] [Indexed: 11/23/2022] Open
Abstract
Socioeconomic inequalities in the detection and treatment of non-communicable diseases represent a challenge for healthcare systems in middle-income countries (MICs) in the context of population ageing. This challenge is particularly pressing regarding hypertension due to its increasing prevalence among older individuals in MICs, especially among those with lower socioeconomic status (SES). Using comparative data for China, Colombia, Ghana, India, Mexico, Russia and South Africa, we systematically assess the association between SES, measured in the form of a wealth index, and hypertension detection and control around the years 2007-15. Furthermore, we determine what observable factors, such as socio-demographic and health characteristics, explain existing SES-related inequalities in hypertension detection and control using a Blinder-Oaxaca decomposition. Results show that the prevalence of undetected hypertension is significantly associated with lower SES. For uncontrolled hypertension, there is evidence of a significant gradient in three of the six countries at the time the data were collected. Differences between rural and urban areas as well as lower and higher educated individuals account for the largest proportion of SES-inequalities in hypertension detection and control at the time. Improved access to primary healthcare in MICs since then may have contributed to a reduction in health inequalities in detection and treatment of hypertension. However, whether this indeed has been the case remains to be investigated.
Collapse
|
5
|
Li J, Llibre‐Guerra JJ, Harrati A, Weiss J, Jiménez‐Velázquez IZ, Acosta D, Llibre‐Rodriguez JDJ, Liu M, Dow WH. Associations between education and dementia in the Caribbean and the United States: An international comparison. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12204. [PMID: 34504942 PMCID: PMC8418669 DOI: 10.1002/trc2.12204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 07/14/2021] [Accepted: 07/28/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Despite high dementia prevalence in Hispanic populations globally, especially Caribbean Hispanics, no study has comparatively examined the association between education and dementia among Hispanics living in the Caribbean Islands and older adults in the United States. METHODS We used data on 6107 respondents aged 65 and older in the baseline wave of the population-based and harmonized 10/66 survey from Cuba, the Dominican Republic, and Puerto Rico, collected between 2003 and 2008, and 11,032 respondents aged 65 and older from the U.S.-based Health and Retirement Study data in 2014, a total of 17,139 individuals. We estimated multivariable logistic regression models examining the association between education and dementia, adjusted for age, income, assets, and occupation. The models were estimated separately for the Caribbean population (pooled and by setting) and the U.S. population by race/ethnicity (Hispanic, Black, and White), followed by pooled models across all populations. RESULTS In the Caribbean population, the relative risk of dementia among low versus high educated adults was 1.45 for women (95% confidence interval [CI] 1.17, 1.74) and 1.92 (95% CI 1.35, 2.49) for men, smaller compared to those in the United States, especially among non-Hispanic Whites (women: 2.78, 95% CI 1.94, 3.61; men: 5.98, 95% CI 4.02, 7.95). DISCUSSION The differential associations between education and dementia across the Caribbean and US settings may be explained by greater disparities in social conditions in the United States compared to the Caribbean, such as access to health care, healthy behaviors, and social stressors, which serve as potentially important mediators.
Collapse
Affiliation(s)
- Jing Li
- Department of Population Health SciencesWeill Cornell Medical CollegeCornell UniversityNew YorkNYUSA
| | | | - Amal Harrati
- Department of Primary Care and Population HealthSchool of MedicineStanford UniversityStanfordCAUSA
| | - Jordan Weiss
- Department of DemographyUniversity of California at BerkeleyBerkeleyCAUSA
| | | | - Daisy Acosta
- Universidad Nacional Pedro Henriquez Ureña (UNPHU)Santo DomingoDominican Republic
| | | | - Mao‐Mei Liu
- Department of DemographyUniversity of California at BerkeleyBerkeleyCAUSA
| | - William H. Dow
- Department of DemographyUniversity of California at BerkeleyBerkeleyCAUSA
- School of Public HealthUniversity of California at BerkeleyBerkeleyCAUSA
| |
Collapse
|
6
|
Cuba's cardiovascular risk factors: International comparison of levels and education gradients. PLoS One 2021; 16:e0247831. [PMID: 33661959 PMCID: PMC7932107 DOI: 10.1371/journal.pone.0247831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 02/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cuba's life expectancy at 79 is third highest in Latin America. Many attribute this to social investments in health and education, but comparative research is sparse, thus we compare Cuba with neighboring Dominican Republic, Costa Rica due to its strong social protections, and the U.S. Given high cardiovascular mortality, we focus on cardiovascular risk factor levels. To assess the role of health care, we distinguish medically amenable biomarkers from behavioral risk factors. To assess the role of Cuba's focus on equity, we compare education gradients in risk factors. METHODS We analyze Cuban data from the 10/66 Dementia Research Group baseline survey of urban adults ages 65 plus. Comparison samples are drawn from the Dominican Republic 10/66 survey, the Costa Rican CRELES, and U.S. NHANES. We analyze cross-country levels and education gradients of medically amenable (hypertension, diabetes, hypercholesterolemia, access to health care) and behavioral (smoking, obesity) risk factors,-using sex-stratified weighted means comparisons and age-adjusted logistic regression. RESULTS Neither medically amenable nor behavioral risk factors are uniformly better in Cuba than comparison countries. Obesity is lower in Cuba, but male smoking is higher. Hypertension, diabetes, and hypercholesterolemia levels are high in all countries, though Cuba's are lower than Costa Rica. Hypertension awareness in Cuba is similar to Costa Rica. Cuba has a higher proportion of hypertensives on treatment than Costa Rica, though lower than the U.S. Comparative gradients by education are similarly mixed. For behavioral factors, Cuba shows the strongest gradients (primarily for men) among the countries compared: smoking improves, but obesity worsens with education. Hypertension awareness also improves with education in Cuba, but Cuba shows no significant differences by education in hypertension treatment. CONCLUSION Smoking is comparatively high in Cuba, but obesity is low, and the resulting biomarkers show comparatively mixed patterns. Cuba's social protections have not eliminated strong educational gradients in behavioral risk factors, but the healthcare system appears to have eliminated disparities such as in hypertension treatment.
Collapse
|
7
|
Santamaría-Ulloa C, Montero-López M. Projected impact of diabetes on the Costa Rican healthcare system. Int J Equity Health 2020; 19:172. [PMID: 33100218 PMCID: PMC7586658 DOI: 10.1186/s12939-020-01291-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 09/24/2020] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Costa Rica, similar to many other Latin American countries is undergoing population aging at a fast pace. As a result of the epidemiological transition, the prevalence of diabetes has increased. This condition impacts not only individual lives, but also the healthcare system. The goal of this study is to examine the expected impact of diabetes, in terms of economic costs on the healthcare system and lives lost. We will also project how long it will take for the number of elderly individuals who are diabetic to double in Costa Rica. METHODS CRELES (Costa Rican Longevity and Healthy Aging Study), a three-wave nationally representative longitudinal study, is the main source of data for this research (n = 2827). The projected impact of diabetes was estimated in three ways: length of time for the number of elderly individuals with diabetes to double; projected economic costs of diabetes-related hospitalizations and outpatient care; and years of life lost to diabetes at age 60. Data analyses and estimations used multiple regression models, longitudinal regression models, and Lee-Carter stochastic population projections. RESULTS Doubling time of the diabetic elderly population is projected to occur in 13 calendar years. This will cause increases in hospitalization and outpatient consultation costs. The impact of diabetes on life expectancy at age 60 around the year 2035 is estimated to lead to a loss of about 7 months of life. The rapid pace at which the absolute number of elderly people with diabetes will double is projected to result in a negative economic impact on the healthcare system. Lives will also be lost due to diabetes. CONCLUSION Population aging will inevitably lead to an increasing number of elderly individuals, who are at greater risk for diabetes due to their lifelong exposure to risk factors. Actions to increase the quality of life of diabetic elderly are warranted. Decreasing the burden of diabetes on elderly populations and the Costa Rican healthcare system are necessary to impact the quantity and quality of life of incoming cohorts. Health promotion and prevention strategies that reduce diabetes risk factors are needed to improve the health of elderly populations.
Collapse
Affiliation(s)
| | - Melina Montero-López
- Instituto de Investigaciones en Salud, Universidad de Costa Rica, San José, Costa Rica
| |
Collapse
|
8
|
Hessel P, Rodríguez-Lesmes P, Torres D. Socio-economic inequalities in high blood pressure and additional risk factors for cardiovascular disease among older individuals in Colombia: Results from a nationally representative study. PLoS One 2020; 15:e0234326. [PMID: 32516351 PMCID: PMC7282633 DOI: 10.1371/journal.pone.0234326] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/24/2020] [Indexed: 12/19/2022] Open
Abstract
Background Studies in high-income countries have documented a consistent gradient between socio-economic status (SES) and high blood pressure (HBP), a key risk factor for cardiovascular disease (CVD). However, evidence from Latin American countries (LA) remains comparatively scarce and inconclusive. Data Data for 3,984 individuals came from a nationally representative survey of individuals aged 60 years or above in Colombia (Encuesta de Salud, Bienestar y Envejecimiento) (SABE) conducted in 2015. SES was measured by educational achievement and household assets. CVD risk factors included objectively measured HBP and body mass index (BMI), as well as behaviors (smoking, alcohol consumption, fruit and vegetables intake, and physical activity). Methods Bivariate methods and multivariate regression models were used to assess associations between SES with HBP as well as additional risk factors for CVD. Results Individuals with lower SES have significantly higher risk of suffering from HBP. Compared to those with no formal education, individuals with secondary or post-secondary education have a 37% lower risk of HBP (odds ratio [OR] = 0.63, P-value<0.001). Being in the highest asset quartile (most affluent) is associated with a 44% lower risk (OR = 56, P-value = 0.001) of HBP compared to those in the lowest asset quartile (most deprived). Individuals with lower SES are more likely to smoke, not engage in regular physical activity and not regularly consume fruits or vegetables. In contrast, individuals with higher SES are more likely to consume alcohol and, those with more assets, more likely to be obese. Conclusions Among older Colombians there exists a marked SES gradient in HBP as well as several additional risk factors for CVD. The results highlight the importance of a public health approach towards HBP and additional CVD risk factors that takes into account the specific conditions of older individuals, especially among disadvantaged groups.
Collapse
Affiliation(s)
- Philipp Hessel
- University of the Andes, Alberto Lleras Camargo School of Government, Bogotá, Colombia
- * E-mail:
| | | | - David Torres
- University of the Andes, Alberto Lleras Camargo School of Government, Bogotá, Colombia
| |
Collapse
|
9
|
Nieddu A, Vindas L, Errigo A, Vindas J, Pes GM, Dore MP. Dietary Habits, Anthropometric Features and Daily Performance in Two Independent Long-Lived Populations from Nicoya peninsula (Costa Rica) and Ogliastra (Sardinia). Nutrients 2020; 12:nu12061621. [PMID: 32492804 PMCID: PMC7352961 DOI: 10.3390/nu12061621] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/16/2020] [Accepted: 05/21/2020] [Indexed: 12/15/2022] Open
Abstract
(1) Background: Longevity Blue Zones (LBZs) are populations characterized by exceptional longevity. The purpose of this cross-sectional study was to compare the food habits of two representative samples of the oldest old subjects from the population residing in the LBZs of Nicoya peninsula (Costa Rica) and in the mountainous part of Ogliastra (Sardinia, Italy). (2) Methods: Data were collected using validated tools, including a food frequency questionnaire, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) scales for functional autonomy, body mass index, and waist and limbs circumferences. (3) Results: A total of 210 subjects, 60 (31 male) from Nicoya (age range 80–109 years), and 150 (61 male) from Ogliastra (age 90–101 years) were included in the study. In both populations, the highest frequencies of consumption were recorded for plant-derived foods (cereals 60–80% daily, legumes ≥ 80% daily in Nicoya, ≥ 60% 2–5 servings/week in Ogliastra), followed by those of animal origin (dairy products, meat) ≥60% and 80% daily, in Nicoya and Ogliastra, respectively. The frequency of milk consumption showed a positive correlation with BADL (ρ = 0.268 for Nicoya and ρ = 0.214 for Ogliastra) and IADL scores (ρ = 0.466 for Nicoya and ρ = 0.471 for Ogliastra), whereas legumes consumption correlated negatively with self-rated health (ρ = −0.264) and IADL (ρ = −0.332). (4) Conclusions: Our results indicate that the dominant dietary model among the elderly of Nicoya and Ogliastra is a plant-based diet complemented by a non-negligible consumption of animal products, mostly dairy products. Further prospective studies are needed to ascertain a possible cause–effect relationship between food habits and increased likelihood of reaching advanced age.
Collapse
Affiliation(s)
- Alessandra Nieddu
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Viale San Pietro 8, I-07100 Sassari, Italy; (A.N.); (G.M.P.)
| | - Laura Vindas
- Asociación Península de Nicoya–Zona Azul, 145-1100 San José, Costa Rica; (L.V.); (J.V.)
| | - Alessandra Errigo
- Dipartimento di Scienze Biomediche, University of Sassari, Viale San Pietro 43/b, I-07100 Sassari, Italy;
| | - Jorge Vindas
- Asociación Península de Nicoya–Zona Azul, 145-1100 San José, Costa Rica; (L.V.); (J.V.)
| | - Giovanni Mario Pes
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Viale San Pietro 8, I-07100 Sassari, Italy; (A.N.); (G.M.P.)
- Sardinia Longevity Blue Zone Observatory, 08040 Ogliastra, Italy
| | - Maria Pina Dore
- Dipartimento di Scienze Mediche, Chirurgiche e Sperimentali, University of Sassari, Viale San Pietro 8, I-07100 Sassari, Italy; (A.N.); (G.M.P.)
- Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
- Correspondence: ; Tel.: +39-079-229886
| |
Collapse
|
10
|
Santamaría-Ulloa C, Montero-López M, Rosero-Bixby L. Diabetes epidemics: inequalities increase the burden on the healthcare system. Health Policy Plan 2019; 34:ii45-ii55. [PMID: 31723964 DOI: 10.1093/heapol/czz109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 12/20/2022] Open
Abstract
Diabetes is a major cause of morbidity and mortality and represents a source of demands on already constrained healthcare systems in Latin America and the Caribbean. We estimate inequalities in diabetes incidence, prevalence and mortality and assess the economic burden on the healthcare system in Costa Rica. The main source of data is the Costa Rican Longevity and Healthy Aging Study, a longitudinal nationally representative survey of the elderly population (n = 2827). Data analyses include descriptive statistics, multiple regression models and survival analysis models. More than a fifth of Costa Rican elderly experience diabetes. Incidence is estimated at 5 per 1000 person-years in the population 30+. Gender and geographical inequalities were found. Men have a significantly lower prevalence (16.51% vs 24.02%, P < 0.05) and incidence (4.3 vs 6.0 per 1000 person-years, P < 0.05), but higher mortality (hazard ratio = 1.31, P < 0.01). Longer time to the closest facility translates into a lower probability of having the condition diagnosed [odds ratio (OR) = 0.77, P < 0.05]. The diabetic as compared to the non-diabetic population imposes a larger economic burden on the healthcare system with a higher probability of using outpatient care (OR = 3.08, P < 0.01), medications (OR = 3.44, P < 0.01) and hospitalizations (OR = 1.24, P > 0.05). Individuals living in the Metro Area have a significantly lower probability of being hospitalized (OR = 0.72, P < 0.05), which may be evidence of better access to primary care that prevents hospitalization. Along the same line, women have higher utilization rates of outpatient care (OR = 2.02, P < 0.01) and medications (OR = 1.73, P < 0.01), which may contribute to lower odds of hospitalization (OR = 0.61, P < 0.01). Aligned with the aim of attaining Sustainable Development Goals, this study highlights the importance of generating health policies focused on prevention of diabetes that take into consideration gender and geographical inequalities. Strategies should booster preventive healthcare utilization by men and aim to make healthcare services accessible to all, regardless of geographical location.
Collapse
Affiliation(s)
| | - Melina Montero-López
- Instituto de Investigaciones en Salud, Universidad de Costa Rica, San José, Costa Rica
| | - Luis Rosero-Bixby
- Centro Centroamericano de Población, Universidad de Costa Rica, San José, Costa Rica
| |
Collapse
|
11
|
Correlates of longitudinal leukocyte telomere length in the Costa Rican Longevity Study of Healthy Aging (CRELES): On the importance of DNA collection and storage procedures. PLoS One 2019; 14:e0223766. [PMID: 31603943 PMCID: PMC6788698 DOI: 10.1371/journal.pone.0223766] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/27/2019] [Indexed: 12/24/2022] Open
Abstract
The objective is to identify cofactors of leukocyte telomere length (LTL) in a Latin American population, specifically the association of LTL with 36 socio-demographic, early childhood, and health characteristics, as well as with DNA sample collection and storage procedures. The analysis is based on longitudinal information from a subsample of 1,261 individuals aged 60+ years at baseline from the Costa Rican Study of Longevity and Healthy Aging (CRELES): a nationally representative sample of elderly population. Random effects regression models for panel data were used to estimate the associations with LTL and its longitudinal changes. Sample collection procedures and DNA refrigerator storage time were strongly associated with LTL: telomeres are longer in blood collected in October-December, in DNA extracted from <1-year-old blood cells, and in DNA stored at 4°C for longer periods of time up to five years. The data confirmed that telomeres are shorter at older ages, as well as among males, and diabetic individuals, whereas telomeres are longer in the high-longevity Nicoya region. Most health, biomarkers, and early childhood indicators did not show significant associations with LTL. Longitudinal LTL variation over approximately two years was mainly associated with baseline LTL levels, as found in other studies. Our findings suggest that if there is unavoidable variability in season of sample collection and DNA storage time, these factors should be controlled for in all demographic and epidemiologic studies of LTL. However, due to unobserved components of measurement variation, statistical control may be inadequate as compared to standardization of data collection procedures.
Collapse
|
12
|
Life-course BMI and biomarkers in persons aged 60 years or older: a comparison of the USA and Costa Rica. Public Health Nutr 2018; 22:314-323. [PMID: 30306887 DOI: 10.1017/s1368980018002276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is a large literature linking current BMI to levels of cardiovascular risk biomarkers, but it is unknown whether measures of BMI earlier in the life course and maximum BMI are predictive of current levels of biomarkers. The objective of the current study was to determine how current, maximum and age-25 BMI among individuals over the age of 60 years are associated with their current levels of cardiovascular risk biomarkers. DESIGN Cross-sectional study with retrospective recall. SETTING Costa Rica (n 821) and the USA (n 4110). SUBJECTS Nationally representative samples of adults aged 60 years or over. RESULTS We used regression models to examine the relationship between multiple meaures of BMI with four established cardiovascular risk biomarkers. The most consistent predictor of current levels of systolic blood pressure, TAG and HDL-cholesterol was current BMI. However, maximum BMI was the strongest predictor of glycosylated Hb (HbA1c) and was also related to HDL-cholesterol and TAG. HbA1c was independent of current BMI. We found that these relationships are consistent between Costa Rica and the USA for HbA1c and for HDL-cholesterol. CONCLUSIONS Current levels of cardiovascular risk biomarkers are not only the product of current levels of BMI, but also of maximum lifetime BMI, particularly for levels of HbA1c and for HDL-cholesterol. Managing maximum obtained BMI over the life course may be most critical for maintaining the healthiest levels of cardiovascular risk.
Collapse
|
13
|
Goodman SM, Mandl LA, Mehta B, Navarro-Millan I, Russell LA, Parks ML, Dey SA, Crego D, Figgie MP, Nguyen JT, Szymonifka J, Zhang M, Bass AR. Does Education Level Mitigate the Effect of Poverty on Total Knee Arthroplasty Outcomes? Arthritis Care Res (Hoboken) 2018; 70:884-891. [PMID: 29164795 DOI: 10.1002/acr.23442] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 10/03/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Total knee arthroplasty (TKA) outcomes are worse for patients from poor neighborhoods, but whether education mitigates the effect of poverty is not known. We assessed the interaction between education and poverty on 2-year Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function. METHODS Patient-level variables from an institutional registry were linked to US Census Bureau data (census tract [CT] level). Statistical models including patient and CT-level variables were constructed within multilevel frameworks. Linear mixed-effects models with separate random intercepts for each CT were used to assess the interaction between education and poverty at the individual and community level on WOMAC scores. RESULTS Of 3,970 TKA patients, 2,438 (61%) had some college or more. Having no college was associated with worse pain and function at baseline and 2 years (P = 0.0001). Living in a poor neighborhood (>20% below poverty line) was associated with worse 2-year pain (P = 0.02) and function (P = 0.006). There was a strong interaction between individual education and community poverty with WOMAC scores at 2 years. Patients without college living in poor communities had pain scores that were ~10 points worse than those with some college (83.4% versus 75.7%; P < 0.0001); in wealthy communities, college was associated with a 1-point difference in pain. Function was similar. CONCLUSION In poor communities, those without college attain 2-year WOMAC scores that are 10 points worse than those with some college; education has no impact on TKA outcomes in wealthy communities. How education protects those in impoverished communities warrants further study.
Collapse
Affiliation(s)
- Susan M Goodman
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Lisa A Mandl
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Bella Mehta
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Linda A Russell
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Michael L Parks
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Shirin A Dey
- Hospital for Special Surgery, New York, New York
| | - Daisy Crego
- Hospital for Special Surgery, New York, New York
| | - Mark P Figgie
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | - Meng Zhang
- Hospital for Special Surgery, New York, New York
| | - Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| |
Collapse
|
14
|
Wang A, Arah OA. The impact of human development on individual health: a causal mediation analysis examining pathways through education and body mass index. PeerJ 2017; 5:e3053. [PMID: 28265517 PMCID: PMC5335675 DOI: 10.7717/peerj.3053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 01/31/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The macro environment we live in projects what we can achieve and how we behave, and in turn, shapes our health in complex ways. Policymaking will benefit from insights into the mechanisms underlying how national socioeconomic context affects health. This study examined the impact of human development on individual health and the possible mediating roles of education and body mass index (BMI). METHODS We analyzed World Health Survey data on 109,448 participants aged 25 or older from 42 low- and middle-income countries with augmented human development index (HDI) in 1990. We used principal components method to create a health score based on measures from eight health state domains, used years of schooling as education indicator and calculated BMI from self-reported height and weight. We used causal mediation analysis technique with random intercepts to account for the multilevel structure. RESULTS Below a reference HDI level of 0.48, HDI was negatively associated with good health (total effect at HDI of 0.23: b = - 3.44, 95% CI [-6.39--0.49] for males and b = - 5.16, 95% CI [-9.24,--1.08] for females) but was positively associated with good health above this reference level (total effect at HDI of 0.75: b = 4.16, 95% CI [-0.33-8.66] for males and b = 6.62, 95% CI [0.85-12.38] for females). We found a small positive effect of HDI on health via education across reference HDI levels (b ranging from 0.24 to 0.29 for males and 0.40 to 0.49 for females) but not via pathways involving BMI only. CONCLUSION Human development has a non-linear effect on individual health, but the impact appears to be mainly through pathways other than education and BMI.
Collapse
Affiliation(s)
- Aolin Wang
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, United States
- California Center for Population Research (CCPR), Los Angeles, CA, United States
| | - Onyebuchi A. Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, United States
- California Center for Population Research (CCPR), Los Angeles, CA, United States
- UCLA Center for Health Policy Research, Los Angeles, CA, United States
| |
Collapse
|
15
|
Harhay MN, Harhay MO, Coto-Yglesias F, Rosero Bixby L. Altitude and regional gradients in chronic kidney disease prevalence in Costa Rica: Data from the Costa Rican Longevity and Healthy Aging Study. Trop Med Int Health 2016; 21:41-51. [PMID: 26466575 PMCID: PMC4718874 DOI: 10.1111/tmi.12622] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Recent studies in Central America indicate that mortality attributable to chronic kidney disease (CKD) is rising rapidly. We sought to determine the prevalence and regional variation of CKD and the relationship of biologic and socio-economic factors to CKD risk in the older-adult population of Costa Rica. METHODS We used data from the Costa Rican Longevity and Health Aging Study (CRELES). The cohort was comprised of 2657 adults born before 1946 in Costa Rica, chosen through a sampling algorithm to represent the national population of Costa Ricans >60 years of age. Participants answered questionnaire data and completed laboratory testing. The primary outcome of this study was CKD, defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 . RESULTS The estimated prevalence of CKD for older Costa Ricans was 20% (95% CI 18.5-21.9%). In multivariable logistic regression, older age (adjusted odds ratio [aOR] 1.08 per year, 95% CI 1.07-1.10, P < 0.001) was independently associated with CKD. For every 200 m above sea level of residence, subjects' odds of CKD increased 26% (aOR 1.26 95% CI 1.15-1.38, P < 0.001). There was large regional variation in adjusted CKD prevalence, highest in Limon (40%, 95% CI 30-50%) and Guanacaste (36%, 95% CI 26-46%) provinces. Regional and altitude effects remained robust after adjustment for socio-economic status. CONCLUSIONS We observed large regional and altitude-related variations in CKD prevalence in Costa Rica, not explained by the distribution of traditional CKD risk factors. More studies are needed to explore the potential association of geographic and environmental exposures with the risk of CKD.
Collapse
Affiliation(s)
- Meera N Harhay
- Division of Nephrology, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Michael O Harhay
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando Coto-Yglesias
- Department of Geriatric Medicine, National Geriatrics and Gerontology Hospital, San José, Costa Rica
| | - Luis Rosero Bixby
- Central American Population Center, University of Costa Rica, San José, Costa Rica
- Department of Demography, University of California, Berkeley, CA, USA
| |
Collapse
|
16
|
Salazar-Villanea M, Liebmann E, Garnier-Villarreal M, Montenegro-Montenegro E, Johnson DK. Depressive Symptoms Affect Working Memory in Healthy Older Adult Hispanics. JOURNAL OF DEPRESSION & ANXIETY 2015; 4:204. [PMID: 27104091 PMCID: PMC4836854 DOI: 10.4172/2167-1044.1000204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Low and middle income nations will experience an unprecedented growth of the elderly population and subsequent increase in age-related neurological disorders. Worldwide prevalence and incidence of all-types of neurological disorders with serious mental health complications will increase with life expectancy across the globe. One-in- ten individuals over 75 has at least moderate cognitive impairment. Prevalence of cognitive impairment doubles every 5 years thereafter. Latin America's population of older adult's 65 years and older is growing rapidly, yet little is known about cognitive aging among healthy older Latinos. Clinically significant depressive symptomatology is common among community-dwelling older adults and is associated with deficits across multiple cognitive domains, however much of the literature has not modeled the unique effects of depression distinct from negative and low positive affect. Our objective was to understand how mental health affects cognitive health in healthy aging Latinos. METHODS The present study used confirmatory factor analysis (CFA) and structural equation modeling (SEM) to examine the relative effects of Negative Affect, Positive Affect and Geriatric Depression on Verbal Memory, Verbal Reasoning, Processing Speed, and Working Memory in healthy aging Latinos. Data was collected from a sample of healthy community dwelling older adults living in San Jose, Costa Rica. Modeling of latent variables attenuated error and improved measurement reliability of cognition, affect, and depression variables. RESULTS Costa Ricans enjoy a notoriety for being much happier than US citizens and are renowned as one of the happiest nations in the world in global surveys. This was born out in these data. Costa Rican affective profiles differed substantively from US profiles. Levels of negative affect and depression were similar to US samples, but their levels of positive affect were much higher. Cognitive performance of these Costa Rican older adults was similar to US-age and education matched peers. CFA and SEM found that increased depressive symptomatology had deleterious effects on Working Memory made up of subtest scores sampling simple attention and vigilance for numbers. Verbal Memory, Verbal Reasoning, and Processing Speed were not affected by self-reported Positive Affect, Negative Affect or Depressive symptoms. CONCLUSION Costa Rican older adults were happy, as evidenced by the high ratio of positive affect to relatively low negative affect. Thus, we were somewhat surprised to find that depressive symptoms were selectively correlated to decrements in working memory and that negative and positive affect contributed negligible amounts of variance to any of the cognitive factors. Because of the methodological rigor of latent variable analysis, these results are very specific. The Working Memory factor is not contaminated with Speed of Processing or other measured cognitive factors. Likewise, the measured Geriatric Depression represents symptoms that are richly cognitive, not overtly affective.
Collapse
|
17
|
Dupre ME, Silberberg M, Willis JM, Feinglos MN. Education, glucose control, and mortality risks among U.S. older adults with diabetes. Diabetes Res Clin Pract 2015; 107:392-9. [PMID: 25649910 DOI: 10.1016/j.diabres.2014.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/09/2014] [Accepted: 12/26/2014] [Indexed: 10/24/2022]
Abstract
AIMS Studies have shown that diabetes mellitus disproportionately afflicts persons of low socioeconomic status and that the burden of disease is greatest among the disadvantaged. However, our understanding of educational differences in the control of diabetes and its impact on survival is limited. This study investigated the associations among education, hemoglobin A1c (HbA1c), and subsequent mortality in adults with diabetes. METHODS Prospective cohort data from the 2006, 2008, and 2010 Health and Retirement Study were linked with biomarker data for U.S. older adults with diabetes (n=3312). Weighted distributions were estimated for all subjects at baseline and by the American Diabetes Association's general guidelines for HbA1c control (<7.0% [53 mmol/mol] vs. ≥7.0% [53 mmol/mol]). Proportional hazard models were used to estimate educational differences in all-cause mortality by HbA1c level with sequential adjustments for contributing risk factors. RESULTS Mortality risks associated with HbA1c≥7.0% [53 mmol/mol] were significantly greater in lower-educated adults than higher-educated adults (P<0.001). We found that the hazard ratios (HR) associated with HbA1c ≥7.0% [53 mmol/mol] were highest among low-educated adults (HR=2.18, 95% CI: 1.62, 2.94) and that a combination of socioeconomic, psychosocial, and behavioral factors accounted for most, but not all, of the associations. CONCLUSIONS Educational differences in HbA1c control have significant implications for mortality and efforts to reduce these disparities should involve more vigilant screening and monitoring of lower-educated adults with diabetes.
Collapse
Affiliation(s)
- Matthew E Dupre
- Duke Clinical Research Institute, Duke University, Durham, NC, USA; Department of Community and Family Medicine, Division of Community Health, Duke University, Durham, NC, USA; Department of Sociology, Duke University, Durham, NC, USA.
| | - Mina Silberberg
- Department of Community and Family Medicine, Division of Community Health, Duke University, Durham, NC, USA
| | - Janese M Willis
- Department of Community and Family Medicine, Division of Community Health, Duke University, Durham, NC, USA
| | - Mark N Feinglos
- Department of Medicine, Division of Endocrinology, Metabolism, and Nutrition, Duke University, Durham, NC, USA
| |
Collapse
|
18
|
Domino ME, Dow WH, Coto-Yglesias F. Educational gradients in psychotropic medication use among older adults in Costa Rica and the United States. Psychiatr Serv 2014; 65:1218-25. [PMID: 24932755 PMCID: PMC4183704 DOI: 10.1176/appi.ps.201300092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The relationship of education, psychiatric diagnoses, and use of psychotropic medication has been explored in the United States, but little is known about this relationship in poorer countries, despite the high burden of mental illness in these countries. This study estimated educational gradients in diagnosis and psychotropic drug use in the United States and Costa Rica, a middle-income country with universal health insurance. METHODS Analyses were conducted by using data of older adults (≥60) from the 2005 U.S. Medical Expenditure Panel Survey (N=4,788) and the 2005 Costa Rican Longevity and Healthy Aging Study (N=2,827). Logistic regressions examined the effect of education level (low, medium, or high) and urban residence on the rates of self-reported mental health diagnoses, screening diagnosis, and psychotropic medication use with and without an associated psychiatric diagnosis. RESULTS Rates of self-reported diagnoses were lower in the United States (12%) than in Costa Rica (20%), possibly reflecting differences in survey wording. In both countries, the odds of having depression were significantly lower among persons with high education. In Costa Rica, use of psychotropic medication among persons with self-reported diagnoses increased by education level. CONCLUSIONS The educational gradients in medication use were different in the United States and Costa Rica, and stigma and access to care in these countries may play an important role in these differences, although type of insurance did not affect educational gradients in the United States. These analyses increase the evidence of the role of education in use of the health care system.
Collapse
|
19
|
Rehkopf DH, Dow WH, Rosero-Bixby L, Lin J, Epel ES, Blackburn EH. Longer leukocyte telomere length in Costa Rica's Nicoya Peninsula: a population-based study. Exp Gerontol 2013; 48:1266-73. [PMID: 23988653 PMCID: PMC3819141 DOI: 10.1016/j.exger.2013.08.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 08/01/2013] [Accepted: 08/13/2013] [Indexed: 12/13/2022]
Abstract
Studies in humans suggest that leukocyte telomere length may act as a marker of biological aging. We investigated whether individuals in the Nicoya region of Costa Rica, known for exceptional longevity, had longer telomere length than those in other parts of the country. After controlling for age, age squared, rurality, rainy season and gender, the mean leukocyte telomere length in Nicoya was substantially longer (81 base pairs, p<0.05) than in other areas of Costa Rica, providing evidence of a biological pathway to which this notable longevity may be related. This relationship remains unchanged (79 base pairs, p<0.05) after statistically controlling for nineteen potential biological, dietary and social and demographic mediators. Thus the difference in the mean leukocyte telomere length that characterizes this unique region does not appear to be explainable by traditional behavioral and biological risk factors. More detailed examination of mean leukocyte telomere length by age shows that the regional telomere length difference declines at older ages.
Collapse
Affiliation(s)
- David H Rehkopf
- Department of Medicine, Stanford University, Stanford, CA 94305, United States.
| | | | | | | | | | | |
Collapse
|
20
|
van der Kooi ALF, Stronks K, Thompson CA, DerSarkissian M, Arah OA. The modifying influence of country development on the effect of individual educational attainment on self-rated health. Am J Public Health 2013; 103:e49-54. [PMID: 24028233 DOI: 10.2105/ajph.2013.301593] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES We investigated how much the Human Development Index (HDI), a global measure of development, modifies the effect of education on self-reported health. METHODS We analyzed cross-sectional World Health Survey data on 217,642 individuals from 49 countries, collected in 2002 to 2005, with random-intercept multilevel linear regression models. RESULTS We observed greater positive associations between educational levels and self-reported good health with increasing HDI. The magnitude of this effect modification of the education-health relation tended to increase with educational attainment. For example, before adjustment for effect modification, at comparable HDI, on average, finishing primary school was associated with better general health (b = 1.49; 95% confidence interval [CI] = 1.18, 1.80). With adjustment for effect modification by HDI, the impact became 4.63 (95% CI = 3.63, 5.62) for every 0.1 increase in HDI. Among those who completed high school, these associations were, respectively, 5.59 (95% CI = 5.20, 5.98) and 9.95 (95% CI = 8.89, 11.00). CONCLUSIONS The health benefits of educational attainment are greater in countries with greater human development. Health inequalities attributable to education are, therefore, larger in more developed countries.
Collapse
Affiliation(s)
- Anne L F van der Kooi
- Anne L. F. van der Kooi, Caroline A. Thompson, Maral DerSarkissian, and Onyebuchi A. Arah are with the Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles. Anne-Lotte van der Kooi and Onyebuchi A. Arah are also with and Karien Stronks is with the Department of Public Health, Academic Medical Center, University of Amsterdam, Netherlands
| | | | | | | | | |
Collapse
|
21
|
Rastrelli G, Corona G, Fisher AD, Silverii A, Mannucci E, Maggi M. Two Unconventional Risk Factors for Major Adverse Cardiovascular Events in Subjects with Sexual Dysfunction: Low Education and Reported Partner's Hypoactive Sexual Desire in Comparison with Conventional Risk Factors. J Sex Med 2012; 9:3227-38. [DOI: 10.1111/j.1743-6109.2012.02947.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
22
|
Hosseinpoor AR, Bergen N, Kunst A, Harper S, Guthold R, Rekve D, d'Espaignet ET, Naidoo N, Chatterji S. Socioeconomic inequalities in risk factors for non communicable diseases in low-income and middle-income countries: results from the World Health Survey. BMC Public Health 2012; 12:912. [PMID: 23102008 PMCID: PMC3507902 DOI: 10.1186/1471-2458-12-912] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 10/22/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Monitoring inequalities in non communicable disease risk factor prevalence can help to inform and target effective interventions. The prevalence of current daily smoking, low fruit and vegetable consumption, physical inactivity, and heavy episodic alcohol drinking were quantified and compared across wealth and education levels in low- and middle-income country groups. METHODS This study included self-reported data from 232,056 adult participants in 48 countries, derived from the 2002-2004 World Health Survey. Data were stratified by sex and low- or middle-income country status. The main outcome measurements were risk factor prevalence rates reported by wealth quintile and five levels of educational attainment. Socioeconomic inequalities were measured using the slope index of inequality, reflecting differences in prevalence rates, and the relative index of inequality, reflecting the prevalence ratio between the two extremes of wealth or education accounting for the entire distribution. Data were adjusted for confounding factors: sex, age, marital status, area of residence, and country of residence. RESULTS Smoking and low fruit and vegetable consumption were significantly higher among lower socioeconomic groups. The highest wealth-related absolute inequality was seen in smoking among men of low- income country group (slope index of inequality 23.0 percentage points; 95% confidence interval 19.6, 26.4). The slope index of inequality for low fruit and vegetable consumption across the entire distribution of education was around 8 percentage points in both sexes and both country income groups. Physical inactivity was less prevalent in populations of low socioeconomic status, especially in low-income countries (relative index of inequality: (men) 0.46, 95% confidence interval 0.33, 0.64; (women) 0.52, 95% confidence interval 0.42, 0.65). Mixed patterns were found for heavy drinking. CONCLUSIONS Disaggregated analysis of the prevalence of non-communicable disease risk factors demonstrated different patterns and varying degrees of socioeconomic inequalities across low- and middle-income settings. Interventions should aim to reach and achieve sustained benefits for high-risk populations.
Collapse
Affiliation(s)
- Ahmad Reza Hosseinpoor
- Department of Health Statistics and Information Systems, World Health Organization, 20, Avenue Appia, Geneva, CH-1211, Switzerland
| | - Nicole Bergen
- Department of Health Statistics and Information Systems, World Health Organization, 20, Avenue Appia, Geneva, CH-1211, Switzerland
| | - Anton Kunst
- Department of Public Health, AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sam Harper
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
| | - Regina Guthold
- Department of Chronic Diseases and Health Promotion, World Health Organization, Geneva, Switzerland
| | - Dag Rekve
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | | | - Nirmala Naidoo
- Department of Health Statistics and Information Systems, World Health Organization, 20, Avenue Appia, Geneva, CH-1211, Switzerland
| | - Somnath Chatterji
- Department of Health Statistics and Information Systems, World Health Organization, 20, Avenue Appia, Geneva, CH-1211, Switzerland
| |
Collapse
|
23
|
Rosero-Bixby L, Dow WH. Predicting mortality with biomarkers: a population-based prospective cohort study for elderly Costa Ricans. Popul Health Metr 2012; 10:11. [PMID: 22694922 PMCID: PMC3507767 DOI: 10.1186/1478-7954-10-11] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 05/22/2012] [Indexed: 01/26/2023] Open
Abstract
Background Little is known about adult health and mortality relationships outside high-income nations, partly because few datasets have contained biomarker data in representative populations. Our objective is to determine the prognostic value of biomarkers with respect to total and cardiovascular mortality in an elderly population of a middle-income country, as well as the extent to which they mediate the effects of age and sex on mortality. Methods This is a prospective population-based study in a nationally representative sample of elderly Costa Ricans. Baseline interviews occurred mostly in 2005 and mortality follow-up went through December 2010. Sample size after excluding observations with missing values: 2,313 individuals and 564 deaths. Main outcome: prospective death rate ratios for 22 baseline biomarkers, which were estimated with hazard regression models. Results Biomarkers significantly predict future death above and beyond demographic and self-reported health conditions. The studied biomarkers account for almost half of the effect of age on mortality. However, the sex gap in mortality became several times wider after controlling for biomarkers. The most powerful predictors were simple physical tests: handgrip strength, pulmonary peak flow, and walking speed. Three blood tests also predicted prospective mortality: C-reactive protein (CRP), glycated hemoglobin (HbA1c), and dehydroepiandrosterone sulfate (DHEAS). Strikingly, high blood pressure (BP) and high total cholesterol showed little or no predictive power. Anthropometric measures also failed to show significant mortality effects. Conclusions This study adds to the growing evidence that blood markers for CRP, HbA1c, and DHEAS, along with organ-specific functional reserve indicators (handgrip, walking speed, and pulmonary peak flow), are valuable tools for identifying vulnerable elderly. The results also highlight the need to better understand an anomaly noted previously in other settings: despite the continued medical focus on drugs for BP and cholesterol, high levels of BP and cholesterol have little predictive value of mortality in this elderly population.
Collapse
Affiliation(s)
- Luis Rosero-Bixby
- University of California at Berkeley, School of Public Health, 239 University Hall, #7360, Berkeley, CA, 94720-7360, USA.
| | | |
Collapse
|
24
|
Mattei J, Malik V, Hu FB, Campos H. Substituting homemade fruit juice for sugar-sweetened beverages is associated with lower odds of metabolic syndrome among Hispanic adults. J Nutr 2012; 142:1081-7. [PMID: 22551801 PMCID: PMC3349979 DOI: 10.3945/jn.111.149344] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Consumption of sugar-sweetened beverages (SSB) has been associated with metabolic syndrome (MetS); however, studies conducted on Hispanic adults are scarce. To determine the association between beverages consumed by Hispanic adults and MetS and its components, data were analyzed in 1872 Costa Rican adults who served as controls of a population-based, case-control study of coronary heart disease. Multivariate-adjusted means were calculated for components of MetS by servings (never, ≤ 1/wk; 2-6/wk, ≥ 1/d) of 2 traditional fruit-based beverages ("fresco" and freshly-squeezed homemade fruit juice, separately) and 2 SSB (instant drinks and regular sodas, separately and combined). The prevalence ratio (PR) of MetS was calculated for each beverage and the OR was calculated by substituting one serving of homemade fruit juice or water for one of SSB. Significant positive trends were observed for increasing servings of instant drinks with plasma TG and waist circumference and for regular soda with waist circumference (all P-trend < 0.001). Increasing servings of homemade fruit juice were positively associated with HDL cholesterol (P-trend = 0.033). Consuming ≥1 serving/d of instant drinks was associated with a higher PR of MetS [1.42 (95% CI: 1.11, 1.83)] compared with no consumption. Substituting one serving of homemade fruit juice for instant drink was associated with 29% (95% CI: 7, 47%) lower odds of MetS and for regular soda with 30% (95% CI: 1, 50%) lower odds. Substituting water for combined SSB was marginally significant (OR = 0.86 (95% CI: 0.74, 1.00). In conclusion, reducing the consumption of SSB and substituting them with homemade fruit juices in moderation may be a culturally appropriate approach to lower MetS among Hispanic adults.
Collapse
Affiliation(s)
- Josiemer Mattei
- Department of Nutrition, Harvard School of Public Health, Boston, MA
| | - Vasanti Malik
- Department of Nutrition, Harvard School of Public Health, Boston, MA
| | - Frank B. Hu
- Department of Nutrition, Harvard School of Public Health, Boston, MA,Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Hannia Campos
- Department of Nutrition, Harvard School of Public Health, Boston, MA,To whom correspondence should be addressed. E-mail:
| |
Collapse
|
25
|
Ernstsen L, Strand BH, Nilsen SM, Espnes GA, Krokstad S. Trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors: repeated cross-sectional surveys from the Nord-Trøndelag Health Study (HUNT) 1984-2008. BMC Public Health 2012; 12:266. [PMID: 22471945 PMCID: PMC3434116 DOI: 10.1186/1471-2458-12-266] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 04/03/2012] [Indexed: 12/18/2022] Open
Abstract
Background There has been an overall decrease in incident ischaemic heart disease (IHD), but the reduction in IHD risk factors has been greater among those with higher social position. Increased social inequalities in IHD mortality in Scandinavian countries is often referred to as the Scandinavian “public health puzzle”. The objective of this study was to examine trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors (smoking, diabetes, hypertension and high total cholesterol) over the last three decades among Norwegian middle-aged women and men. Methods Population-based, cross-sectional data from The Nord-Trøndelag Health Study (HUNT): HUNT 1 (1984–1986), HUNT 2 (1995–1997) and HUNT 3 (2006–2008), women and men 40–59 years old. Educational inequalities were assessed using the Slope Index of Inequality (SII) and The Relative Index of Inequality (RII). Results Smoking prevalence increased for all education groups among women and decreased in men. Relative and absolute educational inequalities in smoking widened in both genders, with significantly higher absolute inequalities among women than men in the two last surveys. Diabetes prevalence increased in all groups. Relative inequalities in diabetes were stable, while absolute inequalities increased both among women (p = 0.05) and among men (p = 0.01). Hypertension prevalence decreased in all groups. Relative inequalities in hypertension widened over time in both genders. However, absolute inequalities in hypertension decreased among women (p = 0.05) and were stable among men (p = 0.33). For high total cholesterol relative and absolute inequalities remained stable in both genders. Conclusion Widening absolute educational inequalities in smoking and diabetes over the last three decades gives rise to concern. The mechanisms behind these results are less clear, and future studies are needed to assess if educational inequalities in secondary prevention of IHD are larger compared to educational inequalities in primary prevention of IHD. Continued monitoring of IHD risk factors at the population level is therefore warranted. The results emphasise the need for public health efforts to prevent future burdens of life-style-related diseases and to avoid further widening in socioeconomic inequalities in IHD mortality in Norway, especially among women.
Collapse
Affiliation(s)
- Linda Ernstsen
- Sør-Trøndelag University College, Mauritz Hansens gt 2, 7004, Trondheim, Norway.
| | | | | | | | | |
Collapse
|
26
|
Goldman N, Turra CM, Rosero-Bixby L, Weir D, Crimmins E. Do biological measures mediate the relationship between education and health: A comparative study. Soc Sci Med 2011; 72:307-15. [PMID: 21159415 PMCID: PMC3039215 DOI: 10.1016/j.socscimed.2010.11.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 09/23/2010] [Accepted: 11/02/2010] [Indexed: 11/28/2022]
Abstract
Despite a myriad of studies examining the relationship between socioeconomic status and health outcomes, few have assessed the extent to which biological markers of chronic disease account for social disparities in health. Studies that have examined this issue have generally been based on surveys in wealthy countries that include a small set of clinical markers of cardiovascular disease. The availability of recent data from nationally representative surveys of older adults in Costa Rica and Taiwan that collected a rich set of biomarkers comparable to those in a recent US survey permits us to explore these associations across diverse populations. Similar regression models were estimated on three data sets - the Social Environment and Biomarkers of Aging Study in Taiwan, the Costa Rican Study on Longevity and Healthy Aging, and the Health and Retirement Study in the USA - in order to assess (1) the strength of the associations between educational attainment and a broad range of biomarkers; and (2) the extent to which these biomarkers account for the relationships between education and two measures of health status (self-rated health, functional limitations) in older populations. The estimates suggest non-systematic and weak associations between education and high risk biomarker values in Taiwan and Costa Rica, in contrast to generally negative and significant associations in the US, especially among women. The results also reveal negligible or modest contributions of the biomarkers to educational disparities in the health outcomes. The findings are generally consistent with previous research suggesting stronger associations between socioeconomic status and health in wealthy countries than in middle-income countries and may reflect higher levels of social stratification in the US. With access to an increasing number of longitudinal biosocial surveys, researchers may be better able to distinguish true variations in the relationship between socioeconomic status and health across different settings from methodological differences.
Collapse
Affiliation(s)
- Noreen Goldman
- Office of Population Research, Princeton University, 243 Wallace Hall, Princeton, NJ 08544, USA.
| | | | | | | | | |
Collapse
|