Geographic variation in the onset of decline of ischemic heart disease mortality in the United States

Birth in the U.S. Plantation South and Racial Differences in all-cause mortality in later life

The American South has been characterized as a Stroke Belt due to high cardiovascular mortality. We examine whether mortality rates and race differences in rates reflect birthplace exposure to Jim Crow-era inequalities associated with the Plantation South. The plantation mode of agricultural production was widespread through the 1950s when older adults of today, if exposed, were children. We use proportional hazards models to estimate all-cause mortality in Non-Hispanic Black and White birth cohorts (1920-1954) in a sample (N = 21,941) drawn from REasons for Geographic and Racial Differences in Stroke (REGARDS), a national study designed to investigate Stroke Belt risk. We link REGARDS data to two U.S. Plantation Censuses (1916, 1948) to develop county-level measures that capture the geographic overlap between the Stroke Belt, two subregions of the Plantation South, and a non-Plantation South subregion. Additionally, we examine the life course timing of geographic exposure: at birth, adulthood (survey enrollment baseline), neither, or both portions of life. We find mortality hazard rates higher for Black compared to White participants, regardless of birthplace, and for the southern-born compared to those not southern-born, regardless of race. Race-specific models adjusting for adult Stroke Belt residence find birthplace-mortality associations fully attenuated among White-except in one of two Plantation South subregions-but not among Black participants. Mortality hazard rates are highest among Black and White participants born in this one Plantation South subregion. The Black-White mortality differential is largest in this birthplace subregion as well. In this subregion, the legacy of pre-Civil War plantation production under enslavement was followed by high-productivity plantation farming under the southern Sharecropping System.

The where of when: Geographic variation in the timing of recent increases in US county-level heart disease death rates

PURPOSE

Within the context of local increases in US heart disease death rates, we estimated when increasing heart disease death rates began by county among adults aged 35-64 years and characterized geographic variation.

METHODS

We applied Bayesian spatiotemporal models to vital statistics data to estimate the timing (i.e., the year) of increasing county-level heart disease death rates during 1999-2019 among adults aged 35-64 years. To examine geographic variation, we stratified results by US Census region and urban-rural classification.

RESULTS

The onset of increasing heart disease death rates among adults aged 35-64 years spanned the two-decade study period from 1999 to 2019. Overall, 43.5% (95% CI: 41.3, 45.6) of counties began increasing before 2011, with early increases more prevalent outside of the most urban counties and outside of the Northeast. Roughly one-in-five (18.4% [95% CI: 15.6, 20.7]) counties continued to decline throughout the study period.

CONCLUSIONS

This variation suggests that factors associated with these geographic classifications may be critical in establishing the timing of changing trends in heart disease death rates. These results reinforce the importance of spatiotemporal surveillance in the early identification of adverse trends and in informing opportunities for tailored policies and programs.

Declining Life Expectancy in the United States: Missing the Trees for the Forest

In recent years, life expectancy in the United States has stagnated, followed by three consecutive years of decline. The decline is small in absolute terms but is unprecedented and has generated considerable research interest and theorizing about potential causes. Recent trends show that the decline has affected nearly all race/ethnic and gender groups, and the proximate causes of the decline are increases in opioid overdose deaths, suicide, homicide, and Alzheimer's disease. A slowdown in the long-term decline in mortality from cardiovascular diseases has also prevented life expectancy from improving further. Although a popular explanation for the decline is the cumulative decline in living standards across generations, recent trends suggest that distinct mechanisms for specific causes of death are more plausible explanations. Interventions to stem the increase in overdose deaths, reduce access to mechanisms that contribute to violent deaths, and decrease cardiovascular risk over the life course are urgently needed to improve mortality in the United States.

US trends in premature heart disease mortality over the past 50 years: Where do we go from here?

Despite the premature heart disease mortality rate among adults aged 25-64 decreasing by 70% since 1968, the rate has remained stagnant from 2011 on and, in 2017, still accounted for almost 1-in-5 of all deaths among this age group. Moreover, these overall findings mask important differences and continued disparities observed by demographic characteristics and geography. For example, in 2017, rates were 134% higher among men compared to women and 87% higher among blacks compared to whites, and, while the greatest burden remained in the southeastern US, almost two-thirds of all US counties experienced increasing rates among adults aged 35-64 during 2010-2017. Continued high rates of uncontrolled blood pressure and increasing prevalence of diabetes and obesity pose obstacles for re-establishing a downward trajectory for premature heart disease mortality; however, proven public health and clinical interventions exist that can be used to address these conditions.

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.

Invited Commentary: The Enduring Role of "Place" in Health-A Historic Perspective

In public health, it has long been observed that "place"-specifically, where one lives-affects individual health, with the main research question distinguishing between the effects of "context" (defined as area characteristics) and "composition" (the characteristics of inhabitants) on health outcomes. There have been many studies in which the spatial patterning of disease has been explored, but they were often ecological in design, used broad census geographic levels, lacked individual-level data, or when available, did not simultaneously analyze community- and individual-level risk factors using appropriate modeling techniques. The paper by Diez-Roux et al. (Am J Epidemiol. 1997;146(1):48-63) represents an important expansion of the literature in terms of analytic methods used and level of geography studied. The authors demonstrated that both neighborhood- and individual-level measures of socioeconomic status work together to play an important role in shaping disease risk. Analyses incorporating both levels of data have the potential to provide epidemiologists with a deeper understanding of the divergent pathways via which neighborhood affects health.

Trends and Patterns of Geographic Variation in Cardiovascular Mortality Among US Counties, 1980-2014

IMPORTANCE

In the United States, regional variation in cardiovascular mortality is well-known but county-level estimates for all major cardiovascular conditions have not been produced.

OBJECTIVE

To estimate age-standardized mortality rates from cardiovascular diseases by county.

DESIGN AND SETTING

Deidentified death records from the National Center for Health Statistics and population counts from the US Census Bureau, the National Center for Health Statistics, and the Human Mortality Database from 1980 through 2014 were used. Validated small area estimation models were used to estimate county-level mortality rates from all cardiovascular diseases, including ischemic heart disease, cerebrovascular disease, ischemic stroke, hemorrhagic stroke, hypertensive heart disease, cardiomyopathy, atrial fibrillation and flutter, rheumatic heart disease, aortic aneurysm, peripheral arterial disease, endocarditis, and all other cardiovascular diseases combined.

EXPOSURES

The 3110 counties of residence.

MAIN OUTCOMES AND MEASURES

Age-standardized cardiovascular disease mortality rates by county, year, sex, and cause.

RESULTS

From 1980 to 2014, cardiovascular diseases were the leading cause of death in the United States, although the mortality rate declined from 507.4 deaths per 100 000 persons in 1980 to 252.7 deaths per 100 000 persons in 2014, a relative decline of 50.2% (95% uncertainty interval [UI], 49.5%-50.8%). In 2014, cardiovascular diseases accounted for more than 846 000 deaths (95% UI, 827-865 thousand deaths) and 11.7 million years of life lost (95% UI, 11.6-11.9 million years of life lost). The gap in age-standardized cardiovascular disease mortality rates between counties at the 10th and 90th percentile declined 14.6% from 172.1 deaths per 100 000 persons in 1980 to 147.0 deaths per 100 000 persons in 2014 (posterior probability of decline >99.9%). In 2014, the ratio between counties at the 90th and 10th percentile was 2.0 for ischemic heart disease (119.1 vs 235.7 deaths per 100 000 persons) and 1.7 for cerebrovascular disease (40.3 vs 68.1 deaths per 100 000 persons). For other cardiovascular disease causes, the ratio ranged from 1.4 (aortic aneurysm: 3.5 vs 5.1 deaths per 100 000 persons) to 4.2 (hypertensive heart disease: 4.3 vs 17.9 deaths per 100 000 persons). The largest concentration of counties with high cardiovascular disease mortality extended from southeastern Oklahoma along the Mississippi River Valley to eastern Kentucky. Several cardiovascular disease conditions were clustered substantially outside the South, including atrial fibrillation (Northwest), aortic aneurysm (Midwest), and endocarditis (Mountain West and Alaska). The lowest cardiovascular mortality rates were found in the counties surrounding San Francisco, California, central Colorado, northern Nebraska, central Minnesota, northeastern Virginia, and southern Florida.

CONCLUSIONS AND RELEVANCE

Substantial differences exist between county ischemic heart disease and stroke mortality rates. Smaller differences exist for diseases of the myocardium, atrial fibrillation, aortic and peripheral arterial disease, rheumatic heart disease, and endocarditis.

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.

Comparing methods of measuring geographic patterns in temporal trends: an application to county-level heart disease mortality in the United States, 1973 to 2010

PURPOSE

To demonstrate the implications of choosing analytical methods for quantifying spatiotemporal trends, we compare the assumptions, implementation, and outcomes of popular methods using county-level heart disease mortality in the United States between 1973 and 2010.

METHODS

We applied four regression-based approaches (joinpoint regression, both aspatial and spatial generalized linear mixed models, and Bayesian space-time model) and compared resulting inferences for geographic patterns of local estimates of annual percent change and associated uncertainty.

RESULTS

The average local percent change in heart disease mortality from each method was -4.5%, with the Bayesian model having the smallest range of values. The associated uncertainty in percent change differed markedly across the methods, with the Bayesian space-time model producing the narrowest range of variance (0.0-0.8). The geographic pattern of percent change was consistent across methods with smaller declines in the South Central United States and larger declines in the Northeast and Midwest. However, the geographic patterns of uncertainty differed markedly between methods.

CONCLUSIONS

The similarity of results, including geographic patterns, for magnitude of percent change across these methods validates the underlying spatial pattern of declines in heart disease mortality. However, marked differences in degree of uncertainty indicate that Bayesian modeling offers substantially more precise estimates.

Urban, rural, and regional variations in physical activity

PURPOSE

There is some speculation about geographic differences in physical activity (PA) levels. We examined the prevalence of physical inactivity (PIA) and whether U.S. citizens met the recommended levels of PA across the United States. In addition, the association between PIA/PA and degree of urbanization in the 4 main U.S. regions (Northeast, Midwest, South, and West) was determined.

METHODS

Participants were 178,161 respondents to the 2000 Behavioral Risk Factor Surveillance System (BRFSS). Data from 49 states and the District of Columbia were included (excluding Alaska). States were categorized by urban status according to the U.S. Department of Agriculture. Physical activity variables were those commonly used in national surveillance systems (PIA = no leisure-time PA; and PA = meeting a PA recommendation).

RESULTS

Nationally, PA levels were higher in urban areas than in rural areas; correspondingly, PIA levels were higher in rural areas than in urban areas. Regionally, the urban-rural differences were most striking in the South and were, in fact, often absent in other regions. Demographic factors appeared to modify the association.

CONCLUSION

The association between PA and degree of urbanization is evident and robust in the South but cannot be generalized to all regions of the United States. For the most part, the Midwest and the Northeast do not experience any relationship between PA and urbanization, whereas, in the West, the trend appears to be opposite of that observed in the South.

Life-course socioeconomic position, area deprivation, and coronary heart disease: findings from the British Women's Heart and Health Study

OBJECTIVES

We sought to determine whether residential area deprivation, over and above the effect of life-course socioeconomic status or position (SEP), is associated with coronary heart disease.

METHODS

We conducted a cross-sectional analysis of 4286 women aged 60 to 79 years from 457 British electoral wards.

RESULTS

After adjustment for age and 10 indicators of individual life-course SEP, the odds of coronary heart disease was 27% greater among those living in wards with a deprivation score above the median compared with those living in a ward with a deprivation score equal to or below the median (odds ratio=1.27; 95% confidence interval=1.02, 1.57).

CONCLUSIONS

Adverse area-level socioeconomic characteristics, over and above individual life-course SEP, are associated with increased coronary heart disease.

Spanish flu and early 20th-century expansion of a coronary heart disease-prone subpopulation

According to Stephen Jay Gould, "we have a strong preference for seeing trends as entities moving somewhere." However, trends may instead be the product of relative expansions and contractions of different subpopulations constituting the system. Variation in attributes of coronary heart disease cases during the decline in coronary heart disease mortality suggests a change in the primary source-subpopulation of cases over time. It is proposed that an early 20th-century expansion of a coronary heart disease-prone subpopulation, characterized by high serum-cholesterol phenotype and high case-fatality--which contributed to most of the coronary heart disease cases and deaths during the 1960s--may have been a late result of the 1918 influenza pandemic. The same unusual immune response to infection that in 1918 killed preferentially men, whites, and those born from 1880 to 1900 (20-40 years old) may have "primed" survivors of those birth cohorts to late coronary heart disease mortality. Ecologic evidence in favor of a birth cohort and geographic association between both epidemics is presented. Cross-reactive auto-immune response upon reinfection could explain the excess coronary heart disease deaths reported during influenza epidemics from the late 1920s onward. Mimicry between the viral hemagglutinin and the apolipoprotein B or the low-density lipoprotein receptor could be the link between infection and hypercholesterolemia. The extinction of those birth cohorts would result in a relative increase in cases coming from a 2nd subpopulation, which was characterized by insulin resistance and chronic expression of low-grade inflammation markers and was comparatively less vulnerable to die acutely from coronary heart disease.

Global burden of cardiovascular diseases: Part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies

This two-part article provides an overview of the global burden of atherothrombotic cardiovascular disease. Part I initially discusses the epidemiological transition which has resulted in a decrease in deaths in childhood due to infections, with a concomitant increase in cardiovascular and other chronic diseases; and then provides estimates of the burden of cardiovascular (CV) diseases with specific focus on the developing countries. Next, we summarize key information on risk factors for cardiovascular disease (CVD) and indicate that their importance may have been underestimated. Then, we describe overarching factors influencing variations in CVD by ethnicity and region and the influence of urbanization. Part II of this article describes the burden of CV disease by specific region or ethnic group, the risk factors of importance, and possible strategies for prevention.

Local increases in coronary heart disease mortality among blacks and whites in the United States, 1985-1995

OBJECTIVES

This study analyzed coronary heart disease (CHD) mortality trends from 1985 to 1995, by race and sex, among Black and White adults 35 years and older to determine whether adverse trends were evident in any US localities.

METHODS

Log-linear regression models of annual age-adjusted death rates provided a quantitative measure of local mortality trends.

RESULTS

Increasing trends in CHD mortality were observed in 11 of 174 labor market areas for Black women, 23 of 175 areas for Black men, 10 of 394 areas for White women, and 4 of 394 areas for White men. Nationwide, adverse trends affected 1.7% of Black women, 8.0% of Black men, 1.1% of White women, and 0.3% of White men.

CONCLUSIONS

From 1985 to 1995, moderate to strong local increases in CHD mortality were observed, predominantly in the southern United States. Black men evidenced the most unfavorable trends and were 25 times as likely as White men to be part of a local population experiencing increases in coronary heart disease mortality.

Metropolitan and non-metropolitan trends in coronary heart disease mortality within Appalachia, 1980-1997

OBJECTIVES

In this article, we report on metropolitan and non-metropolitan trends in coronary heart disease (CHD) mortality within the Appalachian Region for the period 1980 to 1997. We hypothesized that trends in CHD mortality would be less favorable in non-metropolitan populations with diminished access to social, economic, and medical care resources at the community level.

METHODS

Our study population consisted of adults aged 35 years and older who resided within the 399 counties of the Appalachian Region between 1980 and 1997. We examined mortality trends for sixteen geo-demographic groups, defined by gender, age, race, and metropolitan status of county of residence. For each geo-demographic group, we calculated annual age-adjusted CHD mortality rates. Line graphs of these temporal trends were created, and log-linear regression models provided estimates of the average annual percent change in CHD mortality from 1980 to 1997. Data on social, economic, and medical care resources for metropolitan vs. non-metropolitan counties were also analyzed.

RESULTS

Rates of CHD mortality were consistently higher in non-metropolitan areas compared with metropolitan areas for blacks of all ages and for younger whites. CHD mortality declined among almost all geo-demographic groups, but rates of decline were slower among non-metropolitan vs. metropolitan residents, blacks vs. whites, women vs. men, and older vs. younger adults. Non-metropolitan areas had fewer socioeconomic and medical care resources than metropolitan areas in 1990.

CONCLUSIONS

Appalachia, particularly non-metropolitan Appalachia, needs policies and programs that will enhance both primary and secondary prevention of CHD, and help diminish racial inequalities in CHD mortality trends.

Disparities in premature coronary heart disease mortality by region and urbanicity among black and white adults ages 35-64, 1985-1995

OBJECTIVES

Regional and urban-rural disparities in premature coronary heart disease (CHD) mortality were evident in the US as early as 1950. Recent favorable trends at the national level may obscure less favorable outcomes for certain regions and localities. The authors examined trends in premature CHD mortality for 1985-1995 for black and white adults ages 35-64 years for four categories of urbanicity in two regions of the US (South and non-South).

METHODS

All counties in the US (excluding Alaskan counties) were grouped by urbanicity and region. Annual age-adjusted CHD mortality rates were calculated for adults ages 35-64 by racial category (African American or white) and gender for each geographic area for the years 1985- 1995. Loglinear regression models were used to estimate average annual percent declines in mortality for each of 28 geo-demographic groups. Data were also collected on selected socioeconomic resources by urbanicity for the non-South (excluding Alaska) and South.

RESULTS

For both white and black adults ages 35-64, the highest rates of premature CHD mortality and slowest mortality declines were observed in the rural South. For white men and women, marked disparities in premature CHD mortality across categories of urbanicity were noted in the South but not outside the South. Unexpectedly high rates of premature CHD mortality were observed for African Americans in major metropolitan areas outside the South despite favorable levels of socioeconomic resources.

CONCLUSIONS

Disparities in premature CHD mortality by region and urbanicity appear to have widened between 1985 and 1995. Residents of the rural South had the highest rates of premature CHD mortality, and rural communities in the South face significant barriers to effective heart disease prevention and control.

Evidence of increasing coronary heart disease mortality among black men of lower social class

PURPOSE

Few data are available to examine coronary heart disease (CHD) mortality trends by social class in the United States, in contrast to ample data and well-documented social class disparities in CHD in Europe. In addition, previous analyses of U.S. national data indicated that the rate of decline in CHD mortality slowed substantially for blacks in the 1980s. Using a recently published method for calculating mortality rates by social class, we examined trends in CHD mortality for black men and white men aged 35-54 in North Carolina from 1984 to 1993.

METHODS

Men were assigned to one of four social classes: primary white collar (I), secondary white collar (II), primary blue collar (III), or secondary blue collar (IV), based on usual occupation as recorded on the death certificate. Population denominators for each social class were constructed using data from census Public Use Microdata Sample files. Average annual percent change in mortality rates for each race-social class group was derived from linear regression of the log-transformed age-adjusted rates.

RESULTS

For black men, CHD mortality increased by 18% in social class II, by 2% in social class III, and by 6% in social class IV over the 10-year study period. In contrast, CHD mortality decreased by 33% for black men in social class I (the highest class). CHD mortality declined for all white men, with the greatest decline in social class I and the least decline in social class IV.

CONCLUSIONS

These results suggest that CHD prevention efforts have not benefited black men of lower social class, and that public health programs need to be targeted to these men.

Geographic variation in cardiovascular disease mortality in US blacks and whites

Cardiovascular disease mortality rates have dropped significantly over the past several decades, but a shift has occurred over time in the geographic patterns of both coronary heart disease (CHD) and stroke mortality. This article describes these patterns and discusses how they vary by sex, race, age, and over time. Death certificate information for Health Service Areas (HSAs) in 1988-1992 was used to analyze the geographic patterns of CHD and stroke death rates by race, sex, and age. Changes in these patterns from 1979-1993 also were examined. In 1988-1992, considerable geographic variation in both CHD and stroke mortality was demonstrated for each sex and race group. Coronary heart disease rates were particularly high in the lower Mississippi valley and Oklahoma for all four groups, in the Ohio River valley and New York for whites, and to a lesser extent for blacks. Areas of high rates among whites in the Carolinas resemble stroke mortality patterns. There were greater differences by racial group than by gender, by the definition of heart disease. Over time, rates have declined for both CHD and stroke, but regional differences in the rates of change give the appearance of a southwesternly movement of high heart disease rate clusters and a breakup of the "Stroke Belt." Further research is needed to elucidate the cause of regional variation in CHD and stroke mortality. Similar geographic patterns of high rates of CHD and stroke in the southeastern United States may reflect common risk factors. This knowledge can be used to help develop appropriate interventions to target these high-rate areas in the Mississippi and Ohio River valleys.

Community measures of low-fat milk consumption: comparing store shelves with households

OBJECTIVES

This study examined the relationship between the proportion of milk in food stores that is low-fat and consumption of low-fat milk in the community.

METHODS

Data were gathered from 503 stores across 53 New York State zip codes. In 19 zip codes, a telephone survey measured household low-fat milk use. Census data were obtained to examine sociodemographic predictors of the percentage of low-fat milk in stores.

RESULTS

The proportion of low-fat milk in stores was directly related to low-fat milk consumption in households and to the median income and urban level of the zip code.

CONCLUSIONS

These results support using food store shelf-space observations to estimate low-fat milk consumption.

Community occupational structure, medical and economic resources, and coronary mortality among U.S. blacks and whites, 1980-1988

PURPOSE

To examine the association between coronary heart disease (CHD) mortality, economic and medical resources, and county occupational structure.

METHODS

U.S. counties were classified into five occupational structure categories based on the percentage of workers in white-collar occupations. Directly age-adjusted CHD mortality rates (from vital statistics and Census data) and economic and medical care data (from Census and Area Resource File data) were calculated for each occupational structure category. Participants were black and white, men and women, aged 35-64 years, in the U.S. during 1980-88. CHD mortality rates and economic and medical care data were compared across occupational structure categories.

RESULTS

Among blacks, CDH rates were highest in counties with intermediate levels of occupational structure; rates among whites were inversely associated with occupational structure. Per capita levels of income and numbers of medical-care providers were positively associated with occupational structure.

CONCLUSION

Strategies to improve the resources of disadvantaged communities and the access of black workers to local occupational opportunities may be important for CHD prevention in high risk populations.

Differences in cardiovascular disease risk factors in black and white young adults: comparisons among five communities of the CARDIA and the Bogalusa heart studies. Coronary Artery Risk Development In Young Adults

PURPOSE

To examine community differences in cardiovascular disease (CVD) risk factors among black and white young adults by combining data from two large epidemiologic studies.

METHODS

Data are from participants aged 20-31 years in the Coronary Artery Risk Development In Young Adults (CARDIA) study (1987-1988; N = 4129) and the Bogalusa Heart study (1988-1991; N = 1884), adjusting for data collection differences prior to analysis. CARDIA includes four urban sites: Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. Bogalusa is a semi-rural town in Southeastern Louisiana. CVD risk factors examined were smoking status, body habitus, and blood pressure.

RESULTS

In Birmingham and Bogalusa, more white than black women were current smokers; no ethnic differences were observed among men. In Chicago, Minneapolis, and Oakland, more blacks were current smokers than were whites. For all sites, educational level was strongly inversely related to current smoking status; ethnic differences were more apparent among those with up to a high school education. Among white men and women, prevalence of obesity (body mass index > 31.1 kg/m2 in men and 32.3 kg/m2 in women) was greater in Birmingham and Bogalusa than in Chicago. Minneapolis, and Oakland. Mean systolic blood pressures were highest in Bogalusa, and the proportion of black men with elevated blood pressure (> or = 130/85 mmHg) was higher in Bogalusa and Birmingham.

CONCLUSIONS

Community and ethnic differences in CVD risk factors were observed among young adults in two large epidemiologic studies. Further studies may enhance our understanding of the relationship of geographic differences in CVD risk to subsequent disease.

Secular trends in ischemic heart disease mortality in California versus the United States, 1980 to 1991

We compare the recent trends in ischemic heart disease mortality in California and the United States. Because California was among the first states to have declines in ischemic heart disease mortality, an examination of these recent trends may provide important clues for upcoming national trends. Age-adjusted and -specific ischemic heart disease mortality rates were calculated by sex for persons aged 35 and older during the years 1980 to 1991. Log-linear regression modeling was used to estimate the average annual percentage change in mortality. Between 1980 and 1991, the annual age-adjusted ischemic heart disease mortality declined less in California than in the United States for both women (1.9% versus 3.1%) and men (3.1% versus 3.5%). In California, it increased slightly between 1986 and 1990 for the oldest women and men. The slower rates of decline in mortality of this disease in California compared with the United States and the rising rates among the most elderly Californians suggest that careful attention should be paid to these trends in death rates of and risk factors for this disease in California.

Community surveillance of coronary heart disease in the Atherosclerosis Risk in Communities (ARIC) Study: methods and initial two years' experience

The community surveillance component of the Atherosclerosis Risk in Communities (ARIC) Study is designed to estimate patterns and trends of coronary heart disease (CHD) incidence, case fatality, and mortality in four U.S. communities. Community surveillance involves ongoing review of death certificates and hospital discharge records to identify CHD events in community residents aged 35-74 years. Interviews with next of kin and questionnaires completed by physicians and medical examiners or coroners were used to collect information on deaths, and review and abstraction of hospital records were used to collect information on possible fatal and nonfatal myocardial infarctions (MIs). Events were classified using standardized criteria. The initial 2-years' experience with case ascertainment and availability of information needed for classification of events is described. Average annual age-adjusted attack rates of definite MI and CHD mortality rates for blacks in two communities and whites in the four communities are presented and compared with rates based on unvalidated hospital discharge data and vital statistics. Age-adjusted rates based on ARIC classification of definite MI were lower than those based on hospital discharge diagnosis code 410 (e.g., 5.60/1000 and 11.50/1000 among Forsyth County white men, respectively). Age-adjusted rates of definite fatal CHD based on ARIC classification were similarly lower than rates based on underlying cause of death code 410; for example, Jackson black men had rates of 2.82/1000 and 4.52/1000 for definite fatal CHD and UCOD 410-414 or 429.2, respectively.

Ischaemic heart disease mortality among men in Norway: reversal of urban-rural difference between 1966 and 1989

OBJECTIVE

This study aimed to examine regional urban-rural differences in mortality from ischaemic heart disease, including sudden death of unknown cause (IHD/SUD) in Norway from 1966-89, for men and women aged 30-69 years.

DESIGN

Analysis was based on vital statistics. Regional mortality rates were obtained by aggregating the 443 municipalities in Norway into urban, rural, and intermediate municipalities.

SETTINGS AND SUBJECTS

Norway.

RESULTS

In 1966-70 the age adjusted IHD/SUD mortality in the age group 30-69 years was higher in urban than in rural areas; for men by 31% (95% CI 27%, 36%) and for women by 28% (95% CI 19%, 36%). In 1986-89 the IHD/SUD mortality for men showed a reversed urban-rural gradient: it was 8% (95% CI 2%, 13%) higher in rural than in urban areas. The mortality rates for women were equal for both these aggregates. For men the results indicate that IHD/SUD mortality peaked first in urban municipalities and then, but at a lower level, in rural areas. For women there was a substantial decline in IHD/SUD mortality between 1966 and 1989, but an actual peak could not be demonstrated in any of the three aggregates during the period. The decline in IHD/SUD mortality among women was steepest in urban municipalities and least noticeable in rural municipalities, but the decline tapered off towards the end of the study period.

CONCLUSION

The results confirm a phase-shifted peak in IHD/SUD mortality, which began in towns and ended in rural areas, and provides clues to the main underlying factors in the IHD epidemic at the population level.

Community social change and mortality

This paper first reviews the types of explanations that have been used in analyzing unequal distribution in coronary heart disease among different groups and changes in prevalence over time. The explanations have mostly focused on the individual: individual behaviors, personalities, stressors, or social ties. It is suggested here that a shift in focus to community-level characteristics may also aid in understanding changes in mortality. Data are presented from Roseto, PA--a town that became known in the 1960's for its strong Italian traditions and very low mortality from myocardial infarction and that subsequently experienced a sharp rise in mortality--and from the adjacent comparison town of Bangor. Data collected over several decades--in some cases as far back as 1925--on marriages, population composition, organizational memberships, voting patterns, and social class indicators suggest that important community changes that accelerated significantly in the 1960's coincided with and may help to explain Roseto's loss of protection from coronary heart disease deaths after 1965.

Coronary heart disease: trends in spatial inequalities and implications for health care planning in England

The idea of health gain has recently received particular emphasis in health policy in England. One of the areas where there is considerable scope for health gain is in the reduction of mortality due to Coronary Heart Disease. Some reduction in mortality rates due to this cause have already been achieved in England in the 1980s. However, the change in standardised mortality rates varies around the country. A review of studies of geographies of declining CHD mortality shows that such geographical variation is typical of other countries which have recently experienced a reduction in the CHD epidemic. The paper presents the results of an analysis of change in spatial inequality in coronary heart disease mortality among the population aged 35-74 for the 190 District Health Authorities in England over the period 1982-1989. Data were derived from counts of cause-specific deaths and population estimates published by the Office of Population Censuses and Surveys. Various approaches were used to assess the change in spatial disparity which has accompanied the average overall reduction in mortality rates over the study period. The results show that the trends vary between age and sex groups in the population and that, particularly for older people, overall health gain across the country is being achieved at the cost of greater inequality in health between areas. The implications for local health strategies with respect to coronary heart disease reduction are discussed.

Racial differences in mortality from cardiovascular disease in Atlanta, 1979-1985

Mortality from cardiovascular disease (CVD) for the period 1979 to 1985 in the Atlanta metropolitan population was reviewed for racial differences. About 28% of the population was black in 1980. Of 22,585 deaths from hypertension, stroke, ischemic heart disease, and atherosclerosis, 78.7% occurred among whites and 21.3% among blacks. Overall, ischemic heart disease accounted for 47.7% of these four types of CVD deaths for both races and sexes. Age-specific and age-adjusted rates were compared. Among these four causes of death, blacks have the greatest excess of deaths from hypertension over whites for both males and females; the excesses were more than 200% when the rates were age-adjusted. The excess risk of death from hypertension occurred for all ages in blacks, with an excess of about 10 times in 30- to 49-year-olds. An excess risk from stroke also occurred in blacks below the age of 75; the risk reversed afterward. The age-specific mortality rates revealed an excess from ischemic heart disease only between the ages of 30 and 59 years and from atherosclerosis between 40 and 59 years of age for black men. This age-related crossover in females did not occur until the age of 75 years for deaths attributed to these causes. These data suggest that blacks were at highest risk for all four causes at younger age groups.

Geographic and socioeconomic variation in the onset of decline of coronary heart disease mortality in white women

BACKGROUND

Regional, metropolitan, and socioeconomic factors related to the onset of decline of coronary heart disease (CHD) mortality among White women are reported. Such studies are important for planning population-level interventions.

METHODS

Mortality data for 1962 to 1978 were used, to estimate the year of onset of decline. Ecological analyses of socioeconomic data from the US census were used to emphasize structural and organizational aspects of changes in disease, rather than as a substitute for an individual-level design.

RESULTS

Onset of decline of CHD mortality among White women was estimated to have occurred by 1962 in 53% of 507 state economic areas (SEAs), ranging from 79% in the Northeast to 39% in the South. Metropolitan areas experienced earlier onset of decline than did nonmetropolitan areas. Average income, education, and occupational levels were highest in early onset areas and declined across onset categories.

CONCLUSIONS

The results provide additional evidence for previously observed geographic and social patterns of CHD decline. Emphasis on structural economic factors determining the shape of the CHD epidemic curve does not detract from the medical importance of risk factors, but underscores the importance of community development to public health improvements. The results are consistent with the idea that the course of the CHD epidemic in the United States has been strongly influenced by socioeconomic development.

Changes in risk factors and the decline in mortality from cardiovascular disease. The Framingham Heart Study

A decline in mortality from cardiovascular disease over the past 30 years has been well documented, but the reasons for the decline remain unclear. We analyzed the 10-year incidence of cardiovascular disease and death from cardiovascular disease in three groups of men who were 50 to 59 years old at base line in 1950, 1960, and 1970 (the 1950, 1960, and 1970 cohorts) in order to determine the contribution of secular trends in the incidence of cardiovascular disease, risk factors, and medical care to the decline in mortality. The 10-year cumulative mortality from cardiovascular disease in the 1970 cohort was 43 percent less than that in the 1950 cohort and 37 percent less than that in the 1960 cohort (P = 0.04 by log-rank test). Among the men who were free of cardiovascular disease at base line, the 10-year cumulative incidence of cardiovascular disease declined approximately 19 percent, from 190 per 1000 in the 1950 cohort to 154 per 1000 in the 1970 cohort (0.10 less than P less than 0.20 by chi-square test), whereas the 10-year rate of death from cardiovascular disease declined 60 percent (relative risk for the 1950 cohort as compared with the 1970 cohort, 2.53; 95 percent confidence interval, 1.22 to 5.97). Significant improvements were found in risk factors for cardiovascular disease among the men initially free of cardiovascular disease in the 1970 cohort as compared with those in the 1950 cohort, including a lower serum cholesterol level (mean +/- SD, 5.72 +/- 0.98 mmol per liter [221 +/- 38 mg per deciliter], as compared with 5.90 +/- 1.03 mmol per liter [228 +/- 40 mg per deciliter]) and a lower systolic blood pressure (mean +/- SD, 135 +/- 19 mm Hg, as compared with 139 +/- 25 mm Hg), better management of hypertension (22 percent vs. 0 percent were receiving antihypertensive medication), and reduced cigarette smoking (34 percent vs. 56 percent). We propose that these improvements may have had more pronounced effects on mortality from cardiovascular disease than on the incidence of cardiovascular disease in this population. Our data suggest that the improvement in cardiovascular risk factors in the 1970 cohort may have been an important contributor to the 60 percent decline in mortality in that group as compared with the 1950 cohort, although a decline in the incidence of cardiovascular disease and improved medical interventions may also have contributed to the decline in mortality.

Trends in the geographic inequality of cardiovascular disease mortality in the United States, 1962-1982

Substantial geographic variation of cardiovascular disease (CVD) mortality within the U.S. has been recognized for decades. Analyses reported here address the question of whether relative geographic inequality has increased or decreased during the period of rapidly declining CVD mortality 1962-1982. Trends in geographic inequality, as measured by the weighted coefficient of variation of State Economic Area rates, are analyzed for whites and blacks by sex for 10-year age groups 35-44 to 85 and over. The average annual percent change in the coefficient of variation for each demographic group is presented for all cause mortality, all CVD, stroke and ischemic heart disease. In general, geographic inequalities declined in total mortality for all except the youngest age group. This is consistent with reports of a strong convergence of age-adjusted cancer mortality in U.S. counties. By contrast, increasing geographic inequality dominates in the CVD categories, especially for whites in heart disease and stroke. At younger ages, increases in the coefficient of variation for all race-sex groups exceeded 1% per year in stroke and 2% per year in heart disease. These results suggest that factors influencing the percent decline of CVD mortality are not reaching communities of the U.S. equally. Since increases in relative inequality are strongest in the younger age groups, the pattern of inequality may be accentuated as these cohorts move into ages of higher mortality.

Modeling heart disease mortality with census tract rates and social class mixtures

The relationship between social class and 1980 heart disease (HD) mortality in eight urban U.S. counties was examined by regressing age and sex adjusted census tract specific HD rates (N = 1211) on tract social class characteristics. The regression model indicated that lower middle class residents experienced a HD mortality rate 1.9 (95% CI = 1.3, 2.8) times the rate in the upper middle/middle class, while the working poor experienced a HD rate 4.4 (95% CI = 3.5, 5.7) times the rate in the referent class. Similar class effects were seen for both black and nonblack residents. The crude race effect (1.3 with 95% CI = 1.2, 1.4) was explainable by the concentration of blacks in the lower classes. The methods illustrate the ecologic regression of mixtures of mortality rates on mixtures of exposure in the presence of random tract effects which eliminates some of the problems associated with small denominators or zero rates in some tracts.

Geographic variation in the onset of decline of male ischemic heart disease mortality in The Netherlands

We studied variation in the year of onset of ischemic heart disease mortality decline among regions (n = 39) in the Netherlands. Using loglinear regression methods, a quadratic regression model was fitted to the observed numbers of male deaths in each region in the period 1950-84, controlling for changes in age-structure of populations. The quadratic regression model proved inadequate to describe the mortality experience of females. For the country as a whole, the estimated year of onset of male ischemic heart disease mortality decline is 1973.9. The difference between the earliest and the latest region is almost nine years (1970.0 and 1978.9, respectively). An early onset of decline (less than or equal to 1972) is only found in the urbanized, western part of the country. A later (greater than or equal to 1975) onset of decline is characteristically found in more peripheral regions in the South-West and South-East, as well as in the North. Exploratory correlation and regression analyses show that both average income and percent of population living in larger cities have independent, negative associations with the year of onset of male ischemic heart disease mortality decline. We argue that regional variation in the timing of lifestyle changes is a more plausible explanation of these observations than regional variation in the timing of medical care improvements.

Socioenvironmental characteristics associated with the onset of decline of ischemic heart disease mortality in the United States

The relation of community socioenvironmental characteristics to timing of the onset of decline of ischemic heart disease (IHD) mortality was investigated among the 507 State Economic Areas of the continental United States. Onset of decline was measured using data for White men aged 35-74 and classified as early (1968 or before) vs late (after 1968). Ten socioenvironmental characteristics derived from US Census Bureau data were strongly related to onset of decline. Areas with the poorest socioenvironmental conditions were two to 10 times more likely to experience late onset than those areas with the highest levels. We found that income-related characteristics could account for most of the difference in onset of decline of IHD between metropolitan and non-metropolitan places. We conclude that community socioenvironmental characteristics provide the context for changes in risk factors and medical care.

Changing association between community occupational structure and ischaemic heart disease mortality in the United States

The changing association between community occupational structure and ischaemic heart disease mortality in white men and women of the United States from 1968 to 1982 has been investigated. Occupational structure was represented by the proportion of workers in white-collar jobs. A negative association, with lower mortality in communities with higher levels of white-collar employment, emerged over the period in both men and women. The results for men may be interpreted as suggesting a recapitulation in the US of the changing association between social class and heart disease observed in Britain. Occupational structure, however, reflects resources and opportunities in a community derived from its contribution to the national and international economy. Thus the growing inequalities in heart disease mortality presented in this ecological study relate more appropriately to communities than to individual workers.