Association of cumulative loneliness with all-cause mortality among middle-aged and older adults in the United States, 1996 to 2019.

Loneliness is a growing public health concern worldwide. We characterized the association between cumulative loneliness and subsequent all-cause mortality, using data from 9,032 participants aged 50+ in the population-based US Health and Retirement Study (HRS) from 1996 to 2019. Loneliness status (yes; no) was measured biennially from 1996 to 2004, and we categorized the experience of cumulative loneliness over the 8-y period as never, one time point, two time points, and ≥three time points. A multivariable-adjusted age-stratified Cox proportional hazards regression model was fitted to examine the association between cumulative loneliness from 1996 to 2004 and all-cause mortality from 2004 to 2019. Excess deaths due to each category of cumulative loneliness were calculated. Compared to those who never reported loneliness from 1996 to 2004, participants experiencing loneliness at one time point, two time points, and ≥three time points respectively had 1.05 (95% CI: 0.96 to 1.15), 1.06 (95% CI: 0.95 to 1.19), and 1.16 (95% CI: 1.02 to 1.33) times higher hazards of mortality from 2004 to 2019 (P trend = 0.01). These results correspond to 106 (95% CI: 68 to 144), 202 (95% CI: 146 to 259), and 288 (95% CI: 233 to 343) excess deaths per 10,000 person-years, for those experiencing loneliness at each of one, two, or ≥three time points from 1996 to 2004. Cumulative loneliness in mid-to-later life may thus be a mortality risk factor with a notable impact on excess mortality. Loneliness may be an important target for interventions to improve life expectancy in the United States.

Could differential under-reporting of loneliness between men and women bias the gender-specific association between loneliness duration and rate of memory decline? A probabilistic bias analysis of effect modification.

Gender is an observed effect modifier of the association between loneliness and memory aging. However, this effect modification may be a result of information bias due to differential loneliness under-reporting by gender. We applied probabilistic bias analyses to examine whether effect modification of the loneliness-memory decline relationship by gender is retained under three simulation scenarios with various magnitudes of differential loneliness under-reporting between men and women. Data were from biennial interviews with adults aged 50+ in the US Health and Retirement Study from 1996-2016 (5,646 women and 3,386 men). Loneliness status (yes vs. no) was measured from 1996-2004 using the CES-D loneliness item and memory was measured from 2004-2016. Simulated sensitivity and specificity of the loneliness measure were informed by a validation study using the UCLA Loneliness Scale as a gold standard. The likelihood of observing effect modification by gender was higher than 90% in all simulations, although the likelihood reduced with an increasing difference in magnitude of the loneliness under-reporting between men and women. The gender difference in loneliness under-reporting did not meaningfully affect the observed effect modification by gender in our simulations. Our simulation approach may be promising to quantify potential information bias in effect modification analyses.

Racial and Ethnic Disparities in the Monetary Value of Informal Caregiving for Non-Institutionalized People Living With Dementia.

OBJECTIVE: To examine racial and ethnic differences in costs of informal caregiving among older adults with dementia in the United States. METHODS: We used data from the 2002 to 2018 Health and Retirement Survey to estimate annual informal care hours for adults with dementia (n = 10,015). We used regression models to examine racial and ethnic differences in hours of informal care for activities of daily living (ADL) and instrumental ADL, controlling for demographic characteristics, education, and level of disability. RESULTS: Our sample was 70% non-Hispanic White, 19% non-Hispanic Black, and 11% Hispanic. Hispanics received, on average, 35.8 hours of informal care each week, compared to 30.1 for Blacks and 20.1 for Whites. Racial and ethnic differences persisted when controlling for covariates. DISCUSSION: Informal care is a greater cost to racial and ethnic minoritized families. Informal care was valued at a replacement cost of $44,656 for Hispanics, $37,508 for Blacks, and $25,121 for Whites.

The Impact of the Older Person's Grant Expansion on Hypertension Among Older Men in Rural South Africa: Findings From the HAALSI Cohort.

Background and Objectives: Hypertension is a major modifiable contributor to disease burden in sub-Saharan Africa. We exploited an expansion to age eligibility for men in South Africa's noncontributory public pension to assess the impact of pension eligibility on hypertension in a rural, low-income South African setting. Research Design and Methods: Data were from 1 247 men aged ≥60 in the population-representative Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa in 2014/2015. We identified cohorts of men from 0 (controls, aged ≥65 at pension expansion) through 5 years of additional pension eligibility based on their birth year. Using the modified Framingham Heart Study hypertension risk prediction model, and the Wand et al. model modified for the South African population, we estimated the difference in the probabilities of hypertension for men who benefitted from the pension expansion relative to the control. We conducted a negative control analysis among older women, who were not eligible for pension expansion, to assess the robustness of our findings. Results: Older men with 5 additional years of pension eligibility had a 6.9-8.1 percentage point greater probability of hypertension than expected without the pension expansion eligibility. After accounting for birth cohort effects through a negative control analysis involving older women reduced estimates to a 3.0-5.2 percentage point greater probability of hypertension than expected. We observed a mean 0.2 percentage point increase in the probability of hypertension per additional year of pension eligibility, but this trend was not statistically significant. Discussion and Implications: Although the Older Person's Grant is important for improving the financial circumstances of older adults and their families in South Africa, expanded pension eligibility may have a small, negative short-term effect on hypertension among older men in this rural, South African setting.

Educational Attainment and Later-Life Cognitive Function in High- and Middle-Income Countries: Evidence From the Harmonized Cognitive Assessment Protocol.

OBJECTIVES: Identifying social policies that can promote cognitive health is crucial for reducing the global burden of dementia. We evaluated the importance of educational attainment for later-life cognitive function in various social and geographic settings. METHODS: Using harmonized data for individuals aged ≥65 years from the United States Health and Retirement Study (HRS) and its international partner studies in England, Mexico, China, and India, and each study's respective Harmonized Cognitive Assessment Protocol (HCAP), we conducted a cross-national comparative study to examine the role of educational attainment in later-life cognitive function across countries (n = 14,980, 2016-2019). We used multivariable-adjusted regression to estimate associations between educational attainment and harmonized global cognitive function scores. RESULTS: In Mexico, China, and India, the general cognitive function scores on average are approximately one standard deviation of the HRS-HCAP cognitive function score distribution lower compared to the United States and England, paralleling patterns of educational attainment across countries. In all countries, higher educational attainment was associated with progressively higher later-life cognitive function scores. Population-level differences in educational attainment explained about 50%-90% of the observed differences in cognitive function scores across countries. DISCUSSION: The relationship between education and later-life cognitive function across social and geographic contexts underscores the crucial role of education to promote cognitive health and reduce dementia risk. Continual improvement of educational attainment in low- and middle-income settings may yield a significant pay-off in later-life cognitive health.

Measuring spatial availability of children for older adults with disability.

BACKGROUND: Having an adult child living with or nearby may prevent parents with disability from moving to nursing homes and reduce the use of paid care services. Despite the profound implications for care resources and utilization among older adults, there is no measure summarizing the spatial availability of all adult children for an older adult. Our study aims to develop a holistic measure of adult children's spatial availability to assess potential family care resources for older adults with disability. METHODS: Data were obtained from the population-based, longitudinal study in the U.S., the Health and Retirement Study (HRS). We selected a nationally representative sample of older adults 55+ years with disability. Using multivariable two-part regression models, we developed a care-weighted child spatial availability for caregiving (CSAC) index, which summarizes the spatial dispersion of all adult children accounting for potential caregiving associated with distance. We also constructed a reference index of child spatial proximity (CSP) focusing only on spatial distance by employing Gaussian kernel weighting functions. RESULTS: CSAC index highlights the great importance of having an adult child in the same household (vs. nearby or far) for receiving care among older adults with disability, compared to the CSP index, showing relatively a gradual decline over the spatial distance. Both indices vary substantially by older adults' sociodemographic attributes. CONCLUSIONS: The holistic indices of adult child spatial availability will contribute to assessing care resources for older adults, albeit future development is needed to extend the utility of the indices tailored for specific care needs.

Association of Arts Event Attendance With Cognitive Function Among Older Adults Enrolled in the Health and Retirement Study.

Background and Objectives: Among the cognitively impaired, arts engagement is associated with improved neurocognitive symptoms. Less is known about arts engagement as a potentially modifiable lifestyle factor to prevent or slow cognitive decline. Our aim was to evaluate the association between arts event attendance and cognition. Research Design and Methods: We used data from the 2014 and 2016 waves of the Health and Retirement Study to evaluate the association between arts event attendance and cognition using multivariable linear regressions. Arts event attendance in 2014 was our exposure of interest and included visiting an art museum or art gallery; attending an arts or crafts fair; attending a live performance (concert, play, or reading); and/or going to a movie theater. Cognitive function in 2016 measured on a 27-point scale by the Telephone Interview for Cognitive Status was our main outcome of interest. Results: Of the 1,149 participants included in the final analysis, 70.7% attended an arts event. The mean baseline cognitive score was higher among those who attended art events (16.8 [standard deviation {SD}, ±3.8] vs 13.8 [SD, ±5.0]; p < .001). In our multivariable regressions, those who attended arts events in 2014 exhibited higher cognitive scores in 2016 after controlling for demographic, socioeconomic, health, and baseline cognitive covariates (ß, 1.07 [95% confidence interval {CI}, 0.50-1.64]; p < .001). This association was primarily observed in those with lower baseline cognitive function (ß, 1.19 [95% CI, 0.33-2.06]; p = .008). Discussion and Implications: Arts event attendance may be associated with better cognitive function. Given concerns for residual confounding and reverse causality, this association warrants further study.

Changes in Care Use and Financial Status Associated With Dementia in Older Adults.

Importance: Estimating the effects of dementia on care use and financial outcomes is timely, as the population with dementia will more than double in the next few decades. Objective: To determine the incremental changes associated with dementia in regard to older adults' care use and assess financial consequences for individuals, families, and society. Design, Setting, and Participants: This population-based cohort study included propensity score matching on national, longitudinal data using extensive baseline variables of sociodemographic characteristics, economic status, family availability, health conditions, disability status, and outpatient care use among 2 groups of US adults aged 55 years or older who did not have dementia. In total, 2387 adults experienced the onset of dementia during the 2-year follow-up (dementia group) and 2387 adults did not (control group). Participants were followed up for 8 years from the baseline. Data were analyzed from February 2021 to August 2023. Exposure: Dementia determined based on Langa-Weir classification. Main Outcomes and Measures: Outcomes of care use included monthly care hours from family and unpaid helpers, in-home medical services, hospital stay, and nursing facility stay. Financial outcomes included out-of-pocket medical costs, wealth, and the status of having Medicaid. Results: Among the full sample, the mean (SD) age was 75.4 [10.4] years, and 59.7% of participants were female. Care use was similar at baseline between the matched groups but was substantially greater for the dementia group vs control group in subsequent years, especially during the 2-year follow-up: 45 vs 13 monthly care hours from family and unpaid helpers, 548 of 2370 participants (23.1%) vs 342 of 2383 (14.4%) using in-home medical care, 1104 of 2369 (46.6%) vs 821 of 2377 (34.5%) with hospital stay, and 489 of 2375 (20.6%) vs 104 of 2384 (4.4%) using a nursing facility. The increase in use of a nursing facility was especially high if baseline family care availability was low. Over the 8-year follow-up in the dementia group, the 2-year out-of-pocket medical costs increased from $4005 to $10 006, median wealth was reduced from $79 339 to $30 490, and those enrolling in Medicaid increased from 379 of 2358 participants (16.1%) to 201 of 676 participants (29.7%). No statistically significant changes in financial outcomes were found in the control group. Conclusion and Relevance: This cohort study demonstrated that the incremental changes associated with dementia in regard to older adults' long-term care and financial burden are substantial. Family care availability should be accounted for in a comprehensive assessment of predicting the effects of dementia.

Primary care providers' perceived barriers to obesity treatment and opportunities for improvement: A mixed methods study.

BACKGROUND: Primary care patients with obesity seldom receive effective weight management treatment in primary care settings. This study aims to understand PCPs' perspectives on obesity treatment barriers and opportunities to overcome them. STUDY DESIGN: This is an explanatory sequential mixed methods study in which survey data was collected and used to inform subsequent qualitative interviews. SETTINGS AND PARTICIPANTS: PCPs who provide care to adult patients in an academic medical center in the Midwestern US. METHODOLOGY: PCPs (n = 350) were invited by email to participate in an online survey. PCPs were subsequently invited to participate in semi-structured interviews to further explore survey domains. ANALYTIC APPROACH: Survey data were analyzed using descriptive statistics. Interviews were analyzed using directed content analysis. RESULTS: Among 107 survey respondents, less than 10% (n = 8) used evidence-based guidelines to inform obesity treatment decisions. PCPs' identified opportunities to improve obesity treatment including (1) education on local obesity treatment resources (n = 78, 73%), evidence-based dietary counseling strategies (n = 67, 63%), and effective self-help resources (n = 75, 70%) and (2) enhanced team-based care with support from clinic staff (n = 53, 46%), peers trained in obesity medicine (n = 47, 44%), and dietitians (n = 58, 54%). PCPs also desired increased reimbursement for obesity treatment. While 40% (n = 39) of survey respondents expressed interest in obesity medicine training and certification through the American Board of Obesity Medicine, qualitative interviewees felt that pursuing training would require dedicated time (i.e., reduced clinical effort) and financial support. CONCLUSIONS: Opportunities to improve obesity treatment in primary care settings include educational initiatives, use of team-based care models, and policy changes to incentivize obesity treatment. Primary care clinics or health systems should be encouraged to identify PCPs with specific interests in obesity medicine and support their training and certification through ABOM by reimbursing training costs and reducing clinical effort to allow for study and board examination.

Negative wealth shocks in later life and subsequent cognitive function in older adults in China, England, Mexico, and the USA, 2012-18: a population-based, cross-nationally harmonised, longitudinal study.

BACKGROUND: Household wealth is positively related to cognitive health outcomes in later life. However, the association between negative wealth shocks and cognitive function in later life, and whether this association might differ across countries at different levels of economic development, is unclear. We aimed to investigate whether negative wealth shocks in later life are associated with cognitive function in older adults in China, England, Mexico, and the USA, and whether this association is modified by country income level. METHODS: For this population-based, cross-nationally harmonised, longitudinal study, data were analysed from core interviews of the population-based US Health and Retirement Study (2012 and 2016) and its partner studies in China (the China Health and Retirement Longitudinal Study; 2015 and 2018), England (the English Longitudinal Study of Ageing; 2012 and 2016), and Mexico (Mexican Health and Aging Study; 2012 and 2015-16), and their respective Harmonized Cognitive Assessment Protocols (HCAPs). Negative wealth shocks over the follow-up periods of the respective cohorts were defined in two ways: an extreme loss of 75% or greater from the baseline amount of wealth, and a decline in within-population wealth quintile rank. The primary outcome was the harmonised general cognitive function (GCF) factor score, which was constructed with factor analysis on the HCAP neuropsychological assessments of memory, orientation, attention, executive function, and verbal fluency performance (mean 0; SD 1). We used sampling-weighted, multivariable-adjusted linear models to examine associations. FINDINGS: Data from 9465 participants were included in this analysis: 3796 from China, 1184 from England, 1193 from Mexico, and 3292 from the USA. The mean baseline age of participants was 68·5 (SD 5·4) years in China (49·8% women), 72·0 (7·0) years in England (54·6% women), 70·6 (6·8) years in Mexico (55·1% women), and 72·7 (7·5) years in the USA (60·4% women). A wealth loss of 75% or greater was negatively associated with subsequent cognitive function in the USA (ß -0·16 SD units; 95% CI -0·29 to -0·04) and China (-0·14; -0·21 to -0·07), but not in England (-0·01; -0·24 to 0·22) or Mexico (-0·11; -0·24 to 0·03). Similarly, within-population wealth quintile rank declines were negatively associated with subsequent cognitive function in the USA (ß -0·07 per quintile rank decline; 95% CI -0·11 to -0·03) and China (ß -0·07; -0·09 to -0·04), but not in England (-0·05; -0·11 to 0·01) or Mexico (-0·03; -0·07 to 0·01). INTERPRETATION: The impact of wealth shocks in later life on subsequent lower level of cognitive function of older adults in China, England, Mexico, and the USA differed across macro-level socioeconomic structures. These findings suggest that government policies and social safety nets in countries with different levels of economic development might have a role in protecting older adults from adverse health effects of wealth losses in later life. FUNDING: US National Institute on Aging, US National Institutes of Health.

Close enough? Adult child-to-parent caregiving and residential proximity.

Adult children are among the most frequent providers for community-dwelling older adults with a disability. This report assesses the extent to which help received from an adult child by older persons with a disability is contingent on the distance between their residences. Using the national Panel Study of Income Dynamics, we selected persons 55 and older with a disability and their adult children (810 older adults; 1767 dyads of older adult - adult child pairs). The adjusted average hours of help received from an adult child was estimated by the distance between the parent's and the adult child's residences using a two-part model with a linear spline of proximity and adjusting for demographic and socioeconomic factors of the parent and child. We found that average weekly hours of help received from an adult child by older adults with a disability declined dramatically as the distance between older adults and their adult children's residences increased, but only up to 2-5 miles. Adjusted average weekly hours of help received from an adult child were 5.99 (95%CI 3.33, 8.65) if coresident, 3.16 (95%CI 2.04, 4.28) if on the same block, 1.16 (95%CI 0.72, 1.59) if 2-5 miles away, 0.79 (95%CI 0.39, 1.20) if 5-10 miles away, and 0.58 (95%CI 0.25, 0.92) if > 100 miles. The amount of help for parents with a disability may require adult children living very near their parents which has important implications for long-term care for the aging population.

Association of Perceived Job Insecurity With Subsequent Memory Function and Decline Among Adults 55 Years or Older in England and the US, 2006 to 2016.

Importance: Intensified global economic competition and recent financial crises, including those associated with the COVID-19 pandemic, have contributed to uncertainty about job security. However, little is known about the association of perceived job insecurity with memory function and decline among older adults. Objectives: To investigate the association between perceived job insecurity and subsequent memory function and rate of memory decline among older adults in the US and England. Design, Setting, and Participants: This 10-year prospective population-based cohort study used data from the US Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) collected from 2006 to 2016. Participants included 9538 adults 55 years or older. Data were analyzed from August 1 to 31, 2021. Exposures: Perceived job insecurity (yes vs no) at baseline. Main Outcomes and Measures: Episodic memory z scores at baseline and rate of decline during the follow-up. Results: Among the 9538 study participants, the mean (SD) age at baseline was 60.97 (6.06) years, and 4981 (52.22%) were women. A total of 2320 participants (24.32%) reported job insecurity at baseline (1088 of 3949 [27.55%] in England and 1232 of 5589 [22.04%] in the US). Perceived job insecurity after 55 years of age was associated with lower baseline memory z scores in the fully adjusted model (ß = -0.04 [95% CI, -0.08 to -0.01]) but not with rate of memory decline (ß = 0.01 [95% CI, -0.01 to 0.01]). The association appeared to be stronger in the US than in England (job insecurity × US, ß = -0.05 [95% CI, -0.11 to 0.02]), but the estimate was imprecise, potentially owing to low statistical power. Conclusions and Relevance: The findings of this cohort study suggest that exposure to job insecurity in middle to late life was associated with worse memory function among older adults in the US and England. This association may vary across socioeconomic and social welfare contexts, although future studies with large samples from diverse socioeconomic settings are warranted.

Differential Trends in Disability Among Rich and Poor Adults in the United States and England From 2002 to 2016.

OBJECTIVES: Disability in the United States has not improved in recent decades. Comparing temporal trends in disability prevalence across different income groups, both within and between the United States and England, would inform public policy aimed at reducing disparities in disability. METHODS: Using the Health and Retirement Study and the English Longitudinal Study of Ageing, we estimated annual percent change from 2002 to 2016 in disability among community-dwelling adults (197,021 person-years of observations). Disability was defined based on self-report of limitations with 5 instrumental activities of daily living and 6 activities of daily living. We examined the trends by age and income quintile and adjusted for individual-level sociodemographic status and survey design. RESULTS: The adjusted annual percent change (AAPC) in disability prevalence declined significantly in both countries for ages 75 and older during 2002-2016. For ages 55-64 and 65-74, disability prevalence was unchanged in the United States but declined in England. Both countries experienced a widening gap in disability between low- and high-income adults among the younger age groups. For example, for those ages 55-64 in each country, there was no significant improvement in disability for the low-income group but a significant improvement for the high-income group (AAPC = -3.60; 95% confidence interval [CI; -6.57, -0.63] for the United States; AAPC = -6.06; 95% CI [-8.77, -3.35] for England). DISCUSSION: Improvements in disability were more widespread in England than in the United States between 2002 and 2016. In both countries, the disparity in disability between low- and high-income adults widened for middle-aged adults. Policies targeted at preventing disability among low-income adults should be a priority in both countries.

Family Care Availability And Implications For Informal And Formal Care Used By Adults With Dementia In The US.

Despite the important role that family members can play in dementia care, little is known about the association between the availability of family members and the type of care, informal (unpaid) or formal (paid), that is actually delivered to older adults with dementia in the US. Using data about older adults with dementia from the Health and Retirement Study, we found significantly lower spousal availability but greater adult child availability among women versus men, non-Hispanic Blacks versus non-Hispanic Whites, and people with lower versus higher socioeconomic status. Adults with dementia and disability who have greater family availability were significantly more likely to receive informal care and less likely to use formal care. In particular, the predicted probability of a community-dwelling adult moving to a nursing home during the subsequent two years was substantially lower for those who had a co-resident adult child (11 percent) compared with those who did not have a co-resident adult child but had at least one adult child living close (20 percent) and with those who have all children living far (23 percent). Health care policies on dementia should consider potential family availability in predicting the type of care that people with dementia will use and the potential disparities in consequences for them and their families.

Comparison of Health Outcomes Among High- and Low-Income Adults Aged 55 to 64 Years in the US vs England.

Importance: Socioeconomic differences in life expectancy, health, and disability have been found in European countries as well as in the US. Identifying the extent and pattern of health disparities, both within and across the US and England, may be important for informing public health and public policy aimed at reducing these disparities. Objective: To compare the health of US adults aged 55 to 64 years with the health of their peers in England across the high and low ranges of income in each country. Design, Setting, and Participants: Using data from the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) for 2008-2016, a pooled cross-sectional analysis of comparably measured health outcomes, with adjustment for demographic characteristics and socioeconomic status, was conducted. The analysis sample included community-dwelling adults aged 55 to 64 years from the HRS and ELSA, resulting in 46 887 person-years of observations. Data analysis was conducted from September 17, 2019, to May 12, 2020. Exposures: Residence in the US or England and yearly income. Main Outcomes and Measures: Sixteen health outcomes were compared, including 5 self-assessed outcomes, 3 directly measured outcomes, and 8 self-reported physician-diagnosed health conditions. Results: This cross-sectional study included 12 879 individuals and 31 928 person-years from HRS (mean [SD] age, 59.2 [2.8] years; 51.9% women) and 5693 individuals and 14 959 person-years from ELSA (mean [SD] age, 59.3 [2.9] years; 51.0% women). After adjusting for individual-level demographic characteristics and socioeconomic status, a substantial health gap between lower-income and higher-income adults was found in both countries, but the health gap between the bottom 20% and the top 20% of the income distribution was significantly greater in the US than England on 13 of 16 measures. The adjusted US-England difference in the prevalence gap between the bottom 20% and the top 20% ranged from 3.6 percentage points (95% CI, 2.0-5.2 percentage points) in stroke to 9.7 percentage points (95% CI, 5.4-13.9 percentage points) for functional limitation. Among individuals in the lowest income group in each country, those in the US group vs the England group had significantly worse outcomes on many health measures (10 of 16 outcomes in the bottom income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the bottom income decile ranged from 7.6% (95% CI, 6.0%-9.3%) vs 3.8% (95% CI, 2.6%-4.9%) for stroke to 75.7% (95% CI, 72.7%-78.8%) vs 59.5% (95% CI, 56.3%-62.7%) for functional limitation. Among individuals in the highest income group, those in the US group vs England group had worse outcomes on fewer health measures (4 of 16 outcomes in the top income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the top income decile ranged from 36.9% (95% CI, 33.4%-40.4%) vs 30.0% (95% CI, 27.2%-32.7%) for hypertension to 35.4% (95% CI, 32.0%-38.7%) vs 22.5% (95% CI, 19.9%-25.1%) for arthritis. Conclusions and Relevance: For most health outcomes examined in this cross-sectional study, the health gap between adults with low vs high income appeared to be larger in the US than in England, and the health disadvantages in the US compared with England are apparently more pronounced among individuals with low income. Public policy and public health interventions aimed at improving the health of adults with lower income should be a priority in the US.