Immigrant mortality advantage in the United States during the first year of the COVID-19 pandemic.

OBJECTIVES: To investigate the mortality impact of the COVID-19 pandemic on US-born and foreign-born populations by race and Hispanic origin in the United States in 2020. METHODS: Death records from the National Center for Health Statistics and population data from CDC WONDER were used to estimate (1) age-standardized all-cause and cause-specific mortality at ages 25+, 25-64, and 65+ in 2017-2019 and 2020 by nativity, race, Hispanic origin, and sex; (2) changes in mortality between these two periods; and (3) the cause-specific contributions to these changes. RESULTS: Mortality increased in 2020 relative to 2017-2019 for all racial and Hispanic-origin groups. Adjusting for age, mortality increases were larger at ages 25+ among foreign-born males (390 deaths for 100,000 residents) and females (189) than among US-born males (223) and females (144). The large mortality rise among foreign-born Hispanic men (593) contributed to the narrowing of their mortality advantage relative to White men, from 426 to 134. An increase in mortality among both foreign-born and US-born Black males and females increased the Black-White mortality disparities by 318 for males and by 180 for females. Although COVID-19 mortality was the main driver of the increase among foreign-born residents, circulatory diseases and malignant neoplasms also contributed. CONTRIBUTION: We show that the COVID-19 pandemic had a greater impact on foreign-born populations than on their US-born counterparts. These findings highlight the need to address the underlying inequalities and unique challenges faced by foreign-born populations.

Decomposing County-Level Working-Age Mortality Trends in the United States Between 1999-2001 and 2015-2017.

Studies have documented significant geographic divergence in U.S. mortality in recent decades. However, few studies have examined the extent to which county-level trends in mortality can be explained by national, state, and metropolitan-level trends, and which county-specific factors contribute to remaining variation. Combining vital statistics data on deaths and Census data with time-varying county-level contextual characteristics, we use a spatially explicit Bayesian hierarchical model to analyze the associations between working-age mortality, state, metropolitan status and county-level socioeconomic conditions, family characteristics, labor market conditions, health behaviors, and population characteristics between 2000 and 2017. Additionally, we employ a Shapley decomposition to illustrate the additive contributions of each changing county-level characteristic to the observed mortality change in U.S. counties between 1999-2001 and 2015-2017 over and above national, state, and metropolitan-nonmetropolitan mortality trends. Mortality trends varied by state and metropolitan status as did the contribution of county-level characteristics. Metropolitan status predicted more of the county-level variance in mortality than state of residence. Of the county-level characteristics, changes in percent college-graduates, smoking prevalence and the percent of foreign-born population contributed to a decline in all-cause mortality over this period, whereas increasing levels of poverty, unemployment, and single-parent families and declines manufacturing employment slowed down these improvements, and in many nonmetropolitan areas were large enough to overpower the positive contributions of the protective factors.

Excess body weight, cigarette smoking, and type II diabetes incidence in the national FINRISK studies.

PURPOSE: We identify the individual and joint contributions of excess weight and cigarette smoking to national-level type II diabetes (T2D) incidence and to educational and gender disparities therein filling an important gap in T2D epidemiology. METHODS: Based on the FINRISK surveys conducted in 1997, 2002, and 2007 and linked to the Finnish National Drug Reimbursement Register through 2011, we used a regression-counterfactual approach to estimate the percentage of diagnosed drug-treated incident T2D cases attributable to excess body weight and cigarette smoking. Body mass index (BMI) and waist circumference were evaluated. RESULTS: T2D incidence was 10.24 in men and 7.04 in women per 1000 person-years. Excess baseline BMI (≥25.0 kg/m2) explained 69% and 63%, and smoking explained 9% and 14% of T2D incidence, in men and women, respectively. Most of the gender difference was explained by the risk factors. Approximately 90% in men and 98% in women of the higher T2D incidence among those in the lower versus upper third of the educational distribution was explained by excess BMI. The results were similar for waist circumference and lifetime maximum BMI. CONCLUSIONS: Excess body weight is the main risk factor contributing to national-level T2D incidence and disparities by educational attainment and gender in a high-income population.

Children's educational attainment, occupation, and income and their parents' mortality.

Using data from Finland, this paper contributes to a small but growing body of research regarding adult children's education, occupation, and income and their parents' mortality at ages 50+ in 1970-2007. Higher levels of children's education are associated with 30-36 per cent lower parental mortality at ages 50-75, controlling for parents' education, occupation, and income. This association is fully mediated by children's occupation and income, except for cancer mortality. Having at least one child educated in healthcare is associated with 11-16 per cent lower all-cause mortality at ages 50-75, an association that is largely driven by mortality from cardiovascular diseases. Children's higher white-collar occupation and higher income is associated with 39-46 per cent lower mortality in the fully adjusted models. At ages 75+, these associations are much smaller overall and children's schooling remains more strongly associated with mortality than children's occupation or income.

The Contribution of Weight Status to Black-White Differences in Mortality.

This article examines the contribution of weight status to black-white (B-W) differences in mortality at ages 40-79 using data from the National Health and Nutrition Examination Survey. We measured body mass index (BMI) based on the highest BMI attained and contrasted the contribution of BMI to that of smoking and educational attainment. We estimated both additive and multiplicative models. In addition to estimating regression coefficients we asked what would happen to B-W differences in mortality if blacks had the BMI distribution of whites, the smoking prevalence of whites, or the educational distribution of whites. B-W differences in BMI account for close to 30 percent of the B-W difference in female mortality but only about 1 percent of the B-W difference in male mortality at ages 40-79. In contrast, smoking makes a much larger contribution to the B-W difference in male (17 percent) than female (6 percent) mortality. Differences in educational attainment in turn explain 19 to 25 percent of the B-W mortality difference among men and women, respectively. Our results underscore the importance of two key risk factors as well as educational attainment in generating B-W differences in mortality.

International Differences in the Risk of Death from Smoking and Obesity: The Case of the United States and Finland.

Despite much interest in the health risks associated with behavioral factors, little is known about whether individuals residing in different countries experience a different set of risks. International comparisons of the death risks from major behavioral factors can shed light on whether features of health systems and epidemiological histories modify the health effects of risky behaviors. We used nationally representative samples and mortality linkages spanning the 1971-2014 period from the United States and Finland to examine cross-national differences in the risks of death from cigarette smoking and obesity. We evaluated both current and former smoking and current and prior obesity. In 1990, the approximate midpoint of our study, the death risks from current smoking were about 55% higher in U.S. women compared to Finnish women, but similar for men in the two countries. Death risks from smoking significantly increased over the period for women in both countries and there was no parallel increase in risks among men. Death risks from obesity did not significantly differ in the two countries and no significant trend in the risks were detected in either country. Reasons for the relatively high and increasing risks from smoking among American women warrant further evaluation.

Contribution of smoking-attributable mortality to life expectancy differences by marital status among Finnish men and women, 1971-2010.

BACKGROUND: Smoking is known to vary by marital status, but little is known about its contribution to marital status differences in longevity. We examined the changing contribution of smoking to mortality differences between married and never married, divorced or widowed Finnish men and women aged 50 years and above in 1971-2010. DATA AND METHODS: The data sets cover all persons permanently living in Finland in the census years 1970, 1975 through 2000 and 2005 with a five-year mortality follow-up. Smoking-attributable mortality was estimated using an indirect method that uses lung cancer mortality as an indicator for the impact of smoking on mortality from all other causes. RESULTS: Life expectancy differences between the married and the other marital status groups increased rapidly over the 40-year study period because of the particularly rapid decline in mortality among married individuals. In 1971-1975 37-48% of life expectancy differences between married and divorced or widowed men were attributable to smoking, and this contribution declined to 11-18% by 2006-2010. Among women, in 1971-1975 up to 16% of life expectancy differences by marital status were due to smoking, and the contribution of smoking increased over time to 10-29% in 2006-2010. CONCLUSIONS: In recent decades smoking has left large but decreasing imprints on marital status differences in longevity between married and previously married men, and small but increasing imprints on these differences among women. Over time the contribution of other factors, such as increasing material disadvantage or alcohol use, may have increased.

Obesity Among U.S.- and Foreign-Born Blacks by Region of Birth.

INTRODUCTION: Large, recent migration streams from the non-Hispanic Caribbean islands and Africa have increased the share of U.S. blacks born outside of the U.S. Little is known about health patterns in these foreign-born populations. The purpose of this study is to compare obesity levels among self-identified U.S. blacks across birth regions and examine potential explanations for subgroup differences. METHODS: Data were from the 2000-2013 National Health Interview Surveys. Three birthplace subgroups were examined: individuals born in the U.S., Caribbean/South America, and Africa, aged 25-59 years. Data were analyzed in 2013-2014. RESULTS: Compared to U.S.-born participants, foreign-born participants had significantly lower obesity (BMI ≥30) odds. The AORs were 0.51 (Caribbean/South American-born, 95% CI=0.44, 0.58) and 0.41 (African-born, 95% CI=0.34, 0.50) with reference to U.S.-born individuals. Education, income, and cigarette smoking did not explain the favorable weight pattern of the foreign born. Among the foreign born, those residing in the U.S. for ≥15 years had 51% (95% CI=10%, 108%) higher obesity odds compared with those residing for <5 years. No statistically significant differences in obesity odds between those born in the Caribbean/South America and Africa were detected. CONCLUSION: Foreign-born blacks generally had lower obesity levels compared to their U.S.-born counterparts, which was not explained by SES or smoking behaviors. Despite this advantage, obesity prevalence among foreign-born black women was around 30%, suggesting that obesity poses a significant health risk this population.

Extended maternal age at birth of last child and women's longevity in the Long Life Family Study.

OBJECTIVE: This study investigated the association between maternal age at birth of last child and likelihood of survival to advanced age. METHODS: This was a nested case-control study using Long Life Family Study data. Three hundred eleven women who survived past the oldest 5th percentile of survival (according to birth cohort-matched life tables) were identified as cases, and 151 women who died at ages younger than the top 5th percentile of survival were identified as controls. A Bayesian mixed-effect logistic regression model was used to estimate the association between maternal age at birth of last child and exceptional longevity among these 462 women. RESULTS: We found a significant association for older maternal age, whereby women who had their last child beyond age 33 years had twice the odds for survival to the top 5th percentile of survival for their birth cohorts compared with women who had their last child by age 29 years (age between 33 and 37 y: odds ratio, 2.08; 95% CI, 1.13 to 3.92; older age: odds ratio, 1.92; 95% CI, 1.03 to 3.68). CONCLUSIONS: This study supports findings from other studies demonstrating a positive association between older maternal age and greater odds for surviving to an unusually old age.

The changing contribution of smoking to educational differences in life expectancy: indirect estimates for Finnish men and women from 1971 to 2010.

BACKGROUND: We estimated the contribution of smoking to educational differences in mortality and life expectancy between 1971 and 2010 in Finland. METHODS: Eight prospective datasets with baseline in 1970, 1975, 1980, 1985, 1990, 1995, 2000 and 2005 and each linked to a 5-year mortality follow-up were used. We calculated life expectancy at age 50 years with and without smoking-attributable mortality by education and gender. Estimates of smoking-attributable mortality were based on an indirect method that used lung cancer mortality as a proxy for the impact of smoking on mortality from all other causes. RESULTS: Smoking-attributable deaths constituted about 27% of all male deaths above age 50 years in the early 1970s and 17% in the period 2006-2010; these figures were 1% and 4% among women, respectively. The life expectancy differential between men with basic versus high education increased from 3.4 to 4.7 years between 1971-1975 and 2006-2010. In the absence of smoking, these differences would have been 1.5 and 3.4 years, 1.9 years (55%) and 1.3 years (29%) less than those observed. Among women, educational differentials in life expectancy between the most and least educated increased from 2.5 to 3.0 years. This widening was nearly entirely accounted for by the increasing impact of smoking. Among women the contribution of smoking to educational differences had increased from being negligible in 1971-1975 to 16% in 2006-2010. CONCLUSIONS: Among men, the increase in educational differences in mortality in the past decades was driven by factors other than smoking. However, smoking continues to have a major influence on educational differences in mortality among men and its contribution is increasing among women.

The contribution of smoking to black-white differences in U.S. mortality.

Smoking has significantly impacted American mortality and remains a major cause of morbidity and mortality. No previous study has systematically examined the contribution of smoking-attributable deaths to mortality trends among blacks or to black-white mortality differences at older ages over time in the United States. In this article, we employ multiple methods and data sources to provide a comprehensive assessment of this contribution. We find that smoking has contributed to the black-white gap in life expectancy at age 50 for males, accounting for 20 % to 48 % of the gap between 1980 and 2005, but not for females. The fraction of deaths attributable to smoking at ages above 50 is greater for black males than for white males; and among men, current smoking status explains about 20 % of the black excess relative risk in all-cause mortality at ages above 50 without adjustment for socioeconomic characteristics. These findings advance our understanding of the contribution of smoking to contemporary mortality trends and differences and reinforce the need for interventions that better address the needs of all groups.

Migrant selection and the health of U.S. immigrants from the former Soviet Union.

Few prior studies have investigated the health of U.S. immigrants from the former Soviet Union (FSU). Utilizing data from the 2000 U.S. census and the 2000-2007 National Health Interview Survey (NIHS), we compare levels of disability of FSU immigrants with U.S.-born whites (ages 50-84). Our findings suggest an "epidemiologic paradox" in that FSU immigrants possess higher levels of education compared with U.S.-born whites, but report considerably higher disability with and without adjustment for education. Nonetheless, FSU immigrants report lower levels of smoking and heavy alcohol use compared with U.S.-born whites. We further investigate disability by period of arrival among FSU immigrants. Changes in Soviet emigration policies conceivably altered the level of health selectivity among émigrés. We find evidence that FSU immigrants who emigrated during a period when a permission to emigrate was hard to obtain (1970-1986) displayed less disability compared with those who emigrated when these restrictions were less stringent (1987-2000). Finally, we compare disability among Russian-born U.S. immigrants with that of those residing in Russia as a direct test of health selectivity. We find that Russian immigrants report lower levels of disability compared with Russians in Russia, suggesting that they are positively selected for health despite their poor health relative to U.S.-born whites.

Do early-life conditions predict functional health status in adulthood? The case of Mexico.

Relatively few researchers have investigated early antecedents of adult functional limitations in developing countries. In this study, we assessed associations between childhood conditions and adult lower-body functional limitations (LBFL) as well as the potential mediating role of adult socioeconomic status, smoking, body mass index, and chronic diseases or symptoms. Based on data from the Mexican Health and Aging Study (MHAS) of individuals born prior to 1951 and contacted in 2001 and 2003, we found that childhood nutritional deprivation, serious health problems, and family background predict adult LBFL in Mexico. Adjustment for the potential mediators in adulthood attenuates these associations only to a modest degree.

Variations in health and health behaviors by nativity among pregnant Black women in Philadelphia.

OBJECTIVES: We compared health behaviors and health outcomes among US-born, African-born, and Caribbean-born pregnant Black women and examined whether sociodemographic and psychosocial characteristics explained differences among these population subgroups. METHODS: We analyzed data from a prospective cohort study conducted in Philadelphia, Pennsylvania, with a series of nested logistic regression models predicting tobacco, alcohol, and marijuana use and measures of physical and mental health. RESULTS: Foreign-born Black women were significantly less likely to engage in substance use and had better self-rated physical and mental health than did native-born Black women. These findings were largely unchanged by adjustment for sociodemographic and psychosocial characteristics. The foreign-born advantage varied by place of birth: it was somewhat stronger for African-born women than for Caribbean-born women. CONCLUSIONS: Further studies are needed to gain a better understanding of the role of immigrant selectivity and other characteristics that contribute to more favorable health behaviors and health outcomes among foreign-born Blacks than among native-born Blacks in the United States.

Risky health behaviors among mothers-to-be: the impact of adverse childhood experiences.

OBJECTIVES: Adverse childhood experiences (ACEs) are risk factors for health problems later in life. This study aims to assess the influence of ACEs on risky health behaviors among mothers-to-be and determine whether a dose response occurs between ACEs and risky behaviors. METHODS: A prospective survey of women attending health centers was conducted at the first prenatal care visit, and at 3 and 11 months postpartum. Surveys obtained information on maternal sociodemographic and health characteristics, and 7 ACEs prior to age 16. Risky behaviors included smoking, alcohol use, marijuana use, and other illicit drug use during pregnancy. RESULTS: Our sample (N = 1476) consisted of low-income (mean annual personal income, $8272), young (mean age, 24 years), African American (71%), single (75%) women. Twenty-three percent of women reported smoking even after finding out they were pregnant, 7% reported alcohol use, and 7% reported illicit drug use during pregnancy. Nearly three fourths (72%) had one or more ACEs. There was a higher prevalence of each risky behavior among those exposed to each ACE than among those unexposed. The exception was alcohol use during pregnancy, where there was not an increased risk among those exposed when compared with those unexposed to witnessing a shooting or having a guardian in trouble with the law or in jail. The adjusted odds ratio for each risky behavior was >2.5 for those with >3 ACEs when compared with those without. CONCLUSIONS: ACEs were associated with risky health behaviors reported by mothers-to-be. Greater efforts should target the prevention of ACEs to lower the risk for adverse health behaviors that have serious consequences for adults and their children.

Perceived discrimination and depressive symptoms, smoking, and recent alcohol use in pregnancy.

BACKGROUND: Perceived discrimination is associated with poor mental health and health-compromising behaviors in a range of vulnerable populations, but this link has not been assessed among pregnant women. We aimed to determine whether perceived discrimination was associated with these important targets of maternal health care among low-income pregnant women. METHODS: Face-to-face interviews were conducted in English or Spanish with 4,454 multiethnic, low-income, inner-city women at their first prenatal visit at public health centers in Philadelphia, Penn, USA, from 1999 to 2004. Perceived chronic everyday discrimination (moderate and high levels) in addition to experiences of major discrimination, depressive symptomatology (CES-D >or= 23), smoking in pregnancy (current), and recent alcohol use (12 months before pregnancy) were assessed by patients' self-report. RESULTS: Moderate everyday discrimination was reported by 873 (20%) women, high everyday discrimination by 238 (5%) women, and an experience of major discrimination by 789 (18%) women. Everyday discrimination was independently associated with depressive symptomatology (moderate = prevalence ratio [PR] of 1.58, 95% CI: 1.38-1.79; high = PR of 1.82, 95% CI: 1.49-2.21); smoking (moderate = PR of 1.19, 95% CI: 1.05-1.36; high = PR of 1.41, 95% CI: 1.15-1.74); and recent alcohol use (moderate = PR of 1.23, 95% CI: 1.12-1.36). However, major discrimination was not independently associated with these outcomes. CONCLUSIONS: This study demonstrated that perceived chronic everyday discrimination, but not major discrimination, was associated with depressive symptoms and health-compromising behaviors independent of potential confounders, including race and ethnicity, among pregnant low-income women.

Maternal weathering and risk of preterm delivery.

OBJECTIVES: We compared the association between advancing maternal age and risk of preterm delivery across 4 groups (Black smokers, Black nonsmokers, White smokers, White nonsmokers) and within the context of neighborhood deprivation levels. METHODS: We obtained data from linked census and birth records for singletons (n = 182 938) delivered by women aged 20 to 39 years in Philadelphia, Pennsylvania; Baltimore, Maryland; 16 Michigan cities; 3 Maryland counties; and 2 North Carolina counties. Results from area-specific multilevel logistic regression models were combined to obtain pooled estimates of relations between maternal age and risk of preterm delivery. We repeated the models after categorizing women by neighborhood deprivation level (low, medium, and high). RESULTS: Among multiparous women, there was a significant age-related increase in preterm delivery in 3 of the 4 groups. The adjusted odds ratio per 5-year age increase was 1.31 in Black smokers, 1.11 in Black nonsmokers, and 1.16 in White smokers. In each group, the odds ratio increased as neighborhood deprivation increased. CONCLUSIONS: These results support the "weathering" hypothesis, suggesting that Black women, women with high-risk behaviors, and women living in high-deprivation neighborhoods may develop "accelerated aging" that increases preterm delivery risk.

Distinct trajectories of perinatal depressive symptomatology: evidence from growth mixture modeling.

Although heterogeneity in the timing and persistence of maternal depressive symptomatology has implications for screening and treatment as well as associated maternal and child health outcomes, little is known about this variability. A prospective observational study of 1,735 low-income, multiethnic, inner-city women recruited in pregnancy from 2000 to 2002 and followed prospectively until 2004 (1 prenatal and 3 postpartum interviews) was used to determine whether distinct trajectories of depressive symptomatology can be defined from pregnancy through 2 years postpartum. Analysis was carried out through general growth mixture modeling. A model with 5 trajectory classes characterized the heterogeneity seen in the timing and magnitude of depressive symptoms among the study participants from Philadelphia, Pennsylvania. These classes included the following: 1) always or chronic depressive symptomatology (7%); 2) antepartum only (6%); 3) postpartum, which resolves after the first year postpartum (9%); 4) late, present at 25 months postpartum (7%); and 5) never having depressive symptomatology (71%). Women in these trajectory classes differed in demographic (nativity, education, race, parity) health, health behavior, and psychosocial characteristics (ambivalence about pregnancy and high objective stress). This heterogeneity should be considered in maternal depression programs. Additional research is needed to determine the association of these trajectory classes with maternal and child health outcomes.

Factors associated with intention to breastfeed among low-income, inner-city pregnant women.

OBJECTIVES: To examine the relationship between sociodemographic factors, maternal characteristics, and intention to breastfeed among low-income, inner-city pregnant women. METHODS: English and Spanish speaking low-income women recruited from local Philadelphia health centers were surveyed at the time of their first prenatal care visit. At the time of the visit, respondents were asked whether or not they planned to breastfeed their infant. The responses of 2,690 women were included in these analyses. Multivariate logistic regression was used to assess the independent associations of race/ethnicity, nativity status, education, and other factors on the odds of intending to breastfeed. RESULTS: About half (53%) of the respondents reported that they intended to breastfeed their infant. In adjusted logistic regression models, immigrant black (adjusted OR [aOR] 5.82; 95% confidence interval [CI] 3.86, 8.77), other Hispanic (who were predominantly foreign-born) (aOR 6.05; 95% CI 3.92, 9.33), and island-born Puerto Rican (aOR 3.48; 95% CI 2.04, 5.95) women were significantly more likely to report that they intended to breastfeed than non-Hispanic whites. Somewhat surprisingly, non-Hispanic, US-born African Americans in this low-income sample were more likely to report that they intended to breastfeed than non-Hispanic white respondents (aOR 1.59; 95% CI 1.20, 2.11). Lower education, not living with the baby's father, multiparous pregnancy, and smoking were negatively and independently associated with intention to breastfeed. Maternal age, household income, public housing, and depressive symptoms were not significant predictors of breastfeeding intention in adjusted multivariate models. CONCLUSIONS: Significant differences were documented in breastfeeding intention in our sample of low-income, inner-city women. Most notable was the higher likelihood of anticipated breastfeeding among our immigrant sub-groups when compared with non-Hispanic white women. An unexpected finding was the higher likelihood of anticipated breastfeeding among native-born, non-Hispanic African American women than among non-Hispanic white respondents. Because intentions are important predictors of future behavior, more focus needs to be directed towards breastfeeding promotion during the prenatal period and towards a better understanding of why some mothers intend to breastfeed while others do not.