The "double jeopardy" of midlife and old age mortality trends in the United States.

Since 2010, US life expectancy growth has stagnated. Much research on US mortality has focused on working-age adults given adverse trends in drug overdose deaths, other external causes of death, and cardiometabolic deaths in midlife. We show that the adverse mortality trend at retirement ages (65+ y) has in fact been more consequential to the US life expectancy stagnation since 2010, as well as excess deaths and years of life lost in 2019, than adverse mortality trends at working ages. These results reveal that the United States is experiencing a "double jeopardy" that is driven by both mid-life and older-age mortality trends, but more so by older-age mortality. Understanding and addressing the causes behind the worsening mortality trend in older ages will be essential to returning to the pace of life expectancy improvements that the United States had experienced for decades.

Obesity as a Main Threat to Future Improvements in Population Health: Policy Opportunities and Challenges.

Policy Points Obesity has emerged as a main threat to future improvements in population health, and there is little evidence that the epidemic is retreating. The traditional model of "calories in, calories out," which has guided public health policy for decades, is increasingly viewed as far too simple a framing to explain the evolution of the epidemic or guide public policy. Advances in the science of obesity, coming from many fields, highlight the structural nature of the risk, which has provided an evidence base to justify and guide policies toward addressing the social and environmental drivers of obesity. Societies and researchers need to play the long game in that widespread reductions in obesity in the short run are unlikely. Nonetheless, there are opportunities. Policies specifically targeting the food environment such as taxing high-calorie beverages and foods, restricting the marketing of junk foods to children, enhancing food labeling, and improving the dietary environment at schools may yield long-run benefits.

US life expectancy stalls due to cardiovascular disease, not drug deaths.

After decades of robust growth, the rise in US life expectancy stalled after 2010. Explanations for the stall have focused on rising drug-related deaths. Here we show that a stagnating decline in cardiovascular disease (CVD) mortality was the main culprit, outpacing and overshadowing the effects of all other causes of death. The CVD stagnation held back the increase of US life expectancy at age 25 y by 1.14 y in women and men, between 2010 and 2017. Rising drug-related deaths had a much smaller effect: 0.1 y in women and 0.4 y in men. Comparisons with other high-income countries reveal that the US CVD stagnation is unusually strong, contributing to a stark mortality divergence between the US and peer nations. Without the aid of CVD mortality declines, future US life expectancy gains must come from other causes-a monumental task given the enormity of earlier declines in CVD death rates. Reversal of the drug overdose epidemic will be beneficial, but insufficient for achieving pre-2010 pace of life expectancy growth.

Trends in the Risk of Cognitive Impairment in the United States, 1996-2014.

BACKGROUND: Accumulating evidence suggests risk of cognitive impairment is declining in high-income countries. Much of this research uses longitudinal surveys in which learning over repeated tests may bias results. We analyze trends in cognitive impairment in the United States, accounting for prior test experience and selective mortality. METHODS: We use the Health and Retirement Study, a population-based, nationally representative panel dataset and include individuals ages 50 years and older in 1996-2014 (n = 32,784). We measure cognitive impairment and dementia using standard cutpoints of the modified Telephone Interview for Cognitive Status. We estimate logistic regression models for any impairment and dementia over time, adjusting for age, sex, and race/ethnicity, comparing models with and without adjustment for practice effects and education. We examine heterogeneity in trends by age, sex, race/ethnicity, and education. RESULTS: Models not controlling for test experience suggest that risk of cognitive impairment and dementia decreased over the study period. Controlling for test experience reverses the trend. In our primary models, prevalence of any cognitive impairment increased for women from 18.7% to 21.2% (annual change 0.7%, 95% confidence interval [CI], 0.1%, 1.3%) and for men from 17.6% to 21.0% (annual change 1.0%, CI, 0.5%, 1.4%). For dementia, women's annual increase was 1.7% (CI, 0.8%, 2.6%) and men's 2.0% (CI, 1.0%, 2.9%). If not for education, the increase would have been stronger. Increased risk was particularly rapid for Latinas, the least educated, and older ages. CONCLUSIONS: Risk of cognitive impairment increased from 1996 to 2014. Uncovering determinants of increasing cognitive impairment risk should become a research priority. See video abstract: http://links.lww.com/EDE/B702.

Contributions of obesity and cigarette smoking to incident disability: A longitudinal analysis.

Downward trends in U.S. disability levels are stagnating. Assessing the key contributors to U.S. disability incidence is critical to improving the functional status of the U.S. population. Using longitudinal, nationally representative data from waves 2003-2015 of the Panel Study of Income Dynamics (PSID), we estimated age-specific U.S. disability incidence and quantified the individual and joint contributions of obesity (contemporaneous and earlier-life; BMI ≥ 30) and cigarette smoking to disability incidence. Participants were adults ages 33-96 who participated in PSID in 1986 and at least two consecutive waves 2003-2015 (N = 3247). We conducted age-stratified logistic regressions to predict incident disability at middle and older ages (33-69 years, 70-96 years). Next, counterfactual scenarios were used to estimate the contributions of each risk factor to incident disability. Disability incidence was greater in women than men (5.8 and 4.5 cases per 100 person-years, respectively) and increased with age. Obesity and cigarette smoking jointly explained 17-38% of disability incidence; each factor contributed roughly equal amounts in all groups but older men, for whom smoking history appeared more important. Obesity and smoking appeared to explain more of disability at younger ages (women: 33.1%, 95% CI: 25.1 to 41.0%; men: 37.6%, 95% CI: 28.8 to 46.5%) than at older ages (women: 16.5%, 95% CI: 8.2 to 24.9%; men: 24.5.%, 95% CI: 12.7 to 36.3%). This study provides a benchmark for monitoring trends in U.S. disability incidence. Obesity and smoking are key contributors to disability, accounting for 17-38% of incident disability in U.S. adults.

Age at Immigration, Generational Status, and Death Among Children of Immigrant Mothers: A Longitudinal Analysis of Siblings.

Studies have documented that age at immigration and generational status are important predictors of socioeconomic outcomes among children of immigrants. Whether these characteristics are related to long-term risk of death is unknown. Leveraging variation within sibships, we evaluated the association of age at immigration and generational status (i.e., first or second generation) with death among children of immigrant mothers to Sweden. Data included 272,429 individuals (126,701 sibships) aged 15 or more years from the total Swedish population followed between 1990 and 2009. Population-average and sibling fixed-effect regressions were estimated, with the latter controlling for unobserved factors shared by siblings. The foreign-born children of immigrants experienced a 17% higher risk of death than the Swedish-born children of immigrants. This excess risk was evident for external and nonexternal causes of death. In general, a graded association was not detected between age at immigration and death among the foreign-born individuals; however, those arriving during primary school ages appeared especially vulnerable. This study provides robust evidence that among children of immigrants, being foreign born was associated with a long-term death penalty compared with being born in the host country.

Work Disability Among Native-born and Foreign-born Americans: On Origins, Health, and Social Safety Nets.

Public debates about both immigration policy and social safety net programs are increasingly contentious. However, little research has explored differences in health within America's diverse population of foreign-born workers, and the effect of these workers on public benefit programs is not well understood. We investigate differences in work disability by nativity and origins and describe the mix of health problems associated with receiving Social Security Disability Insurance benefits. Our analysis draws on two large national data sources-the American Community Survey and comprehensive administrative records from the Social Security Administration-to determine the prevalence and incidence of work disability between 2001 and 2010. In sharp contrast to prior research, we find that foreign-born adults are substantially less likely than native-born Americans to report work disability, to be insured for work disability benefits, and to apply for those benefits. Overall and across origins, the foreign-born also have a lower incidence of disability benefit award. Persons from Africa, Northern Europe, Canada, and parts of Asia have the lowest work disability benefit prevalence rates among the foreign-born; persons from Southern Europe, Western Europe, the former Soviet Union, and the Caribbean have the highest rates.

County-Level Variation in Cardiovascular Disease Mortality in the United States in 2009-2013: Comparative Assessment of Contributing Factors.

We examined factors responsible for variation in cardiovascular disease (CVD) mortality across US counties in 2009-2013. We linked county-level census, survey, administrative, and vital statistics data to examine 4 sets of features: demographic factors, social and economic factors, health-care utilization and features of the environment, and population health indicators. County-level associations of these features (standardized to a mean of 0 with a standard deviation of 1) with cardiovascular deaths per 100,000 person-years among adults aged 45-74 years was modeled using 2-level hierarchical linear regression with random intercept for state. The percentage of CVD mortality variation (intercounty disparity) modeled by each set of features was quantified. Demographic composition accounted for 36% of county CVD mortality variation, and another 32% was explained after inclusion of economic/social conditions. Health-care utilization, features of the environment, and health indicators explained an additional 6% of CVD mortality variation. The largest contributors to CVD mortality levels were median income (-23.61 deaths/100,000 person-years, 95% CI: -26.95, -20.26) and percentage without a high school education (20.71 deaths/100,000 person-years, 95% CI: 16.48, 24.94). In comparison, the largest health-related contributors were health-care utilization (19.35 deaths/100,000 person-years, 95% CI: 16.36, 22.34) and CVD risk factors (4.80 deaths/100,000 person-years, 95% CI: 2.14, 7.46). Improving health-care access and decreasing the prevalence of traditional CVD risk factors may reduce county CVD mortality levels, but improving socioeconomic circumstances of disadvantaged counties will be required in order to reduce CVD mortality disparities across counties.

Life-Course Body Mass Index Trajectories Are Predicted by Childhood Socioeconomic Status but Not Exposure to Improved Nutrition during the First 1000 Days after Conception in Guatemalan Adults.

BACKGROUND: Latin America has experienced increases in obesity. Little is known about the role of early life factors on body mass index (BMI) gain over the life course. OBJECTIVE: The objective of this research was to examine the role of early life factors [specifically, nutrition supplementation during the first 1000 d (from conception to 2 y of age) and childhood household socioeconomic status (SES)] on the pattern of BMI gain from birth or early childhood through midadulthood by using latent class growth analysis. METHODS: Study participants (711 women, 742 men) who were born in 4 villages in Guatemala (1962-1977) were followed prospectively since participating in a randomized nutrition supplementation trial as children. Sex-specific BMI latent class trajectories were derived from 22 possible measures of height and weight from 1969 to 2004. To characterize early life determinants of BMI latent class membership, we used logistic regression modeling and estimated the difference-in-difference (DD) effect of nutrition supplementation during the first 1000 d. RESULTS: We identified 2 BMI latent classes in women [low (57%) and high (43%)] and 3 classes in men [low (38%), medium (47%), and high (15%)]. Nutrition supplementation during the first 1000 d after conception was not associated with BMI latent class membership (DD test: P > 0.15 for men and women), whereas higher SES was associated with increased odds of high BMI latent class membership in both men (OR: 1.98; 95% CI: 1.09, 3.61) and women (OR: 1.62; 95% CI: 1.07, 2.45) for the highest relative to the lowest tertile. CONCLUSIONS: In a cohort of Guatemalan men and women, nutrition supplementation provided during the first 1000 d was not significantly associated with higher BMI trajectory. Higher childhood household SES was associated with increased odds of high BMI latent class membership relative to the poorest households. The pathways through which this operates still need to be explored.

Early Life Growth Predicts Pubertal Development in South African Adolescents.

BACKGROUND: Given global trends toward earlier onset of puberty and the adverse psychosocial consequences of early puberty, it is important to understand the childhood predictors of pubertal timing and tempo. OBJECTIVE: We examined the association between early growth and the timing and tempo of puberty in adolescents in South Africa. METHODS: We analyzed prospectively collected data from 1060 boys and 1135 girls participating in the Birth-to-Twenty cohort in Soweto, South Africa. Height-for-age z scores (HAZs) and body mass index-for-age z scores (BMIZs) were calculated based on height (centimeters) and body mass index (kilograms per meter squared) at ages 5 y and 8 y. The development of genitals, breasts, and pubic hair was recorded annually from 9 to 16 y of age with the use of the Tanner sexual maturation scale (SMS). We used latent class growth analysis to identify pubertal trajectory classes and also characterized children as fast or slow developers based on the SMS score at 12 y of age. We used multinomial logistic regression to estimate associations of HAZ and BMIZ at ages 5 and 8 y with pubertal development. RESULTS: We identified 3 classes for pubic hair development (for both girls and boys) and 4 classes for breast (for girls) and genital (for boys) development. In girls, both HAZ and BMIZ at age 5 y were positively associated with pubic hair development [relative risk ratio (RRR): 1.57, P < 0.001 and RRR: 1.51, P < 0.01, respectively], as was BMI at age 8 y (RRR: 2.06, P = 0.03); similar findings were observed for breast development. In boys, HAZ and BMIZ at age 5 y were positively associated with pubic hair development (RRR: 1.78, P < 0.001 and RRR: 1.43, P < 0.01, respectively); HAZ at age 5 y was associated with development of genitals (RRR: 2.19, P < 0.01). CONCLUSION: In boys and girls, both height and body mass index in early childhood predicted the trajectory of pubertal development. This may provide a tool to identify children at risk of early pubertal onset.

Pubertal Development and Prepubertal Height and Weight Jointly Predict Young Adult Height and Body Mass Index in a Prospective Study in South Africa.

BACKGROUND: Height and adiposity track over childhood, but few studies, to our knowledge, have longitudinally examined the mediating relation of the timing and progression of puberty. OBJECTIVE: We assessed interrelations between prepubertal height and body mass index, the progression through puberty, and young adult height and adiposity. METHODS: We analyzed data from the Birth to Twenty Plus study (females, n = 823; males, n = 765). Serial measures of anthropometry and pubertal development were obtained between ages 9 and 16 y. We used latent class growth analysis to categorize pubertal development with respect to pubic hair (females and males), breasts (females), and genitalia (males) development. Adult height and weight were obtained at ages 18 to 20 y. RESULTS: Among females, higher latent class (earlier initiation and faster progression through puberty) was associated with an increased risk of obesity [pubic hair class 3 compared with class 1: RR, 3.41 (95% CI: 1.57, 7.44)] and inconsistent associations with height. Among males, higher latent class was associated with increased adult height [pubic hair development class 3 compared with class 1: 2.43 cm (95% CI: 0.88, 4.00)] and increased risk of overweight/obesity [pubic hair development class 3 compared with class 1: OR, 3.44 (95% CI: 1.44, 8.20)]. In females, the association with adult height became inverse after adjusting for prepubertal height [pubic hair development class 3 compared with class 1: females, -1.31 cm (95% CI: -2.32, -0.31)]; in males, the association with height was attenuated with this adjustment [-0.56 cm (95% CI: -1.63, 0.52)]. Associations with adiposity were attenuated after adjusting for prepubertal adiposity. CONCLUSIONS: Progression through puberty modifies the relation between prepubertal and adult anthropometry. Screening for early or rapid progression of puberty might identify children at an increased risk of becoming overweight or obese adults.

Life Expectancy Among U.S.-born and Foreign-born Older Adults in the United States: Estimates From Linked Social Security and Medicare Data.

In recent decades, the geographic origins of America's foreign-born population have become increasingly diverse. The sending countries of the U.S. foreign-born vary substantially in levels of health and economic development, and immigrants have arrived with distinct distributions of socioeconomic status, visa type, year of immigration, and age at immigration. We use high-quality linked Social Security and Medicare records to estimate life tables for the older U.S. population over the full range of birth regions. In 2000-2009, the foreign-born had a 2.4-year advantage in life expectancy at age 65 relative to the U.S.-born, with Asian-born subgroups displaying exceptionally high longevity. Foreign-born individuals who migrated more recently had lower mortality compared with those who migrated earlier. Nonetheless, we also find remarkable similarities in life expectancy among many foreign-born subgroups that were born in very different geographic and socioeconomic contexts (e.g., Central America, western/eastern Europe, and Africa).

The contribution of subsidized food commodities to total energy intake among US adults.

OBJECTIVE: The contribution of subsidized food commodities to total food consumption is unknown. We estimated the proportion of individual energy intake from food commodities receiving the largest subsidies from 1995 to 2010 (corn, soyabeans, wheat, rice, sorghum, dairy and livestock). DESIGN: Integrating information from three federal databases (MyPyramid Equivalents, Food Intakes Converted to Retail Commodities, and What We Eat in America) with data from the 2001-2006 National Health and Nutrition Examination Surveys, we computed a Subsidy Score representing the percentage of total energy intake from subsidized commodities. We examined the score's distribution and the probability of having a 'high' (≥70th percentile) v. 'low' (≤30th percentile) score, across the population and subgroups, using multivariate logistic regression. SETTING: Community-dwelling adults in the USA. SUBJECTS: Participants (n 11 811) aged 18-64 years. RESULTS: Median Subsidy Score was 56·7 % (interquartile range 47·2-65·4 %). Younger, less educated, poorer, and Mexican Americans had higher scores. After controlling for covariates, age, education and income remained independently associated with the score: compared with individuals aged 55-64 years, individuals aged 18-24 years had a 50 % higher probability of having a high score (P<0·0001). Individuals reporting less than high-school education had 21 % higher probability of having a high score than individuals reporting college completion or higher (P=0·003); individuals in the lowest tertile of income had an 11 % higher probability of having a high score compared with individuals in the highest tertile (P=0·02). CONCLUSIONS: Over 50 % of energy in US diets is derived from federally subsidized commodities.

Diabetes among US- and foreign-born blacks in the USA.

OBJECTIVE: Little is known about diabetes status among US blacks by nativity. This study aims to measure differences in diabetes among US blacks by region of birth and examines potential explanations for subgroup differences. DESIGN: Data from 47,751 blacks aged 25-74 pooled from the 2000-2013 waves of the National Health Interview Survey were analyzed. Logistic regression models predicted self-reported diabetes. The roles of education, income, body mass index (BMI), smoking, and duration of US residence were explored. RESULTS: Compared to the US-born, foreign-born blacks had significantly lower reported diabetes prevalence (8.94% vs. 11.84%) and diabetes odds ratio [OR: 0.75; 95% confidence interval (CI): 0.62, 0.89], adjusting for socio-demographic characteristics. Further inclusion of education, income, household size, and smoking did not appreciably change the OR (0.77; 95% CI: 0.61, 0.86). Including an adjustment for BMI entirely eliminated the foreign-born advantage (OR 0.93; 95% CI: 0.78, 1.11). The foreign-born from the Caribbean/Americas had similar diabetes odds compared to the African-born. Among the foreign-born, an increased duration of US residence was associated with a higher diabetes odds, but these associations did not reach statistical significance (p > 0.05). CONCLUSION: The healthy immigrant advantage extended to diabetes among US blacks, a finding that is explained by lower levels of overweight/obesity among the foreign-born compared to the US-born. Nonetheless, more than 71.4% of the foreign-born were overweight or obese. Understanding the mechanisms through which exposure to the US environment leads to higher obesity and diabetes risk may aid prevention efforts for the rapidly growing foreign-born black subpopulation.

Cardiovascular mortality associated with 5 leading risk factors: national and state preventable fractions estimated from survey data.

BACKGROUND: Impressive decreases in cardiovascular mortality have been achieved through risk factor reduction and clinical intervention, yet cardiovascular disease remains a leading cause of death nationally. OBJECTIVE: To estimate up-to-date preventable fractions of cardiovascular mortality associated with elimination and reduction of 5 leading risk factors nationally and by state in the United States. DESIGN: Cross-sectional and cohort studies. SETTING: Nationally representative and state-representative samples of the U.S. population. PARTICIPANTS: Adults aged 45 to 79 years. MEASUREMENTS: Self-reported risk factor status in the BRFSS (Behavioral Risk Factor Surveillance System) 2009-2010 was corrected to approximate clinical definitions. The relative hazards of cardiovascular death (International Classification of Diseases, 10th Revision, codes I00 to I99) associated with risk factors were estimated using data from NHANES (National Health and Nutrition Examination Survey) (1988-1994 and 1999-2004, followed through 2006). RESULTS: The preventable fraction of cardiovascular mortality associated with complete elimination of elevated cholesterol levels, diabetes, hypertension, obesity, and smoking was 54.0% for men and 49.6% for women in 2009 to 2010. When the more feasible target of reducing risk factors to the best achieved levels in the states was considered, diabetes (1.7% and 4.1%), hypertension (3.8% and 7.3%), and smoking (5.1% and 4.4%) were independently associated with the largest preventable fractions among men and women, respectively. With both targets, southern states had the largest preventable fractions, and western states had the smallest. LIMITATION: Self-reported state data; mortality hazards relied on baseline risk factor status. CONCLUSION: Major modifiable cardiovascular risk factors collectively accounted for half of cardiovascular deaths in U.S. adults aged 45 to 79 years in 2009 to 2010. Fewer than 10% of cardiovascular deaths nationally could be prevented if all states were to achieve risk factor levels observed in the best-performing states. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation.

Protein kinase C-beta: An emerging connection between nutrient excess and obesity.

There is currently a global epidemic of obesity as a result of recent changes in lifestyle. Excess body fat deposition is caused by an imbalance between energy intake and energy expenditure due to interactions between genetic and environmental factors. The signals and biological mechanisms that trigger fat accumulation by disrupting energy homeostasis are not well understood. There is considerable evidence now supporting a possible role of protein kinase C beta (PKCß) in energy homeostasis. This review highlights recent findings on the role of PKCß activation in the genesis and progression of obesity, and of PKCß repression in mediating the beneficial effects of physical exercise. Available data support a model in which adipose PKCß activation is among the initiating events that disrupt mitochondrial function through interaction with p66shc and amplify fat accumulation and adipose dysfunction, with systemic consequences. Manipulation of PKCß levels, activity, or signaling could provide a therapeutic approach to combat obesity and associated metabolic disorders.

Health among Black children by maternal and child nativity.

OBJECTIVES: We examined 5 health outcomes among Black children born to US-born and foreign-born mothers and whether differences by mother's region of birth could be explained by maternal duration of US residence, child's place of birth, and familial sociodemographic characteristics. METHODS: Data were from the 2000-2011 National Health Interview Surveys. We examined 3 groups of children, based on mother's region of birth: US origin, African origin, and Latin American or Caribbean origin. We estimated multivariate regression models. RESULTS: Children of foreign-born mothers were healthier across all 5 outcomes than were children of US-born mothers. Among children of foreign-born mothers, US-born children performed worse on all health outcomes than children born abroad. African-origin children had the most favorable health profile. Longer duration of US residence among foreign-born mothers was associated with poorer child health. Maternal educational attainment and other sociodemographic characteristics did little to explain these differences. CONCLUSIONS: Further studies are needed to understand the role of selective migration and the behavioral, cultural, socioeconomic, and contextual origins of the health advantage of Black children of foreign-born mothers.