Declining mental health among disadvantaged Americans.

Although there is little dispute about the impact of the US opioid epidemic on recent mortality, there is less consensus about whether trends reflect increasing despair among American adults. The issue is complicated by the absence of established scales or definitions of despair as well as a paucity of studies examining changes in psychological health, especially well-being, since the 1990s. We contribute evidence using two cross-sectional waves of the Midlife in the United States (MIDUS) study to assess changes in measures of psychological distress and well-being. These measures capture negative emotions such as sadness, hopelessness, and worthlessness, and positive emotions such as happiness, fulfillment, and life satisfaction. Most of the measures reveal increasing distress and decreasing well-being across the age span for those of low relative socioeconomic position, in contrast to little decline or modest improvement for persons of high relative position.

Additive value of interleukin-6 and C-reactive protein in risk prediction for all-cause and cardiovascular mortality among a representative adult cohort in Taiwan.

BACKGROUND/PURPOSE: Interleukin-6 (IL-6) and C-reactive protein (CRP) are inflammatory makers of potential interest in all-cause and cardiovascular death risk prediction, but their additive explanatory value to established risk factors is not well documented among nonwestern populations. METHODS: We investigated the additive value of IL-6 and CRP to the Framingham risk score and lifestyle factors in predicting all-cause and cardiovascular mortality among a population-representative sample of 1023 adults aged 54 years and above in Taiwan. RESULTS: A total of 351 deaths and 82 cardiovascular deaths were identified (median follow-up = 11.2 years). After adjustment for established risk factors, elevated IL-6 and CRP levels were associated with a higher risk of all-cause death: the hazard ratios for the highest risk quartile compared with the lowest quartile were 3.64 (95% confidence interval, 2.44-5.44) for IL-6 and 2.31 (95% confidence interval, 1.62-3.29) for CRP. IL-6 was also significantly associated with cardiovascular mortality. For both all-cause and cardiovascular mortality, IL-6 yielded a substantial and significant increase in the area under the receiver operator characteristic curve (change in the area under the receiver operator characteristic curve = 0.036 and 0.024, respectively), but CRP did not (change in the area under the receiver operator characteristic curve = 0.004 and 0.009, respectively). CONCLUSION: Although both IL-6 and CRP were significantly associated with all-cause mortality, only IL-6 provided a substantial improvement in discrimination. Similarly, IL-6 demonstrated a notable prognostic value for predicting cardiovascular mortality, but not CRP. These findings provide further support for the role of inflammation in the deterioration of health at older ages among a nonwestern population.

Performance-based measures of physical function as mortality predictors: Incremental value beyond self-reports.

BACKGROUND: Although previous studies have indicated that performance assessments strongly predict future survival, few have evaluated the incremental value in the presence of controls for self-reported activity and mobility limitations. OBJECTIVE: We assess and compare the added value of four tests - walking speed, chair stands, grip strength, and peak expiratory flow (PEF) - for predicting all-cause mortality. METHODS: Using population-based samples of older adults in Costa Rica (n = 2290, aged 60+) and Taiwan (n = 1219, aged 53+), we estimate proportional hazards models of mortality for an approximate five-year period. Receiver Operator Characteristic (ROC) curves are used to assess the prognostic value of each performance assessment. RESULTS: Self-reported measures of physical limitations contribute substantial gains in mortality prediction, whereas performance-based assessments yield modest incremental gains. PEF provides the greatest added value, followed by grip strength. Our results suggest that including more than two performance assessments may provide little improvement in mortality prediction. CONCLUSIONS: PEF and grip strength are often simpler to administer in home interview settings, impose less of a burden on some respondents, and, in the presence of self-reported limitations, appear to be better predictors of mortality than do walking speed or chair stands. COMMENTS: Being unable to perform the test is often a strong predictor of mortality, but these indicators are not well-defined. Exclusion rates vary by the specific task and are likely to depend on the underlying demographic, health, social and cultural characteristics of the sample.

Daily exposure to stressors, daily perceived severity of stress, and mortality risk among US adults.

Prior studies of perceived stress and mortality have yielded mixed results, but most are based on one-time measurements of perceived stress. We use daily diary data from the Midlife in the United States study to measure exposure to stressors and perceived severity of stress and investigate their associations with mortality. We also explore whether the associations vary by age and assess whether the associations are stronger for extrinsic than intrinsic mortality, which is more likely to be aging-related. The analysis included 4,756 observations for 2,915 respondents aged 21-95 who participated in at least one of three waves (1996-97, 2004-09, 2017-19) of the National Study of Daily Experiences. Participants reported daily stressors and perceived severity on 8 consecutive evenings at each wave. Mortality was followed through December 31, 2021. In fully-adjusted models, daily exposure to stressors was associated with mortality, but only at younger ages (HR = 1.20 per SD at age 50, 95% CI: 1.01‒1.42). The association was slightly stronger for extrinsic (HR = 1.31 per SD at age 50, 95% CI: 1.01‒1.69) than for intrinsic mortality, which was not significant (HR = 1.24 per SD at age 50, 95% CI: 0.98‒1.56). When we used an alternative measure of daily perceived severity of stress, the demographic-adjusted association appeared to be similar in magnitude, but after careful adjustment for potential confounding with health status, the association weakened and was no longer statistically significant (HR = 1.17 per SD at age 50, 95% CI: 0.99-1.37). Perceived severity was not significantly associated with either extrinsic or intrinsic mortality even at age 50. Most Americans die at older ages, where stress exposure does not appear to be significantly associated with mortality. Nonetheless, our results suggest that stress exposure is more strongly associated with midlife mortality, which has an undue influence on overall life expectancy.

Microbial-mammalian cometabolites dominate the age-associated urinary metabolic phenotype in Taiwanese and American populations.

Understanding the metabolic processes associated with aging is key to developing effective management and treatment strategies for age-related diseases. We investigated the metabolic profiles associated with age in a Taiwanese and an American population. ¹H NMR spectral profiles were generated for urine specimens collected from the Taiwanese Social Environment and Biomarkers of Aging Study (SEBAS; n = 857; age 54-91 years) and the Mid-Life in the USA study (MIDUS II; n = 1148; age 35-86 years). Multivariate and univariate linear projection methods revealed some common age-related characteristics in urinary metabolite profiles in the American and Taiwanese populations, as well as some distinctive features. In both cases, two metabolites--4-cresyl sulfate (4CS) and phenylacetylglutamine (PAG)--were positively associated with age. In addition, creatine and ß-hydroxy-ß-methylbutyrate (HMB) were negatively correlated with age in both populations (p < 4 × 10⁻6). These age-associated gradients in creatine and HMB reflect decreasing muscle mass with age. The systematic increase in PAG and 4CS was confirmed using ultraperformance liquid chromatography-mass spectrometry (UPLC-MS). Both are products of concerted microbial-mammalian host cometabolism and indicate an age-related association with the balance of host-microbiome metabolism.

Perceived stress and mortality in a Taiwanese older adult population.

Perceived stress is associated with poor health outcomes including negative affect, increased susceptibility to the common cold and cardiovascular disease; the consequences of perceived stress for mortality, however, have received less attention. This study characterizes the relationship between perceived stress and 11-year mortality in a population of Taiwanese adults aged 53+ years. Using the Survey of Health and Living Status of the Near Elderly and Elderly of Taiwan, we calculated a composite measure of perceived stress based on six items pertaining to the health, financial situation, and occupation of the respondents and their families. Proportional hazard models were used to determine whether perceived stress predicted mortality. After adjusting for sociodemographic factors only, we found that a one standard deviation increase in perceived stress was associated with a 19% increase in all-cause mortality risk during the 11-year follow-up period (hazard ratio, HR = 1.19, 95% confidence interval, CI 1.13-1.26). The relationship was greatly attenuated when perceptions of stress regarding health were excluded, and was not significant after adjusting for medical conditions, mobility limitations and depressive symptoms. We conclude that the association between perceived stress and mortality is explained by an individual's current health; however, our data do not allow us to distinguish between two possible interpretations of this conclusion: (a) the relationship between perceived stress and mortality is spurious, or (b) poor health acts as the mediator.

Perceived stress and biological risk: is the link stronger in Russians than in Taiwanese and Americans?

Allostatic load theory implies a relationship between exposure to psychological stress and multi-system physiological dysregulation. We used data from population-based samples of men and women in Russia (Moscow; n = 1800; age, mean 68.6 years), Taiwan (n = 1036; 65.6 years) and the United States (US; n = 1054; 58.0 years) -- which are likely to vary widely with respect to levels of stress exposure and biological markers -- to determine the magnitude of the association between perceived stress and physiological dysregulation. The measure of overall dysregulation was based on 15 markers including standard cardiovascular/metabolic risk factors as well as markers of inflammation and neuroendocrine activity. Subjective psychological stress was measured by the perceived stress scale. Only the Moscow sample demonstrated a positive association with overall dysregulation in both sexes. In the US, we found an association among women but not men. Among the Taiwanese, who report the lowest perceived stress, there was no association in women but an unexpected inverse relationship in men. The effects also varied across system-level subscores: the association with perceived stress was most consistent for standard cardiovascular/metabolic factors. Perceived stress was associated with inflammation and neuroendocrine activity in some samples. Although the evidence that perceived stress is the primary source of physiological dysregulation is generally modest, it was stronger in Russia where the level of perceived stress was particularly high. For Russia only, we had information about heart function based on a 24 h ambulatory electrocardiogram; perceived stress was consistently associated with heart rate dysregulation in Russian men and women.

Does exposure to stressors predict changes in physiological dysregulation?

BACKGROUND: The allostatic load framework implies that cumulative exposure to stressors results in multi-system physiological dysregulation. PURPOSE: The purpose of this study was to investigate the effect of stress burden on subsequent changes (2000-2006) in physiological dysregulation. METHODS: Data came from a population-based cohort study in Taiwan (n = 521, aged 54+ in 2000, re-examined in 2006). Measures of stressful events and chronic strain were based on questions asked in 1996, 1999, and 2000. A measure of trauma was based on exposure to the 1999 earthquake. Dysregulation was based on 17 biomarkers (e.g., metabolic, inflammatory, neuroendocrine). RESULTS: There were some small effects among men: chronic strain was associated with subsequent increases in dysregulation (standardized ß = 0.08, 95 % CI = 0.01 to 0.20), particularly inflammation; life events were also associated with increased inflammation (ß = 0.10, CI = 0.01 to 0.26). There were no significant effects in women. CONCLUSIONS: We found weak evidence that stress burden is associated with changes in dysregulation.

Sex differences in trajectories of depressive symptoms among older Taiwanese: the contribution of selected stressors and social factors.

OBJECTIVES: We assessed female-male differences in depressive symptoms among older Taiwanese and quantified the contribution of sex differences in exposure and response to selected covariates in explaining the gap. METHODS: Using data from six survey waves over 18 years for a nationally representative cohort of 4049 Taiwanese aged 60+, we employed growth curve analysis to model individual-level trajectories of depressive symptoms across age. RESULTS: Among older Taiwanese, women's disadvantage with respect to social position and employment accounted for about 40% of the sex difference in depressive symptoms. Sex differences in decision control and exposure to widowhood and financial decline played surprisingly little role. Although we found no evidence that the effects of marriage, recent widowhood or recent child death varied by sex, living apart from one's children appeared to be more detrimental for women than for men in this society. Moreover, the effect of living with children depended on the arrangement: living with an unmarried son was more strongly associated with depressive symptoms than living with a married son and daughter-in-law. CONCLUSION: Sex differentials in social position and employment are major contributors to the sex difference in depressive symptoms among older Taiwanese, yet sex differences in exposure or response to selected stressors appear to play little role. Differential vulnerabilities to particular living arrangements may also contribute to women's excess psychological distress, although more research is needed to elucidate the mechanisms by which living arrangements influence depressive symptoms in Taiwan.

In the midst of a pandemic, more introverted individuals may have a mortality advantage.

Purpose: We investigated whether the relationship between extroversion and mortality changed during the COVID-19 pandemic. Methods: Midlife Americans were surveyed in 1995-96 with mortality follow-up through December 31, 2020. We used a Cox model to estimate age-specific mortality controlling for sex, race/ethnicity, the period trend in mortality, an indicator for the pandemic period (Mar-Dec 2020), extroversion, and an interaction between extroversion and the pandemic indicator. Results: Prior to the pandemic, extroversion was associated with somewhat lower mortality (HR = 0.93 per SD, 95% CI 0.88-0.97), but the relationship reversed during the pandemic. Extroversion was associated with greater pandemic-related excess mortality (HR = 1.29 per SD, 95% CI 1.002-1.67). That is, compared with persons who were more introverted, those who were highly extroverted suffered a bigger increase in mortality during the pandemic relative to pre-pandemic mortality levels. Conclusions: The slight mortality advantage enjoyed by more extroverted Americans prior to the pandemic disappeared during the first 10 months of the COVID-19 pandemic. We suspect that the mortality benefit of introversion during the pandemic is largely a result of reduced exposure to the risk of infection, but it may also derive in part from the ability of more introverted individuals to adapt more easily to reduced social interaction without engaging in self-destructive behavior (e.g., drug and alcohol abuse).

Economic distress, obesity, and the rise in pain.

Growing obesity may have contributed to widening socioeconomic disparities in pain in the US, but some researchers have suggested that deteriorating social and economic conditions among less advantaged Americans could be the root cause. We evaluated whether widening socioeconomic disparities in pain are associated with growing economic distress, particularly among those with low socioeconomic status (SES). We also assessed whether the link between economic distress and pain is mediated by obesity. Using data from nationally-representative samples targeting Americans aged 25-74 in 1995-96 (N = 3034) and 2011-14 (N = 2598), we fit a structural equation model to estimate the contributions of economic distress and obesity to period changes in the SES disparity in different types of pain. Socioeconomic disparities in backaches and joint pain widened substantially over recent decades, although there was no significant widening for headaches. Economic distress accounted for 34% of SES widening for backaches and 41% for joint pain, but the effect was largely independent of obesity. There was little evidence that economic distress led to obesity, which in turn fueled a rise in pain. Obesity alone explained another 8% of the widening SES disparity in backaches and 17% for joint pain. Economic distress played a larger role than obesity because economic distress increased over time for those with low SES whereas it decreased slightly for those with high SES. In contrast, obesity grew at all levels of SES, albeit more for those with low SES. Unfortunately, we cannot establish the direction of causation. Our model assumes that economic distress and obesity affect pain, but it is also possible that pain exacerbates obesity and/or economic distress. If SES disparities in pain continue to widen, it bodes poorly for the overall well-being of the US population, labor productivity, and the prospects for these cohorts as they reach older ages.

Is the Pain killing you? Could Pain interference be a warning signal for midlife mortality?

Although prior studies have documented an association between various measures of pain and mortality, none of those studies has evaluated whether the association between pain and mortality varies significantly by age. We suspect that pain-particularly pain that interferes with the ability to lead a normal life-could be an early warning sign that may portend increased risk of physical impairment and mortality later in life. In this paper, we investigated whether pain was associated with increased mortality risk, particularly in midlife. Data came from the Midlife in the US study, which sampled non-institutionalized, English-speaking adults aged 25-74 in the contiguous United States in 1995-96. Our analysis included 4041 respondents who completed a follow-up self-administered questionnaire in 2004-05, 2703 of whom completed another self-administered questionnaire in 2013-14. We modeled mortality through December 31, 2021. In demographic-adjusted models, pain interference was more strongly associated with mortality than other pain measures, and the association was stronger at younger ages. The hazard ratio for pain interference declined from 1.39 per SD (95% CI 1.26-1.54) at age 60 to 1.14 (95% CI 1.04-1.24) at age 90. Although potential confounders accounted for more than 60% of the association with premature mortality, pain interference remained significantly associated with increased mortality rates (HR = 1.13 at age 60, 95% CI 1.02-1.26). We found no evidence that the association between pain and mortality was driven by cancer. If anything, pain interference was more strongly associated with cardiovascular than cancer mortality. At the oldest ages, physical function is likely to be a better predictor of mortality than pain. Yet, pain interference may be a useful warning sign at younger ages, when there are fewer physical limitations and mortality rates are low. It may be particularly helpful in identifying risk of premature mortality in midlife, before the emergence of severe physical limitations.

Smoking may compromise physical function long before it kills you.

Introduction: Although prior research has demonstrated an association between smoking and worse physical function, most of those studies are based on older people and do not evaluate whether the age-related increase in physical limitations differs by smoking history. We quantify how the magnitude of the smoking differential varies across age. Methods: This cohort study comprised a national sample of Americans aged 20-75 in 1995-1996, who were re-interviewed in 2004-2005 and 2013-2014. Our analysis was restricted to respondents who completed the self-administered questionnaires at Wave 1 (N = 6,325). Follow-up observations for those respondents were included if they completed the self-administered questionnaires at Wave 2 (N = 3,929) and/or Wave 3 (N = 2,849). The final analysis sample comprised 13,103 observations over a follow-up period of up to 19 years (1995-2014). We used a linear mixed model to regress physical limitations on smoking status at baseline adjusted for sex, age, race, socioeconomic status, alcohol abuse, drug abuse, and obesity with an interaction between age and smoking to test whether the age pattern of physical limitations differed by smoking history. Additional models incorporated measures of smoking duration and intensity. Results: In the fully-adjusted model, smokers exhibited a steeper age-related increase in physical limitations than never smokers. Thus, the disparities in physical limitations by smoking status widened with age but were evident even at young ages. The estimated differential between heavy smokers and never smokers rose from 0.24 SD at age 30 to 0.49 SD at age 80. At younger ages, heavy smokers who quit recently fared worse than current light smokers and not much better than current heavy smokers. Discussion: We know smoking is bad for our health, but these results reveal that differences in physical limitations by smoking history are evident even at ages as young as 30. Physical limitations that emerge early in life are likely to have an especially large impact because they can jeopardize health for decades of remaining life. Smoking probably will not kill you at young age, but it may compromise your physical function long before it kills you. Just do not do it.

Cognition and Mortality Risk Among Midlife and Older Americans.

BACKGROUND: Cognitive impairment is associated with increased mortality rates in late life, but it is unclear whether worse cognition predicts working-age mortality. METHODS: The data come from a U.S. national survey (N = 3 973 aged 32-84 at cognitive testing in 2004-06, mean age 56.6, 56.3% female; N = 3 055 retested in 2013-18 at ages 42-94, mean age 64.6, 56.6% female; mortality follow-up through 2019). We use Cox hazard models to investigate whether cognition is associated with mortality below age 65, how the magnitude of this risk compares with the risk in later life, and whether the association persists after adjusting for potential confounders. RESULTS: Worse cognition is associated with mortality, but the demographic-adjusted hazard ratio (HR) diminishes with age from 2.0 per standard deviation (SD; 95% confidence interval [CI], 1.7-2.4) at age 55-1.4 (95% CI, 1.3-1.6) at age 85. In the fully adjusted model, the corresponding HRs are 1.4 (95% CI, 1.2-1.7) and 1.3 (95% CI, 1.1-1.4), respectively. The absolute differences in mortality by level of cognition, however, are larger at older ages because mortality is rare at younger ages. The fully adjusted model implies a 2.7 percentage point differential in the estimated percentage dying between ages 55 and 65 for those with low cognition (1 SD below the overall mean, 5.7%) versus high cognition (1 SD above the mean, 3.0%). The corresponding differential between ages 75 and 85 is 8.4 percentage points (24.6% vs 16.2%, respectively). CONCLUSIONS: Cognitive function may be a valuable early warning sign of premature mortality, even at working ages, when dementia is rare.

Exposure to childhood maltreatment predicts adult physiological dysregulation, particularly inflammation.

Although a growing literature describes the effects of negative childhood experiences on biological outcomes, it is difficult to compare results across studies because of differences in measures of childhood experiences, biological markers, sample characteristics, and included covariates. To ensure comparability across its analyses, this study used a single national survey of adults in the United States-the Midlife in the United States (MIDUS) study-to examine comprehensively the association between adverse childhood experiences, operationalized as childhood maltreatment (CM), and biological markers of risk for poor health and to assess whether these associations differ by type of maltreatment, sex, or race. The sample included 1254, mostly White (78%), adults aged 34-86 years (mean age 57 years), 57% of whom were female. We present incidence rate ratios (IRR) from negative binomial and Poisson regressions to examine the relationships between exposure to CM (emotional, physical, and sexual abuse; emotional and physical neglect; and a CM-index reflecting frequency across all five types of maltreatment) and four biological risk summary scores (overall physiological dysregulation, cardiometabolic risk, inflammation, and hypothalamic pituitary axis/sympathetic nervous system (HPA/SNS) function). We also tested whether the effect of each type of CM varied by sex and by race. The CM-index was associated with higher overall physiological dysregulation and inflammation, but the associations were weaker and not statistically significant for cardiometabolic risk and HPA/SNS function. With the exception of a possible sex difference in the association between sexual abuse and overall physiological dysregulation, there was little evidence that the associations varied systematically by type of CM or by sex or race. We conclude that exposure to CM predicts adult biological risk, particularly inflammation. Inconsistency with previous research suggests that additional research is needed to confirm findings regarding sex and race differences.

Cardiovascular variability, sociodemographics, and biomarkers of disease: the MIDUS study.

Introduction: Like heart rate, blood pressure (BP) is not steady but varies over intervals as long as months to as short as consecutive cardiac cycles. This blood pressure variability (BPV) consists of regularly occurring oscillations as well as less well-organized changes and typically is computed as the standard deviation of multiple clinic visit-to-visit (VVV-BP) measures or from 24-h ambulatory BP recordings (ABPV). BP also varies on a beat-to-beat basis, quantified by methods that parse variation into discrete bins, e.g., low frequency (0.04-0.15 Hz, LF). However, beat-to-beat BPV requires continuous recordings that are not easily acquired. As a result, we know little about the relationship between LF-BPV and basic sociodemographic characteristics such as age, sex, and race and clinical conditions. Methods: We computed LF-BPV during an 11-min resting period in 2,118 participants in the Midlife in the US (MIDUS) study. Results: LF-BPV was negatively associated with age, greater in men than women, and unrelated to race or socioeconomic status. It was greater in participants with hypertension but unrelated to hyperlipidemia, hypertriglyceridemia, diabetes, elevated CRP, or obesity. LF-diastolic BPV (DBPV), but not-systolic BPV (SBPV), was negatively correlated with IL-6 and s-ICAM and positively correlated with urinary epinephrine and cortisol. Finally, LF-DBPV was negatively associated with mortality, an effect was rendered nonsignificant by adjustment by age but not other sociodemographic characteristics. Discussion: These findings, the first from a large, national sample, suggest that LF-BPV differs significantly from VVV-BP and ABPV. Confirming its relationship to sociodemographic risk factors and clinical outcomes requires further study with large and representative samples.

In the Midst of a Pandemic, Introverts May Have a Mortality Advantage.

Extroverts may enjoy lower mortality than introverts under normal circumstances, but the relationship may be different during an airborne pandemic when social contact can be deadly. We used data for midlife Americans surveyed in 1995-96 with mortality follow-up through December 31, 2020 to investigate whether the association between extroversion and mortality changed during the COVID-19 pandemic. We hypothesized that excess mortality during the pandemic will be greater for extroverts than for introverts. Results were based on a Cox model estimating age-specific mortality controlling for sex, race/ethnicity, the period trend in mortality, and an additional indicator for the pandemic period (Mar-Dec 2020). We interacted extroversion with the pandemic indicator to test whether the relationship differed between prepandemic and pandemic periods. Prior to the pandemic, extroversion was associated with somewhat lower mortality (HR=0.93 per SD, 95% CI 0.88-0.97), but the relationship reversed during the pandemic: extroverted individuals appeared to suffer higher mortality than their introverted counterparts, although the effect was not significant (HR=1.20 per SD, 95% CI 0.93-1.54). Extroversion was associated with greater pandemic-related excess mortality (HR=1.20/0.93=1.29 per SD, 95% CI 1.00-1.67). Compared with someone who scored at the mean level of extroversion, mortality rates prior to the pandemic were 10% lower for a person who was very extroverted (i.e., top 12% of the sample at Wave 1), while they were 12% higher for someone who was very introverted (i.e., 11 th percentile). In contrast, mortality rates during the pandemic appeared to be highe r for very extroverted individuals (HR=1.15, 95% CI 0.77-1.71) and l ower for those who were very introverted (HR=0.70, 95% CI 0.43-1.14) although the difference was not significant because of limited statistical power. In sum, the slight mortality advantage enjoyed by extroverts prior to the pandemic disappeared during the first 10 months of the COVID-19 pandemic. It remains to be seen whether that pattern continued into 2021-22. We suspect that the mortality benefit of introversion during the pandemic is largely a result of reduced exposure to the risk of infection, but it may also derive in part from the ability of introverts to adapt more easily to reduced social interaction without engaging in self-destructive behavior (e.g., drug and alcohol abuse). Introverts have been training for a pandemic their whole lives.

Assessment of Mortality Disparities by Wealth Relative to Other Measures of Socioeconomic Status Among US Adults.

Importance: The association between wealth and mortality is likely to be nonlinear and may result from selection and reverse causality. Objective: To compare the magnitude of mortality disparities by wealth relative to other measures of socioeconomic status (SES). Design, Setting, and Participants: This population-based cohort study began in 1995 to 1996, with approximately 18 years of mortality follow-up. These analyses were completed in November 2021. Data were derived from a population-based sample that targeted noninstitutionalized, English-speaking adults aged 25 to 74 years in the contiguous US. The response rate for the telephone interview ranged from 60% (twin subsample) to 70% (main sample). A self-administered questionnaire was completed by 89% of those interviewed by telephone. Exposures: Net assets of the respondent and spouse or partner in 1995 to 1996. Main Outcomes and Measures: All-cause mortality. Results: Among 6320 respondents (mean [SD] age at baseline, 46.9 [12.9] years; 3318 women [52.5%]), 1000 (15.8%) died by May 31, 2013. Adjusted for age, sex, and race, the mortality disparity by wealth was larger than the disparities by education, occupation, income, or childhood SES, especially at the oldest ages. After age 65 years, the hazard ratio [HR] was 2.69 (95% CI, 2.00-3.62) for those with no assets relative to those with at least $300 000 of wealth (in 1995 dollars), which translated into a 31 percentage point differential in estimated probability of surviving from age 65 years to 85 years (40% vs 71%). Additional wealth greater than $500 000 was not associated with lower mortality. In fully adjusted models, there was still a sizeable wealth disparity in mortality after age 65 years (HR, 1.89; 95% CI, 1.33-2.67). After adjustment for confounders, the estimated probability of surviving from age 65 to 85 years was 19 percentage points higher for persons with at least $300 000 in wealth (70%) than for those with no assets (51%), but there was a much larger 37 percentage point differential between never smokers (70%) and current smokers (33%). Conclusions and Relevance: In this cohort study, the fully adjusted disparity in mortality associated with wealth beyond age 65 years remained sizeable but was much smaller than the smoking differential.

Widening Socioeconomic Disparities in Pain and Physical Function Among Americans Are Linked with Growing Obesity.

Objectives: We investigate whether obesity accounts for widening socioeconomic disparities in pain. Methods: Based on nationally representative samples of Americans aged 25-74 in 1995-1996 and 2011-2014, we use logistic regression to model period change in headaches, backaches, and joint aches as well as physical limitations and to determine whether those changes vary by a multidimensional measure of socioeconomic status. Results: Prevalence of backaches, joint aches, physical limitations, and obesity increased between the mid-1990s and the early 2010s, particularly among more disadvantaged Americans. Socioeconomic disparities in frequent backaches, frequent joint pain, and physical limitations more than doubled over this period. We estimate that obesity and health conditions may account for nearly a quarter of the widening disparity in frequent backaches and about half of the widening disparity in frequent joint pain and physical limitations. Discussion: Widening disparities in backaches, joint pain, and physical limitations have coincided with growing obesity.

Income, wealth, and Black-White disparities in cognition.

We investigated the contributions of income and wealth (beyond education) to Black-White disparities in cognition and evaluated whether the role of socioeconomic status (SES) varies by age. Based on data from a national survey of Americans (aged 23-94), we used regression models to quantify the overall racial disparities in episodic memory, executive function, and overall cognition, adjusted for sex and age. Potential mediators (i.e., measures of childhood environment, educational attainment, marital status, occupation, income, and wealth) were added in subsequent models. The age- and sex-adjusted Black-White differential in overall cognitive function was around one standard deviation (SD) between ages 25 and 50, but declined to 0.6 SD by age 80. Executive function followed a similar pattern, but the racial disparity in episodic memory declined more rapidly between ages 35 (0.7 SD) and 80 (0.2 SD). Childhood environment and the respondent's educational attainment accounted for 20-25% of the racial disparities in overall cognition. The incremental contribution of household income was small (1-5%). Although wealth had only a small effect at younger ages, the contribution grew with age. Wealth was much more important than income in explaining Black-White disparities in cognition at older ages. Childhood environment, marital status, and SES (including wealth) accounted for one-third of the racial disparity in overall cognition at ages 35-65, but an even greater share at age 80. Our study is the first to demonstrate that, with increasing age, wealth explains more of the Black-White disparity in cognition. A widening racial gap in wealth and the disproportionate financial impact of the Great Recession and the COVID-19 pandemic on minorities do not bode well for Black-White differentials in cognition. Working-age Americans suffered the brunt of the economic impact of those events; the impact on cognition may increase as those cohorts grow older.