Stay healthy

Kevin Lewis

September 07, 2017

Explaining recent mortality trends among younger and middle-aged White Americans
Ryan Masters, Andrea Tilstra & Daniel Simon
International Journal of Epidemiology, forthcoming

Background: Recent research has suggested that increases in mortality among middle-aged US Whites are being driven by suicides and poisonings from alcohol and drug use. Increases in these ‘despair’ deaths have been argued to reflect a cohort-based epidemic of pain and distress among middle-aged US Whites.

Methods: We examine trends in all-cause and cause-specific mortality rates among younger and middle-aged US White men and women between 1980 and 2014, using official US mortality data. We estimate trends in cause-specific mortality from suicides, alcohol-related deaths, drug-related deaths, ‘metabolic diseases’ (i.e. deaths from heart diseases, diabetes, obesity and/or hypertension), and residual deaths from extrinsic causes (i.e. causes external to the body). We examine variation in mortality trends by gender, age and cause of death, and decompose trends into period- and cohort-based variation.

Results: Trends in middle-aged US White mortality vary considerably by cause and gender. The relative contribution to overall mortality rates from drug-related deaths has increased dramatically since the early 1990s, but the contributions from suicide and alcohol-related deaths have remained stable. Rising mortality from drug-related deaths exhibit strong period-based patterns. Declines in deaths from metabolic diseases have slowed for middle-aged White men and have stalled for middle-aged White women, and exhibit strong cohort-based patterns.

Conclusions: We find little empirical support for the pain- and distress-based explanations for rising mortality in the US White population. Instead, recent mortality increases among younger and middle-aged US White men and women have likely been shaped by the US opiate epidemic and an expanding obesogenic environment.

Association of Lithium in Drinking Water With the Incidence of Dementia
Lars Vedel Kessing et al.
JAMA Psychiatry, forthcoming

Design, Setting, and Participants: This Danish nationwide, population-based, nested case-control study examined longitudinal, individual geographic data on municipality of residence and data from drinking water measurements combined with time-specific data from all patients aged 50 to 90 years with a hospital contact with a diagnosis of dementia from January 1, 1970, through December 31, 2013, and 10 age- and sex-matched control individuals from the Danish population. The mean lithium exposure in drinking water since 1986 was estimated for all study individuals. Data analysis was performed from January 1, 1995, through December 31, 2013.

Results: A total of 73 731 patients with dementia and 733 653 controls (median age, 80.3 years; interquartile range, 74.9-84.6 years; 44 760 female [60.7%] and 28 971 male [39.3%]) were included in the study. Lithium exposure was statistically significantly different between patients with a diagnosis of dementia (median, 11.5 µg/L; interquartile range, 6.5-14.9 µg/L) and controls (median, 12.2 µg/L; interquartile range, 7.3-16.0 µg/L; P < .001). A nonlinear association was observed. Compared with individuals exposed to 2.0 to 5.0 µg/L, the incidence rate ratio (IRR) of dementia was decreased in those exposed to more than 15.0 µg/L (IRR, 0.83; 95% CI, 0.81-0.85; P < .001) and 10.1 to 15.0 µg/L (IRR, 0.98; 95% CI, 0.96-1.01; P = .17) and increased with 5.1 to 10.0 µg/L (IRR, 1.22; 95% CI, 1.19-1.25; P < .001). Similar patterns were found with Alzheimer disease and vascular dementia as outcomes.

Widening Disparities In Infant Mortality And Life Expectancy Between Appalachia And The Rest Of The United States, 1990–2013
Gopal Singh, Michael Kogan & Rebecca Slifkin
Health Affairs, August 2017, Pages 1423-1432


Appalachia — a region that stretches from Mississippi to New York — has historically been recognized as a socially and economically disadvantaged part of the United States, and growing evidence suggests that health disparities between it and the rest of the country are widening. We compared infant mortality and life expectancy disparities in Appalachia to those outside the region during the period 1990–2013. We found that infant mortality disparities widened for both whites and blacks, with infant mortality 16 percent higher in Appalachia in 2009–13, and the region’s deficit in life expectancy increased from 0.6 years in 1990–92 to 2.4 years in 2009–13. The association between area poverty and life expectancy was stronger in Appalachia than in the rest of the United States. We found wide health disparities, including a thirteen-year gap in life expectancy among black men in high-poverty areas of Appalachia, compared to white women in low-poverty areas elsewhere. Higher mortality in Appalachia from cardiovascular diseases, lung cancer, chronic lower respiratory diseases or chronic obstructive pulmonary disease, diabetes, nephritis or kidney diseases, suicide, unintentional injuries, and drug overdose contributed to lower life expectancy in the region, compared to the rest of the country. Widening health disparities were also due to slower mortality improvements in Appalachia.

Knee osteoarthritis has doubled in prevalence since the mid-20th century
Ian Wallace et al.
Proceedings of the National Academy of Sciences, 29 August 2017, Pages 9332–9336


Knee osteoarthritis (OA) is believed to be highly prevalent today because of recent increases in life expectancy and body mass index (BMI), but this assumption has not been tested using long-term historical or evolutionary data. We analyzed long-term trends in knee OA prevalence in the United States using cadaver-derived skeletons of people aged ≥50 y whose BMI at death was documented and who lived during the early industrial era (1800s to early 1900s; n = 1,581) and the modern postindustrial era (late 1900s to early 2000s; n = 819). Knee OA among individuals estimated to be ≥50 y old was also assessed in archeologically derived skeletons of prehistoric hunter-gatherers and early farmers (6000–300 B.P.; n = 176). OA was diagnosed based on the presence of eburnation (polish from bone-on-bone contact). Overall, knee OA prevalence was found to be 16% among the postindustrial sample but only 6% and 8% among the early industrial and prehistoric samples, respectively. After controlling for age, BMI, and other variables, knee OA prevalence was 2.1-fold higher (95% confidence interval, 1.5–3.1) in the postindustrial sample than in the early industrial sample. Our results indicate that increases in longevity and BMI are insufficient to explain the approximate doubling of knee OA prevalence that has occurred in the United States since the mid-20th century. Knee OA is thus more preventable than is commonly assumed, but prevention will require research on additional independent risk factors that either arose or have become amplified in the postindustrial era.

Prevention is better than cure: Addressing anti-vaccine conspiracy theories
Daniel Jolley & Karen Douglas
Journal of Applied Social Psychology, August 2017, Pages 459–469


The current research tested if explicit anti-conspiracy arguments could be an effective method of addressing the potentially harmful effects of anti-vaccine conspiracy theories. In two studies, participants were presented with anti-conspiracy arguments either before, or after reading arguments in favor of popular conspiracy theories concerning vaccination. In both studies, anti-conspiracy arguments increased intentions to vaccinate a fictional child but only when presented prior to conspiracy theories. This effect was mediated by belief in anti-vaccine conspiracy theories and the perception that vaccines are dangerous. These findings suggest that people can be inoculated against the potentially harmful effects of anti-vaccine conspiracy theories, but that once they are established, the conspiracy theories may be difficult to correct.

Making Vaccine Messaging Stick: Perceived Causal Instability as a Barrier to Effective Vaccine Messaging
Graham Dixon
Journal of Health Communication, August 2017, Pages 631-637


Health officials often face challenges in communicating the risks associated with not vaccinating, where persuasive messages can fail to elicit desired responses. However, the mechanisms behind these failures have not been fully ascertained. To address this gap, an experiment (N = 163) tested the differences between loss-framed messages—one emphasizing the consequence of not receiving a flu vaccine; the other emphasizing the consequence of receiving the flu vaccine. Despite an identical consequence (i.e., Guillain–Barre syndrome), the message highlighting the consequence of not receiving the flu vaccine produced lower negative affect scores as compared to the message highlighting the consequence of receiving the flu vaccine. Mediation analyses suggest that one reason for this difference is due to non-vaccination being perceived as temporary and reversible, whereas vaccination is perceived as being permanent. Implications on health communication and future research are discussed.

Addressing the Cultural Challenges of Firearm Restriction in Suicide Prevention: A Test of Public Health Messaging to Protect Those at Risk
Elizabeth Marino et al.
Archives of Suicide Research, forthcoming

Methods: Focus groups and key informant interviews were conducted with rural gun owners in order to develop a suicide prevention message that highlighted the importance of restricting access to firearms during periods of risk without threatening second amendment concerns. The effectiveness of this gun culture message, relative to standard suicide prevention messaging and a control condition, was then tested with a national sample of gun owners.

Results: Relative to all other conditions, respondents who received our culturally-specific message in conjunction with standard suicide prevention content reported the greatest likelihood of taking steps to restrict access to firearms. This tendency was enhanced for individuals who were more politically conservative, lived in more rural areas, and supported gun rights to a stronger degree.

Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): A prospective cohort study
Mahshid Dehghan et al.
Lancet, forthcoming

Methods: The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35–70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7•4 years (IQR 5•3–9•3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering.

Findings: During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1•28 [95% CI 1•12–1•46], ptrend=0•0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0•77 [95% CI 0•67–0•87], ptrend<0•0001; saturated fat, HR 0•86 [0•76–0•99], ptrend=0•0088; monounsaturated fat: HR 0•81 [0•71–0•92], ptrend<0•0001; and polyunsaturated fat: HR 0•80 [0•71–0•89], ptrend<0•0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0•79 [95% CI 0•64–0•98], ptrend=0•0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality.

Interpretation: High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings.

Why did life expectancy decline in the United States in 2015? A gender-specific analysis
Francesco Acciai & Glenn Firebaugh
Social Science & Medicine, forthcoming


In 2015, age-adjusted mortality rates increased for 8 of the 10 leading causes of death in the United States. As a result, life expectancy declined by 0.17 years for both women and men. The decline could be just an anomaly, or it could represent the start of a new trend of stagnation or decline in life expectancy, as some scholars have warned. The first step is to determine the sources of the decline. In this study we analyze the contribution of specific causes of death to the decline in men's versus women's life expectancy, as well as the mechanisms that generated the decline. With regard to mechanisms, we examine whether the decline in life expectancy resulted from reductions in the average age at death for most causes of death, or from a greater risk of dying of causes that disproportionately affect the young and middle-aged. Using CDC mortality data, we construct life tables for men and women separately, based on 20 different underlying causes of death. We find that men's reduction in life expectancy was attributable primarily to changes in midlife mortality, with a greater risk of dying of causes such as accidental poisoning or homicide. The reduction in women's life expectancy, on the other hand, was attributable primarily to changes in old-age mortality, where the mean age at death for most causes (such as heart disease and mental illnesses) was lower in 2015 than it was in 2014. These gender-specific mechanisms that contributed to the decline in life expectancy are common to the major racial/ethnic groups, but the magnitude of the decline differs greatly across racial/ethnic groups. Future research can use the tools provided here to investigate in more detail how the gender-specific mechanisms of the 2015 decline differ by race.

Cyclical Unemployment and Infant Health
Erin Kaplan, Courtney Collins & Frances Tylavsky
Economics & Human Biology, forthcoming


This study provides evidence on the effect of cyclical unemployment on infant health. We match individual-level data from a detailed survey of mothers and their children in Memphis, TN, with 5-year average census-tract unemployment rates from the American Community Survey. Our findings indicate that a one percentage point increase in the local unemployment rate is associated with a statistically significant increase in the probability of having a low birthweight baby (a baby weighing less than 2500 grams). We also find evidence of a statistically significant decrease in gestational age. These effects are concentrated among babies born to mothers without a college education and into households earning less than $25,000 a year.

Assessing the Global Economic and Poverty Effects of Antimicrobial Resistance
Syud Amer Ahmed et al.
World Bank Working Paper, June 2017


This paper assesses the potential impact of antimicrobial resistance on global economic growth and poverty. The analysis uses a global computable general equilibrium model and a microsimulation framework that together capture impact channels related to health, mortality, labor productivity, health care financing, and production in the livestock and other sectors. The effects spread across countries via trade flows that may be affected by new trade restrictions. Relative to a world without antimicrobial resistance, the losses during 2015-50 may sum to $85 trillion in gross domestic product and $23 trillion in global trade (in present value). By 2050, the cost in global gross domestic product could range from 1.1 percent (low case) to 3.8 percent (high case). Antimicrobial resistance is expected to make it more difficult to eliminate extreme poverty. Under the high antimicrobial resistance scenario, by 2030, an additional 24.1 million people would be extremely poor, of whom 18.7 million live in low-income countries. In general, developing countries will be hurt the most, especially those with the lowest incomes.

The Rise and Fall of Pellagra in the American South
Karen Clay, Ethan Schmick & Werner Troesken
NBER Working Paper, August 2017


The result of insufficient niacin consumption, pellagra caused more deaths than any other nutrition-related disease in American history, and it reached epidemic proportions in the South during the early 1900s. In this paper, we explore the forces that drove the rise and fall of pellagra. Historical observers have long-believed that pellagra stemmed from the South’s monoculture in cotton, which displaced the local production of nutritionally-rich foods. To test this hypothesis, we begin by showing that, at the county level, pellagra rates are positively correlated with cotton production. We then exploit the arrival of the boll weevil — which prompted Southern farmers to begin planting food instead of cotton — to show that this correlation is likely causal. We close by studying how fortification laws passed during the 1940s helped to eliminate pellagra.

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