Grants Funded from RFA-AG-11-004, “Regional and International Differences in Health and Longevity at Older Ages (RFA-AG-11-004)”
NIA published an RFA entitled “Regional and International Differences in Health and Longevity at Older Ages” on June 22, 2010 which solicited R01 applications to advance knowledge on the reasons behind the divergent trends that have been observed in health and longevity at older ages, both across industrialized/high life expectancy nations and across geographical areas in the U.S.
NIA funded seven R01 applications from the RFA during the summer of 2011. Four grants are studying the underlying reasons for the large American health disadvantage at older ages compared to their Western European counterparts. These grants are focusing on issues including obesity, social policies addressing work-family strain, physiological dysregulation due to work stress, early life conditions such as childhood health, the impact of the recent financial crisis, and cancer screening rates.
Two grants focus on the U.S. The first is developing a new publicly-available database of historical mortality data by state which will be invaluable for future study of the driving forces behind US mortality trends. The second project is studying how US health disparities among different birth cohorts are related to US geographic region.
Finally, NIA funded a one-year project studying the remarkable increase in life expectancy experienced by East Germans after the 1989-1990 unification of West and East Germany; the aim of this project is to understand the relative impact on increased life expectancy between the increased affluence experienced by East Germans vs. the improved health care system available to East German elderly post-unification.
(See below for the grant abstracts. Also, for more information on the above grants,
go to the NIH RePORTER site at http://projectreporter.nih.gov/ ).
RFA-AG-11-004 was influenced by a National Academy of Sciences panel which determined, based on available evidence, that past smoking rates are a major reason for shorter lifespans in the US compared to other high-income countries, and that obesity rates in the US also appear to be a significant factor (see http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=13089 ). The summary report from the National Research Council, which also identified research gaps, is entitled Explaining Divergent Levels of Longevity in High Income Countries (NRC, 2011) and is available at http://www.nap.edu/catalog.php?record_id=13089 . A volume of background scientific papers is entitled International Differences in Mortality at Older Ages (NRC, 2011) and is available at http://www.nap.edu/catalog.php?record_id=12945 .
DESCRIPTION (provided by applicant): Theory is important in guiding research to penetrate the bewildering surface of myriad age, sex, time and population-specific statistics about mortality at older ages. The goal of the proposed research is to advance theory and thereby empirical knowledge of mortality comparisons by using data from the "natural experiment" of East-West German unification and the resulting rapid convergence of E. German death rates to W. German levels to quantify the relative causal importance of two factors suggested by theory: "prosperity" vs. "healthcare".
DESCRIPTION (provided by applicant): Our first objective examines impacts of early life conditions and childhood health across a set of European countries and the US on salient later life adult outcomes including adult health and socioeconomic status (SES). Differences in early life conditions are potentially an important source of international differences in adult health. Second, we will study dual pathways between SES and health with an emphasis on England and America. Pathways from SES to health are explored by examining whether future onsets of new chronic conditions using self-reports and biomarkers of disease are related to key SES markers- income, wealth, and education. We will examine whether ""innovations"" in economic status affect health-especially during the recent financial crisis. Health feedbacks to labor supply, income, and wealth may be quantitatively important. Health outcomes include physical and mental health, including depression, psycho-social health, overall well-being, and life satisfaction. Our third specific aim examines the relationship between alternative measures of SES and subsequent all cause and cause-specific incident mortality in England and the US. Access to financial resources may be essential in dealing with consequences of health problems after they occur. The final specific aim will examine whether differential cancer screening rates can account for significant parts of country differences in cancer rates, especially those to the disfavor of the United States. Screening is known to vary across types of cancer and is believed to be more aggressive for breast, colon, and prostate cancer in the US than the UK and low for respiratory cancer.
PUBLIC HEALTH RELEVANCE: The research is important since it deals with the level of well-being of older people in the United States compared to the rest of the Industrialized Western World. By using comparative analysis of the United States, England, and other countries, we can assess how and why over-all well-being is related to health and socioeconomic status at older ages in these countries.
DESCRIPTION (provided by applicant): The U.S. appears to have worse health than people in a number of European countries. Because health reflects an accumulation of processes over a lifetime, we will study how stressful events during the working years may affect pre-retirement health and ultimately longevity. The broad aims of this application are to find whether in panel data the health gap between the U.S. and Europe increases during the working years, but not during the post-retirement years, and to explain these broad facts by differences in the stress induced in the labor market and by differences in the ameliorating effects of economic and social policy (including health insurance). Our analysis will use data on 15 countries, which provides a wealth of variation in institutions in time as well as in space. The principal outcomes will be fourfold. First, this study will clarify at what point in the life-cycle health differences emerge and chart their path thereafter. Second, this study will propose a formal economic and biological model linking indicators of physiological functioning to other health and economic outcomes clarifying some of the concepts measured in the literature and guide empirical work on the topic. Third, this study will provide micro as well as cross-country empirical evidence on the relationship between economic stressful events and physiological dysregulation using biomarkers but also reported health measures. Fourth, because of its cross-country design, this study will exploit differences in social policy across countries and over time to see estimate how these policies contribute to the international differences in health through the effect of physiological dysregulation on health.
PUBLIC HEALTH RELEVANCE: The U.S. has fallen behind in terms of life expectancy in the pre-retirement years and large differences in health have emerged between the U.S. and Europe. This project aims to test the hypothesis that differences in physiological dysregulation due to a more stressful working life in the U.S. are responsible for those differences. This project will use a large array of longitudinal datasets in 15 countries to link health outcomes in the pre-retirement years to life histories and exploit differences in social policy across countries.
DESCRIPTION (provided by applicant): Regional disparities in health and mortality in the U.S. have been observed repeatedly, but little attempt has been made to explain them. At best, anecdotal explanations are usually offered. For example, poorer health among southerners is often attributed to diet without any empirical support. Extant literature suffers from several additional shortcomings. First, many studies focus on a single health outcome, like stroke mortality, thereby underestimating the full extent of regional variation in health. Second, many studies measure region coarsely. Often, only one region is contrasted against all others. This approach also leads to underestimation of the full range of regional variation in health and hinders our ability to understand the precise mechanisms that account for it, because within-region cultural and structural heterogeneity is extensive. Third, studies of regional disparities have generally failed to take a life course perspective, instead treating them as existing in a temporal vacuum. The proposed research will address these shortcomings, first by adopting a life course perspective. The life course perspective recognizes that neither region of residence, nor health, nor the relationship between them, is static at the individual level across age. Furthermore, regional characteristics and the distribution of health outcomes also vary across sociohistoric time, implying that the relationship between region and health may differ across birth cohorts. The life course perspective therefore provides a more comprehensive and detailed lens through which to begin to explain regional differences in health. Given this perspective, the proposed research will establish the full extent of regional disparities in health using a variety of longitudinal statistical methods applied to at least three nationally-representative, large sample data sets: the General Social Survey, the Health and Retirement Study, and the National Health Epidemiologic Follow-up Surveys. These data will be augmented via the collection of region-year contextual variables like physician density, climate, etc. Collectively, these surveys contain a wide variety of health measures, including self-rated health, physical functioning, depressive symptoms, mortality, and diabetes, as well as refined measures of region (i.e., the nine-category Census measure). Importantly, these three surveys also contain at least one measure of region of residence in early life (birth and adolescence), which, from a life course perspective, is useful in helping differentiate the role of early life socialization into regional culture from the role of structural characteristics of an individual's current region of residence in influencing health. In addition, this early life region measure, as well as the use of longitudinal methods, will enable the investigation of the extent to which health influences regional mobility, an issue (i.e., endogeneity) commonly ignored in research. Basic descriptive methods, typical regression models, multistate life table methods for both panel and cross-sectional data, and hierarchical growth models, including autoregressive latent trajectory models, will be used to flesh out the extent of regional differences in health as well as the mechanisms that account for them.
PUBLIC HEALTH RELEVANCE: Regional differences in health and mortality in the US have been observed in numerous studies but have been left largely unexplained. Understanding the mechanisms that account for regional differences is important for determining how health disparities can be reduced. Our proposed project aims to determine the full extent of regional differences in health and to explain them (1) by using more refined measures of region and a broader array of health outcomes than used in previous research, and (2) by employing a life course perspective and methods to differentiate with greater precision and accuracy the pathways via which region may affect health.
DESCRIPTION (provided by applicant): The primary objective of this research is to identify the contribution of obesity to international differences in longevity. Adults in the United States have a higher prevalence of obesity than adults in any other country in Europe, North America, or East Asia. At the same time, life expectancy in the United States has fallen below that of most other OECD countries and ranked 32nd in the world in 2008. One of the prime candidates to account for the US disadvantage in health and longevity is its high level of obesity. A key input to evaluating the contribution of obesity to international differences in longevity is the set of individual-level mortality risks associated with different levels of obesity. This project will identify the set of mortality risks associated with obesity that should be used in international and intertemporal comparisons. We do so by explicitly introducing two other factors on which the mortality risks associated with current obesity depend: an individual's history of obesity and his or her smoking status. The omission of obesity histories from earlier studies has led to biased estimates of the effects of current obesity. Non-smokers show a higher mortality risk from obesity than smokers, so that countries that smoke heavily should be expected to have lower risks from obesity. We will apply these sets of obesity risks to calculate population attributable risks and obesity's implications for survivorship and longevity. An important product of our work will be an explanation of the large declines that have been observed in the estimated effect of obesity on mortality. In addition, we will develop a new indirect approach to estimating the contribution of obesity to international differences in longevity by building on previous methods developed to estimate smoking-attributable mortality. Epidemiologic and demographic studies of obesity would benefit greatly from a clarification of the mortality risks associated with obesity. Such a clarification would also contribute to improved projections of mortality in the US and elsewhere. Uncertainty about future of mortality is the single factor to which fiscal balances in the Social Security Trust Fund are most sensitive. The contribution of this project to improved projections is enhanced by its explicit incorporation of obesity histories into the risk analysis, since these histories are revealed well in advance of actual mortality conditions.
PUBLIC HEALTH RELEVANCE: The United States has the highest prevalence of obesity and one of the lowest life expectancies among developed nations. The objective of this research is to identify the contribution of obesity to international differences in longevity. Results will lead to improved mortality projections and a clearer understanding of how obesity is influencing national mortality profiles.
DESCRIPTION (provided by applicant): The purpose of the project is to promote research on historical trends and, in particular, interstate variations in the mortality of the United States since the 1930s. To this end, we will construct a publicly-accessible collection of mortality data series by state, designed to meet the research needs of team members and collaborators as well as those of the greater academic community. The new data series will include indicators of both total (i.e., all causes of death) and cause-specific mortality. We will create state-level estimates of all-cause mortality by age, sex, and year for the period from 1933 to 2007. We will also create annual state-specific estimates of mortality by age, sex, and cause of death for 1959-2007 (possibly, 1950-1958 as well). All data series will have the same format used for country estimates in the Human Mortality Database (HMD, www.mortality.org), helping to facilitate comparative research both within the United States and on an international level. This work will draw on data from various sources, including the vital registration system, the decennial census, and the beneficiary records of Social Security and Medicare. It will require the development of new methodologies for combining such information into coherent and comparable series of mortality estimates, including complete life tables. Our knowledge of the data sources, including their defects and limitations, will be clearly documented and distributed alongside the data within the HMD. The project is intended to catalyze research on mortality patterns and trends by state within the U.S. State-specific mortality data are intrinsically useful for the analysis of health disparities, since geographic differences are an important component of overall inequality in the face of death. The products of the work proposed here will facilitate more detailed analyses of regional mortality differentials by cause within the U.S., which could offer new insights and evidence about the driving forces behind the country's mortality trends in recent decades - in particular the slow pace of decline compared to other high-income nations, especially for women.
PUBLIC HEALTH RELEVANCE: The purpose of the project is to construct a publicly-accessible collection of mortality data series by state since the earliest time available until now (1933-2008). Improved information about mortality patterns by sex, age groups and causes of death contributing to the ongoing disparities in life expectancy across U.S. states will help researchers to identify the underlying conditions and processes that have produced these patterns. A better understanding of geographic differences in U.S. mortality will be a useful tool for guiding future policy efforts to improve the health and longevity of the population and to investigate the historical impact of public health interventions.
DESCRIPTION (provided by applicant): The United States is losing ground in health: our ranking in life expectancy is near the bottom of European countries and comparisons of major chronic conditions in the US and 13 European countries showed the US to have higher disease prevalence than any comparison country. The diverging life expectancy (LE) trends have been most distinct for American women, but the US also fares poorly with regard to male life expectancy and infant mortality. The health gap is largest among socioeconomically disadvantaged groups, but even well- educated Americans have worse health than many of Europeans. We hypothesize that the explanations for the American health disadvantage have roots in the challenging social context faced by families, and in particular women, in post-WWII America. Since WWII, American society has been marked by: high fertility; high female labor market participation; weak labor laws and family protection policies; and family instability, and increased single parenthood. The combination or convergence of these factors created a ""perfect storm"" that threatened vulnerable families and imposed extreme stresses even on the relatively advantaged. Such social conditions might work via influencing health behaviors or through more direct physiological mechanisms. We have developed a theoretical framework for this confluence of conditions that builds on the job strain models incorporating dimensions of demand, control and support but adds an important dimension related to family that extends the strain model beyond work to family life. Over time Americans, especially women, have experienced high demands in terms of full time work often with high family demands, coupled with low formal support ( social protection policies) or informal support from other family members. This combination especially among workers with low job control leads to a cumulative disadvantage taking its toll in health over time. In order to understand whether these social conditions account for cross area variations in risk we must understand whether either the distribution and/or the toxicity of the ""risk"" vary across areas. We draw from ongoing studies including HRS, SHARE and ELSA, mortality data at a country level (using the human mortality files) and data on public policies, collected from the CPS,SIPP and SHARELIFE and OECD. We propose 4 specific aims: Aim 1: Describe the distribution of work-family strain for females born 1920-1960, across the US and EU. Aim 2: Assess the differential toxicity of work-family strain on CVD risk behaviors and biomarkers, incidence of stroke and heart disease, CVD mortality, and life expectancy in the US and Europe. Aim 3: Assess whether distributions or the toxicity of work-family strain explain geographic and temporal variations in CVD and life expectancy. Aim 4: Assess impacts of trends in work-family strain on socioeconomic inequalities in mortality in the US and Europe.
PUBLIC HEALTH RELEVANCE: With the vast majority of women in the labor force who also have young children and with the aging of societies virtually across the globe, there is an urgent public health need to provide both formal (policy) and informal (family) support to women and their families. Evidence suggests that work family strain has an adverse impact on health outcomes for low wage employees and young children and perhaps other groups. Countries in which a number of work family policies have been implemented seem to fewer adverse population health outcomes. This situation is particularly severe in the US where fertility and labor force participation among women is high and where state and federal policies promoting the health of families is very limited.
Prepared December 2012