The physiological impacts of wealth shocks in late life: Evidence from the Great Recession

Negative wealth shocks and subsequent depressive symptoms and trajectories in middle-aged and older adults in the USA, England, China, and Mexico: a population-based, multinational, and longitudinal study

BACKGROUND

The association between negative wealth shocks and depression among middle-aged and older individuals remains unclear. Our study aimed to assess the association between negative wealth shocks and depression and its trajectories, and to explore cross-national differences in these associations.

METHODS

Our sample included 21 999 participants, of which 9519 were from the Health and Retirement Study (2012-2020), 4936 from the English Longitudinal Study of Ageing (2012-2020), 2520 from the China Health and Retirement Longitudinal Study (2011-2020), and 5024 from the Mexican Health and Aging Study (2012-2021). We used latent class trajectory models to identify depressive trajectories, alongside mixed-model logistic regression and multinomial logistic regression to evaluate associations.

RESULTS

In the USA (OR 1.73, 95% CI 1.40-2.16), England (OR 1.71, 95% CI 1.09-2.70), and China (OR 1.38, 95% CI 1.09-1.75), negative wealth shocks were associated with subsequent depressive symptoms, but not in Mexico (OR 1.06, 95% CI 0.86-1.29). Additionally, negative wealth shocks were associated with several depressive trajectories in the USA and China. This association occurred only in increasing-decreasing trajectory in England, while no significant association was found across any trajectory in Mexico.

CONCLUSIONS

Negative wealth shocks were associated with subsequent depressive symptoms, with significant associations observed in some specific depressive trajectories. These associations exhibited cross-national differences, underscoring the importance of considering country-specific contexts when addressing the mental health impacts of wealth shocks.

Association of cigarette smoking with changes in macroeconomic conditions

This study uses data from the 1987-2022 Behavioral Risk Factor Surveillance System and state-level employment rates from the US Bureau of Labor Statistics to estimate the association between macroeconomic conditions and cigarette smoking. Our finding suggests a positive association, which constantly declined with time after the 2001 recession. We find that a one percentage point increase in the employment rate is associated with a 1.4% higher likelihood of smoking cigarettes in the overall sample but declined to 0.4% among cohorts surveyed from 2011 to 2022. We also find strong positive and heterogeneous associations among sociodemographic groups, except among Blacks and persons aged 65 years and older, among whom there is no association; however, the positive associations consistently decreased among these sociodemographic groups. Consequently, the strong positive association disappeared in several sociodemographic groups in cohorts surveyed over the last decade.

Racial Capitalism and Black-White Health Inequities in the United States: The Case of the 2008 Financial Crisis

Scholars cite racist political-economic systems as drivers of health inequities in the United States (i.e., racial capitalism). But how does racial capitalism generate health inequities? I address this open question within the historical context of predatory lending during the 2008 financial crisis. Relevant hypotheses are tested with multiple waves of data from Black and White participants of the National Longitudinal Study of Adolescent to Adult Health (N = 8,877). Across socioeconomic strata, I find that Black participants report higher rates of foreclosure, eviction, repossession, delinquent bills, lost income, and new debts in the wake of the financial crisis. Using structural equation and quasi-experimental models, I then show that Black participants also self-report rapid health declines and increases in prescription drug abuse throughout this period, much of which is explained by chronic financial stress. I conclude that racial capitalism can generate health inequities by ensnaring Black Americans in a toxic web of financial exploitation and stress proliferation.

Building Financial Capability and Assets to Reduce Poverty and Health Disparities: Race/Ethnicity Matters

BACKGROUND

Evidence has documented racial wealth inequity as one of the key pathways linking structural racism and racial health inequity. Most prior studies on the wealth-health relationship use net worth as the measure of wealth. This approach provides little evidence on the most effective interventions as various types of assets and debt affect health differently. This paper examines how U.S. young adults' wealth components (e.g., financial assets, nonfinancial assets, secured debt, and unsecured debt) are associated with physical and mental health, and if the associations differ by race/ethnicity.

METHODS

Data were drawn from the National Longitudinal Survey of Youth 1997. Health outcomes were measured by mental health inventory and self-rated health. Logistic regressions and ordinary least square regressions were used to assess the association between wealth components and physical and mental health.

RESULTS

I found that financial assets and secured debt were positively associated with self-rated health and mental health. Unsecured debt was negatively associated with mental health only. The positive associations between financial assets and health outcomes were significantly weaker for non-Hispanic Black respondents. Unsecured debt was protective of self-rated health for non-Hispanic Whites only. For Black young adults, unsecured debt had more severe negative health consequences compared to other racial/ethnic groups.

CONCLUSION

This study provides a nuanced understanding of the complex relationship among race/ethnicity, wealth components, and health. Findings could inform asset building and financial capability policies and programs to effectively reduce racialized poverty and health disparities.

Socioeconomic inequalities in cardiovascular disease: a causal perspective

Socioeconomic inequalities in cardiovascular disease (CVD) persist in high-income countries despite marked overall declines in CVD-related morbidity and mortality. After decades of research, the field has struggled to unequivocally answer a crucial question: is the association between low socioeconomic position (SEP) and the development of CVD causal? We review relevant evidence from various study designs and disciplinary perspectives. Traditional observational, family-based and Mendelian randomization studies support the widely accepted view that low SEP causally influences CVD. However, results from quasi-experimental and experimental studies are both limited and equivocal. While more experimental and quasi-experimental studies are needed to aid causal understanding and inform policy, high-quality descriptive studies are also required to document inequalities, investigate their contextual dependence and consider SEP throughout the lifespan; no simple hierarchy of evidence exists for an exposure as complex as SEP. The COVID-19 pandemic illustrates the context-dependent nature of CVD inequalities, with the generation of potentially new causal pathways linking SEP and CVD. The linked goals of understanding the causal nature of SEP and CVD associations, their contextual dependence, and their remediation by policy interventions necessitate a detailed understanding of society, its change over time and the phenotypes of CVD. Interdisciplinary research is therefore key to advancing both causal understanding and policy translation.

Negative Wealth Shock and Cognitive Decline and Dementia in Middle-Aged and Older US Adults

Importance

As a financial hardship, negative wealth shock has been implicated in some adverse health outcomes. However, associations between negative wealth shock and cognitive decline and dementia have not been examined.

Objective

To investigate whether negative wealth shock was associated with cognitive decline and incident dementia among middle-aged and older US adults.

Design, Setting, and Participants

The Health and Retirement Study (HRS) is a prospective cohort study conducted biennially among US adults older than 50 years. Data from the HRS from calendar years 1996 to 2020 were analyzed from July 1 to 31, 2023. The final sample included 8082 participants with complete data of interest.

Exposures

Wealth status was quantified with questionnaires. Negative wealth shock was defined as a loss of 75% or more in total wealth over a 2-year period. Asset poverty was defined as zero or less total net wealth.

Main Outcomes and Measures

Cognitive function was assessed with the modified Telephone Interview for Cognitive Status (TICS-m). Dementia status was determined with TICS-m scores and proxy assessment.

Results

Among 8082 participants included (mean [SD] age, 63.7 [5.7] years; 4179 women [51.7%] and 3903 men [48.3%]; 1111 Black [13.7%], 6689 White [82.7%], and 282 other [3.5%]), 1441 developed incident dementia over a median follow-up time of 14 (IQR, 7-20) years. Compared with participants who had positive wealth without shock, those with negative wealth shock had accelerated cognitive decline (β coefficient, -0.014 [95% CI, -0.027 to -0.001]; P = .03) and increased risks of dementia (hazard ratio [HR], 1.27 [95% CI, 1.11-1.46]; P < .001). Higher dementia risks were also found in participants with asset poverty at baseline (HR, 1.61 [95% CI, 1.30-2.00]; P < .001). Associations were found in White participants (HR, 1.34 [95% CI, 1.14-1.58]; P < .001) and participants younger than 65 years (HR, 1.38 [95% CI, 1.13-1.68]; P = .001) but not in other races and ethnicities or those 65 years or older.

Conclusions and Relevance

In this cohort study, negative wealth shock was associated with accelerated cognitive decline and elevated risks of dementia among middle-aged and older US adults, with modifications by age and ethnicity. These findings should be confirmed by further prospective and interventional studies.

Racial and Educational Disparities in Cumulative Exposure to Hardships of the 2008 Great Recession and Inflammation

OBJECTIVE

This cross-sectional analysis examined self-reported economic hardships of the 2008 Great Recession, race/ethnicity, educational attainment, and psychological well-being (PWB) as predictors of systemic inflammatory physiology at midlife. We also tested for differential vulnerability in the relationship between recession hardship and inflammatory physiology by race/ethnicity, education, and PWB.

METHODS

Adults from the Midlife in the United States Refresher sample completed a survey and biomedical assessments after the recession ( n = 592 non-Hispanic White respondents, n = 158 Black/African American respondents, n = 108 respondents with other race/ethnicity). Cumulative recession hardship was the sum of financial, housing, and employment-related events. Outcomes included circulating levels of interleukin 6 and C-reactive protein. General linear regression models tested main effects interactions between primary predictor variables.

RESULTS

Educational attainment was inversely associated with recession hardships ( b = -0.18, 95% confidence interval = -0.26 to -0.11, p < .001). Black/African American respondents reported more recession hardships than White respondents ( b = 1.17, 95% confidence interval = 0.67 to 1.68, p < .001). More recession hardships predicted higher levels of interleukin 6 ( b = 0.06, p < .001) and C-reactive protein ( b = 0.04, p = .004). Analyses did not support race/ethnicity, education, and PWB as moderators of the association between recession hardship and inflammatory markers.

CONCLUSIONS

Race/ethnicity and education independently predicted disparities in cumulative recession hardship exposure. Recession hardship predicted higher blood levels of inflammatory proteins associated with long-term health. The lack of findings for differential vulnerability in the relationship between recession hardship and inflammatory markers by race/ethnicity, education, or PWB was possibly due to the limited sample size.

Inflation hardship, gender, and mental health

Inflation hit a 40 year high in the United States in 2022, yet the impact of inflation related hardships on distress is poorly understood, particularly the impact on women, whose income is already more limited. Using data from the US Household Pulse Survey (September-November 2022), we test whether exposure to inflation hardships is associated with greater distress and whether this association is moderated by gender (n = 119,531). We draw on a list of eighteen inflation related hardships (e.g., purchasing less food, working additional jobs, delaying medical treatment) to construct an ordinal measure of exposure to inflation hardship ranging from "no inflation hardship" to "five or more inflation hardships." We observe that an increasing number of inflation hardships is associated with higher levels of distress. We find no evidence of gender differences in the magnitude of that association at lower levels of inflation hardship (four inflation hardships or less). However, our findings suggest that exposure to five or more inflation hardships is more strongly associated with distress among men compared to women. The current study provides new insights into the cumulative burden of inflation hardships on mental health and the role that gender plays in this association.

Negative wealth shocks in later life and subsequent cognitive function in older adults in China, England, Mexico, and the USA, 2012-18: a population-based, cross-nationally harmonised, longitudinal study

BACKGROUND

Household wealth is positively related to cognitive health outcomes in later life. However, the association between negative wealth shocks and cognitive function in later life, and whether this association might differ across countries at different levels of economic development, is unclear. We aimed to investigate whether negative wealth shocks in later life are associated with cognitive function in older adults in China, England, Mexico, and the USA, and whether this association is modified by country income level.

METHODS

For this population-based, cross-nationally harmonised, longitudinal study, data were analysed from core interviews of the population-based US Health and Retirement Study (2012 and 2016) and its partner studies in China (the China Health and Retirement Longitudinal Study; 2015 and 2018), England (the English Longitudinal Study of Ageing; 2012 and 2016), and Mexico (Mexican Health and Aging Study; 2012 and 2015-16), and their respective Harmonized Cognitive Assessment Protocols (HCAPs). Negative wealth shocks over the follow-up periods of the respective cohorts were defined in two ways: an extreme loss of 75% or greater from the baseline amount of wealth, and a decline in within-population wealth quintile rank. The primary outcome was the harmonised general cognitive function (GCF) factor score, which was constructed with factor analysis on the HCAP neuropsychological assessments of memory, orientation, attention, executive function, and verbal fluency performance (mean 0; SD 1). We used sampling-weighted, multivariable-adjusted linear models to examine associations.

FINDINGS

Data from 9465 participants were included in this analysis: 3796 from China, 1184 from England, 1193 from Mexico, and 3292 from the USA. The mean baseline age of participants was 68·5 (SD 5·4) years in China (49·8% women), 72·0 (7·0) years in England (54·6% women), 70·6 (6·8) years in Mexico (55·1% women), and 72·7 (7·5) years in the USA (60·4% women). A wealth loss of 75% or greater was negatively associated with subsequent cognitive function in the USA (β -0·16 SD units; 95% CI -0·29 to -0·04) and China (-0·14; -0·21 to -0·07), but not in England (-0·01; -0·24 to 0·22) or Mexico (-0·11; -0·24 to 0·03). Similarly, within-population wealth quintile rank declines were negatively associated with subsequent cognitive function in the USA (β -0·07 per quintile rank decline; 95% CI -0·11 to -0·03) and China (β -0·07; -0·09 to -0·04), but not in England (-0·05; -0·11 to 0·01) or Mexico (-0·03; -0·07 to 0·01).

INTERPRETATION

The impact of wealth shocks in later life on subsequent lower level of cognitive function of older adults in China, England, Mexico, and the USA differed across macro-level socioeconomic structures. These findings suggest that government policies and social safety nets in countries with different levels of economic development might have a role in protecting older adults from adverse health effects of wealth losses in later life.

FUNDING

US National Institute on Aging, US National Institutes of Health.

How does debt shape health outcomes for older Americans?

The deleterious effects that debt can have on health outcomes are well documented, yet comprehensive studies of the debt-health link for older adults remain limited even as their indebtedness has increased dramatically in recent decades. Additionally, the literature cannot explain the causal pathway linking poor health with debt. Using data from the Health and Retirement Study (1998-2016), we examine a range of physical and mental health measures and assess how they may be shaped by the amount and type of debt held by older adults. To address the likely endogeneity of debt and health, we employ marginal structural models, developed specifically as an identification strategy in the presence of possible endogeneity, alongside population-averaged models that allow us to compare outcomes for populations with and without debt without relying on unverifiable assumptions regarding the underlying population distribution as is the case with random- and fixed-effects models. Findings indicate that carrying any debt has a negative effect on a range of health outcomes for older adults, including objective and subjective physical and mental health. In addition, the more debt older adults carry, the more detrimental it is for their health. Finally, the type of debt matters: while secured debt has a limited, if any, negative impact on health outcomes, unsecured debt has a substantial negative impact on health. Policymakers should design policies that promote the prudent use of debt and discourage carrying large debt burdens, especially unsecured debt, into retirement as this would promote better health outcomes for older Americans.

The Buffering Effect of State Eviction and Foreclosure Policies for Mental Health during the COVID-19 Pandemic in the United States

The COVID-19 pandemic spurred an economic downturn that may have eroded population mental health, especially for renters and homeowners who experienced financial hardship and were at risk of housing loss. Using household-level data from the Census Bureau's Household Pulse Survey (n = 805,223; August 2020-August 2021) and state-level data on eviction/foreclosure bans, we estimated linear probability models with two-way fixed effects to (1) examine links between COVID-related financial hardship and anxiety/depression and (2) assess whether state eviction/foreclosure bans buffered the detrimental mental health impacts of financial hardship. Findings show that individuals who reported difficulty paying for household expenses and keeping up with rent or mortgage had increased anxiety and depression risks but that state eviction/foreclosure bans weakened these associations. Our findings underscore the importance of state policies in protecting mental health and suggest that heterogeneity in state responses may have contributed to mental health inequities during the pandemic.

Black/white differences in the relationship between debt and risk of heart attack across cohorts

Background

Numerous studies show that increasing levels of education, income, assets, and occupational status are linked to greater improvements in White adults' health than Black adults'. Research has yet to determine, however, whether there are racial differences in the relationship between health and debt and whether this relationship varies across cohorts.

Methods

Using data from the 1992-2018 Health and Retirement Study, we use survival analyses to examine the link between debt and heart attack risk among the Prewar Cohort, born 1931-1941, and Baby Boomers, born 1948-1959.

Results

Higher unsecured debt is associated with increased heart attack risk for Black adults, especially among Baby Boomers and during economic recessions. Higher mortgage debt is associated with lower risk of heart attack for White but not Black Baby Boomers. The relationship between debt and heart attack risk remains after controlling for health behaviors, depressive symptoms, and other economic resources that are concentrated among respondents with high levels of debt.

Conclusion

Debt is predictive of heart attack risk, but the direction and strength of the relationship varies by type of debt, debtors' racial identity, and economic context.

Racial/ethnic differences in the relationship between wealth and health across young adulthood

•Wealth attenuated racial differences in self-rated health during young adulthood.•Wealth had consistent incremental effect on health among White & Hispanic Americans.•For Black Americans, wealth was protective of health in the highest wealth quartile.•Individual wealth, not parental wealth was associated with health among Hispanics.

The Great Recession and Physical Activity of Young Adults

Objective. Since physical inactivity has been identified as a pandemic and a public health priority, it is crucial to understand the role of adverse economic shocks on physical activity. In this study, we examine the impact of job losses during the U.S. Great Recession from January 2008 to June 2009 on the likelihood of physical activities of young adults. Methods. We use individual fixed effects estimation on a nationally representative longitudinal data from 2005 to 2015, the Panel Study of Income Dynamics (PSID), to examine the impact of job losses of young adults, their spouses, and their parents on physical exercise of young adults aged 18 to 27 years. Results. Own job losses during the Great Recession led to a decrease in the likelihood of physical exercise among young adults. However, job losses of parents and partners had no effect on the likelihood of young adults' physical exercise. Conclusion. Our findings indicate a negative impact of the recession on physical activity of young adults and highlights the need for policymakers to consider the impact of major economic downturns on the physical activity of young adults.

Stock volatility and hospital admissions for cardiovascular disease: results from the National Insurance Claims for Epidemiological Research (NICER) study

BACKGROUND

The association between stock volatility and cardiovascular diseases (CVD) was described during the 2008 Global Stock Market Crash; however, whether the finding in an occasional stock market crash is spurious remains unclear.

METHODS

A time-series design was used to evaluate the association between short-term exposure to daily returns of two major indices and daily hospital admissions for CVD and its subtypes based on claims data from the National Insurance Claims for Epidemiological Research (NICER) study covering 174 major cities in China. The average percentage change in daily hospital admissions for cause-specific CVD per 1% change in daily index returns was calculated because the Chinese stock market policy limits its change by 10% of the previous day's closing price. A Poisson regression in a generalised additive model was used to assess the city-specific association; then, overall national estimations were pooled by random-effects meta-analysis.

FINDINGS

Totally 8,234,164 hospital admissions for CVD were recorded during 2014-2017. Points of the Shanghai closing indices ranged from 1991·3 to 5166·4. A U-shaped association was observed between daily index returns and CVD admissions. Changes of 1% in daily returns of the Shanghai index corresponded to 1·28%(95%CI: 1·04%-1·53%), 1·25%(0·99%-1·51%), 1·42%(1·13%-1·72%), and 1·14%(0·39%-1·89%) increases in hospital admissions for total CVD, ischaemic heart disease, stroke, or heart failure on the same day, respectively. Similar results were observed for the Shenzhen index.

INTERPRETATION

Stock market volatility is associated with an increased CVD admission.

FUNDING

Chinese Ministry of Science and Technology (2020YFC2003503) and National Natural Science Foundation of China (81973132, 81961128006).

Net worth poverty and adult health

This study broadens the traditional focus on income as the primary measure of economic deprivation by providing the first analysis of wealth deprivation, or net worth poverty (NWP), and adult health. Net worth poverty-having wealth (assets minus debts) less than one-fourth of the federal poverty line-likely exacerbates the negative effects of income poverty (IP). In 2019, one-third of US households were net worth poor, with substantially higher rates among Black (60%) relative to White (25%) households. We estimate longitudinal growth curve (i.e., linear mixed effects) models to test how NWP, IP, and the interaction of the two predict a diverse set of health measures. We also consider whether NWP resulting from either low assets or high debts is more predictive of health outcomes and test for heterogeneous associations by race. Data come from Panel Study of Income Dynamics on 8,962 individuals ages 25 to 64, observed between 2011 and 2019 (n = 26,776). Adjusting for income poverty, net worth poverty, relative to no poverty, was associated with a one-quarter to one-third increase in the likelihood of reporting poor self-rated health, psychological distress, and work limitations. Simultaneously experiencing both NWP and IP was associated with the largest deficits. Both asset-driven (low asset) and debt-driven (high debt) NWP reduced health, but asset-driven NWP had stronger associations (e.g., a 5-percentage point increase of being in poor health, twice that of debt-driven). White, relative to Black, adults exhibited statistically larger associations for psychological distress (4.3 vs 1.1 percentage points) and work limitations (3.7 vs. 1.5 percentage points). White and Black adults who were jointly net worth and income poor exhibited the most disadvantage. Findings underscore how wealth is a critical component of financial deprivation and that wealth deprivation, particularly the lack of assets, merits attention in socioeconomic studies of health inequalities.

The Financial Correlates of Midlife Obesity

INTRODUCTION

This study explored the associations between midlife obesity and an array of common financial stressors related to wealth loss, debt, and bankruptcy.

METHODS

The analysis was conducted in 2022 with data from the National Longitudinal Survey of Youth 1979. The final sample included 36,122 observations on 8,059 respondents as they aged from ages 31‒39 years in 1996 to ages 51‒59 in 2016. Associations between obesity and financial stressors were estimated with logistic regression models adjusting for a comprehensive set of relevant control variables.

RESULTS

The analysis found significant relationships between obesity and multiple types of financial stressors, including property debt, unsecured debt, and bankruptcy. Property debt and unsecured debt increased the odds of obesity by 29% and 20%, respectively, and bankruptcy increased the odds of obesity by 43%. Average Marginal Effects (AMEs) in combination with model fit statistics confirmed that these stressors-unsecured debt, property debt, and bankruptcy-were important financial correlates of midlife obesity among the National Longitudinal Survey of Youth 1979 cohort.

CONCLUSIONS

The financial correlates of obesity included multiple financial stressors, but the magnitude of associations varied substantially across types of financial stressors. Results suggest that future interventions aimed at reducing obesity disparities should target populations with high levels of debt and bankruptcy.

Stressful life events, neighbourhood characteristics, and systolic blood pressure in South Africa

The relationship between negative events, neighbourhood characteristics, and systolic blood pressure in developing countries is not well-documented, particularly using longitudinal data. To explore this relationship, we analysed panel data from the first three waves of the South African National Income Dynamics Study using a correlated random effects model adjusted for confounding risk factors. Our sample comprised of 15,631 respondents in 2008, 14,443 respondents in 2010/2011, and 14,418 respondents in 2012, all aged above 15 years. The prevalence of at least one negative household event across the three waves was approximately 30%. In any of the three waves, the adjusted prevalence of hypertension was 23.84%. This share was 21.75% in 2008 (95% CI 18.06-25.44), 23.16% in 2010/11 (95% CI 19.18-27.14), and 18.39% in 2012 (95% CI 16.03-20.75). In our adjusted correlated random effects model, we found that systolic blood pressure was significantly higher among respondents from households that reported death of a household member (0.85 mmHg; p =  0.02) and a reduction in grant income and remittances (2.14 mm Hg; p = 0.01). We also found no significant association between systolic blood pressure and neighbourhood income level. In a country with social and economic challenges, our results indicate that grief and negative financial events are adversely associated with blood pressure, which may explain in part the significant burden of hypertension in low- and middle-income countries.

Association of Perceived Job Insecurity With Subsequent Memory Function and Decline Among Adults 55 Years or Older in England and the US, 2006 to 2016

Importance

Intensified global economic competition and recent financial crises, including those associated with the COVID-19 pandemic, have contributed to uncertainty about job security. However, little is known about the association of perceived job insecurity with memory function and decline among older adults.

Objectives

To investigate the association between perceived job insecurity and subsequent memory function and rate of memory decline among older adults in the US and England.

Design, Setting, and Participants

This 10-year prospective population-based cohort study used data from the US Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) collected from 2006 to 2016. Participants included 9538 adults 55 years or older. Data were analyzed from August 1 to 31, 2021.

Exposures

Perceived job insecurity (yes vs no) at baseline.

Main Outcomes and Measures

Episodic memory z scores at baseline and rate of decline during the follow-up.

Results

Among the 9538 study participants, the mean (SD) age at baseline was 60.97 (6.06) years, and 4981 (52.22%) were women. A total of 2320 participants (24.32%) reported job insecurity at baseline (1088 of 3949 [27.55%] in England and 1232 of 5589 [22.04%] in the US). Perceived job insecurity after 55 years of age was associated with lower baseline memory z scores in the fully adjusted model (β = -0.04 [95% CI, -0.08 to -0.01]) but not with rate of memory decline (β = 0.01 [95% CI, -0.01 to 0.01]). The association appeared to be stronger in the US than in England (job insecurity × US, β = -0.05 [95% CI, -0.11 to 0.02]), but the estimate was imprecise, potentially owing to low statistical power.

Conclusions and Relevance

The findings of this cohort study suggest that exposure to job insecurity in middle to late life was associated with worse memory function among older adults in the US and England. This association may vary across socioeconomic and social welfare contexts, although future studies with large samples from diverse socioeconomic settings are warranted.

The Devastating Economic Impact of COVID-19 on Older Black and Latinx Adults: Implications for Health and Well-Being

OBJECTIVES

While disparities in COVID-19 infections and mortality have been documented for older Black and Latinx populations, pandemic-related economic impacts have been less studied for these groups. Minoritized older adults may be particularly vulnerable to financial hardships given their precarious socioeconomic positions. Thus, we aim to highlight the devastating economic impact of the ongoing COVID-19 pandemic and subsequent economic recession on older Black and Latinx adults, with a particular focus on the foreign-born population.

METHODS

This study used data from the 2020 COVID-19 module of the Health and Retirement Study. The sample included adults >50 years of age who were U.S.-born non-Latinx White and Black, U.S.-born Latinx, and foreign-born Latinx (n=2,803). We estimated age-standardized prevalence and means of variables indicating financial impact and economic hardship during the pandemic. We further examined differences in these measures across racial/ethnic and nativity groups.

RESULTS

Our findings document stark racial/ethnic inequalities in the pandemic's economic impact on older adults. Results show the pandemic has negatively affected older Black and Latinx adults across a host of economic factors (e.g., paying bills, affording health-related needs, or purchasing food), with foreign-born Latinx experiencing greater economic hardships relative to other groups.

DISCUSSION

During the COVID-19 pandemic, older Black and Latinx adults are experiencing disparate economic effects, including lacking money to cover basic needs, compared to older White adults. The implications of the economic shocks of the pandemic for the health and well-being of older Black and Latinx adults warrant policy-oriented action towards promoting equity.

Trends in "Deaths of Despair" Among Working-Aged White and Black Americans, 1990-2017

Life expectancy for US White men and women declined between 2013 and 2017. Initial explanations for the decline focused on increases in "deaths of despair" (i.e., deaths from suicide, drug use, and alcohol use), which have been interpreted as a cohort-based phenomenon afflicting middle-aged White Americans. There has been less attention on Black mortality trends from these same causes, and whether the trends are similar or different by cohort and period. We complement existing research and contend that recent mortality trends in both the US Black and White populations most likely reflect period-based exposures to 1) the US opioid epidemic and 2) the Great Recession. We analyzed cause-specific mortality trends in the United States for deaths from suicide, drug use, and alcohol use among non-Hispanic Black and non-Hispanic White Americans, aged 20-64 years, over 1990-2017. We employed sex-, race-, and cause-of-death-stratified Poisson rate models and age-period-cohort models to compare mortality trends. Results indicate that rising "deaths of despair" for both Black and White Americans are overwhelmingly driven by period-based increases in drug-related deaths since the late 1990s. Further, deaths related to alcohol use and suicide among both White and Black Americans changed during the Great Recession, despite some racial differences across cohorts.

The Bidirectional Relationship Between Debts and Common Mental Disorders: Results of a longitudinal Population-Based Study

Researchers and politicians have regularly expressed their worries about a widening of socioeconomic inequalities in physical and mental health. Debts have been relatively understudied as a specific aspect of socioeconomic disadvantage contributing to poor mental health. This study examines the bidirectional association between debts and common mental disorders (CMDs) in the adult population of the Netherlands. Data were obtained from the second ('baseline') and third (3-year follow-up) wave of the Netherlands Mental Health Survey and Incidence Study-2, a representative cohort of adults. Questions were asked about debts and difficulty in repaying debts in the past 12 months. The answers were combined into one variable: no debts, easy, difficult, and very difficult to pay back debts. Twelve-month CMDs were assessed with the Composite International Diagnostic Interview version 3.0. Increasing levels of difficulty in repaying debts predicted onset of CMD at follow-up in those without 12-month CMD at baseline, and persistence of CMD at follow-up in those with 12-month CMD at baseline. Conversely, CMD was not linked to onset of debts at follow-up in those without 12-month debts at baseline, but was associated with persistence of difficulty to pay back debts at follow-up in those with 12-month debts at baseline. These associations remained significant after adjustment for baseline sociodemographic variables, negative life events and physical health. Health professionals and debt counsellors should pay more attention to patients' debts and clients' mental health respectively in order to refer those with financial or mental health problems to the appropriate services.

Effects of the Great Recession on Educational Disparities in Cardiometabolic Health

BACKGROUND

Macroeconomic crises can exaggerate existing educational disparities in health. Few studies, however, have examined whether macroeconomic crises get under the skin to affect educational disparities in health-related biological processes.

PURPOSE

This study aimed to examine the effect of the economic recession of 2008 (i.e., Great Recession) on educational disparities in cardiometabolic risk and self-reported psychological distress.

METHODS

Data were drawn from two subsamples of the Midlife in the United States (MIDUS) study: the second wave of the MIDUS sample (pre-recession cohort, N = 985) and the refresher sample (post-recession cohort, N = 863). Educational attainment was categorized into high school education or less, some college, and bachelor's degree or higher. Outcomes included metabolic syndrome, C-reactive protein, and interleukin-6, as well as self-reported perceived stress, depressive symptoms, and financial distress.

RESULTS

Results showed that having a bachelor's degree or higher (compared to having a high school education or less) was more strongly associated with decreased metabolic syndrome symptoms in the post-recession cohort than the pre-recession cohort, above and beyond demographic, health, and behavioral covariates. These findings did not extend to systemic inflammation or psychological distress.

CONCLUSIONS

Our findings suggest that chronic macroeconomic stressors may widen the educational gap in physical health, particularly cardiometabolic health, by modifying biological and anthropometric risk factors implicated in metabolic syndrome.

Midlife Wealth Mobility and Long-term Cardiovascular Health

Importance

The association of socioeconomic status and cardiovascular outcomes has been well described, but little is known about whether longitudinal changes in wealth are associated with cardiovascular health status.

Objective

To evaluate the association between midlife wealth mobility and risk of cardiovascular events.

Design, Setting, and Participants

This longitudinal, retrospective cohort study included US adults 50 years or older who participated in the Health and Retirement Study. Participants in the primary analysis had no history of cardiovascular disease and had observations in at least two of three 5-year age intervals (50-54, 55-59, and 60-64 years) and follow-up after 65 years of age. Data were collected from January 1, 1992, to December 31, 2016, and analyzed from November 10, 2020, to April 26, 2021.

Exposures

Quintiles of wealth (reflecting total nonhousing assets) were defined within each of 4 birth cohorts (1931-1935, 1936-1940, 1941-1945, and 1946-1950). Wealth mobility was defined as an increase or a decrease of 1 or more wealth quintiles and was compared with wealth stability (same quintile over time) using covariate-adjusted Cox proportional hazards regression models.

Main Outcomes and Measures

Composite outcome of nonfatal cardiovascular event (myocardial infarction, heart failure, cardiac arrhythmia, or stroke) or cardiovascular death.

Results

A total of 5579 participants were included in the primary analysis (mean [SD] age, 54.2 [2.6] years; 3078 women [55.2%]). During a mean (SD) follow-up of 16.9 (5.8) years, 1336 participants (24.0%) experienced a primary end point of nonfatal cardiovascular event or cardiovascular death (14.4 [95% CI, 13.6-15.2] per 1000 patient-years). Higher initial wealth (per quintile) was associated with lower cardiovascular risk (adjusted hazard ratio [aHR] per quintile, 0.89 [95% CI, 0.84-0.95]; P = .001). When compared with stable wealth, participants who experienced upward wealth mobility (by at least 1 quintile) had independently lower hazards of a subsequent nonfatal cardiovascular event or cardiovascular death (aHR, 0.84 [95% CI, 0.73-0.97]; P = .02), and participants who experienced downward wealth mobility had higher risks (aHR, 1.15 [95% CI, 1.00-1.32]; P = .046).

Conclusions and Relevance

These findings suggest that upward wealth mobility relative to peers in late middle age is associated with lower risks of cardiovascular events or death after 65 years of age.

Varieties of Financial Stressors and Midlife Health Problems

OBJECTIVES

Financial stressors such as wealth loss, indebtedness, and bankruptcy have gained the attention of public health scholars since the Great Recession. In this study, we extend this area of research by comparing the mental and physical impact of multiple financial stressors during midlife, a pivotal period in the life course for wealth accumulation and disease onset.

METHODS

With data from the National Longitudinal Survey of Youth 1979 (www.nlsinfo.org), an ongoing survey of adult men and women in the U.S., we used logistic regression to estimate the associations between financial stressors and the risk of a psychiatric disorder or high blood pressure diagnosis from ages 31-39 in 1996 to ages 50-59 in 2016 (N = 7,143). Financial stressors include multiple types of wealth loss, debt, and bankruptcy.

RESULTS

Even after adjusting for a comprehensive set of confounders, many of the financial stressors we considered had similar associations with the risk of a psychiatric disorder, whereas only debt and bankruptcy were associated with the risk of high blood pressure. The best fitting models for both health outcomes included a simple indicator of indebtedness. Stock losses were not significantly associated with either health outcome.

DISCUSSION

Given the recent volatility in the U.S. economy, our results highlight the potential loss of health that may occur if nothing is done to prevent economically vulnerable populations from sliding into financial crisis. Our results also emphasize the need for additional research to develop individual-level interventions to improve health among those already experiencing financial difficulties.

Duration of Poverty and Subsequent Cognitive Function and Decline Among Older Adults in China, 2005-2018

OBJECTIVE

To investigate the relationship between late-life duration of poverty exposure and cognitive function and decline among older adults in China.

METHODS

Data were from 3,209 participants ≥64 years of age in the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Duration of poverty, defined according to urban and rural regional standards from the China Statistical Yearbook, was assessed according to annual household income from 2005 to 2011 (never in poverty; one-third of the period in poverty; two-thirds or more of the period in poverty). Cognitive function was measured by the Chinese Mini-Mental State Examination (CMMSE) from 2011 to 2018. We used attrition-weighted, multivariable mixed-effects Tobit regression to examine the association of duration of poverty with cognitive function and rate of decline.

RESULTS

A total of 1,162 individuals (36.21%) were never in poverty over the period from 2005 to 2011; 1,172 (36.52%) were in poverty one-third of the period; and 875 (27.27%) were in poverty two-thirds or more of the period. A longer poverty duration was associated with lower subsequent CMMSE scores with a dose-response relationship (one-third vs never in poverty: β = -0.98; 95% confidence interval -1.61 to -0.35; two-thirds or more vs never in poverty: β = -1.55; 95% confidence interval -2.29 to -0.81). However, a longer duration of poverty was associated with a slower rate of CMMSE score decline over time from 2011 to 2018.

CONCLUSION

These findings provide valuable evidence for the role of cumulative late-life poverty in relation to cognitive health among older adults in a rapidly urbanizing and aging middle-income country. Our findings may support a compensation hypothesis for cognitive reserve in this setting.

Community-dwelling older adults who are low-income and disabled weathering financial challenges

Despite interventions aiming to improve outcomes among older adults experiencing financial challenges, the challenges and strategies employed to handle them are poorly understood. This study examined the experiences of financial challenges among low-income adults aged ≥65 years. Eleven semi-structured interviews were analyzed using thematic analyses. An overarching theme was "I guess it balances", capturing attempts to maintain hope and proactively address challenges despite stress, uncertainty and limitations. Balancing was demonstrated within four domains, including cognitive bandwidth ("think a lot" versus "I don't dwell on that"), emotional experience ("depressing" versus "be thankful"), learned resilience ("that was a shock" versus "there's always a way"), and meeting daily needs ("we learned to do without" versus "take a dollar and stretch it"). Participants described being weathered by challenges and using predominately high-effort coping strategies to weather the challenges. These findings call for strengthening the safety net for older adults facing financial challenges.

Life-course trajectories of body mass index from adolescence to old age: Racial and educational disparities

No research exists on how body mass index (BMI) changes with age over the full life span and social disparities therein. This study aims to fill the gap using an innovative life-course research design and analytic methods to model BMI trajectories from early adolescence to old age across 20th-century birth cohorts and test sociodemographic variation in such trajectories. We conducted the pooled integrative data analysis (IDA) to combine data from four national population-based NIH longitudinal cohort studies that collectively cover multiple stages of the life course (Add Health, MIDUS, ACL, and HRS) and estimate mixed-effects models of age trajectories of BMI for men and women. We examined associations of BMI trajectories with birth cohort, race/ethnicity, parental education, and adult educational attainment. We found higher mean levels of and larger increases in BMI with age across more recent birth cohorts as compared with earlier-born cohorts. Black and Hispanic excesses in BMI compared with Whites were present early in life and persisted at all ages, and, in the case of Black-White disparities, were of larger magnitude for more recent cohorts. Higher parental and adulthood educational attainment were associated with lower levels of BMI at all ages. Women with college-educated parents also experienced less cohort increase in mean BMI. Both race and education disparities in BMI trajectories were larger for women compared with men.

Debt Stress and Debt Illusion: The Role of Consumer Credit, Reverse and Standard Mortgages

OBJECTIVES

This study examines the relationship of debt stress and reverse mortgage borrowing and compares it to stress from standard mortgages and consumer debt. Debt stress is measured as a self-reported response to the amount of debt.

METHODS

Using a unique national data set of 1,026 homeowners who chose whether to obtain a reverse mortgage in 2010, we estimate the relationship of 2014 levels of debt stress with various types of debt, assets, and income. Using an ordered probit model, we address the endogeneity of our measures of mortgage and consumer debt using an instrumental variables regression model.

RESULTS

We found that consumer debt causes more stress per dollar of debt compared to mortgage debt. Reverse mortgages cause a relatively low level of stress per dollar of debt compared with standard mortgage debt. The average treatment effect of originating a reverse mortgage indicates statistically significantly higher probability of reporting no and not very much debt stress.

DISCUSSION

Reverse mortgage debt causes a complex stress response. Stress per dollar of debt is lower for reverse than standard mortgages 4 years after origination. However, reverse mortgages' loan balance grows over time causing total stress to increase, while stress from a standard mortgage decreases as it is repaid. If an older adult uses reverse mortgage funds to repay consumer debt then total stress is reduced.

Biological embedding of experience: A primer on epigenetics

Biological embedding occurs when life experience alters biological processes to affect later life health and well-being. Although extensive correlative data exist supporting the notion that epigenetic mechanisms such as DNA methylation underlie biological embedding, causal data are lacking. We describe specific epigenetic mechanisms and their potential roles in the biological embedding of experience. We also consider the nuanced relationships between the genome, the epigenome, and gene expression. Our ability to connect biological embedding to the epigenetic landscape in its complexity is challenging and complicated by the influence of multiple factors. These include cell type, age, the timing of experience, sex, and DNA sequence. Recent advances in molecular profiling and epigenome editing, combined with the use of comparative animal and human longitudinal studies, should enable this field to transition from correlative to causal analyses.

Economic influences on population health in the United States: Toward policymaking driven by data and evidence

Atheendar S. Venkataramani and colleagues discuss economic factors and population health in the United States.

Beyond Net Worth: Racial Differences in Wealth Portfolios and Black-White Health Inequality across the Life Course

A large body of research links wealth and health, but most previous work focuses on net worth. However, the assets and debts that comprise wealth likely relate to health in different and meaningful ways. Furthermore, racial differences in wealth portfolios may contribute to racial health gaps. Using longitudinal data from the Panel Study of Income Dynamics (PSID) and mixed effects growth curve models, we examined the associations between various wealth components and multiple health outcomes. We also investigated whether black-white differences in wealth portfolios contributed to racial health inequality. We found that savings, stock ownership, and homeownership consistently improve health, but debt is associated with worse health, even after adjusting for total net worth. We found little evidence that home equity is associated with health. Findings also revealed differential health returns to assets by race. These findings provide new insights into the complex relationship among race, wealth, and health.

How painful is a recession? An assessment of two future-oriented buffering mechanisms

RATIONALE AND OBJECTIVE

Guided by stress process theory, this study investigates the association between the economic downturn and chronic pain interference, as well as the role of two future-oriented buffering mechanisms (anticipated stressor duration and pre-recession financial optimism) in this relationship. This research integrates both an objective measure of the recession based on negative personal experiences, as well as subjective event-based appraisals of how the recession impacted people's lives.

METHOD

Drawing on longitudinal data from the National Survey of Midlife Development in the United States, linear lagged dependent variable models are used to estimate associations between recession-era stressors and chronic pain interference among 1113 adults. The analysis further examines the moderating influences of anticipated stressor duration and pre-recession financial optimism.

RESULTS

Findings reveal that both an accumulation of adverse experiences and global appraisals of the economic recession have harmful associations with chronic pain interference; however, their magnitude varied according to future-oriented moderating factors. Specifically, people with high pre-recession financial optimism fared better when confronted with recession-related stressors than did those with low levels of financial optimism. Moreover, pain interference was greater among individuals who appraised the recession as having a negative impact on their lives, but only if they perceived the recession would extend into the future.

CONCLUSIONS

This study demonstrates distinctive links between two recession-related measures and pain interference. Findings suggest that positive future orientations can be protective during an economic crisis, whereas negative orientations heighten the pain.

The Relationship Between Reverse Mortgage Borrowing, Domain and Life Satisfaction

OBJECTIVES

Reverse mortgages allow adults aged 62 years and older to borrow against the equity in their homes without incurring monthly loan repayments. This study examines the relationship of reverse mortgage borrowing with older adults' satisfaction with their financial situation, housing, health, and daily life/leisure as well as with life as a whole.

METHOD

A new national data set of 1,088 older adults, comprised of loan data, credit histories, and responses to a phone survey, was created. Our estimation strategy compares reverse mortgage borrowers to older adults who obtained mandatory counseling but not a reverse mortgage.

RESULTS

Reverse mortgage borrowers have significantly higher financial and housing satisfaction compared to nonborrowers; no differences were found for health, daily life/leisure, and general satisfaction. These satisfaction domains contribute differently to general satisfaction for reverse mortgage borrowers relative to nonborrowers: housing satisfaction has a greater influence for borrowers and health a greater influence for nonborrowers.

DISCUSSION

Our study provides new knowledge about the longer-term outcomes of reverse mortgage borrowers. The positive association of reverse mortgage borrowing for housing and financial satisfaction and, in turn, general satisfaction, provides insights regarding borrower experiences with this controversial financial tool.

Socioeconomic Status and Biological Risks for Health and Illness Across the Life Course

OBJECTIVES

We assess the temporal properties and biosocial mechanisms underlying the associations between early-life socioeconomic status (SES) and later health. Using a life-course design spanning adolescence to older adulthood, we assess how early life and various dimensions of adult SES are associated with immune and metabolic function in different life stages and examine possible bio-behavioral and psychosocial mechanisms underlying these associations.

METHOD

Data for this study come from 3 national studies that collectively cover multiple stages of the life course (Add Health, MIDUS, and HRS). We estimated generalized linear models to examine the prospective associations between early-life SES, adult SES, and biomarkers of chronic inflammation and metabolic disorder assessed at follow-up. We further conducted formal tests of mediation to assess the role of adult SES in linking early SES to biological functions.

RESULTS

We found that early-life SES exerted consistent protective effects for metabolic disorder across the life span, but waned with time for CRP. The protective effect of respondent education remained persistent for CRP but declined with age for metabolic disorder. Adult income and assets primarily protected respondents against physiological dysregulation in middle and old ages, but not in early adulthood.

DISCUSSION

These findings are the first to elucidate the life-course patterns of SES that matter for underlying physiological functioning during the aging process to produce social gradients in health.

Racial and Ethnic Variations in Mortality Rates for Patients Undergoing Maintenance Dialysis Treated in US Territories Compared with the US 50 States

BACKGROUND AND OBJECTIVES

In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others.

RESULTS

Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P<0.001) and Asians (HR, 2.01; 95% confidence interval, 1.78 to 2.27; P<0.001) living in the territories versus their matched 50 states counterparts. There were no significant differences in mortality among white or black patients in the territories versus the 50 states.

CONCLUSIONS

Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.

Wealth and Obesity Among US Adults Entering Midlife

OBJECTIVE

This study examines the relationship between wealth and obesity among adults entering midlife and whether this relationship varies by sex, race, and measure of wealth.

METHODS

The data were obtained from the National Longitudinal Survey of Youth 1979 (NLSY-79). Population-averaged models were used to examine the associations between multiple measures of wealth and obesity among 6,979 respondents while controlling for education, occupation, income, and relevant sociodemographic variables.

RESULTS

The analysis found a robust association between wealth and midlife obesity as well as heterogeneity in the wealth-obesity association across sex, race, and measure of wealth. With the exception of black men, net worth generally had a significant and inverse relationship with obesity. The net worth-obesity association was largest among women and was driven primarily by home value, in addition to savings and debt for black women. Although home value was significant for white men, the components of wealth were generally unrelated to obesity among men.

CONCLUSIONS

The association between wealth and obesity was generally robust but also complex, depending on sex, race, and measure of wealth. Research that does not consider multiple components of wealth may overlook the importance of economic resources in shaping obesity rates in the US population.

Impact of self-reported bank fraud on self-rated health, comorbidity and pain

OBJECTIVES

As reported in other high-income countries, around the 2008 Great Recession the Spanish banking sector engaged abusive practices that satisfy the definition of fraud. Our objective is to examine the association between self-reported bank fraud and physical health, using a gender perspective.

METHODS

With data from the 2017 Madrid Health Survey, we examined the association between the economic impact of fraud and poor self-rated health (SRH), comorbidity and pain (N = 4425). Interactions of time since fraud and sex with economic impact were tested by Poisson regression models with robust variance.

RESULTS

In total, 11% of adults in Madrid reported bank fraud since 2006. Among men, those who experienced frauds with severe economic impact were more likely to report adverse health than those who did not experience fraud (PR comorbidity: 1.46; PR pain conditions: 2.17). Among men time elapsed since fraud strengthened the association between severe economic impact and poor SRH (p = 0.022; p = 0.006, respectively). Among women, associations did not reach statistical significance.

CONCLUSIONS

Bank frauds are an emerging phenomenon which is likely to damage public health. Stricter regulation to protect people from fraudulent bank practices is needed.

Association of Out-of-Pocket Annual Health Expenditures With Financial Hardship in Low-Income Adults With Atherosclerotic Cardiovascular Disease in the United States

Importance

Health insurance is effective in preventing financial hardship from unexpected major health care events. However, it is also essential to assess whether vulnerable patients, particularly those from low-income families, are adequately protected from longitudinal health care costs for common chronic conditions such as atherosclerotic cardiovascular disease (ASCVD).

Objective

To examine the annual burden of total out-of-pocket health expenses among low-income families that included a member with ASCVD.

Design, Setting, and Participants

In this cross-sectional study of the Medical Expenditure Panel Survey from January 2006 through December 2015, all families with 1 or more members with ASCVD were identified. Families were classified as low income if they had an income under 200% of the federal poverty limit. Analyses began December 2017.

Main Outcomes and Measures

Total annual inflation-adjusted out-of-pocket expenses, inclusive of insurance premiums, for all patients with ASCVD. We compared these expenses against annual family incomes. Out-of-pocket expenses of more than 20% and more than 40% of family income defined high and catastrophic financial burden, respectively.

Results

We identified 22 521 adults with ASCVD, represented in 20 600 families in the Medical Expenditure Panel Survey. They correspond to an annual estimated 23 million or 9.9% of US adults with a mean (SE) age of 65 (0.2) years and included 10.9 million women (47.1%). They were represented in 21 million or 15% of US families. Of these, 8.2 million families (39%) were low income. The mean annual family income was $57 143 (95% CI, $55 377-$58 909), and the mean out-of-pocket expense was $4415 (95% CI, $3735-$3976). While financial burden from health expenses decreased throughout the study, even in 2014 and 2015, low-income families had 3-fold higher odds than mid/high-income families of high financial burden (21.4% vs 7.6%; OR, 3.31; 95% CI, 2.55-4.31) and 9-fold higher odds of catastrophic financial burden (9.8% vs 1.2%; OR, 9.35; 95% CI, 5.39-16.20), representing nearly 2 million low-income families nationally. Further, even among the insured, 1.6 million low-income families (21.8%) experienced high financial burden and 721 000 low-income families (9.8%) experienced catastrophic out-of-pocket health care expenses in 2014 and 2015.

Conclusions and Relevance

One in 4 low-income families with a member with ASCVD, including those with insurance coverage, experience a high financial burden, and 1 in 10 experience a catastrophic financial burden due to cumulative out-of-pocket health care expenses. To alleviate economic disparities, policy interventions must extend focus to improving not only access, but also quality of coverage, particularly for low-income families.

Current smoking and quit-attempts among US adults following Medicaid expansion

The objective of this study was to estimate the influence of the Affordable Care Act (ACA) Medicaid Expansion on current smoking and quit attempts in expanded and non-expanded states. We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) between 2003 through 2015 to evaluate changes in current smoking and quit attempts using multivariable logistic regression and generalized estimating equations (GEE), adjusting for socioeconomic factors. Time periods evaluated were: 2003–2009 (pre-expansion) and 2011–2015 (post-expansion), and in supplemental analysis, also 2011–2017. Overall, smoking prevalence among adults in expanded and non-expanded states were 16% and 17% (p < 0.001), respectively, and quit attempt prevalence for expanded and non-expanded states were 56% and 57% (p = 0.05), respectively. In adjusted models comparing post- versus pre- expansion periods, current smoking declined by 6% in both expanded (RR: 0.94, 95% CI: 0.93–0.94) and non-expanded (RR: 0.94, 95% CI: 0.94–0.95) states. Quit attempts increased by 4% (RR: 1.04, 95% CI: 1.04–1.05) in expanded states, and by 3% (RR: 1.03, 95% CI: 1.02–1.03) in non-expanded states. States that imposed barriers to utilization of smoking cessation services e.g. prior authorization, saw only a 3% increase in quit attempts regardless of expansion status, while expanded states that did not impose barriers experienced a 6% (RR: 1.06, 95% CI: 1.05–1.06) increase in quit attempts. Reducing administrative barriers to smoking cessation programs may enhance further declines in smoking rates among US adults.

Economic hardship over twenty-two consecutive years of adult life and markers of early ageing: physical capability, cognitive function and inflammation

This study assesses the associations between annual measures of economic hardship (EH) across 22 years of adulthood and objective measures of early ageing in a Danish late-middle-aged population (N = 5575). EH (years < 60% of the National median equivalized household disposable income) was experienced by 18% during 1987-2008. Four or more years in EH (reference = null years in EH) was related to poorer physical capability (chair rise: - 1.49 counts/30 s [95% confidence interval (CI) - 2.36, - 0.61], hand grip strength: - 1.22 kg [95% CI - 2.38, - 0.07], jump height: - 1.67 cm [95% CI - 2.44, - 0.91] and balance: 18% [95% CI 9, 28]), poorer cognitive function (Intelligenz-Struktur-Test: - 1.50 points [95% CI - 2.89, - 0.12]) and higher inflammatory levels (C-reactive protein: 22% [95% CI 4, 44], and Interleukin-6: 23% [95% CI 10, 39]). Comparing four EH trajectories, people with a high versus low probability of EH over time had poorer physical capability (chair rise: - 1.70 counts/30 s [95% CI - 3.38, - 0.01], grip: - 4.33 kg [95% CI - 6.50, - 2.16], jump: - 1.68 cm [95% CI - 3.12, - 0.25] and balance: 31% [95% CI 12, 52]). No associations were observed with tumour necrosis factor-α. Results were adjusted for sex, age, long-term parental unemployment/financial problems, education, baseline income and cohort. This study suggested EH for four or more years to be associated with poorer physical capability, cognitive function and increased inflammatory levels in midlife. High probability of EH across adulthood was similarly related to poorer physical capability and CRP, but not cognitive function and the remaining inflammatory markers. In conclusion, preventive initiatives focusing on reducing the burden of sustained economic hardship may lead to increased healthy ageing.

Placing prostate cancer disparities within a psychosocial context: challenges and opportunities for future research

Black men are more likely to be diagnosed with prostate cancer compared with White men. Despite advances in prevention and treatment strategies, disparities in prostate cancer among Black men persist. While research on the causes of higher incidence and mortality is ongoing, there is limited evidence in the existing literature that clearly speaks to the potential psychological or social factors that may contribute to disparities in prostate cancer incidence. Given the lack of attention to this issue, we review scientific evidence of the ways in which social factors, including socioeconomic status and racial segregation, as well as psychological factors, like depression and anxiety, are related to subsequent prostate cancer risk, which could occur through behavioral and biological processes. Our objective is to illuminate psychosocial factors and their context, using a racial disparity lens, which suggests opportunities for future research on the determinants of prostate cancer. Ultimately, we aim to contribute to a robust research agenda for the development of new prostate cancer prevention measures to reduce racial disparities.

Associations of Income Volatility With Incident Cardiovascular Disease and All-Cause Mortality in a US Cohort

BACKGROUND

Income volatility is on the rise and presents a growing public health problem. Because in many epidemiological studies income is measured at a single point in time, the association of long-term income volatility with incident cardiovascular disease (CVD) and mortality has not been adequately explored. The goal of this study was to examine associations of income volatility from 1990 to 2005 with incident CVD and all-cause mortality in the subsequent 10 years.

METHODS

The Coronary Artery Risk Development in Young Adults Study is an ongoing prospective cohort study conducted within urban field centers in Birmingham, AL; Chicago, IL; Minneapolis, MN; and Oakland, CA. We studied 3937 black and white participants 23 to 35 years of age in 1990 (our study baseline). Income volatility was defined as the intraindividual SD of the percent change in income across 5 assessments from 1990 to 2005. An income drop was defined as a decrease of ≥25% from the previous visit and less than the participant's average income from 1990 to 2005. CVD events (fatal and nonfatal) and all-cause mortality between 2005 and 2015 were adjudicated with the use of medical records and death certificates. CVD included primarily acute events related to heart disease and stroke.

RESULTS

A total of 106 CVD events and 164 deaths occurred between 2005 and 2015 (incident rate, 2.76 and 3.66 per 1000 person-years, respectively). From Cox models adjusted for sociodemographic, behavioral, and CVD risk factors, higher income volatility and more income drops were associated with greater CVD risk (high versus low volatility: hazard ratio, 2.07; 95% CI, 1.10-3.90; ≥2 versus 0 income drops: hazard ratio, 2.54; 95% CI, 1.24-5.19) and all-cause mortality (high versus low volatility: hazard ratio, 1.78; 95% CI,1.03-3.09; ≥2 versus 0 income drops: hazard ratio, 1.92; 95% CI, 1.07-3.44).

CONCLUSIONS

In a cohort of relatively young adults, income volatility and drops during a 15-year period of formative earning years were independently associated with a nearly 2-fold risk of CVD and all-cause mortality.

Effects of the 2008 global financial crisis on population health

We compare the transmission channels through which the 2008 global financial crisis affected health. We find that postponing or skipping visits to the doctor after falling ill and stopping buying regular medication had the strongest negative effects on health, followed by a reduced consumption of staple foods, utilities being cut, being forced to move, and having to sell assets. In comparison, experiencing cuts in TV, phone, and internet services, as well as delaying payments for utilities had relatively weaker negative impacts. In contrast, having a household head or household member lose a job also had negative effects on health status, although this effect was relatively lower. Finally, a reduced flow of remittances had the weakest negative effect.

Integrating Biomarkers in Social Stratification and Health Research

This article provides an overview of the integration of biomarkers and biological mechanisms in social science models of stratification and health. The goal in reviewing this literature is to highlight research that identifies the social forces that drive inequalities over the life course and across generations. The article is structured in the following way. First, descriptive background information on biomarkers is presented, followed secondly by a review of the general theoretical paradigms that lend themselves to an integrative approach. Third, the biomarkers used to capture several biological systems that are most responsive to social conditions are described. Fourth, research that explicates how social exposures "get under the skin" to affect physiological functioning and downstream health is discussed, using socioeconomic disadvantage as an illustrative social exposure. The review ends with emerging directions in the use of biomarkers in social science research. This article endeavors to encourage sociologists to embrace biosocial approaches in order to elevate the importance of social factors in biomedical processes and to intervene on the social conditions that create inequities.

Association of a Negative Wealth Shock With All-Cause Mortality in Middle-aged and Older Adults in the United States

Importance

A sudden loss of wealth-a negative wealth shock-may lead to a significant mental health toll and also leave fewer monetary resources for health-related expenses. With limited years remaining to regain lost wealth in older age, the health consequences of these negative wealth shocks may be long-lasting.

Objective

To determine whether a negative wealth shock was associated with all-cause mortality during 20 years of follow-up.

Design, Setting, and Participants

The Health and Retirement Study, a nationally representative prospective cohort study of US adults aged 51 through 61 years at study entry. The study population included 8714 adults, first assessed for a negative wealth shock in 1994 and followed biennially through 2014 (the most recent year of available data).

Exposures

Experiencing a negative wealth shock, defined as a loss of 75% or more of total net worth over a 2-year period, or asset poverty, defined as 0 or negative total net worth at study entry.

Main Outcomes and Measures

Mortality data were collected from the National Death Index and postmortem interviews with family members. Marginal structural survival methods were used to account for the potential bias due to changes in health status that may both trigger negative wealth shocks and act as the mechanism through which negative wealth shocks lead to increased mortality.

Results

There were 8714 participants in the study sample (mean [SD] age at study entry, 55 [3.2] years; 53% women), 2430 experienced a negative wealth shock during follow-up, 749 had asset poverty at baseline, and 5535 had continuously positive wealth without shock. A total of 2823 deaths occurred during 80 683 person-years of follow-up. There were 30.6 vs 64.9 deaths per 1000 person-years for those with continuously positive wealth vs negative wealth shock (adjusted hazard ratio [HR], 1.50; 95% CI, 1.36-1.67). There were 73.4 deaths per 1000 person-years for those with asset poverty at baseline (adjusted HR, 1.67; 95% CI, 1.44-1.94; compared with continuously positive wealth).

Conclusions and Relevance

Among US adults aged 51 years and older, loss of wealth over 2 years was associated with an increased risk of all-cause mortality. Further research is needed to better understand the possible mechanisms for this association and determine whether there is potential value for targeted interventions.

The Great Recession and Immune Function

The Great Recession precipitated unprecedented home foreclosures increases, but documentation of related neighborhood changes and population health is scant. Using the Detroit Neighborhood Health Study (N = 277), we examined associations between neighborhood-level recession indicators and thymic function, a life course immunological health indicator. In covariate-adjusted multilevel models, each 10 percentage point increase in abandoned home prevalence and 1 percentage point increase in 2009 home foreclosures was associated with 1.7-year and 3.3-year increases in thymic aging, respectively. Associations attenuated after adjustment for neighborhood-level social cohesion, suggesting community ties may buffer recession-related immune aging. Effects of neighborhood stressors were strongest in middle-income households, supporting theory of excess vulnerability in this group. Future research should assess whether ongoing foreclosure and blight reduction efforts improve health for residents of recession impacted neighborhoods.