The public-use National Health Interview Survey linked mortality files: methods of reidentification risk avoidance and comparative analysis

Physical activity and risk of cancer mortality in patients with and without cancer: is there a dose-response relationship?

BACKGROUND

The purpose of this study was to examine a dose-response association between aerobic physical activity (APA) and muscle-strengthening exercise (MSE) and their combinations with cancer mortality.

METHODS

The final 575,439 participants involved in this study were derived from 1997 to 2018 longitudinal follow-up data collected in the National Health Interview Survey (NHIS). The APA and MSE were requested via self-reported questionnaires. These records are linked to the National Death Index and classified as cancer deaths based on the International Classification of Diseases (ICD-10). Statistical analysis was performed by Wilcoxon rank-sum test, chi-square test, and the Cox proportional hazards models.

RESULTS

After adjusting for all covariates, the results demonstrated that the cancer mortality risk for cancer survivors decreased by 23.2%, 35.8%, 42.5%, and 46.7% for those engaging in 0-7.4 MET hours/week, 7.5-14.9 MET hours/week, 15-29.9 MET hours/week, and 30 + MET hours/week, respectively. For non-cancer patients, the cancer mortality risk decreased by 6.9%, 11.9%, 15.1%, and 16.7%. Furthermore, the results showed that the cancer mortality risk for cancer survivors decreased by 34.9%, 30.2%, 32.3%, and 10% for those engaging in 2-3 times/week, 4-5 times/week, 6-7 times/week, and 8 + times/week. For non-cancer patients, the cancer mortality risk decreased by 17.4%, 23.7%, 9.5%, and 10.6%. Among non-cancer patients with insufficient MSE, there was no significant negative correlation between APA and cancer mortality.

CONCLUSION

The optimal dose response in reducing the risk of cancer mortality may occur at higher levels of APA with MSE 4-5 times/week and 2-3 times/week for primary and secondary prevention. In addition, primary prevention derives a greater advantage from MSE, and a protocol of APA should be emphasized in secondary prevention.

Dose-response associations of the American Heart Association's new "Life's essential 8" metrics with all-cause and cardiovascular mortality in a nationally representative sample from the United States

BACKGROUND

Our aim was to examine the prospective dose-response associations of American Heart Association's (AHA) LIFE's Essential 8 (LE8) score and number of cardiovascular health (CVH) factors with high score with all-cause and cardiovascular disease (CVD) related mortality.

METHODS

We pooled 6 consecutive waves of the National Health and Nutrition Examination Survey (NHANES) comprising rounds between 2007 and 2008 and 2017-2018. We calculated hazard ratios (HRs) and conducted restricted cubic splines models to assess the dose-response association of LE8 score and CVH factors with all-cause and CVD mortality.

RESULTS

Analyses included 23,531 adults aged 18 years and over (mean [SD] age, 43.6 [16.7] years; 11,979 [51%] female; 8960 [38.1%] non-Hispanic white individuals) with a median follow-up of 7.3 years (IQR 4.3-10.1), corresponding to 168,033 person-years. The dose-response analyses showed a significant inverse curvilinear trend for the association between LE8 score with all-cause and CVD mortality. The optimal risk reduction for all-cause mortality was found at 100 points of the LE8 Score (HR, 0.50; 95% CI, 0.27-0.93) compared to the reference (median LE8 score [62.5 points]). Moreover, the dose-response association between LE8 and CVD mortality also exhibited a significant inverse curvilinear association up to 90 points (HR, 0.41; 95% CI, 0.17-0.99). Optimal levels of LE8 score may be able to avert around 40% of the annual all-cause and CVD deaths among the US adult population.

CONCLUSIONS

Best-case scenario of CVH may reduce around 40% of the all-cause and CVD annual mortality among adults in the United States.

Sociodemographic Factors, Leisure-Time Physical Activity and Mortality

INTRODUCTION

Exploring sociodemographic effect modification is important to provide evidence for developing targeted recommendations and reducing health inequalities. This study evaluated how sociodemographic factors including age, sex, race/ethnicity and socioeconomic status (SES) modify the association between leisure-time physical activity (LTPA) and all-cause and major cause-specific mortality.

METHODS

The study sample included 471,992 people from the 1997-2018 National Health Interview Survey (NHIS) and 41,830 people from the 1999-2018 National Health and Nutrition Examination Survey (NHANES). Data were analyzed in December 2022. Mortality data from the National Death Index were available to December 31, 2019. Sufficient LTPA was defined as at least 150 minutes of moderate and/or vigorous intensity per week.

RESULTS

There were 46,289 deaths in NHIS participants and 4,617 deaths in NHANES participants during a mean follow-up of 10 years. Individuals with sufficient LTPA had lower risk of all-cause (NHIS: hazard ratio, 0.74, 95% CI: [0.74-0.74]; NHANES: 0.73 [0.68-0.79]) and cardiovascular mortality (NHIS: 0.75 [0.75-0.75]; NHANES: 0.80 [0.69-0.93]) compared with inactive participants. The subgroup analysis showed significant interactions between LTPA and all sociodemographic factors. Associations between LTPA and mortality were weaker among younger individuals, males, Hispanic adults or those of low SES, respectively.

CONCLUSIONS

Sociodemographic factors significantly modified the associations between LTPA and mortality. The health benefits of sufficient LTPA were smaller in younger individuals, males, Hispanic adults or those of low SES. These findings can help identify target populations for promotion of physical activity to reduce health inequalities and the development of physical activity guidelines.

Trends in the association between meeting the physical activity guidelines and risk of mortality in US adults

OBJECTIVE

To examine the trends in the association between meeting the physical activity (PA) guidelines and mortality in adults.

METHODS

We included seventeen annual representative samples of US adults 1998-2014 (n = 482,756) and all-cause and cause-specific mortality ascertained through December 2019. Participants were grouped according to PA Guidelines: 150 or more min/week in aerobic PA and muscle-strengthening activities 2 or more times/week. To provide further context, we also examined the trends in mortality risk associated with other modifiable health factors.

RESULTS

Meeting the PA guidelines was associated with lower 5-year mortality risk (HR = 0.59, 95%CI, 0.55, 0.63) based on the pooled analyses. We consistently observed an inverse association in all years, but there was a nonsignificant trend association (P for trend = 0.305) between meeting PA guidelines and 5-year mortality across the seventeen annual surveys. Meeting aerobic (HR = 0.58, 95%CI, 0.56, 0.61) and muscle-strengthening (HR = 0.86, 95%CI, 0.81, 0.90) guidelines were independently associated with 5-year mortality risk in pooled analyses, without any evidence for trends in the associations. Similar results were found with cause-specific mortality and 10-year mortality risk. In pooled analyses, attaining a high educational level, body mass index <30 kg/m2, being noncurrent smoker, nonheavy drinker, and living without history of hypertension and diabetes with 5-year mortality were 0.70 (95%CI, 0.67, 0.73), 1.19 (95%CI, 1.15, 1.23), 0.56 (95%CI, 0.54, 0.59), 0.85 (95%CI,0.79, 0.92), 0.91 (95%CI, 0.88-0.94) and 0.65 (95%CI, 0.88, 0.94), respectively. Only no history of diabetes showed a significant trend analysis (B = 0.77, 95%CI, 0.46, 0.91, P for trend <0.001).

CONCLUSION

Meeting PA guidelines lower mortality risk and this association does not seem to have varied over time. Encouraging adults to meet the PA guidelines may provide substantial health benefits, despite social, demographic and lifestyle changes, as well as the advances in medical technology and pharmacological treatments.

Moderate and vigorous leisure time physical activity in older adults and Alzheimer's disease-related mortality in the USA: a dose-response, population-based study

BACKGROUND

Data for the dose-response associations of moderate physical activity (MPA) and vigorous physical activity (VPA) with Alzheimer's disease-related mortality are scarce. We aimed to examine the prospective associations of such activity with Alzheimer's disease-related mortality.

METHODS

In this dose-response, population-based study, we pooled data from 22 consecutive waves of the US National Health Interview Survey (from 1997 to 2018). Participants aged 68 years or older were included in the study if they had full data for physical or muscle-strengthening activity, chronic conditions, functional limitations, marital status, education level, alcohol consumption, smoking status, and BMI, and follow-up time after study entry. Participants were linked to the National Death Index until Dec 31, 2019. We defined Alzheimer's disease-related mortality as a leading cause by using the G-30 code of the International Statistical Classification of Diseases and Related Health Problems tenth revision. Information on MPA and VPA was self-reported, with participants asked to answer four questions on the frequency and duration of both types of physical activity. We calculated hazard ratios (HRs) and used restricted cubic splines models to assess dose-response associations, and we estimated the annual number of Alzheimer's disease-related deaths that could be prevented through physical activity using adjusted population attributable fractions.

FINDINGS

After excluding 21 377 participants, 91 298 adults were included in the analysis. The weighted mean participant age was 75·8 years (SE 0·0); 55 658 (56·7%) were female and 76 796 (87·6%) were White (weighted percentages). The median follow-up was 6·5 years (IQR 3·6-10·7), corresponding to 703 393 person-years. 2176 (2·4%) participants died due to Alzheimer's disease as the leading cause. For MPA, we did not find a significant dose-response association with Alzheimer's disease-related mortality, whereas for VPA, we observed a significant L-shaped association between 20 weekly min and 190 weekly min. For VPA, we identified a minimal amount (ie, 50% of the optimal amount) at 40 min/week (HR 0·91, 95% CI 0·84-0·95) and an optimal amount (ie, the nadir of the curve) at 140 min/week (0·79, 0·66-0·95) for reducing Alzheimer's disease-related mortality. For the USA, we estimated that 40 weekly min of VPA would prevent 12 238 deaths per year (95% CI 89-23 172) and 140 weekly min of VPA would prevent 37 710 deaths per year (311-63 567), compared with a scenario in which US adults did not do any VPA.

INTERPRETATION

These findings might inform future guidelines for preventing Alzheimer's disease-related mortality by emphasising the importance of VPA over MPA and providing specific VPA targets.

FUNDING

None.

Cigarette smoking in childhood and risk of all-cause and cause-specific mortality in adulthood

Background

This study was aimed to examine the association between cigarette smoking in childhood and mortality in adulthood, and the impact of non-smoking duration among smokers who subsequently quit smoking.

Methods

We used data from 472,887 adults aged 18-85 years examined once in the US National Health Interview Survey in 1997-2014, which was linked to mortality data from the National Death Index up to 31 December 2015. Cigarette smoking status in childhood (age 6 to 17 years) and adulthood (age 18 to 85 years) was self-reported using a standard questionnaire at the time of participation in the survey. The vital status of participants due all-causes, cardiovascular disease (CVD), cancer and chronic lower respiratory diseases was obtained using mortality data from the National Death Index.

Results

During the mean follow-up of 8.75 years, compared with never smoking in childhood and adulthood, the risk of all-cause mortality among current adult smokers decreased slightly according to increasing age at smoking initiation: hazard ratios (HRs; 95% confidence intervals, CIs) were 2.54 (2.24-2.88) at age of 6-9 years, 2.44 (2.31-2.57) at age of 10-14 years, and 2.21 (2.12-2.31) at age of 15-17 years. Smoking cessation before the age of 30 years was not associated with increased risk of all-cause and cause-specific mortality (all p > 0.05) compared to never smoking.

Conclusion

Mortality risk was higher in individuals who started smoking at an earlier age in childhood. Inversely, smoking cessation before the age of 30 years was not associated with an increased risk of mortality compared to never smoking.

All-cause mortality risk for men and women in the United States: the role of partner's education relative to own education

This study examines the association between educational attainment, relative to that of an intimate partner, and all-cause mortality for men and women in different-sex relationships. Research suggests some health benefits for partnered adults that arise from economic benefits and improved access to health-promoting tools. One way these benefits could be gained is through the pairing of the highly educated. While high individual educational attainment lowers mortality risk, less is known about the risks of mortality associated with one's education, relative to their partner's education. Using National Health Interview Survey Linked Mortality Files (NHIS-LMF) for the years 1999-2014 with prospective mortality follow-up through December 2015 (N = 347,994), we document the association between relative educational attainment and mortality for men and women with different-sex partners in the United States. Fully adjusted Cox proportional hazard models revealed a higher risk of all-cause mortality for men and women who have more education than their partner, relative to those having the same education as their partner. For women only, having less education than their male partner was associated with a lower risk of all-cause mortality. A better understanding of relative status within different-sex partnerships provides insights into partnered adult's mortality risks.

Associations between aerobic and muscle-strengthening physical activity, sleep duration, and risk of all-cause mortality: A prospective cohort study of 282,473 U.S. adults

PURPOSE

To examine the joint associations between meeting guidelines for physical activity (PA) and sleep duration and all-cause mortality risk among adults.

METHODS

Participants were adults (n = 282,473) aged 18-84 years who participated in the 2004-2014 U.S. National Health Interview Survey. Mortality status was ascertained using the National Death Index through December 2015. Self-reported PA (Active: meeting both aerobic (AER) and muscle-strengthening (MSA) guidelines, AER only (AER), MSA only (MSA), or not meeting either AER or MSA (Inactive)) and sleep duration (Short, recommended (Rec), or Long) were classified according to guidelines, and 12 PA-sleep categories were derived. Adjusted hazard ratios and 95% confidence intervals (95%CIs) for all-cause mortality risk were estimated using Cox proportional hazards regression models.

RESULTS

A total of 282,473 participants (55% females) were included; 18,793 deaths (6.7%) occurred over an average follow-up of 5.4 years. Relative to the Active-Rec group, all other PA-sleep groups were associated with increased mortality risk except for the Active-Short group (hazard ratio = 1.08; 95%CI: 0.92-1.26). The combination of long sleep with either MSA or Inactive appeared to be synergistic. For a given sleep duration, mortality risk progressively increased among participants classified as AER, MSA, and Inactive. Within each activity level, the mortality risk was greatest among adults with long sleep.

CONCLUSION

Relative to adults meeting guidelines for both PA and sleep duration, adults who failed to meet guidelines for both AER and muscle strengthening PA and who also failed to meet sleep duration guidelines had elevated all-cause mortality risks. These results support interventions targeting both PA and sleep duration to reduce mortality risk.

Association of Physical Activity Intensity with All-Cause Mortality in Cancer Survivors: A National Prospective Cohort Study

We designed this study to investigate the associations between physical activity (PA) and the risk of all-cause mortality in cancer survivors using a nationally representative cohort of US adults. This cohort study included 13 cycles of the National Health Interview Surveys, and by matching participants with the National Death Index (2015), survival status was determined. The main outcome was all-cause mortality during follow-up. A total of 20,088 participants aged 62.2 (15.9) years (62.4% women) were analyzed. After an average follow-up of 117.5 months, 7214 (35.9%) participants died. Compared with inactive cancer survivors, we observed a 25% lower all-cause mortality risk among participants performing PA 10 min to 1 h/week (hazard ratio [HR] = 0.75, 95% confidence interval [CI] = 0.67-0.85), a 28% lower risk among those performing PA 1-2.5 h/week (HR = 0.72, 95% CI = 0.67-0.78), a 34% lower risk among those performing PA 2.5-5 h/week (HR = 0.66, 95% CI = 0.60-0.72), a 37% lower risk among those performing PA 5-7.5 h/week (HR = 0.63, 95% CI = 0.56-0.70), a 47% lower risk among those performing PA 7.5-13.3 h/week (HR = 0.53, 95% CI = 0.47-0.61), and a 43% lower risk among those performing PA 13.3-24 h/week (adjusted HR = 0.53, 95% CI = 0.49-0.66). In cancer survivors, leisure-time PA was associated with a lower all-cause mortality. Inactive cancer survivors should be encouraged to perform more PA to reduce the risk of all-cause mortality.

Association of all Cause and Cause-Specific Mortality With Hearing Loss Among US Adults: A Secondary Analysis Study

Objectives: Previous research revealed the relationship between hearing loss (HL) and all cause mortality. The aim of this study was to determine the association between HL and all causes and cause-specific mortality based on US adults.

Methods: Data were obtained by linking National Health Interview Survey (NHIS) (2004–2013) with linkage to a mortality database to 31 December 2015. HL were categorized into four groups: good hearing, a little hearing difficulty, a lot of hearing difficulty, profoundly deaf. The relationship between HL and mortality risk was analyzed using Cox proportional hazards regression model.

Results: Compared with the reference group (Good), those who had light or moderate hearing problems were at an increased risk of mortality for all causes (A little trouble—HR: 1.17; 95% confidence interval [CI]: 1.13 to 1.20; A lot of trouble—HR: 1.45; 95% CI: 1.40–1.51); deaf—HR: 1.54; 95% CI: 1.38–1.73) respectively.

Conclusion: In addition, those in the deaf category have the highest risk of death from all causes and cause-specific cancer. More older adults are associated with an increased risk of all-cause mortality in American adults.

Psychological distress as a risk factor for all-cause, chronic disease- and suicide-specific mortality: a prospective analysis using data from the National Health Interview Survey

PURPOSE

The risk psychological distress (PD) confers on mortality due to specific chronic diseases compared to suicide is unclear. Using the National Health Interview Survey (NHIS), we investigated the association between PD levels and risk of all-cause and chronic disease-specific mortality and compared the contribution of chronic disease-related mortality to that of suicide.

METHODS

Data from 195, 531 adults, who participated in the NHIS between 1997 and 2004, were linked to the National Death Index records through to 2006. Multivariable Cox regression models were used to estimate hazard ratios (HRs) and their 95% confidence intervals (CIs) across four levels of PD, measured using the Kessler-6 scale. Outcomes included all-cause mortality, and mortality due to all CVDs and subtypes, all cancers and subtypes, diabetes mellitus, alcoholic liver disease and suicide.

RESULTS

During a mean follow-up time of 5.9 years, 7665 deaths occurred. We found a dose-response association between levels of PD and all-cause mortality, with the adjusted HRs (95% CI) elevated for all levels of PD, when compared to asymptomatic levels: subclinical 1.10 (1.03-1.16), symptomatic 1.36 (1.26-1.46) and highly symptomatic 1.57 (1.37-1.81). A similar association was found for all CVDs and certain CVD subtypes, but not for cancers, cerebrovascular diseases diabetes mellitus. Excess mortality attributable to suicide and alcoholic liver disease was evident among those with levels of PD only.

CONCLUSION

PD symptoms, of all levels, were associated with an increased risk of all-cause and CVD-specific mortality while higher PD only was associated with suicide. These findings emphasise the need for lifestyle interventions targeted towards improving physical health disparities among those with PD.

Methodological Challenges in Estimating the Lifetime Medical Care Cost Externality of Obesity

There is a great deal of variability in estimates of the lifetime medical care cost externality of obesity, partly due to a lack of transparency in the methodology behind these cost models. Several important factors must be considered in producing the best possible estimate, including age-related weight gain, differential life expectancy, identifiability, and cost model selection. In particular, age-related weight gain represents an important new component to recent cost estimates. Without accounting for age-related weight gain, a study relies on the untenable assumption that people remain the same weight throughout their lives, leading to a fundamental misunderstanding of the evolution and development of the obesity crisis. This study seeks to inform future researchers on the best methods and data available both to estimate age-related weight gain and to accurately and consistently estimate obesity's lifetime external medical care costs. This should help both to create a more standardized approach to cost estimation as well as encourage more transparency between all parties interested in the question of obesity's lifetime cost and, ultimately, evaluating the benefits and costs of interventions targeting obesity at various points in the life course.

Association of sleep duration with all-cause and disease-specific mortality in US adults

BACKGROUND

Previous studies revealed inconsistent findings regarding the association between sleep duration and all-cause and disease-specific mortality. This study aimed to clarify the association of sleep duration with mortality using a large population-based prospective cohort study from the USA.

METHODS

We used data from the National Health Interview Survey (2004-2014) linked to National Death Index records to 31 December 2015. A total of 284 754 participants aged ≥18 years were included. Self-reported sleep duration (average time slept in a 24-hour period) was categorised into seven groups: ≤4 hours, 5 hours, 6 hours, 7 hours (reference), 8 hours, 9 hours and ≥10 hours. Study outcomes included all-cause, cardiovascular disease-specific and cancer-specific mortality. Cox proportional hazards models were used to examine the association between sleep duration and mortality.

RESULTS

During a median follow-up of 5.25 years, we identified 20 872 deaths, of which 4 129 were cardiovascular disease-related and 5 217 were cancer-related. Compared with 7 hours/day of sleep, both short and long sleep durations were associated with an increased risk of all-cause mortality (≤4 hours: HR=1.46, 95% CI=1.33-1.61; 5 hours: HR=1.22, 95% CI=1.13-1.32; 6 hours: HR=1.10, 95% CI=1.05-1.17; 8 hours: HR=1.22, 95% CI=1.17-1.28; 9 hours: HR=1.41, 95% CI=1.31-1.51; ≥10 hours: HR=2.00, 95% CI=1.88-2.13). Similar results were observed for cardiovascular disease-specific and cancer-specific mortality.

CONCLUSIONS

Our study indicates that both short (≤6 hours/day) and long (≥8 hours/day) sleep durations increase the risk of mortality compared with sleep of 7 hours/day. A normal sleep duration (about 7 hours) every day is recommended for health benefits.

The Effect Of The Supplemental Nutrition Assistance Program On Mortality

The Supplemental Nutrition Assistance Program (SNAP) is the largest food assistance program in the United States. Although participation in it has been shown to reduce food insecurity, there is comparatively less clear causal evidence of positive health effects of participation, particularly among adults. We examined the relationship between SNAP participation and premature mortality using data for 1997-2009 from the National Health Interview Survey, linked to data for 1999-2011 from the National Death Index. Results from bivariate probit models found that participation in SNAP led to a populationwide reduction of 1-2 percentage points in mortality from all causes and a reduction in specific causes of death among people ages 40-64.

Light Cigarette Smoking Increases Risk of All-Cause and Cause-Specific Mortality: Findings from the NHIS Cohort Study

Very few studies have examined the association between light cigarette smoking (i.e., ≤5 cigarettes per day) and mortality. The aim of this study was to examine the association of light cigarette smoking with all-cause and cause-specific mortality among adults in the United States. Data were from 13 waves of the National Health Interview Survey (1997 to 2009) that were linked to the National Death Index records through December 31, 2011. A total of 329,035 participants aged ≥18 years in the United States were included. Deaths were from all cause, cancer, cardiovascular disease (CVD) and respiratory disease and were confirmed by death certification. During a median follow-up of 8.2 years, 34,862 participants died, of which 8415 were from cancer, 9031 from CVD, and 2040 from respiratory disease. Compared with never-smokers, participants who smoked 1–2 (hazard ratios (HR) = 1.94, 95%CI = 1.73–2.16) and 3–5 cigarettes (HR = 1.99, 1.83–2.17) per day were at higher risk of all-cause mortality after adjustment for demographic variables, lifestyle factors and physician-diagnosis of chronic disease. The associations were stronger for respiratory disease-specific mortality, followed by cancer-specific mortality and CVD-specific mortality. For example, the HRs (95% CIs) of smoking 1–2 cigarettes per day were 9.75 (6.15–15.46), 2.28 (1.84–2.84) and 1.93 (1.58–2.36), respectively, for these three cause-specific mortalities. This study indicates that light cigarette smoking increases risk of all-cause and cause-specific mortality in US adults.

Recommended physical activity and all cause and cause specific mortality in US adults: prospective cohort study

OBJECTIVE

To determine the association between recommended physical activity according to the 2018 physical activity guidelines for Americans and all cause and cause specific mortality using a nationally representative sample of US adults.

DESIGN

Population based cohort study.

SETTING

National Health Interview Survey (1997-2014) with linkage to the National Death Index records to 31 December 2015.

PARTICIPANTS

479 856 adults aged 18 years or older.

EXPOSURES

Participant self-reports of the amount of leisure time spent in aerobic physical activity and muscle strengthening activity each week were combined and categorised into four groups: insufficient activity, aerobic activity only, muscle strengthening only, and both aerobic and muscle strengthening activities according to the physical activity guidelines.

MAIN OUTCOME MEASURES

All cause mortality and cause specific mortality (cardiovascular disease, cancer, chronic lower respiratory tract diseases, accidents and injuries, Alzheimer's disease, diabetes mellitus, influenza and pneumonia, and nephritis, nephrotic syndrome, or nephrosis) obtained from the National Death Index records.

RESULTS

During a median follow-up of 8.75 years, 59 819 adults died from all causes, 13 509 from cardiovascular disease, 14 375 from cancer, 3188 from chronic lower respiratory tract diseases, 2477 from accidents and injuries, 1470 from Alzheimer's disease, 1803 from diabetes mellitus, 1135 from influenza and pneumonia, and 1129 from nephritis, nephrotic syndrome, or nephrosis. Compared with those who did not meet the physical activity guidelines (n=268 193), those who engaged in recommended muscle strengthening activity (n=21 428; hazard ratio 0.89, 95% confidence interval 0.85 to 0.94) or aerobic activity (n=113 851; 0.71, 0.69 to 0.72) were found to be at reduced risk of all cause mortality; and even larger survival benefits were found in those engaged in both activities (n=76 384; 0.60, 0.57 to 0.62). In addition, similar patterns were reported for cause specific mortality from cardiovascular disease, cancer, and chronic lower respiratory tract diseases.

CONCLUSIONS

Adults who engage in leisure time aerobic and muscle strengthening activities at levels recommended by the 2018 physical activity guidelines for Americans show greatly reduced risk of all cause and cause specific mortality. These data suggest that the physical activity levels recommended in the guidelines are associated with important survival benefits.

Associations of Exercise Types with All-Cause Mortality among U.S. Adults

PURPOSE

Exercising benefits physical and mental health as well as longevity. However, the extent to which different types of exercise are differentially associated with the risk of mortality is less clear. This study examined whether 15 different types of exercise were uniquely associated with all-cause mortality in a nationally representative sample of noninstitutionalized American adults between 18 and 84 yr old.

METHODS

A total of 26,727 American adults in the National Health Interview Survey who reported their exercise type(s) in 1998 were prospectively followed for all-cause mortality through the end of 2015. We applied a series of discrete time logistic models to estimate odds ratios (OR) and 95% confidence intervals (CI) for all-cause mortality.

RESULTS

During 17 yr of follow-up, 4955 deaths occurred. After adjusting for total volume of other exercises and confounders (demographic factors, socioeconomic status, and health behaviors and status), walking, aerobics, stretching, weight lifting, and stair climbing were related to lower risks of mortality (OR ranged from 0.78 to 0.93). When adjusting for engagement in all exercise types and confounders, stretching (OR = 0.90, 95% CI = 0.83-0.97) and playing volleyball (OR = 0.53, 95% CI = 0.31-0.93) were uniquely associated with lower risks of mortality.

CONCLUSION

These findings suggest that some types of exercise have unique benefits for longevity, but most are indistinguishable in relation to longevity. Future studies should further investigate the unique contribution of specific exercises and the joint contribution of multiple exercises and how to promote greater exercise participation.

Lung cancer mortality among never-smokers in the United States: estimating smoking-attributable mortality with nationally representative data

PURPOSE

Lung cancer mortality among never-smokers is an often overlooked yet important cause of adult mortality. Moreover, indirect approaches for estimating smoking-attributable mortality use never-smoker lung cancer death rates to approximate smoking burden. To date, though, most studies using indirect approaches import rates from the Cancer Prevention Study II (CPS-II), which is not representative of the U.S.

POPULATION

METHODS

We use the nationally representative 1985-2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMF) to calculate lung cancer death rates among never-smokers aged 50 years or older. We then import rates from NHIS-LMF and CPS-II into the Preston-Glei-Wilmoth indirect method to determine whether smoking-attributable fractions differ.

RESULTS

Never-smokers account for 16% of U.S. lung cancer deaths among women and 11% among men. Lung cancer death rates among never-smokers are higher in NHIS-LMF than CPS-II for several age groups. Smoking-attributable fractions of mortality are slightly lower with NHIS-LMF rates (19% of male deaths and 16% of female deaths) than with CPS-II rates (21% of male deaths and 17% of female deaths).

CONCLUSIONS

Fractions based on nonrepresentative CPS-II data may modestly overestimate smoking-attributable mortality. Thus, indirect methods should use never-smoker lung cancer death rates from such nationally representative datasets as NHIS-LMF.

Predicted Lifetime Third-Party Costs of Obesity for Black and White Adolescents with Race-Specific Age-Related Weight Gain

OBJECTIVE

There exists enormous variation in estimates of the lifetime cost of adolescent obesity by race. To justify policy measures to reduce obesity rates nationally in this demographic, the costs of obesity in late adolescence must first be discerned. Although several researchers have sought to quantify obesity's true cost, none has accounted for race-specific age-related weight gain, a vital component in producing an accurate estimate.

METHODS

This paper employs a Markov model of BMI category state changes separately for black and white males and females from age 18 to 75 applied to updated estimates of obesity's costs and effect on mortality to quantify the median lifetime cost of obesity at age 18.

RESULTS

This study found lower lifetime costs than previously, largely because of the dramatic gain in weight among normal-weight individuals, particularly black males, that occurs in early adulthood.

CONCLUSIONS

A substantial portion of obesity's prevalence, and therefore cost, for black males and females comes from age-related weight gain in early adulthood. This speaks to the persistent threat of obesity beyond adolescence for this demographic, and further research should focus on whether policy can modify the behaviors and environment through which and in which this sharp increase in weight occurs.

Psychological distress and mortality among US adults: prospective cohort study of 330 367 individuals

BACKGROUND

Previous studies have shown inconsistent findings on the association between psychological distress and risk of mortality. This study aimed to address this inconsistent association using a large US population-based cohort.

METHODS

This study used data from 1997 to 2009 US National Health Interview Survey, which were linked with National Death Index through 31 December 2011. Psychological distress was measured using Kessler-6 scale and was categorised into six groups based on scores as 0, 1-3, 4-6, 7-9, 10-12 and ≥13. Main outcomes were all-cause, cancer-specific and cardiovascular disease (CVD)-specific mortality. Analyses were completed in 2019. Cox proportional hazards models were used to determine the association between psychological distress and mortality.

RESULTS

A total of 330 367 participants aged ≥18 years were included. During a mean follow-up of 8.2 years, 34 074 deaths occurred, including 8320 cancer-related and 8762 CVD-related deaths. There was a dose-response association between psychological distress and all-cause mortality. Compared with the 0 score category, adjusted HRs (95% CIs) for other categorical psychological distress scores, that is, 1-3, 4-6, 7-9, 10-12 and ≥13, were 1.09 (1.05 to 1.12), 1.22 (1.17 to 1.27), 1.38 (1.31 to 1.46), 1.49 (1.40 to 1.59) and 1.57 (1.47 to 1.68), respectively. Corresponding values for cancer-specific mortality were 1.06 (0.99 to 1.12), 1.13 (1.04 to 1.23), 1.27 (1.14 to 1.42), 1.38 (1.22 to 1.57) and 1.32 (1.15 to 1.51), respectively; those for CVD-specific mortality were 1.11 (1.05 to 1.18), 1.22 (1.12 to 1.32), 1.30 (1.17 to 1.45), 1.38 (1.20 to 1.58), and 1.46 (1.27 to 1.68), respectively.

CONCLUSIONS

We found a dose-response relationship between psychological distress and all-cause and cause-specific mortality, emphasising the need for early prevention strategies among individuals with potential psychological distress.

Investigation of the Obesity Paradox in Chronic Obstructive Pulmonary Disease, According to Smoking Status, in the United States

An obesity paradox in chronic obstructive pulmonary disease (COPD), whereby overweight/obese individuals have improved survival, has been well-described. These studies have generally included smokers. It is unknown whether the paradox exists in individuals with COPD arising from factors other than smoking. Nonsmoking COPD is understudied yet represents some 25%-45% of the disease worldwide. To determine whether the obesity paradox differs between ever- and never-smokers with COPD, 1,723 adult participants with this condition were examined from 2 iterations of the National Health and Nutrition Examination Survey (1988-1994, 2007-2010), with mortality outcomes followed through December 2011. Using Cox proportional hazards models, adjusted for sociodemographic factors, lung function, and survey cycle, ever/never-smoking was found to modify the association between body mass index and hazard of death. Compared with normal-weight participants, overweight/obese participants had lower hazard of death among ever-smokers (for overweight, adjusted hazard ratio (aHR) = 0.56, 95% confidence interval (CI): 0.43, 0.74; for obesity, aHR = 0.66, 95% CI: 0.48, 0.92), but never-smokers did not (overweight, aHR = 1.41, 95% CI: 0.66, 3.03; obesity, aHR = 1.29, 95% CI: 0.48, 3.48). An obesity paradox appeared to be absent among never-smokers with COPD. This, to our knowledge, novel finding might be explained by pathophysiological differences between smoking-related and nonsmoking COPD or by smoking-associated methodological biases.

Rising educational gradients in mortality among U.S. whites: What are the roles of marital status and educational homogamy?

The educational gradient in U.S. mortality has been rising among non-Hispanic whites. A common intuition sees the growing educational divide in marital status and increases in educational homogamy as potential explanations. To empirically assess this possibility, we analyze mortality from 1986 to 2015 using the National Health Interview Survey Linked Mortality Files (562,584 persons; 204,756 deaths). At the individual level, being unmarried and spouse's lower educational attainment are associated with higher mortality. Counterfactual analyses, however, reveal that the growing educational divide in marital status and increases in educational homogamy contribute little (8%-15%) to the widening educational gradient in mortality. Our simulation analyses further show that extreme educational divide in marital status could substantially drive up mortality inequality, whereas educational homogamy, even when pushed to the maximum level, would play a limited role in increasing mortality inequality. Combined, the results suggest that changes in the educational divide in marital status have the potential to affect mortality inequality, but the actual changes over the past decades were not strong enough to have a major impact; increases in education homogamy, in contrast, barely affect mortality inequality by education. Along with other research showing small effects of educational homogamy on income inequality, our research suggests that the consequences of changing marriage patterns for social inequalities in general and health inequalities in particular may be more limited than commonly assumed.

Beneficial associations of low and large doses of leisure time physical activity with all-cause, cardiovascular disease and cancer mortality: a national cohort study of 88,140 US adults

BACKGROUND

Evidence on the role of very low or very high volumes of leisure time physical activity (PA) on the risk of all-cause and cause-specific mortality is limited. We aimed to examine the associations of different levels of leisure time PA with the risk of all-cause, cardiovascular disease (CVD) and cancer-specific mortality.

METHODS

Data were from 12 waves of the National Health Interview Surveys (1997-2008) linked to the National Death Index records through 31 December 2011. A total of 88 140 eligible participants aged 40-85 years were included.

RESULTS

Compared with inactive individuals, those performing 10-59 min/week of PA had 18% lower risk of all-cause mortality (hazard ratio (HR): 0.82, 95% confidence interval (CI): 0.72-0.95). Those who reported 1-2 times (150-299 min/week) the recommended level of leisure time PA had 31% (HR: 0.69, 95%CI: 0.63-0.75) reduced risk of all-cause mortality. Importantly, the continued benefits were observed among those performing leisure time PA 10 or more times (≥1500 min/week) the recommended minimum level (HR: 0.54, 95% CI: 0.45-0.64). For 10-59, 150-299 and ≥1500 min/week of PA, the corresponding HRs (95% CIs) for CVD-specific mortality were 0.88 (0.67-1.17), 0.63 (0.52-0.78) and 0.67 (0.45-0.99), respectively: for cancer-specific mortality were 0.86 (0.66-1.11), 0.76 (0.64-0.89) and 0.53 (0.39-0.73), respectively. In addition, there was a larger reduction in all-cause and cause-specific mortality for vigorous vs. moderate intensity PA.

CONCLUSIONS

We found that beneficial association between leisure time PA and mortality starts from a low dose. Doing more vigorous exercise could lead to additional health benefits.

Black/white differences in mortality among veteran and non-veteran males

U.S. military veterans are a large and racially heterogeneous population. There are reasons to expect that racial disparities in mortality among veterans are smaller than those for non-veterans. For example, blacks are favorably selected into the military, receive relatively equitable treatment within the military, and after service accrue higher socioeconomic status and receive health and other benefits after service. Using the 1997-2009 National Health Interview Survey (N = 99,063) with Linked Mortality Files through the end of 2011 (13,691 deaths), we fit Cox proportional hazard models to estimate whether racial disparities in the risk of death are smaller for veterans than for non-veterans. We find that black/white disparities in mortality are smaller for veterans than for non-veterans, and that this is explained by the elevated socioeconomic resources of black veterans relative to black non-veterans. Leveraging birth cohort differences in military periods, we document that the smaller disparities are concentrated among All-Volunteer era veterans.

Is There a Difference in All-Cause Mortality Between Non-Hispanic Black and Non-Hispanic White Men With the Same Level of Education? Analyses Using the 2000-2011 National Health Interview Surveys

Although men have greater societal and economic privileges, men have higher all-cause mortality rates than women, even after controlling for education. Further, racial/ethnic mortality disparities exist among men with varying levels of education. Few studies have explored the independent effects of education and all-cause mortality between non-Hispanic Black and non-Hispanic White men with the same level of education. Our purpose was to identify trends in racial differences in all-cause mortality between non-Hispanic White and non-Hispanic Black men with the same level of education. Data for the study came from the National Health Interview Surveys 2000-2011 linked to the 2000-2009 Mortality Files. The Student's t and chi-square tests were used to assess the mean and proportional differences between non-Hispanic White and non-Hispanic Black men (≥18 years of age) across a range of demographic and health-related factors. Cox proportional hazard models were specified to examine the association between level of education and all-cause mortality adjusting for the demographic and health characteristics. Except for men who did not complete high school, statistically significant differences in all-cause mortality are present between non-Hispanic Black and non-Hispanic White men with the same level of education. The findings reveal the importance of understanding the level of education on differences in all-cause mortality between non-Hispanic Whites and non-Hispanic Blacks.

Cigarette Smoking and All-Cause and Cause-Specific Adult Mortality in the United States

This study illuminates the association between cigarette smoking and adult mortality in the contemporary United States. Recent studies have estimated smoking-attributable mortality using indirect approaches or with sample data that are not nationally representative and that lack key confounders. We use the 1990-2011 National Health Interview Survey Linked Mortality Files to estimate relative risks of all-cause and cause-specific mortality for current and former smokers compared with never smokers. We examine causes of death established as attributable to smoking as well as additional causes that appear to be linked to smoking but have not yet been declared by the U.S. Surgeon General to be caused by smoking. Mortality risk is substantially elevated among smokers for established causes and moderately elevated for additional causes. We also decompose the mortality disadvantage among smokers by cause of death and estimate the number of smoking-attributable deaths for the U.S. adult population ages 35+, net of sociodemographic and behavioral confounders. The elevated risks translate to 481,887 excess deaths per year among current and former smokers compared with never smokers, 14 % to 15 % of which are due to the additional causes. The additional causes of death contribute to the health burden of smoking and should be considered in future studies of smoking-attributable mortality. This study demonstrates that smoking-attributable mortality must remain a top population health priority in the United States and makes several contributions to further underscore the human costs of this tragedy that has ravaged American society for more than a century.

Self-reported major mobility disability and mortality among cancer survivors

OBJECTIVE

To quantify the prevalence of self-reported major mobility disability (SR-MMD) and its association with mortality in a nationally-representative sample of cancer survivors.

MATERIALS AND METHODS

This study included patients with a history of cancer who participated in the National Health and Nutrition Examination Survey 19992010. SR-MMD was defined as self-reported difficulty or inability to walk a quarter of a mile. Vital status through December 15, 2011 was ascertained from the United States National Center for Health Statistics. Multivariable-adjusted Cox regression models were used to quantify the hazard ratio (HR) and 95% confidence interval (CI) between SR-MMD and mortality.

RESULTS

The study included 1458 cancer survivors who averaged 67.1 years of age. At baseline, 201 (13.7%) participants had SR-MMD. During a median follow-up of 4.7 years, 434 (29.8%) participants died. SR-MMD was independently associated with a higher risk of all-cause mortality [HR: 2.15 (95% CI: 1.56-2.97); P < 0.001] and cancer-specific mortality [HR: 2.49 (95% CI: 1.53-4.07); P < 0.001]. The association between SR-MMD and all-cause mortality was not modified by age, sex, time since cancer diagnosis, body mass index, or comorbid health conditions.

CONCLUSION

SR-MMD is an easily ascertainable metric of physical function that is associated with a higher risk of mortality among cancer survivors. Integrating measures of physical function may help to guide clinical decision-making and improve long-term prognostication in this population. Interventions that prevent the development of SR-MDD, such as physical activity, should be evaluated in this population.

Big Data in Public Health: Terminology, Machine Learning, and Privacy

The digital world is generating data at a staggering and still increasing rate. While these "big data" have unlocked novel opportunities to understand public health, they hold still greater potential for research and practice. This review explores several key issues that have arisen around big data. First, we propose a taxonomy of sources of big data to clarify terminology and identify threads common across some subtypes of big data. Next, we consider common public health research and practice uses for big data, including surveillance, hypothesis-generating research, and causal inference, while exploring the role that machine learning may play in each use. We then consider the ethical implications of the big data revolution with particular emphasis on maintaining appropriate care for privacy in a world in which technology is rapidly changing social norms regarding the need for (and even the meaning of) privacy. Finally, we make suggestions regarding structuring teams and training to succeed in working with big data in research and practice.

Does the Functional Form of the Association Between Education and Mortality Differ by U.S. Region?

To understand the education-mortality association among U.S. adults, recent studies have documented its national functional form. However, the functional form of education-mortality relationship may vary across geographic contexts. The four U.S. Census regions differ considerably in their social and economic policies, employment opportunities, income levels, and other factors that may affect how education lowers the risk of mortality. Thus, we documented regional differences in the functional form of the education-mortality association and examined the role of employment and income in accounting for regional differences. We used data on non-Hispanic white adults (2,981,672, person years) aged 45-84 in the 2000-2009 National Health Interview Survey, with Linked Mortality File through 2011 (37,598 deaths) and estimated discrete-time hazard models. The functional form of education and adult mortality was best characterized by credentialism in the Midwest, Northeast, and for Western men. For Western women, the association was linear, consistent with the human capital model. In the South, we observed a combination of mechanisms, with mortality risk declining with each year of schooling and a step change with high school graduation, followed by steeper decline thereafter. Our work adds to the increasing body of research that stresses the importance of contexts in shaping the education-mortality relationship.

Relationship of Alcohol Consumption to All-Cause, Cardiovascular, and Cancer-Related Mortality in U.S. Adults

BACKGROUND

Previous studies have revealed inconsistent findings regarding the association of light to moderate alcohol consumption with cardiovascular disease (CVD) and cancer mortality.

OBJECTIVES

The aim of this study was to examine the association between alcohol consumption and risk of mortality from all causes, cancer, and CVD in U.S. adults.

METHODS

Data were obtained by linking 13 waves of the National Health Interview Surveys (1997 to 2009) to the National Death Index records through December 31, 2011. A total of 333,247 participants ≥18 years of age were included. Self-reported alcohol consumption patterns were categorized into 6 groups: lifetime abstainers; lifetime infrequent drinkers; former drinkers; and current light, moderate, or heavy drinkers. Secondary exposure included participants' binge-drinking status. The main outcome was all-cause, cancer, or CVD mortality.

RESULTS

After a median follow-up of 8.2 years (2.7 million person-years), 34,754 participants died of all causes (including 8,947 CVD deaths and 8,427 cancer deaths). Compared with lifetime abstainers, those who were light or moderate alcohol consumers were at a reduced risk of mortality for all causes (light-hazard ratio [HR]: 0.79; 95% confidence interval [CI]: 0.76 to 0.82; moderate-HR: 0.78; 95% CI: 0.74 to 0.82) and CVD (light-HR: 0.74; 95% CI: 0.69 to 0.80; moderate-HR: 0.71; 95% CI: 0.64 to 0.78), respectively. In contrast, there was a significantly increased risk of mortality for all causes (HR: 1.11; 95% CI: 1.04 to 1.19) and cancer (HR: 1.27; 95% CI: 1.13 to 1.42) in adults with heavy alcohol consumption. Binge drinking ≥1 d/week was also associated with an increased risk of mortality for all causes (HR: 1.13; 95% CI: 1.04 to 1.23) and cancer (HR: 1.22; 95% CI: 1.05 to 1.41).

CONCLUSIONS

Light and moderate alcohol intake might have a protective effect on all-cause and CVD-specific mortality in U.S. adults. Heavy or binge drinking was associated with increased risk of all-cause and cancer-specific mortality.

Exploring the non-linear association between BMI and mortality in adults with and without diabetes: the US National Health Interview Survey

AIMS

To assess the non-linear relationship between BMI and mortality and to determine the BMI values with the lowest mortality risk in adults with and without diabetes.

METHODS

This observational study assessed the relationship between BMI and mortality with flexible parametric survival models using data from the US National Health Interview Survey. Participants included 25 458 adults with diabetes and 315 939 adults without diabetes, aged 18-84 years at baseline surveys, conducted from 1997 to 2009. Mortality status data were obtained from the linked mortality data up to 2011.

RESULTS

We observed a U-shaped relationship between BMI and mortality in both adults with and without diabetes. With the BMI 25-29.9 kg/m² group as reference, hazard ratios (95% CI) of mortality for those with BMI < 18.5, 18.5-24.9, 30-34.9, 35-39.9 and ≥ 40 kg/m² were 2.67 (2.12, 3.35), 1.26 (1.18, 1.35), 1.04 (0.98, 1.12), 1.12 (1.02, 1.22) and 1.37 (1.24, 1.51), respectively, for adults with diabetes, adjusting for age, sex, race and survey year. The corresponding hazard ratios for adults without diabetes were 2.97 (2.78, 3.17), 1.27 (1.23, 1.30), 1.07 (1.03, 1.12), 1.36 (1.27, 1.45), and 1.77 (1.62, 1.92), respectively. The BMI values associated with the lowest mortality were 29.1 kg/m² for adults with diabetes and 26.7 kg/m² for those without diabetes.

CONCLUSIONS

Regardless of the presence of diabetes, there is a U-shaped relationship between BMI and mortality. The BMI values associated with the lowest mortality were above the current 'normal' range for adults with and without diabetes.

Life years lost associated with diabetes: An individually matched cohort study using the U.S. National Health Interview Survey data

AIM

Previous estimates of life-years lost to diabetes are highly inconsistent. This study provided the updated estimates of life-years lost to diabetes in the United States.

METHODS

Each of a nationally representative sample of 21,829 adults with diabetes in the U.S. National Health Interview Survey 1997-2009 was individually matched to one without diabetes by age, sex, race, survey year, BMI, smoking status, pre-existing cardiovascular disease and pre-existing cancer. All-cause mortality from original surveys to 31 December 2011 and median survival ages were estimated for those with diabetes and their matched controls.

RESULTS

Overall median survival age for adults with diabetes was 10.5years shorter than that for matched controls without diabetes. Estimated life-years lost associated with diabetes decreased with increasing age at diagnosis from 20.0years for those diagnosed before age 20years to no difference for those diagnosed after 80years. Hazard ratios for mortality decreased from 3.03 (95% CI: 2.41, 3.80) for those with diabetes diagnosed before 20years to 1.04 (95% CI: 0.78, 1.39) for those diagnosed after 80years. The estimate of life-years lost associated with diabetes was much higher among those with pre-existing cardiovascular disease (20.3years) than among those without cardiovascular disease (8.5years).

CONCLUSIONS

The effect of diabetes on survival depends on age at first diagnosis of diabetes and the presence of pre-existing diseases. The life-years lost are higher for those with diabetes diagnosed at younger ages. This study provided the updated estimates of life-years lost associated with diabetes in the United States.

Predictive Strength of Self-Rated Health for Mortality Risk Among Older Adults in the United States: Does It Differ by Race and Ethnicity?

Self-rated health (SRH) is widely used to capture racial and ethnic disparities in health. It is therefore critical to understand whether individuals with different racial and ethnic backgrounds assess their SRH differently. Despite the high overall predictive validity of SRH for subsequent mortality, few studies paid attention to potential variations by race and ethnicity. This study examines racial and ethnic differences in the predictive validity of SRH for subsequent mortality risk among older adults (55-84) by estimating Cox Proportional Hazard models using data from the National Health Interview Surveys Linked Mortality Files (1989-2006; N = 289,432). Results indicate that SRH predicts mortality risk less well for non-Hispanic Blacks and Hispanics than non-Hispanic Whites. Three proposed mechanisms-socioeconomic status, immigration status, and cause of death-explain only a modest proportion of the variation. These results suggest that individuals from different racial and ethnic groups may evaluate their heath differently, and thus caution is necessary when using SRH to estimate racial and ethnic health disparities.

Lower Mortality Associated With Overweight in the U.S. National Health Interview Survey: Is Overweight Protective?

It is still debatable whether overweight has protective or detrimental effects on survival. The focus of the ongoing debate is on possible confounding bias due to factors such as preexisting illness and smoking. We aimed to assess the association between overweight and mortality and to examine confounding effects of various factors including smoking and preexisting cancer, cardiovascular disease (CVD), diabetes, asthma, bronchitis, and kidney disease on the overweight-mortality association in adults.The data were extracted from the public-use National Health Interview Survey (NHIS) 1997 to 2009. Mortality data up to December 31, 2011 were linked to 131,813 with normal weight and 120,217 overweight adults. We assessed the association between overweight and mortality using Cox proportional hazard model with adjustments for various sets of confounding factors-age, sex, smoking, race, survey year, diabetes, CVD, cancer, asthma, bronchitis, and kidney disease.During the period from the original surveys to December 31, 2011, 22,513 (11,815 normal weight and 10,698 overweight) adults died. Normal weight and overweight groups differed in the characteristics of age, sex, smoking, and preexisting diseases. After adjusting for age and sex, the risk of dying was lower for overweight than normal weight adults (hazard ratio [HR], 0.82; 95% confidence interval [CI]: 0.80-0.85). Lower mortality risk associated with overweight remained after further adjusting for smoking and preexisting diseases such as diabetes, CVD, cancer, asthma, bronchitis, and kidney disease (HR, 0.80; 95% CI: 0.78-0.82). We observed a similar pattern for men and women, and for those free from preexisting diabetes, hypertension, and CVD.In conclusion, overweight adults have a lower mortality risk than normal weight adults. Our findings do not support that the lower mortality in overweight adults is due to confounding effects of smoking and preexisting diseases.

The risk and burden of smoking related heart disease mortality among young people in the United States

PURPOSE

Although cigarette smoking remains the most common risk factor for heart disease among the young, few studies have explored the relationship of smoking with heart disease mortality risk among young people. This prospective study assesses the risk and burden of all heart disease (HD) and coronary heart disease (CHD) mortality associated with smoking among younger adults from a nationally representative sample of the United States.

METHOD

National Health Interview Survey respondents' data from 1997-2004 were linked to their death records through 2006. The analyses were restricted to individuals 18 to 44 years of age during follow up (n = 121,284). Cox proportional hazard ratios (HR) were estimated with adjustment for sample weights and design effects. Attributable fractions (AF) of smoking were calculated.

RESULTS

After controlling for age, race, body mass index, history of hypertension and diabetes, and leisure time physical activity, current smoking related CHD mortality HR was 14.6 [95 % confidence interval or CI, 3.3-64.9] for females and 3.6 [95 % CI, 1.2-10.4] for males. The HR for all HD mortality was 3.1 [95 % CI, 1.3-7.6] for females and 2.4 [95 % CI, 1.2-4.7] for males. The AF of smoking for CHD deaths for female and male were 0.58 and 0.54 respectively. The AF of all HD mortality was 0.31 for male and 0.32 for female. The mean estimates of all HD deaths attributable to smoking during 1997-2006 among this age group were 52,214, of which 45,147 were CHD deaths.

CONCLUSION

Even after adjustment for multiple risk factors and without addressing passive smoking, our result showed a strong relationship between smoking and HD and CHD mortality among young adults that is likely causal.

Cumulative childhood adversity, educational attainment, and active life expectancy among U.S. adults

Studies of the early-life origins of adult physical functioning and mortality have found that childhood health and socioeconomic context are important predictors, often irrespective of adult experiences. However, these studies have generally assessed functioning and mortality as distinct processes and used cross-sectional prevalence estimates that neglect the interplay of disability incidence, recovery, and mortality. Here, we examine whether early-life disadvantages both shorten lives and increase the number and fraction of years lived with functional impairment. We also examine the degree to which educational attainment mediates and moderates the health consequences of early-life disadvantages. Using the 1998-2008 Health and Retirement Study, we examine these questions for non-Hispanic whites and blacks aged 50-100 years using multistate life tables. Within levels of educational attainment, adults from disadvantaged childhoods lived fewer total and active years, and spent a greater portion of life impaired compared with adults from advantaged childhoods. Higher levels of education did not ameliorate the health consequences of disadvantaged childhoods. However, because education had a larger impact on health than did childhood socioeconomic context, adults from disadvantaged childhoods who achieved high education levels often had total and active life expectancies that were similar to or better than those of adults from advantaged childhoods who achieved low education levels.

The relationship between major depression and nonsuicide mortality for U.S. adults: the importance of health behaviors

OBJECTIVES

We aim to elucidate the role of health behaviors and health conditions in the association between depression and mortality. First, we examine the relationship between major depression and nonsuicide mortality among U.S. adults aged 50 and older. Second, we examine the relationship between major depression and cardiovascular disease and cancer, by baseline disease status. Third, we examine the role of health behaviors as potential mediators of the association between major depression and cause-specific mortality.

METHODS

We use data from the 1999 National Health Interview Study linked to the 2006 National Death Index (N = 11,369; M age = 65, deaths = 2,162) and Cox proportional hazards models to describe the relationships among major depression, health behaviors (alcohol use, cigarette smoking, physical activity), and nonsuicide mortality. We examine cause-specific mortality (cardiovascular and cancer) by baseline disease status.

RESULTS

Major depression remains associated with a 43% increase in the risk of death over the follow-up period, after we account for sociodemographic characteristics, health behaviors, and health conditions. Major depression is associated with 2.68 times the risk of cardiovascular disease mortality among those who did not have cardiovascular disease at baseline and 1.82 times for those with baseline cardiovascular disease. Health behaviors reduce the hazard ratio by 17% for all nonsuicide mortality, 3% for cardiovascular disease mortality, and 12% for cancer mortality.

DISCUSSION

Our results provide evidence of the important role of health behaviors and health conditions in the depression-mortality relationship and highlight the importance of identifying risk factors for depression among aging adults.

Data mashups: potential contribution to decision support on climate change and health

Linking environmental, socioeconomic and health datasets provides new insights into the potential associations between climate change and human health and wellbeing, and underpins the development of decision support tools that will promote resilience to climate change, and thus enable more effective adaptation. This paper outlines the challenges and opportunities presented by advances in data collection, storage, analysis, and access, particularly focusing on “data mashups”. These data mashups are integrations of different types and sources of data, frequently using open application programming interfaces and data sources, to produce enriched results that were not necessarily the original reason for assembling the raw source data. As an illustration of this potential, this paper describes a recently funded initiative to create such a facility in the UK for use in decision support around climate change and health, and provides examples of suitable sources of data and the purposes to which they can be directed, particularly for policy makers and public health decision makers.

Smoking and mortality in stroke survivors: can we eliminate the paradox?

BACKGROUND

Many studies have suggested that smoking does not increase mortality in stroke survivors. Index event bias, a sample selection bias, potentially explains this paradoxical finding. Therefore, we compared all-cause, cardiovascular disease (CVD), and cancer mortality by cigarette smoking status among stroke survivors using methods to account for index event bias.

METHODS

Among 5797 stroke survivors of 45 years or older who responded to the National Health Interview Survey years 1997-2004, an annual, population-based survey of community-dwelling US adults, linked to the National Death Index, we estimated all-cause, CVD, and cancer mortality by smoking status using Cox proportional regression and propensity score analysis to account for demographic, socioeconomic, and clinical factors. Mean follow-up was 4.5 years.

RESULTS

From 1997 to 2004, 18.7% of stroke survivors smoked. There were 1988 deaths in this stroke survivor cohort, with 50% of deaths because of CVD and 15% because of cancer. Current smokers had an increased risk of all-cause mortality (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.14-1.63) and cancer mortality (HR, 3.83; 95% CI, 2.48-5.91) compared with never smokers, after controlling for demographic, socioeconomic, and clinical factors. Current smokers had an increased risk of CVD mortality controlling for age and sex (HR, 1.29; 95% CI, 1.01-1.64), but this risk did not persist after controlling for socioeconomic and clinical factors (HR, 1.15; 95% CI, .88-1.50).

CONCLUSIONS

Stroke survivors who smoke have an increased risk of all-cause mortality, which is largely because of cancer mortality. Socioeconomic and clinical factors explain stroke survivors' higher risk of CVD mortality associated with smoking.

The Nonlinear Relationship between Education and Mortality: An Examination of Cohort, Race/Ethnic, and Gender Differences

Researchers investigating the relationship between education and mortality in industrialized countries have consistently shown that higher levels of education are associated with decreased mortality risk. The shape of the education-mortality relationship and how it varies by demographic group have been examined less frequently. Using the U.S. National Health Interview Survey-Linked Mortality Files, which link the 1986 through 2004 NHIS to the National Death Index through 2006, we examine the shape of the education-mortality curve by cohort, race/ethnicity, and gender. Whereas traditional regression models assume a constrained functional form for the dependence of education and mortality, in most cases semiparametric models allow us to more accurately describe how the association varies by cohort, both between and within race/ethnic and gender subpopulations. Notably, we find significant changes over time in both the shape and the magnitude of the education-mortality gradient across cohorts of women and white men, but little change among younger cohorts of black men. Such insights into demographic patterns in education and mortality can ultimately help increase life expectancies.

Education and the gender gaps in health and mortality

The positive associations between education and health and survival are well established, but whether the strength of these associations depends on gender is not. Is the beneficial influence of education on survival and on self-rated health conditioned by gender in the same way, in opposite ways, or not at all? Because women are otherwise disadvantaged in socioeconomic resources that are inputs to health, their health and survival may depend more on education than will men's. To test this hypothesis, we use data from the National Health Interview Survey-Linked Mortality Files (NHIS-LMF). We find that education's beneficial influence on feeling healthy and on survival are conditional on gender, but in opposite ways. Education has a larger effect on women's self-rated health than on men's, but a larger effect on men's mortality. To further examine the mortality results, we examine specific causes of death. We find that the conditional effect is largest for deaths from lung cancer, respiratory disease, stroke, homicide, suicide, and accidents. Because women report worse health but men's mortality is higher, education closes the gender gap in both health and mortality.

The effects of a psychosocial dimension of socioeconomic position on survival: occupational prestige and mortality among US working adults

The association between education or income and mortality has been explored in great detail. These measures capture both the effects of material disadvantage on health and the psychosocial impacts of a low socioeconomic position on health. When explored independently of educational attainment and income, occupational prestige - a purely perceptual measure - serves as a measure of the impact of a psychosocial phenomenon on health. For instance, a fire-fighter, academician or schoolteacher may carry the social benefits of a higher social status without actually having the income (in all cases) or the educational credentials (in the case of the fire-fighter) to match. We explored the independent influence of occupational prestige on mortality. We applied Cox proportional hazards models to a nationally representative sample of over 380,000 US workers who had worked at any time between 1986 and 1994 with mortality follow up through 2002. We found that occupational prestige is associated with a decrease in the risk of all-cause, cancer, cardiovascular and respiratory-related mortality after controlling for household income and educational attainment. We further investigated the question of whether the effects of prestige are moderated by sex and broader occupational groupings. Prestige effects operate in white-collar occupations for men only and within service occupations for all workers.

The significance of education for mortality compression in the United States

Recent studies of old-age mortality trends assess whether longevity improvements over time are linked to increasing compression of mortality at advanced ages. The historical backdrop of these studies is the long-term improvement in a population's socioeconomic resources that fueled longevity gains. We extend this line of inquiry by examining whether socioeconomic differences in longevity within a population are accompanied by old-age mortality compression. Specifically, we document educational differences in longevity and mortality compression for older men and women in the United States. Drawing on the fundamental cause of disease framework, we hypothesize that both longevity and compression increase with higher levels of education and that women with the highest levels of education will exhibit the greatest degree of longevity and compression. Results based on the Health and Retirement Study and the National Health Interview Survey Linked Mortality File confirm a strong educational gradient in both longevity and mortality compression. We also find that mortality is more compressed within educational groups among women than men. The results suggest that educational attainment in the United States maximizes life chances by delaying the biological aging process.

Occupational vs. industry sector classification of the US workforce: which approach is more strongly associated with worker health outcomes?

OBJECTIVES

Through use of a nationally representative database, we examined the variability in both self-rated health and overall mortality risk within occupations across the National Occupational Research Agenda (NORA) Industry Sectors, as well as between the occupations within the NORA Industry sectors.

METHODS

Using multiple waves of the National Health Interview Survey (NHIS) representing an estimated 119,343,749 US workers per year from 1986 to 2004, age-adjusted self-rated health and overall mortality rates were examined by occupation and by NORA Industry Sector.

RESULTS

There was considerable variability in the prevalence rate of age-adjusted self-rated poor/fair health and overall mortality rates for all US workers. The variability was greatest when examining these data by the Industry Sectors. In addition, we identified an overall pattern of increased poor/fair self-reported health and increased mortality rates concentrated among particular occupations and particular Industry Sectors.

CONCLUSIONS

This study suggests that using occupational categories within and across Industry Sectors would improve the characterization of the health status and health disparities of many subpopulations of workers within these Industry Sectors.

Differential record linkage by Hispanic ethnicity and age in linked mortality studies: implications for the epidemiologic paradox

OBJECTIVE

This study examines how the linkage of surveys to death records differs for Hispanics and non-Hispanic Whites and how such differences affect estimates of ethnic differences in U.S. adult mortality.

METHOD

I use data from the 1989-2000 National Health Interview Survey (NHIS) linked to the National Death Index (NDI) through 2002. Analyses assess how match score and match class vary by ethnicity, nativity, and age and whether mortality hazard ratios are sensitive to shifts in match criteria.

RESULTS

Linkage quality is lower for Hispanic and foreign-born adults than for non-Hispanic White and U.S.-born adults. Modification of the linkage criteria determine whether the Hispanic mortality advantage is observed among middle-aged adults.

DISCUSSION

The accuracy of adult mortality estimates depends on the quality of the linkage between surveys and death records.

Mortality associated with illegal drug use among adults in the United States

OBJECTIVES

To examine all-cause and cause-specific mortality over a 15-year follow-up period in relation to at-baseline reported lifetime use of illegal drugs from five classes (marijuana, cocaine, heroin, hallucinogens, and inhalants) among adults in the United States (US) household population.

METHODS

The study involved 20,983 sample adults who responded to the 1991 National Health Interview Survey Drug and Alcohol Use supplemental questionnaire and also met the eligibility criteria for mortality follow-up. Cox proportional hazards models were estimated to examine the relationships.

RESULTS

Adults who at baseline reported lifetime heroin use were at significantly higher risk of all-cause death over the follow-up period (hazard rate ratio or HR = 2.02; 95% confidence interval or CI 1.26-3.23), compared with those who did not report using drugs from any of the five classes, even after adjusting for age, sex, race, education, marital status, cigarette smoking status, and alcohol use status. Those who at baseline reported lifetime cocaine (no heroin) use had a significantly higher rate of death associated with human immunodeficiency virus diseases over the follow-up period than nonusers of drugs from any of the five classes. Several limitations of the analysis are discussed.

CONCLUSIONS

Further research is needed to understand and track the elevated mortality associated with illegal drug use and the correlates of drug-poisoning deaths.

Trends in the Educational Gradient of U.S. Adult Mortality from 1986 to 2006 by Race, Gender, and Age Group

The educational gradient of U.S. adult mortality became steeper between 1960 and the mid 1980s, but whether it continued to steepen is less clear given a dearth of attention to these trends since that time. This study provides new evidence on trends in the education-mortality gradient from 1986 to 2006 by race, gender, and age among non-Hispanic whites and blacks using data from the 2010 release of the National Health Interview Survey Linked Mortality File. Results show that, for white and black men, the gradient steepened among older ages because declines in mortality risk across education levels were greater among the higher educated. The gradient steepened among white women, and to a much lesser and only marginally significant extent among black women, largely because mortality risk decreased among the college-educated but increased among women with less than a high school degree. Greater returns to higher education and compositional changes within educational strata likely contributed to the trends.