The exceptionally high life expectancy of Costa Rican nonagenarians

Assessing the relationship between multimorbidity, NCD configurations, frailty phenotypes, and mortality risk in older adults

BACKGROUND

Older adults are increasingly susceptible to prolonged illness, multiple chronic diseases, and disabilities, which can lead to the coexistence of multimorbidity and frailty. Multimorbidity may result in various noncommunicable disease (NCD) patterns or configurations that could be associated with frailty and death. Mortality risk may vary depending on the presence of specific chronic diseases configurations or frailty.

METHODS

The aim was to examine the impact of NCD configurations on mortality risk among older adults with distinct frailty phenotypes. The population was analyzed from the Costa Rican Longevity and Healthy Aging Study Cohort (CRELES). A total of 2,662 adults aged 60 or older were included and followed for 5 years. Exploratory factor analysis and various clustering techniques were utilized to identify NCD configurations. The frequency of NCD accumulation was also assessed for a multimorbidity definition. Frailty phenotypes were set according to Fried et al. criteria. Kaplan‒Meier survival analyses, mortality rates, and Cox proportional hazards models were estimated.

RESULTS

Four different types of patterns were identified: 'Neuro-psychiatric', 'Metabolic', 'Cardiovascular', and 'Mixt' configurations. These configurations showed a higher mortality risk than the mere accumulation of NCDs [Cardiovascular HR:1.65 (1.07-2.57); 'Mixt' HR:1.49 (1.00-2.22); ≥3 NCDs HR:1.31 (1.09-1.58)]. Frailty exhibited a high and constant mortality risk, irrespective of the presence of any NCD configuration or multimorbidity definition. However, HRs decreased and lost statistical significance when phenotypes were considered in the Cox models [frailty + 'Cardiovascular' HR:1.56 (1.00-2.42); frailty + 'Mixt':1.42 (0.95-2.11); and frailty + ≥ 3 NCDs HR:1.23 (1.02-1.49)].

CONCLUSIONS

Frailty accompanying multimorbidity emerges as a more crucial indicator of mortality risk than multimorbidity alone. Therefore, studying NCD configurations is worthwhile as they may offer improved risk profiles for mortality as alternatives to straightforward counts.

A Narrative Review Exploring the Similarities between Cilento and the Already Defined "Blue Zones" in Terms of Environment, Nutrition, and Lifestyle: Can Cilento Be Considered an Undefined "Blue Zone"?

Longevity is rightly considered one of the greatest achievements of modern society, not only as a function of lifespan, but, more importantly, as a function of healthspan. There are Longevity Blue Zones (LBZs), regions around the world, such as in Okinawa, Japan; the Nicoya Peninsula, Costa Rica; Loma Linda, California; Icaria, Greece; and Ogliastra, Sardinia, that are characterized by a significant percentage of residents who live exceptionally long lives, often avoiding age-related disability to a significantly higher degree than in the Western way of life. Longevity is not a universal phenomenon, so if there are places in the world with characteristics similar to the LBZs, it is important to identify them in order to better understand what other factors, in addition to the known ones, might contribute to a long and healthy life. This narrative review aims to identify common factors between Cilento and the five LBZs, taking into account environmental, nutritional, and lifestyle factors. Articles from 2004 to the present, limited to studies published in English, German, and Italian, were searched in PubMed/Medline, Scopus, and Google Scholar. The co-authors agreed on 18 final reference texts. In order to evaluate the similarities between Cilento and the LBZs, a descriptive comparative approach was used. Cilento and the LBZs share several common factors, including a hilly altitude ranging from 355 to 600 m; a mild climate throughout the year, with temperatures between 17.4 and 23.5 degrees Celsius; traditional professions, such as agriculture and animal husbandry; and a predominantly Mediterranean or plant-based diet, with typical recipes based on legumes, tubers, vegetables, and extra virgin olive oil. Additionally, maintenance of strong intergenerational family relationships, religious devotion, and social relationships within the community are also prevalent. Given the similarities to Cilento, one might wonder if this is an LBZ waiting to be discovered. The lessons learned from this discovery could be applied to the general population to protect them from non-communicable chronic diseases and help slow the aging process.

Micro- and Macronutrient Intake in Elderly Costa Ricans: The Costa Rican Longevity and Healthy Aging Study (CRELES)

Costa Rica, a middle-income country in Central America, has a life expectancy similar or even higher than richer countries. This survival advantage is more evident among the elderly, who have one of the lowest mortality rates in the world. Dietary factors may play a role in this extended longevity. We have shown that a traditional rural diet is associated with longer leukocyte telomere length—a biomarker of aging—among elderly Costa Ricans. In the present study, we used data from the Costa Rican Longevity and Healthy Aging Study (CRELES) to characterize further rural and urban diets of the elderly (60+ years). A validated food frequency questionnaire was used to assess usual diet. We used energy-adjusted regression models to compare the intake of micro- and macronutrients between rural and urban regions of the country. Elderly rural residents had a higher consumption of carbohydrates (but lower glycemic index), fiber, dietary iron, and used more palm oil for cooking than elderly urban dwellers. On the other hand, elderly subjects living in urban areas had a higher intake of total fat, mono and polyunsaturated fat, alcohol and dietary calcium compared to elderly rural residents. Our results are similar to earlier reports of middle-aged Costa Ricans and add to the characterization of diet differences in rural and urban regions of the country.

Is life expectancy higher in countries and territories with publicly funded health care? Global analysis of health care access and the social determinants of health

Background

To better understand factors influencing life expectancy, this paper examines how the availability of publicly funded health care in a country and multiple social determinants of health impact longevity of life.

Methods

In this descriptive statistical analysis, data regarding publicly funded health care, life expectancy, and social determinants of health were obtained for 196 countries and 4 territories. Social determinants included 10 indicators detailing country-level information to represent 5 key categories: economic stability, education, health & health care, neighbourhood & built environment, and social & community context. Analyses consisted of: 1) comparison of mean life expectancy among countries and territories with- and without- publicly funded health care; 2) correlations in life expectancy across social determinants by health care access and level of burden; and 3) correlations in life expectancy within social determinants for health care access by level of burden.

Results

Overall, life expectancy in countries and territories with- publicly funded health care (Mean (m) = 76.7 years) was significantly longer compared to countries and territories without- publicly funded health care (m = 66.8 years, P < 0.0001). For each social determinant, we observed longer life expectancy continued to be associated with publicly funded health care access across stratum (P < 0.0001), but difference in years of life expectancy existed both by burden of social determinant, as well as access to health care within quartiles of burden (Publicly funded care (yes): 68.12-80.88 years, (no): 62.39-77.33 years, all P < 0.05). Both social determinants as well as the availability of publicly funded health care were individually and simultaneously associated with mean longevity of life between countries and territories worldwide.

Conclusions

These findings demonstrate how, if made widely available, publicly funded health care could extend longevity of life. If combined with programs to reduce the burden of social determinants, a substantial impact can be made to promote more equitable distribution of life expectancies across the world. Ultimately, both access to publicly funded care and reducing inequalities in social determinants are needed in order to promote longer and healthier aging in populations worldwide.

Genome-wide DNA methylation profiling in nonagenarians suggests an effect of PM20D1 in late onset Alzheimer's disease

Background

The aim of this study is to identify differentially methylated regions (DMRs) in the genomes of a sample of cognitively healthy individuals and a sample of individuals with LOAD, all of them nonagenarians from Costa Rica.

Methods

In this study, we compared whole blood DNA methylation profiles of 32 individuals: 21 cognitively healthy and 11 with LOAD, using the Infinium MethylationEPIC BeadChip. First, we calculated the epigenetic age of the participants based on Horvath’s epigenetic clock. DMRcate and Bumphunter were used to identify DMRs. After in silico and knowledge-based filtering of the DMRs, we performed a methylation quantitative loci (mQTL) analysis (rs708727 and rs960603).

Results

On average, the epigenetic age was 73 years in both groups, which represents a difference of over 20 years between epigenetic and chronological age in both affected and unaffected individuals. Methylation analysis revealed 11 DMRs between groups, which contain six genes and two pseudogenes. These genes are involved in cell cycle regulation, embryogenesis, synthesis of ceramides, and migration of interneurons to the cerebral cortex. One of the six genes is PM20D1, for which altered expression has been reported in LOAD. After genotyping previously reported mQTL SNPs for the gene, we found that average methylation in the PM20D1 DMR differs between genotypes for rs708727, but not for rs960603.

Conclusions

This work supports the possible role of PM20D1 in protection against AD, by showing differential methylation in blood of affected and unaffected nonagenarians. Our results also support the influence of genetic factors on PM20D1 methylation levels.

Diet and Leukocyte Telomere Length in a Population with Extended Longevity: The Costa Rican Longevity and Healthy Aging Study (CRELES)

Elderly Costa Ricans have lower mortality rates compared to their counterparts from developed countries. Reasons for this survival advantage are not completely known. In the present study, we aimed to identify dietary factors associated with leukocyte telomere length (LTL), a marker of biologic aging, in the elderly population of Costa Rica. We conducted prospective analysis in 909 participants aged 60+ years from the Costa Rican Longevity and Healthy Aging Study (CRELES). We used a food frequency questionnaire to assess usual diet. We calculated dietary patterns using Principal Component Analysis (PCA). We used generalized linear models to examine the association of dietary patterns and food groups with leukocyte telomere length. We found two major dietary patterns explaining 9.15% and 7.18% of the total variation of food intake, respectively. The first dietary pattern, which represents a traditional Costa Rican rice and beans pattern, was more frequent in rural parts of the country and was positively associated with baseline LTL: β (95% CI) = 42.0 base-pairs (bp) (9.9 bp, 74.1 bp) per one-unit increase of the traditional dietary pattern. In analysis of individual food groups, intake of grains was positively associated with baseline LTL: β (95% CI) = 43.6 bp (13.9 bp, 73.3 bp) per one-serving/day increase of consumption of grains. Our results suggest that dietary factors, in particular a traditional food pattern, are associated with telomere length and may contribute to the extended longevity of elderly Costa Ricans.

Social inequality in incidence and mortality of malignant neoplasms of lip, oral cavity and pharynx: Is Costa Rica an international paradox?

OBJECTIVES

Low socioeconomic position (SEP) has been associated with higher incidences and mortality of lip, oral cavity and pharynx (LOP) cancers in the vast majority of countries with available data. The origins of health inequalities in cancer are socioeconomic, although they vary by time and country. Evidence from Low-and Middle-income Countries (LMICs) remains scarce. This study aims to identify and describe socioeconomic inequalities in LOP cancers incidence and mortality in Costa Rica. The hypothesis tested is that people leaving in low-SEP districts in Costa Rica have greater incidence and mortality rates of lip, oral cavity and pharynx cancers.

METHODS

The 10th revision of the International Classification of Diseases (ICD-10) was used to define cancer sites. Data come from a national population-based Cancer Registry with 100% completeness to study incidence. Incidence rate included all new cases of LOP cancer diagnosed from January 1, 2011, and December 31, 2015, for a total of 2 798 517 individuals, 13 832 524 years of follow-up and 601 LOP cases. Mortality rate was extracted from the National Death Index, including 2 739 733 individuals, 23 950 240 person-years of follow-up and 586 LOP cancer deaths, from January 1, 2010, to December 31, 2018. The 2011 Census (with 94% of Costa Rican inhabitants) was used to characterize the urbanicity and wealth of 477 districts. Survival models were performed for both incidence and mortality, allowing to consider existing competitive risks. Cox models were used for incidence, and parametric survival models based on a Gompertz distribution for mortality.

RESULTS

The study found that people who lived in the most socioeconomically disadvantaged areas had lower probabilities of developing LOP cancers than people in the richest districts. The same pattern for mortality, however, was not significant.

CONCLUSIONS

The hypothesis that incidence and mortality of LOP cancers will show a positive social gradient was not confirmed in this study, contradicting the existing literature. This could be explained by the social distribution of risky health behaviours, more frequent in socially advantaged populations.

Is centenarian rate independent from economy?

BACKGROUND

Economy development and income are compactly associated with mortality of infant, children, young people, and mid age all over the world, and high income brings higher life expectancy, aging rate and 80+ rate as a result. On the contrary, the relationship between income and centenarian rate is obscure, in China, low income regions have lower life expectancy, lower 80+ rate but higher 90+ rate and 100+ rate before 2000, but 90+ rate and centenarian rate in low income regions fall behind high income regions after 2010.

OBJECTIVE

The aim of this study is to explore the relationship between regional economic performance and centenarian rate in long period.

METHOD

Gravity center of five longevity indicators, demographic methodology between age-specific mortality rate and centenarian rate were conducted of 31 provinces in China from 1982 to 2018. We also explored the association between centenarian rate and per capita income using binary logistic regression.

RESULTS

higher income brings better medical care and mortality rate is sharply decreased, among all age stages, the age 70-84 has the highest number of death, and will get most number of extra lives when the mortality rate decreases, and then 80+ rate will be increased immediately. Meanwhile, the extra 70-84 years people increased denominator of 90+ rate and centenarian rate, then 90+ rate and centenarian rate in higher income region will be fall behind. 10-20 years later, benefited from additional 70-84 years population, the number of 90+ will be largely increased. 20-30 years later, the number of 100+ will be largely increased too.

CONCLUSION

Income is positively related with lower mortality rate of oldest-old and higher 90+ rate and centenarian rate, although the effect will be lagged for 10-20 years and 20-30 years, respectively.

SG1002 and Catenated Divalent Organic Sulfur Compounds as Promising Hydrogen Sulfide Prodrugs

Significance: Sulfur has a critical role in protein structure/function and redox status/signaling in all living organisms. Although hydrogen sulfide (H2S) and sulfane sulfur (SS) are now recognized as central players in physiology and pathophysiology, the full scope and depth of sulfur metabolome's impact on human health and healthy longevity has been vastly underestimated and is only starting to be grasped. Since many pathological conditions have been related to abnormally low levels of H2S/SS in blood and/or tissues, and are amenable to treatment by H2S supplementation, development of safe and efficacious H2S donors deserves to be undertaken with a sense of urgency; these prodrugs also hold the promise of becoming widely used for disease prevention and as antiaging agents. Recent Advances: Supramolecular tuning of the properties of well-known molecules comprising chains of sulfur atoms (diallyl trisulfide [DATS], S8) was shown to lead to improved donors such as DATS-loaded polymeric nanoparticles and SG1002. Encouraging results in animal models have been obtained with SG1002 in heart failure, atherosclerosis, ischemic damage, and Duchenne muscular dystrophy; with TC-2153 in Alzheimer's disease, schizophrenia, age-related memory decline, fragile X syndrome, and cocaine addiction; and with DATS in brain, colon, gastric, and breast cancer. Critical Issues: Mode-of-action studies on allyl polysulfides, benzyl polysulfides, ajoene, and 12 ring-substituted organic disulfides and thiosulfonates led several groups of researchers to conclude that the anticancer effect of these compounds is not mediated by H2S and is only modulated by reactive oxygen species, and that their central model of action is selective protein S-thiolation. Future Directions: SG1002 is likely to emerge as the H2S donor of choice for acquiring knowledge on this gasotransmitter's effects in animal models, on account of its unique ability to efficiently generate H2S without byproducts and in a slow and sustained mode that is dose independent and enzyme independent. Efficient tuning of H2S donation characteristics of DATS, dibenzyl trisulfide, and other hydrophobic H2S prodrugs for both oral and parenteral administration will be achieved not only by conventional structural modification of a lead molecule but also through the new "supramolecular tuning" paradigm.

Dietary Habits, Anthropometric Features and Daily Performance in Two Independent Long-Lived Populations from Nicoya peninsula (Costa Rica) and Ogliastra (Sardinia)

(1) Background: Longevity Blue Zones (LBZs) are populations characterized by exceptional longevity. The purpose of this cross-sectional study was to compare the food habits of two representative samples of the oldest old subjects from the population residing in the LBZs of Nicoya peninsula (Costa Rica) and in the mountainous part of Ogliastra (Sardinia, Italy). (2) Methods: Data were collected using validated tools, including a food frequency questionnaire, Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL) scales for functional autonomy, body mass index, and waist and limbs circumferences. (3) Results: A total of 210 subjects, 60 (31 male) from Nicoya (age range 80–109 years), and 150 (61 male) from Ogliastra (age 90–101 years) were included in the study. In both populations, the highest frequencies of consumption were recorded for plant-derived foods (cereals 60–80% daily, legumes ≥ 80% daily in Nicoya, ≥ 60% 2–5 servings/week in Ogliastra), followed by those of animal origin (dairy products, meat) ≥60% and 80% daily, in Nicoya and Ogliastra, respectively. The frequency of milk consumption showed a positive correlation with BADL (ρ = 0.268 for Nicoya and ρ = 0.214 for Ogliastra) and IADL scores (ρ = 0.466 for Nicoya and ρ = 0.471 for Ogliastra), whereas legumes consumption correlated negatively with self-rated health (ρ = −0.264) and IADL (ρ = −0.332). (4) Conclusions: Our results indicate that the dominant dietary model among the elderly of Nicoya and Ogliastra is a plant-based diet complemented by a non-negligible consumption of animal products, mostly dairy products. Further prospective studies are needed to ascertain a possible cause–effect relationship between food habits and increased likelihood of reaching advanced age.

Association of endemic goitre and exceptional longevity in Sardinia: evidence from an ecological study

This study aims to test the hypothesis that a high prevalence of endemic goitre, considered as a proxy measure for subclinically reduced thyroid function in the population, is geographically associated with exceptional longevity. Using historical data available for 377 Sardinian municipalities in the first half of the twentieth century, we performed an ecological study to investigate the geographic distribution of goitre and its spatial association with demographic indicators of population longevity. This analysis was conducted by using both conventional ordinary least square and geographically weighted regression models to take into account spatial autocorrelation and included other longevity-associated factors previously identified in Sardinia. The spatial analysis revealed that the goitre rate (p < 0.0001), the proportion of inhabitants involved in pastoralism (p = 0.016), the terrain inclination (p = 0.008), and the distance from the workplace as a proxy for physical activity (p = 0.023) were consistently associated with population longevity at an aggregated level in the 377 municipalities. Within the limits of an ecological study design, our findings support the existence of a significant association between high goitre prevalence and increased probability to survive into old age. The present study confirms previous results and is consistent with animal studies and epidemiological surveys in other long-lived areas known as Blue Zones. Potential mechanisms underlying this association need to be further investigated.

Costa Rican Mortality 1950-2013: An Evaluation of Data Quality and Trends Compared with Other Countries

Background

Mortality estimates from various sources suggest that Costa Ricans experience record-high life expectancy at birth in Latin America and higher longevity than the populations of many high-income countries, although there is some uncertainty as to the reliability of those estimates.

Objective

We construct a life table series for Costa Rica to assess the quality of national demographic statistics for the period 1950-2013 and to determine whether reliable mortality estimates can be directly calculated from these data.

Methods

We apply the methods from the Human Mortality Database (HMD) to national statistics to construct the Costa Rica life table series without adjusting for data quality, and we validate our results through internal consistency by evaluating the plausibility of the mortality patterns and its change over time and through external consistency by comparing our results with those from other sources.

Results

Our mortality estimates for Costa Rica tend to be lower than others, especially for the period before 1970. They also produce a suspicious age pattern of mortality, with low adult and old-age mortality relative to the infant and child mortality, casting doubt on the quality of national demographic data.

Conclusions

Other organizations have produced mortality estimates for Costa Rica that are higher than our unadjusted estimates, but it is difficult to evaluate the accuracy of the available estimates.

Contribution

This analysis provides a more thorough evaluation of data quality issues regarding Costa Rica mortality than previously available. Unadjusted life tables by sex for 1950-2013 are included as supplemental material, together with the raw data upon which those life tables are based and with links to the detailed methods protocol implemented.

Aging in the Americas: Disability-free Life Expectancy Among Adults Aged 65 and Older in the United States, Costa Rica, Mexico, and Puerto Rico

Objectives

To estimate and compare disability-free life expectancy (DFLE) and current age patterns of disability onset and recovery from disability between the United States and countries in Latin America and the Caribbean.

Method

Disability is measured using the activities of daily living scale. Data come from longitudinal surveys of older adult populations in Costa Rica, Mexico, Puerto Rico, and the United States. Age patterns of transitions in and out of disability are modeled with a discrete-time logistic hazard model, and a microsimulation approach is used to estimate DFLE.

Results

Overall life expectancy for women aged 65 is 20.11 years in Costa Rica, 19.2 years in Mexico, 20.4 years in Puerto Rico, and 20.5 years in the United States. For men, these figures are 19.0 years in Costa Rica, 18.4 years in Mexico, 18.1 years in Puerto Rico, and 18.1 years in the United States. Proportion of remaining life spent free of disability for women at age 65 is comparable between Mexico, Puerto Rico, and the United States, with Costa Rica trailing slightly. Male estimates of DFLE are similar across the four populations.

Discussion

Though the older adult population of Latin America and the Caribbean lived many years exposed to poor epidemiological and public health conditions, their functional health in later life is comparable with the older adult population of the United States.

Trends in Life Expectancy and Its Association with Economic Factors in the Belt and Road Countries-Evidence from 2000⁻2014

In 2013, China launched the Belt and Road (B&amp;R) Initiative in an effort to promote trade and economic collaboration. This study examined the change in life expectancy (LE) among countries along B&amp;R and studied the impact of economic development on LE. Data from 65 B&amp;R countries from 2000 to 2014 were compiled and analyzed. Trend of LE was examined by sex and country. Linear quantile mixed model was used to study the associations between LE and economic factors. In 2014, the average LE in all B&amp;R countries was 69.7 years for men and 73.7 years for women. Across countries in 2014, LE for men ranged from 58.6 years in Afghanistan to 80.2 years in Israel. LE for women ranged from 61.3 years in Afghanistan to 85.9 in Singapore. GDP per capita was positively associated with longevity across B&amp;R countries. The unemployment rate was positively associated with LE only for countries in the top LE quantiles. GDP growth rate and Inflation were negatively associated with LE for the countries in the bottom LE quantiles for men, not for women. LE increased substantially among B&amp;R countries during 2000⁻2014. The influence of macroeconomic factors on LE was related to the distribution of LE.

A fuzzy set qualitative comparative analysis of 131 countries: which configuration of the structural conditions can explain health better?

Background

According to the recommendations of the World Health Organization Commission On Social Determinants of Health (CSDH) for intersectoral action on health, the well-being of and equity in health within a population are achieved via a complex fusion of policies and actions. In this study, following the CSDH’s approach and considering set-theoretic relations, we aimed to unravel this complexity and answer the kinds of questions that are outside the scope of conventional variable-oriented approach.

Methods

A fuzzy-set qualitative comparative analysis of 131 countries was conducted to examine the configurational effects of five macro-level structural conditions on life expectancy at birth. The potential causal conditions were level of country wealth, income inequality, quality of governance, education, and health system. The data collected from different international data sources were recorded during 2004–2015.

Results

The intermediate solution of the truth table analysis indicated a configuration of conditions including high level of governance, education, wealth, and affluent health system to be consistently sufficient for high life expectancy. On the other hand, four configurations, each containing two or three conditions, were consistent with being usually sufficient to cause low life expectancy.

Conclusions

We were able to configurationally explore the cases and specify the combinations of potentially causal conditions which were usually sufficient to explain high or low life expectancy in different countries. As a result, particular cases were identified for further research. In addition, research may provide support for the CSDH’s recommendations emphasizing the importance of intersectoral action for health.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0724-1) contains supplementary material, which is available to authorized users.

Prevalence of Frailty in Latin America and the Caribbean: A Systematic Review and Meta-Analysis

BACKGROUND

Countries in Latin America and the Caribbean (LAC) have experienced a rapid increase in their proportion of older people. This region is marked by a high prevalence of chronic diseases and disabilities among aging adults. Frailty appears in the context of LAC negatively affecting quality of life among many older people.

AIM

To investigate the prevalence of frailty among community-dwelling older people in LAC through a systematic review and meta-analysis.

METHODS

A literature search was performed in indexed databases and in the grey literature. Studies investigating the prevalence of frailty with representative samples of community-dwelling older people in Latin America and the Caribbean were retrieved. Independent investigators carried out the study selection process and the data extraction. A meta-analysis and meta-regression were performed using STATA 11 software. The systematic review was registered at the International Prospective Register of Systematic Reviews under the number CRD42014015203.

RESULTS

A total of 29 studies and 43,083 individuals were included in the systematic review. The prevalence of frailty was 19.6% (95% CI: 15.4-24.3%) in the investigated region, with a range of 7.7% to 42.6% in the studies reviewed. The year of data collection influenced the heterogeneity between the studies.

CONCLUSION

Frailty is very common among older people in LAC. As a result, countries in the region need to adapt their health and social care systems to demands of an older population.

Exploring why Costa Rica outperforms the United States in life expectancy: A tale of two inequality gradients

Mortality in the United States is 18% higher than in Costa Rica among adult men and 10% higher among middle-aged women, despite the several times higher income and health expenditures of the United States. This comparison simultaneously shows the potential for substantially lowering mortality in other middle-income countries and highlights the United States' poor health performance. The United States' underperformance is strongly linked to its much steeper socioeconomic (SES) gradients in health. Although the highest SES quartile in the United States has better mortality than the highest quartile in Costa Rica, US mortality in its lowest quartile is markedly worse than in Costa Rica's lowest quartile, providing powerful evidence that the US health inequality patterns are not inevitable. High SES-mortality gradients in the United States are apparent in all broad cause-of-death groups, but Costa Rica's overall mortality advantage can be explained largely by two causes of death: lung cancer and heart disease. Lung cancer mortality in the United States is four times higher among men and six times higher among women compared with Costa Rica. Mortality by heart disease is 54% and 12% higher in the United States than in Costa Rica for men and women, respectively. SES gradients for heart disease and diabetes mortality are also much steeper in the United States. These patterns may be partly explained by much steeper SES gradients in the United States compared with Costa Rica for behavioral and medical risk factors such as smoking, obesity, lack of health insurance, and uncontrolled dysglycemia and hypertension.

Pulse blood pressure and cardiovascular mortality in a population-based cohort of elderly Costa Ricans

We studied the relationships between blood pressure (BP), pulse pressure (PP) and cardiovascular (CV) death in older adults using data from 2346 participants enrolled in the Costa Rican CRELES study, mean age 76 years (s.d. 10.2), 31% qualified as wide PP. All covariates included and analyzed were collected prospectively as part of a 4-year home-based follow-up; mortality was tracked for an additional 3 years, identifying 266 CV deaths. Longitudinal data revealed little change over time in systolic BP (SBP), a decline in diastolic BP, and widening of PP. Wide PP was associated with higher risk of CV death but only among individuals receiving antihypertensive drug therapy. Individuals with both wide PP and receiving therapy had 2.6 hazard rate of CV death relative to people with normal-PP plus not taking treatment (TRT), even adjusting for SBP. Increasing PP between visits was significantly associated to higher CV death independently of TRT status. SBP and DBP were not significantly associated to CV death when the effect of PP was controlled for. Conclusion: elderly hypertensive patients with wide or increasing PP, especially if receiving TRT, are the highest CV risk group, thus must be carefully assessed, monitored and treated with caution.

Spatio-temporal distribution of human lifespan in China

Based on the data of latest three Chinese population censuses (1990–2010), four lifespan indicators were calculated: centenarians per one hundred thousand inhabitants (CH); longevity index (LI); the percentage of the population aged at least 80 years (ultra-octogenarian index, UOI) and life expectancy at birth (LEB). The spatio-temporal distributions of data at Chinese county level show that high-longevity areas (high values of CH and LI) and low-longevity areas (low CH and LI values) both exhibit clear non-uniformity of spatial distribution and relative immobility through time. Contrarily, the distribution of UOI and LEB shows a decline from the east to the west. The spatial autocorrelation analyses indicate less spatial dependency and several discontinuous clusters regions of high-CH and LI areas. The factors of temperature, topography and wet/dry climate lack of significant influence on CH and LI. It can be inferred that, in addition to genetic factor and living custom, some unique and long-term environmental effects may be related with high or low values of CH and LI.

A life course approach to mortality in Mexico

OBJECTIVE

Research on early life socioeconomic status (SES), education and mortality is less established in developing countries. This analysis aims to determine how SES and education are patterned across the life course and associated with adult mortality in Mexico.

MATERIALS AND METHODS

Data comes from 2001-2012 Mexican Health & Aging Study (Mexican adults age 50+, n= 11,222). Cox proportional hazard models predict mortality using baseline covariates.

RESULTS

In unadjusted analyses, similar mortality was seen across levels of early life SES. Lower early life SES was associated with better survival after accounting for education in the younger cohort. Lower education was only associated with mortality in the younger cohort.

CONCLUSIONS

Early life SES was associated with education but the relationship between education and mortality differed across cohorts in Mexico. Selective survival and differential returns to education may explain differences.

Factors affecting the survival probability of becoming a centenarian for those aged 70, based on the human mortality database: income, health expenditure, telephone, and sanitation

Background

What are the factors that affect the survival probability of becoming a centenarian for those aged 70? Do the factors include income, health expenditure, the use of mobile telephones, or sanitation? The survival probability of becoming a centenarian (SPBC) is defined as an estimate of the production of centenarians by a population. The SPBC (70) is the survival probability of becoming a centenarian for those aged 70. This study estimates the associations between the SPBC (70), and the gross national income, health expenditure, telecommunications, and sanitation facilities in 32 countries.

Methods

The socioeconomic indicators for this study were obtained from the database of the United Nations Development Programme. In addition, the data for the analysis of centenarians in 32 countries were obtained from the Human Mortality Database, which is maintained by the Department of Demography at the University of California, Berkeley, USA, and the Max Planck Institute for Demographic Research in Rostock, Germany. Associations between socioeconomic indicators and SPBC (70) were assessed using Pearson’s correlation coefficients and multiple regression models.

Results

Significant positive correlations were found between the SPBC (70), and the socioeconomic factors of gross national income (GNI), public expenditure on health as a percentage of gross domestic product (PEHGDP), fixed and mobile telephone subscribers (FMTS) as the standard of living, and improved sanitation facilities (ISF). Overall, the SPBC (70) of female and male predictors were used, in order to form a model production of centenarians, with higher GNI and PEHGDP, as well as higher FMTS and ISF as the socioeconomic factors (R²= 0.422, P< 0.001).

Conclusions

The socioeconomic level in all 32 countries appears to have an important latent effect on the production of centenarians in both females and males. This study has identified the following four important aspects of socioeconomic indicators in the survival probability of becoming a centenarian for those aged 70: higher overall economic development level, public expenditure on health, mobile telephone subscribers as the standard of living, and the use of improved sanitation facilities for healthy aging. Thus, the socioeconomic level seems to affect an important on the survival probability of becoming a centenarian.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2318-14-113) contains supplementary material, which is available to authorized users.

Association of apolipoprotein E-e4 and dementia declines with age

OBJECTIVE

To study the association of dementia with apolipoprotein E-e4 (APOE-e4) and its interaction with age in a nonagenarian Costa Rican group (N-sample) and a general elderly contrast group (GE-sample).

METHODS

In both case-control studies, participants were cognitively intact or diagnosed with dementia. The N-sample (N = 112) was at least age 90 years; the GE-sample (N = 98) was at least age 65 years.

RESULTS

Dementia and APOE-e4 were not significantly associated in the N-sample, but were in the GE-sample. There was a significant interaction of age with APOE-e4 in the N-sample, but not in the GE-sample. Descriptively dividing the N-sample at the median (age 93 years) showed a group interaction: APOE-e4 was more associated with dementia in the younger N-sample than in the older N-sample, where six of seven APOE-e4 carriers were cognitively intact.

CONCLUSIONS

The results support the reduction in association of APOE-e4 with dementia in extreme old age, consistent with a survivor effect model for successful cognitive aging.

The Nicoya region of Costa Rica: a high longevity island for elderly males

Reliable data show that the Nicoyan region of Costa Rica is a hot spot of high longevity. A survival follow-up of 16,300 elderly Costa Ricans estimated a Nicoya death rate ratio (DRR) for males 1990-2011 of 0.80 (0.69-0.93 CI). For a 60-year-old Nicoyan male, the probability of becoming centenarian is seven times that of a Japanese male, and his life expectancy is 2.2 years greater. This Nicoya advantage does not occur in females, is independent of socio-economic conditions, disappears in out-migrants and comes from lower cardiovascular (CV) mortality (DRR = 0.65). Nicoyans have lower levels of biomarkers of CV risk; they are also leaner, taller and suffer fewer disabilities. Two markers of ageing and stress-telomere length and dehydroepiandrosterone sulphate-are also more favourable. The Nicoya diet is prosaic and abundant in traditional foods like rice, beans and animal protein, with low glycemic index and high fibre content.

Longer leukocyte telomere length in Costa Rica's Nicoya Peninsula: a population-based study

Studies in humans suggest that leukocyte telomere length may act as a marker of biological aging. We investigated whether individuals in the Nicoya region of Costa Rica, known for exceptional longevity, had longer telomere length than those in other parts of the country. After controlling for age, age squared, rurality, rainy season and gender, the mean leukocyte telomere length in Nicoya was substantially longer (81 base pairs, p<0.05) than in other areas of Costa Rica, providing evidence of a biological pathway to which this notable longevity may be related. This relationship remains unchanged (79 base pairs, p<0.05) after statistically controlling for nineteen potential biological, dietary and social and demographic mediators. Thus the difference in the mean leukocyte telomere length that characterizes this unique region does not appear to be explainable by traditional behavioral and biological risk factors. More detailed examination of mean leukocyte telomere length by age shows that the regional telomere length difference declines at older ages.

Predicting mortality with biomarkers: a population-based prospective cohort study for elderly Costa Ricans

Background

Little is known about adult health and mortality relationships outside high-income nations, partly because few datasets have contained biomarker data in representative populations. Our objective is to determine the prognostic value of biomarkers with respect to total and cardiovascular mortality in an elderly population of a middle-income country, as well as the extent to which they mediate the effects of age and sex on mortality.

Methods

This is a prospective population-based study in a nationally representative sample of elderly Costa Ricans. Baseline interviews occurred mostly in 2005 and mortality follow-up went through December 2010. Sample size after excluding observations with missing values: 2,313 individuals and 564 deaths. Main outcome: prospective death rate ratios for 22 baseline biomarkers, which were estimated with hazard regression models.

Results

Biomarkers significantly predict future death above and beyond demographic and self-reported health conditions. The studied biomarkers account for almost half of the effect of age on mortality. However, the sex gap in mortality became several times wider after controlling for biomarkers. The most powerful predictors were simple physical tests: handgrip strength, pulmonary peak flow, and walking speed. Three blood tests also predicted prospective mortality: C-reactive protein (CRP), glycated hemoglobin (HbA1c), and dehydroepiandrosterone sulfate (DHEAS). Strikingly, high blood pressure (BP) and high total cholesterol showed little or no predictive power. Anthropometric measures also failed to show significant mortality effects.

Conclusions

This study adds to the growing evidence that blood markers for CRP, HbA1c, and DHEAS, along with organ-specific functional reserve indicators (handgrip, walking speed, and pulmonary peak flow), are valuable tools for identifying vulnerable elderly. The results also highlight the need to better understand an anomaly noted previously in other settings: despite the continued medical focus on drugs for BP and cholesterol, high levels of BP and cholesterol have little predictive value of mortality in this elderly population.

Heterogeneity in the Strehler-Mildvan general theory of mortality and aging

This study examines and further develops the classic Strehler-Mildvan (SM) general theory of mortality and aging. Three predictions from the SM theory are tested by examining the age dependence of mortality patterns for 42 countries (including developed and developing countries) over the period 1955-2003. By applying finite mixture regression models, principal component analysis, and random-effects panel regression models, we find that (1) the negative correlation between the initial adulthood mortality rate and the rate of increase in mortality with age derived in the SM theory exists but is not constant; (2) within the SM framework, the implied age of expected zero vitality (expected maximum survival age) also is variable over time; (3) longevity trajectories are not homogeneous among the countries; (4) Central American and Southeast Asian countries have higher expected age of zero vitality than other countries in spite of relatively disadvantageous national ecological systems; (5) within the group of Central American and Southeast Asian countries, a more disadvantageous national ecological system is associated with a higher expected age of zero vitality; and (6) larger agricultural and food productivities, higher labor participation rates, higher percentages of population living in urban areas, and larger GDP per capita and GDP per unit of energy use are important beneficial national ecological system factors that can promote survival. These findings indicate that the SM theory needs to be generalized to incorporate heterogeneity among human populations.

Surprising SES Gradients in mortality, health, and biomarkers in a Latin American population of adults

BACKGROUND

To determine socioeconomic status (SES) gradients in the different dimensions of health among elderly Costa Ricans.

HYPOTHESIS

SES disparities in adult health are minimal in Costa Rican society.

METHODS

Data from the Costa Rican Study on Longevity and Healthy Aging study: 8,000 elderly Costa Ricans to determine mortality in the period 2000-2007 and a subsample of 3,000 to determine prevalence of several health conditions and biomarkers from anthropometry and blood and urine specimens.

RESULTS

The ultimate health indicator, mortality, as well as the metabolic syndrome, reveals that better educated and wealthier individuals are worse off. In contrast, quality of life-related measures such as functional and cognitive disabilities, physical frailty, and depression all clearly worsen with lower SES. Overall self-reported health (SRH) also shows a strong positive SES gradient. Traditional cardiovascular risk factors such as diabetes and cholesterol are not significantly related to SES, but hypertension and obesity are worse among high-SES individuals. Reflecting mixed SES gradients in behaviors, smoking and lack of exercise are more common among low SES, but high calorie diets are more common among high SES.

CONCLUSIONS

Negative modern behaviors among high-SES groups may be reversing cardiovascular risks across SES groups, hence reversing mortality risks. But negative SES gradients in healthy years of life persist.