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9 Cardiometabolic Diseases
Pages 311-362

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From page 311... ... The combination of these trends operated to increase all-cause working-age mortality after 2010 because the slowdown in declines in mortality from ischemic heart disease and other circulatory diseases no longer offset the rise in mortality from ENM diseases and hypertensive heart disease. Read the entire page →
From page 312... ... Among the potential explanations for these patterns are three relevant trends: the obesity epidemic; diminishing returns of medical advances; and social, economic, and cultural changes. While all three sets of factors played some role in cardiometabolic mortality trends, the evidence suggests that rising obesity -- an epidemic that has now spanned four decades -- has exerted the greatest influence. Read the entire page →
From page 313... ... By 2000–2002, mortality from ENM diseases was highest in nonmetros, and this continued to be the case throughout the remainder of the study period among all working-age adults except Black males ages 25–44. The largest increases among these younger Black males occurred in small and medium metropolitan areas (hereafter referred to as "small/ medium metros") Read the entire page →
From page 314... ... . Mortality rates for males are shown in the lefthand panels, while those for females are shown in the righthand panels. Read the entire page →
From page 315... ... Hispanic Males Age 45-64 90 60 80 70 50 60 40 50 30 40 30 20 20 10 10 0 0 1990-1993 2000-2002 2009-2011 2015-2017 1990-1993 2000-2002 2009-2011 2015-2017 Large Central Metro Large Fringe Metro Large Central Metro Large Fringe Metro Small/Medium Metro Nonmetro Small/Medium Metro Nonmetro FIGURE 9-2 Mortality rates (deaths per 100,000 population) from endocrine, nutritional, and metabolic diseases among U.S. Read the entire page →
From page 316... ... Older Black females ages 55–64 were the only group of working-age adults to experience declining mortality from hypertensive heart disease over the period, although these declines slowed in the 2010s and trended slightly upward after 2012. Among Black males ages 45–64 and Black females ages 45–54, mortality due to hypertensive heart disease showed small fluctuations during the 1990s and 2000s before stagnating (Black females) Read the entire page →
From page 317... ... , 1990–1992 and 2015–2017, by region and state. NOTE: Mortality rates are shown for 1990–1992 (blue squares) Read the entire page →
From page 318... ... Deaths per 100,000 Population 10 20 30 40 0 Maine Vermont Pennsylvania Rhode Island New Hampshire FIGURE 9-3 Continued New York Northeast New Jersey Connecticut Massachusetts NORTHEAST Indiana Ohio Iowa Kansas Missouri Michigan North Dakota Midwest South Dakota Nebraska Wisconsin Illinois Minnesota MIDWEST West Virginia Mississippi 1990-1992 Arkansas Kentucky Oklahoma Louisiana Alabama b. Females ages 25-64 2015-2017 South Carolina Tennessee South North Carolina Georgia Delaware Virginia Florida Texas District of Columbia Maryland SOUTH New Mexico Arizona Montana Oregon Idaho Washington Alaska West Utah Wyoming California Nevada Colorado Hawaii WEST 318 Read the entire page →
From page 319... ... . Mortality rates for males are shown in the lefthand panels, while those for females are shown in the righthand panels. Read the entire page →
From page 320... ... In 1990–1993, large central metros had the highest mortality from hypertensive heart disease among White adults and nonmetros the lowest, the exception being White females ages 25–44, among whom mortality did not differ by metropolitan status. During the 2010s, however, mortality from hypertensive heart disease increased sharply in nonmetro areas, while large central metros experienced much smaller increases. Read the entire page →
From page 321... ... Hispanic Males Age 45-64 80 25 70 20 60 50 15 40 30 10 20 5 10 0 0 1990-1993 2000-2002 2009-2011 2015-2017 1990-1993 2000-2002 2009-2011 2015-2017 Large Central Metro Large Fringe Metro Large Central Metro Large Fringe Metro Small/Medium Metro Nonmetro Small/Medium Metro Nonmetro FIGURE 9-5 Mortality rates (deaths per 100,000 population) from hypertensive heart disease among U.S. Read the entire page →
From page 322... ... Hispanic Females Ages 45-64 50 9 45 8 40 7 35 6 30 5 25 20 4 15 3 10 2 5 1 0 0 1990-1993 2000-2002 2009-2011 2015-2017 1990-1993 2000-2002 2009-2011 2015-2017 Large Central Metro Large Fringe Metro Large Central Metro Large Fringe Metro Small/Medium Metro Nonmetro Small/Medium Metro Nonmetro FIGURE 9-5 Continued in large fringe metros; by 2015–2017, the mortality rates were similar in large central metros and large fringe metros and lower in nonmetros and small/medium metros. Among older Hispanic women, mortality from hypertensive heart disease remained steady throughout the study period, a pattern driven by mortality trends in large central metros. Read the entire page →
From page 323... ... , 1990–1992 and 2015–2017, by region and state. NOTE: Mortality rates are shown for 1990–1992 (blue squares) Read the entire page →
From page 324... ... Deaths per 100,000 Population 10 15 20 25 30 0 5 New York Rhode Island Pennsylvania Maine New Jersey FIGURE 9-6 Continued Connecticut Northeast Massachusetts New Hampshire Vermont NORTHEAST Michigan Ohio Illinois Missouri South Dakota Indiana Wisconsin Midwest North Dakota Kansas Iowa Nebraska Minnesota MIDWEST Oklahoma District of Columbia 1990-1992 Mississippi Arkansas Louisiana Georgia Kentucky b. Females ages 25-64 2015-2017 Maryland Tennessee South Alabama Texas West Virginia Delaware Florida South Carolina North Carolina Virginia SOUTH Nevada Arizona Alaska California Wyoming Hawaii Colorado West New Mexico Montana Washington Oregon Idaho Utah WEST 324 Read the entire page →
From page 325... ... largely mirror the patterns noted earlier for all-cause mortality. That is, mortality from ischemic heart disease and other circulatory diseases was highest in nonmetros and lowest in large central metros throughout the study period. Read the entire page →
From page 326... ... Ischemic & Other Circulatory System Diseases Males, ages 55-64 Females, ages 55-64 1000 500 Deaths per 100,000 population Deaths per 100,000 population 800 400 600 300 400 200 200 100 0 0 NH White NH Black Hispanic NH White NH Black Hispanic FIGURE 9-7 Mortality rates (deaths per 100,000 population) from ischemic heart disease and other circulatory system diseases among U.S. Read the entire page →
From page 327... ... Hispanic Males Age 45-64 800 300 700 250 600 500 200 400 150 300 100 200 100 50 0 0 1990-1993 2000-2002 2009-2011 2015-2017 1990-1993 2000-2002 2009-2011 2015-2017 Large Central Metro Large Fringe Metro Large Central Metro Large Fringe Metro Small/Medium Metro Nonmetro Small/Medium Metro Nonmetro FIGURE 9-8 Mortality rate (deaths per 100,000 population) from ischemic heart disease and other diseases of the circulatory system among U.S. Read the entire page →
From page 328... ... Hispanic Females Ages 45-64 400 140 350 120 300 100 250 80 200 60 150 100 40 50 20 0 0 1990-1993 2000-2002 2009-2011 2015-2017 1990-1993 2000-2002 2009-2011 2015-2017 Large Central Metro Large Fringe Metro Large Central Metro Large Fringe Metro Small/Medium Metro Nonmetro Small/Medium Metro Nonmetro FIGURE 9-8 Continued White adults, disparities between large central metros and nonmetros widened, just as they did for all-cause mortality. They widened among younger working-age White adults (ages 25–44) Read the entire page →
From page 329... ... , 1990–1992 and 2015–2017, by region and state. NOTE: Mortality rates are shown for 1990–1992 (blue squares) Read the entire page →
From page 330... ... Deaths per 100,000 Population 25 50 75 0 100 125 150 Pennsylvania Maine New York New Jersey FIGURE 9-9 Continued Rhode Island Vermont Northeast Connecticut Massachusetts New Hampshire NORTHEAST Missouri Indiana Ohio Michigan Kansas Illinois Iowa Midwest South Dakota North Dakota Nebraska Wisconsin Minnesota MIDWEST Alabama Mississippi 1990-1992 Arkansas Louisiana Tennessee Oklahoma Kentucky b. Females ages 25-64 2015-2017 South Carolina District of Columbia South West Virginia Georgia North Carolina Texas Delaware Virginia Florida Maryland SOUTH Nevada Wyoming Alaska Montana Hawaii New Mexico Arizona West Idaho California Washington Utah Oregon Colorado WEST 330 Read the entire page →
From page 331... ... The contribution of cardiometabolic mortality to the recent rise in allcause working-age mortality was therefore due to the net increases in mortality from cardiometabolic diseases after 2010, when mortality declines in ischemic heart disease and other circulatory system diseases stalled and no longer offset the rising rates of mortality from ENM diseases and hypertensive heart disease. These trends in cardiometabolic mortality are likely related; that is, the factors causing the rise in mortality from ENM diseases and hypertensive heart disease may also be related to the recent slowdown in reductions in mortality from ischemic heart disease and other Read the entire page →
From page 332... ... . Turning next to explanations for the related trends in mortality from ENM diseases, hypertensive heart disease, and ischemic heart disease and other circulatory diseases between 1990 and 2017, three important themes are relevant. Read the entire page →
From page 333... ... . Obesity rates vary by age, sex, race, ethnicity, and socioeconomic status. Read the entire page →
From page 334... ... . Given differentials in obesity by socioeconomic status, some research has examined whether obesity explains differentials by socioeconomic status in the recent rise in working-age mortality. Read the entire page →
From page 335... ... The evidence that obese adults are at higher risk of mortality from cardiometabolic diseases relative to nonobese adults is extensive. Obesity increases the risks of hypertension, stroke, CHD, type 2 diabetes, Read the entire page →
From page 336... ... Increasing BMI greatly increased cardiovascular mortality, including deaths from ischemic heart disease, stroke, heart failure, and hypertensive heart disease, as well as from diabetes and kidney disease. The meta-analysis shows that the effects of BMI on heart disease and stroke are mediated in part by increases in blood pressure and diabetes (Prospective Studies Collaboration, 2009) Read the entire page →
From page 337... ... . The evidence indicates that obesity experienced in early life, especially young adulthood, is associated with higher subsequent mortality because obesity tracks across the life course and operates through increased risks of cardiometabolic diseases (e.g., diabetes, hypertension, and CVD) Read the entire page →
From page 338... ... , increases in mortality from ENM diseases and hypertensive heart disease in 1990–2017 make up a larger share of the rise in all-cause mortality at these ages relative to older Black and Hispanic adults (see Tables 4-2 and 4-3, respectively, in Chapter 4) Read the entire page →
From page 339... ... . How have these health behaviors changed since 1990 to affect the risks of obesity and cardiometabolic mortality? Read the entire page →
From page 340... ... . To the extent that these environmental factors have changed over time, they may be influencing mortality trends, although there would be long lag times in their effects given the lengthy causal chains linking these more distal factors to cardiometabolic mortality. Read the entire page →
From page 341... ... . Access to processed food has greatly increased through vending machines, takeaways, cafes, convenience stores, and fast food restaurants (Morland and Evenson, 2009) Read the entire page →
From page 342... ... . Given the evidence of direct links between technological changes in food production and distribution and the rise in obesity, one role for government is to provide incentives for the production and distribution of healthy foods and disincentives for the mass production and promotion of unhealthy foods. Read the entire page →
From page 343... ... The need for solutions is widely recognized in the public and private sectors, driven not only by public health concerns but also by the threat obesity poses for employers, the business community, and the armed services. Further work is needed to build on recent efforts -- some led by the food industry itself and others by public health authorities -- to discourage the production and purchase of unhealthy foods or at least give consumers better information with which to make healthier food choices. Read the entire page →
From page 344... ... Diminishing Returns of Medical Advances Starting in the late 1960s, there was a remarkable turnaround in the century-long trend of increasing cardiovascular mortality in the United States. By the 1970s, death rates due to CVD, and in particular CHD and stroke, were in sharp decline, registering a 70 percent decline by 2010 (Mensah et al., 2017) Read the entire page →
From page 345... ... . Several explanations for the diminishing returns of medical advances in lowering CVD mortality after 2010, detailed in the next section, have been proposed: more incremental development of medical innovations, rising obesity that blunted the impact of medical advances, and differential delivery of or access to the medical advances that enabled the reductions in CVD mortality. Read the entire page →
From page 346... ... . Although all of the 10 countries with high life expectancy in this figure experienced flattening trends in CVD mortality after 2010, the United States has not kept pace with the reductions in CVD mortality seen in these other countries, suggesting that other factors specific to the United States have been stalling continued improvements. Read the entire page →
From page 347... ... Another factor unique to the U.S. context that may explain the diminishing returns of medical advances in reducing CVD mortality is the persistent racial, ethnic, and socioeconomic disparities in chronic health conditions and control of chronic conditions related to cardiometabolic mortality that slow continued gains once those most at risk or those with greater health care access are treated. Read the entire page →
From page 348... ... . Much of the progress in lowering CVD mortality in prior decades may reflect the widespread uptake of these interventions among these more advantaged population groups, but adults who faced greater barriers to care may have been left behind. Read the entire page →
From page 349... ... . Thus, after years of declining CVD mortality due to the broad uptake of pharmacotherapy and smoking cessation among advantaged populations, the recent decline in the pace of progress may reflect the failure to invest adequately in closing the prevention and treatment gap among high-risk populations. Read the entire page →
From page 350... ... Social, Economic, and Cultural Change Social, economic, and cultural shifts over the past 50 years have profoundly changed the family, work, and community environments of daily life in America, and the possibility that these shifts may have contributed to cardiometabolic morbidity and mortality cannot be dismissed. Changes in family structure and rising family instability over the past 50 years have been well documented (Cavanagh and Fomby, 2019; Cherlin, 2009) Read the entire page →
From page 351... ... . These daily, gradual, and long-term influences from the social and physical environments have contributed to cardiometabolic morbidity and mortality risks through multiple pathways, including the influence of financial hardships on health care access and affordability and on adverse living and work conditions that affect endocrine and cardiovascular diseases (Lian, 2018; Steptoe and Kivimäki, 2013) Read the entire page →
From page 352... ... Individuals with chronic conditions and comorbidities cannot afford prescription medications, blood glucose testing, or doctor's appointments, and economic pressures force many families to resort to consuming inexpensive, calorie-dense foods; to live in unhealthy housing and neighborhoods; and to work in jobs that discourage physical activity. Job loss, family breakdowns, and economically depressed neighborhoods increase social isolation and erode social supports that are vital to health and longevity (House, Landis, and Umberson, 1988; Yang et al., 2016) Read the entire page →
From page 353... ... and accompanying cultural changes in American work and home lives in the digital era, but the ways in which such macro-level long-term changes affect cardiometabolic mortality are difficult to ascertain. Research is only beginning to illuminate how daily adverse environmental exposures that chronically activate the brain's stress management system can lead to dysregulation of individual and multiple body systems, including the immune, metabolic, and cardiovascular systems, involved in predisease pathways (Hertzman and Boyce, 2010; McEwen and Lasley, 2002; NRC, 2001) Read the entire page →
From page 354... ... While there have been significant long-term reductions in mortality from ischemic heart disease and other diseases of the circulatory system since 1990, much of that progress stalled after 2010. The combination of these trends acted to increase all-cause mortality after 2010 because the slowdown in mortality declines from ischemic heart disease and other circulatory diseases no longer offset the rise in mortality from ENM diseases and hypertensive heart disease. Read the entire page →
From page 355... ... Much attention has been devoted to the role of the obesogenic environment, defined as an environment that promotes weight gain and is not conducive to weight loss within the home and environment. While substantial evidence indicates how Americans' physical environments have changed to become increasingly obesogenic, the multifactorial and complex pathways by which these changing environments have increased the level and spread of obesity and, by extension, the rise in mortality from ENM diseases and hypertensive heart disease or the slowing declines in mortality from ischemic heart and other circulatory diseases represent major research challenges. Read the entire page →
From page 356... ... IMPLICATIONS FOR RESEARCH AND POLICY The evidence suggests that increasing obesity is the most important explanation for rising rates of cardiometabolic diseases, including diabetes, hypertension, and CVD, in the United States, driving up rates of mortality from ENM diseases and hypertensive heart disease and stalling progress in mortality due to ischemic heart disease and other circulatory diseases. Moreover, research indicates that the earlier in life one becomes obese, the earlier and more severe are the adverse health consequences because most people who become obese do not become nonobese in their lifetime (Harris et al., 2020) Read the entire page →
From page 357... ... Almost all obesity scholars point to the important role of obesogenic factors in the physical and food environments, including individual health behaviors involving diet and physical exercise and societal-level changes in food production, transportation systems, access to green spaces, and sedentary work environments. For example, there is evidence that technological changes in the way food is produced, distributed, and consumed have contributed to the increase in obesity, and that public health policy can play a role in improving the production of healthy foods and reducing the distribution and consumption of unhealthy foods, especially among children and adolescents. Read the entire page →
From page 358... ... With such multilevel longitudinal data, researchers will be able to identify the intervening multilevel mechanisms (e.g., family poverty, consumption of sugary drinks, physical activity) through which macro-level policies and programs (e.g., soda taxes, urban development) Read the entire page →
From page 359... ... RECOMMENDATION 9-2: Federal agencies, in partnership with pri vate foundations and other funding entities, should support research that uses experimental designs and takes advantage of existing neigh borhood experimental projects to examine the causal role of factors in the obesogenic environment and determine which have the greatest role in the rise in obesity prevalence and body mass index levels. The food industry and policy makers alike have contributed to the obesity epidemic in both intentional and unintentional ways. Read the entire page →
From page 360... ... Obesity needs to be avoided in early life because any exposure, and especially prolonged exposure, can greatly increase risks for cardiometabolic diseases and mortality. In addition, the early stages of chronic disease associated with obesity often present as asymptomatic risk factors (e.g., hypertension, hyperlipidemia, glucose intolerance) Read the entire page →
From page 361... ... Persistent disparities in access to evidence-based preventive and therapeutic care for the control of chronic diseases hinder continued progress in lowering CVD mortality. Appropriate use of medications that are effective in controlling hypertension, diabetes, and heart disease and thus in lowering CVD mortality is not as widespread as would be ideal, and persistent disparities in successful management of these chronic diseases continue to slow progress in mortality reduction. Read the entire page →
From page 362... ... This increasing and chronic stress may be contributing to the rising trends in mortality documented in this report, including deaths due to substance use, suicide, and cardiometabolic diseases. The daily sources of stress are not likely to abate, and they are felt more intensely among certain subgroups of the population. Read the entire page →

From page 311...

... The combination of these trends operated to increase all-cause working-age mortality after 2010 because the slowdown in declines in mortality from ischemic heart disease and other circulatory diseases no longer offset the rise in mortality from ENM diseases and hypertensive heart disease.

9 Cardiometabolic Diseases Pages 311-362

9 Cardiometabolic Diseases
Pages 311-362