Educational Level as a Key Predictor of Human Well-Being

Yesterday I was scheduled to be in Vienna presenting a paper on "Educational Level as a Key Predictor of Human Well-Being" at the Wittgenstein Centre on Demography's Conference on Demographic Aspects of Human Wellbeing. Unfortunately, a cabin crew strike at Lufthansa Airlines scuttled my travel plans and so I wasn't there after all. However, thanks to the efforts of the conference organizers, I was able to record my presentation and it played while my slides were being shown. My thanks to Dr. Raquel Guimaraes for sharing some photos of that on Twitter!

I was using data from the Women's Health Survey of Accra (WHSA) that my colleague Dr. Allan Hill  (now at Southampton University in the UK) and I (and many other important collaborators) organized in Accra, Ghana a few years ago. You can find details of the project at the SDSU International Population Center website.

The talk was based on the postulates that good health is the single best (even if clearly not the only) measure of human well-being, and that education is the single most important reason for better health. I tested these ideas with our Ghana data, showing that both self-reported health and biometrically-measured health vary in predictable ways by educational level.  Here is a sample of the findings:

Pregnancy is dangerous; abortion can be lifesaving

The recent passage of an incredibly repressive and regressive anti-abortion piece of legislation in Alabama has sparked outrage everywhere. This is genuinely an example of patriarchy at its very worst. If Americans really value the health of women--which is massively important to the health of society at large--it will pay attention to the message of Dr. Warren Hern's Op-Ed in today's New York Times.

As I have been saying for a long time in my book, the most dangerous thing a woman can do in life is to get pregnant. We need to protect women as much as we can for their good and for the good of their children, and thus for the future of humanity.

Have We Been Fooled About Jeanne Calment Dying at age 122?

A few days ago, Carl Schmertmann tweeted a link to a paper in ResearchGate in which a Russian academic offered evidence that Jeanne Calment--widely recognized to be the oldest verified human being at her death at age 122--had, in fact, died many years earlier and her daughter had assumed her identity. Thus, it was really her daughter who died at age 99, pretending to be her mother who would have been 122 had she not died many years earlier. 

Given the proliferation of fake news, with special suspicion on Russian fake news, I admit that I read the paper but chose not to blog about it. However, Smithsonian Magazine did pick it up, and then today's Washington Post grabbed the Smithsonian story.

Nikolay Zak, of the Moscow Center For Continuous Mathematical Education, said in a report that he believes Calment was actually Yvonne Calment, Jeanne’s daughter, who Zak says assumed her mother’s identity to avoid inheritance taxes in the 1930s. If true, Yvonne Calment would’ve been 99 if she died in 1997.

He points to studies that show Calment had lost less than an inch of her height by the time she was older than 100, significantly less height loss than what would have been expected; Yvonne was taller than Jeanne, he says. A passport for Jeanne in the 1930s lists different eye colors for her than she had later in life. He also raises questions about other physical discrepancies in her forehead and chin. He also claims Calment had destroyed photographs and other family documents when she had been requested to send them to the archives in Arles. 

The study has caused a global stir since it was issued. It has been covered by news media organizations around the world.

The evidence pointing to the sham is all circumstantial and incredibly complex, and Zak himself admits that he hasn't presented an iron-clad case. My view is that it doesn't matter too much, since the odds of any of us reaching an age even close to 120 are very long. It perhaps is more discouraging to those researchers searching for the clues to keep humans alive to ever older ages. 

Why Are More Boys Born Than Girls?

Thanks to both Justin Stoler and Debbie Fugate for linking me to a Christmas Day story from BBC News on the sex ratio at birth. I'm not sure if there was any significance to its publication yesterday, but the headline is a question: Why are more boys than girls born every single year?  This happens all over the world and has been going on for as long as people have been collecting such information. It is well accepted that the "normal" sex ratio at birth is 105 boys born for every 100 girls born. Why?The short answer is that we really don't know for sure. The first theory discussed in the article is the evolutionary theory, although here we can only describe what we see, without knowing for sure why the pattern has evolved as it has.

The article doesn't really articulate the evolutionary theory very well, so let me quote from the 12th edition of my text, first from Chapter 5 (p. 158):

The most basic health difference between males and females is that males have higher death rates than females from conception to the very oldest ages. Seemingly to compensate for this, more males are conceived than females. Fetal mortality is higher for boys than girls, but there are still typically more males born than females. Infant and childhood mortality rates are higher for males, with a roughly equal number of males and females being reached, quite conveniently from an evolutionary perspective, in the prime reproductive ages of the late teens and early twenties. After that, the only bump in the road for females compared to males is high maternal mortality, and by the older ages we can almost always expect to find more women than men.

And then from Chapter 8 (p. 305):

Despite the concern about the high and even increasing sex ratio in some countries, there is still the underlying question of why the “normal” sex ratio is not simply 100. The answer is that no one really knows (Clarke 2000). This is perhaps a biological adaptation to compensate partially for higher male death rates (or vice versa, since we also are not sure why death rates are higher for males, as I mentioned in Chapter 5). In fact, data on miscarriages and fetal deaths suggest that more males are conceived than females, and that death rates are higher for males from the very moment of conception. Thus, some of the variability in the sex ratio at birth could be due to differences in fetal mortality. But we aren’t sure why those differences exist, either. Research done as part of the human genome project suggests a role played by the X chromosome, but that is still just a guess (Gunter 2005).

That pretty well sums up what we know. The patterns are clear--the reasons for those patterns are not.

The Dangers of Getting Pregnant in the U.S.

Last month I blogged about new data from the U.S. Centers for Disease Control & Prevention showing that pregnancy related deaths in the U.S. are higher than in any other rich country. A story appearing in the January 2019 issue of the National Geographic explores the problem in an up close and personal way. The title and subtitle summarize the situation very nicely:

Why giving birth in the U.S. is surprisingly deadly 

Black mothers are particularly at risk.

Better basic care could help.

In the United States the problem is marked by two particularly alarming statistics: African-American women are about three times as likely to die of pregnancy-related causes as white women, and more than 60 percent of maternal deaths are preventable, according to the Centers for Disease Control and Prevention (CDC).

“We have higher maternal mortality than much of the rest of the developed world; we are capable of doing the best in the world,” says William Callaghan, the CDC’s chief of maternal and infant health. The CDC defines a pregnancy-related death as a woman who dies while pregnant or within one year of the end of her pregnancy.

“When deaths are reviewed and we see what the contributing factors were, there are so many instances where communication was not carried out correctly, where people didn’t recognize urgency, or when the patient wasn’t listened to, or the delay in reaction.”

Why are death rates higher among African American women? Here is one possibility:

Valerie Montgomery Rice, president and dean of the Morehouse School of Medicine in Atlanta, Georgia, believes that not only do bias and racism build up to affect the health of black women over time, but that stress from racism and poverty may have adverse effects as early as in utero or soon after a baby is born.

This is consistent with the effect of Trump administration attitudes towards immigrants on the health of Latinas and their babies, as I noted not long ago. 

And, of course, I have often noted that the former slave states of the south have the highest death rates in the country, and these are areas with high proportions of African Americans. Where you live still matters when it comes to your health.

Is 60 the New 50? Chronological vs. Biological Aging

CNN posted a very relevant demographic article a couple of days ago comparing biological aging with chronological aging. The focus was on the research of Morgan Levine at Yale Medical School:

Essentially, everyone has two ages: a chronological age, how old the calendar says you are, and a phenotypic or biological age, basically the age at which your body functions as it compares to average fitness or health levels.

People with a biological age lower than their chronological age have a lower mortality risk, while those aging older from a biological standpoint have a higher mortality risk and are potentially more prone to developing the diseases associated with the higher age range. 

But perhaps what's most important here -- unlike results from genetic testing -- is that these are measures that can be changed. Doctors can take this information and empower patients to make changes to lifestyle, diet, exercise and sleep habits, and hopefully take steps to lower the risk and improve their biological age.

This is very important and useful work, since very few of us want to experience a longer life expectancy that involves many more years of disability. Indeed, researchers at the Institute of Health Metrics and Evaluation at the University of Washington have given us Disability-Adjusted Life Years (DALYs) that attempt to take into account the difference between biological and chronological aging (see Chapter 5 of my text for a discussion). The article didn't mention that. 

However, the most important omission in the CNN article was not mentioning that Dr. Levine's work is being done in collaboration with Dr. Eileen Crimmins and her colleagues at the University of Southern California. Earlier this year the two of them published an article in the journal Demography titled "Is 60 the New 50? Examining Changes in Biological Age Over the Past Two Decades." And a clue to how important this is to demographers is the fact that Dr. Crimmins has just been elected President-Elect of the Population Association of America. 

Suicides and Drug Overdose Deaths are up; Life Expectancy is Down

I recently blogged about the upward trend in suicide in the U.S., which bucks the global trend of declines in suicides. Yesterday, the U.S. Centers for Disease Control and Prevention put out three new reports on death in America (no, not death "to" America)--the news is all-bad, as the Associated Press reports:

Suicides and drug overdoses pushed up U.S. deaths last year, and drove a continuing decline in how long Americans are expected to live. 

Overall, there were more than 2.8 million U.S. deaths in 2017, or nearly 70,000 more than the previous year, the Centers for Disease Control and Prevention said Thursday. It was the most deaths in a single year since the government began counting more than a century ago. 

The increase partly reflects the nation’s growing and aging population. But it’s deaths in younger age groups — particularly middle-aged people — that have had the largest impact on calculations of life expectancy, experts said. 

It is very clear that the widespread availability of opioids is a key factor behind this increase--the means available to kill yourself either deliberately (suicide) or accidentally (drug overdose) are more numerous than ever. But what is the underlying motivating factor? In my earlier blog I mentioned the "sea of despair" that seems to have engulfed middle-aged Americans--especially non-Hispanic Whites. The AP story has a similar story line:

Dr. William Dietz, a disease prevention expert at George Washington University, sees a sense of hopelessness. Financial struggles, a widening income gap and divisive politics are all casting a pall over many Americans, he suggested. “I really do believe that people are increasingly hopeless, and that that leads to drug use, it leads potentially to suicide,” he said.

This gets us back to the increasingly important issue of wealth and income inequality. It was brought to center stage a a few years ago by Thomas Piketty, and it is almost certainly at the root of many of the social problems we are seeing in the richer nations. 

Suicide Rates are Declining Globally, But Not in the U.S.

This week's Economist has a very nice summary of the global trends in suicide (or "intentional self-harm" as it is known in the International Classification of Diseases). In the world as a whole, the rates are declining, but the United States is bucking that trend.

Globally, the rate has fallen by 38% from its peak in 1994. As a result, over 4m lives have been saved—more than four times as many people as were killed in combat over the period. The decline has happened at different rates and different times in different parts of the world. In the West, it started long ago: in Britain, for instance, the male rate peaked at around 30 per 100,000 a year in 1905, and again at the same level in 1934, during the Great Depression; among women it peaked at 12 in 1964. In most of the West, it has been flat or falling for the past two decades.

America is the big exception. Until the turn of the century the rate there dropped along with those in other rich countries. But since then, it has risen by 18% to 12.8—well above China’s current rate of seven. The declines in those other big countries, however, far outweigh the rise in America.

There are a couple of important reasons for the global decline--urbanization and women's liberation. Although in most societies men (especially older men) tend to have the highest suicide rates, in China and India (the world's two most populous countries), the burden of suicide was often on women trapped in a relationship and family that was not of their choosing. Indeed, a few years ago I blogged about the fact that urbanization in China seemed to be lowering their suicide rate.

The graph below, based on data from the University of Washington's Institute for Health Metrics and Evaluation, compares the recent trends among several countries, and you can the U.S. pattern is different from the global pattern:

In the U.S., we have two important things that contribute to the rise, and I've blogged about both in the past: (1) the "sea of despair" that has taken root especially among white working class Americans; and (2) the availability of guns. Both of these are within the purview of public policy, and the lack of legislative initiatives on these underlying contributors to suicide almost certainly explains the rise in the rate of suicides in the U.S.

Pregnancy Related Deaths Higher in US than any other Rich Country

The New York Times today published an article that fortunately has gotten a lot of attention. It details the tragedies of women and their babies dying because of pregnancy-related problems. To be sure, there is a reason why people have always said that "getting pregnant may be the most dangerous thing a woman can do," but maternal mortality rates have come down dramatically all over the world. Yet, here in the United States the rates are higher than in any other rich country, according to data compiled by the World Health Organization, and they have been going up, not down, according to the U.S. Centers for Disease Control and Prevention. Here's their graph of the trend:

The reason for the increase, and for the fact that the U.S. is higher than other rich countries seems to have a simple remedy--examine every such incident and figure out what went wrong and circulate that information so health practitioners won't keep making the same mistakes. You might think that everyone would want to do that, but sadly you would be wrong.

It wasn’t until 2003 that states started adding a pregnancy check box to death certificates, and some didn’t do so until the past two years. “Thiscreated a data mess where nobody could figure out what the national trends were,” she said. She described this as “a huge missed opportunity for intervention in conjunction with the Millennium Development Goal.” At the same time, “the National Center for Health Statistics, which is the government agency responsible for publishing maternal mortality data, completely stopped publishing it.” 

The only exception in the United States was California, where, in 2006, the Stanford University School of Medicine worked with the state to create the California Maternal Quality Care Collaborative. The initiative developed “quality improvement tool kits” that doctors and hospitals could download. They included detailed instructions about best practices for various preventable complications that can arise during or after pregnancy, like hemorrhaging and pre-eclampsia.

As a result of this initiative, between 2006 and 2013, California saw a 55 percent decrease in the maternal mortality rate, from 16.9 to 7.3 deaths for every 100,000 live births. During that same period, according to The Washington Post, the national rate increased — from an estimated 13.3 to 22 deaths in 100,000.

Next door, in Canada, the rate is 7 per 100,000, and in Switzerland it is 5, just to give you a sense of where the U.S. stands. 

The Demographic Power of the Potato--UPDATED

The European "discovery" of the Americas was amazingly consequential in demographic terms. I discuss this in my text, of course, but a story in today's Washington Post has a pretty good summary of the three key elements: (1) bringing the potato to Europe to help fuel population growth; (2) the spread of disease that killed a huge proportion of the indigenous population; and (3) the enslavement of Africans to work on plantations created by Europeans in the Americas. Let me focus here on the first of these:

The potato alone gets credit for population booms in parts of northern Europe that paved the way for urbanization and, in turn, fueled the Industrial Revolution. Tobacco had such value it was used as currency in some places. Some American foods became staples abroad, from the tomato in Italy and cassava in Africa to the peppers that became the paprika of Hungary and the curries of India.

Eventually, starting with a group of monks on Spain’s Canary Islands in the 1600s, Europeans figured out how to cultivate potatoes, which form a nutritionally complete — albeit monotonous — diet when combined with milk to provide vitamins A and D. The effects were dramatic, boosting populations in Ireland, Scandinavia, Ukraine and other cold-weather regions by up to 30 percent, according to Qian’s [Nancy Qian, an economics professor at Northwestern University] research. The need to hunt declined and, as more land became productive, so did conflicts over land.

If you've read my book, you know that the statement above may give a bit more credit to the potato than it deserves. The potato arrived in Europe at about the same time that the plague was leaving, and at about the same time that the Little Ice Age was receding, thus opening up more farmland for cultivation. Still, were it not for the potato, it is unlikely that the health of the European population would have improved as it did, thus helping to set off population growth that eventually revolutionized the world. 

UPDATE:  Maybe this should really be a PRE-DATE instead of an update, but I just realized that I blogged about the demographic impact of the potato six years ago, based upon a paper just published at that time by Professor Qian, who was quoted in the above Washington Post story. Here's a link to that earlier blog post.

What's the Life Expectancy in Your Neighborhood?

Thanks to Professor Rubén Rumbaut for linking me to an incredibly interesting story about a new resource that shows the life expectancy in your own neighborhood, and allows you to compare your neighborhood with other areas near or distant from you. The project is called "United States Small Area Life Expectancy Estimate Project" (USALEEP) and it is coordinated by the CDC's National Center for Health Statistics and the National Association for Public Health Information Systems with funding from the Robert Wood Johnson Foundation.

These new data are available to everyone via the easy-to-use interactive tool available above. Typing in your street address reveals the average life expectancy for a baby born in your census tract or area, if current death rates do not change. You can then compare your area to nearby neighborhoods or communities, to county- and state-level data, as well as the national average. If you have a neighbor down the street who happens to live in a different census tract, your results might even be different, which we hope will spark some conversation about the differences in conditions and opportunities for health where we live. Ultimately, we hope this will inspire residents and leaders to work together to close the gaps these data illuminate.

Here's what the entry pad looks like (don't try to click on this--it's just a picture)--go here for the real thing:

I typed in my address and was surprised in a very pleasant way to see that the life expectancy at birth in my census tract is 87.20, which is higher than San Diego County in general (81.43), which is higher than California in general (80.90), which is higher than the national average of 78.80 (these are rates for both sexes combined). The concern is obviously in finding those places that are below average, and then to figure out why they are low when other places are high. These kinds of spatial inequalities in life expectancy have become an increasing cause of concern, as I noted most recently a few months ago. To be sure, a map of life expectancy by county in the United States that I blogged about four years ago, has a geographic pattern that is very similar to the recent map I posted of counties still feeling the long-term negative impact of slavery.

Hunger is on the Rise

Last week the United Nations' Food and Agricultural Organization (FAO) issued its latest State of Food Security and Nutrition in the World. Its conclusions were not good, as Reuters noted:

World hunger rose in 2017 for a third consecutive year, fueled by conflict and climate change, the United Nations warned on Tuesday, jeopardizing a global goal to end the scourge by 2030.

Hunger appears to be increasing in almost all of Africa and in South America, with 821 million people - one in nine - going hungry in 2017, according to the State of Food Security and Nutrition in the World 2018 report.

Meanwhile, 672 million adults - more than one in eight - are now obese, up from 600 million in 2014.

The rise in hunger is obviously troubling, since we had experienced several years of a falling number and percent of the world's population being hungry, as you can see in the graph below.

The rise in obesity could seem a bit odd, since you might attribute that to over-eating, rather than hunger.  The FAO concludes, however, that this is part of the nutrition transition that has been afflicting the entire planet for the past several decades:

These effects reinforce the already ongoing dietary transition away from a healthy traditional local diet to a greater dependency on imported foods and beverages, often high in fat, sugar and salt, leading to an increase in overweight, obesity and diet-related non-communicable disease (NCDs).

The only good news coming out of the report was that, so far at least, the rise in hunger has not been associated with a rise in child stunting or wasting. 

Max Roser and Our World in Data

Over time I have regularly given shout-outs to the great work that Max Roser and his team at Oxford University do in assembling and presenting data for the world around us--focusing heavily on demographically-related themes (remember, indeed, that nearly everything is connected to demography!). There is no time like the start of the Fall term to go online and access these resources. You could start with the graphs of world population growth, such as:

Or, you may want to start with a YouTube video sponsored by Bill Gates, focusing on the important demographic work that the Bill and Melinda Gates Foundation does around the world:

And there's lots more. Browsing these resources is a great way to start the term.

A Female Impressionist Makes a Demographic Impression

Today's Washington Post carries a very interesting story about a female Impressionist painter from the 19th century with whom I was not familiar--as the writer assumes most of us are not.

Berthe Morisot painted women, mostly, and adolescent girls. Her delight in the way blades of light were scattered by their pinafores and ribbons, pounced off furniture and coaxed bright color from flowers could not mask the sense she developed — and kept close, like a secret dispatch — of life’s brutal transience.

It’s easy to overlook how radical Morisot’s apparently nonchalant brushwork was in the late 1870s. Her work’s lack of finish conveys, like no other Impressionist, a sense of evanescence. We do not live long, her paintings attest. We hesitate, like teenagers, in thresholds. We know almost nothing.

She was an incredibly talented painter in a world that had very little interest in or tolerance for female artists. So, the gender equity issues are very strong in this story. But the other demographic impression the writer wants you to get from this article is the role in life still being played by high mortality as recently as the late 19th century.

Conditions in Paris were harsh. Morisot’s health suffered, and at the end of 1870, she contracted pneumonia. Her studio was destroyed by the Prussian bombardment, which may well have concentrated her mind: Mere months later, as the Paris Commune was getting established, Morisot confessed to Edma that painting was now “the sole purpose” of her existence. Finding buyers for her paintings, she wrote, was now all she cared about.

The years passed, but the shadow of death never lifted. Morisot lost her father in 1874 and, over the following decade, her mother, two brothers-in-law, her mother-in-law, a close confidante (the female sculptor Marcello) and the man one feels sure she loved above all others, Manet.

In 1895, Julie [her daughter] became ill. While caring for her, Morisot contracted pulmonary congestion. “My little Julie, I love you as I die,” she wrote in a farewell note. “I will love you when I’m dead; please don’t cry. . . . I would have liked to survive till your wedding. . . . Work and be good as you have always been; you haven’t made me sad once in your little life.”

For young people growing up in the 21st century this may all sound like ancient history, but in the scope of human history Morisot's life haunted by gender inequity and death in 19th century Paris was only a short time ago.  We have come a long way since then.

Could We Live Forever?

Thanks to Todd Gardner and others for pointing to a research article published this week in Science on the "Demography of Longevity Pioneers." The researchers, who included James Vaupel of the Max Planck Institute for Demographic Research in Germany and Ken Wachter of the UC, Berkeley Department of Demography, used data from older Italians. This had the advantage of choosing a population in which a fairly large number of people have survived to the oldest ages, and using data from a single data source, thus reducing the problem of comparing data collected in different ways. Their findings suggest that while death rates continue to climb up to age 105, after that they are constant, with about a 50% chance of survival each year beyond 105.

Nature picked up on the story and invited comments from people not involved in the study:

If there is a mortality plateau, then there is no limit to human longevity,” says Jean-Marie Robine, a demographer at the French Institute of Health and Medical Research in Montpellier, who was not involved in the study. That would mean that someone like Chiyo Miyako, the Japanese great-great-great-grandmother who, at 117, is the world’s oldest known person, could live for years to come — or even forever, at least hypothetically.

That would fit into the theory of longevity promoted by people like Elmo Keep, a science entrepreneur in the Silicon Valley, as I blogged about last year. On the other hand, not everyone thinks we should yet jump to these big conclusions:

Brandon Milholland, a co-author of the 2016 Nature paper, says that the evidence for a mortality plateau is “marginal”, as the study included fewer than 100 people who lived to 110 or beyond. Leonid Gavrilov, a longevity researcher at the University of Chicago in Illinois, notes that even small inaccuracies in the Italian longevity records could lead to a spurious conclusion.

Others say the conclusions of the study are biologically implausible. “You run into basic limitations imposed by body design,” says Jay Olshansky, a bio-demographer at the University of Illinois at Chicago, noting that cells that do not replicate, such as neurons, will continue to wither and die as a person ages, placing upper boundaries on humans' natural lifespan.

Only time will tell which conclusion is correct, of course. In the meantime, the number of old-old people is increasing in the world, so we'll have a consistently larger population from which to derive data. 

Demography of Aging Revisited

Yesterday I blogged about health disparities in the United States, referencing research by Jennifer Montez and Mark Hayward. The latter comes up again today, because he organized a workshop on the demography of aging for the National Academy of Science (NAS) from which the report has just been made available. Aging and health go together, of course. We wouldn't give nearly as much attention to aging as we do were it not for the fact that our health tends to deteriorate as we age. That is a personal problem, but one that our family and friends and, indeed, the entire society, winds up coping with. Our entire life course is very much influenced by health, as Mark Hayward makes clear in the introduction to the volume:

Changes in fertility, life expectancy, and population-age structure have had profound effects on the opportunities and constraints facing individuals, their families, and their communities. The older population has become more racially/ethnically diverse. Kin relationships have become more complex and fluid, and more people now approaching old age have been divorced and many have never been married. Population health now spans a web of health processes including biological risk, disability, cognition, and disease. The health and well-being of the older population are now seen as the consequences of long-run and cumulative effects of social, economic, and contextual factors over the entire life course.

The participants in the workshop, each with a chapter in this volume, are among the big names in the demography of aging, and this is a deliberate followup to a previous (1994) NAS report on the Demography of Aging. We know a lot more than we did then, thanks in part to the funding of research by the National Institute on Aging, and much of that learning tells us that the world is more complicated than we thought it was 24 years ago. This new volume dives into those complexities. Each chapter would be worthy of a blog post, but you should read it for yourself because if you are reading this you are aging, and you should know what lies ahead.

Health Disparities by State Mainly Reflect Different Levels of Education

I have blogged several times about the differences in health and life expectancy by state in the U.S. In a blog post about a year and half ago I highlighted the research of Professors Jennifer Montez of Syracuse University and Mark Hayward of UT, Austin. Their latest chapter in the story has just been posted on scientia.global and it highlights the finding that the variability in health disparities around the U.S. are largely found among people at lower educational levels.

The researchers analysed extensive data on adults living in the US from two different surveys: the National Longitudinal Mortality Study and the American Community Survey. The researchers also collected data on the policies and characteristics of all US states. For example, they collected information on the states’ economic environment, income inequality, tobacco control policies, Medicaid coverage, and socio-political factors such as whether the state tends to vote for a Republican or Democratic presidential candidate, as well as characteristics of the states’ populations such as age, sex, race, ethnicity, educational levels. The data collected was then analysed in an attempt to gain a better understanding of the factors behind cross-state health disparities.

Drs Montez and Hayward found education level to be one of the strongest predictors of health and mortality rates among US residents. This is aligned with past research findings highlighting the impact of education on an individuals’ health. ‘In the United States, one of the best predictors of how healthy and long someone will live is their education level,’ says Dr Montez. ‘More years of schooling generally translate into better health and longer life.’

When I first saw this I jumped to the conclusion that it might be due to differing levels of access to health care. But the research suggests a more complicated relationship.

‘Education provides people with a large bucket of resources that they can use to create a healthy life,’ explains Dr Montez. ‘For example, people with more schooling tend to be employed in jobs they enjoy and that stimulate their minds, to marry and stay married, to have large and beneficial social networks, to feel in control of their life, and to engage in healthy behaviours like exercising and avoiding tobacco.’

The positive effects of education on health, therefore, go beyond those derived from generally higher salaries, such as access to more expensive medical services. While imparting field-specific knowledge or skills, education also teaches people how to navigate modern society and look after themselves as well as their families and friends. This tends to improve their health and wellbeing, while also opening a broader range of social and economic opportunities for these individuals.

This is important on-going research and we need to keep our eyes open for the next round of findings. 

Plant-Based Diet is Good For You (and the Planet)

Today I came across an op-ed by a physician in south Florida extolling the health virtues of a plant-based diet, and I couldn't help but comment on it. Here's his takeaway:

The U.S. cannot prescribe our way to health. It doesn’t work. We have some of the world’s highest rates of chronic disease yet spend the most on medical care. It’s time for the U.S. to take the lead in lifestyle medicine, particularly plant-based diets, in the same way we have become leaders in prescription-based medicine — to the much greater benefit of our patients and our national healthcare budget!

And what is it that we should be doing and why? Dr. Bansal focuses on diabetes, which is closely related to diet, and which he argues could be controlled better if people adopted a largely plant-based diet.

The key is a reasonable amount of naturally-occurring, unprocessed carbohydrates, specifically from a variety of source plant materials. Additionally, plant-sourced foods provide more than enough protein. In fact, research in the U.S. back in the 1960s showed how much protein the average man and woman needs per day: the maximum is around 60 grams for 70-kg men and 50 for 60-kg women[5],[6],[7],[8]. Research also showed that eating a variety of plant-based foods, even exclusively, will supply all 9 essential amino acids (the other 11 made endogenously)[9],[10],[11]. We now eat too much protein (90 grams/day or more) with no benefit and some risk[12],[13],[14]. First, through a series of pathways, excess intake of protein gets indirectly turned to fat and prevents the burning of fat already present. Next, it overtaxes the liver and the kidneys in the processing of excess protein and then secretion and partial reabsorption in the glomerular filtration system. [The numbers are to books and journals referenced in his article.]

This is all about the Blue Zone diet and lifestyle that I blogged about nearly three years ago. About 1/3 of our healthy life expectancy (and longevity) can be attributed to genetics, but the bulk of it relates to life style and diet is a huge part of that. 

The benefit to the planet is that if we decrease the amount of meat we eat, we also lower methane gas emissions into the atmosphere, and we more efficiently grow food for humans, rather than for animals that we intend to kill for dinner. I first blogged about this back in 2013, and most recently mentioned it on Earth Day this year. And it is unlikely that this will be the last time I blog about--it is that important, in my opinion.

Suicide Is a Disturbingly Common Cause of Death

This week has witnessed two high-profile suicides, that of fashion designer Kate Spade, and of celebrity chef/world cultural explorer Anthony Bourdain. Sadly, those deaths come just as the Washington Post has summarized a new report from the Centers for Disease Control and Prevention revealing that suicide rates are going up in this country.

Suicide rates rose in all but one state between 1999 and 2016, with increases seen across age, gender, race and ethnicity, according to a report released Thursday by the Centers for Disease Control and Prevention. In more than half of all deaths in 27 states, the people had no known mental health condition when they ended their lives.

Increasingly, suicide is being viewed not only as a mental health problem but a public health one. Nearly 45,000 suicides occurred in the United States in 2016 — more than twice the number of homicides — making it the 10th-leading cause of death. Among people ages 15 to 34, suicide is the second-leading cause of death.

Suicides are especially prevalent in rural counties, and this was picked up on by Agweb.com.

“While we’ve seen many causes of death come down in recent years, suicide rates have increased more than 20% from 2001 to 2015. And this is especially concerning in rural areas,” said Brenda Fitzgerald, Centers for Disease Control and Prevention (CDC) director, in a news release. “We need proven prevention efforts to help stop these deaths and the terrible pain and loss they cause.”

The map below tells the story of the rural contribution to suicide rates.

And here is one interpretation of what's going on in these places:

The peace and quiet of country living can be the American dream. But that dream can turn to a nightmare for those who become isolated and disconnected from their communities, says Karen Funkenbusch, University of Missouri Extension safety and health specialist. 

Rural communities are typically tightly-knit towns, where everyone knows everyone. While this may be the case for many, rural life poses risks for marginalized groups, Funkenbusch notes. These groups include racial and ethnic minorities, LGBTQ persons, those living in poverty, and newcomers. 

Funkenbusch says rural communities often lack mental and behavioral health services and transportation. CDC reports that more than half of U.S. counties don’t have a social worker, psychologist or psychiatrist. There also may be sociocultural factors such as stigma against seeking help, especially for males, she says.

More Evidence That Americanization is Bad for Your Health

One of the saddest commentaries about health care in the U.S. is that we pay more per person than any other country, but still wind up with the poorest health outcomes of any rich country. In that general sense, Americanization is bad for your health. The easiest way to see that is to compare the health of immigrants with people who were born in the U.S. A lot of people have done this, including me and my long-time friend and colleague, Dr. Rubèn Rumbaut at UC Irvine. As I noted a few years ago, we published a chapter in an edited volume which we titled "Children of Immigrants: Is Americanization Hazardous to Infant Health?" We also published a paper in the Journal of Immigrant Health that same year based on collaborative work with Dr. Norma Ojeda, who was then at El Colegio de la Frontera Norte in Tijuana, Mexico, but is now a Professor of Sociology here at SDSU. We found that the superior birth outcomes among immigrant women was not just a function of migration selectivity (the "healthy migrant" hypothesis). We compared Mexican women delivering in Tijuana with Mexico-born women delivering in San Diego and found that after controlling for characteristics of the women, birth outcomes were actually better among women in Tijuana than in San Diego. One variable that stood out was that women in Mexico were more likely to have multiple prenatal visits (which can identify problems and allow health care providers to deal with them) than in San Diego. Our research was 20 years ago, and even then health care outcomes were better on the southern side of the border than on this side. And keep in mind that the Mexico-born women had better birth outcomes than non-Hispanic white women in San Diego.

I bring all of this up because a paper has just been published in Public Health Reports that references our research and finds once again that foreign-born Hispanic women have better outcomes than U.S.-born Hispanic women. While our research focused on local outcomes, this research compares birth records for the entire U.S. with outcomes measured for the countries from which the immigrant mothers came. As is so often true with the world, the results are complicated by the fact that women born in Mexico, in particular, tend to have better outcomes than those born in other Latin American countries.

Our study found that US-born Hispanic women had a significantly greater risk of preterm birth, low birth weight, and small for gestational age than that of foreign-born Hispanic women. However, we  also found substantial variation in the rates of adverse birth outcomes among foreign-born women by country of birth, which remained after adjusting for maternal characteristics.

And, of course, this health disadvantage in the U.S. is not just one that shows up at birth. It persists into childhood and adulthood and will continue to do so until collectively we decide to change our diets and our health insurance schemes.