Health risks for mid-life mortality arising in earlier stages of the life course

Kathleen Mullan Harris University of North Carolina at Chapel Hill

Planning Meeting on Socioeconomic Status and Increasing Mid-Life Mortality

June 16, 2017

Outline of presentation

1. Previous research on early-life influences on health and mortality;

2. Life course models and study design issues; 3. Selected data on health risks in adolescence and

young adulthood that have implications for mid-life morbidity and mortality;

4. Implications and conclusions.

Early-life conditions and health and mortality • Large and growing literature on importance of early-life

conditions for the development of adult health and mortality risk. • Demographic research on the “long-arm of childhood” for how early

life circumstances are both directly and indirectly associated with health and chronic disease that occur decades later in adulthood: – Blackwell et al. 2001; Case and Paxson 2010; Elo and Preston 1992;

Hayward and Gorman 2004; Palloni 2006; Preston et al. 1998.

• Epidemiologic and medical research links uterine, birth, and childhood exposures to adult health: – Barker 1997, 1998, 2006; Bengtsson and Brostrom 2009; Cameron and

Demerath 2002; Crimmins and Finch 2006; Hertzman and Boyce 2010; Gluckman et al. 2008; Kuh and Ben-Shlomo 1997, 2004.

Early-life conditions and health and mortality

• Economic research on how childhood health influences human capital and labor force outcomes in adulthood: – Case, Lubotsky, and Paxson 2002; Currie and Stabile 2003; Currie and

Moretti 2007; Case, Fertig, and Paxson 2005; Smith 2009, see reviews in Almond and Currie 2011 and Currie 2009.

• Developmental Origins of Health and Disease (DOHaD) paradigm unites these findings and theoretical orientations to provide testable models of the explanatory pathways by which early life conditions impact later adult health: – Gluckman and Hansen 2004; Gluckman et al. 2008.

Life course (DOHaD) models of early-life conditions and health and mortality

• Critical period/sensitive period • Accumulation • Pathway • Social Mobility • Monumental data demands for testing these

models

Limitations of prior research

• Cross-sectional designs; • Self-reported information on early-life conditions

(typically retrospective) and health and disease risk; • Most research on aging populations or older adults; • Less attention to other early life stages beyond

childhood; • Adolescence and early adulthood important periods

of sensitivity and diverse exposures.

Importance of adolescent life stage for health in adulthood

• Environment becomes increasingly salient as young people spend less time with family and more time with peers in local communities;

• Young people have more control over their environmental and behavioral choices;

• Physical, physiological, and neurological changes linked to puberty make adolescents especially receptive to broadening environments.

• Hormonal changes remodel cortical and limbic circuits that interact with adolescent’s social experiences to affect decision making and behavior into adulthood.

Selected results from Add Health relevant to current trends in mid-life mortality

• Important health trends in transition from adolescence to early adulthood;

• Young adult generation at forefront of the obesity epidemic: – Implications for disease risk among young

adults; – Social and economic consequences.

Prospective Longitudinal Design of Add Health

Adolescence Adulthood Wave I-II Wave III Wave IV Wave V (12-20) (18-26) (24-32) (32-42) 1994-1996 2001-02 2008-09 2016-18 Adolescence Transition to Young Adulthood Adulthood Adulthood

Health trends during transition from adolescence into early adulthood

• Transition from adolescence into early adulthood is a vulnerable period for health that sets trajectories into adulthood;

• Harris, Gordon-Larsen, Chantala, & Udry. 2006. Longitudinal trends in race and ethnic disparities in leading health indicators from adolescence to young adulthood. Archives of Pediatrics and Adolescent Medicine 160:74-81.

• Depression • Suicidal thoughts • Self-reported poor health

• Obesity • No physical activity • No breakfast • Eating fast food • No health insurance • No annual check-up • No dental check-up • Foregone care • Asthma • STDs • Smoking • Marijuana use • Hard drug use • Binge drinking

Health During the Transition to Adulthood

• Depression • Suicidal thoughts • Self-reported poor health

• Obesity • No physical activity • No breakfast • Eating fast food • No health insurance • No annual check-up • No dental check-up • Foregone care • Asthma • STDs • Smoking • Marijuana use • Hard drug use • Binge drinking

Health into Young Adulthood

•Obesity •STDs

•No physical activity •No health insurance •No annual check-up •No dental check-up •Foregone care •Smoking •Marijuana use •Hard drug use •Binge drinking

Smoking from Adolescence into Adulthood

0

5

10

15

20

25

30

Adolescence Transition toAdulthood

Young Adulthood

Per

cent

FemaleMale

Obesity from Adolescence into Adulthood

0

5

10

15

20

25

30

35

40

Adolescence Transition toAdulthood

Young Adulthood

Per

cent

FemaleMale

Young adult health at risk

• Uncovered alarmingly high prevalence of disease risk and chronic conditions at Wave IV when Add Health sample aged 24-32;

• Young adults assumed to be quite healthy; • Routinely not screened for disease risks; • Silent epidemic of hypertension and diabetes;

Young Adults 24-32 yrs, 2008-09 • 37% obese

– In addition, 30% overweight • 51% abdominal obesity • 27% hypertension

– In addition, 49% prehypertension • 6% diabetes;

– In addition, 27% impaired glucose tolerance (prediabetic)

• 17% hyperlipidemia (high total cholesterol) • 38% immune disorder (high inflammation)

Most are unaware of health risks

• Of those with measured hypertension, 75% are unaware (do not have a medical diagnosis); – The majority of the 49% with prehypertension are

unaware (90%) • Of those with measured diabetes, 67% are unaware

they are diabetic; – Virtually all of the 27% with prediabetes are

unaware (98%)

Add Health cohort (ages 24-32) compared

to earlier cohorts of young adults

Percentage with NHANES 1988-94

NHANES 1999-2002

Add Health 2008-09

Diabetesa (ages 20-44) 2.6 3.4 5.8

Hypertensionb, males (ages 20-34) 7.1 8.1 29.3

Hypertensionb, Females (ages 20-34) 2.9 2.7 14.1

a measured or self-reported diagnosis; b measured or taking anti-hypertensive meds.

Disparities in young adult health risk

• Created two summary measures of health risk: • Metabolic syndrome (0-5) and cardiometabolic risk (0-7) • Both higher among:

– older young adults (28+) – Males – Blacks and Hispanics – low parental education – Welfare family before age 18 – Living in the South – Low SES

Percent with cardiometabolic risk (3+) by parental and young adult education (N=8,733)

0

5

10

15

20

25

30

35

40

45

Parents' Educ Young Adult EducHS or less Some College College+

Percent with cardiometabolic risk (CMR) by young adult household income (N=8,733)

0

5

10

15

20

25

30

35

40

45

Household Income< $25K $25K-<$50K $50K-<$75K $75K-$99K $100K+

Educational disparity in CMR by race/ethnicity (N=8,733)

05

101520253035404550

White Black Hispanic AsianHS or less Some college College+

Early-life precursors of CMR (N=8,733)

Percentage with CMR if: No Yes Sig

Low birthweight 34.3 34.9

No breast feeding 29.7 38.0 ***

Any childhood illness before age 16 34.0 36.4

Depression, adolescence 34.3 34.4

Social isolation, adolescence 31.4 35.7 **

Stressful life events through adolescence 34.1 35.2

Neighborhood disadvantage, adolescence 32.9 38.9 ***

Significant predictors of CMR (N=8,733) Coeff SE Age .185 .048 Female (Male) -.261 .039 Race=Black (White) .270 .056 Race=Hispanic (White) .315 .080 First generation immigrant (3+ gen) -.322 .094 Second generation immigrant (3+ gen) -.143 .071 Parents educ college+ (HS or less) -.219 .061 No breastfeeding .148 .044 Any childhood illness .113 .049 Education=college+ (HS) -.311 .072

Other variables in the model included grew up in welfare family, low birth weight, social isolation, stressful life events, neighborhood disadvantage, young adult HH income.

Social and economic consequences of obesity

• Obesity in adolescence and during the transition to young adulthood is associated with: – greater social isolation, depression, and suicidal

thoughts/attempts in young adulthood; – lower rates of marriage and less education; – lower wages, household income, homeownership,

and assets; greater debt and job instability in young adulthood;

• The effects are stronger for women; • The longer one is obese, the stronger the association.

Implications and Conclusion • Today’s young adults in their 30s are the “obesity

cohort.” – First young adult cohort who experienced the dramatic rise

in obesity during adolescence; – thus, they were obese earlier in life, and – have been obese for a longer period of life as young

adults. • They have much higher rates of chronic disease and

disease risk than prior young adult cohorts. • Forebodes an explosion of cardiovascular disease and

metabolic disorder for this cohort in 40s and 50s.

Implications and Conclusion • Impact on mid-life mortality for this cohort of young

adults in 20 years is unknown. • Drugs for hypertension, diabetes, heart disease, and

other comorbidities associated with obesity. • Physical limitations and disability likely to rise. • Deaths of despair may also increase due to social and

economic consequences of obesity. • Time to intervene is now, to avoid permanent biological

damage among young adults and future health care costs to families and society.