Survey Linked Mortality Files Research Articles

Reevaluating the “deaths of despair” narrative: Racial/ethnic heterogeneity in the trend of psychological distress-related death

Despite the significant scientific advancement in deciphering the "deaths of despair" narrative, most relevant studies have focused on drug-, alcohol-, and suicide-related (DAS) deaths. This study directly investigated despair as a determinant of death and the temporal variation and racial heterogeneity among individuals. We used psychological distress (PD) as a proxy for despair and drew data from the US National Health Interview Survey-Linked Mortality Files 1997 to 2014, CDC (Centers for Disease Control and Prevention) Multiple Cause of Death database 1997 to 2014, CDC bridged-race population files 1997 to 2014, Current Population Survey 1997 to 1999, and the American Community Survey 2000 to 2014. We used Cox proportional hazards models to estimate mortality hazard ratios of PD and compared age-standardized PD- and DAS-related mortality rates by race/ethnicity and over time. We found that while Whites had a lower prevalence of PD than Blacks and Hispanics throughout the whole period, they underwent distinctive increases in PD-related death and have had a higher PD-related mortality rate than Blacks and Hispanics since the early 2000s. This was predominantly due to Whites' relatively high and increasing vulnerability to PD less the prevalence of PD. Furthermore, PD induced a more pervasive mortality consequence than DAS combined for Whites and Blacks. In addition, PD- and DAS-related deaths displayed a concordant trend among Whites but divergent patterns for Blacks and Hispanics. These findings suggest that 1) DAS-related deaths underestimated the mortality consequence of despair for Whites and Blacks but overestimated it for Hispanics; and 2) despair partially contributed to the DAS trend among Whites but probably not for Blacks and Hispanics.

Updating the Know Your Chances Website to Include Smoking Status as a Risk Factor for Mortality Estimates

To make wise decisions about the health risks they face, people need information about the magnitude of the threats as well as the context, such as how risks compare. Such information is often presented by age, sex, and race but rarely accounts for smoking status, a major risk factor for many causes of death. To update the National Cancer Institute's Know Your Chances website to present mortality estimates for a broad set of causes of death and all causes combined by smoking status in addition to age, sex, and race. In this cohort study, mortality estimates using life table methods were calculated with the National Cancer Institute's DevCan software package, combining data from the US National Vital Statistics System, National Health Interview Survey-Linked Mortality Files, National Institutes of Health-AARP (American Association of Retired Persons), Cancer Prevention Study II, Nurses' Health and Health Professions follow-up studies, and Women's Health Initiative. Data were collected from January 1, 2009, to December 31, 2018, and analyzed from August 27, 2019, to February 28, 2023. Age-conditional probabilities of dying due to various causes and all causes combined, accounting for competing causes of death, for people aged 20 to 75 years over the next 5, 10, or 20 years by sex, race, and smoking status. A total of 954 029 individuals aged 55 years or older (55.8% women) were included in the analysis. Regardless of sex or race, for never-smokers, coronary heart disease represented the highest 10-year chance of death after about 50 years of age, which is higher than for any malignant neoplasm. Among current smokers, the 10-year chance of death due to lung cancer was almost as high as for coronary heart disease in each group. For Black and White female current smokers aged from the mid-40s onward, the 10-year probability of death due to lung cancer was substantially higher than for breast cancer. After 40 years of age, the observed effect of never vs current smoking on the 10-year chance of death due to all causes approximated adding 10 years of age. After 40 years of age when conditioning on smoking status, mortality risk for Black individuals was approximately that of White individuals 5 years older. Using life table methods and accounting for competing risks, the revised Know Your Chances website presents age-conditional mortality estimates according to smoking status for a broad set of causes in the context of other conditions and all-cause mortality. The findings of this cohort study suggest that failing to account for smoking status results in inaccurate mortality estimates for many causes-namely, they are too low for smokers and too high for nonsmokers.

Association of beta-2-microglobulin with cardiovascular and all-cause mortality in the general and non-CKD population.

β-2 microglobulin, a light chain in the major histocompatibility complex Class 1 molecule, is associated with mortality in dialysis or uremic patients. Current evidence on the relationship between beta-2-microglobulin (B2M) and mortality in the general and non-chronic kidney disease (CKD) population are limited and controversial. Data from the nutrition and health examination survey database and the nutrition and health examination survey linked mortality file were used. In total, 10,388 adults who had complete data for B2M were included. Weighted multivariable Cox proportional hazards regression models and regression splines were employed to evaluate the relationship between B2M with mortality. Moreover, subgroup and sensitivity analyses were performed. During a median follow up of 17.9 years (interquartile range 15.2-18.7), 2780 people died, 902 (32%) from cardiovascular disease. Restricted cubic splines showed that B2M is J-shaped nonlinear positively associated with all-cause mortality and cardiovascular disease mortality in the non-CKD and general population. Based on the multivariable adjustment model, the adjusted hazard ratios comparing the highest versus lowest quartile of the distribution of B2M were 2.50 (95% confidence interval: 1.90, 3.28) for all-cause mortality in the general population, 2.58 (95% confidence interval: 1.52, 4.37) for cardiovascular disease mortality in the general population, 2.58 (1.91, 3.49) for all-cause mortality in the non-CKD population and 2.62 (1.52, 4.53) for cardiovascular disease mortality in the non-CKD population. The positive associations between B2M and outcomes remained broadly significant across subgroups and sensitivity analyses. Higher B2M levels were associated with cardiovascular and all-cause mortality in the general and non-CKD population.

Racial-Ethnic Disparities in Dual-Function Life Expectancy.

This study develops a new concept, dual functionality, that integrates physical and cognitive function. We use the concept to define a measure of dual-function life expectancy (2FLE) and assess racial-ethnic inequalities in aging. Drawing on data from the National Health Interview Survey Linked Mortality Files and the Health and Retirement Study, we define dual functionality as having no limitations in activities of daily living and being free of dementia. We use this measure and Sullivan life tables to estimate age-50 total life expectancy and age-50 2FLE for women and men across 4 racial-ethnic and nativity groups. At ages 50-54, between 79.0% (95% CI: 73.5, 84.5) and 87.6% (95% CI: 84.0, 91.2) of (non-Hispanic) Black, foreign-born Hispanic, and U.S.-born Hispanic women and men remain dual functional as compared with 90.4% (95% CI: 89.3, 91.4) and 91.4% (95% CI: 90.2, 92.5) of (non-Hispanic) White women and men, respectively. These and corresponding racial-ethnic disparities in dual functionality through ages 85 and older translate into substantial inequalities in 2FLE. For instance, the Black-White gap in age-50 2FLE is 6.9years (95% CI: -7.5, -6.4) for women and 6.0years (95% CI: -6.6, -5.4) for men. Black, foreign-born Hispanic, and U.S.-born Hispanic older adults are estimated to live a smaller percentage of their remaining years with dual functionality than White older adults. These results reveal stark racial-ethnic inequalities in aging that have significant implications for quality of life, caregiving, and health needs.

Mortality Relative Risks by Smoking, Race/Ethnicity, and Education

The impact of cigarette smoking on mortality is well studied, with estimates of the relative mortality risks for the overall population widely available. However, age-specific mortality estimates for different sociodemographic groups in the U.S. are lacking. Using the 1987-2018 National Health Interview Survey Linked Mortality Files through 2019, all-cause mortality relative risks (RRs) were estimated for current smokers or recent quitters and long-term quitters compared with those for never smokers. Stratified Cox proportional hazards regression models were used to estimate RRs by age, gender, race/ethnicity, and educational attainment. RRs were also assessed for current smokers or recent quitters by smoking intensity and for long-term quitters by years since quitting. The analysis was conducted in 2021-2022. All-cause mortality RRs among current smokers or recent quitters were generally highest for non-Hispanic White individuals than for never smokers, followed by non-Hispanic Black individuals, and were lowest for Hispanic individuals. RRs varied greatly by educational attainment; generally, higher-education groups had greater RRs associated with smoking than lower-education groups. Conversely, the RRs by years since quitting among long-term quitters did not show clear differences across race/ethnicity and education groups. Age-specific RR patterns varied greatly across racial/ethnic and education groups as well as by gender. Age-specific all-cause mortality rates associated with smoking vary considerably by sociodemographic factors. Among high-education groups, lower underlying mortality rates for never smokers result in correspondingly high RR estimates for current smoking. These estimates can be incorporated in modeling analyses to assess tobacco control interventions' impact on smoking-related health disparities between different sociodemographic groups.

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

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

Labor force status as a buffer against mortality risks associated with alcohol consumption: A study of adult U.S. women, 2001–2015

The association between women's labor force participation, their alcohol consumption patterns, and mortality risk is unclear. This study assessed all-cause mortality risk among women in the United States, considering their labor force status and alcohol drinking. This study used discrete-time hazard models to examine this association using 2001–2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMF) data (n = 147,714) for women aged 25 to 65 with 5725 deaths in this sample. Complex survey-weighted adjustments and E-values calculations were used to limit quantitative and observational biases. Alcohol consumption and labor force status together lead to substantial mortality risks. There is a statistically significant mortality risk among unemployed women (HR 2.15, 95% CI 1.18–3.91) and women not in labor force (HR 2.38, 95% CI 1.87–3.01). In the stratified models, non-Hispanic blacks (HR 1.48, 95% CI 1.30–1.67) and Asians (HR 1.93, 95% CI 1.54–2.44) have heightened mortality risks borne out of employment. Women with higher psychological distress have a 26% higher risk of all-cause mortality when not in labor force. With the help of cross-sectional data, this study demonstrates that women not in labor force and unemployed women are more likely to be affected by their drinking habits, and their employment status is associated with lower mortality risk. Further research should be focused on cause-specific mortality, gender roles and norms, reasons for unemployment, and comorbidities using more recent data, causal modeling techniques, and an extended mortality follow-up period.

The Nexus of Physical and Psychological Pain: Consequences for Mortality and Implications for Medical Sociology.

Although physical pain lies at the intersection of biology and social conditions, a sociology of pain is still in its infancy. We seek to show how physical and psychological pain are jointly parts of a common expression of despair, particularly in relation to mortality. Using the 2002-2014 National Health Interview Survey Linked Mortality Files (N = 228,098), we explore sociodemographic differences in the intersection of physical and psychological pain (referred to as the "pain-distress nexus") and its relationship to mortality among adults ages 25 to 64. Results from regression and event history models reveal that differences are large for the combination of the two, pointing to an overlooked aspect of health disparities. The combination of both high distress and high pain is most prevalent and most strongly predictive of mortality among socioeconomically disadvantaged, non-Hispanic whites. These patterns have several implications that medical sociology is well positioned to address.

Combined alcohol use and weight status effects on mortality risk among adults: Analysis of the National Health Interview Survey linked mortality files, 2001–2015

BackgroundBoth alcohol use and weight status have been linked to increased mortality risk, but evidence of their joint effect is limited. The goal of this study was to examine the combined effects of alcohol and weight status (BMI classes: underweight, normal, overweight, obesity) on mortality using nationally representative data. MethodsUsing data from public-use National Health Interview Survey-Linked Mortality Files (NHIS-LMF), 2001–2011, linked to prospective mortality follow-up through December 2015, we used age-period-cohort Cox proportional hazards models to examine all-cause and cause-specific mortality associated with the joint effects of alcohol use and BMI on 209,317 individuals aged 35–85. ResultsIndividuals with an underweight BMI status had higher all-cause and cause-specific mortality risks than those with a normal BMI status and light/moderate alcohol intake. All-cause mortality risks were 148% (hazard ratio [HR] 2.48, 95% CI 1.60–3.83) higher in underweight heavy drinkers than light/moderate drinkers with normal BMI status. Obese heavy drinkers had a 16% higher chance of dying from all-cause mortality (HR 1.16, 95% CI 1.00–1.35). Individuals in the unknown alcohol and BMI category have a higher chance of death from all-cause (HR 1.35, 95% CI 1.14–1.59) or cause-specific (CVD HR 1.75, 95% CI 1.14–2.69 and Cancer HR 1.33, 95% CI 1.01–1.76). ConclusionsAlcohol drinking levels result in heightened all-cause and cause-specific mortality risks; the risks are compounded among underweight, obese, and unknown BMI individuals across all or cause-specific mortality.

Modeling mortality risk effects of cigarettes and smokeless tobacco: results from the National Health Interview Survey Linked Mortality File Data

BackgroundCigarettes and smokeless tobacco (SLT) products are among a wide range of tobacco products that are addictive and pose a significant health risk. In this study, we estimated smoking- and SLT use-related mortality hazard ratios (HRs) among U.S. adults by sex, age group, and cause of death, for nine mutually exclusive categories of smoking and/or SLT use.MethodsWe used data from the public-use National Health Interview Survey Linked Mortality with mortality follow-up through 2015. We used Cox proportional hazard models to estimate mortality HRs, adjusted by race/ethnicity, education, poverty level, body mass index, and tobacco-use status.ResultsWith never users as reference group, HRs for smoking-related diseases for male exclusive current smokers aged 35–64 and 65+ were 2.18 (95% confidence interval [CI]: 1.79–2.65), and 2.45 (95% CI: 2.14–2.79), respectively. Similar significant HR estimates were found for females and for all-cause mortality (ACM) and other-cause mortality (OCM) outcomes. HRs for exclusive current SLT users were only significant for males aged 35–64 for ACM (HR: 2.04, 95% CI: 1.27–3.27) and OCM (HR: 2.80, 95% CI: 1.50–5.25). HRs for users who switched from cigarettes to SLT products were significant for males aged 65+ for smoking-related diseases (HR: 2.06, 95% CI: 1.47–2.88), SLT-related diseases (HR: 1.99, 95% CI: 1.36–2.89), and ACM (HR: 1.63, 95% CI: 1.21–2.19).ConclusionsMale exclusive current SLT users aged 35–64 had a significant HR for ACM and OCM outcomes, suggesting that deaths not attributed to SLT use could be contributing to the ACM elevated HR for exclusive current SLT users.

Citizenship Status and Mortality Among Latinos: Analyses of the US National Health Interview Survey Linked Mortality Files

Research ObjectiveForty million Latino adults reside in the United States, including eleven million who do not possess US citizenship. Noncitizens disproportionately experience poverty, segregation, and inadequate access to healthcare—pathogenic mechanisms that adversely impact health. Here we examine the association between citizenship status (i.e., US‐born citizens, naturalized citizens, or noncitizens) and mortality among Latinos.Study DesignCohort study using data from the National Health Interview Survey (NHIS, 1998–2014) and mortality follow‐up through the end of 2015. We examined all‐cause and cause‐specific mortality. We used Poisson regressions adjusted for demographic factors (i.e., age, sex, origin, and region of residence) to estimate mortality rates and examine mortality risk differences. We also conducted mediation analysis to evaluate the extent to which socioeconomic factors (i.e., English fluency, educational attainment, poverty, and health insurance) explain the associations between citizenship status and mortality. All analyses were stratified by age‐group (<55 or ≥ 55 years).Population StudiedLatino adults who are long‐term residents of the US (≥10 years, n = 177,219), including US‐born citizens (n = 90,494), naturalized citizens (n = 37,676), and noncitizen (n = 49,049).Principal FindingsAmong younger Latinos (<55 years), noncitizens (incidence rate ratio (IRR] 1.40 [95% confidence interval [CI]: 1.31, 1.49)) and naturalized citizens (IRR 1.15 [CI: 1.06, 1.25] have higher all‐cause mortality rates than US‐born citizens. Socioeconomic factors explained a substantial proportion of mortality risk differences between the US‐born population and noncitizens (43% [CI 20%, 67%)) and naturalized citizens (20% (CI: −1%, 41%]). Younger noncitizens were also at higher risk for deaths due to cancer (IRR 2.13 [CI: 1.86, 2.45), cardiometabolic diseases (IRR 1.42 [CI: 1.21, 1.66]), and accidents (IRR 1.54 [CI 1.31, 1.82)) than their US‐born counterparts. Among older Latinos (≥55 years), however, noncitizens had lower all‐cause mortality rates (IRR 0.91 [CI: 0.84, 0.99] than US‐born citizens—socioeconomic factors did not explain this mortality advantage.ConclusionsYounger Latino noncitizens and, to a lesser extent, naturalized citizens are at higher risk of death than US‐born citizens. Future work should examine the role of structural barriers to health in explaining the mortality disadvantage among young and middle‐aged Latino noncitizens. Research should also focus on the potential role of survival bias in explaining why older Latino noncitizens have a modest mortality advantage.Implications for Policy or PracticeAs noncitizens experience systemic exclusions from labor, healthcare, and wealth, policies to address health disparities in the Latino population should acknowledge that citizenship status is a structural determinant of health.Primary Funding SourceThe Robert Wood Johnson Foundation.

Mortality among workers employed in the mining industry in the United States: A 29-year analysis of the National Health Interview Survey-Linked Mortality File, 1986-2014.

Working in the mining industry increases the risk of chronic diseases and mortality. We investigated overall and cause-specific mortality rates among workers employed in the mining sector in the United States. We pooled 29 years of National Health Interview Survey (NHIS) public-use data from 1986 to 2014, with mortality follow-up until 31 December 2015. We grouped respondents into the mining and nonmining sectors based on the responses given at the time of the NHIS interview. We compared the overall and cause-specific mortality rates using standardized mortality ratios (SMR) and 95% confidence interval (CI) adjusted for the competing cause of death. From 1986 to 2014, an estimated 14 million deaths were recorded among subjects eligible for mortality follow-up. Of these, an estimated 50,000 deaths occurred among those working in the mining sector. A significantly higher overall mortality (SMR = 1.26, 95% CI: 1.17-1.36), and mortality from heart diseases (adjusted SMR = 1.56, 95% CI: 1.31-1.83), cancer (adjusted SMR = 1.30, 95% CI: 1.14-1.48) and unintentional injuries (adjusted SMR = 1.41, 95%CI: 1.03-1.85) were observed among those employed in the mining sector. When the analyses were restricted to men, only the SMRs for heart disease and cancer remained statistically significant. No elevated SMR for deaths from chronic lower respiratory disease was observed in the study. Workers employed in the mining sector have a significantly increased total death rate and death rates from heart disease, cancer, and unintentional injuries.

Occupation, employment status, and “despair”-associated mortality risk among working-aged U.S. adults, 1997–2015

The recent rise in U.S. midlife mortality has been conceptualized as a “working-class” crisis, defined by increasing mortality among blue-collar and/or unemployed workers and the decline of manual labor; yet research on the topic overwhelmingly focuses on educational attainment as the key socioeconomic determinant of midlife mortality, especially among “despair”-related deaths. The present study addresses this gap by using data on 360,146 adults ages 25–64 from restricted-use National Health Interview Survey-Linked Mortality Files (1997–2015; average follow-up 9.87 years) to estimate associations between individuals' occupation and employment status and alcoholic liver disease, suicide, or accidental poisoning mortality risk, net of confounders. Adults in service, manual labor, and transport occupations exhibited two-to-three times the risk of mortality from accidental poisonings compared to those in managerial/administrative positions. Notably, health professionals exhibited the highest accidental poisoning mortality risks. Relative to managerial/administrative professionals, adults not in the labor force had double the suicide risk and nearly seven times the accidental poisoning risk, net of confounders. Unemployed adults and those having never worked also had elevated risks from accidental poisoning mortality. Critically, the fact that individuals' occupations and employment status are independently associated with midlife mortality due to deaths of despair – especially accidental poisoning – highlights the need for measures of socioeconomic status beyond educational attainment and income in understanding rising midlife mortality. Moreover, policies addressing working-aged mortality must target particular workplace contexts and the consequences of unemployment, both of which affect a large and growing segment of the working-aged U.S. population.

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

PurposeLung cancer mortality among never-smokers is an often overlooked yet important cause of adult mortality. Moreover, indirect approaches for estimating smoking-attributable mortality use never-smoker lung cancer death rates to approximate smoking burden. To date, though, most studies using indirect approaches import rates from the Cancer Prevention Study II (CPS-II), which is not representative of the U.S. population. MethodsWe use the nationally representative 1985–2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMF) to calculate lung cancer death rates among never-smokers aged 50 years or older. We then import rates from NHIS-LMF and CPS-II into the Preston–Glei–Wilmoth indirect method to determine whether smoking-attributable fractions differ. ResultsNever-smokers account for 16% of U.S. lung cancer deaths among women and 11% among men. Lung cancer death rates among never-smokers are higher in NHIS-LMF than CPS-II for several age groups. Smoking-attributable fractions of mortality are slightly lower with NHIS-LMF rates (19% of male deaths and 16% of female deaths) than with CPS-II rates (21% of male deaths and 17% of female deaths). ConclusionsFractions based on nonrepresentative CPS-II data may modestly overestimate smoking-attributable mortality. Thus, indirect methods should use never-smoker lung cancer death rates from such nationally representative datasets as NHIS-LMF.

Family Socioeconomic Status and Early Life Mortality Risk in the United States.

We examine the association between several dimensions of parental socioeconomic status (SES) and all-cause and cause-specific mortality among children and youth (ages 1-24) in the United States. We use Cox proportional hazard models to estimate all-cause and cause-specific mortality risk based on data from the 1998 to 2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMFs), restricted to children and youth ages 1-17 at the time of survey followed through age 24, or the end of the follow-up period in 2015 (N = 377,252). Children and youth in families with lower levels of mother's education, father's education, and/or family income-to-needs ratio exhibit significantly higher all-cause mortality risk compared with children and youth living in higher SES families. For example, compared to children and youth living with mothers who earned college degrees, those living with mothers who have not graduated high school experience 40% higher risk of early life mortality over the follow-up period, due in part to higher mortality risks of unintentional injuries and homicides. Similarly, children/youth whose fathers did not graduate high school experience a 41% higher risk of dying before age 25 compared to those with fathers who completed college. Today's children and youth experience clear disparities in mortality risk across several dimensions of parental SES. As the U.S. continues to lag behind other high-income countries in health and mortality, more attention and resources should be devoted to improving children's health and well-being, including the family and household contexts in which American children live.

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

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

Flavonoid Intake and Cardiovascular Disease Mortality Among US Adults, Data from Third National Health and Nutrition Examination Survey Linked Mortality File (P18-013-19)

ObjectivesThe objective of this research was to examine the association between total flavonoid intake and flavonoid sub-classes and CVD mortality among a nationally representative sample of US adults aged 40+ years at baseline and free of CVD. MethodsA nationally representative sample of adults from the NHANES III data (1988–1994; n = 7900; age > = 40 years) were matched with mortality data reported by the National Death Index through 2015 to examine associations between estimated usual intakes of total flavonoid intake and flavonoid sub-classes and CVD mortality. Cox Proportional Hazards regression models were constructed to estimate hazard ratios and 95% confidence intervals for CVD mortality. Up to four 24-hour recalls were used to estimate total flavonoid intake and flavonoid sub-class intake for participants at baseline. ResultsDuring a median follow-up of 17.9 years, there were 4245 death; 1629 CVD deaths (767 males, 862 females) documented. Mean flavonoid intake was 247.7 mg/day for males and 216 mg/day for males. We did not observe an inverse association between total flavonoid intake and CVD mortality for males (HR: 0.95, 95% CI 0.87, 1.03) or females (HR: 1.03, 95% CI 0.93, 1.14), after adjustments for demographic, lifestyle, clinical and dietary quality variables. We also did not find significant associations between intake of flavonoid sub-classes and CVD mortality. However, for males only, intake of flavanones was inversely associated with CVD mortality after adjustments for demographic variables, lifestyle, clinical variables and diet quality (HR: 0.93, 95% CI 0.87, 0.99, p-value < 0.04). ConclusionsIn this nationally representative study, with detailed information on flavonoid intake and CVD mortality data, we did not find an inverse association between total flavonoid intake and most flavonoid sub-classes and CVD mortality for adults aged 40+ years at baseline; however our findings do indicate a marginally significant inverse association between flavanone intake and CVD mortality for males only, after controlling for confounders. Funding SourcesNo funding sources to declare.

The Economic Value of Education for Longer Lives and Reduced Disability.

Policymakers often frame the value of educational attainment in terms of economic outcomes (eg, employment, productivity, wages). But that approach may understate the value of education if it ignores the economic value of both longer lives and the reduced disability associated with more education. In this article, we estimated the present value of the longer life and reduced disability associated with higher educational attainment at age 25 through age 84. We used prospective survival data and cross-sectional disability data from the National Health Interview Survey-Linked Mortality Files and drew on published estimates of the economic value of a statistical life. In addition, we used data from the Current Population Survey-Annual Social and Economic supplement to estimate the present value of education for lifetime earnings at age 25 through age 64 in order to provide a benchmark for comparing the value of education for health. Compared with those with less than a high school degree, the longer lives of those with a high school degree are worth an additional $450,000 for males and $479,000 for females, and the additional disability-adjusted life for those with a high school degree is worth $693,000 for males and $757,000 for females. By comparison, the additional lifetime earnings for those with a high school degree, rather than less than a high school degree, is $213,000 for males and $194,000 for females. Compared with those with a high school degree, the longer lives for those with a baccalaureate degree are worth an additional $446,000 for males and $247,000 for females. The value of the additional disability-adjusted life associated with having a baccalaureate degree rather than a high school degree is $611,000 for males and $407,000 among females. By comparison, the additional lifetime earnings for those with a baccalaureate degree, rather than a high school degree, is $628,000 for males and $459,000 for females. The value of education for longer, healthier lives may surpass the value for earnings. Estimates of the economic value of the social determinants of health, such as education, can help policymakers prioritize those policies that provide the greatest value for population health.

Population risk and burden of health behavioral–related all-cause, premature, and amenable deaths in Ontario, Canada: Canadian Community Health Survey–linked mortality files

PurposeTo examine the association of all-cause and premature mortality with four modifiable lifestyle behaviors and quantify the burden of behavioral-related premature death in Ontario, Canada. MethodsWe analyzed a cohort of 149,262 adults in the 2000–2010 Canadian Community Health Surveys, linked to vital statistics data to ascertain deaths until December 31, 2015. The strength of the association between behaviors (smoking, body mass index, physical inactivity, and alcohol consumption) and all-cause and premature mortality was estimated using sex-specific Cox proportional hazards models. We estimated the proportion of deaths from causes amenable to the health system by behavior. ResultsAfter full adjustment, hazard ratios (95% confidence interval) for premature mortality were significantly increased for heavy smokers versus nonsmokers [males: 5.48 (4.55–6.60); females 4.45 (3.49–5.66)]; obese class III versus normal weight [males: 2.47 (1.76–3.48); females: 1.73 (1.29–2.31)]; and physically inactive versus active [males: 1.25 (1.07–1.45); females: 1.70 (1.41–2.04)]. In both sexes, a disproportionate burden of amenable deaths were experienced by heavy smokers, severely obese, physically inactive, and heavy drinkers. ConclusionsThe findings emphasize the importance of prevention to reduce the prevalence of risk behaviors that contribute to a large burden of premature deaths that are amenable to the health system.

Comparability of Mortality Estimates from Social Surveys and Vital Statistics Data in the United States

Social surveys prospectively linked with death records provide invaluable opportunities for the study of the relationship between social and economic circumstances and mortality. Although survey-linked mortality files play a prominent role in U.S. health disparities research, it is unclear how well mortality estimates from these datasets align with one another and whether they are comparable with U.S. vital statistics data. We conduct the first study that systematically compares mortality estimates from several widely-used survey-linked mortality files and U.S. vital statistics data. Our results show that mortality rates and life expectancies from the National Health Interview Survey Linked Mortality Files, Health and Retirement Study, Americans' Changing Lives study, and U.S. vital statistics data are similar. Mortality rates are slightly lower and life expectancies are slightly higher in these linked datasets relative to vital statistics data. Compared with vital statistics and other survey-linked datasets, General Social Survey-National Death Index life expectancy estimates are much lower at younger adult ages and much higher at older adult ages. Cox proportional hazard models regressing all-cause mortality risk on age, gender, race, educational attainment, and marital status conceal the issues with the General Social Survey-National Death Index that are observed in our comparison of absolute measures of mortality risk. We provide recommendations for researchers who use survey-linked mortality files.