Luis Rosero-Bixby University of Costa Rica William H. Dow University of California at Berkeley

1. Surprising SES gradients in mortality,health, and biomarkers in a Latin American population of adults Luis Rosero-Bixby University of Costa Rica William H. Dow University of California at Berkeley Support from the Wellcome Trust

2. Rosero-Bixby, 1993

3. life expectancy vs. gross domestic product

4. 80 60 Infant Mortality 40 20 0 1973 1960 1970 1980 1990 Year Infant Mortality Trend, 1960-1990

7. Some Possible Explanations for Good Health • Health care: Good access? Equitable access? High quality? Primary health focus? Insurance? • Public health: Clean water? Sanitation, air quality? • Health behaviors: Good diet? Smoking, exercise, obesity? Modern health beliefs? • Historical Accident: Temperate climate? Genes? • Social determinants: High female education? Low poverty? Social equity and inclusion? Low stress society?

9. Costa Rica: middle income country, high social development, strong public sector, advanced demographic transition Source: World Bank

10. SES differentials shed light on good health in CR? • Does public health lead to less exposure among low SES, despite few resources? • Does health care access buffer effects of exposures from low SES? • Is there a smaller gradient, consistent with stress stories? • First step: document differentials

11. Small SES gradients in CR health? • Research elsewhere finds SES gradients persist: • Into old age (though shrink with age) • Even with good health care access • But previous work shows little CR adult mortality gradients. • Is this true of other health indicators?

12. Previous work:Insurance and other determinants of elderly longevity in a Costa Rican panel Rosero-Bixby, Dow, and Lacle Journal of Biosocial Science 2005

13. Mortality data • Panel of 876 individuals aged 60+ in 1984 • Semi urban community near San Jose (100% sample from the 1984 census) • Observed from June 1984 to December 2001 • Interview data from the 1984 census and visits in 1985 and 1986 • Survival from 1988 and 2002 contacts, and computer follow up in the civil registration.

14. Result 3. No clear SES effect

15. New data from CRELES: Costa Rican study of Longevity and Healthy Aging • National sample of 8,000 born before 1946, from the 2000 census. • 6-year survival follow up • Sub-sample of 3,000 interviewed in 2005-6: • First wave of a panel (resurvey 2007,2009) • 90 minute interview and 10 minute diet • Anthropometry, fasting blood and overnight urine samples

16. Health outcomes SES Mortality Education Metabolic syndrome Income & wealth Functional decline Place development Biological risks Physical decline Blood pressure Cognitive impairment Health behavior Cholesterol Self reported health & Lifestyles Triglycerides Demography Smoking Obesity Age Exercising Creatinine Sex Diet Cortisol Marriage Social support Epinephrine Depression APoe gene Seeking care Etc... Health care supply Study framework: 3 levels of health indicators Level 3 Level 1 Level 2 All indicators are poor-health dummies Control demography with logistic regression

18. Health Outcomes by Age

19. Poor-health biomarkers by age

20. Poor-health lifestyles

21. The low old-age mortality in Costa Rica challenges the notion of an SES gradient

22. The puzzling SES gradient:mortality vs. self-reported health(controlling for age, sex, marital)

23. The puzzling SES gradient 2

24. Health-SES gradients from logistic OR(Controlling age, sex, marital. *p<.05)

25. Biomarker-SES gradients from logistic OR(Controlling age, sex, marital. *p<.05)

26. Lifestyle-SES gradients from logistic OR(Controlling age, sex, marital. *p<.05)

28. Summary • Flat mortality gradient contrasts other measures. • Quality of life shows strong gradient. • CVD is major cause of death, so lack of mortality gradients reflects mixed CVD risk factors: • Smoking, low exercise worse for low SES • Diabetes and hypertension not related to SES • Cholesterol and obesity worse for high SES (worse diets) => Lack of mortality gradient not imply Costa Rica has eliminated SES-health gradient

29. Reflects nutritional transition? • Possible that Costa Rica is early in nutritional transition, and SES gradients in nutrition-related indicators will flip. • But external surveys show female obesity (BMI>25) rising for decades: • 1982: 56% women age 45-59 overweight • 1996: 75% women age 45-59 overweight

30. What Next? • New data: • 1984 census-mortality linkage to measure SES trends over time. • Younger cohort: 1945-55 birth cohorts. • Further analyses: • Compare gradients to other countries. • Rehkopf: comparison with U.S. NHANES • Test if stress has small relation to health. • Gersten: life stressor and neuroendocrine allostatic load • Modrek: inequality and health • Investigate role of health care: hypertension.

31. David H. Rehkopf, University of California, San Francisco, Department of Epidemiology and Biostatistics William H. Dow, University of California, Berkeley, Department of Health Policy and Management Luis Rosero-Bixby, Universidad de Costa Rica, Centro Centroamericano de Poblacion Differences in the association of cardiovascular risk factors with education: a comparison of Costa Rica (CRELES) and the United States (NHANES)

32. Objectives of this paper • Compare risk factor levels across countries • Compare education gradients in risk • Inexact education comparison – so focus on direction of gradients

33. data • Costa Rica (Costa Rican Healthy Aging Study) • 2000-2006, n = 2827, age 60+, 17 outcomes • education: 0-2, 3-6, 7+ • United States (National Health and Nutrition Examination Survey) • 1999-2004, n= 5607, age 60+, 17 outcomes • education: <12, 12, 12+

34. 17 outcomes • behavioral • current smoking, lifetime smoking, sedentary, high saturated fat, high carbohydrates, high calorie diet • Anthropometric • obese, severely obese, large waist, body mass index • biomarkers • HDL cholesterol, LDL cholesterol, triglycerides, hemoglobin A1c, fasting glucose, C-reactive protein, systolic blood pressure

36. Table 1/Figure 1: Comparing means • Age and marital distributions roughly similar. Education not easily comparable. • Smoking: • Men: Similar. • Women: Lower in CR. • Diet: Comparability concerns, but CR appears lower fat, maybe worse other dimensions. • Obesity: • Men: CR much lower • Women: CR only slightly lower.For men, CR much lower; for women CR only slightly lower than US. • Hypertension, cholesterol, diabetes: • Men: CR lower than US (diabetes ~same) • Women: CR similar (diabetes higher than US)

37. comparison of means of biological risk factors for cardiovascular risk factors

38. Costa Rica United States men women men women • Current smoking • Lifetime smoking • Sedentary • Saturated fat • carbohydrates • High calorie diet • obese • Severely obese • Large waist

39. Costa Rica United States men women men women • HDL cholesterol • LDL cholesterol • Triglycerides • Hemoglobin A1c • Fasting glucose • C-reactive protein • Systolic blood pressure • Body mass index

40. Figures 2/3: Education gradients (from regressions controlling for age) • Smoking: • Males: gradient both US and CR • Females: gradient only in CR • Diet: High calorie • Reverse gradient especially in CR • Obesity: • Males in CR have reverse gradient. • Females have expected gradient (both US, CR). • Cholesterol: • HDL: only US women have expected gradient • LDL: CR men have gradient • Blood pressure: gradient only in CR men • HbA1c: Expected gradients, except none in CR men • C-reactive protein: Expected gradient in US, but none in CR

41. Summary • Mixed gradients tell complex story, raise more questions. • C-reactive protein: why no CR gradient? (obesity, or buffers?) • Obesity worrisome in CR: • Women already close to US levels. • Male reverse gradient: low SES may rise next. • Next steps: • Study time trends in mortality by SES and cause of death (1984 census-mortality linkage) • Examine treatment for hypertension, cholesterol, diabetes. Why are levels so high when medicines can help control? Why are there gradients in (male) blood pressure and LDL control in CR’s vaunted system?

42. Education differentials in coronary heart disease mortality among those 60 and older Costa Rica United States

43. CRELES – all ages, all-cause

44. Life stressors and neuroendocrine allostatic load in Costa Rica Omer Gersten, Ph.D. Academia Sinica Population Association of America Detroit, Michigan May 1, 2009

45. Research question • Is greater AL predictive of worse health outcomes? • Are various indicators of life stress linked to greater AL? Year 2004-6 Earlier life history/ ------------------------> Biomarker Current situation collection/survey

46. Research hypothesis Early life events | low edu. of mother | live w/out biological father | econ. problems (index) | health problems (index) | Loss | death of children | widowhood/years widowed | 2004-2006 Social deprivation | ---------------------> High AL low/no church attendance | lives alone | Spousal characteristics | low edu. | poor health | Demographic | low edu. | rural residence | Economic| low household wealth |

47. Data: dependent variable “Neuroendocrine allostatic load” (NAL) BiomarkersPhysiologic sub-systemsPhysiologic system Epinephrine ----------> Sympathetic nervous | Norepinephrine system (SNS) | |----> Neuroendocrine Cortisol ----------------> Hypothalamic-pituitary- | DHEAS adrenal (HPA) axis | • Epi., norepi., & cortisol initiate body’s most immediate stress response • Survey measures resting, nonstressed levels

49. Conclusions Q: Are early and other negative life events linked to riskier neuroendocrine allostatic load (NAL) levels? A: No.

50. Gracias! Visit the CRELES web pages: http://ccp.ucr.ac.cr