Field Notes

Deaths From CVD Increased Among Younger US Adults in Rural Areas

CVD deaths increased by about 21% for adults aged 25 to 64 living in rural areas between 2010 and 2022; however, the rate declined by 9% for adults aged 65 or older living in urban areas, according to a study presented at the American Heart Association’s Scientific Sessions 2024, and simultaneously published in the Journal of the American College of Cardiology.

Using data from the CDC’s WONDER database, researchers analyzed national death data for more than 11 million adults from 2010 to 2022. The study investigated the cardiovascular death rates for people living in rural vs urban (large metropolitan) areas of the United States. According to the National Center for Health Statistics, large metropolitan areas are defined as those with a population of more than 1 million people; small/medium metro areas as those with 250,000 to 999,999 people; and rural areas as those that are near cities with less than 50,000 people or not near any major metropolitan area.

“Previous research has demonstrated disparities in cardiovascular mortality between rural and urban Americans, with, historically, more people in rural areas dying from heart disease compared to people living in cities,” says lead study author Lucas X. Marinacci, MD, a cardiology fellow at Beth Israel Deaconess Medical Center and a postdoctoral research fellow under the mentorship of Rishi Wadhera, MD, MPP, MPhil, the corresponding study author, at the Richard A. and Susan F. Smith Center for Outcomes Research, also at Beth Israel Deaconess Medical Center in Boston. “Rural communities bear a disproportionate burden of cardiovascular risk factors, as well as economic hardship and health care system challenges, such as hospital closures, physician shortages, and lack of public health infrastructure, all of which were exacerbated by the COVID-19 pandemic.”

The analysis found that between 2010 and 2022, cardiovascular mortality rates increased in rural areas and decreased in urban areas of the United States, resulting in a widening rural-urban disparity. There was a concerning rise in cardiovascular mortality among younger adults that was concentrated in rural areas. There was a sharp increase in cardiovascular mortality rates following the onset of the COVID-19 pandemic, a change that was more pronounced in rural populations. Specifically:

The age-adjusted cardiovascular mortality rate, or number of deaths from CVD per 100,000 people, increased by 0.8% in rural areas between 2010 and 2022 but decreased by 6.4% in urban areas.
Younger, rural adults aged 25 to 64 experienced a 21% relative increase in their cardiovascular death rate in 2022 compared with 2010, whereas death rates among younger adults in urban areas increased by only 3%.
Conversely, cardiovascular mortality rates declined significantly among adults older than age 65 between 2010 and 2022, with a 4.4% decrease for older adults in rural areas and an 8.5% decrease among those living in urban areas.
After the onset of the COVID-19 pandemic in 2020, cardiovascular death rates increased nationwide, yet the relative increase was significantly larger in rural (8.3%) vs urban (3.6%) areas.

“Leading up to the pandemic, the cardiometabolic health of rural communities was already in decline, particularly among younger adults. This may have made them more vulnerable to both the direct and indirect cardiovascular effects of COVID-19,” Marinacci explains. “Cardiovascular risk factor control worsened during the pandemic, and those in rural areas experienced greater interruptions in health care coverage, access, and affordability. The unprecedented surge in economic and psychosocial distress that occurred during the wake of the pandemic also disproportionately impacted rural populations.

“Therefore, a growing burden of cardiometabolic disease combined with other risk-enhancing factors—all of which were likely exacerbated by the pandemic—may have caused rural-urban disparities in death rates to widen even further during the 12-year study period,” he adds.

According to Marinacci, there’s an urgent need to implement public health initiatives specifically focused on reducing cardiovascular risk among working-age rural adults.

“Aggressive risk factor modification is needed to reverse these trends. Community health workers may be able to strengthen the connection between rural adults and the health care team and resources that can help manage these chronic conditions. Finally, policy interventions that improve access to health care, make it more affordable, and increase health insurance coverage for rural populations could go a long way in reducing the disparity in cardiovascular death,” Marinacci says.

Study background and details include the following:

The study included death certificate data from the CDC’s WONDER database from 2010 to 2022.
The study sample included 11,017,255 adults; 18.9% were aged 25 to 64 and 81.1% were aged 65 or older.
Researchers analyzed overall cardiovascular deaths for adults living in rural, small to medium metropolitan, and large metropolitan, or urban, areas of the United States.
They further analyzed cardiovascular deaths for younger (aged 25 to 64) and older (aged 65 and older) adults. All cardiovascular death rates were age-standardized to the 2010 US population.

“Rural communities face a number of unique challenges when it comes to cardiovascular health, including a high burden of cardiovascular risk factors like type 2 diabetes and hypertension, as well as worse access to specialty care and cardiovascular technologies,” says Karen E. Joynt Maddox, MD, MPH, FAHA, chair of the American Heart Association’s Presidential Advisory Forecasting the Burden of Cardiovascular Disease and Stroke in the United States Through 2050. “We need new solutions, including cardiovascular-specific interventions like telehealth-based specialist visits, as well as policy interventions to improve the affordability of care, to help people in rural areas reverse these alarming trends.”

— Source: American Heart Association

Experiences of Discrimination Linked to Postpartum Weight Retention

Researchers have been unable to explain why, after giving birth, Black patients are two to three times as likely to retain or gain additional weight compared with their white counterparts, even when prepregnancy weight and gestational-weight trajectories are comparable. A first-of-its-kind study by University of Pittsburgh epidemiologists points to the stress of lived experiences with racism and gender-based discrimination as a possible explanation. The study was reported in the American Journal of Epidemiology.

Since postpartum weight retention is associated with increased cardiovascular risk and other negative health outcomes that persist throughout one’s life, the new research suggests interventions that address the underlying stressors of discrimination could be an important complement to community and clinical interventions.

“Beyond individual choices and behavior, we have to account for an individual's environment, because that can have an impact on health, too,” says lead author Dara Méndez, PhD, MPH, an associate professor of epidemiology and associate director of the Center for Health Equity at Pitt Public Health. “Context matters, and lived experiences matter. How can we link people to appropriate services and support in the postpartum period, in light of exposure to stress and experiences of discrimination?”

As part of the Postpartum Mothers Mobile Study, researchers recruited 313 pregnant individuals between 2017 and 2020, following them from their second trimester through one year postpartum.

Study participants weighed themselves on a weekly basis using Bluetooth-enabled scales, and completed brief surveys via smartphone once a day, on average. Study participants were asked about everyday experiences, including daily experiences of stress and discrimination. The surveys were administered using a method called ecological momentary assessment, which aims to capture data on thoughts and behaviors in real-time, while the participant is in their natural environment. In addition, the study captured acute exposure to discrimination with major institutions such as applying for loans, interacting with teachers or academic advisors, searching for or retaining employment, and interacting with police, including being unfairly stopped, searched, questioned, threatened, or abused.

Black participants retained 0.3 more pounds for every 10% increase in the number of days they experienced racial discrimination in the previous month. Gender discrimination was also associated with weight retention, with 0.4 more pounds retained per 10% increase in days with these experiences. These findings persisted even when pregnancy-health factors had been comparable to those of participants who experienced less racial and gender discrimination.

— Source: University of Pittsburgh