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November 27, 1998 / 47(46);1005-8,1015
Although heart disease-associated mortality has declined steadily since the 1960s, heart disease remains the leading cause of death for both men and women of all races/ethnicities in the United States (1). This report compares temporal trends in coronary heart disease (CHD) death rates for blacks and whites from 1980 to 1993 (the latest year for which data were available) in the Appalachian Region * with trends for the entire United States. The findings indicate that among whites aged greater than or equal to 35 years the burden of CHD is greater in Appalachia than in the entire United States, with the disparity increasing over time, and among blacks, only slight differences in CHD rates between Appalachia and the United States were observed.
From 1980 through 1993, annual age-adjusted CHD death rates for persons aged greater than or equal to 35 years were calculated using mortality data compiled by CDC and population estimates from the Bureau of the Census. For both Appalachia and the United States, CHD death rates were calculated separately for blacks and whites by sex and age group (i.e., ages 35-64 and greater than or equal to 65 years). The 1980 U.S. population aged greater than or equal to 35 years was the standard for age adjustment. CHD deaths were defined as deaths for which the underlying cause was listed on the death certificate as codes 410.0-414.0 and 429.2 of the International Classification of Diseases, Ninth Revision (ICD-9). The cause of death is reported by attending physicians, medical examiners, and coroners on death certificates and is subsequently coded according to the ICD-9. Linear regression models, with year as the independent variable and log-transformed annual CHD death rate as the dependent variable, were estimated separately for each group. Beta coefficients from each model were used to calculate the average annual percentage change in CHD mortality.
CHD mortality declined from 1980 through 1993 for each of the demographic groups for both Appalachia and the United States; however, Appalachia and the United States differed in both the level of CHD mortality and the magnitude of decline for most demographic groups. Among persons aged 35-64 years, CHD death rates for whites in Appalachia were consistently higher than those for the entire United States (Figure_1). CHD death rates were 15% higher among white men aged 35-64 years in Appalachia than among white men in the United States in 1980; in 1993, rates were 19% higher for white men in Appalachia. Similarly, CHD death rates were 15% higher among white women aged 35-64 years in Appalachia than among white women in the United States in 1980; in 1993, rates were 21% higher for white women in Appalachia. In comparison, CHD death rates for blacks aged 35-64 years only differed slightly between Appalachia and the entire United States (Figure_1).
For Appalachian residents aged 35-64 years, the average annual declines in CHD mortality from 1980 through 1993 were 2.3% for black women, 3.1% for black men, 3.3% for white women, and 3.9% for white men. In the United States, average annual declines in the same age group were 2.7% for black men, 2.8% for black women, 3.4% for white women, and 4.3% for white men.
Among persons aged greater than or equal to 65 years, whites in Appalachia had slightly higher CHD death rates than whites in the same age group in the entire United States (6% higher in 1980 and 5% higher in 1993) (Figure_2). In comparison, blacks aged greater than or equal to 65 years experienced slightly lower CHD death rates in Appalachia than blacks in the same age group in the entire United States (Figure_2).
From 1980 through 1993, average annual declines in CHD mortality for Appalachian residents aged greater than or equal to 65 years were 1.8% for black men, 2.3% for black women, 3.2% for white men, and 3.3% for white women. In the United States, average annual declines for persons in the same age group were 1.6% for black men, 1.7% for black women, 3.1% for white women, and 3.3% for white men.
Reported by: E Barnett, PhD, VE Braham, MA, JA Halverson, MA, Dept of Community Medicine; GA Elmes, PhD, Dept of Geology and Geography, West Virginia Univ, Morgantown, West Virginia. Cardiovascular Health Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
Editorial Note: The findings of this report corroborate recent reports showing important geographic and race/ethnicity variability in both levels and rates of decline in CHD mortality (3-7). The burden of CHD mortality observed among whites in Appalachia increased during 1980-1993. In both Appalachia and the entire United States, CHD death rates for blacks remained higher than rates for whites; however, among blacks there were only slight differences in CHD death rates between Appalachia and the entire United States.
The findings in this report are subject to at least two limitations. First, data used to calculate CHD death rates in this study include census undercounts of black populations and variations in the accuracy of reporting underlying cause of death on death certificates. Second, examination of CHD death rates for a large region such as Appalachia obscures important geographic variation in risk for heart disease within the region. Rural and less affluent counties within Appalachia were at highest risk for CHD mortality and were least likely to have adequate economic and medical-care resources (8).
The findings in this report suggest that the social and environmental conditions and resources that influence CHD mortality for whites aged greater than or equal to 35 years may differ between Appalachia and the United States. The Appalachian region is characterized by low levels of urbanization and lower standards of living than the nation (9). Life expectancy for both men and women is lower in Appalachian counties than the United States (10). In addition to low levels of economic resources, many Appalachian counties lack medical-care facilities (e.g., hospital coronary-care units and cardiac-rehabilitation units) for treatment of CHD (8). The population of Appalachia is predominantly white; however, blacks comprise 6% of the population, with several rural counties of southern Appalachia having black populations that are more than 20%. The similarity of CHD death rates for blacks in Appalachia with those in the nation overall suggests the need to examine the similarities in socioenvironmental conditions and resources for blacks in Appalachia compared with the United States. Increasing inequalities in CHD mortality trends for whites between Appalachia and the nation from 1980 through 1993 indicate the need for public health interventions focused on this disadvantaged region.
In Appalachia, policies and programs should be instituted that enhance both primary and secondary prevention of heart disease mortality. Secondary prevention of heart disease requires improved access to medical-care facilities and health-care professionals, especially for residents of isolated rural counties. In addition, persons with heart disease require social support from their families and communities, and access to facilities and programs for cardiac rehabilitation. Primary prevention of heart disease mortality requires communitywide improvements in the social environment, including full employment in healthy work environments, access to affordable healthy foods and recreational facilities, and opportunities for social interaction and participation in civic life.
American Heart Association. 1998 heart and stroke statistical update. Dallas, Texas: American Heart Association, 1997.
Appalachian Regional Commission. Annual report, 1992. Washington, DC: Appalachian Regional Commission, 1992.
Sempos C, Cooper R, Kovar MG, McMillen M. Divergence of the recent trends in coronary mortality for the four major race-sex groups in the United States. Am J Public Health 1988;78:1422-7.
Wing S, Dargent-Molina P, Casper M, Riggan W, Hayes CG, Tyroler HA. Changing association between community occupational structure and ischaemic heart disease mortality in the United States. Lancet 1987;2:1067-70.
Wing S, Casper M, Davis W, Hayes C, Riggan W, Tyroler HA. Trends in the geographic inequality of cardiovascular disease mortality in the United States, 1962-1982. Soc Sci Med 1990;30:261-6.
Wing S, Barnett E, Casper M, Tyroler HA. Geographic and socioeconomic variation in the onset of decline of coronary heart disease mortality in white women. Am J Public Health 1992;82:204-9.
Barnett E, Strogatz D, Armstrong D, Wing S. Urbanization and coronary heart disease mortality among African Americans in the United States South. J Epidemiol Commun Health 1996; 50:252-7.
Barnett E, Elmes GA, Braham VE, Halverson JA, Lee JY, Loftus S. Heart disease in Appalachia: an atlas of county economic conditions, mortality, and medical care resources. Morgantown, West Virginia: Prevention Research Center, West Virginia University, 1998.
Isserman AM. Appalachia then and now: an update of "The Realities of Deprivation" reported to the President in 1964. J Appalachian Stud 1997;3:43-69.
Murray CJL, Michaud CM, McKenna MT, Marks JS. U.S. patterns of mortality by county and race: 1965-1994. Cambridge, Massachusetts: Harvard University Center for Population and Development Studies, 1998.
Appalachia is comprised of 399 counties, including all of West Virginia and parts of Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia (2).
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