1. Very low CHD mortality among men aged 35-44 in several states in the United States Akira Sekikawa, MD, PhD, PhD Lewis H Kuller, MD, DrPH Department of EpidemiologyDepartment of Epidemiology, Graduate School of Public Health, University of Pittsburgh, USAGraduate School of Public HealthUniversity of Pittsburgh

2. Learning objectives To learn the trends in risk factors for coronary heart disease in the US To learn some unique features of mortality from CHD among men aged 35-44 To learn geographic variation in mortality from CHD by state and race in the US To learn possible reasons for this variation in CHD mortality in the US

3. Background Methods Results Very low CHD mortality among men aged 35-44 in several states in the United States Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, USA

4. Important changes in lifestyle that have major effects on risk of CHD have occurred since the end of World War II decline in total serum cholesterol decline in prevalence of cigarette smoking improved treatment of high blood pressure increase in prevalence of obesity Post World War II birth cohort aged 35- 44 are most likely to be affected by these changes

5. Trends in the levels of total cholesterol in men in the Unite States

6. Trends in the prevalence of hypertension in men in the Unite States

7. Trends in the prevalence of cigarette smoking in men in the Unite States

8. Why young adult men (aged 35-44)? Mortality rates from CHD among men aged 35-44 are 29/100,000 in the US

9. Several unique features of mortality in this young age group (35-44 year old men) Cohort alternations in risk factors would emerge more rapidly in younger age groups Deaths from CHD in this age group are most likely to be incident, rather than from long-standing chronic clinical CHD Data on this age group would describe the difference between white and black better than older age groups and age-adjusted rates (cohort selection effect)

10. Background Methods Results Very low CHD mortality among men aged 35-44 in several states in the United States Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, USA

11. Mortality data on CHD CDC Wonder Age (35-44)-, sex (men)-, race (white and black)-, and state-specific data in 1994 for domestic comparison CHD (ICD codes 410-414, 429.2) for international comparison CHD (ICD codes 410-414) Mortality data which were not valid because of the small number were excluded from the analysis

12. Mortality data - International WHO Statistics Annuals Country specific mortality among men aged 35-44 in 1994 CHD (ICD codes 410-414) Australia, Canada, Chile, Finland, Greece, Mexico, Hong Kong, Hungary, Israel, Japan, Poland, Singapore, South Korea, Spain, Switzerland, Trinidad, and UK

13. Ecological Analyses Sex-, state-, and race-specific mortality from cancer of lung and bronchus (age-adjusted data) - surrogate of cigarette smokingCDC WonderCDC Wonder State-, and race-specific data on percent of not-a-high-school graduate in the largest 25 states in 1992 Current Population Survey by Census Bureau

14. Background Methods Results Very low CHD mortality among men aged 35-44 in several states in the United States Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, USA

15. CHD mortality (ICD 410-414, 429.2) among white men aged 35-44 in 1994 in the US by state (highest, middle, lowest)

16. CHD mortality (/100,000) >= 42 32 - 42 25 - 32 < 25

17. CHD mortality (ICD 410-414, 429.2) among black men aged 35-44 in 1994 in the US by state (highest, middle, lowest)

18. CHD mortality (/100,000) >= 42 32 - 42 25 - 32 < 25

23. Why are there such differences in CHD mortality among men aged 35-44 in the US by state and race? Accuracy of diagnosis on death certificate Quality of medical care Differences in risk factors

24. White Black

25. White Black

26. Conclusions I Differences in CHD mortality among black and white men aged 35-44 by state are as large as the differences observed between Poland and France, one of the highest and the lowest in the mortality from CHD around the world. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, USA

27. Conclusions II The relatively strong correlation between CHD mortality and educational attainment as well as lung cancer mortality suggests that smoking and other CHD risk factors are the potential candidates for the CHD mortality difference. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, USA

28. Conclusions III If the differences are attributed to the variations in the distribution of traditional risk factors, the reduction of these risk factors could substantially reduce the mortality from CHD. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, USA