Health Mystery in New York: Heart Disease
- From: "georgia" <jwissmille@xxxxxxx>
- Date: 12 Sep 2005 13:55:32 -0700
New York Times
August 18, 2005
Health Mystery in New York: Heart Disease
By FORD FESSENDEN
Death rates from heart disease in New York City and its suburbs are
among the highest recorded in the country, and no one quite knows why.
Heart disease is more common among poorer people. Yet Nassau County,
one of the 15 highest-income counties in the country, suffers heart
disease death at a rate 20 percent above the norm, a review of death
certificate records by The New York Times shows. Some New Jersey
counties have similar rates. All the city boroughs except Manhattan
have rates as high as rural counties in the South and Appalachia.
The pattern has raised questions about whether people in the New York
area live with an excess of heart disease risks - stress, bad diets,
too little exercise. But it has also prompted speculation that doctors
in the area may lump deaths with more subtle causes into the heart
disease category, making that toll look worse than it actually is.
"It's an absolute paradox, and absolutely fascinating," said Thomas
Pearson, an epidemiologist at the University of Rochester School of
Medicine.
Now, there are efforts under way to sort out the mystery: The New York
City health department and the National Institutes of Health are
conducting extensive studies to better assess poorly measured factors
like stress, blood pressure and cholesterol in people in the New York
area.
And the Centers for Disease Control and Prevention, at the health
department's request, has sent specialists to determine whether doctors
in New York City ascribe causes of death substantially differently.
"Heart disease is high compared to the national average, and the first
thing you do as an epidemiologist is to ask, is it real?" said Dr.
Lorna Thorpe, the city's deputy commissioner of health. "I don't see
strong evidence that we have more risk factors. But that said, New York
is a unique living environment." Dr. George Howard, a researcher at the
University of Alabama at Birmingham, is enrolling hundreds in the New
York area in a nationwide study of stroke and heart disease. "It really
is a head-scratcher," he said. "This is something we should be
embarrassed that we don't know."
New York State has had one of the country's highest rates of heart
disease deaths for many years. In 1994, a group of epidemiologists at
the State University at Albany set out to see if it was a consequence
of poor health in New York City and concluded it was not: Suburban
areas, where the incidence of the disease was lower than in the city,
still had worse death rates than in 42 other states.
"Communities in all areas of New York State have a substantially
increased risk of death," they said in a study published in the journal
of the United States Public Health Service.
But the phenomenon is only now drawing attention, as epidemiologists
become more interested in geographic variation in disease.
In the Bronx, Brooklyn and Queens and on Staten Island, death rates
from heart disease are more than 300 per 100,000, compared with a
national average of 253, according to figures from the Centers for
Disease Control. Manhattan's is lower, about average. The rates were
calculated for 1999 through 2002 and adjusted for age. Dr. Thorpe said
poverty accounted for some of the higher rate. "The national poverty
level is 12 percent, and citywide we're a lot higher than that," she
said. "Part of the answer is poverty. But it doesn't entirely explain
it."
The worst death rate among the city's boroughs, for instance, is Staten
Island's, where the median income is high and there are few living in
poverty. (The borough, however, has the highest smoking rate in New
York City.) The reported heart disease death rate there is comparable
to that of the Pine Ridge Indian Reservation in South Dakota, one of
the nation's poorest areas.
Suburban counties show a similar pattern of death from heart disease
that does not correspond with wealth or education. Nassau and Suffolk
Counties have nearly 300 deaths per 100,000, far higher than most other
wealthy areas. Suburban counties outside Washington are under 200.
Among the nation's 50 highest-income counties, only nine have death
rates over 250 - two outside Atlanta and the rest outside New York.
"New York certainly does have affluence, but it seems like even
well-off individuals are not doing as well compared to their peers from
other states," said David Strogatz, the chairman of the department of
epidemiology at the School of Public Health at the State University at
Albany and an author of the 1994 study. "There's something about New
York."
There is no obvious explanation. Some speculate about the potential
role of stress. It is widely believed that life in New York is more
difficult, and stress has been linked to higher heart disease
mortality. A 1999 study showed that people were more likely to die of a
heart attack in New York City than elsewhere. The authors suggested
stress could play a role because the excess death rate affected both
visitors and residents; they found no other explanation.
"There's an acute effect of being in New York," said Nicholas
Christenfeld, a psychologist at the University of California at San
Diego who did the study. "You're wired the whole time." But stress is
difficult to measure, and there is no proof that life is more stressful
in and around New York, despite the popular notions.
There is also a growing volume of research showing that heart disease
death rates are higher in places with big gaps between the rich and the
poor. Metropolitan areas with less income inequality - Seattle,
Minneapolis, Salt Lake City - have lower heart disease death rates. New
York's metropolitan area ranks at the top in income inequality.
"There's something about inequality in communities that affects all
residents, not just the poor," Dr. Strogatz said. But the studies,
while tantalizing, have not yet explained why there is a connection.
Are there psychological issues that increase stress in places with
unequal income distribution? Are there fewer services available to the
poor in places with more income inequality? The answers are not clear.
The clearest predictors of heart disease are certain risky behaviors,
like smoking and eating a high-fat diet. But according to the Centers
for Disease Control's Behavioral Risk Factor Surveillance System, an
annual national survey, people in the New York area, whether the city
or suburbs, smoke less than average and are less likely to be obese
than those in the rest of the country. They may not get as much
exercise, however, and they may also have higher cholesterol levels.
Among 105 metropolitan areas surveyed, Nassau-Suffolk was eighth worst
in the number of people at risk because of high cholesterol. The New
York metropolitan area, which includes the city along with Westchester,
Rockland and Putnam Counties and northern New Jersey, was the 28th
worst. Two New Jersey metropolitan subdivisions - four counties around
Edison and six counties from Newark west - also ranked above average in
risk because of high cholesterol and lack of exercise.
Connecticut metropolitan areas tended to be below average in risks.
Some researchers find the cholesterol numbers provocative because they
may be related to another anomaly in New York: Death from stroke is
low. Dr. Howard, who has specialized in stroke death in the South,
became interested in New York's high heart disease rates after
discovering its unusually low rate of stroke death.
Heart disease death rates often march arm in arm with death from stroke
- the risk factors for the diseases are similar, and in many
populations where heart disease is high, so is stroke. But counties in
the New York metropolitan area have some of the lowest rates of stroke
death in the country. Nassau's stroke death rate puts it in the bottom
1 percent of the nation's counties.
"The things that put you at highest risk for heart disease are not the
same as for stroke," Dr. Howard said. The main difference, he said, is
cholesterol. "The role of lipids is very large in heart disease," he
said, adding: "People think we eat badly in the South, but the worst
meal I ever had was at a deli in New York. I'd never heard of schmaltz
before that," referring to chicken fat.
Further muddying the waters, the measures for risks like cholesterol,
along with stress and high blood pressure, are widely acknowledged to
be flawed. Survey questions about whether a doctor has told you that
you have high cholesterol, or whether you feel depressed, are not as
simple as questions about smoking or weight and may not elicit reliable
results, researchers say.
Dr. Howard has begun a study, financed by the National Institutes of
Health, that is intended to help unravel some of the geographic
mystery, although it may take several years. Hundreds of volunteers in
New York and New Jersey will be part of an experiment involving 30,000
people nationwide.
Their blood pressure and cholesterol will be tested, and they will be
asked a battery of questions about stress - how often do you feel
unable to control things in your life, are you unable to cope with the
things you need to cope with? The city's health department is also
testing the blood pressure and cholesterol of 2,000 randomly selected
volunteers. The survey began in 2004; results may begin to come in
later this year.
The discordant rates for stroke and heart disease in the New York area
also lead some authorities to suggest that doctors and hospitals lump
deaths from other causes into heart disease categories.
"It may very well be that there's a practice of writing cardiovascular
disease on the death certificate for stroke," said Bob Anderson, chief
of the mortality statistics branch at the National Center for Health
Statistics.
Dr. David Ackman, the Nassau County health commissioner, agreed that
the answer could lie in record-keeping. "In New York State hospitals,
if they are more likely to list ischemic heart disease as the primary
cause than doctors in other places, you have to at least consider that
it is a coding issue and not a biological issue."
But others find that implausible.
Since Dr. Strogatz's study, which was based on death rates from the
1980's, there has been little change in New York's high rate of heart
disease death. "If geographic differences in mortality were due to
errors in coding, I would have expected those differences to change
over time as diagnostic methods improved," he said.
The answer may come soon. The Centers for Disease Control, at the
request of the city's health department, has a group of cardiologists
studying patient charts from a sample of 500 deaths in the city in
2004. They will judge the actual cause of death, and their results will
be compared with death certificates.
The variations will then be compared with what was found in a 2001
four-city study of the differences between death certificates and
patient charts. "If they're comparable, we know that this is a real
phenomenon," Dr. Thorpe said. "If not, then we know that there is
something about reporting that is aberrant to the rest of the country."
Copyright 2005 The New York Times Company Home Privacy Policy Search
Corrections XML Help Contact Us Work for Us Back to Top
.
- Prev by Date: Treatment of Lyme disease
- Next by Date: Illinois - Lyme disease
- Previous by thread: Treatment of Lyme disease
- Next by thread: Illinois - Lyme disease
- Index(es):
Relevant Pages
|
