Abstract
Purpose:
There are limited data on the relationship between neighborhood level factors and their association with lung health independent of individual socioeconomic status. We soughto determine whether baseline neighborhood level socioeconomic deprivation in young adults is associated with greater 20-year decline in lung function and higher risk of future lung disease, independent of baseline individual income, education, and smoking status.
Methods:
This multi-center population-based cohort study included 2689 CARDIA participants for whom neighborhood deprivation was determined at year 10 (baseline for study) and who had complete lung function measurements at years 10 and 30. Baseline neighborhood deprivation was defined using 1990 Census blocks as a combination of four factors involving median household income, poverty level, and educational achievement. The outcomes were decline in lung function over 20 years (year 10 to 30) and odds of emphysema (year 25).
Results:
In multivariable regression models, greater baseline neighborhood deprivation was associated with greater decline in lung function (−2.34 mL/year excess annual decline in FEV1 in the highest versus lowest deprivation quartile (p=0.014)). Furthermore, baseline neighborhood deprivation was independently associated with greater odds of emphysema (OR 2.99, 95% CI 1.42–6.30).
Conclusions:
Residence in neighborhoods with greater socioeconomic deprivation in young adulthood, independent of individual income and smoking, is associated with greater 20-year decline in FEV1 and higher risk of future emphysema.
Keywords: lung disease, population health, population characteristics, public health
Background:
Lung function is dependent on physiologic factors such as body habitus, age, and sex, and maximum pulmonary function is reached during the third decade of life.1 However, there is a growing body of evidence that a broader set of social determinants of health in early adulthood influence lung function. Lower socioeconomic status is associated with chronic obstructive pulmonary disease.2 Adults in Scotland with higher socioeconomic status had a higher forced expiratory volume in 1 second (FEV1) than adults with lower socioeconomic status independent of smoking.3 Previous cross-sectional studies have found social class, education level, and residential deprivation to be independent predictors of forced expiratory volume in 1 second (FEV1).4,5 Adults who were raised in lower socioeconomic status households have lower forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) (up to 160 mL and 110 mL respectively) independent of tobacco exposure.6
Beyond individual social determinants of health, neighborhood factors such as air pollution, walkability, access to healthcare, and residential segregation influence individual health behaviors and are associated with a variety of chronic health conditions including subclinical atherosclerosis, functional deterioration in the elderly, and coronary heart disease independent of individual socioeconomic status.7–11 Whether neighborhood socioeconomic deprivation is similarly associated with an accelerated decline in pulmonary function and greater risk of chronic lung disease over the life-course is unknown.
Using longitudinal data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, we examined the association of socioeconomic deprivation when participants were aged 28–40 years old with change in lung function over the subsequent 20 years and odds of future emphysema. We hypothesized that neighborhood socioeconomic deprivation is associated with greater decline in lung function and greater risk of emphysema independent of individual socioeconomic status and smoking.
Methods:
Study Design and Participants:
CARDIA recruited 5115 participants ages 18–30 years old from 1985–1986. Participants have been examined up to 8 times through 2015–2016 (30 years). Men and women were recruited via community-based strategies (random-digit telephone dialing and door-to-door) and population registries in Birmingham, AL, Chicago, IL, Minneapolis, MN, and from a health plan in Oakland, CA. The CARDIA study was approved by the IRB at each field center. Participants were recruited to include nearly equal number of individuals who self-identify as Black and White, men and women, individuals under 25 and above 25 years of age, and persons with a high-school education or less and more than a high school education at each center. Baseline data and interviews were conducted during 1985–1986. Participants followed up every 2–5 years for the next 30 years. Participants self-reported race and ethnicity. For the present analysis, we will use the 10 year follow-up examination (1995–96) as our baseline because it is the first year we have simultaneous assessment of our key measurements.
Retention rate at year 30 was 71% of the surviving participants. One participant withdrew consent, 1165 did not attend year 10 and 949 did not attend the year 30 visits. 269 participants were missing year 10 and 30 spirometry data. 40 participants were missing a year 10 covariate. 1 participant was missing year 30 body mass index (BMI) and 1 was missing data to calculate a neighborhood deprivation score. This left 2689 participants with complete data to calculate lung function decline over 30 years. 160 participants did not attend their year 25 visit and 214 did not have thoracic computed tomography scans, leaving data from 2315 participants to determine future risk of emphysema (Figure 1).
Figure 1.
Numbers of participants included based on availability of baseline and year 10, 25, and 30 follow-up data.
Neighborhood Deprivation
We defined neighborhood deprivation, as a composite score of four factors12–15 since deprivation is comprised of multiple separate factors that might influence health in different ways. As such this composite score is more comprehensive and includes multiple dimensions. The four factors included were median household income, proportion of population at or below the 150% federal poverty level, proportion of the population aged 25 or greater with less than a high school education, and proportion of the population aged 25 or greater with a college degree or higher. Data used to calculate the neighborhood deprivation score was drawn from US Census data in year 1990. Census-defined block groups were proxies for individuals’ neighborhoods based on year 10 home addresses. A composite z-score was calculated for each of these variables and summed for a neighborhood deprivation score. These scores were divided into four quartiles with the highest quartile indicating the greatest neighborhood deprivation.
Outcomes:
Standard spirometry procedures as recommended by the American Thoracic Society were followed at all examinations.16–19 Because of the young age of CARDIA participants at inception and the fact that a significant number of participants had not yet achieved peak lung health at the baseline of the study (1985–86) when they were 18–30 years old, we considered year 10 spirometry to be baseline as this reflects the time point where nearly all CARDIA participants had achieved their peak measured lung function over the course of the study20. Annual decline in lung function was estimated by subtracting the year 10 value from the year 30 value and dividing by 20 years for both the forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). Incident obstructive physiology was defined as FEV1/FVC < 0.70 at year 30 but not at year 10.
Thoracic computed tomography scans were obtained at year 25. Images were reviewed by three separate readers. The first reader reviewed all thescans and categorized them as either having emphysema or not. The second reader reviewed all the emphysema containing scans and a random sample of 10% of the remaining scans. A third reader settled any disagreements between the first two readers.20,21
Statistical Analysis
Multivariable linear regression models were used to test the association between year 10 neighborhood deprivation and lung function decline over 20 years. Covariates included baseline sex, race, field center, year 10 age, height, cigarettes smoked per day at year10, year10 body mass index (BMI), year 10 self-reported individual income, lung function, and year 10 self-reported asthma. Additional covariates included twenty-year change in body mass index (year 30 minus year 10), cumulative pack-years smoking at year 30, and maximum educational attainment. In one analysis, excess decline in lung function by neighborhood deprivation quartile was determined in reference to quartile 1, the least deprived quartile. An additional model treated neighborhood deprivation as a continuous predictor variable with change in lung function as the outcome.
Multivariable logistic regression was used to determine the association between year 10 neighborhood deprivation and incident obstructive physiology at year 30 and emphysema at year 25. Covariates included sex, race, and field center, age, cigarettes smoked per day at year 10, year 10 body mass index, year 10 self-reported individual income, year 10 self-reported asthma, maximum educational attainment, and cumulative pack-years smoking at year 25 for emphysema or year 30 for obstruction. Odds ratios were determined for quartiles of neighborhood deprivation in reference to the lowest quartile. An additional analysis treated neighborhood deprivation as a continuous predictor variable. All analyses were done in the whole cohort and stratified by race.
Results:
Participant characteristics:
Baseline demographic information is shown in Table 1. Of the 2689 participants, 44% were men, 56% were women, 46% were Black and 54% were White. Characteristics of participants who were excluded compared with those included are documented in the online supplement (Table E1). Participants living in neighborhoods with higher deprivation scores at baseline were more often Black, with the most deprived quartile having 82% Black population compared to 15% in the least deprived quartile. Participants living in neighborhoods with greater baseline neighborhood deprivation also reported lower individual income. Baseline lung function across all neighborhood deprivation quartiles was normal. However, lung function decline was higher for participants living in neighborhoods with high deprivation scores.
Table 1.
Baseline (CARDIA year 10) characteristics.
| Quartiles of Neighborhood Deprivation (baseline) (Z-score range) |
|||||
|---|---|---|---|---|---|
| Quartile 1 N=672 (−4.09 to <−1.18) |
Quartile 2 N=667 (−1.18 to <−0.44) |
Quartile 3 N=678 (−0.44 to <0.35) |
Quartile 4 N=672 (0.35 to <3.56) |
||
| Age, yr, (SD) | 35.9 (3.3) | 35.3 (3.5) | 34.9 (3.7) | 34.3 (3.8) | |
| Body mass index, kg/m2, (SD) | 25.8 (5.0) | 26.2 (5.3) | 28.0 (6.4) | 29.0 (7.0) | |
| Sex, F, n, % | 357 (53.1) | 351 (52.6) | 403 (59.4) | 405 (60.3) | |
| Race, black, n,% | 102 (15.2) | 222 (33.3) | 355 (52.4) | 548 (81.6) | |
| Smoking, n, (%) | Never | 425 (63.2) | 431 (64.6) | 410 (60.5) | 385 (57.3) |
| Former | 162 (24.1) | 120 (18.0) | 103 (15.2) | 72 (10.7) | |
| Current | 85 (12.7) | 116 (17.4) | 165 (24.3) | 215 (32.0) | |
| Cigarettes per day (year 10) | 1.4 (4.7) | 2.1 (5.8) | 3.2 (7.1) | 3.9 (7.6) | |
| Cumulative Pack years (year 30), (SD) | 4.1 (8.4) | 4.5 (9.7) | 5.9 (11.2) | 7.4 (12.4) | |
| Individual annual income, n, (%) | <$25,000 | 48 (7.1) | 108 (16.2) | 190 (28.0) | 298 (44.4) |
| $25–49,000 | 148 (22.0) | 226 (33.9) | 287 (42.3) | 253 (37.7) | |
| ≥$50,000 | 476 (70.8) | 333 (49.9) | 201 (29.7) | 121 (18.0) | |
| Maximum education, years, (SD) | 16.9 (2.3) | 16.4 (2.5) | 15.5 (2.6) | 14.7 (2.4) | |
| Self-reported asthma, n, (%) | 64 (9.5) | 76 (11.4) | 70 (10.3) | 78 (11.6) | |
| Forced Vital Capacity (FVC), % predicted (baseline), (SD) | 103 (11) | 103 (12) | 102 (13) | 101 (13) | |
| Forced Expiratory Volume in 1 second (FEV1), % predicted (baseline), (SD) | 100 (12) | 99 (12) | 99 (13) | 98 (14) | |
| Forced Vital Capacity (FVC) decline, mL/year, (SD) | −36.1 (17.8) | −36.0 (18.9) | −36.0 (19.6) | −36.8 (21.0) | |
| Forced Expiratory Volume in 1 second (FEV1) decline, mL/year, (SD) | −34.2 (14.8) | −33.7 (14.7) | −34.3 (16.3) | −36.0 (18.3) | |
Results are reported as mean (SD) unless otherwise specified. Quartiles go from least (quartile 1) to most (quartile 4) neighborhood deprivation. Definition of abbreviation: FVC = forced vital capacity; FEV1 = forced expiratory volume in 1 second
Adjusted decline in lung function:
In a multivariable model, neighborhood deprivation was associated with greater rate of decline of both forced expiratory volume in 1 second (−0.90 mL/year per increment change in deprivation score) and forced vital capacity (−0.75 mL/year per increment change in deprivation score) (Table 2). For forced expiratory volume in 1 second, the quartile with the highest deprivation had −2.34 mL/year of excess decline compared to quartile with least deprivation, quartile 1, (p=0.014). In the highest deprivation neighborhood (quartile 4), forced vital capacity was noted to decline at −1.64 mL/year in excess of the lowest deprivation quartile (p=0.14). When race-stratified analysis was conducted, similar direction of associations were seen among both Black and White participants, although only the association between neighborhood deprivation and forced expiratory volume in 1 second in Black participants was statistically significant (β=−1.17 mL/year, p=0.02).
Table 2.
Multivariable linear regression model for excess decline in lung function across quartiles of neighborhood socioeconomic deprivation score (referent to the lowest quartile of deprivation (quartile 1)) and beta-coefficients for the association treating the deprivation score as a continuous variable.
| Excess Decline in Lung Function (versus Quartile 1) | β coefficient (per unit change in deprivation score) | P value for β | ||||
|---|---|---|---|---|---|---|
| Quartile 2 | Quartile 3 | Quartile 4 | ||||
| Forced expiratory volume in 1 second (FEV1) (mL/y) | Whole Cohort | 0.64 | −0.038 | −2.34 * | −0.90 | 0.005 |
| White adults | 0.99 | −0.29 | −2.13 | −0.57 | 0.19 | |
| Black adults | −3.71 | −2.10 | −2.90 | −1.17 | 0.02 | |
| Forced vital capacity (FVC) (mL/y) | Whole Cohort | 0.57 | −0.034 | −1.64 | −0.75 | 0.043 |
| White adults | 0.92 | −0.27 | −2.20 | −0.51 | 0.31 | |
| Black adults | −4.82 | −3.17 | −2.93 | −0.95 | 0.09 | |
Model covariates: Age, race, sex, center, height, cigarettes per day (baseline), year 30 cumulative pack-years smoking, body mass index (baseline), change in body mass index (over 20 years), lung function (baseline), maximum educational attainment, self-reported asthma, and individual income (baseline).
P<0.05 vs. quartile 1 of neighborhood socioeconomic deprivation
Adjusted odds of future emphysema and obstruction:
In fully adjusted models in Table 3, we noted that neighborhoods in the quartile with highest deprivation had 2.99 higher odds of emphysema at year 25 (95% CI 1.36–5.93) compared to the lowest quartile, with similar associations seen in both Black and White participants. In the whole cohort, neighborhood deprivation was not associated with higher odds of incident airflow obstruction, although after stratification a significant association was seen in Black participants.
Table 3.
Multivariable logistic regression model for the association between neighborhood socioeconomic deprivation score and incident emphysema and airflow obstruction across deprivation quartiles (referent to the lowest quartile) as well as the association treating the deprivation scare as a continuous variable.
| Odds Ratio (95% CI) vs. Quartile 1 | Odds Ratio (95% CI) per unit change in deprivation score | ||||
|---|---|---|---|---|---|
| Quartile 2 | Quartile 3 | Quartile 4 | |||
| Emphysema (Year 25) |
Whole Cohort
(N=2315, Cases=151, 6.5%) |
1.71 (0.83 – 3.51)
N = 572 Cases = 29 |
1.65 (0.78 – 3.49)
N = 583 Cases = 35 |
2.99 (1.42 – 6.30)
N = 581 Cases = 73 |
1.44 (1.14–1.82) |
| White adults (N=1267, Cases=54, 4.3%) |
2.52 (1.0–6.36) N = 391 Cases = 19 |
3.06 (1.16–8.06) N = 283 Cases = 18 |
3.00 (0.94–9.58) N = 103 Cases = 9 |
1.41 (0.95–2.09) | |
| Black adults (N=1048, Cases=97, 9.7%) |
2.20 (0.92–5.30) N = 181 Cases = 10 |
1.53 (0.67–3.48) N = 300 Cases = 17 |
3.89 (1.48–10.21) N = 478 Cases = 64 |
1.51 (1.12–2.04) | |
| Airflow Obstruction (Year 30) |
Whole Cohort
(N=2525, Cases=252, 10.0%) |
0.90 (0.60 – 1.36)
N = 613 Cases = 53 |
1.00 (0.65 – 1.53)
N = 643 Cases = 61 |
1.47 (0.93 – 2.33) N = 638 Cases = 77 | 1.12 (0.96–1.32) |
| White adults (N=1357, Cases=147, 10.8%) |
0.95 (0.61–1.47) N = 404 Cases = 43 |
0.86 (0.52–1.42) N = 304 Cases = 33 |
0.77 (0.38–1.56) N = 114 Cases = 13 |
0.88 (0.70–1.10) | |
| Black adults (N=1168, Cases=105, 9.0%) |
0.51 (0.24–1.05) N = 209 Cases =10 |
1.00 (0.57–1.76) N = 339 Cases = 28 |
1.76 (0.87–3.57) N = 524 Cases = 64 |
1.61 (1.24–2.09) | |
Model covariates: Age, race, sex, center, cigarettes per day (baseline), cumulative pack-years smoking, body mass index (baseline), maximum educational attainment, physician-diagnosed asthma, and individual income (baseline).
Discussion:
In this prospective population-based cohort study, we report that participants who lived in the most socioeconomically deprived neighborhoods during early adulthood experienced an accelerated decline in lung function and higher odds of future emphysema over 20 years, independent of individual socioeconomic status, as well as cumulative smoking burden and change in body mass index over time. We report a stronger association in Black participants, possibly due to additional neighborhood level factors not captured in this study.
We defined neighborhood deprivation as a composite of four factors rather than any one of the single indicators, which is limitation of prior neighborhood based research. These particular four factors were chosen based on an exploratory factor analysis conducted on a larger set of neighborhood socioeconomic indicators and validated in previous studies.22 Furthermore, since neighborhood socioeconomic deprivation is a complex interaction of multiple factors that influence health along separate dimensions, using a composite deprivation score is a more comprehensive measure.
Few studies have examined the relationship between neighborhood deprivation and lung health, but there is some support of our findings in the literature. A cross-sectional study looking at neighborhood typologies based on a variety of indicators found that participants who resided in neighborhoods characterized as high poverty, mixed race, and a moderate-poor physical environment had lower lung function than those living in neighborhoods characterized as White, wealthy, and a good physical environment.23 Another cross-sectional study found participants living in socioeconomically deprived neighborhoods (based on occupation, education, and Townsend deprivation index) had significantly lower forced expiratory volume in 1 second than those living in less deprived areas, independent of individual socioeconomic status and smoking.4 There have been no other studies to our knowledge to examine the association between neighborhood socioeconomic deprivation on lung function longitudinally.
There are several pathways through which neighborhood socioeconomic deprivation could impact lung function. Neighborhood socioeconomic deprivation is often associated with congested housing settings and use of gas stoves which can impact respiratory health and lead to increased infection.24 In addition, previous studies have shown a disproportionate prevalence of higher tobacco use in lower socioeconomic neighborhoods and concomitant increase in chronic obstructive pulmonary disease.1–4 Moreover, secondhand smoke has also been shown to be an independent risk factor for chronic obstructive pulmonary disease.25,26 Individuals residing in higher deprivation neighborhoods may be inadvertently exposed to more secondhand smoke than those in lower deprivation neighborhoods, thus leading to poor lung function. Although our analysis adjusted for pack years smoked, we were not able to account for household, neighborhood, and occupational exposure to secondhand smoke. Exposure to neighborhood deprivation has also been tied to an increased cancer risk, and some data suggests it may be mediated through air pollution.27,28
Similar findings have been noted in the cardiovascular literature regarding cardiovascular disease outcomes and neighborhood deprivation. Although the exact biosocial pathway is not known, postulations have been made about increased prevalence of health damaging behaviors (i.e. physical inactivity and obesity) and their associations with cardiovascular disease outcomes29, which may also impact lung health. Indeed, physical inactivity also has been showed to be associated with impairments in respiratory health.30
Our study has several strengths. CARDIA is a population-based cohort which is relatively free from participation bias due to a high retention rate and allows us to ask questions about neighborhood deprivation and its associations with lung function independent of individual income. Furthermore, our baseline in this study, at mean age 28–40 years old, corresponds to an age of peak respiratory health and allows us to assess the impacts of neighborhood deprivation going forward from this period of maximum lung function. The ability to ascertain lung function decline over 20 years after this peak period in young adulthood is a unique feature of our study as is our ability to evaluate for emphysema as an important complement to the physiologic measures of spirometry. There are areas for further exploration in our study. We do not know the specific factors within neighborhoods which influence lung health, and this is an important area for future study. In addition, the magnitude of lung function declines we associate with neighborhood deprivation could be viewed as relatively small but is clinically relevant. The fact that neighborhood deprivation is associated with both decline in lung function and emphysema, however, lends credence to the physiologic significance of the estimated annual decline in lung function that we report.
Conclusion:
In a large, population-based cohort study of healthy adults, we report that residence in neighborhoods with greater deprivation during early adulthood is associated with a 20-year accelerated decline in lung function and higher odds of emphysema. Further studies to investigate the interplay of neighborhood and individual level factors on lung health are needed. These studies will also be informative for targeted interventions to improve lung health and intercept disease.
Supplementary Material
Clinical Significance.
In this population-based cohort, baseline neighborhood socioeconomic deprivation was associated with increased rate of lung function decline and increased odds of future emphysema and obstructive lung disease independent of individual socioeconomic status and smoking.
Residence in neighborhoods with higher socioeconomic deprivation is adversely associated with lung health independent of individual socioeconomic status over a 20 year period, and may represent a target for public health strategies to improve respiratory health.
Funding:
The CARDIA Lung study is funded by NHLBI (R01 HL122477). The Coronary Artery Risk Development in Young Adults Study (CARDIA) is conducted and supported by the National Heart, Lung, and Blood Institute (NHLBI) in collaboration with the University of Alabama at Birmingham (HHSN268201800005I & HHSN268201800007I), Northwestern University (HHSN268201800003I), University of Minnesota (HHSN268201800006I), and Kaiser Foundation Research Institute (HHSN268201800004I). This manuscript has been reviewed by CARDIA for scientific content.
Conflicts of Interest:
MTD reports grants from the American Lung Association, NIH, and Department of Defense and personal fees from AstraZeneca, GlaxoSmithKline, PulmonX, and Teva. SRR reports grants from the NIH, American Lung Association, and AstraZeneca and personal fees from GlaxoSmithKline. GRW reports grants from NIH, Boehringer Ingelheim, BTG Interventional Medicine, and Janssen Pharmaceuticals; personal fees from Boehringer Ingelheim, Janssen Pharmaceuticals, PulmonX, Novartis, Philips, Vertex, and is a co-founder and equity share holder of Quantitative Imaging Solutions; his spouse is an employee of Biogen. RK reports grants from the NIH and American Lung association, and personal fees from AstraZeneca, GlaxoSmithKline, and CVS Caremark. The remaining authors report no potential conflicts of interest related to this manuscript.
Footnotes
This article has an online data supplement (Table E1)
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