Health issues tied to income, environment in Knox County

May 04--Want to predict whether someone will die early?

Look at his health. Look at his wealth.

Look at his address.

That's the conclusion of a study done last month by Knox County Health Department, looking at people who die before the age of 75 -- what they die of, and where they live.

There's not much variation around causes of death. We die mostly of cancers, heart disease, accidents and the other things that kill people across the state and, for that matter, most of the rest of the country.

But in certain ZIP codes, you're much more likely to die sooner: The number of years of life lost from dying younger is five times higher in Knox County's poorest ZIP code than in its wealthiest.

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It's oversimplifying things to say premature death is higher in certain geographical locations -- if that were true, people could just move.

It's what's associated with these areas: income, education, safety, access to the things that can make and keep you healthier.

"It's the environment in which you live and work and play, or not play, that really impacts your health -- more than genetics, more than whether or not you have a doctor to go to," said Knox County Health Department Director Dr. Martha Buchanan. "Those social determinants of health are the ones that impact health more, and how do we, as a society, change that? If we improve the health of the least healthy, everybody's health improves, and we have an overall healthier community."

Over the next four Sundays, the News Sentinel will look at certain ZIP codes and their rates and causes of premature death. We'll also look at what's being done to improve health in those communities.

But first, let's look at what's more likely to kill Knox Countians early.

What's killing us?

Like the state as a whole, Knox County's top causes of death before age 75 are cancers. Cancers account for 27 percent of all premature deaths, followed by heart disease (17 percent) and unintentional injury (nearly 8 percent). Together, these three caused more than half of all premature deaths in Knox County in 2011 and in Tennessee in 2010. The statistics for those years are the most recent available.

Knox County had a higher percentage of death from chronic lower respiratory disease than the state overall did (6 percent vs. 3 percent), perhaps owing to our smoking rate and/or our valley location, which affects air quality.

Nearly 5 percent of Knox Countians who died younger than 75 died of liver disease (including hepatitis) and cirrhosis, which didn't make the state's Top 10. One percent in Knox County died of kidney disease, which didn't make the state's Top 10. Knox County fared better than the state average of losing younger people from birth complications (No. 5 on the state list) and homicide (No. 7). The state's and county's percentages of people younger than 75 lost to cerebrovascular disease (like strokes and brain aneurysms), diabetes and congenital abnormalities (birth defects) were comparable.

In 2011, 1,842 Knox County residents died before their 75th birthdays. That rate has been fairly stable for five years.

Epidemiologists look at premature death rates to see what diseases are affecting the community most, to help decide what public health priorities should be. They look at differences among genders and ethnicities as well.

For example, the overall rate of black Knox County residents who die before age 75 is higher than the rate of whites who do, a rate of 525.7 people per 100,000 vs. 459.2 per 100,000. White residents were more likely to die of chronic lower respiratory disease and suicide; black residents were much more likely to die young of homicide, sepsis and stroke.

Knox County men were much more likely than women to die before age 75, especially of suicide (5 percent vs. 1.7 percent) and homicide. Women were a little more likely to die of kidney disease or sepsis.

What are we losing?

Epidemiologists also use premature death to figure a community's years of potential life lost. This number represents the years someone who died younger than 75 otherwise would have been contributing to the community -- working, volunteering, parenting and interacting with others.

"Loss of productivity is not limited to that one household when a person dies early," Buchanan said.

Some of these deaths leave children parentless, or elderly parents and relatives without caregivers, said Dr. Kathy Brown, director of community assessment and health promotion for Knox County, whose department produced the study on premature death and years of potential life lost. That affects not only family members, but the community as a whole, if those left behind have to be financially or emotionally provided for.

"When people are dying early, it has this associated impact that's not always considered," Brown said.

Altogether, premature death costs Knox County about 33,662 years of potential life lost each year.

Though most of the deaths are from cancer, heart disease is a bigger contributor to years of potential life lost, because it takes people at younger ages, when they would have more years left to live.

People die before age 75 in every residential ZIP code in the county -- but it tends to be a larger percentage of residents from ZIP codes where most people's income is below Knox County's median.

Poorer people, poorer health

Study after study has linked poverty and poor health. Most people attribute that to access to medical care, and that can be one factor.

A 2012 survey by Knox County Health Department found a clear "gradient of health" for adults based on income.

Among people with an annual household income of less than $15,000 through $24,999, around 30 percent said they needed to see a doctor in the past year but could not because of cost, compared to 12 percent of those in the $35,000-$49,999 income bracket and just 4 percent of those with annual incomes of $50,000 or greater.

About 66 percent of the lowest income people said they hadn't visited a dentist in the past year, compared to 40 percent of those whose household income was $25,000-$34,999, a quarter of those who made $35,000-$49,000 and 14 percent of those who made $50,000 or more.

Among women 40 and older, 91 percent with a household income of $50,000 or more had a mammogram in the past two years, which gradually dropped to 71 percent of those in the lowest income bracket. About 60 percent of the lowest-income Knox County residents 50 and older had gotten a colonoscopy; it gradually climbed to around 75 percent as income levels increased.

Just 3 percent of those 18-64 with a household income of $50,000 or more reported having no health insurance. That went up to 24 percent in the $25,000-$34,999 income bracket and 40 percent in the $15,000-$24,999 bracket before dropping back down to 36 percent among the poorest, some of whom qualify for TennCare.

The Affordable Care Act may help level some of those numbers by putting many of the "working poor" on health insurance. The government is betting earlier intervention, especially in some of the chronic problems that plague the poor -- hypertension, diabetes, chronic obstructive pulmonary disease -- will save money by reducing the number of people who die early or become disabled.

But the answer to cutting the premature death rate is a lot more complex than just medical care.

Poverty and responsibility

Eat better, don't smoke, stay physically active, and you can be healthy.

Sounds simple, right?

And in many places, in many socioeconomic statuses, it is, Buchanan and Brown say. But there are also many places it's not.

Premature death and other health indicators "are explained by a very complex set of factors, and I worry when we simplify it by saying, 'Eat better, be active and don't smoke -- that's the formula,' " Brown said. "It is -- but there's a whole lot more to it."

Take food, for example. Eating lean meats, whole grains, fresh fruits and vegetables has a host of potentially good benefits, including decreasing cancer risk and obesity, which can raise the risk of hypertension, heart problems and diabetes.

"It's great in concept, but in reality, these people don't have the same access to healthy, nutritious foods that you or I might," Brown said. "It's not just dollars, but what does that infrastructure look like around their neighborhoods?"

If you lack reliable transportation, for example, getting to a grocery source other than the small store within walking distance takes time and planning. Plant a garden? Maybe, if you aren't working multiple jobs and parenting and have time to garden. Or if you live in a place that has space for you to garden, a place where your crops won't be stolen or vandalized. "Community gardens," where several families share the work and the harvest, are becoming more popular in Knox County, but they aren't everywhere.

Food "commodities" issued to the poor are only now getting healthier, Buchanan said.

"They go a long way, but do they really provide the nutrition?" she said. Only within the past decade has WIC (the supplemental nutrition program for Women, Infants and Children) added fruits and vegetables.

Sometimes it does just come down to cost, and convenience, she added.

"It's not that people don't know that they should eat healthy," she said. "It's that I'm looking at $5, and that bag of fish sticks is going to feed my family longer than that head of broccoli. That's a really simplified version of what people face."

Nonprofits and government agencies alike offer "healthy cooking on a budget" classes, especially for families with young children, but adults have to have both the interest and the ability to attend.

Exercise, too, is easier when people can drive to a fitness club, or a safe, well-lighted park. It's not impossible otherwise, of course -- it just takes much more effort and may be a lower priority in the shuffle of daily living, Buchanan said.

Does poverty contribute to poor health? Studies suggest it does. Poverty can cause stress, which can definitely affect health, Buchanan said.

"People in poverty have a level of stress that a lot of us don't know anything about," she said. "I personally have never wondered where my next meal was coming from. Am I going to be able to feed my kids every day this week? Most of us do not live that way, and haven't lived that way in a long time."

Snow days can be especially challenging for people who rely on the free lunch program to feed their children, she said. KCHD's 2012 study found 31 percent of people with a household income of less than $15,000, and 20 percent of people whose household income was $15,000-$24,999, said they were "always or usually stressed about having enough money to buy nutritious meals."

"It's not just about practicing yoga to reduce your stress," Brown said. "It's constantly living in an environment of 'Are my lights going to be shut off,' 'Am I going to get shot when I walk outside,' 'Am I going to have money for food for my kids,' 'Is my car going to hold up?' You can almost see it on the faces of people; you can know right away that they're dealing with that weight."

Knox County's median household income in 2010 was $42,270, according to the U.S. Census. Excluding the University of Tennessee, eight ZIP codes have a median household income lower than this benchmark. In the poorest, East Knoxville's 37915, the median household income is $9,732.

With the exception of Northeast Knox County's 37924, which had a median household income of $47,411 but the second-highest rate of years of potential life lost, all the ZIP codes with higher income levels had lower years of potential life lost in 2011.

So if you live in a higher-income ZIP code, where fewer people are dying before age 75, how does people dying younger in poorer ZIP codes affect you?

To be blunt, "they work for me," if I'm a higher-income resident, Buchanan said. "Maybe they're not employed by me, but they probably provide something I benefit from.

"We're losing overall productivity in our community, from everything from people who aren't at work anymore because they're no longer living, to people who don't realize their full potential because of health problems."

MAKE KNOX COUNTY HEALTHIER

What ideas do you have to make Knox County healthier? Where do you see room to improve?

The Knox County Health Department's Health and Quality of Life Survey gives you a chance to share.

Conducted online and at various community events through the end of May, the survey is part of a yearlong assessment process that includes interviews, focus groups and other means of data collection. The process is designed to yield a wide range of information, including opinions about access to affordable food, health education information, physical activity and mental health services, as well as views about the county's health issues, the quality of the environment and safety. The health department will use the data to compile reports, and other nonprofits will use it to develop or evaluate programs.

Find it online at www.knoxcounty.org/health/public_health_assessment.php.

These assessments are administered every five years. Previous reports are available online at www.healthyknox.org.

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