The association of personal and neighborhood socioeconomic indicators with subclinical cardiovascular disease in an elderly cohort. The cardiovascular health study

Socioeconomic status and subclinical atherosclerosis in older adults

OBJECTIVE

This study investigated the long-term effects of socioeconomic status (SES) on atherosclerosis.

METHODS

Data from the Epidemiology of Hearing Loss Study and the Beaver Dam Eye Study (Beaver Dam, WI, 1998-2000), were used to examine adult SES (education, household income, and longest-held job) and childhood SES (household density and parental home ownership at age 13) associations with carotid intima-media thickness (IMT) and carotid plaque in a cohort of 2042 men and women aged 53 to 94 years.

RESULTS

For education, income, and occupation (women), those in the lowest SES group had statistically larger age-sex-adjusted IMT than those in the highest SES group (<12 vs. >12 years education: 0.92 vs. 0.86 mm respectively, P<0.0001), (<$10,000 vs. >$45,000: 0.97 vs. 0.87 mm, P<0.0001), (operator/fabricator/labor vs. manager/professional: 0.89 vs. 0.82 mm, P<0.001). Associations were similar using carotid plaque as the outcome. Participants with low levels of both adult and childhood SES measures had age-sex-adjusted IMT greater than those with persistently high levels of SES (0.93 vs. 0.84 mm, P<0.0001).

CONCLUSIONS

Measures of SES at two points in the life-span were associated with subclinical atherosclerosis.

Socioeconomic status in one's childhood predicts offspring cardiovascular risk

OBJECTIVE

To test whether effects of socioeconomic environments can persist across generations, we examined whether parents' childhood socioeconomic status (SES) could predict blood pressure (BP) trajectories in their youth across a 12-month study period and C-reactive protein (CRP) levels at one year follow-up.

METHODS

BP was assessed in 88 healthy youth (M age = 13 ± 2.4) at three study visits, each 6 months apart. CRP was also assessed in youth at baseline and one year follow-up. Parents reported on current and their own childhood SES (education and crowding).

RESULTS

If parents' childhood SES was lower, their children displayed increasing SBP and CRP over the 12-month period, or conversely, the higher parents' childhood SES, the greater the decrease in SBP and CRP in their youth over time. These effects persisted even after controlling for current SES. A number of other factors, including child health behaviors, parent psychosocial characteristics, general family functioning, and parent physiology could not explain these effects.

CONCLUSION

Our study suggests that the SES environment parents grow up in may influence physical health across generations, here, SBP and CRP in their children, and hence that intergenerational histories are important to consider in predicting cardiovascular health in youth.

Neighbourhood socioeconomic status and biological 'wear and tear' in a nationally representative sample of US adults

OBJECTIVE

To assess whether neighbourhood socioeconomic status (NSES) is independently associated with disparities in biological 'wear and tear' measured by allostatic load in a nationally representative sample of US adults.

DESIGN

Cross-sectional study.

SETTING

Population-based US survey, the Third National Health and Nutrition Examination Survey (NHANES III), merged with US census data describing respondents' neighbourhoods.

PARTICIPANTS

13,184 adults from 83 counties and 1805 census tracts who completed NHANES III interviews and medical examinations and whose residential addresses could be reliably geocoded to census tracts.

MAIN OUTCOME MEASURES

A summary measure of biological risk, incorporating nine biomarkers that together represent allostatic load across metabolic, cardiovascular and inflammatory subindices.

RESULTS

Being male, older, having lower income, less education, being Mexican-American and being both black and female were all independently associated with a worse allostatic load. After adjusting for these characteristics, living in a lower NSES was associated with a worse allostatic load (coefficient -0.46; CI -0.079 to -0.012). The relationship between NSES and allostatic load did not vary significantly by gender or race/ethnicity.

CONCLUSIONS

Living in a lower NSES in the USA is associated with significantly greater biological wear and tear as measured by the allostatic load, and this relationship is independent of individual SES characteristics. Our findings show that where one lives is independently associated with allostatic load, thereby suggesting that policies that improve NSES may also yield health returns.

Do neighborhood socioeconomic deprivation and low social cohesion predict coronary calcification?: the CARDIA study

Growing evidence suggests that neighborhood characteristics may influence the risk of coronary heart disease. No studies have yet explored associations of neighborhood attributes with subclinical atherosclerosis in younger adult populations. Using data on 2,974 adults (1,699 women, 1,275 men) aged 32-50 years in 2000 from the Coronary Artery Disease Risk Development in Young Adults (CARDIA) Study and 2000 US Census block-group-level data, the authors estimated multivariable-adjusted associations of neighborhood socioeconomic deprivation and perceived neighborhood cohesion with odds of coronary artery calcification (CAC) 5 years later. Among women, the quartiles of highest neighborhood deprivation and lowest cohesion were associated with higher odds of CAC after adjustment for individual-level demographic and socioeconomic factors (for deprivation, odds ratio = 2.49, 95% confidence interval: 1.22, 5.08 (P for trend = 0.03); for cohesion, odds ratio = 1.87, 95% confidence interval: 1.10, 3.16 (P for trend = 0.02)). Associations changed only slightly after adjustment for behavioral, psychosocial, and biologic factors. Among men, neither neighborhood deprivation nor cohesion was related to CAC. However, among men in deprived neighborhoods, low cohesion predicted higher CAC odds (for interaction between neighborhood deprivation and cohesion, P = 0.03). This study provides evidence on associations of neighborhood deprivation and cohesion with CAC in younger, asymptomatic adults. Neighborhood attributes may contribute to subclinical atherosclerosis.

Neighborhood and weight-related health behaviors in the Look AHEAD (Action for Health in Diabetes) study

Background

Previous studies have shown that neighborhood factors are associated with obesity, but few studies have evaluated the association with weight control behaviors. This study aims to conduct a multi-level analysis to examine the relationship between neighborhood SES and weight-related health behaviors.

Methods

In this ancillary study to Look AHEAD (Action for Health in Diabetes) a trial of long-term weight loss among individuals with type 2 diabetes, individual-level data on 1219 participants from 4 clinic sites at baseline were linked to neighborhood-level data at the tract level from the 2000 US Census and other databases. Neighborhood variables included SES (% living below the federal poverty level) and the availability of food stores, convenience stores, and restaurants. Dependent variables included BMI, eating patterns, weight control behaviors and resource use related to food and physical activity. Multi-level models were used to account for individual-level SES and potential confounders.

Results

The availability of restaurants was related to several eating and weight control behaviors. Compared to their counterparts in neighborhoods with fewer restaurants, participants in neighborhoods with more restaurants were more likely to eat breakfast (prevalence Ratio [PR] 1.29 95% CI: 1.01-1.62) and lunch (PR = 1.19, 1.04-1.36) at non-fast food restaurants. They were less likely to be attempting weight loss (OR = 0.93, 0.89-0.97) but more likely to engage in weight control behaviors for food and physical activity, respectively, than those who lived in neighborhoods with fewer restaurants. In contrast, neighborhood SES had little association with weight control behaviors.

Conclusion

In this selected group of weight loss trial participants, restaurant availability was associated with some weight control practices, but neighborhood SES was not. Future studies should give attention to other populations and to evaluating various aspects of the physical and social environment with weight control practices.

Trajectories of neighborhood poverty and associations with subclinical atherosclerosis and associated risk factors: the multi-ethnic study of atherosclerosis

The authors used data from the Multi-Ethnic Study of Atherosclerosis and latent trajectory class modeling to determine patterns of neighborhood poverty over 20 years (1980-2000 residential history questionnaires were geocoded and linked to US Census data). Using these patterns, the authors examined 1) whether trajectories of neighborhood poverty were associated with differences in the amount of subclinical atherosclerosis (common carotid intimal-media thickness) and 2) associated risk factors (body mass index, hypertension, diabetes, current smoking) at baseline (January 2000-August 2002). The authors found evidence of 5 stable trajectory groups with differing levels of neighborhood poverty ( approximately 6%, 12%, 20%, 30%, and 45%) and 1 group with 29% poverty in 1980 and approximately 11% in 2000. Mostly for women, higher cumulative neighborhood poverty was generally significantly associated with worse cardiovascular outcomes. Trends generally persisted after adjustment for adulthood socioeconomic position and race/ethnicity, although they were no longer statistically significant. Among women who had moved during the 20 years, the long-term measure had stronger associations with outcomes (except smoking) than a single, contemporaneous measure. Results indicate that cumulative 20-year exposure to neighborhood poverty is associated with greater cardiovascular risk for women. In residentially mobile populations, single-point-in-time measures underestimate long-term effects.

Disparities in vascular surgery: is it biology or environment?

Disparities in health care are well documented for several racial, ethnic, and gender groups. In peripheral arterial disease, differences in prevalence, treatment selection, treatment outcomes, and resulting quality of life have negative effects on some minority groups and women. It may be easy to document disparities, but it is harder to understand their underlying causes. Are there biologic differences between members of racial and ethnic groups that influence disease presentation and outcomes? Or is the socioeconomic environment that surrounds them the true driver of observed differences? This article reviews the evidence for racial and gender disparities in vascular surgery and presents some potential mechanisms that may explain the disparities.

Socio-economic status, place of residence and dietary habits among the elderly: the Mediterranean islands study

OBJECTIVE

To investigate whether the socio-economic status (SES) of elderly eastern Mediterranean islanders is associated with their dietary habits, particularly with adherence to the traditional Mediterranean diet.

DESIGN

Cross-sectional.

SETTING

Adherence to the Mediterranean diet was measured by the MedDietScore (range: 0-55), whereas SES was estimated using education and financial status.

SUBJECTS

During 2005-2007, 300 men and women from Cyprus, 100 from Samothraki, 142 from Mitilini, 114 from Kefalonia, 131 from Crete, 150 from Lemnos, 150 from Corfu and 103 from Zakynthos (aged 65-100 years), free of known chronic diseases, participated in the survey.

RESULTS

Multiple linear regression analysis revealed that belonging to the highest SES was associated with a higher MedDietScore (P < 0.01), after adjusting for potential sociodemographic, lifestyle, dietary and clinical confounders. A significant positive association was also found between MedDietScore and years of school (P = 0.004), as well as financial status (P = 0.001).

CONCLUSIONS

Older Greek people of higher SES seem to follow a relatively healthier diet. Both education and income seem to play a role in this issue. Thus, public health policy makers should focus on people with low SES in order to improve their quality of diet and, consequently, their health status.

Neighborhoods and chronic disease onset in later life

OBJECTIVES

To strengthen existing evidence on the role of neighborhoods in chronic disease onset in later life, we investigated associations between multiple neighborhood features and 2-year onset of 6 common conditions using a national sample of older adults.

METHODS

Neighborhood features for adults aged 55 years or older in the 2002 Health and Retirement Study were measured by use of previously validated scales reflecting the built, social, and economic environment. Two-level random-intercept logistic models predicting the onset of heart problems, hypertension, stroke, diabetes, cancer, and arthritis by 2004 were estimated.

RESULTS

In adjusted models, living in more economically disadvantaged areas predicted the onset of heart problems for women (odds ratio [OR] = 1.20; P < .05). Living in more highly segregated, higher-crime areas was associated with greater chances of developing cancer for men (OR = 1.31; P < .05) and women (OR = 1.25; P < .05).

CONCLUSIONS

The neighborhood economic environment is associated with heart disease onset for women, and neighborhood-level social stressors are associated with cancer onset for men and women. The social and biological mechanisms that underlie these associations require further investigation.

[Longitudinal studies on aging: past, present and future]

Longitudinal studies on aging have played an important role in the development of gerontology and geriatrics, and have multiplied in the last 30 years. This is related to methodological advantages of this type of design and to issues closely connected to geriatrics itself. The understanding of the complex process of aging and its associated clinical and functional consequences, which are usually slow, requires a sufficiently long observation and follow-up. In this article, along with historical and methodological aspects, we examine possible future lines development for longitudinal studies on ageing.

Does the Relationship Between Neighborhood Socioeconomic Status and Health Outcomes Persist Into Very Old Age? A Population-Based Study

Objective: The purpose of this article is (a) to extend previous research on the relationship between neighborhood socioeconomic status (SES) and health by considering a wide range of health-related measures derived from administrative health care records and (b) to explore whether this relationship persists into old age. Method: The study involved a complete cohort of community-dwelling residents in Winnipeg, Canada, who were 65 years or older in 2004/2005 ( N = 77,930). Health measures were derived from administrative claims data. Census data were used to derive neighborhood-level SES. Results: Multilevel logistic regressions indicated that, relative to individuals living in the most affluent areas, those in the poorest areas had significantly higher odds of having arthritis, diabetes, hypertension, congestive heart failure, ischemic heart disease, chronic obstructive pulmonary disease, depression, and stroke. Significant neighborhood income effects tended to be evident among individuals age 65 to 75 as well as those age 75+. Discussion: A wide range of health conditions among older adults are disproportionately clustered into the poorest areas. Programs and services should be designed to meet the needs of older adults of any age in such neighborhoods.

Associations of environmental factors with elderly health and mortality in China

OBJECTIVES

We examined the effects of community socioeconomic conditions, air pollution, and the physical environment on elderly health and survival in China.

METHODS

We analyzed data from a nationally representative sample of 15 973 elderly residents of 866 counties and cities with multilevel logistic regression models in which individuals were nested within each county or city.

RESULTS

After control for individual-level factors, communities' gross domestic product per capita, adult labor force participation rate, and illiteracy rate were significantly associated with physical, mental, and overall health and mortality among the elderly in China. We also found that air pollution increased the odds of disability in activities of daily living (ADLs), cognitive impairment, and health deficits; more rainfall was protective, reducing the odds of ADL disability and cognitive impairment; low seasonal temperatures increased the odds of ADL disability and mortality; high seasonal temperatures increased the odds of cognitive impairment and deficits; and living in hilly areas decreased the odds of ADL disability and health deficits.

CONCLUSIONS

Efforts to reduce pollution and improve socioeconomic conditions could significantly improve elderly health and survival.

Investigating the spatial variability in incidence of coronary heart disease in the Gazel cohort: the impact of area socioeconomic position and mediating role of risk factors

STUDY OBJECTIVE

The aim of the study was to improve understanding of the relationships between contextual socioeconomic characteristics and coronary heart disease (CHD) incidence in France. Several authors have suggested that CHD risk factors (diabetes, hypertension, cholesterol, overweight, tobacco consumption) may partly mediate associations between socioeconomic environmental variables and CHD. Studies have assessed the overall mediating role of CHD risk factors, but have never investigated the specific mediating role of each risk factor, not allowing their specific contribution to the area socioeconomic position-CHD association to be disentangled.

DESIGN

After assessing geographical variations in CHD incidence and socioeconomic environmental effects on CHD using a multilevel Cox model, the extent to which this contextual effect was mediated by each of the CHD risk factors was assessed.

PARTICIPANTS

Data of the French GAZEL cohort (n=19,808) were used.

MAIN RESULTS

After adjustment for several individual socioeconomic indicators, it was found, in men from highly urbanised environments, that CHD incidence increased with decreasing socioeconomic position of the residential environment. After individual-level adjustment, a higher risk of obesity, smoking and cholesterol was observed in the most deprived residential environments. When risk factors were introduced into the model, a modest decrease was observed in the magnitude of the association between the socioeconomic contextual variable and CHD. Risk factors that contributed most to the decrease of the association were smoking and cholesterol.

CONCLUSIONS

Classic risk factors, although some of them more than others, mediated a modest part of the association between area socioeconomic position and CHD.

Neighborhood environment in studies of health of older adults: a systematic review

CONTEXT

Epidemiologists and public health researchers are studying neighborhood's effect on individual health. The health of older adults may be more influenced by their neighborhoods as a result of decreased mobility. However, research on neighborhood's influence on older adults' health, specifically, is limited.

EVIDENCE ACQUISITION

Recent studies on neighborhood and health for older adults were identified. Studies were identified through searches of databases including PsycINFO, CINAHL, PubMed, Academic Search Premier, Ageline, Social Science Citation Index, and Health Source. Criteria for inclusion were as follows: human studies; English language; study sample included adults aged > or =55 years; health outcomes, including mental health, health behaviors, morbidity, and mortality; neighborhood as the primary exposure variable of interest; empirical research; and studies that included > or =10 neighborhoods. Air pollution studies were excluded. Five hundred thirty-eight relevant articles were published during 1997-2007; a total of 33 of these articles met inclusion criteria.

EVIDENCE SYNTHESIS

The measures of objective and perceived aspects of neighborhood were summarized. Neighborhood was primarily operationalized using census-defined boundaries. Measures of neighborhood were principally derived from objective sources of data; eight studies assessed perceived neighborhood alone or in combination with objective measures. Six categories of neighborhood characteristics were socioeconomic composition, racial composition, demographics, perceived resources and/or problems, physical environment, and social environment. The studies are primarily cross-sectional and use administrative data to characterize neighborhood.

CONCLUSIONS

These studies suggest that neighborhood environment is important for older adults' health and functioning.

Do socioeconomic gradients in subclinical atherosclerosis vary according to acculturation level? Analyses of Mexican-Americans in the multi-ethnic study of atherosclerosis

OBJECTIVE

To examine whether the association between socioeconomic position (SEP) and subclinical atherosclerosis in Mexican-Americans would be moderated by acculturation. Although SEP shows a consistent, inverse relationship with cardiovascular disease (CVD) risk in westernized non-Hispanic white populations, the relationship in ethnic minorities, including Hispanics, is often weak or even reversed (i.e., worse health with higher SEP).

METHODS

Participants were 801 Hispanics of Mexican origin (49.6% = female; average age = 60.47 years) from the Multi-Ethnic Study of Atherosclerosis cohort who underwent computed tomography of the chest for coronary artery calcium (CAC) and thoracic aortic calcium (TAC). SEP was represented by a composite of self-reported education and income. Acculturation was a composite score, including language spoken at home, generation, and years of "exposure" to U.S. culture.

RESULTS

Small but statistically significant SEP by acculturation interaction effects were identified in relation to prevalent CAC, prevalent TAC, and extent of TAC (all p < .05). Follow-up analyses revealed that the direction of the SEP gradient on detectable CAC changed as individuals progressed from low to high acculturation. Specifically, the association between SEP and calcification was positive at low levels of acculturation (i.e., a "reversed" gradient), and negative in circumstances of high acculturation (i.e., the expected, protective effect of higher SEP).

CONCLUSIONS

The findings support the utility of examining SEP and acculturation simultaneously, and of disaggregating large ethnic groupings (e.g., "Hispanic") into meaningful subgroups to better understand health risks.

Geographic life environments and coronary heart disease: a literature review, theoretical contributions, methodological updates, and a research agenda

A growing literature investigates associations between neighborhood social environments and coronary heart disease (CHD). After reviewing the literature, we present a theoretical model of the mechanisms through which geographic life environments may influence CHD, focusing particularly on the social-interactional environment. We suggest that, in addition to the common notions of social cohesion or fragmentation and social disorder, eco-epidemiologists should consider neighborhood identities and stigmatization processes. We posit that neighborhood social interactions affect the wide set of affective, cognitive, and relational experiences individuals have in their neighborhoods, which in turn influence the psycho-cognitive antecedents of behavior and in the end shape health behavior. Finally, we discuss key methodological challenges relevant to the advent of a new generation of neighborhood studies, including the operational definition of neighborhoods, non-residential environments, ecometric measurement, model specification strategies, mediational models, selection processes and notions of empirical/structural confounding, and the relevance of observational versus interventional studies.

Environments for healthy ageing: a critical review

Population health outcomes are shaped by complex interactions between individuals and the environments in which they live, work and play. Environments encompass streets and buildings (physical environment), attitudes, supports and relationships with others (social environment), as well as social and political systems and policies. The impact of environments on the physical, mental health and functioning of individuals has emerged as a growing body of research in population health and health disparities. Yet, the majority of studies in this area do not focus on older adults even though older adults are particularly susceptible to the characteristics of their local environments. In this paper we review the current state of the health literature on physical environments for healthy ageing, using the International Classification of Functioning Disability and Health as a framework. Collectively, the literature emphasizes the role of supportive, barrier-free environments particularly for older adults who are at greater risk for disability and poor health. As part of our review we identify conceptual as well as methodological limitations in the current literature, including (i) a theoretical and empirical neglect of the underlying mechanisms behind the person-environment relationship; (ii) a lack of studies using nationally representative samples; (iii) over-reliance on cross-sectional data; and (iv) a need for better definition and measurement of person-centered environments. We conclude by offering some suggestions and directions for future research in this area.

Socioeconomic status and the course of quality of life in older patients with coronary heart disease

Background

Previous research suggests that socioeconomic status (SES) might be related to the course of quality of life (QoL) in coronary heart disease (CHD) patients. The authors sought to determine whether there are differences in the course of QoL before and after the incidence of CHD among older persons of differing SES.

Method

Two hundred two CHD patients were followed up longitudinally using a community-based survey. Data on patients’ QoL were collected before the diagnosis and at three follow-up assessments.

Results

High SES patients reported better outcomes at the premorbid assessment with fewer depressive feelings and better physical functioning. In physical functioning, similar results were repeated 6 and 12 months after the diagnosis. Additionally, high SES patients showed better role and social functioning 1 year after CHD. A multivariate analysis of variance revealed differential longitudinal pathways in relation to SES in role, social, and physical functioning.

Conclusion

CHD modulates premorbid differences in depressive feelings. Conversely, high SES leads to better outcomes in all functional domains in the long-term after diagnosis. Postmorbid differences in physical functioning are not directly related to CHD, but rather the reestablishment of a premorbid situation. In contrast, socioeconomic inequalities in social and role functioning are a direct response to the impact of the disease.

Frailty and mortality among Chinese at advanced ages

OBJECTIVES

This study investigates the factors associated with frailty and the association of frailty with mortality in a national sample of adults aged 65-109 in China.

METHODS

Using the 2002 wave of the Chinese Longitudinal Healthy Longevity Survey, we construct a frailty index (FI) based on 39 measures available in the data set. We use ordinal logistic regressions to examine the factors associated with the FI and use Weibull hazard regression to examine the association between frailty and 3-year mortality from 2002 to 2005.

RESULTS

Age, sex, ethnicity, urban-rural residence, economic condition, religious involvement, and daily exercise are significantly associated with levels of frailty. Hazard analyses further reveal that the FI is a robust predictor of mortality at advanced ages and that the relationship between frailty and mortality is independent of various covariates. Discussion The measurement and analysis of frailty have broad implications for public health initiatives designed to target individuals with the diminished capacity to effectively compensate for external stressors and to prevent further declines associated with aging and mortality. A key to healthy longevity is the prevention, postponement, and potential recovery from physical and cognitive deficits at advanced ages through enhanced medical interventions and treatments.

Life-course socioeconomic positions and subclinical atherosclerosis in the multi-ethnic study of atherosclerosis

A major limitation of past work on the social patterning of atherosclerosis has been the reliance on measures of neighborhood or individual-level socioeconomic position (SEP) assessed at a single point in time in adulthood. Risk of chronic disease is thought to accumulate throughout the life-course, so the use of a measure for a single point in time may result in inaccurate estimates of the social patterning of subclinical disease. Using data from the US Multi-Ethnic Study of Atherosclerosis (MESA), we examined the relation between childhood SEP [CSEP] (father or caretaker's education), adulthood SEP [ASEP] (a summary score of income, education, and wealth), and 20-year average exposure to neighborhood poverty [NSEP] (residential addresses geocoded and linked to census data) and the prevalence of subclinical atherosclerosis, as assessed by common carotid intimal-medial thickness (IMT) in mid to late adulthood. Participants were 45-84 years of age at baseline and were sampled from six study sites in the United States. After adjustment for age, CSEP and ASEP were both inversely and independently associated with IMT in men. All three indicators CSEP, ASEP, and NSEP were inversely and independently associated with IMT in women. Associations were somewhat reduced after adjustment for cardiovascular risk factors, suggesting that these factors may play a mediating role. There was evidence of heterogeneity in effects of NSEP by gender, and in the effects of ASEP and NSEP by race/ethnicity. Our results contribute to the growing body of work that shows that SEP at multiple points in the life-course, and at the individual and neighborhood level, contributes to the development of atherosclerosis.

Individual and neighborhood socioeconomic status characteristics and prevalence of metabolic syndrome: the Atherosclerosis Risk in Communities (ARIC) Study

OBJECTIVE

The objective of this study was to examine the association of individual socioeconomic status (iSES) and neighborhood SES (nSES) on the prevalence of metabolic syndrome (MetS) in the Atherosclerosis Risk in Communities Study (1987-1999).

METHODS

Participants included 2932 black and 9777 white men and women aged 45 to 64 years without diabetes at baseline. Total combined family income for the past 12 months and six census tract socioeconomic measures combined into a composite index were used to quantify iSES and nSES, respectively. Poisson regression was used to assess associations of the joint contribution of iSES and nSES on the MetS, stratified by gender and race and adjusting for multiple covariates. For analyses that included nSES, hierarchical modeling techniques were used.

RESULTS

Using 2005 Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults criteria, MetS was identified in 40% of black women, 30% of white women, 28% of black men, and 35% of white men. Among black and white men, there was no association between MetS and iSES or nSES. In contrast, after adjustment for risk factors, black and white women with low (L)-iSES and medium (M)-iSES were more likely to have MetS than those with high (H)-iSES. Similar but weaker patterns were noted for L-nSES and M-nSES.

CONCLUSIONS

In summary, both iSES and nSES were independently associated with an increased prevalence of MetS among women but not men. Efforts aimed at understanding the causes of these gender differences may offer insight into avenues for reducing the prevalence of the MetS and its chronic disease sequelae.

Subclinical coronary atherosclerosis and neighbourhood deprivation in an urban region

Inhabitants of deprived neighbourhoods are at higher risk of coronary heart disease. In this study we investigate the hypothesis that social inequalities at neighbourhood level become already manifest in subclinical coronary atherosclerosis, as defined by electron-beam computed tomography derived measures. Coronary artery calcification was assessed as a marker of atherosclerosis in a population based sample of 4301 men and women (45-75 years) without a history of coronary heart disease. Participants lived in three adjacent cities in Germany and were examined between 2000 and 2003 as part of the Heinz Nixdorf Recall Study. Individual level data was combined with neighbourhood level information about unemployment, welfare and living space per inhabitant. This dataset was analysed with descriptive and multilevel regression methods. An association between neighbourhood deprivation and subclinical coronary calcification was observed. After adjustment for age and individual socioeconomic status male inhabitants of high unemployment neighbourhoods had an odds ratio of 1.45 (1.11, 1.96) of exhibiting a high calcification score (>75th percentile) compared to men living in low unemployment areas. The respective odds for women was 1.29 (0.97, 1.70). Additional explorative analyses suggest that clustering of unhealthy lifestyles in deprived neighbourhoods contributes to the observed association. In conclusion, findings suggest that certain neighbourhood characteristics promote the emergence of coronary atherosclerosis. This might point to a pathway from neighbourhood deprivation to manifest coronary heart disease.

Neighborhood psychosocial hazards and cardiovascular disease: the Baltimore Memory Study

OBJECTIVES

We examined associations between cardiovascular disease and neighborhood psychosocial hazards, such as violent crime, abandoned buildings, and signs of incivility, to evaluate whether features of place are associated with older adult health.

METHODS

We analyzed first-visit data from the Baltimore Memory Study of randomly selected residents aged 50 to 70 years (n=1140) of 65 contiguous neighborhoods in Baltimore, Maryland. We looked for associations between self-reports of history of selected cardiovascular diseases and scores on the 12-item neighborhood psychosocial hazards scale.

RESULTS

After adjustment for established individual risk factors for cardiovascular disease, residents in neighborhoods with scores in the highest quartile of the psychosocial hazards scale had more than 4 times higher odds of a history of myocardial infarction and more than 3 times higher odds of myocardial infarction, stroke, transient ischemic attack, or intermittent claudication compared with residents living in neighborhoods scoring in the lowest quartile.

CONCLUSIONS

Neighborhood psychosocial hazards were significantly associated with self-reported cardiovascular disease after adjustment for individual-level risk factors. This is consistent with the hypothesis that environmental stress plays a role in the etiology of cardiovascular disease.

Community socioeconomic status is associated with circulating interleukin-6 and C-reactive protein

OBJECTIVE

To examine the association of both individual and community socioeconomic status (SES) with inflammatory mediators relevant to cardiovascular pathophysiology, i.e., interleukin (IL)-6 and C-reactive protein (CRP), in a midlife community sample. Growing evidence suggests that socioeconomic attributes of both individuals and communities confer risk for cardiovascular morbidity and mortality.

METHODS

Subjects were 851 men and women, 30 to 54 years of age (Caucasian = 77%, African-American = 23%). Individual SES was indexed by a composite of educational attainment and family income, and community SES was indexed by corresponding indicators derived from US Census data for participants' census tracts of residence. Plasma concentrations of IL-6 and CRP were determined from blood samples.

RESULTS

Regression analyses adjusting for age, sex, and race showed individual SES to be associated inversely with IL-6 (B = -0.126, p < .01), and community SES to be associated inversely with both IL-6 and CRP (B = -0.144, p < .01, B = -0.097, p < .01, respectively). The relationship of community SES with IL-6, but not CRP, persisted on multivariable adjustment for both lifestyle risk factors (smoking, alcohol consumption, sleep, exercise, body mass index) and individual SES (IL-6: B = -0.084, p < .05; CRP: B = -0.047, p > .10). After adjustment for lifestyle factors, however, individual SES was no longer associated with IL-6.

CONCLUSIONS

Independent of personal income or educational attainment, midlife adults living in less advantaged neighborhoods exhibit higher levels of circulating proinflammatory markers than residents of more affluent areas. This association may help explain the increased risk of atherosclerotic cardiovascular morbidity and mortality conferred by low community-level SES.

Neighborhood socioeconomic status and fruit and vegetable intake among whites, blacks, and Mexican Americans in the United States

BACKGROUND

Socioeconomic and racial-ethnic disparities in health status across the United States are large and persistent. Obesity rates are rising faster in black and Hispanic populations than in white populations, and they foreshadow even greater disparities in chronic illnesses such as diabetes and cardiovascular disease in years to come. Factors that influence dietary intake of fruit and vegetables in these populations are only partly understood.

OBJECTIVES

We examined associations between fruit and vegetable intake and neighborhood socioeconomic status (SES), analyzed whether neighborhood SES explains racial differences in intake, and explored the extent to which neighborhood SES has differential effects by race-ethnicity of US adults.

DESIGN

Using geocoded residential addresses from the Third National Health and Nutrition Examination Survey, we merged individual-level data with county and census tract-level US Census data. We estimated 3-level hierarchical models predicting fruit and vegetable intake with individual characteristics and an index of neighborhood SES as explanatory variables.

RESULTS

Neighborhood SES was positively associated with fruit and vegetable intake: a 1-SD increase in the neighborhood SES index was associated with consumption of nearly 2 additional servings of fruit and vegetables per week. Neighborhood SES explained some of the black-white disparity in fruit and vegetable intake and was differentially associated with fruit and vegetable intake among whites, blacks, and Mexican Americans.

CONCLUSIONS

The positive association of neighborhood SES with fruit and vegetable intake is one important pathway through which the social environment of neighborhoods affects population health and nutrition for whites, blacks, and Hispanics in the United States.

Inter-rater and intra-rater reliability of the Bahasa Melayu version of Rose Angina Questionnaire

The objective of the study is to translate the Rose Questionnaire (RQ) into a Bahasa Melayu version and adapt it cross-culturally, and to measure its inter-rater and intrarater reliability. This cross sectional study was conducted in the respondents' homes or workplaces in Kelantan, Malaysia. One hundred respondents aged 30 and above with different socio-demographic status were interviewed for face validity. For each inter-rater and intra-rater reliability, a sample of 150 respondents was interviewed. Inter-rater and intra-rater reliabilities were assessed by Cohen's kappa. The overall inter-rater agreements by the five pair of interviewers at point one and two were 0.86, and intrarater reliability by the five interviewers on the seven-item questionnaire at poinone and two was 0.88, as measured by kappa coefficient. The translated Malay version of RQ demonstrated an almost perfect inter-rater and intra-rater reliability and further validation such as sensitivity and specificity analysis of this translated questionnaire is highly recommended.

Education, psychosocial resources, and metabolic syndrome variables in Latinas

BACKGROUND

Individuals with low socioeconomic position (SEP) and Latino ethnicity are at high risk for the metabolic syndrome. In part, this may reflect that these populations benefit from fewer resilient resources to manage stressful environments, resulting in accentuated psychological and physiological costs (1).

PURPOSE

We examined the direct effects of educational attainment (an indicator of SEP) and psychosocial resources on metabolic syndrome variables, and tested indirect effects of education, via resources.

METHODS

Participants were 145 middle-aged (M=47.07 years) Latinas recruited from health clinics along the California-Mexico border. Women completed assessments of demographics and resilient resources; metabolic syndrome variables were measured (blood pressure [BP], waist circumference [WC]) or abstracted from medical charts (lipids, glucose).

RESULTS

Women with less education reported fewer psychosocial resources (DeltaR2=.14, p<.0001) and showed a higher risk profile on measures of BP, WC, and plasma glucose (3-7% of variance explained, all ps<.05), relative to those with more education. Resources independently predicted lower WCs (DeltaR2=.07, p<.05). Education exerted an indirect effect (p<.05) through resources on WC, a core factor underlying the metabolic syndrome.

CONCLUSIONS

Additional research is warranted to further explore the roles of resilient resources in relationships among SEP, metabolic risk factors, and chronic disease processes.

A multilevel analysis of urban neighborhood socioeconomic disadvantage and health in late life

The associations between neighborhood context and various indicators of health are receiving growing empirical attention, but much of this research is regionally circumscribed or assumes similar effects across the life course. This study utilizes a U.S. national sample to investigate the association between urban neighborhood socioeconomic disadvantage and health specifically among older adults. Data are from 3442 participants aged 70 years and older in the 1993 Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, and the 1990 U.S. Census. Our approach underscores the importance of multiple dimensions of health (self-reported physician-diagnosed cardiovascular disease [CVD], functional status, and self-rated health) as well as multiple dimensions of neighborhood disadvantage, which are conceptualized as environmental hazards that may lead to a physiologically consequential stress response. We find that individual-level factors attenuate the association between neighborhood disadvantage and both CVD and functional status, but not self-rated health. Net of covariates, high neighborhood socioeconomic disadvantage is significantly associated with reporting poor health. In late life, neighborhood socioeconomic disadvantage is more consequential to subjective appraisals of health than diagnosed CVD or functional limitations.

Educational status and cardiovascular risk profile in Indians

The inverse graded relationship of education and risk factors of coronary heart disease (CHD) has been reported from Western populations. To examine whether risk factors of CHD are predicted by level of education and influenced by the level of urbanization in Indian industrial populations, a cross-sectional survey (n = 19,973; response rate, 87.6%) was carried out among employees and their family members in 10 medium-to-large industries in highly urban, urban, and periurban regions of India. Information on behavioral, clinical, and biochemical risk factors of CHD was obtained through standardized instruments, and educational status was assessed in terms of the highest educational level attained. Data from 19,969 individuals were used for analysis. Tobacco use and hypertension were significantly more prevalent in the low- (56.6% and 33.8%, respectively) compared with the high-education group (12.5% and 22.7%, respectively; P < 0.001). However, dyslipidemia prevalence was significantly higher in the high-education group (27.1% as compared with 16.9% in the lowest-education group; P < 0.01). When stratified by the level of urbanization, industrial populations located in highly urbanized centers were observed to have an inverse graded relationship (i.e., higher-education groups had lower prevalence) for tobacco use, hypertension, diabetes, and overweight, whereas in less-urbanized locations, we found such a relationship only for tobacco use and hypertension. This study indicates the growing vulnerability of lower socioeconomic groups to CHD. Preventive strategies to reduce major CHD risk factors should focus on effectively addressing these social disparities.

Geographical Gerontology: The constitution of a discipline

Health and healthcare have always been central considerations in geographical gerontology. This paper reviews progress in this part of the field over the past decade (1995-2006) and also looks to the future. It demonstrates how geographical gerontology is currently constituted of multiple fields of empirical interest studied by multiple academic disciplines. Specifically, the continuation and development of traditional perspectives on older population health--in terms of dynamics, distributions and movements--are traced, as well as emerging post-modern perspectives and qualitative approaches that sensitively investigate the complex relationships between older people and the varied places within which they live and are cared for. Mirroring theoretical developments and diversity in the social sciences, the future research challenges that lie ahead will involve the articulation of varied and often hidden cultural practices and social processes, and hitherto taken-for-granted--as well as new--social and spatial relations, between older people, health and place. If however geographical gerontology is to meet these challenges most effectively, there has to be greater collaboration and communication within and between its constituent disciplines and diverse empirical areas. This will help it become recognized to a greater degree as a distinct discipline.

Neighborhood context and ethnicity differences in body mass index: a multilevel analysis using the NHANES III survey (1988-1994)

A growing body of literature has documented a link between neighborhood context and health outcomes. However, little is known about the relationship between neighborhood context and body mass index (BMI) or whether the association between neighborhood context and BMI differs by ethnicity. This paper investigates several neighborhood characteristics as potential explanatory factors for the variation of BMI across the United States; further, this paper explores to what extent segregation and the concentration of disadvantage across neighborhoods help explain ethnic disparities in BMI. Using data geo-coded at the census tract-level and linked with individual-level data from the Third National Health and Examination Survey in the United States (U.S.), we find significant variation in BMI across U.S. neighborhoods. In addition, neighborhood characteristics have a significant association with body mass and partially explain ethnic disparities in BMI, net of individual-level adjustments. These data also reveal evidence that ethnic enclaves are not in fact advantageous for the body mass index of Hispanics-a relationship counter to what has been documented for other health outcomes.

Assessment of the magnitude of geographical variations and socioeconomic contextual effects on ischaemic heart disease mortality: a multilevel survival analysis of a large Swedish cohort

BACKGROUND

In a public health perspective, it is of interest to assess the magnitude of geographical variations in ischaemic heart disease (IHD) mortality and quantify the strength of contextual effects on IHD.

OBJECTIVE

To investigate whether area effects vary according to the individual and contextual characteristics of the population, socioeconomic contextual influences were assessed in different age groups and within territories of differing population densities.

DESIGN

Multilevel survival analysis of a 28-year longitudinal database.

PARTICIPANTS

341 048 residents of the Scania region in Sweden, reaching age 50-79 years in 1996, followed up over 7 years.

RESULTS

After adjustment for several individual socioeconomic indicators over the adult age, Cox multilevel models indicated geographical variations in IHD mortality and socioeconomic contextual effects on the mortality risk. However, the magnitude of geographical variations and strength of contextual effects were modified by the age of individuals and the population density of their residential area: socioeconomic contextual effects were much stronger among non-elderly than among elderly adults, and much larger within urban territories than within rural ones. As a consequence, among non-elderly residents of urban territories, the socioeconomic contextual effect was almost as large as the effect of individual 20-year cumulated income.

CONCLUSIONS

Non-elderly residents of deprived urban neighbourhoods constitute a major target for both contextual epidemiology of coronary disease and public health interventions aimed at reducing the detrimental effects of the social environment on IHD.

Neighborhoods and obesity in older adults: the Baltimore Memory Study

BACKGROUND

Obesity has reached epidemic proportions. Although its causes are not well understood, its increasing prevalence is not likely to be due to genetic factors or underlying biology. This has led to interest in the role of environmental factors, although few studies have focused on the role of the social environment. This study investigated whether neighborhood psychosocial hazards independent of individual risk factors were associated with increased odds of obesity.

METHODS

Baseline data were analyzed in 2005 from a cohort study of 1140 randomly selected community-dwelling men and women aged 50 to 70 years from 65 contiguous neighborhoods in Baltimore MD. Body mass index (BMI in kilograms/meters squared) was calculated from measured height and weight at baseline (2001-2002). People with a BMI of 30 and higher were considered obese. Multilevel logistic regression was used to examine associations between a 12-item scale of neighborhood psychosocial hazards and the odds of obesity.

RESULTS

Thirty-eight percent of the cohort were obese. Residents of neighborhoods in the highest quartile of the Neighborhood Psychosocial Hazards scale were nearly twice as likely to be obese compared to residents in the least-hazardous neighborhoods (53% vs 27%). After adjustment for age, gender, race/ethnicity, education, household wealth, alcohol consumption, tobacco use, self-reported physical activity, and dietary intake, living in more hazardous neighborhoods was associated with a graded increase in the odds of obesity. This association was partially mediated by physical activity.

CONCLUSIONS

Even after controlling for a large set of demographic, behavioral, and socioeconomic individual-level risk factors, living in a neighborhood with greater psychosocial hazards was independently associated with obesity.

Neighborhood socioeconomic deprivation and residential instability: effects on incidence of ischemic heart disease and survival after myocardial infarction

BACKGROUND

Previous literature has shown that neighborhood socioeconomic position influences the risk of ischemic heart disease, but little is known about the mechanisms linking the residential context to ischemic heart disease incidence and mortality. We examined whether neighborhood socioeconomic position and neighborhood residential stability (as a determinant of social interaction patterns) have an influence on ischemic heart disease risk. Moreover, we investigated whether dissimilar contextual influences operate at different stages of the disease process, ie, on incidence, 1-day case-fatality, and long-term survival after acute myocardial infarction (MI).

METHODS

Using a large 27-year longitudinal cohort (baseline: 1 January 1996) defined in the Scania region, Sweden, we estimated multilevel survival models adjusted for individual sociodemographic factors and previous diseases of the persons.

RESULTS

After adjustment, multilevel survival models indicated that the incidence of ischemic heart disease increased with neighborhood socioeconomic deprivation but was only weakly associated with neighborhood residential instability (for high vs low residential instability, hazard ratio = 1.2; 95% credible interval = 1.0-1.4). Conversely, beyond effects of individual and contextual socioeconomic circumstances and distance to the hospital, we saw a markedly higher 1-day case-fatality (4.9; 1.8-15) and shorter survival time after MI among individuals still alive 28 days after MI (4.3; 1.2-17) in neighborhoods with a high versus low residential instability.

CONCLUSIONS

Effects of residential instability on post-MI survival may be mediated by the lower availability of social support in residentially unstable neighborhoods, suggesting a new class of intermediate processes that should be taken into account when investigating contextual influences on ischemic heart disease. Moreover, dissimilar contextual effects may operate at various stages of the disease process (ie, on incidence, case-fatality, and survival after MI).

Cumulative socioeconomic status across the life course and subclinical atherosclerosis

PURPOSE

The purpose of this study is to investigate the relationship between individual-level and neighborhood-level socioeconomic status (SES) across the life course and subclinical atherosclerosis.

METHODS

Participants from the Atherosclerosis Risk in Communities Study (n=12,332) were queried about individual-level SES and residential addresses across the life course. Individual-level measures were scored and summed to obtain a summary score (I-CumSES), whereas residential addresses were geocoded and linked to census data to obtain a summary neighborhood z score (N-CumSES) to evaluate the association of SES with intima-media thickness (IMT) and peripheral arterial disease (PAD).

RESULTS

A 1-SD lower I-CumSES was associated with greater mean IMT in each race-sex group and greater odds of PAD in white men (odds ratio [OR], 1.28; 95% confidence interval [CI], 0.99-1.64), white women (OR, 1.18; 95% CI, 1.02-1.36), and black women (OR, 1.33; 95% CI, 1.00-1.76). Compared with the highest tertile of N-CumSES, the lowest tertile was associated with greater mean IMT among whites, but was not associated with PAD for whites or blacks. When I-CumSES and N-CumSES were considered simultaneously, associations remained for only I-CumSES and were attenuated after adjustment for cardiovascular disease (CVD) risk factors.

CONCLUSIONS

Lower cumulative individual-level SES across the life course was associated with a greater burden of subclinical atherosclerosis, and this association was mediated in part by CVD risk factors.

Relation of low socioeconomic status to C-reactive protein in patients with coronary heart disease (from the heart and soul study)

Low socioeconomic status (SES) is associated with poor health outcomes in patients who have coronary heart disease (CHD). Inflammation is a potential mechanism by which low SES may lead to adverse cardiovascular outcomes, but it is not known whether low SES is associated with inflammation in patients who have CHD. We measured high-sensitivity C-reactive protein (CRP) levels in a cross-sectional study of 985 adults who had CHD. Income and education were determined by self-report. We used ordinal logistic regression to examine the association of income and education with CRP. Of the 985 participants, 390 had high CRP levels (>3 mg/dl). The proportion of participants who had high CRP levels ranged from 30% (103 of 340) in those who had a college degree to 51% (65 of 127) in those who had less than a high school degree (p<0.0001). The proportion of subjects who had a high CRP level ranged from 28% (52 of 183) in those who had annual income>or=$50,000 to 42% (199 of 974) in those who had an annual income<$20,000 (p<0.001). After adjustment for traditional cardiovascular risk factors and other potential confounding variables, lower income and education remained associated with higher CRP levels. In conclusion, low SES is associated with high CRP levels in patients who have CHD. This observation raises the possibility that inflammation may contribute to the adverse cardiovascular outcomes associated with low SES.

Socioeconomic differences in the progression of carotid atherosclerosis in middle-aged men and women with subclinical atherosclerosis in Sweden

While the persistence of socioeconomic differences in cardiovascular disease (CVD) has been recognized for many years, less is known about whether socioeconomic factors are of importance to CVD before symptoms of the disease appear. In this study the associations among educational level, occupational status and progression of atherosclerosis were investigated in 1016 Swedish middle-aged men and women with signs of subclinical atherosclerosis, i.e., carotid plaque (defined as focal intima-media thickness (IMT) > 1.2 mm). IMT in the common carotid artery (CCA) and in the carotid bifurcation area, as well as carotid plaque score, was determined by B-mode ultrasound. Results showed only weak associations between educational level, occupational status and age-, sex- and baseline IMT-adjusted progression of IMT in the CCA. However, in the age, sex- and baseline IMT-adjusted analyses, those in unskilled manual occupations showed a significantly higher yearly progression of carotid IMT in the bifurcation area compared to those in high- or medium-level non-manual occupations. Those with primary education tended to show a higher yearly progression of carotid IMT in the bifurcation area compared to those with completed secondary education. After adjustment for risk factors, the magnitude of these associations were somewhat attenuated. Similar patterns of associations were seen for the change of carotid plaque score. We conclude that low socioeconomic status (SES) is associated with progression of atherosclerosis in a middle-aged population with signs of subclinical atherosclerosis. Even though socioeconomic differences in cardiovascular risk factor levels could explain part of the found differences in progression rate in women, the mechanisms involved remain to be further established.