Coronary risk factors and socioeconomic status in Eastern Finland

Inequalities in mortality by marital status during socio-economic transition in Lithuania

OBJECTIVES

To analyse the changes in mortality inequalities by marital status over the period of socio-economic transition in Lithuania and to estimate the contribution of major causes of death to marital-status differences in overall mortality.

METHODS

A survey based on routine mortality statistics and census data for 1989 and 2001 for the entire country.

RESULTS

The proportion of married population has declined over the past decade. Widowed men and never married women were found to be at highest risk of mortality throughout the period under investigation. Although inequalities have not grown considerably, mortality rates have increased significantly for divorced populations and for never married men, widening the mortality gap. Cardiovascular diseases contributed most to excess mortality of never married and divorced men, as well as all unmarried groups of women. The excess mortality of widowed men from external causes was greatest in 2001.

CONCLUSIONS

Marriage can be considered as a health protecting factor, particularly in relation to mortality from cardiovascular diseases and external causes. Local and national policies aimed at health promotion must focus primarily on improving the position of unmarried groups and providing psychological support.

Employment status and high blood pressure in women: variations by time and by sociodemographic characteristics

PURPOSE

The association between employment status and high blood pressure in women was examined at two time periods to determine if associations between employment status and high blood pressure varied by time period or by age, race, education, marital status, or parental status.

METHODS

Women participants from the National Health Examination Survey (1960) and the Second National Health and Nutrition Survey (1976-1980) between the ages of 25 and 64 and currently employed or keeping house were included. Logistic regression analysis was used to examine the cross-sectional association between employment status and high blood pressure in each survey, taking into account potential effect modifiers and covariates.

RESULTS

In 1960 employment was associated with a slight, but not statistically significant, elevation in odds of high blood pressure. In 1976-1980, it was associated with a modest but significant reduction in odds of high blood pressure. Variations in associations occurred by marital status (protective associations were limited to unmarried women) and race (associations were of stronger magnitude among African-American women).

CONCLUSIONS

The employment status-high blood pressure relationship shifted across surveys. Changes in the composition of the employed and nonemployed groups account for at least part of the varying relationships.

Behavior of 3-year old children in a prospective randomized trial of reduced saturated fat and cholesterol diet since infancy: the STRIP baby project

Interventions aimed at decreased exposure of children to known atherosclerosis risk factors may have untoward behavioral side effects. We examined how children's behavior or parent's perception of the behavior of the children at 3 years of age was influenced by the intervention in a prospective randomized trial that began in infancy and effectively decreased serum cholesterol concentration. This Special Turku coronary Risk factor Intervention Project for babies (STRIP) began when the infant was 7 months old. Half of 1,062 children received individualized dietary counseling at 1 to 3-month intervals during the first 2 years of age and then half-yearly; the other half had an unrestricted diet. At 3 years of age a standardized questionnaire of the child's behavior was sent to 791 families (76% returned the questionnaire). At the onset of the trial the sociodemographic data of the families and serum lipid values of the intervention and control children were similar. Later, mean serum cholesterol values of the intervention children remained constantly at a level 6% to 10% below the values of the control children. At 3 years of age the parental perceptions of the child's behavior suggested minimal differences between the intervention and control children. The intervention children were slightly less jealous and more active and creative but showed slightly more negative signs of behavior (bed-wetting, problems in falling asleep, fears) than the controls. We conclude that long-term, individualized dietary and lifestyle intervention that begins in infancy slightly influences children's behavior or parent's recognition of the behavior of the children at the age of 3 years.

Life style as a blood pressure determinant

In Belgium, an affluent Western European country, participation in sports, alcohol intake, and living in a working class area were identified as the life style factors with the closest associations with the blood pressure level. Obesity was another important blood pressure correlate. Sodium intake, determined from the 24 h urinary output, and smoking were not associated with blood pressure. Controlled intervention studies have proven that weight reduction, endurance training and alcohol abstinence effectively reduce blood pressure. In the light of these intervention studies, the Belgian findings and the published work highlight the potential of preventive strategies aimed at these major life style factors.

[Occupational status and prevalence of cardiovascular risk indicators in employed men in German-speaking Switzerland]

Based on a sample of 623 employed men from the Berne Workplace Health Project ("Härz-As-Project") we studied the relationship between the occupational status and prevalence of cardiovascular risk indicators. Besides "biological" risk indicators, like high total cholesterol, low HDL-cholesterol, hypertension, and overweight, we also studied two behavioral risk indicators (current smoking, physical inactivity in leisure time) and a summary risk score. Odds ratios for several risk indicators controlled for age, were markedly different among different occupational status groups. High cholesterol/HDL-cholesterol ratios were more common in lower occupational status groups, while the likelihood for hypertension and high total cholesterol was highest among qualified workers. There was a strong association between occupational status and the behavioral risk indicators smoking and physical inactivity in leasure time. Similarly, 1 or more risk indicators, and more than 2 risk indicators, respectively, were also found to be strongly related to occupational status. Our results confirm former findings of unequal distribution of cardiovascular disease risk indicators among groups of different occupational status. Future studies will have to focus upon the underlying causes for these inequities.

Coronary risk factor levels: differences between educational groups in 1972-87 in eastern Finland

STUDY OBJECTIVE

To compare differences in coronary heart disease (CHD) risk factor levels between educational groups in the 1970s and 1980s in eastern Finland.

DESIGN AND PARTICIPANTS

Independent, cross sectional population surveys were undertaken in 1972, 1977, 1982, and 1987 of randomly selected men and women aged 30-59 living in two provinces in eastern Finland. Altogether 20,096 subjects participated. The lowest observed level of participation in either sex or province in any year was 77%. Serum cholesterol values and blood pressure measurements, body mass index, smoking, and the level of education were determined in each survey using comparable methodology.

MAIN RESULTS

More poorly educated men and women had higher levels of all risk factors at the end of the study period (1987). There was no change between 1972 and 1987 in differences between educational groups in mean serum cholesterol values and the diastolic blood pressure level in either sex, and in smoking in men. In women, the proportion of smokers was highest in the better educated in the 1970s but lowest in this group in the 1980s (interaction between year of examination and educational level p < 0.01). Differences between educational groups in mean body mass index increased with time in both men (p < 0.001) and women (p = 0.06).

CONCLUSIONS

Relative differences between socioeconomic groups in CHD mortality have increased in Finland in the 1970s and 1980s. Present results from eastern Finland show no reduction in differences between educational groups in risk factor levels, and even some evidence of increasing differences. Although a comparison between mortality trends and risk factor trends is problematic, trends in the risk factors analysed do not seem to be a major cause for the increasing differences in CHD mortality in Finland, at least in men. On the other hand, the risk factor trends analysed show no progress towards reducing inequalities in health, a major goal of public health policy.

Cardiovascular risks and socioeconomic status: differences between men and women in Finland

STUDY OBJECTIVE

The study aimed to assess the association of different indicators of socioeconomic status with levels of cardiovascular disease risk factors in men and women aged 25-64 years.

DESIGN

This was a cross sectional survey, using a community based random sample.

SETTING

The provinces of North Karelia and Kuopio in eastern Finland and the cities of Turku and Loimaa and surrounding communities in southwestern Finland in 1987.

PARTICIPANTS

Altogether 2164 men and 2182 women aged 25-64 years took part.

MEASUREMENTS AND MAIN RESULTS

Data were collected using self administered questionnaires and the measurement of height, body weight, and blood pressure and blood sampling for lipid determinations were done at the survey site. The risk of cardiovascular disease was determined by calculating a simple risk factor score based on the observed values of HDL and total cholesterol, leisure time, physical activity, blood pressure, medication for hypertension, body mass index, and smoking. Indicators of socioeconomic position used were years of education, family income, marital status, and the person's occupation. Lower levels of education, occupation, and income were all significantly associated with an unfavorable risk factor profile in men and women. Education and occupation showed the strongest associations with the risk factor score in both men and women. The results changed little when adjusting for income and marital status. Family income was more strongly associated with the risk factor score in women than men. When adjusting for occupation and education, income was no longer significantly associated with the risk factor score in men. Marital status was not significantly associated with the risk factor score in either sex.

CONCLUSIONS

Using the strength of the association with the cardiovascular risk factor score as the criterion for a good socioeconomic indicator, the present study suggests that education and occupation may be equally good indicators in both men and women. Family income may have some additional importance, especially in women.

Social class and cardiovascular risk factors in Danish men

During the last 25 years, a series of epidemiological studies in North-Western Europe and U.S.A. have demonstrated a negative association between social class and the incidence of cardiovascular disease (CVD), that is, an increasing incidence the lower the social class. In studies where possible explanations of this negative gradient have been analyzed, it was concluded that the traditional individual risk factors, such as elevated blood pressure, high serum cholesterol, and smoking, could explain about one half of the differences demonstrated. In a prospective study of a cohort of 504 men from the County of Copenhagen, the participants were examined when 40 and 51 years old. At both examinations the social class of the participants was recorded in addition to a number of cardiovascular risk factors. The latter included both the traditional risk factors and some not previously analyzed in relation to social class. At the 51-year examination we found statistically significant negative associations between social class and the following risk factors: plasma fibrinogen (p less than 0.001), short height (p less than 0.001), smoking (p less than 0.05), physical inactivity in leisure time (p less than 0.01), shift work (p less than 0.05), job strain (p less than 0.05), living alone (p less than 0.01), and having a poor social network (p less than 0.05). Two factors showed a significant opposite association with social class: Type A behaviour (p less than 0.001) and physical inactivity at work (p less than 0.001). In the last 10-15 years, a tendency has been demonstrated in many countries towards a strengthened association between social class and cardiovascular risk factors. This tendency was not found in our cohort. It has been discussed whether some of the social inequalities observed could be due to selection, so that people with a favourable cardiovascular risk profile socially were upward mobile. We found no support for such a selection hypothesis in our study.

Coronary heart disease prevention: relationship between socio-economic status and knowledge, motivation and behaviour in a free-living male, adult population

A questionnaire concerning knowledge, motivation and behaviour connected with coronary heart disease (CHD) prevention was administered to 6074 men aged 46 yrs, residents of Rome. The aim of this analysis was to evaluate whether differences exsisted between three socio-economic (SE) classes arbitrarily defined as medium-high (MH), intermediate (I), and medium-low (ML). Knowledge on CHD and its prevention was more satisfactory in the MH class than in the ML class. The same was observed for attitudes toward prevention (the MH class demonstrated more attention to prevention than ML class). Data were less straightforward for behaviour, which seemed to be dependent on both economic status and education. In fact the MH class claimed to smoke less than ML class, to spend more leisure time in physical activity and to check blood pressure and serum cholesterol more often. Their diets, however, were more expensive and rich than those of the ML class. By contrast the ML class, when compared to MH class, seemed to drink more alcoholic beverages and to be heavier, but they walked more and their diet resembled more closely the Mediterranean one. Altogether, in this study population, the highest social class seemed to be associated with better behaviours toward CHD prevention.

A longitudinal study on the significance of environmental and individual factors associated with the development of essential hypertension

Altogether 379 men of the same age have been followed for more than 40 years, mainly as regards socioeconomic conditions during the first 10 years as well as cognitive ability measured at the ages of 10 and 20, education, income development, and psychosocial conditions in adulthood. At the age of 48 a health investigation was performed. In order to identify possible risk factors associated with the development of raised blood pressure 38 subjects with essential hypertension were compared with 155 men without any obvious mental or somatic diseases. No differences regarding socioeconomic conditions during childhood could be observed between the two groups. However, there was a very strong difference between father's education and the son's cognitive ability in the group with hypertension. The low income development for the group with hypertension can probably be explained partly by the lower cognitive ability. In the total group there was a positive correlation between IQ at the age of 10 and income at the age of 43 (r = 0.42; p less than 0.001). The hypertensive men were psychosocially disadvantaged with respect to divorce rate and job dissatisfaction, and furthermore they reported low physical activity during leisure time. Hypertensive men were more obese and had inferior respiratory function. The observation that a lower cognitive ability seems to be related to the development of hypertension is compatible with the observation that early mortality in this investigated group has a correlation of a low IQ with poor socioeconomic conditions in childhood.

[Smoking habits in relation to socioeconomic factors]

Smoking habits are analyzed by SEG for men and women, aged 15-74. The SEGs are constructed using education and income and here only the middle-class, with three sub-groups, is considered. Over-achievers are more often smokers. There are less quitters and more heavy smokers in this sub-group than among under-achievers. Smoking habits of female over- and middle-achievers are similar to those of male over-achievers. Female and male under-achievers show similar smoking habits. These observations are consistent with the hypothesis that socio-economic factors are influential in determining smoking habits.

Atherosclerosis precursors in Finnish children and adolescents. IX. Socioeconomic status and risk factors of coronary heart disease

Relationships between parental socioeconomic status and CHD risk factors were examined in the Finnish Multicentre Study on Atherosclerosis Precursors comprising a material of 3,596 study subjects aged 3-18 years in five university cities and 12 rural communes. The work is based on the hypothesis that socioeconomic status has associations with important lifestyle factors related to the evolution of CHD risk factors. Although there is some indication that parental status variables correlate with CHD risk factors, the majority of the data point to the conclusion that socioeconomic status indicators have little relevance for children's CHD risk factor levels. The main exceptions to the above stated were the lower P/S ratio of the diet in farmers' children compared to the other socioeconomic groups in all age cohorts, and the higher serum total and LDL-cholesterol levels in the farmers' children as compared to the others in some age cohorts. The explanation to these findings is the dietary practice in farmers' households, full milk and butter being favoured instead of other milk types and vegetable margarine, respectively. Our findings illustrate the importance of the families' dietary habits with regard to certain CHD risk factors.

Change in risk factors for coronary heart disease during 10 years of a community intervention programme (North Karelia project)

A comprehensive community based programme to control cardiovascular diseases was started in North Karelia, Finland, in 1972. Reductions in smoking, serum cholesterol concentrations, and blood pressure were among the central intermediate objectives. The effect of the programme during the 10 year period 1972-82 was evaluated by examining independent random population samples at the outset (1972) and five (1977) and 10 (1982) years later both in the programme and in a matched reference area. Over 10 000 subjects were studied in 1972 and 1977 (participation rate about 90%) and roughly 8000 subjects in 1982 (participation rate about 80%). Analyses were conducted of the estimated effect of the programme on the risk factor population means by comparing the baseline and five year and 10 year follow up results in the age range 30-59 years. The effect of the programme (net reduction in North Karelia) at 10 years among the middle aged male population was estimated to be a 28% reduction in smoking (p less than 0.001), a 3% reduction in mean serum cholesterol concentration (p less than 0.001), a 3% fall in mean systolic blood pressure (p less than 0.001), and a 1% fall in mean diastolic blood pressure (p less than 0.05). Among the female population the reductions were respectively, 14% (NS), 1% (NS), 5% (p less than 0.001), and 2% (p less than 0.05). During the first five years of the project (1972-7) the programme effectively reduced the population mean values of the major coronary risk factors. At 10 years the effects had persisted for serum cholesterol concentrations and blood pressure and were increased for smoking.

Occupational morbidity based on social insurance records in Finland

Daily allowances and invalidity pensions were studied in order to identify morbidity differences between different occupational groups. The highest age-standardized number of daily allowances was found in 'industry' (males 257/1 000, females 373/1 000), and the lowest in administration (males 116/1 000, females 170/1 000). The greatest number of new invalidity pensions for males was also in industry (20.3/1 000), and was 2.9 times as high as in administration. The greatest number of invalidity pensions to females was found in agriculture (18.3/1 000), and was 2.8 times as high as administration. These invalidity pension and daily allowances data measure the morbidity, which is closely associated with socio-economic development and the advances made in the insurance system of the country. Occupational differences in invalidity pensions and daily allowances can be affected by differences in working conditions or by differences in social conditions and life style. The morbidity differences are also affected by selection and survival processes. However, there were also real morbidity differences between occupational groups even after adjusting for bias and errors.

Risk factors for coronary heart disease among Jerusalem schoolchildren: preliminary findings

The presence of risk factors for cardiovascular diseases were investigated in 7- and 11-year-old schoolchildren (808 subjects). Data analysis was performed according to sex, age, and country of origin of the father. The following variables were investigated: weight, height, total plasma cholesterol (TCH), high density lipoprotein cholesterol (HDL), plasma triglycerides, and systolic and diastolic blood pressure. Significant differences were found between sex, age, and origin groups for most variables. The prevalence of hypercholesterolemia (greater than 180 mg/dl) varied between 9.6 and 14.1%, in the different sex and age groups, and that of low HDL cholesterol (less than 40 mg/dl), 6.8-12.1%. Elevated systolic blood pressure (greater than 130 mm Hg) was found in 4.4-6.7% of the 7-year-old children, and in 13,4-18.6% of the 11 year-olds. Elevated diastolic blood pressure (greater than 85 mm Hg) was found predominantly in the 11-year-old children, 6.2-9.1%. These findings demonstrate the necessity to initiate health programs related to prevention of cardiovascular diseases in childhood.

Bias due to non-participation and heterogenous sub-groups in population surveys

A random sample of men in the age-group 30-39 years from the general population in Göteborg, Sweden, has been investigated with respect to socioeconomic factors and risk factors for coronary artery disease. The total sample could well be characterized with socioeconomic variables obtained from public registers. All the individuals of the sample were invited to an examination which 68% attended (participants). It was found that those not attending the examination (non-participants) greatly differed from the participants. The non-participants were more often unmarried, and had lower annual incomes and more sickness benefit days. There were more foreigners and more individuals registered for intemperance among the non-participants than the participants. Among the participants the foreigners reported lower physical activity and had higher serum cholesterol than the participating Swedes and individuals registered for intemperance stated a higher tobacco consumption and had higher systolic and diastolic blood pressures than those not registered. This highlights that consideration of factors discriminating participants and non-participants is important for proper estimation of population parameters. The same is true for comparisons between cases and controls recruited from cross-sectional population surveys.

Characteristics of males with myocardial infarction below age 40

All cases of initial myocardial infarctions (MI) diagnosed among men below age 40 in Göteborg during 1970-1977 have been studied. The cases have been compared with a random sample from the general population in Göteborg with respect to socio-economic factors and conventional risk factors. The MI-cases showed a special socio-economic pattern prior to the infarction and were more often single and of foreign origin, had more previous sickness benefit days and were more often registered for alcohol abuse than contemporaries in the general population. Moreover, the surviving MI-cases were found to be heavily burdened with the conventional risk factors smoking, cholesterolemia and high blood pressure.

Racism, society, and disease: an exploration of the social and biological mechanisms of differential mortality

Racial differentials in mortality provide important insight into the nature of mass disease in capitalist society. Not only are the differentials sizable in magnitude, they are consistent for multiple causes of death and appear to evolve in response to social development. The relationships among social factors and the biological and physical agents of disease can be identified through racial contrasts and a pattern of causation which applies to both the minority and majority populations described. Furthermore, the impact of exploitation as the primary disease-mediating factor under capitalist social relations can be estimated. This paper attempts to combine an analysis of bio-medical mechanisms with Marxist social theory in a comprehensive framework for the study of the social origins of racial differentials.

Hypertension control in North Karelia before the intervention of the North Karelia Project

The baseline survey of the North Karelia Project was carried out to measure the level of cardiovascular risk factors in the target population. These data on the prevalence, detection and treatment of hypertension obtained in the survey were utilized in planning the main programme. The survey was carried out in 1972 and 4275 persons aged from 25 to 59 (6.5% random sample) were examined. The prevalence of hypertension was high--21% of women and 15% of men were judged as being in need of treatment for hypertension. The blood pressure level of men was higher than that of women below 45 years of age, but in all age groups women were more often undergoing treatment. Although majority of people had had their blood pressure checked recently, only half of those who were aware of hypertension had ever been under treatment, and at the time of examination only 13% of those men and 10% of those women had restored normotension. Only one-fifth and one-third of the women who had used drugs had been under treatment for more than 5 years. Thus, the need to provide a systematic hypertension control scheme in North Karelia was urgent, as described in many other communities in the developed world. The main reason for this lies in the inability of the health care system which has not been able to maintain patients on long-term follow-up and treatment.