Education inequalities in cardiovascular and coronary heart disease in Italy and the role of behavioral and biological risk factors

Behavioral risk factors and socioeconomic inequalities in ischemic heart disease mortality in the United States: A causal mediation analysis using record linkage data

BACKGROUND

Ischemic heart disease (IHD) is a major cause of death in the United States (US), with marked mortality inequalities. Previous studies have reported inconsistent findings regarding the contributions of behavioral risk factors (BRFs) to socioeconomic inequalities in IHD mortality. To our knowledge, no nationwide study has been conducted on this topic in the US.

METHODS AND FINDINGS

In this cohort study, we obtained data from the 1997 to 2018 National Health Interview Survey with mortality follow-up until December 31, 2019 from the National Death Index. A total of 524,035 people aged 25 years and older were followed up for 10.3 years on average (SD: 6.1 years), during which 13,256 IHD deaths occurred. Counterfactual-based causal mediation analyses with Cox proportional hazards models were performed to quantify the contributions of 4 BRFs (smoking, alcohol use, physical inactivity, and BMI) to socioeconomic inequalities in IHD mortality. Education was used as the primary indicator for socioeconomic status (SES). Analyses were performed stratified by sex and adjusted for marital status, race and ethnicity, and survey year. In both males and females, clear socioeconomic gradients in IHD mortality were observed, with low- and middle-education people bearing statistically significantly higher risks compared to high-education people. We found statistically significant natural direct effects of SES (HR = 1.16, 95% CI: 1.06, 1.27 in males; HR = 1.28, 95% CI: 1.10, 1.49 in females) on IHD mortality and natural indirect effects through the causal pathways of smoking (HR = 1.18, 95% CI: 1.15, 1.20 in males; HR = 1.11, 95% CI: 1.08, 1.13 in females), physical inactivity (HR = 1.16, 95% CI: 1.14, 1.19 in males; HR = 1.18, 95% CI: 1.15, 1.20 in females), alcohol use (HR = 1.07, 95% CI: 1.06, 1.09 in males; HR = 1.09, 95% CI: 1.08, 1.11 in females), and BMI (HR = 1.03, 95% CI: 1.02, 1.04 in males; HR = 1.03, 95% CI: 1.02, 1.04 in females). Smoking, physical inactivity, alcohol use, and BMI mediated 29% (95% CI, 24%, 35%), 27% (95% CI, 22%, 33%), 12% (95% CI, 10%, 16%), and 5% (95% CI, 4%, 7%) of the inequalities in IHD mortality between low- and high-education males, respectively; the corresponding proportions mediated were 16% (95% CI, 11%, 23%), 26% (95% CI, 20%, 34%), 14% (95% CI, 11%, 19%), and 5% (95% CI, 3%, 7%) in females. Proportions mediated were slightly lower with family income used as the secondary indicator for SES. The main limitation of the methodology is that we could not rule out residual exposure-mediator, exposure-outcome, and mediator-outcome confounding.

CONCLUSIONS

In this study, BRFs explained more than half of the educational differences in IHD mortality, with some variations by sex. Public health interventions to reduce intermediate risk factors are crucial to reduce the socioeconomic disparities and burden of IHD mortality in the general US population.

Does the time spent in retirement improve health? An IV-Poisson assessment on the incidence of cardiovascular diseases

In recent decades, pension reforms have been implemented to address the financial sustainability of social security systems, resulting in an increase in the retirement age. This adjustment has led to ongoing debates about the relationship between retirement and health. This study investigates the impact of time spent in retirement on the risk of cardiovascular disease (CVD) in Italy. It uses a comprehensive dataset that includes socioeconomic, health, and behavioural risk factors, which is linked to administrative hospitalisation and mortality registers. To address the potential endogeneity of retirement, we employ an instrumental variables approach embedded in a Poisson rate model. The results show that, on average, years spent in retirement have a beneficial effect on the risk of CVD for both men and women. Each additional year spent in retirement reduces the incidence of such diseases by about 17% for men and 29% for women. Stratified analyses and robustness tests show that the benefits of retirement appear to be more robust and pronounced in men and in certain groups, particularly men in manual occupations or with poor ergonomic conditions at work. These results highlight that delaying access to retirement may lead to an increased burden of CVD in the older population. In addition, the protective effect of retirement on the development of CVD among workers with poorer ergonomic conditions underlines the different impact of increasing the retirement age on different categories of workers and the need for targeted and differentiated policies to avoid hitting the more vulnerable.

Incidence of knee and hip joint replacement associated with cumulative exposure to physical factors at work

BACKGROUND

Knee osteoarthritis (OA) has been quite consistently associated with high physical workload and specific physical factors at work, while for hip OA, fewer studies are available, which still indicate possible associations with heavy lifting and physical workload. The objective of the study was to assess the association between exposure to workplace physical factors and incidence of knee and hip arthroplasty, as markers of severe OA in these joints.

METHODS

The study population was composed of employees 25-60 years who participated in the Turin 2011 census. For each job held since 1995, exposure to physical factors was assigned to individuals in the cohort through a Job-Exposure Matrix constructed from the Italian O*NET database. Using Poisson regression models, the incidence of knee and hip arthroplasty for OA, identified through hospitalizations from 2012 to 2018, was examined in relation to cumulative exposure to 7 different physical hazards and a composite indicator of physical workload constructed from 17 physical factors (Ergo-Index).

RESULTS

The risk of knee OA was significantly increased in the highest cumulative exposure quartile of physical workload (incidence rate ratio = 1.98, 95% confidence interval: 1.24-3.16) and of all single hazards examined, compared to the lowest quartile, with significant trends in risk with increasing exposure. In contrast, no association was found with hip OA, whose relative risks were close to or below one in all higher-exposure quartiles of physical workload and of each single hazard.

CONCLUSIONS

Our results indicate that exposure to physical hazards at work increases the likelihood of developing knee OA, but not hip OA.

Correlation among job-induced stress, overall well-being, and cardiovascular risk in Italian workers of logistics and distribution

Introduction

Work-related stress is an occupational risk that has been linked to the development of cardiovascular disease (CVD). While previous studies have explored this association in various work contexts, none have focused specifically on logistics and distribution personnel. These workers may be exposed to significant job stress, which potentially increases the risk of CVD.

Methods

In this study, we aimed to examine the relationship between work-related stress and cardiovascular risk in a sample of 413 healthy workers of a logistics and distribution company. To assess work-related stress and cardiovascular risk, we used the organisational well-being questionnaire proposed by the Italian National Anti-Corruption Authority, the Framingham Heart Study General Cardiovascular Disease (CVD) Risk Prediction Score and the WHO General Wellbeing Index (WHO-5).

Results

Our results revealed that individuals with low job support had a significantly higher CVD risk score and lower well-being index than those reporting high job support. Furthermore, workers with high-stress tasks showed higher well-being index scores than those with passive tasks. Approximately 58% of the subjects were classified as low CVD risk (CVD risk <10%), approximately 31% were classified as moderate risk (CVD risk between 10 and 20%) and 11% were considered high risk (CVD risk >20%). The overall median CVD risk for the population was moderate (6.9%), with individual scores ranging from 1 to 58%.

Discussion

Further analyses confirmed the protective effect of work support, also identifying physical inactivity, regular alcohol consumption and low educational level as factors contributing to an increased risk of CVD. Interestingly, factors such as job control and work support demonstrated a positive impact on psychological well-being. These results emphasise the importance of intervention strategies aimed at promoting health in the workplace. By addressing these combined factors, organisations can effectively reduce the risk of CVD and improve the general well-being of their workforce.

Occupational physical activity, all-cause mortality and incidence of cardiovascular diseases: results from three Italian cohorts

PURPOSE

To examine the association of exposure to Occupational Physical Activity (OPA) with all-cause mortality and incidence of cardiovascular diseases (CVD).

METHODS

The study population was composed of three Italian cohorts: a national cohort of employees participating in the National Health Survey 2005, followed-up until 2014 (ILS 2005), and two urban cohorts of employees resident in Turin at 2001 and 2011 censuses (TLS 2001 and TLS 2011, respectively), both followed-up until 2018. Follow-up was conducted through individual record-linkage with death registries and hospital admissions archives. Exposure to OPA was assigned through an Italian job-exposure matrix (JEM). Relative Risks of both CVD incidence and overall mortality associated with OPA quartiles (IRR) were estimated using Poisson regression models adjusted for socio-demographics and health, and in the national cohort, also for leisure time physical activity, BMI, smoking, diabetes, and hypertension.

RESULTS

Compared to the lowest quartile, the highest OPA quartile was associated in both genders with significantly increased mortality in TLS 2001 (IRR = 1.11 among men, IRR = 1.20 among women) and in TLS 2011 (IRR = 1.27 among men and IRR = 1.73 among women), whereas in the ILS 2005 cohort no association was found. Among women, high OPA was also associated with CVD risk in TLS 2001 and 2011 (IRR = 1.39 and IRR = 1.16 for the highest quartile, respectively), while in the ILS cohort in both genders only the third quartile showed a significantly higher risk.

CONCLUSION

Our results indicate that OPA does not have a beneficial effect on CVD and mortality, but rather suggest that it may produce deleterious health effects.

Trends in social inequality in mortality in Denmark 1995-2019: the contribution of smoking- and alcohol-related deaths

BACKGROUND

During the past decades, social inequality in mortality has increased in several countries, including Denmark. Modifiable risk factors, such as smoking and harmful alcohol consumption, have been suggested to moderate the association between socioeconomic position and health-related outcomes. The present study aims to investigate the contribution of smoking- and alcohol-related deaths to the trends in educational inequality in mortality in Denmark 1995-2019 among individuals aged 30-74 years.

METHODS

Nationwide data on mortality and highest attained educational level divided into quartiles were derived from administrative registers. Alcohol-related mortality was directly estimated using information on alcohol-related deaths from death certificates. Smoking-related mortality was indirectly estimated using the Peto-Lopez method. The contribution of smoking- and alcohol-related deaths to the social inequality gap in mortality 1995-2019 was calculated.

RESULTS

Alongside a decrease in all-cause mortality in Denmark 1995-2019, absolute differences in the mortality rate (per 100 000 person-year) between the lowest and the highest educational quartile increased from 494 to 607 among men and from 268 to 376 among women. Among both men and women, smoking- and alcohol-related deaths explained around 60% of the social inequality in mortality and around 50% of the increase in mortality inequality.

CONCLUSION

Smoking and harmful alcohol consumption continue to be important risk factors and causes of social inequality in mortality, with around half of the increase in Denmark 1995-2019 being attributable to smoking- and alcohol-related deaths. Future healthcare planning and policy development should aim at reducing social inequality in modifiable health risk behaviours and their negative consequences.

Cardiovascular disease threat and perceived efficacy of selected preventive behaviors among Polish men: an analysis based on the extended parallel process model

Considering the low rate of preventive behaviors (5%), it is important to increase the effectiveness of actions that motivate the public to engage in health-promoting behaviors. The purpose of this study was to assess the way in which Polish men perceive the threat of cardiovascular diseases (CVDs) and the effectiveness of five preventive behaviors in the context of CVDs. We aimed to identify groups of recipients, based on the extended parallel process model (EPPM), for five preventive behaviors and to compare the identified groups in terms of selected characteristics. We conducted the survey in November 2022, using the computer-assisted web interviewing technique, on a representative sample of 1,000 men aged 18-65 years. Polish men showed relatively low levels of perceived susceptibility to CVDs (15.1%), but at the same time tended to perceive the consequences of CVDs as severe (54.2%). Segmentation of audiences according to the EPPM showed that regardless of the type of preventive behavior, the most numerous groups are responsive (31-37%) and indifferent (29-31%). This study revealed the need to increase awareness of the importance of a healthy diet to prevent CVDs among male population. Less than half of the men indicated that they would be able to implement effective stress management (49.8%) and smoking avoidance (39.4%), indicating the need to implement measures to increase self-efficacy in the areas.

Inverse Association between Educational Status and Coronary CT Calcium Scores: Should We Reflect This in Our ASCVD Risk Assumptions?

Education is not a factor included in most cardiovascular risk models, including SCORE2. However, higher education has been associated with lower cardiovascular morbidity and mortality. Using CACS as a proxy for ASCVD, we studied the association between CACS and educational status. Subjects, aged 40-69, from the Paracelsus 10,000 cohort, who underwent calcium scoring as part of screening for subclinical ASCVD, were classified into low, medium, and high educational status using the Generalized International Standard Classification of Education. CACS was dichotomised as either 0 or >0 for logistic regression modelling. Our analysis showed that higher educational status was associated with higher odds for 0 CACS (aOR 0.42; 95%CI 0.26-0.70; p = 0.001). However, there was no statistically significant association between the levels of total, HDL or LDL cholesterol and educational status, nor any statistical differences in HbA1c. SCORE2 did not differ between the three educational categories (4 ± 2% vs. 4 ± 3% vs. 4 ± 2%; p = 0.29). While our observations confirmed the relationship between increased educational status and lower ASCVD risk, the effect of educational status was not mediated via its impact on classical risk factors in our cohort. Thus, perhaps educational status should be taken into account to more accurately reflect individual risk in cardiovascular risk models.

Education Level and Self-Reported Cardiovascular Disease in Norway-The Tromsø Study, 1994-2016

BACKGROUND

Cardiovascular disease (CVD) is a leading source of morbidity and mortality, and research has shown education level to be a risk factor for the disease. The aim of this study was to investigate the association between education level and self-reported CVD in Tromsø, Norway.

METHODS

This prospective cohort study included 12,400 participants enrolled in the fourth and seventh surveys of the Tromsø Study (Tromsø4 and Tromsø7) in 1994-1995 and 2015-2016, respectively. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

For every 1-level increase in education, the age-adjusted risk of self-reported CVD decreased by 9% (OR = 0.91, 95% CI: 0.87-0.96), but after adjustment for covariates, the association was weaker (OR = 0.96, 95% CI: 0.92-1.01). The association was stronger for women (OR = 0.86, 95% CI: 0.79-0.94) than men (OR = 0.91, 95% CI: 0.86-0.97) in age-adjusted models. After adjustment for covariates, the associations for women and men were similarly weak (women: OR = 0.95, 95% CI: 0.87-1.04; men: OR = 0.97, 95% CI: 0.91-1.03). In age-adjusted-models, higher education level was associated with a lower risk of self-reported heart attack (OR = 0.90, 95% CI: 0.84-0.96), but not stroke (OR = 0.97, 95% CI: 0.90-1.05) or angina (OR = 0.98, 95% CI: 0.90-1.07). There were no clear associations observed in the multivariable models for CVD components (heart attack: OR = 0.97, 95% CI: 0.91-1.05; stroke: OR = 1.01, 95% CI: 0.93-1.09; angina: OR = 1.04, 95% CI: 0.95-1.14).

CONCLUSIONS

Norwegian adults with a higher education level were at lower risk of self-reported CVD. The association was present in both genders, with a lower risk observed in women than men. After accounting for lifestyle factors, there was no clear association between education level and self-reported CVD, likely due to covariates acting as mediators.

Declining trends of premature mortality from ischemic heart disease and regional differences in Italy from 2011 to 2017

AIMS

Data regarding the premature mortality (<65 years of age) due to ischemic heart disease (IHD) in Italy are scant. We sought to analyze the incidence of premature death due to IHD in Italy and its time trend between years 2011 and 2017.

METHODS AND RESULTS

We used the free publicly available EUROSTAT death certificate database to examine premature age-adjusted IHD mortality rates (per 100.000) and relative average annual percentage change (AAPC) in Italy from 2011 to 2017 using ICD-codes I20-I25. Over the study period, the proportional IHD-related mortality rates decline from 8.09% to 7.1% in the entire population (p for trend 0.012), showing a significant reduction in women (from 4.06% to 3.40%, p for trend: 0.02) but not in men (from 10.3% to 9.3%, p for trend 0.062). The age-adjusted IHD mortality rate decreased with an AAPC of -4.1 per year [(95% CI, -5.1 to -3.0), p < 0.001], resulting more pronounced in women [AAPC: -4.4 per year (95% CI: -6.4 to -2.3,), p = 0.001)] than in men [AAPC: -3.7 per year (95% CI: -5.4 to -2.0, p = 0.003)]. Age-adjusted IHD premature death rates above the 90th percentile were distributed in Italian southern regions and islands of Italy while premature death rates below the 10th percentile were clustered in the western and northeastern regions of the country.

CONCLUSIONS

In Italy, premature IHD-related mortality remains an important contributor to overall mortality. Age-adjusted mortality declined in the last decade, especially in the northern regions and among women. Moreover, a marked region-level variations were observed.

Hidden educational inequalities in high blood pressure and high blood glucose levels in Kerala: evidence from the National Family Health Survey (2019-2021)

OBJECTIVE

This study assesses educational inequalities in measured as well as self-reported high blood pressure (BP) and high blood glucose (BG) in the southern Indian state of Kerala, which is known to have high chronic disease morbidity.

DESIGN

The present findings are drawn from a large-scale, nationally representative cross-sectional study.

SETTINGS AND PARTICIPANTS

India's Demographic and Health Survey (conducted in 2019-2021) had data on 36 526 individuals aged 15 years and above in the state of Kerala, India.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Measured high BP and BG; self-reported high BP and BG; as well as self-reported BP and BG testing. Descriptive statistics, bivariate analysis, along with multivariate statistics, were used. Educational inequalities were assessed through absolute and relative complex measures of inequality, namely the Slope Index of Inequality (SII) and Relative Concentration Index (RCI), respectively, with 95% CIs.

RESULTS

The largest margin of inequality in Kerala, between the least and the most educated groups, was observed for measured high BP (57.7% and 17.6%). Measured high BP (SII -45.4% (95% CI -47.3% to -43.4%); RCI -26.6% (95% CI -27.9% to -25.3%)), self-reported high BP (SII -34.5% (95% CI -36.3% to -32.7%); RCI -19.0% (95% CI -20.1% to -17.9%)). High BG levels were concentrated among those with lower educational attainment (SII -26.6% (95% CI -28.6% to -24.7%); RCI -15.7% (95% CI -16.9% to -14.5%)), represented by negative SII and RCI values.

CONCLUSIONS

The study findings suggest that research and programme efforts need to be redoubled to determine what is driving greater vulnerability to non-communicable diseases among population with lower educational attainment on the one hand and the possible role that improving education access can be on health outcomes, on the other hand. Further research should explore relevant intersections with low education.

Predictors of Adverse Outcomes in Healthy Aging Adults: Coronary Artery Disease, Lower Educational Status and Higher P-Selectin Levels

Background

Societal aging – as a global demographic phenomenon – shows no indication of abating. As a result, the problem of age-associated disability and related long-term care is emerging as a major public health challenge. It is important that methods for identifying older adults at risk of adverse outcomes are implemented early.

Methods

The study group consisted of 145 individuals, 44.1% women, who were randomized from community-dwelling 60–74-year-old adults. A comprehensive geriatric assessment was supplemented with Fried frailty phenotype evaluation and blood tests (including adhesion molecules, matrix metalloproteinases and neurotrophic factors). A follow-up by phone call was made for at least 3 years after the initial examination. Composite endpoint (CE) included falls, hospitalization, institutionalization and death.

Results

Mean study group age was 66.5 ± 4.1 years (\documentclass[12pt]{minimal} \usepackage{wasysym} \usepackage[substack]{amsmath} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage[mathscr]{eucal} \usepackage{mathrsfs} \DeclareFontFamily{T1}{linotext}{} \DeclareFontShape{T1}{linotext}{m}{n} {linotext }{} \DeclareSymbolFont{linotext}{T1}{linotext}{m}{n} \DeclareSymbolFontAlphabet{\mathLINOTEXT}{linotext} \begin{document} $$\overline {\rm{X}} {\rm{ \pm SD}}$$ \end{document}) and mean number of diseases was 3.7 ± 2.2. Functional status of the subjects was good, as indicated by high Barthel Index scores of 99.1 ± 2.4, MMSE scores of 29.0 ±1.5 and no frailty case. During a three-year follow-up, 71 participants (49.0%) experienced any CE-events. The Wilcoxon-Gehan test indicates that a higher probability of three-year CE completion was associated with an age >65 years (P = 0.006), coronary artery disease (CAD) (P = 0.008), 6-Minute Walk Test <432 m (P = 0.034), serum glucose >120 mg/dL (P = 0.047), serum cortisol >10 μg/dL (P = 0.011), leptin ≥15 ng/mL (P = 0.018), P-selectin ≥23 ng/mL (P = 0.006) and GDNF ≥20 pg/mL (P = 0.004). CAD (OR = 3.64, 95% CI = 1.53−8.69, P = 0.004), educational status (OR = 0.87, 95% CI = 0.77−0.98, P = 0.022) and P-selectin levels (OR = 1.07, 95% CI = 1.02−1.13, P = 0.013) were independent measures predicting three-year CE occurrence in multivariate logistic regression analysis adjusted for clinical and functional measures, and blood tests.

Conclusion

Coronary artery disease, poorer lower educational status and higher P-selectin levels were predictive of adverse outcomes in the community-dwelling healthy-aging early-old adults during three-year follow-up.

Physical Health and Work Ability among Healthcare Workers. A Cross-Sectional Study

Healthcare workers’ age is increasingly rising, negatively affecting their physical health. In particular, workability is an emerging phenomenon that predominantly affects healthcare workers. This study aims to assess physical health status and workability among ageing healthcare workers. A cross-sectional study using the Work Ability Index (WAI) was performed. Data were collected in a university hospital in northern Italy. Data were collected voluntary through a questionnaire. Healthcare workers participating in the survey were contacted personally by two resident physicians. Thus, the total number of study participants was 220 among nursing aides, nurses, and physicians. Data were analyzed by performing ANOVA and regression to assess the differences between the healthcare workers and age groups. A generalized linear model was tested to evaluate the effect of age and task on workability. The majority of healthcare workers had good WAI values. Physicians’ workability was higher than nursing aides. Nursing aides suffered more from cardiovascular disorders, while physicians and nurses had more musculoskeletal disorders. However, the distribution was statistically different (χ² = 24.03, p = 0.00), as most of the physicians’ workability values were good and good, while those of nursing aides and nurses were good and medium. In line with previous studies, the decrease in WAI with ageing is strictly dependent on the type of task assigned. Due to heavy physical tasks, nurses and nurses’ aides showed a greater WAI than physicians. This study highlights the critical issues faced by ageing healthcare professionals. In the near future, it is necessary to find solutions to cope with these changes and devise possible interventions aimed at ameliorating workability.