Contribution of contemporaneous risk factors to social inequality in coronary heart disease and all causes mortality

Housing and Cardiometabolic Risk Among Older Renters and Homeowners

Scholars consistently find that renters have poorer health outcomes when compared with homeowners. Health disparities between renters and homeowners likely widen over the life course, yet few studies have examined this link among older adults, and the connection is not fully understood. Homeowners' relative socioeconomic advantage may explain their better health; renters also more commonly experience adverse housing conditions and financial challenges, both of which can harm health. In this paper, we analyze the extent to which socioeconomic advantage, housing conditions, and financial strain explain the relationship between homeownership and health among adults over age 50, using Health and Retirement Study 2010/2012 data to assess cardiometabolic risk levels using biomarkers for inflammation, cardiovascular health, and metabolic function. We find that people living with poor housing conditions and financial strain have higher cardiometabolic risk levels, even taking socioeconomic advantage into account. This analysis sheds light on the housing-related health challenges of older adults, especially older renters.

Are there sex differences in crash and crash-related injury between men and women? A 13-year cohort study of young drivers in Australia

BACKGROUND

Young men have long been known to be disproportionately impacted by road crash and crash-related injury compared to young women and older drivers. However, there is limited insight into how sex differences in crash and crash-related injury changes over time as men and women get older and gain more driving experience. To explore sex differences in crash and crash-related injury, we undertook a sex disaggregated analysis in a large longitudinal cohort of over 20,000 young drivers in New South Wales, Australia, for up to 13 years after they first attained their independent car driver licence.

METHODS

DRIVE Study survey data from 2003-04 were linked with police, hospital and deaths data up to 2016. Sex differences were analysed using cumulative incidence curves investigating time to first crash and in negative binominal regression models adjusted for driver demographics and crash risk factors.

RESULTS

After adjusting for demographics and driving exposure, compared with women, men had 1.25 (95% CI 1.18-1.33), 2.07 (1.75-2.45), 1.28 (95% CI 1.13-1.46), 1.32 (95% CI 1.17-1.50) and 1.59 (95% CI 1.43-1.78) times higher rates of any crash, single vehicle crash, crash on streets with a speed limit of 80 km/h or above, crash in wet conditions and crash in the dark, respectively. By contrast, men were less likely to be involved in crashes that resulted in hospitalisation compared to women 0.73 (95% CI 0.55-0.96).

CONCLUSIONS

Young men are at increased risk of crash, and this risk persists as they get older and gain more driving experience. Despite lower risk of crash, women are at higher risk of crash related injury requiring hospitalisation. These differences in men's and women's risk of crash and injury signal the need for better understanding of how sex and/or gender may contribute to risk of crash and injury across the life-course.

Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: two prospective cohort studies

OBJECTIVE

To examine whether overall lifestyles mediate associations of socioeconomic status (SES) with mortality and incident cardiovascular disease (CVD) and the extent of interaction or joint relations of lifestyles and SES with health outcomes.

DESIGN

Population based cohort study.

SETTING

US National Health and Nutrition Examination Survey (US NHANES, 1988-94 and 1999-2014) and UK Biobank.

PARTICIPANTS

44 462 US adults aged 20 years or older and 399 537 UK adults aged 37-73 years.

EXPOSURES

SES was derived by latent class analysis using family income, occupation or employment status, education level, and health insurance (US NHANES only), and three levels (low, medium, and high) were defined according to item response probabilities. A healthy lifestyle score was constructed using information on never smoking, no heavy alcohol consumption (women ≤1 drink/day; men ≤2 drinks/day; one drink contains 14 g of ethanol in the US and 8 g in the UK), top third of physical activity, and higher dietary quality.

MAIN OUTCOME MEASURES

All cause mortality was the primary outcome in both studies, and CVD mortality and morbidity in UK Biobank, which were obtained through linkage to registries.

RESULTS

US NHANES documented 8906 deaths over a mean follow-up of 11.2 years, and UK Biobank documented 22 309 deaths and 6903 incident CVD cases over a mean follow-up of 8.8-11.0 years. Among adults of low SES, age adjusted risk of death was 22.5 (95% confidence interval 21.7 to 23.3) and 7.4 (7.3 to 7.6) per 1000 person years in US NHANES and UK Biobank, respectively, and age adjusted risk of CVD was 2.5 (2.4 to 2.6) per 1000 person years in UK Biobank. The corresponding risks among adults of high SES were 11.4 (10.6 to 12.1), 3.3 (3.1 to 3.5), and 1.4 (1.3 to 1.5) per 1000 person years. Compared with adults of high SES, those of low SES had higher risks of all cause mortality (hazard ratio 2.13, 95% confidence interval 1.90 to 2.38 in US NHANES; 1.96, 1.87 to 2.06 in UK Biobank), CVD mortality (2.25, 2.00 to 2.53), and incident CVD (1.65, 1.52 to 1.79) in UK Biobank, and the proportions mediated by lifestyle were 12.3% (10.7% to 13.9%), 4.0% (3.5% to 4.4%), 3.0% (2.5% to 3.6%), and 3.7% (3.1% to 4.5%), respectively. No significant interaction was observed between lifestyle and SES in US NHANES, whereas associations between lifestyle and outcomes were stronger among those of low SES in UK Biobank. Compared with adults of high SES and three or four healthy lifestyle factors, those with low SES and no or one healthy lifestyle factor had higher risks of all cause mortality (3.53, 3.01 to 4.14 in US NHANES; 2.65, 2.39 to 2.94 in UK Biobank), CVD mortality (2.65, 2.09 to 3.38), and incident CVD (2.09, 1.78 to 2.46) in UK Biobank.

CONCLUSIONS

Unhealthy lifestyles mediated a small proportion of the socioeconomic inequity in health in both US and UK adults; therefore, healthy lifestyle promotion alone might not substantially reduce the socioeconomic inequity in health, and other measures tackling social determinants of health are warranted. Nevertheless, healthy lifestyles were associated with lower mortality and CVD risk in different SES subgroups, supporting an important role of healthy lifestyles in reducing disease burden.

PCSK9 Gene E670G Polymorphism and Coronary Artery Disease: An Updated Meta-Analysis of 5,484 Subjects

Objective: Research has shown a possible relationship between the E670G polymorphism of the proprotein convertase subtilisin/kexin type 9 (PCSK9) gene and an increased risk of coronary artery disease (CAD). However, there is no clear consensus on the subject because of conflicting results in the literature. The current meta-analysis was performed to better elucidate the potential relationship between the PCSK9 gene E670G polymorphism and CAD.

Methods: There were 5,484 subjects from 13 individual studies who were included in the current meta-analysis. The fixed- or random-effects models were used to evaluate the pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CIs).

Results: The current meta-analysis found a significant association between PCSK9 gene E670G polymorphism and CAD under allelic (OR = 1.79, 95% CI = 1.42–2.27, P = 1.00 × 10⁻⁶), dominant (OR = 2.16, 95% CI = 1.61–2.89, P = 2.22 × 10⁻⁷), heterozygous (OR = 2.02, 95% CI = 1.55–2.64, P = 2.47 × 10⁻⁷), and additive genetic models (OR = 1.92, 95% CI = 1.49–2.49, P = 6.70 × 10⁻⁷).

Conclusions:PCSK9 gene E670G polymorphism was associated with an elevated risk of CAD, especially in the Chinese population. More specifically, carriers of the G allele carriers of the PCSK9 gene may be predisposed to developing CAD.

Direct and Indirect Influences of Objective Socioeconomic Position on Adolescent Health: The Mediating Roles of Subjective Socioeconomic Status and Lifestyles

The use of composite indices and subjective measures to evaluate socioeconomic position, taking into account the effect of inequalities on adolescent health-related behaviors, can contribute to understanding the effect of inequalities on health during adolescence. The aim of this study was to examine the direct and indirect contribution of objective and subjective socioeconomic factors in a broad range of health and lifestyles outcomes. The data come from a representative sample of adolescents (N = 15,340; M age = 13.69) of the Health Behavior in School-aged Children study in Spain. Structural equation modeling was used for data analysis. A global index for evaluating objective socioeconomic position predicted both health and healthy lifestyles. Subjective socioeconomic status mediated the relationship between objective socioeconomic position and health but did not have a significant effect on healthy lifestyles when objective indicators were considered. Lastly, fit indices of the multiple-mediator model—including the direct effect of objective socioeconomic position on health and its indirect effects through the subjective perception of wealth and lifestyles—explained 28.7% of global health variance. Interventions aimed at reducing the impact of health inequalities should address, in addition to material deprivation, the psychological and behavioral consequences of feeling poor.

The contribution of health behaviors to socioeconomic inequalities in health: A systematic review

Unhealthy behaviors and their social patterning have been frequently proposed as factors mediating socioeconomic differences in health. However, a clear quantification of the contribution of health behaviors to the socioeconomic gradient in health is lacking. This study systematically reviews the role of health behaviors in explaining socioeconomic inequalities in health. Published studies were identified by a systematic review of PubMed, Embase and Web-of-Science. Four health behaviors were considered: smoking, alcohol consumption, physical activity and diet. We restricted health outcomes to cardiometabolic disorders and mortality. To allow comparison between studies, the contribution of health behaviors, or the part of the socioeconomic gradient in health that is explained by health behaviors, was recalculated in all studies according to the absolute scale difference method. We identified 114 articles on socioeconomic position, health behaviors and cardiometabolic disorders or mortality from electronic databases and articles reference lists. Lower socioeconomic position was associated with an increased risk of all-cause mortality and cardiometabolic disorders, this gradient was explained by health behaviors to varying degrees (minimum contribution -43%; maximum contribution 261%). Health behaviors explained a larger proportion of the SEP-health gradient in studies conducted in North America and Northern Europe, in studies examining all-cause mortality and cardiovascular disease, among men, in younger individuals, and in longitudinal studies, when compared to other settings. Of the four behaviors examined, smoking contributed the most to social inequalities in health, with a median contribution of 19%. Health behaviors contribute to the socioeconomic gradient in cardiometabolic disease and mortality, but this contribution varies according to population and study characteristics. Nevertheless, our results should encourage the implementation of interventions targeting health behaviors, as they may reduce socioeconomic inequalities in health and increase population health.

Childhood socioeconomic status and lifetime health behaviors: The Young Finns Study

BACKGROUND

Differences in health behaviors partly explain the socioeconomic gap in cardiovascular health. We prospectively examined the association between childhood socioeconomic status (SES) and lifestyle factors in adulthood, and the difference of lifestyle factors according to childhood SES in multiple time points from childhood to adulthood.

METHODS AND RESULTS

The sample comprised 3453 participants aged 3-18 years at baseline (1980) from the longitudinal Young Finns Study. The participants were followed up for 31 years (N = 1675-1930). SES in childhood was characterized as reported annual family income and classified on an 8-point scale. Diet, smoking, alcohol intake and physical activity were used as adult and life course lifestyle factors. Higher childhood SES predicted a healthier diet in adulthood in terms of lower consumption of meat (β ± SE -3.6 ± 0.99,p < 0.001), higher consumption of fish (1.1 ± 0.5, p = 0.04) and higher diet score (0.14 ± 0.044, p = 0.01). Childhood SES was also directly associated with physical activity index (0.059 ± 0.023, p = 0.009) and inversely with the risk of being a smoker (RR 0.90 95%CI 0.85-0.95, p < 0.001) and the amount of pack years (-0.47 ± 0.18, p = 0.01). Life course level of smoking was significantly higher and physical activity index lower among those below the median childhood SES when compared with those above the median SES.

CONCLUSIONS

These results show that childhood SES associates with several lifestyle factors 31 years later in adulthood. Therefore, attention could be paid to lifestyle behaviors of children of low SES families to promote cardiovascular health.

How family socioeconomic status, peer behaviors, and school-based intervention on healthy habits influence adolescent eating behaviors

Psychologists in schools can play an important role in developing policies and programs to promote healthy eating habits. This study analyses the contributions of family socioeconomic status, peer influence (schoolmates’ food consumption), and school-based nutrition interventions to explain adolescent eating behaviors. Data were obtained from the 2014 Health behaviour in school-aged children survey in Spain, with a sample of 6,851 adolescents (11- to 16-years-old). The results suggest that school-based healthy-eating programs could improve by considering parental education level and by implementing interventions focused on the peer social network. Policies that limit access to unhealthy products in schools – rather than simply offering healthy foods alongside unhealthy products – could be more effective.

Recommendations on Arresting Global Health Challenges Facing Adolescents and Young Adults

BACKGROUND

The health challenges faced by young people are more complex than adults and can compromise their full growth and development. Attention must be paid to the health of this age group, yet adolescents and youth remain largely invisible and often disappear from the major global datasets.

OBJECTIVE

The aim of this paper is to discuss the global health challenges faced by adolescents and youth, global legislations and guidelines pertaining to this particular age group, recommendations to arrest these challenges, and research priorities.

RESULTS

Major direct and indirect global health risks faced by adolescents include early pregnancy and childbirth, femicide, honor killing, female genital mutilation, nutritional habits and choices, social media, and peer pressure. There are no standard legal age cut-offs for adulthood; rather, the age varies for different activities, such as age of consent or the minimum age that young people can legally work, leave school, drive, buy alcohol, marry, be held accountable for criminal action, and make medical decisions. This reflects the fact that the existing systems and structures are focused on either children or adults, with very few investments and interventions directed specifically to young people. Existing legislation and guidelines need transformation to bring about a specific focus on adolescents in the domains of substance use and sexual behaviors, and the capacity for adolescent learning should be exploited through graduated legal and policy frameworks.

CONCLUSION

Sustainable development goals provide an opportunity to target this neglected and vulnerable age group. A multisectoral approach is needed to bring about healthy change and address the challenges faced by adolescents and youth, from modifications at a broader legislative and policy level to ground-level (community-level) implementations.

Socioeconomic variation in incidence of primary and secondary major cardiovascular disease events: an Australian population-based prospective cohort study

BACKGROUND

Cardiovascular disease (CVD) disproportionately affects disadvantaged people, but reliable quantitative evidence on socioeconomic variation in CVD incidence in Australia is lacking. This study aimed to quantify socioeconomic variation in rates of primary and secondary CVD events in mid-age and older Australians.

METHODS

Baseline data (2006-2009) from the 45 and Up Study, an Australian cohort involving 267,153 men and women aged ≥ 45, were linked to hospital and death data (to December 2013). Outcomes comprised first event - death or hospital admission - for major CVD combined, as well as myocardial infarction and stroke, in those with and without prior CVD (secondary and primary events, respectively). Cox regression estimated hazard ratios (HRs) for each outcome in relation to education (and income and area-level disadvantage), separately by age group (45-64, 65-79, and ≥ 80 years), adjusting for age and sex, and additional sociodemographic factors.

RESULTS

There were 18,207 primary major CVD events over 1,144,845 years of follow-up (15.9/1000 person-years), and 20,048 secondary events over 260,357 years (77.0/1000 person-years). For both primary and secondary events, incidence increased with decreasing education, with the absolute difference between education groups largest for secondary events. Age-sex adjusted hazard ratios were highest in the 45-64 years group: for major CVDs, HR (no qualifications vs university degree) = 1.62 (95% CI: 1.49-1.77) for primary events, and HR = 1.49 (1.34-1.65) for secondary events; myocardial infarction HR = 2.31 (1.87-2.85) and HR = 2.57 (1.90-3.47) respectively; stroke HR = 1.48 (1.16-1.87) and HR = 1.97 (1.42-2.74) respectively. Similar but attenuated results were seen in older age groups, and with income. For area-level disadvantage, CVD gradients were weak and non-significant in older people (> 64 years).

CONCLUSIONS

Individual-level data are important for quantifying socioeconomic variation in CVD incidence, which is shown to be substantial among both those with and without prior CVD. Findings reinforce the opportunity for, and importance of, primary and secondary prevention and treatment in reducing socioeconomic variation in CVD and consequently the overall burden of CVD morbidity and mortality in Australia.

The Association between Educational Level and Cardiovascular and Cerebrovascular Diseases within the EPICOR Study: New Evidence for an Old Inequality Problem

BACKGROUND

A consistent association has been reported between low socioeconomic status (SES) and cardiovascular events (CE), whereas the association between SES and cerebrovascular events (CBVD) is less clear. The aim of this study was to investigate the association between SES (measured using education) and CE/CBVD in a cohort study, as well as to investigate lifestyle and clinical risk factors, to help to clarify the mechanisms by which SES influences CE/CBVD.

MATERIAL AND METHODS

We searched for diagnoses of CE and CBVD in the clinical records of 47,749 members of the EPICOR cohort (average follow-up time: 11 years). SES was determined by the relative index of inequality (RII).

RESULTS

A total of 1,156 CE and 468 CBVD were found in the clinical records. An increased risk of CE was observed in the crude Cox model for the third tertile of RII compared to the first tertile (hazard ratio [HR] = 1.39; 95% confidence interval [CI] 1.21-1.61). The increased risk persisted after adjustment for lifestyle risk factors (HR = 1.19; 95%CI 1.02-1.38), clinical risk factors (HR = 1.35; 95%CI 1.17-1.56), and after full adjustment (HR = 1.17; 95%CI 1.01-1.37). Structural equation model showed that lifestyle rather than clinical risk factors are involved in the mechanisms by which education influences CE. No significant association was found between education and CBVD. A strong relationship was observed between education and diabetes at baseline.

CONCLUSION

The most important burden of inequality in CE incidence in Italy is due to lifestyle risk factors.

Education and cause-specific mortality: the mediating role of differential exposure and vulnerability to behavioral risk factors

BACKGROUND

Differential exposures to behavioral risk factors have been shown to play an important mediating role on the education-mortality relation. However, little is known about the extent to which educational attainment interacts with health behavior, possibly through differential vulnerability.

METHODS

In a cohort study of 76,294 participants 30 to 70 years of age, we estimated educational differences in cause-specific mortality from 1980 through 2009 and the mediating role of behavioral risk factors (smoking, alcohol intake, physical activity, and body mass index). With the use of marginal structural models and three-way effect decomposition, we simultaneously regarded the behavioral risk factors as intermediates and clarified the role of their interaction with educational exposure.

RESULTS

Rate differences in mortality comparing participants with low to high education were 1,277 (95% confidence interval = 1,062 to 1,492) per 100,000 person-years for men and 746 (598 to 894) per 100,000 person-years for women. Smoking was the strongest mediator for cardiovascular disease, cancer, and respiratory disease mortality when conditioning on sex, age, and cohort. The proportion mediated through smoking was most pronounced in cancer mortality as a combination of the pure indirect effect, owing to differential exposure (men, 42% [25% to 75%]; women, 36% [17% to 74%]) and the mediated interactive effect, owing to differential vulnerability (men, 18% [2% to 35%], women, 26% [8% to 50%]). The mediating effects through body mass index, alcohol intake, or physical activity were partial and varied for the causes of deaths.

CONCLUSION

Differential exposure and vulnerability should be addressed simultaneously, as these mechanisms are not mutually exclusive and may operate at the same time.

Factors associated with unhealthy behaviours and health outcomes: a cross-sectional study among Tuscan adolescents (Italy)

BACKGROUND

We aimed to determine the extent to which three core variables (school environment, peer group and family affluence) were associated with unhealthy behaviours and health outcomes among Tuscan adolescents. The unhealthy behaviours considered were smoking, alcohol consumption, sedentary lifestyle and irregular breakfast consumption; health outcomes were classified as self-reported health, multiple health complaints and life satisfaction. School environment was measured in terms of liking school, school pressure, academic achievement and classmate support; peer groups were evaluated in terms of the number of peers and frequency of peer contact. Family affluence was measured on a socioeconomic scale.

METHODS

Data were taken from the Tuscan 2009/10 survey of "Health Behaviour in School-aged Children", a WHO cross-national survey. A binary logistic multiple regression (95% confidence intervals) was implemented.

RESULTS

The total sample comprised 3291 school students: 1135 11-year-olds, 1255 13-year-olds and 901 15-year-olds. Peer group and school environment were associated with unhealthy behaviours such as smoking, alcohol consumption and sedentary lifestyle. Family affluence proved to have less impact on unhealthy behaviours, except in the case of adolescents living in low-income families. Poor health outcomes were directly related to a negative school environment. Regarding the influence of family affluence, the results showed higher odds of life dissatisfaction and poor self-reported health status in medium-income families, while low-income families had higher odds only with regard to life dissatisfaction. A consistent pattern of gender differences was found in terms of both unhealthy behaviours and health outcomes.

CONCLUSIONS

Unhealthy behaviours are strongly related to the school environment and peer group. A negative school environment proved to have the strongest relation with poor health outcomes.

The potential for reducing differences in life expectancy between educational groups in five European countries: the effects of obesity, physical inactivity and smoking

INTRODUCTION

This study assesses the effects of obesity, physical inactivity and smoking on life expectancy (LE) differences between educational groups in five European countries in the early 2000s.

METHODS

We estimate the contribution of risk factors on LE differences between educational groups using the observed risk factor distributions and under a hypothetically more optimal risk factor distribution. Data on risk factor prevalence were obtained from the Survey of Health, Ageing and Retirement in Europe study, and data on mortality from census-linked data sets for the age between 50 and 79 according to sex and education.

RESULTS

Substantial differences in LE of up to 2.8 years emerged between men with a low and a high level of education in Denmark, Austria and France, and smaller differences among men in Italy and Spain. The educational differences in LE were not as large among women. The largest potential for reducing educational differences was in Denmark (25% among men and 41% among women) and Italy (14% among men).

CONCLUSIONS

The magnitude of the effect of unhealthy behaviours on educational differences in LE varied between countries. LE among those with a low or medium level of education could increase in some European countries if the behavioural risk factor distributions were similar to those observed among the highly educated.

Association of socioeconomic position with smoking and mortality: the contribution of early life circumstances in the 1946 birth cohort

BACKGROUND

A large part of the socioeconomic mortality gradient can be statistically accounted for by social patterning of adult health behaviours. However, this statistical explanation does not consider the early life origins of unhealthy behaviours and increased mortality risk.

METHODS

Analysis is based on 2132 members of the MRC National Survey of Health and Development with mortality follow-up and complete data. Smoking behaviour was summarised by pack-years of exposure. Socioeconomic circumstances were measured in childhood (father's social class (age 4), maternal education (age 6)) and age 26 (education attainment, home ownership, head of household social class). We estimated the direct effect of early circumstances, the indirect effect through smoking and the independent direct effect of smoking on inequality in all-cause mortality from age 26 to 66.

RESULTS

Mortality risk was higher in those with lower socioeconomic position at age 26, with a sex-adjusted HR (relative index of inequality) of 1.97 (95% CI 1.18 to 3.28). Smoking and early life socioeconomic indicators together explained 74% of the socioeconomic gradient in mortality (the gradient). Early life circumstances explained 47% of the gradient, 23.5% directly and 23.0% indirectly through smoking. The explanatory power of smoking behaviour for the gradient was reduced from 50.8% to 28% when early life circumstances were added to the model.

CONCLUSIONS

Early life socioeconomic circumstances contributed importantly to social inequality in adult mortality. Our life-course model focusing on smoking provides evidence that social inequalities in health will persist unless prevention strategies tackle the intergenerational transmission of disadvantage and risk.

Cohort effects in age-associated cognitive trajectories

BACKGROUND

The age-specific prevalence and incidence of dementia and cognitive impairment in the United States have either remained stable or even slightly declined during the 1980s-1990s. A suggested but untested reason for this improvement in cognitive function over time is higher educational attainment among more recent cohorts.

METHODS

We used data from two large prospective population-based epidemiological dementia studies conducted in two adjacent regions during the period 1987-2012. We examined whether (i) cohort effects could be observed in age-associated trajectories of cognitive functions and (ii) the observed cohort effects could be explained by educational attainment. Trajectories of neuropsychological tests tapping three domains (psychomotor speed, executive function, and language) were compared among cohorts born between 1902 and 1911, 1912 and 1921, 1922 and 1931, and 1932 and 1943. We examined Age × Cohort interactions in mixed-effects models with/without controlling for education effects.

RESULTS

Cohort effects in age-associated trajectories were observed in all three domains, with consistent differences between the earliest born cohort and the most recent cohort. Executive functions showed the strongest and persistent differences between the most recent and other three cohorts. Education did not attenuate any of these associations.

CONCLUSIONS

Cohort effects were observed in all examined cognitive domains and, surprisingly, remained significant after controlling for educational effects. Factors other than education are likely responsible for the cohort effects in cognitive decline.

Quantifying the contributions of behavioral and biological risk factors to socioeconomic disparities in coronary heart disease incidence: the MORGEN study

Quantifying the impact of different modifiable behavioral and biological risk factors on socioeconomic disparities in coronary heart disease (CHD) may help inform targeted, population-specific strategies to reduce the unequal distribution of the disease. Previous studies have used analytic approaches that limit our ability to disentangle the relative contributions of these risk factors to CHD disparities. The goal of this study was to assess mediation of the effect of low education on incident CHD by multiple risk factors simultaneously. Analyses are based on 15,067 participants of the Dutch Monitoring Project on Risk Factors for Chronic Diseases aged 20-65 years examined 1994-1997 and followed for events until January 1, 2008. Path analysis was used to quantify and test mediation of the low education-CHD association by behavioral (current cigarette smoking, heavy alcohol use, poor diet, and physical inactivity) and biological (obesity, hypertension, diabetes, and hypercholesterolemia) risk factors. Behavioral and biological risk factors accounted for 56.6 % (95 % CI 42.6-70.8 %) of the low education-incident CHD association. Smoking was the strongest mediator, accounting for 27.3 % (95 % CI 17.7-37.4 %) of the association, followed by obesity (10.2 %; 95 % CI 4.5-16.1 %), physical inactivity (6.3 %; 95 % CI 2.7-10.0 %), and hypertension (5.3 %; 95 % CI: 2.8-8.0 %). In summary, in a Dutch cohort, the majority of the relationship between low education and incident CHD was mediated by traditional behavioral and biological risk factors. Addressing barriers to smoking cessation, blood pressure and weight management, and physical activity may be the most effective approaches to eliminating socioeconomic inequalities in CHD.

The contribution of diet and lifestyle to socioeconomic inequalities in cardiovascular morbidity and mortality

BACKGROUND

The role of differences in diet on the relationship between socioeconomic factors and cardiovascular diseases remains unclear. We studied the contribution of diet and other lifestyle factors to the explanation of socioeconomic inequalities in cardiovascular diseases.

METHODS

We prospectively examined the incidence of coronary heart disease (CHD) and stroke events amongst 33,106 adults of the EPIC-NL cohort. Education and employment status indicated socioeconomic status. We used Cox proportional models to estimate hazard ratios ((HR (95% confidence intervals)) for the association of socioeconomic factors with CHD and stroke and the contribution of diet and lifestyle.

RESULTS

During 12 years of follow-up, 1617 cases of CHD and 531 cases of stroke occurred. The risks of CHD and stroke were higher in lowest (HR=1.98 (1.67;2.35); HR=1.55 (1.15;2.10)) and lower (HR=1.50 (1.29;1.75); HR=1.42 (1.08;1.86)) educated groups than in the highest. Unemployed and retired subjects more often suffered from CHD (HR=1.37 (1.19;1.58); HR=1.20 (1.05;1.37), respectively), but not from stroke, than the employed. Diet and lifestyle, mainly smoking and alcohol, explained more than 70% of the educational differences in CHD and stroke and 65% of employment status variation in CHD. Diet explained more than other lifestyle factors of educational and employment status differences in CHD and stroke (36% to 67% vs. 9% to 27%).

CONCLUSION

The socioeconomic distribution of diet, smoking and alcohol consumption largely explained the inequalities in CHD and stroke in the Netherlands. These findings need to be considered when developing policies to reduce socioeconomic inequalities in cardiovascular diseases.

Socioeconomic assessment and impact of social security on outcome in patients admitted with suspected coronary chest pain in the city of salta, Argentina

Low socioeconomic status is associated with increased mortality from coronary heart disease. We assessed total mortality, cardiac death, and sudden cardiac death (SCD) in relation to socioeconomic class and social security in 982 patients consecutively admitted with suspected coronary chest pain, living in the city of Salta, northern Argentina. Patients were divided into three socioeconomic classes based on monthly income, residential area, and insurance coverage. Five-year follow-up data were analyzed accordingly, applying univariate and multivariate analyses. At follow-up, 173 patients (17.6%) had died. In 92 patients (9.4%) death was defined as cardiac, of whom 59 patients (6.0%) were characterized as SCD. In the multivariate analysis, the hazard ratios (HRs) for all-cause and cardiac mortality in the highest as compared to the lowest socioeconomic class were 0.42 (95% confidence interval (CI), 0.22-0.80), P = 0.008, and 0.39 (95% CI, 0.15-0.99), P = 0.047, respectively. Comparing patients in the upper socioeconomic class to patients without healthcare coverage, HRs were 0.46 (95% CI, 0.23-0.94), P = 0.032, and 0.37 (95% CI, 0.14-1.01), P = 0.054, respectively. In conclusion, survival was mainly tied to socioeconomic inequalities in this population, and the impact of a social security program needs further attention.

The changing contribution of smoking to educational differences in life expectancy: indirect estimates for Finnish men and women from 1971 to 2010

BACKGROUND

We estimated the contribution of smoking to educational differences in mortality and life expectancy between 1971 and 2010 in Finland.

METHODS

Eight prospective datasets with baseline in 1970, 1975, 1980, 1985, 1990, 1995, 2000 and 2005 and each linked to a 5-year mortality follow-up were used. We calculated life expectancy at age 50 years with and without smoking-attributable mortality by education and gender. Estimates of smoking-attributable mortality were based on an indirect method that used lung cancer mortality as a proxy for the impact of smoking on mortality from all other causes.

RESULTS

Smoking-attributable deaths constituted about 27% of all male deaths above age 50 years in the early 1970s and 17% in the period 2006-2010; these figures were 1% and 4% among women, respectively. The life expectancy differential between men with basic versus high education increased from 3.4 to 4.7 years between 1971-1975 and 2006-2010. In the absence of smoking, these differences would have been 1.5 and 3.4 years, 1.9 years (55%) and 1.3 years (29%) less than those observed. Among women, educational differentials in life expectancy between the most and least educated increased from 2.5 to 3.0 years. This widening was nearly entirely accounted for by the increasing impact of smoking. Among women the contribution of smoking to educational differences had increased from being negligible in 1971-1975 to 16% in 2006-2010.

CONCLUSIONS

Among men, the increase in educational differences in mortality in the past decades was driven by factors other than smoking. However, smoking continues to have a major influence on educational differences in mortality among men and its contribution is increasing among women.

Trends in adult cardiovascular disease risk factors and their socio-economic patterning in the Scottish population 1995-2008: cross-sectional surveys

OBJECTIVES

To examine secular and socio-economic changes in cardiovascular disease risk factor prevalences in the Scottish population. This could contribute to a better understanding of why the decline in coronary heart disease mortality in Scotland has recently stalled along with a widening of socio-economic inequalities.

DESIGN

Four Scottish Health Surveys 1995, 1998, 2003 and 2008 (6190, 6656, 5497 and 4202 respondents, respectively, aged 25-64 years) were used to examine gender-stratified, age-standardised prevalences of smoking, alcohol consumption, physical activity, fruit and vegetable consumption, discretionary salt use and self-reported diabetes or hypertension. Prevalences were determined according to education and social class. Inequalities were assessed using the slope index of inequality, and time trends were determined using linear regression.

RESULTS

There were moderate secular declines in the prevalence of smoking, excess alcohol consumption and physical inactivity. Smoking prevalence declined between 1995 and 2008 from 33.4% (95% CI 31.8% to 35.0%) to 29.9% (27.9% to 31.8%) for men and from 36.1% (34.5% to 37.8%) to 27.4% (25.5% to 29.3%) for women. Adverse trends in prevalence were noted for self-reported diabetes and hypertension. Over the four surveys, the diabetes prevalence increased from 1.9% (1.4% to 2.4%) to 3.6% (2.8% to 4.4%) for men and from 1.7% (1.2% to 2.1%) to 3.0% (2.3% to 3.7%) for women. Socio-economic inequalities were evident for almost all risk factors, irrespective of the measure used. These social gradients appeared to be maintained over the four surveys. An exception was self-reported diabetes where, although inequalities were small, the gradient increased over time. Alcohol consumption was unique in consistently showing an inverse gradient, especially for women.

CONCLUSIONS

There has been only a moderate decline in behavioural cardiovascular risk factor prevalences since 1995, with increases in self-reported diabetes and hypertension. Adverse socio-economic gradients have remained unchanged. These findings could help explain the recent stagnation in coronary heart disease mortalities and persistence of related inequalities.

Occupational and behavioural factors in the explanation of social inequalities in premature and total mortality: a 12.5-year follow-up in the Lorhandicap study

The respective contribution of occupational and behavioural factors to social disparities in all-cause mortality has been studied very seldom. The objective of this study was to evaluate the role of occupational and behavioural factors in explaining social inequalities in premature and total mortality in the French working population. The study population consisted of a sample of 2,189 and 1,929 French working men and women, who responded to a self-administered questionnaire in mid-1996, and were followed up until the end of 2008. Mortality was derived from register-based information and linked to the baseline data. Socioeconomic status was measured using occupation. Occupational factors included biomechanical and physical exposures, temporary contract, psychological demands, and social support, and behavioural factors, smoking, alcohol abuse, and body mass index. Significant social differences were observed for premature and total mortality. Occupational factors reduced the hazard ratios of mortality for manual workers compared to managers/professionals by 72 and 41%, from 1.88 (95% CI: 1.17-3.01) to 1.25 (95% CI: 0.74-2.12) for premature mortality, and from 1.71 (95% CI: 1.18-2.47) to 1.42 (95% CI: 0.95-2.13) for total mortality. The biggest contributions were found for biomechanical and physical exposures, and job insecurity. The role of behavioural factors was very low. Occupational factors played a substantial role in explaining social disparities in mortality, especially for premature mortality and men. Improving working conditions amongst the lowest social groups may help to reduce social inequalities in mortality.

Effects of a convenience drink fortified with n-3 fatty acids on the n-3 index

There is strong evidence that the intake of EPA and DHA reduces the risk of adverse cardiac events. Fish and fish oil capsules are not necessarily an ideal source of EPA and DHA for every individual. The aim of the present study was to evaluate the effect of a convenience drink enriched with 500 mg EPA and DHA on the n-3 index, a biomarker of EPA and DHA status in an individual. Of the 190 subjects with atherosclerotic disease screened between February and June 2009, 50 were recruited based on an n-3 index < 5 %. Participants were randomly assigned to receive a convenience drink supplemented either with n-3 fatty acids (n 40, 200 mg EPA and 300 mg DHA) or placebo (n 10, 1.1 g linoleic acid, C18 : 2n-6, from maize oil) daily for 8 weeks. The primary end point was a change in the n-3 index. Intention-to-treat analysis was done. After 8 weeks of daily intake of 200 mg EPA+300 mg DHA, the mean n-3 index increased from 4.37 (sd 0.51) to 6.80 (sd 1.45) % (P < 0.001). Interindividual variability in response was high (CV of the Delta, cv = 0.21). The control group showed no change in the n-3 index. The results showed that daily intake of a convenience drink supplemented with n-3 fatty acids leads to a significant increase of the n-3 index with high interindividual variability in response. Dose and preparation used were safe, well tolerated and highly palatable.

Association of socioeconomic position with health behaviors and mortality

CONTEXT

Previous studies may have underestimated the contribution of health behaviors to social inequalities in mortality because health behaviors were assessed only at the baseline of the study.

OBJECTIVE

To examine the role of health behaviors in the association between socioeconomic position and mortality and compare whether their contribution differs when assessed at only 1 point in time with that assessed longitudinally through the follow-up period.

DESIGN, SETTING, AND PARTICIPANTS

Established in 1985, the British Whitehall II longitudinal cohort study includes 10 308 civil servants, aged 35 to 55 years, living in London, England. Analyses are based on 9590 men and women followed up for mortality until April 30, 2009. Socioeconomic position was derived from civil service employment grade (high, intermediate, and low) at baseline. Smoking, alcohol consumption, diet, and physical activity were assessed 4 times during the follow-up period.

MAIN OUTCOME MEASURES

All-cause and cause-specific mortality.

RESULTS

A total of 654 participants died during the follow-up period. In the analyses adjusted for sex and year of birth, those with the lowest socioeconomic position had 1.60 times higher risk of death from all causes than those with the highest socioeconomic position (a rate difference of 1.94/1000 person-years). This association was attenuated by 42% (95% confidence interval [CI], 21%-94%) when health behaviors assessed at baseline were entered into the model and by 72% (95% CI, 42%-154%) when they were entered as time-dependent covariates. The corresponding attenuations were 29% (95% CI, 11%-54%) and 45% (95% CI, 24%-79%) for cardiovascular mortality and 61% (95% CI, 16%-425%) and 94% (95% CI, 35%-595%) for noncancer and noncardiovascular mortality. The difference between the baseline only and repeated assessments of health behaviors was mostly due to an increased explanatory power of diet (from 7% to 17% for all-cause mortality, respectively), physical activity (from 5% to 21% for all-cause mortality), and alcohol consumption (from 3% to 12% for all-cause mortality). The role of smoking, the strongest mediator in these analyses, did not change when using baseline or repeat assessments (from 32% to 35% for all-cause mortality).

CONCLUSION

In a civil service population in London, England, there was an association between socioeconomic position and mortality that was substantially accounted for by adjustment for health behaviors, particularly when the behaviors were assessed repeatedly.

Socioeconomic inequalities in coronary heart disease risk in older age: contribution of established and novel coronary risk factors

BACKGROUND

Evidence on socioeconomic inequalities in coronary heart disease (CHD) and their pathways in the elderly is limited. Little is also known about the contributions that novel coronary risk factors (particularly inflammatory/hemostatic markers) make to socioeconomic inequalities in CHD.

OBJECTIVES

To examine the extent of socioeconomic inequalities in CHD in older age, and the contributions (relative and absolute) of established and novel coronary risk factors.

METHODS

A population-based cohort of 3761 British men aged 60-79 years was followed up for 6.5 years for CHD mortality and incidence (fatal and non-fatal). Social class was based on longest-held occupation recorded at 40-59 years.

RESULTS

There was a graded relationship between social class and CHD incidence. The hazard ratio for CHD incidence comparing social class V (unskilled workers) with social class I (professionals) was 2.70 [95% confidence interval (CI) 1.37-5.35; P-value for trend = 0.008]. This was reduced to 2.14 (95% CI 1.06-4.33; P-value for trend = 0.11) after adjustment for behavioral factors (cigarette smoking, physical activity, body mass index, and alcohol consumption), which explained 38% of the relative risk gradient (41% of absolute risk). Additional adjustment for inflammatory markers (C-reactive protein, interleukin-6, and von Willebrand factor) explained 55% of the relative risk gradient (59% of absolute risk). Blood pressure and lipids made little difference to these estimates; results were similar for CHD mortality.

CONCLUSIONS

Socioeconomic inequalities in CHD persist in the elderly and are at least partly explained by behavioral risk factors; novel (inflammatory) coronary risk markers made some further contribution. Reducing inequalities in behavioral factors (especially cigarette smoking) could reduce these social inequalities by at least one-third.

Does fibrinogen add to prediction of cardiovascular disease? Results from the Scottish Heart Health Extended Cohort Study

Plasma fibrinogen is an established risk factor for cardiovascular disease (CVD), but it has not been established whether it adds predictive value to risk scores. In the Scottish Heart Health Extended Cohort Study, we measured plasma fibrinogen in 13 060 men and women, aged 30-74 years, initially free of CVD. After follow-up for a median of 19.2 years, 2626 subjects had at least one CVD event. After adjusting for classical CVD risk factors and socio-economic status, the hazard ratios (95% confidence interval) for a one unit (g/l) increase in plasma fibrinogen were 1.09 (1.02, 1.16) for men and 1.10 (1.02, 1.19) for women. Although fibrinogen added significantly to the discrimination of the Framingham risk score for women, it failed to do so for men. Fibrinogen did not add significantly to the ASSIGN risk score. Fibrinogen added between 1.3% and 3.2% to the classification of CVD status by the existing risk scores. We conclude that the added value of fibrinogen to two currently used risk scores is low; hence population screening with fibrinogen for this purpose is unlikely to be clinically useful or cost-effective.

Preventing socioeconomic inequalities in health behaviour in adolescents in Europe: background, design and methods of project TEENAGE

Background

Higher prevalence rates of unhealthy behaviours among lower socioeconomic groups contribute substantially to socioeconomic inequalities in health in adults. Preventing the development of these inequalities in unhealthy behaviours early in life is an important strategy to tackle socioeconomic inequalities in health. Little is known however, about health promotion strategies particularly effective in lower socioeconomic groups in youth. It is the purpose of project TEENAGE to improve knowledge on the prevention of socioeconomic inequalities in physical activity, diet, smoking and alcohol consumption among adolescents in Europe. This paper describes the background, design and methods to be used in the project.

Methods/design

Through a systematic literature search, existing interventions aimed at promoting physical activity, a healthy diet, preventing the uptake of smoking or alcohol, and evaluated in the general adolescent population in Europe will be identified. Studies in which indicators of socioeconomic position are included will be reanalysed by socioeconomic position. Results of such stratified analyses will be summarised by type of behaviour, across behaviours by type of intervention (health education, environmental interventions and policies) and by setting (individual, household, school, and neighbourhood). In addition, the degree to which effective interventions can be transferred to other European countries will be assessed.

Discussion

Although it is sometimes assumed that some health promotion strategies may be particularly effective in higher socioeconomic groups, thereby increasing socioeconomic inequalities in health-related behaviour, there is little knowledge about differential effects of health promotion across socioeconomic groups. Synthesizing stratified analyses of a number of interventions conducted in the general adolescent population may offer an efficient guidance for the development of strategies and interventions to prevent socioeconomic inequalities in health early in life.

Severity of depression and risk for subsequent dementia: cohort studies in China and the UK

BACKGROUND

Depression and dementia often exist concurrently. The associations of depressive syndromes and severity of depression with incident dementia have been little studied.

AIMS

To determine the effects of depressive syndromes and cases of depression on the risk of incident dementia.

METHOD

Participants in China and the UK aged > or =65 years without dementia were interviewed using the Geriatric Mental State interview and re-interviewed 1 year later in 1254 Chinese, and 2 and 4 years later in 3341 and 2157 British participants respectively (Ageing in Liverpool Project Health Aspects: part of the Medical Research Council - Cognitive Function and Ageing study).

RESULTS

Incident dementia was associated with only the most severe depressive syndromes in both Chinese and British participants. The risk of dementia increased, not in the less severe cases of depression but in the most severe cases. The multiple adjusted hazard ratio (HR)=5.44 (95% CI 1.67-17.8) for Chinese participants at 1-year follow-up, and HR=2.47 (95% CI 1.25-4.89) and HR=2.62 (95% CI 1.18-5.80) for British participants at 2- and 4-year follow-up respectively. The effect was greater in younger participants.

CONCLUSIONS

Only the most severe syndromes and cases of depression are a risk factor for dementia.

Income and recurrent events after a coronary event in women

Strong evidence supports the existence of a social gradient in poor prognosis in patients with coronary heart disease (CHD). However, knowledge regarding what factors may explain this relationship is limited. We aimed to analyze in women CHD patients the association between personal income and recurrent events and to determine whether lifestyle, biological and psychosocial factors contribute to the explanation of this relationship. Altogether 188 women hospitalized for a cardiac event were assessed for personal income, demographic factors, lipids, inflammatory markers, cortisol, creatinine, lifestyle and psychosocial factors, i.e. alcohol consumption, smoking habits, body-mass index, depressive symptoms, anxiety, vital exhaustion, availability of social interaction, hostility and anger-related characteristics and were followed for cardiovascular death and recurrent acute myocardial infarction (AMI). During the 6-year follow-up 18 patients deceased and 31 experienced cardiovascular death or non-fatal AMI. After adjustment for confounders, patients with medium and high income had lower risk for recurrent events relative to those with low income (HR (95% CI): 0.38 (0.15-0.97) and 0.39 (0.17-0.93), respectively). Controlling for smoking reduced by 12.8% the risk for recurrent events associated with high versus low income, while adjusting for depression decreased the risk for middle versus low income by 13.5%. Anger symptoms explained 16.7% of the risk for recurrent events associated with middle versus low income and 10.2% of the risk for high versus low income. We suggest that in women with CHD low income is associated with recurrent events and that smoking, depressive symptomatology and anger symptoms may contribute to the explanation of this relationship.

[Historical advances in health inequality research]

The socioeconomic inequalities in health have recently become an important public health concern in South Korea, and the issue has gained increasing attention from many South Korean researchers due to the increasing income inequality and widening social polarization following its economic crisis in the late 1990s. However, despite the mounting literature on health inequalities published in recent years, the history of research on health inequality in South Korea is premature in comparison to the long histories in several Western countries. Understanding the historical background underlying the issue of health inequality research may aid in establishing and accumulating scientifically solid evidence in South Korea. It may also direct the South Korean research community to develop research agendas that are more politically and academically appropriate for South Korean society. This paper describes the historical development of health inequality research in the West and introduces several important issues contributing to the advancement of health inequality research. Specifically, the major studies conducted before and after the UK Black Report are presented. In addition, the history and current status of health inequality research in South Korea are documented and evaluated. Finally, several research agendas for the quantitative and qualitative improvement of health inequality research in South Korea are proposed.

Waist-hip ratio is the dominant risk factor predicting cardiovascular death in Australia

OBJECTIVE

To evaluate clinical measures of obesity for their ability to predict death from cardiovascular disease (CVD) and coronary heart disease (CHD), in parallel with conventional cardiovascular risk factors.

DESIGN, PARTICIPANTS AND SETTING

Cross-sectional analysis of an age- and sex-stratified sample of 9206 adults aged 20-69 years from Australian capital cities (1989 Australian Risk Factor Prevalence Survey). Blood pressure, fasting serum lipid levels, smoking, history of heart disease or diabetes, and obesity as measured by body mass index (BMI), waist circumference and waist-hip ratio were recorded. These data were linked with the National Death Index to determine causes of death of the 473 survey subjects who had died to 31 December 2000.

MAIN OUTCOME MEASURES

Hazard ratios for the risk factors predicting CVD mortality and CHD mortality.

RESULTS

Of the modifiable risk factors, obesity, as measured by waist-hip ratio, is a dominant, independent, predictive variable for CVD and CHD deaths in Australian men and women. Self-reported angina/myocardial infarction in both sexes, and cigarette smoking in women, are also independent risk factors.

CONCLUSIONS

Obesity assessed by waist-hip ratio is a better predictor of CVD and CHD mortality than waist circumference, which, in turn, is a better predictor than BMI. The recognition of central obesity is clinically important, as lifestyle intervention is likely to provide significant health benefits.

Health behaviours as explanations for educational level differences in cardiovascular and all-cause mortality: a follow-up of 60 000 men and women over 23 years

BACKGROUND

Health behaviours are potential explanatory factors for socioeconomic differences in mortality. We examined the extent to which seven health behaviours covering dietary habits, smoking and physical activity, can account for relative differences in cardiovascular and all-cause mortality by educational level.

METHODS

Health behaviour data derived from nationwide Finnish health behaviour surveys from the years 1979 to 2001. These annually repeated cross-sectional surveys were linked to register-based information on educational level and subsequent mortality from the year of the survey until the end of 2001 (average follow-up time 11.9 years). The analyses included 29 065 men and 31 543 women of whom 4263 died. Cardiovascular disease (CVD), coronary heart disease (CHD), stroke and all-cause mortality was studied.

RESULTS

Educational level showed a graded association with all mortality outcomes. Health behaviours explained 54% of the relative difference between primary and higher educational level in CVD mortality among in men and 22% among in women. For all-cause mortality the corresponding figures were 45 and 38%. Smoking, vegetable use and physical activity were the most important health behaviours explaining educational level differences in all mortality outcomes, while the effects of type of fat used on bread, coffee drinking, relative weight and alcohol use were small.

CONCLUSIONS

Smoking, low vegetable use and physical inactivity explained a substantial part of educational level differences in cardiovascular and all-cause mortality among men and women. Socioeconomic trends in these behaviours are of crucial importance in determining whether socioeconomic mortality differences will widen or narrow in the future.

Does Sex Matter in the Associations between Classic Risk Factors and Fatal Coronary Heart Disease in Populations from the Asia-Pacific Region?

BACKGROUND

There is much interest in promoting healthy heart awareness among women. However, little is known about the reasons behind the lower rates of heart disease among women compared with men, and why this risk difference diminishes with age. Previous comparative studies have generally had insufficient numbers of women to quantify such differences reliably.

METHODS

We carried out an individual participant data meta-analysis of 39 cohort studies (32 from Asian countries and 7 from Australia and New Zealand). Cox models were used to estimate hazard ratios (HR) for coronary death, comparing men to women. Further adjustments were made for several proven coronary risk factors to quantify their contributions to the sex differential. Sex interactions were tested for the same risk factors.

RESULTS

During 4 million person-years of follow-up, there were 1989 (926 female) deaths from coronary heart disease (CHD). The age-adjusted and study-adjusted male/female HR (95% confidence interval [95% CI]) was 2.05 (1.89-2.22). At baseline, 54% of men vs. 7% of women were current smokers; hence, adjustment for smoking explained the largest component (20%) of this HR. A significant sex interaction was observed between systolic blood pressure (SBP) and CHD mortality such that a 10 mm Hg increase was associated with a 15% greater increase in the relative risk (RR) of coronary death in women compared with men (p = 0.002).

CONCLUSIONS

Only a small amount of the sex differential in coronary death could be explained by differences in the prevalence of classic risk factors. Alternative explanations are required to explain the age-related attenuation of the sex difference in CHD risk.

Psychosocial stress and cardiovascular diseases

Fifty five years after the first finding relating mood disturbances and cardiovascular diseases, there is still debate on the formation of a cogent conception embracing all the fragments of insight within the various aspects relating psychosocial stress to cardiovascular diseases. The clinical comorbidity is empirically evident, but there are ambiguous research results limiting the value of the proposed pathophysiological mechanisms. Psychosocial stress represents here any event that relates psychological phenomena to the social environment and to the associated pathophysiological changes. Stress denotes the external or environmental factors to which people are exposed, as well as the behavioural or biological reaction to it (response that some authors call "distress"). Cardiovascular diseases will be considered here only when being the consequence of chronic inflammatory disease of arteries (atherosclerosis). The question is: are there pathophysiological reliable mechanisms relating psychosocial stress to the development of cardiovascular diseases?

Circulating inflammatory markers and risks of cardiovascular and non-cardiovascular disease

There is current interest in the associations of circulating inflammatory markers (C-reactive protein, fibrinogen, white cell count, albumin, erythrocyte sedimentation rate, the factor VIII:von Willebrand factor complex, the tissue plasminogen activator:plasminogen activator inhibitor type 1 complex, fibrin D-dimer) not only with prognosis in acute coronary syndromes and acute stroke, but also in prediction of cardiovascular events in the general population. Recent meta-analyses of long-term prospective studies have established their associations with coronary heart disease (CHD) events, which may be cause, consequence or coincidence. These markers are also associated in epidemiologic studies of general populations with many cardiovascular risk factors (which may confound their associations with CHD risk), and also with asymptomatic arterial disease (of which they be consequences: 'reverse causality'). The causality of their associations with cardiovascular events is questioned by their lack of specificity for risk of cardiovascular events; and by the lack of association of their functional genotypes with CHD in 'Mendelian randomized trials'. Hence, proof of causality awaits testing in randomized-controlled trials of long-term selective reduction by future agents. Markers are of little additional predictive value to current cardiovascular risk scores, and it is premature to advocate their use in screening for cardiovascular risk prior to careful evaluation of costs, risks, and benefits.

Influence of material and behavioural factors on occupational class differences in health

OBJECTIVE

To examine material and behavioural factors as explanations for occupational class differences in health, while taking into account the interrelations between these two groups of factors.

METHODS

Data from cross sectional surveys among middle aged women and men employed by the City of Helsinki (n = 6062, response rate 68%) were used. The contribution of four material and seven behavioural factors to occupational class differences in self rated health was examined by logistic regression techniques. After examining the contribution of each material and behavioural factor individually these were combined into two groups, whose independent and shared effects on occupational class differences in health were examined.

RESULTS

In women, each material factor reduced the association between occupational class and health, while only financial difficulties and financial satisfaction were statistically significant in men. Smoking, dietary habits, and relative body weight were the strongest behavioural factors explaining the association in both women and men. When grouped, both material and behavioural factors explained a large part of occupational class differences in health. The direct effect of material factors was larger than their effect through behavioural factors, and the effect of behavioural factors depending on material factors was about half of their independent effect.

CONCLUSIONS

Material and behavioural factors explained more than a half of occupational class differences in self rated health among women and one third among men. The effects of material and behavioural factors were mostly independent of each other, although some part of their contribution was shared, especially in women.

Explaining socioeconomic inequality in mortality among South Koreans: an examination of multiple pathways in a nationally representative longitudinal study

BACKGROUND

South Korea has a different cause-specific structure of mortality compared with North America and northern European countries where studies on pathways to socioeconomic mortality inequalities have been performed. We examined the ability of multiple pathways to explain socioeconomic differentials in all-cause mortality in South Korea.

METHODS

The 1998 National Health and Nutrition Survey data of South Korea were linked to data on mortality. The socioeconomic position (SEP) indicator was household income. Twelve variables represented biological risk factors (body mass index, systolic blood pressure, cholesterol, and glucose), health behaviours (smoking, alcohol consumption, and regular exercise), psychosocial factors (feelings of sadness and depression, perceived level of stress, and marital status), and early life exposures (education and adulthood height).

RESULTS

Mortality differentials by income level did not decrease after exclusion of subjects with severe chronic illness or functional limitation. Biological risk factors, health behaviours, and psychosocial factors caused minor reductions in relative risk for income levels. The ability of early life exposures to explain socioeconomic differentials in mortality was greater than that of biological risk factors, health behaviours, and psychosocial factors.

CONCLUSIONS

The contribution of multiple pathways to socioeconomic differentials in all-cause mortality may vary in place with the different cause-specific structure of mortality. Future studies with specific pathway variables and specific disease outcomes would provide better understanding of causal mechanisms between SEP and health.

Evidence-based Medicine: Why do Opponents and Proponents use the same Arguments?

There is quite some ethical controversy on Evidence-based Medicine (EbM) with regard to issues of physician autonomy as well as its allocative implications. Yet, there are some shortcomings in the current debate. First of all, some of the arguments brought up against EbM are similarly defaults of "classical medicine" as well, for instance its negligence of social aspects of medicine. Second, it is often maintained that EbM is just a tool to attain cost containment. This argument is false in two regards for neither is there any idea of cutting costs in the roots of EbM nor does EbM once practiced necessarily lead to less costs as there can be underuse as well as overuse. Third, both opponents and proponents of EbM come up with the same arguments against each other. Both maintain that the other way of practicing medicine does not allow for physicians' autonomy and free judgment. Therefore, we are going to search for the different presuppositions on which these "reproaches" rely. In this way we can demonstrate that both opponents and proponents rely on different notions of autonomy and free judgment in their argument. Finally, we hope to show that some of the ethical criticism may be raised against classical medicine as well and that allocation in terms of costs is not primarily an aim of EbM.

Fibrinogen and other coronary risk factors

The association between plasma fibrinogen concentration and other coronary risk factors diverged in previous studies, and the impact from complex lipoprotein patterns has not been studied. Our research involved 24 healthy subjects without coronary heart disease (control) and 22 patients who had survived having acute myocardial infarction before the age of 41 years (cases), overall 40 men and 6 women with age range of 34 to 54 years. In multiple linear regression analyses concerning control subjects, family disposition, social class, a score based on serum triglyceride and high-density lipoprotein (HDL) cholesterol concentrations, and fasting capillary blood glucose concentration were significantly associated with plasma fibrinogen concentration (P < .00005, R2 = 0.81). For case subjects, the ratio between serum low-density lipoprotein cholesterol and high-density lipoprotein cholesterol concentrations was significantly associated with plasma fibrinogen concentration (P = .0018, R2 = 0.39). Thus, for healthy subjects, 4 coronary risk factors explained three quarters of the variation of plasma fibrinogen concentration, and for patients with a previous acute myocardial infarction, another coronary risk factor explained one third of the variation. In conclusion, the pattern of coronary risk factors associated with plasma fibrinogen concentration differed between those without coronary heart disease and those with a previous acute myocardial infarction.

Psychosocial factors in the development of coronary artery disease

The fact that traditional risk factors only account for approximately two thirds of cases of coronary artery disease (CAD) has stimulated increasing interest in the relationship between CAD and psychosocial factors. Five areas--chronic stress, socioeconomic status (SES), personality, depression, and social support--have been most thoroughly examined. There is evidence to support a causal relationship between chronic stress, SES, depression, and social support and development of CAD. In this article, we discuss the epidemiologic evidence linking psychosocial factors and CAD, and review the effects of psychosocial factors on several pathophysiologic mechanisms that have been proposed as potential mediators of CAD. The hypothalamic-pituitary-adrenal axis, hypertension and cardiovascular reactivity, endothelial function, inflammatory markers, platelets, coagulation factors, fibrinogen, lipids, glucose metabolism, and lifestyle factors have all been implicated in this process. Recently, the first intervention trials have been carried out, although with initially disappointing results. Reducing the cardiovascular risk due to these psychosocial factors will be one of the major health care challenges in the future.