Unequal Exposure or Unequal Vulnerability? Contributions of Neighborhood Conditions and Cardiovascular Risk Factors to Socioeconomic Inequality in Incident Cardiovascular Disease in the Multi-Ethnic Study of Atherosclerosis

Trends in Income Inequities in Cardiovascular Health Among US Adults, 1988-2018

BACKGROUND

Mean cardiovascular health has improved over the past several decades in the United States, but it is unclear whether the benefit is shared equitably. This study examined 30-year trends in cardiovascular health using a suite of income equity metrics to provide a comprehensive picture of cardiovascular income equity.

METHODS

The study evaluated data from the 1988-2018 National Health and Nutrition Examination Survey. Survey groupings were stratified by poverty-to-income ratio (PIR) category, and the mean predicted 10-year risk of a major cardiovascular event or death based on the pooled cohort equations (PCE) was calculated (10-year PCE risk). Equity metrics including the relative and absolute concentration indices and the achievement index-metrics that assess both the prevalence and the distribution of a health measure across different socioeconomic categories-were calculated.

RESULTS

A total of 26 633 participants aged 40 to 75 years were included (mean age, 53.0-55.5 years; women, 51.9%-53.0%). From 1988-1994 to 2015-2018, the mean 10-year PCE risk improved from 7.8% to 6.4% (P<0.05). The improvement was limited to the 2 highest income categories (10-year PCE risk for PIR 5: 7.7%-5.1%, P<0.05; PIR 3-4.99: 7.6%-6.1%, P<0.05). The 10-year PCE risk for the lowest income category (PIR <1) did not significantly change (8.1%-8.7%). In 1988-1994, the 10-year PCE risk for PIR <1 was 6% higher than PIR 5; by 2015-2018, this relative inequity increased to 70% (P<0.05). When using metrics that account for all income categories, the achievement index improved (8.0%-7.1%, P<0.05); however, the achievement index was consistently higher than the mean 10-year PCE risk, indicating the poor persistently had a greater share of adverse health.

CONCLUSIONS

In this serial cross-sectional survey of US adults spanning 30 years, the population's mean 10-year PCE risk improved, but the improvement was not felt equally across the income spectrum.

Risk Prediction for Atherosclerotic Cardiovascular Disease With and Without Race Stratification

Importance

Use of race-specific risk prediction in clinical medicine is being questioned. Yet, the most commonly used prediction tool for atherosclerotic cardiovascular disease (ASCVD)-pooled cohort risk equations (PCEs)-uses race stratification.

Objective

To quantify the incremental value of race-specific PCEs and determine whether adding social determinants of health (SDOH) instead of race improves model performance.

Design, Setting, and Participants

Included in this analysis were participants from the biracial Reasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort study. Participants were aged 45 to 79 years, without ASCVD, and with low-density lipoprotein cholesterol level of 70 to 189 mg/dL or non-high-density lipoprotein cholesterol level of 100 to 219 mg/dL at baseline during the period of 2003 to 2007. Participants were followed up to 10 years for incident ASCVD, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke. Study data were analyzed from July 2022 to February 2023.

Main outcome/measures

Discrimination (C statistic, Net Reclassification Index [NRI]), and calibration (plots, Nam D'Agostino test statistic comparing observed to predicted events) were assessed for the original PCE, then for a set of best-fit, race-stratified equations including the same variables as in the PCE (model C), best-fit equations without race stratification (model D), and best-fit equations without race stratification but including SDOH as covariates (model E).

Results

This study included 11 638 participants (mean [SD] age, 61.8 [8.3] years; 6764 female [58.1%]) from the REGARDS cohort. Across all strata (Black female, Black male, White female, and White male participants), C statistics did not change substantively compared with model C (Black female, 0.71; 95% CI, 0.68-0.75; Black male, 0.68; 95% CI, 0.64-0.73; White female, 0.77; 95% CI, 0.74-0.81; White male, 0.68; 95% CI, 0.64-0.71), in model D (Black female, 0.71; 95% CI, 0.67-0.75; Black male, 0.68; 95% CI, 0.63-0.72; White female, 0.76; 95% CI, 0.73-0.80; White male, 0.68; 95% CI, 0.65-0.71), or in model E (Black female, 0.72; 95% CI, 0.68-0.76; Black male, 0.68; 95% CI, 0.64-0.72; White female, 0.77; 95% CI, 0.74-0.80; White male, 0.68; 95% CI, 0.65-0.71). Comparing model D with E using the NRI showed a net percentage decline in the correct assignment to higher risk for male but not female individuals. The Nam D'Agostino test was not significant for all race-sex strata in each model series, indicating good calibration in all groups.

Conclusions

Results of this cohort study suggest that PCE performed well overall but had poorer performance in both BM and WM participants compared with female participants regardless of race in the REGARDS cohort. Removal of race or the addition of SDOH did not improve model performance in any subgroup.

Neighborhood socioeconomic position, living arrangements, and cardiometabolic disease among older Puerto Ricans: An examination using PREHCO 2002-2007

Cardiometabolic diseases are among the leading causes of mortality worldwide and are increasingly prevalent in rapidly aging populations. Neighborhood socioeconomic position (SEP) and living arrangements are increasingly recognized as important determinants of cardiometabolic health but have not been examined within Puerto Rico. This study examined the association between neighborhood SEP, living arrangements, and incidence of cardiometabolic conditions among island-dwelling older Puerto Ricans, using longitudinal data from the Puerto Rican Elderly Health Conditions Project (Waves I 2002/03 and II 2006/07) linked with 2000 Census data for neighborhood-level conditions. Our sample consists of non-institutionalized adults aged 60 and older who remained in the same residence over both waves of data collection (N = 2,769). We used multilevel multinomial logistic regression models to examine the relationship between neighborhood SEP and the prevalence and incidence of cardiometabolic disease. Findings show that residence in a socioeconomically advantaged neighborhood was positively associated with reporting having one cardiometabolic condition at baseline, but not associated with the incidence of cardiometabolic conditions at follow-up. Living without a partner was negatively associated with reporting having cardiometabolic conditions compared to living with a partner. Similar results were found for the incidence of cardiometabolic conditions. Living arrangements significantly modified the relationship between neighborhood SEP and cardiometabolic conditions. Compared to living with a partner, living alone in a socioeconomically advantaged neighborhood was associated with a reduced risk of reporting having one condition. Living with children in a socioeconomically advantaged neighborhood was associated with a reduced risk of developing one cardiometabolic condition than living with a partner. Living arrangements are more salient to cardiometabolic health than neighborhood SEP. Social programs and services focused on household composition and familial support are needed to identify older Puerto Ricans potentially at risk of underdiagnosed chronic conditions, especially as ongoing economic, demographic, environmental, and healthcare crises potentially exacerbate social inequalities.

Do associations of physical activity and sedentary behaviour with cardiovascular disease and mortality differ across socioeconomic groups? A prospective analysis of device-measured and self-reported UK Biobank data

OBJECTIVE

To examine if individual-level and area-level socioeconomic status (SES) modifies the association of moderate-to-vigorous physical activity (MVPA), domain-specific physical activity and sedentary behaviour with all-cause mortality (ACM) and incident cardiovascular disease (CVD).

METHODS

We used self-reported (International Physical Activity Questionnaire short form) and accelerometer-measured physical activity and sedentary behaviour data from the UK Biobank. We created an individual-level composite SES index using latent class analysis of household income, education and employment status. The Townsend Index was the measure of area-level SES. Cox proportional hazards regression models stratified across SES were used.

RESULTS

In 328 228 participants (mean age 55.9 (SD 8.1) years, 45% men) with an average follow-up of 12.1 (1.4) years, 18 033 deaths and 98 922 incident CVD events occurred. We found an increased ACM risk of low physical activity and high sedentary behaviour and an increased incident CVD risk of low accelerometer-measured moderate-to-vigorous physical activity (ACCEL_MVPA) and high sitting time. We observed statistically significant interactions for all exposures in ACM analyses by individual-level SES (p<0.05) but only for screen time in area-level SES-ACM analysis (p<0.001). Compared with high self-reported moderate-to-vigorous physical activity (IPAQ_MVPA), adjusted ACM HRs for low IPAQ_MVPA were 1.14 (95% CI 1.05 to .25), 1.15 (95% CI 1.06 to 1.24) and 1.22 (95% CI 1.13 to 1.31) in high, medium and low individual-level SES, respectively. There were higher detrimental associations of low ACCEL_MVPA with decreasing area-level SES for both outcomes and of high screen time with ACM in low area-level SES.

CONCLUSION

We found modest evidence suggesting that the detrimental associations of low MVPA and high screen time with ACM and incident CVD are accentuated in low SES groups.

A qualitative crossroads of rhythm and race: Black patients' experiences living with atrial fibrillation

Importance

Race-based disparities in atrial fibrillation (AF) outcomes are well-documented, but few studies have investigated individuals' experiences of living with the condition, particularly among Black individuals.

Objective

We aimed to identify common themes and challenges experienced by individuals of Black race with AF.

Design

A tailored, qualitative script was developed to assess the perspectives of participants in focus groups.

Setting

Virtual focus groups.

Participants

Three focus groups of 4-6 participants (16 participants total) were recruited from the racial/ethnic minority participants in the Mobile Relational Agent to Enhance Atrial Fibrillation Self-care Trial.

Main outcomes and measures

Focus group transcripts were inductively coded to identify common themes.

Results

Nearly all participants self-identified as Black race (n = 15, 93.8 %). Participants were mostly male (62.5 %) with mean age of 67 (range 40-78) years. Three themes were identified. First, participants described physical and mental burdens associated with having AF. Second, participants described AF as being a condition that is difficult to manage. Lastly, participants identified key tenets to support self-management of AF (self-education, community support, and patient-provider relationships).

Conclusions and relevance

Participants reported AF is unpredictable and challenging to manage, and that social and community supports are essential. The social and behavioral themes identified in this qualitative research highlight the need for tailored clinical strategies for AF self-management which incorporate individuals' social contexts.

Trial registration

National Clinical Trial number 04075994.

Current practice and recommendations for advancing how human variability and susceptibility are considered in chemical risk assessment

A key element of risk assessment is accounting for the full range of variability in response to environmental exposures. Default dose-response methods typically assume a 10-fold difference in response to chemical exposures between average (healthy) and susceptible humans, despite evidence of wider variability. Experts and authoritative bodies support using advanced techniques to better account for human variability due to factors such as in utero or early life exposure and exposure to multiple environmental, social, and economic stressors.This review describes: 1) sources of human variability and susceptibility in dose-response assessment, 2) existing US frameworks for addressing response variability in risk assessment; 3) key scientific inadequacies necessitating updated methods; 4) improved approaches and opportunities for better use of science; and 5) specific and quantitative recommendations to address evidence and policy needs.Current default adjustment factors do not sufficiently capture human variability in dose-response and thus are inadequate to protect the entire population. Susceptible groups are not appropriately protected under current regulatory guidelines. Emerging tools and data sources that better account for human variability and susceptibility include probabilistic methods, genetically diverse in vivo and in vitro models, and the use of human data to capture underlying risk and/or assess combined effects from chemical and non-chemical stressors.We recommend using updated methods and data to improve consideration of human variability and susceptibility in risk assessment, including the use of increased default human variability factors and separate adjustment factors for capturing age/life stage of development and exposure to multiple chemical and non-chemical stressors. Updated methods would result in greater transparency and protection for susceptible groups, including children, infants, people who are pregnant or nursing, people with disabilities, and those burdened by additional environmental exposures and/or social factors such as poverty and racism.

Vulnerability to Hypertension Is a Major Determinant of Racial Disparities in Alzheimer's Disease Risk

BACKGROUND

Higher incidence levels of Alzheimer's disease (AD) in Black Americans are well documented. However, quantitative explanations of this disparity in terms of risk-factor diseases acting through well-defined pathways are lacking.

METHODS

We applied a Blinder-Oaxaca-based algorithm modified for censored data to a 5% random sample of Medicare beneficiaries age 65+ to explain Black/White disparities in AD risk in terms of differences in exposure and vulnerability to morbidity profiles based on 10 major AD-risk-related diseases.

RESULTS

The primary contribution to racial disparities in AD risk comes from morbidity profiles that included hypertension with about 1/5th of their contribution due to differences in prevalence (exposure effect) and 4/5ths to differences in the effects of the morbidity profile on AD risk (vulnerability effect). In total, disease-related effects explained a higher proportion of AD incidence in Black Americans than in their White counterparts.

CONCLUSIONS

Disease-related causes may represent some of the most straightforward targets for targeted interventions aimed at the reduction of racial disparities in health among US older adults. Hypertension is a manageable and potentially preventable condition responsible for the majority of the Black/White differences in AD risk, making mitigation of the role of this disease in engendering higher AD incidence in Black Americans a prominent concern.

Life-Course Neighborhood Socioeconomic Status and Cardiovascular Events in Black and White Adults in the Atherosclerosis Risk in Communities Study

It has been reported that residents of low-socioeconomic-status (SES) neighborhoods have a higher risk of developing cardiovascular disease (CVD). However, most of the previous studies focused on 1-time measurement of neighborhood SES in middle-to-older adulthood and lacked demographic diversity to allow for comparisons across different race/ethnicity and sex groups. We examined neighborhood SES in childhood and young, middle, and older adulthood in association with CVD risk among Black and White men and women in the Atherosclerosis Risk in Communities Study (1996-2019). We found that lower neighborhood SES in young, middle, and older adulthood, but not in childhood, was associated with a higher risk of CVD later in life. When compared with the highest quartile, the lowest quartile of neighborhood SES in young, middle, and older adulthood was associated with 18% (hazard ratio (HR) = 1.18, 95% confidence interval (CI): 1.02, 1.36), 21% (HR = 1.21, 95% CI: 1.04, 1.39), and 12% (HR = 1.12, 95% CI: 0.99, 1.26) increases in the hazard of total CVD, respectively. The association between lower neighborhood SES in older adulthood and higher CVD hazard was particularly strong among Black women. Our study findings support the role of neighborhood SES in cardiovascular health in both Black and White adults.

Educational Attainment and Lifestyle Risk Factors Associated With All-Cause Mortality in the US

Question

To what extent can the association between socioeconomic status (SES) and mortality be explained by differential exposure to lifestyle factors (such that unhealthy lifestyle factors are more prevalent in groups with lower SES) and differential vulnerability to lifestyle factors (such that the same exposure to unhealthy lifestyle factors is associated with more deleterious outcomes in groups with lower SES)?

Findings

In this nationwide cohort study of 415 764 US adults, a mediation analysis showed that lifestyle factors explained 66% (men) and 80% (women) of the association between educational attainment and all-cause mortality. Inequalities in mortality were primarily a result of greater exposure and clustering of unhealthy lifestyle factors among groups with lower educational attainment; with some exception, there was little evidence for differential vulnerability to lifestyle factors.

Meaning

Public health interventions to create equality in the socioenvironmental contexts that shape lifestyle factors and to reduce exposure to lifestyle risk factors among groups with low SES have the potential to significantly increase life expectancy and reduce socioeconomic inequalities in mortality.

Importance

The US has experienced increasing socioeconomic inequalities and stagnating life expectancy. Past studies have not disentangled 2 mechanisms thought to underlie socioeconomic inequalities in health, differential exposure and differential vulnerability, that have different policy implications.

Objective

To evaluate the extent to which the association between socioeconomic status (SES) and all-cause mortality can be decomposed into a direct effect of SES, indirect effects through lifestyle factors (differential exposure), and joint effects of SES with lifestyle factors (differential vulnerability).

Design, Setting, and Participants

This nationwide, population-based cohort study used the cross-sectional US National Health Interview Survey linked to the National Death Index. Civilian, noninstitutionalized US adults aged 25 to 84 years were included from the 1997 to 2014 National Health Interview Survey and were followed up until December 31, 2015. Data were analyzed from May 1 to October 31, 2021. A causal mediation model using an additive hazard and marginal structural approach was used.

Exposures

Both SES (operationalized as educational attainment) and lifestyle risk factors (smoking, alcohol use, obesity, and physical inactivity) were assessed using self-reported questionnaires.

Main Outcomes and Measures

Time to all-cause mortality.

Results

Participants included 415 764 adults (mean [SD] age, 49.4 [15.8] years; 55% women; 64% non-Hispanic White), of whom 45% had low educational attainment and 27% had high educational attainment. Participants were followed up for a mean (SD) of 8.8 (5.2) years during which 49 096 deaths (12%) were observed. Low educational attainment (compared with high) was associated with 83.6 (men; 95% CI, 81.8-85.5) and 54.8 (women; 95% CI, 53.4-56.2) additional deaths per 10 000 person-years, of which 66% (men) and 80% (women) were explained by lifestyle factors. Inequalities in mortality were primarily a result of greater exposure and clustering of unhealthy lifestyle factors among low SES groups; with some exceptions among women, little evidence of differential vulnerability was identified.

Conclusions and Relevance

In this cohort study, differential exposure to lifestyle risk factors was an important mediator of socioeconomic inequalities in mortality. Public health interventions are needed, particularly among low SES groups, to address smoking, physical inactivity, alcohol use, and the socioenvironmental contexts within which these risk factors develop.

Multilevel resilience resources and cardiovascular disease in the United States: A systematic review and meta-analysis

Objective: This systematic review and meta-analysis aimed to quantify the relationship between resilience resources at the individual (e.g., optimism), interpersonal (e.g., social support), and neighborhood (e.g., social environment) levels, and cardiovascular outcomes among adults in the United States. Method: On 9/25/2020, electronic databases (PubMed, Embase, CINAHL, PsycINFO) were systematically searched for randomized controlled trials, nonrandomized intervention studies, and prospective cohort studies that examined the relationship between resilience resources at the individual, interpersonal, or neighborhood level and cardiovascular outcomes. Studies that met the eligibility criteria were summarized narratively and quantitatively. Because relevant search results yielded only observational studies, risk of bias was assessed using an adapted version of the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool. Results: From 4,103 unique records, 13 prospective cohort studies with a total of 310,906 participants met the eligibility criteria, and six of these studies were included in the meta-analyses. Most relevant studies found that higher levels of individual-level resilience resources were associated with lower incidence of adverse cardiovascular outcomes, with point estimates ranging from .46 to 1.18. Interpersonal-level resilience resources (i.e., social network) were associated with a lower coronary heart disease risk (risk ratio, .76; 95% CI [.56, 1.02]). Neighborhood-level resilience resources (i.e., perceived social cohesion and residential stability) were associated with a lower odds of stroke (odds ratio, .92; 95% CI [.84, 1.01]). Conclusions: Evidence suggests that higher levels of resilience resources are associated with better cardiovascular outcomes. However, more prospective studies with diverse populations are needed to strengthen the evidence. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Associations between neighborhood socioeconomic cluster and hypertension, diabetes, myocardial infarction, and coronary artery disease within a cohort of cardiac catheterization patients

Background

Neighborhood-level socioeconomic status (SES) is associated with health outcomes, including cardiovascular disease and diabetes, but these associations are rarely studied across large, diverse populations.

Methods

We used Ward’s Hierarchical clustering to define eight neighborhood clusters across North Carolina using 11 census-based indicators of SES, race, housing, and urbanicity and assigned 6992 cardiac catheterization patients at Duke University Hospital from 2001 to 2010 to clusters. We examined associations between clusters and coronary artery disease index > 23 (CAD), history of myocardial infarction, hypertension, and diabetes using logistic regression adjusted for age, race, sex, body mass index, region of North Carolina, distance to Duke University Hospital, and smoking status.

Results

Four clusters were urban, three rural, and one suburban higher-middle-SES (referent). We observed greater odds of myocardial infarction in all six clusters with lower or middle-SES. Odds of CAD were elevated in the rural cluster that was low-SES and plurality Black (OR 1.16, 95% CI 0.94-1.43) and in the rural cluster that was majority American Indian (OR 1.31, 95% CI 0.91-1.90). Odds of diabetes and hypertension were elevated in two urban and one rural low- and lower-middle SES clusters with large Black populations.

Conclusions

We observed higher prevalence of cardiovascular disease and diabetes in neighborhoods that were predominantly rural, low-SES, and non-White, highlighting the importance of public health and healthcare system outreach into these communities to promote cardiometabolic health and prevent and manage hypertension, diabetes and coronary artery disease.

Joint effects of alcohol use, smoking and body mass index as an explanation for the alcohol harm paradox: causal mediation analysis of eight cohort studies

BACKGROUND AND AIMS

Lower socio-economic status (SES) is associated with higher alcohol-related harm despite lower levels of alcohol use. Differential vulnerability due to joint effects of behavioural risk factors is one potential explanation for this 'alcohol harm paradox'. We analysed to what extent socio-economic inequalities in alcohol-mortality are mediated by alcohol, smoking and body mass index (BMI), and their joint effects with each other and with SES.

DESIGN

Cohort study of eight health examination surveys (1978-2007) linked to mortality data.

SETTING

Finland.

PARTICIPANTS

A total of 53 632 Finnish residents aged 25+ years.

MEASUREMENTS

The primary outcome was alcohol-attributable mortality. We used income as an indicator of SES. We assessed the joint effects between income and mediators (alcohol use, smoking and BMI) and between the mediators, adjusting for socio-demographic indicators. We used causal mediation analysis to calculate the total, direct, indirect and mediated interactive effects using Aalen's additive hazards models.

FINDINGS

During 1 085 839 person-years of follow-up, we identified 865 alcohol-attributable deaths. We found joint effects for income and alcohol use and income and smoking, resulting in 46.8 and 11.4 extra deaths due to the interaction per 10 000 person-years. No interactions were observed for income and BMI or between alcohol and other mediators. The lowest compared with the highest income quintile was associated with 5.5 additional alcohol deaths per 10 000 person-years (95% confidence interval = 3.7, 7.3) after adjusting for confounders. The proportion mediated by alcohol use was negative (-69.3%), consistent with the alcohol harm paradox. The proportion mediated by smoking and BMI and their additive interactions with income explained 18.1% of the total effect of income on alcohol-attributable mortality.

CONCLUSIONS

People of lower socio-economic status appear to be more vulnerable to the effects of alcohol use and smoking on alcohol-attributable mortality. Behavioural risk factors and their joint effects with income may explain part of the alcohol harm paradox.

Does a physical activity supportive environment ameliorate or exacerbate socioeconomic inequities in incident coronary heart disease?

BACKGROUND

Efforts to reduce socioeconomic inequities in cardiovascular disease include interventions to change the built environment. We aimed to explore whether socioeconomic inequities in coronary heart disease (CHD) incidence are ameliorated or exacerbated in environments supportive of physical activity (PA).

METHODS

We used data from the Reasons for Geographic and Racial Differences in Stroke study, which recruited US residents aged 45 or older between 2003 and 2007. Our analyses included participants at risk for incident CHD (n=20 808), followed until 31 December 2014. We categorised household income and treated it as ordinal: (1) US$75 000+, (2) US$35 000-US$74 000, (3) US$20 000-US$34 000 and (4)

RESULTS

We found a 25% (95% CI 1.17% to 1.34%) increased hazard of CHD per 1-category decrease in household income category. Adjusting for PA-supportive environments slightly reduced this association (HR=1.24). The income-CHD association was strongest in areas without walking destinations (HR=1.57), an interaction which reached statistical significance in analyses among men. In contrast, the income-CHD association showed a trend towards being strongest in areas with the highest percentage of green land cover.

CONCLUSIONS

Indicators of a PA supportive environment show divergent trends to modify socioeconomic inequities in CHD . Built environment interventions should measure the effect on socioeconomic inequities.

Collapse

Key Words

• cardiovascular disease
• neighborhood/place
• socio-economic

Collapse

MESH Headings Collapse

Grants

• DP5 OD026429 NIH HHS
• R01 AG049970 NIA NIH HHS
• U01 NS041588 NINDS NIH HHS

Collapse

Affiliation(s)

Pedro Gullon Public Health and Epidemiology Research Group, Universidad de Alcala de Henares Facultad de Medicina y Ciencias de la Salud, Alcala de Henares, Spain Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
Usama Bilal Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA Epidemiology and Statistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
Jana A Hirsch Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA Epidemiology and Statistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA
Andrew G Rundle Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
Suzanne Judd Department of Biostatistics, University of Alabama at Birmingham College of Arts and Sciences, Birmingham, Alabama, USA
Monika M Safford Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, New York, USA
Gina S Lovasi Urban Health Collaborative, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA Epidemiology and Statistics, Drexel University School of Public Health, Philadelphia, Pennsylvania, USA

Collapse

Long-term Predictions of Incident Coronary Artery Calcium to 85 Years of Age for Asymptomatic Individuals With and Without Type 2 Diabetes

OBJECTIVE

To examine the utility of repeated computed tomography (CT) coronary artery calcium (CAC) testing, we assessed risks of detectable CAC and its cardiovascular consequences in individuals with and without type 2 diabetes ages 45-85 years.

RESEARCH DESIGN AND METHODS

We included 5,836 individuals (618 with type 2 diabetes, 2,972 without baseline CAC) from the Multi-Ethnic Study of Atherosclerosis. With logistic and Cox regression we evaluated the impact of type 2 diabetes, diabetes treatment duration, and other predictors on prevalent and incident CAC. We used time-dependent Cox modeling of follow-up data (median 15.9 years) for two repeat CT exams and cardiovascular events to assess the association of CAC at follow-up CT with cardiovascular events.

RESULTS

For 45 year olds with type 2 diabetes, the likelihood of CAC at baseline was 23% vs. 17% for those without. Median age at incident CAC was 52.2 vs. 62.3 years for those with and without diabetes, respectively. Each 5 years of diabetes treatment increased the odds and hazard rate of CAC by 19% (95% CI 8-33) and 22% (95% CI 6-41). Male sex, White ethnicity/race, hypertension, hypercholesterolemia, obesity, and low serum creatinine also increased CAC. CAC at follow-up CT independently increased coronary heart disease rates.

CONCLUSIONS

We estimated cumulative CAC incidence to age 85 years. Patients with type 2 diabetes develop CAC at a younger age than those without diabetes. Because incident CAC is associated with increased coronary heart disease risk, the value of periodic CAC-based risk assessment in type 2 diabetes should be evaluated.

Roles of allostatic load, lifestyle and clinical risk factors in mediating the association between education and coronary heart disease risk in Europe

BACKGROUND

Previous studies have shown that differential exposure to lifestyle factors may mediate the association between education and coronary heart diseases (CHD). However, few studies have examined the potential roles of allostatic load (AL) or differential susceptibility.

METHODS

25 310 men and 26 018 women aged 35-74 and CHD free at baseline were identified from 21 European cohorts and followed for a median of 10 years, to investigate the mediating role of AL, as well as of smoking, alcohol use and body mass index (BMI), on educational differences in CHD incidence, applying marginal structural models and three-way decomposition.

RESULTS

AL is a mediator of the association between educational status and CHD incidence, with the highest proportion mediated observed among women and largely attributable to differential exposure, (28% (95% CI 19% to 44%)), with 8% (95% CI 0% to 16%) attributable to differential susceptibility. The mediating effects of smoking, alcohol and BMI, compared with AL, were relatively small for both men and women.

CONCLUSION

Overall, the educational inequalities in CHD incidence were partially mediated through differential exposure to AL. By contrast, the mediation of the educational gradient in CHD by investigated lifestyle risk factors was limited. As differential susceptibility in men was found to have a predominant role in the accumulation of AL in low educational classes, the investigation of AL-related risk factors is warranted.

Recreational substance use among patients with premature atherosclerotic cardiovascular disease

OBJECTIVE

Despite an upsurge in the incidence of atherosclerotic cardiovascular diseases (ASCVD) among young adults, the attributable risk of recreational substance use among young patients has been incompletely evaluated. We evaluated the association of all recreational substances with premature and extremely premature ASCVD.

METHODS

In a cross-sectional analysis using the 2014-2015 nationwide Veterans Affairs Healthcare database and the Veterans wIth premaTure AtheroscLerosis (VITAL) registry, patients were categorised as having premature, extremely premature or non-premature ASCVD. Premature ASCVD was defined as having first ASCVD event at age <55 years for men and <65 years for women. Extremely premature was defined as having first ASCVD event at age <40 years while non-premature ASCVD was defined as having first ASCVD event at age ≥55 years for men and ≥65 years for women. Patients with premature ASCVD (n=135 703) and those with extremely premature ASCVD (n=7716) were compared against patients with non-premature ASCVD (n=1 112 455). Multivariable logistic regression models were used to study the independent association of all recreational substances with premature and extremely premature ASCVD.

RESULTS

Compared with patients with non-premature ASCVD, patients with premature ASCVD had a higher use of tobacco (62.9% vs 40.6%), alcohol (31.8% vs 14.8%), cocaine (12.9% vs 2.5%), amphetamine (2.9% vs 0.5%) and cannabis (12.5% vs 2.7%) (p<0.01 for all comparisons). In adjusted models, the use of tobacco (OR 1.97, 95% CI 1.94 to 2.00), alcohol (OR 1.50, 95% CI 1.47 to 1.52), cocaine (OR 2.44, 95% CI 2.38 to 2.50), amphetamine (OR 2.74, 95% CI 2.62 to 2.87), cannabis (OR 2.65, 95% CI 2.59 to 2.71) and other drugs (OR 2.53, 95% CI 2.47 to 2.59) was independently associated with premature ASCVD. Patients with polysubstance use had a graded response with the highest risk (~9-fold) of premature ASCVD among patients with use of ≥4 recreational substances. Similar trends were observed among patients with extremely premature ASCVD. Gender interactions with substance use were significant (p-interaction <0.05), with recreational substance use and premature ASCVD showing stronger associations among women than in men with premature ASCVD.

CONCLUSIONS

All subgroups of recreational substances were independently associated with a higher likelihood of premature and extremely premature ASCVD. Recreational substance use confers a greater magnitude of risk for premature ASCVD among women. A graded response relationship exists between increasing number of recreational substances used and higher likelihood of early-onset ASCVD.

Exposure to Community Homicide During Pregnancy and Adverse Birth Outcomes: A Within-Community Matched Design

BACKGROUND

Community violence is an understudied aspect of social context that may affect risk of preterm birth and small-for-gestational age (SGA).

METHODS

We matched California mothers with live singleton births who were exposed to a homicide in their Census tract of residence in 2007-2011 to unexposed mothers within the same tract. We estimated risk differences with a weighted linear probability model, with weights corresponding to the matched data structure. We estimated the average treatment effect on the treated of homicide exposure on the risk of preterm birth and SGA during the preconception period and first and second trimester.

RESULTS

We found a small increase in risk of SGA associated with homicide exposure in the first trimester (0.14% [95% confidence interval (CI) = -0.01%, 0.30%]), but not for exposure during the preconception period (-0.01% [95% CI = -0.17%, 0.15%]) or the second trimester (-0.06% [95% CI = -0.23%, 0.11%]). Risk of preterm birth was not affected by homicide exposure. When women were exposed to homicides during all three exposure windows, there was a larger increase in risk of SGA (1.09% [95% CI = 0.15%, 2.03%]) but not preterm birth (0.14% [95% CI = -0.74%, 1.01%]). Exposure to three or more homicides was also associated with greater risk of SGA (0.78% [95% CI = 0.15%, 1.40%]). Negative controls indicated that residual confounding by temporal patterning was unlikely.

CONCLUSIONS

Homicide exposure during early pregnancy is associated with a small increased risk of SGA.

Decomposing the educational gradient in allostatic load across European populations. What matters the most: differentials in exposure or in susceptibility?

Background

We investigate whether socially disadvantaged individuals are more susceptible to the detrimental effects of smoking and alcohol intake on allostatic load (AL), a marker of physiological ‘wear and tear’, resulting from adaptation to chronic stress.

Methods

In a cross-sectional analysis, 27 019 men and 26 738 women aged 35–74 years were identified from 21 European cohorts in the BiomarCaRE consortium. We defined three educational classes (EDs) according to years of schooling and an AL score as the sum of z-scores of eight selected biomarkers from the cardiovascular, metabolic and inflammatory systems. We used the Oaxaca-Blinder decomposition to disentangle the ED gradient in AL score into the differential exposure (DE, attributable to different distribution of smoking and alcohol intake across EDs) and the differential susceptibility (DS, attributable to a different effect of risk factors on AL across EDs) components.

Results

Less-educated men (mean AL difference: 0.68, 95% CI 0.57 to 0.79) and women (1.52, 95% CI 1.40 to 1.64) had higher AL scores. DE accounted for 7% and 6% of the gradient in men and women, respectively. In men, combining smoking and alcohol intake, DS accounted for 42% of the gradient (smoking DS coefficient=0.177, 26% of the gradient; alcohol DS coefficient=0.109; 16%, not statistically significant). DS contribution increased to 69% in metabolic markers. DS estimates were consistent across age groups, irrespective of comorbidities and robust to unmeasured confounding. No DS was observed in women.

Conclusions

In men, a DS mechanism substantially contributes to the educational class gradient in allostatic load.

Temporal trends and demographic risk factors for hospital admissions due to carbon monoxide poisoning in England

Unintentional non-fire related (UNFR) carbon monoxide (CO) poisoning is a preventable cause of morbidity and mortality. Epidemiological data on UNFR CO poisoning can help monitor changes in the magnitude of this burden, particularly through comparisons of multiple countries, and to identify vulnerable sub-groups of the population which may be more at risk. Here, we collected data on age- and sex- specific number of hospital admissions with a primary diagnosis of UNFR CO poisoning in England (2002-2016), aggregated to small areas, alongside area-level characteristics (i.e. deprivation, rurality and ethnicity). We analysed temporal trends using piecewise log-linear models and compared them to analogous data obtained for Canada, France, Spain and the US. We estimated age-standardized rates per 100,000 inhabitants by area-level characteristics using the WHO standard population (2000-2025). We then fitted the Besag York Mollie (BYM) model, a Bayesian hierarchical spatial model, to assess the independent effect of each area-level characteristic on the standardized risk of hospitalization. Temporal trends showed significant decreases after 2010. Decreasing trends were also observed across all countries studied, yet France had a 5-fold higher risk. Based on 3399 UNFR CO poisoning hospitalizations, we found an increased risk in areas classified as rural (0.69, 95% CrI: 0.67; 0.80), highly deprived (1.77, 95% CrI: 1.66; 2.10) or with the largest proportion of Asian (1.15, 95% CrI: 1.03; 1.49) or Black population (1.35, 95% CrI: 1.20; 1.80). Our multivariate approach provides strong evidence for the identification of vulnerable populations which can inform prevention policies and targeted interventions.

Temporal trends and demographic risk factors for hospital admissions due to carbon monoxide poisoning in England

Unintentional non-fire related (UNFR) carbon monoxide (CO) poisoning is a preventable cause of morbidity and mortality. Epidemiological data on UNFR CO poisoning can help monitor changes in the magnitude of this burden, particularly through comparisons of multiple countries, and to identify vulnerable sub-groups of the population which may be more at risk. Here, we collected data on age- and sex- specific number of hospital admissions with a primary diagnosis of UNFR CO poisoning in England (2002-2016), aggregated to small areas, alongside area-level characteristics (i.e. deprivation, rurality and ethnicity). We analysed temporal trends using piecewise log-linear models and compared them to analogous data obtained for Canada, France, Spain and the US. We estimated age-standardized rates per 100,000 inhabitants by area-level characteristics using the WHO standard population (2000-2025). We then fitted the Besag York Mollie (BYM) model, a Bayesian hierarchical spatial model, to assess the independent effect of each area-level characteristic on the standardized risk of hospitalization. Temporal trends showed significant decreases after 2010. Decreasing trends were also observed across all countries studied, yet France had a 5-fold higher risk. Based on 3399 UNFR CO poisoning hospitalizations, we found an increased risk in areas classified as rural (0.69, 95% CrI: 0.67; 0.80), highly deprived (1.77, 95% CrI: 1.66; 2.10) or with the largest proportion of Asian (1.15, 95% CrI: 1.03; 1.49) or Black population (1.35, 95% CrI: 1.20; 1.80). Our multivariate approach provides strong evidence for the identification of vulnerable populations which can inform prevention policies and targeted interventions.

Differential vulnerability and susceptibility: how to make use of recent development in our understanding of mediation and interaction to tackle health inequalities

This paper discusses the concepts of vulnerability and susceptibility and their relevance for understanding and tackling health inequalities. Tackling socioeconomic inequalities in health is based on an understanding of how an individual's social position influences disease risk. Conceptually, there are two possible mechanisms (not mutually exclusive): there is either some cause(s) of disease that are unevenly distributed across socioeconomic groups (differential exposure) or the effect of some cause(s) of disease differs across groups (differential effect). Since differential vulnerability and susceptibility are often used to denote the latter, we discuss these concepts and their current use and suggest an epidemiologically relevant distinction. The effect of social position can thus be mediated by causes that are unevenly distributed across social groups and/or interact with social position. Recent improvements in the methodology to estimate mediation and interaction have made it possible to calculate measures of relevance for setting targets and priorities in policy for health equity which include both mechanisms, i.e. equalize exposure or equalize effects. We finally discuss the importance of differential susceptibility and vulnerability for the choice of preventive strategies, including approaches that target high-risk individuals, whole populations and vulnerable groups.

Longitudinal associations of neighborhood socioeconomic status with cardiovascular risk factors: A 46-year follow-up study

OBJECTIVES

Neighborhood characteristics are increasingly recognized as important determinants of cardiovascular disease (CVD) risk. However, longitudinal studies on the health impacts of neighborhood characteristics are rare. We sought to investigate whether neighborhood socioeconomic status (NSES) during birth, childhood and adulthood is associated with CVD risk factors in adulthood.

METHODS

Using longitudinal data from the New England Family Study (n = 671) with 46-years of follow-up, participants' home addresses were geocoded at birth (mean age = 1.6 months), childhood (mean age = 7.1 years), and adulthood (mean age = 44.2 years) across Massachusetts and Rhode Island in the US from 1961 to 2007. We used multilevel models to evaluate associations of NSES across the life-course with systolic blood pressure, diastolic blood pressure and body mass index (BMI) in adulthood, adjusting for age, sex, race/ethnicity, mother's race, individual SES, and parental SES.

RESULTS

In fully adjusted models, one standard deviation higher NSES at birth was associated with a 1.9 mmHg lower SBP (95% CI: 3.8, -0.1) and 1.3 mmHg lower DBP (95%CI: 2.6,-0.03) in adulthood; while one standard deviation of higher NSES at adulthood was associated with 0.87 kg/m2 lower BMI (95%CI: 1.7, -0.1).

CONCLUSIONS

We found that living in a socioeconomically disadvantaged neighborhood early in life and in adulthood was associated with blood pressure and BMI, respectively, two established risk factors for CVD. Our findings support a longitudinal association between exposure to socioeconomically disadvantaged neighborhoods in early life and CVD risk factors in adulthood.

Intersectional decomposition analysis with differential exposure, effects, and construct

In recent years a wide array of proposals for bringing intersectional perspectives into quantitative studies of health disparities have appeared, from studies of interaction, predictive discrimination, to mediation. Bauer and Scheim, in a companion set of articles, extend these proposals by developing new attribution-blind measures of perceived discrimination and using VanderWeele's 3-way decomposition to quantify its contribution to disparities through differential exposure and differential effects (sometimes called differential vulnerability or susceptibility). In this commentary, after providing an overview of causal inference interpretations with social characteristics, we provide a broad overview of old and new decomposition methods in the social sciences literature and contrast their strengths and weaknesses for studying intersectional inequalities. We then examine how different forms of differential effects can be expressed within these decompositions and discuss their utility for the purpose of informing interventions for reducing disparities. Last, we discuss the tension in social sciences research when prominent explanatory variables represent constructs that are only defined or exist for certain marginalized populations and may not neatly fit within the decomposition methods framework. Through these discussions, we aim to provide greater conceptual clarity for applied researchers who are interested in using decomposition methods and other approaches to advance intersectional equity.

Widening health inequalities between the employed and the unemployed: A decomposition of trends in Canada (2000-2014)

Recent developments in the social epidemiological literature indicate that health inequalities between the employed and the unemployed are widening in many advanced capitalist countries. At present, we know relatively little about why these inequalities are worsening. Drawing on nationally-representative data from the largest health survey in Canada, we explored this question by analyzing changes in self-rated health inequalities between employed and unemployed Canadians from 2000 to 2014. Using a regression-based method that decomposes a given inequality into its component sources, we investigated the extent to which risk factors that account for unemployment-related health inequalities at a single point in time can also explain the extent and direction of change in these unemployment-related health inequalities over time. Our results indicate that relative and absolute health inequalities between employed and unemployed Canadians widened over the study period. Between 2000 and 2014, the prevalence of poor self-rated health among unemployed Canadians increased from 10.8% to 14.6%, while rates among employed Canadians were stable at around 6%. Our findings suggest that the demographic, socioeconomic, and proximal risk factors that are routinely used to explain unemployment-related health inequalities may not be as powerful for explaining how and why these inequalities change over time. In the case of unemployment-related health inequalities in Canada, these risk factors explain neither the increasing prevalence of poor self-rated health among the unemployed nor the growing gap between the unemployed and their employed counterparts. We provide several possible explanations for these puzzling findings. We conclude by suggesting that widening health inequalities may be driven by macrosocial trends (e.g. widening income inequality and declining social safety nets) which have changed the meaning and context of unemployment, as well as its associated risk factors, in ways that are not easy to capture using routinely available survey data.

Neighborhood Environments and Diabetes Risk and Control

PURPOSE OF REVIEW

The objective of this review is to highlight the evidence on the association between contextual characteristics of residential environments and type 2 diabetes, to provide an overview of the methodological challenges and to outline potential topics for future research in this field.

RECENT FINDINGS

The link between neighborhood socioeconomic status or deprivation and diabetes prevalence, incidence, and control is robust and has been replicated in numerous settings, including in experimental and quasi-experimental studies. The association between characteristics of the built environment that affect physical activity, other aspects of the built environment, and diabetes risk is robust. There is also evidence for an association between food environments and diabetes risk, but some conflicting results have emerged in this area. While the evidence base on the association of neighborhood socioeconomic status and built and physical environments and diabetes is large and robust, challenges remain related to confounding due to neighborhood selection. Moreover, we also outline five paths forward for future research on the role of neighborhood environments on diabetes.

Health inequalities in hospitalisation and mortality in patients diagnosed with heart failure in a universal healthcare coverage system

BACKGROUND

Information regarding the effect of social determinants of health on heart failure (HF) community-dwelling patients is scarce. We aimed to analyse the presence of socioeconomic inequalities, and their impact on hospitalisations and mortality, in patients with HF attended in a universal healthcare coverage system.

METHODS

A retrospective cohort study carried out in patients with HF aged >40 and attended at the 53 primary healthcare centres of the Institut Català de la Salut in Barcelona (Spain). Socioeconomic status (SES) was determined by an aggregated deprivation index (MEDEA). Cox proportional hazard models and competing-risks regression based on Fine and Gray's proportional subhazards were performed to analyse hospitalisations due to of HF and total mortality that occurred between 1 January 2009 and 31 December 2012.

RESULTS

Mean age was 78.1 years (SD 10.2) and 56% were women. Among the 8235 patients included, 19.4% died during the 4 years of follow-up and 27.1% were hospitalised due to HF. A gradient in the risk of hospitalisation was observed according to SES with the highest risk in the lowest socioeconomic group (sHR 1.46, 95% CI 1.27 to 1.68). Nevertheless, overall mortality did not differ among the socioeconomic groups.

CONCLUSIONS

In spite of finding a gradient that linked socioeconomic deprivation to an increased risk of hospitalisation, there were no differences in mortality regarding SES in a universal healthcare coverage system.