Trends in risk factors for lifestyle-related diseases by socioeconomic position in Geneva, Switzerland, 1993-2000: health inequalities persist

Twelve-year (2008-2019) trends in socioeconomic inequalities in cardiovascular risk factors in a Swiss representative survey of the general population

Objective

We assessed trends in socioeconomic inequalities in cardiovascular risk factors prevalence among Swiss adults from 2008 to 2019.

Methods

Using data from the Bus Santé study, an annual survey of adults living in Geneva, Switzerland, we calculated the prevalence per period and by demographic and socioeconomic indicators, assessing inequality trends using the relative index of inequality (RII) and the slope index of inequality (SII).

Results

Among 10,739 participants, most CVD risk factors decreased over time, while diabetes, obesity, and smoking prevalence remained steady. In 2017-2019, prevalence of most CVD risk factors was higher in socioeconomically disadvantaged groups. Relative and absolute inequalities decreased over time, but mostly remained, for hypertension [in 2017-2019, education-RII (95 % CI) = 1.27 (1.12-1.46), income-RII = 1.27 (1.10-1.47)], hypercholesterolemia [education-RII = 1.15 (1.00-1.32)], and sedentarity [education-RII = 1.95 (1.52-2.51), income-RII = 1.69 (1.28-2.23)], and appeared to have reversed for hazardous alcohol use [income-RII = 0.75 (0.60-0.93)]. Substantial and persistent relative and absolute inequalities in diabetes prevalence were observed [education-RII = 2.39 (1.75-3.27), income-RII = 3.18 (2.25-4.48), and subsidy-RII = 2.77 (1.89-4.05)]. Inequalities were also marked across all socioeconomic indicators for obesity prevalence [education-RII = 3.32 (2.63-4.19), income-RII = 2.37 (1.85-3.04), subsidy-RII = 1.98 (1.48-2.66)] and for smoking [education-RII = 2.42 (2.06-2.84), income-RII = 2.37 (1.99-2.84), subsidy-RII = 1.91 (1.56-2.35)].

Conclusions

Over 12 years in Geneva, Switzerland, socioeconomic inequalities in hypertension, hypercholesterolemia, hazardous alcohol use, and sedentarity decreased but persist, while substantial inequalities in diabetes, obesity, and smoking remained unchanged.

Investigating the individual and joint effects of socioeconomic status and lifestyle factors on mild cognitive impairment in older Italians living independently in the community: results from the NutBrain study

OBJECTIVES

Despite extensive research, a clear understanding of the role of the interaction between lifestyle and socioeconomic status (SES) on cognitive health is still lacking. We investigated the joint association of socioeconomic factors in early to midlife and lifestyle in later life and Mild Cognitive Impairment (MCI).

DESIGN

Observational cross-sectional study.

SETTING

NutBrain study in northern Italy.

PARTICIPANTS

773 community-dwelling adults aged 65 years and older (73.2 ± 6.0 SD, 58.6% females) participating in the NutBrain study (2019-2023).

MEASUREMENTS

Three SES indicators (home ownership, educational level, occupation) and five lifestyle factors (adherence to Mediterranean diet, physical activity, smoking habits, social network, leisure activities) were selected. Each factor was scored and summed to calculate SES and healthy lifestyle scores; their joint effect was also examined. The association with MCI was assessed by logistic regression controlling for potential confounders. Sex-stratified analysis was performed.

RESULTS

In total, 24% of the subjects had MCI. The multivariable logistic model showed that a high SES and a high lifestyle score were associated with 81.8% (OR0.182; 95%CI 0.095-0.351), and 44.1% (OR0.559; 95%CI 0.323-0.968) lower odds of having MCI, respectively. When examining the joint effect of SES and lifestyle factors, the cognitive benefits of a healthy lifestyle were most pronounced in participants with low SES. A healthier lifestyle score was found to be significantly associated with lower odds of MCI, only in females.

CONCLUSIONS

According to our findings, SES was positively associated with preserved cognitive function, highlighting the importance of active lifestyles in reducing socioeconomic health inequalities, particularly among those with a relatively low SES.

TRIAL REGISTRATION

Trial registration number NCT04461951, date of registration July 7, 2020 (retrospectively registered, ClinicalTrials.gov).

Socioeconomic inequalities in sport participation: pattern per sport and time trends - a repeated cross-sectional study

BACKGROUND

Sport participation is an important component of a healthy lifestyle and is known to be more common among privileged individuals. However, few studies examined socio-demographic patterns of participation by type of activity. This study aims at quantifying socio-economic inequalities in sport participation by sport type, and to analyse their trend over 15 years.

METHODS

We used 2005-2019 data from the Bus Santé study, a yearly population-based cross-sectional survey of Geneva adults. Sport participation was defined as reporting at least one sporting activity over the previous week; educational level, household income and occupational position were used as indicators of socio-economic position. Socio-economic inequalities in sport participation, and their trend over time, were examined using the relative and slope indexes of inequality (RII/SII).

RESULTS

Out of 7769 participants (50.8% women, mean age 46 years old), 60% participated in a sporting activity. Results showed that the higher the socioeconomic circumstances, the higher the sport participation (RII = 1.78; 95% Confidence Interval (CI): 1.64-1.92; SII = 0.33; 95%CI: 0.29-0.37 for education). Relative inequalities varied per sport e.g., 0.68 (95%CI: 0.44-1.07) for football and 4.25 (95%CI: 2.68-6.75) for tennis/badminton for education. Yearly absolute inequalities in sport participation tended to increase between 2005 and 2019 for household income, especially among women and older adults.

CONCLUSIONS

We observed strong socio-economic inequalities in sport participation in Geneva, with different magnitude depending on the sport type. These inequalities seemed to increase over the 2005-2019 period. Our results call for tailored measures to promote the participation of socially disadvantaged populations in sporting activities.

The association between a lifestyle score, socioeconomic status, and COVID-19 outcomes within the UK Biobank cohort

BACKGROUND

Infection with SARS-CoV-2 virus (COVID-19) impacts disadvantaged groups most. Lifestyle factors are also associated with adverse COVID-19 outcomes. To inform COVID-19 policy and interventions, we explored effect modification of socioeconomic-status (SES) on associations between lifestyle and COVID-19 outcomes.

METHODS

Using data from UK-Biobank, a large prospective cohort of 502,536 participants aged 37-73 years recruited between 2006 and 2010, we assigned participants a lifestyle score comprising nine factors. Poisson regression models with penalised splines were used to analyse associations between lifestyle score, deprivation (Townsend), and COVID-19 mortality and severe COVID-19. Associations between each exposure and outcome were examined independently before participants were dichotomised by deprivation to examine exposures jointly. Models were adjusted for sociodemographic/health factors.

RESULTS

Of 343,850 participants (mean age > 60 years) with complete data, 707 (0.21%) died from COVID-19 and 2506 (0.76%) had severe COVID-19. There was evidence of a nonlinear association between lifestyle score and COVID-19 mortality but limited evidence for nonlinearity between lifestyle score and severe COVID-19 and between deprivation and COVID-19 outcomes. Compared with low deprivation, participants in the high deprivation group had higher risk of COVID-19 outcomes across the lifestyle score. There was evidence for an additive interaction between lifestyle score and deprivation. Compared with participants with the healthiest lifestyle score in the low deprivation group, COVID-19 mortality risk ratios (95% CIs) for those with less healthy scores in low versus high deprivation groups were 5.09 (1.39-25.20) and 9.60 (4.70-21.44), respectively. Equivalent figures for severe COVID-19 were 5.17 (2.46-12.01) and 6.02 (4.72-7.71). Alternative SES measures produced similar results.

CONCLUSIONS

Unhealthy lifestyles are associated with higher risk of adverse COVID-19, but risks are highest in the most disadvantaged, suggesting an additive influence between SES and lifestyle. COVID-19 policy and interventions should consider both lifestyle and SES. The greatest public health benefit from lifestyle focussed COVID-19 policy and interventions is likely to be seen when greatest support for healthy living is provided to the most disadvantaged groups.

Health-related biological and non-biological consequences of forgoing healthcare for economic reasons

Forgoing healthcare for economic reasons has been previously associated with adverse health outcomes, including a higher risk of hospitalization, a lower quality of life, and worse self-reported health. However, the exact cause-to-effect relation between forgoing healthcare and health-related outcomes has been insufficiently described. Here, we investigate the prospective health consequences of forgoing healthcare for economic reasons using data from “ReBus” (N = 400), a prospective study examining the health consequences of forgoing healthcare (Baseline: 2008–2013, Follow-up: 2014–2016). Using regression models, we explored the baseline determinants of forgoing healthcare, including socioeconomic, demographic, and pre-existing health-risk factors, and examined the associations between forgoing healthcare at baseline and health deterioration at follow-up, using highly pertinent biomarkers (glucose, glycated hemoglobin, lipids, blood pressure) and SF-36 questionnaire data.

Low income, low occupation, low education, and smoking were associated with higher odds of forgoing healthcare at baseline. Forgoing healthcare for economic reasons at baseline was subsequently related to detrimental changes in glucose, high-density lipoprotein cholesterol (HDL), and blood pressure (BP) at follow-up, independently of baseline socioeconomic factors (Glucose-β = 0.19, 95%CI[0.03;0.34], HDL-β = -0.07, 95%CI[-0.14;0.01], BP-β = 3.30, 95%CI[-0.01;6.60]). Moreover, we found strong associations between forgoing healthcare and adverse SF-36 health scores at follow-up, with individuals forgoing healthcare systematically displaying worse health scores (6%–11% lower scores).

For the first time, we show that forgoing healthcare for economic reasons predicts adverse health-related consequences 2–8 years later. Our findings shall further encourage the implementation of public health measures aimed at identifying individuals who forgo healthcare and preventing the adverse health consequences of unmet medical needs.

MIND Diet and Cognitive Function over Eight Years in Puerto Rican Older Adults

BACKGROUND

Healthy diets have been associated with better cognitive function. Socio-economic factors including education, poverty and job complexity may modify the relationship between diet and cognition.

METHODS

We used adjusted linear mixed models to examine the association between long-term adherence to the Mediterranean-Dietary Approaches to Stop Hypertension - Intervention for Neurodegenerative Delay (MIND) diet and cognitive function over 8 years of follow-up in Puerto Rican adults residing in the Boston, MA area (aged 45 to 75 years at baseline). We also examined whether the MIND diet - cognition association was confounded or modified by socioeconomic measures.

RESULTS

In both cross-sectional and longitudinal analyses the highest, vs lowest, MIND quintile was associated with better cognition function (ß = 0.093; 95% CI: 0.035, 0.152; P trend = 0.0019), but not with cognitive trajectory over 8 years. Education <=8 th grade (ß = -0.339; 95% CI: 0.394, -0.286; P < 0.0001) and income-to-poverty ratio <120% (ß = -0.049; 95% CI: -0.092, -0.007; P = 0.024) were significantly associated with lower cognitive function, while higher job complexity (ß = 0.008; 95% CI: 0.006, 0.011; P < 0.0001) was associated with better cognition function. These variables acted confounders, but not effect modifiers of the MIND-diet - cognitive function relationship.

CONCLUSION

Adherence to the MIND diet was associated with better cognitive function at baseline and over 8 years of follow-up, however MIND diet was not associated with 8-year cognitive trajectory. More studies are needed to better understand whether the MIND diet is protective against long-term cognitive decline.

Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension

High blood pressure is one of the most important risk factors for ischaemic heart disease, stroke, other cardiovascular diseases, chronic kidney disease and dementia. Mean blood pressure and the prevalence of raised blood pressure have declined substantially in high-income regions since at least the 1970s. By contrast, blood pressure has risen in East, South and Southeast Asia, Oceania and sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low-income and middle-income countries than in high-income countries. In 2015, an estimated 8.5 million deaths were attributable to systolic blood pressure >115 mmHg, 88% of which were in low-income and middle-income countries. Measures such as increasing the availability and affordability of fresh fruits and vegetables, lowering the sodium content of packaged and prepared food and staples such as bread, and improving the availability of dietary salt substitutes can help lower blood pressure in the entire population. The use and effectiveness of hypertension treatment vary substantially across countries. Factors influencing this variation include a country's financial resources, the extent of health insurance and health facilities, how frequently people interact with physicians and non-physician health personnel, whether a clear and widely adopted clinical guideline exists and the availability of medicines. Scaling up treatment coverage and improving its community effectiveness can substantially reduce the health burden of hypertension.

Geographic and socioeconomic disparity in cardiovascular risk factors in Indonesia: analysis of the Basic Health Research 2018

Background

Cardiovascular diseases (CVDs) accounted for over 17 million deaths and 353 million disability-adjusted life years lost in 2016. The risk factors are also high and increasing with high blood pressure, smoking, and high body mass index contributed to up to 212 million disability-adjusted life years in 2016. To help reduce the burden, it is crucial to understand the geographic and socioeconomic disparities in CVD risk factors.

Methods

Employing both geospatial and quantitative analyses, we analyzed the disparities in the prevalence of smoking, physical inactivity, obesity, hypertension, and diabetes in Indonesia. CVD data was from Riskesdas 2018, and socioeconomic data was from the World Bank.

Results

Our findings show a very high prevalence of CVD risk factors with the prevalence of smoking, physical activity, obesity, hypertension ranged from 28 to 33%. Results also show the geographic disparity in CVD risk factors in all five Indonesian regions. Moreover, results show socioeconomic disparity with the prevalence of obesity, hypertension, and diabetes are higher among urban and the richest and most educated districts while that physical inactivity and smoking is higher among rural and the least educated districts.

Conclusion

The CVD burden is high and increasing in particularly among urban areas and districts with higher income and education levels. While the government needs to continue tackling the persistent burden from maternal mortality and infectious diseases, they need to put more effort into the prevention and control of CVDs and their risk factors.

Assessment of Changes in Body Composition During the First Postoperative Year After Bariatric Surgery

BACKGROUND

The potential effect of bariatric surgery on weight reduction and improvement of associated comorbidities is known, but the ratio obtained between the components of body weight, including lean body mass, body fat mass, and bone mass, is still not determined. This study aims to verify the changes in body composition during the first year after bariatric surgery.

METHODS

We conducted a prospective observational cohort study. Fifty patients who underwent bariatric surgery and maintained follow-ups were selected. Patients were assessed preoperatively and postoperatively for periods of 1, 3, 6, and 12 months using tetrapolar bioelectrical impedance analysis and laboratory testing of lipids and serum albumin levels. Data were statistically analyzed.

RESULTS

Statistically significant differences (p < 0.001) were obtained between the preoperative and 12-month evaluation respectively, for body mass index (BMI) (45.8 ± 7.5 to 30.0 ± 4.8 kg/m²), FM (64.7 ± 15.5 to 30.6 ± 9.8 kg), PFM (51.6 ± 4.17 to 37.3 ± 7.6%), and total cholesterol levels (197.1 ± 49.8 to 169.8 ± 31.0 mg/dL). The decrease in PFM shows a better proportion between the body components. PFM showed significantly higher decrease in males than in females (p = 0.012). Lean body mass (p = 0.000) reduction was highest for patients operated by the Unified Health System (SUS, Government of Brazil) probably because of its few financial resources to maintain postoperative care.

CONCLUSION

The change in body composition of patients who underwent Roux-en-Y gastric bypass was statistically significant for all variables examined during the first year postoperatively. This shows the effectiveness of the surgical procedure and clinical protocol set, which tends to favor a better health prognosis and weight maintenance in the long term.

Socioeconomic status, cardiac risk factors, and cardiovascular disease: A novel approach to determination of this association

BACKGROUND

Socioeconomic inequality is one of the important issues in cardiovascular diseases (CVDs). The aim of this study was to investigate the distribution and relation between selected cardiac risk factors, type of CVD, and the socioeconomic status (SES) in the hospitalized patients with heart disease in Isfahan, Iran.

METHODS

This analytical and cross-sectional study was conducted in Isfahan in 2013. The population consisted of all patients with CVD admitted to the public and private hospitals. The sample size was 721. Data collection was conducted through one researcher-made questionnaire with three sections: demographic, disease, and SES questionnaires. To determine the SES of the patients, the indicators of income, housing status, occupation, family size, and education were used. Data analysis was conducted in two statistical levels of descriptive and inferential.

RESULTS

69.1% of the patients were placed in the poor status, and there was no wealthy status within the subjects. The five most frequent CVDs were chronic ischemia, unstable angina, arrhythmia, congestive heart failure (CHF), and acute myocardial infarction (MI), respectively. The three highest frequent risk factors in the patients were hypertension (HTN) (47.2%), diabetes (33.6%), and hyperlipidemia (32.6%). Regression analysis of the risk factors and the type of heart disease on the SES revealed that there were statistically significant differences between patients who were smokers (P = 0.030) and those who had valve disease (P = 0.010), adjusted for age, gender, and marital status.

CONCLUSION

Our findings showed that the frequency of CVD risk factors were higher in lower SES groups and thus SES can be a strong predictor for the occurrence of the CVD risk factors as well as the CVDs.

An evidence-based toolbox for the design and implementation of selective-prevention primary-care initiatives targeting cardio-metabolic disease

Cardio-metabolic diseases (CMD; cardiovascular disease, type 2 diabetes, chronic kidney disease) represent a global public health problem. Worldwide, nearly half a billion people are currently diagnosed with diabetes, and cardiovascular disease is the leading cause of death. Most of these diseases can be assuaged/prevented through behavior change. However, the best way to implement preventive interventions is unclear. We aim to fill this knowledge gap by creating an evidence-based and adaptable “toolbox” for the design and implementation of selective prevention initiatives (SPI) targeting CMD. We built our toolbox based on evidence from a pan-European research project on primary-care SPIs targeting CMD. The evidence includes (1) two systematic reviews and two surveys of patient and general practitioner barriers and facilitators of engaging with SPIs, (2) a consensus meeting with leading experts to establish optimal SPI design, and (3) a feasibility study of a generic, evidence-based primary-care SPI protocol in five European countries. Our results related primarily to the five different national health-care contexts from which we derived our data. On this basis, we generated 12 general recommendations for how best to design and implement CMD-SPIs in primary care. We supplement our recommendations with practical, evidence-based suggestions for how each recommendation might best be heeded. The toolbox is generic and adaptable to various national and systemic settings by clinicians and policy makers alike. However, our product needs to be kept up-to-date to be effective and we implore future research to add relevant tools as they are developed.

Are socioeconomic inequalities in the incidence of small-for-gestational-age birth narrowing? Findings from a population-based cohort in the South of England

OBJECTIVES

To investigate socioeconomic inequalities, using maternal educational attainment, maternal and partner employment status, and lone motherhood indicators, in the risk of small-for-gestational-age (SGA) births, their time trend, potential mediation by maternal smoking and body mass index, and effect modification by parity.

DESIGN

Population-based birth cohort using routine antenatal healthcare data.

SETTING

Babies born at University Hospital Southampton, UK, between 2004 and 2016.

PARTICIPANTS

65 909 singleton live births born to mothers aged ≥18 years between 24-week and 42-week gestation.

MAIN OUTCOME MEASURES

SGA (birth weight <10th percentile for others born at the same number of completed weeks compared with 2013/2014 within England and Wales).

RESULTS

Babies born to mothers educated up to secondary school level (adjusted OR (aOR) 1.32, 99% CI 1.19 to 1.47), who were unemployed (aOR 1.27, 99% CI 1.16 to 1.38) or with unemployed partners (aOR 1.27, 99% CI 1.13 to 1.43), were at greater risk of being SGA. There was no statistically significant change in the magnitude of this risk difference by these indicators over time between 2004 and 2016, as estimated by linear interactions with year of birth. Babies born to lone mothers were not at higher risk compared with partnered mothers after adjusting for maternal smoking (aOR 1.05, 99% CI 0.93 to 1.20). The inverse association between maternal educational attainment and SGA risk appeared greater in multiparous (aOR 1.40, 99% CI 1.10 to 1.77) compared with primiparous women (aOR 1.28, 99% CI 1.12 to 1.47), and the reverse was true for maternal and partner's unemployment where the association was stronger in primiparous women.

CONCLUSIONS

Socioeconomic inequalities in SGA risk by educational attainment and employment status are not narrowing over time, with differences in association strength by parity. The greater SGA risk in lone mothers was potentially explained by maternal smoking. Preventive interventions should target socially disadvantaged women, including preconception and postpartum smoking cessation to reduce SGA risk.

Socioeconomic Inequalities in the Rise of Adult Obesity: A Time-Trend Analysis of National Examination Data from Germany, 1990-2011

OBJECTIVE

Despite extensive study of the obesity epidemic, research on whether obesity has risen faster in lower or in higher socioeconomic groups is inconsistent. This study examined secular trends in obesity prevalence by socioeconomic position and the resulting obesity inequalities in the German adult population.

METHODS

Data were drawn from three national examination surveys conducted in 1990-1992, 1997-1999 and 2008-2011 (n = 18,541; age range: 25-69 years). Obesity was defined by a body mass index ≥30 kg/m2 using standardised measurements of body height and weight. Education and equivalised household disposable income were used as indicators of socioeconomic position. Time trends in socioeconomic inequalities in obesity were examined using linear probability and log-binomial regression models.

RESULTS

In each survey period, the highest socioeconomic groups had the lowest prevalence of obesity. The low and medium socioeconomic groups showed increases in obesity prevalence, whereas no such trend was observed in the high socioeconomic groups. Absolute inequalities in obesity by income increased by an average of 0.53 percentage points per year (95% confidence interval [CI] 0.01-1.05, p = 0.047) among men and 0.47 percentage points per year (95% CI 0.05-0.90, p = 0.029) among women. Absolute inequalities in obesity by education increased on average by 0.64 percentage points per year (95% CI 0.19-1.08, p = 0.005) among women but not among men (0.33 percentage points, 95% CI -0.27 to 0.92, p = 0.283).

CONCLUSIONS

These findings suggest a widening obesity gap between the top and the bottom of the socioeconomic spectrum. This has the potential to have adverse consequences for population health and health inequalities in coming decades. Interventions that are effective in preventing and reducing obesity in socially disadvantaged groups are needed.

The effect of lifestyle on late-life cognitive change under different socioeconomic status

This study aimed to identify lifestyle factors associated with cognitive change and to explore whether the effect of lifestyle varies by socioeconomic status (SES). Participants aged 65 years and older were recruited from elderly health checkup programs from 2011 to 2013 in Taiwan. Neuropsychological tests, including tests of global cognition, logical memory, executive function, verbal fluency and attention, were administered at baseline (N = 603) and 2 years later (N = 509). After literature review, 9 lifestyle factors and 3 SES indicators were chosen and their effects on cognitive change were evaluated using linear regression adjusting for age, sex, education, APOE ε4 status, and baseline cognitive score. Five lifestyle factors (high vegetable and fish intake, regular exercise, not smoking, and light to moderate alcohol consumption) and 3 SES indicators [annual household income (> 33,333 USD vs. less), occupational complexity (high vs. low mental demanding job), and years of education (> 12 years vs. less)] were found to be protective against cognitive decline (P < 0.1 in any cognitive domains, ß ranging from 0.06 to 0.38). After further adjusting for all the lifestyle and SES factors, fish intake, higher income and occupational complexity remained protective. Significant interactions were found between a healthful lifestyle (defined as having ≥ 3 healthful lifestyle factors) and income on changes of global cognition and verbal fluency (P_interaction = 0.02 and 0.04). The protective effect of a healthful lifestyle was observed only among participants with lower income in global cognition and logical memory [ß = 0.17, 95% confidence interval (CI) = 0.07–0.26; ß = 0.30, 95% CI = 0.14–0.46]. To the best of our knowledge, this study for the first time explored how the interactions of lifestyle and SES affect cognitive change. Our findings will aid in developing dementia prevention programs and reduce health inequalities.

Ethnic differences in current smoking and former smoking in the Netherlands and the contribution of socioeconomic factors: a cross-sectional analysis of the HELIUS study

OBJECTIVES

Data exploring how much of the ethnic differences in smoking prevalence and former smoking are explained by socioeconomic status (SES) are lacking. We therefore assessed ethnic differences in smoking prevalence and former smoking and the contribution of both educational level and occupational-related SES to the observed ethnic differences in smoking behaviour.

METHODS

Data of 22 929 participants (aged 18-70 years) from the multiethnic cross-sectional Healthy Life in an Urban Setting study in the Netherlands were analysed. Poisson regression models with a robust variance were used to estimate prevalence ratios.

RESULTS

Compared with the Dutch, after adjustment for age and marital status, smoking prevalence was higher in men of Turkish (prevalence ratio 1.69, 95% CI 1.54 to 1.86), African Surinamese (1.55, 95% CI 1.41 to 1.69) and South-Asian Surinamese origin (1.53, 95% CI 1.40 to 1.68), whereas among women, smoking prevalence was higher in Turkish, similar in African Surinamese but lower in all other ethnic origin groups. All ethnic minority groups, except Ghanaians, had a significantly lower smoking cessation prevalence than the Dutch. Socioeconomic gradients in smoking (higher prevalence among those lower educated and with lower level employment) were observed in all groups except Ghanaian women (a higher prevalence was observed in the higher educated). Ethnic differences in smoking prevalence and former smoking are largely, but not completely, explained by socioeconomic factors.

CONCLUSIONS

Our findings imply that antismoking policies designed to target smoking within the lower socioeconomic groups of ethnic minority populations may substantially reduce ethnic inequalities in smoking particularly among men and that certain groups may benefit from targeted smoking cessation interventions.

Changing educational inequalities in sporting inactivity among adults in Germany: a trend study from 2003 to 2012

BACKGROUND

Social inequalities in health can be explained in part by the social patterning of leisure-time physical activity, such as non-participation in sports. This study is the first to explore whether absolute and relative educational inequalities in sporting inactivity among adults have changed in Germany since the early 2000s.

METHODS

Data from four cross-sectional national health surveys conducted in 2003 (n = 6890), 2009 (n = 16,418), 2010 (n = 17,145) and 2012 (n = 13,744) were analysed. The study population was aged 25-69 years in each survey. Sporting inactivity was defined as no sports participation during the preceding 3 months. The regression-based Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were calculated to estimate the extent of absolute and relative educational inequalities in sporting inactivity, respectively.

RESULTS

Sporting inactivity was consistently more prevalent in less-educated groups. The overall prevalence of sporting inactivity declined significantly over time. However, the decline was observed only in the high and medium education groups, while no change was observed in the low education group. Both absolute and relative educational inequalities in sporting inactivity were found to have widened significantly between 2003 (SII = 0.30, 95% CI = 0.25-0.35; RII = 2.08, 95% CI = 1.83-2.38) and 2012 (SII = 0.41, 95% CI = 0.37-0.45; RII = 3.44, 95% CI = 3.03-3.91). Interaction analysis showed that these increases in inequalities were larger in the younger population under the age of 50 than among the elderly.

CONCLUSIONS

The findings suggest that the gap in sports participation between adults with high and low educational attainment has widened in both absolute and relative terms because of an increase in sports participation among the better educated. Health-enhancing physical activity interventions specifically targeted to less-educated younger adults are needed to prevent future increases in social inequalities in health.

Trends in educational inequalities in obesity in 15 European countries between 1990 and 2010

BACKGROUND

The prevalence of obesity increased dramatically in many European countries in the past decades. Whether the increase occurred to the same extent in all socioeconomic groups is less known. We systematically assessed and compared the trends in educational inequalities in obesity in 15 different European countries between 1990 and 2010.

METHODS

Nationally representative survey data from 15 European countries were harmonized and used in a meta-regression of trends in prevalence and educational inequalities in obesity between 1990 and 2010. Educational inequalities were estimated by means of absolute rate differences and relative rate ratios in men and women aged 30-64 years.

RESULTS

A statistically significant increase in the prevalence of obesity was found for all countries, except for Ireland (among men) and for France, Hungary, Italy and Poland (among women). Meta-regressions showed a statistically significant overall increase in absolute inequalities of 0.11% points [95% CI 0.03, 0.20] per year among men and 0.12% points [95% CI 0.04, 0.20] per year among women. Relative inequalities did not significantly change over time in most countries. A significant reduction of relative inequalities was found among Austrian and Italian women.

CONCLUSION

The increase in the overall prevalence aligned with a widening of absolute but not of relative inequalities in obesity in many European countries over the past two decades. Our findings urge for a further understanding of the drivers of the increase in obesity in lower education groups particularly, and an equity perspective in population-based obesity prevention strategies.

Independent association between socioeconomic indicators and macro- and micro-nutrient intake in Switzerland

BACKGROUND

Socioeconomic differences in diet are rarely assessed with more than one indicator. We aimed to assess differences in macro- and micro-nutrient intake in both sexes according to education, income, and occupation.

METHODS

We used data from validated food frequency questionnaire measured dietary intake in 5087 participants (2157 women) from yearly adult population-based cross-sectional surveys conducted from 2005 to 2012 in the canton of Geneva, Switzerland. We used two ANOVA models: age-adjusted and multivariable adjusted simultaneously for all three socioeconomic indicators.

RESULTS

Low-education men consumed more calcium but less vitamin D than high-education men; low-income men consumed less total and animal protein (80.9±0.9 vs 84.0±0.6 g/d; 55.6±1.0 vs 59.5±0.7 g/d) and more total carbohydrates and sugars (246±2 vs 235±2 g/d; 108±2 vs 103±1 g/d) than high-income men. Occupation and diet showed no association. Low-education women consumed less vegetable protein (20.7±0.2 vs 21.6±0.2 g/d), fibre (15.7±0.3 vs 16.8±0.2 g/d), and carotene (4222±158 vs 4870±128 μg/d) than high-education women; low-income women consumed more total carbohydrates (206±2 vs 197±1 g/d) and less monounsaturated fat (27.7±0.4 vs 29.3±0.3 g/d) than high-income women. Finally, low-occupation women consumed more total energy (1792±27 vs 1714±15 kcal/d) and total carbohydrates (206±2 vs 200±1 g/d), but less saturated fat (23.0±0.3 vs 24.4±0.2 g/d), calcium (935±17 vs 997±10 mg/d) and vitamin D (2.5±0.1 vs 2.9±0.1 μg/d), than high-occupation women.

CONCLUSION

In Switzerland, the influence of socioeconomic factors on nutrient intake differs by sex; income and education, but not occupation, drive differences among men; among women, all three indicators seem to play a role. Interventions to reduce inequalities should consider the influence of education, income, and occupation in diet to be most effective.

Accumulation of material and lifestyle problems among daily smokers in Norway 1999 to 2013 - a cross-sectional analysis

Background

International studies have found that smoking is increasingly concentrated among lesser-privileged individuals and marginalised groups, indicating a possible rise in daily smokers’ accumulated problem burden. The study asks whether material shortages and occurrence of behaviours related to poor health are increasing among daily smokers in Norway, and whether the time trends differ between daily smokers on the one hand, and occasional and non-smokers on the other.

Method

The study used data acquired by biennial cross-sectional surveys from 1999 to 2013 of the adult (i.e. over 15) Norwegian population. Time trends in individual and accumulated material and lifestyle problems among daily smokers and non-daily and non-smokers combined were assessed using logistic regression analyses for men and women separately.

Results

The accumulation of problems in any isolated survey is higher among daily smokers than other respondents. Over the longer term, however, there are few signs of decline in any group, except in regards to frequent alcohol drinking, which increased in all studied groups. The only problem factor differentiating daily smokers from occasional smokers/non-smokers that did change during the period was quality of diet. While problem accumulation declined in all but one group, i.e., male daily smokers, the difference between them and the group of occasional smokers and non-smokers was not significant.

Conclusion

Daily smokers are generally worse off than occasional smokers and non-smokers combined. However, the accumulation of material problems and health-risk behaviours by daily smokers and occasional smokers/non-smokers did not change significantly and all groups had fewer problems in 2013 than in 1999.

Environmental Health Related Socio-Spatial Inequalities: Identifying "Hotspots" of Environmental Burdens and Social Vulnerability

Differential exposure to multiple environmental burdens and benefits and their distribution across a population with varying vulnerability can contribute heavily to health inequalities. Particularly relevant are areas with high cumulative burdens and high social vulnerability termed as “hotspots”. This paper develops an index-based approach to assess these multiple burdens and benefits in combination with vulnerability factors at detailed intra-urban level. The method is applied to the city of Dortmund, Germany. Using non-spatial and spatial methods we assessed inequalities and identified “hotspot” areas in the city. We found modest inequalities burdening higher vulnerable groups in Dortmund (CI = −0.020 at p < 0.05). At the detailed intra-urban level, however, inequalities showed strong geographical patterns. Large numbers of “hotspots” exist in the northern part of the city compared to the southern part. A holistic assessment, particularly at a detailed local level, considering both environmental burdens and benefits and their distribution across the population with the different vulnerability, is essential to inform environmental justice debates and to mobilize local stakeholders. Locating “hotspot” areas at this detailed spatial level can serve as a basis to develop interventions that target vulnerable groups to ensure a health conducive equal environment.

Finding big shots: small-area mapping and spatial modelling of obesity among Swiss male conscripts

BACKGROUND

In Switzerland, as in other developed countries, the prevalence of overweight and obesity has increased substantially since the early 1990s. Most of the analyses so far have been based on sporadic surveys or self-reported data and did not offer potential for small-area analyses. The goal of this study was to investigate spatial variation and determinants of obesity among young Swiss men using recent conscription data.

METHODS

A complete, anonymized dataset of conscription records for the 2010-2012 period were provided by Swiss Armed Forces. We used a series of Bayesian hierarchical logistic regression models to investigate the spatial pattern of obesity across 3,187 postcodes, varying them by type of random effects (spatially unstructured and structured), level of adjustment by individual (age and professional status) and area-based [urbanicity and index of socio-economic position (SEP)] characteristics.

RESULTS

The analysed dataset consisted of 100,919 conscripts, out of which 5,892 (5.8 %) were obese. Crude obesity prevalence increased with age among conscripts of lower individual and area-based SEP and varied greatly over postcodes. Best model's estimates of adjusted odds ratios of obesity on postcode level ranged from 0.61 to 1.93 and showed a strong spatial pattern of obesity risk across the country. Odds ratios above 1 concentrated in central and north Switzerland. Smaller pockets of elevated obesity risk also emerged around cities of Geneva, Fribourg and Lausanne. Lower estimates were observed in North-East and East as well as south of the Alps. Importantly, small regional outliers were observed and patterning did not follow administrative boundaries. Similarly as with crude obesity prevalence, the best fitting model confirmed increasing risk of obesity with age and among conscripts of lower professional status. The risk decreased with higher area-based SEP and, to a lesser degree - in rural areas.

CONCLUSION

In Switzerland, there is a substantial spatial variation in obesity risk among young Swiss men. Small-area estimates of obesity risk derived from conscripts records contribute to its understanding and could be used to design further studies and interventions.

Dietary Intake according to Gender and Education: A Twenty-Year Trend in a Swiss Adult Population

We assessed trends in dietary intake according to gender and education using repeated cross-sectional, population-based surveys conducted between 1993 and 2012 in Geneva, Switzerland (17,263 participants, 52.0 ± 10.6 years, 48% male). In 1993–1999, higher educated men had higher monounsaturated fatty acids (MUFA), carotene and vitamin D intakes than lower educated men, and the differences decreased in 2006–2012. In 1993–1999, higher educated women had higher fiber, iron, carotene, vitamin D and alcohol intakes than lower educated women, and the differences decreased in 2006–2012. Total energy, polyunsaturated fatty acids, retinol and alcohol intakes decreased, while mono/disaccharides, MUFA and carotene intake increased in both genders. Lower educated men had stronger decreases in saturated fatty acid (SFA) and calcium intakes than higher educated men: multivariate-adjusted slope and 95% confidence interval −0.11 (−0.15; −0.06) vs. −0.03 (−0.08; 0.02) g/day/year for SFA and −5.2 (−7.8; −2.7) vs. −1.03 (−3.8; 1.8) mg/day/year for calcium, p for interaction <0.05. Higher educated women had a greater decrease in iron intake than lower educated women: −0.03 (−0.04; −0.02) vs. −0.01 (−0.02; 0.00) mg/day/year, p for interaction = 0.002. We conclude that, in Switzerland, dietary intake evolved similarly between 1993 and 2012 in both educational groups. Educational differences present in 1993 persisted in 2012.

Using drug sales data to evaluate the epidemiology of cardiometabolic risk factors and their inequality: an ecological study on atorvastatin and total cholesterol in Iran

BACKGROUND

Statins have been effective medications in lowering serum total cholesterol (TC) concentrations across populations over time. The aim of this study was to estimate national and provincial trends in atorvastatin sales in Iran, to systematically quantify its relationship with socioeconomic indicators, and changes in TC level.

METHODS

In this retrospective ecological study, conducted in Iran, we examined trends in atorvastatin sales, the wealth index (WI) as a validly-available socio-economic indicator, and TC level between 2004 and 2011. The main outcome variable was mean atorvastatin sold in defined daily dose per 100,000 people per day (DPD). We analyzed the relationship between WI and DPD and between DPD and mean TC across time and space.

RESULTS

At national level, both mean WI and mean DPD showed increasing trend over time, while we observed decreasing trend for TC. Mean WI and DPD in 2011 was nearly 5 and 50 time that of their respective figures in 2004, while the mean TC decreased for nearly 10%. Increases in both WI and DPD had happened in every province, but with different patterns. The maximum and minimum changes in DPD versus WI were seen in Gilan and North Khorasan respectively.

CONCLUSION

A striking increase occurred in the sales for atorvastatin in Iran from 2004-2012 in most provinces examined. The wealthier a province became, the more sales were seen for atorvastatin. TC optimistically decreased from 2005 to 2011 and its decrease was positively correlated with increasing sales for atorvastatin.

Socioeconomic disparities in osteoporosis prevalence: different results in the overall Korean adult population and single-person households

OBJECTIVES

The present study was conducted in order to examine the association between socioeconomic status (SES) and osteoporosis prevalence in Korea and to assess whether different associations are found in single-person households.

METHODS

A cross-sectional population-based study was conducted using the Korea National Health and Nutrition Examination Survey, from 2008 to 2011. The study subjects were people aged ≥ 50 years with osteoporosis as defined by bone mineral density. Multivariate logistic models were used to estimate prevalence odds ratios (pORs) and 95% confidence intervals (CIs). Gender differences in the likelihood of osteoporosis were analyzed based on household income, education level, and residential area.

RESULTS

There were 8221 osteoporosis patients aged ≥ 50 years, of whom 927 lived in single-person households. There was a gender-specific association between osteoporosis prevalence and all three SES factors that we analyzed: income, education, and residential area. After adjusting for age, SES, and health behaviors, including body mass index (BMI), low household income was only significantly associated with osteoporosis in men, whereas education level had an inverse relationship with osteoporosis only in women (p = 0.01, p < 0.001, respectively). However, after controlling for age and BMI, rural residency was only associated with osteoporosis in women living in single-person households (pOR, 1.59; 95% CI, 1.05 to 2.43).

CONCLUSIONS

The Korean adult population showed a gender-specific relationship between SES and osteoporosis prevalence, with a different pattern found in single-person households.

Cardiovascular Risk Assessment and Effects on Behavior in Switzerland The Swiss Heart Foundation HerzCheck(®)/Cardio-Test(®)

Background:

“CardioTest^®” is a tool for cardiovascular risk assessment. The aim of this study was to evaluate if this test used in Swiss pharmacies provides risk stratification and if it had impact on individual behaviour.

Methods:

Individuals were evaluated (blood pressure, body waist circumference, random blood samples and coronary artery disease risk factors). The cardiovascular risk was calculated (AGLA Risk Score (ARS) a modified PROCAM Score) and participants were informed about their result. One year after the initial testing individuals were followed up by questionnaire with respect to the action they had taken based upon the ARS results. The relation between ARS results and events during follow-up were assessed. Events were defined as cardiovascular events due to chest pain, myocardial infarction or stroke.

Result:

A total of 1415 individuals were contacted for follow-up, 746 (53%) with a mean age of 62.7 (±12.8) years (60% were male) returned their questionnaire. The cardiovascular risk throughout the study-population turned out to be low: 73.9% had a low ARS <10%, 21.7% an intermediate ARS 10-20% and 4.4% had a high ARS >20%. Significantly more participants with ARS >20% consulted their family doctor (46.2%) than those with ARS 10-20% (25.2%) and ARS <10% (10.4%), respectively (p<0,01 for both comparisons). Sixty-four individuals (9%) suffered a cardiovascular event. The event rates increased as a function of ARS.

Conclusion:

The overall cardiovascular risk of individuals participating in a pharmacy based risk assessment program seems to be low. CardioTest ^® provided risk stratification with respect to future cardio-vascular events. CardioTest ^® seems to have impact on individual behavior and lifestyle modification. Other settings and locations for screening might be considered to reach higher risk individuals at an earlier stage.

Socio-demographic and behavioural determinants of weight gain in the Swiss population

Background

In Switzerland, socio-demographic and behavioural factors are associated with obesity, but no study ever assessed their impact on weight gain using prospective data.

Methods

Data from 4,469 participants (53.0% women), aged 35 to 75 years at baseline and followed for 5.5 years. Weight gain was considered as a rate (kg/year) or as gaining ≥5 kg during the study period.

Results

Rate of weight gain was lower among participants who were older (mean ± standard deviation: 0.46 ± 0.92, 0.33 ± 0.88, 0.21 ± 0.86 and 0.06 ± 0.74 kg/year in participants aged [35-45], [45-55], [55–65] and [65+] years, respectively, P<0.001); physically active (0.27 ± 0.82 vs. 0.35 ± 0.95 kg/year for sedentary, P < 0.005) or living in couple (0.29 ± 0.84 vs. 0.35 ± 0.96 kg/year for living single, P < 0.05), and higher among current smokers (0.41 ± 0.97, 0.26 ± 0.84 and 0.29±0.85 kg/year for current, former and never smokers, respectively, p<0.001). These findings were further confirmed by multivariable analysis. Multivariable logistic regression showed that receiving social help, being a current smoker or obese increased the likelihood of gaining ≥5 Kg: Odds ratio (OR) and 95% confidence interval (CI) 1.43 (1.16-1.77); 1.63 (1.35-1.95) and 1.95 (1.57-2.43), respectively, while living in couple or being physically active decreased the risk: 0.73 (0.62-0.86) and 0.72 (0.62-0.83), respectively. No association was found between weight gain and gender, being born in Switzerland or education.

Conclusions

In Switzerland, financial difficulties (indicated by receiving social help) and current smoking were associated with increases in body weight over a 5 years follow-up. Living in couple, being older or physically active were protective against weight gain.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1451-9) contains supplementary material, which is available to authorized users.

Combined effects of socioeconomic position, smoking, and hypertension on risk of ischemic and hemorrhagic stroke

BACKGROUND AND PURPOSE

Combined effects of socioeconomic position and well-established risk factors on stroke incidence have not been formally investigated.

METHODS

In a pooled cohort study of 68 643 men and women aged 30 to 70 years in Denmark, we examined the combined effect and interaction between socioeconomic position (ie, education), smoking, and hypertension on ischemic and hemorrhagic stroke incidence by the use of the additive hazards model.

RESULTS

During 14 years of follow-up, 3613 ischemic strokes and 776 hemorrhagic strokes were observed. Current smoking and hypertension were more prevalent among those with low education. Low versus high education was associated with greater ischemic, but not hemorrhagic, stroke incidence. The combined effect of low education and current smoking was more than expected by the sum of their separate effects on ischemic stroke incidence, particularly among men: 134 (95% confidence interval, 49-219) extra cases per 100 000 person-years because of interaction, adjusted for age, cohort study, and birth cohort. There was no clear evidence of interaction between low education and hypertension. The combined effect of current smoking and hypertension was more than expected by the sum of their separate effects on ischemic and hemorrhagic stroke incidence. This effect was most pronounced for ischemic stroke among women: 178 (95% confidence interval, 103-253) extra cases per 100 000 person-years because of interaction, adjusted for age, cohort study, and birth cohort.

CONCLUSIONS

Reducing smoking in those with low socioeconomic position and in those with hypertension could potentially reduce social inequality stroke incidence.

Socioeconomic, temporal and regional variation in body mass index among 188,537 Swiss male conscripts born between 1986 and 1992

Background

Rising levels of overweight and obesity are important public-health concerns worldwide. The purpose of this study is to elucidate their prevalence and trends in Switzerland by analyzing variations in Body Mass Index (BMI) of Swiss conscripts.

Methods

The conscription records were provided by the Swiss Army. This study focussed on conscripts 18.5–20.5 years of age from the seven one-year birth cohorts spanning the period 1986–1992. BMI across professional status, area-based socioeconomic position (abSEP), urbanicity and regions was analyzed. Two piecewise quantile regression models with linear splines for three birth-cohort groups were used to examine the association of median BMI with explanatory variables and to determine the extent to which BMI has varied over time.

Results

The study population consisted of 188,537 individuals. Median BMI was 22.51 kg/m² (22.45–22.57 95% confidence interval (CI)). BMI was lower among conscripts of high professional status (−0.46 kg/m²; 95% CI: −0.50, −0.42, compared with low), living in areas of high abSEP (−0.11 kg/m²; 95% CI: −0.16, −0.07 compared to medium) and from urban communities (−0.07 kg/m²; 95% CI: −0.11, −0.03, compared with peri-urban). Comparing with Midland, median BMI was highest in the North-West (0.25 kg/m²; 95% CI: 0.19–0.30) and Central regions (0.11 kg/m²; 95% CI: 0.05–0.16) and lowest in the East (−0.19 kg/m²; 95% CI: −0.24, −0.14) and Lake Geneva regions (−0.15 kg/m²; 95% CI: −0.20, −0.09). Trajectories of regional BMI growth varied across birth cohorts, with median BMI remaining high in the Central and North-West regions, whereas stabilization and in some cases a decline were observed elsewhere.

Conclusions

BMI of Swiss conscripts is associated with individual and abSEP and urbanicity. Results show regional variation in the levels and temporal trajectories of BMI growth and signal their possible slowdown among recent birth cohorts.

Surveillance of social and geographic inequalities in housing-related issues: the case of the Eastern Townships, Quebec (Canada)

Even though health inequalities are conditioned by many aspects of the environment, much of the existing research focuses on the social environment. This emphasis has the effect to neglect other environmental aspects such as its physical dimension. The physical environment, which is linked to housing conditions, may contribute to the uneven distribution of health. In this study, we examined 19 housing-related issues among a representative sample of 2,000 adults residing in a Quebec (Canada) health region characterized by a mix of rural, semi-rural, and urban areas. The distribution of these issues was examined according to socioeconomic and geographic indicators of social position. Summary measures of inequalities were assessed. Our results showed that the prevalence of nearly all housing-related issues was higher among low-income households compared to more affluent ones. Highly educated individuals showed better housing conditions, whereas different issues tended to cluster in deprived or densely populated areas. To conclude, we observed steep gradients between social class and poor housing conditions. This may explain a substantial part of health inequality on the regional scale. The surveillance of housing-related issues is therefore essential to properly inform and mobilize local stakeholders and to develop interventions that target vulnerable groups on this level.

Are social inequalities widening in generalised and abdominal obesity and overweight among English adults?

BACKGROUND

Obesity is now more common in lower socioeconomic groups in developed nations, but the socio-economic patterning of obesity has changed over time. This study examines the time trends in the socioeconomic patterning of generalised and abdominal obesity and overweight in English adults.

METHODS

Data were from core annual samples of the Health Survey for England 1993-2008, including 155 661 participants aged 18-75 years. The prevalence of generalised and abdominal obesity and overweight was reported as crude and age-adjusted estimates. Binomial regression was used to model measures of obesity and overweight with age, sex, survey years, and two indicators of socioeconomic position: Registrar General's Social Class (manual and non-manual occupational groups) and relative length of full time education. Trends in socioeconomic patterning were assessed by formal tests for interactions between socioeconomic position measures and survey periods in these models.

RESULTS

The prevalence of generalised and abdominal overweight and obesity increased consistently between 1993 and 2008. There were significant differences in the four outcomes between the two socioeconomic position (SEP) groups in men and women, except for generalised and abdominal overweight with social class in men. The prevalence of obesity and overweight across the whole period was higher in subgroups with lower SEP (differences of 0.2% to 9.5%). There was no significant widening of the socioeconomic gradient of most indicators of greater body fat since the early 1990s, except for educational gradient in generalised obesity in men and women (P = 0.001).

CONCLUSIONS

Substantial social class and education gradients in obesity and overweight are still present in both sexes. However, there is limited evidence that these socioeconomic inequalities have changed since 1993.

Obesity prevalence and unfavorable health risk behaviors among German kindergarten teachers: cross-sectional results of the kindergarten teacher health study

Background

The aim of the study was to investigate obesity status and associated health risk behaviors in a sample of German kindergarten teachers. At present, such data are not available, despite the fact that kindergarten teachers educate children at a formative time in their lives.

Methods

Kindergarten teachers aged 18–62 years (n = 313) were invited to participate in the Kindergarten Teacher Health Study (KTHS) by completing a self-reported questionnaire. We analyzed their obesity status, health risk behaviors (i.e., habitual physical activity, screen time activities, eating behavior patterns, smoking), and their general ability to identify overweight children and the associated health risks of overweight and obesity based on special age- and sex-specific silhouettes. After adjusting for covariates, bivariate correlations were conducted for associations between body mass index (BMI) and health risk behaviors, while analyses of variance (ANOVAs) were used to analyze differences of health risk behaviors between BMI groups. Logistic regression analyses were conducted to predict determinants of kindergarten teachers who did not correctly identify the overweight silhouettes and their associated physical and mental health risks. Additionally, data regarding kindergarten teachers’ weight status and smoking behavior were compared with nationally representative data from the 2009 Microcensus (n = 371310) using the Mann–Whitney U-test.

Results

The prevalence rates of overweight and obesity were 41.2% and 17.9%, respectively. The prevalence of obesity was significantly higher in kindergarten teachers (p < 0.001) compared to national Microcensus data. Only 44.6% of teachers were able to identify overweight children correctly. The fact that being overweight is associated with physical and mental health risks was only reported by 40.1% and 21.2% of teachers, respectively. Older kindergarten teachers were more likely to misclassify the overweight silhouettes, while younger, normal-weight, and overweight kindergarten teachers were more likely to underestimate the associated health risks. Obese kindergarten teachers reported spending more time in front of computer and television screens than their normal-weight counterparts, especially on weekends. In addition, obese kindergarten teachers reported eating less often with their families and more frequently reported watching television during meals.

Conclusions

Advanced monitoring and multifaceted interventions to improve the health behaviors of kindergarten teachers should be given high priority. Because kindergarten teachers’ behavioral modeling presumably mediates children’s health behaviors, additional research is needed about kindergarten teachers’ health and its proposed interaction with children’s health.

Neighborhood walkability and cardiometabolic risk factors in Australian adults: an observational study

BACKGROUND

Studies repeatedly highlight associations between the built environment and physical activity, particularly walking. Fewer studies have examined associations with cardiometabolic risk factors, with associations with obesity inconsistent and scarce evidence examining associations with other cardiometabolic risk factors. We aim to investigate the association between neighborhood walkability and the prevalence of obesity, hypertension, hypercholesterolaemia, and type-2 diabetes mellitus.

METHODS

Cross-sectional study of 5,970 adults in Western Australia. Walkability was measured objectively for a 1,600 m and 800 m neighborhood buffer. Logistic regression was used to assess associations overall and by sex, adjusting for socio-demographic factors. Mediation by physical activity and sedentary behavior was investigated.

RESULTS

Individuals living in high compared with less walkable areas were less likely to be obese (1,600 m OR: 0.84, 95% CI: 0.7 to 1; 800 m OR: 0.75, 95% CI: 0.62 to 0.9) and had lower odds of type-2 diabetes mellitus at the 800 m buffer (800 m OR: 0.69, 95% CI: 0.51 to 0.93). There was little evidence for an association between walkability and hypertension or hypercholesterolaemia. The only significant evidence of any difference in the associations in men and women was a stronger association with type-2 diabetes mellitus at the 800 m buffer in men. Associations with obesity and diabetes attenuated when additionally adjusting for physical activity and sedentary behavior but the overall association with obesity remained significant at the 800 m buffer (800 m OR: 0.78, 95% CI: 0.64 to 0.96).

CONCLUSIONS

A protective association between neighborhood walkability and obesity was observed. Neighborhood walkability may also be protective of type-2 diabetes mellitus, particularly in men. No association with hypertension or hypercholesterolaemia was found. This warrants further investigation. Findings contribute towards the accumulating evidence that city planning and policy related strategies aimed at creating supportive environments could play an important role in the prevention of chronic diseases.

Inequalities in non-communicable diseases and effective responses

In most countries, people who have a low socioeconomic status and those who live in poor or marginalised communities have a higher risk of dying from non-communicable diseases (NCDs) than do more advantaged groups and communities. Smoking rates, blood pressure, and several other NCD risk factors are often higher in groups with low socioeconomic status than in those with high socioeconomic status; the social gradient also depends on the country's stage of economic development, cultural factors, and social and health policies. Social inequalities in risk factors account for more than half of inequalities in major NCDs, especially for cardiovascular diseases and lung cancer. People in low-income countries and those with low socioeconomic status also have worse access to health care for timely diagnosis and treatment of NCDs than do those in high-income countries or those with higher socioeconomic status. Reduction of NCDs in disadvantaged groups is necessary to achieve substantial decreases in the total NCD burden, making them mutually reinforcing priorities. Effective actions to reduce NCD inequalities include equitable early childhood development programmes and education; removal of barriers to secure employment in disadvantaged groups; comprehensive strategies for tobacco and alcohol control and for dietary salt reduction that target low socioeconomic status groups; universal, financially and physically accessible, high-quality primary care for delivery of preventive interventions and for early detection and treatment of NCDs; and universal insurance and other mechanisms to remove financial barriers to health care.

Age and gender differences in the social patterning of cardiovascular risk factors in Switzerland: the CoLaus study

OBJECTIVES

We examined the social distribution of a comprehensive range of cardiovascular risk factors (CVRF) in a Swiss population and assessed whether socioeconomic differences varied by age and gender.

METHODS

Participants were 2960 men and 3343 women aged 35-75 years from a population-based survey conducted in Lausanne, Switzerland (CoLaus study). Educational level was the indicator of socioeconomic status used in this study. Analyses were stratified by gender and age group (35-54 years; 55-75 years).

RESULTS

There were large educational differences in the prevalence of CVRF such as current smoking (Δ = absolute difference in prevalence between highest and lowest educational group:15.1%/12.6% in men/women aged 35-54 years), physical inactivity (Δ = 25.3%/22.7% in men/women aged 35-54 years), overweight and obesity (Δ = 14.6%/14.8% in men/women aged 55-75 years for obesity), hypertension (Δ = 16.7%/11.4% in men/women aged 55-75 years), dyslipidemia (Δ = 2.8%/6.2% in men/women aged 35-54 years for high LDL-cholesterol) and diabetes (Δ = 6.0%/2.6% in men/women aged 55-75 years). Educational inequalities in the distribution of CVRF were larger in women than in men for alcohol consumption, obesity, hypertension and dyslipidemia (p<0.05). Relative educational inequalities in CVRF tended to be greater among the younger (35-54 years) than among the older age group (55-75 years), particularly for behavioral CVRF and abdominal obesity among men and for physiological CVRF among women (p<0.05).

CONCLUSION

Large absolute differences in the prevalence of CVRF according to education categories were observed in this Swiss population. The socioeconomic gradient in CVRF tended to be larger in women and in younger persons.

Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity among European adults: a systematic review

Background

This study systematically reviewed the evidence pertaining to socioeconomic inequalities in different domains of physical activity (PA) by European region.

Methods

Studies conducted between January 2000 and December 2010 were identified by a systematic search in Pubmed, Embase, Web of Science, Psychinfo, Sportdiscus, Sociological Abstracts, and Social Service Abstracts. English-language peer-reviewed studies undertaken in the general population of adults (18–65 years) were classified by domain of PA (total, leisure-time including sport, occupational, active transport), indicator of socioeconomic position (education, income, occupation), and European region. Distributions of reported positive, negative, and null associations were evaluated.

Results

A total of 131 studies met the inclusion criteria. Most studies were conducted in Scandinavia (n = 47). Leisure-time PA was the most frequently studied PA outcome (n = 112). Considerable differences in the direction of inequalities were seen for the different domains of PA. Most studies reported that those with high socioeconomic position were more physically active during leisure-time compared to those with low socioeconomic position (68% positive associations for total leisure-time PA, 76% for vigorous leisure-time PA). Occupational PA was more prevalent among the lower socioeconomic groups (63% negative associations). Socioeconomic differences in total PA and active transport PA did not show a consistent pattern (40% and 38% positive associations respectively). Some inequalities differed by European region or socioeconomic indicator, however these differences were not very pronounced.

Conclusions

The direction of socioeconomic inequalities in PA in Europe differed considerably by domain of PA. The contradictory results for total PA may partly be explained by contrasting socioeconomic patterns for leisure-time PA and occupational PA.

Socioeconomic patterning of childhood overweight status in Europe

There is growing evidence of social disparities in overweight among European children. This paper examines whether there is an association between socioeconomic inequality and prevalence of child overweight in European countries, and if socioeconomic disparities in child overweight are increasing. We analyse cross-country comparisons of household inequality and child overweight prevalence in Europe and review within-country variations over time of childhood overweight by social grouping, drawn from a review of the literature. Data from 22 European countries suggest that greater inequality in household income is positively associated with both self-reported and measured child overweight prevalence. Moreover, seven studies from four countries reported on the influence of socioeconomic factors on the distribution of child overweight over time. Four out of seven reported widening social disparities in childhood overweight, a fifth found statistically significant disparities only in a small sub-group, one found non-statistically significant disparities, and a lack of social gradient was reported in the last study. Where there is evidence of a widening social gradient in child overweight, it is likely that the changes in lifestyles and dietary habits involved in the increase in the prevalence of overweight have had a less favourable impact in low socio-economic status groups than in the rest of the population. More profound structural changes, based on population-wide social and environmental interventions are needed to halt the increasing social gradient in child overweight in current and future generations.

Regional surveillance of social and geographic inequalities in smoking: the case of Montréal, Canada

Surveillance of social inequalities in health is a platform for action. We examined the trends in smoking behaviours (current and ever smoking, quit ratios) according to education and place of residence and we quantified the observed inequalities. Data were from repeated cross-sectional surveys (2003-2009) of Montreal (Canada) residents ≥15 years (n=12,053). Trends in smoking behaviours according to education were measured with logistic and log-binomial regressions. Spatial distribution of smoking behaviours across local areas was assessed with Morans' Index. Observed inequalities were quantified with prevalence ratio and difference, population attributable risk, and slope index of inequality. Results showed that ever smoking rose among low-educated individuals. Among their high-educated fellow-citizens, current smoking decreased and quit ratios increased. Adverse smoking behaviours (current and ever smoking) were clustered in south-central areas. We conclude that smoking inequalities in Montreal are growing. We thus encourage a closer monitoring of smoking social differentials.

The social nature of chronic noncommunicable diseases and how to tackle them through communication technology, training, and outreach

As world leaders prepare for the United Nations High Level Meeting on Noncommunicable Diseases, to take place in September 2011, international organizations, nongovernmental organizations, and economic and business fora have created new alliances and initiatives to accelerate research, advocacy, and political commitment. This article argues that the time is propitious to reflect on the social nature of the most common behavioral noncommunicable disease determinants, including tobacco and alcohol use, physical inactivity, and unhealthy diet. Evidence is presented related to the fact that these diseases are profoundly rooted in social and community ties and points to the need for a modern communication strategy to serve as a linchpin of any successful action to address these public health threats. Several proposals, aimed at promoting health literacy, strengthening health workforce skills, capturing the power of new media and technologies, and targeting vulnerable groups, are discussed.

Social class differences in secular trends in established coronary risk factors over 20 years: a cohort study of British men from 1978-80 to 1998-2000

BACKGROUND

Coronary heart disease (CHD) mortality in the UK since the late 1970s has declined more markedly among higher socioeconomic groups. However, little is known about changes in coronary risk factors in different socioeconomic groups. This study examined whether changes in established coronary risk factors in Britain over 20 years between 1978-80 and 1998-2000 differed between socioeconomic groups.

METHODS AND FINDINGS

A socioeconomically representative cohort of 7735 British men aged 40-59 years was followed-up from 1978-80 to 1998-2000; data on blood pressure (BP), cholesterol, body mass index (BMI) and cigarette smoking were collected at both points in 4252 survivors. Social class was based on longest-held occupation in middle-age. Compared with men in non-manual occupations, men in manual occupations experienced a greater increase in BMI (mean difference = 0.33 kg/m(2); 95%CI 0.14-0.53; p for interaction = 0.001), a smaller decline in non-HDL cholesterol (difference in mean change = 0.18 mmol/l; 95%CI 0.11-0.25, p for interaction≤0.0001) and a smaller increase in HDL cholesterol (difference in mean change = 0.04 mmol/l; 95%CI 0.02-0.06, p for interaction≤0.0001). However, mean systolic BP declined more in manual than non-manual groups (difference in mean change = 3.6; 95%CI 2.1-5.1, p for interaction≤0.0001). The odds of being a current smoker in 1978-80 and 1998-2000 did not differ between non-manual and manual social classes (p for interaction = 0.51).

CONCLUSION

Several key risk factors for CHD and type 2 diabetes showed less favourable changes in men in manual occupations. Continuing priority is needed to improve adverse cardiovascular risk profiles in socially disadvantaged groups in the UK.

Trends in the prevalence, awareness, treatment, and control of cardiovascular risk factors across educational level in the 1995-2005 period

PURPOSE

To determine the differences and trends in the prevalence, awareness, treatment and control of cardiovascular risk factors and lifestyle variables across educational level in the 1995-2005 period in a country with a universal free health care system.

METHODS

Data from three consecutive independent population-based surveys were used. Cardiovascular risk factors, lifestyle variables, and self-reported educational level were collected in 9646 individuals ages 35-74 years throughout the decade.

RESULTS

The prevalence of hypertension and diabetes was inversely associated with education. An increase in the proportion of hypertension and dyslipidemia awareness, treatment, and control in all educational level groups was observed. This increase was greater among the lowest education group, reducing the disparities between groups. The prevalence of lifestyle-related risk factors decreased in the greatest but increased in the lowest education group, widening the disparities between groups.

CONCLUSIONS

A universal free health care system is effective in avoiding inequalities in the diagnosis, treatment, and control of cardiovascular risk factors. However, other social determinants seem to explain the social inequalities in the prevalence of these risk factors and in the adoption of healthy lifestyles.

Prevalence of obesity in Switzerland 1992-2007: the impact of education, income and occupational class

Prevalence of excess weight varies substantially by socioeconomic position (SEP). SEP can be defined with different indicators. The strength of the association of SEP with excess weight differs by SEP indicator, between populations and over time. We examined the prevalence of overweight and obesity (body mass index 25-29.9 and ≥30 kg m(-2) ) in Switzerland by educational level, household income tertile and occupational class (three categories for each indicator). Self-reported data stem from four cross-sectional population surveys including 53 588 persons aged between 25 and 74 years. The overall prevalence of overweight increased between 1992 and 2007 from 37.4% to 41.4% in men and from 18.8% to 21.9% in women. Obesity prevalence increased from 7.2% to 9.7% in men and from 5.4% to 8.6% in women. Inequalities were calculated with multivariable logistic regression. Inequalities were larger in women than in men and for obesity than for overweight. However, overweight and obesity inequalities did not significantly change over time, despite overall increasing prevalence. Although all SEP indicators were independently associated with excess weight, the association was strongest with education, particularly in women. Programmes and policies aimed at preventing excess weight should target individuals with low education early in life.

Prevalence of modifiable cardiovascular risk factors in German adolescents

BACKGROUND

The distribution and clustering of cardiovascular risk factors among German adolescents is only poorly understood.

OBJECTIVES

To describe the prevalence of major modifiable cardiovascular disease (CVD) risk factors and the clustering of risk factors in German adolescents aged 11-17 years.

DESIGN

Cross-sectional study.

METHODS

The German Health Interview and Examination Survey for Children and Adolescents was conducted between 2003 and 2006. The prevalence of major CVD risk factors (smoking, obesity, physical inactivity, hypertension, dyslipidaemia and diabetes) and their clustering among 6813 11-17 year old adolescents was calculated according to age and sex. Associations with sociodemographic variables were investigated in multivariate logistic regression analysis.

RESULTS

The prevalence of all risk factors apart from diabetes and obesity increased significantly across age groups. At the age of 17 years smoking and physical inactivity were the most frequent risk factors. In addition to age, most consistent and strongest associations were observed between socioeconomic status and CVD risk factors. Although the age of 11 years the majority of boys and girls were free of CVD risk factors, at age 17 years more than three-quarters were exposed to at least one risk factor.

CONCLUSION

Results indicate that the prevalence of CVD risk factors is increasing rapidly across age groups from 11 to 17 years. In late adolescence the majority of boys and girls are exposed to one or more CVD risk factor. Preventive actions will have to be expanded substantially to reduce the future burden of CVD.

A systematic review of studies on socioeconomic inequalities in dietary intakes associated with weight gain and overweight/obesity conducted among European adults

This Review examined socioeconomic inequalities in intakes of dietary factors associated with weight gain, overweight/obesity among adults in Europe. Literature searches of studies published between 1990 and 2007 examining socioeconomic position (SEP) and the consumption of energy, fat, fibre, fruit, vegetables, energy-rich drinks and meal patterns were conducted. Forty-seven articles met the inclusion criteria. The direction of associations between SEP and energy intakes were inconsistent. Approximately half the associations examined between SEP and fat intakes showed higher total fat intakes among socioeconomically disadvantaged groups. There was some evidence that these groups consume a diet lower in fibre. The most consistent evidence of dietary inequalities was for fruit and vegetable consumption; lower socioeconomic groups were less likely to consume fruit and vegetables. Differences in energy, fat and fibre intakes (when found) were small-to-moderate in magnitude; however, differences were moderate-to-large for fruit and vegetable intakes. Socioeconomic inequalities in the consumption of energy-rich drinks and meal patterns were relatively under-studied compared with other dietary factors. There were no regional or gender differences in the direction and magnitude of the inequalities in the dietary factors examined. The findings suggest that dietary behaviours may contribute to socioeconomic inequalities in overweight/obesity in Europe. However, there is only consistent evidence that fruit and vegetables may make an important contribution to inequalities in weight status across European regions.

Socioeconomic disparities in behavioral risk factors and health outcomes by gender in the Republic of Korea

BACKGROUND

Few studies have examined socioeconomic disparities in health and behavioral risk factors by gender in Asian countries and in South Korea, specifically. We investigated the relationship between socioeconomic position (education, income, and occupation) and subjective and acute and chronic health outcomes and behavioral risk factors by gender, and compared results from 1998 and 2005, in the Republic of Korea.

METHODS

We examined data from a nationally representative stratified random sample of 4213 men and 4618 women from the 1998 Korea National Health and Nutrition Examination Survey, and 8289 men and 8827 women from the 2005 Korea National Health and Nutrition Examination Survey using General Linear Modeling and multiple logistic regression methods.

RESULTS

Controlling for behavioral risk factors (smoking, drinking, obesity, exercise, and sleep), those in lower socioeconomic positions had poorer health outcomes in both self-reported acute and chronic disease and subjective measures; differences were especially pronounced among women. A socioeconomic gradient for education and income was found for both men and women for morbidity and self-reported health status, but the gradient was more pronounced in women. In 1998, the odds ratios (ORs) of higher morbidity for illiterate vs. college educated females was 5.4:1 and 1.9:1 for females in the lowest income quintile vs. the highest. The OR for education decreased in 2005 to 2.9:1 and that for income quintiles remained the same at 1.9:1. The OR of lower self-reported health status for illiterate vs. college educated females was 2.9:1 and 1.6:1 for females in the lowest income quintile vs. the highest in 1998, and 3.3:1 and 2.3:1 in 2005.

CONCLUSIONS

Among Korean adults, men and women in lower socioeconomic position, as denoted by education, income, and somewhat less by occupation, experience significantly higher levels of morbidity and lower self-reported health status, even after controlling for standard behavioral risk factors. Disparities were more pronounced for women than for men. Efforts to reduce health disparities in South Korea require attention to the root causes of socioeconomic inequality and gender differences in the impact of socioeconomic position on health.

Quality, but not cost, of diet is associated with 5-year incidence of CVD: the ATTICA study

OBJECTIVE

The aim of the present work was to calculate the current cost of the Mediterranean diet in Greece and to evaluate the role of diet cost in the development of cardiovascular events after a 5-year follow-up.

DESIGN

Cross-sectional. Cost of diet was measured in €/week based on common Greek dietary choices, while baseline dietary habits were assessed through a semi-quantitative FFQ (Greek-EPIC). The Mediterranean Diet Score (MedDietScore) was applied to assess overall adherence to this pattern using scores of eleven food variables and alcohol, according to the principles of the Mediterranean diet.

SETTING

Five-year follow-up of the ATTICA study, a nutrition and health survey of a representative, free-living sample of the Greek population resident in the province of Attica, where Athens is a major metropolis.

SUBJECTS

From 2001 to 2002, 1514 men and 1528 women (aged >18 years) without known CVD were enrolled. In 2006, the 5-year follow-up was performed.

RESULTS

The weekly cost of participants' diets varied from 5·35 to 83·57 €/week in men (mean 25·45 (sd 6·80) €/week) and from 10·89 to 55·49 €/week in women (mean 25·63 (sd 6·30) €/week). Diet cost was correlated marginally to MedDietScore (r = 0·060, P = 0·05) as well as being associated with history of hypercholesterolaemia (mean (sd), yes v. no: 24·90 (5·73) v. 25·82 (6·95) €/week, P = 0·027), physical activity (mean (sd), yes v. no: 26·42 (6·90) v. 24·82 (6·20) €/week, P < 0·001) and current smoking (mean (sd), yes v. no: 24·99 (6·40) v. 25·98 (6·70) €/week, P = 0·017). No significant association was found between diet cost and 5-year incidence of CVD (hazard ratio = 1·021, 95 % CI 0·965, 1·081). However, adherence to the traditional Mediterranean diet was inversely associated with the development of CVD (relative risk per 1-unit increase in MedDietScore = 0·92, 95 % CI 0·89, 0·94) after adjustment for various potential confounders including diet cost.

CONCLUSIONS

Quality but not cost of the diet is associated with the development of CVD.