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Socioeconomic inequalities in cardiovascular mortality and the role of childhood socioeconomic conditions and adulthood risk factors: a prospective cohort study with 17-years of follow up.

Kamphuis CB, Turrell G, Giskes K, Mackenbach JP, van Lenthe FJ - BMC Public Health (2012)

Bottom Line: A low adulthood SEP was associated with increased CVD mortality for men (HR 1.84; 95% CI: 1.41-2.39) and women (HR 1.80; 95%CI: 1.04-3.10).Alcohol consumption and BMI showed a U-shaped relationship with CVD mortality among women, with the risk being significantly greater for both abstainers and heavy drinkers, and among women who were underweight or obese.Childhood socioeconomic circumstances made a modest contribution, mainly via their association with adulthood risk factors.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Public Health, Erasmus University Medical Centre, PO Box 2040, Rotterdam, CA 3000, The Netherlands. c.kamphuis@erasmusmc.nl

ABSTRACT

Background: The mechanisms underlying socioeconomic inequalities in mortality from cardiovascular diseases (CVD) are largely unknown. We studied the contribution of childhood socioeconomic conditions and adulthood risk factors to inequalities in CVD mortality in adulthood.

Methods: The prospective GLOBE study was carried out in the Netherlands, with baseline data from 1991, and linked with the cause of death register in 2007. At baseline, participants reported on adulthood socioeconomic position (SEP) (own educational level), childhood socioeconomic conditions (occupational level of respondent's father), and a broad range of adulthood risk factors (health behaviours, material circumstances, psychosocial factors). This present study is based on 5,395 men and 6,306 women, and the data were analysed using Cox regression models and hazard ratios (HR).

Results: A low adulthood SEP was associated with increased CVD mortality for men (HR 1.84; 95% CI: 1.41-2.39) and women (HR 1.80; 95%CI: 1.04-3.10). Those with poorer childhood socioeconomic conditions were more likely to die from CVD in adulthood, but this reached statistical significance only among men with the poorest childhood socioeconomic circumstances. About half of the investigated adulthood risk factors showed significant associations with CVD mortality among both men and women, namely renting a house, experiencing financial problems, smoking, physical activity and marital status. Alcohol consumption and BMI showed a U-shaped relationship with CVD mortality among women, with the risk being significantly greater for both abstainers and heavy drinkers, and among women who were underweight or obese. Among men, being single or divorced and using sleep/anxiety drugs increased the risk of CVD mortality. In explanatory models, the largest contributor to adulthood CVD inequalities were material conditions for men (42%; 95% CI: -73 to -20) and behavioural factors for women (55%; 95% CI: -191 to -28). Simultaneous adjustment for adulthood risk factors and childhood socioeconomic conditions attenuated the HR for the lowest adulthood SEP to 1.34 (95% CI: 0.99-1.82) for men and 1.19 (95% CI: 0.65-2.15) for women.

Conclusions: Adulthood material, behavioural and psychosocial factors played a major role in the explanation of adulthood SEP inequalities in CVD mortality. Childhood socioeconomic circumstances made a modest contribution, mainly via their association with adulthood risk factors. Policies and interventions to reduce health inequalities are likely to be most effective when considering the influence of socioeconomic circumstances across the entire life course and in particular, poor material conditions and unhealthy behaviours in adulthood.

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Simplified causal diagram with hypothesized associations between childhood socioeconomic conditions, adulthood educational level, adulthood risk factors and CVD mortality.
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Figure 1: Simplified causal diagram with hypothesized associations between childhood socioeconomic conditions, adulthood educational level, adulthood risk factors and CVD mortality.

Mentions: Another gap in our understanding of inequalities in CVD mortality is the role of childhood socioeconomic conditions. Adverse conditions in childhood (e.g. little parental social support, both parents being heavy smokers, illness) may occur more often in families with a low SEP, and may be associated with higher levels of risk factors in later life [14,15], thereby indirectly contributing to adulthood inequalities in CVD mortality (the so-called pathway model) [16]. On the other hand, it is also possible that childhood socioeconomic conditions may affect CVD risk in later life more directly, independent of adulthood risk factors. This may occur, for instance, when certain exposures, if experienced during pregnancy or infancy, lead to unfavourable and unalterable biological development, which affects CVD risk in later life (critical period model)[16,17]. A directed acyclic graph (DAG) was created (Figure‚ÄČ1) to visualise the possible associations between the factors involved in the different lifecourse models [18,19].


Socioeconomic inequalities in cardiovascular mortality and the role of childhood socioeconomic conditions and adulthood risk factors: a prospective cohort study with 17-years of follow up.

Kamphuis CB, Turrell G, Giskes K, Mackenbach JP, van Lenthe FJ - BMC Public Health (2012)

Simplified causal diagram with hypothesized associations between childhood socioeconomic conditions, adulthood educational level, adulthood risk factors and CVD mortality.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3539932&req=5

Figure 1: Simplified causal diagram with hypothesized associations between childhood socioeconomic conditions, adulthood educational level, adulthood risk factors and CVD mortality.
Mentions: Another gap in our understanding of inequalities in CVD mortality is the role of childhood socioeconomic conditions. Adverse conditions in childhood (e.g. little parental social support, both parents being heavy smokers, illness) may occur more often in families with a low SEP, and may be associated with higher levels of risk factors in later life [14,15], thereby indirectly contributing to adulthood inequalities in CVD mortality (the so-called pathway model) [16]. On the other hand, it is also possible that childhood socioeconomic conditions may affect CVD risk in later life more directly, independent of adulthood risk factors. This may occur, for instance, when certain exposures, if experienced during pregnancy or infancy, lead to unfavourable and unalterable biological development, which affects CVD risk in later life (critical period model)[16,17]. A directed acyclic graph (DAG) was created (Figure‚ÄČ1) to visualise the possible associations between the factors involved in the different lifecourse models [18,19].

Bottom Line: A low adulthood SEP was associated with increased CVD mortality for men (HR 1.84; 95% CI: 1.41-2.39) and women (HR 1.80; 95%CI: 1.04-3.10).Alcohol consumption and BMI showed a U-shaped relationship with CVD mortality among women, with the risk being significantly greater for both abstainers and heavy drinkers, and among women who were underweight or obese.Childhood socioeconomic circumstances made a modest contribution, mainly via their association with adulthood risk factors.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Public Health, Erasmus University Medical Centre, PO Box 2040, Rotterdam, CA 3000, The Netherlands. c.kamphuis@erasmusmc.nl

ABSTRACT

Background: The mechanisms underlying socioeconomic inequalities in mortality from cardiovascular diseases (CVD) are largely unknown. We studied the contribution of childhood socioeconomic conditions and adulthood risk factors to inequalities in CVD mortality in adulthood.

Methods: The prospective GLOBE study was carried out in the Netherlands, with baseline data from 1991, and linked with the cause of death register in 2007. At baseline, participants reported on adulthood socioeconomic position (SEP) (own educational level), childhood socioeconomic conditions (occupational level of respondent's father), and a broad range of adulthood risk factors (health behaviours, material circumstances, psychosocial factors). This present study is based on 5,395 men and 6,306 women, and the data were analysed using Cox regression models and hazard ratios (HR).

Results: A low adulthood SEP was associated with increased CVD mortality for men (HR 1.84; 95% CI: 1.41-2.39) and women (HR 1.80; 95%CI: 1.04-3.10). Those with poorer childhood socioeconomic conditions were more likely to die from CVD in adulthood, but this reached statistical significance only among men with the poorest childhood socioeconomic circumstances. About half of the investigated adulthood risk factors showed significant associations with CVD mortality among both men and women, namely renting a house, experiencing financial problems, smoking, physical activity and marital status. Alcohol consumption and BMI showed a U-shaped relationship with CVD mortality among women, with the risk being significantly greater for both abstainers and heavy drinkers, and among women who were underweight or obese. Among men, being single or divorced and using sleep/anxiety drugs increased the risk of CVD mortality. In explanatory models, the largest contributor to adulthood CVD inequalities were material conditions for men (42%; 95% CI: -73 to -20) and behavioural factors for women (55%; 95% CI: -191 to -28). Simultaneous adjustment for adulthood risk factors and childhood socioeconomic conditions attenuated the HR for the lowest adulthood SEP to 1.34 (95% CI: 0.99-1.82) for men and 1.19 (95% CI: 0.65-2.15) for women.

Conclusions: Adulthood material, behavioural and psychosocial factors played a major role in the explanation of adulthood SEP inequalities in CVD mortality. Childhood socioeconomic circumstances made a modest contribution, mainly via their association with adulthood risk factors. Policies and interventions to reduce health inequalities are likely to be most effective when considering the influence of socioeconomic circumstances across the entire life course and in particular, poor material conditions and unhealthy behaviours in adulthood.

Show MeSH
Related in: MedlinePlus