Lifetime socioeconomic position and mortality: prospective observational study

Association and mediation between educational attainment and respiratory diseases: a Mendelian randomization study

BACKGROUND

Respiratory diseases are a major health burden, and educational inequalities may influence disease prevalence. We aim to evaluate the causal link between educational attainment and respiratory disease, and to determine the mediating influence of several known modifiable risk factors.

METHODS

We conducted a two-step, two-sample Mendelian randomization (MR) analysis using summary statistics from genome-wide association studies (GWAS) and single nucleotide polymorphisms (SNPs) as instrumental variables for educational attainment and respiratory diseases. Additionally, we performed a multivariable MR analysis to estimate the direct causal effect of each exposure variable included in the analysis on the outcome, conditional on the other exposure variables included in the model. The mediating roles of body mass index (BMI), physical activity, and smoking were also assessed.

FINDINGS

MR analyses provide evidence of genetically predicted educational attainment on the risk of FEV1 (β = 0.10, 95% CI 0.06, 0.14), FVC (β = 0.12, 95% CI 0.07, 0.16), FEV1/FVC (β = - 0.005, 95% CI - 0.05, 0.04), lung cancer (OR = 0.54, 95% CI 0.45, 0.65) and asthma (OR = 0.86, 95% CI 0.78, 0.94). Multivariable MR dicated the effect of educational attainment on FEV1 (β = 0.10, 95% CI 0.04, 0.16), FVC (β = 0.07, 95% CI 0.01, 0.12), FEV1/FVC (β = 0.07, 95% CI 0.01, 0.01), lung cancer (OR = 0.55, 95% CI 0.42, 0.71) and asthma (OR = 0.88, 95% CI 0.78, 0.99) persisted after adjusting BMI and cigarettes per day. Of the 23 potential risk factors, BMI, smoking may partially mediate the relationship between education and lung disease.

CONCLUSION

High levels of educational attainment have a potential causal protective effect on respiratory diseases. Reducing smoking and adiposity may be a target for the prevention of respiratory diseases attributable to low educational attainment.

Geographical variation in cardiovascular disease mortality in Norway: The role of life course socioeconomic position and parental health

Despite substantial geographical variation in cardiovascular (CVD) mortality within countries, little is known about whether this variation can be explained by individuals' life course socioeconomic position (SEP) or differences in family history of premature CVD deaths. Cox proportional hazards models were used to investigate the association between the county of residence at ages 50-59 and CVD death in Norwegians born between 1940 and 1959 and survived to at least age 60, using national data. Individual life course SEP and family history of premature CVD death reduced the geographical variation in CVD mortality across Norwegian counties, but some significant differences remained. Furthermore, CVD risk varied by residents' migration histories between two counties with distinct CVD and socioeconomic profiles.

Latent class trajectories of socioeconomic position over four time points and mortality: the Uppsala Birth Cohort Study

BACKGROUND

The study assessed socioeconomic position (SEP) over four time points and employed a latent class analysis (LCA) to explore the associations between longitudinal SEP trajectories and late-life mortality.

METHODS

We analyzed a cohort of 11 336 members born at the Uppsala University Hospital, Sweden during 1915-29 and followed up for mortality during 1980-2008. SEP was measured at birth, age 10, mid-adulthood and late adulthood. LCA was used to identify SEP trajectories, which were linked to all-cause and cause-specific mortality through Cox proportional hazard regression models.

RESULTS

The age and birth cohort adjusted hazard ratio (HR) of all-cause mortality among the upwardly mobile from middle vs. stable low SEP was 28% lower in men [HR: 0.72; 95% confidence interval (95% CI): 0.65, 0.81] and 30% lower in women (HR: 0.70; 95% CI: 0.62, 0.78). The corresponding HR of cardiovascular mortality was 30% lower in men (HR: 0.70; 95% CI: 0.60, 0.82) and 31% lower in women (HR: 0.69; 95% CI: 0.58, 0.83). Upward mobility was also associated with decreased HR of mortality from respiratory diseases and injuries among men and from cancer, respiratory diseases, injuries and mental disorders among women. The upwardly mobile were similar to the stable high group in terms of their HRs of mortality from all-causes and cardiovascular, cancer and mental diseases.

CONCLUSIONS

Upward mobility appeared to be protective of mortality from a wide range of causes. Interventions aiming to prevent deaths can benefit from creating optimal conditions earlier in the life course, letting disadvantaged children maximize their socioeconomic and health potentials.

Income and outcomes of patients with incident atrial fibrillation

BACKGROUND

Socioeconomic disparities can be associated with adverse outcomes in patients with cardiovascular diseases. The impact of personal income on the outcomes of patients with atrial fibrillation (AF) is unclear.

METHODS

Nationwide observational registry-based study on patients with incident AF in Finland during 2007-2018.

RESULTS

203 154 patients (mean age 73.0±13.5; females 49.0%) were diagnosed with incident AF during the study period. Overall, 16 272 (8.0%) patients experienced first-ever ischaemic stroke and 63 420 (31.2%) died (mean follow-up 4.3±3.3 years). After adjusting for confounding factors, low personal income was associated with increased risk of overall mortality in all age strata and the incidence of first-ever stroke in patients aged <65 years and 65-74 years, but not in those ≥75 years. The magnitude of this effect was greatest in patients aged <65 years. After propensity score matching of patients <65 years in the lowest and highest quintiles of maximum personal annual income, at 10 years, those in the highest income quintile (≥€54 000) had significantly lower risk of first-ever stroke (subdistribution HR 0.495, 95% CI 0.391 to 0.628) and overall mortality (HR 0.307, 95% CI 0.269 to 0.351) compared with patients in the lowest income quintile (≤€12 000).

CONCLUSIONS

Personal annual income has a significant impact on the incidence of first-ever ischaemic stroke and overall mortality among patients with incident AF, particularly among patients of working age. Low-income indicate the need for intervention strategies to improve outcomes of AF.

TRIAL REGISTRATION NUMBER

NCT04645537.

The Effect of Neighborhood Deprivation on Mortality in Newly Diagnosed Diabetes Patients: A Countrywide Population-Based Korean Retrospective Cohort Study, 2002-2013

Background: Neighborhood environmental factors along with individual factors are beginning to make a mark as factors which influence individual health outcomes. The goal of this study is to look at the combined impact of individual and neighborhood socioeconomic status on all-cause mortality in diabetic patients who have just been diagnosed. Methods: The Korean National Health Insurance (2002–2013) was employed in this cohort research, which used a stratified random sample. During the years 2003–2006, a total of 15,882 individuals who were newly diagnosed with diabetes and using oral disease-controlling medication were included in the study. Individual income and neighborhood deprivation index were used to examine the combined effect on all-cause mortality. The frailty model was performed using Cox’s proportional hazard regression. Results: During the study period, 28.3 percent (n = 4493) of the 15,882 eligible individuals died. In a Cox regression analysis after adjusting for all covariates, with advantaged and disadvantaged neighborhoods classified according to individual household income, the adjusted HR for patients living in a disadvantaged area was higher compared to patients living in an advantaged area in patients with middle income, compared to the reference group (a high income within an advantaged neighborhood) (HR, 1.22; 95% CI, 1.09–1.35; HR, 1.13; 95% CI, 1.02–1.25, respectively). The adjusted HR for patients with low income who lived in a disadvantaged location was greater than for patients who lived in an advantaged area (HR, 1.34; 95% CI, 1.18–1.53 vs. HR, 1.28; 95% CI, 1.14–1.49). Conclusions: Individual SES has a greater impact on all-cause mortality among diabetic patients when they live in a low-income neighborhood.

Racial and Socioeconomic Disparities in Necrotizing Soft-Tissue Infection

Necrotizing soft-tissue infection (NSTI) is a medical emergency. We investigated the impact of racial, socioeconomic disparities, and comorbidities on mortality, complications, length of stay, and charges in patients with NSTI.

Data were acquired from the National Inpatient Sample from Q4 2015 to 2017. ICD-10, Clinical Modification codes were utilized to identify relevant cases. Logistic regression was used to assess socioeconomic, racial, and health risk factors for adverse outcomes in NSTI patients.

Of 16,071,053 cases identified during the study period, 15,078 (0.094%) NSTI cases were recognized. Black patients had increased odds of amputation (OR 1.40 95% CI 1.24-1.58, p < 0.001), prolonged hospital stay (OR 1.40 95% CI 1.24-1.58, p < 0.001), excessive charges (OR 1.22 95% CI 1.03-1.43, p = 0.019), and adverse discharge disposition (OR 1.32 95% CI 1.19-1.46, p < 0.001) compared to white patients. Hispanic patients had increased odds of mortality (OR 1.30 95% CI 1.05-1.60, p = 0.014) and amputation (OR 1.21 95% CI 1.04-1.42, p = 0.016) compared to white patients. Medicare patients had increased odds of mortality (OR 1.35 95% CI 1.09-1.67, p = 0.006), Medicaid patients had increased odd of amputation (OR 1.33 95% CI 1.17-1.51, p < 0.001) and prolonged LOS (OR 1.33 95% CI 1.17-1.51, p < 0.001). Patients in the lower income quartiles had decreased odds of amputation compared to the highest income quartile, including the 26^th to 50^th income quartile (OR 0.84 95% CI 0.73-0.98, p = 0.022) and 51^st to 75^th income quartile (OR 0.84 95% CI 0.73-0.98, p = 0.022).

Racial and socioeconomic disparities exist for patients being treated for NSTIs.

Socio-demographic and psychosocial predictors of salivary cortisol from older male participants in the Speedwell prospective cohort study

INTRODUCTION

Associations between measures of socio-economic position and cortisol remain controversial. We examined the association between social class and cortisol reactivity in an aging male population.

METHODS

The Speedwell cohort study recruited 2348 men aged 45-59 years from primary care between 1979 and 1982 (phase I) where occupational social class was used to classify socioeconomic position. Men were seen on four more occasions, the last being between 1997 and 1999 (phase 5) when salivary samples were obtained capturing cortisol reactivity to stressors (cognitive test and venepuncture) and circadian variations (awakening and night-time cortisol levels, circadian slope and area under curve) at morning and afternoon clinic sessions. Longitudinal association between social class at phase 3 and log-transformed salivary cortisol measures at phase 5 was assessed using multivariable linear regression adjusted for variables associated with sampling time and age as a potential confounder, stratified by time of clinic session. We also explored possible mediation by psychosocial factors (e.g. work dislike) and health-related factors (e.g. waist-to-hip ratio and high-density lipoprotein cholesterol).

RESULTS

From 1768 living men, 1003 men (57%) attended a clinic at phase five, 854 participants (85% of attendees) returned home cortisol samples (mean age 71.7 years). We found little evidence of association between social class and baseline cortisol (i.e. prior to stress), cortisol response to stressors, and cortisol diurnal variation. However, we found lower social class was associated with higher and delayed post-stress recovery cortisol for participants that visited the clinic in the morning (adjusted β coefficient for manual versus non-manual 0.25 ng/ml; 95% CI: 0.06-0.48; P = 0.008). This association did not appear to be mediated by any of the measured psychosocial or health-related factors.

CONCLUSION

Our data did not show an overall association between social class and cortisol variability either diurnal or in response to a stressor. Lower social class was associated with a slower time to recover from exposure to stress in the morning, thereby increasing overall cortisol exposure. These findings provide some evidence for a mechanism that may contribute to the association between lower social class and a higher risk of adverse health outcomes.

Evaluating the Cumulative Impact of Childhood Misfortune: A Structural Equation Modeling Approach

Most studies of the early origins of adult health rely on summing dichotomously measured negative exposures to measure childhood misfortune (CM), neglect, adversity, or trauma. There are several limitations to this approach, including that it assumes each exposure carries the same level of risk for a particular outcome. Further, it often leads researchers to dichotomize continuous measures for the sake of creating an additive variable from similar indicators. We propose an alternative approach within the structural equation modeling (SEM) framework that allows differential weighting of the negative exposures and can incorporate dichotomous and continuous observed variables as well as latent variables. Using the Health and Retirement Study data, our analyses compare the traditional approach (i.e., adding indicators) with alternative models and assess their prognostic validity on adult depressive symptoms. Results reveal that parameter estimates using the conventional model likely underestimate the effects of CM on adult health outcomes. Additionally, while the conventional approach inhibits testing for mediation, our model enables testing mediation of both individual CM variables and the cumulative variable. Further, we test whether cumulative CM is moderated by the accumulation of protective factors, which facilitates theoretical advances in life course and social inequality research. The approach presented here is one way to examine the cumulative effects of early exposures while attending to diversity in the types of exposures experienced. Using the SEM framework, this versatile approach could be used to model the accumulation of risk or reward in many other areas of sociology and the social sciences beyond health.

Do associations between education and obesity vary depending on the measure of obesity used? A systematic literature review and meta-analysis

Background

Consistent evidence suggests a relationship between lower educational attainment and total obesity defined using body mass index (BMI); however, a comparison of the relationships between educational attainment and total obesity (BMI ≥30 kg/m²) and central obesity (waist circumference (WC) > 102 cm for men and WC > 88 cm for women) has yet to be carried out. This systematic literature review (SLR) and meta-analyses aimed to understand whether i) the associations between education and obesity are different depending on the measures of obesity used (BMI and WC), and ii) to explore whether these relationships differ by gender and region.

Methods

Medline, Embase and Web of Science were searched to identify studies investigating the associations between education and total and central obesity among adults in the general population of countries in the Organisation for Economic Co-operation and Development (OECD). Meta-analyses and meta-regression were performed in a subset of comparable studies (n=36 studies; 724,992 participants).

Results

86 eligible studies (78 cross-sectional and eight longitudinal) were identified. Among women, most studies reported an association between a lower education and total and central obesity. Among men, there was a weaker association between lower education and central than total obesity (OR central vs total obesity in men 0.79 (95% CI 0.60, 1.03)). The association between lower education and obesity was stronger in women compared with men (OR women vs men 1.66 (95% CI 1.32, 2.08)). The relationship between lower education and obesity was less strong in women from Northern than Southern Europe (OR Northern vs Southern Europe in women 0.37 (95% CI 0.27, 0.51)), but not among men.

Conclusions

Associations between education and obesity differ depending on whether total or central obesity is used among men, but not in women. These associations are stronger among women than men, particularly in Southern European countries.

Occupational groups and its physical and mental health correlates: results from the Singapore Mental Health Study 2016

Purpose

The physical and mental wellbeing of an individual is impacted by the type occupation one does. This study aims to establish the prevalence of mental and physical disorders, the association of occupational groups and health-related quality of life, and the extent of work-loss and work-cut back in past 30 days among the employed in the Singapore resident population.

Methods

Data from a population-based, epidemiological survey of a representative sample of Singapore citizens and permanent residents aged 18 years and above were used. Lifetime diagnosis of select mental disorders was established using the World Health Organization’s Composite International Diagnostic Interview version 3.0 (WHO-CIDI 3.0). Data on nicotine dependence, work productivity, quality of life and socio-demographics were obtained via self-report. Ten major occupational groups based on the Singapore Standard Occupational Classification were included in the analysis.

Results

The sample comprised 4021 employed individuals who were predominantly males (54.7%) and aged 35–49 years (35.4%). ‘Service and sales workers’ (22.6%), ‘Professionals’ (17.3%) and ‘Legislators, senior officials and managers’ (16.4%) were the three largest occupational groups. Socio-demographic characteristics differed significantly (p < 0.001) across all occupational groups. Lifetime prevalence of mood disorders among the employed was 8.4% and the most prevalent physical disorder was chronic pain (18.9%). No significant differences were observed in work productivity loss across the occupational groups.

Conclusions

The disparities in the socio-demographic characteristics and prevalence of mental and physical disorders across occupational categories provide policymakers with vital information to pilot effective interventions that can improve the psychosocial and physical conditions at work.

Explaining subjective social status in two countries: The relative importance of education, occupation, income and childhood circumstances

In the literature on social inequalities in health, subjective socioeconomic position (SEP) is increasingly applied as a determinant of health, motivated by the hypothesis that having a high subjective SEP is health-enhancing. However, the relative importance of determinants of subjective SEP is not well understood. Objective SEP indicators, such as education, occupation and income, are assumed to determine individuals' position in the status hierarchy. Furthermore, an extensive literature has shown that past childhood SEP affects adult health. Does it also affect subjective SEP? In this paper, we estimate the relative importance of i) the common objective SEP indicators (education, occupation and income) in explaining subjective SEP, and ii) childhood SEP (childhood financial circumstances and parents' education) in determining subjective SEP, after controlling for objective SEP. Given that the relative importance of these factors is expected to differ across institutional settings, we compare data from two countries: Australia and Norway. We use data from an online survey based on adult samples, with N ≈ 1400 from each country. Ordinary least squares regression is conducted to assess how objective and childhood SEP indicators predict subjective SEP. We use Shapley value decomposition to estimate the relative importance of these factors in explaining subjective SEP. Income was the strongest predictor of subjective SEP in Australia; in Norway, it was occupation. Of the childhood SEP variables, childhood financial circumstances were significantly associated with subjective SEP, even after controlling for objective SEP. This association was the strongest in the Norwegian sample. Only the mother's education had a significant impact on subjective SEP. Our findings highlight the need to understand the specific mechanisms between objective and subjective SEP as determinants of inequalities in health, and to assess the role of institutional factors in influencing these complex relationships.

Assessing the contribution of alcohol-specific causes to socio-economic inequalities in mortality in England and Wales 2001-16

BACKGROUND AND AIMS

When measuring inequalities in health, public health and addiction research has tended to focus on differences in average life-span between socio-economic groups. This does not account for the extent to which age of death varies between individuals within socio-economic groups or whether this variation differs between groups. This study assesses (1) socio-economic inequalities in both average life-span and variation in age at death, (2) the extent to which these inequalities can be attributed to alcohol-specific causes (i.e. those attributable only to alcohol) and (3) how this contribution has changed over time.

DESIGN

Cause-deleted life table analysis of national mortality records.

SETTING

England and Wales, 2001-16.

CASES

All-cause and alcohol-specific deaths for all adults aged 18+, stratified by sex, age and quintiles of the index of multiple deprivation (IMD).

MEASUREMENTS

Life expectancy at age 18 yearss and standard deviation in age at death within IMD quintiles and the contribution of alcohol to overall differences in both measures between the highest and lowest IMD quintiles by comparing observed and cause-deleted inequality 'gaps'.

FINDINGS

In 2016, alcohol-specific causes reduced life expectancy for men and women by 0.26 and 0.14 years, respectively, and increased the standard deviation in age at death. These causes also increased the inequality gap in life expectancy by 0.33 years for men and 0.17 years for women, and variation in age at death by 0.14 years and 0.13 years, respectively. For both measures, the contribution of alcohol to mortality inequalities rose after 2001 and subsequently fell back. For women, alcohol accounted for 3.6% of inequality in age at death and 6.0% of life-span uncertainty, suggesting that using only the former may underestimate alcohol-induced inequalities. There was no comparable difference for men.

CONCLUSIONS

Deaths from alcohol-specific causes increase inequalities in both life expectancy and variation in age of death between socio-economic groups. Using both measures can provide a fuller picture of overall inequalities in health.

Socioeconomic Factors and Intensive Care Unit-Related Cognitive Impairment

OBJECTIVE

We aimed to identify socioeconomic and clinical risk factors for post-intensive care unit (ICU)-related long-term cognitive impairment (LTCI).

SUMMARY BACKGROUND DATA

After delirium during ICU stay, LTCI has been increasingly recognized, but without attention to socioeconomic factors.

METHODS

We enrolled a prospective, multicenter cohort of ICU survivors with shock or respiratory failure from surgical and medical ICUs across 5 civilian and Veteran Affairs (VA) hospitals from 2010 to 2016. Our primary outcome was LTCI at 3- and 12 months post-hospital discharge defined by the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS) global score. Covariates adjusted using multivariable linear regression included age, sex, race, AHRQ socioeconomic index, Charlson comorbidity, Framingham stroke risk, Sequential Organ Failure Assessment, duration of coma, delirium, hypoxemia, sepsis, education level, hospital type, insurance status, discharge disposition, and ICU drug exposures.

RESULTS

Of 1040 patients, 71% experienced delirium, and 47% and 41% of survivors had RBANS scores >1 standard deviation below normal at 3- and 12 months, respectively. Adjusted analysis indicated that delirium, non-White race, lower education, and civilian hospitals (as opposed to VA), were associated with at least a half standard deviation lower RBANS scores at 3- and 12 months (P ≤ 0.03). Sex, AHRQ socioeconomic index, insurance status, and discharge disposition were not associated with RBANS scores.

CONCLUSIONS

Socioeconomic and clinical risk factors, such as race, education, hospital type, and delirium duration, were linked to worse PICS ICU-related, LTCI. Further efforts may focus on improved identification of higher-risk groups to promote survivorship through emerging improvements in cognitive rehabilitation.

Sex and ethnicity modify the associations between individual and contextual socioeconomic indicators and ideal cardiovascular health: MESA study

BACKGROUND

Low socioeconomic status (SES) is associated with cardiovascular disease (CVD) risk, but its association with different markers of SES may be heterogeneous by sex and race/ethnicity.

METHODS

We have examined the relationships of four SES markers (education, family income, occupation and neighborhood SES) to ideal cardiovascular health (ICH), an index formed by seven variables. A total of 6792 cohort participants from six regions in the USA: Baltimore City and Baltimore County, MD; Chicago, IL; Forsyth County, NC; Los Angeles County, CA; New York, NY; and St. Paul, MN of the Multi-Ethnic Study of Atherosclerosis (MESA) (52.8% women) were recruited at baseline (2000-2) and included in the present analysis.

RESULTS

ICH was classified as poor, intermediate or ideal. Level of education was significantly and inversely associated with ICH in non-Hispanic White men and women, in Chinese-American and Hispanic American men and African-American women. Family income was inversely and significantly associated with poor ICH in African-American men only.

CONCLUSIONS

We conclude that the strength of the associations between some SES markers and ICH differ between sexes and race/ethnic groups.

How does socioeconomic status affect the incidence of hospital-treated poisonings? A retrospective study

BACKGROUND

Hospital-treated poisonings have a good outcome in general. The role of regional differences and socioeconomic status has been established in intensive care admissions and various causes of death, but not yet in hospital-treated poisonings. We set out to determine whether the incidence of hospital-treated poisonings is affected by the annual income of the residential area.

METHODS

All poisonings in Northern Ostrobothnia region of Finland treated in Oulu University Hospital during 2013-2016 were studied. Oulu University Hospital is the primary hospital in the area. Postal code areas of the county were categorized on the basis of their median annual net income as low-, middle- and high-income areas.

RESULTS

A total of 2142 poisoning cases were studied. The number of individual patients was 1525. In the low-income areas, the crude incidence of poisonings was more than 2-fold when compared with the middle- and high-income areas. In adolescents aged 13 to 17 years, the incidence in the low-income areas was almost 3-fold compared with the other two categories at 335/100 000/year (95% CI, 236-463). Four patients (0.2%) died during the hospital stay and 50 patients (2.3%) died within 6 months from the last admission.

CONCLUSIONS

The incidence of hospital-treated poisoning was at least 2-fold in low-income areas when compared with middle- or high-income areas. For adolescent population from 13 to 17 years, the incidence in low-income areas was almost 3-fold when compared with other areas.

The Intersectionality of Gender and Wealth in Adolescent Health and Behavioral Outcomes in Brazil: The 1993 Pelotas Birth Cohort

PURPOSE

Brazilian society is characterized by deep socioeconomic inequalities. Using data from a population-based birth cohort, we explored how the intersectionality of family income and gender may affect adolescent health and behavioral outcomes.

METHODS

Children born in 1993 in the Brazilian city of Pelotas have been followed up prospectively at the age of 15 years when the follow-up rate was 85.7% of the original cohort. Participants answered standardized questionnaires, and anthropometric measures were obtained. Outcomes in five domains were studied: overweight (body mass index above +1 SD of the World Health Organization standard for age and sex), cigarette smoking (in the previous month), violence (fight in which someone was injured, in the past year), self-reported unhappiness (based on a face scale), and psychological symptoms (Strengths and Difficulties Questionnaire). Monthly family income was recoded in quintiles.

RESULTS

Results were available for more than 4,101-4,334 adolescents, depending on the outcome. Overweight was more common among boys than girls (29.7% and 25.6%; p = .004) and was directly related to family income among boys (p < .001), but not among girls (p = .681). Smoking was less common among boys than girls (12.3% and 21.0%, p < .001) and showed strong inverse association with income among girls (p < .001), but not among boys (p = .099). Reported violence was twice as common among boys than girls (16.4% vs. 8.0%; p < .001); an inverse association with income was present among girls (p < .001), but not for boys (p = .925). Boys and girls were similarly likely to report being unhappy (18.4% and 20.1%; p = .176), with an inverse association with family income in girls. Psychological symptoms were slightly less common among boys than girls (25.3% and 28.3%; p = .014), with strong inverse associations with income in both sexes (p < .001). Adolescent girls from poor families were the group with the highest prevalence for three of the five outcomes: smoking, unhappiness, and psychological problems.

CONCLUSIONS

Gender norms influence adolescent health and behavioral outcomes, but the direction and strength of the associations are modified by socioeconomic position. Preventive strategies must take into account the intersectionality of gender and wealth.

Birth month, birth season, and overall and cardiovascular disease mortality in US women: prospective cohort study

OBJECTIVES

To evaluate the associations between birth month, birth season, and overall and cardiovascular disease mortality, and to examine the role of familial and socioeconomic factors in these associations.

DESIGN

Prospective cohort study.

SETTING

Nurses' Health Study, established in 1976, an ongoing prospective cohort study in the United States.

PARTICIPANTS

Female registered nurses who reported information on date of birth at study enrolment (n=116 911, 1976-2014, followed for 38 years).

EXPOSURE

Birth month and astronomical birth season (based on solstices and equinoxes as boundaries of the season categories).

MAIN OUTCOME MEASURES

Age and various multivariable adjusted hazard ratios and 95% confidence intervals for the association between birth months (using November as the reference), astronomical birth season (using autumn as the reference), and overall and cardiovascular disease specific mortality were assessed using Cox proportional hazards models.

RESULTS

Among study participants, 43 248 overall deaths were documented during 4 136 364 person years of follow-up since enrolment, including 8360 cardiovascular disease related deaths. In fully adjusted multivariable analyses, no significant association was observed between birth month, birth season, and overall mortality. Compared with women born in November, increased cardiovascular disease mortality was observed among those born from March to July (hazard ratio for March, 1.09, 95% confidence interval 0.98 to 1.21; April, 1.12, 1.00 to 1.24; May, 1.08, 0.98 to 1.20; June, 1.07, 0.96 to 1.19; and July 1.08, 0.98 to 1.20). Those born in April had the highest cardiovascular disease mortality, and those born in December had the lowest (December, 0.95, 0.85 to 1.06). The relative difference between the lowest and highest risk month was 17.89%. Women born in spring (1.10, 1.04 to 1.17) and summer (1.09, 1.03 to 1.16) had a higher cardiovascular disease mortality than women born in the autumn. Adjustment for familial and socioeconomic factors did not change these results. The relative difference between the lowest and highest risk season was 10.00%.

CONCLUSION

Participants born in the spring and summer (especially those born in March-July) had a slight but significant increase in cardiovascular disease specific mortality. However, no seasonal birth month effect was observed among women for overall mortality. Familial and socioeconomic factors did not appear to alter these associations. Further studies are required to confirm these findings and reveal mechanisms of these seasonal birth month effects in cardiovascular disease mortality.

Poverty dynamics and health in late childhood in the UK: evidence from the Millennium Cohort Study

OBJECTIVE

To assess the prevalence of different trajectories of exposure to child poverty and their association with three indicators of adolescent physical and mental health in UK children.

METHODS

We analysed data on 10 652 children from a large, prospective, nationally representative sample in the UK Millennium Cohort Study. The outcomes were mental health, measured by the Strengths and Difficulties Questionnaire (SDQ), physical health, measured by obesity and any longstanding illness, at age 14. The exposure was relative poverty (<60% of median of equivalised household income), measured at 9 months, 3, 5, 7, 11 and 14 years. Poverty trajectories were characterised using latent class analysis. ORs and 95% CIs were estimated using multivariable logistic regression, adjusted for maternal education and ethnicity.

RESULTS

Four poverty trajectories were identified: never in poverty (62.4%), poverty in early childhood (13.4%), poverty in late childhood (5.0%) and persistent poverty (19.4%). Compared with children who never experienced poverty, those in persistent poverty were at increased risk of mental health problems (SDQ score≥17 (adjusted OR (aOR): 3.17; 95% CI: 2.40 to 4.19)), obesity (aOR: 1.57; 95% CI: 1.20 to 2.04) and longstanding illness (aOR: 1.98; 95% CI: 1.55 to 2.52). Poverty in early childhood was related to higher risk of obesity than that in late childhood, while the opposite is observed for mental health problems and longstanding illness.

CONCLUSIONS

Persistent poverty affects one in five children in the UK. Any exposure to poverty was associated with worse physical and mental health outcomes. Policies that reduce child poverty and its consequences are likely to improve health in adolescence.

Updating EuroSCORE by including emotional, behavioural, social and functional factors to the risk assessment of patients undergoing cardiac surgery: a study protocol

INTRODUCTION

Conventional risk assessment in cardiac surgery focus on medical and physiological factors and have been developed to predict mortality. Other relevant risk factors associated with increased risk of poor outcomes are not included. Adding non-medical variables as potential prognostic factors to risk assessments direct attention away from specific diagnoses towards a more holistic view of the patients and their predicament. The aim of this paper is to describe the method and analysis plan for the development and validation of a prognostic screening tool as a supplement to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict mortality, readmissions and prolonged length of admission in patients within 90 days after cardiac surgery, as individual outcomes.

METHODS AND ANALYSIS

The development of a prognostic screening tool with inclusion of emotional, behavioural, social and functional factors complementing risk assessment by EuroSCORE will adopt the methods recommended by the PROGnosis RESearch Strategy Group and report using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis statement. In the development stage, we will use data derived from three datasets comprising 1143, 3347 and 982 patients for a prospective cohort study of patients undergoing cardiac surgery, respectively. We will construct logistic regression models to predict mortality, prolonged length of admission and 90-day readmissions. In the validation stage, we will use data from a separate sample of 333 patients planned to undergo cardiac surgery to assess the performance of the developed prognostic model. We will produce validation plots showing the overall performance, area under the curve statistic for discrimination and the calibration slope and intercept.

ETHICS AND DISSEMINATION

The study will follow the requirements from the Ethical Committee System ensuring voluntary participation in accordance with the Helsinki declarations. Data will be filed in accordance with the requirements of the Danish Data Protection Agency.

Traumatic dental injuries and experiences along the life course - a study among 16-yr-old pupils in western Norway

The study assessed risk factors for traumatic dental injuries (TDI) using experiences along the life course. A retrospective longitudinal study, including historical clinical data, was conducted on 16-yr-old pupils in western Norway. All first-grade pupils born in 1997 and attending public high schools were invited to participate (n = 5,184). Participants responded to an electronically administered closed-ended questionnaire (39.6%, n = 2,055). Information on the occurrence of TDI and events during the life course (categorized as socio-economic, biological, psychosocial, and behavioural indicators) was collected. Variables with a significant bivariate association with three different dependent variables (TDI, severity of TDI, and multiple episodes of TDI) were tested in a hierarchical logistic regression analysis. Traumatic dental injuries were more frequent among boys, adolescents of higher socio-economic status, and adolescents with adverse psychosocial and behavioural scores. Moderate and severe TDIs were more frequent among adolescents with adverse psychosocial and behavioural scores and among adolescents participating in the sport of wrestling. Multiple episodes of TDI were more frequent among adolescents with adverse psychosocial and behavioural scores and among adolescents participating in sports activities. Incorporation of different life-course indicators is important in evaluating TDI severity and repeated incidents.

Socioeconomic trajectories across the life course and risk of total and cause-specific mortality: prospective findings from the Moli-sani Study

Background

A life course approach has been suggested as the most appropriate to establish the total impact of socioeconomic status (SES) on adult health outcomes; however, such an approach has been poorly used within Mediterranean populations. We aimed to examine the SES trajectories from childhood to adulthood associated with mortality risk in a large general population-based cohort and to test potential pathways (eg, inflammation) underlying such associations.

Methods

Longitudinal analyses on 22 194 subjects recruited in the Moli-sani Study, Italy (2005–2010). Low and high SES in childhood, educational attainment (low/high) and SES during adulthood (measured by a score including material resources and dichotomised as low/high) were used to define overall trajectories.

Results

Over 8.3 years of follow-up, 1155 deaths occurred. In the group with poor childhood SES, an upward trajectory in both educational and material circumstances was associated with lower risk of all-cause death (HR=0.64; 95% CI 0.47 to 0.87), as opposed to subjects who remained stably low (low education and adulthood SES). Subjects with high childhood SES, but not educational achievement, were at increased risk of total and cardiovascular disease (CVD) death, although reporting higher material SES in adult life, as compared with the stably high SES group (HR=1.44; 1.02 to 2.02 and HR=1.90; 1.10 to 3.28, respectively). Inflammatory markers marginally accounted for such associations.

Conclusion

For individuals with low SES in early life, an educational and material upward trajectory over the life course was associated with lower mortality risk. In the high SES childhood group, lack of a higher educational attainment appeared to be unfavourably associated with survival.

Association between socioeconomic status and comorbidities among patients with rheumatoid arthritis: results of a nationwide cross-sectional survey

Objectives

We examined the association between socioeconomic status (SES) and comorbidity distribution among patients with RA.

Methods

Information on comprehensive health status of 1088 RA patients (weighted n = 612 303) was obtained from the 2007–2015 Korea National Health and Nutrition Examination Survey database. SES components were household equivalence income, education and area of residence. To minimize confounding by age, patients were stratified by median age (63 years). Age-adjusted odds ratio (OR) with 95% confidence interval (95% CI) was estimated, comparing weighted prevalence of individual comorbidities between low and high SES groups in each age stratum.

Results

Among RA patients aged <63 years (mean 49 years, 70% female), we observed age-adjusted associations of depression (OR 2.13, 95% CI 1.01, 4.53), depressive mood (OR 2.68, 95% CI 1.54, 4.65), suicide ideation (OR 3.01, 95% CI 1.79, 5.07), diabetes (OR 3.09, 95%CI 1.31, 7.29), obesity (OR 2.04, 95% CI 1.30, 3.20), hypertriglyceridemia (OR 2.36, 95% CI 1.28, 4.34) and osteoarthritis (OR 2.12, 95% CI 1.13, 3.99) with low income, of suicide ideation with low education (OR 2.25, 95% CI 1.14, 4.44), but no association of any comorbidities with area of residence. Unhealthy behavior patterns were comparable between low- and high-income groups but patients with low income reported a numerically higher rate of failed access to necessary healthcare services. We did not find any association between SES and comorbidities among those aged ⩾63 years (mean 72 years, 83% female).

Conclusion

Among Korean RA patients aged <63 years, socioeconomic inequalities of multiple comorbidities in mental, cardiometabolic and musculoskeletal systems were found.

Non-alcoholic fatty liver disease and cerebral small vessel disease in Korean cognitively normal individuals

We aimed to investigate the association between nonalcoholic fatty liver disease (NAFLD) and cerebral small vessel disease (CSVD) burden, especially according to the NAFLD severity. A total of 1,260 participants were included. The CSVD burden was assessed with white matter hyperintensities (WMH), lacunes, and microbleeds (MBs) on brain MRI. An ultrasound diagnosis of fatty liver was made based on standard criteria, and the Fibrosis-4 (FIB-4) index was used to classify participants with NAFLD with having a high-intermediate (FIB-4 ≥1.45) or low (FIB-4 < 1.45) probability of advanced fibrosis. A multivariable logistic regression analysis was used to assess the association between NAFLD and the presence of moderate to severe WMH, lacunes, and MBs. NAFLD had a significant association only with moderate to severe WMH (OR: 1.64, 95% CI: 1.10-2.42), even after controlling for cardiometabolic risk factors. A linear trend test showed a significant association between the severity of NAFLD fibrosis and the presence of moderate to severe WMH (p for trend <0.001). Our findings suggest that NAFLD, especially NAFLD with fibrosis, has a significant association with the presence of moderate to severe WMH in cognitively normal individuals, and NAFLD severity predicted more frequent moderate to severe WMH.

Socioeconomic position over the life course from childhood and smoking status in mid-adulthood: results from a 25-year follow-up study

Background

It remains unclear how life course socioeconomic position (SEP) variations impact later smoking status. We aimed to investigate the associations using a novel methodology – a structured regression framework and to explore the potential underlying mechanisms.

Methods

Data were from an Australian national cohort (n = 1489). SEP was measured in childhood (aged 7–15 years), young- (aged 26–36 years) and mid-adulthood (aged 31–41 years), including highest parental occupation in childhood and self-occupation in young- and mid-adulthood. Smoking status was self-reported in mid-adulthood. Four smoking-related variables in childhood including exposure to parental smoking, smoking experimentation, self-rated importance to be a non-smoker and intention to smoke were tested as potential mediators. A structured life course modelling approach was used to select the best-fit life course model(s). The log multinomial model was used to estimate the smoking risk in mid-adulthood with never smokers as the excluded category.

Results

63.6% of participants were classified as stable non-manual occupation across the life course from childhood. The sensitive period and the accumulation model described the data equally as well as the saturated model. In the sensitive period model, compared to the non-manual group, those who had highest parental occupation of manual had a 21% lower risk of being former smokers and a 32% greater risk of being current smokers in mid-adulthood, and those who were occupied manually in mid-adulthood reported a 55% greater risk of being current smokers in mid-adulthood. In the accumulation model, compared to those who consistently reported non-manual occupations across the life course, those with manual occupations for longer had higher risk of being current smokers in mid-adulthood, with a 43% risk increase per time point in a manual occupation. Exposure to parental smoking and intention to smoke during childhood explained up to 40.2% of the excess risk of being current smokers in mid-adulthood associated with manual occupations in the sensitive period and the accumulation model.

Conclusions

Childhood, young- and mid-adulthood are all important, but SEP in childhood and mid-adulthood may be of more importance in determining mid-adulthood smoking status. Exposure to parental smoking and intention to smoke in childhood seems to moderately mediate the associations.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6483-0) contains supplementary material, which is available to authorized users.

Interpreting mutual adjustment for multiple indicators of socioeconomic position without committing mutual adjustment fallacies

Research into the effects of Socioeconomic Position (SEP) on health will sometimes compare effects from multiple, different measures of SEP in "mutually adjusted" regression models. Interpreting each effect estimate from such models equivalently as the "independent" effect of each measure may be misleading, a mutual adjustment (or Table 2) fallacy. We use directed acyclic graphs (DAGs) to explain how interpretation of such models rests on assumptions about the causal relationships between those various SEP measures. We use an example DAG whereby education leads to occupation and both determine income, and explain implications for the interpretation of mutually adjusted coefficients for these three SEP indicators. Under this DAG, the mutually adjusted coefficient for education will represent the direct effect of education, not mediated via occupation or income. The coefficient for occupation represents the direct effect of occupation, not mediated via income, or confounded by education. The coefficient for income represents the effect of income, after adjusting for confounding by education and occupation. Direct comparisons of mutually adjusted coefficients are not comparing like with like. A theoretical understanding of how SEP measures relate to each other can influence conclusions as to which measures of SEP are most important. Additionally, in some situations adjustment for confounding from more distal SEP measures (like education and occupation) may be sufficient to block unmeasured socioeconomic confounding, allowing for greater causal confidence in adjusted effect estimates for more proximal measures of SEP (like income).

Comparing Observed and Unobserved Components of Childhood: Evidence From Finnish Register Data on Midlife Mortality From Siblings and Their Parents

In this study, we argue that the long arm of childhood that determines adult mortality should be thought of as comprising an observed part and its unobserved counterpart, reflecting the observed socioeconomic position of individuals and their parents and unobserved factors shared within a family. Our estimates of the observed and unobserved parts of the long arm of childhood are based on family-level variance in a survival analytic regression model, using siblings nested within families as the units of analysis. The study uses a sample of Finnish siblings born between 1936 and 1950 obtained from Finnish census data. Individuals are followed from ages 35 to 72. To explain familial influence on mortality, we use demographic background factors, the socioeconomic position of the parents, and the individuals' own socioeconomic position at age 35 as predictors of all-cause and cause-specific mortality. The observed part-demographic and socioeconomic factors, including region; number of siblings; native language; parents' education and occupation; and individuals' income, occupation, tenancy status, and education-accounts for between 10 % and 25 % of the total familial influence on mortality. The larger part of the influence of the family on mortality is not explained by observed individual and parental socioeconomic position or demographic background and thus remains an unobserved component of the arm of childhood. This component highlights the need to investigate the influence of childhood circumstances on adult mortality in a comprehensive framework, including demographic, social, behavioral, and genetic information from the family of origin.

Childhood poverty dynamics and adulthood overweight/obesity: Unpacking the black box of childhood

Integrating several life course models, this study examines how childhood poverty dynamics shape the risk of adulthood overweight/obesity. Growth mixture models of yearly poverty data from age 0-16 from the U.S. Panel Study of Income Dynamics identify four childhood poverty trajectories: chronic poverty, early childhood poverty, downward mobility, and poverty-free. Chronic poverty and early childhood poverty groups have higher risk of adulthood overweight/obesity than the poverty-free group. Overweight/obesity risk is not significantly different between the chronic poverty group and the early childhood poverty group, suggesting that the effects of early childhood exposure persist despite subsequent upward mobility. Downward mobility in the absence of early childhood poverty does not significantly increase adulthood obesity risk, providing further evidence that early childhood is a critical period for developing risk of overweight and obesity. These findings shed new light on the timing model, social mobility model, cumulative model, and cumulative inequality theory.

Community characteristics and regional variations in sepsis

Background

Sepsis may contribute to more than 200 000 annual deaths in the USA. Little is known about the regional patterns of sepsis mortality and the community characteristics that explain this relationship. We aimed to determine the influence of community characteristics upon regional variations in sepsis incidence and case fatality.

Methods

We performed a retrospective analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Using US sepsis mortality data, we used two strategies for defining geographic regions: (i) Sepsis 'Belt' vs Non-Belt and (ii) Sepsis 'Cluster' vs Non-Cluster. We determined sepsis incidence and case fatality among REGARDS participants in each region, adjusting for participant characteristics. We examined the mediating effect of community characteristics upon regional variations in sepsis incidence and case fatality.

Results

Among 29 680 participants, 16 493 (55.6%) resided in the Sepsis Belt and 2958 (10.0%) resided in a Sepsis Cluster. Sepsis incidence was higher for Sepsis Belt than Non-Belt participants [adjusted hazard ratio (HR) = 1.14; 95% confidence interval (CI) = 1.02-1.24] and higher for Sepsis Cluster than Non-Cluster participants (adjusted HR = 1.18; 95% CI = 1.01-1.39). Sepsis case fatality was similar between Sepsis Belt and Non-Belt participants, as well as between Cluster and Non-Cluster participants. Community poverty mediated the regional differences in sepsis incidence.

Conclusions

Regional variations in sepsis incidence may be partly explained by community poverty. Other community characteristics do not explain regional variations in sepsis incidence or case fatality.

Life course models: improving interpretation by consideration of total effects

Life course epidemiology has used models of accumulation and critical or sensitive periods to examine the importance of exposure timing in disease aetiology. These models are usually used to describe the direct effects of exposures over the life course. In comparison with consideration of direct effects only, we show how consideration of total effects improves interpretation of these models, giving clearer notions of when it will be most effective to intervene. We show how life course variation in the total effects depends on the magnitude of the direct effects and the stability of the exposure. We discuss interpretation in terms of total, direct and indirect effects and highlight the causal assumptions required for conclusions as to the most effective timing of interventions.

Time to expand risk evaluation systems for cardiac surgery? Looking beyond physiological parameters

Risk assessment in cardiac surgery traditionally consists of medical and physiological parameters. However, non-physiological factors have also been found to be predictive of poor outcomes following cardiac surgery. Therefore, the isolated focus on physiological parameters is questionable. This paper describes the emotional, behavioural, social and functional factors that have been established to play a role in outcomes following cardiac surgery. This forms a basis for future research, testing the value of these factors above and beyond the physiological parameters. By including such non-physiological factors, the accuracy of the existing risk scoring systems could potentially be improved.

Life course socioeconomic position, alcohol drinking patterns in midlife, and cardiovascular mortality: Analysis of Norwegian population-based health surveys

BACKGROUND

Socioeconomically disadvantaged groups tend to experience more harm from the same level of exposure to alcohol as advantaged groups. Alcohol has multiple biological effects on the cardiovascular system, both potentially harmful and protective. We investigated whether the diverging relationships between alcohol drinking patterns and cardiovascular disease (CVD) mortality differed by life course socioeconomic position (SEP).

METHODS AND FINDINGS

From 3 cohorts (the Counties Studies, the Cohort of Norway, and the Age 40 Program, 1987-2003) containing data from population-based cardiovascular health surveys in Norway, we included participants with self-reported information on alcohol consumption frequency (n = 207,394) and binge drinking episodes (≥5 units per occasion, n = 32,616). We also used data from national registries obtained by linkage. Hazard ratio (HR) with 95% confidence intervals (CIs) for CVD mortality was estimated using Cox models, including alcohol, life course SEP, age, gender, smoking, physical activity, body mass index (BMI), systolic blood pressure, heart rate, triglycerides, diabetes, history of CVD, and family history of coronary heart disease (CHD). Analyses were performed in the overall sample and stratified by high, middle, and low strata of life course SEP. A total of 8,435 CVD deaths occurred during the mean 17 years of follow-up. Compared to infrequent consumption (

CONCLUSIONS

Moderately frequent consumers had a lower risk of CVD mortality compared with infrequent consumers, and we observed that this association was more pronounced among participants with higher SEP throughout their life course. Frequent binge drinking was associated with a higher risk of CVD mortality, but it was more uncertain whether the risk differed by life course SEP. It is unclear if these findings reflect differential confounding of alcohol consumption with health-protective or damaging exposures, or differing effects of alcohol on health across socioeconomic groups.

Collapse

Key Words Collapse

MESH Headings

• Adult
• Alcohol Drinking/epidemiology
• Cardiovascular Diseases/epidemiology
• Cardiovascular Diseases/etiology
• Cardiovascular Diseases/mortality
• Female
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Norway/epidemiology
• Proportional Hazards Models
• Prospective Studies
• Risk Factors
• Socioeconomic Factors

Collapse

Grants

• MC_UU_00011/1 Medical Research Council
• Norges Forskningsråd

Collapse

Affiliation(s)

Eirik Degerud Norwegian Institute of Public Health, Oslo, Norway
Inger Ariansen Norwegian Institute of Public Health, Oslo, Norway
Eivind Ystrom Norwegian Institute of Public Health, Oslo, Norway Department of Psychology, University of Oslo, Oslo, Norway School of Pharmacy, University of Oslo, Oslo, Norway
Sidsel Graff-Iversen Norwegian Institute of Public Health, Oslo, Norway
Gudrun Høiseth Norwegian Institute of Public Health, Oslo, Norway Diakonhjemmet Hospital, Center for Psychopharmacology, Oslo, Norway
Jørg Mørland Norwegian Institute of Public Health, Oslo, Norway Institute of Clinical Medicine, University of Oslo, Oslo, Norway
George Davey Smith MRC Integrative Epidemiology Unit, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
Øyvind Næss Norwegian Institute of Public Health, Oslo, Norway Institute of Health and Society, University of Oslo, Oslo, Norway

Collapse

Adolescent reserve capacity, socioeconomic status and school achievement as predictors of mortality in Finland - a longitudinal study

Background

Despite robust evidence on the inverse relationship between socioeconomic status (SES) and mortality, deviations from expected results have been observed likely due to school achievement and psychosocial resources, termed as “reserve capacity.” Since adolescence is a critical period in developing sound psychological and behavioural patterns and adolescent markers of SES were seldom used, we determine if family SES in adolescence predicts later mortality. We also study how reserve capacity (perceived health, health-promoting behaviour and social support) and school achievement modify this relationship and reduce the negative effects of low SES.

Methods

A longitudinal study was designed by linking baseline data on 12 to 18 year-old Finns in 1985–95 (N = 41,833) from the Adolescent Health and Lifestyle Surveys with register data on mortality and SES from Statistics Finland. Average follow-up time was 18.4 years with a total of 770,161 person-years. Cox regression models, stratified by sex, were fitted to determine the effects of variables measured during adolescence: family SES, reserve capacity and school achievement on mortality risk.

Results

All reserve capacity dimensions significantly predicted mortality in boys. Perceived health and social support predicted that in girls. Adolescents with the lowest school achievement were more than twice at risk of dying compared to those with better school performance. Low SES increased the risk of death in boys (Hazard ratios: 1.6, 95% CI 1.1–2.4) but not in girls. Reserve capacity and school achievement weakened the effects of low SES on boys’ risk of death.

Conclusions

High reserve capacity and good school achievement in adolescence significantly reduce the risk of mortality. In boys, these also mitigate the negative effect of low SES on mortality. These findings underscore the roles of reserve capacity and school achievement during adolescence as likely causal or modifying factors in SES-health inequalities.

Are objective measures of physical capability related to accelerated epigenetic age? Findings from a British birth cohort

OBJECTIVES

Our aim was to investigate the association of epigenetic age and physical capability in later life. Having a higher epigenetic than chronological age (known as age acceleration (AA)) has been found to be associated with an increased rate of mortality. Similarly, physical capability has been proposed as a marker of ageing due to its consistent associations with mortality.

SETTING

The MRC National Survey of Health and Development (NSHD) cohort study.

PARTICIPANTS

We used data from 790 women from the NSHD who had DNA methylation data available.

DESIGN

Epigenetic age was calculated using buccal cell (n=790) and matched blood tissue (n=152) from 790 female NSHD participants. We investigated the association of AA at age 53 with changes in physical capability in women from ages 53 to 60-64. Regression models of change in each measure of physical capability on AA were conducted. Secondary analysis focused on the relationship between AA and smoking, alcohol, body mass index (BMI) and socioeconomic position.

OUTCOME MEASURES

Three objective measures of physical capability were used: grip strength, standing balance time and chair rise speed.

RESULTS

Epigenetic age was lower than chronological age (mean 53.4) for both blood (50.3) and buccal cells (42.8). AA from blood was associated with a greater decrease in grip strength from ages 53 to 60-64 (0.42 kg decrease per year of AA, 95% CI 0.03, 0.82 kg; p=0.03, n=152), but no associations were observed with standing balance time or chair rise speed. Current smoking and lower BMI were associated with lower epigenetic age from buccal cells.

CONCLUSIONS

We found evidence that AA in blood is associated with a greater decrease in grip strength in British females aged between 53 and 60-64, but no association with standing balance time or chair rise speed was found.

Socially disadvantaged city districts show a higher incidence of acute ST-elevation myocardial infarctions with elevated cardiovascular risk factors and worse prognosis

BACKGROUND

The importance of socioeconomic status (SES) for coronary heart disease (CHD)-morbidity is subject of ongoing scientific investigations. This study was to explore the association between SES in different city-districts of Bremen/Germany and incidence, severity, treatment modalities and prognosis for patients with ST-elevation myocardial infarctions (STEMI).

METHODS

Since 2006 all STEMI-patients from the metropolitan area of Bremen are documented in the Bremen STEMI-registry. Utilizing postal codes of their home address they were assigned to four groups in accordance to the Bremen social deprivation-index (G1: high, G2: intermediate high, G3: intermediate low, G4: low socioeconomic status).

RESULTS

Three thousand four hundred sixty-two consecutive patients with STEMI admitted between 2006 and 2015 entered analysis. City areas with low SES showed higher adjusted STEMI-incidence-rates (IR-ratio 1.56, G4 vs. G1). This elevation could be observed in both sexes (women IRR 1.63, men IRR 1.54) and was most prominent in inhabitants <50 yrs. of age (women IRR 2.18, men IRR 2.17). Smoking (OR 1.7, 95%CI 1.3-2.4) and obesity (1.6, 95%CI 1.1-2.2) was more prevalent in pts. from low SES city-areas. While treatment-modalities did not differ, low SES was associated with more extensive STEMIs (creatine kinase > 3000 U/l, OR 1.95, 95% CI 1.4-2.8) and severe impairment of LV-function post-STEMI (OR 2.0, 95% CI 1.2-3.4). Long term follow-up revealed that lower SES was associated with higher major adverse cardiac or cerebrovascular event (MACCE)-rates after 5 years: G1 30.8%, G2 35.7%, G3 36.0%, G4 41.1%, p (for trend) = 0.02. This worse prognosis could especially be shown for young STEMI-patients (<50 yrs. of age) 5-yr. mortality-rates(G4 vs. G1) 18.4 vs. 3.1%, p = 0.03 and 5-year-MACCE-rates (G4 vs. G1) 32 vs. 6.3%, p = 0.02.

CONCLUSIONS

This registry-data confirms the negative association of low socioeconomic status and STEMI-incidence, with higher rates of smoking and obesity, more extensive infarctions and worse prognosis for the socio-economically deprived.

Intergenerational social mobility and subjective wellbeing in later life

Whereas a great deal of literature has been devoted to investigating the link between intergenerational social mobility and health, the few studies that have examined the association between social mobility and life satisfaction have produced conflicting findings. In the present study, we attempt to rectify several shortcomings common to previous work by examining the association between intergenerational social mobility and both life satisfaction and self-rated health as measured in later-life. Our sample consisted of individuals born in Scotland in 1936, who took part in the Scottish Mental Survey 1947 and were subsequently followed-up into later-life. Regression analyses demonstrated that satisfaction with life at age 78 was not significantly predicted by childhood or adulthood socioeconomic status, or by the amount of social mobility experienced from parental occupational social class. In contrast, self-rated health at age 78 was significantly predicted by adult socioeconomic status and by education, but not by social mobility from parental occupational social class. These results suggest that efforts to promote upwards social mobility may not result in better subjective wellbeing, despite the apparent benefits for health.

Depressive Symptoms During Adolescence Predict Adulthood Obesity Among Black Females

AIM

This study aimed to investigate gender differences in the association between baseline depressive symptoms and subsequent changes in obesity in a sample of urban Black youth in the USA.

METHODS

The current study followed 681 Black youth (335 male and 346 female) for up to 18 years from 1994 to 2012. All youth were selected from an economically disadvantaged urban area in MI, USA. The main independent variable was baseline depressive symptoms measured in 1994. The main outcome was change in body mass index (BMI) from 1999 to 2012, calculated based on self-reported height and weight. Scio-demographics (age, number of parents in the household, and parental employment) were covariates. Gender was the focal moderator. We used linear regressions to test the predictive role of baseline depressive symptoms on change in BMI (from 1999 to 2012) in the pooled sample, and also based on gender.

RESULTS

Among Black females, but not Black males, baseline depressive symptoms predicted the BMI change from 1999 to 2012. The association remained significant for Black females after controlling for covariates.

CONCLUSION

High depressive symptoms at baseline better predict BMI change over the next decade for female than male Black youth. As a result, detection and reduction of depressive symptoms may be a vital element of obesity prevention programs for Black females. Policies and programs that address determinants of psychological distress as a strategy to prevent obesity among female Black youth in disadvantaged neighborhoods may be especially useful.

Neo-Marxian social class inequalities in self-rated health among the employed in South Korea: the role of material, behavioral, psychosocial, and workplace environmental factors

BACKGROUND

The aim of this study was to examine the pattern of social inequality in self-rated health among the employed using the Wright's social class location indicator, and to assess the roles of material, behavioral, psychosocial, and workplace environmental factors as mediating factors in explaining the social class inequality in self-rated health in South Korea.

METHODS

This study used data from the 4th Korea National Health and Nutrition Examination Survey from 2007 to 2009. Study subjects included the employed population of 4392 men and 3309 women aged 19-64 years. Subjects were classified into twelve social class positions based on the Wright's social class map. The health outcome was self-rated health. Material, psychosocial, behavioral, and workplace environmental factors were considered as potential mediators in explaining social class health inequality. We calculated prevalence ratios of poor self-rated health according to social class, adjusted for age and mediating factors using Poisson regression models.

RESULTS

Nonskilled workers and petty bourgeoisie reported worse self-rated health than other social classes among men. The age-adjusted prevalence of petty bourgeoisie and nonskilled workers were about four-fold greater than that of managers. Expert supervisors in the contradictory class location had a greater prevalence of poor self-rated health than experts in men. In women, the prevalence of poor self-rated health was greater in most social classes than their male counterparts, while the differences among social classes within women were not statistically significant. Workplace environmental factors explained the social class inequality by from 24 to 31% in nonskilled and skilled workers and nonskilled supervisors, respectively, and material factors showed an explanatory ability of about 8% for both nonskilled workers and petty bourgeoisie in men.

CONCLUSIONS

We showed the inequality in self-rated health according to the Wright's social class in an industrialized Asian country. Policy efforts to improve workplace environments in nonskilled and skilled workers and nonskilled supervisors would have a moderate effect on reducing the magnitude of social class inequality in self-rated health. Furthermore, the means to improve power relations in the workplace should be devised to further reduce the social class inequalities in health.

Life course indices for social determinants of self-rated health trajectory in Korean elderly

OBJECTIVES

This study investigated the self-rated health trajectories of the Korean older population and revealed life-course factors that affect the trajectories over the life course.

METHODS

Around 1000 older adults were randomly allocated by stratified multi-stage sampling based on the population census, and underwent face-to-face interviews. Self-rated health status, socioeconomic variables over the life course, and demographic variables were included in the analysis. A group-based trajectory model was used to investigate the association between self-rated health and explanatory variables.

RESULTS

The enrolled men and women were divided into three groups by trajectory analysis, which showed marked differences in self-rated health trajectories from childhood to senescence. Among older men, those who experienced skipping meals in childhood and those with chronic disease conditions were more likely to be in the lower trajectory groups. Compared to the older men, the likelihood of being in the lower trajectory groups in older women was increased by experience of skipping meals, lower household income, housekeeping labor, receiving Basic Livelihood Security and chronic disease conditions.

CONCLUSION

Various self-rated health trajectories of the Korean older population were identified, and differed according to socioeconomic variables during their life course. Therefore, socioeconomic variables during the life course should be monitored, and health policies directed at the elderly should focus on initial health status from the perspective of a life-course approach.

Residual Effects of Restless Sleep over Depressive Symptoms on Chronic Medical Conditions: Race by Gender Differences

BACKGROUND

Sleep and depression are comorbid problems that contribute to the development of chronic medical conditions (CMC) over time. Although racial and gender differences in the bidirectional associations between sleep, depression, and CMC are known, very limited information exists on heterogeneity of the residual effects of sleep problems over depressive symptoms on CMC across race by gender groups.

AIM

Using a life-course perspective, the present study compared race by gender groups for residual effects of restless sleep over depressive symptoms on CMC.

METHODS

We used data from waves 1 (year 1986), 4 (year 2001), and 5 (year 2011) of the Americans' Changing Lives Study (ACL). The study followed 294 White men, 108 Black men, 490 White women, and 237 Black women for 25 years. Restless sleep, depressive symptoms (Center for Epidemiological Studies-Depression scale [CES-D]), and number of chronic medical conditions (hypertension, diabetes, chronic lung disease, heart disease, stroke, cancer, and arthritis) were measured in 1986, 2001, and 2011. We employed multi-group cross-lagged modeling, with chronic medical conditions as the outcome and race by gender as the groups.

RESULTS

Major group differences were found in the residual effect of restless sleep on CMC over depressive symptoms across race by gender groups. Restless sleep in 2001 predicted CMC 10 years later in 2011 among Black women (standardized adjusted B = .135, P < .05) and White men (standardized adjusted = .145, P < .01) and White women (standardized adjusted B = .171, P < .001) but not Black men (standardized adjusted B = .001, P > .05).

CONCLUSION

Race by gender heterogeneity in the residual effect of restless sleep over depressive symptoms on CMC over 25 years suggests that comorbid poor sleep and depressive symptoms differently contribute to development of multi-morbidity among subpopulations based on the intersection of race and gender. Thus, interventions that try to prevent comorbid sleep problems and depression as a strategy to prevent medical conditions may benefit from tailoring based on the intersection of race and gender.

Estimating direct effects of parental occupation on Spaniards' health by birth cohort

Background

Social health inequalities in adult population are partly due to socioeconomic circumstances in childhood. A better understanding of how those circumstances affect health during adulthood may improve the opportunities for reducing health disparities. The objective of this study is to investigate the effect of parental socioeconomic status, which is proxied by occupation, on adult Spaniards’ health by birth cohort. The analysis will allow checking not only the direct impact of parental occupation on their offspring’s health, but also whether inherited inequality has been reduced over time.

Methods

We use data from the Bank of Spain’s Survey of Household Finances on Spanish households from 2002 to 2008. Sequential models were used to estimate the influence of the father’s and mother’s occupation on their offspring’s health, trying to disentangle direct from indirect effects. With a sample of 26,832 persons we consider effects for four different cohorts by birth periods ranging from 1916 to 1981.

Results

The results show that parental occupation has a significant direct impact on individuals’ health (p < 0.01). The effect of father’s occupation exceeds that of mother’s. For those born before 1936, the probability of reporting a good health status ranges from 0.31 (95% confidence interval (CI) 0.14–0.48), when fathers were classified as unskilled elementary workers, to 0.98 (95% CI 0.98–0.99) when they were managers or mid-level professionals. For those born during the period 1959–1975, those probabilities are 0.49 (95% CI 0.39–0.59) and 0.97 (95% CI 0.96–0.98), respectively. Therefore, health inequalities linked to parental socioeconomic status have been noticeably reduced, although discrimination against unskilled workers persists over time.

Conclusions

Great progress has been made in the health area during the twentieth century, so that the impact of parental socioeconomic status on individuals’ health has been significantly tempered for those at the bottom of the social scale. However, more efforts focused on the improvement of living conditions for most socioeconomically disadvantaged are needed in order to further reduce social inequalities in health.

US Mortality: Influence of Race, Geography and Cardiovascular Risk Among Participants in the Population-Based REGARDS Cohort

OBJECTIVES

We evaluated whether differences in cardiovascular risk factors, as assessed by the Framingham risk scores for stroke and cardiovascular disease (FSRS and FCRS), contributed to disparities in all-cause mortality across race and regional strata of USA.

DESIGN

Race-region-specific FSRS and FCRS scores were computed for 30,086 REGARDS participants who were recruited between January 2003 and October 2007. They were divided across six regions of the "Eight Americas" and then compared after adjusting for race and sex. Kaplan-Meier curves and hazard ratios for all-cause mortality were estimated between regions, first adjusted for age and sex, and then for the risk scores.

RESULTS

After adjustment for age, sex, FCRS, and FSRS, there was no difference in mortality among Middle-America Whites versus Low-Income White. However, mortality was lower among Middle-America Blacks (-23 %; p = 0.06) and High-Risk Urban Blacks (-24 %; p = 0.01) compared to Southern Low-Income Rural Blacks. Compared to Middle-American Whites, mortality was higher among Middle-America Blacks (+39 %; p < 0.001), High-Risk Urban Blacks (+35 %; p < 0.001) and Southern Low-Income Rural Blacks (+85 %; p < 0.001).

CONCLUSION

Accounting for cardiovascular risk unmasked a greater disparity in mortality between Blacks and Whites and among Southern Rural Blacks compared to Middle-America Blacks and High-Risk Urban Blacks.

Socioeconomic status and psychosocial work environment: results from a Danish national study

Objective: The aim of this study was to analyse the associations between socioeconomic status (SES) and a number of psychosocial work environment factors with a potential impact on inequality in health. Methods: A representative sample of 1,684 adult Danish employees fi lled in a standardized questionnaire or were interviewed by telephone. The response rate was 62%. The population was divided into four levels of SES (I to IV). The psychosocial work environment was described with 19 scales. Results: Quantitative, cognitive, and emotional job demands and a number of dimensions related to active and developmental work showed higher levels among high SES individuals. Job insecurity was highest among women with low SES. Dimensions describing interpersonal relations, social support, and leadership showed no clear associations with SES. Conclusions: Prevention aiming at improving health and reducing inequality in health should focus on the dimensions of active and developmental work: infl uence at work, possibilities for development, degrees of freedom, and meaning of work. Furthermore, job insecurity should be reduced.

Effect of living conditions in the parental home and youth paths on the social class differences in mortality among women

Aims: A longitudinal study was undertaken to assess the effects of parental home and youth paths on the adult social class differences in mortality among women. Methods: The study used population registration data on all Finnish women aged 30 - 34 in 1990 for whom information on their childhood characteristics and youth paths were available from the 1970, 1975, 1980, 1985, and 1990 censuses. Cause of death follow-up was for the period 1991-98 (1,185 deaths). Results: Adjusting for parental social class, family type, and number of siblings attenuated the effects of adult social class on cardiovascular disease mortality by 27%; for all external causes this attenuation was negligible. Educational, marital, and employment paths accounted for a substantial part (30 - 85%) of the social class differences in mortality for all specific causes of death. Conclusions: Although living conditions in the parental home were associated with mediating life trajectories in youth their effect on adult social class differences in mortality was moderate. Youth paths have a pervasive influence on mortality risks and social class differences in mortality in middle adulthood.

Social mobility, marital status, and mortality risk in an adult life course perspective: The Malmö Preventive Project

Aims: Adverse social factors predict increased mortality. This study aimed to assess the influence of social class and marital status on mortality, adding an adult life course perspective. Methods: In total, 32,907 males and 20,204 females were evaluated based on census data in Malmö, Sweden. Of these subjects, 22,444 males and 10,902 females also took part in health screening. The main outcomes were all-cause and cause-specific mortality rates in subgroups based on social class and marital status, either measured once or repeatedly in adult life. Results were based on a total of 522,807 years of follow-up in men (5,761 deaths) and 239,815 in women (1,354 deaths). Results: Total and cardiovascular mortality were significantly higher in manual male employees with age-adjusted risk ratios (RR) of 1.7 (95% CI 1.5—1.9) and 1.6 (1.3—2.0) in skilled manual workers, and 2.0 (1.7—2.2) and 1.9 (1.6—2.3) in unskilled manual workers, compared with high-level non-manual employees. The differences remained after adjustment for baseline risk factors and prevalent cardiovascular disease, and were similar for women. Increased mortality risk was also documented for subjects who were divorced or unmarried (adjusted for social class), as well as being downward socially mobile or in a permanent low social class (manual) position. Conclusions: Social class based on occupation, either measured once or repeatedly in adult life, is associated with marked differences in mortality risk in middle-aged subjects. People who remain married/cohabiting or remarry are at lower risk of early death than people who remain unmarried or divorced.

Epidemiology and Sociology as Incommensurate Games: Accounts from the Study of Health and Ethnicity

The ‘discrete variables’ methodology of epidemiology is contrasted with the contextuality and complexity of sociology in general and of qualitative fieldwork in particular. Sociology has always interrogated the categories which it deploys. The lessons of the contemporary interrogation of the category ‘ethnic group’ are applied in a critique of positivistic methodologies which have tended to treat ethnic groups as natural divisions of the population. The meanings of ethnicity in health research are explored and then illustrated by detailed accounts from fieldwork. The article closes with comments on the contribution which qualitative and sociologically informed methodologies may make to epidemiological studies.

Socio-economic Position, Gender and Health

There is a large research literature on socio-economic inequalities in health (and explanations for these inequalities); there is also a large literature on gender differences in health (and explanations for these differences). However, the two bodies of research are rarely integrated to ask, for example, whether socio-economic inequalities vary by gender, or whether gender differences vary by socio-economic position. The separation of these two research traditions may be to the detriment of theoretical development in both of them; and in particular, asymmetrical treatment of men and women in research in inequalities in health may hinder our ability to explain the mechanisms producing inequalities. This article reviews the intersection of socio-economic position and gender, and argues for more systematic and symmetrical examination of the interaction between socio-economic position and gender in the social patterning of health.

Combined Racial and Gender Differences in the Long-Term Predictive Role of Education on Depressive Symptoms and Chronic Medical Conditions

BACKGROUND

Despite a well-established literature on the protective effect of education on health, less is known about group differences in the mechanisms underlying this association. Using a life course approach and cumulative advantage theory, this study compared Black men, Black women, White men, and White women to assess the long-term gradient (education as a continuous measure) and threshold (>12 years) effects of baseline education on change in chronic medical conditions (CMC) and depressive symptoms (DS) from baseline to 25 years later.

METHODS

Data came from the Americans' Changing Lives Study, 1986-2011. The study followed Black and White respondents for up to 25 years, among whom 1271 individuals who had survived and were under follow-up were interviewed in 2011 and reported their number of chronic medical conditions and depressive symptoms (Center for Epidemiological Studies-Depression; CES-D 11). Multi-group structural equation modeling was used to compare gradient and threshold effects of education on change in chronic medical conditions and depressive symptoms from baseline (1986) to 25 years later (2011) among Black men, Black women, White men, and White women.

RESULTS

There were group differences in the long-term association between education measured as a gradient and the change in depressive symptoms and chronic medical conditions during the follow-up, and in the association between education measured at the threshold of 12 years on change in depressive symptoms from baseline to follow-up. However, the association between education measured at this threshold and change in chronic medical conditions did not differ across race-gender groups. With the exception of Black men, who showed a gradient protective effect for baseline education against increase in the number of chronic medical associations (threshold or gradient) with change in chronic medical conditions. Among White men and White women, education had a threshold protective effect against increase in depressive symptoms from baseline to 25 years later. Black men and women showed a gradient protective effect of baseline education against an increase in depressive symptoms over the 25-year follow-up period, but unexpectedly, a threshold effect of education was also found to be associated with an increase in depressive symptoms over the follow-up period among Black men. This finding suggests that although Black men benefit from each incremental increase in education, those who graduated from high school were at an additional risk of depressive symptoms over a 25-year period.

CONCLUSION

Findings suggest that the intersection of race and gender influences how education is associated with long-term changes in physical and mental health of individuals from baseline to 25 years later. As the shape of the association between education and health depends on the intersection of race and gender, these groups may vary for operant mechanisms by which education operates as a main social determinant of health.