Family socioeconomic position at birth and future cardiovascular disease risk: findings from the Aberdeen Children of the 1950s cohort study

Childhood Risk Factors and Adulthood Cardiovascular Disease: A Systematic Review

OBJECTIVE

To conduct a comprehensive review of the literature on childhood risk factors and their associations with adulthood subclinical and clinical cardiovascular disease (CVD).

STUDY DESIGN

A systematic search was performed using the MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases to identify English-language articles published through June 2018. Articles were included if they were longitudinal studies in community-based populations, the primary exposure occurred during childhood, and the primary outcome was either a measure of subclinical CVD or a clinical CVD event occurring in adulthood. Two independent reviewers screened determined whether eligibility criteria were met.

RESULTS

There were 210 articles that met the predefined criteria. The greatest number of publications examined associations of clinical risk factors, including childhood adiposity, blood pressure, and cholesterol, with the development of adult CVD. Few studies examined childhood lifestyle factors including diet quality, physical activity, and tobacco exposure. Domains of risk beyond "traditional" cardiovascular risk factors, such as childhood psychosocial adversity, seemed to have strong published associations with the development of CVD.

CONCLUSIONS

Although the evidence was fairly consistent in direction and magnitude for exposures such as childhood adiposity, hypertension, and hyperlipidemia, significant gaps remain in the understanding of how childhood health and behaviors translate to the risk of adulthood CVD, particularly in lesser studied exposures like glycemic indicators, physical activity, diet quality, very early life course exposure, and population subgroups.

The Mediating Effect of Self-Regulation in the Association Between Poverty and Child Weight: A Systematic Review

Deficits in self-regulation (SR) have been proposed as a potential contributor to child overweight/obesity, a public health concern that disproportionately affects children living in poverty. Although poverty is known to influence SR, SR has not been considered as a potential mechanism in the association between poverty and child obesity. The aim of the current paper was to systematically review the current literature to determine whether SR is a viable mechanism in the relationship between child exposure to poverty and later risk of overweight/obesity. We systematically review and summarize literature in three related areas with the aim of generating a developmentally informed model that accounts for the consistent association between poverty and child weight, specifically how: (1) poverty relates to child weight, (2) poverty relates to child SR, and (3) SR is associated with weight. To quantify the strength of associations for each pathway, effect sizes were collected and aggregated. Findings from the studies included suggest small but potentially meaningful associations between poverty and child SR and between SR and child weight. The conceptualization and measurement of SR, however, varied across literature studies and made it difficult to determine whether SR can feasibly connect poverty to child obesity. Although SR may be a promising potential target for obesity intervention for low-income children, additional research on how SR affects risk of obesity is crucial, especially based on the lack of success of the limited number of SR-promoting interventions for improving children's weight outcomes.

The impact of socioeconomic position on non-communicable diseases: what do we know about it?

AIMS

Non-communicable diseases (NCDs) have become a primary health concern for most countries around the world. The aim of this research is to analyze the relevant evidence that determines the effect of socioeconomic position (SEP) on the incidence and prevalence of NCDs.

METHODS

A systematic literature search was performed using PubMed, Cochrane Library, and Web of Science to identify evidence regarding the relationship between income inequalities and NCDs, between 2005 and 2015. The final selection of papers was based on applied studies focusing on Organisation for Economic Co-operation and Development (OECD) countries and articles referring to three main groups of chronic diseases: cardiovascular and heart diseases, cancer, and diabetes.

RESULTS

A final set of 47 selected studies were fully taken into account in this review. Despite significant heterogeneity in exposure and outcomes measures, overall the evidence suggests that having low SEP increases the risk of developing cardiovascular diseases (CVDs), lung and breast cancer, and type 2 diabetes. SEP is also associated with multiple NCD risk factors such as smoking and physical inactivity.

CONCLUSION

Low socioeconomic status appears to have a significant consistent impact on mortality and morbidity caused by NCDs in OECD countries. Social and economic disadvantages are associated with health inequalities in terms of access to care, increased incident risk of NCDs, and early death. These findings point to the need for public health strategies and research to address socioeconomic status disparity among individuals.

Prevalence of secondary care multimorbidity in mid-life and its association with premature mortality in a large longitudinal cohort study

OBJECTIVES

Multimorbidity is the coexistence of two or more health conditions in an individual. Multimorbidity in younger adults is increasingly recognised as an important challenge. We assessed the prevalence of secondary care multimorbidity in mid-life and its association with premature mortality over 15 years of follow-up, in the Aberdeen Children of the 1950s (ACONF) cohort.

METHOD

A prospective cohort study using linked electronic health and mortality records. Scottish ACONF participants were linked to their Scottish Morbidity Record hospital episode data and mortality records. Multimorbidity was defined as two or more conditions and was assessed using healthcare records in 2001 when the participants were aged between 45 and 51 years. The association between multimorbidity and mortality over 15 years of follow-up (to ages 60-66 years) was assessed using Cox proportional hazards regression. There was also adjustment for key covariates: age, gender, social class at birth, intelligence at age 7, secondary school type, educational attainment, alcohol, smoking, body mass index and adult social class.

RESULTS

Of 9625 participants (51% males), 3% had multimorbidity. The death rate per 1000 person-years was 28.4 (95% CI 23.2 to 34.8) in those with multimorbidity and 5.7 (95% CI 5.3 to 6.1) in those without. In relation to the reference group of those with no multimorbidity, those with multimorbidity had a mortality HR of 4.5 (95% CI 3.4 to 6.0) over 15 years and this association remained when fully adjusted for the covariates (HR 2.5 (95% CI 1.5 to 4.0)).

CONCLUSION

Multimorbidity prevalence was 3% in mid-life when measured using secondary care administrative data. Multimorbidity in mid-life was associated with premature mortality.

Impact of educational attainment on the association between social class at birth and multimorbidity in middle age in the Aberdeen Children of the 1950s cohort study

OBJECTIVE

Multimorbidity (the coexistence of two or more health conditions) is increasingly prevalent. No long-term cohort study has examined the impact of contemporaneously measured birth social class along with educational attainment on adult self-reported multimorbidity. We investigated the impact of educational attainment on the relationship between social class at birth and adult self-reported multimorbidity in the Aberdeen Children of the 1950s (ACONF) cohort.

METHODS

A prospective cohort study using the ACONF cohort. ACONF included 12 150 individuals born in Aberdeen, Scotland 1950-1956. In 2001, 7184 (64%) responded to a questionnaire providing information including self-reported morbidity and educational attainment. The exposure was father's social class at birth from birth records and the outcome was self-reported multimorbidity.Logistic regression assessed the association between social class and multimorbidity with adjustment for gender, then by educational attainment and finally by childhood cognition and secondary school type. ORs and 95% CIs were presented.

RESULTS

Of 7184 individuals (mean age 48, 52% female), 5.4% reported multimorbidity. Birth social class was associated with adult multimorbidity. For example, the OR of multimorbidity adjusted by gender was 0.62 (95% CI 0.39 to 1.00) in the highest social class group (I/II) in relation to the reference group (III (manual)) and was 1.85 (95% CI 1.19 to 2.88) in the lowest social class group. This was partially attenuated in all social class categories by educational attainment, for example, the OR was 0.74 (95% CI 0.45 to 1.21) in group I/II following adjustment.

CONCLUSION

Lower social class at birth was associated with developing multimorbidity in middle age. This was partially mediated by educational attainment and future research should consider identifying the other explanatory variables. The results are relevant to researchers and to those aiming to reduce the impact of multimorbidity.

Education, Socioeconomic Status, and Intelligence in Childhood and Stroke Risk in Later Life: A Meta-analysis

BACKGROUND

Stroke is the second most common cause of death, and a common cause of dependency and dementia. Adult vascular risk factors and socioeconomic status (SES) are associated with increased risk, but less is known about early life risk factors, such as education, childhood SES, or intelligence (IQ).

METHODS

We comprehensively searched Medline, PsycINFO, and EMBASE from inception to November 2015. We included all studies reporting data on >50 strokes examining childhood/premorbid IQ, SES, and education. Two reviewers independently screened full texts and extracted and cross-checked data, including available risk factor adjustments. We meta-analyzed stroke risk using hazard ratios (HR), odds ratios (OR), and mean differences (MD). We tested effects of study and participant characteristics in sensitivity analyses and meta-regression, and assessed heterogeneity and publication bias.

RESULTS

We identified 90 studies examining stroke risk and education (79), SES (10), or IQ (nine) including approximately 164,683 stroke and over 5 million stroke-free participants. Stroke risk increased with lower education (OR = 1.35, 95% CI = 1.24, 1.48), SES (OR = 1.28, 95% CI = 1.12, 1.46), and IQ (HR = 1.17, 95% CI = 1.00, 1.37) in studies reporting point estimates, with similar associations for MD. We found minimal publication bias. Between-study heterogeneity was partly explained by participant age and case ascertainment method.

CONCLUSIONS

Education, childhood SES, and intelligence have modest but important associations with lifetime stroke, and hence dementia, risks. Future studies distinguishing between the individual and combined effects of education, childhood SES and intelligence are needed to determine the independent contribution of each factor to stroke risk. See video abstract at, http://links.lww.com/EDE/B210.

Association of Childhood Body Mass Index and Change in Body Mass Index With First Adult Ischemic Stroke

Importance

The incidence of ischemic stroke among young adults is rising and is potentially due to an increase in stroke risk factors occurring at younger ages, such as obesity.

Objectives

To investigate whether childhood body mass index (BMI) and change in BMI are associated with adult ischemic stroke and to assess whether the associations are age dependent or influenced by birth weight.

Design, Setting, and Participants

This investigation was a population-based cohort study of schoolchildren born from 1930 to 1987, with follow-up through national health registers from 1977 to 2012 in Denmark. Participants were 307 677 individuals (8899 ischemic stroke cases) with measured weight and height at ages 7 to 13 years. The dates of the analysis were September 1, 2015, to May 27, 2016.

Main Outcomes and Measures

Childhood BMI, change in BMI, and birth weight. Ischemic stroke events were divided into early (≤55 years) or late (>55 years) age at diagnosis.

Results

The study cohort comprised 307 677 participants (approximately 49% female and 51% male). During the study period, 3529 women and 5370 men experienced an ischemic stroke. At all ages from 7 to 13 years, an above-average BMI z score was positively associated with early ischemic stroke. At age 13 years, a BMI z score of 1 was associated with hazard ratios (HRs) of 1.26 (95% CI, 1.11-1.43) in women and 1.21 (95% CI, 1.10-1.33) in men. No significant associations were found for below-average BMI z scores. Among children with above-average BMI z scores at age 7 years, a score increase of 0.5 from ages 7 to 13 years was positively associated with early ischemic stroke in women (HR, 1.10; 95% CI, 1.01-1.20) and in men (HR, 1.08; 95% CI, 1.00-1.16). Similarly, among children with below-average BMI z scores at age 7 years, a score increase of 0.5 from ages 7 to 13 years was positively associated with early ischemic stroke in women (HR, 1.14; 95% CI, 1.06-1.23) and in men (HR, 1.10; 95% CI, 1.04-1.18). Adjusting for birth weight minimally affected the associations.

Conclusions and Relevance

Independent of birth weight, above-average childhood BMI and increases in BMI during childhood are positively associated with early adult ischemic stroke. To avoid the occurrence of early ischemic stroke associated with childhood overweight and obesity, these results suggest that all children should be helped to attain and maintain healthy weights.

Number of Chronic Medical Conditions Fully Mediates the Effects of Race on Mortality; 25-Year Follow-Up of a Nationally Representative Sample of Americans

BACKGROUND

Despite the well-established literature on the effects of race and socioeconomic status (SES) on mortality, limited information exists on mediators of these effects. Taking a life-course epidemiology approach, and using a nationally representative sample of adults in the USA, the current study has two aims: (1) to assess the effects of race and SES at baseline on all-cause mortality over a 25-year follow-up and (2) to test whether the number of chronic medical conditions (CMCs) as a time-varying covariate mediates the effects of race and SES on all-cause mortality.

METHODS

Data came from the Americans' Changing Lives (ACL) Study, a nationally representative longitudinal cohort of US adults 25 and older. The study followed 3361 Blacks or Whites for all-cause mortality for up to 25 years from 1986 to 2011. The predictors of interest were race and SES (education and family income) at baseline measured in 1986. Confounders included baseline age and gender. CMC was the potential time-varying mediator measured in 1986, 1989, 1991, 2001, and 2011. We ran Cox proportional hazard models with and without CMC as time-varying covariates.

RESULTS

In separate models, race and SES were predictors of all-cause mortality. In the model that tested the combined effect of race and SES, SES but not race was predictive of all-cause mortality. We also found evidence suggesting that CMC fully mediates the effect of race on all-cause mortality. Number of CMC only partially mediated the effect of SES on mortality.

CONCLUSION

The number of CMC fully mediates the effects of race and partially mediates the effects of SES on all-cause mortality in the USA. Mortality prevention for minority populations will benefit tremendously from elimination of CMC disparities as well as enhancement of CMC management by minority populations. Elimination of the gap due to SES may be more challenging than the elimination of the racial gap in mortality.

Family socioeconomic position in early life and onset of depressive symptoms and depression: a prospective cohort study

PURPOSE

To investigate whether low parental socioeconomic position (SEP) at birth is associated only with early-onset depressive symptoms in offspring.

METHODS

This prospective cohort study used data on 9193 individuals (4768 females, 4425 males) from the Avon Longitudinal Study of Parents and Children. Depressive symptoms during three age periods (10-12, 12-16, 16-20 years) were assessed using the Short Mood and Feelings Questionnaire, and ICD-10 depression at age 18 was assessed using the Clinical Interview Schedule-Revised.

RESULTS

Low SEP was associated with increased incidence rates of depressive symptoms in all age periods, with indicators of low standard of living showing the strongest associations. For instance, incidence rate ratios for material hardship were 1.75 (95% CI [1.42-2.15]) at 10-12 years, 1.36 (1.16-1.61) at 12-16 years and 1.39 (1.21-1.59) at 16-20 years. Low SEP was also associated with increased odds of ICD-10 depression at 18 years, ranging from OR = 1.20 (95% CI [0.94-1.52]) for manual social class to 1.74 (1.35-2.24) for material hardship.

CONCLUSIONS

There was no evidence that depressive symptoms can be "subtyped" by the age of onset, because the association with low SEP was evident for early- and later-onset symptoms. If socioeconomic inequalities in early life have long-term adverse impacts on mental health, policies addressing these inequalities could benefit the mental health of the population.

Novel coronary heart disease risk factors at 60-64 years and life course socioeconomic position: the 1946 British birth cohort

Social disadvantage across the life course is associated with a greater risk of coronary heart disease (CHD) and with established CHD risk factors, but less is known about whether novel CHD risk factors show the same patterns. The Medical Research Council National Survey of Health and Development was used to investigate associations between occupational socioeconomic position during childhood, early adulthood and middle age and markers of inflammation (C-reactive protein, interleukin-6), endothelial function (E-selectin, tissue-plasminogen activator), adipocyte function (leptin, adiponectin) and pancreatic beta cell function (proinsulin) measured at 60–64 years. Life course models representing sensitive periods, accumulation of risk and social mobility were compared with a saturated model to ascertain the nature of the relationship between social class across the life course and each of these novel CHD risk factors. For interleukin-6 and leptin, low childhood socioeconomic position alone was associated with high risk factor levels at 60–64 years, while for C-reactive protein and proinsulin, cumulative effects of low socioeconomic position in both childhood and early adulthood were associated with higher (adverse) risk factor levels at 60–64 years. No associations were observed between socioeconomic position at any life period with either endothelial marker or adiponectin. Associations for C-reactive protein, interleukin-6, leptin and proinsulin were reduced considerably by adjustment for body mass index and, to a lesser extent, cigarette smoking. In conclusion, socioeconomic position in early life is an important determinant of several novel CHD risk factors. Body mass index may be an important mediator of these relationships.

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We examine associations of life course socioeconomic position (SEP) with novel coronary heart disease risk markers using novel methods to compare different life course models.

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SEP during childhood was important for IL-6 and leptin, while SEP during both childhood and early adulthood was important for CRP and proinsulin.

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BMI (but not smoking) explained a large part of these relationships.

Childhood socioeconomic position, young adult intelligence and fillings of prescribed medicine for prevention of cardiovascular disease in middle-aged men

OBJECTIVES

To explore the relationship between childhood socioeconomic position (SEP) and filling of medicine prescriptions for prevention of cardiovascular diseases (CVDs), with young adult intelligence (IQ) as a potential mediator.

DESIGN

Birth cohort study with logistic and Cox-proportional hazard regression analyses of associations between childhood SEP, retrieved from birth certificates, and prevalence, initiation of and refill persistency for CVD preventive medicine.

SETTING

Denmark.

PARTICIPANTS

8736 Danish men born in 1953, who had no CVD at the start of follow-up in 1995, were followed in the Danish National Prescription Register for initiation of and refill persistency for antihypertensives and statins, until the end of 2007 (age 54 years).

RESULTS

Low childhood SEP at age 18 was not associated with prescription fillings of antihypertensives, but was weakly associated with initiation of statins (HR = 1.19 (95% CI 1.00 to1.42)). This estimate was attenuated when IQ was entered into the model (HR=1.10 (95% CI 0.91 to 1.23)). Low childhood SEP was also associated with decreased refill persistency for statins (HR=2.23 (95% CI 1.13 to 4.40)). Thus, the HR for SEP only changed slightly (HR=2.24 (95% CI 1.11 to 4.52)) when IQ was entered into the model, but entering other covariates (education and body mass index in young adulthood and income in midlife) into the model attenuated the HR to 2.04 (95% CI 1.00 to 4.16).

CONCLUSIONS

Low childhood SEP was related to more frequent initiation of and poorer refill persistency for statins. IQ in young adulthood explained most of the association between childhood SEP and initiation of statins, but had no impact on refill persistency.

Sibling composition during childhood and adult blood pressure among native Amazonians in Bolivia

Sibling configuration, including birth order, or the number, age, and sex of siblings is associated with parental resource allocation between children and is thus associated with a person's well-being. Little is known about the association between specific types of siblings and adult health outcomes. Here we test several hypotheses about sibling composition (number of older brothers, older sisters, younger sisters, younger brothers) and adult blood pressure in a foraging-farming society of native Amazonians in Bolivia (Tsimane'). We collected data in 2007 from 374 adults (16-60years of age) from 196 households in 13 villages. Household random-effects multiple regressions were run using systolic (SBP) or diastolic blood pressure (DBP) as outcomes; covariates included the four sibling categories and control variables (e.g., sex, age, education, body mass index [BMI]). Mean SBP and DBP were 114 (SD=14) and 66 (SD=11)mmHg. The prevalence of hypertension was 5.08%. Having an additional younger brother bore a small (3.3-5.9%) positive association with both SBP and DBP, with the effect weakening as people aged. Having an additional younger sister was associated with a small (3.8%) increase in SBP among women, with the magnitude shrinking as people aged. In a large family, the number of younger brothers may exert an impact on an individual's blood pressure.

Implicit measures of early-life family conditions: relationships to psychosocial characteristics and cardiovascular disease risk in adulthood

OBJECTIVES

An implicit measure of early-life family conditions was created to help address potential biases in responses to self-reported questionnaires of early-life family environments. We investigated whether a computerized affect attribution paradigm designed to capture implicit, affective responses (anger, fear, warmth) regarding early-life family environments was (a) stable over time, (b) associated with self-reports of childhood family environments, (c) able to predict adult psychosocial profiles (perceived social support, heightened vigilance), and (d) able to predict adult cardiovascular risk (blood pressure) either alone or in conjunction with a measure of early-life socioeconomic status.

METHOD

Two studies were conducted to examine reliability and validity of the affect attribution paradigm (Study 1, N = 94) and associated adult psychosocial outcomes and cardiovascular risk (Study 2, N = 122).

RESULTS

Responses on the affect attribution paradigm showed significant correlations over a 6-month period, and were moderately associated with self-reports of childhood family environments. Greater attributed negative affect about early-life family conditions predicted lower levels of current perceived social support and heightened vigilance in adulthood. Attributed negative affect also interacted with early-life socioeconomic status (SES) to marginally predict resting systolic blood pressure (SBP), such that those individuals high in early-life SES but who had implicit negative affect attributed to early-life family conditions had SBP levels that were as high as individuals low in early-life SES.

CONCLUSION

Implicit measures of early-life family conditions are a useful approach for assessing the psychosocial nature of early-life environments and linking them to adult psychosocial and physiological health profiles.

Lifecourse socioeconomic circumstances and multimorbidity among older adults

BACKGROUND

Many older adults manage multiple chronic conditions (i.e. multimorbidity); and many of these chronic conditions share common risk factors such as low socioeconomic status (SES) in adulthood and low SES across the lifecourse. To better capture socioeconomic condition in childhood, recent research in lifecourse epidemiology has broadened the notion of SES to include the experience of specific hardships. In this study we investigate the association among childhood financial hardship, lifetime earnings, and multimorbidity.

METHODS

Cross-sectional analysis of 7,305 participants age 50 and older from the 2004 Health and Retirement Study (HRS) who also gave permission for their HRS records to be linked to their Social Security Records in the United States. Zero-inflated Poisson regression models were used to simultaneously model the likelihood of the absence of morbidity and the expected number of chronic conditions.

RESULTS

Childhood financial hardship and lifetime earnings were not associated with the absence of morbidity. However, childhood financial hardship was associated with an 8% higher number of chronic conditions; and, an increase in lifetime earnings, operationalized as average annual earnings during young and middle adulthood, was associated with a 5% lower number of chronic conditions reported. We also found a significant interaction between childhood financial hardship and lifetime earnings on multimorbidity.

CONCLUSIONS

This study shows that childhood financial hardship and lifetime earnings are associated with multimorbidity, but not associated with the absence of morbidity. Lifetime earnings modified the association between childhood financial hardship and multimorbidity suggesting that this association is differentially influential depending on earnings across young and middle adulthood. Further research is needed to elucidate lifecourse socioeconomic pathways associated with the absence of morbidity and the presence of multimorbidity among older adults.

Determinants of infant growth: Evidence from Hong Kong's "Children of 1997" birth cohort

PURPOSE

A high rate of infant growth may be associated with adult cardiovascular disease. We investigated factors associated with infant weight growth in a large sample from the recently transitioned population of Hong Kong.

METHODS

We used a nonlinear shape invariant model with random effects among 5949 term, singletons (77% follow-up) from a population-representative Hong Kong Chinese birth cohort "Children of 1997" to investigate factors associated with weight growth in the first year of life.

RESULTS

Overall birth weight was lower but infant growth was more rapid than the 2006 WHO standards. Shorter gestation and lower birth order were associated with lower birth weight and faster infant growth. Female sex, maternal smoking in pregnancy, and a mother born in Hong Kong were associated with lower birth weight, but not with faster growth. Higher maternal education was associated with faster infant growth, grades 10-11 (1.03, 95% confidence interval [CI] = 1.03-1.05), greater than or equal to grade12 (1.07, CI = 1.04-1.09) compared with less than or equal to grade 9.

CONCLUSIONS

Infant growth may respond more rapidly to socio-economic development than birth weight. Whether mother's education is associated with rapid infant growth via current conditions or her own "constitution" is unclear, nevertheless we believe this study illustrates the importance of contextually specific research for understanding the determinants of population health.

Coronary heart disease from a life-course approach: findings from the health and retirement study, 1998-2004

OBJECTIVE

Guided by a life-course approach to chronic disease, this study examined the ways in which childhood deprivation (low parental education and father's manual occupation) may be associated with coronary heart disease (CHD).

METHOD

Multilevel modeling techniques and a nationally representative sample of Americans above age 50 from the Health and Retirement Study (HRS; N = 18,465) were used to examine childhood and CHD relationships over the course of 6 years (1998-2004).

RESULTS

Having a father with </=8 years of education was associated with 11% higher odds of CHD, accounting for demographic characteristics, adult socioeconomic status (SES; education, income, and wealth), CHD risks (diabetes, hypertension, cigarette smoking, and obesity), and other factors (childhood health, exercise, stroke, and marital status).

DISCUSSION

Policies and programs aimed at improving the conditions of poor children and their families may effectively reduce the prevalence of CHD in later life.

Social origins, early hardship and obesity: a strong association in women, but not in men?

This study investigates the relation between early life conditions and adult obesity in France, using a rich data set collected through the 2003 nationally representative Life History Survey. No salient factor emerged in men, while in women, after controlling for current socio-demographic characteristics, a relation was found between obesity and the following factors: father's occupation (OR=3.2 for women whose father was a clerical worker, versus those whose father was in a higher-level occupation); experience of economic hardship in childhood (OR=2.0), and; high parity (OR=2.1 for parities of more than 3 versus parity of 1). Neither early family history nor mother's working status surfaced as significant factors. Those findings highlight a definite gender pattern, with a strong association between early disadvantage and obesity in women, but not in men. Potential mechanisms are discussed, particularly the "habitus", the "thrifty phenotype" and the "feast-famine" hypotheses, and possible interactions with childbearing and motherhood. An integration of social and biological perspectives is needed to reach a better understanding of the processes involved, and to achieve progress in primary and secondary prevention.

Early childhood poverty and adult body mass index

OBJECTIVES

We estimated associations between poverty in early, middle, and later childhood and adult body mass index to further elucidate the effects of socioeconomic status on health.

METHODS

We conducted secondary analyses of data from men and women (N = 885) born between 1968 and 1975 who were tracked between their prenatal and birth years and adulthood in the nationally representative Panel Study of Income Dynamics. We used multivariate regression techniques and spline models to estimate the relationship between income in different stages of childhood and adult body mass index, overweight, and obesity. We controlled for other family characteristics, including income in other periods of childhood.

RESULTS

Mean annual family income in the prenatal and birth years for children whose annual family incomes averaged less than $25,000 was significantly associated with increased adult body mass index, but mean annual family income between 1 and 5 years of age and between 6 and 15 years of age was not.

CONCLUSIONS

Our results indicated that economic conditions in the earliest period of life (during the prenatal and birth years) may play an important role in eventual anthropometric measures.

Childhood socioeconomic position, gender, adult body mass index, and incidence of type 2 diabetes mellitus over 34 years in the Alameda County Study

OBJECTIVES

We examined the association between childhood socioeconomic position and incidence of type 2 diabetes and the effects of gender and adult body mass index (BMI).

METHODS

We studied 5913 participants in the Alameda County Study from 1965 to 1999 who were diabetes free at baseline (1965). Cox proportional hazards models estimated diabetes risk associated with childhood socioeconomic position and combined childhood socioeconomic position-adult BMI categories in pooled and gender-stratified samples. Demographic confounders and potential pathway components (physical inactivity, smoking, alcohol consumption, hypertension, depression, health care access) were included as covariates.

RESULTS

Low childhood socioeconomic position was associated with excess diabetes risk, especially among women. Race and body composition accounted for some of this excess risk. The association between childhood socioeconomic position and diabetes incidence differed by adult BMI category in the pooled and women-only groups. Adjustment for race and behaviors attenuated the risk attributable to low childhood socioeconomic position among the obese group only.

CONCLUSIONS

Childhood socioeconomic position was a robust predictor of incident diabetes, especially among women. A cumulative risk effect was observed for both childhood socioeconomic position and adult BMI, especially among women.

Childhood poverty and health: cumulative risk exposure and stress dysregulation

A massive literature documents the inverse association between poverty or low socioeconomic status and health, but little is known about the mechanisms underlying this robust relation. We examined longitudinal relations between duration of poverty exposure since birth, cumulative risk exposure, and physiological stress in two hundred seven 13-year-olds. Chronic stress was assessed by basal blood pressure and overnight cortisol levels; stress regulation was assessed by cardiovascular reactivity to a standard acute stressor and recovery after exposure to this stressor. Cumulative risk exposure was measured by multiple physical (e.g., substandard housing) and social (e.g., family turmoil) risk factors. The greater the number of years spent living in poverty, the more elevated was overnight cortisol and the more dysregulated was the cardiovascular response (i.e., muted reactivity). Cardiovascular recovery was not affected by duration of poverty exposure. Unlike the duration of poverty exposure, concurrent poverty (i.e., during adolescence) did not affect these physiological stress outcomes. The effects of childhood poverty on stress dysregulation are largely explained by cumulative risk exposure accompanying childhood poverty.

Obstetrician-assessed maternal health at pregnancy predicts offspring future health

BACKGROUND

We aimed to examine the association between obstetrician assessment of maternal physical health at the time of pregnancy and offspring cardiovascular disease risk.

METHODS AND PRINCIPAL FINDINGS

We examined this association in a birth cohort of 11,106 individuals, with 245,000 person years of follow-up. We were concerned that any associations might be explained by residual confounding, particularly by family socioeconomic position. In order to explore this we used multivariable regression models in which we adjusted for a range of indicators of socioeconomic position and we explored the specificity of the association. Specificity of association was explored by examining associations with other health related outcomes. Maternal physical health was associated with cardiovascular disease: adjusted (socioeconomic position, complications of pregnancy, birthweight and childhood growth at mean age 5) hazard ratio comparing those described as having poor or very poor health at the time of pregnancy to those with good or very good health was 1.55 (95%CI: 1.05, 2.28) for coronary heart disease, 1.91 (95%CI: 0.99, 3.67) for stroke and 1.57 (95%CI: 1.13, 2.18) for either coronary heart disease or stroke. However, this association was not specific. There were strong associations for other outcomes that are known to be related to socioeconomic position (3.61 (95%CI: 1.04, 12.55) for lung cancer and 1.28 (95%CI:1.03, 1.58) for unintentional injury), but not for breast cancer (1.10 (95%CI:0.48, 2.53)).

CONCLUSIONS AND SIGNIFICANCE

These findings demonstrate that a simple assessment of physical health (based on the appearance of eyes, skin, hair and teeth) of mothers at the time of pregnancy is a strong indicator of the future health risk of their offspring for common conditions that are associated with poor socioeconomic position and unhealthy behaviours. They do not support a specific biological link between maternal health across her life course and future risk of cardiovascular disease in her offspring.

The association of life course socio-economic position with diagnosis, treatment, control and survival of women with diabetes: findings from the British Women's Heart and Health Study

OBJECTIVES

To examine the association of socio-economic position (SEP) with the diagnosis, treatment and control of diabetes, and with survival in women with and without Type 2 diabetes.

METHODS

Prospective cohort study of 4277 women from 23 centres in Great Britain, aged 60-79 years at baseline.

RESULTS

Of the 4277 women, 220 (5.1%) were known to have Type 2 diabetes and a similar number [n = 188 (4.4%)] had undiagnosed diabetes based on a single fasting glucose level > or = 7.0 mmol/l. Neither childhood nor adult SEP was associated with being correctly diagnosed amongst the 408 women with either diagnosed or undiagnosed diabetes. In both women with and without diabetes, SEP was associated with more adverse levels of fasting insulin, triglycerides, high-density lipoprotein cholesterol and body mass index, but was not associated with glycated haemoglobin in either group. Over the follow-up period, 395 women died. The hazard ratio for all-cause mortality per additional indicator of adverse SEP in adulthood in women with diabetes [1.40 (1.05, 1.85)] was similar to that in women without diabetes [1.26 (1.12, 1.41], P for difference in the two estimates = 0.70). Childhood SEP was not associated with survival.

CONCLUSION/INTERPRETATION

A considerable number of older women with Type 2 diabetes are not diagnosed, but SEP is not related to being correctly diagnosed. The marked socio-economic gradient for all-cause mortality is the same for women with and without diabetes and is not fully explained by conventional risk factors.

Does the new International Diabetes Federation definition of the metabolic syndrome predict CHD any more strongly than older definitions? Findings from the British Women's Heart and Health Study

AIMS/HYPOTHESIS

We compared the associations between three definitions of the metabolic syndrome and CHD risk. The definitions studied were the new International Diabetes Federation (IDF) definition, and those of the World Health Organization (WHO) and the National Cholesterol Education Programme (NCEP). Our aim was to determine whether the magnitudes of the associations for any of the syndrome definitions are greater than for the individual components.

MATERIALS AND METHODS

A prospective cohort study of a random sample of 3,589 British women who were aged 60-79 years and free of CHD at baseline was performed. Among these women there were 194 incident cases of CHD (40 of them fatal) during 15,778 woman-years of follow-up.

RESULTS

Insulin resistance (homeostasis model assessment), triglyceride levels, systolic blood pressure, waist and waist-to-hip ratio were positively and linearly associated with CHD risk; HDL cholesterol was inversely associated with risk. All three definitions of the metabolic syndrome were modestly and similarly (to each other) associated with CHD risk. The age-adjusted hazard ratio (95% CI) was 1.32 (1.03, 1.70) for IDF syndrome, 1.45 (1.00, 2.10) for WHO syndrome, and 1.38 (1.00, 1.93) for NCEP syndrome. Adjustment for smoking, inactivity and life-course socioeconomic position resulted in attenuation of these associations to 1.25 (0.96, 1.61), 1.31 (0.90, 1.90) and 1.27 (0.90, 1.79), respectively. The magnitudes of the associations for individual components of the syndrome were similar to those for any of the syndrome definitions. CONCLUSIONS/ INTERPRETATION: The metabolic syndrome, defined by any of the three methods, is only modestly associated with CHD risk in this study of older women. Life-course socioeconomic position appears to be an important confounder in the association of the metabolic syndrome with CHD risk.