Neighborhood socioeconomic environment and incidence of coronary heart disease: a follow-up study of 25,319 women and men in Sweden

In this study, the authors examined whether neighborhood socioeconomic environment predicted incident coronary heart disease after adjustment for individual-level characteristics. A random sample of the Swedish population (25,319 women and men aged 35-74 years) was interviewed between 1986 and 1993 and was followed through December 1997 for incident coronary heart disease (1,189 events). Neighborhood socioeconomic environment was defined by small-area market statistics (6,145 neighborhoods) and measured by two indicators: neighborhood education (proportion of people with less than 10 years of education in the neighborhood) and neighborhood income (proportion of people with incomes in the lowest national income quartile). Separate multilevel Cox proportional hazards models showed that low neighborhood education and low neighborhood income each predicted incident coronary heart disease after adjustment for age, sex, and individual-level education and income (hazard ratios were 1.25 and 1.23, respectively). The authors conclude that neighborhood socioeconomic environment predicts incident coronary heart disease, having a significant effect on coronary heart disease risk beyond the individual effect.     

Neighbourhood income and mental health: a multilevel follow-up study of psychiatric hospital admissions among 4.5 million women and men

This multilevel study followed 4.5 million Swedish women and men from 1 January 1998 until 31 December 1999 in order to examine the association between neighbourhood income (defined as proportions of individuals with low income) and psychiatric hospital admissions. Individuals living in the poorest neighbourhoods exhibited a statistically significantly higher risk of being hospitalised for mental disorder than individuals living in the richest neighbourhoods, after adjustment for individual demographic and socioeconomic characteristics. The neighbourhood variance indicated statistically significant differences in psychiatric hospital admissions between neighbourhoods. Both individuals and neighbourhoods need to be targeted in order to enhance mental health in low-income neighbourhoods.     

Social participation and coronary heart disease: a follow-up study of 6900 women and men in Sweden

Few studies have examined the relationship between social, cultural and religious participation, political empowerment and coronary heart disease (CHD). The aim of this study was to examine whether low social participation, as described in a social participation index, predicted incidence rates of CHD. This is a follow-up study, from 1990-91 to 31 December 2000, of 6861 Swedish women and men, who were interviewed about their social participation, education, housing tenure and smoking habits. A social participation index was constructed, based on 18 variables from the survey. The outcome measure was CHD morbidity and mortality. Respondents with a CHD incident from 1986 until interview were excluded from the study. Data were analysed using Cox' regression and the results are presented as hazard ratios (HR) with 95% confidence intervals (CI). In the sex- and age-adjusted model there was a gradient between the social participation index and CHD, so that persons with low social participation had the highest risk of CHD with HR=2.15; CI=1.57-2.94, followed by HR=1.67; CI=1.23-2.27 for those with middle social participation. In the full model, when education, housing tenure and smoking habits were included, the increased risk of CHD for persons with low social participation remained high, with HR=1.69, CI=1.21-2.37.We conclude that persons with low social participation in the social participation index exhibited an increased risk of CHD that remained after adjustment for education, housing tenure and smoking habits.     

Neighbourhood non-employment and daily smoking: a population-based study of women and men in Sweden

BACKGROUND: To examine whether neighbourhood non-employment is associated with daily smoking after adjustment for individual characteristics, such as employment status. METHODS: Cross-sectional study of a simple, random sample of 31,164 women and men aged 25-64, representative of the entire population in Sweden. Data were collected from the years 1993-2000. The individual variables included age, sex, employment status, occupation and housing tenure. Logistic regression was used in the analysis with neighbourhood non-employment rates measured at small area market statistics level. RESULTS: There was a significant association between neighbourhood non-employment rates and daily smoking for both women and men. After adjustment for employment status and housing tenure the odds ratios of daily smoking were 1.39 (95% CI = 1.22-1.58) for women and 1.41 (95% CI = 1.23-1.61) for men living in neighbourhoods with the highest non-employment rates. The individual variables of unemployment, low occupational level and renting were associated with daily smoking. CONCLUSION: Neighbourhood non-employment is associated with daily smoking. Smoking prevention in primary health care should address both individuals and neighbourhoods.     

Psychosocial determinants of coronary heart disease in middle-aged women: a prospective study in Sweden

A social gradient in coronary heart disease (CHD) has been documented in a variety of settings, predominantly among men. This study aimed to establish whether a social gradient in CHD existed in a group of Swedish women and whether it could be explained by established coronary risk factors or psychosocial factors. The Women's Lifestyle and Health Cohort Study includes 49,259 women from Sweden aged 30-50 years at baseline (1991-1992), when an extensive questionnaire was completed. There was complete follow-up through linkages to national registries until the end of 2002, during which time 210 cases of incident fatal CHD or nonfatal myocardial infarction occurred. Risk of CHD was significantly inversely related to years of education, the socioeconomic status proxy (hazard ratio comparing the lowest with the highest education group = 3.3, 95% confidence interval: 2.2, 4.7). This association was reduced after adjustment for established coronary risk factors (smoking, body mass index, alcohol consumption, diabetes, hypertension, exercise; hazard ratio = 1.9, 95% confidence interval: 1.3, 2.8). Job strain and social support were weakly related to CHD and did not explain the gradient by years of education. Self-rated health was strongly related to CHD, mediated by established coronary risk factors. Results show a strong gradient in CHD by years of education explained by established coronary risk factors but not by job strain or social support.     

Low linking social capital as a predictor of coronary heart disease in Sweden: a cohort study of 2.8 million people

This study investigated the association between the recently minted concept of linking social capital and incidence of coronary heart disease (CHD). A follow-up study of 1,358,932 men and 1,446,747 women in Sweden aged 45-74 years was conducted between 1 January 1998 and 31 December 1999. Neighbourhood linking social capital was conceptualised as proportions of individuals voting in local government elections at neighbourhood level. The neighbourhood- and individual-level factors were analysed within a multilevel framework. Linking social capital was associated with CHD in both men and women beyond individual-level factors: in neighbourhoods with low linking social capital the odds ratios were 1.19 (CI = 1.14-1.24) and 1.29 (CI = 1.21-1.38) for men and women, respectively, after adjustment for age, country of birth, education, marital status, and housing tenure. The significant between-neighbourhood variance (i.e. the random intercept) showed significant differences in CHD incidence between neighbourhoods. Even in a relatively egalitarian society, as exemplified by the Swedish Welfare State, individual health is affected by differences between neighbourhoods in linking social capital. The use of linking social capital represents a novel conceptual advance in research on the association between CHD, one of the major causes of death in Western countries, and the multidimensional aspects of social capital.     

Socioeconomic inequalities in coronary heart disease in Italy: a multilevel population-based study

This longitudinal study evaluates the role of individual and contextual socioeconomic determinants in the socioeconomic inequalities in incidence and mortality for coronary events in Turin, Italy, using hierarchical models. All residents aged 35-74 at the start of 1997 were included in the study population. We considered as outcomes all incident cases and deaths that occurred in the study population in the period 1997-2002. The socioeconomic indicators were educational level, job status and median income per census tract. A neighbourhood deprivation index was also used, which combines, in an aggregated measure, a series of poor individual socioeconomic conditions. The analyses were performed using hierarchical Poisson models, with individuals (n = 523,755) considered as level I units and neighbourhoods (n = 23) as level II units. Among men, we observed an inverse gradient in incidence by educational level and an excess risk for persons who were not actively employed. More marked excesses were found for mortality (RR: 1.63; 95% CI: 1.05-2.55, for unemployed persons compared to employed persons). Among women, greater socioeconomic differences were observed for both incidence and mortality; all of the individual indicators contributed to these differences. The differentials in mortality were particularly great for the retired and for housewives (RR: 1.98; 95% CI: 1.40-2.81). Slight excesses in incidence were observed among men for the most deprived areas. The results of this study reveal that job status is the most important individual factor explaining socioeconomic inequalities for coronary events, whereas context seems to play a marginal role.     

Linking social capital and self-rated health: a multilevel analysis of 11,175 men and women in Sweden

This multilevel study included 11,175 participants interviewed 2000-2002 in Sweden. The association between neighbourhood linking social capital (voting in national elections) and self-rated health was analysed. Individuals living in neighbourhoods with the lowest levels of linking social capital exhibited a significantly higher risk of poor health than individuals living in neighbourhoods with the highest levels of linking social capital, after adjustment for individual characteristics, including individual voting. The neighbourhood variance indicated significant differences in self-rated health between neighbourhoods. Both individuals and neighbourhoods need to be targeted in order to enhance people's health in neighbourhoods with low linking social capital.     

Income differences in mortality: a register-based follow-up study of three million men and women

OBJECTIVES: We analyse whether the relationship between net household income and mortality form a continuous linear gradient or is curvilinear, assess the attenuation of this association after adjusting for confounding and reverse causality, and assess the strength of the association by age and cause of death. DESIGN AND SETTING: Prospective study of mortality in Finland among all men and women over 30 years old. Information on household income and sociodemographic factors was from the records of the Finnish tax authorities and the 1990 census. Income data were available for more than 95% of the cohort. Follow-up was by record linkage to death certificates in 1991-1996; altogether about 261 000 deaths. RESULTS: The all-cause mortality ratio between the lowest and the highest household income decile is 2.37 (95% CI : 2.30-2.44) among men and 1.73 (95% CI : 1.67-1.80) among women. Adjusting for household structure, spouse's economic activity, social class, education and own economic activity attenuates the relationship by 61% among men and 52% among women. The association between income and mortality is mainly linear before and after adjusting for confounding, and the association is strong for all 5-year age groups below 60-64 years, after which it declines rapidly in strength. CONCLUSIONS: The mainly linear nature of the relationship and the strong attenuation after adjustment for other socioeconomic factors and economic activity status, and the age pattern of the relationship indicate that a large part of the relationship is unlikely to be due to direct causal effects of poverty and material hardship. Rather, income seems to be related to accumulation of factors that increase mortality over the whole range of incomes.     

Body mass index, waist circumference, and risk of coronary heart disease: a prospective study among men and women

OBJECTIVE: The purpose of the study was to assess the risk of CHD associated with excess weight measured by BMI and waist circumference (WC) in two large cohorts of men and women. DESIGN, SETTING, SUBJECTS: Participants in two prospective cohort studies, the Health Professionals Follow-up Study (N = 27,859 men; age range 39-75 years) and the Nurses' Health Study (N = 41,534 women; 39-65 years) underwent 16-year follow-up through 2004. RESULTS: 1,823 incident cases of CHD among men and 1,173 cases among women were documented. Compared to men with BMI 18.5 to 22.9 kg/m2, those with a BMI > 30.0 kg/m2 had a multivariate-adjusted RR of CHD of 1.81 (95% CI 1.48 - 2.22). Among women, those with a BMI > 30.0 kg/m2 had a RR of CHD of 2.16 (95% CI 1.81 - 2.58). Compared to men with a WC < 84.0 cm, those with WC of greater than 102.0 cm had a RR of 2.25 (95% CI 1.77 - 2.84). Among women, the RR of CHD was 2.75 (95% CI 2.20 - 3.45) for those with WC of greater than 88.0 cm. CONCLUSIONS: In these analyses from two large ongoing prospective cohort studies, both BMI and WC strongly predicted future risk of CHD. Furthermore, WC thresholds as low as 84.0 cm in men and 71.0 cm in women may be useful in identifying those at increased risk of developing CHD. The findings have broad implications in terms of CHD risk assessment in both clinical practice and epidemiologic studies.     

Disability predicted mortality in men but not women with coronary heart disease

OBJECTIVE: Disability increases mortality in patients with myocardial infarction in acute clinical settings, but the impact of disability on mortality in persons with coronary heart disease (CHD) at the population level is largely unknown. STUDY DESIGN AND SETTING: We assessed disability as a predictor of mortality among 4,501 men and women aged 45 and over in a national sample of the Finnish population, examined in 1978-1980. RESULTS: During follow-up until the end of 1994, 897 men and 846 women died. Disability was related to increased all-cause and CHD mortality after adjustment for cardiovascular risk factors in men regardless of baseline CHD status. In women with CHD at baseline, disability was not related to excess mortality, although disability predicted mortality in women without baseline CHD. CONCLUSION: Disability predicts mortality in men with CHD, but not in women. This may reflect a gender difference in the nature of CHD, but these findings need to be verified in other large-scale population studies.     

White blood cell count and incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in African-American and White men and women: atherosclerosis risk in communities study

The authors examined the association between white blood cell (WBC) count and incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in 13,555 African-American and White men and women from the Atherosclerosis Risk in Communities (ARIC) Study. Blood was drawn at the ARIC baseline examination, beginning in 1987-1989. During an average of 8 years of follow-up (through December 1996), there were 488 incident coronary heart disease events, 220 incident strokes, and 258 deaths from cardiovascular disease. After adjustment for age, sex, ARIC field center, and multiple risk factors, there was a direct association between WBC count and incidence of coronary heart disease (p < 0.001 for trend) and stroke (p for trend < 0.001) and mortality from cardiovascular disease (p for trend < 0.001) in African Americans. The African Americans in the highest quartile of WBC count (> or =7,000 cells/mm(3)) had 1.9 times the risk of incident coronary heart disease (95% confidence interval (CI): 1.19, 3.09), 1.9 times the risk of incident ischemic stroke (95% CI: 1.03, 3.34), and 2.3 times the risk of cardiovascular disease mortality (95% CI: 1.38, 3.72) as their counterparts in the lowest quartile of WBC count (<4,800 cells/mm(3)). These associations were similar in Whites and in never smokers. An elevated WBC count is directly associated with increased incidence of coronary heart disease and ischemic stroke and mortality from cardiovascular disease in African-American and White men and women.     

Serum triglycerides and risk of coronary heart disease among Japanese men and women

To examine the relation of triglycerides with coronary heart disease among populations with low mean total cholesterol, the authors conducted a 15.5-year prospective study ending in 1997 of 11,068 Japanese aged 40-69 years (4,452 men and 6,616 women with mean total cholesterol = 4.73 mmol/liter and 5.03 mmol/liter, respectively), initially free of coronary heart disease or stroke. There were 236 coronary heart disease events comprising 133 myocardial infarctions, 68 angina pectoris events, and 44 sudden cardiac deaths. The coronary heart disease incidence was greater in a dose-response manner across increasing quartiles of nonfasting triglycerides for both sexes. The multivariate relative risk of coronary heart disease adjusting for coronary risk factors and time since last meal associated with a 1-mmol/liter increase in triglycerides was 1.29 (95% confidence interval (CI): 1.09, 1.53; p = 0.004) for men and 1.42 (95% CI: 1.15, 1.75; p = 0.001) for women. The trend was similar for myocardial infarction, angina pectoris, and sudden cardiac death. The relation of triglycerides with coronary heart disease was not influenced materially by total cholesterol levels or, in a subsample analysis (51% of total sample), by high density lipoprotein cholesterol levels. Nonfasting serum triglycerides predict the incidence of coronary heart disease among Japanese men and women who possess low mean values of total cholesterol. Further adjustment for high density lipoprotein cholesterol suggests an independent role of triglycerides on the coronary heart disease risk.     

Childhood cultural experience and the incidence of coronary heart disease in Hawaii Japanese men.

Possible effects of cultural variables on the risk of coronary heart disease (CHD) were examined in 7705 men of Japanese ancestry living in Hawaii. The six-year incidence of CHD was related to birthplace (Japan or elsewhere), number of years spent in Japan, ability to read and write Japanese, ability to speak Japanese, and to an index of preference for a traditional Japanese diet. Statistically significant inverse relationships were found between CHD incidence and all of these variables which reflect the degree of exposure to Japanese culture during childhood. In multivariate analyses where the major CHD risk factors were taken into account, years spent in Japan and ability to read and write Japanese remained significant. Hence, exposure to Japanese culture during childhood appears to protect against CHD in adulthood. This may explain, in part, the gradient of CHD frequency among Japanese in Japan, Japanese-Americans, and Caucasians that could not be entirely attributed to the established risk factors.     

Alcohol consumption, diet, coronary risk factors, and prevalent coronary heart disease in men and women in the Scottish heart health study.

STUDY OBJECTIVE--To measure the relationship between reported alcohol consumption and prevalent diagnosed and undiagnosed coronary heart disease (CHD) in men and women to see how much could be explained by covariation with diet, lifestyle, and biomedical factors. DESIGN AND SETTING--This was a cross sectional, random population survey covering 22 districts of Scotland and using general practitioner patient lists as the sampling frame. Odds ratios for prevalent CHD at different levels of alcohol consumption taken from a seven day recall were analysed. These ratios were then adjusted for lifestyle and biomedical factors. PARTICIPANTS--Male and female responders aged 40-59 years who completed the survey questionnaire and attended the survey clinic. MAIN RESULTS--The participation rate of those invited was 74%. Of the 10,359 responders, 658 were excluded because of missing alcohol data or ambiguous cardiovascular status. The questionnaire was used to designate 7058 drinkers and 2643 non-drinkers, who were then classified as having diagnosed or undiagnosed CHD, or who were controls. The prevalence of diagnosed CHD decreased with increasing alcohol consumption while undiagnosed CHD had a "U" shaped relationship. Patterns were similar in men and women if allowance was made for the lower alcohol consumption in women. Adjustment for several diet and lifestyle factors and for additional biomedical factors reduced the apparent protective effect of alcohol, leaving a modest but statistically insignificant (p > 0.05) reduction in CHD prevalence among light to moderate consumers compared with those who drank no alcohol. Wine drinkers seemed to be at lower risk than beer drinkers in both sexes. CONCLUSIONS--These results tend to confirm that intermediate alcohol consumption is a component and contributor to a low coronary risk lifestyle. Its effects are largely explained by adjusting for both confounding lifestyle associations and for biomedical effects but the remaining effect, and the lower risk with wine drinking compared with beer, are intriguing. Advice on alcohol habits should not be determined solely by the moderate apparent benefit to risk of CHD, however, as other disease risks cannot be ignored.     

Neighborhood violent crime and unemployment increase the risk of coronary heart disease: a multilevel study in an urban setting

Little is known about the association between neighborhood social disorganization and coronary heart disease (CHD). This study used the theoretical frameworks of the Chicago school and the Stirling County group in order to analyze the impact of neighborhood violent crime and neighborhood unemployment on CHD in an urban setting, the capital of Sweden. The entire population of Stockholm County aged 35-64 years on January 1, 1998 was included in the study. All individuals were followed for CHD until December 31, 1998. Small area neighborhood units were used to define neighborhoods. The neighborhood-level variables were calculated as rates of violent crime or unemployment in the small area neighborhood units, categorized in quintiles. Multilevel logistic regression was used to estimate odds ratios and neighborhood-level variance in three different models. When rates of neighborhood violent crime or neighborhood unemployment increased, the risk of CHD increased among both women and men. In neighborhoods with the highest rates of violent crime (quintile 5), the odds ratios were 1.75 (CI=1.37-2.22) and 1.39 (CI=1.19-1.63) for women and men, respectively. In neighborhoods with the highest unemployment rates, the corresponding odds ratios were 2.05 (CI=1.62-2.59) and 1.50 (CI=1.28-1.75). These average neighborhood effects on CHD (fixed effects) remained almost unaltered after inclusion of the individual-level variables. The neighborhood-level variance indicated significant differences in CHD between neighborhoods, and the neighborhood-level and individual-level variables partly explained the variance between neighborhoods (random effects). Public safety and social stability in socially disorganized neighborhoods need to be improved in order to promote cardiovascular health.     

Coronary artery calcium score and coronary heart disease events in a large cohort of asymptomatic men and women

Coronary artery calcium (CAC), a measure of subclinical coronary heart disease (CHD), may be useful in identifying asymptomatic persons at risk of CHD events. The current study included 10,746 adults who were 22-96 years of age, were free of known CHD, and had their CAC quantified by electron-beam tomography at baseline as part of a preventive medical examination at the Cooper Clinic (Dallas, Texas) during 1995-2000. During a mean follow-up of 3.5 years, 81 hard events (CHD death, nonfatal myocardial infarction) and 287 total events (hard events plus coronary revascularization) occurred. Age-adjusted rates (per 1,000 person-years) of hard events were computed according to four CAC categories: no detectable CAC and incremental sex-specific thirds of detectable CAC; these rates were, respectively, 0.4, 1.5, 4.8, and 8.7 (trend p<0.0001) for men and 0.7, 2.3, 3.1, and 6.3 (trend p=0.02) for women. CAC levels also were positively associated with rates of total CHD events for women and men (trend p<0.0001 each). The association between CAC and CHD events remained significant after adjustment for CHD risk factors. CAC was associated with CHD events in persons with no baseline CHD risk factors and in younger (aged <40 years) and older (aged >65 years) study participants. These findings show that CAC is associated with an increased risk of CHD events in asymptomatic women and men.