Contesting lifestyle risk and gendering coronary candidacy: lay epidemiology of heart disease in Finland in the 1970s

This study addresses two issues currently under critical discussion in the epidemiology of cardiovascular diseases (CVD), the relative neglect of women and the individualised nature of key risk factors. It focuses on the North Karelia project (NKP), a community programme aimed at coronary heart disease (CHD) prevention in a predominantly rural Finnish region in the early 1970s, that is, during a period when the epidemiological understanding of CVD still was relatively new and actively promoted. Adopting the notions of lay epidemiology and coronary candidacy, culturally mediated explanatory models lay people use to assess who is likely to develop heart disease and why, the study shows that locals targeted by the project critically engaged with both of these bias. Based on the rich materials resulting from project activities the study shows, first, how many locals subsumed the individualised and lifestyle‐based approach to CHD prevention promoted by NKP under a more general framework emphasising the health effects of ongoing structural changes in the area, and second, how women constructed themselves as viable coronary candidates. The case supports the position in the current discussions on lay expertise that wants to integrate lay experiences more firmly into epidemiological studies and public health.     

Strategies of prevention revisited: effects of imprecise measurement of risk factors on the evaluation of "high-risk" and "population-based" approaches to prevention of cardiovascular disease

Imprecise measurement of risk factors causes misclassification of individuals, limits sensitivity to detect those with high true levels, and dilutes associations between risk factors and disease. The implications of these effects for two particular examples were explored using data from a large prospective study relating plasma cholesterol to coronary heart disease (CHD) mortality and diastolic blood pressure (DBP) to fatal stroke. The absolute and relative effectiveness of three "high-risk" strategies of screening and treatment and a "population-based" shift in the risk factor distribution were compared, assuming different degrees of measurement error. The absolute benefits of each strategy were greater than suggested by unadjusted estimates from survey data. For cholesterol and CHD (a linear relationship in this cohort), uncorrected estimates tended to exaggerate the effectiveness of "high-risk" strategies relative to the "population-based" approach. For DBP and stroke (an exponential relationship), the relative effectiveness of screening and treatment was underestimated if no allowance was made for measurement error. These findings are strictly applicable only to the middle-aged men from whom they were derived, but the effects of misclassification and regression dilution need to be considered in any assessment of preventive strategies.     

In search of the cancer candidate: can lay epidemiology help?

First published in 1991, the ideas embedded in ‘Lay epidemiology and the prevention paradox’ offered a novel and rational explanation for the lay public’s failure to fully engage with the lifestyle messages offered by health educators. During the course of a large ethnographic study in South Wales, Davison and colleagues described the emergence of what they termed the coronary candidate. Candidacy provides a ‘cultural mechanism’ that facilitates the estimation of risk for coronary heart disease. The model has rarely been applied to other major illnesses. This article presents findings from a study that sought to explore the lay epidemiology model, candidacy and cancer. In a series of in‐depth individual interviews, members of the lay public discussed their ideas about cancer, and what emerged was an explanatory hierarchy to account for cancer events. Yet the random and unpredictable nature of cancer was emphasised as well as a general reluctance to accept the idea of cancer candidacy.     

Collective memory, candidacy, and victimisation: community epidemiologies of breast cancer risk

Collectively shared ideas of community may be equally relevant for the study of health disparities as quantifying the relationship between community structures and health. Data from focus groups (N = 18) that explored understandings of breast cancer and breast cancer risk in African American neighbourhoods revealed three conceptual domains where shared ideas of community informed responses: collective memory, community candidacy, and community victimisation by external aggressors. Reading the focus group responses in terms of these domains identified perceptions of risk and of candidacy that may be overlooked by individualised or quantitative approaches to studying breast cancer risk perceptions and related behaviours. These include novel perceived risks, such as the 'risk of knowing', as well as community-level constructions of breast cancer candidacy. 'Lay epidemiologies' of breast cancer within this population might therefore be better understood as 'community epidemiologies', where community is central to the interpretation and operationalisation of breast cancer risk. Paying attention to such community epidemiologies of breast cancer provides theoretical insights for studying breast cancer disparities and risk perceptions as well as useful guidance for designing interventions.     

Beyond beliefs: risk assessment technologies shaping patients' experiences of heart disease prevention

Social science research on lifestyle-related diseases typically focuses on patients' understandings and beliefs and takes the clinical risk for granted. We interviewed 30 healthy UK patients at high risk of heart disease, recruited from a family history trial at 2 weeks and 6 months after a discussion with a clinician about their risk, lifestyle and medications. The participants took four different paths: (i) pharmaceutical (most common, risk reduction with cholesterol lowering statins), (ii) mixed (statins and behaviour change), (iii) behavioural (behaviour change, focus on wellbeing) and (iv) 'lost' (no prevention, difficult social/personal circumstances). Drawing on Berg we argue that coronary heart disease (CHD) risk assessment technologies are formal tools that generate, rather than represent, high risk in a way that patients often experience lifestyle change as futile, because it rarely reduces their cholesterol to targets defined by the tools. We suggest social scientists studying incipient or 'proto-diseases', such as CHD risk, should not only focus on understandings but also investigate the technologies (and the associated guidelines, policies, clinical practice and pharmaceutical industry operations) that generate incipient diseases and patients' experiences of them. However, technologies do not determine experience and we also discuss elements that direct patients down other than the pharmaceutical path.     

Contextualising lifestyles: how socially contrasting places in Fife,Scotland influence lay understandings of lifestyle and health behaviours in relation to coronary heart disease

Coronary heart disease (CHD) is a significant public health issue showing persistent geographical health inequalities. However, little attention has focussed on lay perspectives of how contrasting social contexts influence lifestyles and health behaviour in relation to CHD. The aim of this qualitative study is to explore lay perspectives of lifestyle and behaviour in socioeconomically contrasting places, with women and men who had survived a heart attack in Fife, Scotland. This study contributes to knowledge on CHD health inequalities and health promotion, particularly cardiac rehabilitation, emphasising the importance of situating experiences and understandings of health, geographically.     

Framingham study data and "established wisdom" about cigarette smoking and coronary heart disease

With the Framingham Heart Study widely recognized as the most comprehensive, sustained investigation of the precursors of coronary heart disease (CHD), an examination was made of its manifold published data on the relationship of cigarette smoking to CHD and the results were compared with the "conventional wisdom" about cigarette smoking and CHD as projected by the Surgeon General. The analysis of data in the Framingham Heart Study shows that its results are inconsistent with the Surgeon General's views about cigarette smoking and coronary heart disease. The inconsistencies refer to (1) the magnitude of the association between cigarette smoking and CHD; (2) the relative incidence of CHD in "heavy" smokers and nonsmokers; (3) the independent effect of cigarette smoking on CHD; (4) the increasing risk of developing CHD with duration of cigarette smoking; (5) the effect of smoking cessation; and (6) the association between cigarette smoking and CHD in women.     

Coronary risk appraisal for primary prevention of coronary heart disease in a community

PURPOSE: In discussion on application of "National Health Promotion Toward 21st Century in Japan" in Kanagawa prefecture, it was noted that the age-adjusted mortality rate of death from ischemic heart disease in this part of Japan was higher than that for the whole nation in 1996. To facilitate development of a strategy for primary prevention of coronary heart disease (CHD), the present study was conducted to predict 2-yr incidence of CHD and decrease with simulations assuming improvement in CHD risk factors. METHODS: Using CHD risk prediction algorithm; the Weibull accelerated failure regression model based on the Framingham Heart Study, a 2-yr incidence of CHD was predicted for 1652 residents (515 male, 1137 female) on the basis of results of a health check up in 1998. We then estimated the probable decrease in CHD recalculated assuming decrease in total cholesterol (TC), increase in HDL-cholesterol (HDL-C), decrease in systolic blood pressure (SBP), or quitting the smoking habit. RESULTS: 1. The 2-yr probability of developing CHD for men free of heart disease was 2.79 +/- 2.17%, and that for men who had heart disease was 10.25 +/- 2.17%. The 2-yr probability for women free of heart disease was 16.80 +/- 14.40%, and that for women who had heart disease was 3.66 +/- 1.09%. As the reported probability of developing CHD in the U.S.A. is remarkably higher than in Japan, the fact that the present model was based on American data explains why these predicted probabilities are higher than values reported from Japanese cohort studies. 2. For men free of heart disease, a strategy for high risk case such as a decrease in TC and an increase in HDL-C, or quitting the smoking habit, was more effective than a population-based strategy. For women free of heart disease, the population-based strategy was more effective. 3. Women more than 60-yrs old who had a high 2-yr probability of developing CHD were divided into three groups; high, middle, and low risk. The mean body weight, mean body mass index, mean diastolic blood pressure, and mean blood glucose in the high risk group were significantly higher than the values in the other groups. Decrease in systolic blood pressure was a more effective strategy for decrease in CHD incidence in the high risk group than in the other groups. CONCLUSIONS: CHD risk prediction of this type may be considered useful for setting target CHD risk factors and for focusing interventions to prevent CHD effectively.     

Cardiovascular health promotion in children: "Heart Smart" and the changing role of physicians

Despite encouraging reductions in mortality rates from coronary heart disease (CHD), it remains a major public health problem and the leading cause of death in the United States. Although various explanations have been proposed for declining death rates, a consensus exists regarding the importance of lifestyle alterations for risk factor reduction. Because cardiovascular (CV) risk-related behavioral patterns are acquired during childhood, numerous school-based CV health promotion programs have been implemented. The effectiveness of CV research studies for children during the last decade are reviewed. Intervention strategies to prevent heart disease include (1) the population or public health approach and (2) the high-risk approach. The "Heart Smart" model intervention project is utilized to describe these two main strategies. Policy, position statements, and initiatives on CV risk factors from major professional societies and associations, in addition to governmental organizations and offices, are also provided. Primary care physicians, particularly pediatricians and family practitioners, as well as cardiologists can play a crucial role in the prevention of CHD and essential hypertension through efforts and practices in their offices, the schools, and the community at large. The changing and expanding role of physicians interested in preventive child health care is emphasized, including involvement in school- and community-based CV health promotion programs. More comprehensive CV model projects such as "Heart Smart," which intervene on the total school environment, are critical to the reduction of CV disease in the United States and abroad.     

Invisible women? The importance of gender in lay beliefs about heart problems

Coronary heart disease (CHD) accounts for over a quarter of deaths in Britain, yet few qualitative studies have explored beliefs about 'heart problems' in the general population. A previous study of lay beliefs about coronary candidacy (or 'the kind of person who gets heart trouble') paid little attention to gender. However, semi‐structured interviews with 61 men and women reveal that gender plays a vital role in lay perceptions. Respondents' accounts of people who were likely 'candidates' for heart problems all centred on men. More surprisingly, their accounts of unlikely candidates also focused exclusively on men. Only when specifically asked about relatives, did respondents discuss women with heart problems. While accounts of male 'victims' focused on sudden, fatal heart attacks, accounts of women usually concentrated on long‐term CHD morbidity. We argue that CHD continues to be perceived as a male disease and that women remain 'invisible' in discourses about heart disease.     

Evaluation of coronary heart disease risk model by carotid ultrasonography in the occupational setting--intima-media thickness and coronary heart disease risk]

Recently, because of an increase in aged workers with high risk health conditions in Japan, it is becoming necessary to have a preventive control system for work-related diseases, such as coronary heart disease. We have already built a system by applying the prediction model of Framingham's risk equation for management after an annual check-up since 1999. At that time, we considered the relationship between CHD risk and intimamedia thickness (IMT) as an index of actual atherosclerosis. Correlation coefficients among max IMT, CHD risk and the several health factors in the corporate annual health check-up were obtained by Spearman's method. Significant associations with max IMT were only for CHD risk and systolic blood pressure. Correlation coefficients were 0.30 and 0.21 for CHD risk and systolic blood pressure, respectively. Furthermore, when we divided findings into those for the atherosclerotic and non-atherosclerotic groups defined by a max IMT over 1.1 mm or less, the difference between the two groups in CHD risks was investigated by t-test. The CHD risk for the atherosclerotic group was revealed to be significantly higher than that for the non-atherosclerotic group, with the means +/- SD in the two groups being 21.4 +/- 9.4% and 17.0 +/- 7.7%, respectively. CHD risk was therefore concluded to be important for the objective index of atherosclerosis from the viewpoint of high-risk-strategy in the worksite.     

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.     

Milk consumption and prevalence of coronary heart disease in men and women from the Scottish Heart Health Study

This report uses cross-sectional results from the Scottish Heart Health Study to investigate whether milk consumption has an independent effect on the prevalence of coronary heart disease. Milk consumption was assessed by questionnaire in men and women aged 40–59 years (n = 10359) who participated in a survey of risk factors for coronary heart disease between 1984 and 1986. Odds ratios for coronary heart disease were calculated according to volume and type of milk consumed for subjects with and without symptoms of coronary heart disease. Statistical adjustment was made for the classicial risk factors.
A higher percentage of men and women with diagnosed coronary heart disease (CHD) usually consume low-fat milk, compared with asymptomatic controls. Odds ratios for having undiagnosed heart disease did not differ significantly with volume or type of milk. However, the odds ratios for having diagnosed heart disease were lower in the moderate (0.5–1 pint/d) milk consumption group. Patterns of milk consumption in patients diagnosed as having CHD are likely to be confounded by dietary changes post-diagnosis. Milk consumption appears to have little independent effect on the prevalence of coronary heart disease in this Scottish population.     

Social class differences in coronary heart disease in middle-aged British men: implications for prevention

BACKGROUND: Though social class differences in coronary heart disease (CHD) are well recognized, few studies have assessed the effect of imprecision in social class assessment on the relationship or the overall contribution of social class to attributable CHD risk. METHODS: Prospective observational study of the relationship between occupational social class (assessed at baseline and after 20 years), major CHD (coronary death and non-fatal myocardial infarction) and all-cause mortality rates over 20 years among 5628 middle-aged British men with no previous evidence of CHD. RESULTS: The age-adjusted hazard of major CHD for manual men relative to non-manual men was 1.41 (95% CI: 1.21, 1.64) before correction and 1.50 (95% CI: 1.25, 1.79) after correction for imprecision of social class measurement. The imprecision-corrected estimate was attenuated to 1.28 (95% CI: 1.06, 1.54) after adjustment for the adult coronary risk factors (blood cholesterol, blood pressure, body mass index, cigarette smoking, alcohol, physical activity, and lung function) and to 1.20 (95% CI: 0.99, 1.45) following further adjustment for height. The population attributable risk fraction of major CHD for social class (manual versus non-manual) was 22% after correction for imprecision in social class, which was reduced to 14% after adjustment for the adult coronary risk factors, and 10% after further adjustment for height. Similar results were obtained for all-cause mortality. CONCLUSIONS: Even taking account of measurement imprecision, the contribution of social class to overall CHD risk is modest. Population-wide strategies to reduce major CHD risk factors are likely to have greater potential benefits for CHD prevention than strategies designed specifically to reduce social inequalities in CHD.     

Coronary heart disease: prevalence and dietary sugars in Scotland.

STUDY OBJECTIVE--The aim was to investigate the effects of dietary intakes of different types of sugars (extrinsic, intrinsic, and lactose) and the dietary fat to sugar ratio on prevalent coronary heart disease (CHD). DESIGN--This was a baseline cross sectional survey of CHD risk factors. SETTING--Twenty two Scottish health districts were surveyed between 1984 and 1986. PARTICIPANTS--A total of 10,359 men and women aged 40-59 years were screened as part of the Scottish Heart Health Study, and a further 1267 men and women aged 25-39 and 60-64 years were screened as part of the Scottish MONICA (monitoring trends and determinants in cardiovascular disease) Study. The response rates were 74% and 64% respectively. METHODS--Subjects completed a questionnaire which included sociodemographic, health, and food frequency information. Medical history, response to the Rose chest pain questionnaire, and results of a 12 lead ECG recording were used to categorize subjects into CHD diagnosed, previously CHD undiagnosed, or no CHD groups. The chi 2 statistic was used to determine whether the CHD groups differed in their sugar consumption, and multiple logistic regression analysis, with adjustment for other potential coronary risk factors, was used to calculate odds ratios for prevalent CHD by intake fifths of dietary sugars. MAIN RESULTS--Men, but not women, differed in their sugar consumption by CHD group. The odds ratios showed a tendency for a U shaped relationship for extrinsic sugar intake with CHD prevalence, but no significant effect of the fat to sugar ratio (possible marker of obesity) on CHD was seen. CONCLUSIONS--The results suggest that neither extrinsic sugar, intrinsic sugar, nor the fat to sugar ratio are significant independent predictors of prevalent CHD in the Scottish population, when the other major risk factors such as cigarette smoking, blood cholesterol concentration, and antioxidant vitamins intake are accounted for. These new data for different sugar types agree with the consensus view that total sugar intake is not a major marker of coronary heart disease.     

Cardiovascular disease and the aging woman: overcoming barriers to lifestyle changes

Coronary heart disease (CHD) is the leading cause of death in women aged 60 years and older, yet 40% of this group believe they are unlikely to have a heart attack. Recent data show that the lack of a low-risk lifestyle may account for approximately 82% of coronary events in women. Underappreciation of CHD risk may prevent aging women from making significant changes in dietary habits, activity levels, and tobacco use to decrease their risk. In addition, many physicians may not treat cardiovascular risk factors aggressively in middle-aged and older women, despite data from primary and secondary prevention trials supporting the efficacy of interventions. This article addresses age-related changes in cardiovascular risk factors in women, with a focus on lifestyle interventions.     

四川省城市居民冠心病主要危险因素定量评价标准的研究

目的 制定冠心病危险因素的定量评价标准,为预测个体冠心病的患病危险奠定基础。方法 通过文献检索收集冠心病危险因素的病例对照和队列研究资料及四川省的行为危险因素监测资料,运用meta分析软件对各危险因素与冠心病的比值比(OR)、相对危险度(RR)值进行合并,运用统计模型将不同暴露水平的危险因素转换成危险分数。结果 以5岁为1个年龄组,建立了15-69岁不同性别的冠心病主要危险因素：吸烟、被动吸烟、高血压、高血脂、体重指数、体育锻炼、饮酒、高脂饮食、糖尿病、冠心病家族史和高血压家族史的定量评价标准(危险分数转换表),无这些危险因素(体育锻炼除外)者其危险分数均≤1．00(进行体育锻炼者危险分数＜1．00),而伴有这些危险因素者其危险分数均＞1．00,且危险分数随危险程度的增加而增高。结论 冠心病危险分数转换表是计算冠心病存在死亡危险的基础,后者可预测个体未来10年发生冠心病死亡的危险性。该方法是健康教育的有力依据,也是当前深入开展社区卫生服务的重要方法。     

左室射血分数及冠心病常见危险因素与冠脉病变严重程度的相关性研究

目的探讨左室射血分数及冠心病常见危险因素与冠脉病变严重程度的相关性。方法对2008年12月至2009年4月于本院行选择性冠状动脉造影术的305例患者进行临床资料的采集及冠脉造影结果的分析,冠脉病变的严重程度采用Gensini积分系统,根据冠脉造影的结果先将研究对象分为冠心病组（251例）和非冠心病组（54例）进行临床资料的比较,再采用多元线性回归（nmltiplelinearregression）分析冠脉病变严重程度与冠心病常见危险因素之间的相关性并采用直线相关（1inearcorrelation）分析冠脉病变严重程度与左室射血分数的相关性。结果冠心病组和非冠心病组相比在年龄、性别、吸烟指数、高血压患病率、血糖异常及糖尿病患病率、代谢综合征患病率差异有统计学意义（P〈0．05）。在多元线性回归中年龄（β1=0．251,P〈0．01）、性别（β2=0．235,P〈0．01）、低密度脂蛋白胆固醇（LDL—C）（β3=0．241,P〈0．01）、糖尿病病程（β4=0．226,P〈0．01）进入直线回归方程,在冠脉病变严重程度与左室射血分数直线相关的研究中发现两者呈负相关（r=-0．362,P〈0．01）。结论在对临床上高度怀疑患冠心病的患者进行冠脉造影前需充分考虑患者的年龄、性别、吸烟指数、是否患高血压、是否伴有血糖异常、是否患有代谢综合征等以提高冠脉造影的阳性率,年龄、性别、LDL—C、糖尿病病程是影响冠脉病变严重程度的独立危险因素,冠心病患者随着冠脉狭窄程度的加重,左室射血功能呈减退趋势。