When does cardiovascular risk start? Past and present socioeconomic circumstances and risk factors in adulthood

STUDY OBJECTIVES: To compare associations of childhood and adult socioeconomic position with cardiovascular risk factors measured in adulthood. To estimate the effects of adult socioeconomic position after adjustment for childhood circumstances. DESIGN: Cross sectional survey, using the relative index of inequality method to compare socioeconomic differences at different life stages. SETTING: The Whitehall II longitudinal study of men and women employed in London offices of the Civil Service at study baseline in 1985-88. PARTICIPANTS: 4774 men and 2206 women born in the period 1930-53 who were administered questions on early socioeconomic circumstances. MAIN RESULTS: Adult occupational position (employment grade) was inversely associated (high status-low risk) with current smoking and leisure time physical inactivity, with waist/height, and with metabolic risk factors HDL cholesterol, triglycerides, post-load glucose and fibrinogen. Associations of these variables with childhood socioeconomic position (father's Registrar General Social Class) were weaker or absent, with the exception of smoking in women. Childhood social position was associated with adult weight in both sexes and with current smoking, waist/height, HDL cholesterol and fibrinogen in women. Height, a measure of health capital or constitution, was weakly linked with father's social class and more strongly linked with own employment grade. The combination of childhood disadvantage (low father's class) together with a low status clerical occupation in men was particularly associated with higher body mass index as an adult (interaction test p < 0.001). Adjustment for earlier socioeconomic position--using father's class and own education level simultaneously--did not weaken the effects of adult socioeconomic position, except in the case of smoking in women, when the grade effect was reduced by 59 per cent. CONCLUSIONS: Cardiovascular risk factors in adulthood were in general more strongly related to adult than to childhood socioeconomic position. Among women but not men there was a strong but unexplained link between father's class and adult smoking habit. In both sexes degree of obesity was associated with both childhood and adulthood social position. These findings suggest that the socially patterned accumulation of health capital and cardiovascular risk begins in childhood and continues, according to socioeconomic position, during adulthood.     

Social and economic background and class inequalities in health among young adults

This paper considers which socio-economic factors in childhood and early adulthood are most strongly associated with social class differences in health at age 23. Longitudinal data from the 1958 (NCDS) cohort were used for this purpose. By age 23 class gradients were evident for several health measures, including self-rated health, 'malaise', psychological morbidity and height. The contribution of earlier socio-economic background was established by assessing how far class differences in the health indicators were reduced by controlling for earlier circumstances. While class differentials were not eliminated after taking account of earlier circumstances, substantial reductions were associated with a number of factors in childhood, in particular social class, housing tenure, crowding, family size and receipt of free school meals. More recent experiences of unemployment and family formation were also important.     

Impact of childhood and adulthood socioeconomic position on cause specific mortality: the Oslo Mortality Study

OBJECTIVE: To study the impact of childhood and adulthood social circumstances on cause specific adult mortality. DESIGN: Census data on housing conditions from 1960 and Personal Register income data for 1990 were linked to 1990-94 death registrations, and relative indices of inequality were computed for housing conditions in 1960 and for household income in 1990. PARTICIPANTS: The 128 723 inhabitants in Oslo aged 31-50 years in 1990. MAIN RESULTS: Adulthood mortality was strongly associated with both childhood and adulthood social circumstances among both men and women. Cardiovascular disease mortality was more strongly associated with childhood than with adulthood social circumstances, while the opposite was found for psychiatric and accidental/violent mortality. Smoking related cancer mortality was related to both adulthood and childhood social circumstances in men, but considerably more strongly to adult social circumstances. CONCLUSIONS: Childhood social circumstances have an important influence on cardiovascular disease risk in adulthood. Current increases in child poverty that have been seen in Norway over the past two decades could herald unfavourable future trends in adult health.     

Education and occupational social class: which is the more important indicator of mortality risk?

STUDY OBJECTIVES: In the UK, studies of socioeconomic differentials in mortality have generally relied upon occupational social class as the index of socioeconomic position, while in the US, measures based upon education have been widely used. These two measures have different characteristics; for example, social class can change throughout adult life, while education is unlikely to alter after early adulthood. Therefore different interpretations can be given to the mortality differentials that are seen. The objective of this analysis is to demonstrate the profile of mortality differentials, and the factors underlying these differentials, which are associated with the two socioeconomic measures. DESIGN: Prospective observational study. SETTING: 27 work places in the west of Scotland. PARTICIPANTS: 5749 men aged 35-64 who completed questionnaires and were examined between 1970 and 1973. FINDINGS: At baseline, similar gradients between socioeconomic position and blood pressure, height, lung function, and smoking behaviour were seen, regardless of whether the education or social class measure was used. Manual social class and early termination of full time education were associated with higher blood pressure, shorter height, poorer lung function, and a higher prevalence of smoking. Within education strata, the graded association between smoking and social class remains strong, whereas within social class groups the relation between education and smoking is attenuated. Over 21 years of follow up, 1639 of the men died. Mortality from all causes and from three broad cause of death groups (cardiovascular disease, malignant disease, and other causes) showed similar associations with social class and education. For all cause of death groups, men in manual social classes and men who terminated full time education at an early age had higher death rates. Cardiovascular disease was the cause of death group most strongly associated with education, while the non- cardiovascular non-cancer category was the cause of death group most strongly associated with adulthood social class. The graded association between social class and all cause mortality remains strong and significant within education strata, whereas within social class strata the relation between education and mortality is less clear. CONCLUSIONS: As a single indicator of socioeconomic position occupational social class in adulthood is a better discriminator of socioeconomic differentials in mortality and smoking behaviour than is education. This argues against interpretations that see cultural-- rather than material--resources as being the key determinants of socioeconomic differentials in health. The stronger association of education with death from cardiovascular causes than with other causes of death may reflect the function of education as an index of socioeconomic circumstances in early life, which appear to have a particular influence on the risk of cardiovascular disease.       

Socioeconomic position in childhood and cardiovascular risk factors in older Spanish people

OBJECTIVE: To investigate the association between childhood social class and the prevalence of cardiovascular risk factors in the elderly. METHODS: Cross-sectional study of 4009 subjects representative of the Spanish non-institutionalized population aged >or =60 years, for whom information was available on father's occupation. We estimated the prevalence of hypertension, obesity, diabetes mellitus, physical inactivity, smoking, and alcohol intake. RESULTS: Belonging to a working social class in childhood is associated with increased hypertension, having ever smoked, and heavy alcohol intake, independent of adult social class in men. No association was found between social class in childhood and the other cardiovascular risk factors in men. Belonging to a working social class in childhood is associated with increased general obesity, abdominal obesity, diabetes mellitus, and physical inactivity in women, but the size of the association for abdominal obesity and diabetes mellitus decreases and the statistical significance disappears after adjusting for adult social class. The highest smoking prevalence was observed in women who were in social class I in childhood and the lowest in women who were in social class IV. CONCLUSIONS: The results of this study show increased prevalence of some cardiovascular risk factors in men who belong to a working social class in childhood, but they do not support the existing evidence about an association between adverse social circumstances in childhood and increased prevalence of cardiovascular risk factors in later life in women.     

Are childhood socio-economic circumstances related to coronary heart disease risk? Findings from a population-based study of older men

BACKGROUND: The independent influence of childhood social circumstances on health in later life remains uncertain. We examined the extent to which childhood socio-economic circumstances are related to the risk of coronary heart disease (CHD) in older British men, taking account of adult social class and behavioural risk factors. METHODS: A socio-economically representative sample of 5552 British men (52-74 years) with retrospective assessment of childhood socio-economic circumstances (father's occupation and childhood household amenities) who were followed up for CHD (fatal and non-fatal) for 12 years. RESULTS: Men whose childhood social class was manual had an increased hazard ratio (HR) 1.34 (95% CI 1.11-1.63)-this effect was diminished when adjusted for adult social class and adult behavioural risk factors (cigarette smoking, alcohol, physical activity and body weight) (HR 1.19; 95% CI 0.97-1.46). Men whose family did not own a car in their childhood were at increased CHD risk even after adjustments for adult social class and behaviours (HR 1.35, 95% CI 1.04-1.75). Men with combined exposure to both childhood and adult manual social class had the highest risk of CHD (HR 1.51; 95% CI 1.19-1.91); this was substantially reduced by adjustment for adult behavioural risk factors (adjusted HR 1.28; 95% CI 0.99-1.65). CONCLUSIONS: Less affluent socio-economic conditions in childhood may have a modest persisting influence on risk of CHD in later life.     

Physical activity and social status in adolescence as predictors of physical inactivity in adulthood

BACKGROUND: Physical inactivity is related to an increased risk of certain chronic diseases. The aim here was to evaluate how physical activity and social status in adolescence are associated with physical inactivity in adulthood. METHODS: The sample comprised 3664 males and 4130 females who answered questions on physical activity and social status at 14 and 31 years of age in follow-up surveys of the Northern Finland birth cohort of 1966. Associations between explanatory factors and physical inactivity in adulthood were analyzed using multivariable logistic regression. RESULTS: Infrequent participation in sports after school hours at 14 years of age and, in males, additionally a low grade in school sports, was associated with physical inactivity at the age of 31 years, independent of social circumstances in adulthood. Low social class of the childhood family was associated with physical inactivity in adolescence but not with inactivity at 31 years of age. Poor school achievement in adolescence was associated with adult inactivity independent of adolescent physical activity. CONCLUSION: Infrequent participation in sports, a low grade in school sports, and poor school achievements in adolescence were associated with physical inactivity in adulthood. Participation in sports is to be strongly supported among all adolescents because of its long-term beneficial effects on adult health through its tendency to reduce the probability of adult inactivity.     

Inequalities in mortality by social class measured at 3 stages of the lifecourse.

OBJECTIVES: This study examined how social class, measured at 3 staged of life, contributes to mortality risk. METHODS: A cohort of employed Scottish men (n = 5567) provided their fathers'' occupation and their own first and current occupations, from which social class in childhood, at labor-market entry, and at screening (1970 to 1973) was determined. Relative rates of mortality and relative indices of inequality were calculated from 21 years of follow-up. RESULTS: Mortality risk was similar at each stage of life, with men in the higher social classes having the lowest risk. Social class at screening produced the greatest relative indices of inequality. CONCLUSIONS: The widening of inequalities in mortality in adulthood suggests the importance of the accumulation of poor socioeconomic circumstances throughout life.     

Socioeconomic position in childhood and early adult life and risk of mortality: a prospective study of the mothers of the 1958 British birth cohort

OBJECTIVES: We sought to establish whether women's childhood socioeconomic position influenced their risk of mortality separately from the effects of adult socioeconomic position. METHODS: We examined 11855 British women aged 14 to 49 years, with mortality follow-up over a 45-year period. RESULTS: Trends according to childhood social class were observed for all-cause mortality, circulatory disease, coronary heart disease, respiratory disease, chronic obstructive pulmonary disease, stroke, lung cancer, and stomach cancer, with higher death rates among members of unskilled manual groups. Associations attenuated after adjustment for adult social class, smoking, and body mass index. No trend was seen for breast cancer or accidents and violence. Adverse social conditions in both childhood and adulthood were associated with higher death rates from coronary heart disease and respiratory disease. Stomach cancer was influenced primarily by childhood conditions and lung cancer by factors in adult life. CONCLUSIONS: Socioeconomic position in childhood was associated with adult mortality in a large sample of British women.     

Systematic review of the influence of childhood socioeconomic circumstances on risk for cardiovascular disease in adulthood

PURPOSE: Adverse socioeconomic circumstances in childhood may confer a greater risk for adult cardiovascular disease (CVD). The purpose of this review is to systematically evaluate evidence for an association between socioeconomic circumstances during childhood and specific CVD subtypes, independent of adult socioeconomic conditions. METHODS: We systematically retrieved individual-level studies of morbidity and mortality from CVD and specific CVD subtypes linked to early life influences, including coronary heart disease (CHD), ischemic and hemorrhagic stroke, peripheral vascular disease, markers of atherosclerosis (carotid intima-media thickness and stenosis), and rheumatic heart disease. Indicators of socioeconomic position in childhood varied, although most studies relied on father's occupation. RESULTS: We located 40 studies (24 prospective, 11 case-control, and 5 cross-sectional) reported in 50 publications. Thirty-one studies (19 prospective, 7 case-control, and all 5 cross-sectional) found a robust inverse association between childhood circumstances and CVD risk, although findings sometimes varied among specific outcomes, socioeconomic measures, and sex. Case-control studies reported mixed results. The association was stronger for stroke and, in particular, hemorrhagic stroke, than for CHD. Childhood socioeconomic conditions remained important predictors of CVD, even in younger cohorts. CONCLUSION: Childhood and adulthood socioeconomic circumstances are important determinants of CVD risk. The specific contribution of childhood and adulthood characteristics varies across different CVD subtypes. Disease-specific mechanisms are likely to explain the childhood origins of these adult health inequalities.     

Is subjective social status a more important determinant of health than objective social status? Evidence from a prospective observational study of Scottish men

Both subjective and objective measures of lower social position have been shown to be associated with poorer health. A psychosocial, as opposed to material, aetiology of health inequalities predicts that subjective social status should be a stronger determinant of health than objective social position. In a workplace based prospective study of 5232 Scottish men recruited in the early 1970s and followed up for 25 years we examined the association between objective and subjective indices of social position, perceived psychological stress, cardiovascular disease risk factors and subsequent health. Lower social position, whether indexed by more objective or more subjective measures, was consistently associated with an adverse profile of established disease risk factors. Perceived stress showed the opposite association. The main subjective social position measure used was based on individual perceptions of workplace status (as well as their actual occupation, men were asked whether they saw themselves as "employees", "foremen", or "managers"). Compared to foremen, employees had a small and imprecisely estimated increased risk of all cause mortality, whereas managers had a more marked decreased risk. The strongest predictors of increased mortality were father's manual as opposed to non-manual occupation; lack of car access and shorter stature, (an indicator of material deprivation in childhood). In the fully adjusted analyses, perceived work-place status was only weakly associated with mortality. In this population it appears that objective material circumstances, particularly in early life, are a more important determinant of health than perceptions of relative status. Conversely, higher perceived stress was not associated with poorer health, presumably because, in this population, higher stress was not associated with material disadvantage. Together these findings suggest that, rather than targeting perceptions of disadvantage and associated negative emotions, interventions to reduce health inequalities should aim to reduce objective material disadvantage, particularly that experienced in early life.     

Economic stress in childhood and adulthood, and self rated health: a population based study concerning risk accumulation, critical period and social mobility

ABSTRACT: BACKGROUND: Research in recent decades increasingly indicates the importance of conditions in early life for health in adulthood. Only few studies have investigated socioeconomic conditions in both childhood and adulthood in relation to health testing the risk accumulation, critical period, and social mobility hypotheses within the same setting. This study investigates the associations between economic stress in childhood and adulthood, and self-rated health with reference to the accumulation, critical period and social mobility hypotheses in life course epidemiology, taking demographic, social support, trust and lifestyle factors into account. METHODS: The public health survey in Skane (southern Sweden) in 2008 is a cross-sectional postal questionnaire study based on a random sample, in which 28,198 persons aged 18--80 years participated (55% participation). Logistic regression models were used to investigate associations between economic stress in childhood and adulthood, and self-rated health. RESULTS: Three life-course socioeconomic models concerning the association between economic stress and self-rated health (SRH) were investigated. The results showed a graded association between the combined effect of childhood and adulthood economic stress and poor SRH in accordance with the accumulation hypothesis. Furthermore, upward social mobility showed a protecting effect and downward mobility increased odds ratios of poor SRH in accordance with the social mobility hypothesis. High/severe economic stress exposures in both stages of life were independently associated with poor SRH in adulthood. Furthermore, stratifying the study population into six age groups showed similar odds ratios of poor SRH regarding economic stress exposure in childhood and adulthood in all age groups among both men and women. CONCLUSIONS: The accumulation and social mobility hypotheses were confirmed. The critical period model was confirmed in the sense that both economic stress in childhood and adulthood had independent effects on poor SRH. However, it was not confirmed in the sense that a particular window in time (in childhood or adulthood) had a specifically high impact on self rated health.     

Early-life and adult socioeconomic status and inflammatory risk markers in adulthood

BACKGROUND: Associations between childhood and adult socioeconomic status (SES) and adult levels of inflammatory markers (C-reactive protein [CRP], fibrinogen, white blood cell count [WBC], and von Willebrand factor [vWF]) were examined in the Atherosclerosis Risk in Communities (ARIC) Study cohort. METHODS: A total of 12,681 white and African-American participants provided information on SES (via education and social class) and place of residence in childhood and adulthood. Residences were linked to census data for neighborhood SES information. Multiple imputation was used to impute missing data. Hierarchical and linear regression were used to estimate the effects of SES and possible mediation by adult cardiovascular disease (CVD) risk factors. FINDINGS: Low childhood social class and education were associated with elevated levels of CRP, fibrinogen, WBC, and vWF (increments of 17%, 2%, 4% and 3% for lowest versus highest education in childhood, respectively) among whites. Findings were less consistent among African-Americans. Adult SES was more strongly associated with inflammation than childhood SES. Individual-level SES measures were more consistently associated with inflammation than neighborhood-level measures. Fibrinogen and WBC showed the most consistent associations with SES; the largest changes in inflammation by SES were observed for CRP. Covariate adjustment strongly attenuated these associations. Mediation of the SES-inflammation associations by BMI, smoking and HDL cholesterol (HDL-C) are suggested by these data. CONCLUSION: Low individual- and neighborhood-level SES in childhood and adulthood are associated with modest increments in adult inflammatory burden. These associations may operate through the influence of low SES on traditional CVD risk factors, especially BMI, smoking and HDL-C.     

Life-course influences on health in British adults: effects of socio-economic position in childhood and adulthood

BACKGROUND: Little evidence exists on the role of socio-economic position (SEP) in early life on adult disease other than for cardiovascular mortality; data is often retrospective. We assess whether childhood SEP influences disease risk in mid-life, separately from the effect of adult position, and establish how associations vary across multiple measures of disease risk. METHODS: Prospective follow-up to adulthood of all born in England, Scotland and Wales during 1 week in 1958, and with medical data at age 45 years (n = 9377). Outcomes include: blood pressure, body mass index (BMI), glycosylated haemoglobin (HbA1c), total and high density lipoprotein (HDL) cholesterol, triglycerides, fibrinogen, total immunoglobulin E (IgE), one-second forced expiratory volume (FEV1), hearing threshold (4 kHz), visual impairment, symptoms of depression and anxiety, chronic widespread pain. RESULTS: Social class in childhood was associated with blood pressure, BMI, HbA1c, HDL cholesterol, triglycerides, fibrinogen, FEV1, hearing threshold, depressive symptoms and chronic widespread pain, with a general trend of deteriorating health from class I to V. Adult social class was also associated with these measures. Mutually adjusted analyses of child and adult social class suggest that both contribute to disease risk in mid-life: in general, associations for childhood class were as strong as for adult class. Individuals with a manual class at both time-points tended to have the greatest health deficits in adulthood. CONCLUSIONS: Adverse SEP in childhood is associated with a poorer health profile in mid-adulthood, independently of adult social position, and across diverse measures of disease risk and physical and mental functioning.     

Social class differences in bladder cancer in Catalonia]

OBJECTIVE: To assess the presence of socio-economic differences in bladder cancer in a heavily industrialised area of Catalonia, Spain and to evaluate risk factors associated with the presence of these differences. METHODS: 218 cases and 344 population controls resident in the area of Vallès Occidental, Barcelona, were identified prospectively and interviewed during 1993-1995. Socio-economic level was evaluated through attained education and social class on the basis of the last and longest held occupation. Logistic regression was used to derive adjusted odds ratios and 95% confidence intervals. RESULTS: There was no association between education and bladder cancer risk. Social class, evaluated on the basis of longest held job, was weakly related with bladder cancer, with the highest risk occurring in the highest social classes. This pattern was more pronounced when the analysis was done using the last occupation. Occupational exposures modified minimally these results. Among controls, the overall prevalence of smoking did not differ between social class but the prevalence of heavy-smokers (> 48.76 packs-year) was highest among subjects in social class V (35.5%) and lowest in social class I (10%). Adjusting for smoking enlarged social class differences. CONCLUSION: Similarly to the pattern in other European countries, no pronounced differences by social class were observed for bladder cancer in this area of Catalonia. The evaluation of social class patterns was crucially affected by the type of socioeconomic information examined. Measures of life-time experience should be preferred rather than socio-economic level at the time of the disease. Smoking seems to be one of the main mediators for the occurrence of bladder cancer differentials but other, yet unidentified risk factors, must be associated with bladder cancer risk, especially among the highest social classes.     

Cumulative social class and mortality from various causes of adult men

STUDY OBJECTIVE: It is possible that circumstances over the lifecourse contribute to social inequalities in mortality in adulthood. The aim of this study is to assess the cumulative effect of social class at childhood and adulthood on mortality from various causes of death in young adult men. DESIGN: The data consist of census records for all Finnish men born in 1956-60 (112,735 persons and 895,001 person years), and death records (1834 deaths) by cause of death for 1991-98. MAIN RESULTS: Mortality from each cause of death increased from the stable non-manual group to mobile groups, and further to the stable manual group. However, mortality in the downwardly mobile group was 150% higher than in the upwardly mobile group. Furthermore, analyses show that mortality was mainly related to current adult social class, though, within each adult social class men with a manual parental background showed slightly increased mortality from cardiovascular disease and from alcohol related causes. CONCLUSIONS: In these data the effects of adult social class were stronger than childhood class for all causes of death. It is more useful to differentiate between childhood and adulthood effects than to use a combined measure of social class to assess the contribution of social class at different stages of life on mortality.     

The contribution of risk factors to stroke differentials, by socioeconomic position in adulthood: the Renfrew/Paisley Study

OBJECTIVES: This study investigated stroke differentials by socioeconomic position in adulthood. METHODS: The relation of risk of stroke to deprivation category and social class was assessed among 6955 men and 7992 women who were aged 45 to 64 years and had been screened in 1972 to 1976. RESULTS: A total of 594 men and 677 women had a hospital admission for stroke or died from stroke. There were large differences in stroke by deprivation category or social class. Adjustment for risk factors (smoking, blood pressure, height, respiratory function, body mass index, cholesterol, diabetes, and preexisting heart disease) attenuated these differences. CONCLUSIONS: Risk factors for stroke can explain some of the socioeconomic differences in stroke risk. Women living in the most deprived areas seem particularly at risk of stroke.     

Childhood family income and life outcomes in adulthood: findings from a 30-year longitudinal study in New Zealand

The aims of this study were to use data gathered over the course of a 30-year longitudinal study to examine the linkages between economic circumstances in childhood and subsequent developmental outcomes spanning educational achievement; economic circumstances; crime; mental health; and teenage pregnancy. All of these outcomes have been linked with childhood economic conditions and it is frequently argued that reducing income inequalities will mitigate psychosocial risks of children reared in families facing economic hardship. Alternatively it may be suggested that the associations between childhood family economic circumstances and later outcomes are mediated by individual, family and social factors that are correlated with low family income and contribute to later outcomes. To examine these issues, data were drawn from a birth cohort of New Zealand children born in 1977 and followed to age 30. Declining childhood family income was associated with a range of negative outcomes in adulthood, including: lower educational achievement; poorer economic circumstances; higher rates of criminal offending; higher rates of mental health problems; and higher rates of teenage pregnancy. After covariate adjustment, childhood family income remained significantly associated with educational achievement and economic circumstances, but was no longer significantly associated with the mental health, offending and teenage pregnancy outcomes. These findings suggest that, after due allowance has been made for social, family and individual contextual factors, low family income during childhood is associated with a range of educational and economic disadvantages in adulthood but is not directly related to increased risks of crime, mental health problems or teen pregnancy.