Research article
Neighborhood Socioeconomic Status and Leisure-Time Physical Activity After Myocardial Infarction: A Longitudinal Study

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Background

Area-level SES is independently associated with myocardial infarction (MI) prognosis, yet the mechanisms for this association remain speculative.

Purpose

Using a population-based cohort of MI patients, this study examined whether neighborhood SES predicts long-term trajectory of leisure-time physical activity (LTPA), an established prognostic factor.

Methods

Patients aged ≤65 years (n=1410) admitted to hospital in central Israel with first MI in 1992–1993, were followed up through 2005. LTPA was reported on five successive occasions: at baseline, 3–6 months, 1–2 years, 5 years, and 10–13 years post-MI. Generalized estimating equations (GEEs) with ordinal outcome variable (LTPA classified as regular, irregular, or none) were used to determine the independent predictive role of neighborhood SES in LTPA trajectory post-MI. Analyses were conducted in 2010–2011.

Results

Engagement in LTPA was poor, with point prevalence rates ranging from 33% to 37% for inactivity and from 19% to 27% for irregular activity throughout follow-up. The GEE-derived ORs (95% CIs) for decreased LTPA level in the lower and middle vs upper neighborhood SES tertiles were 2.49 (2.05, 3.02) and 1.60 (1.33, 1.92) after age and gender adjustment, and 1.55 (1.26, 1.90) and 1.23 (1.02, 1.49) after multivariable adjustment for individual SES measures, cardiovascular risk factors, MI characteristics, and disease-severity indices, respectively (p for trend <0.001).

Conclusions

Low neighborhood SES is a powerful predictor of poor LTPA uptake in MI survivors, even after extensive adjustment for individual SES and baseline clinical profile. LTPA may thus represent an intermediate mechanism between neighborhood SES and post-MI outcome, which provides prevention opportunities.

Introduction

Although low SES has been widely recognized as a risk factor for cardiovascular disease (CVD),1, 2 recent evidence has pointed to the detrimental effects of neighborhood deprivation above and beyond individual SES factors. Area-level SES is independently associated with CVD incidence and outcome, as demonstrated in the general population3, 4, 5 and in post–myocardial infarction (post-MI) patients.6, 7, 8 A prospective cohort study demonstrated elevated rates of ischemic stroke, cardiac mortality, and all-cause mortality in post-MI patients from deprived neighborhoods, even after controlling for MI severity, traditional risk factors, and multiple individual SES measures.8, 9 However, the mechanisms for these associations remain speculative.10, 11

Epidemiologic evidence has revealed a clear association between engagement in leisure-time physical activity (LTPA) and both primary and secondary CVD prevention in different settings.12, 13, 14, 15, 16 A recent study showed that regularly active MI survivors had approximately 50% reduced risk of mortality compared with inactive patients, independent of activity patterns prior to MI.17 Despite this clear advantage, only 18% of these patients were regularly active during 13 years of follow-up.17

Although several studies have examined the association between neighborhood deprivation and reduced physical activity,18, 19, 20, 21, 22, 23 they were mostly based on cross-sectional analyses of healthy populations and their results were conflicting and potentially subject to confounding because of insufficient adjustment for individual SES and clinical variables. Using a geographically defined community cohort of MI patients followed up longitudinally, the current study examined whether area of residence predicts long-term trajectory of LTPA. The study benefits from comprehensive socioeconomic and clinical data, long-term follow-up, and repeated measures of LTPA—a substantial advantage because physical activity patterns often vary with time.24 The primary hypothesis was that neighborhood SES would be associated with engagement in LTPA after MI above and beyond individual SES characteristics and clinical covariates.

Section snippets

Study Design and Sample

The Israel Study of First Acute Myocardial Infarction is a longitudinal, prospective cohort study investigating the role of sociodemographic, medical, and psychosocial variables in long-term clinical outcomes in patients hospitalized with MI. Details of the study methods have been previously reported.8, 9, 25 Briefly, 1626 consecutive patients aged ≤65 years were admitted to the eight medical centers in central Israel with first MI between February 15, 1992, and February 15, 1993. Ninety-five

Results

A total of 1410 patients discharged from hospital after first MI were included in the study analysis. The mean age of participants was 53.8 (SD=8.3) years and 19% were women. Engagement in LTPA after MI was low, with point prevalence rates ranging from 33% to 37% for inactivity and from 19% to 27% for irregular activity throughout follow-up. Baseline patient characteristics across neighborhood SES tertiles are shown in Table 1. Residence in a poorer neighborhood was associated with pre-MI

Discussion

In this post-MI cohort, participants from disadvantaged neighborhoods were less likely to be engaged in LTPA in the decade following MI than participants from wealthier neighborhoods. This association was strongest in the first 5 years following MI. Neighborhood SES was a powerful predictor of LTPA levels, remaining so after extensive adjustment for individual SES and baseline clinical profile. LTPA may represent an intermediate mechanism between neighborhood SES and post-MI outcome. Indeed,

References (45)

  • K.E. Pickett et al.

    Multilevel analyses of neighbourhood socioeconomic context and health outcomes: a critical review

    J Epidemiol Community Health

    (2001)
  • K. Sundquist et al.

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

    Am J Epidemiol

    (2004)
  • A.V. Diez Roux et al.

    Neighborhood of residence and incidence of coronary heart disease

    N Engl J Med

    (2001)
  • C. Tonne et al.

    Long-term survival after acute myocardial infarction is lower in more deprived neighborhoods

    Circulation

    (2005)
  • Y. Gerber et al.

    Neighborhood socioeconomic context and long-term survival after myocardial infarction

    Circulation

    (2010)
  • Y. Gerber et al.

    Poor neighborhood socioeconomic status and risk of ischemic stroke after myocardial infarction

    Epidemiology

    (2011)
  • A.V. Diez Roux et al.

    Neighborhoods and cardiovascular risk: beyond individual-level risk factors

    Curr Cardiovasc Risk Rep

    (2008)
  • J. Spertus

    Broadening our understanding of survival after myocardial infarction: the association of neighborhood with outcomes

    Circulation

    (2010)
  • R.S. Paffenbarger et al.

    Physical activity, all-cause mortality, and longevity of college alumni

    N Engl J Med

    (1986)
  • S.C. Smith et al.

    AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute

    Circulation

    (2006)
  • P.D. Thompson et al.

    Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity)

    Circulation

    (2003)
  • C.B. Eaton et al.

    Self-reported physical activity predicts long-term coronary heart disease and all-cause mortalitiesTwenty-one-year follow-up of the Israeli Ischemic Heart Disease Study

    Arch Fam Med

    (1995)
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