Elsevier

Social Science & Medicine

Volume 68, Issue 3, February 2009, Pages 444-451
Social Science & Medicine

Life-course socioeconomic positions and subclinical atherosclerosis in the multi-ethnic study of atherosclerosis

https://doi.org/10.1016/j.socscimed.2008.10.038Get rights and content

Abstract

A major limitation of past work on the social patterning of atherosclerosis has been the reliance on measures of neighborhood or individual-level socioeconomic position (SEP) assessed at a single point in time in adulthood. Risk of chronic disease is thought to accumulate throughout the life-course, so the use of a measure for a single point in time may result in inaccurate estimates of the social patterning of subclinical disease. Using data from the US Multi-Ethnic Study of Atherosclerosis (MESA), we examined the relation between childhood SEP [CSEP] (father or caretaker's education), adulthood SEP [ASEP] (a summary score of income, education, and wealth), and 20-year average exposure to neighborhood poverty [NSEP] (residential addresses geocoded and linked to census data) and the prevalence of subclinical atherosclerosis, as assessed by common carotid intimal–medial thickness (IMT) in mid to late adulthood. Participants were 45–84 years of age at baseline and were sampled from six study sites in the United States. After adjustment for age, CSEP and ASEP were both inversely and independently associated with IMT in men. All three indicators CSEP, ASEP, and NSEP were inversely and independently associated with IMT in women. Associations were somewhat reduced after adjustment for cardiovascular risk factors, suggesting that these factors may play a mediating role. There was evidence of heterogeneity in effects of NSEP by gender, and in the effects of ASEP and NSEP by race/ethnicity. Our results contribute to the growing body of work that shows that SEP at multiple points in the life-course, and at the individual and neighborhood level, contributes to the development of atherosclerosis.

Introduction

Numerous studies have shown that cardiovascular risk is socially patterned, with persons of low income or low education having higher prevalence, incidence and mortality from cardiovascular disease than persons of high income or education (Kaplan & Keil, 1993). Recent work has also shown that cardiovascular risk is patterned by neighborhood socioeconomic characteristics, with persons living in socioeconomically disadvantaged neighborhoods having higher prevalence, incidence, and mortality from cardiovascular disease than those living in more advantaged neighborhoods, even after controlling for measures of personal socioeconomic position (SEP) (Cubbin and Winkleby, 2005, Diez Roux et al., 2004, Diez-Roux et al., 1997, Diez Roux et al., 2001, Stjarne et al., 2006, Sundquist et al., 2004, Sundquist et al., 2004).

The biological processes responsible for this social patterning of cardiovascular events are not completely known. SEP could be related to the development of atherosclerosis and/or to the triggering of clinical events or deaths in persons with underlying atherosclerotic disease. A number of studies have investigated the social patterning of subclinical atherosclerosis and have consistently reported a higher prevalence of subclinical atherosclerosis in late adulthood among persons of lower SEP compared to those of higher SEP, as characterized by individual-level or neighborhood-level (Diez-Roux et al., 1995, Lamont et al., 2000, Lynch et al., 1995, Lynch et al., 1997, Nordstrom et al., 2004, Rosvall et al., 2000). These findings suggest that social factors may pattern the development of atherosclerosis itself.

A major limitation of past work on the social patterning of atherosclerosis has been the reliance on measures of neighborhood or individual-level SEP assessed at a single point in time in adulthood. Atherosclerosis is known to develop over the life-course, possibly beginning as early as childhood (Brownson et al., 1998, Labarthe, 1998). Thus, the investigation of measures of SEP assessed late in life could result in inaccurate estimates of the social patterning of subclinical disease, particularly if SEP changes over a person's life-course and if childhood exposures are important to the development of atherosclerosis later in life. Although several studies have reported associations of life-course SEP with cardiovascular events (Pollitt, Rose, & Kaufman, 2005), only one study of which we are aware has investigated associations of life-course measures of SEP, measured at both the individual and neighborhood-level, with the presence of subclinical atherosclerosis (Carson et al., 2007). Identifying an association between life-course SEP and the presence of subclinical atherosclerosis in adulthood would argue for targeting preventative efforts at disadvantaged groups early in life.

Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), a large, multi-ethnic, cohort study of the determinants of subclinical atherosclerotic disease, we examined if childhood SEP, adulthood SEP, and 20-year average exposure to neighborhood poverty are related to the amount of subclinical atherosclerosis present in mid and late adulthood. We hypothesized that all three measures would be independently related to subclinical atherosclerosis, as assessed by carotid artery intimal–medial thickness (IMT), a validated measure of early atherosclerosis (Bots, 2006, Poredos, 2004).

Section snippets

Methods

The MESA is a population-based study of 6814 men and women recruited from six US Communities (Baltimore, MD; Chicago, IL; Forsyth County, NC; Los Angeles County, CA; northern Manhattan, NY; and St. Paul, MN). Participants were 45–84 years old and clinically free of cardiovascular disease at baseline. The methods used for sampling and study design have been reported elsewhere (Bild et al., 2002). Approximately 38% of the cohort is white, 28% African American, 23% Hispanic, and 11% Chinese. The

Results

Of 6814 participants at baseline, 5871 (86%) completed the residential history questionnaire. Of these, 797 were excluded because one or more addresses could not be geocoded and 132 were excluded because poverty values were not available for one or more of the tracts in which they had lived since January of 1980, leaving at total of 4942 participants with complete neighborhood poverty information. An additional 55 were excluded because carotid IMT information was not available, and 464 were

Discussion

We found clear evidence that carotid atherosclerosis (as assessed by IMT) is patterned by socioeconomic position over the life-course. Both CSEP and ASEP were inversely and independently associated with IMT in men. Higher childhood and higher adult SEP as well as higher NSEP (lower exposure to neighborhood poverty) were independently associated with greater IMT in women. Associations were somewhat reduced after adjustment for cardiovascular risk factors suggesting that these factors may play a

Acknowledgements

This study was supported by grant R01-HL071759 from the National Heart, Lung, and Blood Institute (A.D.R. PI). The Multi-Ethnic Study of Atherosclerosis (MESA) is supported by contracts N01-HC-95159 through N01-HC-95165 and N01-HC-95169 from the National Heart, Lung, and Blood Institute. The authors thank the MESA investigators and staff for their valuable contributions. A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org.

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