Educational inequalities in cardiovascular disease are evident in many countries, especially those in northern Europe. Cardiovascular disease also strongly contributes to overall health inequalities in these countries due to its relatively high prevalence. However, much less is known about biological mechanisms accounting for these inequalities. The metabolic syndrome is one potential factor behind educational and other socioeconomic inequalities in cardiovascular disease.
The metabolic syndrome is a metabolic state characterized by many classical risk factors of cardiovascular disease, i.e. abdominal obesity, low high-density lipoprotein (HDL) cholesterol, elevated triglycerides, hyperinsulinaemia, and hyperglycaemia. The causes of the metabolic syndrome are not yet well understood. In addition to behavioural factors, such as diet and physical activity, previous research indicates a strong genetic influence. It has also been suggested that undernutrition during fetal life and early childhood may cause permanent changes in human metabolism and thus affect the development of the metabolic syndrome in later life.6 Thus, the metabolic syndrome may mediate the effect of early material resources on later cardiovascular disease risk.
Inequalities in the prevalence of the metabolic syndrome by occupational status or education have been examined by three previous studies. In the Whitehall II Study with a large sample of British civil servants, a clear negative association was found between occupational status and the prevalence of the metabolic syndrome. Among men, the prevalence of the metabolic syndrome decreased across the six categories of the occupational scale, but among women a higher prevalence was found only in the three lowest categories. In a follow-up study in the UK, negative, but statistically insignificant, associations were found between the metabolic syndrome and socioeconomic class in childhood or in adulthood.
However, the sample size was smaller than in the Whitehall II study, which may explain the statistically insignificant results. In a study of Swedish women, an inverse gradient in the prevalence of the metabolic syndrome was found across categories of education.9 In this study, the age-adjusted prevalence of the metabolic syndrome was 2.6 times higher among women with basic education compared with women who had college or university level education. Adjustment for other risk factors only slightly decreased the occupational gradient in the Whitehall II study and the educational gradient in the Swedish study.
The social gradient in the metabolic syndrome could help explain socioeconomic inequalities in coronary heart disease (CHD). If so, then factors that cause the metabolic syndrome may also be important in the formation of social inequalities in CHD risk. Further, the metabolic syndrome may offer a simple screening tool to find sub-groups and individuals at high risk for CHD. If educational variation is found in the metabolic syndrome, then interventions to prevent and treat metabolic abnormalities, especially in people with low social position, may help to narrow socioeconomic inequalities in CHD. In this study, we examined educational disparities in the metabolic syndrome in a cohort of Finnish middle-aged men and women.
Education is a good indicator of social position in epidemiological studies because it precedes other indicators, such as occupational based social position or income, is comparable between men and women, does not usually change in adulthood, and shapes health behaviours through attitudes, values, and knowledge. First, we investigated whether there were educational differences in the prevalence of the metabolic syndrome and whether adjusting for other risk factors attenuated these differences. Second, we investigated whether the educational differences in the prevalence of the metabolic syndrome at baseline explained educational inequalities in CHD incidence.
Thursday, January 14, 2010
Educational Inequalities In Cardiovascular Disease
Diagnosis of Diabetes
Diabetes once diagnosed is for life. The perseverance and self discipline needed over a lifetime can often tax even the most robust of people to the limit. Those caring for them also require perseverance and an understanding of humanity combined with a cautious optimism, to guide those with diabetes through the peaks and troughs of their lives.
Definition of Diabetes
Diabetes occurs either because of a lack of insulin or because of the presence of factors that oppose the action of insulin. The result of insufficient action of insulin is an increase in blood glucose concentration (hyperglycaemia). Many other metabolic abnormalities occur, notably an increase in ketone bodies in the blood when there is a severe lack of insulin.
Diagnosis of diabetes
The diagnosis of diabetes must always be established by a blood glucose measurement made in an accredited laboratory.
Glucose tolerance test
The glucose tolerance test is not normally needed in routine clinical practice, and then only if uncertainty exists in younger patients, or to establish an exact diagnosis in pregnancy. For reliable results, glucose tolerance tests should be performed in the morning after an overnight fast, with the patient sitting quietly and not smoking; it is also important that the patient should have normal meals for the previous three days and should not have been dieting.
False results may also occur if the patient has been ill recently or has had prolonged bed rest. Blood glucose concentrations are measured fasting and then one and two hours after a drink of 75 g of glucose in 250-350 ml water (in children 1•75 g/kg to a maximum of 75 g), preferably flavoured, for example, with pure lemon juice. Urine tests should be performed before the glucose drink and at one and two hours. Interpretation of blood glucose values according to WHO criteria is shown in the table.
Adapted from Diabetes Care 1997;20:1183-119
Coronary Artery Disease And Its Risk Factors
Coronary heart disease is the commonest cause of heart failure in Western countries. In the studies of left ventricular dysfunction (SOLVD) coronary artery disease accounted for almost 75% of the cases of chronic heart failure in male white patients, although in the Framingham heart study, coronary heart disease accounted for only 46% of cases of heart failure inmen and 27% of chronic heart failure cases in women. Coronary artery disease and hypertension (either alone or in combination) were implicated as the cause in over 90% of cases of heart failure in the Framingham study. Recent studies that have allocated aetiology on the basis of non invasive investigations—such as the Hillingdon heart failure study—have identified coronary artery disease as the primary aetiology in 36% of cases of heart failure. In the Hillingdon study, however, researchers were not able to identify the primary aetiology in 34% of cases; this methodological failing has been addressed in the current Bromley heart failure study, which uses coronary angiography as well as historical and non invasive findings.
Coronary risk factors, such as smoking and diabetes mellitus, are also risk markers of the development of heart failure. Smoking is an independent and strong risk factor for the development of heart failure in men, although the findings in women are less consistent. In the prevention arm of SOLVD diabetes was an independent risk factor (about twofold) for mortality, the development of heart failure, and admission to hospital for heart failure, whereas in the Framingham study diabetes and left ventricular hypertrophy were the most significant risk markers of the development of heart failure. Body weight and a high ratio of total cholesterol concentration to high density lipoprotein cholesterol concentration are also independent risk factors for heart failure. Clearly, these risk factors may increase the risks of heart failure through their effects on coronary artery disease, although diabetes alone may induce important structural and functional changes in the myocardium, which further increase the risk of heart failure.
(Source: ABC of Heart Failure)
Controlling STI (Sexually Transmitted Infections)
The approach to controlling STIs and the emphasis placed on different components will depend on the local pattern and distribution of STIs in the community and whether one is working in a setting that is resource rich or resource poor.
However, the same general principles will apply. Prevention can be aimed at uninfected people in the community to prevent them from acquiring infection (primary prevention) or at infected people to prevent the onward transmission of the infection to their sexual partners (secondary prevention).
Although effective primary prevention can theoretically reduce the prevalence of viral and bacterial STIs, secondary prevention is much more effective at reducing the prevalence of bacterial STIs, which all are curable with antibiotics. In fact, the population prevalence of a bacterial STI can be reduced entirely through effective secondary prevention activities without any reduction in risky sexual behavior occurring.
Countries that combine primary and secondary prevention approaches, at the individual and population levels, have managed substantially to reduce the burden of infection in their population. Effective implementation of prevention programmes requires strong political leadership and genuine commitment, without which the most well designed and appropriate programmes are likely to founder. Countries such as Thailand, Brazil, Uganda, and Senegal have seen a dramatic impact on their rates of STIs and HIV, which has been facilitated greatly by political support at the highest level.
Interventions that reduce the rate of STI can be aimed at the entire community or targeted at specific groups who are at high risk of, or are particularly vulnerable to, infection. One to one prevention interventions can take place in clinic settings, such as:
Primary Prevention
Primary prevention interventions aim to keep people uninfected. These approaches are obviously not mutually exclusive. Individual behaviour change probably will be best sustained in a community that is broadly supportive. In addition, the broader cultural mores of the community will influence greatly the feasibility of delivering education in that community and will also affect how people respond to it.
• Behavioural interventions are aimed at enhancing knowledge, skills, and attitudes to help people protect themselves against infection (for example, health promotion to decrease partner change and increase condom use)
• Structural interventions are aimed at broader societal and economic issues that drive the spread of STIs
• Biomedical interventions include condoms, vaccines, vaginal microbicides, or male circumcision to prevent the acquisition of infection
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic obstructive pulmonary disease (COPD) is a growing health problem in women. The major causative agent behind the disease is smoking, but there are few longitudinal studies concerning women’s health problems in this field.
In 1968, a population study of women in Göteborg, Sweden, was initiated; engaging 1462 women aged 38–60, representative of the female population of Göteborg. Subsequently, four follow-up examinations have been performed, the latest in
2000-2001, i.e. 32 years after the initial examination.
Lung function was measured as peak expiratory flow (PEF) by a peak flow meter in 1968-1969 and as PEF, vital capacity (VC) and forced expiratory volume in one second (FEV1) at the 2000-2001 examination. A 12-year follow-up study on lung function has previously been presented from this population, in which reduced PEF increased the risk of cardiovascular disease (CVD) and death twelve years later, independent of the presence of risk factors for CVD.
In this paper, we present data concerning lung function, airway symptoms and health status in those women who were 38 years old at the initial examination and 70 years old at the 32-year follow up in 2000-2001. As there are only a few longitudinal studies concerning women’s health problems in this field and epidemiological studies of lung function impairment in women and risk factors in a long-term perspective are scarce we aimed to assess the possible association between selected risk factors among women and lung function, health status as well as airway symptoms in a 32-year perspective.
