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Original Investigation |

Association of Childhood Socioeconomic Status With Subsequent Coronary Heart Disease in Physicians FREE

Michelle M. Kittleson, MD, PhD; Lucy A. Meoni, ScM; Nae-Yuh Wang, PhD; Audrey Y. Chu, BS; Daniel E. Ford, MD, MPH; Michael J. Klag, MD, MPH
[+] Author Affiliations

Author Affiliations: Divisions of Cardiology (Dr Kittleson) and General Internal Medicine (Ms Meoni and Drs Wang, Ford, and Klag), Department of Medicine, The Johns Hopkins School of Medicine, and Departments of Epidemiology (Ms Chu and Drs Ford and Klag), Biostatistics (Ms Meoni), and Health Policy and Management (Drs Ford and Klag), Johns Hopkins Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Md. Dr Kittleson is now with the Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angles, Calif.


Arch Intern Med. 2006;166(21):2356-2361. doi:10.1001/archinte.166.21.2356.
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Background  Adult socioeconomic status (SES) is an independent risk factor for the development of coronary heart disease (CHD), but whether low childhood SES has an effect in adults who have achieved high SES is unknown.

Methods  We examined the risk of CHD and mortality associated with low childhood SES in 1131 male medical students from The Johns Hopkins Precursors Study, a prospective cohort of graduates of The Johns Hopkins University School of Medicine from 1948 to 1964 with a median follow-up of 40 years.

Results  Of 1131 subjects, 216 (19.1%) were from low-SES families. Medical students from low-SES families were slightly older at graduation (26.8 vs 26.2 years; P = .004) and gained more weight over time (P = .01). Low childhood SES conferred a 2.40-fold increased hazard of developing CHD on or before age 50 years (95% confidence interval, 1.21-4.74) but not at older ages. The impact of low SES on early CHD was not reduced by adjusting for other CHD risk factors, including body mass index, cholesterol level, amount of exercise, depression, coffee drinking, smoking, hypertension, diabetes mellitus, and parental CHD history. Low childhood SES did not confer an increased risk of all-cause mortality.

Conclusions  Low childhood SES is associated with an increased incidence of CHD before age 50 years among men with high adulthood SES. This risk is not mediated by traditional risk factors for CHD. These findings highlight the importance of childhood events on the development of CHD early in adulthood and the persistent effects of low SES.

Figures in this Article

Despite advances in medical and surgical care, coronary heart disease (CHD) remains the primary cause of morbidity and mortality in the United States.1 In addition to traditional risk factors such as older age, male sex, cigarette smoking, hypertension, diabetes mellitus, and hypercholesterolemia, low socioeconomic status (SES) is a consistent, moderately strong predictor of CHD risk.27 Individuals with low SES have poorer health outcomes compared with high-SES populations,210 and the health care community has been challenged to eliminate this disparity.11

Most studies of the effect of childhood SES on CHD in adulthood have focused on middle-aged or older populations; in these studies, no distinction was made between early vs late onset of CHD.1229 Because most cardiovascular risk factors are more prevalent at older ages, the effects of childhood SES may play less of a role in the development of CHD at older ages.

The Johns Hopkins Precursors Study measures physicians' health outcomes over their lifetime and provides a unique opportunity to prospectively examine the effects of childhood SES on the development of CHD before and after middle age and to adjust for traditional risk factors measured throughout adult life. It also provides the results of a natural experiment: do physicians who are born into low-SES families but who have high levels of adulthood SES, medical knowledge, and access to high-quality health care have optimal health care outcomes? We hypothesized that the risk of poor health outcomes, particularly CHD presenting at a young age, would be greater in physicians with low childhood SES compared with those who grew up in a high-SES family.

STUDY POPULATION

The Johns Hopkins Precursors Study was designed and initiated by Caroline Bedell Thomas, MD, in 1947 to identify precursors for cardiovascular disease. It is an ongoing, longitudinal cohort study of 1337 former medical students at The Johns Hopkins University School of Medicine in the classes of 1948 to 1964. Excluded from this analysis were the small number of women (n = 121), men of non-European ancestry (n = 36), those who did not answer the questions about parental occupation (n = 56), and those who were unavailable for follow-up (n = 15), leaving 1131 white male medical students for analysis of incident CHD (some individuals met >1 exclusion criterion).

DATA COLLECTION

At baseline during medical school, each participant provided a detailed medical history and underwent physical examination, including measurement of blood pressure, height, and weight. After medical school, follow-up data were collected using annual mailed questionnaires. In general, yearly response rates exceeded 70% and, during any 5-year interval, at least 85% of participants responded at least once. In addition, ongoing mortality surveillance is conducted by review of alumni records and obituaries and by periodic National Death Index searches. A committee of internists (including M.J.K. and D.E.F.) reviews copies of the death certificates, medical records, and self-reports to assign disease outcomes and assess cause of death.

MEASURE OF CHILDHOOD SES

Childhood SES was defined on the basis of the subject's father's occupation as reported from a 10-item checklist on a medical school questionnaire, derived from the occupations listed on the 1950 census of the population.30 A subject was classified as having a low childhood SES if he reported that his father was a farmer, laborer, service worker, clerical worker, sales worker, machine operator, or craftsman. A subject was classified as having a high childhood SES if he reported that his father was a professional (such as an accountant, banker, scientist, engineer, or lawyer), manager, or physician. In sensitivity analyses, alternate definitions of childhood SES were based on the mother’s, as well as the father’s, occupation. Socioeconomic status was also categorized as a 3-level variable: low (farmers, machine operators, service workers, and laborers), middle (clerical workers, sales workers, and craftsmen), and high (professionals, physicians, and managers).

COVARIATES

Information about other risk factors for CHD was also collected at baseline and during follow-up using annual questionnaires and medical records. Starting with the class of 1949, nonfasting serum cholesterol level was measured during medical school.31 Physical activity was assessed during medical school and follow-up using the question, “How much physical training have you had in the past month?” Possible responses were “none,” “little,” “moderate,” and “much.” Parental history of premature CHD was defined as development of CHD before age 55 years in a participant's father or before age 65 years in his mother. Prevalence of CHD in parents was assessed at baseline and throughout follow-up.32

Body mass index (BMI) was defined as weight in kilograms divided by the square of height in meters. Number of cigarettes smoked per day was categorized as follows: 0, 1 to 10, 11 to 20, 21 to 39, and 40 or more. Participants indicated their current coffee intake based on 8 possible responses ranging from 0 to 7 or more cups a day.

Hypertension was defined as a blood pressure of 160/105 mm Hg or greater on 1 annual questionnaire, 140/90 mm Hg on at least 2 readings at least 1 week apart, or pharmacologic treatment of hypertension. Type 2 diabetes mellitus was defined as report of pharmacologically treated diabetes on a single questionnaire, report of nonpharmacologically treated diabetes on 2 or more questionnaires, physician diagnosis of diabetes in medical records, or report of a fasting plasma glucose level of at least 140 mg/dL (7.8 mmol/L) or a nonfasting plasma glucose level of at least 200 mg/dL (11.1 mmol/L).33 Incidence of clinical depression was measured on the mailed surveys with direct questions concerning the occurrence of depression and associated treatment.34

OUTCOME MEASURES

The primary dependent variable for this analysis was the incidence of CHD occurring on or before age 50 years. Secondary dependent variables were all CHD (incident events, fatal and nonfatal) occurring at any age, CHD mortality, and total mortality. Coronary heart disease was defined as myocardial infarction, sudden death, angina pectoris, chronic ischemic heart disease, and other coronary disease requiring coronary bypass surgery or percutaneous coronary intervention.

STATISTICAL ANALYSIS

Follow-up began at graduation from medical school and continued through December 31, 2001. Baseline characteristics for physicians from low- and high-SES families were summarized and compared using means and t tests for continuous variables and percentages and χ2 tests for categorical variables. Kaplan-Meier methods and the log-rank test were used to compare the time to event for incident CHD and mortality between physicians with low and high childhood SES. Proportional hazards models were used to assess the impact of possible CHD risk factors on the relationship between childhood SES and CHD. These factors were serum cholesterol level and exercise during medical school and the presence of parental history of premature CHD and of hypertension, diabetes mellitus, depression, smoking, coffee drinking, and BMI as time-dependent covariates. Follow-up was truncated at age 50 years in models used to assess the effects of covariates on incidence at or before age 50 years. The relatively few CHD events at and before age 50 years limited our ability to adjust for multiple variables simultaneously. Thus, bivariate models were used to determine whether the effect of childhood SES on CHD was mediated through other CHD risk factors. The proportionality of hazards was confirmed with log-log plots and by examining the Schoenfeld residuals.35 A 2-tailed P≤.05 was considered statistically significant. All statistical analyses were carried out with commercially available software (Stata Release 8.0; StataCorp, College Station, Tex).

BASELINE CHARACTERISTICS

The baseline characteristics of the 1131 men in this study assessed during medical school are given in Table 1. Of 1131 subjects, 216 (19.1%) were from low-SES families. Medical students from low-SES families were slightly older at graduation (26.8 vs 26.2 years; P = .004), and there was no difference in other CHD risk factors at the time of medical school graduation, including BMI, serum cholesterol levels, cigarette smoking, amount of exercise, or family history of premature CHD.

Table Graphic Jump LocationTable 1. Baseline Characteristics According to Childhood SES in 1131 White Male Medical School Graduates in The Johns Hopkins Precursors Study*
CHANGES IN CARDIOVASCULAR DISEASE RISK FACTORS OVER TIME

Body mass index increased over time in physicians from both low-SES and high-SES families (Table 2). Physicians from low-SES families, however, had a significantly higher mean BMI at ages 40 to 49, 50 to 59, and 60 to 69 years. While the rates of cigarette smoking decreased in both groups over time, physicians from low-SES families had higher smoking rates in each decade, although the differences were not statistically significant.

Table Graphic Jump LocationTable 2. BMI and Cigarette Smoking During Follow-up by Childhood SES in 1131 White Male Medical School Graduates in The Johns Hopkins Precursors Study*

The mean age of developing hypertension and diabetes mellitus was similar in the 2 groups. Physicians from low-SES families developed hypertension 1 year earlier than did physicians from high-SES families, with a mean (SD) age at onset of 54.1 (13.3) vs 55.0 (13.0) years, although this difference was not significant. There was no difference in the age at onset of diabetes mellitus, with a mean age of 57 years in both groups.

CHILDHOOD SES AND RISK OF CHD

Median follow-up time in this analysis was 40 years, yielding 43 160 person-years of observation. During this period, 217 men experienced CHD events. The incidence of CHD from age 40 to age 75 years was consistently greater in men from lower childhood SES backgrounds than in those from higher SES families (Figure). During the entire follow-up, differences in incidence between the groups did not achieve a conventional level of statistical significance (P = .11; Figure), but the incidence of CHD on or before age 50 years was significantly greater in physicians with low compared with high childhood SES (P = .01). Incidence of CHD, fatal CHD, and total mortality by 50 and 70 years are given in Table 3.

Place holder to copy figure label and caption
Figure.

Cumulative probability of coronary heart disease in 1131 white male medical school graduates according to childhood socioeconomic status (SES).

Graphic Jump Location
Table Graphic Jump LocationTable 3. Kaplan-Meier Analysis of All CHD, CHD Mortality, and Total Mortality by Ages 50 and 70 Years in The Johns Hopkins Precursors Study

In univariate proportional hazards analysis, the unadjusted relative risk of developing CHD on or before age 50 years associated with low childhood SES was 2.40 (95% confidence interval [CI], 1.21-4.74; Table 4). In bivariate Cox proportional hazards models, the risk of developing early CHD associated with low childhood SES was not reduced after adjusting for serum cholesterol level during medical school, amount of exercise during medical school, amount of cigarette smoking or coffee drinking during follow-up, BMI during follow-up, parental history of premature CHD, or development of diabetes mellitus, hypertension, or depression during follow-up (Table 4).

Table Graphic Jump LocationTable 4. Risk of CHD Associated With Low Childhood SES at Different Age Thresholds in 1131 White Male Medical School Graduates in The Johns Hopkins Precursors Study*
CHILDHOOD SES AND MORTALITY

During a median follow-up of 40 years, 52 deaths related to CHD and 224 total deaths occurred. When the entire follow-up was considered, participants with low childhood SES demonstrated a trend toward increased CHD mortality (hazard ratio [HR], 2.0; 95% CI, 0.99-3.90) compared with physicians with high childhood SES, but no such association was seen for all-cause mortality (HR, 1.08; 95% CI, 0.78-1.48). There were few events by age 50 years (6 deaths due to CHD and 42 total deaths). When only these events were considered, there was the suggestion of an association of low SES with CHD death (HR, 4.27; 95% CI, 0.86-21.17), but not with all-cause mortality (HR, 0.99; 95% CI, 0.46-2.14).

SENSITIVITY ANALYSIS

When information on the mother's occupation was used to reclassify 19 of the participants with low childhood SES as high-SES subjects, our results were unchanged. In addition, analyses using 3 levels of childhood SES also showed a higher risk of premature CHD in the lowest SES group (data not shown).

The present study found that low childhood SES is a risk factor for incident CHD before age 50 years in men with uniformly high adulthood SES. We noted a trend toward increased CHD mortality in physicians of low childhood SES, but no difference in all-cause mortality. This increased risk exists despite physicians' high level of SES as adults, their medical knowledge, and their access to high-quality health care. The higher risk of early CHD was not mediated by BMI, cholesterol level, exercise, depression, coffee drinking, smoking, hypertension, diabetes mellitus, or parental history of CHD.

Several conceptual models have been proposed to explain how lower childhood and adulthood SES may lead to increased risk for cardiovascular disease.7 The latent effects model proposes that adverse early life experiences permanently affect the individual in a way that is not influenced by adult experiences. The pathway model suggests that early life experiences affect adult health by influencing adult behavior and risk factors. The cumulative model hypothesizes that health is determined by the cumulative number of years that an individual spends in either a low- or high-SES category. Individuals with low childhood SES in our study did have higher BMI and were more likely to smoke cigarettes than were individuals with high childhood SES, supporting the pathway model. Low childhood SES was associated with higher CHD risk only before the age of 50 years. After that age, individuals with low SES in childhood in this cohort had spent proportionately more of their lifetime at a high SES than at a low SES.

Low childhood SES may confer an increased risk of CHD on or before age 50 years but not later in life for several reasons. First, other CHD risk factors are more prevalent later in life; thus, the proportionate effect of low childhood SES may be reduced. A similar relationship has been noted in The Johns Hopkins Precursors Study cohort with other risk factors.36 Second, the current study may have been underpowered to detect a small risk of CHD at older ages. For example, in the Nurses’ Health Study of 117 006 participants, the age-adjusted risk of total cardiovascular disease events was 1.13 (95% CI, 1.02-1.24) for nurses with low vs high childhood SES,17 similar to the risk seen in the present study for incident CHD over the lifespan, 1.29. Likewise, the lack of statistical significance for the 2-fold increase in the risk of CHD mortality associated with low childhood SES likely reflects lack of statistical power.

Three other studies have examined the risks of CHD in individuals who have moved from lower SES to higher SES. Two of them, a case-control study of former Harvard University students37 and the Nurses’ Health Study,17 found a higher risk in persons with low childhood SES. A study of Finnish men born in the late 1950s found that adulthood SES had a greater effect on mortality than did childhood SES, although childhood SES had a persistent effect on mortality from cardiovascular disease.38

Besides these studies, which specifically examined the move from low childhood SES to high adulthood SES, many other studies have investigated the relationship between childhood SES and cardiovascular events.1229 However, most of these studies were conducted outside the United States,1216,18,19,2129 ascertained childhood SES in late adulthood,1214,19,21,2527,29 or, if a prospective design was used, started follow-up in midlife, assessing only for possible confounders occurring later than age 40 years.20,28 Nevertheless, low childhood SES was associated with a higher risk of cardiovascular events in all of the studies, although the effects of adjustment for established CHD risk factors and adulthood SES varied.15,16,18 Thus, compared with all studies of childhood SES and CHD, the present study offers a unique perspective of early CHD in a well-defined cohort of medical school graduates.

The present study adds to the body of information on childhood SES and CHD in several ways. First, data on childhood SES were collected earlier in adulthood, before clinical events had occurred, minimizing possible recall bias. Second, all of the participants graduated from medical school and thus had uniformly high adulthood SES, thereby eliminating confounding by changes in adulthood SES. Finally, unlike the other studies, we examined the relationship between childhood SES and early CHD.

Although different life-course models help to conceptualize the relationship between childhood SES and the development of CHD in adulthood, the underlying biological factors are less clear. The association between lower SES in adulthood and CHD risk has been ascribed to a higher prevalence of CHD risk factors in adults with low SES, including hypertension,39 the metabolic syndrome,40 and unhealthy behaviors, including smoking, high-fat diets, and low levels of physical activity.41 Evidence also suggests that adults with low SES have differential activation of biological pathways that are implicated in the development of CHD. Compared with adults of high SES, those with lower SES have higher levels of cortisol,42 higher levels of C-reactive protein,43 greater platelet activation,44 and more atherogenic lipid profiles.45 More data are needed on the persistence of the relationships between low SES and these biological variables.

Some limitations of our study deserve mention. Our exposure definition, parental occupation, is based on self-report, which can be subject to error. If persons with low childhood SES systematically reported higher levels, as defined by parental occupation, then the true association between low SES and CHD would most likely be diluted. In addition, these findings should be generalized with caution to groups other than male physicians of European ancestry. Furthermore, our conclusions are based on a relatively small number of events before age 50 years. Another limitation is the use of paternal occupation as a measure of childhood SES. Socioeconomic status is a multidimensional construct, and other studies have used parents' level of education, occupation, and/or income as measures.46,47 Income may be the best marker of childhood SES,4850 but occupation is used in about a quarter of studies and is a reasonable surrogate for childhood SES.6,4850

Nevertheless, The Johns Hopkins Precursors Study cohort offers study strengths. The strengths of the present study include a long follow-up period and an excellent response rate from participants. The cohort design also allows for accurate measurement of confounders that vary over time and for precise measurement of exposure status before disease onset without the risk of recall bias or reverse causality. In addition, self-reports of CHD risk factors and clinical outcomes have been validated in this cohort.51

In conclusion, these results indicate that, even for individuals with uniformly high SES in adulthood, the presence of low SES in childhood confers an increased risk of developing CHD before age 50 years. This increased risk is not mediated by established CHD risk factors. These findings highlight the importance of childhood events in the development of CHD in adulthood. More importantly, the data illustrate the difficulty in eliminating health status disparities between low-SES and high-SES populations: even an intervention that allowed low-SES individuals to assume the lifestyle of physicians did not totally eliminate disparities in early CHD outcomes.

Correspondence: Michelle M. Kittleson, MD, PhD, The Johns Hopkins Precursors Study, 2024 E Monument St, Suite 2-200, Baltimore, MD 21205 (mkittleson@mednet.ucla.edu).

Accepted for Publication: August 29, 2006.

Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kittleson, Wang, Ford, and Klag. Acquisition of data: Kittleson, Wang, Ford, and Klag. Analysis and interpretation of data: Kittleson, Meoni, Wang, Chu, Ford, and Klag. Drafting of the manuscript: Kittleson. Critical revision of the manuscript for important intellectual content: Kittleson, Meoni, Wang, Chu, Ford, and Klag. Statistical analysis: Kittleson, Meoni, Wang, Chu, Ford, and Klag. Obtained funding: Klag. Administrative, technical, and material support: Ford and Klag. Study supervision: Ford and Klag.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grants K24 DK02856, R01 AG01760, and T32 HL007227-30 from the National Institutes of Health.

Anderson  RNSmith  BL Deaths: leading causes for 2001. Natl Vital Stat Rep 2003;52 ((9)) 1- 85
PubMed
Smith  GDShipley  MJRose  G Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study. J Epidemiol Community Health 1990;44265- 270
PubMed Link to Article
Rose  GMarmot  MG Social class and coronary heart disease. Br Heart J 1981;4513- 19
PubMed Link to Article
Rosengren  AOrth-Gomer  KWilhelmsen  L Socioeconomic differences in health indices, social networks and mortality among Swedish men: a study of men born in 1933. Scand J Soc Med 1998;26272- 280
PubMed
Woodward  MOliphant  JLowe  GTunstall-Pedoe  H Contribution of contemporaneous risk factors to social inequality in coronary heart disease and all causes mortality. Prev Med 2003;36561- 568
PubMed Link to Article
Kaplan  GAKeil  JE Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation 1993;881973- 1998
PubMed Link to Article
Pollitt  RARose  KMKaufman  JS Evaluating the evidence for models of life course socioeconomic factors and cardiovascular outcomes: a systematic review. BMC Public Health 2005;57
PubMed Link to Article
Ward  EJemal  ACokkinides  V  et al.  Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin 2004;5478- 93
PubMed Link to Article
Bagger  JPZindrou  DTaylor  PK Postoperative infection with meticillin-resistant Staphylococcus aureus and socioeconomic background. Lancet 2004;363706- 708
PubMed Link to Article
Stockwell  EGGoza  FWLuse  VO Infectious disease mortality among adults by race and socioeconomic status: metropolitan Ohio, 1989-1991. Soc Biol 1997;44148- 152
PubMed
Isaacs  SLSchroeder  SA Class—the ignored determinant of the nation's health. N Engl J Med 2004;3511137- 1142
PubMed Link to Article
Burr  MLSweetnam  PM Family size and paternal unemployment in relation to myocardial infarction. J Epidemiol Community Health 1980;3493- 95
PubMed Link to Article
Notkola  VPunsar  SKarvonen  MJHaapakoski  J Socio-economic conditions in childhood and mortality and morbidity caused by coronary heart disease in adulthood in rural Finland. Soc Sci Med 1985;21517- 523
PubMed Link to Article
Coggon  DMargetts  BBarker  DJ  et al.  Childhood risk factors for ischaemic heart disease and stroke. Paediatr Perinat Epidemiol 1990;4464- 469
PubMed Link to Article
Hasle  H Association between living conditions in childhood and myocardial infarction. BMJ 1990;300512- 513
PubMed Link to Article
Lundberg  O The impact of childhood living conditions on illness and mortality in adulthood. Soc Sci Med 1993;361047- 1052
PubMed Link to Article
Gliksman  MDKawachi  IHunter  D  et al.  Childhood socioeconomic status and risk of cardiovascular disease in middle aged US women: a prospective study. J Epidemiol Community Health 1995;4910- 15
PubMed Link to Article
Marmot  MShipley  MBrunner  EHemingway  H Relative contribution of early life and adult socioeconomic factors to adult morbidity in the Whitehall II study. J Epidemiol Community Health 2001;55301- 307
PubMed Link to Article
Wamala  SPLynch  JKaplan  GA Women's exposure to early and later life socioeconomic disadvantage and coronary heart disease risk: the Stockholm Female Coronary Risk Study. Int J Epidemiol 2001;30275- 284
PubMed Link to Article
Lynch  JWKaplan  GACohen  RD  et al.  Childhood and adult socioeconomic status as predictors of mortality in Finland. Lancet 1994;343524- 527
PubMed Link to Article
Vagero  DLeon  D Effect of social class in childhood and adulthood on adult mortality. Lancet 1994;3431224- 1225
PubMed Link to Article
Smith  GDHart  CBlane  DHole  D Adverse socioeconomic conditions in childhood and cause specific adult mortality: prospective observational study. BMJ 1998;3161631- 1635
PubMed Link to Article
Smith  GDHart  C Life-course socioeconomic and behavioral influences on cardiovascular disease mortality: the collaborative study. Am J Public Health 2002;921295- 1298
PubMed Link to Article
Hart  CLSmith  GDBlane  D Inequalities in mortality by social class measured at 3 stages of the lifecourse. Am J Public Health 1998;88471- 474
PubMed Link to Article
Dedman  DJGunnell  DDavey  SGFrankel  S Childhood housing conditions and later mortality in the Boyd Orr cohort. J Epidemiol Community Health 2001;5510- 15
PubMed Link to Article
Frankel  SSmith  GDGunnell  D Childhood socioeconomic position and adult cardiovascular mortality: the Boyd Orr Cohort. Am J Epidemiol 1999;1501081- 1084
PubMed Link to Article
Claussen  BDavey  Smith GThelle  D Impact of childhood and adulthood socioeconomic position on cause specific mortality: the Oslo Mortality Study. J Epidemiol Community Health 2003;5740- 45
PubMed Link to Article
Osler  MAndersen  AMDue  PLund  RDamsgaard  MTHolstein  BE Socioeconomic position in early life, birth weight, childhood cognitive function, and adult mortality: a longitudinal study of Danish men born in 1953. J Epidemiol Community Health 2003;57681- 686
PubMed Link to Article
Kaplan  GASalonen  JT Socioeconomic conditions in childhood and ischaemic heart disease during middle age. BMJ 1990;3011121- 1123
PubMed Link to Article
 Alphabetical Index of Industries and Occupations: 1950 Census of Population. Rev ed. Washington, DC US Bureau of the Census1951;
Klag  MJFord  DEMead  LA  et al.  Serum cholesterol in young men and subsequent cardiovascular disease. N Engl J Med 1993;328313- 318
PubMed Link to Article
 Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993;2693015- 3023
PubMed Link to Article
Golden  SHWang  NYKlag  MJMeoni  LABrancati  FL Blood pressure in young adulthood and the risk of type 2 diabetes in middle age. Diabetes Care 2003;261110- 1115
PubMed Link to Article
Chang  PPFord  DEMead  LACooper-Patrick  LKlag  MJ Insomnia in young men and subsequent depression: The Johns Hopkins Precursors Study. Am J Epidemiol 1997;146105- 114
PubMed Link to Article
Schoenfeld  D Partial residuals for the proportional hazard regression model. Biometrika 1982;69239- 241
Link to Article
Chang  PPFord  DEMeoni  LAWang  NYKlag  MJ Anger in young men and subsequent premature cardiovascular disease: the Precursors Study. Arch Intern Med 2002;162901- 906
PubMed Link to Article
Gillum  RFPaffenbarger  RS  Jr Chronic disease in former college students, XVII: sociocultural mobility as a precursor of coronary heart disease and hypertension. Am J Epidemiol 1978;108289- 298
PubMed
Pensola  THMartikainen  P Cumulative social class and mortality from various causes of adult men. J Epidemiol Community Health 2003;57745- 751
PubMed Link to Article
Colhoun  HMHemingway  HPoulter  NR Socio-economic status and blood pressure: an overview analysis. J Hum Hypertens 1998;1291- 110
PubMed Link to Article
Brunner  EJMarmot  MGNanchahal  K  et al.  Social inequality in coronary risk: central obesity and the metabolic syndrome: evidence from the Whitehall II study. Diabetologia 1997;401341- 1349
PubMed Link to Article
Hellerstedt  WLJeffery  RW The association of job strain and health behaviours in men and women. Int J Epidemiol 1997;26575- 583
PubMed Link to Article
Steptoe  AKunz-Ebrecht  SOwen  N  et al.  Socioeconomic status and stress-related biological responses over the working day. Psychosom Med 2003;65461- 470
PubMed Link to Article
Owen  NPoulton  THay  FCMohamed-Ali  VSteptoe  A Socioeconomic status, C-reactive protein, immune factors, and responses to acute mental stress. Brain Behav Immun 2003;17286- 295
PubMed Link to Article
Steptoe  AMagid  KEdwards  SBrydon  LHong  YErusalimsky  J The influence of psychological stress and socioeconomic status on platelet activation in men. Atherosclerosis 2003;16857- 63
PubMed Link to Article
Brunner  EJMarmot  MGWhite  IR  et al.  Gender and employment grade differences in blood cholesterol, apolipoproteins and haemostatic factors in the Whitehall II study. Atherosclerosis 1993;102195- 207
PubMed Link to Article
Lynch  JWKaplan  GASalonen  JT Why do poor people behave poorly? variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Soc Sci Med 1997;44809- 819
PubMed Link to Article
Winkleby  MARobinson  TNSundquist  JKraemer  HC Ethnic variation in cardiovascular disease risk factors among children and young adults: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. JAMA 1999;2811006- 1013
PubMed Link to Article
Daly  MCDuncan  GJMcDonough  PWilliams  DR Optimal indicators of socioeconomic status for health research. Am J Public Health 2002;921151- 1157
PubMed Link to Article
Lantz  PMHouse  JSLepkowski  JMWilliams  DRMero  RPChen  J Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA 1998;2791703- 1708
PubMed Link to Article
Davey Smith  GHart  CHole  D  et al.  Education and occupational social class: which is the more important indicator of mortality risk? J Epidemiol Community Health 1998;52153- 160
PubMed Link to Article
Klag  MJHe  JMead  LAFord  DEPearson  TALevine  DM Validity of physicians' self-reports of cardiovascular disease risk factors. Ann Epidemiol 1993;3442- 447
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure.

Cumulative probability of coronary heart disease in 1131 white male medical school graduates according to childhood socioeconomic status (SES).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Baseline Characteristics According to Childhood SES in 1131 White Male Medical School Graduates in The Johns Hopkins Precursors Study*
Table Graphic Jump LocationTable 2. BMI and Cigarette Smoking During Follow-up by Childhood SES in 1131 White Male Medical School Graduates in The Johns Hopkins Precursors Study*
Table Graphic Jump LocationTable 3. Kaplan-Meier Analysis of All CHD, CHD Mortality, and Total Mortality by Ages 50 and 70 Years in The Johns Hopkins Precursors Study
Table Graphic Jump LocationTable 4. Risk of CHD Associated With Low Childhood SES at Different Age Thresholds in 1131 White Male Medical School Graduates in The Johns Hopkins Precursors Study*

References

Anderson  RNSmith  BL Deaths: leading causes for 2001. Natl Vital Stat Rep 2003;52 ((9)) 1- 85
PubMed
Smith  GDShipley  MJRose  G Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall Study. J Epidemiol Community Health 1990;44265- 270
PubMed Link to Article
Rose  GMarmot  MG Social class and coronary heart disease. Br Heart J 1981;4513- 19
PubMed Link to Article
Rosengren  AOrth-Gomer  KWilhelmsen  L Socioeconomic differences in health indices, social networks and mortality among Swedish men: a study of men born in 1933. Scand J Soc Med 1998;26272- 280
PubMed
Woodward  MOliphant  JLowe  GTunstall-Pedoe  H Contribution of contemporaneous risk factors to social inequality in coronary heart disease and all causes mortality. Prev Med 2003;36561- 568
PubMed Link to Article
Kaplan  GAKeil  JE Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation 1993;881973- 1998
PubMed Link to Article
Pollitt  RARose  KMKaufman  JS Evaluating the evidence for models of life course socioeconomic factors and cardiovascular outcomes: a systematic review. BMC Public Health 2005;57
PubMed Link to Article
Ward  EJemal  ACokkinides  V  et al.  Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin 2004;5478- 93
PubMed Link to Article
Bagger  JPZindrou  DTaylor  PK Postoperative infection with meticillin-resistant Staphylococcus aureus and socioeconomic background. Lancet 2004;363706- 708
PubMed Link to Article
Stockwell  EGGoza  FWLuse  VO Infectious disease mortality among adults by race and socioeconomic status: metropolitan Ohio, 1989-1991. Soc Biol 1997;44148- 152
PubMed
Isaacs  SLSchroeder  SA Class—the ignored determinant of the nation's health. N Engl J Med 2004;3511137- 1142
PubMed Link to Article
Burr  MLSweetnam  PM Family size and paternal unemployment in relation to myocardial infarction. J Epidemiol Community Health 1980;3493- 95
PubMed Link to Article
Notkola  VPunsar  SKarvonen  MJHaapakoski  J Socio-economic conditions in childhood and mortality and morbidity caused by coronary heart disease in adulthood in rural Finland. Soc Sci Med 1985;21517- 523
PubMed Link to Article
Coggon  DMargetts  BBarker  DJ  et al.  Childhood risk factors for ischaemic heart disease and stroke. Paediatr Perinat Epidemiol 1990;4464- 469
PubMed Link to Article
Hasle  H Association between living conditions in childhood and myocardial infarction. BMJ 1990;300512- 513
PubMed Link to Article
Lundberg  O The impact of childhood living conditions on illness and mortality in adulthood. Soc Sci Med 1993;361047- 1052
PubMed Link to Article
Gliksman  MDKawachi  IHunter  D  et al.  Childhood socioeconomic status and risk of cardiovascular disease in middle aged US women: a prospective study. J Epidemiol Community Health 1995;4910- 15
PubMed Link to Article
Marmot  MShipley  MBrunner  EHemingway  H Relative contribution of early life and adult socioeconomic factors to adult morbidity in the Whitehall II study. J Epidemiol Community Health 2001;55301- 307
PubMed Link to Article
Wamala  SPLynch  JKaplan  GA Women's exposure to early and later life socioeconomic disadvantage and coronary heart disease risk: the Stockholm Female Coronary Risk Study. Int J Epidemiol 2001;30275- 284
PubMed Link to Article
Lynch  JWKaplan  GACohen  RD  et al.  Childhood and adult socioeconomic status as predictors of mortality in Finland. Lancet 1994;343524- 527
PubMed Link to Article
Vagero  DLeon  D Effect of social class in childhood and adulthood on adult mortality. Lancet 1994;3431224- 1225
PubMed Link to Article
Smith  GDHart  CBlane  DHole  D Adverse socioeconomic conditions in childhood and cause specific adult mortality: prospective observational study. BMJ 1998;3161631- 1635
PubMed Link to Article
Smith  GDHart  C Life-course socioeconomic and behavioral influences on cardiovascular disease mortality: the collaborative study. Am J Public Health 2002;921295- 1298
PubMed Link to Article
Hart  CLSmith  GDBlane  D Inequalities in mortality by social class measured at 3 stages of the lifecourse. Am J Public Health 1998;88471- 474
PubMed Link to Article
Dedman  DJGunnell  DDavey  SGFrankel  S Childhood housing conditions and later mortality in the Boyd Orr cohort. J Epidemiol Community Health 2001;5510- 15
PubMed Link to Article
Frankel  SSmith  GDGunnell  D Childhood socioeconomic position and adult cardiovascular mortality: the Boyd Orr Cohort. Am J Epidemiol 1999;1501081- 1084
PubMed Link to Article
Claussen  BDavey  Smith GThelle  D Impact of childhood and adulthood socioeconomic position on cause specific mortality: the Oslo Mortality Study. J Epidemiol Community Health 2003;5740- 45
PubMed Link to Article
Osler  MAndersen  AMDue  PLund  RDamsgaard  MTHolstein  BE Socioeconomic position in early life, birth weight, childhood cognitive function, and adult mortality: a longitudinal study of Danish men born in 1953. J Epidemiol Community Health 2003;57681- 686
PubMed Link to Article
Kaplan  GASalonen  JT Socioeconomic conditions in childhood and ischaemic heart disease during middle age. BMJ 1990;3011121- 1123
PubMed Link to Article
 Alphabetical Index of Industries and Occupations: 1950 Census of Population. Rev ed. Washington, DC US Bureau of the Census1951;
Klag  MJFord  DEMead  LA  et al.  Serum cholesterol in young men and subsequent cardiovascular disease. N Engl J Med 1993;328313- 318
PubMed Link to Article
 Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993;2693015- 3023
PubMed Link to Article
Golden  SHWang  NYKlag  MJMeoni  LABrancati  FL Blood pressure in young adulthood and the risk of type 2 diabetes in middle age. Diabetes Care 2003;261110- 1115
PubMed Link to Article
Chang  PPFord  DEMead  LACooper-Patrick  LKlag  MJ Insomnia in young men and subsequent depression: The Johns Hopkins Precursors Study. Am J Epidemiol 1997;146105- 114
PubMed Link to Article
Schoenfeld  D Partial residuals for the proportional hazard regression model. Biometrika 1982;69239- 241
Link to Article
Chang  PPFord  DEMeoni  LAWang  NYKlag  MJ Anger in young men and subsequent premature cardiovascular disease: the Precursors Study. Arch Intern Med 2002;162901- 906
PubMed Link to Article
Gillum  RFPaffenbarger  RS  Jr Chronic disease in former college students, XVII: sociocultural mobility as a precursor of coronary heart disease and hypertension. Am J Epidemiol 1978;108289- 298
PubMed
Pensola  THMartikainen  P Cumulative social class and mortality from various causes of adult men. J Epidemiol Community Health 2003;57745- 751
PubMed Link to Article
Colhoun  HMHemingway  HPoulter  NR Socio-economic status and blood pressure: an overview analysis. J Hum Hypertens 1998;1291- 110
PubMed Link to Article
Brunner  EJMarmot  MGNanchahal  K  et al.  Social inequality in coronary risk: central obesity and the metabolic syndrome: evidence from the Whitehall II study. Diabetologia 1997;401341- 1349
PubMed Link to Article
Hellerstedt  WLJeffery  RW The association of job strain and health behaviours in men and women. Int J Epidemiol 1997;26575- 583
PubMed Link to Article
Steptoe  AKunz-Ebrecht  SOwen  N  et al.  Socioeconomic status and stress-related biological responses over the working day. Psychosom Med 2003;65461- 470
PubMed Link to Article
Owen  NPoulton  THay  FCMohamed-Ali  VSteptoe  A Socioeconomic status, C-reactive protein, immune factors, and responses to acute mental stress. Brain Behav Immun 2003;17286- 295
PubMed Link to Article
Steptoe  AMagid  KEdwards  SBrydon  LHong  YErusalimsky  J The influence of psychological stress and socioeconomic status on platelet activation in men. Atherosclerosis 2003;16857- 63
PubMed Link to Article
Brunner  EJMarmot  MGWhite  IR  et al.  Gender and employment grade differences in blood cholesterol, apolipoproteins and haemostatic factors in the Whitehall II study. Atherosclerosis 1993;102195- 207
PubMed Link to Article
Lynch  JWKaplan  GASalonen  JT Why do poor people behave poorly? variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Soc Sci Med 1997;44809- 819
PubMed Link to Article
Winkleby  MARobinson  TNSundquist  JKraemer  HC Ethnic variation in cardiovascular disease risk factors among children and young adults: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. JAMA 1999;2811006- 1013
PubMed Link to Article
Daly  MCDuncan  GJMcDonough  PWilliams  DR Optimal indicators of socioeconomic status for health research. Am J Public Health 2002;921151- 1157
PubMed Link to Article
Lantz  PMHouse  JSLepkowski  JMWilliams  DRMero  RPChen  J Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA 1998;2791703- 1708
PubMed Link to Article
Davey Smith  GHart  CHole  D  et al.  Education and occupational social class: which is the more important indicator of mortality risk? J Epidemiol Community Health 1998;52153- 160
PubMed Link to Article
Klag  MJHe  JMead  LAFord  DEPearson  TALevine  DM Validity of physicians' self-reports of cardiovascular disease risk factors. Ann Epidemiol 1993;3442- 447
PubMed Link to Article

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