Systematic Review of the Influence of Childhood Socioeconomic Circumstances on Risk for Cardiovascular Disease in Adulthood
Introduction
Chronic diseases have long induction times. Geoffrey Rose (1) reported that the ecologic correlation between cholesterol level, systolic and diastolic blood pressure (BP), and coronary heart disease (CHD) mortality increased with time, suggesting that the induction period between exposure to these risk factors and CHD mortality may extend over decades. More recently, a growing body of evidence showed that adult diseases are influenced by a variety of early-life exposures 2, 3, 4 that may have a role in the early asymptomatic phases of the disease process. For example, autopsy studies found atherosclerotic lesions in children and young adults 5, 6, and carotid arterial thickening was observed in children with high levels of risk factors (7). Two recent studies showed links between high levels of risk factors early in life and atherosclerosis later in adulthood. Systolic BP, low-density lipoprotein cholesterol level, cigarette smoking, and body mass index (BMI) measured between 12 to 18 years of age in the Cardiovascular Risk in Young Finns Study were associated with greater adult carotid intima-media thickness (IMT), independently of adult levels of these risk factors (8). Likewise, the Bogalusa Heart Study reported greater carotid IMT in persons who had greater levels of low-density lipoprotein cholesterol and BMI during childhood (9).
Socioeconomic circumstances are important determinants of cardiovascular disease (CVD), partly because of their associations with adult risk factors (10); thus, it is not surprising that socioeconomic conditions experienced during childhood also may be relevant to clinically recognized adult disease (11). Such ideas are not new. For example, in 1961, Christenson and Hinkle (12) studied a group of men working in managerial positions and found a greater risk for angina and electrocardiogram abnormalities in men who had experienced less favorable childhood socioeconomic circumstances. Christenson and Hinkle (12) pointed out the potential contribution of socioeconomic factors occurring early in life to adult CVD risk.
Several studies assessed the link between childhood socioeconomic circumstances and adult CVD risk. Considerations of study design and outcome subtype may help in interpreting reported results, but these have not been assessed systematically. Our objective is to present a systematic review of the evidence on whether adverse socioeconomic circumstances in childhood confer greater risk for CVD and its specific subcategories.
Section snippets
Methods
We systematically reviewed titles and abstracts of all individual-level studies evaluating the association between childhood socioeconomic circumstances and CVD from MEDLINE, EMBASE, and ISI Web of Science up to September 2004 and added publications that appeared afterward. We retrieved studies that included morbidity and mortality from CVD and specific disease subtypes, including CHD, ischemic and hemorrhagic stroke, peripheral vascular disease, markers of atherosclerosis (carotid IMT and
Results
We located 40 studies (24 prospective, 11 case–control, and 5 cross-sectional), reported in 50 publications, assessing the relation between childhood SEP and adult CVD or CVD subtypes (Table 1, Table 2, Table 3, Table 4). Thirty-one studies (19 prospective [12, 17–41], 7 case–control [42–48], and all 5 cross-sectional [49–53] studies) found a robust inverse association between childhood circumstances and CVD risk, although findings sometimes varied among specific outcomes, SEP measure, or
Discussion
The bulk of the evidence from individual-level studies confirms that those who experienced worse socioeconomic conditions in their childhood, independently of their circumstances during adult life, generally were at greater risk for developing and dying of CVD. The majority (80%) of prospective studies, the study design that can present the strongest evidence, and all cross-sectional studies found an association between poor childhood circumstances and greater risk for CHD, angina, stroke, and
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J.W.L. and G.D.S. were supported in part by a Robert Wood Johnson Foundation Investigators Award in Health Policy Research. Funds from this award also partly supported B.G.
The views expressed in this review are those of the authors and not necessarily any funding bodies.