One of our readings for this week was Social Justice is Good for Our Hearts by Dennis Raphael. Raphael explains in the article that poverty and social exclusion cause cardiovascular disease (CVD). Raphael even goes so far as to say that lifestyle only plays a small role compared to poverty and social exclusion. The following is an excerpt from the article:
“Yet like so many other public discussions of the causes of CVD, the risk factors discussed in that document are limited to age, gender, family history, unhealthy behaviours such as tobacco use and physical inactivity, and biomedical indicators such as high blood pressure and blood cholesterol. This is surprising as numerous studies indicate that while these medical and lifestyle risk factors contribute to heart disease and stroke, they account for only a small proportion in the variation in their incidence.”
I understand that the social determinants of health have a great effect on our health but I'm struggling with Raphael’s notion that lifestyle factors only play a small role. My perception was that lifestyle choices such as poor eating habits, physical inactivity, and obesity or overweight were known to be risk factors for developing CVD. I thought this was common knowledge. In FNN 301 we were taught that the modifiable risk factors for CVD were hypertension, management of diabetes, inflammation, smoking, weight and waist circumference, a sedentary lifestyle and high cholesterol and the unmodifiable risk factors were family history, genetics, age, gender and having diabetes. I guess this is the other side of the coin- all medical and lifestyle risk factors and no mention of social determinants of health. I can’t help but think that the real answer in somewhere in the middle.
I decided to look into the articles that were given as supporting the above Raphael quote. Although he states that ‘numerous’ studies indicate that medical and lifestyle factors play only a small role in the incidence of CVD, he only references three. The three studies he referenced were published in 1978, 1998 and 1989. Since Social Justice is Good for Our Hearts was published in 2002, Raphael was citing articles that were 13 and 24 years old. In addition, the articles weren’t focused on whether lifestyle or the social determinants of health cause CVD. They were titled “Employment Grade and Coronary Heart Disease in British Civil Servants”, “Socioeconomic Factors, Health Behaviors, and Mortality”, and “National Trends in Educational Differentials in Mortality”. If there are numerous studies that show that medical and lifestyle factors only play a small role in the incidence of CVD, why did Raphael use out-dated research that didn’t focus on what he was trying to prove?
The number of articles that maintains these truths continue to be published. Wake up please.
ReplyDeleteKuh D, Ben-Shilmo Y, editors. A Life Course Approach to Chronic Disease Epidemiology. 2nd ed. Ocford, UK: Oxford University Press; 2004.
Davey Smith G, editor. Inequalities in Health: Life Course Perspectives. Bristol UK: Policy Press; 2003.
Barker D, Forsen T, Uutela A, Osmond C, Eriksson J. Size at Birth and Resilience to Effects of Poor Living Conditions in Adult Life: Longitudinal Study. BMJ - Clinical Research 2001;323(7324):1273-6.
Meany MJ, Szyf M, Seckl JR. Epigenetic mechanims of perinatal programming of hypothalamic-pituitary,adrenal function and health. Trend in Nuclear Medicine 2007;13(7):269-277.
Davey Smith G, Gordon D. Poverty across the life-course and health. In: Pantazis C, Gordon D, editors. Tackling Inequalities: Where Are We Now and What Can Be Done? Bristol, UK: Policy Press; 2000.
Evans G, Kim P. Childhood Poverty and Health: Cumulative Risk Exposure and Stress Dysregulation. Psychological Science 2007;18:953-957.
ReplyDeleteRecent enough for you?
Lawlor DA, Smith GD, Ebrahim S. Association Between Childhood Socioeconomic Status and Coronary Heart Disease Risk Among Postmenopausal Women: Findings From the British Women's Heart and Health Study. Am J Public Health 2004;94(8):1386-1392.
ReplyDeleteLynch J, Davey Smith G. A life course approach to chronic disease epidemiology. Annual Review of Public Health 2005;26:1-35.
Maty SC, Lynch JW, Raghunathan TE, Kaplan GA. Childhood Socioeconomic Position, Gender, Adult Body Mass Index, and Incidence of Type 2 Diabetes Mellitus Over 34 Years in the Alameda County Study. Am J Public Health 2008;98(8):1486-1494.
Ebrahim S, Montaner D, Lawlor DA. Clustering of risk factors and social class in childhood and adulthood in British women's heart and health study: cross sectional analysis. BMJ 2004 328 (7444 ):861
Lawlor DA, Ebrahim S, Smith GD. Socioeconomic position in childhood and adulthood and insulin resistance: cross sectional survey using data from British women's heart and health study. BMJ 2002 325 (7368 ):805
Hertzman C, Power C. Health and human development: Understandings from life-course research. Developmental Neuropsychology 2003;24((2&3)):719-744.
Kramer M, Seguin L, Lydon J, Goulet L. Socio-economic Disparities in Pregnancy Outcomes: Why do the Poor fare so Poorly? Paediatric and Perinatal Epidemiology 2000;14(3):194-210.
see http://thecanadianfacts.org
ReplyDeleteRebecca, my understanding of this is that the social determinants of health, i.e. income and social support, are greater predictors of CVD since a LACK of these creates a barrier to being able to lead a "healthy lifestyle". So if your income is minimal and/or you lack a social support network and on top of that you have family responsibilities, for example, doing exercise is not going to be on your priority list. And even if it were, could you afford it? Can you afford a pair of running shoes? Instead you might smoke. I used to smoke and I can tell you smoking can be company as well as a stress and tension reliever. So in sum, the more determinants an individual experiences, the greater the barrier to good health, thus, the greater likelihood that the individual will develop CVD.
ReplyDeleteOne more thing. In the Raphael article that you are talking about "Social Justice is Good for our Hearts", and I also recently saw this in another article, he mentions that if the CVD rate in Canada was that of the CVD rate of the highest income quintile, there would be over 6000 fewer deaths from CVD. Interesting.
ReplyDeleteVioleta- Thank you for your comments.
ReplyDeleteJust building off your comment and assumptions- If having a low income causes CVD because you can't lead a "healthy lifestyle" then yes, income is a problem but the cause of the disease is still an unhealthy lifestyle. Not everyone with a low income will get CVD and not everyone with a high income wont get CVD. It seems like the key is the lifestyle- access to nutritious foods and the ability to be physically active. If you provided these things to someone who is low income keeping all other aspects of their life the same, would they get CVD? Not according to your logic. So it isn't low income per se, it is the lifestyle resulting from low income.
Just as a disclaimer, I don't know the specific and exact causes of CVD (does anybody really?). The point of my post was that I think that health related claims should be backed by solid (and timely) evidence.
Hi Rebecca,
ReplyDeleteI agree with you. Aside from genetic predisposition, it is ultimately lifestyle factors that influence CVD. I suppose Raphael looks at the root of the problem. So if you don't have the income and education, it is unlikely that you'll have the preventative tools. But having said that, you're right, no one is immune to developing CVD. For most people it isn't enough to have an education, but it helps.
Rebecca, no. Lifestyle is just one pathway to CVD and a minor one at that. If all poor people were exercise and fruits fanatics, their CVD rates would only be reduced 20% as compared to the wealthiest group.In the 1970s it was recognized that all lifestyle and biomedical risk factors explain at best 25% of variation in incidence of CVD.
ReplyDeletelook at http://www.unnaturalcauses.org
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