Abstract: Little is known about pathways by which socioeconomic status (SES) translates into individual differences in cardiovascular disease (CVD) risk factors. Because the socioeconomic structure is not the same for all ethnic subgroups, the pathways that lead to the development of CVD risk factors may vary by both SES and ethnicity. We used data from a large national survey to examine the independent associations of two indicators of SES (education and income) and ethnicity with six primary CVD risk factors. We then used data on smoking that reflected a temporal sequence to examine the extent to which SES and ethnicity influenced smoking at three different time points, from smoking onset, to a serious quit attempt, to successful quitting. These analyses provide an understanding of the relationships between SES, ethnicity, and CVD risk factors and suggest that if the timing, focus, and content of intervention programs take pathways into account they will result in more successful outcomes.

CONTEXT:Cardiovascular disease (CVD) risk factors are higher among ethnic minority women than among white women in the United States. However, because ethnic minority women are disproportionately poor, socioeconomic status (SES) may substantially explain these risk factor differences.OBJECTIVE:To determine whether differences in CVD risk factors by ethnicity could be attributed to differences in SES.DESIGN:Third National Health and Nutrition Examination Survey conducted between 1988 and 1994.SETTING:Eighty-nine mobile examination centers.PARTICIPANTS:A total of 1762 black, 1481 Mexican American, and 2023 white women, aged 25 to 64 years, who completed both the home questionnaire and medical examination.MAIN OUTCOME MEASURES:Ethnicity and years of education (SES) in relation to systolic blood pressure, cigarette smoking, body mass index (BMI, a measure of weight in kilograms divided by the square of height in meters), physical inactivity, non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]), and non-insulin-dependent diabetes mellitus.RESULTS:As expected, most CVD risk factors were higher among ethnic minority women than among white women. After adjusting for years of education, highly significant differences in blood pressure, BMI, physical inactivity, and diabetes remained for both black and Mexican American women compared with white women (P<.001). In addition, women of lower SES from each of the 3 ethnic groups had significantly higher prevalences of smoking and physical inactivity and higher levels of BMI and non-HDL-C than women of higher SES (P<.001).CONCLUSIONS:These findings provide the greatest evidence to date of higher CVD risk factors among black and Mexican American women than among white women of comparable SES. The striking differences by both ethnicity and SES underscore the critical need to improve screening, early detection, and treatment of CVD-related conditions for black and Mexican American women, as well as for women of lower SES in all ethnic groups.

Ninety-seven male homosexuals with the acquired immunodeficiency syndrome or other group IV human immunodeficiency virus disease were studied for anal human papillomavirus infection and intra-anal cytological abnormalities. Human papillomavirus DNA was detected in 52 subjects (54%), and 38 subjects (39%) were found to have abnormal anal cytological findings; anal intraepithelial neoplasia was detected in 15 specimens (15%). Abnormalities on anal cytological smear were significantly associated with the presence of human papillomavirus DNA, with a risk ratio of 4.6. Infection with multiple human papillomavirus types was common (12%) and was associated with a risk ratio for cytological abnormalities of 39.0. Median T4 counts of subjects with abnormal cytological findings were significantly lower than those with normal findings. These studies indicate that immunosuppressed male homosexuals have a high prevalence of anal human papillomavirus infection and anal intraepithelial neoplasia, and this population may be at significant risk for the development of anal cancer.

The economic consequences of an Occupational Work Evaluation designed to identify low risk patients recovering from uncomplicated acute myocardial infarction (AMI) and hasten their return to work was evaluated in a randomized trial. Two hundred one employed, clinically low risk men recovering from AMI were randomized to undergo an intervention (intervention group, 99 patients) consisting of an Occupational Work Evaluation or to receive usual care (usual care group, 102 patients). The time to return to work was reduced from 75 days in usual care patients to 51 days in intervention patients (p less than 0.002). Significant differences were found between groups for medical costs and occupational income during follow-up. Total medical costs per patient were lower in the intervention patients than in the usual care patients in the 6 months after AMI ($2,970 vs $3,472). Occupational income per patient was higher in intervention patients than in the usual care group in the 6 months after AMI ($9,655 vs $7,553). The per capita benefit accounting for medical costs and occupational income was $6,685 for intervention patients and $4,081 for usual care patients. Projected to the greater than 300,000 low risk, employed survivors of AMI annually in this country, the savings generated by the Occupational Work Evaluation could yield an annual economic benefit greater than 800 million dollars.

CL, Albright; CB, Taylor; CA, Dennis; DK, Ahn; HC, Kraemer; RF, DeBusk Author Information

Research in exercise training of healthy persons, which has been conducted almost exclusively in supervised group programs, is relatively expensive for the investigator and inconvenient for the participant. To overcome these obstacles, self-monitored moderate-intensity home-based exercise training was prescribed for 28 middle-aged men and 26 middle-aged women. The median energy expenditure prescribed for each of 5 weekly exercise sessions was 4 cal/kg body weight, or 317 kcal for men and 265 kcal for women, corresponding to a median duration of 45 and 60 minutes, respectively. In the next 24 weeks, peak oxygen uptake increased 13.7% in men who exercised, from 31 ± 4 to 37 ± 4 ml/kg/min, and 10% in women who exercised, from 26 ± 4 to 29 ± 5 ml/kg/min (p <0.001 for both comparisons). The proportion of prescribed caloric expenditure per session, which was documented by a solid-state heart rate recorder, was 108% in men and 90% in women. The duration of training at heart rates above the prescribed range approximated 10 minutes per session for both men and women; the proportion of total caloric expenditure represented by exercise at heart rates exceeding the prescribed limit was 9% for men and 4% for women. The proportion of time spent within the prescribed heart rate range during training sessions was 76% for men and 84% for women. Training-induced musculoskeletal problems were reported by 6 men and no women. No subject sought medical attention and all resumed training within 1 week. The high level of adherence to self-monitored, moderate-intensity, home-based exercise training in these healthy middle-aged persons indicates the feasibility of performing exercise training studies outside the laboratory.

A portable solid-state recorder-display system was used to measure and analyze heart rate during the waking hours of 3 consecutive days in free-living sedentary normal middle-aged men who were randomized to undergo 3 regimens of physical activity during a 12-week period: low-intensity exercise training at home (n = 21), high-intensity exercise training at home (n = 23) and customary activity (n = 20). This was done to determine whether the system could detect changes in heart rate and, indirectly, in physical activity within the 3 groups. In both training groups the percentage of total recorded time spent within the prescribed high or low heart rate range recorded at 6 or 12 weeks increased significantly (p < 0.05), whereas control subjects showed no increase above baseline values. Peak oxygen consumption increased by 8% and 17% in men undergoing low- and high-intensity training, whereas in control subjects it did not change. This solid-state system reliably measures prescribed increases in heart rate and provides an indirect measure of physical activity in normal sedentary men undergoing exercise training at home.

The effects of 12 weeks of home-based exercise training on peak oxygen consumption (VO2 max) in healthy sedentary middle-aged men, mean age 49 ± 6 years, were evaluated. Twenty-one men trained at low intensity, 23 trained at high intensity and 20 were control subjects. Individually prescribed low- and high-intensity training was performed 5 times per week within a range of 42 to 60% and 63 to 81% of baseline VO2 max, corresponding to average heart rates of 102 to 122 and 128 to 148 beats/min, respectively. Caloric expenditure per training session approximated 350 kcal in both groups; adherence was at least 90% in both groups. VO2 max increased 8% in patients who trained at low intensity, 17% in those who trained at high intensity (both p < 0.001), and not at all in control subjects. Low-intensity exercise training at home significantly augments functional capacity in healthy sedentary middle-aged men.

To determine the effects of exercise training programs on psychosocial improvement in uncomplicated postmyocardial infarction patients, 210 male patients hospitalized for an acute myocardial infarction (MI) were randomized to (1) three week symptom limited treadmill (TM) plus home exercise training, (2) TM plus medically supervised gym training, (3) TM without formal exercise program or (4) control, where patients were seen only at six months post MI. Patients in this sample were at low risk for psychosocial disturbance (13% were moderate to severely depressed, 23% reported marital disturbance and 3% were extremely anxious). Patients in the training groups improved from 3 to 26 weeks post MI on all depression and anxiety measures. The gym training group showed a significant reduction on one depression measure compared to no training and on one anxiety measure compared to controls.