Tracking Social and Biological Experiences

The social gradient in cardiovascular disease (CVD) is well known. There are literally scores of studies showing that men and women who are socially disadvantaged are at increased risk of developing CVD and have a worse prognosis once they develop the disease.1 During the last 40 years, in most industrialized countries, a clear pattern has emerged showing that each increase in socioeconomic position confers a decreased risk in cardiovascular morbidity and mortality. Men between the ages of 25 and 64 who are the most disadvantaged have an ≈2.5-fold risk of dying of CVD. For women, the risks are even greater (3.4-fold risk).2 Similar trends are seen for risk-related disorders, including hypertension and diabetes. The causes and mediating pathways by which this occurs are not nearly as well characterized, however. Identifying the biological and behavioral mechanisms that link economic and social disadvantage to cardiovascular morbidity and mortality provides valuable insights into the causes of CVD and information about where along the spectrum of disease development we may effectively intervene to improve outcomes in disadvantaged populations. There is little debate about the social patterning and distribution of CVD. There is, however, ongoing debate about the reason for the observed patterns.See p 3071 Much of the social gradient was attributed originally to the uneven distribution of a number of health behaviors related to diet, tobacco consumption, physical inactivity, compliance with therapeutic regimens, and differential access to high-quality medical care. As the story goes, as better educated, economically advantaged men and women learned about the risks that are related to tobacco, obesity, and inactivity, they changed their behaviors and subsequently reduced their cardiovascular risks, often giving rise to even greater disparities in coronary heart disease (CHD). We now know that differences in health behaviors account for a part of the disparities …