Inequalities In Cardiovascular Health Research Articles

Income variability and incident cardiovascular disease in diabetes: a population-based cohort study.

Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D). Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders. High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results. Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.

Engaging Predominantly Black Churches in an Intervention to Improve Cardiovascular Health and Reduce Racial Inequities

Cardiovascular disease (CVD) is the leading cause of mortality in the United States and disproportionately impacts Black adults. Effective implementation of interventions to improve cardiovascular health in the Black community is needed to reduce health inequities. The Church-Based Health Intervention to Eliminate Health Inequalities in Cardiovascular Health (CHERISH) study is implementing interventions recommended by the 2019 American College of Cardiology/American Heart Association guideline on the primary prevention of CVD in Black communities to improve cardiovascular health and reduce health disparities. The recently completed 3-year planning phase of CHERISH has focused on engaging with the predominantly Black church community in New Orleans with the goals of informing study protocol development and recruiting churches for study participation. Community engagement approaches include convening a community advisory board (CAB), conducting qualitative and quantitative needs assessments, and hosting and attending church events. These activities have resulted in an engaged CAB that has contributed meaningfully to planning activities and the study protocol. The needs assessment found that while there are substantial barriers to cardiovascular health, such as knowledge, access to healthy foods, and safe spaces for physical activity, people are willing to make lifestyle changes and think that the proposed intervention components are feasible. Community engagement activities have resulted in the recruitment of 50 geographically and denominationally diverse predominantly Black churches willing to participate in the study (exceeding our goal of 42). Overall, a multicomponent approach to extensive community engagement has produced effective church enrollment for study participation and meaningful input on study design and implementation.

Addressing inequalities in cardiovascular health remains an urgent priority.

Addressing inequalities in cardiovascular health remains an urgent priority.

Tackling cardiovascular health inequalities in European countries

Tackling cardiovascular health inequalities in European countries

Increasing Equity of Physical Activity Promotion for Optimal Cardiovascular Health in Adults: A Scientific Statement From the American Heart Association.

Fewer than 1 in 4 adults achieves the recommended amount of physical activity, with lower activity levels reported among some groups. Addressing low levels of physical activity among underresourced groups provides a modifiable target with the potential to improve equity in cardiovascular health. This article (1) examines physical activity levels across strata of cardiovascular disease risk factors, individual level characteristics, and environmental factors; (2) reviews strategies for increasing physical activity in groups who are underresourced or at risk for poor cardiovascular health; and (3) provides practical suggestions for physical activity promotion to increase equity of risk reduction and to improve cardiovascular health. Physical activity levels are lower among those with elevated cardiovascular disease risk factors, among certain groups (eg, older age, female, Black race, lower socioeconomic status), and in some environments (eg, rural). There are strategies for physical activity promotion that can specifically support underresourced groups such as engaging the target community in designing and implementing interventions, developing culturally appropriate study materials, identifying culturally tailored physical activity options and leaders, building social support, and developing materials for those with low literacy. Although addressing low physical activity levels will not address the underlying structural inequities that deserve attention, promoting physical activity among adults, especially those with both low physical activity levels and poor cardiovascular health, is a promising and underused strategy to reduce cardiovascular health inequalities.

Abstract P148: Perceived Religious Influence on Health is Associated With Beneficial Cardiovascular Health Behaviors Within Predominantly Black Churches in New Orleans, Louisiana

Introduction: CVD is the leading cause of death in the US. Black populations are disproportionately affected by CVD. Further, Black populations have substantially high rates of religiosity. Previous research has demonstrated a positive correlation between religiosity and health, but the mechanisms are unclear. In this study, we describe the relationship between perceived religious influence on CVD health behaviors, risk factors and confidence in participating in medical care within predominantly Black churches in New Orleans, Louisiana. Hypothesis: Perceived religious influence on health is positively associated with CVD health behaviors, risk factors and confidence in participating in medical care. Methods: A survey in 302 members of 13 churches with predominantly Black congregations was conducted during the needs assessment of the Church-based Health Intervention to Eliminate Racial Inequalities in Cardiovascular Health (CHERISH) trial. Religious influence on health was assessed with two statements, (1) “Religious beliefs have great influence on my health” and (2) “I tend to avoid things harmful to my body because of religious beliefs” and measured with a five-point Likert scale ranging from “strongly disagree” to “strongly agree”. Outcomes included fruit and vegetable intake, physical activity, smoking status, self-reported hypertension, hypercholesterolemia, diabetes, and confidence in asking questions to provider and understanding treatment plans. Logistic regression and cumulative odds logistic regression models were used to examine the association with individual and composite outcomes, respectively, adjusting for age, sex, and education. Results: Survey respondents were 77% (233/302) female with a mean age of 65.5 years, and 72% (218/302), 56% (168/302), and 37% (111/302) reported hypertension, hypercholesterolemia, and diabetes, respectively. Perceived religious influence on health was associated with daily fruit and vegetable consumption (OR = 1.64; 95% CI: 1.01, 2.67), physical activity (OR = 1.76; 95% CI: 1.05, 2.96), composite health behaviors (OR = 1.59; 95% CI: 1.03, 2.48), confidence in asking questions to provider (OR = 3.46; 95% CI: 1.41, 9.12), and the composite confidence outcome (OR = 2.11; 95% CI: 1.06, 4.26). Avoiding harmful things because of religion was associated with physical activity (OR = 1.97; 95% CI: 1.17, 3.38) and composite health behaviors (OR = 1.56; 95% CI: 1.01, 2.42). There was no association between the exposures and self-reported hypertension, hypercholesterolemia, or diabetes. Conclusion: Perceived religious influence on health was associated with beneficial CVD health behaviors and confidence in participating in medical care. These findings may inform cultural tailoring of interventions to reduce CVD among the US Black population.

Life course traumas and cardiovascular disease-the mediating role of accelerated aging.

The complex relationship between life course traumas and cardiovascular disease (CVD) and the underpinning pathways are poorly understood. We aimed to (1) examine the associations of three separate assessments including childhood, adulthood (after 16 years of age), and lifetime traumas (childhood or adulthood) with CVD; (2) examinethe associations between diverse life course traumatic profiles and CVD; and (3) examine the extent to which PhenoAge, a well-developed phenotypic aging measure,mediated these associations. Using data from 104,939 participants from the UK Biobank, we demonstrate that subgroups of childhood, adulthood, and lifetime traumas were associated with CVD. Furthermore, life course traumatic profiles were significantly associated with CVD. For instance, compared with the subgroup experiencing nonsevere traumas across life course, those whoexperienced nonsevere childhood and severe adulthood traumas, severe childhood and nonsevere adulthood traumas, or severe traumas across life course had significantly higher odds of CVD (odds ratios: 1.07-1.33). Formal mediation analyses suggested that phenotypic aging partially mediated the above associations. These findings suggest a potential pathway from life course traumas to CVD through phenotypic aging, and underscore the importance of policy programs targeting traumas over the life course in ameliorating inequalities in cardiovascular health.

Cross-mapping medical records to NANDA-I to identify nursing diagnoses in a vulnerable population.

To assess the association between vulnerable populations and nursing care needs, using NANDA-I diagnostics, in the population of the Canary Islands, Spain. Nursing social epidemiology study. Cross Mapping of Medical Records to NANDA-I to Identify Nursing Diagnoses in a Population usinga medical, epidemiological follow-up study of a cohort of 7,190 people. The level of vulnerability of the participants was assigned, among those who were also assigned nursing diagnoses, using the "ICE index" to calculate the expected associations. The most prevalent nursing diagnosis in our sample was Sedentary lifestyle (60.5%), followed by Ineffective health self-management (33.8%) and Risk-prone health behaviour (28.7%). Significant differences were found by sex, age group and social class, with the nursing diagnoses included in the study being more prevalent among the most socio-economically disadvantaged social class. The cross-mapping method is useful to generate diagnostic information in terms of care needs, using the NANDA-I classification. The expected associations between high social vulnerability and care needs have been verified in a comprehensive and representative sample of the Canarian population (Spain). From an epidemiological perspective, identifying nursing diagnoses at the population level allows us to find the most prevalent needs in the different community groups and to focus appropriate nursing interventions for their implementation and impact assessment.

It's time to 'Build Back Fairer': what can we do to reduce health inequalities in cardiology?

Disparities in cardiovascular morbidity and mortality are among the leading health and social care concerns in the UK. The disruption of the COVID-19 pandemic to health services has further placed cardiovascular care and the respective patient communities at the sharp end, not least in exacerbating existing health inequalities across service interfaces and patients' health outcomes. While the pandemic engenders unprecedented constraints within established cardiology services, it conduces to a unique opportunity to embrace novel transformative approaches within the way we deliver patient care in maintaining best practices during and beyond the crisis. As the first step in navigating toward the 'new norm', a clear recognition of the challenges inherent in cardiovascular health inequalities is critical, primarily in preventing the widening of extant inequalities as cardiology workforces continue to build back fairer. We may consider the challenges through the lens of health services' diverse facets, including the aspects of universality, interconnectivity, adaptability, sustainability, and preventability. This article explores the pertinent challenges and provides a focused narration concerning potential measures to foster equitable and resilient cardiology services that are patient centred in the post-pandemic landscape.

Abstract P468: Geographic and Socioeconomic Inequalities in Poor Cardiovascular Health in Canada

Background: Poor cardiovascular health (CVH), characterized by clinical risk and unhealthy lifestyle habits, is a leading cause of death and disease worldwide. Despite advances in healthcare and policy, there remains an inequitable burden of poor CVH among Canadian sub-populations based on socioeconomic status and geographic region. Using recently published data and a national toolkit, this study aimed to quantify inequalities in poor CVH across the Canadian population. Methods: We conducted a cross-sectional study on Canadian adults, ≥20 years, from the nationally representative Canadian Community Health Survey 2017. Using the American Heart Association’s CVH Index, CVH was defined for each individual as a summed score of 7 components, where 1 point was awarded for achieving ideal health in each component. A total score of 0-2 points indicated poor overall CVH. The Canadian Institute for Health Information (CIHI) Measuring Health Inequalities Toolkit, a standardized methodological approach to analyzing health inequalities in population-based data using pre-defined stratifications and second-level interactions, was used to quantify inequalities in poor CVH based on Toolkit-defined stratifications in sex, income, urban/rural status, and region of residence. The regional distribution of CVH was mapped using ArcGIS software. Results: Approximately 7% of Canadians had poor CVH, representing 2 million Canadians. Poor dietary habits were noted in 99.0% of the population, with poor body mass index and poor physical activity noted in 58.1% and 42.3%, respectively. The eastern provinces of Newfoundland and Labrador and New Brunswick had the greatest proportion of health regions with poor CVH. An examination of the largest CVH inequalities across provinces revealed that females in the lowest income tercile residing in Prince Edward Island were 8-times more likely to experience poor CVH than females in the highest income tercile (RR 8.43, 95%CI 7.09-10.04). Additionally, females in New Brunswick residing in rural regions were almost 3-times more likely to experience poor CVH than females residing in urban regions (RR 3.07, 95%CI 1.07-4.87). In most provinces, income and urban/rural inequalities among males were observed but were of smaller magnitude than the inequalities among females. Conclusion: The greatest inequalities in poor CVH were experienced by females in the lowest income groups. Urban/rural inequalities in CVH were complex and varied by geographic region. The CIHI toolkit is a robust and systematic approach to understanding health inequalities that will enable comparison between studies and health/disease states, and thus facilitate comparative policy evaluation and population health priority setting.

Metrics of Ideal Cardiovascular Health are Unequally Distributed between Peruvian Men and Women: Analysis of a National Population-Based Survey in 2017.

Background:To determine socioeconomic inequalities in cardiovascular health (CVH) metrics among Peruvian adults as well as differences according to sex.Methods:An observational, cross-sectional study was conducted in 26,175 individuals aged 18–65 years using the 2017 Peruvian Demographic and Health Survey. According to the American Heart Association, 5 CVH metrics which comprised three ideal health behaviors (diet, non smoking, ideal body mass index [BMI]), and two ideal health factors (ideal blood pressure and no history of diabetes) were evaluated. The concentration curves (CC) methodology was used to analyze whether CVH metrics vary between socioeconomic status and sex. The concentration index (CI) was used to quantify socioeconomic-related inequality in health variables.Results:Overall, the mean age was 36.5 years (SD = 11.9) and 51.2% were women. Only 2.4% had 5 ideal CVH metrics (women 3.7%, men 1.0%) with a CI very close to the equality line (0.0135). (0.0135; higher in women [0.0262], compared to men [0,0002]). A greater prevalence of ideal CHV metrics (3 or more) was found in women (P < 0.001). Ideal health factors were more prevalent (52.1%) than ideal health behaviors (13.8%). Regarding inequality measures, CCs for most CVH metrics had a higher concentration in the lowest wealth population, except for ideal diet, which was more frequent among higher levels of wealth. An ideal BMI was the CVH metric with the lowest CI (overall: −0.0817; men: −0.2699).Conclusions:Peruvian women presented a higher prevalence of ideal CVH metrics and fewer inequalities. Ideal CVH metrics tend to be concentrated in the wealthiest women. Low- and middle-income countries should consider socioeconomic inequalities in cardiovascular disease prevention programs.

A8096 Socioeconomic inequalities in cardiovascular health in 45 enterprises involving 27 607 employees from China

A8096 Socioeconomic inequalities in cardiovascular health in 45 enterprises involving 27 607 employees from China

The role of spoken language in cardiovascular health inequalities: a cross-sectional study of people with non-English language preference.

BackgroundSocioeconomic and ethnic factors are established determinants of cardiovascular health inequalities. The role of low proficiency in the majority language as a mediator of these inequalities is uncertain.AimThis study aimed to investigate the association between non-English language preference and cardiovascular health inequalities in a community in London.Design & settingRetrospective, cross-sectional analysis of anonymised patient-level data collected from general practices in Lambeth, south London.MethodCardiovascular disease prevalence, monitoring, and risk-identification data were compared between non-English and English language groups using multiple logistic regression.ResultsOf the total number of patients registered at the 49 participating practices, 302 404 (83%) patients were aged ≥18 years. Preferred language was recorded by 69.4%: English 53.6%, Portuguese 3.2%, Spanish 2.6%, French 1.6%, Polish 1.4%, Somali 0.5%, and others 7.1%; 30.6% had no record of language preference. The non-English language preference group had a greater likelihood of coronary heart disease ([CHD], odds ratio [OR] 1.18, 95% confidence interval [CI] = 1.03 to 1.34); diabetes mellitus ([DM], OR = 1.33, 95% CI = 1.23 to 1.43); obesity (OR = 1.08, 95% CI = 1.04 to 1.13); and smoking (OR = 1.18, 95% CI = 1.14 to 1.21), but no difference in the prevalence of hypertension or stroke. Cardiovascular monitoring was not less intense in this group. Portuguese-speakers (the largest non-English language preference group) had a greater likelihood of hypertension (OR = 1.43, 95% CI = 1.30 to 1.57); DM (OR = 1.74, 95% CI = 1.50 to 2.02); stroke (OR = 1.40, 95% CI = 1.08 to 1.81); obesity (OR = 1.53, 95% CI = 1.36 to 1.73); and smoking (OR = 1.13, 95% CI = 1.02 to 1.25).ConclusionThe non-English language preference group was associated with a greater risk of some aspects of cardiovascular disease than the English language preference group, probably reflecting shared cultural and behavioural risk. Non-English language preference was not associated with lower rates of cardiovascular monitoring, providing some evidence of equitable primary care access in this group.

Environmental Factors and Hypertension.

Environmental factors are a major cause of poor health worldwide. The most solid evidence is for air pollution, leading to increased disability-adjusted life years. Outdoor temperature and other seasonal climate changes may also influence cardiovascular health, according to their direct modulation of air pollution. Moreover, an increasing body of evidence associates environmental exposure to noise with poor cardiovascular outcome, and in particular with hypertension. This review is aimed at reviewing current evidence about the role of these environmental factors in cardiovascular disease and specifically hypertension. In particular, the impact of air pollution, with its short-term and long-term effects, the outdoor temperature and noise pollution will be investigated. People belonging to low social classes, as well as children, women, older people and those with established cardiovascular diseases, seem to have a greater susceptibility to the effects of environmental stressors, recalling the concept of "environmental justice". The accumulating strong scientific evidence may thus support public health policies aimed at reducing social inequalities in cardiovascular health.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study.

PurposePeople with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK.MethodsE-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers.ResultsIn primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3–1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007–2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)).ConclusionsThere is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Inequalities in Cardiovascular Health Between Local and Migrant Residents: A Cross-Sectional Study of 6934 Participants in Longhua District, Shenzhen.

Household registration status is one social determinant that influences health disparities. This study aimed to investigate the disparities in cardiovascular health between local and migrant residents, which may provide important implications for public health services and may help improve cardiovascular health for residents in Shenzhen.A cross-sectional study was conducted in Shenzhen City Longhua district. Participants were selected for face-to-face interview surveys by using a multistage cluster random sampling design. Chi-square tests and multiple logistic regression models were constructed to compare cardiovascular health between the migrant and local residents.A total of 6934 eligible respondents, of whom 1400 were local and 5534 were migrants, completed the face-to-face interview surveys. The local residents were more likely to have hypertension (3.1% vs. 2.0%, P < 0.05) and diabetes mellitus (1.4% vs. 0.5%, P < 0.05), whilst to be overweight or obese (20.3% vs. 16.4%, P < 0.05) when compared with their migrant counterparts. A higher proportion of local residents than migrant ones had ≥2 cardiovascular risk factors, 2.4% and 1.2%, respectively (P < 0.01). Compared with migrants, the locals were more likely to know their BP values (65.4% vs. 54.5%, P < 0.05) and know the symptoms of diabetes (63.1% vs. 49.7%, P < 0.01).Our study suggests that household registration status is an important driver of social disparities in cardiovascular health except for the factors regarding socioeconomic status. Programs to improve the awareness of hypertension and diabetes are suggested to be initiated among the migrants.

Socio-Economic Differences in Cardiovascular Health: Findings from a Cross-Sectional Study in a Middle-Income Country.

BackgroundA relatively consistent body of literature, mainly from high-income countries, supports an inverse association between socio-economic status (SES) and risk of cardiovascular disease (CVD). Data from low- and middle-income countries are scarce. This study explores SES differences in cardiovascular health (CVH) in the Republic of Srpska (RS), Bosnia and Herzegovina, a middle-income country.MethodsWe collected information on SES (education, employment status and household’s relative economic status, i.e. household wealth) and the 7 ideal CVH components (smoking status, body mass index, physical activity, diet, blood pressure, total cholesterol, and fasting blood glucose) among 3601 participants 25 years of age and older, from the 2010 National Health Survey in the RS. Based on the sum of all 7 CVH components an overall CVH score (CVHS) was calculated ranging from 0 (all CVH components at poor levels) to 14 (all CVH components at ideal levels). To assess the differences between groups the chi-square test, t-test and ANOVA were used where appropriate. The association between SES and CVHS was analysed with multivariate linear regression analyses. The dependent variable was CVHS, while independent variables were educational level, employment status and wealth index.ResultsAccording to multiple linear regression analysis CVHS was independently associated with education attainment and employment status. Participants with higher educational attainment and those economically active had higher CVHS (b = 0.57; CI = 0.29–0.85 and b = 0.27; CI = 0.10–0.44 respectively) after adjustment for sex, age group, type of settlement, and marital status. We failed to find any statistically significant difference between the wealth index and CVHS.ConclusionThis study presents the novel information, since CVHS generated from the individual CVH components was not compared by socio-economic status till now. Our finding that the higher overall CVHS was independently associated with a higher education attainment and those economically active supports the importance of reducing socio-economic inequalities in CVH in RS.

Sex inequalities in cardiovascular health: a cross-sectional study.

The aim of this study was to determine sex differences in the prevalence of cardiovascular health (CVH) metrics according to the CVH status. The cross-sectional, population-based study involved 2250 women and 1920 men aged ≥18 years that participated in the 2010 National Health Survey in the Republic of Srpska, Bosnia and Herzegovina. Prevalence of CVH behaviours (smoking, body mass index, physical activity, diet), CVH factors (cholesterol, fasting blood glucose and blood pressure, plus smoking) and ideal CVH were estimated according to the American Heart Association criteria for ideal, intermediate and poor levels. Association between sex and ideal CVH categories was analyzed with multivariable logistic regression analysis across three age stratums. A higher prevalence of ideal CVH metrics was seen in women for smoking status, body mass index, healthy diet score and blood pressure, and in men for physical activity and total cholesterol. Women from all age groups had better CVH behaviours (odds ratio [OR] = 1.40 for the youngest; OR = 2.05 for middle-aged; and OR = 2.03 for older-aged women), while only women from the youngest age group had better CVH factors (OR = 5.09). In line with this, ideal overall CVH prevailed in younger and middle-aged women in comparison to men of the same ages (OR = 3.01 and OR = 2.25, respectively), while disappeared in older ones. Significant differences in the prevalence of CVH metrics between men and women in the Republic of Srpska should be considered in cardiovascular disease prevention.

Shim, J. K. Heart‐Sick: The Politics of Risk, Inequality, and Heart Disease. New York: New York University Press. 2014. 288pp £16.99 (pbk) ISBN 978‐0‐8147‐8685‐7

Heart disease is a significant cause of death worldwide. According to the World Health Organisation, 46 per cent of all deaths from non-communicable diseases in 2012 were caused by cardiovascular disease, and coronary heart disease was the leading cause of premature death in 2014. It is the leading cause of death in both the USA and the UK, and despite advances in understanding and treating heart disease, and substantial investments in research and treatment, inequalities persist in terms of ‘who develops it, who lives with it, and who dies from it’ (p. 191). Janet K. Shim is an associate professor of sociology in the School of Nursing at the University of California, San Francisco, who is interested in social inequalities in health, science, technology and medicine studies, and race, gender, and class. She brings all these interests into play in this fascinating book which explores the different meanings that heart disease has for different groups of people. In particular, her focus is on how epidemiologists studying heart disease and ‘people of color’ (p. 25) experiencing heart disease differ in the way they explain who gets it and why. Her key argument is that conventional accounts of inequalities in cardiovascular health are inadequate and unconvincing, resulting in many of the fundamental causes of those inequalities being ignored in public health interventions. The book begins with Shim clearly setting out the theoretical bases for her study in some detail. In her discussion of the politics of disease causation, she outlines and explains the role of her key concepts: biopower and biopolitics, intersectionality, and fundamental causality. These concepts intertwine in quite complex ways as she then examines the development of epidemiology in what she refers to as a ‘selective contemporary history of cardiovascular epidemiology’ (p. 48). Her discussion of the way the Framingham Study began and expanded is fascinating, particularly her documentation of the shifts in study objectives and methods over time. She argues that it breached many of what would now be regarded as fundamental research principles, which is remarkable for such a significant study, in terms of the history of epidemiology and the contribution it made to the understanding of cardiovascular disease. She also argues that it pioneered an expansion of surveillance and intervention, a point she returns to later in the book in her discussion of the ever widening role of epidemiology and its influence on self-care, self-monitoring and self-knowledge which risks the exacerbation of widening inequalities and social stratification of risks. The core of the book comprises three chapters where Shim discusses the significance of race, gender and class as competing explanations for the differing incidence of heart disease across different groups in America, with a chapter devoted to each of these classifications. She argues that there is a fundamental flaw with epidemiology in the way it accepts race, gender and class as unproblematic classifications, seeing them as ‘the usual suspects’ (p. 18) in relation to the way that epidemiologists regard them as individual and often separate explanations for the cause of heart disease. Indeed, she argues that even when individual epidemiologists see problems with the way the ‘usual suspects’ are deployed, they still fall back on using them. Alongside this critique of conventional epidemiological approaches to understanding heart disease, Shim specifically explores the intersectionality of causes of and explanations for heart disease, and makes the suggestion that the people she spoke to for her study, all ‘people of color’, had a more complex and nuanced understanding of how gender and class were inextricably linked to race in their experience of heart disease. A particularly interesting aspect of Shim's approach is the way she has carried out research with epidemiologists (interviews, observation, attending relevant conferences) and with people who have heart disease, and the contrasts she draws between the ways different groups talk about disease; in particular, lay views appear to be much more at ease with complex understandings of the intersectionality which Shim focuses on so well. The book is very much focused on the USA. It would be interesting and useful to place the USA in a broader international context, particularly given the significance of heart disease as a cause of death worldwide, and this would give the book a broader appeal to an international audience. It would also be interesting to compare research on inequalities in health in the USA with some of the enormous body of work that has been carried out in the UK and more widely in the EU on social determinants of health. However, even without an international focus, this book is well worth reading for anyone interested in inequalities in health.

OP82 The health equity and effectiveness of future policy options to reduce dietary salt in England: modelling study

Background Between 2001 and 2011, UK adult salt-intake fell by 15%, reflecting a comprehensive strategy led by the Food Standards Agency. Yet hypertension remains common in the UK, suggesting that further progress on salt-reduction could bring additional public health benefits. However, it is unclear how the overall effect of such policies might impact socio-economic class (SEC) inequalities in cardiovascular health. Our study therefore aimed to help inform decision making on salt-reduction policies during the next UK parliament, 2015 to 2020. Methods We extended the IMPACT SEC socially-stratified epidemiological model. We linked policy effects on salt, via systolic blood pressure, to premature CHD deaths (ages 35–74 years) in England 2015 to 2020. We used data from the Health Survey for England, published meta-analyses, and the Office for National Statistics. SEC was quantified by quintiles of the Index of Multiple Deprivation. We assessed the effects of product reformulation (voluntary or mandatory), social marketing and nutrition labelling against a forecast counterfactual of premature CHD deaths. We supplemented the scarce evidence-base on key policy parameters with expert opinion. Ten experts participated; all were scientists or policy experts in the academic or non-governmental sectors. Expert data were obtained using a pre-piloted, one-page questionnaire on the perceived effectiveness and inequality of salt-reduction interventions up to 2020. For each parameter, we elicited best, minimum, and maximum estimates. We estimated each intervention’s impact on inequality by its effect on the mortality gap between the least and most deprived SEC groups. Uncertainty was quantified using probabilistic sensitivity analysis. Results Our results suggest that, measured cumulatively over our study period, mandatory reformulation might prevent or postpone approximately 8300 premature CHD deaths ( 95% confidence interval: 5300, 11400 ) and reduce the inequality gap by some 1800 ( 1200, 2600 ) deaths. Voluntary reformulation could prevent or postpone approximately 1000 ( 200, 3800 ) deaths and reduce inequality by approximately 200 ( 0, 900 ) deaths. The estimated effects of behaviour change policies (social marketing and labelling) appeared much weaker: each might prevent or postpone approximately 100 ( 0, 400 ) deaths. They also had negligible effects on inequality: social marketing might change inequality by –6 ( –50, 20 ) deaths and labelling by –4 ( –50, 20 ) deaths. Conclusion Our model for England suggests that reformulation could be the most effective and equitable intervention against premature CHD deaths, especially if mandatory. By contrast, social marketing and labelling might have relatively little impact on the number of deaths or inequality.