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REPORT OF THE CONFERENCE ON 
SOCIOECONOMIC STATUS AND 
CARDIOVASCULAR HEALTH AND DISEASE

November 6-7, 1995
Bethesda, Maryland

National Heart, Lung, and Blood Institute
National Institutes of Health
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EXECUTIVE SUMMARY

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Jeremiah Stamler, M.D.
Helen P. Hazuda, Ph.D.
Cochairs

Disease prevention is an essential part of the mission of
the National Heart, Lung, and Blood Institute (NHLBI).  Over
the years, the Institute has developed some remarkably
effective preventive strategies based on research to
identify the major risk factors for cardiovascular disease
(CVD).  It is no surprise that the sharp declines in CVD
mortality that occurred during the past 30 years coincided
with our understanding that such factors as smoking,
hypertension, high blood cholesterol, obesity, and diabetes
increase a person's risk of developing CVD.

Gratifying as this progress is, we still have far to go. 
Much evidence indicates that the beneficial trends in CVD
mortality have not been felt equally across all segments of
society.  Rather, the most striking improvements in
cardiovascular health have occurred among wealthier, better-
educated Americans, while progress among groups with lower
socioeconomic status (SES) has lagged.  The observation that
the gap between high-SES and low-SES populations may be
widening is particularly disturbing.

To address these important public health issues, the
Conference on Socioeconomic Status and Cardiovascular Health
and Disease was convened November 6-7, 1995, in Bethesda,
Maryland.  More than 120 persons attended, representing such
fields as cardiovascular and preventive medicine,
epidemiology and biostatistics, behavioral and social
sciences, and health policy research.  The goals of the
meeting were to assess the extent to which SES is related to
CVD mortality, morbidity, and risk factors in men and women
of various ages, races/ethnicities, and geographical
locations; to assess time trends in the SES-CVD association;
to explore possible biological, psychosocial, and lifestyle-
related pathways by which SES may relate to CVD; to identify
strategies for reducing SES-based disparities in
cardiovascular health; and to recommend promising avenues
for future research on this topic.

Several crosscutting themes emerged from the conference
presentations and discussions.  First is the need to improve
our understanding of the concept of SES and the ways in
which it reflects the conditions of everyday life for people
of various strata.  This task will involve development of
more sophisticated and refined measures of SES.  The
importance of seeking input from other related fields (e.g.,
sociology, demography, economics) was emphasized.

The conference also highlighted the importance of rapidly
transferring new scientific knowledge into practice and,
most critical, of more effectively applying what we already
know about risk reduction strategies (e.g., smoking
cessation, blood pressure control, diet), especially to
population strata that have not yet been reached.  In this
regard, the superb national leadership taken by the NHLBI
through its education programs was repeatedly acknowledged.

Irrefutable evidence that an SES gradient in CVD risk exists 
-  that there is room for improvement at every SES level  - 
speaks to the importance of a population-wide approach to
reducing the burden of CVD. Sustained and focused efforts
among all SES groups of various races/ethnicities are
needed. 

SESSION HIGHLIGHTS

Session I:  Setting the Stage

The first session focused on U.S. national data relating SES
to CVD morbidity and mortality; to lifestyle, biomedical,
and psychosocial risk factors; and to medical care
utilization.  Presenters gave an overview of data in the
Chartbook of U.S. National Data on Socioeconomic Status and
Cardiovascular Health and Disease, which had been prepared
as background to the conference.

The national data document that SES relates to CVD, to
lifestyles, and to major lifestyle-related biomedical CVD
risk factors (with variations by age, gender, ethnicity, and
specific aspects of lifestyle, as well as with variations
over time).  The general finding is that more adverse
patterns of these variables exist for lower-SES strata than
for higher-SES strata in the U.S. population.  For instance,
a wealth of information on smoking shows strong and
consistent relationships with SES (i.e., for all age groups,
both genders, and all racial/ethnic groups, the lower the
SES, the higher the prevalence of smoking and the lower the
quit rate during recent decades).

Strong and consistent inverse relationships also prevail  - 
for adults of every age and both genders, for blacks, non-
Hispanic whites, Hispanics, Asian Americans, Native
Americans  -  between SES and high blood pressure, and
between SES and obesity.  Lower-SES groups have higher rates
of both hypertension and obesity than higher-SES groups. 
Upward trends in body weight and in prevalence of overweight
during the last decades have been more marked in lower- than
higher-SES strata.

Other SES-risk factor relationships are less strong and
consistent  -  for example, the relationship between SES and
serum cholesterol.  However, trend data from successive
national population surveys indicate that declines in adult
average serum cholesterol levels have been smaller in lower-
than in higher-SES strata.  National data are limited about
such relevant aspects of lifestyle as diet and physical
activity and their time trends across SES strata.

National data are also sparse with respect to psychosocial
risk factors across SES strata.  In particular, data are
lacking on psychosocial variables for SES groups of various
ethnic backgrounds.  Furthermore, little information exists
about such variables as job change, unemployment, job and
income instability, work-related psychosocial variables,
social support, and social isolation, and how these
variables influence relationships of SES to CVD, CVD risks,
and their trends.  

As the Chartbook documents and the presenters noted,
national mortality data show clearly that for major ethnic
groups in the U.S. population, lower-SES strata have higher
mortality rates than higher-SES strata for coronary heart
disease (CHD), all CVD, and all causes.  National morbidity
surveys give generally concordant findings.

Discussants noted that SES is related to many aspects of
daily life, experiences at work and in the community,
stresses and strains, and access to and utilization of
medical care, including preventive services and state-of-
the-art diagnostic and therapeutic services.  To understand
better how SES influences CVD, an epidemiology of everyday
life that encompasses these phenomena needs to be developed.

Recommendations

*  Promote measurement of SES, in both observational and 
   interventional research, using established, valid, 
   reproducible, acceptable indices appropriate for a given  
   study and its aims.  Encourage data analysis approaches 
   that include use of information on SES as both a control  
   and a stratification variable.

*  Develop, validate, and incorporate more sophisticated 
   measures of SES and SES-related aspects of everyday life  
   into research with a major focus on SES and CVD.  In 
   studies of women, minorities, and rural residents, give 
   explicit attention to special features that may condition 
   the definition, meaning, and impact of SES.

*  Investigate the relationships between SES and CVD 
   initiation, progression, prognosis, morbidity, 
   disability, and death.  Emphasize greater use of methods  
   to measure preclinical disease (e.g., echocardiography, 
   electrocardiography, sonographic measurement of carotid 
   artery intima-media wall thickness, measurement of 
   ankle-arm blood pressure ratio) to achieve earlier and 
   more comprehensive assessments of the impact of SES-
   related exposures on CVD.  Link such findings to data on  
   nonfatal and fatal clinical CVD.

Session II:  Pathways Linking SES and CVD

Several presenters reviewed data on SES-CVD relationships
and on possible pathways of these relationships, in men and
women from specific U.S. population strata (i.e., blacks,
whites, Hispanics, Asians and Pacific Islanders, Native
Americans, rural populations, and employed groups).  Two
other presenters discussed evidence from psychosocial
studies and from research on stress, work, and social
support.  The last speaker addressed medical care access,
utilization, and costs.

In agreement with national data, findings from studies of
specific U.S. population groups generally show an inverse
relationship between SES and CVD (i.e., higher CVD rates
with lower SES).  Two broad pathways were noted linking SES
and CVD:  1) less favorable patterns of established major
lifestyle and biomedical risk factors (smoking, adverse
diet, sedentary lifestyle, high serum cholesterol, high
blood pressure, obesity, diabetes) in lower- compared with
higher-SES strata; 2) less favorable patterns of
psychosocial factors (hostility, depression, low social
support, social isolation, racism, job instability-
insecurity-strain- powerlessness, unemployment) in lower-
compared with higher-SES strata.  Data are sparse on
possible SES-related biological mediators of relationships
between psychosocial factors and CVD (e.g., altered
sympathetic and parasympathetic nervous system function,
altered  hypothalamic-pituitary-adrenal axis function,
altered cellular-molecular biology of key cells), and on
social-environmental mechanisms whereby lower SES leads
inordinately  -  from early childhood on  -  to development
of more adverse behavioral and psychosocial patterns. 

Men with low levels of all established biomedical risk
factors (blood pressure, cholesterol, smoking, diabetes,
previous heart attack) have been found to experience lower
CHD and CVD mortality rates than men without such a
favorable profile.  Such a favorable profile is found in
less than 10 percent of the population.  These findings
indicate that controlling the established biomedical risk
factors has the potential to achieve low CHD-CVD rates for
all groups in the United States, including low-SES strata of
various racial/ethnic backgrounds.

These observations underscore the importance of primary
prevention and control of the established major biological
risk factors for CHD-CVD.  Improved understanding of the
reasons why lower-SES groups have more adverse levels of the
major risk factors, the pathways producing these patterns,
and the contributory role of more adverse behavioral and
psychosocial patterns is key to achieving this goal.  Also
important is improved understanding of the lifestyle,
behavioral, psychosocial, cultural, metabolic, and genetic
components of maintaining low-risk status into middle age. 
Such knowledge will lead to development and application of
better approaches for the primary (including "primordial")
prevention and control of the major risk factors, with a
focused emphasis on lower- as well as higher-SES strata of
all racial/ethnic groups.

Recommendations

*  Investigate relationships between SES and 
   development/evolution of lifestyles, behaviors, and risk  
   factors, including both adverse and favorable patterns.

*  Analyze existing data and data currently being collected  
   by trials and demonstration projects to document further  
   the effectiveness of interventions in lower- and higher-  
   SES groups of various races/ethnicities; report and 
   disseminate such data and their implications for programs 
   to control CVD in lower-SES groups.

*  Conduct research to enhance understanding of mechanisms   
   underlying clustering of adverse lifestyles, behaviors, 
   and risk factors in lower-SES groups of various 
   races/ethnicities.

*  Study SES and precursors of adult lifestyles and 
   behaviors, from childhood on, including influences of the 
   family, community, school, and workplace.

*  Elucidate the mechanisms whereby conditions of everyday 
   life for lower-SES groups  -  exposures during prenatal
   life, infancy, childhood, and adulthood  -  contribute to
   the development of more adverse patterns of lifestyles, 
   behaviors, risk factors, and psychosocial traits.  
   Include studies of the roles of racism; sexism; 
   deprivation; relative and absolute income levels and 
   their trends; knowledge and attitudes; home, school, 
   workplace, community, and mass-media exposures; peer 
   pressures; housing conditions; relationships to 
   organizations; early exposures to food, alcohol, and 
   drugs; and barriers to adoption of heart-healthy 
   behavior.

*  Investigate the interrelationships between psychosocial 
   traits and lifestyles in lower-SES groups  with the aim 
   of clarifying environmental and biological mediators and  
   pathways of these interrelationships (including 
   neurological, endocrine, cellular, and molecular 
   pathways) and thereby enhancing understanding of how 
   psychosocial factors and acculturation influence CVD 
   risk.

Session III:  Experience in Educational and Preventive
Interventions Across SES Groups

This session focused on preventive strategies that, if
applied more broadly, have potential to reduce the SES
gradient in CVD health and disease.  Speakers reviewed
evidence from clinical trials and a broad range of
intervention studies to determine whether observed
reductions in CVD risk factors, morbidity, and mortality
extended equally to low- and high-SES participants,
including those from ethnic minorities.  Findings clearly
indicate that, although there is more to be learned, much is
already known about how to reduce CVD in low-SES groups.

Interventions in several large NHLBI-supported primary
prevention trials were efficacious in reducing CVD risk
factors, morbidity, and mortality in multiple SES-race
substrata, although only limited special efforts were made
to tailor the interventions for lower-SES, nonwhite
participants.  Interventions consisted of antihypertensive
drug treatment involving stepped care as well as multifactor
behavioral interventions aimed at smoking cessation,
reduction of total serum cholesterol, weight control,
increased physical activity, and reduction of salt and
alcohol intake.  Lower SES was not a barrier to intervention
success for either the drug treatment or the behavioral
components.  In one antihypertensive trial, the SES gradient
in mortality was eliminated in the intervention group.

Studies in communities, worksites, and schools confirm that
public health interventions can be designed to benefit all
segments of society.  Favorable changes in lifestyles and
lifestyle-related biomedical risk factors have been achieved
across all SES groups in community interventions that have
used a broad, multimedia communication approach with special
efforts to target and involve low-SES, culturally diverse
groups.   Worksite interventions incorporating on-site
classes and payroll incentives have also achieved favorable
results in both blue- and white-collar employees.  The
success of school-based programs in achieving similar
magnitudes of risk factor reduction in both low- and high-
SES students is particularly noteworthy given the schools'
potential for building lifelong heart-healthy habits and,
thereby, contributing importantly to the key strategic goal
of preventing the development of major risk factors.

Preliminary findings from programs specifically designed to
address the need for nutrition education materials suitable
for English-speaking adults with limited literacy skills
indicate that the approaches developed result in high
utilization of intervention materials among ethnically
diverse, low-SES persons and  can lead to gradual, sustained
progress toward favorable risk factor change over time. 
Most programs use multimedia, client-centered instructional
approaches that include interactive computer technology,
videotapes, audiocassettes, compact discs, and printed
materials.

Across all SES groups, self-help is the method of choice for
smoking cessation by more than 90 percent of smokers. 
Programs that combine media presentations with telephone
counseling hotlines or distribution of self-help materials
have been particularly effective with lower-SES smokers.  A
community organization approach used in one study had the
greatest effect in low-SES individuals.  Counseling of
smokers by physicians or dentists has also been shown to
increase their likelihood of quitting smoking significantly.

Sedentary lifestyle is particularly prevalent among lower-
SES persons and ethnic minorities.  Experience from
community-based heart-health programs suggests that
interventions promoting moderate- rather than vigorous-
intensity activities are more likely to be successful, and
that exercise campaign events tied to preexisting community
structures or traditional community events have the greatest
participation levels.  Worksite interventions have
demonstrated that clinically significant increases in
physical activity can be achieved in both low- and high-SES
employees.

The National High Blood Pressure Education Program and
National Cholesterol Education Program have been prime
movers in the substantial progress made in achieving the
Healthy People 2000 blood pressure and cholesterol
objectives.  Their achievements underscore the effectiveness
of science-based public health strategies that rely on
broad-based cooperation between government and the private
sector in overcoming the barriers to reducing CVD in all
sectors of the population.

The overall conclusion is that more widespread application
of interventions already known to work across multiple SES
and ethnic groups can make a substantial contribution to
eliminating the SES gradient and ending the CVD epidemic in
all segments of society.

Recommendations

*  Incorporate nonsmoking messages into educational efforts  
   targeting all SES-ethnic groups, with a particular focus  
   on more habituated smokers and on do-it-yourself 
   approaches to smoking cessation.

*  Evaluate existing obesity intervention programs; look for 
   successes and develop approaches based on them, with the  
   aim of achieving national goals for obesity prevention 
   and control for all SES strata, including reversal of the 
   decades-long rise in obesity rates among children, youth, 
   and adults.

*  Intensify efforts to increase consumption of heart- 
   healthy foods  -  reduced in total fat, saturated fat, 
   cholesterol, salt, refined sugars, and calories  -  in
   lower-SES communities.

*  Enhance efforts to prevent and control high alcohol 
   intake among lower-SES groups of various 
   races/ethnicities.

*  Enhance efforts to achieve daily or near-daily physical 
   activity by lower-SES groups from childhood on and to 
   increase the proportion of people who regularly engage in 
   moderate activity.

*  Emphasize the potential contribution of stress reduction  
   to modifying risk factors and subsequent CVD morbidity 
   and mortality.

*  Encourage assessment of literacy as a relevant aspect for 
   improving ability to intervene effectively in lower-SES 
   groups; use group-specific programs appropriate for 
   literacy level and sensitive to group culture.

*  Develop effective strategies to promote favorable 
   behavior changes in lower-SES groups.

*  Conduct demonstration research in communities, 
   workplaces, and schools with persons from lower-SES 
   groups of various ethnicities.  Include participation of  
   community outreach workers (including workers trained and 
   supervised by nurses and dieticians) and community 
   representatives in all aspects of such projects (i.e., 
   planning, intervention, data evaluation) to enhance the 
   potential for lasting accomplishments.

REPORT ORGANIZATION

The report that follows is organized in three sections that
parallel the structure of the conference.  Each section
includes an overview of the session, prepared by its chair,
and summaries of the individual topical presentations,
prepared by the presenters and their colleagues.

Rosters of conference chairs and speakers, contributing
authors, and NHLBI coordination staff are provided at the
end of this report.

.