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Socioeconomic inequality and its impact on health is a growing concern in the European public health debate. In many countries, the issue is moving away from description towards the identification of the determinants of inequalities and the development of policies explicitly aimed at reducing inequalities in health. In Italy, ten years after the publication of the first report on inequalities in health, this topic is seldom present on the agenda of public policy makers. The purpose of this report is to update the Italian profile of social variation in health and health care in order to stimulate the debate on ways to tackle inequalities in health that are preventable. In the first section of this book, the threefold objective is to describe the principal mechanisms involved in the generation of social inequalities in health (Introduction); to report Italian data on the distribution and magnitude of this phenomenon in the last decade; and to evaluate policies and interventions in both the social (chapter 1.9, Section I) and the health sector (chapter 2.3, Section I), which are potentially useful to reduce health inequalities. It is intended for anyone who is in a position to contribute t o decision-making that will benefit the health of communities. For this reason, chapters are organized by specific determinants of inequalities on which interentions may have an impact. The methodological approach in the second section focuses on the best methods to monitor social inequalities including recommendations on social indicators, sources of information and study models, based on European guidelines revised for the Italian situation. According to data from national and local studies, mortality increases linearly with social disadvantage for a wide range of indicators at both the individual (education, social class, income, quality of housing) and the geographical level (deprivation indexes computed at different levels of aggregation). This positive correlation is evident for both sexes, with the steepest gradient observed among adults of working age, although differences persist also among the elderly. The causes of death found to be most highly correlated with social inequality, and largely responsible for the increasing inequality over the last decade, are those associated with addiction and exclusion (drug, alcohol and violence related deaths), with smoking (lung cancer) and with safety in the workplace and on the roads (accidents). Similar gradients and trends have been observed with different outcomes, such as self-reported morbidity, disability and cancer incidence (chapter 1.1, Section I). Reproductive outcomes confiirm this picture: compared to women belonging to the upper classes, those women in low conditions experience more spontaneous abortions and their children suffer from higher infant mortality and low birth weight. This is a critical issue since poor infant health, particularly for metabolic and respiratory pathologies, affects health in adult life. There is now substantive evidence showing that also socioeconomic circumstances at birth or during adolescence may have a strong impact on adult health (chapter 1.2, Section I). Differences in harmful lifestyles, such as smoking, heavy drinking, drug use, unhealthy diet, obesity and physical inactivity, have a similar effect. The only exception is smoking among women, which is positively correlated with socioeconomic status; however, since women in the upper classes have a greater tendency to quit smoking, the gradient will soon be reversed (chapter 1.7, Section I). On the other hand, most of these behaviours do not follow from free and conscious individual choice; they are a form of adaptation to chronic stress originating in the work-place (chapter 1.4, Section I), or to particularly unfavourable events and conditions, such as unemployment (chapter 1.5, Section I) or lack of family and social support (chapter 1.6, Section I). Poor socioeconomic circumstances are the threshold of absolute poverty and may lead to social exclusion, a condition with a heavy impact on health, which in Italy includes marginal groups of the native population and broader classes of immigrants (chapter 1.3, Section I). Finally, there is recent and consistent evidence on the existence of a "contextual" effect on health, as opposed to the "compositional" effect given solely by the aggregation of individual processes. According to this hypothesis, characteristics of the infrastructure, and the physical and socioeconomic environment of an area would have an impact on individual health independent from the cultural and economic resources personally available to people living in that area (chapter 1.8, Section I). With respect to the health care system, various studies are in agreement in demonstrating that poor and less educated people have inadequate access both to primary prevention and early diagnosis (chapter 2.1, Section I), and to early and appropriate care (chapter 2.2, Section I). They also experience higher rates of hospitalization, particularly in emergencies and with advanced levels of severity.
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PMID:[Inequalities in health in Italy]. 1553 46

There is considerable debate about the association between individual socio-economic status, community socio-economic status and health. The current study examines individual data from a case-control study of stroke (n = 3489) conducted in Auckland, New Zealand. The study sought to identify whether individual socio-economic status (as measured by income from lifetime occupation) and community socio-economic status (measured in a number of ways) predicts the onset of stroke both independently and after controlling for individual risk factors (e.g., smoking, obesity and hypertension). Logistic regression results show that individual socio-economic status and all of the community socio-economic status measures predict the onset of stroke before controlling for individual risk factors. However, there is a high correlation between the various measures of community socio-economic status. Stepwise regression results suggest that average household income is the measure of community-level socio-economic status with the greatest predictive power. The results suggest that individual income and average household income are significant predictors of onset of stroke both independently and after controlling for behavioural and medical risk factors. Logistic regression analysis of the pathway suggests that individual income is a significant predictor of smoking and obesity, and that community socio-economic status is a significant predictor of heart disease, heavy drinking, diabetes, smoking and obesity.
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PMID:Individual socio-economic status, community socio-economic status and stroke in New Zealand: a case control study. 1597 Feb 29

Several factors for chronic kidney disease (CKD), including diabetes, hypertension, and obesity, are described consistently in the literature; studies describing modifiable lifestyle factors, including smoking and consumption of alcohol, are sparse, sometimes contradictory. The authors examined the factors associated with CKD in a population-based cohort in Wisconsin, with emphasis on smoking and consumption of alcohol. CKD was defined as an estimated glomerular filtration rate of less than 60 ml/minute per 1.73 m(2) from serum creatinine. The authors performed two analyses: 1) cross-sectional analysis among 4,898 persons with prevalent CKD (n = 324) as the outcome of interest and 2) longitudinal analysis among 3,392 CKD-free persons at baseline, with 5-year incident CKD (n = 114) between 1993 and 1995 as the outcome of interest. Smoking and heavy drinking, defined as consumption of four or more servings of alcohol per day, were associated with CKD, independent of several important confounders. Compared with that among never smokers, the odds ratio of developing CKD was 1.12 (95% confidence interval (CI): 0.63, 2.00) among former smokers and 1.97 (95% CI: 1.15, 3.36) among current smokers. Heavy drinking was associated with CKD, with an odds ratio of 1.99 (95% CI: 0.99, 4.01). Joint exposure to both current smoking and heavy drinking was associated with almost fivefold odds of developing CKD compared with their absence (odds ratio = 4.93, 95% CI: 2.45, 9.94). Smoking and consumption of four or more servings of alcohol per day are associated with CKD.
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PMID:The association among smoking, heavy drinking, and chronic kidney disease. 1738 12

Although significant advancements have been made in the treatment of esophageal cancer, this aggressive malignancy commonly presents as locally advanced disease with a poor prognosis. Despite improvements in the detection of premalignant pathology, newer preventative strategies, and the development of more effective combination therapies, the overall incidence of esophageal carcinomas has risen. A clear association has been established between the development of esophageal cancer and Helicobacter pylori infection, gastroesophageal reflux disease, smoking, and heavy alcohol use. However, the growing number of newly diagnosed esophageal adenocarcinomas, despite widespread treatments with proton pump inhibitors and the eradication of H. pylori, leaves the medical community searching for more answers. There is a potential link between esophageal adenocarcinoma and obesity. Common presenting symptoms of esophageal cancer are dysphagia, odynophagia, and progressive weight loss. The initial assessment for patients with these symptoms is made with double-contrast barium esophagraphy. Treatment modalities include surgery, chemotherapy, radiation therapy, or a combination of modalities. Prevention strategies include smoking and alcohol cessation.
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PMID:Esophageal cancer: a review and update. 1683 35

Four behavioural risk factors are common in primary care and are often clustered in individuals. Smoking is present from I cigarette per day, excessive alcohol use is defined either by drinking regularly more than 2-3 standard glasses per day or by occasional heavy drinking of more than 4-5 glasses at a time. Patients who don't have regular moderate physical activity of at least 30 minutes during 5 days of a week or intensive physical activity of at least 20 minutes 3 times a week are sedentary. A Body Mass Index of over 30 defines obesity. We propose a "generic" counselling tool in 5 steps, the 5 As, that can be used for any of the four behavioural risk factors during routine consultations. With this counselling guide, practitioners can help patients change behaviour in a motivational style that allows shared decision-making.
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PMID:[Practitioners confronted with the four main health behavioral risk factors]. 1706 47

Chronic kidney disease (CKD) is increasingly recognized not only as a cause of end-stage renal disease but also as a cause of cardiovascular disease. Importantly, it is intimately associated with non-healthy lifestyles such as obesity, metabolic syndrome, hypertension, diabetes mellitus, smoking, and heavy drinking. To define CKD direct measurement of GFR or estimation of GFR (eGFR) is required. Japan Society of Nephrology is asking nationwide project to create "original" equation without using ethnic factor to obtain eGFR. Early detection and early treatment are vital to prevent not only CKD progression but also cardiovascular events. A comprehensive health education campaign and screening of the general populace are needed in order to detect CKD early. The control of hypertension, dyslipidemia, proteinuria, obesity, are intervention strategies that retard or prevent progression of CKD. Blockade of the renin-angiotensin system can be beneficial, especially if proteinuria is present.
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PMID:[New concept of chronic kidney disease and blockade of renin-angiotensin system]. 1787 2

The primary purpose of this article was to examine the associations between life satisfaction level and health-related quality of life (HRQOL), chronic illness, and adverse health behaviors among adults in the U.S. and its territories. Data were obtained from the 2005 Behavioral Risk Factor Surveillance System, an ongoing, state-based, random-digit telephone survey of the noninstitutionalized U.S. population aged >or=18 years. An estimated 5.6% of U.S. adults (about 12 million) reported that they were dissatisfied/very dissatisfied with their lives. As the level of life satisfaction decreased, the prevalence of fair/poor general health, disability, and infrequent social support increased as did the mean number of days in the past 30 days of physical distress, mental distress, activity limitation, depressive symptoms, anxiety symptoms, sleep insufficiency, and pain. The prevalence of smoking, obesity, physical inactivity, and heavy drinking also increased with decreasing level of life satisfaction. Moreover, adults with chronic illnesses were significantly more likely than those without to report life dissatisfaction. Notably, all of these associations remained significant after adjusting for sociodemographic characteristics. Our findings showed that HRQOL and health risk behaviors varied with level of life satisfaction. As life satisfaction appears to encompass many individual life domains, it may be an important concept for public health research.
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PMID:The associations between life satisfaction and health-related quality of life, chronic illness, and health behaviors among U.S. community-dwelling adults. 1808 Feb 7

Adverse health behaviors and obesity are key determinants of major chronic diseases. Evidence on work-related determinants of these behavioral risk factors is inconclusive, and comparative studies are especially lacking. We aimed to examine the associations between job strain, working overtime, adverse health behaviors, and obesity among 45-60-year-old white-collar employees of the Whitehall II Study from London (n=3,397), Helsinki Health Study (n=6,070), and the Japanese Civil Servants Study (n=2,213). Comparable data from all three cohorts were pooled, and logistic regression analysis was used, stratified by cohort and sex. Models were adjusted for age, occupational class, and marital status. Outcomes were unhealthy food habits, physical inactivity, heavy drinking, smoking, and obesity. In London, men reporting passive work were more likely to be physically inactive. A similar association was repeated among women in Helsinki. Additionally, high job strain was associated with physical inactivity among men in London and women in Helsinki. In London, women reporting passive work were less likely to be heavy drinkers and smokers. In Japan, men working overtime reported less smoking, whereas those with high job strain were more likely to smoke. Among men in Helsinki the association between working overtime and non-smoking was also suggested, but it reached statistical significance in the age-adjusted model only. Obesity was associated with working overtime among women in London. In conclusion, job strain and working overtime had some, albeit mostly weak and inconsistent, associations with adverse health behaviors and obesity in these middle-aged white-collar employee cohorts from Britain, Finland, and Japan.
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PMID:Associations of job strain and working overtime with adverse health behaviors and obesity: evidence from the Whitehall II Study, Helsinki Health Study, and the Japanese Civil Servants Study. 1826 33

The aim of the present review was to: (i) highlight epidemiological and other studies that have generated important data on the harmful patterns of drinking that increase the risk for chronic diseases, including alcohol dependence, and on the mechanisms by which alcohol produces and, in some instances, may protect against damage; and (ii) discuss a conceptual basis for quantifying risk criteria for alcohol-induced chronic disease based on the quantity, frequency, and pattern of drinking. The relationship between heavy drinking and risk for adverse health conditions such as alcoholic liver disease (ALD), dementia, and alcohol dependence is well known. However, not everyone who drinks chronically develops ALD or dementia, and the major risk factors for disease development and the mechanisms by which this occurs have remained unclear. Large-scale, general population-based studies have provided the evidence by which quantifying the frequency of a pattern of high-risk drinking can be related directly to risk and the severity of alcohol dependence. Cellular and molecular biology studies have identified the major pathways of alcohol metabolism and how genetics and the environment can interact in some individuals to further increase the risk of organ damage. Extant databases should allow scientists and clinicians jointly to develop the framework for quantifying the drinking patterns that increase the risk of alcohol-induced organ pathologies, to develop clinical practice guidelines, such as those used to diagnose other common complex diseases (e.g. diabetes and hypertension), and to propose future studies for refining such guidelines. Attention must be paid to comorbid conditions such as hepatitis B and C infections, HIV, obesity, and environmental exposures other than alcohol. Developing trait and state biomarkers is critical to the process of discovery and to fulfilling the promise of personalized medicine.
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PMID:Quantifying the risk for alcohol-use and alcohol-attributable health disorders: present findings and future research needs. 1833 58

This study evaluated the impact of an integrated population health enhancement program on employee health risks, health conditions, and productivity. Specifically, we analyzed changes in these measures among a cohort of 543 employees who completed a health risk assessment in both 2003 and 2005. We compared these findings with 2 different sets of employees who were not offered health enhancement programming. We found that the DIRECTV cohort showed a significant reduction in health risks after exposure to the program. Relative to a matched comparison group, the proportion of low-risk employees at DIRECTV in 2005 was 8.2 percentage points higher; the proportion of medium-risk employees was 7.1 percentage points lower; and the proportion of high-risk employees was 1.1 percentage points lower (p < 0.001). The most noticeable changes in health risk were a reduction in the proportion of employees with high cholesterol; an improvement in diet; a reduction of heavy drinking; management of high blood pressure; improved stress management; increased exercise; fewer smokers; and a drop in obesity rates. We also found that a majority of employees who improved their risk levels from 2003 to 2005 maintained their gains in 2006. Employees who improved their risks levels also demonstrated relative improvement in absenteeism. Overall, this study provides additional evidence that integrated population health enhancement positively impacts employees' health risk and productivity; it also reinforces the view that "good health is good business."
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PMID:The impact of an integrated population health enhancement and disease management program on employee health risk, health conditions, and productivity. 1910 44


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