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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.088096
RESEARCH AND PRACTICE |
C. Mary Schooling, Tai Hing Lam, G. Neil Thomas, Michelle Heys, Xiangqian Lao, and Gabriel M. Leung are with the Department of Community Medicine, School of Public Health, University of Hong Kong, Hong Kong, People’s Republic of China. Chaoqiang Jiang and Weisen Zhang are with the Guangzhou Occupational Disease Prevention and Treatment Centre, Guangzhou No.12 Hospital, Guangzhou, People’s Republic of China. Peymane Adab and Kar Keung Cheng are with the Department of Public Health and Epidemiology, University of Birmingham, Birmingham, England.
Correspondence: Requests for reprints should be sent to Tai Hing Lam, MD, Department of Community Medicine, William M. Mong Building, 21 Sassoon Road, Pokfulam, Hong Kong, China (e-mail: commed{at}hkucc.hku.hk).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. Better childhood conditions, inferred from height and specifically leg length, are usually protective against ischemic heart disease and its risk factors in Western countries. In other geoethnic populations, height is less clearly protective, casting doubt on there being a biological etiology. To clarify the role of childhood conditions, we examined the associations of height and its components with cardiovascular risk among older Chinese people.
Methods. We used multivariable regression to examine the associations of height and its components with blood pressure, lipid profile, and diabetes in 10413 older Chinese adults (mean age=64.6 years).
Results. After we adjusted for age, gender, socioeconomic status, and lifestyle habits, greater sitting height was associated with diabetes and dyslipidemia. Longer legs were associated with lower pulse pressure and lower low-density lipoprotein cholesterol.
Conclusions. We provide indirect anthropometric evidence for the role of pre-pubertal and pubertal exposures on cardiovascular risk. Pubertal exposures are stronger than are prepubertal exposures but may be influenced by osteoporotic decline in old age. Further research should establish whether the observed relations are ethnically specific or relate to the stage or trajectory of socioeconomic development.
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INTRODUCTION |
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Height, a marker of childhood growth, is usually associated with lower mortality and morbidity from ischemic heart disease (IHD)1,2 and from associated risk factors.3–5 It is thought that better childhood conditions, such as improved nutrition and fewer respiratory infections, result in both greater adult height and lower rates of IHD.6 Recently, leg length has been identified as the component of height associated with a lower risk of death from IHD,7–9 the absence of diabetes,10 lower blood pressure,4 and a more favorable cardiovascular risk profile overall,11,12 whereas relatively greater sitting height may be associated with a greater risk of IHD and antecedent conditions.10–13 Most leg growth occurs in the prepubertal period, which suggests that an exposure to some risk factors at that time determines risk of cardiovascular disease and possibly diabetes.
There are, however, exceptions in the relationship between height and cardiovascular risk14–19 that cast doubt on the significance of height—and hence of childhood conditions, either prepubertal or pubertal—to IHD. Most of the reports describing height and IHD are from Western Europe and North America and are comparatively recent (i.e., within the last 60 years), coming many decades after the industrialization of the economies in those regions. By contrast, studies finding little relation between height and IHD or its risk factors mainly come from locations that are economically underdeveloped, such as Brazil15,17 and Nigeria,19 or where economic development is more recent, such as South Korea.18 In addition, the social patterning of IHD in Western White men changed over the course of the 20th century, from being associated with higher social position to being associated with lower social position.20 Currently, the social patterning of risk factors such as hypertension and obesity vary with level of economic development21,22; however, height is usually associated with social advantage.
The evidence concerning leg length and IHD risk comes from wealthy, developed Western countries, where there is a long history of increasing height over many generations as living standards have gradually improved. In the West, this increase in height has been driven mainly by an increase in leg length,23 and mortality from IHD is clearly associated with socioeconomic conditions.24 By contrast, there was very little industrial development in China before the 20th century,25 and little improvement in the standard of living from preindustrial levels before the establishment of the People’s Republic of China in 1949,25,26 although some haphazard minor growth around the treaty ports along the eastern seaboard (e.g., Shanghai and, to a lesser extent, Guangzhou) prior to this date is possible.27,28 In China, the emergence of the IHD epidemic is recent, the social patterning of risk is less clear than in western Europe,29–31 and the social restructuring since the establishment of the People’s Republic may have weakened the relationship between social position in childhood and in adulthood.32 To clarify the etiological role of childhood conditions, we investigated the relation of height and its components with risk factors for IHD and diabetes in a Chinese population.
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METHODS |
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Materials
The Guangzhou Biobank Cohort Study, a collaboration between the Guangzhou No. 12 Hospital, the University of Hong Kong, and the University of Birmingham, England, was a prospective study of approximately 300 000 older people that was intended to examine genetic, lifestyle, occupational, and environmental factors and causes of common chronic diseases.33 Recruitment of participants, which took place in 2003 and 2004, drew from the Guangzhou Health and Happiness Association for the Respectable Elders (GHHARE), a community social and welfare association aligned with the municipal government; its membership is open to anyone aged 50 years or older for a monthly nominal fee of 4 yuan (US $0.50). Approximately 7% of permanent Guangzhou residents aged 50 years and older are members of GHHARE, of whom 11% were randomly drawn volunteers who had registered their interest and participated in this study. Volunteers were eligible if they were capable of consenting, were ambulatory, and were not receiving treatment (e.g., chemotherapy or radiotherapy for cancer, dialysis for renal failure) that, if omitted, could result in immediate life-threatening risk. Of those eligible, 90% of the men and 99% of the women participated. Participants included in this analysis underwent a half-day detailed medical interview, which included a physical examination and a questionnaire that asked about disease history, health-related habits, and demographic characteristics.33
The detailed methods of measurement have been previously reported.33 In brief, we recorded seated blood pressure as the average of the last 2 of 3 measurements, using the Omron 705CP sphygmomanometer (Omron Corp, Kyoto, Japan). Standing height without shoes was measured to the nearest 0.1 cm. For measurement of sitting height (from the base of the spine to the top of the head), the participant sat upright on a standard stool. Leg length was calculated as the difference between height and sitting height. Weight (with participants dressed in light clothing) was measured to the nearest 0.1 kg. Hip circumference was measured at the greatest circumference around the buttocks below the iliac crest. Waist circumference was measured horizontally around the smallest circumference between the ribs and iliac crest, or at the level of the naval for obese participants. Levels of fasting total serum cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, and glucose were determined with a Shimadzu CL-8000 clinical chemical analyzer (Shimadzu Corp, Kyoto, Japan) in the hospital laboratory.
Validation of the initial questionnaire was performed 6 months into recruitment by recalling 200 randomly selected participants for a second interview. Kappa values of questions were as follows: smoking, 0.96 and 0.88 (2 questions); drinking, 0.60; education, 0.90; occupation, 0.80. These values indicate that the questions were probably understood and answered accurately.
Variable Assessment
Because of secular trends toward increasing height and shrinkage from conditions associated with age (such as osteoporosis, which mainly affects the trunk), older people are usually shorter than are younger people. Our initial analysis revealed that, whether height or its components were considered as gender-specific standard deviations or as z scores from gender-specific fitted curves that used age, age2, and age3, results were similar. Therefore, for simplicity and to facilitate comparisons between men and women and with other studies that also used gender-specific standard deviations, we used gender-specific standard deviations of height and its components for our analysis. We also included sitting height-to-trunk ratio, because somatic disproportion could be important,34 particularly for diabetes.13
Biological Risk Factors of Ischemic Heart Disease
Eight biological outcome measures were examined: systolic blood pressure; diastolic blood pressure; pulse pressure; levels of fasting plasma glucose, HDL cholesterol, LDL cholesterol, and triglyceride; and presence of diabetes (defined as fasting plasma glucose 
7.0 mmol/L, previous diagnosis, or use of antidiabetic medication). These outcome measures were chosen to reflect the biological risk factors in the Framingham equation,35 a risk prediction equation for heart disease. In younger people, systolic and diastolic blood pressure track together. In older people, however, whereas systolic pressure continues to rise, diastolic pressure falls, and the difference between the two (pulse pressure) contributes to IHD risk.36 HDL and LDL cholesterol were analyzed instead of total cholesterol because they have different associations with IHD. Triglycerides and fasting plasma glucose were included because they are risk factors in the Diabetes Prediction Model, another clinical risk-scoring system.37
Statistical Analysis
We used multivariable regression to assess the relationship between standard deviations of height and its components and IHD risk factors. Men and women and all ages were analyzed together in their respective groupings unless there was evidence of effect modification (i.e., a significant interaction term or different effect sizes by strata). We tested for interactions by running models with and without the interaction term and examining the statistical significance of the likelihood ratio test of the difference between the 2 models on the relevant 
2 distribution. Potential confounders considered were age (treated as a continuous variable), gender, socioeconomic status (determined from education, personal annual income, and job type), lifestyle habits (smoking status, alcohol use, and physical activity [assessed with the International Physical Activity Questionnaire37]), and use of appropriate medication. Obesity was also considered as a potential confounder because it may represent adult experiences unrelated to childhood conditions, such as moving to an environment where food is more plentiful.
Models were initially built to investigate the possible effects of each confounder in turn. We present 3 models: the first adjusted for age and gender only (model 1), the second adjusted for age and gender, as well as for socioeconomic status, lifestyle, and use of appropriate medication (model 2), and the third model adjusted for all confounders in model 2 as well as for 2 commonly used proxies of obesity: body mass index (weight in kilograms divided by height in meters squared) and waist–hip ratio (model 3).
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RESULTS |
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Of the 10413 participants examined, 10304 (99%) had complete data on all items of interest apart from longest-held occupation and personal income. We used dummy categories for the 501 participants who did not state their occupation and the 712 who did not report their personal income, so no multiple imputations were done. Analysis was based on these 10304 participants, of whom 3021 were men (mean age=66.2 years [SD ± 5.7]) and 7283 were women (mean age=64.0 years [SD ± 6.0]); ages ranged from 50 to 93 years. Almost all participants (98%) were Han Chinese.
Mean height was 163.9 cm (SD ± 5.7) and 152.8 cm (SD ± 5.4) for men and women, respectively. Greater height was associated with younger age, more years of formal education, nonmanual job, higher income, and use of alcohol (Table 1
). Longer legs were associated with higher income, and among men, with smoking and alcohol use. Greater sitting height was associated with younger age, more years of formal education, having a non-manual job, and higher income and, among women, use of alcohol, and never smoking.
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Because there was little evidence that the association of height or its components with the risk factors varied by gender, we analyzed data for men and women together (Table 2
). The association of sitting height and sitting height–to-leg ratio with blood pressure was different in the older (aged 65 years) and younger (aged 50–64 years) age groups. For example, greater sitting height was associated with lower systolic blood pressure only in the older age group and with higher diastolic blood pressure only in the younger age group, as seen in Table 3, which additionally shows height and its components stratified by gender and age group, greater sitting height was associated with lower pulse in both age groups; for the younger group, the mean difference was –0.89 per 1 SD increase in sitting height (95% confidence interval [CI] = –1.27, –0.50) and for the older group it was –1.18 (95% CI = –1.62, –0.75
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We present 3 models in Table 2
. In model 1 (adjusted for age and gender only) and model 2 (adjusted for age and gender, as well as for medication use, socioeconomic status, and lifestyle), longer legs were associated with lower pulse pressure and lower LDL cholesterol but also with lower HDL cholesterol. These associations remained similar after additional adjustment for body mass index and waist–hip ratio (model 3). In all models, greater sitting height was associated with lower pulse pressure and lower LDL cholesterol but also with higher fasting plasma glucose, lower HDL cholesterol, higher triglycerides, and the presence of diabetes. Greater sitting height–to-leg ratio was associated with the presence of diabetes. Greater height was associated with lower pulse pressure and lower LDL cholesterol but also with higher triglycerides and lower HDL cholesterol. |
DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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In a population different from those used in similar studies with regard to both ethnicity and historical socioeconomic development, we found that both leg length and sitting height were associated with cardiovascular risk and diabetes. Both greater sitting height and longer legs were associated with lower pulse pressure and lower LDL cholesterol but also with lower HDL cholesterol. Greater sitting height was also associated with diabetes and its antecedents. These relationships were little changed after adjustment for obesity. An association of longer legs with lower pulse pressure is consistent with findings from Western populations, although the association was small and not evident for systolic or diastolic blood pressure considered separately. Pulse pressure increases with age (making it preferable for use in a cross-sectional study of older people), and the influence of shorter legs on pulse pressure is greater and potentially more obvious at older ages.39
Overall, longer legs were less clearly associated with a favorable cardiovascular risk profile than in other studies.4,10,11 An association of greater sitting height with diabetes and its risk factors is consistent with the weak positive association between relatively greater sitting height and insulin resistance and diabetes observed among Western populations.10,13 Thus, overall, in this recently and rapidly socioeconomically developing population of older Chinese, we found longer legs somewhat protective against cardiovascular risk, but to a lesser extent than seen elsewhere, and longer trunks more strongly associated with risk, particularly for diabetes.
Longer legs are thought to be associated with lower cardiovascular risk as a marker of better childhood conditions, and there are several potential explanations for the weak relationships observed in our setting. First, shorter legs may be associated with both a poorer childhood environment and a more traditional and protective lifestyle and diet in adulthood, although shorter legs were not consistently associated with lower educational attainment. Second, in China, where age of menarche is falling,40 the beneficial effects of better childhood conditions on leg growth may have been counteracted by the fact that these same conditions also promote earlier sexual maturity, which reduces leg growth.41 Third, in this specific context there could be less residual confounding by lifetime and intergenerational social position, because we found little association between health behaviors and body dimensions or between socioeconomic status and leg length.
Greater sitting height was associated with lower pulse pressure but with higher prevalence of diabetes and its antecedents. Very sudden improvements in childhood living conditions between generations can accelerate the tempo of sexual maturation,42 which may result in greater pubertal growth,43 mainly in sitting height. Greater sitting height may represent a growth pattern with a relatively greater or more intense pubertal growth spurt, which upregulates some aspect of the complex growth hormone–insulinlike growth factor–leptin axis, with long-term metabolic consequences.10 Growth patterns involving accelerated growth, early or late, are associated with cardiovascular risk and diabetes.44–47 Increases in height (especially in sitting height) across generations indicate accelerated growth—mainly during puberty—relative to the parents’ generation.
The cohort in this study was taller than people of previous generations.48 Among men, the increase was mainly in sitting height: 87.9 cm compared with 83.0 to 84.6 cm among men in a 1925 study,49 the only study before World War II from which relevant data are available. In 1925, Chinese men’s body proportions (but not sizes) were similar to those of modern European men.50 We could not find similar information for women, but there were intergenerational increases in sitting height among women, with little change in leg length, in the United States in the late 19th and early 20th centuries.51 Intergenerational increases in sitting height and leg length have been observed in other populations with a recent history of economic development, such as Hong Kong52 and Mexico,53 although in long-term developed populations, increases in leg length appear to underlie the secular increase in height since the mid-19th century.23
We speculate that height represents an interplay between the cardioprotective qualities of greater overall growth and the cardiodetrimental qualities of accelerated growth during puberty, so that the overall effect of height on IHD risk is specific to the context of how the anthropometric dimensions were achieved. Clearly, at the population level, this could lead to a finding that height is not associated with IHD mortality, as has been observed in Korea,18 where there is an ethnically similar East Asian population with a recent history of economic development.
Conceptualizing height as having such an interplay has 3 implications, consistent with historic trends in the epidemic of IHD. First, height should be more strongly protective at the end of the epidemiological transition, when differences in living conditions and height between generations are small, but less protective during rapid transition, when there is more change between generations. Second, the social patterning should change across the epidemiological transition, because social groups experiencing the least childhood intergenerational change should always be at least risk. The social group experiencing least intergenerational change most likely changes during the transition from the less socially advantaged groups to the more socially advantaged groups. Third, IHD should be an epidemic that peaks with rapid economic development and wanes after several generations of economic development, when differences between the living conditions of the parents and their offspring disappear.
Limitations
Although this was a very large study, there were some limitations. Leg length does not usually change in adulthood, but it may be more prone to measurement error than is sitting height, because leg length was calculated as the difference between standing and sitting height, each of which has its own variances. Although this measurement error might have attenuated associations with leg length, our large sample compensates for this attenuation. Greater trunk length may signify less osteoporosis, which shares some risk factors with cardiovascular disease, so we cannot discount the possibility that the association between greater sitting height and lower risk may have been because of "reverse causality"; however, any association between greater sitting height and higher cardiovascular risk would also be attenuated.
Without direct measurements of body fat from bioimpedance or skinfold thickness, adjustment for obesity through proxy measures, such as body mass index, may over- or underadjust, because these proxies may also indirectly measure body proportions or dimensions. Body mass index increases with sitting height–to-leg ratio,53 and other proxies may vary similarly—for example, hip circumference could increase with leg length.
Survival bias is also possible. If survivor-ship were an issue, we would have expected differences in association between the older (aged 65 years) and younger (aged 50–64 years) age groups, of which we found little evidence. The infrastructure to facilitate fully representative cohort studies in developing countries such as China is not readily available, which could preclude evidence from a large proportion of the global developing population during a period of transition. Although this cohort may not be representative, the prevalences of relevant morbidities such as hypertension and diabetes were similar to those in a recent, representative sample of urban Chinese.33 Our findings would be biased if people with specific body proportions and disease risks—such as short-bodied people with diabetes or long-bodied people with higher blood pressure—were systematically excluded; however, we have little reason to believe either case is likely to have occurred.
Conclusions
In a recently socioeconomically developed population with little social patterning of IHD, we found variables associated with or resulting in pubertal growth mainly were associated with IHD risk, with only weak protective effects of undetermined prepubertal exposures. Height had a weak relationship with IHD risk not because childhood circumstances have no effect but because they have period-specific (prepubertal and pubertal) opposing effects, which may explain why a protective effect of height on IHD is not always seen. Height could represent the cardioprotective properties of greater growth and the cardiodetrimental properties of accelerated growth, so that the effect is contextually driven, depending on the developmental history experienced by the population. Thus, the IHD risk that develops as a result of socioeconomic or environmental factors, besides arising from deprivation over the life course, could also arise from recent deprivation in the population or subpopulation history.
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Acknowledgments |
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This study was funded by The University of Hong Kong Foundation for Educational Development and Research, Hong Kong; the Guangzhou Public Health Bureau and the Guangzhou Science and Technology Committee, Guangzhou, China; and the University of Birmingham, Birmingham, England.
We thank the Clinical Trial Service Unit, University of Oxford, for its support and the Guangzhou Health and Happiness Association for the Respectable Elders for convoking the participants. The Guangzhou Biobank Cohort Study investigators include the following: Guangzhou No. 12 Hospital: M. Cao, T. Zhu, and B. Liu; the University of Hong Kong: S.M. McGhee and R. F. Fielding.
Human Participant Protection
The Guangzhou Medical Ethics Committee of the Chinese Medical Association approved the study, and all participants gave written, informed consent prior to participation.
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Footnotes |
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Peer Reviewed
Contributors
C. M. Schooling carried out the statistical analysis and wrote the article. C. Jiang, T.H. Lam, and K. K. Cheng initiated and oversaw the Guangzhou Biobank Cohort Study. G.N. Thomas, X. Lao, W. Zhang, and P. Adab assisted in the planning and coordination of the study. M. Heys assisted in the statistical analyses and commented on the article. G. M. Leung helped to conceptualize ideas, interpret findings, and review drafts of the article.
Accepted for publication October 16, 2006.
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