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AJPH First Look, published online ahead of print Sep 27, 2007
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November 2007, Vol 97, No. 11 | American Journal of Public Health 1927-1928
© 2007 American Public Health Association
DOI: 10.2105/AJPH.2007.119248

LETTER

SOCIOECONOMIC POSITION, CLUSTERING OF RISK FACTORS, AND THE RISK OF MYOCARDIAL INFARCTION

Rickard Ljung, MD, PhD, MPH and Johan Hallqvist, MD, PhD

Rickard Ljung is with the National Board of Health and Welfare, Stockholm, and the Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. Johan Hallqvist is with the Centre for Health Equity Studies, Stockholm, and the Department of Public Health Sciences, Karolinska Institutet, Stockholm.

Correspondence: Requests for reprints should be sent to Rickard Ljung, Centre for Epidemiology, the National Board of Health and Welfare, 106 30 Stockholm, Sweden (e-mail: rickard.ljung{at}socialstyrelsen.se).

We read with great interest the article by Kivimäki et al. on socioeconomic position (SEP), clustering of behavioral risk factors, and the risk of coronary heart disease published in the May 2007 issue of the Journal.1 To contribute to the sparse discussion on SEP and risk factor clustering, we propose the use of the wording of between-group clustering to describe the clustering of risk factors in different socioeconomic groups, as seen in Table 1Go of the cited paper, and within-group clustering to describe the clustering of risk factors within a socioeconomic group, taking the group-specific prevalence of risk factors into account, as seen in Table 2Go in that same article. (There may be a possible error in the table: Men, 3–4 rf, low SEP, Exp. No., reads 283, should probably read 213). We acknowledge the large study sample and the clarity of the article.


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  		TABLE 1—— Risk of Myocardial Infarction by Socioeconomic Position (SEP) and Exposure to Increasing Number of Risk Factors: Stockholm Heart Epidemiology Program, Stockholm, Sweden, 1992–1994
 

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  		TABLE 2—— Age-Adjusted Observed and Expected Prevalence of Exposure to Increasing Number of Risk Factors and Observed-to-Expected Comparison, by Socioeconomic Position (Manual or Nonmanual Worker), in Childhood and Adulthood Among the Male Control Group: Stockholm Heart Epidemiology Program, Stockholm, Sweden, 1992–1994
 
We analyzed trajectories of SEP, clustering of 7 risk factors (diabetes, hypertension, low life control, low social network, obesity, physical inactivity, and smoking) and risk of acute myocardial infarction in the Stockholm Heart Epidemiology Program, a population-based case-control study. Accumulation of SEP over the entire life course, risk factor exposure, and acute myocardial infarction incidence have previously been analyzed in the same data.2 Our results confirm the findings by Kivimäki et al., with a larger risk factor burden on lower SEP trajectories, a greater than expected prevalence of null- and multiex-posed individuals in most trajectories of SEP, and an increased risk of acute myocardial infarction with exposure to an increasing number of risk factors. There was also no systematic socioeconomic difference in risk of acute myocardial infarction in the group unexposed to all 7 risk factors (Tables 1Go and 2Go). The larger prevalence of multiexposed individuals among low SEP groups and the larger prevalence of null-exposed individuals in higher SEP trajectories does not seem to be the effect of differential individual clustering among different SEPs, because the within-group clustering is similar in all SEPs. Rather, it seems to be the effect of risk factor accumulation correlated to the socioeconomic career on the group level (i.e., between-group clustering). This is important for future attempts to reveal this part of the etiology of health inequalities, because it leads us to look for determinants of risk factor clustering that are distributed differentially between socioeconomic groups.

Acknowledgments

This work was supported by the Swedish National Institute of Public Health, Swedish Council for Working Life and Social Support, and the Stockholm County Council.

Footnotes

Contributors
R Ljung and J Hallqvist originated the idea and drafted the letter. R Ljung analyzed the data.

Accepted for publication May 23, 2007.

References

1. Kivimäki M, Lawlor DA, Davey Smith G, et al. Socioeconomic position, co-occurrence of behavior-related risk factors, and coronary heart disease: the Finnish Public Sector study. Am J Public Health. 2007;97: 874–879.[Abstract/Free Full Text]

2. Ljung R, Hallqvist J. Accumulation of adverse socioeconomic position over the entire life course and the risk of myocardial infarction among men and women: results from the Stockholm Heart Epidemiology Program (SHEEP). J Epidemiol Community Health.2006;60:1080–1084.[Abstract/Free Full Text]




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