24
SES AND HYPERTENSION SES AND HYPERTENSION Dr. Prin Vathesatogkit EGAT investigator EGAT investigator Mahidol University
SES AND HYPERTENSIONSES AND HYPERTENSION
Dr. Prin VathesatogkitEGAT investigatorEGAT investigator
Mahidol University
BackgroundBackground
Socioeconomic status (SES) has impacts on health
Lower SES poses health risks behavior and negative
biological factorsbiological factors
Hypertension is a major cardiovascular (CV) risk factorHypertension is a major cardiovascular (CV) risk factor
Whether SES affects incidence of hypertension is
unknown
Level of Income & MortalityLevel of Income & Mortality
5
Hazard Ratio for Level of Income: Multivariable AnalysisAdjusted for Age, Sex, DM, HT, Smoking, Alcohol, BMI, TChol, LDL, HDL
3.85 3.854
2.13 2.17
3 <5,ooo5K-10,ooo
1.33 1.231 1
1
2,
10K-20,ooo>20,ooo
0
1
p<0.001
p<0.01<5K 10k 20k >20k <5K 10k 20k >20k
CVD All-causep
Level of Education & MortalityLevel of Education & Mortality
5
Hazard Ratio for Level of Education: Multivariable AnalysisAdjusted for Age, Sex, DM, HT, Smoking, Alcohol, BMI, TChol, LDL, HDL
3 13
4
3.13
2.383 Primary
S d1.72 1.72
1 11
2 SecondaryBachelor
y dary
y dary
0
1
p<0.01
p<0.001
Prim
ary
Seco
nd
Prim
ary
BA BASeco
n d
CVD All-causep 0.00
How SES affects outcome…How SES affects outcome…
Access to Medical
Health-
Medical Care
NegativeHealth-Risk
Behavior
Nega veBiological FactorsBehavior Factors
Low SES
ObjectiveObjective
To analyze effects of each socioeconomic
fparameter on prevalence of hypertension in a
cohort study from Thailandcohort study from Thailand
MethodMethod
A cohort study
3 499 Participants from the Electricity Generating Authority 3,499 Participants from the Electricity Generating Authority
of Thailand (EGAT) study: 22 years follow up
Completed SES data in 1985
Repeated surveys in 1997 2002 and 2007Repeated surveys in 1997, 2002 and 2007
Blood pressure measurement
Socioeconomic measures
Data analysis; Logistic regression model
Blood pressure measurementBlood pressure measurement
Sitting position / after 5-minute rest
Calculated suitable cuff size
2 d d b i hi2 standard measurement by automatic machine
Operated by trained nursesOperated by trained nurses
Definition of HypertensionDefinition of Hypertension
JNC 7
Systolic blood pressure ≥ 140 mmHgSystolic blood pressure ≥ 140 mmHg
Diastolic blood pressure ≥ 90 mmHg
Currently taking antihypertensive medication for at least 2 weeks
Cross-sectional - prevalence in 1985Cross sectional prevalence in 1985
Longitudinal – progression to HTN in 1997
Longitudinal – Incidence rate over 22 years (1985-2007)
Socioeconomic status measuresSocioeconomic status measures
*Level of Level of Occupational Income (baht)
• <5 000
Education
• Primary or Less
pclass
• Non skilled• <5,000• 5k – 10k• 10k 20k
• Primary or Less
• Secondary• Bachelor or more
• Non-skilled• Skilled
manual• 10k – 20k• > 20,000
Bachelor or more manual• Non-manual• ManagerManager
*Level of income in 1985 multiply by 2.25 = income in 2007 (Consumer Price Index; BOT)
Statistical AnalysisStatistical Analysis
Logistic model
prevalence in 1985prevalence in 1985
progression to HTN in 1997
Cox-proportional hazard model
incidence rate over 22 years (1985-2007)incidence rate over 22 years (1985 2007)
Adjusted for age, sex, diabetes, HDL- and LDL-
cholesterol, BMI, smoking status, alcohol consumption and physical
activity in 1985y 9
Results: Prevalence of Hypertension by year of survey
65.8
60
70
(%)
48 4950
60
rten
sion
(
2030
40
e of
hyp
e
Overall incidence from 1985 to 2007 = 58%
10
20
reva
lenc
e
0
1985 1997 2002 2007
P
1985 1997 2002 2007Year of survey
Distribution of SESDistribution of SES
45%
Level of Income
52 40%60%
Level of Education42.20%45%
Occupational Status
38.30%36.30%
30%
35%
40%52.40%
40%
50%
27.00%30%
35%
40%
19.60%
15%
20%
25%
20.40%
27.20%
20%
30%
15.20% 15.50%
15%
20%
25%
5.80%
0%
5%
10%
0%
10%
0%
5%
10%
0% 0%
Prevalence of HT by Education LevelsPrevalence of HT by Education Levels
25 23 21
Primary school Secondary school University
p <0.001
15
20
25 23 2116
nce
(%
)
1985
0
5
10
Prev
alen
6060 80
0
Primary school Secondary school University
p 0 001 p 0 001p 0 001
30
40
50
60
vale
nce
(%)
30
40
50
60
vale
nce
(%)
50
60
70
80
vale
nce
(%)p 0.001 p 0.001p 0.001
20
30
Prev
Education Level20
30
Prev
Education Level40
50
Prev
Education Level1997 20072002
Prevalence of hypertension in 1985 and 1997 di i l l1997 according to income level
25 49
1985 1997
20
25
1820 21 22
%) 48
4949
4848.4
%)
p 0.36 p 0.67
10
15
vale
nce
(%
46
4746
vale
nce
(%0
5Prev
44
45Prev
0<5K 5K -
10K10K -20K
>20K
Income Level
44<5K 5K - 10K 10K -
20K>20K
Income LevelIncome Level Income Level
Prevalence of hypertension in 1985 and 1997 di i l l1997 according to occupational class
1985 1997
20
25
19
2422
) 50
6051
55
45
)
10
15
20
13
alen
ce (%
)
30
4038
alen
ce (%
)0
5
10
Prev
a
0
10
20
Prev
a0
Non-skill labour
Skill labour
Office worker
Executive
Occupational class
0Non-skill labour
Skill labour
Office worker
Executive
Occupational classOccupational class Occupational class
SES & HTN prevalence in 1985:SES & HTN prevalence in 1985:
1.6
multivariable analysisAdjusted for Age, Sex, DM, Smoking, Alcohol, BMI, LDL, HDL, Physical activity
1.2
1.4
1.6
atio
p 0.037 p 0.001p 0.12
0.8
1
Odd
Ra
0.4
0.6O
SES & Progression to HTN at 1997SES & Progression to HTN at 1997
multivariable analysisAdjusted for Age, Sex, DM, Smoking, Alcohol, BMI, LDL, HDL, Physical activity
0.9
1
1.1
Risk
p <0.001 p 0.064p 0.15
p for trend <0.05
0.6
0.7
0.8
elat
ive
0.4
0.5Re
HTN in 1985 removed
SES & incidence rate of HTNSES & incidence rate of HTN
Predictor n no. of events Incidence rate/1000 person‐years
Education ≤6 569 249 (44%) 38.7( )
6 to 12 1436 719 (50%) 39.1
>12 786 362 (46%) 31.8
Income <5,000 571 261 (46%) 37.5
5,000‐10,000 1077 486 (45%) 35.1
10,000‐20,000 985 507 (51%) 37.9
>20,000 154 76 (49%) 38.2
Occupation Non‐skilled worker 427 191 (45%) 38.6
Skilled manual 1092 567 (52%) 41.0
Skilled non manual 801 367 (46%) 31.8
Manager 416 202 (49%) 36.1
SES & incidence rate of HTNSES & incidence rate of HTN
multivariable analysisAdjusted for Age, Sex, DM, Smoking, Alcohol, BMI, LDL, HDL, Physical activity
1 1
Ratio
0.9
1
1.1p 0.039 p 0.051p 0.66
p for trend <0.05
azar
d R
0.6
0.7
0.8
Ha
0.4
0.5
0.6
ConclusionConclusion
Education is an independent predictor for development of hypertension after adjusting for metabolic risk factors Income has a trend association with future development of hypertensionOccupation also shows different risks among classes Occupation also shows different risks among classes before adjusting with others HTN risk factors
AcknowledgementAcknowledgement
All Staff of the EGAT study
Ramathibodi Hospital
Mahidol Universityy
Thai Research FundThai Research Fund
Original EGAT CohortOriginal EGAT Cohort
The largest and longest cohort study in Thailand 7CardiologistNe rologist
started in 1985
C di l Ri k F S
NeurologistGastroenterologist
Nephrologistd lCardiovascular Risk Factor Survey
4 waves of survey in 1985-1997-2002-2007
EndocrinologistOncologistToxicologisty
Multidisciplinary team & International collaborationNutritionist
DentistGeneral practitioner
Follow up time 22 yearsp
PharmarcistBiologist
Social scienceSocial science
Demographic CharacteristicDemographic CharacteristicTable 2: Demographic data of each SES indicators
n=652 n=1275 n=1207 n=193 n=3,327
Income (baht) <5,000 5,000-10,000 10,000-20,000 >20,000 Total
% Female 31.1 20.5* 22.2* 13.5* 22.8
Age (year) 41.9 42 43.7* 47.5* 42.9
Hypertension 17.3 19.9 20.8* 21.8* 21.8
Diabetes 7.5 6* 7.0 6.2* 6.7
Heart Rate (BPM) 74.4 75.3* 76 76.5 75.5
Systolic BP (mmHg) 119 120 121 122 121
Diastolic BP (mmHg) 74 75 76* 77* 75
BMI 23 23 23 23.6 23.1
Smoking 49.1 44.8 38.9* 36.8* 43
Alcohol beverage 65.6 67.1 62.8 69.4 65.4
FBG 90.6 88.9 90.1 89.2 89.7
Total Cholesterol 214.3 223.6* 225.9* 228.9* 222.9
HDL-C 45.6 46.7 48.3* 48.1 47.1
LDL-C 139.5 148.5* 148.5* 149.4* 146.8
All Cause Mortality 19.5 16.9* 11.4* 8.8* 14.9
Cardiovascular Mortality 4.9 5.2 3.8* 3.1* 4.5
n=680 n=1742 n=905 n=3,327
Ed i P i B l S d B h l Ab T lEducation Primary or Below Secondary Bachelor or Above Total
% Female 20.9 20.8 28.1* 22.8
Age (year) 44.4 42.6* 42.4* 42.9
Hypertension 22.1 21 15.8* 21.8
Diabetes 8.4 6.9 5* 6.7
Heart Rate (BPM) 74.1 75.5* 76.4* 75.5
Systolic BP (mmHg) 121 121 119* 121
Diastolic BP (mmHg) 75 75 74* 75
BMI 23.4 23.1 22.7* 23.1
Smoking 54.4 43.3 33.8 43g
Alcohol beverage 67.5 66.7 61.2* 65.4
FBG 91.4 89.6 88.3* 89.7
Total Cholesterol 216 224 226 222.9
HDL-C 45 47.2* 48.5* 47.1
LDL-C 140.6 147.4* 150.4* 146.8
All Cause Mortality 26.5 13.4* 9.2* 14.9
Cardiovascular Mortality 8.1 4.2* 2.3* 4.5
n=507 n=1405 n=900 n=515 n=3,327
Occupation Non-skilled worker Skilled manual Skilled non manual Manager Total
% Female 29.4 2.3* 53.6* 18.4* 22.8
Age (year) 43.6 42.9* 41.7* 44.3 42.9
Hypertension 18.8 23.6 13.2* 22.1* 21.8
Diabetes 7.3 6.8 5.8 7.2 6.7
Heart Rate (BPM) 74 74 78.2* 76* 75.5
Systolic BP (mmHg) 120 122* 117 123 121
Diastolic BP (mmHg) 75 77* 73 76* 75
BMI 23.6 23* 22.8 23.3 23.1
Smoking 48.1 54.8* 24.6* 38.1* 43
Alcohol beverage 67.7 74.4 51.5* 62.8 65.4
FBG 91.2 90.5 87 90.5 89.7
Total Cholesterol 219 222.7 222.8 227.4* 222.9
HDL-C 45.5 46 49.7* 47.3* 47.1
LDL-C 144.5 145.6 147.9 150.6 146.8
All Cause Mortality 23.5 17* 8* 12.8* 14.9
Cardiovascular Mortality 6.1 5.1 2.9* 4.1* 4.5
