IJE Advance Access published online on March 20, 2008
International Journal of Epidemiology, doi:10.1093/ije/dyn052
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Risk factors in the Midspan family study by social class in childhood and adulthood
1Public Health and Health Policy, Division of Community Based Sciences, University of Glasgow, UK.
2Robertson Centre for Biostatistics, University of Glasgow, UK.
3Woodlands Family Medical Centre, Stockton-on-Tees, UK.
4General Practice and Primary Care, Division of Community Based Sciences, University of Glasgow, UK.
*Corresponding author. Public Health and Health Policy, Division of Community Based Sciences, Faculty of Medicine, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK. E-mail: c.l.hart{at}udcf.gla.ac.uk
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Abstract |
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Background Social class in childhood and in adulthood have been shown to be important determinants of risk factors in later life. Often the childhood information is retrospective and liable to bias. We use data from a family study of two generations of adults to investigate the effects of social class in childhood, adulthood and social mobility on risk factors.
Methods In 1996, 2338 adult offspring of participants of the 1970s Renfrew/Paisley study took part in a screening examination. They provided information on sociological, behavioural and clinical risk factors, as their parents had done 20 years previously. Social class and father's social class were available, enabling their influence on risk factors to be investigated.
Results Generally risk factors improved for offspring compared with parents, except for Body mass index and obesity, which worsened. Risk factors were less favourable in manual compared with non-manual offspring, and were more closely related to own than father's social class. There was a large amount of upward social mobility involving 35% of sons and 50% of daughters. Risk factors for the upwardly mobile tended to be more favourable than the class they left behind but less favourable than the class they joined.
Conclusions The concomitants of social mobility may reflect behavioural choices, such as smoking, and adverse factors, which are more difficult to leave behind. The relatively fast changes in social class profile may not be reflected in as quick changes in population health, as the upwardly mobile bring their earlier life adversities with them.
Keywords Social class, risk factors, epidemiology, family studies, social mobility
Accepted 18 February 2008
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Introduction |
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Recent research has identified the importance of the lifecourse on disease risk, with both social class during childhood and during adulthood contributing to adult health and mortality.1 Studies often use retrospective data to determine social class during childhood, which could be biased. In this study, we use social class reported by parents and by their adult offspring over 20 years later, and examine risk factors in the offspring with regard to their father's social class and their own social class. The Midspan family study is perhaps the only study similar to the renowned North American Framingham offspring study, which was conducted a generation previously. Family studies can provide valuable insights on health development, via the aggregation of health variables within families, as a result of shared environments, behaviours and genes.2 A weakness of cross-sectional designs, is that the second generation is often not old enough to allow observation of adult health characteristics. In this study, we are also able to compare risk factors in two generations of adult family members.
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Methods |
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The Midspan family study took place between March and December 1996 and included adult sons and daughters of couples who had both participated in the Renfrew/Paisley prospective cohort study between 1972 and 1976.3 The original Renfrew/Paisley study consisted of 7049 men and 8353 women aged between 45 and 64, who lived in the towns of Renfrew and Paisley4 and included 4064 known married couples. In 1993–94, the couples (or if both were deceased the informant on the death certificate) were written to for information on any offspring. Offspring aged 30–59 years and living locally formed the eligible population (3202 offspring from 1767 families). This was the age range of the offspring in 1996. The offspring were invited, in random order, to complete a questionnaire and attend a screening examination, similar to their parents 20 years previously. In all, 1040 male and 1298 female offspring from 1477 families took part, an individual response rate of 73% and a family response rate of 84%.3 Ineligible offspring (1813) included those too old or too young, those not living locally, those with problematic addresses or who died before the study commenced.
Participants in both studies completed a questionnaire, which they took to a screening examination. Questions common to both studies included age, smoking habit, occupation from which social class was derived,5,6 chronic sputum production,3 the Rose angina questionnaire7 and the home address from which the Carstairs deprivation category was derived.8,9 Smoking information was defined as never smoked, current smoker or ex-smoker and the number of cigarettes smoked per day. In the parental study, women's social class was based on their own occupation, except where it was described as housewife, when their husband's occupation was used. In the offspring study, women's own occupation was used10 unless they were housewives/homemakers and did not give a previous occupation, in which case their husband's or father's occupation was used. Unemployed or retired participants reported their last job. Social class was further defined as manual (social class III manual, IV or V) or non-manual (social class I, II or III non-manual). Father's social class for the offspring, taken from occupation reported in the parental survey, was missing for 20 offspring. For 15 of these the mother's social class was available. For the remaining five, it was obtained from reports of their father's occupation in the 1970s at the offspring screening examination. Chronic sputum production was defined as positive answers to two questions on (i) usually bringing up phlegm from the chest first thing in the morning in winter and (ii) bringing up phlegm on most days for as much as 3 months in the winter each year.3 Angina was defined as reporting definite or possible angina grades I or II.11 Deprivation category was recoded as deprived (5–7) and not deprived (1–4).
Variables measured at the screening examination in both studies were weight, height, blood pressure, forced expiratory volume in 1 s (FEV1)12 and plasma cholesterol from a non-fasting blood sample.13 Body mass index (BMI) was calculated as weight divided by height squared. Obesity was defined as having a BMI of 30 kg/m2 or more.
In the offspring study, blood pressure was taken with the subject seated, using an automated Dinamapp 8100 instrument.14 In the parental study, blood pressure was recorded as the mean of two measurements taken in the seated position using London School of Hygiene sphygmomanometer. In the offspring study, FEV1 was measured with a Fleisch pneumotachograph that was connected to Spirotrac III software (Vitalograph UK) and in the parental study it was measured with a Garthur Vitalograph spirometer with the participant standing. The percent predicted FEV1 was defined as the actual FEV1 as a percentage of the expected FEV1, derived from regression equations for parents and offspring separately based on healthy cohort members.15,16
Additional offspring variables
Some variables were available in the offspring study but not the parental study. Questions on educational experience provided information on years of full-time education.17 The total units of alcohol consumed per week was obtained from questions on beer, spirits and wine (and similar drinks) consumption each day of the previous week. The type of accommodation occupied was classified as owner-occupier or other. The number of cars available to the household was converted to none or at least one. Exercise was obtained from answers to questions on usual daily activity and physical activity during non-working time. Participants who were not very, or not at all physically active during their usual daily activities and who were physically active outside work less than once a week or never, were classified as having no exercise. The waist circumference was measured under clothing. The age of non-participants was calculated at the date of the midpoint of screening.
Statistical methods
Analyses were carried out using Stata release 9, adjusting for clustering of offspring within families. Means and proportions were standardized by 5-year age groups. A series of sex-specific regression and logistic regression models were run for each risk factor as the dependent variable and age, father's social class and own social class simultaneously as independent variables. Father's and own social class were taken as continuous variables (1–6) for these models, with lower numbers representing higher social classes.
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Results |
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Comparison of participants and non-participants in offspring
More non-participants than participants were male (55 vs 44.5%, P < 0.0001) (Table 1). There were no differences between non-participants and participants in age or parental deprivation category, but more female non-participants than female participants had fathers with manual social classes (75.6 vs 69.3%, P = 0.031). There was no such difference seen in males.
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Comparison between sons and daughters
The 1040 sons and 1298 daughters did not differ by age at screening (Table 2). Sons had significantly higher blood pressure, cholesterol and BMI than daughters. Sons were taller and the current smokers smoked more cigarettes per day than daughters. The percent predicted FEV1 was similar in sons and daughters. More daughters than sons had never smoked and more sons than daughters had given up smoking. More sons than daughters reported chronic sputum. There was no difference between the proportions of sons and daughters who currently smoked, were obese, reported angina or lived in deprived areas. More sons than daughters had manual occupations.
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Comparison between parents and offspring
Comparisons between parental and offspring data used the age group common to both cohorts, but excluded the 55–59 age group which contained few offspring (6.5%). In the age group 45–54, fathers were on average 2 years older than sons and had higher blood pressure and cholesterol (Table 2). Sons were 3 cm taller than fathers, had higher BMI and better percent predicted FEV1, but fathers and sons who were current smokers smoked the same amount. Compared with the fathers, about double the proportion of sons had never smoked and about half the proportion of sons were current smokers. More sons had given up smoking than fathers. Obesity in sons was double that in fathers and more fathers reported chronic sputum, had manual occupations and lived in deprived areas.
Mothers were 1 year older than daughters and had higher blood pressure and cholesterol. Daughters were 3 cm taller than mothers, had higher BMI and better percent predicted FEV1, but mothers and daughters who were current smokers smoked the same amount. The proportion of daughters who smoked was about half the proportion of mothers who smoked. More daughters than mothers had never smoked and more had given up smoking. More daughters than mothers were obese. More mothers than daughters reported chronic sputum, angina, had manual occupations and lived in deprived areas. The parent/offspring analyses were repeated using only married offspring with essentially the same results (data not shown).
Comparison between manual and non-manual social class in offspring
Sons and daughters in manual social classes were 2 cm shorter than sons and daughters in non-manual social classes (Table 3). They also had fewer years of education, had fewer never smokers, more current smokers, more chronic sputum, more taking exercise, more living in deprived areas, less owner occupiers and more without a car. Sons in manual social classes were older than sons in non-manual social classes. Daughters in manual social classes had higher BMI, larger waists and more were obese than daughters in non-manual social classes. They smoked more cigarettes per day, had worse percent predicted FEV1 and more had angina. The social class relationships differed in direction for alcohol consumption, with the higher consumers being daughters in non-manual social classes and sons in manual classes. No social class differences were seen in both sons and daughters for blood pressure, cholesterol or proportion of ex-smokers.
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Sons and daughters whose fathers were in manual social classes were 1 cm shorter than sons and daughters with fathers in non-manual social classes (Table 3). They also had poorer percent predicted FEV1, fewer years of education, less were owner occupiers and there were more with no car. More sons with fathers from manual social classes lived in deprived areas. Daughters with fathers from manual social classes had higher BMI, consumed less alcohol and had larger waists than daughters with fathers from non-manual classes. There were also more current smokers, fewer ex-smokers and more obese daughters of manual fathers than there were of non-manual fathers.
Regression analyses
Years of education, living in deprived areas, owner-occupation and car ownership were significantly associated with both own and father's social class in sons (Table 4). The regression coefficients were larger for own than father's social class. Height, alcohol consumption, never smoked, current smokers, chronic sputum, angina and exercise were significantly associated only with own social class in sons. In daughters, percent predicted FEV1, alcohol consumption, years of education, current smokers, owner-occupation and car ownership were associated with both father's and own social class. In all these variables (except percent predicted FEV1 and alcohol), the coefficient was larger for own than father's social class. Height, waist circumference, never smoked, chronic sputum, exercise and deprived areas were significantly associated with own social class only, and ex-smoker was associated with father's social class only.
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Social mobility
In sons, 35% were upwardly socially mobile, moving from having a manual father's social class to having their own social class as non-manual (Table 5). In daughters, 50% were upwardly socially mobile. Only 8% of sons and 4% of daughters were downwardly socially mobile. Twenty-three percent of sons and 27% of daughters remained stable in non-manual classes and 34% of sons and 19% of daughters were stable in manual classes. Offspring risk factors were generally at most favourable levels for the stable non-manual sons and daughters, at worst values for the stable manual sons and daughters and at intermediate levels for the upwardly and downwardly mobile, although there were some exceptions. Downwardly mobile sons had the highest blood pressure and the highest BMI, smoked more cigarettes per day, consumed the most alcohol and had the largest waist circumference. This group had the lowest proportion who had never smoked and the highest who were former smokers, the most obese and the most men doing exercise. Sons in the stable manual group had the worst percent predicted FEV1, more were current smokers, reported chronic sputum and angina, lived in deprived areas, were not owner occupiers and did not have a car. There were more obese upwardly mobile sons than stable non-manual sons, but fewer than in the other two groups and such patterns were also seen for angina, owner occupiers, car ownership, smokers, low deprivation category, years of education and alcohol consumption.
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Downwardly mobile daughters had fewest never smokers and most ex-smokers, most reporting chronic sputum and most taking exercise. Daughters in the stable manual group had higher blood pressure and BMI, were shorter, smoked more cigarettes per day, had the worst percent predicted FEV1, consumed less alcohol, had the largest waists and had less education. This group had the highest proportions who were smokers, obese (25%), had angina, lived in deprived areas, were not owner occupiers and did not have a car. Upwardly mobile daughters smoked more cigarettes per day than stable non-manual daughters but they smoked less cigarettes than the other two groups and this pattern was also seen with waist circumference, years of education, proportion of current smokers, chronic sputum, angina and owner occupiers.
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Discussion |
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Comparison with National surveys
Compared with participants of the Scottish Health Survey of 1995 and the Health Survey for England of 1996, the offspring were less likely to be manual workers, more likely to be never smokers, had lower systolic blood pressure, lower FEV1 and reported more phlegm.18 Anthropometric measures were similar in the three surveys.
The offspring had virtually the same social class distributions in childhood and in adulthood as participants of the nationally representative 1958 birth cohort study19 (1958 cohort manual social class: 68% men and 70% women in childhood and 42% men and 27% women at age 45; offspring 69% men and 69% women in childhood and 42% men and 23% women in adulthood).
Parent-offspring comparisons
The North American Framingham offspring study, which screened parents and offspring and their spouses, found that in the age group closest to the current study (45–49), sons were 4.3 cm taller than the fathers and daughters were 2 cm taller than the mothers.20 This increase was higher for the sons and lower for the daughters than in the current study. BMI in Framingham sons was higher than their fathers, whereas BMI in daughters was lower than in their mothers. In the current study, sons and daughters had higher BMI than fathers and mothers, with significant increases in obesity levels, especially in men.21 As in the current study, the Framingham offspring had lower cholesterol and blood pressure than the parents and there were fewer cigarette smokers. In this way, the trends first seen in the Framingham offspring study have been continued in the Midspan family study. A 2-fold increase in asthma between the generations in this study has previously been reported.3 Although, there were fewer current smokers in the offspring, the number of cigarettes smoked per day by sons and daughters was not different from their parents. The social class distribution was a major change across the generations, with 23% of daughters and 45% of sons being in manual classes compared with 52% of mothers and 68% of fathers (in ages 45–54). This reflects the changing availability of occupations, as the area has changed from heavy industry to service industry.22 Between 1981 and 2001, Glasgow experienced a doubling of the population in social classes I and II to 38% of the population.22 Although, in principle the comparison of effect sizes between father's and own social class might be affected by the changing social class distribution over time, similar results were obtained using the relative index of inequality.23 A limitation of the parent/offspring comparison could be that different measurement devices for blood pressure between the studies may have resulted in systolic blood pressures 8 mm Hg higher in the offspring, on average.24 Subtracting 8 mm Hg from the offspring systolic blood pressures would have led to an even greater difference between parent and offspring systolic blood pressure than presented in Table 2 so does not affect the direction of the results.
Father's and own social class
Overall, risk factors were more strongly associated with own than father's social class. This has been seen in other studies with smoking,25 and other cardiovascular risk factors.26 In women (but not men) from the Whitehall II study, smoking was associated with both own and father's social class,26 as we have found in the current cohort. In an earlier cohort of employed men from the west of Scotland, current smoking and recreational exercise were associated with own social class only, BMI was associated with father's social class only and blood pressure, cholesterol and FEV1 were associated with both own and father's social class.27 In men in the current study, these same relationships between own social class and smoking and exercise were seen, but not the other relationships. In women in the current study, exercise was also associated with own social class, and FEV1 and smoking were associated with both own and father's social class. The Whitehall II study found no relationships with blood pressure or cholesterol26 (as in the Family study), so this could reflect period effects. However the 1958 birth cohort study did find relationships with blood pressure for both own and father's social class.19
Most social class differences in risk factors had less favourable levels for manual than non-manual social class, as expected from other studies.23,28 The exception was with exercise, where sons and daughters from manual social classes and sons from manual father's social classes did more exercise than those from non-manual social classes. This was due to manual workers doing more exercise during normal daily activities than non-manual workers, whereas exercise outside work was similar for manual and non-manual social classes. There was a different relationship for sons and daughters between alcohol consumption and either own or father's social class, with non-manual daughters and manual sons consuming the most alcohol per week. This effect was also seen in the Scottish Heart Health Study conducted in 1984–86.29 In the Scottish Health Survey 2003, women from higher social classes consumed more alcohol than women from lower social classes, but there was no clear pattern in men.30 BMI, waist circumference and obesity were worse in manual own social class and father's social class in women but not in men. This relationship has been observed in adult women in other studies.19,31 Downwardly mobile sons, but stable manual daughters had the worst BMI, waist circumference and obesity.
Several risk factors had a similar pattern, with the upwardly mobile group having a less favourable profile than the stable non-manual group and a more favourable profile than the downwardly manual or the stable manual groups, although confidence intervals often overlapped. This is more evidence of the upwardly mobile being less advantaged than the socially stable they join in their class of destination but more advantaged than the stable group they leave in their class of origin.19,32
Strengths of the study include the unusual design of parents and adult offspring and the accurate reporting of father's social class, which was given by the parents rather than by recall of the offspring. Future studies using the offspring data will be able to investigate mortality and morbidity (from hospital discharge data) by social class and social mobility. However it will take some time for events to accrue.
To conclude, the Family study has shown an improvement in risk factors for offspring compared with parents, with the exception of BMI and obesity, which have worsened. Risk factors were less favourable in manual compared with non-manual offspring, and were more closely related to own than father's social class. There was a large amount of upward social mobility. Risk factors for the upwardly mobile tended to be more favourable than the class they left behind but less favourable than the class they joined. The relatively fast changes in social class profile may not be reflected in as quick changes in population health, as the upwardly mobile take their earlier life adversities with them.
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Acknowledgements |
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We thank Victor Hawthorne, who initiated the original Renfrew/Paisley study; the people of Renfrew and Paisley who participated; and Pauline MacKinnon for ongoing contributions. We also thank the following people who contributed in 1996: Catherine Ferrell, who traced offspring and led recruitment; Jane Goodfellow, Michere Beaumont and Helen Richards, who contacted participants; Claire Bidwell, who led the fieldwork, Julie Hunter, Evelyn Lapsley, Iona MacTaggart, Nicola McPherson and Sarah Morgan who carried out the fieldwork; Alistair Carson for database development; and the scientific advisory committee for its support. The offspring study was supported by grants from the Wellcome Trust and the NHS Research & Development Programme. NHS Health Scotland supported the current research.
Conflict of interest: None declared.
KEY MESSAGES
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