Prime Time Replay:
Dr. Nancy Adler
on socioeconomic status and health
MsgId: *breakthrough(49)
Date: Wed Jul 9 20:58:25 EDT 1997
From: moderator At: 152.163.207.137
Hello, and welcome to Breakthrough Medicine. I'm your host, Madeleine Lebwohl, and tonight I'm speaking with Dr. Nancy Adler. Welcome, Dr. Adler!
MsgId: *breakthrough(50)
Date: Wed Jul 9 21:02:19 EDT 1997
From: DrAdler At: 128.218.119.73
Thank you. I'm very glad to be here.
MsgId: *breakthrough(51)
Date: Wed Jul 9 21:04:21 EDT 1997
From: moderator At: 152.163.207.137
Let's begin by talking about your current work on how socioeconomic status effects (SES) health.
MsgId: *breakthrough(52)
Date: Wed Jul 9 21:05:21 EDT 1997
From: DrAdler At: 128.218.119.73
Great. Where would you like to start?
MsgId: *breakthrough(53)
Date: Wed Jul 9 21:06:30 EDT 1997
From: moderator At: 152.163.207.137
How serious are the differences in how economic levels effect our health? Are the differences strictly along poverty lines?
MsgId: *breakthrough(54)
Date: Wed Jul 9 21:08:11 EDT 1997
From: DrAdler At: 128.218.119.73
There are major differences in health at different levels of SES. It's no surprise that people in poverty have dramatically worse health than those who are more fortunate. What may be more surprising is that SES continues to affect health all the way up the SES hierarchy. As you go up the SES hierarchy, up to the very top, peoples' health improves.This was shown most dramatically in a British study of civil servants. There are 9 levels of the Civil Service and the people at all levels were studied for over 10 years. It turned out that not only was there better health and lower l0-year mortality for those at the top versus those at the bottom, but there was a significant improvement in health and longevity among the very top civil servants (those at level 9) compared to those just below (level 8) who were also quite high in the civil service hierarchy.
MsgId: *breakthrough(57)
Date: Wed Jul 9 21:12:57 EDT 1997
From: moderator At: 152.163.207.137
Does access to health care affect the numbers? Do all people at low levels of SES have limited access?
MsgId: *breakthrough(58)
Date: Wed Jul 9 21:14:47 EDT 1997
From: DrAdler At: 128.218.119.73
Access to health care doesn't seem to account for much of the difference. In the Whitehall studies of the British Civil Servants, everyone from the lowest to the highest levels had universal coverage through the National Health Service. The level 8 civil servants were themselves professionals--doctors and lawyers, etc. -- who had access to private health care as well, yet their health was poorer.In the United States, access to health care may play a somewhat greater role, but it still doesn't account for most of the difference in health associated with SES. You see the gradient between SES and health in almost every country in which it has been studied and you see it for diseases where health care makes a difference as well as in those for which there isn't much that health care can do. This suggests that access is not the key aspect.
MsgId: *breakthrough(60)
Date: Wed Jul 9 21:18:16 EDT 1997
From: moderator At: 152.163.207.137
I'm surprised that doctors and lawyers aren't in the elite of health. Who is in that top level?
MsgId: *breakthrough(61)
Date: Wed Jul 9 21:20:44 EDT 1997
From: DrAdler At: 128.218.119.73
They actually are in the elite of health compared to those in levels 1-7 but they have relatively poorer health compared to those at the very top. The level 9 Civil servants are the top ministers who are running the Civil Service.
MsgId: *breakthrough(62)
Date: Wed Jul 9 21:22:27 EDT 1997
From: moderator At: 152.163.207.137
If access to health care isn't the major determinant, then what is?
MsgId: *breakthrough(63)
Date: Wed Jul 9 21:24:34 EDT 1997
From: DrAdler At: 128.218.119.73
That is the major scientific question that we (and a number of others) are exploring right now. Having determined that there is this robust gradient between SES and health, the question arises as to what the mechanisms are by which this occurs. We know some of the pathways. A number of important health behaviors such as smoking cigarettes, not getting enough exercise, etc. show the same association with SES and account for about a third of the association of SES and health. We have some clues about other pathways.One in which my colleagues and I are particularly interested is the extent to which people at different levels of SES are exposed to chronic stressors which create a wear and tear on the body which can adversely affect health. This may be important both in the etiology of disease as well as in the liklihood of recovery from disease once the disease procerss starts.
MsgId: *breakthrough(65)
Date: Wed Jul 9 21:29:31 EDT 1997
From: moderator At: 152.163.207.137
Are the stress factors experienced by people in lower SES also experienced in the higher levels? Do people in the higher react the same way when they have those same stresses?
MsgId: *breakthrough(66)
Date: Wed Jul 9 21:32:50 EDT 1997
From: DrAdler At: 128.218.119.73
Most of the work on stress has been on acute stress and we don't know precisely what life is like at different levels of SES. We do know from surveys which have included a measure of perceived stress (which is a summative measure of the degree to which individuals are experiencing stress in their lives) that the lower one's SES, the higher their reported perceived stress. We believe that lower SES individuals both experience more stressors with which they have to deal, and have fewer resources to deal with these stressors. People at the upper ends of the SES hierarchy still experience stress (it seems to be an unwavoidable part of life), but at the upper ends we generally have more control over the situations in which we get ourselves and the degree of stress or challenge that we will experience. With repeated exposures to stresses that are not controllable, our physiological mechansisms for responding to stress may become dysregulated and, while functional for responding to immediate stresses, may create longer-term health problems.Let me give you an example of how the same stressor would have different effects at different levels of SES. Imagine that you had a close relative who was dying in a distant city and you needed to get there as soon as possible. This would be stressful for anyone, but the process would feel quite different depending on the resources you had for making the trip. If you are very poor, this becomes an emergency. You may need to borrow a car and drive through the night to get there--you have to make lots of calls to cajole someone to lend you a car or to get bus fare to get there. If you have your own car, you can leave right away but you still need to drive through the night. If you can afford a plane ticket, you may have the hassle of going on public transportation to the airport. At the next level up, you can afford to take a cab but you may get a driver who alternates between driving 80 mph and 20 mph. At the next level up you have a sedan service with a comfortable car. At the very upper levels, you have a private jet waiting for you so you don't have to worry about dashing for a commercial airline. You can imagine the physiological correlates of these different experiences.
MsgId: *breakthrough(73)
Date: Wed Jul 9 21:45:10 EDT 1997
From: moderator At: 152.163.207.137
The mind-body connection seems to strongly affect our health in this scenario. Has work been done on the biological side of this subject?
MsgId: *breakthrough(74)
Date: Wed Jul 9 21:47:27 EDT 1997
From: DrAdler At: 128.218.119.73
There is quite a bit of research on the impact of stress on human physiology and on disease risk. Our group, which is funded by the John D. and Catherine T. MacArthur Foundation to examine the mechanisms by which SES affects health, is very interested in this aspect of the problem. We have been developing measures of "allostatic load" which reflects this kind of wear and tear on the body of repeated exposure to stress. One aspect of this is the HPA axis and the impact of stress hormones. In response to stress, the body secretes cortisol which is functional for immediate response. However, if there is prolonged or elevated levels of cortisol, there may be adverse effects on the metabolic and cardiovascular systems. When individuals are exposed to repeated stresses, the system may show a number of abnormalities. It may fail to turn off even after the stressor has ended, leaving the body subject to the cascade of effects of cortisol levels. Or it may fail to turn on and leave the body unable to mount the counterregulatory functions that cortisol provides in response to a stressor.One result of prolonged exposure to cortisol is that the body may deposit more fat abdominally (when rats are stressed, they excrete more cortisol and show greater abdominal fat deposition). Abdominal fat deposition is a risk factor for a variety of diseases, including cardiovascular disease and diabetes. Abdominal fat deposition also varies by SES -- the lower one's SES, the greater the abdominal fat deposition. This may be one pathway by which SES affects health through stress exposure and the body's response to stress.
MsgId: *breakthrough(77)
Date: Wed Jul 9 21:58:10 EDT 1997
From: moderator At: 152.163.207.137
Have you seen any successful strategies that people use when they are in stressful situations?
MsgId: *breakthrough(78)
Date: Wed Jul 9 22:01:32 EDT 1997
From: DrAdler At: 128.218.119.73
Yes, there are a number of stress reduction approaches that people can take, some of which involve learning how to plan to reduce their future exposure to stressors and some of which (e.g. relaxation techniques) may help reduce the physiological responses to stressors that do occur. Ironically, however, these techniques are more available to people at higher SES levels. In companies where such stress reduction classes are offered, they are generally available to executives, not to the lower-level workers. To reduce the SES inequalities in health that are associated with stress means that we need to think about how to help lower SES individuals lower their stress exposure and help with responses that may not be health-damaging.
MsgId: *breakthrough(79)
Date: Wed Jul 9 22:04:16 EDT 1997
From: moderator At: 152.163.207.137
It would be good for your health to move up the SES ladder, it appears. Education is often a way to do that. Does education figure in the equation that raises you up the ladder and lowers stress?
MsgId: *breakthrough(80)
Date: Wed Jul 9 22:05:40 EDT 1997
From: DrAdler At: 128.218.119.73
There are a number of components of SES which include income, education and occupation. Surprisingly, although these are correlated with one another, they are not highly related. The higher you are on any of them, however, the better your health. However, the particualar advantages may differ for different supgroups in our population.For example, more income seems to be related to better health for everyone. Education doesn't work in quite the same way. There are some preliminary data that show that fow white males, every higher level of education is related to better health. However, for white women and for African-American men and women, while there are health benefits of graduating from high school versus not graduating, there are few benefits of higher education for health. It may be that patterns of discrimination in our society mean that these groups get less benefit from higher education in terms of resources that would buffer them from stress.
MsgId: *breakthrough(82)
Date: Wed Jul 9 22:09:24 EDT 1997
From: moderator At: 152.163.207.137
Are these statistics only applicable in the US, or do they hold worldwide?
MsgId: *breakthrough(83)
Date: Wed Jul 9 22:11:45 EDT 1997
From: DrAdler At: 128.218.119.73
There is a SES-health gradient in virtually every country in which it's been studied, but the strength of the association differs in different countries. There is some fascinating work by a British researcher, Richard Wilkinson, who has shown that longevity is greatest in countries (e.g. Scandanavian countries, Japan) where there is the least income inequality (i.e. where there is less gap between those at the top and the bottom). Two recent articles from the U.S. have shown the same effect among states in the United States--people live longest in those states within the U.S. where there is less income inequality.
MsgId: *breakthrough(84)
Date: Wed Jul 9 22:13:14 EDT 1997
From: moderator At: 152.163.207.137
Where do you see your work heading?
MsgId: *breakthrough(85)
Date: Wed Jul 9 22:15:22 EDT 1997
From: DrAdler At: 128.218.119.73
We're mostly trying to understand the mechanisms and pathways by which SES "gets under the skin." We hope that this may be useful in policy debates about factors that affect SES differences and may also lead to interventions that can be useful in ameliorating some of the effects that are associated with lower SES. We still have quite a long way to do and our first goal is to be sure we have a solid understanding of the pathways.
MsgId: *breakthrough(86)
Date: Wed Jul 9 22:16:19 EDT 1997
From: moderator At: 152.163.207.137
Good luck with your work. I think everyone is affected by the outcomes that you reach.
MsgId: *breakthrough(87)
Date: Wed Jul 9 22:16:58 EDT 1997
From: DrAdler At: 128.218.119.73
Good night. Thank you very much for having me participate.
MsgId: *breakthrough(88)
Date: Wed Jul 9 22:19:29 EDT 1997
From: moderator At: 152.163.207.137
Goodnight, and thank you for joining me on Breakthrough Medicine.
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