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Health Disparities Beginning in Childhood:A Life-Course Perspective
abstractIn this article we argue for the utility of the life-course perspective as atool for understanding and addressing health disparities across socio-economic and racial or ethnic groups, particularly disparities thatoriginate in childhood. Key concepts and terms used in life-courseresearch are briefly defined; as resources, examples of existing liter-ature and the outcomes covered are provided along with examples oflongitudinal databases that have often been used for life-course re-search. The life-course perspective focuses on understanding howearly-life experiences can shape health across an entire lifetime andpotentially across generations; it systematically directs attention tothe role of context, including social and physical context along withbiological factors, over time. This approach is particularly relevant tounderstanding and addressing health disparities, because social andphysical contextual factors underlie socioeconomic and racial/ethnicdisparities in health. A major focus of life-course epidemiology hasbeen to understand how early-life experiences (particularly experi-ences related to economic adversity and the social disadvantages thatoften accompany it) shape adult health, particularly adult chronic dis-ease and its risk factors and consequences. The strong life-courseinfluences on adult health could provide a powerful rationale for poli-cies at all levels—federal, state, and local—to give more priority toinvestment in improving the living conditions of children as a strategyfor improving health and reducing health disparities across the entirelife course. Pediatrics 2009;124:S163–S175
AUTHORS: Paula Braveman, MD, MPH and ColleenBarclay, MPH
Center on Social Disparities in Health and Department of Familyand Community Medicine, University of California, SanFrancisco, California
KEY WORDSadult, child, chronic disease, educational level,Europe/epidemiology, health status, health status disparities,longitudinal studies, morbidity, mortality, social class,socioeconomic factors, United States/epidemiology
The views presented in this article are those of the authors, notthe organizations with which they are affiliated.
www.pediatrics.org/cgi/doi/10.1542/peds.2009-1100
doi:10.1542/peds.2009-1100D
Accepted for publication Jul 20, 2009
Address correspondence to Paula Braveman, MD, MPH, Centeron Social Disparities in Health, University of California, SanFrancisco, 3333 California St, Suite 365, San Francisco, CA 94118-0943. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.
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A life-course perspective will not strikepediatricians, family physicians, orother providers of health care to chil-dren as an alien concept. The develop-mental perspective is a standard com-ponent of their training, throughwhichthey learn to consider the dynamic na-ture of growth during childhood andchildren’s evolving needs at differentphysical, cognitive, and socioemo-tional developmental stages. What,then, is newwhenwe focus on the “life-course?”
LOOKING ACROSS MULTIPLE LIFESTAGES
A life-course perspective encom-passes a developmental approach andadds important new elements. Themost prominent difference between alife-course and a developmental ap-proach is that, whereas a developmen-tal perspective generally focuses ondevelopment during childhood or ado-lescence (occasionally extending intoearly adulthood), a life-course studygenerally extends across multiple lifestages, typically examining links be-tween early childhood and later adulthealth. A life-course study focuses onunderstanding how early-life experi-ences can shape health across an en-tire lifetime and potentially acrossgenerations. A life-course study mightexamine child or adolescent health asintermediate outcomes while investi-gating links between childhood experi-ences and adult health. A life-courseperspective can be thought of as ex-tending the developmental perspec-tive across the life span.
EXAMINING THE ROLE OF SOCIALCONTEXT OVER TIME
Although developmental researchersoften examine social influences onphysical, cognitive, or socioemotionaldevelopment, the social context is notnecessarily an inherent component ofdevelopmental studies. In contrast, alife-course perspective explicitly con-
siders the psychosocial as well as thephysical environment, along with bio-logical factors, as potential influenceson child development and adult health.This perspective focuses attention onthe role of context, including socialcontext, over time. A major focus oflife-course epidemiology has been tounderstand how early-life experiences(particularly experiences related toeconomic adversity and the social dis-advantages that often accompany it)shape adult health (particularly adultchronic disease and its risk factorsand consequences).1 Again, the life-course perspective is entirely compat-ible with a developmental perspective,but it explicitly broadens the focusto include contextual elements thatmight not always be applied by investi-gators using the developmentalmodel.
Important concepts in life-course re-search include the notions of critical orsensitive periods, cumulative effectsover time, trajectories or pathways, andintergenerational models. A “critical pe-riod” generally refers to a window oftime during the life course when a givenexposure has a critical or even perma-nent influence on later health. Accordingto the “Barker hypothesis” or “fetal orbiological programming,” the fetal pe-riod is a particularly critical period dur-ing which certain exposures can perma-nently alter particular organ structuresand metabolic functions. According toBarker’s hypothesis, adult cardiovascu-lar disease, type 2 diabetes, stroke, hy-pertension, and other adverse adulthealth outcomes have their origins in aresponse to inadequate nutrition duringfetal and infant growth, leading to al-tered metabolic and endocrine functionand/or increased vulnerability to the ef-fects of later adverse living conditions.2
Some reserve the term “critical period”for a period during which exposures re-sult in unalterable changes; they mayuse the term “sensitive period” to referto periods during which exposures have
large effects that might be modified bylater experiences. Others use “criticalperiod” more generally to encompassthe latter. Cumulative effects result fromthe accumulation of risk (or protection)over time in additive or synergisticways.Kuh et al3 have discussed different waysin which risks can accumulate over timeand how the relationships can be con-ceptualized in a life-course study. The no-tion of cumulative risk is that long-termdamage occurs through the compound-ing of environmental, socioeconomic,and behavioral exposures over the life-course; risks may accumulate throughindependent exposures, or exposureclusters related to, for example, an indi-vidual’s or family’s socioeconomic posi-tion. Another model posits a chain of se-quential exposures, with each exposureincreasing the probability of the nextexposure aswell as influencing later dis-ease risk in an additive effect, indepen-dently of subsequent exposures. Alter-nately, in amodelwith a so-called triggereffect, exposures follow one another se-quentially (andprobabilistically), butdis-ease risk is not increased until the effectof the final event in the chain.1 “Trajec-tory” or “pathway” generally refers tothe sequence of exposures and out-comes over an individual’s lifetime,whereas intergenerational studies focuson the transmission of health or illhealth, and the predictors of both,across more than 1 generation.
Several excellent reviews of the life-course literature have been pub-lished.4–12 In this article we provide abrief introduction to the life-courseperspective to discuss its relevance tounderstanding and addressing healthdisparities.
WHAT EVIDENCE SUPPORTS THELIFE-COURSE PERSPECTIVE?
Considerable epidemiologic evidencehas accumulated, particularly over thepast 2 decades, linking exposures in
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early life to health at later life stages. Arange of predictors and outcomes hasbeen examined, but a recurring themehas been consideration of early-life so-cial factors and their links to adultchronic disease. Behavioral and men-tal health outcomes in adulthood alsohave been linked to early experience oftrauma or adversity. In the retrospec-tive Adverse Events in Childhood (ACE)study, adult respondents were as-signed scores on the basis of their re-ports of abuse (emotional, physical, orsexual) or 5 types of household dys-function in their first 18 years of life; agraded relationship was observed be-tween this ACE score and adverse out-comes inmeasures of depression, anx-iety, substance abuse, and sexual riskbehaviors in adulthood.13 Data fromthe same population also revealed astrong dose response between thelevel of exposure to abuse or family
dysfunction during childhood and riskfactors for several leading causes ofdeath.14
The life-course literature is particu-larly rich in studies that have investi-gated the early-life antecedents of car-diovascular disease; outcomes havespanned ischemic heart disease andstroke, associated mortality, and riskfactors, including hypertension, otherbiological markers, and behavioralrisk factors. As shown in Table 1, child-hood socioeconomic conditions alsohave been linked to adult-onset diabe-tes mellitus and mortality from diabe-tes, respiratory disease, smoking-related cancer, stomach cancer, andother adult outcomes.
Table 2 lists selected studies (also notan exhaustive list) that have linked lowbirth weight to adult ill health or itspredictors. Other studies have linkedlow birth weight of offspring to ad-verse socioeconomic conditions dur-ing their parents’ childhood.53–56 Someintergenerational studies have exam-ined low birth weight as an intermedi-ate outcome between childhood adver-sity in 1 generation and adult ill health(or its predictors) in the subsequentgeneration.57
QUESTIONS UNANSWERED BYEXAMINING ONLY PROXIMATEEXPOSURES (ie, EXPOSURESOCCURRING SHORTLY BEFORE ANOUTCOME)
Some of us have been drawn to con-sider a life-course approach as weconfront persistent gaps in knowl-edge from research focused on expo-sures occurring not long before out-comes. For example, the two- tothreefold disparity in low birthweight and preterm birth betweenblack and white newborns is not ex-plained by the known risk factors foradverse birth outcomes; these riskfactors include current or recentsmoking, drug use, underweight orinadequate pregnancy weight gain,and chronic disease.79
As we attempt to understand the so-cial patterning of birth-outcome dis-parities according to class and nativ-ity as well as to race, many of us havecome to suspect that stressful expe-riences over women’s lives beforepregnancy represent a biologicallyplausible missing piece of the puzzle.At every level of current income andeducation, black women are morelikely than their white counterpartsto have experienced chronic stressas children caused by economic dif-ficulties, racial discrimination, orboth.80 Accumulating evidence aboutthe physiology of stress demon-strates that stressful experiences,particularly when they are chronic,could result in hypothalamic-pituitary-adrenal axis and/or im-mune function dysregulation, mak-ing a woman more likely to have anexcessive physiologic response toeven minor stress.81,82 High cortisollevels or immune dysfunction duringpregnancy could lead to adversebirth outcomes through immune, in-flammatory, or vascular pathways ora combination of these pathways.83–88
TABLE 1 Adult Health Outcomes AssociatedWith Childhood SocioeconomicConditions
All-cause mortality15–19
Cause-specific mortalityAlcoholic cirrhosis20
Cancer, smoking-related18,20,21
Cancer, stomach18,20,21
Cardiovascular disease15,16,18,21–24
Diabetes20
Respiratory disease18,21
Cardiovascular diseaseCarotid atherosclerosis25
Coronary heart disease26–28
Ischemic heart disease29
Myocardial infarction26,29
Stroke30
Metabolic outcomesInsulin resistance31
Obesity32–38
Type 2 diabetes39,40
Behavioral outcomesAlcohol or drug abuse41–43
Smoking44–47
Other health outcomesDepression48
Functional limitations19,49
Inflammatory markers50
Periodontal disease42,51
Self-rated health52
This list is not exhaustive; it is provided to indicate thescope of adult health outcomes that have been examinedwith life-course research.
TABLE 2 Adult Health Outcomes AssociatedWith Low Birth Weight
All-cause mortality58
Cause-specific mortalityCardiovascular disease58,59
Respiratory disease60
Cardiovascular diseaseCoronary heart disease61–64
Hypertension65–69
Ischemic heart disease70,71
Metabolic outcomesImpaired glucose tolerance72
Metabolic syndrome73
Type 2 diabetes61,72,74,75
Other health outcomesChronic kidney disease76
Depression77
Spontaneous hypothyroidism78
This list is not exhaustive; it is provided to indicate thescope of adult health outcomes that have been examinedwith life-course research.
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HOW IS THE LIFE-COURSEPERSPECTIVE RELEVANT TO HEALTHDISPARITIES?
The term “health disparities” oftenmeans different things to differentpeople.89,90 Although the dictionarycould lead one to conclude that theterm refers generically to all differ-ences in health, it is used here to referto potentially avoidable differences inhealth among groups of people whohave different levels of social and eco-nomic advantage or disadvantage; itrefers to differences in health onwhich socially disadvantaged groups(eg, people of low incomes or educa-tional attainment or members of a ra-cial or ethnic group that historicallyhas experienced discrimination) sys-tematically do worse.89 For example,the large and persistent black-whitedisparities in low birth weight, infantmortality, and maternal mortality areexamples of health disparities; thehigher incidence of breast canceramong white women compared withblack women is a health differencethat deserves attention, but it is notwhat is meant by the term health dis-parity according to established usagein public health.91 In other words,health disparities are a subset of dif-ferences in health that deserve partic-ular attention not only because theymay be avoidable but also becausethey are unfair and unjust.
People might be socially advantagedor disadvantaged by virtue of theirrace or ethnic group or because ofsuch socioeconomic factors as in-come, accumulated wealth, education,or residence in a socioeconomicallyadvantaged or disadvantaged commu-nity. Other relevant dimensions in-clude gender, religion, sexual orienta-tion, disability, and other socialcharacteristics that are associatedwith different levels of social stigma orinfluence and, hence, with different re-sources and opportunities in life. In
this article, the term “health dispari-ties” refers to differences in health ac-cording to race or ethnic group, socio-economic factors, or both, on whichthe socially disadvantaged groups sys-tematically experience worse health.
Figure 1 illustrates disparities inhealth by showing national data onchild health levels (as assessed by par-ents) according to family income andrace or ethnic group. It shows a strik-ing stepwise gradient in health accord-ing to income within each of the larg-est racial or ethnic groups; as incomerises, health improves.
The patterns are noted here to make 2important points. First, substantial so-cioeconomic and racial disparities inhealth adversely affect the middle-class and low-income groups; thesepatterns have been observed for awide range of health indicators amongadults and children.93 Second, when in-vestigating health disparities, oneneeds to consider not only socioeco-nomic factors such as income and ed-ucation (the socioeconomic factorsmost frequently used in health re-search in the United States) but alsoracial or ethnic identity. Socioeco-nomic factors do not fully reflect someexperiences of race-based discrimina-tion that could have large health ef-fects. Neither socioeconomic dispari-ties nor disparities according to racial
or ethnic group can be reduced to theother; although many epidemiologicstudies fail to do so, both must beexamined.
Figure 2 demonstrates the importanceof examining a range of social factors,including socioeconomic characteris-tics and other measures (such as ra-cial residential segregation) associ-ated with racial or ethnic group thatmight not be captured by socioeco-nomic information. The figure illus-trates the need for a new way of exam-ining health and health disparities.This new perspective does not negatethe importance of medical care butrecognizes the need to look beyond itat the circumstances in which peoplelive, work, learn, and play. Thisbroader perspective is necessary toimprove the health of all Americansand reduce the large health disparitiesamong different groups according toclass and race or ethnic group.
The prevailing view has been that indi-viduals are solely responsible for theirhealth-related behaviors. In line withthat thinking, our health-promotion ef-forts have focused heavily on inform-ing and encouraging individuals tochange their behaviors. The contentionin this monograph, however, is that weneed to take a fresh look, because cur-rent approaches have not providedan acceptable return on investment.
FIGURE 1In every racial or ethnic group, children’s health varies according to family income. (Adapted withpermission from Egerter et al.92)
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Some public health campaigns haveactually led to awidening of disparitiesas individuals in more socially advan-taged groups experience greaterhealth improvements because theyhave fewer obstacles to adoptinghealthier behaviors; this was the casewith antitobacco efforts and, at leastinitially, with efforts to reduce theprevalence of sudden infant death syn-drome.94,95 Moreover, we spend farmore per capita on medical care thanany other country, yet our rank islower than that of most other affluentnations (and lower than that of evensome resource-poor nations) on keyindicators such as infant mortality andlife expectancy.96
Perhaps our lack of success stemsfrom a failure to examine the factorsthat can constrain or enable people tobehave in health-promoting ways, tolook at the factors that society mustinfluence because they are beyond thecontrol of individuals by themselves.This perspective does not question in-dividual responsibility; it does, how-ever, emphasize the importance ofdeveloping policies to remove the ob-stacles that—by exposing individualsto more hazards, providing them withfewer options for healthy behaviors, or
both—systematically make some peo-ple less healthy than others.
As shown in Fig 1, although those withthe least income suffer from the worsthealth, even those who are in the mid-dle class are less healthy than moreaffluent people. We need to overcomeobstacles to good health for everyone,with particularly concerted efforts to
improve the health of those who are atgreatest social and economic disad-vantage (ie, those with more obstaclesand fewer resources to address thoseobstacles). We need initiatives that willimprove the health of the society as awhole while reducing disparities.
Figures 2 and 3 are relevant to the life-course perspective because they illus-trate a way of drawing attention to so-cial context at 2 levels. The first level isthe underlying resources and opportu-nities that people have, reflectedpartly by income and education as wellas by race or ethnic group, because itis so strongly associated with differen-tial access to resources and opportu-nities. The second level is the living andworking conditions into which peopleare sorted according to their income,education, and race or ethnic group(and other underlying resources andopportunities). Figure 2 illustrates abuilding block for a life-course per-spective, without the dimension oftime; it is a static view of how socialfactors can influence health directly
FIGURE 2Influences on health: what shapes the conditions that shape health? (Reprinted with permission fromBraveman, Egerter.93)
FIGURE 3Health is shaped by social advantages and disadvantages across lifetimes and generations. (Re-printed with permission from Braveman, Egerter.93)
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and indirectly by shaping health-related behaviors.
Figure 3 adds the dimension of time,depicting how underlying resourcesand opportunities shape living andworking conditions, which, in turn, in-fluence health at each stage of life. Fig-ure 3 also depicts the ways in whichsocial context early in life can have astrong influence on resources and op-portunities (and, thus, on living andworking conditions) at later stages.The figure shows not only an individu-al’s trajectory across a lifetime fromchildhood to adulthood but also the in-tergenerational transmission of socialadvantage or disadvantage and, hence,of health.
Figure 4 offers a deeper look at howhealth disparities are created and sus-tained or compounded over a lifetimeand across generations. Starting atthe top, it shows how social stratifica-tion or social inequality (the formationof social hierarchies that systemati-cally give some groups, such as socialclasses or racial and ethnic groups,more resources and opportunitiesthan others) results in differentgroups that have differential exposureto health hazards or to health-promoting factors.
Also as a result of social stratification,some groups are systematically morelikely to develop health damage if theyare exposed to a given hazard. Thesegroups are then more likely to sufferthe adverse social consequences ofdeveloping a given disease. For exam-ple, someone with limited schoolingwho becomes disabled is more likelyto become unemployable than some-one with good computer technicalskills, because these skills are com-patible with telecommuting. This re-sults in more social stratification—widening inequality—over the lifetimeof an individual and across genera-tions as the children of adults who aredisadvantaged socially and by ill
health grow up in adversity. Figure 4depicts what can be a vicious or virtu-ous cycle of social disadvantage or ad-vantage, producing health damages orbenefits across a lifetime or acrossgenerations.
CHALLENGES IN APPLYING THELIFE-COURSE PERSPECTIVE TORESEARCH, POLICY, AND PRACTICE
The gold standard in life-course re-search is a longitudinal study that pro-spectively follows a birth cohort intoadulthood and, ideally, across genera-tions. In the ideal study design, the in-vestigators collect extensive informa-tion on the physical and socialenvironments and on psychosocial orbehavioral and biological measures;the researchers then repeat thesemeasures for the same individualsover time. Much of the life-course liter-ature comes from Europe, where in-vestigators have had access to high-quality longitudinal databases rich incontextual information. In Table 1, 28(73.7%) of the 38 listed studies, docu-menting a wide array of adult health
outcomes associated with childhoodsocioeconomic conditions, were con-ducted in Europe or Australia/New Zea-land, and of these, 13 used longitudinaldata sources that measured variablesfrom birth onward. The scope anddepth of these data sources are exem-plified by the Centre for LongitudinalStudies’ 1970 British Birth Cohort, thecurrent participants of which are thesurvivors from an original sample ofover 17 000 births in England, Wales,and Scotland during 1 week in 1970. Asof 2006, analysis of these data hadyieldedmore than 300 publications, re-porting key findings in areas such asprenatal and perinatal antecedents ofconditions, social circumstances andhealth outcomes, adult outcomes ofchildhood disease and health status,and predictors of adult health status.Research based on this birth cohorthas provided crucial evidence in anumber of government inquiries thatled to policy and practice changes.97
In the United States, however, manylife-course studies have had to rely on
FIGURE 4Why are some social groups more likely to experience ill health? Considering living conditions acrosslifetimes and generations. (Adapted with permission from Finn Diderichsen, Karolinska Institutet,Stockholm, Sweden.)
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retrospective approaches, includingcase-control and retrospective cohortstudies that often have long recall pe-riods for early exposures. In contrastwith prospective longitudinal mea-surement of information from individ-uals followed over time, life-course re-search, particularly in the UnitedStates, often depends on record link-age, natural experiments, or historicalcohorts with limited follow-up acrosslife stages. Given the United States’high per-capita gross domestic prod-uct (in 2007 only those of 2 Organisa-tion for Economic Co-operation and De-velopment countries were higher98),lower levels of investment in admit-tedly costly longitudinal databases
and studies may be assumed to reflectprimarily differences in prioritiesrather than resources.
Table 3 lists longitudinal health-focused databases that US investiga-tors often have used for life-coursestudies. Table 4 lists longitudinal data-bases for which the primary focus isnot health but which contain health in-formation and have been used byhealth researchers. None of the exist-ing primarily health-focused data-bases begin at birth, and the EarlyChildhood Longitudinal Study-BirthCohort follows children from birthonly through preschool. Table 5 is alist of selected European longitudi-
nal databases that include somedata on participants from birththrough adulthood.
An exciting opportunity for many UShealth researchers is provided by theNational Children’s Study,115 which isscheduled to begin collecting datasoon on a representative sample of100 000 newborns and to follow the co-hort through the age of 21 years. TheNational Institutes of Health is leadingthe study but has been collaboratingextensively with other sectors to en-sure the collection of a rich array ofcontextual information.
As anyonewhohas analyzed longitudinaldata knows, it is exceedingly challenging
TABLE 3 Examples of Major Health-Focused Longitudinal Databases: United States
Name of Study, Lead Agency Initial Sample Follow-up
Alameda County Study,99 NIA 6928 noninstitutionalized Alameda County residents, aged�21 y atentry in 1965 (�16 y if married)
1965, 1974, 1994, and 1995
Coronary Artery RiskDevelopment in Young Adults(CARDIA),100 NHLBI
5115 black and white men and women aged 18–30 y at entry in1986, in 4 major US cities
7 waves over 20 y
Framingham Heart Study,101 NHLBI Original cohort: 5209 men and women aged 30–62 y in 1948 inFramingham, MA; offspring (1971): 5124 adult children andspouses in 1971; third generation (2005): 4095 adultgrandchildren of original participants
Every 2 y until present
Health and Retirement Study(HRS),102 NIA
�22 000 men and women aged�50 y in 1988 Biennially to present
Midlife Development in the UnitedStates (MIDUS),103 NIA
7000 men and women aged 25–74 y in 1995 (MIDUS I) Second wave�10 y later (MIDUS II)
National Longitudinal Study ofAdolescent Health (ADDHealth),104 NICHD
�90 000 students in grades 7–12 in 1994 at 145 schools; morethan�20 000 students and their parents interviewed at home
Reinterviewed at ages 18–26 and 24–32 y
Nurses’ Health Study (NHS),105 NIH Original cohort:�122 000 married registered nurses, aged30–55 y in 1976; NHS II: 116 686 women aged 25–42 y in 1989
Biennially to present
NIA indicates National Institute on Aging; NHLBI, National Heart, Lung and Blood Institute; NICHD, Eunice Kennedy Shriver National Institute of Child Health and Human Development; NIH,National Institutes of Health.
TABLE 4 Examples of Other Longitudinal Databases: United States
Name of Study, Lead Agency Initial Sample Follow-up
Early Childhood Longitudinal Study Birth Cohort(ECLS-B),106 Department of Education
14 000 children born in 2001 Data collection at birth, 9 mo, 2 y, preschool age,and entry to kindergarten
Early Childhood Longitudinal Study KindergartenCohort (ECLS-K),106 Department of Education
Nearly 4 million kindergartners enrolled in 1998–1999 Additional data collection in 1st, 3rd, 5th, and8th grades
National Longitudinal Survey of Youth (NLSY79),107
Bureau of Labor Statistics12 686 men and women aged 14–22 y in 1979 Interviewed annually through 1994, and
biennially to presentNLSY79 Children and Young Adults,107 Bureau ofLabor Statistics
Ongoing enrollment of NLSY79 women’s offspring,beginning in 1986
Biennially to present
NLS Original Cohorts,107 Bureau of Labor Statistics 5159 women aged 14–24 y in 1968; 5083 women aged20–44 y in 1967; 5225 men aged 14–24 y and 5020men aged 45–59 y in 1966
Women: biennially to present; men: interviewsceased in 1981
Panel Study of Income Dynamics (PSID),108
National Science Foundation4800 families in 1968 core sample;�7400 families by2005
Annually 1968–1996, biennially to present
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to study complex pathways over time,taking into account the temporal andpotential relationships at any given pointin time. In addition, previous researchtells us that socioeconomic conditions inearly life are strongly associated withlater-life socioeconomic conditions,116,117
which, in turn, have demonstrated linkswith adult health.
To tease out the “independent” impact ofearly socioeconomic circumstances onlater health (ie, to assess whether earlyadverse exposures themselves areman-ifested in later irreversible or difficult-to-reverse health damage, regardless oflater experiences), most life-coursestudies have attempted to control for so-cioeconomic circumstances later in life.Such adjustments can lead to underesti-mates of the influence of early-life fac-tors on subsequent health. For example,“overcontrolling” could mask the influ-ence of key mediators on the causalpathway from early conditions to lateradult health.
Life-course studies designed to betterunderstand health disparities have aneven greater challenge than life-course studies in general. To under-stand disparities not only in childhealth but also in adult health in rela-tion to experiences during childhood,we must examine multiple determi-nants of health and of health dispari-ties. The risk factors for disparities in
a given health indicator are not alwaysthe same as those for levels of thathealth indicator on average.
To understand the underlying basis fordisparities in a particular health out-come, we need to understand not onlythe causal exposures that occur inclose temporal proximity to the out-come but also the more fundamentalcauses or, in other words, the causesof the causes. We must consider thesocial and physical environments thatcreate great opportunities or dauntingobstacles to health, in part by con-straining choices. We must considermultiple dimensions of material depri-vation, social disadvantage, discrimi-nation, and marginalization. Thesedimensions include poverty- and race-based discrimination and their healthconsequences, as well as the health ef-fects of chronic stress that arise fromhaving inadequate resources to dealwith crushing demands. These aresome of the factors that belong in the 2outer arches of Fig 2 as examples ofeconomic and social resources andopportunities and of the living andworking conditions that they produce.These are the factors that producehealth disparities by tracking differentgroups of people into different expo-sures, different vulnerabilities to expo-sure, and different consequences of illhealth. These harmful or protective
factors should be examined atmultiplelevels of aggregation or analysis fromthe individual, family, community, andsocietal levels. A life-course study, fur-thermore, must examine these multi-ple dimensions of social advantageand disadvantage over time.
This is a tall order to fill. It is impossi-ble to describe fully all of the signifi-cant social and economic influences atthe individual, family, and communitylevels at any given point in time, letalone across a lifetime. We must beaware of this limitation aswe interpretresearch findings that will inevitablybe incomplete in some regard. Wemust also be careful not to invokegenes or “culture” to explain racial orethnic disparities in health withoutconsidering the potential roles of un-measured differences in social or eco-nomic experiences and in chronicallystressful experiences related to low in-come or to racial discrimination.
The challenges in conducting life-course research are considerable,but the challenges in applying thelife-course perspective to policy andpractice are even greater. One majorobstacle is that when the costs andbenefits of proposed policies are beingweighed, the time frame for outcomemeasurement is very short (typically 3to 5 years) for the Office of Manage-ment and Budget,118 which assesses
TABLE 5 Examples of Major Longitudinal Health-Focused Databases: Europe
Name of Study Initial Sample Follow-up
Avon Longitudinal Study of Parents andChildren (ALSPAC)109
�14 000 mothers enrolled during pregnancy in Bristol, United Kingdom,during 1991 and 1992
Ongoing
1970 British Birth Cohort Study110 �17 200 infants born in England, Wales, Scotland, and North Ireland ina week in April 1970
6 follow-ups, 1975–2004
Millennium Cohort Study (MCS)111 18 818 infants born in the United Kingdom over a 12-mo period in 2000–2001 and living in selected UK wards at 9 mo of age
4 waves between June 2001 and present
National Child Development Study (NCDS)112 17 500 infants born in England, Scotland, and Wales in a week in March1958
7 waves to the present
Newcastle Thousand Families Study113 All 1142 infants born to mothers in Newcastle Upon Tyne, UnitedKingdom, May–June 1947
At ages 15, 22, 32, 50, and 54 y
Population, Cancer, Cause of Death, andHospital Discharge Registries
Population-wide registries in the Scandinavian countries, linkablethrough the personal identification code
NA
Understanding Society Study114 Household members aged�10 y in 40 000 households across theUnited Kingdom
Annually from 2009
NA indicates not applicable.
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proposed federal legislation. Politi-cians typically want credit for the initi-atives they enact, but a life-course per-spective tells us that it can often take1 or more generations to realize thefull benefits of investments in earlychildhood.
Perhaps even more challenging arethe “silos” that isolate different sec-tors. In the current structures, the ed-ucation and social welfare sectors willnot receive credit for improvements inadult health that result from invest-ments in high-quality early-childhooddevelopment programs and improvedK-12 schooling. The transportation sec-tor will not receive credit for the healthbenefits that result from improvingpublic transportation in ways that pro-vide communities with more employ-ment opportunities. The agencies thatmust invest in improving early-childhood living conditions to producehealthy adults are not the same agen-cies that will receive the credit or anymonetary savings from improved adulthealth. The political and bureaucraticstructures that separate differentagencies, particularly across differentsectors, are among the greatest obsta-cles to translating knowledge fromlife-course research into effective pol-icy and practice.
AN AGENDA FOR RESEARCH ANDACTION INFORMED BY LIFE-COURSEPERSPECTIVES
We need more life-course research,which will require longitudinal studieswith extensive multilevel informationon social and physical context as wellas biology and behavior over time. TheNational Children’s Study is a step inthe right direction. However, futurefunding to follow the cohort into adult-hood is not ensured. In addition, al-though the National Children’s Studywill provide a rich source of contextualinformation, no single study can coverall important research questions, and
many items desired by researchersare not included in the study.
We also need to incorporate more in-formation on life-course social con-text into routine cross-sectional datasources as well as special studies.More investment is needed for devel-oping measures that can, despite longrecall periods, capture important in-formation about past experiences. Weneed more research on the early-lifeorigins of adult chronic disease. Un-derstanding birth outcome disparitiesshould receive special priority, givenhow powerfully low birth weight andpreterm birth predict developmentand health across the life course.
In addition to more research, we needto apply the knowledge that we cur-rently have; the available knowledgegives considerable guidance. Currentevidence tells us that we need to give ahigher priority to identifying and im-plementing policies that will ensure fa-vorable living conditions in early child-hood and that health care is importantbut not sufficient for achieving goodhealth and reducing health dispari-ties.119–121 Available evidence alsoshows that we must reduce child pov-erty and its social consequences if weare to improve adult health. We knowthat we must reduce multiple dimen-sions of disadvantage. We also knowthat effective interventions are avail-able, including high-quality programsmodeled on the most effective earlyHead Start approaches, high-qualitychild care, and support for par-ents.122,123 In the United Kingdom, the1998 Report of the Independent Inquiryinto Inequalities in Health, chaired bySir Donald Acheson, recommended39 actions that are intended to ame-liorate health inequalities primarilyby improving living conditions forvulnerable groups such as children,pregnant women, older people, andethnic minorities. On the basis of theAcheson Commission’s findings, the
Labor government enacted policies de-signed to reduce poverty and adversityin early childhood, targeting improve-ments in housing, schools, and childcare in deprived areas, as well aswage, tax, and welfare reform.114,124,125
Figure 4 is useful not only for elucidat-ing the relationships involved in theproduction of health or disease acrossa lifetime and generations but also forcalling our attention to the multiplepoints at which society can intervenethrough policies to interrupt the vi-cious cycles leading to health dispari-ties that begin in early childhood. Poli-cies can reduce social stratification,for example, by reducing poverty, ra-cial discrimination, or both. Policiescan reduce harmful exposures forthosewho aremost disadvantaged, forexample, by creating affordable andadequate housing, improving neigh-borhood environments, and enforcingantidiscrimination measures that af-fect access to health-promoting hous-ing and neighborhoods. Policies canalso reduce susceptibility to develop-ing ill health once people are exposedto risk factors by, for example, sup-porting after-school programs for at-risk youth. Policies can markedly alterthe social consequences of ill healththrough, for example, programs suchas Social Security and Medicaid.
The life-course perspective tells usthat we must change the time framefor evaluating policy outcomes andimpact, and we must break down thesector-specific silos, which will re-quire action at the highest levels ofgovernment. Child health advocatesmust recognize that children livewith adults. As a result, we cannotimprove children’s experiences with-out addressing the needs and im-proving the experiences of theiradult caregivers.
Child health advocates should under-stand that a life-course perspectiveoffers a very powerful argument for
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more investment in childhood be-cause of the impact of childhood ex-periences on later adult health. Theyshould understand, however, that theevidence indicates that investment inmedical care alone will not achievethe desired effect;119–121 investmentin children’s living and learning con-ditions is required. Adult health ef-fects might be more compelling thanchild health effects to many policymakers, because adults can vote and
adult health translates into economicproductivity.
The current economic crisis could cre-ate even more barriers to enactingbold new initiatives that require sub-stantial resources, such as efforts todrastically reduce childhood poverty.Perhaps this is also a time of uniqueopportunity, when we might be willingto reexamine many of our most funda-mental assumptions in the face of evi-dence that the course we have been
following is not working. That evidenceincludes our country’s low standing onkey health indicators compared withother affluent nations, although wespend more on medical care.96 The ev-idence also includes our rates of childpoverty, which are among the highestamong affluent nations.126 Can we af-ford to address child poverty in theUnited States? The life-course perspec-tive indicates that we cannot afford notto address it.
REFERENCES
1. Lynch J, Smith GD. A life course approachto chronic disease epidemiology. Annu RevPublic Health. 2005;26:1–35
2. Barker DJ. The developmental origins ofadult disease. Eur J Epidemiol. 2003;18(8):733–736
3. Kuh D, Ben-Shlomo Y, Lynch J, Hallqvist J,Power C. Life course epidemiology [pub-lished correction appears in J EpidemiolCommunity Health. 200;57(11):914]. J Epi-demiol Community Health. 2003;57(10):778–783
4. Byrne CD, Phillips DI. Fetal origins of adultdisease: epidemiology and mechanisms.J Clin Pathol. 2000;53(11):822–828
5. Elford J, Whincup P, Shaper AG. Early life ex-perience and adult cardiovascular disease:longitudinal and case-control studies. Int JEpidemiol. 1991;20(4):833–844
6. FisherD,BairdJ, PayneL, et al. Are infant sizeand growth related to burden of disease inadulthood?Asystematic reviewof literature.Int J Epidemiol. 2006;35(5):1196–1210
7. Galobardes B, Lynch JW, Davey Smith G.Childhood socioeconomic circumstancesand cause-specific mortality in adulthood:systematic review and interpretation. Epi-demiol Rev. 2004;26:7–21
8. Galobardes B, Lynch JW, Smith GD. Is theassociation between childhood socioeco-nomic circumstances and cause-specificmortality established? Update of a system-atic review. J Epidemiol CommunityHealth. 2008;62(5):387–390
9. Galobardes B, Smith GD, Lynch JW. System-atic review of the influence of childhoodsocioeconomic circumstances on risk forcardiovascular disease in adulthood. AnnEpidemiol. 2006;16(2):91–104
10. OsmondC, Barker DJ. Fetal, infant, and child-hood growth are predictors of coronaryheart disease, diabetes, and hypertension in
adult men and women. Environ Health Per-spect. 2000;108(suppl 3):545–553
11. Parsons TJ, Power C, Logan S, SummerbellCD. Childhood predictors of adult obesity:a systematic review. Int J Obes RelatMetab Disord. 1999;23(suppl 8):S1–S107
12. Shoham DA, Vupputuri S, Kshirsagar AV.Chronic kidney disease and life course so-cioeconomic status: a review. Adv ChronicKidney Dis. 2005;12(1):56–63
13. Anda RF, Felitti VJ, Bremner JD, et al. Theenduring effects of abuse and related ad-verse experiences in childhood: a conver-gence of evidence from neurobiology andepidemiology. Eur Arch Psychiatry ClinNeurosci. 2006;256(3):174–186
14. Felitti VJ, Anda RF, Nordenberg D, et al. Re-lationship of childhood abuse and house-hold dysfunction to many of the leadingcauses of death in adults. The AdverseChildhood Experiences (ACE) Study. Am JPrev Med. 1998;14(4):245–258
15. Beebe-Dimmer J, Lynch JW, Turrell G, Lust-garten S, Raghunathan T, Kaplan GA. Child-hood and adult socioeconomic conditionsand 31-year mortality risk in women. Am JEpidemiol. 2004;159(5):481–490
16. Frankel S, Smith GD, Gunnell D. Childhood so-cioeconomic position and adult cardiovascular mortality: the Boyd Orr cohort.Am J Epidemiol. 1999;150(10):1081–1084
17. Kuh D, Hardy R, Langenberg C, Richards M,Wadsworth ME. Mortality in adults aged26–54 years related to socioeconomicconditions in childhood and adulthood:post war birth cohort study. BMJ. 2002;325(7372):1076–1080
18. Smith GD, Hart C, Blane D, Hole D. Adversesocioeconomic conditions in childhoodand cause specific adult mortality: pro-spective observational study. BMJ. 1998;316(7145):1631–1635
19. Turrell G, Lynch JW, Leite C, Raghunathan T,
Kaplan GA. Socioeconomic disadvantage inchildhood and across the life course andall-cause mortality and physical functionin adulthood: evidence from the AlamedaCounty Study. J Epidemiol CommunityHealth. 2007;61(8):723–730
20. Lawlor DA, Sterne JA, Tynelius P, DaveySmith G, Rasmussen F. Association ofchildhood socioeconomic position withcause-specific mortality in a prospectiverecord linkage study of 1,839,384 individu-als. Am J Epidemiol. 2006;164(9):907–915
21. Naess O, Strand BH, Smith GD. Childhoodand adulthood socioeconomic positionacross 20 causes of death: a prospectivecohort study of 800,000 Norwegian menand women. J Epidemiol CommunityHealth. 2007;61(11):1004–1009
22. Claussen B, Davey Smith G, Thelle D. Impactof childhood and adulthood socioeconomicposition on cause specificmortality: the OsloMortality Study. J Epidemiol CommunityHealth. 2003;57(1):40–45
23. Kauhanen L, Lakka HM, Lynch JW, KauhanenJ. Social disadvantages inchildhoodandriskof all-cause death and cardiovascular dis-ease in later life: a comparison of historicaland retrospective childhood information. IntJ Epidemiol. 2006;35(4):962–968
24. Strand BH, Kunst A. Childhood socioeco-nomic position and cause-specific mortal-ity in early adulthood. Am J Epidemiol.2007;165(1):85–93
25. Rosvall M, Ostergren PO, Hedblad B, Isacs-son SO, Janzon L, Berglund G. Life-courseperspective on socioeconomic differencesin carotid atherosclerosis. ArteriosclerThromb Vasc Biol. 2002;22(10):1704–1711
26. Gliksman MD, Kawachi I, Hunter D, et al.Childhood socioeconomic status and riskof cardiovascular disease in middle agedUS women: a prospective study. J Epide-miol Community Health. 1995;49(1):10–15
S172 BRAVEMAN and BARCLAY by guest on September 20, 2020www.aappublications.org/newsDownloaded from
27. Lawlor DA, Batty GD, Morton SM, Clark H,Macintyre S, Leon DA. Childhood socioeco-nomic position, educational attainment, andadult cardiovascular risk factors: the Aber-deen children of the 1950s cohort study.Am J Public Health. 2005;95(7):1245–1251
28. Wamala SP, Lynch J, Kaplan GA. Women’s ex-posure to early and later life socioeconomicdisadvantage and coronary heart diseaserisk: the Stockholm Female Coronary RiskStudy. Int J Epidemiol. 2001;30(2):275–284
29. Wannamethee SG, Whincup PH, Shaper G,Walker M. Influence of fathers’ social classon cardiovascular disease in middle-agedmen. Lancet. 1996;348(9037):1259–1263
30. Glymour MM, Avendano M, Haas S, BerkmanLF. Lifecourse social conditions and racialdisparities in incidence of first stroke. AnnEpidemiol. 2008;18(12):904–912
31. Lawlor DA, Davey Smith G, Ebrahim S. Lifecourse influences on insulin resistance:findings from the British Women’s Heartand Health Study. Diabetes Care. 2003;26(1):97–103
32. Ball K, Mishra GD. Whose socioeconomicstatus influences a woman’s obesity risk:her mother’s, her father’s, or her own? IntJ Epidemiol. 2006;35(1):131–138
33. Giskes K, van Lenthe FJ, Turrell G, KamphuisCB, Brug J, Mackenbach JP. Socioeconomicposition at different stages of the life courseand its influence on body weight and weightgain in adulthood: a longitudinal study with13-year follow-up. Obesity (Silver Spring).2008;16(6):1377–1381
34. James SA, Fowler-Brown A, RaghunathanTE, Van Hoewyk J. Life-course socioeco-nomic position and obesity in AfricanAmerican Women: the Pitt County Study.Am J Public Health. 2006;96(3):554–560
35. Laitinen J, Power C, Jarvelin MR. Familysocial class, maternal body mass index,childhood body mass index, and age atmenarche as predictors of adult obesity.Am J Clin Nutr. 2001;74(3):287–294
36. Langenberg C, Hardy R, Kuh D, Brunner E,Wadsworth M. Central and total obesity inmiddle aged men and women in relation tolifetime socioeconomic status: evidencefrom a national birth cohort. J EpidemiolCommunity Health. 2003;57(10):816–822
37. Lawlor DA, Ebrahim S, Davey Smith G. So-cioeconomic position in childhood andadulthood and insulin resistance: crosssectional survey using data from Britishwomen’s heart and health study [pub-lished correction appears in BMJ. 2003;326(7387):488]. BMJ. 2002;325(7368):805
38. Power C, Manor O, Matthews S. Child toadult socioeconomic conditions and obe-
sity in a national cohort. Int J Obes RelatMetab Disord. 2003;27(9):1081–1086
39. Lidfeldt J, Li TY, Hu FB, Manson JE, KawachiI. A prospective study of childhood andadult socioeconomic status and incidenceof type 2 diabetes in women. Am J Epide-miol. 2007;165(8):882–889
40. Maty SC, Lynch JW, Raghunathan TE, KaplanGA. Childhood socioeconomic position, gen-der, adult bodymass index, and incidence oftype 2 diabetes mellitus over 34 years in theAlameda County Study. Am J Public Health.2008;98(8):1486–1494
41. Melchior M, Moffitt TE, Milne BJ, Poulton R,Caspi A. Why do children from socioeco-nomically disadvantaged families sufferfrom poor health when they reach adult-hood? A life-course study. Am J Epidemiol.2007;166(8):966–974
42. Poulton R, Caspi A, Milne BJ, et al. Associ-ation between children’s experience of so-cioeconomic disadvantage and adulthealth: a life-course study. Lancet. 2002;360(9346):1640–1645
43. Yang S, Lynch JW, Raghunathan TE, Kau-hanen J, Salonen JT, Kaplan GA. Socioeco-nomic and psychosocial exposures acrossthe life course and binge drinking inadulthood: population-based study. Am JEpidemiol. 2007;165(2):184–193
44. Brunner E, Shipley MJ, Blane D, Smith GD,Marmot MG. When does cardiovascularrisk start? Past and present socioeco-nomic circumstances and risk factors inadulthood. J Epidemiol Community Health.1999;53(12):757–764
45. Gilman SE, Abrams DB, Buka SL. Socioeco-nomic status over the life course andstages of cigarette use: initiation, regularuse, and cessation. J Epidemiol Commu-nity Health. 2003;57(10):802–808
46. Jefferis BJ, Power C, Graham H, Manor O.Effects of childhood socioeconomic cir-cumstances on persistent smoking. Am JPublic Health. 2004;94(2):279–285
47. Kestila L, Koskinen S, Martelin T, et al. In-fluence of parental education, childhoodadversities, and current living conditionson daily smoking in early adulthood. Eur JPublic Health. 2006;16(6):617–626
48. GilmanSE, Kawachi I, FitzmauriceGM,BukaL.Socio-economic status, family disruptionand residential stability in childhood: rela-tion to onset, recurrence and remission ofmajor depression. Psychol Med. 2003;33(8):1341–1355
49. Guralnik JM, Butterworth S, WadsworthME, Kuh D. Childhood socioeconomic sta-tus predicts physical functioning a half
century later. J Gerontol A Biol Sci Med Sci.2006;61(7):694–701
50. Pollitt RA, Kaufman JS, Rose KM, Diez-RouxAV, Zeng D, Heiss G. Early-life and adult so-cioeconomic status and inflammatory riskmarkers in adulthood. Eur J Epidemiol.2007;22(1):55–66
51. Thomson WM, Poulton R, Milne BJ, Caspi A,Broughton JR, Ayers KM. Socioeconomicinequalities in oral health in childhood andadulthood in a birth cohort. CommunityDent Oral Epidemiol. 2004;32(5):345–353
52. Hyde M, Jakub H, Melchior M, Van Oort F, Wey-ers S. Comparison of the effects of low child-hood socioeconomic position and low adult-hood socioeconomic position on self ratedhealth in four European studies. J EpidemiolCommunity Health. 2006;60(10):882–886
53. Astone NM, Misra D, Lynch C. The effect ofmaternal socio-economic status throughoutthe lifespan on infant birthweight. PaediatrPerinat Epidemiol. 2007;21(4):310–318
54. Colen CG, Geronimus AT, Bound J, JamesSA. Maternal upward socioeconomic mo-bility and black-white disparities in infantbirthweight. Am J Public Health. 2006;96(11):2032–2039
55. Currie J, Moretti E. Biology as destiny?Short- and long-run determinants of inter-generational transmission of birth weight.J Labor Econ. 2007;25(2):231–263
56. Gisselmann MD. The influence of maternalchildhood and adulthood social class onthe health of the infant. Soc Sci Med. 2006;63(4):1023–1033
57. Osler M, Andersen AM, Due P, Lund R,Damsgaard MT, Holstein BE. Socioeco-nomic position in early life, birth weight,childhood cognitive function, and adultmortality: a longitudinal study of Danishmen born in 1953. J Epidemiol CommunityHealth. 2003;57(9):681–686
58. Kajantie E, Osmond C, Barker DJ, Forsen T,Phillips DI, Eriksson JG. Size at birth as apredictor of mortality in adulthood: afollow-up of 350 000 person-years. Int JEpidemiol. 2005;34(3):655–663
59. Syddall HE, Sayer AA, Simmonds SJ, et al.Birth weight, infant weight gain, andcause-specific mortality: the Hertford-shire Cohort Study. Am J Epidemiol. 2005;161(11):1074–1080
60. Barker DJ, Godfrey KM, Fall C, Osmond C,Winter PD, Shaheen SO. Relation of birthweight and childhood respiratory infec-tion to adult lung function and death fromchronic obstructive airways disease. BMJ.1991;303(6804):671–675
61. Barker DJ, Eriksson JG, Forsen T, OsmondC. Fetal origins of adult disease: strength
SUPPLEMENT ARTICLE
PEDIATRICS Volume 124, Supplement 3, November 2009 S173 by guest on September 20, 2020www.aappublications.org/newsDownloaded from
of effects and biological basis. Int J Epide-miol. 2002;31(6):1235–1239
62. Frankel S, Elwood P, Sweetnam P, Yarnell J,Smith GD. Birthweight, body-mass index inmiddle age, and incident coronary heart dis-ease. Lancet. 1996;348(9040):1478–1480
63. Lawlor DA, Davey Smith G, Ebrahim S. Birthweight is inversely associated with coro-nary heart disease in post-menopausalwomen: findings from the British women’sheart and health study. J Epidemiol Com-munity Health. 2004;58(2):120–125
64. Rich-Edwards JW, Kleinman K, Michels KB,et al. Longitudinal study of birth weightand adult body mass index in predictingrisk of coronary heart disease and strokein women. BMJ. 2005;330(7500):1115
65. Barker DJ, Bull AR, Osmond C, SimmondsSJ. Fetal and placental size and risk of hy-pertension in adult life. BMJ. 1990;301(6746):259–262
66. Barker DJ, Forsen T, Eriksson JG, Osmond C.Growth and living conditions in childhoodand hypertension in adult life: a longitudinalstudy. J Hypertens. 2002;20(10):1951–1956
67. Eriksson J, Forsen T, Tuomilehto J, Os-mond C, Barker D. Fetal and childhoodgrowth and hypertension in adult life. Hy-pertension. 2000;36(5):790–794
68. Koupilova I, Leon DA, Vågero D. Can con-founding by sociodemographic and behav-ioural factors explain the association be-tween size at birth and blood pressure atage 50 in Sweden? J Epidemiol CommunityHealth. 1997;51(1):14–18
69. Mogren I, Hogberg U, Stegmayr B, LindahlB, Stenlund H. Fetal exposure, heredity andrisk indicators for cardiovascular diseasein a Swedish welfare cohort. Int J Epide-miol. 2001;30(4):853–862
70. Barker DJ, Winter PD, Osmond C, MargettsB, Simmonds SJ. Weight in infancy anddeath from ischaemic heart disease. Lan-cet. 1989;2(8663):577–580
71. KaijserM, Bonamy AK, Akre O, et al. Perinatalrisk factors for ischemic heart disease: dis-entangling the roles of birth weight and pre-termbirth. Circulation. 2008;117(3):405–410
72. Al Salmi I, Hoy WE, Kondalsamy-ChennakesavanS, et al. Disorders of glucoseregulation in adults andbirthweight: resultsfrom the Australian Diabetes, Obesity andLifestyle (AUSDIAB) Study. Diabetes Care.2008;31(1):159–164
73. Ramadhani MK, Grobbee DE, Bots ML, et al.Lower birth weight predicts metabolicsyndrome in young adults: the Atheroscle-rosis Risk in Young Adults (ARYA)-study.Atherosclerosis. 2006;184(1):21–27
74. Forsen T, ErikssonJ, Tuomilehto J, Reunanen
A, Osmond C, Barker D. The fetal and child-hood growth of persons who develop type 2diabetes. Ann Intern Med. 2000;133(3):176–182
75. Rich-Edwards JW, Colditz GA, Stampfer MJ,et al. Birthweight and the risk for type 2diabetes mellitus in adult women. Ann In-tern Med. 1999;130(4 pt 1):278–284
76. Li S, Chen SC, Shlipak M, et al. Low birthweight is associated with chronic kidneydisease only in men. Kidney Int. 2008;73(5):637–642
77. Nomura Y, Brooks-Gunn J, Davey C, Ham J,Fifer WP. The role of perinatal problems inrisk of co-morbid psychiatric and medicaldisorders in adulthood. Psychol Med.2007;37(9):1323–1334
78. Kajantie E, Phillips DI, Osmond C, Barker DJ,Forsen T, Eriksson JG. Spontaneous hypothy-roidism in adult women is predicted by smallbody size at birth and during childhood. J ClinEndocrinolMetab. 2006;91(12):4953–4956
79. Institute of Medicine, Committee on Under-standing Premature Birth and AssuringHealthy Outcomes and Board on HealthSciences Policy. Preterm Birth: Causes,Consequences, and Prevention. BehrmanRE, Butler AS, eds. Washington, DC: Na-tional Academies Press; 2007
80. Braveman PA, Cubbin C, Egerter S, et al.Socioeconomic status in health research:one size does not fit all. JAMA. 2005;294(22):2879–2888
81. Hertzman C, Power C. Health and humandevelopment: understandings from life-course research. Dev Neuropsychol. 2003;24(2–3):719–744
82. McEwen BS. Stress, adaptation, and disease:allostasis and allostatic load. Ann N Y AcadSci. 1998;840:33–44
83. Dominguez TP. Race, racism, and racialdisparities in adverse birth outcomes. ClinObstet Gynecol. 2008;51(2):360–370
84. Dominguez TP, Schetter CD, Mancuso R, RiniCM, Hobel C. Stress in African Americanpregnancies: testing the roles of variousstress concepts in prediction of birth out-comes. Ann Behav Med. 2005;29(1):12–21
85. Hobel CJ, Dunkel-Schetter C, Roesch SC, Cas-tro LC, Arora CP. Maternal plasmacorticotropin-releasing hormone associatedwith stress at 20 weeks’ gestation in preg-nancies ending in pretermdelivery. AmJOb-stet Gynecol. 1999;180(1 pt 3):S257–S263
86. Holzman C, Jetton J, Siler-Khodr T, FisherR, Rip T. Second trimester corticotropin-releasing hormone levels in relation topreterm delivery and ethnicity. Obstet Gy-necol. 2001;97(5 pt 1):657–663
87. LuMC, HalfonN. Racial andethnic disparities
in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7(1):13–30
88. Wadhwa PD, Culhane JF, Rauh V, Barve SS.Stress and preterm birth: neuroendo-crine, immune/inflammatory, and vascu-lar mechanisms. Matern Child Health J.2001;5(2):119–125
89. Braveman P. Health disparities and healthequity: concepts and measurement. AnnuRev Public Health. 2006;27:167–194
90. Carter-Pokras O, Baquet C. What is a“health disparity?” Public Health Rep.2002;117(5):426–434
91. The Secretary’s Advisory Committee on Na-tional Health Promotion andDisease Preven-tion objectives for 2020: phase 1 report—recommendations for the framework andformat of Healthy People 2020. October 28,2008. Available at: www.healthypeople.gov/hp2020/advisory/PhaseI/PhaseI.pdf. Ac-cessed December 19, 2008
92. Egerter S, BravemanP, Pamuk E, et al.Amer-ica’s Health Starts with Healthy Children:How Do States Compare? Washington, DC:Robert Wood Johnson Foundation Commis-sion to Build a Healthier America; 2008
93. Braveman P, Egerter S. Overcoming Obsta-cles to Health: Report From the Robert WoodJohnson Foundation to the Commission toBuild a Healthier America. Washington, DC.Robert Wood Johnson Foundation Commis-sion to Build a Healthier America; 2008
94. Pickett KE, Luo Y, Lauderdale DS. Wideningsocial inequalities in risk for sudden in-fant death syndrome. Am J Public Health.2005;95(11):1976–1981
95. Pierce JP, Fiore MC, Novotny TE, HatziandreuEJ, Davis RM. Trends in cigarette smoking inthe United States: educational differencesare increasing. JAMA. 1989;261(1):56–60
96. Organisation for Economic Co-operationand Development. OECD health data 2005:how does the United States compare?Available at: www.oecd.org/dataoecd/15/23/34970246.pdf. Accessed June 9, 2009
97. Elliott J, Shepherd P. Cohort profile: 1970British Birth Cohort (BCS70). Int J Epide-miol. 2006;35(4):836–843
98. Organisation for Economic Co-operation andDevelopment. Gross domestic product: GDPper head, US $, current prices, current PPPs.Available at: http://stats.oecd.org/Index.aspx?datasetcode�SNA�TABLE1. Ac-cessed June 10, 2009
99. National Institute on Aging. Longitudi-na l s tudies search . Ava i lab le at :www.nia.nih.gov/ResearchInformation/ScientificResources/StudyInfo.htm?id�42.Accessed October 28, 2008
100. University of Alabama at Birmingham, Divi-
S174 BRAVEMAN and BARCLAY by guest on September 20, 2020www.aappublications.org/newsDownloaded from
sion of Preventive Medicine. Coronary Ar-tery Risk Development in Young Adults(CARDIA) study: brief description. Avail-able at: www.cardia.dopm.uab.edu/o�brde.htm. Accessed October 29, 2008
101. National Heart, Lung, and Blood Institute;Boston University. History of the Framing-ton Heart Study . Ava i lab le at :www.framinghamheartstudy.org/about/history.html. Accessed October 27, 2008
102. National Institute on Aging. The Health &Retirement Study: growing older in Amer-ica. Available at: www.nia.nih.gov/ResearchInformation/ExtramuralPrograms/BehavioralAndSocialResearch/HRSfull.htm.Accessed October 28, 2008
103. University of Wisconsin, Institute on Aging.Midlife in the U.S. (MIDUS). Available at:http://aging.wisc.edu/research/midus.php.Accessed October 29, 2008
104. Eunice Kennedy Shriver National Institute ofChild Health and Human Development. Na-tional Longitudinal Study of AdolescentHealth (AddHealth). Available at: www.nichd.nih.gov/health/topics/add� health�study.cfm. Accessed October 28, 2008
105. Harvard University. History of the Nurses’Health Study. Available at: www.channing.harvard.edu/nhs/index.php/history. Ac-cessed October 27, 2008
106. Department of Education. Early ChildhoodLongitudinal Program. Available at: http://nces.ed.gov/ecls/index.asp. Accessed Octo-ber 27, 2008
107. Bureau of Labor Statistics. National longi-tudinal surveys. Available at: www.bls.gov/nls/nlsy79.htm. Accessed October 27, 2008
108. University of Michigan. An overview of thePanel Study of Income Dynamics. Availableat: http://psidonline.isr.umich.edu/Guide/Overview.html. Accessed October 29, 2008
109. University of Bristol. Avon LongitudinalStudy of Parents and Children. Available at:www.bristol.ac.uk/alspac/public/history.Accessed October 29, 2008
110. University of London, Centre for Longitudi-nal Studies. 1970 British Birth CohortStudy. Available at: www.cls.ioe.ac.uk/studies.asp?section�000100020002. Ac-cessed October 29, 2008
111. University of London, Centre for Longitudi-nal Studies. Millennium Cohort Study.Ava i lab le a t : www.c ls . i oe .ac .uk/studies.asp?section�000100020001. Ac-cessed December 18, 2008
112. University of London, Centre for Longitudi-nal Studies. National Child DevelopmentStudy. Available at: www.cls.ioe.ac.uk/text.asp?section�000100020003. Ac-cessed December 19, 2008
113. University of Newcastle Upon Tyne, Paediat-ric and Lifecourse Epidemiology ResearchGroup. Welcome to the Newcastle ThousandFamilies Study. Available at: www.ncl.ac.uk/plerg/Research/1000F/1000�home.htm. Ac-cessed October 29, 2008
114. Institute for Social and Economic Research.Understanding Society Study. Available at:www.understandingsociety.info. AccessedDecember 18, 2008
115. Eunice Kennedy Shriver National Institute ofChild Health and Human Development. Whatis the National Children’s Study? Available at:www.nationalchildrensstudy.gov/Pages/default.aspx. Accessed October 28, 2008
116. An CB. Teen Out-of-Wedlock Births and Wel-fare Receipt: The Role of Childhood Eventsand Economic Circumstances. Madison,WI: Wisconsin University Institute for Re-search on Poverty; 1991
117. JencksC,MayerSE. Thesocial consequencesof growing up in a poor neighborhood. In:Lynn LE Jr, McGeary MGH, ed. Inner-City Pov-
erty in the United States. Washington, DC: Na-tional Academy Press; 1990:111–185
118. Penner RG. Federal revenue forecasting. In:Handbook of Government Budget Forecast-ing. New York, NY: Taylor & Francis; 2009:11–26
119. Marmot M, Friel S, Bell R, Houweling TA,Taylor S. Closing the gap in a generation:health equity through action on the socialdeterminants of health. Lancet. 2008;372(9650):1661–1669
120. McGinnis JM, Williams-Russo P, KnickmanJR. The case for more active policy atten-tion to health promotion. Health Aff (Mill-wood). 2002;21(2):78–93
121. Schroeder SA. We can do better: improvingthe health of the American people. N EnglJ Med. 2007;357(12):1221–1228
122. HertzmanC,WiensM. Child development andlong-term outcomes: a populationhealth perspective and summary of suc-cessful interventions. Soc Sci Med. 1996;43(7):1083–1095
123. ReynoldsAJ, Temple JA, OuSR, et al. Effectsofa school-based, early childhood interventionon adult health and well-being: a 19-yearfollow-up of low-income families. Arch Pedi-atr Adolesc Med. 2007;161(8):730–739
124. Department of Health. Independent InquiryInto Inequalities in Health Report. London,United Kingdom: The Stationery Office; 1998
125. Department of Health. Saving Lives: OurHealthier Nation. London, United Kingdom:The Stationery Office; 1998
126. Forster M, d’Ercole M. Income Distributionand Poverty in OECD Countries in the SecondHalf of the 1990s. Paris, France: Organisationfor Economic Co-operation andDevelopmentPublishing; 2005. OECD Social Employmentand Migration Working Paper No. 22
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