BRIEF COMMUNICATION

Early Life and Adult Socioeconomic Influences on Mortality Risk:

Preliminary Report of a ‘Pauper Rich’ Paradox in a Chilean Adult Cohort
ELARD KOCH, TOMÁS ROMERO, CAMILA X. ROMERO, HERNÁN AGUILERA,
MARIO PAREDES, MIGUEL VARGAS, AND CARLOS AHUMADA

PURPOSE: The inverse relationship between early life and adult socioeconomic measures and mortality
risk has been well established in developed countries, but remains practically unexplored in Latin American
societies. The setting was Chile; the study included 11,600 adults living in the urban center of San Francisco
de Mostazal. This was a prospective cohort study of a weighted random sample of 795 subjects followed up
during 8 years.
METHODS: Education (elementary, high school and college), height (percentiles 50 and 75), and
income (population quartiles) were assessed at baseline. Relative risks of all-cause mortality were computed
in Cox regression models adjusting for age, gender, body mass index, smoking status, and joint effects of the
socioeconomic measures.
RESULTS: A graded inverse relationship with all-cause mortality was observed for education (risk: 1.0,
0.67, and 0.30, p for trend ! 0.01) and height (risk: 1.0, 0.75, and 0.56, p for trend ! 0.01), but not for
income (p for trend Z 0.94).
CONCLUSIONS: These findings suggest a ‘pauper rich’ paradox in transitioning Latin American
economies. Income level does not seem sufficient to improve survival in cohorts exposed to adverse early
life influences reflected by education and height.
Ann Epidemiol 2010;20:487–492. Ó 2010 Elsevier Inc. All rights reserved.
KEY WORDS: Developing Country, Education, Income, Height, Mortality Risk, Socioeconomic Position,
Survival Analysis.

country in an advanced stage of economic and epidemiologic

INTRODUCTION
Occupation and income are important measures of adult life
socioeconomic position (SEP) (1) influencing health and
mortality (2–10). Educational level (5–7, 11–16) and adult
height (2, 17–24), both considered early life environmental
exposure measures (25, 26), have also been identified as
strong predictors for adult survival. However, these assertions
have been obtained mostly from studies conducted in specific
gender or ethnic groups living in developed-industrialized
countries characterized by wealthier and more egalitarian
economies (27, 28). We present data from a prospective
cohort study conducted in Chile, testing the hypothesis of
an inverse relationship between different SEP measures
and all-cause mortality risk in a middle-income developing
From the Department of Family Medicine, Faculty of Medicine (E.K., C.
X.R., H.A.); Division of Epidemiology, School of Public Health, Doctoral
Program (E.K.), Faculty of Medicine; School of Medical Technology (E.K.),
Faculty of Medicine, University of Chile; University of California, School
of Medicine San Diego (T.R.); and the Health Center of Mostazal, San
Francisco de Mostazal (M.P., M.V., C.A.), Chile.
Address correspondence to: Elard Koch, MSc, PhD(s), Department of
Family Medicine, Faculty of Medicine, University of Chile, 3100 Gran
Avenida, Santiago, Chile. Tel: 56-02-555-2716; Fax: 56-02-556-3211. E-
mail: elardkoch@gmail.com.
Received September 3, 2009; accepted March 2, 2010.
transition in Latin America (29).
METHODS
The characteristics of the population included in the study
have been described elsewhere (30). Briefly, this research
was carried out in the city of San Francisco de Mostazal
(San Francisco Project), with a population of 21,896, and
with demographic features similar to the national average
(31). There were 17,903 individuals identified as stable resi-
dents in the urban sector of San Francisco de Mostazal. A
simple random sample of 518 neighborhoods was selected
and a population census was carried out from August to
December 1996, generating a simple random list of 1,980
eligible individuals for a general health survey conducted
by the health primary care center of the district. Data
were collected through medical examinations, laboratory
tests, and population surveys performed between January
1997 and December 1999, with an overall response rate of
73% (32). Thus the cross-sectional sample was initially
composed of 1,446 subjects 20 to 97 years of age. Excluded
were 423 individuals younger than 30 years and older than
79 years since they had the lowest and highest age-related

Ó 2010 Elsevier Inc. All rights reserved. 1047-2797/$–see front matter

360 Park Avenue South, New York, NY 10010 doi:10.1016/j.annepidem.2010.03.009
488 Koch et al.
EARLY LIFE AND ADULT INFLUENCES ON MORTALITY
mortality risk, respectively. These exclusions likely mini-
mize the effect of recent secular trends observed in Chile,
with the younger generations presenting with a higher
education level and height than the older ones (30). Finally,
208 individuals with documented heart disease, cancer,
chronic renal failure, chronic obstructive lung disease, and
physical or mental incapacities were excluded at baseline,
and another 20 individuals were excluded by incomplete
data over the total follow-up period. After these exclusions,
a sample of 795 subjects who were representative of an
apparently healthy population of 11,600 adults remained
for the present study.
Demographic and socioeconomic information was ob-
tained through a questionnaire at the baseline of the study
during a home visit. The education level was assessed by
self-report and coded as elementary school (<8 years), high
school (9–12 years), and college (>13 years). Annual house-
hold income was self reported in Chilean currency and
converted to U.S. dollars and categorized in the following
population quartiles (Q): Q1, !$4,200; Q2, $4,200–
$6,000; Q3, $6,000–$10,200; Q4, O$10,200. Correlations
between self-reported education and income with official
SEP measures obtained in the Social Characterization Survey
by the municipal government of Mostazal showed Spearman-
rho coefficients of 0.91 and 0.77, respectively (32).
Weight and height were measured using a calibrated
physician scale to the nearest 0.1 kg and a height-rod to
the nearest 0.1 cm. Standard procedures to determine
body mass index (BMI) and to establish smoking status
have been described elsewhere (33).
The participants were followed up by questionnaires,
telephone calls, home visits, reports from family members,
and review of medical records. Follow-up time for incident
mortality events was determined by the number of days
between the baseline survey and either death, last contact,
or Jan. 31, 2006, whichever came first. All-cause mortality
was ascertained by official death certificate from the
National Office of Vital Records and National Health
Service in Chile, as described elsewhere (31). These govern-
mental institutions use the International Classification of
Diseases, Tenth Revision (ICD-10) to classify the causes of
death. Nowadays, the Chilean system of vital statistics, espe-
cially regarding the mortality registrydintegrity 100%,
medical certification 99%, ill-defined causes of death 2.8%
(34)dis similar to the ones in use in developed nations,
differentiating location versus residence in every case of
death occurrence.
To correct prevalence estimates and especially to minimize
selection bias in statistical analyses, we computed individual
mixed sample weights (integer and proportional) based on
sex- and age-specific census data from the population under
study. Continuous data were expressed as means G standard
deviations. Pearson correlations were used for exploring the
AEP Vol. 20, No. 6
June 2010: 487–492
relationship between baseline characteristics. Kaplan-Meier
curves were used to describe survival trends for SEP categories.
The relative risks of mortality were computed by increasing
categories of education (reference group, elementary school),
categories of height based on sex-specific percentiles 50 and 75
(reference group, !167 cm for men; !155 cm for women)
and income quartiles (reference group, Q1 ! $4,200) using
age-adjusted (linear, quadratic, and age O65 years) Cox
regression models. Since no difference in the association of
education, height, and income with mortality according to
gender was found, mortality risk estimates for men and women
were combined.
RESULTS
The mean age of participants was 47.9 G 16.1 years (31 to
79 years). The median for education and annual household
income was 8 years (interquartile range, 5 to 12 years) and
$6,000 (interquartile range, $4,200 to $10,800), respec-
tively. From the total sample, 49.8% had elementary,
38.1% high school, and 12.1% college education. The
mean height was 167.3 G 6.9 cm for men and 154.7 G
6.0 cm for women.
An inverse correlation between education and age was
observed (r Z 0.46, p ! 0.001) and a very small correla-
tion between income and age was also noted (r Z 0.03
p ! 0.01). A moderate age-adjusted partial correlation
between education years and income was observed
(r Z 0.33, p ! 0.001). Height showed an inverse correlation
with age (r Z 0.21, p ! 0.001) and a positive correlation
with education (r Z 0.19, p ! 0.001) and income (r Z 0.14,
p ! 0.001).
Over a follow-up period of 8 years (average, 8.1 G 0.92
years), 46 cases of death were observed. The causes of death
in this cohortdaccording to the ICD-10 codesdwere
similar to ones observed in the rest of the country. The three
main causes were cardiovascular diseases (33%), cancer
(24%), and respiratory diseases (17%). Kaplan-Meier log
survival curves showed stepped and graded survival trends
for education and height with the lower categories present-
ing premature mortality (Fig 1). However, survival trends
for income categories overlapped. Table 1 shows the
mortality risk for education, height, and income categories.
In multivariate regression models, education and height
showed an inverse dose-response gradient on risk of all-
cause mortality. The high school and college groups had
33% and 70% less risk of dying from any cause as compared
to the elementary school group. The tallest groups had 25%
and 44% less risk of dying from any cause as compared to the
shortest group. The observed effects were independent of
age, gender (model 1), BMI, smoking (model 2), and joint
effects of the other socioeconomic measures (model 3). In
AEP Vol. 20, No. 6
June 2010: 487–492
FIGURE 1. Kaplan-Meier log survival curves for education (A),
height (B), and income categories (C). Education level was catego-
rized as elementary school (!9 years), high school (9–12 years),
and college (>13 years). Height was categorized in centimeters ac-
cording to 50th and 75th percentiles by sex. Males: short, !67 cm;
medium, 167–175 cm; and tall O175 cm. Females: short, !155 cm;
medium, 155–163 cm; and tall O163 cm. Income was categorized
according to population quartiles (Q) in U.S. dollars. Q1:
!$4,200; Q2: $4,200– 6,000; Q3: $6,000–10,200; Q4: O $10,200.
Koch et al. 489
EARLY LIFE AND ADULT INFLUENCES ON MORTALITY
contrast, income level did not show a protective influence
on survival in any of the multivariate regression models.
DISCUSSION
This preliminary analysis of an adult cohort followed for
8 years in a Latin American developing country showed
that increasing levels of education and height have an
inverse and graded relationship with mortality risk indepen-
dently of differences in age, gender, BMI, and smoking. In
contrast with other studies (3–5, 8, 10, 35–37), higher
income levels did not show a protective influence on
all-cause mortality risk after the adjustments for education
and height. We have described this group of individuals
exposed to socioeconomic disadvantages in early life who
are not able to improve these adverse influences with
increasing levels of income gained in adulthood with the
term ‘pauper rich’.
The inverse association between early SEP measures and
mortality (38) remains practically unexplored in Latin
American economically transitioning societies. Despite
a sustained development process and a formal economic
system with a per capita income over $5,000 (39), Chile still
struggles with significant inequalities regarding income
distribution (40)dGini coefficient of 0.57 (41)dand has
a recent past of malnutrition and poverty (42). Therefore
many in the study cohort born before 1970 were exposed
to adverse life circumstances during childhood––poverty,
high infant and maternal mortality, undernutrition, and
infectious disease epidemics (43–45).
The independent effect of education and height suggests
that these measures are not only simply interchangeable;
they also represent distinct early exposure patterns leading
to deleterious consequences for health in adult life. Educa-
tion would be a measure of both early life circumstances,
as the opportunities available to an individual are likely to
be patterned by parental social class, and future socioeco-
nomic trajectory (26). Therefore education may have an
‘‘antecedent’’ role to income and behavioral risk factors
(30). On the other hand, height is a biological marker influ-
enced by environmental exposures such as infectious
disease, malnutrition, poor socioeconomic circumstances,
and chronic psychological stress during sensitive growth
periods (25, 46). Furthermore, fetal programming related
with an adverse maternal environment during gestational
period can simultaneously influence attained height and
health risk in adult lifetime (47). Finally, income represents
material resources and mirrors experiences in adult life influ-
encing the mortality risk, likely via psychological factors
such as stress, frustration, or depression especially in people
relatively deprived (e.g., the ‘pauper rich’ groups) (27, 28,
30). Thus, from the life course perspective, education,
490 Koch et al. AEP Vol. 20, No. 6
EARLY LIFE AND ADULT INFLUENCES ON MORTALITY June 2010: 487–492

TABLE 1. Relative risks with 95% confidence intervals for mortality events based on education, height and income categories
Category No.* Crude risk Model 1 Model 2 Model 3
Education
!9 yr (elementary) 422 (6092) 1.0 1.0 1.0 1.0
9–12 yr (high school) 270 (4003) 0.24 (0.19–0.30) 0.68 (0.54–0.86) 0.67 (0.53–0.85) 0.67 (0.53–0.85)
> 13 years (college) 103 (1505) 0.09 (0.05–0.15) 0.27 (0.16–0.49) 0.31 (0.18–0.55) 0.30 (0.17–0.53)
p for trend !0.001 !0.01 !0.01 !0.01

Height
F: !155 cm; M: !167 cm 396 (5749) 1.0 1.0 1.0 1.0
F: 155–163 cm; M: 167–175 cm 201 (2949) 0.53 (0.43–0.64) 0.77 (0.63–0.93) 0.73 (0.61–0.89) 0.75 (0.62–0.92)
F: O163 cm; M O175 cm. 198 (2905) 0.23 (0.17–0.30) 0.64 (0.49–0.85) 0.57 (0.43–0.75) 0.56 (0.42–0.74)
p for trend !0.001 !0.01 !0.01 !0.01

Annual income quartiles

Q1, !$4,200 181 (2498) 1.0 1.0 1.0 1.0
Q2, $4,200–$6,000 227 (3368) 0.37 (0.30–0.46) 0.91 (0.74–1,11) 0.81 (0.66–1.00) 0.86 (0.69–1.06)
Q3, $6,000–$10,200 188 (2810) 0.34 (0.27–0.42) 1.00 (0.79–1.25) 0.97 (0.78–1.23) 1.11 (0.88–1.40)
Q4, O$10,200 199 (2924) 0.38 (0.31–0.47) 0.97 (0.78–1.19) 0.88 (0.71–1.08) 1.05 (0.84–1.31)
p for trend 0.01 0.629 0.173 0.970
F/M Z female/male.
Relative risks refer to hazard ratios obtained from Cox proportional regression hazard models.
Model 1: Adjusted for age (linear, quadratic, and O65 years) and gender.
Model 2: Adjusted for age (linear, quadratic, and O65 years), gender, body mass index, and smoking status.
Model 3: Adjusted for age (linear, quadratic, and O65 years), gender, body mass index, smoking status, and joint effects for education, height, and income.
*In brackets weighted size by sex- and age-specific sample weights based on geographic distribution and census data.

height and income may plausibly influence mortality risk by
different and/or complementary causal pathways.
The null effect of income has already been reported by
others. Albert et al. (15) conducted a study among U.S. female
health workers; after controlling for traditional chronic
disease risk factors, they found no independent effect of
income on cardiovascular events including death. In contrast,
education had a protective effect after controlling for tradi-
tional and novel risk factors. In a recent complementary study
of the San Francisco Project cohort, we evaluated the effect of
different biological and behavioral chronic disease risk factors
on the relationships among education, income, and mortality
(30). Only 24% of the inverse relationship between education
and mortality was accounted for by combined effects of
chronic disease risk factors and income. Thus our preliminary
results corroborate and extend these findings to all-cause
mortality in a population with a much lower annual household
income and education level. Furthermore, the present report
adds evidence supporting height as biomarker of early expo-
sures and subsequent risk of adult mortality in developing
societies with a recent past of poverty and malnutrition.
LIMITATIONS
Several limitations in this study should be taken into account.
The original sampling frame of 1,980 representative of the
general population studied was substantially reduced after
the exclusion criteria. To address this problem of ‘‘representa-
tiveness’’ and selection bias, we used mixed sample weights
based on census data to compensate for differences between
the sample and the original population, allowing for scaling
of risk estimators to the population (48). In addition, although
we cannot rule out that the low number of deaths may be
skewing results in a particular direction, we had no empty cells
throughout all the categories. Moreover, we observe a clear
inverse dose-response gradient for education and height that
is consistent with findings of most cohorts in developed coun-
tries (11–24). As it was discussed above, from the life-course
perspective it is unlikely that the statistical results for height,
education, and income in the Chilean context appear to be
picking up the same SEP association; this is supported by
the absence of colinearity in joint-effect regression models.
In addition, if height, education, or income were reflecting
the same phenomena, a non-significant beta coefficient for
height or education would have been observed in the joint-
effect models. Finally, because of the limited number of
deaths, it was not possible to assess interaction terms in alter-
native explanatory models in this phase of the study.
CONCLUSION
These preliminary results provisionally support the hypothesis
that early life socioeconomic influences on mortality risk in
societies undergoing rapid economic and epidemiologic tran-
sition may be more important than adult life influences, such
as income level. Moreover, the null effect of income is unex-
pected and counterintuitive, suggesting a ‘pauper rich’ paradox
in transitioning Latin American economies where increasing
AEP Vol. 20, No. 6
June 2010: 487–492
levels of income via material and health resources are not able
to adequately improve survival of individuals exposed to
adverse early-life influences reflected by present levels of
education and height. Furthermore, unfulfilled lifestyle expec-
tations of those in the higher end of a still low absolute income
distribution, that is, individuals relatively deprived in the cate-
gory described as the ‘pauper rich’ may have a detrimental
effect manifested in psychological and emotional factors
such as stress, frustration, or depression offsetting the potential
health benefits of increasing income level during a rapid
process of economic transition. Nevertheless, because of the
small number of deaths in this cohort, a longer follow-up
period and possible interaction among socioeconomic
measures are required to assess the validity of these findings.
The San Francisco Project Cohort Study is sponsored by ‘‘Fundación
Araucaria’’ (grants FA121999, FA052005, FA122006 and FA032008),
with headquarters in San Diego, CA. E.K. is partially supported by ME-
CESUP UCH-0219, a PhD fellowship, Faculty of Medicine, University
of Chile.
We are indebted to all the participants of the San Francisco Cohort
Study and the staff from this Health Centre.
Conflicts of interest: None.
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