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Lack of education important risk factor for cardiovascular disease globally


The risk of developing myocardial infarction or stroke among people with little or no education was more than twice that of people with high education, according to a large international study published in The Lancet Global Health. The association was more marked in poorer countries.

The Prospective Urban Rural Epidemiologic (PURE) study investigated adults from 20 countries and found that low education was associated with increased risk of cardiovascular events (myocardial infarction, stroke or heart failure). The association was observed in countries at all economic levels, but it was more marked in poorer countries.

The study examined data on education, wealth, risk factors, and medications in 154,169 adults aged 35 to 50 years from five low-income, 11 middle-income, and four high-income countries between 2003 and 2018. These individuals were followed for events until September, 2017.

Among the people in the study, 6,936 had a cardiovascular event during the average, 7.5 years they were followed. In high-income countries (mainly Canada and Sweden) there was only a 26% increased risk of CVD events in those with low compared to those with high education, after the levels of risk factors and wealth were taken into account. By contrast, this was 59% higher in in middle income countries and 123% higher in low income countries.

Modifiable risk factor

Use of any medication used to treat cardiovascular disease was very low among people with little or no education in low income countries hospitalized with either myocardial infarction or stroke, Only 9% used any cardiovascular medication, compared to 32% among those with high education, whereas all education groups in high-income countries used medications to a much higher extent (75% to 84%, with the highest use among those with low education).

“We do not really understand what causes the high rates among the people with low education in low-income countries, other than lack of knowledge and markedly substandard health care. If we want to reduce health inequalities globally, barriers to care in those with lower education must be overcome, and low education should be considered as a modifiable risk factor” said Annika Rosengren, M.D., Ph.D. professor of medicine at Sahlgrenska Academy, University of Gothenburg, and cardiologist at Sahlgrenska University Hospital in Gothenburg, Sweden and lead author of the report.

No similar study

“The impact of low education on health has been long recognized and so efforts at improving education may be a sustainable approach to improving health in countries at all levels of economic development” said Salim Yusuf of the Population Health Research Institute, at McMaster University and Hamilton Health Sciences , in Canada, and the lead investigator of the PURE study. The PURE study includes 200,000 people from 26 countries and has currently followed them for about a decade.

Thus far, there has been no similar study in the world that has investigated so many people across many countries using the same methods. It took a study as large and long-term as this one to have enough statistical power to examine these associations.

Title: Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study

Contact: Annika Rosengren