Educational Attainment Inversely Associated With Lifetime Risk of CVD

How much education a person gets is the most important socioeconomic factor in determining their lifetime risk of CVD, highlighting the need for more initiatives that address gaps in learning, a new observational study suggests.

The findings should give clinicians a clear understanding of how education affects CVD outcomes and offer public health officials knowledge on how CVD develops in different populations, making it possible for them to raise awareness appropriately, say researchers.

“We know a lot about risk factors, and [we] know it’s important to control those,” study co-author Aaron Folsom, MD (University of Minnesota, Minneapolis, MN), told TCTMD. “But if those are partly the result of less awareness, less education about how to prevent cardiovascular disease, then you know this is important and you can imagine that we can do a better job of reducing education inequalities in the United States and [how] that might have an impact on cardiovascular disease.”

The new analysis, led by Yasuhiko Kubota, MD (University of Minnesota), was published June 12, 2017, in JAMA Internal Medicine.

Experts have known for quite some time that CVD inequalities are related to education, type of occupation, and salary. For example, the higher an individual’s education level, the more likely he or she is to be informed about healthy living and have a job that provides access to quality medical coverage.

Folsom says education should be considered clinically both to identify people who are maybe going to have complications of cardiovascular disease or are in need of special treatment. Physicians should take into account differences in education that may affect patients’ ability to follow treatment guidelines and prevent the development of CVD, said Folsom.

Nancy Adler, PhD (University of California, San Francisco, CA), who wrote an editorial accompanying the study, told TCTMD that a patient lacking much education raises several issues for physicians. For one, low education level should be a red flag for other health problems and comorbidities that could develop that may actually affect diagnosis or choice of treatment. The other aspect is health literacy more generally; healthcare providers need to be clear with patients about disease prognosis and trying to make sure they understand what their treatment regimen will be, she said.

Lower Education Status Means Higher CVD Risk

In the study, Kubota et al analyzed 13,948 people (ages 45 to 64), of whom 6,108 were men and 7,840 were women. The majority of participants were white or African-American. Participants were categorized into five groups based on education level: grade school (8.9%), high school without graduation (32.6%), vocational school (8.5%), college with or without graduation (26.1%), and graduate/professional school (10.4%). They were assessed from their age at the start of the study until the onset of coronary heart disease, heart failure, or stroke; their last follow-up contact; or December 31, 2013, whichever occurred first.

The data showed educational attainment to be inversely associated with CVD. For men, lifetime risks of CVD were 59.0% for grade school, 52.5% for high school without graduation, 50.9% for high school, 47.2% for vocational school, 46.4% for college with or without graduation, and 42.2% for graduate/professional school.

For women, the lifetime risks of CVD were 50.8% for grade school, 49.3% for high school education without graduation, 36.3% for high school graduation, 32.2% for vocational school, 32.8% for college with or without graduation, and 28.0% for graduate/professional school.

The association between education and CVD was evident for both African-American and white individuals, although this link was weaker for African-American men and women than for their white counterparts.

“Educational attainment was inversely associated with CVD even within categories of family income, income change, occupation, or parental educational level,” the researchers report.

Caveats to Consider

Kubota et al say the research has limitations, noting that “estimates of lifetime risks of CVD should be interpreted carefully because they may be to some degree confounded by other CVD risk factors.” Moreover, since educational attainment was evaluated only at baseline, it’s possible, albeit unlikely, that some study participants may have sought higher education later in life

“What we don’t know is whether it’s years of education or achieving milestones, like graduating from high school, graduating from college,” Alder said. “There is something called the sheepskin effect that suggests getting a diploma is health-promoting. It’s health-promoting in part because it certifies you for better jobs and then your whole life trajectory is better. That’s very different than thinking that each year of education [is] adding an increment to the benefits.”

Limitations aside, the researchers state, “Our findings emphasize the need for further efforts to reduce CVD inequalities related to educational disparities.”