Job Stress, Low Income Help Explain Link Between Less Education and Cardiovascular Risk

January 07, 2020

Healthy adults with a lower level of education have an increased risk of developing cardiovascular (CV) disease or diabetes, a relationship that is partly explained by reduced income and more job-related stress, suggests a study based on middle-aged adults across Denmark.

In a separate analysis restricted to people with incident CV disease or diabetes, "we found the same picture," Elisabeth Framke, MSc, PhD, told theheart.org | Medscape Cardiology. "When we accounted for income and job strain, the higher risk among those with low educational level became attenuated to some extent, but a part of the association between educational level and dying of cardiovascular disease still remained," said Framke, from the National Research Centre for the Working Environment, Copenhagen.

In men with existing CV disease or diabetes, for example, income and stress accounted for more than half the link between education and death from CV causes.

Framke is lead author on the analysis published December 17 in the European Heart Journal that looked at more than 1.6 million residents of Denmark, aged 30 to 59 years in 2000, followed in multiple national data bases for 14 years. They included about 42,000 people with cardiometabolic disease (CD) — that is coronary heart disease, cerebrovascular disease, or diabetes — at baseline.

They were categorized as having low, medium, or high levels of income, education level, and job strain. Job strain was defined by criteria from the Danish Work Environment Cohort Study (DWECS) that account for a person's level of control in a job and its psychological demands, the report notes.

Low education level was associated with an increased risk for incident CV disease, compared with high education level, for both men and women.

For men with a low education level, for example, the risk for CV disease was 62% higher than for those with a high education level in an analysis adjusted for age, migration status, family type, and use of health services. But it was only increased by 46% with further adjustment for income level and job strain.

The corresponding risk increase among women was 66%, attenuated to 53% after adjustment for income and job strain.

Influence of Income and Job Strain on Hazard Ratio (HR) for Incident CV Disease, Low vs High Education Level, in Men and Women
End Point Men Women
HR (95% CI)* 1.62 (1.58–1.66) 1.66 (1.61–1.72)
HR (95% CI)* further adjusted for income and job strain 1.46 (1.42–1.50) 1.53 (1.47–1.58)
*Adjusted for age, migration background, and use of health services

For both men and women, adjustment for income accounted for most of the attenuated risk increase.

The results were similar in a separate analysis of men and women with CVD at baseline for the end point of CV mortality.

Influence of Income and Job Strain on Hazard Ratio (HR)* for CV Mortality, Low vs High Education Level, in Men and Women With Cardiometabolic Disease
End Point Men Women
HR (95% CI) 1.52 (1.31–1.77) 2.18 (1.57–3.03)
HR (95% CI) further adjusted for income and job strain 1.24 (1.06–1.45) 1.79 (1.27–2.52)
*Adjusted for age, migration background, and use of health services

Regarding the study's public health message, Framke observed that "educational attainment is usually determined relatively early in the life, and it may be difficult to improve the level of education in middle-aged adults."

But if income and job strain are a big part of the link between low education level and CV risk, she said, "then improvement of disposable income and reduction of job strain may help to reduce the increased risk of cardiovascular morbidity and mortality among individuals with low educational attainment."

The authors report no conflicts.

Eur Heart J. Published online December 17, 2019.

Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

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