Cardiovascular Disease and Socioeconomic Status: It Is Mainly Education That Counts and Not Wealth !

Dimitris Tousoulis; Evangelos Oikonomou; Georgia Vogiatzi; Panos Vardas


Eur Heart J. 2020;41(34):3213-3214. 

Over time, cardiovascular diseases in general and coronary artery disease in particular have been linked to genetic, dietary, and behavioural factors,[1] which have been investigated by a large number of studies. Socioeconomic status (SES), as a composite measurement of an individual's economic and sociological standing, assessed as a combination of educational attainment, income, occupation, and overall wealth, has long been recognized as a key component that is linked in multiple ways to the development of cardiovascular diseases.[2]

More specifically, the economic situation of each country, healthcare expenditure per capita, information and prevention policies and of course, citizens' access to modern diagnostic and therapeutic modalities are some of the key factors that determine the prevalence of cardiovascular disease, as well as its morbidity and mortality.[3]

The statistics, as presented in recent reports by the World Health Organization, are revealing. Over three-quarters of cardiovascular deaths occur in low- and middle-income countries, while 80% of cases of cardiovascular disease today are in countries with medium or low gross national product (GNP) per capita.[3,4]

Contrast this with the systematic citizen information campaign that was introduced in recent years in Europe. This campaign, which targets mainly the countries of the European Union and aims at improvement of health and dietary behaviour and the avoidance of smoking, is clearly bearing fruit, as in a significant number of countries coronary artery disease is showing a clear decline.[5,6]

Focusing more closely on the importance of SES for the management or even the reduction of cardiovascular disease in high-, middle-, and low-income countries, the following points should be noted (Figure 1).

Figure 1.

From Socioeconomic status to cardiovascular risk. There is a complex interplay between established risk factors, socioeconomic status and intermediate steps leading to increased cardiovascular disease prevalence in individuals of low socioeconomic status. Blue arrows: Direct connection/association; Red arrows: Intermediate steps.

  1. Citizens of high-income countries, i.e. those with a high GNP, are affected by a combination of factors, which include their financial situation, their education, their professional occupation and any inherent problems associated with it, as well as a number of environmental issues.[5–7]

  2. In particular, it is necessary to point out that mainly education, but also wider health literacy, has a decisive influence on citizens who belong to the lower strata of countries that are characterized as high GNP. It is precisely this portion of the population who experience the worst professional stress and are most prone and vulnerable to dietary and behavioural aberrations (e.g. smoking), often as a reaction to a stressful daily routine.

It is clear that in such cases, proper education and, to an even greater extent, proper health literacy, could contribute to limiting the potential risks.[8,9]

Of course, it should be stressed that, as a rule, no one single socioeconomic factor is sufficient to alter the outcomes of a population and individuals, since there is usually an interaction between a number of such factors.[5,10]

When analysing the significance of SES for citizens of countries and societies with low or medium GNP, it is important to note the following: (i) often the risk factors for cardiovascular diseases for these populations are fewer than for high-income populations; and (ii) it is extremely important for people with low incomes to enjoy basic healthcare, to have proper secondary care after a cardiac event, and to show compliance with long-term treatment.[3]

From socioeconomic status to cardiovascular risk. There is a complex interplay between established risk factors, socioeconomic status, and intermediate steps leading to increased cardiovascular disease prevalence in individuals of low socioeconomic status. Blue arrows, direct connection/association; red arrows, intermediate steps

For these populations, a number of important studies have highlighted education as the most important socioeconomic factor in reducing cardiovascular disease.[3,11,12] This finding is reasonable, since low-income populations are not primarily concerned with taming their tendency to overconsume, but they do need to be well educated to take care of their health and choose behaviours in the face of everyday difficulties that will help them avoid cardiovascular diseases.

Summarizing the above, we can argue that education, and not wealth, is the primary factor that modifies and improves behaviours and dietary habits, especially for those individuals who experience occupational stress, financial difficulties, and limited access to modern diagnostic and therapeutic methods of cardiovascular care.