Sex Differences in the Relationship of Socioeconomic Position With Cardiovascular Disease, Cardiovascular Risk Factors, and Estimated Cardiovascular Disease Risk: Results of the German National Cohort

Abstract

Background: Using data from the largest German cohort study, we aimed to investigate sex differences in the relationship of socioeconomic position (SEP) with cardiovascular disease (CVD), CVD risk factors, and estimated CVD risk.

Methods and results: A total of 204 780 (50.5% women) participants from the baseline examination of the population-based NAKO (German National Cohort) were included. Logistic, multinomial, and linear regression models were used to estimate sex-specific odds ratios (ORs) and β coefficients with 95% CIs of CVD, CVD risk factors, and very high-risk score (Systemic Coronary Risk Estimation-2) for CVD associated with SEP. Women-to-men ratios of ORs (RORs) with 95% CIs were estimated. In women compared with men, low versus high SEP (educational attainment and relative income) was more strongly associated with myocardial infarction, hypertension, obesity, overweight, elevated blood pressure, antihypertensive medication, and current alcohol consumption, but less strongly with current and former smoking. In women with the lowest versus highest educational level, the OR for a very high 10-year CVD risk was 3.61 (95% CI, 2.88-4.53) compared with 1.72 (95% CI, 1.51-1.96) in men. The women-to-men ROR was 2.33 (95% CI, 1.78-3.05). For the comparison of low versus high relative income, the odds of having a very high 10-year CVD risk was 2.55 (95% CI, 2.04-3.18) in women and 2.25 (95% CI, 2.08-2.42) in men (women-to-men ROR, 1.31 [95% CI, 1.05-1.63]).

Conclusions: In women and men, there was an inverse relationship between indicators of SEP and the likelihood of having several CVD risk factors and a very high 10-year CVD risk. This association was stronger in women, suggesting that CVD risk is more strongly influenced by SEP in women compared with men.

Keywords: cardiovascular disease; cardiovascular risk; educational attainment; income; socioeconomic position.

Figure 1. Associations between educational attainment and CVD or CVD risk factors in the NAKO study baseline assessment in women and men (n=200 279, 50.5% women, 49.5% men).

Presented are age‐adjusted ORs with 95% CIs for low and middle education (reference is high education) from logistic or multinomial regression models. Analysis is based on the entire population at baseline. Reference categories in the multinomial logistic regression models are for BMI categories (normal weight), smoking status (never), and alcohol consumption (never). 95% CI for low vs high education in risky alcohol consumption is not visible due to sample size. BMI indicates body mass index; CVD, cardiovascular disease; NAKO, German National Cohort; and OR, odds ratio.

Figure 2. Women‐to‐men ratio of ORs with 95% CIs for CVD or CVD risk factors in the NAKO‐baseline assessment according to educational attainment and relative income.

A, Educational attainment (reference is high education). B, Relative income (reference is relative income >150%). Analysis is based on the entire population at baseline. Reference categories in the multinomial logistic regression models are BMI categories (normal weight), smoking status (never), and alcohol consumption (never). Study participants are low education (n=3993 women, n=2462 men), middle education (n=46 777 women, n=37 470 men), and high education (n=50 302 women, n=59 275 men). Study participants are household income <60% (n=15 087 women, n=12 999 men), 60% to 79% (n=16 315 women, n=12 687 men), 80% to 99% (n=15 686 women, n=13 267 men), 100% to 149% (n=31 375 women, n=31 321 men), and >150% (n=22 609 women, n=28 934 men). Numbers correspond to the average estimates across all of the imputations. BP indicates blood pressure; CVD, cardiovascular disease; MI, myocardial infarction; NAKO, German National Cohort; and OR, odds ratio.

Figure 3. Sex‐specific OR with 95% CIs for a very high 10‐year risk of CVD in the NAKO‐baseline assessment according to educational attainment and relative income.

A, Educational attainment. B, Relative income. Analysis is based on the population 40 to 69 years of age. Groups 40 to 49 and 50 to 59 years of age were merged. CVD indicates cardiovascular disease; NAKO, German National Cohort; and OR, odds ratio.

Figure 4. Women‐to‐men ratio of ORs with 95% CIs for very high 10‐year risk of CVD in the NAKO‐baseline assessment according to educational attainment and relative income.

A, Educational attainment. B, Relative income. Analysis is based on the population 40 to 69 years of age. CVD indicates cardiovascular disease; NAKO, German National Cohort; OR, odds ratio; and ROR, ratio of ORs.