The impact of the combination of income and education on the incidence of coronary heart disease in the prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study.

Marquita W Lewis,Yulia Khodneva,Virginia J Howard,Monika M Safford,Nicole Redmond,Raegan W Durant,Suzanne E Judd,Larrell L Wilkinson

doi:10.1186/s12889-015-2630-4

Abstract

BackgroundWe investigated the association between income-education groups and incident coronary heart disease (CHD) in a national prospective cohort study.MethodsThe REasons for Geographic And Racial Differences in Stroke study recruited 30,239 black and white community-dwelling adults between 2003 and 2007 and collected participant-reported and in-home physiologic variables at baseline, with expert adjudicated CHD endpoints during follow-up. Mutually exclusive income-education groups were: low income (annual household income <$35,000)/low education (< high school), low income/high education, high income/low education, and high income/high education. Cox models estimated hazard ratios (HR) for incident CHD for each exposure group, examining differences by age group.ResultsAt baseline, 24,461 participants free of CHD experienced 809 incident CHD events through December 31, 2011 (median follow-up 6.0 years; interquartile range 4.5–7.3 years). Those with low income/low education had the highest incidence of CHD (10.1 [95 % CI 8.4–12.1]/1000 person-years). After full adjustment, those with low income/low education had higher risk of incident CHD (HR 1.42 [95 % CI: 1.14–1.76]) than those with high income/high education, but findings varied by age. Among those aged <65 years, compared with those reporting high income/high education, risk of incident CHD was significantly higher for those reporting low income/low education and low income/high education (adjusted HR 2.07 [95 % CI 1.42–3.01] and 1.69 [95 % CI 1.30–2.20], respectively). Those aged ≥65 years, risk of incident CHD was similar across income-education groups after full adjustment.ConclusionFor younger individuals, low income, regardless of education, was associated with higher risk of CHD, but not observed for ≥65 years. Findings suggest that for younger participants, education attainment may not overcome the disadvantage conferred by low income in terms of CHD risk, whereas among those ≥65 years, the independent effects of income and education are less pronounced.

Highlights

We investigated the association between income-education groups and incident coronary heart disease (CHD) in a national prospective cohort study
Findings suggest that for younger participants, education attainment may not overcome the disadvantage conferred by low income in terms of CHD risk, whereas among those ≥65 years, the independent effects of income and education are less pronounced
The differences in incidence for either low or high income and education alone were not as pronounced as those observed when considering the combined effects of education and income. These results suggest the importance of examining income and education together, as those with low attainment in both categories were observed to have the highest risk. These effects varied by age, with low income and low education associated with the greatest CHD risk for participants

Summary

Introduction

We investigated the association between income-education groups and incident coronary heart disease (CHD) in a national prospective cohort study. Low income and low education have both been associated with higher CHD risk. Individuals who never completed high school are less likely to have health insurance. They are more likely to have lower levels of literacy, a decreased understanding of diseases and heart attack symptoms, and more physician recommendations [8, 18, 19]. Previous findings have suggested that individuals possessing multiple adverse social determinants such as low income and low education may be at increased risk for poor health outcomes [21, 22]

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