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Differences in the association of cardiovascular risk factors with education: a comparison of Costa Rica (CRELES) and the United States (NHANES)
  1. David Rehkopf1,*,
  2. William Dow2,
  3. Luis Rosero Bixby3
  1. 1 University of California, San Francisco, United States;
  2. 2 University of California, Berkeley, United States;
  3. 3 Universidad de Costa Rica, Costa Rica
  1. Correspondence to: David Rehkopf, University of California, San Francisco, 185 Berry Street, Lobby 5, Suite 5700, San Francisco, 94107, United States; drehkopf{at}


Background: Despite different levels of economic development, Costa Rica and the United States have similar mortality rates among adults. However, in the United States there are substantial differences in mortality by educational attainment, and in Costa Rica there are only minor differences. This contrast motivates an examination of behavioral and biological correlates underlying this difference.

Methods: We used data on adults aged 60 and above from the Costa Rican Longevity and Healthy Aging Study (CRELES) (n=2827) and from the United States National Health and Nutrition Examination Survey (NHANES) (n=5607) to analyze the cross-sectional association between educational level and the following risk factors for cardiovascular disease (CVD): ever smoked, current smoker, sedentary, high saturated fat, high carbohydrates, high calorie diet, obesity, severe obesity, large waist circumference, HDL cholesterol, LDL cholesterol, triglycerides, hemoglobin A1c, fasting glucose, C-reactive protein, systolic blood pressure, and BMI.

Results: There were significantly less hazardous levels of risk biomarkers at higher levels of education for more than half (10 out of 17) of the risk factors in the United States, but for less than a third of the outcomes in Costa Rica (5 out of 17).

Conclusions: Our results are consistent with the context specific nature of educational differences in risk factors for CVD and with a non-uniform nature of association of CVD risk factors with education within countries. Our results also demonstrate that social equity in mortality is achieved without uniform equity in all risk factors.

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