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Differences in the association of cardiovascular risk factors with education: a comparison of Costa Rica (CRELES) and the USA (NHANES)
  1. David H Rehkopf1,
  2. William H Dow2,
  3. Luis Rosero-Bixby3
  1. 1Univesity of California, San Francisco, Department of Epidemiology & Biostatistics, San Francisco, USA
  2. 2University of California, Berkeley, Department of Health Policy and Management, Berkeley, USA
  3. 3Universidad de Costa Rica, Centro Centroamericano de Poblacion, San Jose, Costa Rica
  1. Correspondence to Dr David H Rehkopf, Department of Epidemiology & Biostatistics, University of California, San Francisco 185 Berry Street, Lobby 3, Suite 6600, San Francisco, CA 94107, USA; drehkopf{at}


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

Methods The authors used data on adults aged 60 and above from the Costa Rican Longevity and Healthy Ageing Study (CRELES) (n=2827) and from the US National Health and Nutrition Examination Survey (NHANES) (n=5607) to analyse 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 fewer hazardous levels of risk biomarkers at higher levels of education for more than half (10 out of 17) of the risk factors in the USA, but for less than a third of the outcomes in Costa Rica (five out of 17).

Conclusions These 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.

  • Heart disease
  • international collaboration
  • social differences
  • social inequalities

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  • Funding The CRELES project (Costa Rican Longevity and Healthy Ageing Study) is a longitudinal study of the Universidad de Costa Rica, carried out by the Centro Centroamericano de Población in collaboration with the Instituto de Investigaciones en Salud, with the support of the Wellcome Trust Foundation (grant no 072406).

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the Universidad de Costa Rica and University of California, Berkeley.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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