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Sex differences in the relationship between socioeconomic status and cardiovascular disease: a systematic review and meta-analysis
  1. Kathryn Backholer1,2,
  2. Sanne A E Peters3,
  3. Sophie H Bots3,
  4. Anna Peeters1,2,
  5. Rachel R Huxley4,
  6. Mark Woodward3,5
  1. 1School of Health and Social Development, Deakin University, Geelong, Victoria, Australia
  2. 2Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  3. 3The George Institute for Global Health, University of Oxford, Oxford, UK
  4. 4School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
  5. 5The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Kathryn Backholer, Deakin University, School of Health and Social Development, Obesity and Population Health, Locked Bag 20000, Geelong, VIC 3220, Australia; kathryn.backholer{at}


Background Low socioeconomic status (SES) is a known risk factor for cardiovascular disease (CVD) but whether its effects are comparable in women and men is unknown.

Methods PubMed MEDLINE was systematically searched. Studies that reported sex-specific estimates, and associated variability, of the relative risk (RR) for coronary heart disease (CHD), stroke or CVD according to a marker of SES (education, occupation, income or area of residence), for women and men were included. RRs were combined with those derived from cohort studies using individual participant data. Data were pooled using random effects meta-analyses with inverse variance weighting. Estimates of the ratio of the RRs (RRR), comparing women with men, were computed.

Results Data from 116 cohorts, over 22 million individuals, and over 1 million CVD events, suggest that lower SES is associated with increased risk of CHD, stroke and CVD in women and men. For CHD, there was a significantly greater excess risk associated with lower educational attainment in women compared with men; comparing lowest with highest levels, the age-adjusted RRR was 1.24 (95% CI 1.09 to 1.41) and the multiple-adjusted RRR was 1.34 (1.09 to 1.63). For stroke, the age-adjusted RRR was 0.93 (0.72 to 1.18), and the multiple-adjusted was RRR 0.79 (0.53 to 1.19). Corresponding results for CVD were 1.18 (1.03 to 1.36), 1.23 (1.03 to 1.48), respectively. Similar results were observed for other markers of SES for all three outcomes.

Conclusions Reduction of socioeconomic inequalities in CHD and CVD outcomes might require different approaches for men and women.

  • Epidemiology of cardiovascular disease

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  • KB and SAEP contributed equally.

  • Twitter Follow Kathryn Backholer at @KBackholer

  • Contributors KB, SAEP and MW designed the study and drafted the paper. KB, SAEP and SHB collated and analysed the data. AP and RRH contributed to interpretation of results and redrafting of the manuscript.

  • Funding KB is supported by a National Heart Foundation of Australia (NHF) Post-Doctoral Fellowship (PH 12M6824) and Collaboration and Exchange Award. MW was supported by an Australian National Health and Medical Research Council (NHMRC) Principal Research Fellowship. AP is supported by a NHMRC Career Development Award.

  • Competing interests None declared.

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