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Roles of allostatic load, lifestyle and clinical risk factors in mediating the association between education and coronary heart disease risk in Europe
  1. Blánaid Hicks1,
  2. Giovanni Veronesi2,
  3. Marco M Ferrario2,
  4. Hannah Forrest2,
  5. Margaret Whitehead3,
  6. Finn Diderichsen4,
  7. Hugh Tunstall-Pedoe5,
  8. Kari Kuulasmaa6,
  9. Susana Sans7,
  10. Veikko Salomaa6,
  11. Barbara Thorand8,
  12. Annette Peters8,9,
  13. Stefan Soderberg10,
  14. Giancarlo Cesana11,
  15. Martin Bobak12,
  16. Licia Iacoviello2,
  17. Luigi Palmieri13,
  18. Tanja Zeller14,
  19. Stefan Blankenberg14,
  20. Frank Kee1
  21. On behalf of the MORGAM/BiomarCaRE consortium
  1. 1Centre for Public Health, Queen’s University Belfast, Belfast, UK
  2. 2Research Center in Epidemiology and Preventive Medicine, Department of Medicine and Surgery, University of Insubria, Varese, Italy
  3. 3Department of Public Health and Policy, Institute of Population Health and Sciences, University of Liverpool, Liverpool, UK
  4. 4Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
  5. 5Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research, University of Dundee, Dundee, UK
  6. 6Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
  7. 7Catalan Department of Health, Barcelona, Spain
  8. 8Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
  9. 9German Centre for Cardiovascular Research (DZHK), Partner site Munich Heart Alliance, Munich, Germany
  10. 10Department of Public Health and Clinical Medicine, Umea Universitet, Umea, Sweden
  11. 11Research Centre on Public Health, Department of Medicine and Surgery, University of Milan–Bicocca, Monza, Italy
  12. 12Department of Epidemiology and Public Health, University College London, London, UK
  13. 13Department of Cardiovascular, Endocrine-Metabolic Diseases, and Ageing, National Institute of Health, Roma, Lazio, Italy
  14. 14Department of Cardiology, University Heart and Vascular Centre, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
  1. Correspondence to Dr Blánaid Hicks, Centre for Public Health, Queen's University Belfast, Belfast, Belfast, UK; B.Hicks{at}


Background Previous studies have shown that differential exposure to lifestyle factors may mediate the association between education and coronary heart diseases (CHD). However, few studies have examined the potential roles of allostatic load (AL) or differential susceptibility.

Methods 25 310 men and 26 018 women aged 35–74 and CHD free at baseline were identified from 21 European cohorts and followed for a median of 10 years, to investigate the mediating role of AL, as well as of smoking, alcohol use and body mass index (BMI), on educational differences in CHD incidence, applying marginal structural models and three-way decomposition.

Results AL is a mediator of the association between educational status and CHD incidence, with the highest proportion mediated observed among women and largely attributable to differential exposure, (28% (95% CI 19% to 44%)), with 8% (95% CI 0% to 16%) attributable to differential susceptibility. The mediating effects of smoking, alcohol and BMI, compared with AL, were relatively small for both men and women.

Conclusion Overall, the educational inequalities in CHD incidence were partially mediated through differential exposure to AL. By contrast, the mediation of the educational gradient in CHD by investigated lifestyle risk factors was limited. As differential susceptibility in men was found to have a predominant role in the accumulation of AL in low educational classes, the investigation of AL-related risk factors is warranted.

  • cardiovascular diseases
  • education
  • health inequalities

Data availability statement

No additional data are available from each of the cohorts. Data may be made available to researchers upon reasonable request.

Statistics from

Data availability statement

No additional data are available from each of the cohorts. Data may be made available to researchers upon reasonable request.

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  • Contributors Authors’ contributions: GV, FK, MMF and BH conceived the research question. BH, FK, GV drafted the manuscript along with MMF and HF. GV conducted the statistical analyses. KK, TZ and SB are guarantor of the MORGAM/BiomarCaRE database. HT-P, SSa, VS, BT, FK, MMF, BT, SSo, GC, LI, LP are the principal investigators of the cohorts included in the current analyses. MW, FD, KK, HT-P, SSa, VS, BT, AP, TB, AP, SSo, GC, LI, LP, MB, TZ and SB actively contributed to the interpretation of the results and made critical revision of the manuscript.

  • Funding The BiomarCaRE Project is funded by the EU Seventh Framework Programme (FP7/2007– 2013) under grant agreement HEALTH-F2–2011–278913. The activities of the MORGAM Data Centre have also been sustained by recent funding from EU FP7 project CHANCES (HEALTH-F3–2010–242244). A part of the biomarker determinations in the population cohorts was funded by the Medical Research Council London (G0601463, identification No.80983: Biomarkers in the MORGAM Populations). The MONICA/KORA Augsburg study was initiated and financed by the Helmholtz Zentrum München—German Research Center for Environmental Health, which is funded by the German Federal Ministry of Education and Research (BMBF) and by the State of Bavaria.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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