Skip to main content
Have a personal or library account? Click to login
Lifestyle and Cardiovascular Risk Factors by Educational Attainment in a Mediterranean Setting: A Cross-Sectional Analysis of a Population-Based Sample Cover

Lifestyle and Cardiovascular Risk Factors by Educational Attainment in a Mediterranean Setting: A Cross-Sectional Analysis of a Population-Based Sample

Open Access
|Jul 2026

References

  1. World Health Organization. WHO mortality database. Geneva: World Health Organization; 2024. https://www.who.int/data/data-collection-tools/who-mortality-database (January 2026, date last accessed).
  2. Flores-Mateo G, Grau M, O’Flaherty M, Ramos R, Elosua R, Violan-Fors C, Quesada M, Marti R, Sala J, Marrugat J, Capewell S. Analyzing the coronary heart disease mortality decline in a Mediterranean population: Spain 1988–2005. Revista Española de Cardiología. 2011;64:988996. DOI: 10.1016/j.recesp.2011.05.033
  3. World Health Organization. World health statistics 2017: monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization; 2017. https://www.who.int/publications/i/item/world-health-statistics-2017 (January 2026, date last accessed).
  4. Barroso M, Zomeño MD, Díaz JL, Pérez-Fernández S, Martí-Lluch R, Cordón F, Ramos R, Cabezas C, Salvador G, Castell C, Schröder H. Control of cardiovascular risk factors with tailored recommendations: A randomized controlled trial. Preventive Medicine. 2020;141:106302. DOI: 10.1016/j.ypmed.2020.106302
  5. Barroso M, Zomeño MD, Díaz JL, Pérez S, Martí-Lluch R, Cordón F, Ramos R, Cabezas C, Salvador G, Castell C, Schröder H. Efficacy of tailored recommendations to promote healthy lifestyles: a post hoc analysis of a randomized controlled trial. Translational Behavioral Medicine. 2021;11:15481557. DOI: 10.1093/tbm/ibab035
  6. Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, Gómez-Gracia E, Ruiz-Gutiérrez V, Fiol M, Lapetra J, Lamuela-Raventos RM. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. New England Journal of Medicine. 2018;378:e34. DOI: 10.1056/NEJMoa1800389
  7. Bach-Faig A, Fuentes-Bol C, Ramos D, Carrasco JL, Roman B, Bertomeu IF, Cristia E, Geleva D, Serra-Majem L. The Mediterranean diet in Spain: adherence trends during the past two decades using the Mediterranean Adequacy Index. Public Health Nutrition. 2011;14:622628. DOI: 10.1017/S1368980010002752
  8. Obeid C, Oenema A, Jaalouk D, Kremers SPJ, Gubbels JS. Determinants of adherence to the Mediterranean diet among adults in Mediterranean countries: a systematic literature review. Public Health Nutrition. 2025;28:e194. DOI: 10.1017/S1368980025101432
  9. Dégano IR, Marrugat J, Grau M, Salvador-González B, Ramos R, Zamora A, Martí R, Elosua R. The association between education and cardiovascular disease incidence is mediated by hypertension, diabetes, and body mass index. Scientific Reports. 2017;7:12370. DOI: 10.1038/s41598-017-10775-3
  10. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, Ricceri F, d’Errico A, Barros H, Bochud M, Chadeau-Hyam M. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: A multicohort study and meta-analysis of 1.7 million men and women. Lancet. 2017;389:12291237. DOI: 10.1016/S0140-6736(16)32380-7
  11. Mackenbach JP, Kulhánová I, Artnik B, Bopp M, Borrell C, Clemens T, Costa G, Dibben C, Kalediene R, Lundberg O, Martikainen P. Changes in mortality inequalities over two decades: register based study of European countries. British Medical Journal. 2016;353:i1732. DOI: 10.1136/bmj.i1732
  12. Bann D, Wright L, Hughes A, Chaturvedi N. Socioeconomic inequalities in cardiovascular disease: A causal perspective. Nature Reviews Cardiology. 2024;21:238249. DOI: 10.1038/s41569-023-00941-8
  13. Xia M, An J, Safford MM, Colantonio LD, Sims M, Reynolds K, et al. Cardiovascular risk associated with social determinants of health at individual and area levels. JAMA Netw Open. 2024;7:e248584. DOI: 10.1001/jamanetworkopen.2024.8584
  14. Kislaya I, Perelman J, Tolonen H, Nunes B. Do self-reported data accurately measure health inequalities in risk factors for cardiovascular disease? International Journal of Public Health. 2019;64:721729. DOI: 10.1007/s00038-019-01232-1
  15. Grau M, Elosua R, Cabrera de León A, Guembe MJ, Baena-Díez JM, Vega Alonso T, Felix FJ, Zorrilla B, Rigo F, Lapetra J, Gavrila D. Cardiovascular risk factors in Spain in the first decade of the 21st Century, a pooled analysis with individual data from 11 population-based studies: the DARIOS study. Revista Española de Cardiología. 2011; 64:295304. DOI: 10.1016/j.recesp.2010.11.005
  16. Gullón P, Díez J, Cainzos-Achirica M, Franco M, Bilal U. Social inequities in cardiovascular risk factors in women and men by autonomous regions in Spain. Gaceta Sanitaria. 2021;35:326332. DOI: 10.1016/j.gaceta.2020.04.014
  17. Barroso M, Pérez-Fernández S, Vila MM, Zomeño MD, Martí-Lluch R, Cordon F, Ramos R, Elosua R, Degano IR, Fito M, Cabezas C. Validity of a method for the self-screening of cardiovascular risk. Clinical Epidemiology. 2018;10:549560. DOI: 10.2147/CLEP.S158358
  18. Schröder H, Fitó M, Estruch R, Martínez-González MA, Corella D, Salas-Salvadó J, Lamuela-Raventós R, Ros E, Salaverría I, Fiol M, Lapetra J. A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. Journal of Nutrition. 2011;141:11401145. DOI: 10.3945/jn.110.135566
  19. Molina L, Sarmiento M, Peñafiel J, Donaire D, Garcia-Aymerich J, Gomez M, Ble M, Ruiz S, Frances A, Schröder H, Marrugat J. Validation of the Regicor short physical activity questionnaire for the adult population. PLoS One. 2017;12:e0168148. DOI: 10.1371/journal.pone.0168148
  20. Team RC. RA Language and environment for statistical computing. Vienna: Austria: R Foundation for Statistical Computing; 2025. https://www.R-project.org/
  21. Backholer K, Peters SAE, Bots SH, Peeters A, Huxley RR, Woodward M. Sex differences in the relationship between socioeconomic status and cardiovascular disease: a systematic review and meta-analysis. Journal of Epidemiology and Community Health. 2017;71:550557. DOI: 10.1136/jech-2016-207890
  22. Institute for Health Metrics and Evaluation (IHME). Social determinants of health and cardiovascular disease: state of the evidence. Seattle, WA: IHME; 2023.
  23. Lou SP, Han D, Kuczmarski MF, Evans MK, Zonderman AB, Crews DC. Health literacy, numeracy, and dietary approaches to stop hypertension accordance among hypertensive adults. Health Education & Behavior. 2023;50:4957. DOI: 10.1177/10901981221079742
  24. Zomeño MD, Álamo-Junquera D, Pericas C, Vilaplana-Carnerero C, Domínguez À, Toledo D, Soldevila N, Pagès-Fernández C, Redondo A, Tor-Roca A, Grau M. Cardiovascular disease prevention by personalized health promotion considering educational attainment. Scientific Reports. 2026;16:6604. DOI: 10.1038/s41598-026-36654-4
  25. Reig-García G, Martínez-Sancho J, Baltasar-Bagué A, Mateu-Figueras G, Buxó M, Martí-Lluch R, Zacarías-Pons L, Puig J, Ramos-Blanes R, Fernández-Real JM, Garre-Olmo J. Adherence to Mediterranean diet and physical activity practice in general population: an intersectional analysis of inequalities by sex and economic status. Frontiers in Public Health. 2025;13:1727223. DOI: 10.3389/fpubh.2025.1727223
  26. Zhang YB, Chen C, Pan XF, Guo J, Li Y, Franco OH, Liu G, Pan A. Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: two prospective cohort studies. British Medical Journal. 2021;373:n604. DOI: 10.1136/bmj.n604
  27. Stormacq C, Van den Broucke S, Wosinski J. Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review. Health Promotion International. 2019;34:e1e17. DOI: 10.1093/heapro/day062
  28. Beasant B, Anderson K, Lee G, Lotfaliany M, Tembo M, McCoombe S, Vaughan V, Pasco JA, Hosking SM. Health literacy and primary prevention of cardiovascular disease: A scoping review. Public Health Reports. 2025;140:342357. DOI: 10.1177/00333549251322649
  29. Metlock FE, Kwapong YA, Evans C, Ouyang P, Vaidya D, Kwapong YA, Hladek MD, Ouyang P, Hall JL, Sharma G, Commodore-Mensah Y. Cardiovascular health literacy among women of reproductive age in the SAFE HEART Study: An American Heart Association Research Goes Red Initiative. Health Literacy and Communication Open. 2025;3:2553042. DOI: 10.1080/28355245.2025.2553042
  30. Lindt N, van Berkel J, Mulder BC. Determinants of overburdening among informal carers: a systematic review. BMC Geriatrics. 2020;20:304. DOI: 10.1186/s12877-020-01708-3
  31. Ahn S, Son EH, Mogos MF, Muchira JM, Sheng Y, Park C, Lee LJ. Patterns of lifestyle risk behaviors for cardiovascular disease in family caregivers: a latent class analysis. Frontiers in Public Health. 2025;13:1593898. DOI: 10.3389/fpubh.2025.1593898
  32. Skinner MS, Sogstad M. Social and gender differences in informal caregiving for sick, disabled, or elderly persons: A cross-sectional study. SAGE Open Nursing. 2022;8:23779608221130585. DOI: 10.1177/23779608221130585
  33. Lawrence WR, Hong HG, Williams F, Dyer Z, Bergeron NQ, Brewer LC, Chen Y, Crittendon DR, Freedman ND, Haas CB, Jackson SS. Manifestations of structural racism and inequities in cardiovascular health across US neighborhoods. Journal of the American Medical Association. 2025;6:e253864. DOI: 10.1001/jamahealthforum.2025.3864
  34. OECD. Gender equality in a changing world: taking stock and moving forward. Paris: OECD Publishing; 2025. DOI: 10.1787/e808086f-en
  35. Vogel B, Acevedo M, Appelman Y, Bairey Merz CN, Chieffo A, Figtree GA, Guerrero M, Kunadian V, Lam CS, Maas AH, Mihailidou AS. The Lancet women and cardiovascular disease commission: Reducing the global burden by 2030. Lancet. 2021;397:23852438. DOI: 10.1016/S0140-6736(21)00684-X
  36. Bugiardini R, Rahaman T, Manfrini O, Maas A, Bergami M, Badimon L, Mendieta G, Vavlukis M, Merkely B, Vasiljevic Z, Gale CP. Diet and sex inequities in ischemic heart disease mortality across Europe: Findings from the global burden of disease study. Cardiovascular Research. 2025;121:24322446. DOI: 10.1093/cvr/cvaf176
DOI: https://doi.org/10.5334/gh.1574 | Journal eISSN: 2211-8179
Language: English
Submitted on: Mar 24, 2026
Accepted on: Jul 3, 2026
Published on: Jul 14, 2026
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services

© 2026 Dolores Álamo-Junquera, Carles Vilaplana-Carnerero, Constança Pagès-Fernández, Diana Toledo, Núria Soldevila, Alba Tor-Roca, Àngela Domínguez, María Grau, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.