The Relationship Between Socioeconomic Status and CV Risk Factors The CRONICAS Cohort Study of Peruvian Adults

Background: Variations in the distribution of cardiovascular disease and risk factors by socioeconomic status (SES) have been described in affluent societies, yet a better understanding of these patterns is needed for most lowand middle-income countries. Objective: This study sought to describe the relationship between cardiovascular risk factors and SES using monthly family income, educational attainment, and assets index, in 4 Peruvian sites. Methods: Baseline data from an ageand sex-stratified random sample of participants, ages 35 years, from 4 Peruvian sites (CRONICAS Cohort Study, 2010) were used. The SES indicators considered were monthly family income (n 1⁄4 3,220), educational attainment (n 1⁄4 3,598), and assets index (n 1⁄4 3,601). Behavioral risk factors included current tobacco use, alcohol drinking, physical activity, daily intake of fruits and vegetables, and no control of salt intake. Cardiometabolic risk factors included obesity, elevated waist circumference, hypertension, insulin resistance, diabetes mellitus, low high-density lipoprotein cholesterol, and high triglyceride levels. Results: In the overall population, 41.6% reported a monthly family income <US$198, and 45.6% had none or primary education. Important differences were noted between the socioeconomic indicators: for example, higher income and higher scores on an asset index were associated with greater risk of obesity, whereas higher levels of education were associated with lower risk of obesity. In contrast, higher SES according to all 3 indicators was associated with higher levels of triglycerides. Conclusions: The association between SES and cardiometabolic risk factors varies depending on the SES indicator used. These results highlight the need to contextualize risk factors by socioeconomic groups in Latin American settings. The negative effects of urbanization and unhealthy lifestyles along with population aging are particularly challenging for lowand middle-income countries (LMIC) [1e4]. Variations in the distribution of cardiovascular disease and risk factors by socioeconomic status (SES) have been described in high-income countries. However, a better understanding of these patterns is needed for most LMIC as the prevalence of risk factors for cardiovascular disease, such as obesity, hypertension, or diabetes mellitus, is increasing in Latin America [5e8]. Previous studies have found that the prevalence of dietary habits [9,10], cardiometabolic risk factors, and cardiovascular events [11e29] vary across sociodemographic groups and by the country’s Human Development Index. For example, in high-income countries, there is a negative association between obesity and higher income and educational attainment, whereas in low-income countries, there is a positive association between education and obesity [17,21]. In Peru, over one-third of the population lives in the large urban capital, Lima, but a substantial population still lives in rural areas where access to resources, including health care and education, are limited. These rural populations are often poorer and less educated than the urban areas with limited access to medical care and chronic disease treatment [30]. The impact of these sociodemographic factors, together with urbanization and geographical features, for example, populations residing at high altitudes, and the prevalence of cardiovascular disease are not well established [1,31e33]. Previous studies in Peru have reported associations between different SES indicators and cardiometabolic risk factors [32,34e36]; however, the L.D. Howe is supported by a Career Development Award from the UK Medical Research Council (MR/ M020894/1) and works in a unit that receives funding from the University of Bristol and the UK Medical Research Council (MC_UU_12013/5) L. Smeeth is a Wellcome Trust Senior Clinical Fellow (098504/Z/12/Z), and A. Bernabé-Ortiz is a Wellcome Trust Research Training Fellow in Public Health and Tropical Medicine (103994/Z/14/Z). W. Checkley was supported by a Pathway to Independence Award (R00HL096955) from the National Heart, Lung, and Blood Institute. J.J. Miranda is supported by Fogarty International Centre (R21TW009982), Grand Challenges Canada (0335-04), International Development Research Center Canada (106887001), Inter-American Institute for Global Change Research (IAI CRN3036), Medical Research Council UK (M007405), National Heart, Lung, and Blood Institute (U01HL114180), and National Institutes of Mental Health (U19MH098780). The other authors report no relationships that could be construed as a conflict of interest. This research was supported in whole with federal funds from the U.S. National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, under contract number HHSN268200900033C. R. Quispe and C.P. Benziger contributed equally to this work. From the *CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; yDivision of Cardiology, University of Washington, Seattle, WA, GLOBAL HEART, VOL. 11, NO. 1, 2016 121 March 2016: 121-130 ORIGINAL RESEARCH gSCIENCEj