Fornari et al. BMC Public Health 2010, 10:574 http://www.biomedcentral.com/1471-2458/10/574 proxy of socioeconomic status [42]. In the Centre and the South of Italy different cardiovascular event risk by educational level was not revealed, but, as mentioned before, in those areas the level of education of the gen- eral population was reportedly lower (70% of the men resulted in the low educational level), contributing to the homogenisation of the risk. The incidence differ- ences by education in the North did not produce differ- ences in the rates of cardiovascular incidence and case fatality between the North and the South. This may indicate that while, the influence of education is small, the positive influences may be expected by improving such a variable. Results confirm the presence of gender differences in the relationship between marital status and cardiovascular risk factors: being married or cohabitating was associated with greater protection in men compared to women [33,43]. As regards the association with cardiovascular events and case-fatality, a threefold higher case-fatality of events was found in men living alone, but not in women. In the Medi- terranean culture, the percentage of married or cohabitat- ing men is higher than the percentage in women, and, due to the elevated consideration of family ties, remaining sin- gle and living alone (8% of men and 6% of women) is usually not a choice, but probably indicates isolation and the lack of social support. This is particularly true for aging men, more affected by cardiovascular disease occur- rence, and less capable of being independent and coping with the stress of life and disease. However, loneliness did not appear to negatively affect women’s cardiovascular health and actually, with the exception of smoking, the CVD risk factors resulted lower. Our Mediterranean women seem to better tolerate loneliness, mostly due to widowhood, which results in living alone but does not abolish family ties with children and relatives. These find- ings in women seem peculiar of our population as they are not reported in studies of Northern populations [44]. It must be noted that the same observation had also been recently reported in a Dutch study, the authors of which attributed their findings to less decisive effects of family bonds in women [45]. If this is a gender issue, culturally or biologically determined, it deserves further exploration. Study limitations include the lack of information in rela- tion to income and occupation that would have been help- ful in improving the definition of socioeconomic status. Even though the use of education is simple and character- ized by a low non-response rate, it may introduce some degree of bias due to large birth cohort differences in the level of education. In addition, while education is stable over time in an adulthood population, marital status is not. Finally, cardiovascular risk factors were assessed at one point in time. The major strengths of this study are the inclusion of several cohorts, representative of different socio-cultural Page 7 of 9 contexts in Italy, and the large number of observed events during an average follow-up of 11 years. More- over, most of the risk factors were not self-reported but directly measured by standardised protocols. Conclusions The analysis here reported evidences that there are simi- larities, but also important differences, between Northern and Southern Europe in the effects of social factors on cardiovascular risk, event occurrence and mortality. Higher education in Italy has the same protective influ- ences observed in Northern Europe as regards cardiovas- cular risk factors, while it may be less important for the prevention of disease. It is worth noting the exception of northern Italian men, whose social context is more simi- lar to the northern European one. Family is still a stable institution in Italy and it appears to determine a signifi- cant protective effect on men’s cardiovascular risk score and a dramatic one on case fatality. In women the effect of cohabitation appears opposed and less pronounced and not at all statistically significant. The lack of cohabi- tation may not exclude social support and its protective effects. If women, and Mediterranean women in particu- lar, better tolerate loneliness, at least from the point of view of cardiovascular health, is an interesting gender issue which deserves further exploration. Acknowledgements The CUORE Project is funded by grants from the Italian Ministry of Health, supported by the Italian National Centre for Prevention and Disease Control (CCM), coordinated by the Istituto Superiore di Sanità, Rome, Italy. The Progetto CUORE Research Group - Longitudinal studies. Giampaoli S, Palmieri L, Dima F, Lo Noce C, Donfrancesco C, Caiola De Sanctis P, Ciccarelli P, Vannucchi S, Istituto Superiore di Sanità, Centro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Rome, Italy. Cesana G, Sega R, Sarman S, Fornari C, Corrao G, Bolognesi L, Centro Studi di Sanità Pubblica, Università degli Studi Milano-Bicocca, Monza, Italy. Ferrario MM, Dipartimento di Scienze Cliniche e Biologiche, Università degli Studi dell’Insubria, Varese, Italy. Vanuzzo D, Pilotto L, Mirolo R, Zanier L, Mattiussi F, Picco G, Martini M, Zanin E, Centro di Prevenzione Cardiovascolare, ASS 4 “Medio Friuli” e Agenzia Regionale della Sanità del Friuli-Venezia Giulia, Udine, Italy. Panico S, Celentano E, Mattiello A, Galasso R, Del Pezzo M, Santucci de Magistris M, Chiodini P, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi Federico II, Naples, Italy. Author details 1Research Centre on Public Health, Department of Clinical and Preventive Medicine, University of Milano-Bicocca, Monza, Italy. 2Laboratory of Epidemiology and Biostatistics, National Institute of Public Health, Rome, Italy. 3Department of Clinical and Experimental Medicine, University Federico II of Naples, Naples, Italy. 4Centro per la Prevenzione Cardiovascolare, Azienda Socio-Sanitaria 4 Medio Friuli and Agenzia Regionale della Sanità, Udine, Italy. 5Department of Clinical and Biological Science, University of Insubria, Varese, Italy. Authors’ contributions CF was involved in the statistical analysis of data, made substantial contribution to the interpretation of data and in drafting the manuscript. CD made substantial contribution to statistical analysis and interpretation of