Association of lifelong occupation and educational level with subclinical atherosclerosis in different European regions. Results from the IMPROVE study


      • Socioeconomic status is a major determinant of intima-media thickness (IMT).
      • This social inequality of IMT is more marked in northern Europe than in Italy.
      • The effect of social class on IMT is not only due to difference in CV risk factors.


      Background and aims

      We aimed to examine the association between socioeconomic status (SES) and subclinical atherosclerosis, as assessed by carotid intima-media-thickness (C-IMT) and to investigate whether the effect of social inequality on C-IMT is mediated by cardiovascular (CV) risk factors and whether it is dissimilar in men and women, and in different European countries.


      We assessed the association of lifelong occupation and educational level with C-IMT in the IMPROVE study cohort including 3703 subjects (median age 64.4 years; 48% men) from Southern (Italy), Western (France and the Netherlands) and Northern Europe (Finland and Sweden). Three summary measures of C-IMT (IMTmean, IMTmax, IMTmean-max), obtained from four segments of both carotids, were considered.


      After adjusting for conventional CV risk factors, current employment status and diet, C-IMT was higher in manual workers than in white collars (+7.7%, +5.3%, +4.6% for IMTmax, IMTmean-max and IMTmean, respectively; all p<.0001). Similar results were obtained by stratification for educational level. The effect of occupation on C-IMT was comparable in men and women and in different age groups, and was only partially mediated by differences in CV risk factors. Of note, the association of C-IMT with occupation was significant in Western and Northern Europe but not in Italy, with a significant statistical interaction (p = .0005).


      Low SES was associated with subclinical atherosclerosis in subjects with at least three CV risk factors. Such association was stronger in Northern and Western Europe than in Italy. This difference was not completely explained by inequalities in CV risk factors and behavioural variables.



      C-IMT (carotid Intima-media-thickness), CV (cardiovascular), CVD (cardiovascular disease), SES (socioeconomic status), IMTmean (mean of all local mean measures), IMTmax (maximum of all local maximal measures), IMTmean-max (mean of all local maximal measures), hs-CRP (high sensitive C reactive protein), BMI (body mass index), RRs (risk ratios), MI (myocardial infarction)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Atherosclerosis
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Schwalm J.D.
        • McKee M.
        • Huffman M.D.
        • et al.
        Resource effective strategies to prevent and treat cardiovascular disease.
        Circulation. 2016; 133: 742-755
        • Kaplan G.A.
        • Keil J.E.
        Socioeconomic factors and cardiovascular disease: a review of the literature.
        Circulation. 1993; 88: 1973-1998
        • Gallo V.
        • Mackenbach J.P.
        • Ezzati M.
        • et al.
        Social inequalities and mortality in Europe–results from a large multi-national cohort.
        PLoS One. 2012; 7e39013
        • Diez-Roux A.V.
        • Nieto F.J.
        • Tyroler H.A.
        • et al.
        Social inequalities and atherosclerosis. The atherosclerosis risk in communities study.
        Am. J. Epidemiol. 1995; 141: 960-972
        • Lynch J.
        • Kaplan G.A.
        • Salonen R.
        • et al.
        Socioeconomic status and carotid atherosclerosis.
        Circulation. 1995; 92: 1786-1792
        • Camelo L.V.
        • Giatti L.
        • Chor D.
        • et al.
        Associations of life course socioeconomic position and job stress with carotid intima-media thickness. The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).
        Soc. Sci. Med. 2015; 141: 91-99
        • Carson A.P.
        • Rose K.M.
        • Catellier D.J.
        • et al.
        Cumulative socioeconomic status across the life course and subclinical atherosclerosis.
        Ann. Epidemiol. 2007; 17: 296-303
        • Fujishiro K.
        • Diez Roux A.V.
        • Landsbergis P.
        • et al.
        Associations of occupation, job control and job demands with intima-media thickness: the Multi-Ethnic Study of Atherosclerosis (MESA).
        Occup. Environ. Med. 2010; 68: 319-326
        • Grimaud O.
        • Lapostolle A.
        • Berr C.
        • et al.
        Gender differences in the association between socioeconomic status and subclinical atherosclerosis.
        PLoS One. 2013; 8e80195
        • Lamotte C.
        • Iliescu C.
        • Beghin L.
        • et al.
        Association of socioeconomic status, truncal fat and sICAM-1 with carotid intima-media thickness in adolescents: the HELENA study.
        Atherosclerosis. 2013; 228: 460-465
        • Lemelin E.T.
        • Diez Roux A.V.
        • Franklin T.G.
        • et al.
        Life-course socioeconomic positions and subclinical atherosclerosis in the multi-ethnic study of atherosclerosis.
        Soc. Sci. Med. 2009; 68: 444-451
        • Lutsey P.L.
        • Diez Roux A.V.
        • Jacobs Jr., D.R.
        • et al.
        Associations of acculturation and socioeconomic status with subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis.
        Am. J. Publ. Health. 2008; 98: 1963-1970
      1. SD. Nash, KJ. Cruickshanks, R. Klein, et al, Socioeconomic status and subclinical atherosclerosis in older adults, Prev. Med. 52 208–212.

        • Ranjit N.
        • Diez-Roux A.V.
        • Chambless L.
        • et al.
        Socioeconomic differences in progression of carotid intima-media thickness in the Atherosclerosis Risk in Communities study.
        Arterioscler. Thromb. Vasc. Biol. 2006; 26: 411-416
        • Rosvall M.
        • Ostergren P.O.
        • Hedblad B.
        • et al.
        Occupational status, educational level, and the prevalence of carotid atherosclerosis in a general population sample of middle-aged Swedish men and women: results from the malmo diet and cancer Study.
        Am. J. Epidemiol. 2000; 152: 334-346
        • Rosvall M.
        • Ostergren P.O.
        • Hedblad B.
        • et al.
        Life-course perspective on socioeconomic differences in carotid atherosclerosis.
        Arterioscler. Thromb. Vasc. Biol. 2002; 22: 1704-1711
        • Thurston R.C.
        • El Khoudary S.R.
        • Derby C.A.
        • et al.
        Low socioeconomic status over 12 years and subclinical cardiovascular disease: the study of women's health across the nation.
        Stroke; J. cerebr. circ. 2014; 45: 954-960
        • Amato M.
        • Montorsi P.
        • Ravani A.
        • et al.
        Carotid intima-media thickness by B-mode ultrasound as surrogate of coronary atherosclerosis: correlation with quantitative coronary angiography and coronary intravascular ultrasound findings.
        Eur. Heart J. 2007; 28: 2094-2101
      2. D. Baldassarre, K. Nyyssonen, R. Rauramaa, et al, Cross-sectional analysis of baseline data to identify the major determinants of carotid intima-media thickness in a European population: the IMPROVE study, Eur. Heart J. 31 614–622.

        • O'Leary D.H.
        • Polak J.F.
        • Kronmal R.A.
        • et al.
        Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. Cardiovascular Health Study Collaborative Research Group.
        N. Engl. J. Med. 1999; 340: 14-22
        • Baldassarre D.
        • Hamsten A.
        • Veglia F.
        • et al.
        Measurements of carotid intima-media thickness and of interadventitia common carotid diameter improve prediction of cardiovascular events: results of the IMPROVE (Carotid Intima Media Thickness [IMT] and IMT-Progression as Predictors of Vascular Events in a High Risk European Population) study.
        J. Am. Coll. Cardiol. 2012; 60: 1489-1499
        • Mackenbach J.P.
        • Stirbu I.
        • Roskam A.J.
        • et al.
        Socioeconomic inequalities in health in 22 European countries.
        N. Engl. J. Med. 2008; 358: 2468-2481
        • Karvanen J.
        • Veronesi G.
        • Kuulasmaa K.
        Defining thirds of schooling years in population studies.
        Eur. J. Epidemiol. 2007; 22: 487-492
        • Kershaw K.N.
        • Droomers M.
        • Robinson W.R.
        • et al.
        Quantifying the contributions of behavioral and biological risk factors to socioeconomic disparities in coronary heart disease incidence: the MORGEN study.
        Eur. J. Epidemiol. 2013; 28: 807-814
        • Veronesi G.
        • Ferrario M.M.
        • Kuulasmaa K.
        • et al.
        Educational class inequalities in the incidence of coronary heart disease in Europe.
        Heart. 2016; 102: 958-965
        • Andersen I.
        • Gamborg M.
        • Osler M.
        • et al.
        Income as mediator of the effect of occupation on the risk of myocardial infarction: does the income measurement matter?.
        J. Epidemiol. Community Health. 2005; 59: 1080-1085
        • Geyer S.
        • Hemstrom O.
        • Peter R.
        • et al.
        Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice.
        J. Epidemiol. Community Health. 2006; 60: 804-810
        • Brezinka V.
        • Kittel F.
        Psychosocial factors of coronary heart disease in women: a review.
        Soc. Sci. Med. 1996; 42: 1351-1365
        • Mackenbach J.P.
        • Cavelaars A.E.
        • Kunst A.E.
        • et al.
        Socioeconomic inequalities in cardiovascular disease mortality; an international study.
        Eur. Heart J. 2000; 21: 1141-1151
        • Prattala R.
        • Hakala S.
        • Roskam A.J.
        • et al.
        Association between educational level and vegetable use in nine European countries.
        Publ. Health Nutr. 2009; 12: 2174-2182
        • Lorenz M.W.
        • Markus H.S.
        • Bots M.L.
        • et al.
        Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis.
        Circulation. 2007; 115: 459-467