European Journal of Epidemiology

, Volume 28, Issue 10, pp 807–814 | Cite as

Quantifying the contributions of behavioral and biological risk factors to socioeconomic disparities in coronary heart disease incidence: the MORGEN study

  • Kiarri N. KershawEmail author
  • Mariël Droomers
  • Whitney R. Robinson
  • Mercedes R. Carnethon
  • Martha L. Daviglus
  • W. M. Monique Verschuren


Quantifying the impact of different modifiable behavioral and biological risk factors on socioeconomic disparities in coronary heart disease (CHD) may help inform targeted, population-specific strategies to reduce the unequal distribution of the disease. Previous studies have used analytic approaches that limit our ability to disentangle the relative contributions of these risk factors to CHD disparities. The goal of this study was to assess mediation of the effect of low education on incident CHD by multiple risk factors simultaneously. Analyses are based on 15,067 participants of the Dutch Monitoring Project on Risk Factors for Chronic Diseases aged 20–65 years examined 1994–1997 and followed for events until January 1, 2008. Path analysis was used to quantify and test mediation of the low education-CHD association by behavioral (current cigarette smoking, heavy alcohol use, poor diet, and physical inactivity) and biological (obesity, hypertension, diabetes, and hypercholesterolemia) risk factors. Behavioral and biological risk factors accounted for 56.6 % (95 % CI 42.6–70.8 %) of the low education-incident CHD association. Smoking was the strongest mediator, accounting for 27.3 % (95 % CI 17.7–37.4 %) of the association, followed by obesity (10.2 %; 95 % CI 4.5–16.1 %), physical inactivity (6.3 %; 95 % CI 2.7–10.0 %), and hypertension (5.3 %; 95 % CI: 2.8–8.0 %). In summary, in a Dutch cohort, the majority of the relationship between low education and incident CHD was mediated by traditional behavioral and biological risk factors. Addressing barriers to smoking cessation, blood pressure and weight management, and physical activity may be the most effective approaches to eliminating socioeconomic inequalities in CHD.


Socioeconomic status Coronary heart disease Health behaviors Risk factors 



K. N. Kershaw was supported by Grant T32-HL-069771-07. The Monitoring Project on Risk Factors and Chronic Diseases in the Netherlands (MORGEN) Study was supported by the Ministry of Health, Welfare and Sport of the Netherlands, the National Institute of Public Health and the Environment, Bilthoven, the Netherlands and the Europe Against Cancer Program of the European Union. The authors thank the epidemiologists and field workers of the Municipal Health Services in Amsterdam, Doetinchem, and Maastricht for their important contribution to the data collection for this study.

Supplementary material

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Supplementary material 1 (DOCX 64 kb)


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Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Kiarri N. Kershaw
    • 1
    Email author
  • Mariël Droomers
    • 2
  • Whitney R. Robinson
    • 3
  • Mercedes R. Carnethon
    • 1
  • Martha L. Daviglus
    • 1
    • 5
  • W. M. Monique Verschuren
    • 4
  1. 1.Department of Preventive MedicineNorthwestern University Feinberg School of MedicineChicagoUSA
  2. 2.Department of Public Health, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
  3. 3.Department of EpidemiologyUNC Gillings School of Global Public HealthChapel HillUSA
  4. 4.National Institute for Public Health and the EnvironmentBilthovenThe Netherlands
  5. 5.Department of MedicineUniversity of Illinois at ChicagoChicagoUSA

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