Associations between education and ideal cardiovascular health metrics across 36 low- and middle-income countries.

Background: The relationship between education and cardiovascular health (CVH) metrics in low- and middle-income countries (LMICs) remains unclear. This study explores the associations between education and ideal cardiovascular health score (CVHS), as well as seven CVH metrics.

Methods: This cross-sectional study extracted data from the STEPwise approach to surveillance surveys in 36 LMICs between 2010 and 2020. We assessed CVHS using the sum score in seven metrics defined by American Heart Association: (1) ≥ 150 min/week of moderate, or 75 min/week of vigorous activity, or an equivalent combination; (2) BMI < 25 kg/m for non-Asians (< 23 kg/m for Asians); (3) fruit and vegetable intake ≥ 4.5 servings per day; (4) nonsmoking; (5) blood pressure < 120/80 mmHg (untreated); (6) total cholesterol < 200 mg/dL (untreated); and (7) fasting blood glucose < 100 mg/dL (untreated). The ideal CVHS score ranged from 5 to 7. We disaggregated prevalence of ideal CVHS and seven metrics by education, and constructed Poisson regression models to adjust for other socioeconomic factors.

Results: Among 81,327 adult participants, the overall ideal CVHS prevalence for the studied countries was highest among individuals with primary education (52.9%, 95% CI: 51.0-54.9), surpassing those of other education levels - 48.0% (95% CI: 44.6-51.3, P = 0.003) for those with no education and 39.1% (95% CI: 36.5-41.8, P < 0.001) for those with tertiary education. Five (ideal physical activity, BMI, blood pressure, total cholesterol, and blood glucose) in seven CVH metrics peaked among participants with primary or secondary education. For instance, the prevalence of ideal blood pressure among individuals with primary education was 34.4% (95% CI: 32.7-36.1), higher than the prevalence in other education levels, ranging from 28.6% to 32.3%. These patterns were concentrated in low-income countries and lower-middle-income countries, while in upper-middle-income countries, the prevalence of ideal CVHS increased with higher education levels, ranging from 15.4% for individuals with no education to 33.1% for those with tertiary education.

Conclusions: In LMICs, the association between education and ideal CVHS, along with several CVH metrics, exhibited un inverted U-shape, which may be closely related to the different stages of epidemiologic transition.