title: The impact of level of education on vascular events and mortality in patients with type 2 diabetes mellitus: Results from the ADVANCE study.
abstract: OBJECTIVE
  The relationship between educational level and the risk of all-cause mortality is well established, whereas the association with vascular events in individuals with type 2 diabetes is not well described. Any association may reflect a link with common cardiovascular or lifestyle-based risk factors.
  
  
  METHODS
  The relationships between the highest level of educational attainment and major cardiovascular events, microvascular complications and all-cause mortality were explored in a cohort of 11,140 individuals with type 2 diabetes. Completion of formal education before the age of 16 was categorized as a low level of education. Regional differences between Asia, East Europe and Established Market Economies were also assessed.
  
  
  RESULTS
  During a median of 5years of follow up, 1031 (9%) patients died, 1147 (10%) experienced a major cardiovascular event and 1136 (10%) a microvascular event. After adjustment for baseline characteristics and risk factors, individuals with lower education had an increased risk of cardiovascular events (hazard ratio (HR) 1.31, 95% CI 1.16-1.48, p<0.0001), microvascular events (HR 1.23, 95% CI 1.08-1.39, p=0.0013) and all-cause mortality (HR 1.34, 95% CI 1.18-1.52, p<0.0001). In regional analyses the increased risk of studied outcomes associated with lower education was weakest in Established Market Economies and strongest in East Europe.
  
  
  CONCLUSIONS
  A low level of education is associated with an increased risk of vascular events and death in patients with type 2 diabetes, independently of common lifestyle associated cardiovascular risk factors. The effect size varies between geographical regions.
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, Australia; University of Turku, Turku, Finland. Electronic address: jmakinen@georgeinstitute.org.au.
authors.forename: J I
authors.initials: JI
authors.lastname: Blomster
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, Australia; School of Public Health, Monash University, Melbourne, Australia.
authors.forename: S
authors.initials: S
authors.lastname: Zoungas
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, Australia; Department of Epidemiology, Johns Hopkins University, Baltimore, USA; The George Institute for Global Health, University of Oxford, UK.
authors.forename: M
authors.initials: M
authors.lastname: Woodward
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, Australia.
authors.forename: B
authors.initials: B
authors.lastname: Neal
authors.affiliation: Department of Physiology, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia.
authors.forename: S
authors.initials: S
authors.lastname: Harrap
authors.affiliation: Imperial College London and Hammersmith Hospital, London, UK.
authors.forename: N
authors.initials: N
authors.lastname: Poulter
authors.affiliation: Service d'Endocrinologie Diabétologie Nutrition, Groupe Hospitalier Bichat-Claude Bernard, Paris, France.
authors.forename: M
authors.initials: M
authors.lastname: Marre
authors.affiliation: University College London and the National Institute for Health Research UCL Hospitals Biomedical Research Centre, London, UK.
authors.forename: B
authors.initials: B
authors.lastname: Williams
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Chalmers
authors.affiliation: The George Institute for Global Health, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Australia.
authors.forename: G S
authors.initials: GS
authors.lastname: Hillis
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000209:etiology* / Q000401:mortality; D015331:Cohort Studies; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000401:mortality; D004522:Educational Status; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors
keywords: Cardiovascular events; Level of education; Microvascular events; Type 2 diabetes