Background/Aims: Low socioeconomic status (SES) is linked to higher incidence/mortality of cardiovascular disease, but emerging evidence inconsistently reported that education level, a proxy for SES, is related to cardiovascular risk and metabolic syndrome (MetS) in Koreans. Furthermore, limited information is available on whether dietary components would mediate the relationship between education level and cardiovascular risk. We hypothesized that selected food consumption mediates the association between education level and MetS prevalence. Methods: Data from the Korea National Health and Nutritional Examination Survey (2008-2011) were included in cross-sectional analyses (n = 11,029, 30-64 years). The possible mediating effect of selected food groups (fruits, raw vegetables, red meat, milk, and soft drinks) on the association between education level and MetS was tested using a multiple mediation model. Results: Education level was negatively associated with MetS prevalence. The association between lower education level and higher MetS prevalence was partially mediated by selected food consumption (lower intakes of fruit, red meat and milk; higher intakes of vegetable and soft drink) after adjusted for covariates. Gender also modified the association between education level and MetS prevalence that was more prominent in women than in men. Conclusions: Selected food consumption substantially contributes to the association between education level and MetS in Korean adults, especially among women.

Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ: Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367:1747-1757.
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Despres JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jimenez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER 3rd, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB: Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation 2016;133:e38-e360.
Statistics Korea: Causes of Death Statistics in 2014. Daejeon, Statistics Korea, 2015.
Statistics Korea: Causes of Death Statistics in 2015. Daejeon, Statistics Korea, 2016.
Statistics Korea: Korea Health Statistics 2013: Korea National Health and Nutrition Examination Survey (KNHANES VI-1). Daejeon, Statistics Korea, 2014.
Alberti KG, Zimmet P, Shaw J: Metabolic syndrome - a new world-wide definition. A consensus statement from the international diabetes federation. Diabet Med 2006;23:469-480.
Borrell C, Rue M, Pasarin MI, Rohlfs I, Ferrando J, Fernandez E: Trends in social class inequalities in health status, health-related behaviors, and health services utilization in a Southern European urban area (1983-1994). Prev Med 2000;31:691-701.
Kaplan GA, Keil JE: Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation 1993;88:1973-1998.
Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB: State of disparities in cardiovascular health in the United States. Circulation 2005;111:1233-1241.
Winkleby MA, Jatulis DE, Frank E, Fortmann SP: Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health 1992;82:816-820.
Liu K, Cedres LB, Stamler J, Dyer A, Stamler R, Nanas S, Berkson DM, Paul O, Lepper M, Lindberg HA, Marquardt J, Stevens E, Schoenberger JA, Shekelle RB, Collette P, Shekelle S, Garside D: Relationship of education to major risk factors and death from coronary heart disease, cardiovascular diseases and all causes, findings of three Chicago epidemiologic studies. Circulation 1982;66:1308-1314.
Kim JH, Jeong MH, Park IH, Choi JS, Rhee JA, Lee DH, Park SH, Kim IS, Jeong HC, Cho JY, Jang SY, Lee KH, Park KH, Sim DS, Kim KH, Hong YJ, Park HW, Kim JH, Ahn Y, Cho JG, Park JC: The association of socioeconomic status with three-year clinical outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention. J Korean Med Sci 2014;29:536-543.
Seo SR, Kim SY, Lee SY, Yoon TH, Park HG, Lee SE, Kim CW: The incidence of stroke by socioeconomic status, age, sex, and stroke subtype: a nationwide study in Korea. J Prev Med Public Health 2014;47:104-112.
Kim SR, Han K, Choi JY, Ersek J, Liu J, Jo SJ, Lee KS, Yim HW, Lee WC, Park YG, Lee SH, Park YM: Age- and sex-specific relationships between household income, education, and diabetes mellitus in Korean adults: the Korea National Health and Nutrition Examination Survey, 2008-2010. PLoS One 2015;10:e0117034.
Baek TH, Lee HY, Lim NK, Park HY: Gender differences in the association between socioeconomic status and hypertension incidence: the Korean genome and epidemiology study (KoGES). BMC Public Health 2015;15:852.
Cha SH, Park HS, Cho HJ: Socioeconomic disparities in prevalence, treatment, and control of hypertension in middle-aged Koreans. J Epidemiol 2012;22:425-432.
Nam GE, Cho KH, Park YG, Han KD, Choi YS, Kim SM, Lee KS, Ko BJ, Kim YH, Han BD, Kim do H: Socioeconomic status and dyslipidemia in Korean adults: the 2008-2010 Korea National Health and Nutrition Examination Survey. Prev Med 2013;57:304-309.
Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, Davey-Smith G, Dennison-Himmelfarb CR, Lauer MS, Lockwood DW, Rosal M, Yancy CW: Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2015;132:873-898.
Kershaw KN, Mezuk B, Abdou CM, Rafferty JA, Jackson JS: Socioeconomic position, health behaviors, and C-reactive protein: a moderated-mediation analysis. Health Psychol 2010;29:307-316.
Lantz PM, Golberstein E, House JS, Morenoff J: Socioeconomic and behavioral risk factors for mortality in a national 19-year prospective study of U.S. adults. Soc Sci Med 2010;70:1558-1566.
Huey-Jen Hsu S, Chen MF, Chen DR, Su TC: Validation of the estimation of low-density lipoprotein cholesterol by the modified Friedewald equation in ethnic Chinese adults living in Taiwan. Intern Med 2015;54:2291-2297.
Yun SH, Shim JS, Kweon S, Oh K: Development of a food frequency questionnaire for the Korea National Health and Nutrition Examination Survey: data from the fourth Korea National Health and Nutrition Examination Survey (KNHANES IV). Korean J Nutr 2013;46:186-196.
Kim DW, Song S, Lee JE, Oh K, Shim J, Kweon S, Paik HY, Joung H: Reproducibility and validity of an FFQ developed for the Korea National Health and Nutrition Examination Survey (KNHANES). Public Health Nutr 2015;18:1369-1377.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): Third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III) final report. Circulation 2002;106:3143-3421.
WHO Expert Consultation: Waist Circumference and Waist-Hip Ratio. Report of a WHO Expert Consultation. Geneva, World Health Organization, 2008, pp 8-11.
Hayes AF: Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. Guilford Press, 2013.
Kreatsoulas C, Anand SS: The impact of social determinants on cardiovascular disease. Can J Cardiol 2010;26(suppl C):8C-13C.
Loucks EB, Rehkopf DH, Thurston RC, Kawachi I: Socioeconomic disparities in metabolic syndrome differ by gender: evidence from NHANES III. Ann Epidemiol 2007;17:19-26.
Carnethon MR, Loria CM, Hill JO, Sidney S, Savage PJ, Liu K: Risk factors for the metabolic syndrome: the Coronary Artery Risk Development in Young Adults (CARDIA) study, 1985-2001. Diabetes Care 2004;27:2707-2715.
Park SJ, Kang HT, Nam CM, Park BJ, Linton JA, Lee YJ: Sex differences in the relationship between socioeconomic status and metabolic syndrome: the Korean National Health and Nutrition Examination Survey. Diabetes Res Clin Pract 2012;96:400-406.
Yang JJ, Yoon HS, Lee SA, Choi JY, Song M, Han S, Lee JK, Kang D: Metabolic syndrome and sex-specific socio-economic disparities in childhood and adulthood: the Korea National Health and Nutrition Examination Surveys. Diabet Med 2014;31:1399-1409.
Gilman SE, Abrams DB, Buka SL: Socioeconomic status over the life course and stages of cigarette use: initiation, regular use, and cessation. J Epidemiol Community Health 2003;57:802-808.
Park SH, Kim CH, Kim DJ, Suk KT, Park HY, Lee JG, Shin KJ, Park JH, Kim TO, Yang SY, Moon YS, Lee HY: Secular trends in prevalence of alcohol use disorder and its correlates in Korean adults: results from Korea National Health and Nutrition Examination Survey 2005 and 2009. Subst Abus 2012;33:327-335.
Mullie P, Clarys P, Hulens M, Vansant G: Dietary patterns and socioeconomic position. Eur J Clin Nutr 2010;64:231-238.
Giskes K, Avendano M, Brug J, Kunst AE: A systematic review of studies on socioeconomic inequalities in dietary intakes associated with weight gain and overweight/obesity conducted among European adults. Obes Rev 2010;11:413-429.
Gidlow C, Johnston LH, Crone D, Ellis N, James D: A systematic review of the relationship between socio-economic position and physical activity. Health Edu J 2006;65:338-367.
Hong SA, Kim K, Kim MK: Educational attainment and differences in fruit and vegetable consumption among middle-aged adults in the Korean National Health and Nutrition Examination Survey IV. Nutr Res Prac 2012;6:263-269.
Satheannoppakao W, Aekplakorn W, Pradipasen M: Fruit and vegetable consumption and its recommended intake associated with sociodemographic factors: Thailand National Health Examination Survey III. Public Health Nutr 2009;12:2192-2198.
Giskes K, Turrell G, Patterson C, Newman B: Socio-economic differences in fruit and vegetable consumption among Australian adolescents and adults. Public Health Nutr 2002;5:663-669.
World Cancer Research Fund, American Institute for Cancer Research: Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. American Institute for Cancer Research, 2007.
Hung HC, Joshipura KJ, Jiang R, Hu FB, Hunter D, Smith-Warner SA, Colditz GA, Rosner B, Spiegelman D, Willett WC: Fruit and vegetable intake and risk of major chronic disease. J Natl Cancer Inst 2004;96:1577-1584.
Djousse L, Arnett DK, Coon H, Province MA, Moore LL, Ellison RC: Fruit and vegetable consumption and LDL cholesterol: the National Heart, Lung, and Blood Institute Family Heart Study. Am J Clin Nutr 2004;79:213-217.
Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi F: Dairy consumption is inversely associated with the prevalence of the metabolic syndrome in Tehranian adults. Am J Clin Nutr 2005;82:523-530.
Beydoun MA, Gary TL, Caballero BH, Lawrence RS, Cheskin LJ, Wang Y: Ethnic differences in dairy and related nutrient consumption among US adults and their association with obesity, central obesity, and the metabolic syndrome. Am J Clin Nutr 2008;87:1914-1925.
Malik VS, Popkin BM, Bray GA, Després JP, Willett WC, Hu FB: Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care 2010; 33:2477-2483.
Barbeau EM, Krieger N, Soobader MJ: Working class matters: socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. Am J Public Health 2004;94:269-278.
Kaplan GA, Keil JE: Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation 1993;88(4 pt 1):1973-1998.
You J, Choo J: Adolescent overweight and obesity: links to socioeconomic status and fruit and vegetable intakes. Int J Environ Res Public Health 2016;13:pii:E307.
Micha R, Wallace SK, Mozaffarian D: Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: a systematic review and meta-analysis. Circulation 2010;121:2271-2283.
Lee JE, McLerran DF, Rolland B, Chen Y, Grant EJ, Vedanthan R, Inoue M, Tsugane S, Gao YT, Tsuji I, Kakizaki M, Ahsan H, Ahn YO, Pan WH, Ozasa K, Yoo KY, Sasazuki S, Yang G, Watanabe T, Sugawara Y, Parvez F, Kim DH, Chuang SY, Ohishi W, Park SK, Feng Z, Thornquist M, Boffetta P, Zheng W, Kang D, Potter J, Sinha R: Meat intake and cause-specific mortality: a pooled analysis of Asian prospective cohort studies. Am J Clin Nutr 2013;98:1032-1041.
Galobardes B, Shaw M, Lawlor DA, Lynch JW, Davey Smith G: Indicators of socioeconomic position (part 1). J Epidemiol Community Health 2006;60:7-12.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.