Article Text

Download PDFPDF

Association between educational level and total and cause-specific mortality: a pooled analysis of over 694 000 individuals in the Asia Cohort Consortium
  1. Keming Yang1,
  2. Ying Zhang2,
  3. Eiko Saito3,
  4. Md Shafiur Rahman4,
  5. Prakash Chandra Gupta5,
  6. Norie Sawada6,
  7. Akiko Tamakoshi7,
  8. Yu-Tang Gao8,
  9. Woon-Puay Koh9,
  10. Xiao-Ou Shu10,
  11. Ichiro Tsuji11,
  12. Atsuko Sadakane12,
  13. Chisato Nagata13,
  14. San-Lin You14,
  15. Jian-Min Yuan15,
  16. Myung-Hee Shin16,
  17. Yu Chen17,
  18. Wen-Harn Pan18,
  19. Mangesh S Pednekar5,
  20. Shoichiro Tsugane6,
  21. Hui Cai10,
  22. Yong-Bing Xiang8,
  23. Kotaro Ozasa12,
  24. Yasutake Tomata11,
  25. Seiki Kanemura11,
  26. Yumi Sugawara11,
  27. Keiko Wada13,
  28. Renwei Wang15,
  29. Yoon-Ok Ahn19,
  30. Keun-Young Yoo20,
  31. Habibul Ahsan21,
  32. Kee Seng Chia22,
  33. Paolo Boffetta23,
  34. Daehee Kang19,
  35. John D Potter24,
  36. Manami Inoue6,
  37. Wei Zheng10,
  38. Hongmei Nan1
  1. 1 Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
  2. 2 Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
  3. 3 Division of Cancer Statistics Integration, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan
  4. 4 Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
  5. 5 Healis - Sekhsaria Institute for Public Health, Navi Mumbai, India
  6. 6 Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
  7. 7 Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
  8. 8 State Key Laboratory of Oncogene and Related Genes & Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
  9. 9 Health Services and Systems Research, Duke-NUS Medical School, Singapore
  10. 10 Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  11. 11 Tohoku University Graduate School of Medicine, Sendai, Japan
  12. 12 Department of Epidemiology, Radiation Effects Research Foundation, Hiroshima, Japan
  13. 13 Department of Epidemiology and Preventive Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
  14. 14 School of Medicine, Big Data Research Centre, Fu-Jen Catholic University, Taipei, Taiwan
  15. 15 Division of Cancer Control and Population Sciences, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  16. 16 Department of Social and Preventive Medicine, Sungkyunkwan University School of Medicine, Seoul, The Republic of Korea
  17. 17 Department of Population Health, Department of Environmental Medicine, New York University School of Medicine, New York City, New York, USA
  18. 18 Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
  19. 19 Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, The Republic of Korea
  20. 20 Armed Forces Capital Hospital, Seoul National University College of Medicine, Seoul, The Republic of Korea
  21. 21 Department of Public Health Sciences, The University of Chicago, Chicago, Illinois, USA
  22. 22 Epidemiology Program, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
  23. 23 Icahn School of Medicine at Mount Sinai, New York, New York, USA
  24. 24 Centre for Public Health Research, Massey University, Wellington, New Zealand
  1. Correspondence to Dr Hongmei Nan; hnan{at}iu.edu

Abstract

Objective To study the association of educational level and risk of death from all causes, cardiovascular disease (CVD) and cancer among Asian populations.

Design A pooled analysis of 15 population-based cohort studies.

Setting and participants 694 434 Asian individuals from 15 prospective cohorts within the Asia Cohort Consortium.

Interventions None.

Main outcome measures HRs and 95% CIs for all-cause mortality, as well as for CVD-specific mortality and cancer-specific mortality.

Results A total of 694 434 participants (mean age at baseline=53.2 years) were included in the analysis. During a mean follow-up period of 12.5 years, 103 023 deaths were observed, among which 33 939 were due to cancer and 34 645 were due to CVD. Higher educational levels were significantly associated with lower risk of death from all causes compared with a low educational level (≤primary education); HRs and 95% CIs for secondary education, trade/technical education and ≥university education were 0.88 (0.85 to 0.92), 0.81 (0.73 to 0.90) and 0.71 (0.63 to 0.80), respectively (ptrend=0.002). Similarly, HRs (95% CIs) were 0.93 (0.89 to 0.97), 0.86 (0.78 to 0.94) and 0.81 (0.73 to 0.89) for cancer death, and 0.88 (0.83 to 0.93), 0.77 (0.66 to 0.91) and 0.67 (0.58 to 0.77) for CVD death with increasing levels of education (both ptrend <0.01). The pattern of the association among East Asians and South Asians was similar compared with ≤primary education; HR (95% CI) for all-cause mortality associated with ≥university education was 0.72 (0.63 to 0.81) among 539 724 East Asians (Chinese, Japanese and Korean) and 0.61 (0.54 to 0.69) among 154 710 South Asians (Indians and Bangladeshis).

Conclusion Higher educational level was associated with substantially lower risk of death among Asian populations.

  • education
  • cancer
  • Asia
  • mortality
  • cardiovascular

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

View Full Text

Statistics from Altmetric.com

Footnotes

  • Contributors HN was responsible for the study concept and design. PCG, NS, AT, Y-TG, W-PK, X-OS, IT, AS, CN, S-LY, J-MY, M-HS, YC, W-HP, MSP, ST, HC, Y-BX, KO, YT, SK, YS, KW, RW, Y-OA, K-YY, HA, KSC, PB, DK, JDP, MI and WZ were involved in data collection and contributed to study materials. ES and MSR were involved in data management. KY analyzed the data and drafted the manuscript. All authors (KY, YZ, ES, MSR, PCG, NS, AT, Y-TG, W-PK, X-OS, IT, AS, CN, S-LY, J-MY, M-HS, YC, W-HP, MSP, ST, HC, Y-BX, KO, YT, SK, YS, KW, RW, Y-OA, K-YY, HA, KSC, PB, DK, JDP, MI, WZ, HN) contributed to the interpretation of the results and revision of the manuscript critically for important intellectual content. KY and HN are guarantors. All authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding There is no funding for this specific analysis. The cohorts participating in the pooled analysis were supported by the following grants: Japan Public Health Center-based prospective Study (JPHC Study), National Cancer Center Research and Development Fund (23-A-31(toku) and 26-A-2) (since 2011) and a Grant-in-Aid for Cancer Research from the Ministry of Health, Labour and Welfare of Japan (from 1989 to 2010); Japan Collaborative Cohort Study (JACC), National Cancer Center Research and Development Fund, A Grant-in-Aid for Cancer Research; Grant for Health Services and Grant for Comprehensive Research on Cardiovascular and Life-Style Related Diseases from the Ministry of Health, Labour and Welfare, Japan; Grant for the Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology, Japan; Shanghai Women’s Health Study (SWHS), the US National Cancer Institute (grant numbers R37 CA070867 and UM1 CA182910); Singapore Chinese Health Study (SCHS), National Institutes of Health (R01CA144034, UM1CA182876); Shanghai Men’s Health Study (SMHS), the US National Cancer Institute (R01 CA082729 and UM1 CA173640); Shanghai Cohort Study (SCS), National Institutes of Health (R01CA144034, UM1CA182876); Ohsaki National Health Insurance Cohort Study, Grants-in-Aid for Cancer Research and for the Third Term Comprehensive Ten-Year Strategy for Cancer Control (H21-3jigan-ippan-003), Ministry of Health, Labour and Welfare; Miyagi Cohort, Grants-in-Aid for Cancer Research and for the Third Term Comprehensive Ten-Year Strategy for Cancer Control (H21-3jigan-ippan-003), Ministry of Health, Labour and Welfare; Life Span Study Cohort, The Japanese Ministry of Health, Labour and Welfare and the US Department of Energy; Takayama Study, National Cancer Center Research and Development Fund; CardioVascular Disease risk FACtor Two-township Study (CVDFACTS), Department of Health, Taiwan (DOH80-27, DOH81-021, DOH8202-1027, DOH83-TD-015 and DOH84-TD-006); Community-Based Cancer Screening Program (CBCSP), National Science Council and Department of Health, Taiwan; Seoul Male Cancer Cohort, National R&D Program for Cancer Control, Ministry of Health and Welfare, Republic of Korea (0520160-1); Health Effects of Arsenic Longitudinal Study (HEALS), National Institutes of Health (P42ES010349, R01CA102484, R01CA107431); Mumbai Cohort Study, International Agency for Research on Cancer, Lyon, France; Clinical Trials Service Unit, Oxford, UK; World Health Organisation, Geneva, Switzerland. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the ethics committees of each individual cohort study and by the institutional review board of the ACC coordinating center (Fred Hutchinson Cancer Research Center, Seattle, USA; National Cancer Center, Tokyo, Japan).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The datasets analysed during the current study (deidentified participant data) are available from the corresponding author upon reasonable request.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.