Marital status, gender and cardiovascular mortality: Behavioural, psychological distress and metabolic explanations

Abstract

The intermediate processes through which the various unmarried states can increase the risk of subsequent cardiovascular disease (CVD) mortality are incompletely understood. An understanding of these processes and how they may vary by gender is important for understanding why marital status is strongly and robustly associated with subsequent cardiovascular disease. In a prospective study of 13,889 men and women (mean age 52.3, SD: 11.8 yrs, range 35-95, 56.1% female) without a history of clinically diagnosed CVD, we examined the extent to which health behaviours (smoking, alcohol, physical activity), psychological distress (General Health Questionnaire-12 item) and metabolic dysregulation (obesity levels, and the presence of hypertension and diabetes) account for the association between marital status and cardiovascular mortality. There were 258 cardiovascular deaths over an average follow up of 7.1 (SD=3.3) years. The risk of cardiovascular mortality was greatest in single, never married men and separated/divorced women compared with those that were married in gender stratified models that were adjusted for age and socioeconomic group. In models that were separately adjusted, behavioural factors explained up to 33% of the variance, psychological distress explained up to 10% of the variance and metabolic dysregulation up to 16% of the variance in the observed significant associations between marital status and cardiovascular mortality. Behavioural factors were particularly important in accounting for the relationship between being separated/divorced and cardiovascular mortality in both men and women (33% and 21% of variability, respectively). The present findings suggest that health behaviour, psychological distress and metabolic dysregulation data have varying explanatory power for understanding the observed relationship between CVD mortality and unmarried states.