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Canadian Journal of Cardiology

Sex and gender determinants of vascular disease in the global context

      ABSTRACT

      Globally, vascular diseases are a leading cause of morbidity and mortality. Many of the most significant risk factors for vascular disease have a gendered dimension, and sex differences in vascular diseases incidence are apparent, worldwide. In this narrative review, we provide a contemporary picture of sex and gender-related determinants of vascular disease. We illustrate key factors underlying sex-specific risk stratification, consider similarities and sex differences in vascular disease risk and outcomes comparing data from the global North (i.e., developed high income countries in the Northern hemisphere and Australia) and the global South (i.e., regions outside Europe and North America), and explore the relationship between country-level gendered inequities in vascular disease risk and the United Nation’s gender inequality index. Review findings suggest that the rising incidence of vascular disease in women is partly explained by an increase in the prevalence of traditional risk factors linked to gender-related determinants such as shifting roles and relations related to the double burden of employment and caregiving responsibilities, lower educational attainment, lower socioeconomic status, and higher psychosocial stress. Social isolation partly explained the higher incidence of vascular disease in men. These patterns were found to be apparent across the global North and South. Study findings emphasize the necessity of taking into account sex differences and gender-related factors in the determination of the vascular disease risk profiles and management strategies. As we move towards the era of precision medicine, future research is needed that identifies, validates and measures gender-related determinants and risk factors in the global South.
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      REFERENCES

        • Turin T.C.
        • Shahana N.
        • Wangchuk L.Z.
        • et al.
        Burden of cardio-and cerebro-vascular diseases and the conventional risk factors in South Asian population.
        Global Heart. 2013; 8: 121-130
      1. Gaziano T, Reddy KS, Paccaud F, Horton S, Chaturvedi V. Cardiovascular disease. Disease Control Priorities in Developing Countries 2nd edition. 2006.

        • Roth G.A.
        • Mensah G.A.
        • Johnson C.O.
        • et al.
        Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study.
        J Am Col Cardiol. 2020; 76: 2982-3021
      2. World Health Organization. Global status report on noncommunicable diseases 2014. Available at https://apps.who.int/iris/handle/10665/148114. Accessed on January 23, 2022.

        • Bugiardini R.
        • Cenko E.
        Sex differences in myocardial infarction deaths.
        Lancet (London, England). 2020; 396: 72-73
        • Teo K.K.
        • Rafiq T.
        Cardiovascular risk factors and prevention: A perspective from developing countries.
        Can J Cardiol. 2021; 37: 733-743
        • Zhao D.
        Epidemiological Features of Cardiovascular Disease in Asia.
        JACC: Asia. 2021; 1: 1-13
        • Bhattarai S.
        • Aryal A.
        • Pyakurel M.
        • et al.
        Cardiovascular disease trends in Nepal–An analysis of global burden of disease data 2017.
        Int J Cardiol Heart Vasc. 2020; 30100602
        • Kumar A.S.
        • Sinha N.
        Cardiovascular disease in India: a 360 degree overview.
        Med J Armed Forces of India. 2020; 76: 1-3
        • Vogel B.
        • Acevedo M.
        • Appelman Y.
        • et al.
        The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030.
        Lancet. 2021; 397: 2385-2438
        • Jagannathan R.
        • Patel S.A.
        • Ali M.K.
        • Narayan K.M.
        Global updates on cardiovascular disease mortality trends and attribution of traditional risk factors.
        Curr Diab Rep. 2019; 19: 44
        • Gaziano T.A.
        • Bitton A.
        • Anand S.
        • Abrahams-Gessel S.
        • Murphy A.
        Growing epidemic of coronary heart disease in low-and middle-income countries.
        Curr Probl Cardiol. 2010; 35: 72-115
        • O’Neil A.
        • Scovelle A.J.
        • Milner A.J.
        • Kavanagh A.
        Gender/sex as a social determinant of cardiovascular risk.
        Circulation. 2018; 137: 854-864
        • Vlassoff C.
        Gender differences in determinants and consequences of health and illness.
        Health Popul Nutr. 2007; 25: 47-61
      3. Johnson JL, Greaves L, Repta R. Better science with sex and gender: A primer for health research. Women's Health Research Network Vancouver; 2007. Available at https://www.researchgate.net/publication/261774053_Better_science_with_sex_and_gender_A_primer_for_health_research. Accessed on February 2, 2022.

      4. Canadian Institutes of Health Research. What is gender? What is sex? Available at https://cihr-irsc.gc.ca/e/48642.html. Accessed on March 28, 2022.

        • Joseph P.
        • Leong D.
        • McKee M.
        • et al.
        Reducing the global burden of cardiovascular disease, part 1: the epidemiology and risk factors.
        Circ Res. 2017; 121: 677-694
        • Azizi Z.
        • Gisinger T.
        • Bender U.
        • et al.
        Sex, Gender Factors and Cardiovascular Health in Canadian and Austrian Populations.
        Can J Cardiol. 2021; 37: 1240-1247
        • de Ritter R.
        • de Jong M.
        • Vos R.C.
        • et al.
        Sex differences in the risk of vascular disease associated with diabetes.
        Biol Sex Differ. 2020; 11: 1-11
        • Leopold J.A.
        • Antman E.M.
        A precision medicine approach to sex-based differences in ideal cardiovascular health.
        Sci Rep. 2021; 1114848
        • Millett E.R.C.
        • Peters S.A.E.
        • Woodward M.
        Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants.
        BMJ. 2018; 363: k4247
        • Ji H.
        • Kim A.
        • Ebinger J.E.
        • et al.
        Sex differences in blood pressure trajectories over the life course.
        JAMA Cardiol. 2020; 5: 19-26
        • Peters S.A.E.
        • Muntner P.
        • Woodward M.
        Sex differences in the prevalence of, and trends in, cardiovascular risk factors, treatment, and control in the United States, 2001 to 2016.
        Circulation. 2019; 139: 1025-1035
        • Young L.
        • Cho L.
        Unique cardiovascular risk factors in women.
        Heart. 2019; 105: 1656-1660
        • Garcia M.
        • Mulvagh S.L.
        • Bairey Merz C.N.
        • Buring J.E.
        • Manson J.E.
        Cardiovascular disease in women: clinical perspectives.
        Circ Res. 2016; 118: 1273-1293
        • Gao Z.
        • Chen Z.
        • Sun A.
        • Deng X.
        Gender differences in cardiovascular disease.
        Med Nov Technol Devices. 2019; 4100025
        • Mulvagh S.L.
        • Mullen K.-A.
        • Nerenberg K.A.
        • et al.
        The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women-Chapter 4: Sex-and Gender-Unique Disparities: CVD Across the Lifespan of a Woman.
        CJC Open. 2021; 4: 115-132
        • Miller V.M.
        Sex-based differences in vascular function.
        Womens Health. 2010; 6: 737-752
        • Walli-Attaei M.
        • Joseph P.
        • Rosengren A.
        • et al.
        Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.
        Lancet. 2020; 396: 97-109
        • Hamberg K.
        Gender bias in medicine.
        Women’s Health. 2008; 4: 237-243
        • Chieffo A.
        • Hoye A.
        • Mauri F.
        • et al.
        Gender-based issues in interventional cardiology: a consensus statement from the Women in Innovations (WIN) Initiative.
        Rev Esp Cardiol. 2010; 63: 200-208
      5. Cassata C. Heart disease affects women differently: What we can do about it. Healthline. Available at https://www.healthline.com/health-news/gender-disparities-in-heart-health-what-women-need-to-know. Accessed on January 17, 2021.

        • Leening M.J.G.
        • Ferket B.S.
        • Steyerberg E.W.
        • et al.
        Sex differences in lifetime risk and first manifestation of cardiovascular disease: prospective population based cohort study.
        BMJ. 2014; 349: g5992
        • Rajadurai J.
        • Lopez E.A.
        • Rahajoe A.U.
        • Ping G.P.
        • Uboldejpracharak Y.
        • Zambahari R.
        Women's cardiovascular health: perspectives from South-East Asia.
        Nat Rev Cardiol. 2012; 9: 464-477
        • Amegah A.K.
        Tackling the growing burden of cardiovascular diseases in sub-Saharan Africa: Need for dietary guidelines.
        Circulation. 2018; 138: 2449-2451
        • Vikulova D.N.
        • Grubisic M.
        • Zhao Y.
        • et al.
        Premature atherosclerotic cardiovascular disease: trends in incidence, risk factors, and sex‐related differences, 2000 to 2016.
        J Am Heart Assoc. 2019; 8e012178
        • Woodward M.
        Cardiovascular disease and the female disadvantage.
        Int J Environ Res Public Health. 2019; 16: 1165
        • Norris C.M.
        • Yip C.Y.Y.
        • Nerenberg K.A.
        • et al.
        State of the science in women's cardiovascular disease: a Canadian perspective on the influence of sex and gender.
        J Am Heart Assoc. 2020; 9e015634
        • Worrall‐Carter L.
        • Ski C.
        • Scruth E.
        • Campbell M.
        • Page K.
        Systematic review of cardiovascular disease in women: assessing the risk.
        Nurs Health Sci. 2011; 13: 529-535
        • Keates A.K.
        • Mocumbi A.O.
        • Ntsekhe M.
        • Sliwa K.
        • Stewart S.
        Cardiovascular disease in Africa: epidemiological profile and challenges.
        Nat Rev Cardiol. 2017; 14: 273-293
      6. Kadiri S. Tackling cardiovascular disease in Africa. British Medical Journal Publishing Group; 2005. p. 711-712.

        • Gooneratne M.D.P.
        Coronary Heart Disease in South-Asian Women.
        J SAFOMS. 2013; 1: 84
        • Kundu J.
        • Kundu S.
        Cardiovascular disease (CVD) and its associated risk factors among older adults in India: Evidence from LASI Wave 1.
        Clin Epidemiol Glob Health. 2022; 100937
        • Madavanakadu Devassy S.
        • Webber M.
        • Scaria L.
        • et al.
        Social and behavioural risk factors in the prevention and management of cardiovascular disease in Kerala, India: a catchment area population survey.
        BMC Cardiovasc Disord. 2020; 20: 327
        • Boden-Albala B.
        • Sacco R.L.
        Lifestyle factors and stroke risk: exercise, alcohol, diet, obesity, smoking, drug use, and stress.
        Curr Atheroscler Rep. 2000; 2: 160-166
        • Peiris D.
        • Ghosh A.
        • Manne-Goehler J.
        • et al.
        Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data.
        PLoS Med. 2021; 18e1003485
        • Schultz W.M.
        • Kelli H.M.
        • Lisko J.C.
        • et al.
        Socioeconomic status and cardiovascular outcomes: challenges and interventions.
        Circulation. 2018; 137: 2166-2178
        • Carson A.P.
        • Rose K.M.
        • Catellier D.J.
        • Diez-Roux A.V.
        • Muntaner C.
        • Wyatt S.B.
        Employment status, coronary heart disease, and stroke among women.
        Ann Epidemiol. 2009; 19: 630-636
        • Eshak E.S.
        • Honjo K.
        • Iso H.
        • et al.
        Changes in the employment status and risk of stroke and stroke types.
        Stroke. 2017; 48: 1176-1182
        • Rubee D.
        • Valeria R.
        • Louise P.
        • et al.
        Cardiovascular Health through a sex and gender lens in six South Asian countries: Findings from the WHO STEPS surveillance.
        J Glob Health. 2022; 1204020
        • Cho C.-M.
        • Lee Y.-M.
        The relationship between cardiovascular disease risk factors and gender.
        Health. 2012; 4: 309-315
        • Aggarwal B.
        • Mosca L.
        Heart disease risk for female cardiac caregivers.
        Female Patient. 2009; 34: 42-45
        • Aggarwal B.
        • Liao M.
        • Christian A.
        • Mosca L.
        Influence of caregiving on lifestyle and psychosocial risk factors among family members of patients hospitalized with cardiovascular disease.
        J Gen Intern Med. 2009; 24: 93-98
        • Xu X.Y.
        • Kwan R.Y.C.
        • Leung A.Y.M.
        Factors associated with the risk of cardiovascular disease in family caregivers of people with dementia: a systematic review.
        J Int Med Res. 2020; 48300060519845472
        • Lahoz R.
        • Proudfoot C.
        • Fonseca A.F.
        • et al.
        Caregivers of patients with heart failure: burden and the determinants of health-related quality of life.
        Patient Prefere Adherence. 2021; 15: 1153-1164
        • Lee S.
        • Colditz G.A.
        • Berkman L.F.
        • Kawachi I.
        Caregiving and risk of coronary heart disease in US women: a prospective study.
        Am J Prev Med. 2003; 24: 113-119
        • Lee S.
        • Colditz G.
        • Berkman L.
        • Kawachi I.
        Caregiving to children and grandchildren and risk of coronary heart disease in women.
        Am J Public Health. 2003; 93: 1939-1944
        • Mortensen J.
        • Dich N.
        • Lange T.
        • et al.
        Weekly hours of informal caregiving and paid work, and the risk of cardiovascular disease.
        European J Public Health. 2018; 28: 743-747
        • Schultz W.M.
        • Hayek S.S.
        • Samman Tahhan A.
        • et al.
        Marital status and outcomes in patients with cardiovascular disease.
        J Am Heart Assoc. 2017; 6e005890
        • Dhindsa D.S.
        • Khambhati J.
        • Schultz W.M.
        • Tahhan A.S.
        • Quyyumi A.A.
        Marital status and outcomes in patients with cardiovascular disease.
        Trends Cardiovasc Med. 2020; 30: 215-220
        • Manfredini R.
        • De Giorgi A.
        • Tiseo R.
        • et al.
        Marital status, cardiovascular diseases, and cardiovascular risk factors: a review of the evidence.
        J Womens Health. 2017; 26: 624-632
        • Ramezankhani A.
        • Azizi F.
        • Hadaegh F.
        Associations of marital status with diabetes, hypertension, cardiovascular disease and all-cause mortality: a long term follow-up study.
        PLoS One. 2019; 14e0215593
        • Raman Mishra M.
        Determinants of cardiovascular disease and sequential decision-making for treatment among women: A Heckman’s approach.
        SSM Popul Health. 2019; 7100365
        • Wong C.W.
        • Kwok C.S.
        • Narain A.
        • et al.
        Marital status and risk of cardiovascular diseases: a systematic review and meta-analysis.
        Heart. 2018; 104: 1937-1948
        • Compare A.
        • Zarbo C.
        • Manzoni G.M.
        • et al.
        Social support, depression, and heart disease: a ten year literature review.
        Front Psychol. 2013; 4: 384
        • Uzuki T.
        • Konta T.
        • Saito R.
        • et al.
        Relationship between social support status and mortality in a community-based population: a prospective observational study (Yamagata study).
        BMC Public Health. 2020; 20: 1630
        • Brummett B.H.
        • Barefoot J.C.
        • Siegler I.C.
        • et al.
        Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality.
        Psychosom Med. 2001; 63: 267-272
        • Valtorta N.K.
        • Kanaan M.
        • Gilbody S.
        • Ronzi S.
        • Hanratty B.
        Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies.
        Heart. 2016; 102: 1009-1016
        • Holt-Lunstad J.
        • Smith T.B.
        Loneliness and social isolation as risk factors for CVD: implications for evidence-based patient care and scientific inquiry.
        Heart. 2016; 102: 987-989
        • Naito R.
        • Leong D.P.
        • Bangdiwala S.I.
        • et al.
        Impact of social isolation on mortality and morbidity in 20 high-income, middle-income and low-income countries in five continents.
        BMJ Glob Health. 2021; 6e004124
        • Hu J.
        • Fitzgerald S.M.
        • Owen A.J.
        • et al.
        Social isolation, social support, loneliness and cardiovascular disease risk factors: A cross‐sectional study among older adults.
        Int J Geriatr Psychiatry. 2021; 36: 1795-1809
        • Tawakol A.
        • Ishai A.
        • Takx R.A.P.
        • et al.
        Relation between resting amygdalar activity and cardiovascular events: a longitudinal and cohort study.
        Lancet. 2017; 389: 834-845
        • Santosa A.
        • Rosengren A.
        • Ramasundarahettige C.
        • et al.
        Psychosocial risk factors and cardiovascular disease and death in a population-based cohort from 21 low-, middle-, and high-income countries.
        JAMA Netw Open. 2021; 4e2138920
        • Osborne M.T.
        • Shin L.M.
        • Mehta N.N.
        • Pitman R.K.
        • Fayad Z.A.
        • Tawakol A.
        Disentangling the links between psychosocial stress and cardiovascular disease.
        Circ Cardiovasc Imaging. 2020; 13e010931
        • Gawlik K.S.
        • Melnyk B.M.
        • Tan A.
        Associations between stress and cardiovascular disease risk factors among million hearts priority populations.
        Am J Health Promot. 2019; 33: 1063-1066
        • Rosengren A.
        • Hawken S.
        • Ôunpuu S.
        • et al.
        Association of psychosocial risk factors with risk of acute myocardial infarction in 11 119 cases and 13 648 controls from 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 953-962
        • Pimple P.
        • Lima B.B.
        • Hammadah M.
        • et al.
        Psychological distress and subsequent cardiovascular events in individuals with coronary artery disease.
        J Am Heart Assoc. 2019; 8e011866
        • Silverman A.L.
        • Herzog A.A.
        • Silverman D.I.
        Hearts and minds: stress, anxiety, and depression: unsung risk factors for cardiovascular disease.
        Cardiol Rev. 2019; 27: 202-207
        • Roest A.M.
        • Martens E.J.
        • de Jonge P.
        • Denollet J.
        Anxiety and risk of incident coronary heart disease: a meta-analysis.
        J Am Coll Cardiol. 2010; 56: 38-46
        • Vogelzangs N.
        • Seldenrijk A.
        • Beekman A.T.F.
        • van Hout H.P.J.
        • de Jonge P.
        • Penninx B.W.J.H.
        Cardiovascular disease in persons with depressive and anxiety disorders.
        J Affect Disord. 2010; 125: 241-248
        • Jalnapurkar I.
        • Allen M.
        • Pigott T.
        Sex differences in anxiety disorders: a review.
        J Psychiatr Depress Anxiety. 2018; 4: 3-16
      7. National Comorbidity Survey (NCS). Table 1. Lifetime prevalence of DSM-IV/WMH-CIDI disorders by sex and cohort. Available at https://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_Lifetime_Prevalence_Estimates.pdf. Accessed on May 11, 2022.

        • Vasiliadis H.-M.
        • Desjardins F.
        • Roberge P.
        • Grenier S.
        Sex differences in anxiety disorders in older adults.
        Curr Psychiatry Rep. 2020; 22: 75
        • Reiner I.C.
        • Tibubos A.N.
        • Werner A.M.
        • et al.
        The association of chronic anxiousness with cardiovascular disease and mortality in the community: results from the Gutenberg Health Study.
        Sci Rep. 2020; 1012436
        • Albert M.A.
        • Glynn R.J.
        • Buring J.
        • Ridker P.M.
        Impact of traditional and novel risk factors on the relationship between socioeconomic status and incident cardiovascular events.
        Circulation. 2006; 114: 2619-2626
        • Abdalla S.M.
        • Yu S.
        • Galea S.
        Trends in cardiovascular disease prevalence by income level in the United States.
        JAMA Netw Open. 2020; 3e2018150
        • Coulter S.A.
        Epidemiology of cardiovascular disease in women: risk, advances, and alarms.
        Tex Heart Inst J. 2011; 38: 145-147
        • Kim Y.J.
        • Lee J.S.
        • Park J.
        • et al.
        Trends in socioeconomic inequalities in five major risk factors for cardiovascular disease in the Korean population: a cross-sectional study using data from the Korea National Health and Nutrition Examination Survey, 2001–2014.
        BMJ Open. 2017; 7e014070
        • Williams J.
        • Allen L.
        • Wickramasinghe K.
        • Mikkelsen B.
        • Roberts N.
        • Townsend N.
        A systematic review of associations between non-communicable diseases and socioeconomic status within low-and lower-middle-income countries.
        J Glob Health. 2018; 8020409
        • Janković J.
        • Erić M.
        • Stojisavljević D.
        • Marinković J.
        • Janković S.
        Socio-economic differences in cardiovascular health: findings from a cross-sectional study in a middle-income country.
        PLoS One. 2015; 10e0141731
        • Schwenk T.L.
        • Kubota Y.
        Lower education level is associated with higher risk for cardiovascular disease.
        JAMA Intern Med. 2017;
        • Carter A.R.
        • Gill D.
        • Davies N.M.
        • et al.
        Understanding the consequences of education inequality on cardiovascular disease: mendelian randomisation study.
        BMJ. 2019; 365: I1855
        • Rosengren A.
        • Smyth A.
        • Rangarajan S.
        • et al.
        Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study.
        Lancet Glob Health. 2019; 7: e748-e760
        • Yusuf S.
        • Rangarajan S.
        • Teo K.
        • et al.
        Cardiovascular risk and events in 17 low-, middle-, and high-income countries.
        New England Journal of Medicine. 2014; 371: 818-827
        • Yusuf S.
        • Joseph P.
        • Rangarajan S.
        • et al.
        Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.
        N Engl J Med. 2014; 371: 818-827
        • Hamad R.
        • Nguyen T.T.
        • Bhattacharya J.
        • Glymour M.M.
        • Rehkopf D.H.
        Educational attainment and cardiovascular disease in the United States: A quasi-experimental instrumental variables analysis.
        PLoS Med. 2019; 16e1002834
        • Kilander L.
        • Berglund L.
        • Boberg M.
        • Vessby B.
        • Lithell H.
        Education, lifestyle factors and mortality from cardiovascular disease and cancer. A 25-year follow-up of Swedish 50-year-old men.
        Int J Epidemiol. 2001; 30: 1119-1126
        • Wu H.
        • Lau E.S.H.
        • Kong A.P.S.
        • et al.
        Association between educational level and cardiovascular disease and all-cause mortality in patients with type 2 diabetes: a prospective study in the Joint Asia Diabetes Evaluation Program.
        Clin Epidemiol. 2018; 10: 1561-1571
      8. Framke E. Low income and work stress contribute to link between education, heart disease and stroke. European Society of Cardiology. 2019. Available at https://www.escardio.org/The-ESC/Press-Office/Press-releases/Low-income-and-work-stress-contribute-to-link-between-education-heart-disease-and-stroke. Accessed on February 21, 2022.

        • Wong Y-k
        • Dawkins K.D.
        • Ward M.E.
        The association between deaths from myocardial infarction and household size in England and Wales.
        J Cardiovasc Risk. 2001; 8: 159-163
        • Dev R.
        • Raparelli V.
        • Pilote L.
        • et al.
        Cardiovascular health through a sex and gender lens in six South Asian countries: Findings from the WHO STEPS surveillance.
        J Glob Health. 2022; 1204020
        • Jeemon P.
        • Harikrishnan S.
        • Ganapathi S.
        • et al.
        Efficacy of a family-based cardiovascular risk reduction intervention in individuals with a family history of premature coronary heart disease in India (PROLIFIC): an open-label, single-centre, cluster randomised controlled trial.
        Lancet Glob Health. 2021; 9: e1442-e1450
        • van der Ham M.
        • Bolijn R.
        • de Vries A.
        • Ponce M.C.
        • van Valkengoed I.G.M.
        Gender inequality and the double burden of disease in low-income and middle-income countries: an ecological study.
        BMJ Open. 2021; 11e047388
        • Hassanzadeh J.
        • Moradi N.
        • Esmailnasab N.
        • Rezaeian S.
        • Bagheri P.
        • Armanmehr V.
        The correlation between gender inequalities and their health related factors in world countries: a global cross-sectional study.
        Epidemiol Res Intl. 2014; 521569
      9. Mascarenhas A. Cardiovascular diseases among women on the rise in India, finds The Lancet. Available at at https://indianexpress.com/article/india/cardiovascular-diseases-among-women-on-the-rise-in-india-finds-the-lancet-7321351/. Accessed on January 18, 2022.

        • Wells J.C.K.
        • Marphatia A.A.
        • Cole T.J.
        • McCoy D.
        Associations of economic and gender inequality with global obesity prevalence: understanding the female excess.
        Soc Sci Med. 2012; 75: 482-490
        • Jeong I.
        • Rhie J.
        • Kim I.
        • et al.
        Working hours and cardiovascular disease in Korean workers: a case‐control study.
        J Occup Health. 2013; 55: 385-391
        • Kim S.
        • McLean G.N.
        • Park S.
        The cultural context of long working hours: Workplace experiences in Korea.
        New Horizons in Adult Education and Human Resource Development. 2018; 30: 36-51
        • Pega F.
        • Náfrádi B.
        • Momen N.C.
        • et al.
        Global, regional, and national burdens of ischemic heart disease and stroke attributable to exposure to long working hours for 194 countries, 2000–2016: A systematic analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.
        Environ In. 2021; 154106595
        • Raparelli V.
        • Norris C.M.
        • Bender U.
        • et al.
        Identification and inclusion of gender factors in retrospective cohort studies: the GOING-FWD framework.
        BMJ Glob Health. 2021; 6e005413
        • Tadiri C.P.
        • Raparelli V.
        • Abrahamowicz M.
        • et al.
        Methods for prospectively incorporating gender into health sciences research.
        J Clin Epidemiol. 2021; 129: 191-197
        • Day S.
        • Mason R.
        • Lagosky S.
        • Rochon P.A.
        Integrating and evaluating sex and gender in health research.
        Health Res Policy Syst. 2016; 14: 75
        • Hoare E.
        • Stavreski B.
        • Kingwell B.A.
        • Jennings G.L.
        Australian adults' behaviours, knowledge and perceptions of risk factors for heart disease: A cross-sectional study.
        Prev Med Rep. 2017; 8: 204-209
        • Dai H.
        • Younis A.
        • Kong J.D.
        • Bragazzi N.L.
        • Wu J.
        Trends and Regional Variation in Prevalence of Cardiovascular Risk Factors and Association With Socioeconomic Status in Canada, 2005-2016.
        JAMA Netw Open. 2021; 4e2121443
        • Grau M.
        • Elosua R.
        • de Leon A.C.
        • et al.
        Cardiovascular risk factors in Spain in the first decade of the 21st Century, a pooled analysis with individual data from 11 population-based studies: the DARIOS study.
        Rev Esp Cardiol. 2011; 64: 295-304
        • Rhee E.-J.
        Prevalence and current management of cardiovascular risk factors in Korean adults based on fact sheets.
        Endocrinol Metab. 2020; 35: 85-94
        • Gebremariam L.W.
        • Chiang C.
        • Yatsuya H.
        • et al.
        Non-communicable disease risk factor profile among public employees in a regional city in northern Ethiopia.
        Sci Rep. 2018; 8: 1-11
        • Khanam F.
        • Hossain M.B.
        • Mistry S.K.
        • Afsana K.
        • Rahman M.
        Prevalence and risk factors of cardiovascular diseases among Bangladeshi adults: findings from a cross-sectional study.
        J Epidemiol Glob Health. 2019; 9: 176
        • Dhungana R.R.
        • Thapa P.
        • Devkota S.
        • et al.
        Prevalence of cardiovascular disease risk factors: a community-based cross-sectional study in a peri-urban community of Kathmandu, Nepal.
        Indian Heart J. 2018; 70: S20-S27
        • Xi Y.
        • Cao N.
        • Niu L.
        • et al.
        Prevalence and treatment of high cardiovascular disease risk in Inner Mongolia, China.
        Rev Cardiovasc Med. 2021; 22: 521-529
      10. Global Burden of Disease Compare, Viz Hub, Institute of Health Metrics and Evaluation. Available at https://vizhub.healthdata.org/gbd-compare/. Accessed on February 12, 2022.

      11. Human Development Report 2020. The next frontier. Human development and the Anthropocene. Available at https://hdr.undp.org/sites/default/files/hdr2020.pdf. Accessed on February 12, 2021.