Abstract
Background/Objectives: To investigate the associations between educational attainment and 20-year cardiovascular disease (CVD) incidence, mortality, lifetime risk, and burden, and to explore the mediating role of healthy and sustainable dietary habits through a sex-specific lens. Methods: A total of 3042 CVD-free adults from the ATTICA Study were included at the 2001/2002 baseline. Educational level was treated as both continuous and ordinal variable. Adherence to the EAT-Lancet diet pattern (EAT-LDP) was assessed at baseline. Participants were followed for 20 years, with complete data on CVD outcomes available for 1988 individuals. Generalized structural equation and nested Cox regression models were used to estimate the direct and indirect effects between education attainment and 20-year CVD incidence. Moderation analysis was also conducted by incorporating interaction terms in Cox models. Results: An inverse educational gradient in CVD risk and burden was observed, particularly among females for lifetime risk estimates. Each additional year of education was associated with higher EAT-LDP adherence (β = 0.45, 95% CI: 0.40-0.50) and increased odds of physical activity (OR: 1.01, 95% CI: 1.00-1.01). These behaviors mediated part of the relationship between education and long-term CVD incidence. Among females, the cardioprotective role of EAT-LDP adherence was more evident at lower educational levels, suggesting potential effect modification. Conclusions: Educational disparities in long-term CVD outcomes are partly mediated by sustainable dietary habits. These findings highlight the need for gender-responsive and equity-focused strategies in cardiovascular prevention.