As expected, the prevalence of seven out of nine well-established cardiovascular risk factors was higher in males than in females. Among women, the prevalence of most of the studied cardiovascular risk factors was higher in lower SEP groups. The main exception was smoking, which increased with education and occupation. Among men, lower SEP was associated with a higher prevalence of diabetes, excessive alcohol intake and depression in a graded mode.
Portugal is an interesting case-study due to the behavioral changes associated with a rapid transition to political democracy occurring in the seventies. This transition, catalyzed by the cultural elite, resulted in a rapid improvement in living standards, essentially marked by an increased access to consumer’s goods, not always accompanied by parallel social and cultural changes, particularly among the lowest SEP group. Although these changes were led to by an economic capital improvement across all social strata, this increment was proportionally smaller among the lower SEP groups, resulting in an increasingly unequal society in the economic dimension 
. In fact, compared to other European Union nations, Portugal is still one of the most unequal countries 
. The fact that our sample was composed by subjects aged 40 years or older around the year 2000 implies that participants have been differently exposed to both historic periods. We believe that the historical cultural beliefs and practices captured throughout the lifecourse frame the wide socioeconomic gaps discernible in our study.
While health related practices occurring in the early years of life impact on later health behaviors, they are also strongly associated with other social constructions such as education or occupation in adulthood. Consistent with other studies 
, socioeconomic gradients were steeper and more common among females. The clear gradients observed in women imply that the adoption of particular health behaviors is more dependent on material and symbolic conditions. For example, in our sample, the social meanings attached to smoking symbolize higher position for women, while fruits and vegetables consumption translate concern with the promotion of healthy lifestyles which is more evident among higher SEP women. The direction of these social gradients may seem contradictory, but they should be interpreted as reflecting the different mechanisms underlying the associations between SEP and specific risk factors, in a given secular time frame.
Hypertension was more prevalent among lower SEP women, as in other Mediterranean populations 
. The fact that lower SEP women were more frequently aware of their condition suggests a differential healthcare service utilization pattern and its role in hypertension diagnosis. However, heterogeneity in the white coat effect across gender, SEP and behavior categories could also explain this observation. The ambulatory white coat effect has been reported to be higher in women, in older, obese and non-smoking subjects and in patients on antihypertensive drug treatment 
. If the same applies to our population, part of the increment in prevalence of hypertension among the lower SEP females may be explained by these factors, since hypertensive women were older, more obese, less frequently smokers and more frequently treated with antihypertensive drugs (data not shown).
Among women, education, but not occupation, was associated with hypercholesterolemia, which is consistent with other studies 
. Education has a more profound effect than occupation on behaviors and attitudes associated with hypercholesterolemia 
. Hypercholesterolemia was less prevalent among the least educated women and among men with 5–11 complete years of education, which implies that education has a more expectable effect on hypercholesterolemia among females. Conversely, hypercholesterolemia was more prevalent among men engaged in upper white collar occupations. Although chance may account for this pattern, another explanation is possible. In Portugal, upper white collar occupations are more dependent on education in women than in men 
. In our sample, among upper white collar subjects, the proportion of less than 5 completed years of education was 3 times higher in men than in women. Thus, the higher than expected prevalence of hypercholesterolemia in upper white collar men may be partially explained by the relative excess of less educated men in the highest occupations.
Smoking was more common among higher SEP women, reflecting Portugal’s position in the smoking epidemic 
. Although most western populations are now at the fourth and last stage of the epidemic, with the prevalence declining in both sexes, and smoking being more common in lower social classes 
, southern European countries are still at the third stage, with the prevalence of smoking rapidly decreasing in men and reaching its peak among women 
. However, it is important to note that the data used throughout this paper were collected circa 2000 and do not represent the present Portuguese situation regarding smoking habits. In fact, according to the 2005/2006 National Health Survey 
, the most educated women presented a lower smoking prevalence than those with an intermediate educational level, reinforcing the expected dynamic nature of these associations. Furthermore, although our sample only comprised people 40 years or older, cohort effects were notable. The gradient between SEP and smoking was steeper among older women, when compared to those of younger age (data not shown). Although the cross-sectional nature of our study limits our ability to assess time-trends in health inequalities, we argue that this observation points to a decreasing impact of a higher social position on smoking among females.
The lowest levels of education or occupation were associated with a higher prevalence of sedentariness among women, which is consistent with other European populations 
. On the other hand, education was not associated with this outcome among men. Only blue collar men presented a higher prevalence of this risk factor. Either these men believe that their more physically demanding occupations argue against the need for any additional physical activity or they engage in less physically demanding leisure-time activities. These hypotheses are supported by the fact that occupational physical activity is an important determinant of leisure-time physical activity, particularly among individuals of low social standing 
The prevalence of excessive alcohol intake was higher and the socioeconomic gradient steeper in men than in women. In a review of social inequalities in alcohol consumption, the prevalence of heavy drinking tended to be higher among the most educated women and the least educated men. The exception to this pattern was observed in the Italian population, where heavy alcohol consumption was more common among the least educated women 
. Our results agree with this observation and point to the specificity of southern European populations regarding this behavior.
Gender is grounded on cultural and ideological uses and meanings that vary with time and space 
. In general, there is consensus within societies regarding what are adequate feminine or masculine characteristics 
. Contrasting with femininity, hegemonic masculinity is commonly associated with potentially harmful health-related beliefs in contemporary western societies and men tend to experience comparatively greater social pressure to endorse corresponding behaviors 
. High social classes can change their “gender’s repertoire” on health and illness narratives in order to maintain social distinction and authority, particularly in domains where conventional gender roles are threatened 
. In endorsing hegemonic gender ideals with health behaviors, whereas men reproduce cultural beliefs that they are stronger and less vulnerable, women feel responsible for the promotion of healthy lifestyles 
. The fact that most of our studied outcomes were more prevalent among men is in agreement with this vision, since most of these are related to unhealthy behaviors such as low consumption of fresh fruits and vegetables, smoking or drinking.
Study Strengths and Limitations
This study adds to the literature a comparison of the gender-specific distribution of several important risk factors across categories of education and occupation in a European developed population. Specifically, the relevance of approaching this issue in Portugal is reinforced by reported large health inequalities 
. The population-based nature of our study design allowed a comprehensive case ascertainment, minimizing detection bias. Most of the studied outcomes were defined using objective and valid instruments, avoiding problems of differential misclassification that are more common with the exclusive use of self-reported information. The studied population included subjects with prevalent coronary heart disease. We repeated the analysis after excluding 77 (7.8%) women and 65 (9%) men with personal history of prevalent coronary heart disease (self-reported angina or myocardial infarction, or electrocardiographic evidence of previous myocardial infarction). The standardized prevalence of all risk factors across education or occupation categories remained similar. Thus, the overall interpretation of results remains the same.
Some limitations of the present study warrant discussion. The proportion of participation of 70% may introduce selection bias. However, in a previous methodological article on the effects of the sampling procedures in this community-based study 
, Ramos et al. showed that participants were significantly younger and more likely to be females than non-participants, while there were no significant differences regarding education, occupation or marital status. Furthermore, non-participation had little or no impact on risk estimates of myocardial infarction, according to the demographic and social variables assessed, including education and occupation. This does not mean that data are free from selection bias, because it only involves the limited amount of information obtained from non-participants. Although the studied outcomes were not the same, the outcomes in the current study are in fact established risk factors for myocardial infarction. Therefore, non-response bias with respect to the characteristics assessed is unlikely to have played a major part in this study. Although limiting the generalizability of our findings, we excluded participants aged less than 40 years due to the low prevalence of most risk factors in younger ages and to avoid extreme cohort effects when comparing education or occupation categories. Also limiting the external validity of our study is the fact that our sample was exclusively drawn from an urban population. Non-inclusion of subjects belonging to rural settings may have led to an overall underestimation of the frequency of lower SEP subjects. However, we believe it is of interest to thoroughly characterize urban inequalities, especially since the proportion of urban population has been rising. Also, it is plausible that the same education and occupation might not represent the same SEP, and the frequency of cardiovascular risk factors by education/occupation may vary according to urban or rural settings. Women categorized as housewives are a heterogeneous socioeconomic group, and the absence of information on education or occupation of other household elements, usually the one with highest SEP, made it impossible to classify women that reported never having had a paid occupation. There is a large amount of studies showing that unemployed people incur in a multiplicity of elevated health risks, namely those related to cardiovascular disease 
, through a variety of mechanisms 
. The small number of unemployed participants in our sample hampered our ability to analyze them as an independent stratum. Although we used a validated scale to quantify depressive symptoms, this measure is not equivalent to a clinical diagnosis of depression. Additionally, we could not assess this risk factor in a subsample of older, lower SEP subjects. Still, we observed an increase in depressive symptoms frequency across lowering categories of SEP, especially among women. Assuming subjects excluded from this analysis were more likely to be depressed, we may have underestimated the prevalence of this risk factor among subjects belonging to lower SEP groups.
The historical cultural beliefs and practices captured throughout the lifecourse frame the wide socioeconomic gradients observable in our study. While men were more exposed to most risk factors, the clearer associations between SEP and risk factors among women support that their adoption of particular healthy behaviors is more dependent on material and symbolic conditions. Thus, the adoption of healthier lifestyles may depend on a reconfiguration of hegemonic gender roles. Although behavioral factors like smoking, physical activity and fruit and vegetable consumption account for an important fraction of cardiovascular disease, preventive efforts focusing entirely on individual behaviors are unlikely to significantly modify socioeconomic inequalities in health outcomes. To fully address the issue of health inequalities, interventions within the health systems should be complemented with population-based policies and health promotion initiatives specifically designed to reduce socioeconomic gradients.