Context Previous studies may have underestimated the contribution of health behaviors to social inequalities in mortality because health behaviors were assessed only at the baseline of the study. Objective To examine the role of health behaviors in the association between socioeconomic position and mortality and compare whether their contribution differs when assessed at only one point in time to that assessed longitudinally through the follow-up. Main outcome measures All-cause and cause-specific mortality. Design, Setting, and Participants Participants are drawn from the British Whitehall II longitudinal cohort study, established in 1985 on 10,308 London based civil servants, aged 35–55 years. Analyses are based on 9,590 men and women followed for mortality until 2009. Socioeconomic position was derived from civil service employment grade (high, intermediate and low) at baseline. Smoking, alcohol consumption, diet and physical activity were assessed four times over the follow-up. Results 654 participants died during the follow-up. In analysis adjusted for sex and year of birth, those in the low socioeconomic position had 1.60 times higher risk of death from all causes than those in the high position (a rate difference of 1.94 per 1000 person-years). This association was attenuated by 42% (95% CI, 21%–94%) when health behaviors assessed at baseline were entered into the model and by 72% (95% CI, 42%–154%) when they were entered as time dependent covariates. The corresponding attenuations were 29% (95% CI, 11%–54%) and 45% (95% CI, 24%–79%) for cardiovascular mortality and 61% (95% CI, 16%–425%) and 94% (95% CI, 35%–595%) for non-cancer non-cardiovascular mortality. The difference between the baseline only and repeated assessments of health behaviors was mostly due to an increased explanatory power of diet (from 7% to 17% for all-cause mortality), physical activity (from 5% to 21% for all-cause mortality) and alcohol consumption (from 3% to 12% for all-cause mortality). The role of smoking, the strongest mediator in these analyses, did not change when using baseline or repeat assessments (from 32% to 35% for all-cause mortality). Conclusions In a civil service population in London, there was an association between socioeconomic position and mortality that was substantially accounted for by adjustment for health behaviors, particularly when the behaviors were assessed repeatedly.

AimThe metabolically healthy obese (MHO) phenotype refers to obese individuals with a favourable metabolic profile. Its prognostic value is unclear and may depend on the health outcome being examined. We examined the association of MHO phenotype with incident cardiovascular disease (CVD) and type 2 diabetes.Methods and resultsBody mass index and metabolic health, assessed using the Adult Treatment Panel-III (ATP-III) criteria, were assessed on 7122 participants (69.7% men) from the Whitehall II study, aged 39–63 years in 1991–93. Incident CVD (coronary heart disease or stroke) and type 2 diabetes were ascertained from medical screenings (every 5 years), hospital data, and registry linkage until 2009. A total of 657 individuals (9.2% of the cohort) were obese and 42.5% of these were classified as MHO in 1991–93. Over the median follow-up of 17.4 years, there were 828 incident cases of CVD and 798 incident cases of type 2 diabetes. Compared with metabolically healthy normal weight individuals, MHO subjects were at increased risk for CVD (HR = 1.97, 95% CI: 1.38–2.80) and type 2 diabetes (3.25, 95% CI: 2.32–4.54). There was excess risk in metabolically unhealthy obese compared with MHO for type 2 diabetes (1.98, 95% CI: 1.39–2.83) but not CVD (1.23, 95% CI: 0.81–1.87). Treating all measures as time varying covariates produced similar findings.ConclusionFor type 2 diabetes, the MHO phenotype is associated with lower risk than the metabolically unhealthy obese, but for CVD the risk is as elevated in both obesity phenotypes.