Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: two prospective cohort studies

Abstract

Objective To examine whether overall lifestyles mediate associations of socioeconomic status (SES) with mortality and incident cardiovascular disease (CVD) and the extent of interaction or joint relations of lifestyles and SES with health outcomes. Design Population based cohort study. Setting US National Health and Nutrition Examination Survey (US NHANES, 1988-94 and 1999-2014) and UK Biobank. Participants 44 462 US adults aged 20 years or older and 399 537 UK adults aged 37-73 years. Exposures SES was derived by latent class analysis using family income, occupation or employment status, education level, and health insurance (US NHANES only), and three levels (low, medium, and high) were defined according to item response probabilities. A healthy lifestyle score was constructed using information on never smoking, no heavy alcohol consumption (women ≤1 drink/day; men ≤2 drinks/day; one drink contains 14 g of ethanol in the US and 8 g in the UK), top third of physical activity, and higher dietary quality. Main outcome measures All cause mortality was the primary outcome in both studies, and CVD mortality and morbidity in UK Biobank, which were obtained through linkage to registries. Results US NHANES documented 8906 deaths over a mean follow-up of 11.2 years, and UK Biobank documented 22 309 deaths and 6903 incident CVD cases over a mean follow-up of 8.8-11.0 years. Among adults of low SES, age adjusted risk of death was 22.5 (95% confidence interval 21.7 to 23.3) and 7.4 (7.3 to 7.6) per 1000 person years in US NHANES and UK Biobank, respectively, and age adjusted risk of CVD was 2.5 (2.4 to 2.6) per 1000 person years in UK Biobank. The corresponding risks among adults of high SES were 11.4 (10.6 to 12.1), 3.3 (3.1 to 3.5), and 1.4 (1.3 to 1.5) per 1000 person years. Compared with adults of high SES, those of low SES had higher risks of all cause mortality (hazard ratio 2.13, 95% confidence interval 1.90 to 2.38 in US NHANES; 1.96, 1.87 to 2.06 in UK Biobank), CVD mortality (2.25, 2.00 to 2.53), and incident CVD (1.65, 1.52 to 1.79) in UK Biobank, and the proportions mediated by lifestyle were 12.3% (10.7% to 13.9%), 4.0% (3.5% to 4.4%), 3.0% (2.5% to 3.6%), and 3.7% (3.1% to 4.5%), respectively. No significant interaction was observed between lifestyle and SES in US NHANES, whereas associations between lifestyle and outcomes were stronger among those of low SES in UK Biobank. Compared with adults of high SES and three or four healthy lifestyle factors, those with low SES and no or one healthy lifestyle factor had higher risks of all cause mortality (3.53, 3.01 to 4.14 in US NHANES; 2.65, 2.39 to 2.94 in UK Biobank), CVD mortality (2.65, 2.09 to 3.38), and incident CVD (2.09, 1.78 to 2.46) in UK Biobank. Conclusions Unhealthy lifestyles mediated a small proportion of the socioeconomic inequity in health in both US and UK adults; therefore, healthy lifestyle promotion alone might not substantially reduce the socioeconomic inequity in health, and other measures tackling social determinants of health are warranted. Nevertheless, healthy lifestyles were associated with lower mortality and CVD risk in different SES subgroups, supporting an important role of healthy lifestyles in reducing disease burden.

Psychological Distress and All-Cause, Cardiovascular Disease, Cancer Mortality Among Adults with and without Diabetes

“… 28 A RERI >0 and the lower limit of 95% CI > 0 suggests a synergistic (biological) interaction. 29 , 30 Generally, the effect of baseline exposure on mortality lags for several years. Therefore, we conducted sensitivity analysis by excluding participants with <2, <5, and <10 yrs of follow-up times to examine the influence of reverse causation/confounding due to pre-existing diseases in our main findings.…”

Socioeconomic Status and Its Relation to Hypertension in Rural Nepal

“…The inconsistencies in the SES and hypertension association warrant exploration of potential modifiable mediators. Lifestyle factors such as body mass index (BMI), alcohol intake, physical activity, and smoking are commonly viewed as mediators between SES and health and that healthy lifestyle might attenuate the socioeconomic inequities in health [ 26 , 27 ]. Studies from high-income countries suggest that variations in BMI, smoking, and alcohol between different SES groups [ 28 ] account for substantial proportion of inequalities in hypertension [ 10 , 29 ].…”

Regional and socioeconomic disparities in cardiovascular disease in Canada during 2005–2016: evidence from repeated nationwide cross-sectional surveys

“…The association between socioeconomic status and CVD has been well documented in previous studies. [27][28][29] However, to the best of our knowledge, the changing pattern of socioeconomic disparities in CVD in Canada over the past decade remains unclear. In this study, we found persistent absolute and relative socioeconomic inequalities in heart disease and stroke in Canada from 2005 to 2016, and the narrowing socioeconomic inequalities were only observed for heart disease among men, suggesting a failure to achieve an equitable improvement in CVD prevalence.…”