Introduction: Individuals with lower socioeconomic position (SEP) are at a higher risk of developing cardiovascular disease (CVD). Harmful neighborhood conditions may contribute to higher allostatic loads and also make it more difficult to achieve healthy behaviors. We investigated the relationship between SEP and incident CVD and aimed to determine whether the environment independently, and jointly with lifestyle factors, mediated this association. Methods: Data from 7,195 participants with a mean age of 59.5 years from The Maastricht Study in the Netherlands were used. The measure for SEP was education level. A standardized composite score was calculated for the environment (food environment, walkability, social cohesion) and lifestyle factors (diet, moderate-to-vigorous physical activity, alcohol, smoking). CVD incidence was defined by self-reported non-fatal events in an annual questionnaire over up to an 11-year follow-up period. Generalized structural equation modeling tested the mediating effects of the environmental and lifestyle factors, and the serial pathway of the environment through lifestyle factors between education and CVD. Results: Lower education was associated with a higher risk of developing CVD (HR: 1.08; 95% CI: 1.03, 1.12). Harmful environments independently mediated 12.4% of this association (HR: 1.01; 95% CI: 1.00, 1.02), while 62% was mediated by harmful lifestyle factors (HR: 1.04; 95% CI: 1.03, 1.05). Harmful environments through harmful lifestyle factors mediated a small proportion (3.1%) of the effect of lower education and CVD (HR: 1.00; 95% CI: 1.00, 1.00). Conclusion: This study shows that harmful lifestyle factors mediated a greater proportion of the association between low SEP and CVD while the neighborhood environment had a smaller influence, both independently and jointly. Further studies should investigate additional environmental exposures, behaviors, and risk factors on the pathway to CVD.
Chan et al. (Tue,) studied this question.