Key result
A systematic review of 6 studies found the highest all-cause mortality in those with the unhealthiest lifestyle factors and least advantaged socioeconomic status, suggesting an additive effect.
Why the study?
Less advantaged socioeconomic status groups may be disproportionately vulnerable to unhealthy lifestyle factors, but interactions between them remain poorly understood.
Does socioeconomic status modify the association between combinations of unhealthy lifestyle factors and adverse health outcomes (mortality, CVD, cancer) in adults?
Systematic Review
Does socioeconomic status modify the association between combinations of unhealthy lifestyle factors and adverse health outcomes (mortality, CVD, cancer) in adults?
Socioeconomic status may have an additive effect on the association between unhealthy lifestyle factors and mortality, with the highest risk in the least advantaged groups with the unhealthiest lifestyles.
Highest mortality in disadvantaged groups with unhealthy lifestyles supports targeted prevention; extends observational data on additive effects but leaves causal questions open.
<ns4:p> <ns4:bold>Background:</ns4:bold> <ns4:bold/> Combinations of lifestyle factors (LFs) and socioeconomic status (SES) are independently associated with cardiovascular disease (CVD), cancer, and mortality. Less advantaged SES groups may be disproportionately vulnerable to unhealthy LFs but interactions between LFs and SES remain poorly understood. This review aimed to synthesise the available evidence for whether and how SES modifies associations between combinations of LFs and adverse health outcomes. </ns4:p> <ns4:p> <ns4:bold>Methods:</ns4:bold> <ns4:bold/> Systematic review of studies that examine associations between combinations of <ns4:underline>></ns4:underline> 3 LFs and health outcomes and report data on SES influences on associations. Databases (PubMed/EMBASE/CINAHL), references, forward citations, and grey-literature were searched from inception to December 2021. Eligibility criteria were analyses of prospective adult cohorts that examined all-cause mortality or CVD or cancer mortality/incidence. </ns4:p> <ns4:p> <ns4:bold>Results:</ns4:bold> Six studies (n=42,467–399,537; 46.5–56.8 years old; 54.6–59.3% women) of five cohorts were included. All examined all-cause mortality; three assessed CVD/cancer outcomes. Four studies observed multiplicative interactions between LFs and SES, but in opposing directions. Two studies tested for additive interactions; interactions were observed in one cohort (UK Biobank) and not in another (NHANES). All-cause mortality HRs (95% CIs) for unhealthy LFs ( <ns4:italic>versus</ns4:italic> healthy LFs) from the most advantaged SES groups ranged from 0.68 (0.32–1.45) to 4.17 (2.27–7.69). Equivalent estimates from the least advantaged ranged from 1.30 (1.13–1.50) to 4.00 (2.22–7.14). In 19 analyses (including sensitivity analyses) of joint associations between LFs, SES, and all-cause mortality, highest all-cause mortality was observed in the unhealthiest LF-least advantaged suggesting an additive effect. </ns4:p> <ns4:p> <ns4:bold>Conclusions:</ns4:bold> Limited and heterogenous literature suggests that the influence of SES on associations between combinations of unhealthy LFs and adverse health could be additive but remains unclear. Additional prospective analyses would help clarify whether SES modifies associations between combinations of unhealthy LFs and health outcomes. </ns4:p> <ns4:p> <ns4:bold>Registration:</ns4:bold> <ns4:bold/> Protocol is registered with PROSPERO ( <ns4:ext-link xmlns:ns5="http://www.w3.org/1999/xlink" ext-link-type="uri" ns5:href="https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=172588">CRD42020172588</ns4:ext-link> ; 25 June 2020). </ns4:p>
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Foster et al. (2023) conducted a systematic review in Adverse health outcomes (mortality, cardiovascular disease, cancer). Unhealthy lifestyle factors and low socioeconomic status vs. Healthy lifestyle factors and high socioeconomic status was evaluated on All-cause mortality, cardiovascular disease, or cancer mortality/incidence. A systematic review of 6 studies found the highest all-cause mortality in those with the unhealthiest lifestyle factors and least advantaged socioeconomic status, suggesting an additive effect.
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