December 8, 2023Open Access
The influence of socioeconomic status on the association between unhealthy lifestyle factors and adverse health outcomes: a systematic review
Key Result
Combinations of unhealthy lifestyle factors and least advantaged socioeconomic status were associated with the highest all-cause mortality, suggesting an additive effect, though the literature remains limited and heterogeneous.
Study Design
Type
Systematic Review
Structured PICO
Does socioeconomic status modify the association between combinations of unhealthy lifestyle factors and adverse health outcomes in adults?
P
Population
Adults from 5 prospective cohorts across 6 studies, age 46.5-56.8 years, 54.6-59.3% women. Eligibility criteria were analyses of prospective adult cohorts that examined all-cause mortality or CVD/cancer mortality/incidence.
I
Intervention
Combinations of >3 unhealthy lifestyle factors (e.g., smoking, physical activity, diet) evaluated across different socioeconomic status (SES) groups.
C
Comparator
Healthy lifestyle factors within the most advantaged and least advantaged socioeconomic status groups.
O
Outcome
All-cause mortalityhard clinical
The influence of socioeconomic status on the association between combinations of unhealthy lifestyle factors and adverse health outcomes could be additive, with the highest mortality observed in those with the unhealthiest lifestyles and least advantaged SES.
Limitations
- Limited and heterogenous literature
- Meta-analysis was not appropriate due to the heterogeneity of included studies
- Only two studies examined more than one SES measure
- Only three studies attempted to reduce the chance of reverse causality by demonstrating participants were free from disease at the start of the study
Abstract
Background: 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. Methods: Systematic review of studies that examine associations between combinations of >3 LFs (eg.smoking/physical activity/diet) and health outcomes and report data on SES (eg.income/education/poverty-index) 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/cancer mortality/incidence. Results: 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 (National Health and Nutrition Examination Survey (NHANES)). All-cause mortality HRs (95% confidence intervals) for unhealthy LFs (versus 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. Conclusions: 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. Registration: Protocol is registered with PROSPERO (CRD42020172588;25 June 2020).