The influence of socioeconomic status on the association between unhealthy lifestyle factors and adverse health outcomes: a systematic review

Hamish M E Foster; Peter Polz; Jason M R Gill; Carlos Celis-Morales; Frances S Mair; Catherine A O'Donnell

doi:10.12688/wellcomeopenres.18708.2

The influence of socioeconomic status on the association between unhealthy lifestyle factors and adverse health outcomes: a systematic review

Wellcome Open Res. 2023 Dec 8:8:55. doi: 10.12688/wellcomeopenres.18708.2. eCollection 2023.

Authors

Hamish M E Foster¹, Peter Polz¹, Jason M R Gill², Carlos Celis-Morales², Frances S Mair¹, Catherine A O'Donnell¹

Affiliations

¹ General Practice and Primary Care, School of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland, G12 9LX, UK.
² School of Cardiovascular and Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scoland, G12 8TA, UK.

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).

Keywords: Epidemiology; Health Behaviour; Healthcare Disparities; Lifestyle; Public Health; Socioeconomic Factors.

Publication types

Systematic Review

Associated data

figshare/10.6084/m9.figshare.21701519

Grants and funding

This work was supported by Wellcome [223499; to FM]; and a Medical Research Council Clinical Research Training Fellowship [MR/T001585/1; to HF] entitled 'Understanding interactions between lifestyle and deprivation to support policy and intervention development'.