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.

Fig 1

Associations of healthy lifestyle score with mortality and incident cardiovascular disease (CVD) by socioeconomic status (SES). In the US National Health and Nutrition Examination Survey (US NHANES), models included US population and study design weights to account for the complex survey design. Hazard ratios were adjusted for age, sex, marital status (US NHANES only), self-reported race, acculturation, study center (UK Biobank only), body mass index, and prevalent comorbidities (including history of hypertension, diabetes, CVD, cancer, chronic bronchitis, emphysema, or chronic obstructive pulmonary disease). Only those free from CVD at baseline were included in the analysis for incident CVD. Multiplicative interaction was evaluated using hazard ratios for the product term between the healthy lifestyle score (0 or 1 point v 3 or 4 points) and SES (low v high), and the multiplicative interaction was statistically significant when its confidence interval did not include 1. Additive interaction was evaluated using relative excess risk due to interaction (RERI) between the healthy lifestyle score (0 or 1 point v 3 or 4 points) and SES (low v high), and the additive interaction was statistically significant when its confidence interval did not include 0

Fig 2

Joint associations of healthy lifestyle score and socioeconomic status with mortality and incident cardiovascular disease (CVD). In the US National Health and Nutrition Examination Survey (US NHANES), models included US population and study design weights to account for the complex survey design. Hazard ratios were adjusted for age, sex, marital status (US NHANES only), self-reported race, acculturation, study center (UK Biobank only), body mass index, and prevalent comorbidities (including history of hypertension, diabetes, CVD, cancer, chronic bronchitis, emphysema, or chronic obstructive pulmonary disease). Only those free from CVD at baseline were included in the analysis for incident CVD