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. 2025 Dec 10;80(1):3-9.
doi: 10.1136/jech-2025-224476.

Does lifestyle explain the relationship between socioeconomic position and multimorbidity of cancer and cardiometabolic diseases? A mediation analysis applied to the European Prospective Investigation into Cancer and Nutrition

Luca Manfredi  1 , Federica Buscema  2 , Maria Teresa Giraudo  2 , Barbara Sodano  2   3 , Lisa Padroni  2 , Cinzia Destefanis  2 , Heinz Freisling  4 , Pietro Ferrari  4 , Giulia Cesaroni  5 , Sergio Uzzau  6 , Matthias B Schulze  7   8 , Calogero Saieva  9 , Rosario Tumino  10 , Elisabete Weiderpass  4 , Komodo Matta  4 , Salvatore Vaccarella  4 , Marcela Guevara  11   12   13 , Jytte Halkjær  14 , Anne Tjønneland  15 , Marta Crous-Bou  16   17 , Verena Katzke  18   19 , Toktam Pour  19 , Salvatore Panico  20 , Valeria Pala  21 , Ioanna Tzoulaki  22   23 , Sandar Tin Tin  24 , Christina C Dahm  25 , MªDolores Chirlaque  26   27 , Carlotta Sacerdote  28 , Fulvio Ricceri  2
Affiliations

Does lifestyle explain the relationship between socioeconomic position and multimorbidity of cancer and cardiometabolic diseases? A mediation analysis applied to the European Prospective Investigation into Cancer and Nutrition

Luca Manfredi et al. J Epidemiol Community Health. .

Abstract

Background: Multimorbidity is socially patterned, with lower socioeconomic position (SEP) linked to higher risk. We examined whether a Healthy Lifestyle Index (HLI) mediates the SEP-multimorbidity association and whether pathways differ by sex.

Methods: We used data from 244 886 participants in the European Prospective Investigation into Cancer and Nutrition study. HLI was derived from smoking, alcohol consumption, physical activity, body mass index and diet. SEP was categorised into low, medium and high-SEP based on education. Multimorbidity was defined as the coexistence of at least two diseases among cancer, type 2 diabetes and cardiovascular diseases. Logistic regression assessed SEP-HLI association, Cox regression SEP-multimorbidity and HLI-multimorbidity associations. Counterfactual mediation analysis estimated the natural indirect effect (NIE) and pure direct effect (PDE). Analyses were stratified by sex.

Results: Participants from lower SEP categories were older with worse health outcomes. Women had a healthier lifestyle than men across all SEP levels. In men, the hazard ratio of developing multimorbidity was 1.40 (95% CI: 1.26 to 1.54) for those with low SEP compared with high SEP, in women 1.74 (95% CI: 1.52 to 2.00). Comparing low versus high SEP, PDE for men was 1.28 (95% CI: 1.15 to 1.41), NIE was 1.09 (95% CI: 1.07 to 1.11) (proportion mediated (PM)=29%). In women, PDE was 1.65 (95% CI: 1.47 to 1.90), NIE 1.05 (95% CI: 1.03 to 1.06) (PM=11%).

Conclusions: Lifestyle behaviours partly mediated the SEP-multimorbidity association, underscoring the need to integrate considerations of socioeconomic disparities into the planning of lifestyle interventions.

Keywords: EPIDEMIOLOGY; Health inequalities; Healthy Aging; LIFE STYLE; PUBLIC HEALTH.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. Where authors are identified as personnel of the International Agency for Research on Cancer/WHO, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer/WHO.

Figures

Figure 1
Figure 1. Causal structure represented by a directed acyclic graph. C, confounders vector (age at enrolment, enrolment centre, year of enrolment, menopausal status (women)); HLI, Healthy Lifestyle Index; MM, multimorbidity; SEP, socioeconomic position.
See this image and copyright information in PMC

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