Report on the Joint Workshop on the Relations between Health Inequalities, Ageing and Multimorbidity, Iceland, May 3-4, 2023.

This paper is a summary of key presentations from a workshop in Iceland on May 3-4, 2023 arranged by Aarhus University and with participation of the below-mentioned scientists. Below you will find the key messages from the presentations made by: Professor Jan Vandenbroucke, Department of Clinical Epidemiology, Aarhus University, Emeritus Professor, Leiden University; Honorary Professor, London School of Hygiene & Tropical Medicine, UKProfessor, Chair Henrik Toft Sørensen, Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, DenmarkProfessor David H. Rehkopf, Director, the Stanford Center for Population Health Sciences, Stanford University, CA., USProfessor Jaimie Gradus, Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USProfessor Johan Mackenbach, Emeritus Professor, Department of Public Health, Erasmus University Rotterdam, HollandProfessor, Chair M Maria Glymour, Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, Massachusetts, USProfessor, Dean Sandro Galea, School of Public Health, Boston University, Boston, Massachusetts, USProfessor Victor W. Henderson, Departments of Epidemiology & Population Health and of Neurology & Neurological Sciences, Stanford University, Stanford, CA, US; Department of Clinical Epidemiology, Aarhus University, Aarhus, DK.

Widening educational inequalities in mortality in more recent birth cohorts: a study of 14 European countries.

BACKGROUND: Studies of period changes in educational inequalities in mortality have shown important changes over time. It is unknown whether a birth cohort perspective paints the same picture. We compared changes in inequalities in mortality between a period and cohort perspective and explored mortality trends among low-educated and high-educated birth cohorts. DATA AND METHODS: In 14 European countries, we collected and harmonised all-cause and cause-specific mortality data by education for adults aged 30-79 years in the period 1971-2015. Data reordered by birth cohort cover persons born between 1902 and 1976. Using direct standardisation, we calculated comparative mortality figures and resulting absolute and relative inequalities in mortality between low educated and high educated by birth cohort, sex and period. RESULTS: Using a period perspective, absolute educational inequalities in mortality were generally stable or declining, and relative inequalities were mostly increasing. Using a cohort perspective, both absolute and relative inequalities increased in recent birth cohorts in several countries, especially among women. Mortality generally decreased across successive birth cohorts among the high educated, driven by mortality decreases from all causes, with the strongest reductions for cardiovascular disease mortality. Among the low educated, mortality stabilised or increased in cohorts born since the 1930s in particular for mortality from cardiovascular diseases, lung cancer, chronic obstructive pulmonary disease and alcohol-related causes. CONCLUSIONS: Trends in mortality inequalities by birth cohort are less favourable than by calendar period. In many European countries, trends among more recently born generations are worrying. If current trends among younger birth cohorts persist, educational inequalities in mortality may further widen.

Socioeconomic inequalities in cancer mortality between and within countries in Europe: a population-based study.

Background: Reducing socioeconomic inequalities in cancer is a priority for the public health agenda. A systematic assessment and benchmarking of socioeconomic inequalities in cancer across many countries and over time in Europe is not yet available. Methods: Census-linked, whole-of-population cancer-specific mortality data by socioeconomic position, as measured by education level, and sex were collected, harmonized, analysed, and compared across 18 countries during 1990-2015, in adults aged 40-79. We computed absolute and relative educational inequalities; temporal trends using estimated-annual-percentage-changes; the share of cancer mortality linked to educational inequalities. Findings: Everywhere in Europe, lower-educated individuals have higher mortality rates for nearly all cancer-types relative to their more highly-educated counterparts, particularly for tobacco/infection-related cancers [relative risk of lung cancer mortality for lower- versus higher-educated = 2.4 (95% confidence intervals: 2.1-2.8) among men; = 1.8 (95% confidence intervals: 1.5-2.1) among women]. However, the magnitude of inequalities varies greatly by country and over time, predominantly due to differences in cancer mortality among lower-educated groups, as for many cancer-types higher-educated have more similar (and lower) rates, irrespective of the country. Inequalities were generally greater in Baltic/Central/East-Europe and smaller in South-Europe, although among women large and rising inequalities were found in North-Europe (relative risk of all cancer mortality for lower- versus higher-educated ≥1.4 in Denmark, Norway, Sweden, Finland and the England/Wales). Among men, rate differences (per 100,000 person-years) in total-cancer mortality for lower-vs-higher-educated groups ranged from 110 (Sweden) to 559 (Czech Republic); among women from approximately null (Slovenia, Italy, Spain) to 176 (Denmark). Lung cancer was the largest contributor to inequalities in total-cancer mortality (between-country range: men, 29-61%; women, 10-56%). 32% of cancer deaths in men and 16% in women (but up to 46% and 24%, respectively in Baltic/Central/East-Europe) were associated with educational inequalities. Interpretation: Cancer mortality in Europe is largely driven by levels and trends of cancer mortality rates in lower-education groups. Even Nordic-countries, with a long-established tradition of equitable welfare and social justice policies, witness increases in cancer inequalities among women. These results call for a systematic measurement, monitoring and action upon the remarkable socioeconomic inequalities in cancer existing in Europe. Funding: This study was done as part of the LIFEPATH project, which has received financial support from the European Commission (Horizon 2020 grant number 633666), and the DEMETRIQ project, which received support from the European Commission (grant numbers FP7-CP-FP and 278511). SV and WN were supported by the French Institut National du Cancer (INCa) (Grant number 2018-116). PM was supported by the Academy of Finland (#308247, # 345219) and the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No 101019329). The work by Mall Leinsalu was supported by the Estonian Research Council (grant PRG722).

Estimation of Socioeconomic Inequalities in Mortality in Japan Using National Census-linked Longitudinal Mortality Data.

BACKGROUND: We aimed to develop census-linked longitudinal mortality data for Japan and assess their validity as a new resource for estimating socioeconomic inequalities in health. METHODS: Using deterministic linkage, we identified, from national censuses for 2000 and 2010 and national death records, persons and deceased persons who had unique personal identifiers (generated using sex, birth year/month, address, and marital status). For the period 2010-2015, 1,537,337 Japanese men and women aged 30-79 years (1.9% in national census) were extracted to represent the sample population. This population was weighted to adjust for confounding factors. We estimated age-standardized mortality rates (ASMRs) by education level and occupational class. The slope index of inequality (SII) and relative index inequality (RII) by educational level were calculated as inequality measures. RESULTS: The reweighted sample population's mortality rates were somewhat higher than those of the complete registry, especially in younger age-groups and for external causes. All-cause ASMRs (per 100,000 person-years) for individuals aged 40-79 years with high, middle, and low education levels were 1,078 (95% confidence interval [CI], 1,051-1,105), 1,299 (95% CI, 1,279-1,320), and 1,670 (95% CI, 1,634-1,707) for men, and 561 (95% CI, 536-587), 601 (95% CI, 589-613), and 777 (95% CI, 745-808) for women, respectively, during 2010-2015. SII and RII by educational level increased among both sexes between 2000-2005 and 2010-2015, which indicates that mortality inequalities increased. CONCLUSION: The developed census-linked longitudinal mortality data provide new estimates of socioeconomic inequalities in Japan that can be triangulated with estimates obtained with other methods.

Socioeconomic inequalities in self-rated health in Japan, 32 European countries and the United States: an international comparative study.

AIMS: Japan is known as a country with low self-rated health despite high life expectancy. We compared socioeconomic inequalities in self-rated health in Japan with those in 32 European countries and the US using nationally representative samples. METHODS: We analysed individual data from the Comprehensive Survey of Living Conditions (Japan), the European Union Statistics on Income and Living Conditions, and the Behavioral Risk Factor Surveillance System (US) in 2016. We used ordered logistic regression models with four ordinal categories of self-rated health as an outcome, and educational level or occupational class as independent variables, controlling for age. RESULTS: In Japan, about half the population perceived their health as 'fair', which was much higher than in Europe (≈20-40%). The odds ratios of lower self-rated health among less educated men compared with more educated were 1.72 (95% confidence interval (CI) 1.61-1.85) in Japan, and ranged from 1.67 to 4.74 in Europe (pooled; 2.10 (95% CI 2.01-2.20)), and 6.65 (95% CI 6.22-7.12) in the US. The odds ratios of lower self-rated health among less educated women were 1.79 (95% CI 1.65-1.95) in Japan, and ranged from 1.89 to 5.30 in Europe (pooled; 2.43 (95% CI 2.33-2.54)), and 8.82 (95% CI 8.29-9.38) in the US. Socioeconomic inequalities were large when self-rated health was low for European countries, but Japan and the US did not follow the pattern. CONCLUSIONS: Japan has similar socioeconomic gradient patterns to European countries for self-rated health, and our findings revealed smaller socioeconomic inequalities in self-rated health in Japan compared with those in western countries.

Projecting years in good health between age 50-69 by education in the Netherlands until 2030 using several health indicators - an application in the context of a changing pension age.

OBJECTIVE: We investigate whether there are changes over time in years in good health people can expect to live above (surplus) or below (deficit) the pension age, by level of attained education, for the past (2006), present (2018) and future (2030) in the Netherlands. METHODS: We used regression analysis to estimate linear trends in prevalence of four health indicators: self-assessed health (SAH), the Organization for Economic Co-operation and Development (OECD) functional limitation indicator, the OECD indicator without hearing and seeing, and the activities-of-daily-living (ADL) disability indicator, for individuals between 50 and 69 years of age, by age category, gender and education using the Dutch National Health Survey (1989-2018). We combined these prevalence estimates with past and projected mortality data to obtain estimates of years lived in good health. We calculated how many years individuals are expected to live in good health above (surplus) or below (deficit) the pension age for the three points in time. The pension ages used were 65 years for 2006, 66 years for 2018 and 67.25 years for 2030. RESULTS: Both for low educated men and women, our analyses show an increasing deficit of years in good health relative to the pension age for most outcomes, particularly for the SAH and OECD indicator. For high educated we find a decreasing surplus of years lived in good health for all indicators with the exception of SAH. For women, absolute inequalities in the deficit or surplus of years in good health between low and high educated appear to be increasing over time. CONCLUSIONS: Socio-economic inequalities in trends of mortality and the prevalence of ill-health, combined with increasing statutory pension age, impact the low educated more adversely than the high educated. Policies are needed to mitigate the increasing deficit of years in good health relative to the pension age, particularly among the low educated.

Patient cost-sharing, mental health care and inequalities: A population-based natural experiment at the transition to adulthood.

BACKGROUND: Patient cost-sharing has been increasing around the world, despite the evidence that it reduces both unnecessary and necessary health care utilisation. Financial barriers could compound to poor transitional care into adulthood, when forgoing mental health treatment may have long-term consequences on health and development. We evaluate the impact of increasing deductibles on mental health care use by young adults, and the heterogeneous effects for vulnerable groups. METHODS: We use individual administrative records for 1,541,210 individuals between 17 and 19 years of age, living in the Netherlands. We implement a difference-in-discontinuity design that exploits an increase in the deductible of about 180 euros, between 2009 and 2014, and the deductible exemption for those below 18 years old. Finally, we study subgroup effects by household income, level of mental health care expenditure and medication use for mental disorders. RESULTS: Our results show that increasing deductibles reduced the probability of mental health care use at the transition to adulthood by 13.6% for females (-13.6%, CI 95%: -22.1%, -5.2%), and by 5.3% for males (-5.3%, CI 95%: -11.8%, 1.2%). The reduction was larger among females in the lowest (-18.9%, CI 95%: -35.4%, -2.3%) and second lowest (-21.3%, CI 95%: -36.7%, -5.9%) income quartiles. Additionally, we find increased treatment cessation in high deductible years to happen across all levels of mental health care need. CONCLUSIONS: Our findings indicate that cost-sharing is compounding to existing disruptions in care at the transition between children/adolescent and adult services. The larger reductions in mental health care use among low-income females uncover the role of the deductible increase in widening mental health care inequalities. Increased treatment cessation even among high-intensity users suggests potential long-term consequences for individuals, the health system, and society.

Trends and socioeconomic inequalities in self-rated health in Japan, 1986-2016.

INTRODUCTION: Despite having very high life expectancy, Japan has relatively poor self-rated health, compared to other high-income countries. We studied trends and socioeconomic inequalities in self-rated health in Japan using nationally representative data. METHODS: The Comprehensive Survey of Living Conditions was analyzed, every 3 years (n ≈ 0.6-0.8 million/year) from 1986 to 2016. Whereas previous studies dichotomized self-rated health as an outcome, we used four categories: very good, good, fair, and bad/very bad. Proportional odds ordinal logistic regression models are used, with ordinal scale self-rated health as an outcome, and age category, survey year and occupational class or educational level as independent variables. RESULTS: In 2016, the age-adjusted percentages for self-rated health categorized as very good, good, fair, and bad/very bad, were 24.0, 17.1, 48.7, and 10.2% among working-age men, and 21.6, 17.5, 49.4, and 11.5% among working-age women, respectively. With 1986 as the reference year, the odds ratios (ORs) of less good self-rated health were lowest in 1995 (0.69; 95% Confidence Interval [95% CI]: 0.66-0.71 of working-age men), and highest in 2010 (1.23 [95% CI: 1.19-1.27]). The ORs of male, lower non-manual workers (compared to upper non-manual) increased from 1.12 (95% CI: 1.07-1.17) in 2010 to 1.20 (95% CI: 1.15-1.26) in 2016. Between 2010 and 2016, the ORs of working-age men with middle and low levels of education (compared to a high level of education) increased from 1.22 (95% CI: 1.18-1.27) to 1.34 (95% CI: 1.29-1.38), and from 1.47 (95% CI: 1.39-1.56) to 1.75 (95% CI: 1.63-1.88), respectively. The ORs of working-age women with middle and low levels of education also increased from 1.22 (95% CI: 1.17-1.28) to 1.32 (95% CI: 1.26-1.37), and from 1.74 (95% CI: 1.61-1.88) to 2.03 (95% CI: 1.87-2.21) during the same period. CONCLUSION: Japan has the unique feature that approximately 50% of the survey respondents rated their self-rated health as fair, but with important variations over time and between socioeconomic groups. In-depth studies of the role of socioeconomic conditions may shed light on the reasons for the high prevalence of poor self-rated health in Japan.

Trends in inequalities in disability in Europe between 2002 and 2017.

BACKGROUND: Monitoring socioeconomic inequalities in population health is important in order to reduce them. We aim to determine if educational inequalities in Global Activity Limitation Indicator (GALI) disability have changed between 2002 and 2017 in Europe (26 countries). METHODS: We used logistic regression to quantify the annual change in disability prevalence by education, as well as the annual change in prevalence difference and ratio, both for the pooled sample and each country, as reported in the European Union Statistics on Income and Living Conditions (EU-SILC) and the European Social Survey (ESS) for individuals aged 30-79 years. RESULTS: In EU-SILC, disability prevalence tended to decrease among the high educated. As a result, both the prevalence difference and the prevalence ratio between the low and high educated increased over time. There were no discernible trends in the ESS. However, there was substantial heterogeneity between countries in the magnitude and direction of these changes, but without clear geographical patterns and without consistency between surveys. CONCLUSIONS: Socioeconomic inequalities in disability appear to have increased over time in Europe between 2002 and 2017 as per EU-SILC, and have persisted as measured by the ESS. Efforts to further harmonise disability instruments in international surveys are important, and so are studies to better understand international differences in disability trends and inequalities.

Determinants of educational inequalities in disability-free life expectancy between ages 35 and 80 in Europe.

Socioeconomic inequalities in disability-free life expectancy (DFLE) exist across all European countries, yet the driving determinants of these differences are not completely known. We calculated the impact on educational inequalities in DFLE of equalizing the distribution of eight risk factors for mortality and disability using register-based mortality data and survey data from 15 European countries for individuals between 35 and 80 years old. From the selected risk factors, the ones that contribute the most to the educational inequalities in DFLE are low income, high body-weight, smoking (for men), and manual occupation of the father. Potentially large reductions in inequalities can be achieved in Eastern European countries, where educational inequalities in DFLE are also the largest.

Smoking and inequalities in mortality in 11 European countries: a birth cohort analysis.

PURPOSE: To study the trends of smoking-attributable mortality among the low and high educated in consecutive birth cohorts in 11 European countries. METHODS: Register-based mortality data were collected among adults aged 30 to 79 years in 11 European countries between 1971 and 2012. Smoking-attributable deaths were estimated indirectly from lung cancer mortality rates using the Preston-Glei-Wilmoth method. Rate ratios and rate differences among the low and high-educated were estimated and used to estimate the contribution of inequality in smoking-attributable mortality to inequality in total mortality. RESULTS: In most countries, smoking-attributable mortality decreased in consecutive birth cohorts born between 1906 and 1961 among low- and high-educated men and high-educated women, but not among low-educated women among whom it increased. Relative educational inequalities in smoking-attributable mortality increased among both men and women with no signs of turning points. Absolute inequalities were stable among men but slightly increased among women. The contribution of inequality in smoking-attributable mortality to inequality in total mortality decreased in consecutive generations among men but increased among women. CONCLUSIONS: Smoking might become less important as a driver of inequalities in total mortality among men in the future. However, among women, smoking threatens to further widen inequalities in total mortality.

Determinants of inequalities in years with disability: an international-comparative study.

BACKGROUND: Persons with a lower socioeconomic position spend more years with disability, despite their shorter life expectancy, but it is unknown what the important determinants are. This study aimed to quantify the contribution to educational inequalities in years with disability of eight risk factors: father's manual occupation, low income, few social contacts, smoking, high alcohol consumption, high body-weight, low physical exercise and low fruit and vegetable consumption. METHODS: We collected register-based mortality and survey-based disability and risk factor data from 15 European countries covering the period 2010-14 for most countries. We calculated years with disability between the ages of 35 and 80 by education and gender using the Sullivan method, and determined the hypothetical effect of changing the prevalence of each risk factor to the prevalence observed among high educated ('upward levelling scenario'), using Population Attributable Fractions. RESULTS: Years with disability among low educated were higher than among high educated, with a difference of 4.9 years among men and 5.5 years among women for all countries combined. Most risk factors were more prevalent among low educated. We found the largest contributions to inequalities in years with disability for low income (men: 1.0 year; women: 1.4 year), high body-weight (men: 0.6 year; women: 1.2 year) and father's manual occupation (men: 0.7 year; women: 0.9 year), but contributions differed by country. The contribution of smoking was relatively small. CONCLUSIONS: Disadvantages in material circumstances (low income), circumstances during childhood (father's manual occupation) and high body-weight contribute to inequalities in years with disability.

Widening Socioeconomic Inequalities in Smoking in Japan, 2001-2016.

BACKGROUND: Japan is one of the world's largest tobacco epidemic countries but few studies have focused on socioeconomic inequalities. We aimed to examine whether socioeconomic inequalities in smoking have reduced in Japan in recent times. METHODS: We analyzed data from the Comprehensive Survey of Living Conditions, a large nationally representative survey conducted every 3 years (n ≈ 700,000 per year) in Japan, during 2001-2016. Age-standardized smoking prevalence was computed based on occupational class and educational level. We calculated smoking prevalence difference (PD) and ratio (PR) of (a) manual workers versus upper non-manual workers and (b) low versus high educational level. The slope index of inequality (SII) and relative index inequality (RII) by educational level were used as inequality measures. RESULTS: Overall smoking prevalence (25-64 years) decreased from 56.0% to 38.4% among men and from 17.0% to 13.0% among women during 2001-2016. The PD between manual and upper non-manual workers (25-64 years) increased from 11.9% (95% confidence interval [CI], 11.0-12.9%) to 14.6% (95% CI, 13.5-15.6%) during 2001-2016. In 2016, smoking prevalence (25-64 years) for low, middle, and highly educated individuals were 57.8%, 43.9%, and 27.8% for men, and 34.7%, 15.9%, and 5.6% for women, respectively. SII and RII by educational level increased among both sexes. Larger socioeconomic differences in smoking prevalence were observed in younger generations, which suggests that socioeconomic inequalities in smoking evolve in a cohort pattern. CONCLUSIONS: Socioeconomic inequalities in smoking widened between 2001 and 2016 in Japan, which indicates that health inequalities will continue to exist in near future.

Changing social inequalities in smoking, obesity and cause-specific mortality: Cross-national comparisons using compass typology.

BACKGROUND: In many countries smoking rates have declined and obesity rates have increased, and social inequalities in each have varied over time. At the same time, mortality has declined in most high-income countries, but gaps by educational qualification persist-at least partially due to differential smoking and obesity distributions. This study uses a compass typology to simultaneously examine the magnitude and trends in educational inequalities across multiple countries in: a) smoking and obesity; b) smoking-related mortality and c) cause-specific mortality. METHODS: Smoking prevalence, obesity prevalence and cause-specific mortality rates (35-79 year olds by sex) in nine European countries and New Zealand were sourced from between 1980 and 2010. We calculated relative and absolute inequalities in prevalence and mortality (relative and slope indices of inequality, respectively RII, SII) by highest educational qualification. Countries were then plotted on a compass typology which simultaneously examines trends in the population average rates or odds on the x-axis, RII on the Y-axis, and contour lines depicting SII. FINDINGS: Smoking and obesity. Smoking prevalence in men decreased over time but relative inequalities increased. For women there were fewer declines in smoking prevalence and relative inequalities tended to increase. Obesity prevalence in men and women increased over time with a mixed picture of increasing absolute and sometimes relative inequalities. Absolute inequalities in obesity increased for men and women in Czech Republic, France, New Zealand, Norway, for women in Austria and Lithuania, and for men in Finland. Cause-specific mortality. Average rates of smoking-related mortality were generally stable or increasing for women, accompanied by increasing relative inequalities. For men, average rates were stable or decreasing, but relative inequalities increased over time. Cardiovascular disease, cancer, and external injury rates generally decreased over time, and relative inequalities increased. In Eastern European countries mortality started declining later compared to other countries, however it remained at higher levels; and absolute inequalities in mortality increased whereas they were more stable elsewhere. CONCLUSIONS: Tobacco control remains vital for addressing social inequalities in health by education, and focus on the least educated is required to address increasing relative inequalities. Increasing obesity in all countries and increasing absolute obesity inequalities in several countries is concerning for future potential health impacts. Obesity prevention may be increasingly important for addressing health inequalities in some settings. The compass typology was useful to compare trends in inequalities because it simultaneously tracks changes in rates/odds, and absolute and relative inequality measures.

Educational inequalities in mortality amenable to healthcare. A comparison of European healthcare systems.

BACKGROUND: Educational inequalities in health and mortality in European countries have often been studied in the context of welfare regimes or political systems. We argue that the healthcare system is the national level feature most directly linkable to mortality amenable to healthcare. In this article, we ask to what extent the strength of educational differences in mortality amenable to healthcare vary among European countries and between European healthcare system types. METHODS: This study uses data on mortality amenable to healthcare for 21 European populations, covering ages 35-79 and spanning from 1998 to 2006. ISCED education categories are used to calculate relative (RII) and absolute inequalities (SII) between the highest and lowest educated. The healthcare system typology is based on the latest available classification. Meta-analysis and ANOVA tests are used to see if and how they can explain between-country differences in inequalities and whether any healthcare system types have higher inequalities. RESULTS: All countries and healthcare system types exhibited relative and absolute educational inequalities in mortality amenable to healthcare. The low-supply and low performance mixed healthcare system type had the highest inequality point estimate for the male (RII = 3.57; SII = 414) and female (RII = 3.18; SII = 209) population, while the regulation-oriented public healthcare systems had the overall lowest (male RII = 1.78; male SII = 123; female RII = 1.86; female SII = 78.5). Due to data limitations, results were not robust enough to make substantial claims about typology differences. CONCLUSIONS: This article aims at discussing possible mechanisms connecting healthcare systems, social position, and health. Results indicate that factors located within the healthcare system are relevant for health inequalities, as inequalities in mortality amenable to medical care are present in all healthcare systems. Future research should aim at examining the role of specific characteristics of healthcare systems in more detail.

Special Report: The Biology of Inequalities in Health: The Lifepath Consortium.

Funded by the European Commission Horizon 2020 programme, the Lifepath research consortium aimed to investigate the effects of socioeconomic inequalities on the biology of healthy aging. The main research questions included the impact of inequalities on health, the role of behavioral and other risk factors, the underlying biological mechanisms, the efficacy of selected policies, and the general implications of our findings for theories and policies. The project adopted a life-course and comparative approach, considering lifetime effects from childhood and adulthood, and pooled data on up to 1.7 million participants of longitudinal cohort studies from Europe, USA, and Australia. These data showed that socioeconomic circumstances predicted mortality and functional decline as strongly as established risk factors currently targeted by global prevention programmes. Analyses also looked at socioeconomically patterned biological markers, allostatic load, and DNA methylation using richly phenotyped cohorts, unraveling their association with aging processes across the life-course. Lifepath studies suggest that socioeconomic circumstances are embedded in our biology from the outset-i.e., disadvantage influences biological systems from molecules to organs. Our findings have important implications for policy, suggesting that (a) intervening on unfavorable socioeconomic conditions is complementary and as important as targeting well-known risk factors, such as tobacco and alcohol consumption, low fruit and vegetable intake, obesity and a sedentary lifestyle, and that (b) effects of preventive interventions in early life integrate interventions in adulthood. The report has an executive summary that refers to the different sections of the main paper.

How does cultural capital keep you thin? Exploring unique aspects of cultural class that link social advantage to lower body mass index.

A widely used indicator for cultural class is strongly related to a lower body mass index (BMI): cultural capital measured as 'highbrow' taste. This study's objective was to theorise and measure aspects of cultural class that are more plausibly linked to low BMI, and subsequently explore their relevance. Building on Bourdieusian theory we derive four of those aspects: 'refinement' (valuing form and appearance over function and substance), 'asceticism' (self-imposed constraints), 'diversity' (appreciation of variety in and of itself) and 'reflexivity' (reflexive deliberation and internal dialogue). Using standardised interviews with 597 participants in the Dutch GLOBE study in 2016, we subsequently demonstrate: (i) newly developed survey items can reliably measure four aspects of cultural class: 'asceticism', 'general refinement', 'food refinement' and 'reflexivity' (Cronbach's alphas between 0.67-0.77); (ii) embodied/objectified cultural capital (i.e. 'highbrow' taste) was positively associated with general refinement, food refinement and reflexivity, whereas institutionalised cultural capital (i.e. education) was positively associated with asceticism and reflexivity; (iii) asceticism, general refinement, reflexivity, but not food refinement, were associated with a lower BMI; (iv) asceticism, general refinement and reflexivity together accounted for 52% of the association between embodied/objectified cultural capital and BMI, and 38% of the association between institutionalised cultural capital and BMI.