gms | German Medical Science

Past research has consistently demonstrated a correlation between socioeconomic status (SES) and health outcomes [1]. However, within the context of Germany, most studies exploring the link between social inequality and health rely solely on single socioeconomic indicators. This study aims to enhance our understanding by employing socioeconomic indices to paint a more complex picture of SES. Therefore, this work compares three socioeconomic subgroups within the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC) study, examining their diet, lifestyle, and mortality.

The EPIC study is a comprehensive cohort study spanning multiple study sides across Europe including Heidelberg, designed to explore the interplay between diet, lifestyle, genetic factors, and the onset of cancer and other chronic diseases through extensive participant data collection [2], [3]. For this work, two socioeconomic indices were applied gender-specific: The “Gesundheit in Deutschland aktuell“ (GEDA) index, developed by the Robert Koch Institute (RKI), and the EPIC-Heidelberg score (EHS), which is data-driven and created during this work with a broader array of variables [4]. The Mediterranean diet score was used to assess healthy diet and a dichotomic lifestyle score was created to compare lifestyle quality between the socioeconomic subgroups [5]. A survival analysis was performed to investigate the relationship between SES, lifestyle, and mortality. SAS and R version 4.1.3. were applied to perform statistical analysis.

Regarding healthy diet, a significant greater proportion of healthy eaters was observed for the highest GEDA group of women compared to the lowest group (by 3%). Between the EHS groups, the proportion is also larger for women with high socioeconomic status (by 4%) and greater for men of the highest EHS group (3%). Women have overall higher lifestyle scores in comparison to men. The general trend, which can be observed for both indices and sexes, is that with elevated SES, especially when comparing the middle group to the lowest group, the lifestyle score is decreasing. For both socioeconomic indices, the proportion of current or former smoker is the smallest with high SES. The most alcohol is consumed in the high SES group, especially for women and the BMI is bigger in the low SES group. Regarding physical activity, the performance is the poorest in high SES group, especially for men.

Compared to a low SES, a high SES is inversely associated with mortality, especially in the male cohort for both indices (HR=0.65/0.67 for women and 0.41/0.52 for men). Differences within the sexes were bigger in the GEDA index for women and in the EHS index for men.

Low SES and low lifestyle scores seem to increase the mortality risks for both sex (HR=1.46/1.76 for women and 2.90/3.85 for men). SES appears to have a bigger effect on mortality than lifestyle.

In conclusion, this work stresses the importance of socioeconomic indices and more complex depictions of SES for health and prevention research. Including more variables and using a data driven approach like the EHS index instead of templates like the GEDA index could offer better insight.

The authors declare that they have no competing interests.

The authors declare that an ethics committee vote is not required.