{
  "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.",
  "authors": [
    {
      "affiliations": [
        "Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy"
      ],
      "name": "Luca Manfredi"
    },
    {
      "affiliations": [
        "Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy"
      ],
      "name": "Federica Buscema"
    },
    {
      "affiliations": [
        "Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy"
      ],
      "name": "Maria Teresa Giraudo"
    },
    {
      "affiliations": [
        "Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy",
        "Statistics, Computer Science, Applications, University of Florence, Florence, Italy"
      ],
      "name": "Barbara Sodano"
    },
    {
      "affiliations": [
        "Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy"
      ],
      "name": "Lisa Padroni"
    },
    {
      "affiliations": [
        "Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy"
      ],
      "name": "Cinzia Destefanis"
    },
    {
      "affiliations": [
        "International Agency for Research on Cancer, Lyon, France"
      ],
      "name": "Heinz Freisling"
    },
    {
      "affiliations": [
        "International Agency for Research on Cancer, Lyon, France"
      ],
      "name": "Pietro Ferrari"
    },
    {
      "affiliations": [
        "Department of Epidemiology, Lazio Region Health Service, Rome, Italy"
      ],
      "name": "Giulia Cesaroni"
    },
    {
      "affiliations": [
        "Department of Biomedical Sciences, Unit of Microbiology and Virology, University of Sassari, Sassari, Italy"
      ],
      "name": "Sergio Uzzau"
    },
    {
      "affiliations": [
        "Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany",
        "Institute of Nutritional Science, University of Potsdam, Nuthetal, Germany"
      ],
      "name": "Matthias B Schulze"
    },
    {
      "affiliations": [
        "Clinical Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network, Florence, Italy"
      ],
      "name": "Calogero Saieva"
    },
    {
      "affiliations": [
        "Hyblean Association for Epidemiology Research, AIRE - ONLUS, Ragusa, Italy"
      ],
      "name": "Rosario Tumino"
    },
    {
      "affiliations": [
        "International Agency for Research on Cancer, Lyon, France"
      ],
      "name": "Elisabete Weiderpass"
    },
    {
      "affiliations": [
        "International Agency for Research on Cancer, Lyon, France"
      ],
      "name": "Komodo Matta"
    },
    {
      "affiliations": [
        "International Agency for Research on Cancer, Lyon, France"
      ],
      "name": "Salvatore Vaccarella"
    },
    {
      "affiliations": [
        "Instituto de Salud Pública y Laboral de Navarra, Pamplona, Spain",
        "Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain",
        "Navarra Institute for Health Research, Pamplona, Spain"
      ],
      "name": "Marcela Guevara"
    },
    {
      "affiliations": [
        "Danish Cancer Society Institute of Cancer Biology, Copenhagen, Denmark"
      ],
      "name": "Jytte Halkjær"
    },
    {
      "affiliations": [
        "The Institute of Cancer Epidemiology, Danish Cancer Society Research Center, Unit of Diet, Genes and Environment, Copenhagen, Denmark"
      ],
      "name": "Anne Tjønneland"
    },
    {
      "affiliations": [
        "Unit of Nutrition and Cancer, Catalan Institute of Oncology Cancer Epidemiology Research Programme, Barcelona, Spain",
        "Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA"
      ],
      "name": "Marta Crous-Bou"
    },
    {
      "affiliations": [
        "Deutsches Krebsforschungszentrum, Heidelberg, Germany",
        "Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany"
      ],
      "name": "Verena Katzke"
    },
    {
      "affiliations": [
        "Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany"
      ],
      "name": "Toktam Pour"
    },
    {
      "affiliations": [
        "Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Napoli, Italy"
      ],
      "name": "Salvatore Panico"
    },
    {
      "affiliations": [
        "Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy"
      ],
      "name": "Valeria Pala"
    },
    {
      "affiliations": [
        "Department of Epidemiology and Biostatistics, Imperial College London, London, UK",
        "Biomedical Research Foundation Academy of Athens, Athens, Greece"
      ],
      "name": "Ioanna Tzoulaki"
    },
    {
      "affiliations": [
        "Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK"
      ],
      "name": "Sandar Tin Tin"
    },
    {
      "affiliations": [
        "Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, UK"
      ],
      "name": "Christina C Dahm"
    },
    {
      "affiliations": [
        "CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain",
        "Department of Epidemiology, Regional Health Council, IMIB-Arrixaca, University of Murcia, Murcia, Spain"
      ],
      "name": "MªDolores Chirlaque"
    },
    {
      "affiliations": [
        "Department of Health Sciences, University of Eastern Piedmont, Novara, Italy"
      ],
      "name": "Carlotta Sacerdote"
    },
    {
      "affiliations": [
        "Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy"
      ],
      "name": "Fulvio Ricceri"
    }
  ],
  "title": "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",
  "uid": "1cf1bd47-b9a2-5b12-b8ad-74759737ed53"
}