{"title":"Independent associations of social determinants of health with mortality and added predictive value beyond life's essential 8.","authors":"Yuansong Zhuang, Xinlong Zhao, Siqi Tang, Yakun Zhao, Yanbo Liu, Yuxiong Chen, Yitao Han, Jinyan Lei, Zhongjie Fan","doi":"10.1186/s41043-025-01038-3","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Social Determinants of Health (SDoHs) exert their influence primarily through social structures and environmental conditions. However, limited evidence exists regarding which specific SDoHs are associated with all-cause and cardiovascular mortality, and whether incorporating SDoHs into the Life's Essential 8 (LE8) framework improves mortality prediction.</p><p><strong>Methods: </strong>Data were analyzed from the 2005-2018 National Health and Nutrition Examination Survey (NHANES). Weighted Cox proportional hazards models were used to estimate associations between SDoHs and mortality. Additive interaction effects were quantified using the relative excess risk due to interaction (RERI). Predictive performance was assessed using continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) for all-cause and cardiovascular mortality.</p><p><strong>Results: </strong>Among 22,938 participants, 2,344 all-cause deaths (7.29%) and 720 cardiovascular deaths (2.12%) were observed over a median follow-up of 7.83 years. Multivariable analyses revealed that unemployment (HR = 1.44, 95% CI: 1.25-1.66), low-income status (poverty-to-income ratio (PIR) < 1; HR = 1.75, 95% CI: 1.32-2.31), severe food insecurity (HR = 1.45, 95% CI: 1.19-1.78), and being unmarried or living alone (HR = 1.43, 95% CI: 1.28-1.59) were independent predictors of all-cause mortality (all P < 0.001). Low PIR (HR = 1.90, 95% CI: 1.21-2.97) and being unmarried or living alone (HR = 1.52, 95% CI: 1.26-1.85) were also significantly associated with cardiovascular mortality. Significant additive interactions were found between unemployment and low PIR (RERI = 0.90), food insecurity (RERI = 0.59), and unmarried or living alone (RERI = 0.37) for all-cause mortality. An additive interaction between low PIR and unmarried or living alone (RERI = 0.46) was observed for cardiovascular mortality. Including these SDoHs significantly improved 1-, 3-, 5-, and 10-year prediction of all-cause and cardiovascular mortality (NRI and IDI, all P < 0.05).</p><p><strong>Conclusion: </strong>Unemployment, low PIR, severe food insecurity, and being unmarried or living alone were identified as independent predictors of increased all-cause mortality. Low PIR and being unmarried or living alone were also associated with cardiovascular mortality. Incorporating these SDoHs into the LE8 framework improved predictive performance for both mortality outcomes.</p>","PeriodicalId":15969,"journal":{"name":"Journal of Health, Population, and Nutrition","volume":"44 1","pages":"286"},"PeriodicalIF":2.8000,"publicationDate":"2025-08-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12341271/pdf/","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Health, Population, and Nutrition","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1186/s41043-025-01038-3","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"ENVIRONMENTAL SCIENCES","Score":null,"Total":0}
引用次数: 0
Abstract
Background: Social Determinants of Health (SDoHs) exert their influence primarily through social structures and environmental conditions. However, limited evidence exists regarding which specific SDoHs are associated with all-cause and cardiovascular mortality, and whether incorporating SDoHs into the Life's Essential 8 (LE8) framework improves mortality prediction.
Methods: Data were analyzed from the 2005-2018 National Health and Nutrition Examination Survey (NHANES). Weighted Cox proportional hazards models were used to estimate associations between SDoHs and mortality. Additive interaction effects were quantified using the relative excess risk due to interaction (RERI). Predictive performance was assessed using continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) for all-cause and cardiovascular mortality.
Results: Among 22,938 participants, 2,344 all-cause deaths (7.29%) and 720 cardiovascular deaths (2.12%) were observed over a median follow-up of 7.83 years. Multivariable analyses revealed that unemployment (HR = 1.44, 95% CI: 1.25-1.66), low-income status (poverty-to-income ratio (PIR) < 1; HR = 1.75, 95% CI: 1.32-2.31), severe food insecurity (HR = 1.45, 95% CI: 1.19-1.78), and being unmarried or living alone (HR = 1.43, 95% CI: 1.28-1.59) were independent predictors of all-cause mortality (all P < 0.001). Low PIR (HR = 1.90, 95% CI: 1.21-2.97) and being unmarried or living alone (HR = 1.52, 95% CI: 1.26-1.85) were also significantly associated with cardiovascular mortality. Significant additive interactions were found between unemployment and low PIR (RERI = 0.90), food insecurity (RERI = 0.59), and unmarried or living alone (RERI = 0.37) for all-cause mortality. An additive interaction between low PIR and unmarried or living alone (RERI = 0.46) was observed for cardiovascular mortality. Including these SDoHs significantly improved 1-, 3-, 5-, and 10-year prediction of all-cause and cardiovascular mortality (NRI and IDI, all P < 0.05).
Conclusion: Unemployment, low PIR, severe food insecurity, and being unmarried or living alone were identified as independent predictors of increased all-cause mortality. Low PIR and being unmarried or living alone were also associated with cardiovascular mortality. Incorporating these SDoHs into the LE8 framework improved predictive performance for both mortality outcomes.
期刊介绍:
Journal of Health, Population and Nutrition brings together research on all aspects of issues related to population, nutrition and health. The journal publishes articles across a broad range of topics including global health, maternal and child health, nutrition, common illnesses and determinants of population health.