Cohort Profile: Understanding socioeconomic inequalities in health and health behaviours: the GLOBE study

Exposome-Wide Association Study of Body Mass Index Using a Novel Meta-Analytical Approach for Random Forest Models

BACKGROUND

Overweight and obesity impose a considerable individual and social burden, and the urban environments might encompass factors that contribute to obesity. Nevertheless, there is a scarcity of research that takes into account the simultaneous interaction of multiple environmental factors.

OBJECTIVES

Our objective was to perform an exposome-wide association study of body mass index (BMI) in a multicohort setting of 15 studies.

METHODS

Studies were affiliated with the Dutch Geoscience and Health Cohort Consortium (GECCO), had different population sizes (688-141,825), and covered the entire Netherlands. Ten studies contained general population samples, others focused on specific populations including people with diabetes or impaired hearing. BMI was calculated from self-reported or measured height and weight. Associations with 69 residential neighborhood environmental factors (air pollution, noise, temperature, neighborhood socioeconomic and demographic factors, food environment, drivability, and walkability) were explored. Random forest (RF) regression addressed potential nonlinear and nonadditive associations. In the absence of formal methods for multimodel inference for RF, a rank aggregation-based meta-analytic strategy was used to summarize the results across the studies.

RESULTS

Six exposures were associated with BMI: five indicating neighborhood economic or social environments (average home values, percentage of high-income residents, average income, livability score, share of single residents) and one indicating the physical activity environment (walkability in 5 -km buffer area). Living in high-income neighborhoods and neighborhoods with higher livability scores was associated with lower BMI. Nonlinear associations were observed with neighborhood home values in all studies. Lower neighborhood home values were associated with higher BMI scores but only for values up to € 300,000 . The directions of associations were less consistent for walkability and share of single residents.

DISCUSSION

Rank aggregation made it possible to flexibly combine the results from various studies, although between-study heterogeneity could not be estimated quantitatively based on RF models. Neighborhood social, economic, and physical environments had the strongest associations with BMI. https://doi.org/10.1289/EHP13393.

Developmental epigenomic effects of maternal financial problems

Early-life adversity as neglect or low socioeconomic status is associated with negative physical/mental health outcomes and plays an important role in health trajectories through life. The early-life environment has been shown to be encoded as changes in epigenetic markers that are retained for many years.We investigated the effect of maternal major financial problems (MFP) and material deprivation (MD) on their children's epigenome in the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Epigenetic aging, measured with epigenetic clocks, was weakly accelerated with increased MFP. In subsequent EWAS, MFP, and MD showed strong, independent programing effects on children's genomes. MFP in the period from birth to age seven was associated with genome-wide epigenetic modifications on children's genome visible at age 7 and partially remaining at age 15.These results support the hypothesis that physiological processes at least partially explain associations between early-life adversity and health problems later in life. Both maternal stressors (MFP/MD) had similar effects on biological pathways, providing preliminary evidence for the mechanisms underlying the effects of low socioeconomic status in early life and disease outcomes later in life. Understanding these associations is essential to explain disease susceptibility, overall life trajectories and the transition from health to disease.

Is the association between financial scarcity and health behaviours moderated by cultural capital? The GLOBE study

BACKGROUND

Experiencing financial scarcity taxes cognitive bandwidth. This leaves less capacity to withhold temptations and makes relying on easiest default options more likely. Whether this default option is (un)healthy may depend on the amount of cultural capital acquired during life course. This study examined whether the association between financial scarcity and health behaviours is moderated by cultural capital.

METHODS

Self-reported data were used from Dutch adults of the 2014-survey of the GLOBE study (N = 2466). Using linear regression analysis, financial strain (no, some, great) and cultural capital (institutionalized, objectivized, incorporated) were related to body mass index (BMI), alcohol intake, sports participation, cycling and walking, fruit intake and vegetable consumption. The interaction between financial strain and cultural capital was used to assess moderation.

RESULTS

Experiencing some financial strain was associated with a higher BMI (0.7 kg/m2) and less sport participation (-31.8 min/week). Great financial strain was associated with less sport participation (-41.4 min/week). Being in the lowest tertile of cultural capital was associated with a higher BMI (1.3 kg/m2), drinking less alcohol (-10.0 units/week), less sport participation (-31.5 min/week) and consuming less fruit (-2.9 pieces/week). Cultural capital had no significant moderating effect on the relationship between financial strain and these health behaviours.

CONCLUSION

Financial strain and cultural capital seem associated with different health behaviours. Cultural capital had no moderating effect on the relationship between financial strain and different health behaviours. While financial strain and cultural capital could both be entry points for interventions to improve health behaviour, underlying mechanisms require further attention.

Testing conditionality with Bourdieu's capital theory: How economic, social, and embodied cultural capital are associated with diet and physical activity in the Netherlands

Although Bourdieu's capital theory emphasized that economic, social, and embodied cultural capital interact to shape health behavior, existing empirical research mainly considered separate associations of the three forms of capital. Our aim was to investigate if and how economic, social, and embodied cultural capital are conditional on each other in their associations with adults' diet and physical activity. Cross-sectional, self-reported data from the 2014 GLOBE survey of 2812 adults aged between 25 and 75 years residing in Eindhoven, the Netherlands were used. Step-wise multiple logistic regression models included economic, social, and embodied cultural capital and adjustment for potential confounders. The models estimated odds ratios of main effects and two-way interactions of the forms of capital with fruit consumption, vegetable consumption, sports participation, and leisure time walking or cycling. In the main effects models, embodied cultural capital was consistently positively associated with all outcomes. Social capital was positively associated with sports participation, fruit consumption, and vegetable consumption, and economic capital was positively associated with sports participation and vegetable consumption. In the two-way interaction models, having specific higher levels of both economic and social capital strengthened their positive association with sports participation. No other combinations of capital were conditional on each other. Economic and social capital were conditional on each other in their association with sports participation, so interventions that provide both economic and social support may be especially effective for increasing this type of physical activity. As its association was strong with all outcomes but not conditional on other forms of capital, embodied cultural capital may operate distinctly from economic and social resources. Policy that takes differences in embodied cultural capital into account or changes to the environment that dampen the importance of embodied cultural resources for health behavior may help improve both diet and physical activity.

A Community-Based Participatory Action Research with Women from Disadvantaged Populations: Strengths and Weaknesses of a Multiple Health Behaviour Change Intervention

Disadvantaged populations usually adopt risk behaviours, resulting in obesity and mental health-related disorders. Grounded in the socioecological model and self-determination theory, the aims were firstly to describe and implement a two-year multiple health behaviour change intervention, and secondly, to assess the strengths and weaknesses of the intervention. In total, 11 women from a disadvantaged population participated in this programme, which encompassed 117 sessions. Qualitative techniques were used to collect data and a thematic analysis was conducted. The variety of activities and the group-based intervention were the main strengths, and the decrease in attendance and the programme’s tight schedule were the main weaknesses. This is the first intervention in a disadvantaged population mainly comprised of Roma women. The design described in detail and its assessment provide relevant knowledge to improve their health status and decrease inequalities. The practical implications for future research are useful for replicating interventions in similar contexts.

Socioeconomic inequalities in health behaviors: exploring mediation pathways through material conditions and time orientation

BACKGROUND

Socioeconomic inequalities in health behaviors have been attributed to both structural and individual factors, but untangling the complex, dynamic pathways through which these factors influence inequalities requires more empirical research. This study examined whether and how two factors, material conditions and time orientation, sequentially impact socioeconomic inequalities in health behaviors.

METHODS

Dutch adults 25 and older self-reported highest attained educational level, a measure of socioeconomic position (SEP); material conditions (financial strain, housing tenure, income); time orientation; health behaviors including smoking and sports participation; and health behavior-related outcomes including body mass index (BMI) and self-assessed health in three surveys (2004, 2011, 2014) of the longitudinal GLOBE (Dutch acronym for "Health and Living Conditions of the Population of Eindhoven and surroundings") study. Two hypothesized pathways were investigated during a ten-year time period using sequential mediation analysis, an approach that enabled correct temporal ordering and control for confounders such as baseline health behavior.

RESULTS

Educational level was negatively associated with BMI, positively associated with sports participation and self-assessed health, and not associated with smoking in the mediation models. For smoking, sports participation, and self-assessed health, a pathway from educational level to the outcome mediated by time orientation followed by material conditions was observed.

CONCLUSIONS

Time orientation followed by material conditions may play a role in determining socioeconomic inequalities in certain health behavior-related outcomes, providing empirical support for the interplay between structural and individual factors in socioeconomic inequalities in health behavior. Smoking may be determined by prior smoking behavior regardless of SEP, potentially due to its addictive nature. While intervening on time orientation in adulthood may be challenging, the results from this study suggest that policy interventions targeted at material conditions may be more effective in reducing socioeconomic inequalities in certain health behaviors when they account for time orientation.

Do perceived social neighborhood factors explain the association between neighborhood age composition and mental health among Dutch older adults?

BACKGROUND

In the light of urbanization and aging, a crucially relevant policy question is how to shape neighborhoods to foster healthy aging. An important debate is whether older adults should group in neighborhoods, or whether a more mixed neighborhood age composition is more beneficial to health and well-being. We therefore assessed the association between neighborhood age structure and mental health and the mediating role of individual perceptions of neighborhood social factors.

METHODS

We conducted multivariable linear regression models and causal mediation analyses in 1255 older adults of the Dutch Globe study. The neighborhood age structure was measured in 2011 as the homogeneity of the age composition (using the Herfindahl-Hirschman index, range from 0 to 100, a higher score indicating more homogeneity) and the percentage of specific age groups in a neighborhood. Mental health was measured in 2014 by the Mental Health Inventory-5 score (range 0 to 100, a higher score indicating better mental health). Potential mediators were assessed in 2011 and included perceptions of neighborhood social cohesion, feeling at home in a neighborhood, and social participation.

RESULTS

A more homogeneous age composition (not specified for age) and a higher percentage of children living in a neighborhood were associated with better mental health, the other age categories were not. Social cohesion, feeling at home and social participation did not mediate the associations.

CONCLUSIONS

The neighborhood age composition may be an interesting but currently insufficiently understood entry point for policies to improve older adult's mental health status.

Land use mix and physical activity in middle-aged and older adults: a longitudinal study examining changes in land use mix in two Dutch cohorts

Background

With urbanization and aging increasing in coming decades, societies face the challenge of keeping aging populations active. Land use mix (LUM) has been associated with cycling and walking, but whether changes in LUM relate to changes in cycling/walking is less known.

Objectives

Our objective was to study the effect of LUM on cycling/walking in two Dutch aging cohorts using data with 10 years of follow-up.

Methods

Data from 1183 respondents from the Health and Living Conditions of the Population of Eindhoven and Surroundings (GLOBE) study and 918 respondents from the Longitudinal Aging Study Amsterdam (LASA) were linked to LUM in 1000-m sausage network buffers at three time-points. Cycling/walking outcomes were harmonized to include average minutes spent cycling/walking per week. Data was pooled and limited to respondents that did not relocate between follow-up waves. Associations between LUM and cycling/walking were estimated using a Random Effects Within-Between (REWB) model that allows for the estimation of both within and between effects. Sensitivity analyses were performed on smaller (500-m) and larger (1600-m) buffers.

Results

We found evidence of between-individual associations of LUM in 1000-m buffers and walking (β: 11.10, 95% CI: 0.08; 21.12), but no evidence of within-associations in 1000-m buffers. Sensitivity analyses using 500-m buffers showed similar between-associations, but negative within-associations (β: -35.67, 95% CI: − 68.85; − 2.49). We did not find evidence of between-individual associations of LUM in any buffer size and cycling, but did find evidence of negative within-associations between LUM in 1600-m buffers and cycling (β: -7.49, 95% CI: − 14.31; − 0.66).

Discussion

Our study found evidence of positive associations between LUM and average walking time, but also some evidence of negative associations between a change in LUM and cycling/walking. LUM appears to be related to cycling/walking, but the effect of changes in LUM on cycling/walking is unclear.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01083-1.

Green spaces, subjective health and depressed affect in middle-aged and older adults: a cross-country comparison of four European cohorts

Background

Studies on associations between urban green space and mental health have yielded mixed results. This study examines associations of green space exposures with subjective health and depressed affect of middle-aged and older adults in four European cohorts.

Methods

Data came from four Western-European and Central-European ageing cohorts harmonised as part of the Mindmap project, comprising 16 189 adults with an average age of 50–71 years. Green space exposure was based on the distance to the nearest green space and the amount of green space within 800 m buffers around residential addresses. Cohort-specific and one-step individual participant data (IPD) meta-analyses were used to examine associations of green space exposures with subjective health and depressed affect.

Results

The amount of green spaces within 800 m buffers was lowest for Residential Environment and CORonary heart Disease (Paris, 15.0 hectares) and highest for Health, Alcohol and Psychosocial factors In Eastern Europe (Czech Republic, 35.9 hectares). IPD analyses indicated no evidence of an association between the distance to the nearest green space and depressed affect (OR 0.98, 95% CI 0.96 to 1.00) or good self-rated health (OR 1.01, 95% CI 0.99 to 1.02). Likewise, the amount of green space within 800 m buffers did not predict depressed affect (OR 0.98, 95% CI 0.96 to 1.00) or good self-rated health (OR 1.01, 95% CI 0.99 to 1.02). Findings were consistent across all cohorts.

Conclusions

Data from four European ageing cohorts provide no support for the hypothesis that green space exposure is associated with subjective health or depressed affect. While longitudinal evidence is required, these findings suggest that green space may be less important for older urban residents.

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.

Influence of deprivation on initial severity and prognosis of patients admitted to the ICU: the prospective, multicentre, observational IVOIRE cohort study

Background

The influence of socioeconomic status on patient outcomes is unclear. We assessed the impact of socioeconomic deprivation on severity of illness at intensive care unit (ICU) admission, and on the risk of death at 3 months after ICU admission.

Methods

The IVOIRE study was a prospective, observational, multicentre cohort study in the ICU of 8 participating hospitals in France, including patients aged ≥ 18 years admitted to the ICU and receiving at least one life support therapy for organ failure. The primary outcomes were severity at admission (assessed by SAPSII score), and mortality at 3 months. Socioeconomic data were obtained from interviews with patients or family. Deprivation was assessed using the EPICES score.

Results

Among 1294 patents included between 2013 and 2016, 629 (48.6%) were classed as deprived and differed significantly from non-deprived subjects in terms of sociodemographic characteristics and pre-existing conditions. The mean SAPS II score at admission was 50.1 ± 19.4 in deprived patients and 52.3 ± 17.3 in non-deprived patients, with no significant difference by multivariable analysis (β = − 1.85 [95% CI − 3.86; + 0.16, p = 0.072]). The proportion of death was 31.1% at 3 months, without significant differences between deprived and non-deprived patients, even after adjustment for confounders.

Conclusions

Deprivation is frequent in patients admitted to the ICU and is not associated with disease severity at admission, or with mortality at 3 months between deprived and non-deprived patients.

Trial registration The IVOIRE cohort is registered with ClinicalTrials.gov under the identifier NCT01907581, registration date 17/7/2013

Educational inequality in patient-reported outcomes but not mortality among cardiac patients: Results from the national DenHeart survey with register follow-up

Aims: This study aimed to explore whether educational level is associated with mental and physical health status, anxiety and depression symptoms and quality of life at hospital discharge and predicts cardiac events and all-cause mortality 1 year after hospital discharge in patients with ischaemic heart disease, arrhythmias, heart failure or heart valve disease. Methods: The DenHeart survey is cross-sectional and combined with data from national registers. Information on educational level and co-morbidity at hospital discharge and cardiac events and mortality 1-year post-discharge was obtained from registers. Patient-reported outcomes included SF-12, Hospital Anxiety and Depression Scale and HeartQoL. Multivariate linear and logistic regression and Cox proportional hazards regression models were used. Results: A total of 13,145 patients were included. A significant educational gradient was found in patient-reported mental and physical health status, anxiety and depression symptoms and quality of life, with lower educational groups reporting worse outcomes in adjusted analyses. No association was found between educational level and risk of cardiac events or all-cause mortality within 1 year after hospital discharge in adjusted analyses. Conclusions: In a large population of patients with cardiac disease a significant educational gradient was found in mental and physical health and quality of life at hospital discharge. There was, however, no association between educational level and risk of cardiac events or mortality 1 year after hospital discharge.

Longitudinal effects of urban green space on walking and cycling: A fixed effects analysis

This study examined whether changes in green space within the living environment were associated with changes in walking and cycling frequencies in a cohort of 3,220 Dutch adults between 2004, 2011 and 2014. Data on self-reported weekly time spent walking and cycling for active commute and leisure were linked to geographic information system (GIS) measures of total green areas within 1000 m buffer zones around each participant's home address, and distance to the nearest green space. First, cross-sectional linear regression models showed no statistically significant associations between green space measures and walking and cycling. Second, fixed effects (FE) models were used to analyze whether changes in green space were associated with changes in walking and cycling, using longitudinal data from respondents who did not relocate over time. As distance to the nearest green area increased by 100 m, individuals spent 22.76 fewer (95% CI: -39.92, -5.60) minutes walking for leisure per week and 3.21 more (95% CI: 0.46, 5.96) minutes walking for active commute. Changes in distance to green space were not significantly related to changes in cycling measures. No clear associations between changes in green areas within 1000 m buffers and changes in walking and cycling were observed. Overall, there was weak evidence of an effect of changes in green space area on changes in walking, and no evidence for cycling.

How does bridging social capital relate to health-behavior, overweight and obesity among low and high educated groups? A cross-sectional analysis of GLOBE-2014

Background

Social capital is an important determinant of health, but how specific sub-dimensions of social capital affect health and health-related behaviors is still unknown. To better understand its role for health inequalities, it is important to distinguish between bonding social capital (connections between homogenous network members; e.g. similar educational level) and bridging social capital (connections between heterogeneous network members). In this study, we test the hypotheses that, 1) among low educational groups, bridging social capital is positively associated with health-behavior, and negatively associated with overweight and obesity, and 2) among high educational groups, bridging social capital is negatively associated with health-behavior, and positively with overweight and obesity.

Methods

Cross-sectional data on educational level, health-behavior, overweight and obesity from participants (25–75 years; Eindhoven, the Netherlands) of the 2014-survey of the GLOBE study were used (N = 2702). Social capital (“How many of your close friends have the same educational level as you have?”) was dichotomized as: bridging (‘about half’, ‘some’, or ‘none of my friends’), or bonding (‘all’ or ‘most of my friends’). Logistic regression models were used to study whether bridging social capital was related to health-related behaviors (e.g. smoking, food intake, physical activity), overweight and obesity, and whether these associations differed between low and high educational groups.

Results

Among low educated, having bridging social capital (i.e. friends with a higher educational level) reduced the likelihood to report overweight (OR 0.73, 95% CI 0.52–1.03) and obesity (OR 0.58, 95% CI 0.38–0.88), compared to low educated with bonding social capital. In contrast, among high educated, having bridging social capital (i.e. friends with a lower educational level) increased the likelihood to report daily smoking (OR 2.11, 95% CI 1.37–3.27), no leisure time cycling (OR 1.55, 95% CI 1.17–2.04), not meeting recommendations for vegetable intake (OR 2.09, 95% CI 1.50–2.91), and high meat intake (OR 1.39, 95% CI 1.05–1.83), compared to high educated with bonding social capital.

Conclusions

Bridging social capital had differential relations with health-behavior among low and high educational groups. Policies aimed at reducing segregation between educational groups may reduce inequalities in overweight, obesity and unhealthy behaviors.

Effect of changes in green spaces on mental health in older adults: a fixed effects analysis

Background

Urban green spaces have been linked to different health benefits, but longitudinal studies on the effect of green spaces on mental health are sparse and evidence often inconclusive. Our objective was to study the effect of changes in green spaces in the residential environment on changes in mental health using data with 10 years of follow-up (2004–2014).

Methods

Data from 3175 Dutch adults were linked to accessibility and availability measures of green spaces at three time points (2004/2011/2014). Mental health was measured with the Mental Health Inventory-5. Fixed effects analyses were performed to assess the effect of changes in green spaces on mental health.

Results

Cross-sectional analysis of baseline data showed significant associations between Euclidean distances to the nearest green space and mental health, with an increase of 100 m correlating with a lower mental health score of approximately 0.5 (95% CI −0.87 to −0.12) on a 0–100 scale. Fixed effects models showed no evidence for associations between changes in green spaces and changes in mental health both for the entire sample as well as for those that did not relocate during follow-up.

Conclusions

Despite observed cross-sectional correlations between the accessibility of green space in the residential environment and mental health, no evidence was found for an association between changes in green spaces and changes in mental health. If mental health and green spaces are indeed causally linked, then changes in green spaces in the Eindhoven area between 2004 and 2014 are not enough to produce a significant effect.

Are socio-economic inequalities in diet and physical activity a matter of social distinction? A cross-sectional study

OBJECTIVES

To explore whether 'distinction', a well-known mechanism that produces and reproduces social inequalities, can explain the socio-economic gradient in healthy diet and physical activity in contemporary obesogenic environments. If this is the case, we would expect a well-established indicator of distinction, 'highbrow' cultural participation, to be associated with a healthy diet and physical activity, while adjusting for education and income.

METHODS

Data from participants (25-75 years) of the 2014 wave of the Dutch GLOBE study (N = 2812) were used to analyse the association between 'highbrow' cultural participation (e.g. annual frequency of visits to museums, ballet, concerts, theatre) and sports participation, leisure-time walking and cycling, and fruit and vegetable intake, adjusted for education, income and other confounders.

RESULTS

Both highbrow cultural participation and healthy behaviours were more prevalent among high educational groups. Cultural participation was strongly associated with all health behaviours, even when adjusted for education and income.

CONCLUSIONS

Our findings suggest that health behaviours, similar to highbrow cultural participation, are adopted as an expression of social distinction. This distinction mechanism may be an important determinant of health behaviour inequalities.

The role of financial strain and self-control in explaining health behaviours: the GLOBE study

Background

Why lower socioeconomic groups behave less healthily can only partly be explained by direct costs of behaving healthily. We hypothesize that low income increases the risk of facing financial strain. Experiencing financial strain takes up cognitive 'bandwidth' and leads to less self-control, and subsequently results in more unhealthy behaviour. We therefore aim to investigate (i) whether a low income increases the likelihood of experiencing financial strain and of unhealthy behaviours, (ii) to what extent more financial strain is associated with less self-control and, subsequently, (iii) whether less self-control is related to more unhealthy behaviour.

Methods

Cross-sectional survey data were obtained from participants (25-75 years) in the fifth wave of the Dutch GLOBE study (N = 2812) in 2014. The associations between income, financial strain, self-control and health-behaviour-related outcomes (physical inactivity in leisure-time, obesity, smoking, excessive alcohol intake, and weekly fruit and vegetable intake) were analysed with linear regression and generalized linear regression models (log link).

Results

Experiencing great compared with no financial strain increased the risk of all health-behaviour-related outcomes, independent of income. Low self-control, as compared with high self-control, also increased the risk of an unhealthy lifestyle. Taking self-control into account slightly attenuated the associations between financial strain and the outcomes.

Conclusion

Great financial strain and low self-control are consistently associated with unhealthy behaviours. Self-control may partly mediate between financial strain and unhealthy behaviour. Interventions that relieve financial strain may free up cognitive bandwidth and improve health behaviour.

Material, behavioural, cultural and psychosocial factors in the explanation of socioeconomic inequalities in oral health

Background

This study aimed to assess the contribution of material, behavioural, cultural and psychosocial factors in the explanation of socioeconomic inequalities (education and income) in oral health of Dutch adults.

Methods

Cross-sectional data from participants (25-75 years of age) of the fifth wave of the GLOBE cohort were used (n = 2812). Questionnaires were used to obtain data on material factors (e.g. financial difficulties), behavioural factors (e.g. smoking), cultural factors (e.g. cultural activities) and psychosocial factors (e.g. psychological distress). Oral health outcomes were self-reported number of teeth and self-rated oral health (SROH). Mediation analysis, using multivariable negative binomial regression and logistic regression, was performed.

Results

Education level and income showed a graded positive relationship with both oral health outcomes. Adding material, behavioural, cultural and psychosocial factors substantially reduced the rate ratio for the number of teeth of the lowest education group from 0.79 (95% confidence interval (CI): 0.75-0.83) to 0.92 (95% CI: 0.87-0.97) and of the lowest income group from 0.80 (95% CI: 0.73-0.88) to 1.04 (95% CI: 0.96-1.14). Inclusion of all factors also substantially reduced the odds ratio for poor SROH of the lowest education group from 1.61 (95% CI: 1.28-2.03) to 1.12 (95% CI: 0.85-1.48) and of the lowest income groups from 3.18 (95% CI: 2.13-4.74) to 1.48 (95% CI: 0.90-2.45).

Conclusion

In general, behavioural factors contributed most to the explanation of socioeconomic inequalities in adult oral health, followed by material factors. The contribution of cultural and psychosocial factors was relatively moderate.

The Moderating Role of Self-Control and Financial Strain in the Relation between Exposure to the Food Environment and Obesity: The GLOBE Study

Low self-control and financial strain may limit individuals’ capacity to resist temptations in the local food environment. We investigated the moderating role of self-control and financial strain in the relation between the food environment and higher body weight. We used data from 2812 Dutch adults who participated in the population-based GLOBE study in 2014. Participants’ home addresses and the location of food retailers in 2013 were mapped using GIS. The density of fast food retailers and the totality of food retailers in Euclidean buffers of 250, 400 and 800 m around the home were linked to body mass index and overweight status. A higher density of fast food outlets (B (95% confidence interval (CI)) = −0.04 (−0.07; −0.01)) and the totality of food outlets (B (95% CI) = −0.01 (−0.01; −0.00)) were associated with a lower body mass index. Stratification showed that associations were strongest for those experiencing low self-control or great financial strain. For example, every additional fast food outlet was associated with a 0.17 point lower BMI in those with great financial strain, while not significantly associated with BMI in those with no financial strain. In conclusion, we did find support for a moderating role of self-control and financial strain, but associations between the food environment and weight status were not in the expected direction.

Does cultural capital contribute to educational inequalities in food consumption in the Netherlands? A cross-sectional analysis of the GLOBE-2011 survey

BACKGROUND

The importance of culture for food consumption is widely acknowledged, as well as the fact that culture-based resources ("cultural capital") differ between educational groups. Since current explanations for educational inequalities in healthy and unhealthy food consumption (e.g. economic capital, social capital) are unable to fully explain this gradient, we aim to investigate a new explanation for educational inequalities in healthy food consumption, i.e. the role of cultural capital.

METHODS

Data were obtained cross-sectionally by a postal survey among participants of the GLOBE study in the Netherlands in 2011 (N = 2953; response 67.1%). The survey measured respondents' highest attained educational level, food-related cultural capital (institutionalised, objectivised and incorporated cultural capital), economic capital (e.g. home ownership, financial strain), social capital (e.g. social support, health-related social leverage, interpersonal relationships), and frequency of consumption of healthy and unhealthy food products. Two general outcomes (overall healthy food consumption, and overall unhealthy food consumption), and seven specific food consumption outcomes were constructed, and prevalence ratios (PR) were estimated in Poisson regression models with robust variance.

RESULTS

Cultural capital was significantly associated with all food outcomes, also when social and economic capital were taken into account. Those with low levels of cultural capital were more likely to have a lower overall healthy food consumption (PR 1.35, 95% CI 1.22-1.49), a lower consumption of whole wheat bread (PR 1.21, 95% CI 1.05-1.38), vegetables (PR 1.55, 95% CI 1.40-1.71), and meat-substitutes and fish (PR 1.74, 95% CI 1.53-1.97), and a higher consumption of fried food (PR 1.59, 95% CI 1.31-1.93). Social capital was positively associated with overall healthy food consumption, whole wheat bread consumption, and the consumption of fish and meat-substitutes, and economic capital with none of the outcomes. The PR of the lowest educational group to have a low overall healthy food consumption decreased from 1.48 (95% CI 1.28-1.73) to 1.22 (95% CI 1.04-1.43) when cultural, social and economic capital were taken into account.

CONCLUSIONS

Cultural capital contributed to the explanation of educational inequalities in food consumption in The Netherlands, over and above economic and social capital. The socialisation processes through which cultural capital is acquired could offer new entry-points for the promotion of healthy food consumption among low educational groups.

The impact of individual and environmental interventions on income inequalities in sports participation: explorations with an agent-based model

Background

Income inequalities in sports participation are shaped by a system in which individuals and the environment interact. We developed an agent-based model (ABM) that could represent this system and used it to provide a proof-of-concept of its potential to explore the impact of individual and environmental interventions on reducing inequalities in sports participation.

Methods

Our ABM simulates sports participation of individuals in the Dutch city of Eindhoven. In the model, sports participation is determined by an individual’s tendency to start sports (at a fitness center, sports club or self-organized), which is influenced by attributes of individuals (i.e. age, sex, income), sports facilities (i.e. price, accessibility) and the social environment (i.e. social cohesion, social influence). Sports facilities can adapt to changes in the demand by closures or startups, which in turn influence the tendency of individuals to participate in sport. We explored the impact of five interventions scenarios.

Results

Explorative results show that providing health education, increasing the availability of sports facilities, lowering prices of facilities and improving safety levels can increase sports participation and modestly reduce absolute income inequalities in sports participation. The largest gain can be attained through health education, if the effect and reach is sufficiently large. Environmental interventions alone have a modest impact. Marked effects are only achieved after five to 10 years.

Conclusions

ABMs have much potential to test the population-level effects of various interventions in the context of a system. Our study highlights the challenges of ABM development and reveals gaps in empirical data. With further refinements, our model could aid in understanding and finding optimal pathways to reduce income inequalities in sports participation.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0740-y) contains supplementary material, which is available to authorized users.

What's the difference? A gender perspective on understanding educational inequalities in all-cause and cause-specific mortality

Background

Material and behavioural factors play an important role in explaining educational inequalities in mortality, but gender differences in these contributions have received little attention thus far. We examined the contribution of a range of possible mediators to relative educational inequalities in mortality for men and women separately.

Methods

Baseline data (1991) of men and women aged 25 to 74 years participating in the prospective Dutch GLOBE study were linked to almost 23 years of mortality follow-up from Dutch registry data (6099 men and 6935 women). Cox proportional hazard models were used to calculate hazard ratios with 95% confidence intervals, and to investigate the contribution of material (financial difficulties, housing tenure, health insurance), employment-related (type of employment, occupational class of the breadwinner), behavioural (alcohol consumption, smoking, leisure and sports physical activity, body mass index) and family-related factors (marital status, living arrangement, number of children) to educational inequalities in all-cause and cause-specific mortality, i.e. mortality from cancer, cardiovascular disease, other diseases and external causes.

Results

Educational gradients in mortality were found for both men and women. All factors together explained 62% of educational inequalities in mortality for lowest educated men, and 71% for lowest educated women. Yet, type of employment contributed substantially more to the explanation of educational inequalities in all-cause mortality for men (29%) than for women (− 7%), whereas the breadwinner’s occupational class contributed more for women (41%) than for men (7%). Material factors and employment-related factors contributed more to inequalities in mortality from cardiovascular disease for men than for women, but they explained more of the inequalities in cancer mortality for women than for men.

Conclusions

Gender differences in the contribution of employment-related factors to the explanation of educational inequalities in all-cause mortality were found, but not of material, behavioural or family-related factors. A full understanding of educational inequalities in mortality benefits from a gender perspective, particularly when considering employment-related factors.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5940-5) contains supplementary material, which is available to authorized users.

Urban population density and mortality in a compact Dutch city: 23-year follow-up of the Dutch GLOBE study

We investigated the association and underlying pathways between urban population density and mortality in a compact mid-sized university city in the Netherlands. Baseline data from the GLOBE cohort study (N = 10,120 residents of Eindhoven) were linked to mortality after 23 years of follow up and analyzed in multilevel models. Higher population density was modestly related to increased mortality, independently of baseline socioeconomic position and health. Higher population density was related to more active transport, more perceived urban stress and smoking. Increased active transport suppressed the mortality-increasing impact of higher population density. Overall, in dense cities with good infrastructure for walking and cycling, high population density may negatively impact mortality.

REAC neuromodulation treatments in subjects with severe socioeconomic and cultural hardship in the Brazilian state of Pará: a family observational pilot study

PURPOSE

The purpose of this preliminary observational study was to evaluate the usefulness of a humanitarian initiative, aimed at improving the neuropsychological and behavioral attitude of children with severe socioeconomic and cultural hardship, in the Brazilian state of Pará. This humanitarian initiative was realized through the administration of two neuromodulation protocols, with radioelectric asymmetric conveyor (REAC) technology. During several years of clinical use, the REAC neuromodulation protocols have already proved to be effective in countering the effects of environmental stress on neuropsycho-physical functions.

PATIENTS AND METHODS

After the preliminary medical examination, all subjects were investigated with the Strengths and Difficulties Questionnaire (SDQ), including the impact supplement with teacher's report. After the SDQ, they received the neuromodulation treatment with REAC technology named neuro postural optimization (NPO), to evaluate their responsiveness. Subsequently, every 3 months all subjects underwent a treatment cycle of neuropsycho-physical optimization (NPPO) with REAC technology, for a total of three cycles. At the end of the last REAC-NPPO treatment cycle, all subjects were investigated once again with the SDQ. For the adequacy of the data, the Wilcoxon and the Signs tests were used. For the subdivision into clusters, the Kruskal-Wallis test was applied for the adequacy of the procedure. For all the applied tests, a statistical significance of p<0.5 was found.

RESULTS

The results showed that the REAC-NPO and REAC-NPPO neuromodulation protocols are able to improve the quality of life, the scholastic and socialization skills, and the overall state of physical and mental health in children of a family with severe socioeconomic and cultural hardship.

CONCLUSION

The REAC-NPO and REAC-NPPO neuromodulation protocols, due to their non-invasive characteristics, painlessness, and speed of administration, can be hypothesized as a treatment to improve the overall state of physical and mental health in a large number of people with socioeconomic and cultural discomfort.

Socio-economic differences in the change of fruit and vegetable intakes among Dutch adults between 2004 and 2011: the GLOBE study

Objective

To investigate socio-economic differences in changes in fruit and vegetable intake between 2004 and 2011 and explore the mediating role of financial barriers in this change.

Design

Respondents completed a self-reported questionnaire in 2004 and 2011, including questions on fruit and vegetable intake (frequency per week), indicators of socio-economic position (education, income) and perceived financial barriers (fruits/vegetables are expensive, financial distress). Associations were analysed using ordinal logistic regression. The mediating role of financial barriers in the association between socio-economic position and change in fruit and vegetable intake was studied with the Baron and Kenny approach.

Setting

Longitudinal GLOBE study.

Subjects

A total of 2978 Dutch adults aged 25–75 years.

Results

Respondents with the lowest income in 2004 were more likely to report a decrease in intake of cooked vegetables (P-trend<0·001) and raw vegetables (P-trend<0·001) between 2004 and 2011, compared with those with the highest income level. Respondents with the lowest education level in 2004 were more likely to report a decrease in intake of fruits (P-trend=0·021), cooked vegetables (P-trend=0·033), raw vegetables (P-trend<0·001) and fruit juice (P-trend=0·027) between 2004 and 2011, compared with those with the highest education level. Financial barriers partially mediated the association between income and education and the decrease in fruit and cooked vegetable intake between 2004 and 2011.

Conclusions

These results show a widening of relative income and educational differences in fruit and vegetable intake between 2004 and 2011. Financial barriers explained a small part of this widening.

The role of the built environment in explaining educational inequalities in walking and cycling among adults in the Netherlands

BACKGROUND

This study examined whether characteristics of the residential built environment (i.e. population density, level of mixed land use, connectivity, accessibility of facilities, accessibility of green) contributed to educational inequalities in walking and cycling among adults.

METHODS

Data from participants (32-82 years) of the 2011 survey of the Dutch population-based GLOBE study were used (N = 2375). Highest attained educational level (independent variable) and walking for transport, cycling for transport, walking in leisure time and cycling in leisure time (dependent variables) were self-reported in the survey. GIS-systems were used to obtain spatial data on residential built environment characteristics. A four-step mediation-based analysis with log-linear regression models was used to examine to contribution of the residential built environment to educational inequalities in walking and cycling.

RESULTS

As compared to the lowest educational group, the highest educational group was more likely to cycle for transport (RR 1.13, 95% CI 1.04-1.23), walk in leisure time (RR 1.12, 95% CI 1.04-1.21), and cycle in leisure time (RR 1.12, 95% CI 1.03-1.22). Objective built environment characteristics were related to these outcomes, but contributed minimally to educational inequalities in walking and cycling. On the other hand, compared to the lowest educational group, the highest educational group was less likely to walk for transport (RR 0.91, 95% CI 0.82-1.01), which could partly be attributed to differences in the built environment.

CONCLUSION

This study found that objective built environment characteristics contributed minimally to educational inequalities in walking and cycling in the Netherlands.

Does social distinction contribute to socioeconomic inequalities in diet: the case of 'superfoods' consumption

BACKGROUND

The key mechanisms underlying socioeconomic inequalities in dietary intake are still poorly understood, hampering the development of interventions. An important, but sparsely mentioned mechanism is that of 'social distinction', whereby those in a higher socioeconomic position adopt dietary patterns by which they can distinguish themselves from lower socioeconomic groups. We investigated the importance of distinction as a mechanism, by testing the socioeconomic gradient in the consumption of so-called 'superfoods' and the contribution of a well-established indicator of distinction, cultural participation.

METHODS

Data from participants (25-75 years) of the 2014 survey of the Dutch population-based GLOBE study were used (N = 2812). Multivariable regression models were used to analyse the association between education, income and cultural participation (e.g. visits to museums, opera, theatre, concerts) and the consumption of superfoods (spelt, quinoa and goji berries, chia seeds or wheatgrass).

RESULTS

The consumption of superfoods is far more prevalent among higher socioeconomic groups. Adjusting for cultural participation strongly attenuated the educational and income gradient in superfoods consumption, whereas cultural participation remained strongly associated with superfoods consumption. Those in the highest quintile of cultural participation reported the highest consumption of spelt products (OR = 2.97, 95% CI = 2.10;4.18), quinoa (OR = 3.50, 95% CI = 2.12;5.79) and goji berries, chia seeds or wheatgrass (OR = 2.69, 95% CI = 1.73;4.17).

CONCLUSIONS

The associations between socioeconomic position and the consumption of 'superfoods' seem to be partially driven by a process of social distinction. These findings suggest that distinction may be an important, but currently neglected mechanism in generating socioeconomic inequalities in dietary intake. It deserves a more prominent role in interventions to reduce these inequalities.

Explaining socioeconomic inequalities in self-rated health: a systematic review of the relative contribution of material, psychosocial and behavioural factors

BACKGROUND

Material, psychosocial and behavioural factors are important explanatory pathways for socioeconomic inequalities in health. The aim of this systematic review was to summarise the available evidence on empirical studies and to analyse the relative contribution of these factors for explaining inequalities in self-rated health.

METHODS

The study was performed in compliance with PRISMA guidelines. The literature search was conducted in the electronic databases PubMed and Web of Science (1996-2016) as well as by screening of reference lists of obtained articles. Two reviewers performed the search and critical appraisal of the studies. All studies that focus on explaining socioeconomic inequalities in self-rated health, including at least 2 of the 3 main pathways and analysing the relative contribution of these approaches in separate and joint models, were included.

RESULTS

Eleven publications were included. Separate analyses showed that material, psychosocial and behavioural factors contribute to the explanation of socioeconomic inequalities in self-rated health. However, the combined analyses revealed that material factors contributed most to differences in self-rated health because of their higher independent (direct) effect and additional shared (indirect) effect (through psychosocial and behavioural factors). These results were largely independent of age, gender and indicator of socioeconomic status.

CONCLUSIONS

The evidence presented might be used for policymakers to identify and to justify prioritisation in terms of prevention and health promotion. The findings show that multiple factors are important for tackling social inequalities in health. Strategies for reducing these inequalities should focus on material/structural living conditions as they shape conditions of psychosocial resources and health behaviour.

Reducing Income Inequalities in Food Consumption: Explorations With an Agent-Based Model

INTRODUCTION

Individual and environmental factors dynamically interact in shaping income inequalities in healthy food consumption. The agent-based model, Health Behaviors Simulation (HEBSIM), was developed to describe income inequalities in healthy food consumption. It simulates interactions between households and their environment. HEBSIM was used to explore the impact of interventions aimed at reducing food consumption inequalities.

METHODS

HEBSIM includes households and food outlets. Households are characterized by location, composition, income, and preference for food. Decisions about where to shop for food (fruit/vegetable stores, supermarkets, or discount supermarkets) and whether to visit fast food outlets are based on distance, price, and food preference. Food outlets can close and new food outlets can enter the system. Three interventions to reduce healthy food consumption inequalities were tested: (1) eliminating residential segregation; (2) lowering the prices of healthy food; and (3) providing health education. HEBSIM was quantified using data from Statistics Netherlands, Statistics Eindhoven, and the GLOBE study (2011).

RESULTS

The model mimicked food consumption in Eindhoven. High-income households visited healthy food shops more often than low-income households. Eliminating residential segregation had the largest impact in reducing income inequalities in food consumption, but resulted partly from a worsening in healthy food consumption in high-income households. Lowering prices and health education could also substantially reduce inequalities. Most interventions took 5-10 years to reach their (almost) full effects.

CONCLUSIONS

HEBSIM is a promising tool for studying dynamic interactions between households and their environment and for assessing the impact of interventions on income inequalities in food consumption.

Representativeness of the LifeLines Cohort Study

BACKGROUND

LifeLines is a large prospective population-based three generation cohort study in the north of the Netherlands. Different recruitment strategies were adopted: recruitment of an index population via general practitioners, subsequent inclusion of their family members, and online self-registration. Our aim was to investigate the representativeness of the adult study population at baseline and to evaluate differences in the study population according to recruitment strategy.

METHODS

Demographic characteristics of the LifeLines study population, recruited between 2006-2013, were compared with the total adult population in the north of the Netherlands as registered in the Dutch population register. Socioeconomic characteristics, lifestyle, chronic diseases, and general health were further compared with participants of the Permanent Survey of Living Conditions within the region (2005-2011, N = 6,093). Differences according to recruitment strategy were assessed.

RESULTS

Compared with the population of the north of the Netherlands, LifeLines participants were more often female, middle aged, married, living in a semi-urban place and Dutch native. Adjusted for differences in demographic composition, in LifeLines a smaller proportion had a low educational attainment (5% versus 14%) or had ever smoked (54% versus 66%). Differences in the prevalence of various chronic diseases and low general health scores were mostly smaller than 3%. The age profiles of the three recruitment groups differed due to age related inclusion criteria of the recruitment groups. Other differences according to recruitment strategy were small.

CONCLUSIONS

Our results suggest that, adjusted for differences in demographic composition, the LifeLines adult study population is broadly representative for the adult population of the north of the Netherlands. The recruitment strategy had a minor effect on the level of representativeness. These findings indicate that the risk of selection bias is low and that risk estimates in LifeLines can be generalized to the general population.

Bourdieu's Cultural Capital in Relation to Food Choices: A Systematic Review of Cultural Capital Indicators and an Empirical Proof of Concept

OBJECTIVE

Unhealthy food choices follow a socioeconomic gradient that may partly be explained by one's 'cultural capital', as defined by Bourdieu. We aim 1) to carry out a systematic review to identify existing quantitative measures of cultural capital, 2) to develop a questionnaire to measure cultural capital for food choices, and 3) to empirically test associations of socioeconomic position with cultural capital and food choices, and of cultural capital with food choices.

DESIGN

We systematically searched large databases for the key-word 'cultural capital' in title or abstract. Indicators of objectivised cultural capital and family institutionalised cultural capital, as identified by the review, were translated to food choice relevant indicators. For incorporated cultural capital, we used existing questionnaires that measured the concepts underlying the variety of indicators as identified by the review, i.e. participation, skills, knowledge, values. The questionnaire was empirically tested in a postal survey completed by 2,953 adults participating in the GLOBE cohort study, The Netherlands, in 2011.

RESULTS

The review yielded 113 studies that fulfilled our inclusion criteria. Several indicators of family institutionalised (e.g. parents' education completed) and objectivised cultural capital (e.g. possession of books, art) were consistently used. Incorporated cultural capital was measured with a large variety of indicators (e.g. cultural participation, skills). Based on this, we developed a questionnaire to measure cultural capital in relation to food choices. An empirical test of the questionnaire showed acceptable overall internal consistency (Cronbach's alpha of .654; 56 items), and positive associations between socioeconomic position and cultural capital, and between cultural capital and healthy food choices.

CONCLUSIONS

Cultural capital may be a promising determinant for (socioeconomic inequalities in) food choices.

Neighbourhood socioeconomic disadvantage and fruit and vegetable consumption: a seven countries comparison

BACKGROUND

Low fruit and vegetable consumption is a risk factor for poor health. Studies have shown consumption varies across neighbourhoods, with lower intakes in disadvantaged neighbourhoods. However, findings are inconsistent, suggesting that socio-spatial inequities in diet could be context-specific, highlighting a need for international comparisons across contexts. This study examined variations in fruit and vegetable consumption among adults from neighbourhoods of varying socioeconomic status (SES) across seven countries (Australia, Canada, Netherlands, New Zealand, Portugal, Scotland, US).

METHODS

Data from seven existing studies, identified through literature searches and knowledge of co-authors, which collected measures of both neighbourhood-level SES and fruit and vegetable consumption were used. Logistic regression was used to examine associations between neighbourhood-level SES and binary fruit and vegetable consumption separately, adjusting for neighbourhood clustering and age, gender and education. As much as possible, variables were treated in a consistent manner in the analysis for each study to allow the identification of patterns of association within study and to examine differences in the associations across studies.

RESULTS

Adjusted analyses showed evidence of an association between neighbourhood-level SES and fruit consumption in Canada, New Zealand and Scotland, with increased odds of greater fruit intake in higher SES neighbourhoods. In Australia, Canada, New Zealand and Portugal, those residing in higher SES neighbourhoods had increased odds of greater vegetable intake. The other studies showed no evidence of a difference by neighbourhood-level SES.

CONCLUSIONS

Acknowledging discrepancies across studies in terms of sampling, measures, and definitions of neighbourhoods, this opportunistic study, which treated data in a consistent manner, suggests that associations between diet and neighbourhood-level socioeconomic status vary across countries. Neighbourhood socioeconomic disadvantage may differentially impact on access to resources in which produce is available in different countries. Neighbourhood environments have the potential to influence behaviour and further research is required to examine the context in which these associations arise.

Factors affecting food choices of older adults from high and low socioeconomic groups: a discrete choice experiment

BACKGROUND

Healthiness, price, and convenience are typically indicated as important motives for food choices; however, it is largely unknown to what extent older adults from high and low socioeconomic groups differ in these underlying motives. A discrete choice experiment (DCE) is an innovative way to elicit implicit motives for food choices.

OBJECTIVE

The aim was to investigate differences in food motives between socioeconomic groups by means of a DCE.

DESIGN

A DCE was carried out during a face-to-face interview among older adults as part of the Health and Living Conditions in Eindhoven and surrounding cities (GLOBE) cohort study, The Netherlands. Participants (n = 399; mean age: 63.3 y) were offered a series of choice sets about a usual dinner at home and were asked to choose in each choice set between 2 meals and an opt-out choice, with different combinations of attribute levels. We included 5 meal attributes (taste, healthiness, preparation time, travel time to shops, and price) and 3 or 4 levels for each attribute. Data were analyzed by multinomial logit models.

RESULTS

Healthiness, taste, price, and travel time to the grocery store proved to significantly influence older adults' meal decisions; preparation time was not significant. Healthiness was the most important attribute for all of the participants. More highly educated participants rated a healthy and less expensive meal to be more important than did less educated participants. Those with a high income rated a meal that was healthy and very tasteful to be more important than did those with a lower income.

CONCLUSIONS

Healthiness, taste, price, and travel time to grocery shops influenced older adults' meal decisions. Higher socioeconomic groups valued health more than did lower socioeconomic groups. DCEs represent a promising method to gain insight into the relative importance of motives for food choices. This trial was registered at www.isrctn.com as ISRCTN60293770.

Understanding socio-economic inequalities in food choice behaviour: can Maslow's pyramid help?

Socio-economic groups differ in their material, living, working and social circumstances, which may result in different priorities about their daily-life needs, including the priority to make healthy food choices. Following Maslow's hierarchy of human needs, we hypothesised that socio-economic inequalities in healthy food choices can be explained by differences in the levels of need fulfilment. Postal survey data collected in 2011 (67·2 % response) from 2903 participants aged 20-75 years in the Dutch GLOBE (Gezondheid en Levens Omstandigheden Bevolking Eindhoven en omstreken) study were analysed. Maslow's hierarchy of human needs (measured with the Basic Need Satisfaction Inventory) was added to age- and sex-adjusted linear regression models that linked education and net household income levels to healthy food choices (measured by a FFQ). Most participants (38·6 %) were in the self-actualisation layer of the pyramid. This proportion was highest among the highest education group (47·6 %). Being in a higher level of the hierarchy was associated with a higher consumption of fruits and vegetables as well as more healthy than unhealthy bread, snack and dairy consumption. Educational inequalities in fruit and vegetable intake (B= -1·79, 95 % CI -2·31, -1·28 in the lowest education group) were most reduced after the hierarchy of needs score was included (B= -1·57, 95 % CI - ·09, -1·05). Inequalities in other healthy food choices hardly changed after the hierarchy of needs score was included. People who are satisfied with higher-level needs make healthier food choices. Studies aimed at understanding socio-economic inequalities in food choice behaviour need to take differences in the priority given to daily-life needs by different socio-economic groups into account, but Maslow's pyramid offers little help.