Public Health · Nov 10, 2026

Upstream behavioural and biological contributions to socioeconomic disparities in cardiovascular disease

By Khanna S, Tan S, Ramkumar S et al.

Objectives To evaluate the relative contributions of smoking and adiposity phenotypes to the association between socioeconomic status (SES) and prevalent cardiovascular disease (CVD). Study design Cross-sectional observational study. Methods We analysed 4772 adults from the National Health and Nutrition Examination Survey (NHANES) with available socioeconomic, anthropometric, controlled attenuation parameter (CAP), and cardiovascular data. SES was defined using the poverty income ratio (high/low), with continuous SES examined in sensitivity analyses. Prevalent CVD comprised self-reported myocardial infarction, coronary heart disease, or heart failure. Primary mediators included smoking, body mass index, waist circumference, waist-to-height ratio (WHtR), and CAP. Counterfactual mediation analyses with 1000 bootstrap simulations were adjusted for age, sex, and ethnicity. Results The cohort comprised 1683 individuals with low SES and 3089 with high SES. Low SES was associated with higher smoking prevalence (24.0% vs 9.6%) and CVD prevalence (13% vs 8.6%; both p < 0.001). Higher SES was associated with lower odds of prevalent CVD (OR 0.80, 95% CI 0.75–0.85; p < 0.001), with attenuation after adjustment for behavioural, adiposity, and cardiometabolic factors (OR 0.87, 95% CI 0.81–0.94; p < 0.001). Smoking demonstrated the largest mediated proportion, accounting for 19.9% of the SES–CVD association (95% CI 7.3–34.2). Among adiposity measures, WHtR demonstrated the largest contribution (10.4%), exceeding waist circumference (5.0%), body mass index (4.6%), and CAP (1.4%). Conclusions Smoking and central adiposity represent important pathways underlying socioeconomic disparities in prevalent CVD. Smoking demonstrated the largest mediated proportion, while WHtR was the strongest adiposity-related mediator. These findings highlight potentially modifiable behavioural and adiposity-related pathways alongside broader socioeconomic determinants of cardiovascular health.

doi.org/10.1016/j.puhe.2026.106558PubMed 43008582Populations