Decomposing the educational gradient in allostatic load across European populations. What matters the most: differentials in exposure or in susceptibility?

Giovanni Veronesi, Frank Kee, Blanaid Hicks, Hannah Forrest, Hugh Tunstall-Pedoe, Kari Kuulasmaa, Susana Sans, Veikko Salomaa, Barbara Thorand, Augusto Di Castelnuovo, Stefan Soderberg, Giancarlo Cesana, Martin Bobak, Roberto De Ponti, Licia Iacoviello, Luigi Palmieri, Tanja Zeller, Stefan Blankenberg, Marco M. Ferrario (Lead / Corresponding author)

Research output: Contribution to journalArticlepeer-review

4 Citations (Scopus)


Background: We investigate whether socially disadvantaged individuals are more susceptible to the detrimental effects of smoking and alcohol intake on allostatic load (AL), a marker of physiological 'wear and tear', resulting from adaptation to chronic stress.

Methods: In a cross-sectional analysis, 27 019 men and 26 738 women aged 35-74 years were identified from 21 European cohorts in the BiomarCaRE consortium. We defined three educational classes (EDs) according to years of schooling and an AL score as the sum of z-scores of eight selected biomarkers from the cardiovascular, metabolic and inflammatory systems. We used the Oaxaca-Blinder decomposition to disentangle the ED gradient in AL score into the differential exposure (DE, attributable to different distribution of smoking and alcohol intake across EDs) and the differential susceptibility (DS, attributable to a different effect of risk factors on AL across EDs) components.

Results: Less-educated men (mean AL difference: 0.68, 95% CI 0.57 to 0.79) and women (1.52, 95% CI 1.40 to 1.64) had higher AL scores. DE accounted for 7% and 6% of the gradient in men and women, respectively. In men, combining smoking and alcohol intake, DS accounted for 42% of the gradient (smoking DS coefficient=0.177, 26% of the gradient; alcohol DS coefficient=0.109; 16%, not statistically significant). DS contribution increased to 69% in metabolic markers. DS estimates were consistent across age groups, irrespective of comorbidities and robust to unmeasured confounding. No DS was observed in women.

Conclusions: In men, a DS mechanism substantially contributes to the educational class gradient in allostatic load.

Original languageEnglish
Pages (from-to)1008-1015
Number of pages8
JournalJournal of Epidemiology and Community Health
Issue number12
Early online date27 Aug 2020
Publication statusPublished - 1 Dec 2020


  • Epidemiological methods
  • Epidemiology of cardiovascular disease
  • Social inequalities
  • Stress

ASJC Scopus subject areas

  • Epidemiology
  • Public Health, Environmental and Occupational Health


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