The mediating role of healthy lifestyle between socioeconomic status and hypertension: a nationwide cross-sectional study from NHANES 2017-2020

Abstract Background: Hypertension is a leading global health issue, with socioeconomic status (SES) and lifestyle behaviors significantly influencing its development. However, the mechanisms linking SES to hypertension, particularly the role of a healthy lifestyle as a mediator, remain inadequately explored in existing research. Objective: This study aims to investigate the associations between SES, healthy lifestyle, and hypertension risk, with a focus on the mediating role of lifestyle factors in the SES-hypertension relationship, using nationally representative data. Methods: Data from 5,993 adults aged ≥20 years from the 2017-2020 National Health and Nutrition Examination Survey (NHANES) were analyzed. SES was assessed using latent class analysis, incorporating household income, education, occupation, and health insurance. A composite score reflecting smoking, alcohol consumption, physical activity, and diet was used to define healthy lifestyle. Hypertension was identified based on self-reports and blood pressure measurements in accordance with the ACC/AHA 2017 guidelines. Multilevel logistic regression models, adjusting for demographic and clinical covariates, were used to examine associations. Mediation analysis via structural equation modeling and bootstrapping assessed the indirect effect of healthy lifestyle on the SES-hypertension relationship. Results: Lower SES was strongly associated with higher hypertension prevalence, while middle SES exhibited a protective effect after full adjustment (OR=0.715, 95% CI: 0.595-0.858). Higher SES was linked to healthier lifestyle behaviors (OR=2.595, 95% CI: 2.121-3.174), and a healthier lifestyle was inversely associated with hypertension risk (OR=0.746, 95% CI: 0.638-0.873). Mediation analyses confirmed that healthy lifestyle behaviors partially mediated the relationship between SES and hypertension, explaining about 24.4% of the total association. Subgroup analyses indicated variations in these associations by age, gender, race, and BMI. Conclusions: Higher SES is associated with lower hypertension risk, partly through healthier lifestyle behaviors. Public health interventions should focus on promoting healthier lifestyles alongside socioeconomic improvements to reduce hypertension-related health disparities, particularly in vulnerable groups. Tailored strategies considering sociodemographic factors are essential to optimize cardiovascular health outcomes.