Publication Details

Mao, F., Astell-Burt, T., Feng, X., Liu, Y., Dong, J., Liu, S., Wang, L., Jiang, Y., Dong, W., Zhou, M. & Wang, L. (2019). Social and spatial inequalities in allostatic load among adults in China: A multilevel longitudinal study. BMJ Open, 9 (11),


Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Objectives To investigate potential geographical and socioeconomic patterning of allostatic load (AL) in China. Design Multilevel longitudinal study of the 2010 Chronic Disease Risk Factor Surveillance linked to the National Death Surveillance up to 31 December 2015. Setting All 31 provinces in China, not including Hong Kong, Macao or Taiwan. Participants 96 466 ≥ 18 years old (women=54.3%). Exposures Person-level educational attainment and mean years of education in counties. Outcome AL was measured using clinical guidelines for nine biomarkers: body mass index; waist circumference; systolic blood pressure; diastolic blood pressure; fasting blood glucose; total cholesterol; triglycerides; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol. Results Multilevel logistic regressions adjusted for sex, age, marital status, person-level education, county mean years of education and urban/rural reported ORs of 1.22 (95% CI 1.08 to 1.38) for 5-year all-cause mortality (n=3284) and 1.20 (1.04-1.37) for deaths from non-communicable diseases (n=2891) among people in AL quintile 5 (high) compared with quintile 1 (low). The median rate ratio estimated from unadjusted multilevel negative binomial regression showed AL clustered geographically (province=1.14; county=1.12; town=1.11; village=1.14). After adjusting for aforementioned confounders, AL remained higher with age (rate ratio 1.02, 95% CI 1.02 to 1.02), higher in women compared with men (1.17, 1.15 to 1.19), lower among singletons (0.83, 0.81 to 0.85) and widowers (0.96, 0.94 to 0.98). AL was lower among people with university-level compared with no education (0.92, 0.89 to 0.96), but higher in counties with higher mean education years (1.03, 1.01 to 1.05). A two-way interaction suggested AL was higher (1.04, 1.02 to 1.06) among those with university-level compared with no education within counties with higher mean years of education. Similar results were observed for alternative constructions of AL using 75th and 80th percentile cut-points. Conclusions AL in China is patterned geographically. The degree of association between AL and person-level education seems to be dependent on area-level education, which may be a proxy for other contextual factors that warrant investigation.



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