sSocial Determinants of Health and Cumulative Incidence of Mortality among U.S. Adults without Major Chronic Diseases

Background Social determinants of health (SDOH) are widely known to contribute to poor health outcomes and premature mortality among individuals with prevalent diseases. Understanding the impact of SDOH on mortality among adults without major chronic diseases may inform public policy in the United States (U.S.). Methods We conducted a prospective observational study using the National Health and Nutrition Examination Survey data (1999-2018) among 11,413 adults without hypertension, diabetes, hyperlipidemia, severe obesity, chronic kidney disease, cardiovascular disease, chronic respiratory disease, cancer, liver disease, arthritis, hepatitis B or C, human immunodeficiency virus, or pregnancy. We calculated 15-year adjusted cumulative incidences of all-cause mortality by baseline SDOH and described the trends in the prevalence of adverse SDOH. Results The mean ±SD age was 34.9±11.2 years. Over a median follow-up of 10.3 years, 275 participants died. The prevalence of low educational attainment decreased over the study period from 19.8% to 12.1%, while the prevalence of food insecurity increased from 11.5% to 23.1%. The 15-year adjusted cumulative incidences of all-cause mortality were 5.6% (95% CI, 2.8-8.5), 5.2% (95%CI, 3.2-7.3), 4.9% (95%CI, 2.7-7.2), 4.0% (95%CI, 2.8-5.2) for participants who had < 100 % of the federal poverty level, below high school education, food insecurity, and were born in the U.S., respectively. In the final adjusted model, a 1-point increase in cumulative SDOH score was associated with 33% increased risk of all-cause mortality. Conclusions In this study of community-dwelling U.S. adults without major chronic diseases, we demonstrate a pronounced increase in all-cause mortality associated with adverse SDOH. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number R38HL143584. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The data used in this study are publicly available at . I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data are publicly available at