Intersectional inequality through economic difficulties and lifestyle on body mass index in Sweden

Abstract Background A high body mass index (BMI) is listed among the top five risk factors for the Swedish population. Socially disadvantaged groups, including women, low-educated, and immigrants, are even at higher risk of a high BMI who may also face economic constraints, physical inactivity, and poor-quality diets. However, complex intersectional transmission of inequalities to BMI remains unexplored. Therefore, we aimed to examine intersectional inequalities in BMI mediated by economic strain and lifestyle in the Swedish population. Methods By using the Health on Equal Terms cross-sectional surveys in 2016, 2018, 2020, and 2021 in the Swedish population (n = 44,177 inhabitants aged 24 and over), we performed an intersectional mediation analysis to estimate how inequalities across intersectional strata, by gender (women or men), education (primary, secondary or university), and migration status (Swedish native or migrant), may be sequentially transmitted through economic strain (yes or not in the last 12 months) and unhealthy lifestyle (physical inactivity or inadequate fruit/vegetables consumption) to BMI (continuous). Results Compared with high-educated native men, socially disadvantaged strata experienced more economic strain, which in turn led to poorer health-related lifestyles and ultimately to a higher BMI. Some strata such as high-educated women, despite having a lower BMI, still experienced more pronounced transmissions of inequality on BMI through economic difficulties. Conclusions Not only inequalities in BMI, but also the material and behavioral pathways underpinning the inequalities, act by intersectional patterns. Public health interventions should ensure adequate economic resources to access healthy food and physical activity across all social strata groups. Key messages • Intersectional inequalities in BMI were driven by economic strain and lifestyle. • Economic strain and poorer lifestyles were not only more prevalent in lower stratus but also more detrimental.