Health Inequalities
In brief
Section titled “In brief”- People with lower education live on average 6 years shorter and 15 years longer in poor health
- Causes: material circumstances, chronic stress, behavioral factors, and unequal access
- Stress and scarcity directly affect behavior and biological aging
- Lifestyle interventions work, but must be adapted to the context
- Focus on feasibility, local embedding, and removing practical barriers
The numbers in the Netherlands
Section titled “The numbers in the Netherlands”Life expectancy by education
Section titled “Life expectancy by education”| Education level | Life expectancy | Years in good health |
|---|---|---|
| High (bachelor/master) | ~84 years | ~72 years |
| Middle (vocational) | ~81 years | ~64 years |
| Low (secondary or lower) | ~78 years | ~57 years |
Which conditions occur more frequently?
Section titled “Which conditions occur more frequently?”- Type 2 diabetes - 2-3x more common with low SES
- Cardiovascular disease - 1.5-2x more common
- Obesity - 2x more common
- Depression and anxiety - 2x more common
- Lung diseases (COPD) - strongly linked to smoking and occupational exposure
- Some forms of cancer - particularly lung, stomach, and cervical cancer
How do health inequalities arise?
Section titled “How do health inequalities arise?”The mechanism in layers
Section titled “The mechanism in layers”Societal factors ↓┌─────────────────────────────────────────┐│ Material circumstances ││ (income, work, housing) │└─────────────────────────────────────────┘ ↓┌─────────────────────────────────────────┐│ Psychosocial factors ││ (stress, control, social support) │└─────────────────────────────────────────┘ ↓┌─────────────────────────────────────────┐│ Behavioral factors ││ (nutrition, smoking, exercise, alcohol)│└─────────────────────────────────────────┘ ↓┌─────────────────────────────────────────┐│ Biological effects ││ (inflammation, aging, organ damage) │└─────────────────────────────────────────┘ ↓ Disease and mortality1. Material circumstances
Section titled “1. Material circumstances”| Factor | Effect on health |
|---|---|
| Low income | Less money for healthy food, sports, healthcare |
| Insecure work | Chronic stress, little control |
| Poor housing | Dampness, cold, no space for exercise |
| Debt | Constant mental burden |
| Neighborhood | Less green space, more fast food, fewer facilities |
2. Psychosocial factors
Section titled “2. Psychosocial factors”Chronic stress from uncertainty and lack of control has direct biological effects:
- Elevated cortisol → insulin resistance, belly fat, high blood pressure
- Inflammation activation → accelerated atherosclerosis, increased disease risk
- Shortened telomeres → accelerated biological aging
- Disrupted sleep → metabolic dysregulation, reduced recovery
3. Behavioral factors
Section titled “3. Behavioral factors”| Behavior | Low educated | Highly educated |
|---|---|---|
| Smoking | ~25% | ~10% |
| Overweight | ~60% | ~40% |
| Sufficient exercise | ~40% | ~55% |
| Vegetables and fruit | Less | More |
These differences explain approximately 30-40% of health inequalities. The rest is in material and psychosocial factors.
4. Access to healthcare
Section titled “4. Access to healthcare”- Seeking help less quickly
- Fewer health skills (health literacy)
- Less assertive in contact with healthcare providers
- More often postponement due to costs (deductible)
- Less access to preventive programs
The role of the environment
Section titled “The role of the environment”Obesogenic environment
Section titled “Obesogenic environment”In neighborhoods with low SES:
- More fast food per square kilometer
- Fewer supermarkets with fresh food
- Less green space and sports facilities
- More advertising for unhealthy products
- Social norm: unhealthy eating is “normal”
Social networks
Section titled “Social networks”- Smoking, overweight, and eating patterns spread through social networks
- In networks with a lot of unhealthy behavior, deviating is harder
- Peer support can also work positively (see community approach)
What works with lifestyle interventions?
Section titled “What works with lifestyle interventions?”Characteristics of effective interventions
Section titled “Characteristics of effective interventions”| Works | Works less |
|---|---|
| Accessible and nearby | Expensive programs far away |
| Group approach and peer support | Only individual advice |
| Focus on small steps | Big changes at once |
| Removing practical barriers | Only providing information |
| Connecting to what people already do | Imposing new behavior |
| Respectful and without judgment | Blame and shame |
Concrete examples
Section titled “Concrete examples”Nutrition on a limited budget:
- Focus on affordable protein sources (eggs, legumes, quark)
- Frozen vegetables are cheap and nutritious
- Batch cooking saves time and money
- Less ultra-processed is often cheaper too
Exercise without a gym:
- Walking is free and effective
- Stair climbing in apartment or building entrance
- Household activities count
- Exercise groups in the neighborhood (often free)
Stress reduction:
- Breathing exercises cost nothing
- Maintaining social contacts
- Seeking nature (park, green space)
- Debt assistance and budget coaching where needed
What can healthcare providers do?
Section titled “What can healthcare providers do?”In the consultation
Section titled “In the consultation”-
Ask about context
- “How are things at home?”
- “Are there concerns about money or work?”
- “What makes it difficult to follow [advice]?”
-
Adapt advice
- Take into account budget and time
- Give concrete, small steps
- Avoid expensive supplements or programs
-
Refer specifically
- To welfare coach, social neighborhood team
- To local exercise initiatives
- To debt assistance if needed
-
Avoid blame
- Acknowledge that circumstances are difficult
- Focus on what does work
- Celebrate small successes
Systemic approach
Section titled “Systemic approach”The neighborhood approach
Section titled “The neighborhood approach”Why local works
Section titled “Why local works”- Familiar environment lowers threshold
- Social support from neighbors
- Connection to existing networks
- Visible role models from own circle
Examples from practice
Section titled “Examples from practice”| Initiative | Approach |
|---|---|
| Power of nutrition | Cooking workshops in community center with affordable recipes |
| Exercise garden | Free outdoor fitness with guidance |
| Welfare on prescription | GP refers to welfare activities |
| Debt-free | Combined approach to debt + lifestyle |
| JLAM Community | Peer support via online groups |
The biological link: how poverty makes people sick
Section titled “The biological link: how poverty makes people sick”Chronic stress and the body
Section titled “Chronic stress and the body”| Stress response | Consequence with chronic activation |
|---|---|
| Cortisol ↑ | Insulin resistance, belly fat, high blood pressure |
| Adrenaline ↑ | Elevated heart rate, sleep problems |
| Inflammation ↑ | Atherosclerosis, diabetes, depression |
| Telomere shortening | Accelerated cell aging |
Epigenetics
Section titled “Epigenetics”Poverty and stress can influence gene expression - not the DNA code itself, but which genes are turned on or off. These effects can even be partly passed on to subsequent generations.
What is needed at the macro level?
Section titled “What is needed at the macro level?”Lifestyle interventions alone do not solve health inequalities. Structural measures are needed:
- Security of existence - sufficient income, stable work
- Affordable healthy food - VAT reduction, subsidies
- Smoke-free generation - excise duties, sales restrictions
- Healthy living environment - green space, sports facilities, less fast food
- Accessible healthcare - lowering thresholds, revising deductibles
- Education - health skills from a young age
Veelgestelde vragen
What are health inequalities?
Health inequalities are systematic differences in health between groups of people, often linked to socioeconomic status (education, income, occupation). In the Netherlands, people with lower education live on average 6 years shorter and 15 years longer in poor health than highly educated people.
What causes health inequalities?
Through an interplay of factors: material circumstances (income, housing), psychosocial stress (uncertainty, lack of control), behavioral factors (nutrition, smoking, exercise), and unequal access to healthcare and information. These factors often reinforce each other.
Can lifestyle interventions reduce health inequalities?
Yes, if well designed. Effective interventions are accessible, locally embedded, take into account limited resources and stress, and focus on small achievable steps. Group approaches and peer support often work better than individual advice.
Why is stress such an important factor?
Chronic stress from financial worries, insecure work, or poor living conditions raises cortisol, promotes unhealthy eating behavior, disrupts sleep, and accelerates biological aging. This partly explains why poverty literally makes people sick.
What can I do as a healthcare provider?
Ask about practical barriers (money, time, stress), adapt advice to the context, refer to local initiatives, and avoid blame and shame. Small concrete steps work better than big lifestyle changes that are unachievable.
Medische Disclaimer: De informatie van Stichting Je Leefstijl Als Medicijn over leefstijl, ziektes en stoornissen mag niet worden opgevat als medisch advies. In geen geval adviseren wij mensen om hun bestaande behandeling te veranderen. We raden mensen met chronische aandoeningen aan om zich over hun behandeling goed door bevoegde medische professionals te laten adviseren.
Medical Disclaimer: The information provided by Stichting Je Leefstijl Als Medicijn regarding lifestyle, diseases, and disorders should not be construed as medical advice. Under no circumstances do we advise people to alter their existing treatment. We recommend that people with chronic conditions seek advice regarding their treatment from qualified medical professionals.