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Cited by 579Health disparities and outcomesStress Responses and CortisolPublic Health and Social Inequalities

Socio‐economic differentials in peripheral biology: Cumulative allostatic load

Open access
Seeman, Teresa, Epel, Elissa, Gruenewald, Tara, Karlamangla, Arun, McEwen, Bruce S.·2010·Annals of the New York Academy of Sciences
DOI 10.1111/j.1749-6632.2009.05341.x
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Abstract

This chapter focuses on evidence linking socio‐economic status (SES) to “downstream” peripheral biology. Drawing on the concept of allostatic load, we examine evidence linking lower SES with greater cumulative physiological toll on multiple major biological regulatory systems over the life course. We begin by reviewing evidence linking lower SES to poorer trajectories of aging in multiple, individual physiological systems, followed by evidence of the resulting cumulative, overall burdens of physiological dysregulation seen among those of lower SES. The role of cumulative physiological dysregulation in mediating SES gradients in morbidity and mortality is then examined. We conclude with discussion of the question of interactions between SES (and other such environmental factors) and genetic endowment, and their potential consequences for patterns of physiological activity—an area of research that appears poised to contribute significantly to our understanding of how social conditions “get under the skin” to affect health and aging.

AI snapshot

Written from the paper’s full text.

TL;DR

This chapter reviews evidence that lower socioeconomic status (SES) is linked to greater cumulative physiological dysregulation across major regulatory systems, conceptualized as allostatic load (AL). It argues that cumulative multisystem AL helps explain SES gradients in morbidity and mortality and may serve as an intermediate outcome for evaluating policies to reduce health disparities.

Key findings

  • Lower SES is associated with higher AL across the life course; SES gradients in AL emerge as early as the first 5 years of life and persist through childhood, adulthood, and older age.
  • In the MacArthur Study of Successful Aging, the total AL index mediated about 35% of the education gradient in mortality, whereas none of its component items or subscales accounted for anything close to this, with most accounting for under 15%.
  • The original simple count AL index showed correlations with decline in cognitive and physical function of 0.12 and 0.30, respectively, compared with 0.17 and 0.39 for a canonical AL index (Karlamangla and Seeman, unpublished data).
  • NHANES data show SES gradients in AL by education and age; higher SES older adults exhibit AL levels similar to those of lower SES middle-aged adults.

Methods

  • Narrative review/chapter synthesizing evidence linking SES to peripheral biology and allostatic load, including conceptual background and empirical literature.
  • Draws on cohorts and surveys including the MacArthur Study of Successful Aging (70–79-year-olds), NHANES III (1988–1994), CARDIA, and Whitehall II.
  • The initial AL operationalization used 10 biological parameters across HPA, SNS, cardiovascular, and metabolic systems, counting parameters in the top quartile (bottom quartile for HDL cholesterol and DHEA-S); later work added inflammatory markers CRP and IL-6. Main analyses reviewed associations of AL with mortality, cardiovascular disease, cognitive and physical decline, and mediation of SES gradients.

Limitations

  • The paper states that AL is multifaceted and difficult to operationalize, with no accepted “gold standard”; debate continues about which systems and aspects to measure and how to summarize them into cumulative indices.
  • The paper states that comparative data on scoring methods remain sparse, and more work is needed before “best practice” guidelines can be offered for AL scoring.
  • The paper states that the literature on whether AL mediates SES differentials in health outcomes is small, and additional work is needed to clarify how SES contributes to AL accumulation. Evident from the text: this is a narrative review rather than a systematic review or meta-analysis, and it presents no new primary data collection.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1111/j.1749-6632.2009.05341.x

Cites

225 of 225 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 81 cited sources checked · 0 supported · 0 flagged

  • Findingreasoning

    SES gradients in accumulated allostatic load narrow in the oldest age group.

    “Although SES gradients in accumulated AL narrow in the oldest age group, consistent with the hypothesis that all are susceptible to age-associated increases in AL”
    Quote in the paperSubstantial claim
  • Findingcitation

    The effects of allostatic load on outcomes result from contributions of multiple regulatory systems represented in the index.

    “the effects were found to result from the contributions of multiple regulatory systems represented in the index, 164”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [164] source

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  • Findingown data

    Gradients in HgA1c levels are seen even as early as ages 1-5, with those from lower income (lower PIR) households showing higher prevalence of elevated HgA1c levels compared with children from higher income (higher PIR) families.

    “As shown in Figure 1A, gradients in HgA1c levels are seen even as early as ages 1-5, with those from lower income (lower PIR) households showing higher prevalence of elevated HgA1c levels compared with children from higher income (higher PIR) families”
    Quote in the paperSubstantial claim
  • Findingown data

    Baseline allostatic load is associated with significantly increased risks for mortality, incident and recurrent cardiovascular disease, cognitive and physical decline.

    “Using this simple count index, analyses of the MacArthur Study data demonstrated that baseline AL was associated with significantly increased risks for a range of major outcomes, including risks for mortality, incident and recurrent cardiovascular disease, cognitive and physical decline.”
    Quote in the paperSubstantial claim
  • Findingcitation

    In the MacArthur Aging Study, the original simple count index captures a majority of relevant health risk information, with correlations of 0.12 and 0.30 with decline in cognitive and physical function, respectively, compared with correlations of 0.17 and 0.39 for the canonical allostatic load index.

    “For example, data from the MacArthur Aging Study suggests that the original simple count index captures a majority of the relevant health risk information-e.g., correlations with decline in cognitive and physical function of 0.12 and 0.30, respectively, for the count index as compared with correlations of 0.17 and 0.39 based on the canonical AL index (Karlamangla and Seeman, unpublished data).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Karlamangla and Seeman, unpublished data

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  • May combine two claims. 23
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 13

  • May combine two claims.

    Findingcitation

    Similar SES gradients are seen for blood pressure, total and HDL cholesterol, and C-reactive protein, with lower SES associated with a higher prevalence of high-risk values for all of these parameters.

    “As shown in Figure 2, similar SES gradients are seen for a wide array of additional biological risk factors, including blood pressure, total and HDL cholesterol, and C-reactive protein (CRP) with lower SES associated with a higher prevalence of”
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  • May combine two claims.

    Findingown data

    Figure 3 shows SES gradients in each of three adult age groupings and greater cumulative allostatic load among those of lower SES within each age group.

    “Figure 3 illustrates both of these trends, showing SES gradients in each of three adult age groupings as well as the greater cumulative AL among those of lower SES within each of these age groups.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    The associations between baseline allostatic load and major outcomes were found over an initial 2.5-year follow-up and a longer 7-year follow-up.

    “These associations were found both with respect to an initial 2.5 year follow-up period 176 as well as a longer 7-year period, 164”
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    • cites [176] source

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  • May combine two claims.

    Findingcitation

    In the MacArthur Study of Successful Aging, the total allostatic load index mediates about 35% of the education gradient in mortality, while none of its component items or subscales accounts for close to this, with most accounting for under 15%.

    “Analyses from the MacArthur Study of Successful Aging, for example, document that the total AL index mediates some 35% of the education gradient in mortality while none of its component items or subscales accounts for anything close to this, with most accounting for under 15%.85”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [85] source

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  • The quote only partly states this claim.

    Interpretationreasoning

    Lower SES is associated with more rapid aging of all major physiological systems.

    “Although lower SES is nearly always associated with poorer trajectories of physiological aging when individual biological parameters are examined, the gradients are generally relatively modest while larger gradients are frequently evident when examining”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Chronically elevated inflammation processes are linked to increased risks for osteoporosis, cardiovascular disease, and cognitive decline.

    “Exposure to chronically elevated inflammation processes has also been increasingly recognized as a significant health risk with links to increased risks for osteoporosis, 38,39 cardiovascular disease, [40][41][42][43][44][45] and cognitive decline.[46][47][48]”
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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    High blood pressure, particularly systolic, is associated with higher death rates, onset of cardiovascular disease, and loss of physical and cognitive functioning.

    “The negative health consequences of high blood pressure (particularly systolic) have been recognized for decades, including higher death rates, the onset of cardiovascular disease, and the loss of both physical and cognitive functioning.[6][7][8][9]”
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    Premisecitation

    More chronic elevations in SNS activity can raise blood pressure and heart rate that promotes atherosclerosis, and appear independently associated with cancer mortality.

    “Similarly, more chronic elevations in SNS activity can raise blood pressure and heart rate that promotes atherosclerosis, and appears to be independently associated with cancer mortality.37”
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    High resting heart rate is associated with increased mortality risk.

    “Several studies have also found that high resting heart rate is associated with increased mortality risk (see Ref. 10 for review).”
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    Premisecitation

    Elevated glucose levels, indexed by fasting glucose or glycosylated hemoglobin, are related to heart disease risk, higher mortality, and poorer cognitive and physical function.

    “Elevated glucose levelsas indexed by fasting glucose or more integrated assessments of glucose metabolism such as glycosylated hemoglobin (HgA1c)-have also been related to heart disease risk; 15 to higher mortality; 16 and to poorer cognitive [17][18][19][20] and physical function.8”
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    Premisecitation

    Higher total serum and LDL cholesterol, lower HDL cholesterol, and higher relative weight are recognized risk factors for poor health outcomes including mortality, cardiovascular disease, and functioning loss.

    “Metabolic parameters, including higher total serum and LDL cholesterol, lower HDL cholesterol, and higher relative weight, are also recognized risk factors for poor health outcomes including mortality, cardiovascular disease, and functioning loss.7,[11][12][13][14]”
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  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    The capacity of human brains to imagine scenarios contributes a special feature to human stress responses, so that prolonged stress responses can occur solely due to perceptions or beliefs regardless of the actual, objective presence of danger or stressors.

    “Specifically, the capacity of our brains to imagine scenarios (e.g., potential outcomes of situations) contributes a special feature to human stress responses, so that in the extreme case, one could experience prolonged stress responses solely due to perceptions/beliefs regardless of the actual, objective presence of danger or stressors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A growing body of evidence documents consistent SES gradients for nearly all major biological risk parameters, with lower SES groups exhibiting higher levels of risk.

    “A growing body of evidence documents consistent SES gradients for nearly all of these biological risk parameters-with lower SES groups exhibiting higher levels of risk.”
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    Premisecitation

    Inflammatory processes in the body are associated with reductions in volume of the hippocampus and poor sleep.

    “Accumulating evidence also indicates that inflammatory processes in the body are associated with reductions in volume of a key brain structure, the hippocampus 55 as well as poor sleep 56”
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    Premisecitation

    Use of cumulative assessment is now recommended for clinical decision-making regarding cardiovascular disease risk management.

    “Indeed, use of such cumulative assessment is now recommended for clinical decision-making related cardiovascular disease risk management.80,180”
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  • May combine two claims.

    Premisecitation

    SES-related gradients in allostatic load emerge as early as the first 5 years of life and persist throughout childhood, adulthood, and older age.

    “Consistent with the hypothesis that lower SES is associated with faster accumulation of AL (i.e., greater “wear-and-tear” on physiological regulatory systems), SES related gradients emerge as early as the first 5 years of life and persist throughout childhood, adulthood, and older age.58,83,85,[185][186][187]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites 58,83,85,[185][186][187]

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  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisereasoning

    Some individuals may respond only minimally to what most would view as major life challenges.

    “Conversely, some individuals may respond only minimally if at all to what most would view as major life challenges.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Analyses of nationally representative U.S. NHANES data for adults aged 20 and over documented SES gradients in allostatic load and faster age-specific accumulation associated with poverty.

    “Analyses of nationally representative U.S. data for adults aged 20 and over from the National Health & Nutrition Survey (NHANES) have also documented these same SES gradients in AL [188][189][190] and the faster age-specific accumulation associated with poverty.191”
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  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisereasoning

    Additional factors likely to influence the frequency of reactivity include environmental exposures and individual differences in what is perceived as threatening.

    “Though supported by less empirical evidence, additional factors likely to influence the frequency of reactivity include: (1) environmental exposures (e.g., neighborhoods where you live and work);”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Individual differences in the interpretation of situations can result in dramatically different patterns of response at cognitive/emotional, behavioral, and physiological levels.

    “Indeed, such individual differences in the interpretation of situations can result in dramatically different patterns of response at all levels (cognitive/emotional, behavioral, and physiological).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Each mediator involved in allostasis is part of a nonlinear network in which each mediator has biphasic effects on physiological outcomes and reciprocal regulatory influences on other mediators.

    “Moreover, each mediator involved in allostasis is part of a nonlinear network in which each mediator has biphasic effects on physiological outcomes and also has reciprocal regulatory influences on other mediators.115”
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    Premisecitation

    Characteristic patterns of physiological reactivity are influenced by age, genetic influences, lifestyle/behavioral influences, psychological influences, inter-personal/social influences, and chronic stressor experience.

    “Factors that may influence characteristic patterns of reactivity (i.e., maximum change from basal levels and duration of the response) include such things as (1) age (e.g., prolonged neuroendocrine responses at older ages have been found in some studies 124,128 though not all (see Epel et al., 2007 129 for review), as well as decreased vagal tone at rest, 130 decreased cardiovagal baroreflex”
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  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Evidence to date points to the value of evaluating the multiple, cumulative impacts of SES on physiology to understand how consistent and persistent SES gradients in nearly all health outcomes come to be.

    “evidence to date clearly points to the value of finding ways to evaluate the multiple, cumulative impacts of SES on our physiology if we are to gain a true understanding of how the consistent and persistent SES gradients in nearly all health outcomes come to be”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Examination of specific biological parameters or regulatory systems provides more modest evidence of mediation, with the most extensive mediation seen when the broadest array of biological systems is taken into account.

    “Consistent with the basic concept of AL (focusing on the known co-occurrence of biological risks), examination of specific biological parameters or regulatory systems/processes provides more modest evidence of mediation, with the most extensive/complete mediation seen when the broadest array of biological systems are taken into account.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Adverse early childhood conditions increase the genetic contribution to patterns of morning cortisol rise and cortisol reactivity to an unfamiliar situation, with MZ twins showing increased concordance compared with DZ twins.

    “Adverse early childhood conditions, for example, have been found to increase the genetic contribution to patterns of morning cortisol rise 196 as well as cortisol reactivity to an unfamiliar situation 197 with MZ twins showing increased concordance as compared with DZ twins.”
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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Shift work and short-turnaround time for air crews on trans-meridianal flights have health and cognitive effects that could be ameliorated by work policies.

    “For example, shift work 201 and short-turn around time for air crews on trans-meridianal flights 202 have health and cognitive effects that could be ameliorated by work policies.”
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  • May combine two claims.

    Premisecitation

    Among those reporting changes in SES, increases in SES from childhood to adulthood are associated with allostatic load levels closer to the consistently high SES group, while downward mobility is associated with levels closer to the consistently low SES group.

    “Among those reporting changes in SES, increases in SES from childhood to adulthood were associated with levels of AL closer to the “consistently high SES” group while downward mobility was associated with levels closer to the “consistently low SES” group.184”
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  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Evidence linking lower SES conditions to greater or faster cumulative dysregulation in nearly all major biological systems provides clear evidence of the health toll such socio-economic conditions exact.

    “Evidence linking lower SES conditions to greater/faster cumulative dysregulation in nearly all major biological systems provides clear evidence of the health toll such socio-economic conditions exact.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Peripheral biological parameters represent a potentially valuable category of intermediate or short-term outcomes for evaluating interventions.

    “Peripheral biological parameters represent a potentially valuable category of such “intermediate” or short-term outcomes.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Peripheral biological parameters have shorter time horizons than downstream disease outcomes in terms of responsiveness to changing conditions.
    • Rests on an assumption: Peripheral biological parameters are known risk factors for major disease outcomes.

  • May combine two claims.

    Interpretationreasoning

    Peripheral biological profiles are good candidates for shorter-term evaluations because they have likely shorter time horizons and provide early evidence of program or policy impact on risk profiles known to predict longer-term disease risks.

    “With their likely shorter time horizon, peripheral biological profiles would appear to be good candidates for such shorter-term evaluations-providing early evidence of the impact of a program or policy on risk profiles that are known to predict longer-term disease risks.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Peripheral biological parameters have shorter time horizons than downstream disease outcomes in terms of responsiveness to changing conditions.
    • Rests on an assumption: Peripheral biological parameters are known risk factors for major disease outcomes.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A small but growing body of evidence points to significant interactions between genetic endowment and environmental conditions, with different genetic profiles rendering individuals more or less responsive to environmental conditions.

    “To date, a small but growing body of evidence points to significant interactions between genetic endowment and environmental conditions, with different genetic profiles rendering individuals more or less responsive to environmental conditions.134”
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  • May combine two claims.

    Premisecitation

    Poorer childhood conditions are associated with differences in neural responses to negative emotional stimuli and differences in physiological reactivity to challenge in college-aged students.

    “Poorer childhood conditions have also been associated with differences in neural responses to negative emotional stimuli 199 as well as differences in physiological reactivity to challenge in college-aged students.84”
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32 of 32

  • The authors state this as an assumption.

    Excessive fluctuations in physiologic activity in extent, duration, or frequency can result in wear and tear on the body's regulatory systems.

    “The premise is that while relatively short-term fluctuations in levels of physiologic activity are necessary for the body to respond successfully to stimuli (e.g., the fight or flight response in the face of various types of danger), excessive fluctuations either in terms of the extent, duration or frequency (e.g., responding to perceived”

  • The authors state this as an assumption.

    Allostatic load develops over the life course, with individuals accumulating allostatic load at different rates.

    “As a cumulative phenomenon, allostatic load is postulated to develop over the life course, with individuals accumulating AL at different rates.”

  • The authors state this as an assumption.

    The initiation and progression of allostatic load dysregulation is driven by individual differences in the frequency of exposure to real and perceived challenges and differences in patterns of physiological responses to these challenges.

    “Both the initiation and progression of such dysregulation is postulated to be driven by individual differences in the frequency of exposure to real and perceived challenges and differences in their patterns of physiological responses to these challenges.”

  • The authors state this as an assumption.

    Population differences in allostatic load develop over time as a result of individual differences in exposure to different situations and stimuli and individual differences in cognitive/emotional reactions to these stimuli.

    “Over time, as a result of individual differences in exposure to different situations and stimuli, and individual differences in cognitive/emotional reactions to these stimuli, population differences in allostatic load are postulated to develop.”

  • The paper relies on this without support.

    Older individuals generally have more cumulative allostatic load; within any given age group, there is a range of allostatic loads reflecting differences in prior exposures and reactions to life-time experiences.

    “Older individuals will generally have more cumulative load; but within any given age group, there will be a range of allostatic loads that reflect differences in prior exposures and reactions to one's life-time experiences.”

  • The authors state this as an assumption.

    Relatively modest dysregulation when cumulated across multiple systems may have significant impacts on health risks, even if none of the individual effects would be deemed statistically or clinically significant.

    “This view of biological risk proposes that relatively modest dysregulation (e.g., somewhat elevated BP and/or more frequent or prolonged elevations in response to stimuli) when cumulated across multiple systems may have significant impacts on health risks, even if none of the individual effects would be deemed either statistically or clinically”

  • The paper relies on this without support.

    Peripheral biological parameters have shorter time horizons than downstream disease outcomes in terms of responsiveness to changing conditions.

    “Because such parameters are known risk factors for major disease outcomes but have shorter time horizons than do more downstream disease outcomes in terms of their responsiveness to changing conditions”

  • The paper relies on this without support.

    Peripheral biological parameters are known risk factors for major disease outcomes.

    “such parameters are known risk factors for major disease outcomes”
8 of 8

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Chronic stress is a key mechanism explaining the association between disadvantaged social environments and adverse health outcomes.

    “A key mechanism for explaining this association is chronic stress, which is believed to degrade physiological functioning (3)(4)(5)(6)”

    From Social disadvantage, genetic sensitivity, and children's telomere length (2014) · cites this paper as [5]

Cites

Flagged first, then by citations

Research works printed but not linked: 4

  1. Seeman T., 2007, Social determinants of health inequalities: drivers of cumulative risks and biological consequences
  2. Bernard C., 1878, Les Phenomenes de la vie
  3. Epel E., 2007, Handbook of health psychology of aging, 119
  4. Seeman T., In press. Modeling multi‐system biological risk in young adults: coronary artery risk development in young adults study (CARDIA), Am. J. Hum. Biol.

Cited by

Sorted by citations

Related

Authors
Seeman, T., Epel, E., Gruenewald, T., Karlamangla, A., & McEwen, B. S.
Affiliations
  • University of California, Los Angeles (US)
  • University of California, San Francisco (US)
  • Rockefeller University (US)
Corresponding author
Seeman, Teresa
ORCID
Venue
Annals of the New York Academy of Sciences
Publisher
Wiley
Published
2010-02
Volume
1186
Issue
1
Pages
223-239
ISSN
  • 0077-8923 (ISSN-L)
  • 1749-6632
DOI
10.1111/j.1749-6632.2009.05341.x
OpenAlex
W1619226291
Cited by
579
References
219
Citations by year
2026: 17 · 2025: 15 · 2024: 24 · 2023: 32 · 2022: 33 · 2021: 44 · 2020: 38 · 2019: 56 · 2018: 50 · 2017: 39 · 2016: 39 · 2015: 34 · 2014: 46 · 2013: 33 · 2012: 40
FWCI
7.04
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor, 15 d)
Locations
  • Annals of the New York Academy of Sciences (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Social Sciences › Health › Health disparities and outcomes
  • Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
  • Social Sciences › Health › Public Health and Social Inequalities
Keywords
socioeconomic status, allostatic load, physiological dysregulation, aging trajectories, life course, health disparities, morbidity and mortality, gene-environment interaction
MeSH terms
Adaptation, Physiological, Health Status, Humans, Social Class, Social Environment, Socioeconomic Factors, Allostasis

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