Educational differences in mortality associated with central obesity: Decomposing the contribution of risk and prevalence

Thousands of preventable deaths are attributed to obesity in the United States. However, the harmfulness of obesity varies across the population; individuals’ education determines access to healthful resources and exposure to competing risks, dampening/amplifying obesity-associated mortality risk. Using restricted U.S. National Health and Nutrition Examination Survey data (N = 40,058; 1988–2015), this study estimates educational differences in mortality attributable to central obesity (waist-to-height ratio ≥0.5) – a dangerous form of abdominal adiposity. Over 30% of excess deaths are attributable to central obesity among college-educated adults, compared to 1–10% among their less-educated counterparts. This difference is larger for cardiometabolic-related mortality, as central obesity may explain 60–70% of excess deaths among college-educated adults. Decomposition analyses show differences are driven by greater obesity-associated risk among college-educated adults, rather than prevalence. Policies targeting health disparities should recognize central obesity as a key risk among highly-educated adults, but only one of many encountered by those with less education. •Obesity is a leading preventable cause of mortality in the United States.•Educational attainment may be a key moderator of the obesity-mortality relationship.•Central obesity accounts for 30–70% of excess deaths among college-educated adults.•Less-educated adults have lower obesity-associated mortality risk and proportion of excess deaths.•Population-wide anti-obesity efforts may widen educational health disparities.