Olstad Dana Lee, McIntyre Lynn
Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Adv Nutr. 2025 Jul 17;16(9):100482. doi: 10.1016/j.advnut.2025.100482.
Inequities in diet quality are evident worldwide and reflect structural disadvantages. There is increasing evidence that dietary inequities may be most meaningful in relation to educational attainment, a finding that contradicts the common belief that dietary inequities are primarily attributable to material disadvantage (i.e. inadequate incomes). Moreover, diet quality declines with each step down the educational ladder, and therefore, these educational inequities affect all of society. The purpose of this perspective is to posit that educational attainment is a key structural stratifier of diet quality and dietary inequities-what we term a super determinant-and that greater research attention should be given to interrogating pathways through which educational attainment shapes diet quality. To inform our perspective, we conducted extensive keyword searches in PubMed and Google Scholar to identify concepts, theories, and empirical data pertaining to educational inequities in diet quality, health, and mortality, followed by a conceptual synthesis of findings. On the basis of these findings, we first describe pathways through which educational attainment shapes diet quality. We then demonstrate that educational inequities in diet quality are often much larger than they are for income. For instance, absolute gaps and gradients in Healthy Eating Index-2015 scores between the most and least educated adults were 7-11 points in Canada, whereas they were just 2-5 points in relation to household income. We provide converging evidence related to large and growing educational inequities in diet quality, health, and mortality internationally. We subsequently consider an important counterfactual-that the affordability of a healthy diet is the key determinant of dietary inequities-and empirically demonstrate that economic factors are not primary drivers of socioeconomic inequities in diet quality. We conclude that attributing dietary inequities primarily to the higher costs of healthy foods is overly simplistic and ignores the critical role of educational attainment as a structural stratifier of dietary inequities.
饮食质量方面的不平等在全球范围内都很明显，反映了结构性劣势。越来越多的证据表明，饮食不平等在与教育程度的关系中可能最为显著，这一发现与普遍认为饮食不平等主要归因于物质劣势（即收入不足）的观点相矛盾。此外，随着教育阶梯上的每一步下降，饮食质量都会下降，因此，这些教育不平等影响着整个社会。本文观点的目的是提出，教育程度是饮食质量和饮食不平等的关键结构性分层因素——我们称之为超级决定因素——并且应该更加关注研究教育程度影响饮食质量的途径。为了形成我们的观点，我们在PubMed和谷歌学术上进行了广泛的关键词搜索，以识别与饮食质量、健康和死亡率方面的教育不平等相关的概念、理论和实证数据，随后对研究结果进行了概念性综合。基于这些发现，我们首先描述教育程度影响饮食质量的途径。然后我们证明，饮食质量方面的教育不平等往往比收入方面的不平等大得多。例如，在加拿大，受教育程度最高和最低的成年人在2015年健康饮食指数得分上的绝对差距和梯度为7 - 11分，而与家庭收入相关的差距仅为2 - 5分。我们提供了与国际上饮食质量、健康和死亡率方面巨大且不断扩大的教育不平等相关的趋同证据。随后，我们考虑一个重要的反事实情况——健康饮食的可承受性是饮食不平等的关键决定因素——并通过实证证明经济因素不是饮食质量社会经济不平等的主要驱动因素。我们得出结论，将饮食不平等主要归因于健康食品的较高成本过于简单化，忽视了教育程度作为饮食不平等结构性分层因素的关键作用。
