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  • Ricci, Cristian; Wood, Angela; Muller, David; Gunter, Marc J.; Agudo, Antonio; Boeing, Heiner; van der Schouw, Yvonne T.; Warnakula, Samantha; Saieva, Calogero; Spijkerman, Annemieke; Sluijs, Ivonne; Tjonneland, Anne; Kyro, Cecilie; Weiderpass, Elisabete; Kuehn, Tilman; Kaaks, Rudolf; Sanchez, Maria-Jose; Panico, Salvatore; Agnoli, Claudia; Palli, Domenico; Tumino, Rosario; Engstrom, Gunnar; Melander, Olle; Bonnet, Fabrice; Boer, Jolanda M. A.; Key, Timothy J.; Travis, Ruth C.; Overvad, Kim; Verschuren, W. M. Monique; Quiros, J. Ramon; Trichopoulou, Antonia; Papatesta, Eleni-Maria; Peppa, Eleni; Iribas, Conchi Moreno; Gavrila, Diana; Forslund, Ann-Sofie; Jansson, Jan-Hakan; Matullo, Giuseppe; Arriola, Larraitz; Freisling, Heinz; Lassale, Camille; Tzoulaki, Ioanna; Sharp, Stephen J.; Forouhi, Nita G.; Langenberg, Claudia; Saracci, Rodolfo; Sweeting, Michael; Brennan, Paul; Butterworth, Adam S.; Riboli, Elio (2018)
    OBJECTIVE To investigate the association between alcohol consumption (at baseline and over lifetime) and non-fatal and fatal coronary heart disease (CHD) and stroke. DESIGN Multicentre case-cohort study. SETTING A study of cardiovascular disease (CVD) determinants within the European Prospective Investigation into Cancer and nutrition cohort (EPIC-CVD) from eight European countries. PARTICIPANTS 32 549 participants without baseline CVD, comprised of incident CVD cases and a subcohort for comparison. MAIN OUTCOME MEASURES Non-fatal and fatal CHD and stroke (including ischaemic and haemorrhagic stroke). RESULTS There were 9307 non-fatal CHD events, 1699 fatal CHD, 5855 non-fatal stroke, and 733 fatal stroke. Baseline alcohol intake was inversely associated with non-fatal CHD, with a hazard ratio of 0.94 (95% confidence interval 0.92 to 0.96) per 12 g/day higher intake. There was a J shaped association between baseline alcohol intake and risk of fatal CHD. The hazard ratios were 0.83 (0.70 to 0.98), 0.65 (0.53 to 0.81), and 0.82 (0.65 to 1.03) for categories 5.0-14.9 g/day, 15.0-29.9 g/day, and 30.0-59.9 g/day of total alcohol intake, respectively, compared with 0.1-4.9 g/ day. In contrast, hazard ratios for non-fatal and fatal stroke risk were 1.04 (1.02 to 1.07), and 1.05 (0.98 to 1.13) per 12 g/day increase in baseline alcohol intake, respectively, including broadly similar findings for ischaemic and haemorrhagic stroke. Associations with cardiovascular outcomes were broadly similar with average lifetime alcohol consumption as for baseline alcohol intake, and across the eight countries studied. There was no strong evidence for interactions of alcohol consumption with smoking status on the risk of CVD events. CONCLUSIONS Alcohol intake was inversely associated with non-fatal CHD risk but positively associated with the risk of different stroke subtypes. This highlights the opposing associations of alcohol intake with different CVD types and strengthens the evidence for policies to reduce alcohol consumption.
  • Oksanen, Tuula; Kawachi, Ichiro; Subramanian, S. V.; Kim, Daniel; Shirai, Kokoro; Kouvonen, Anne; Pentti, Jaana; Salo, Paula; Virtanen, Marianna; Vahtera, Jussi; Kivimaki, Mika (2013)
  • Dudel, Christian; Myrskylä, Mikko (2020)
    Background Markov models are a key tool for calculating expected time spent in a state, such as active life expectancy and disabled life expectancy. In reality, individuals often enter and exit states recurrently, but standard analytical approaches are not able to describe this dynamic. We develop an analytical matrix approach to calculating the expected number and length of episodes spent in a state. Methods The approach we propose is based on Markov chains with rewards. It allows us to identify the number of entries into a state and to calculate the average length of episodes as total time in a state divided by the number of entries. For sampling variance estimation, we employ the block bootstrap. Two case studies that are based on published literature illustrate how our methods can provide new insights into disability dynamics. Results The first application uses a classic textbook example on prednisone treatment and liver functioning among liver cirrhosis patients. We replicate well-known results of no association between treatment and survival or recovery. Our analysis of the episodes of normal liver functioning delivers the new insight that the treatment reduced the likelihood of relapse and extended episodes of normal liver functioning. The second application assesses frailty and disability among elderly people. We replicate the prior finding that frail individuals have longer life expectancy in disability. As a novel finding, we document that frail individuals experience three times as many episodes of disability that were on average twice as long as the episodes of nonfrail individuals. Conclusions We provide a simple analytical approach for calculating the number and length of episodes in Markov chain models. The results allow a description of the transition dynamics that goes beyond the results that can be obtained using standard tools for Markov chains. Empirical applications using published data illustrate how the new method is helpful in unraveling the dynamics of the modeled process.
  • Baars, Adája E.; Rubio-Valverde, Jose R.; Hu, Yannan; Bopp, Matthias; Brønnum-Hansen, Henrik; Kalediene, Ramune; Leinsalu, Mall; Martikainen, Pekka; Regidor, Enrique; White, Chris; Wojtyniak, Bogdan; Mackenbach, Johan P.; Nusselder, Wilma J. (2019)
    ObjectivesTo assess to what extent educational differences in total life expectancy (TLE) and disability-free life expectancy (DFLE) could be reduced by improving fruit and vegetable consumption in ten European countries.MethodsData from national census or registries with mortality follow-up, EU-SILC, and ESS were used in two scenarios to calculate the impact: the upward levelling scenario (exposure in low educated equals exposure in high educated) and the elimination scenario (no exposure in both groups). Results are estimated for men and women between ages 35 and 79years.ResultsVarying by country, upward levelling reduced inequalities in DFLE by 0.1-1.1years (1-10%) in males, and by 0.0-1.3years (0-18%) in females. Eliminating exposure reduced inequalities in DFLE between 0.6 and 1.7years for males (6-15%), and between 0.1years and 1.8years for females (3-20%).ConclusionsUpward levelling of fruit and vegetable consumption would have a small, positive effect on both TLE and DFLE, and could potentially reduce inequalities in TLE and DFLE.
  • Luiro, Kaisu; Aittomäki, Kristiina; Jousilahti, Pekka; Tapanainen, Juha S. (2019)
    Objective: To study the use of hormone therapy (HT), morbidity and reproductive outcomes of women with primary ovarian insufficiency (POI) due to FSH-resistant ovaries (FSHRO). Design: A prospective follow-up study in a university-based tertiary clinic setting. Methods: Twenty-six women with an inactivating A189V FSH receptor mutation were investigated by means of a health questionnaire and clinical examination. Twenty-two returned the health questionnaire and 14 were clinically examined. Main outcome measures in the health questionnaire were reported as HT, morbidity, medication and infertility treatment outcomes. In the clinical study, risk factors for cardiovascular disease (CVD) and metabolic syndrome (MetS) were compared to age-matched controls from a national population survey (FINRISK). Average number of controls was 326 per FSHRO subject (range 178-430). Bone mineral density and whole-body composition were analyzed with DXA. Psychological and sexual well-being was assessed with Beck Depression Inventory (BDI21), Generalized Anxiety Disorder 7 (GAD-7) and Female Sexual Function Index (FSFI) questionnaires. Results: HT was initiated late (median 18 years of age) compared with normal puberty and the median time of use was shorter (20-22 years) than the normal fertile period. Osteopenia was detected in 9/14 of the FSHRO women despite HT. No major risk factors for CVD or diabetes were found. Conclusions: HT of 20 years seems to be associated with a similar cardiovascular and metabolic risk factor profile as in the population control group. However, optimal bone health may require an early-onset and longer period of HT, which would better correspond to the natural fertile period.
  • Stenholm, Sari; Head, Jenny; Kivimaki, Mika; Kawachi, Ichiro; Aalto, Ville; Zins, Marie; Goldberg, Marcel; Zaninotto, Paola; Hanson, Linda Magnuson; Westerlund, Hugo; Vahtera, Jussi (2016)
    Background: Smoking, physical inactivity and obesity are modifiable risk factors for morbidity and mortality. The aim of this study was to examine the extent to which the co-occurrence of these behaviour-related risk factors predict healthy life expectancy and chronic disease-free life expectancy in four European cohort studies. Methods: Data were drawn from repeated waves of four cohort studies in England, Finland, France and Sweden. Smoking status, physical inactivity and obesity (body mass index >= 30 kg/m(2)) were examined separately and in combination. Health expectancy was estimated by using two health indicators: suboptimal self-rated health and having a chronic disease (cardiovascular disease, cancer, respiratory disease and diabetes). Multistate life table models were used to estimate sex-specific healthy life expectancy and chronic disease-free life expectancy from ages 50 to 75 years. Results: Compared with men and women with at least two behaviour-related risk factors, those with no behaviour-related risk factors could expect to live on average8 years longer in good health and 6 years longer free of chronic diseases between ages 50 and 75.Having any single risk factor was also associated with reduction in healthy years. No consistent differences between cohorts were observed. Conclusions: Data from four European countries show that persons with individual and co-occurring behaviour-related risk factors have shorter healthy life expectancy and shorter chronic disease-free life expectancy. Population level reductions in smoking, physical inactivity and obesity could increase life-years lived in good health.
  • d'Errico, Angelo; Ricceri, Fulvio; Stringhini, Silvia; Carmeli, Cristian; Kivimaki, Mika; Bartley, Mel; McCrory, Cathal; Bochud, Murielle; Vollenweider, Peter; Tumino, Rosario; Goldberg, Marcel; Zins, Marie; Barros, Henrique; Giles, Graham; Severi, Gianluca; Costa, Giuseppe; Vineis, Paolo; LIFEPATH Consortium (2017)
    Background Several social indicators have been used in epidemiological research to describe socioeconomic position (SEP) of people in societies. Among SEP indicators, those more frequently used are education, occupational class and income. Differences in the incidence of several health outcomes have been reported consistently, independently from the indicator employed. Main objectives of the study were to present the socioeconomic classifications of the social indicators which will be employed throughout the LIFEPATH project and to compare social gradients in all-cause mortality observed in the participating adult cohorts using the different SEP indicators. Methods Information on the available social indicators (education, own and father's occupational class, income) from eleven adult cohorts participating in LIFEPATH was collected and harmonized. Mortality by SEP for each indicator was estimated by Poisson regression on each cohort and then evaluated using a meta-analytical approach. Results In the meta-analysis, among men mortality was significantly inversely associated with both occupational class and education, but not with father's occupational class; among women, the increase in mortality in lower social strata was smaller than among men and, except for a slight increase in the lowest education category, no significant differences were found. Conclusions Among men, the proposed three-level classifications of occupational class and education were found to predict differences in mortality which is consistent with previous research. Results on women suggest that classifying them through their sole SEP, without considering that of their partners, may imply a misclassification of their social position leading to attenuation of mortality differences.
  • Lallukka, Tea; Ervasti, Jenni; Mittendorfer-Rutz, Ellenor; Tinghog, Petter; Kjeldgard, Linnea; Pentti, Jaana; Virtanen, Marianna; Alexanderson, Kristina (2016)
    Aims: We aimed to examine how newly diagnosed diabetes and work disability jointly predict death during working age. Methods: We used prospective population-based register data of 25-59-year-old adults who had lived in Sweden since 2002. All those with onset of diabetes recorded in 2006 were included (n=14266). A 2% random sample (n=78598) was drawn from the general population, comprising people with no indication of diabetes during 2003-2010. Net days of sickness absence and disability pension in 2005-2006 were examined; the follow-up time for mortality was 2007-2010. Cox regression models were fitted (hazard ratios, HR, 95% confidence interval, CI) adjusting for sociodemographics and time-dependent health conditions. Results: Individuals with diabetes and work disability for over 6 months were at a higher risk of premature death (HR=14.2, 95% CI 12.0-16.8) than their counterparts without diabetes and work disability. A high risk was also observed among people without diabetes but equally prolonged work disability (HR=6.4, 95% CI 5.4-7.6). Diabetes was associated with premature death even without work disability (HR=3.5, 95% CI 2.8-4.4). The associations were particularly attenuated after adjustment for health conditions assessed over the follow-up. Conclusions: Diabetes and work disability jointly increase the risk of death during working age. Diabetes with long-term work disability is associated with the highest risk of premature death, which highlights the importance of their prevention and early detection.
  • Stenholm, Sari; Kivimaki, Mika; Jylha, Marja; Kawachi, Ichiro; Westerlund, Hugo; Pentti, Jaana; Goldberg, Marcel; Zins, Marie; Vahtera, Jussi (2016)
    Poor self-rated health is associated with increased risk of mortality, but no previous study has examined how long-term trajectories of self-rated health differ among people at risk of subsequent death compared to those who survive. Data were drawn from French occupational cohort (the GAZEL study, 1989-2010). This nested case-control study included 915 deceased men and women and 2578 controls matched for sex, baseline age, occupational grade and marital status. Self-rated health was measured annually and dichotomized into good versus poor health. Trajectories of poor self-rated health up to 15 years were compared among people who subsequently died to those who survived. Participants contributed to an average 10.3 repeated assessments of self-rated health. Repeated-measures log-binomial regression analysis with generalized estimating equations showed an increased prevalence of poor self-rated health in cases 13-15 years prior to death from ischemic and other cardiovascular disease [multivariable-adjusted risk ratio 2.06, 95 % confidence interval (CI) 1.55-2.75], non-smoking-related cancers (1.57, 95 % CI 1.30-1.89), and suicide (1.78, 95 % CI 1.00-3.16). Prior to death from ischemic and other cardiovascular disease, increased rates of poor self-rated health were evident even among persons who were free of cardiovascular diseases (2.05, 95 % CI 1.50-2.78). In conclusion, perceptions of health diverged between the surviving controls and the deceased already 15 years prior to death. For cardiovascular mortality, decline in self-rated health started before diagnosis of the disease leading to death. The findings suggest that declining self-rated health might capture pathological changes before and beyond the disease diagnosis.
  • McMinn, Megan A.; Martikainen, Pekka; Gorman, Emma; Rissanen, Harri; Härkänen, Tommi; Tolonen, Hanna; Leyland, Alastair H.; Gray, Linsay (2019)
    Introduction Decreasing participation levels in health surveys pose a threat to the validity of estimates intended to be representative of their target population. If participants and non-participants differ systematically, the results may be biased. The application of traditional non-response adjustment methods, such as weighting, can fail to correct for such biases, as estimates are typically based on the sociodemographic information available. Therefore, a dedicated methodology to infer on non-participants offers advancement by employing survey data linked to administrative health records, with reference to data on the general population. We aim to validate such a methodology in a register-based setting, where individual-level data on participants and non-participants are available, taking alcohol consumption estimation as the exemplar focus. Methods and analysis We made use of the selected sample of the Health 2000 survey conducted in Finland and a separate register-based sample of the contemporaneous population, with follow-up until 2012. Finland has nationally representative administrative and health registers available for individual-level record linkage to the Health 2000 survey participants and invited non-participants, and the population sample. By comparing the population sample and the participants, synthetic observations representing the non-participants may be generated, as per the developed methodology. We can compare the distribution of the synthetic non-participants with the true distribution from the register data. Multiple imputation was then used to estimate alcohol consumption based on both the actual and synthetic data for non-participants, and the estimates can be compared to evaluate the methodology's performance. Ethics and dissemination Ethical approval and access to the Health 2000 survey data and data from administrative and health registers have been given by the Health 2000 Scientific Advisory Board, Statistics Finland and the National Institute for Health and Welfare. The outputs will include two publications in public health and statistical methodology journals and conference presentations.
  • Silventoinen, Karri; Tynelius, Per; Rasmussen, Finn (2014)