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Journal Epidemiology and Community Health

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Journal of Epidemiology & Community Health

Studies reporting ‘new’ associations of food ingredients with diseases are common, and sensational headlines appear almost daily in the news media. Thus, in a recent provocative paper, Schoenfeld and Ioannidis,1 randomly selected 50 common ingredients from a cookbook, and reported that 40 were apparently associated with increased cancer risk in peer reviewed studies. Unsurprisingly, most of these associations disappeared in subsequent meta-analyses.1 The net result: increases in media profits, public anxiety and a number of confused politicians. Indeed, the current landscape in nutritional epidemiology research is blighted by an oversaturation of contradictory evidence which risks confusing policy makers, journalists and public about what aspects of the Western diet deserve attention and then intervention. Randomised controlled trails and meta-analyses offer an evidence ‘gold standard’ relatively free of biases. However, trials are simply not feasible, affordable or ethical for many of the most important dietary questions. We...


Trends in migration in the European Union

Migration flows have changed in the European Union (EU) since the beginning of the worldwide economic crisis in 2008.1 Eurostat estimates indicate that net migration (statistically adjusted for total population growth) increased in the region throughout the 1990s and peaked in 2003. Since then, it has declined. During 2011, there were an estimated 1.7 million immigrants to the EU-27 member states from a country outside the region. Additionally, 1.3 million people previously residing in an EU-27 member state migrated to another member state. As a result, 16 out of the EU-27 member states reported more immigration than emigration in 2011, but in 11 out of the 27 member states emigrants outnumbered immigrants. Therefore, in total, compared with 2007, the year just before the economic crash, immigration into EU member states is estimated to have decreased by 6% and emigration...


Background

Household measures of socioeconomic position may better account for the shared nature of material resources, lifestyle, and social position of cohabiting persons, but household measures of education are rarely used. We aimed to evaluate the association of combined educational attainment of married couples on mortality and life expectancy in Switzerland.

Methods

The study included 3 496 163 ever-married persons aged ≥30 years. The 2000 census was linked to mortality records through 2008. Mortality by combined educational attainment was assessed by gender-age-specific HRs, with 95% CIs from adjusted models, life expectancy was derived using abridged life tables.

Results

Having a less educated partner was associated with increased mortality. For example, the HR comparing men aged 50–64 years with tertiary education married to women with tertiary education to men with compulsory education married to women with compulsory education was 2.05 (1.92–2.18). The estimated remaining life expectancy in tertiary educated men aged 30 years married to women with tertiary education was 4.6 years longer than in men with compulsory education married to women with compulsory education. The gradient based on individual education was less steep: the HR comparing men aged 50–64 years with tertiary education with men with compulsory education was 1.74 (1.67–1.81).

Conclusions

Using individual educational attainment of married persons is common in epidemiological research, but may underestimate the combined effect of education on mortality and life expectancy. These findings are relevant to epidemiologic studies examining socio-demographic characteristics or aiming to adjust results for these characteristics.


Background

In the last decade, the Neighbourhoods Law in Catalonia (Spain) funded municipalities that presented urban renewal projects within disadvantaged neighbourhoods focusing on physical, social and economic improvements. The objective of the study was to evaluate the effects of this law on the health and health inequalities of residents in the intervened neighbourhoods in the city of Barcelona.

Methods

A quasi-experimental predesign and postdesign was used to compare adult residents in five intervened neighbourhoods with eight non-intervened comparison neighbourhoods with similar socioeconomic characteristics. The Barcelona Health Survey was used for studying self-rated and mental health in pre (2001, 2006) and post (2011) years. Poisson regression models stratified by sex were used to compute prevalence ratios comparing 2011 with 2006, and later stratified by social class, to study health inequalities.

Results

The intervened neighbourhoods had a significant decrease in poor self-rated health in both sexes while no significant changes occurred in the comparison group. When stratified by social class, a significant improvement was observed in poor self-rated health in the manual group of the intervened neighbourhoods in both sexes, resulting in a decrease in self-rated health inequalities. Similar results were observed in poor mental health of women, while in men, poor mental health worsens in both neighbourhood groups but mostly in the comparison group.

Conclusions

The Neighbourhoods Law had a positive effect on self-rated health and seems to prevent poor mental health increases in both sexes and especially among manual social classes.


Background

Socioeconomic disadvantage may cause individuals to have lower expectations of longevity and not engage in healthy behaviours because they judge the long-term health benefits of these to be minimal.

We explored demographic, health behaviour, health and socioeconomic correlates of subjectively estimated lifespan (‘anticipated survival’); the ability of anticipated survival to predict actual survival; and whether the predictive ability of anticipated survival differed by other variables, particularly socioeconomic position.

Methods

Data were from wave 1 of the English Longitudinal Study of Ageing. Anticipated survival for up to 25 years was measured on a scale of 0–100. Actual survival was measured over a mean of 6 years, and socioeconomic position using education, household income, occupational class and area deprivation.

Results

Of 10 768 participants, 2255 (21%) died during follow-up. Anticipated survival was positively associated with socioeconomic position, and was greater in women, younger individuals, non-smokers and those who were not widowed, consumed more alcohol, were more physically active, and reported better physical and mental health. After full adjustment, anticipated survival remained positively associated with actual survival. Those reporting low anticipated survival were more likely to die over time than those reporting moderate anticipated survival (HR (95% CIs 1.11 (1.00 to 1.23). The relationship differed significantly by income and age, being strongest in younger individuals and those with higher household income.

Conclusions

Anticipated survival varied with other variables as expected and reflected actual survival. Younger individuals and those with higher household income were better able to identify subtle differences associated with actual survival.


Background

Although mortality and health inequalities at birth have increased both geographically and in socioeconomic terms, little is known about inequalities at age 85, the fastest growing sector of the population in Great Britain (GB).

Aim

To determine whether trends and drivers of inequalities in life expectancy (LE) and disability-free life expectancy (DFLE) at age 85 between 1991 and 2001 are the same as those at birth.

Methods

DFLE at birth and age 85 for 1991 and 2001 by gender were calculated for each local authority in GB using the Sullivan method. Regression modelling was used to identify area characteristics (rurality, deprivation, social class composition, ethnicity, unemployment, retirement migration) that could explain inequalities in LE and DFLE.

Results

Similar to values at birth, LE and DFLE at age 85 both increased between 1991 and 2001 (though DFLE increased less than LE) and gaps across local areas widened (and more for DFLE than LE). The significantly greater increases in LE and DFLE at birth for less-deprived compared with more-deprived areas were still partly present at age 85. Considering all factors, inequalities in DFLE at birth were largely driven by social class composition and unemployment rate, but these associations appear to be less influential at age 85.

Conclusions

Inequalities between areas in LE and DFLE at birth and age 85 have increased over time though factors explaining inequalities at birth (mainly social class and unemployment rates) appear less important for inequalities at age 85.


Background

Polychlorinated biphenyls (PCB) are persistent organic pollutants (POP) that are consumed because of their bioaccumulation through the food chain. Recent studies have suggested the implication of POPs in the development of metabolic diseases such as type 2 diabetes and obesity. However, this relationship is not entirely consistent, and has not been investigated in longitudinal studies. The purpose of this study was to prospectively examine the association between dietary intake of PCBs and the incidence of obesity in the Seguimiento Universidad de Navarra (SUN) Project.

Methods

Our study included 12 313 participants without obesity at baseline, who were followed-up for a median of 8.1 years. Dietary intakes of PCBs, expressed as WHO toxic equivalents, were assessed at baseline through a 136-item semiquantitative food-frequency questionnaire. The published concentration levels of PCBs measured in samples of food consumed in Spain were used to estimate intakes. Multivariable Cox regression models were fitted to estimate HRs and 95% CI for incident obesity.

Results

During follow-up, we observed 621 incident cases of obesity. After adjustment for total energy intake and additional adjustment for potential confounders, participants in the fifth quintile of PCBs intake were at higher risk of becoming obese (adjusted HR: 1.58; (95% CI 1.21 to 2.06)) compared to those in the first quintile. The linear trend test was statistically significant (p<0.001).

Conclusions

Dietary intake of PCBs as estimated using a food frequency questionnaire was associated with a higher incidence of obesity. Nevertheless, further longitudinal studies are needed to confirm our results.


Background

Despite comparatively lower socioeconomic status (SES), immigrants tend to have lower body weight and weaker SES gradients relative to US-born individuals. Yet, it is unknown how changes in SES over the life-course relate to body weight in immigrants versus US-born individuals.

Methods

We used longitudinal data from a nationally representative, diverse sample of 13 701 adolescents followed into adulthood to investigate whether associations between SES mobility categories (educational attainment reported by individuals as adults and by their parents during adolescence) and body mass index (BMI) measured in adulthood varied by immigrant generation. Weighted multivariable linear regression models were adjusted for age, sex, race/ethnicity and immigrant generation.

Results

Among first-generation immigrants, although parental education was not associated with adult BMI, an immigrant's own education attainment was inversely associated with BMI (β=–2.6 kg/m2; SE=0.9, p<0.01). In addition, upward educational mobility was associated with lower adult mean BMI than remaining low SES (β=–2.5 kg/m2; SE=1.2, p<0.05). In contrast, among US-born respondents, college education in adulthood did not attenuate the negative association between parental education and adult BMI. Although an SES gradient emerged in adulthood for immigrants, remaining low SES from adolescence to adulthood was not associated with loss of health advantage relative to US-born respondents of US-born parents of similar SES.

Conclusions

Immigrants were able to translate higher SES in adulthood into a lower adult mean BMI regardless of childhood SES, whereas the consequences of lower childhood SES had a longer reach even among the upwardly mobile US born.


Background

Estimation of relative contribution of Body Mass Index (BMI) and waist circumference (WC) on health outcomes requires a regression model that includes both obesity metrics. But, multicollinearity could yield biased estimates.

Methods

To address the multicollinearity issue between BMI and WC, we used the residual model approach. The standard WC (Y-axis) was regressed on the BMI (X-axis) to obtain residual WC. Data from two adult population surveys (Nunavik Inuit and James Bay Cree) were analysed to evaluate relative effect of BMI and WC on four cardiometabolic risk factors: insulin, triglycerides, systolic blood pressure and high-density lipoprotein levels.

Results

In multivariate models, standard WC and BMI were significantly associated with cardiometabolic outcomes. Residual WC was not linked with any outcomes. The BMI effect was weakened by including standard WC in the model, but its effect remained unchanged if residual WC was considered.

Conclusions

The strong correlation between standard WC and BMI does not allow assessment of their relative contributions to health in the same model without a risk of making erroneous estimations. By contrast with BMI, fat distribution (residual WC) does not add valuable information to a model that already contains overall adiposity (BMI) in Inuit and Cree.


Background

Governments worldwide recommend daily consumption of fruit and vegetables. We examine whether this benefits health in the general population of England.

Methods

Cox regression was used to estimate HRs and 95% CI for an association between fruit and vegetable consumption and all-cause, cancer and cardiovascular mortality, adjusting for age, sex, social class, education, BMI, alcohol consumption and physical activity, in 65 226 participants aged 35+ years in the 2001–2008 Health Surveys for England, annual surveys of nationally representative random samples of the non-institutionalised population of England linked to mortality data (median follow-up: 7.7 years).

Results

Fruit and vegetable consumption was associated with decreased all-cause mortality (adjusted HR for 7+ portions 0.67 (95% CI 0.58 to 0.78), reference category <1 portion). This association was more pronounced when excluding deaths within a year of baseline (0.58 (0.46 to 0.71)). Fruit and vegetable consumption was associated with reduced cancer (0.75 (0.59–0.96)) and cardiovascular mortality (0.69 (0.53 to 0.88)). Vegetables may have a stronger association with mortality than fruit (HR for 2 to 3 portions 0.81 (0.73 to 0.89) and 0.90 (0.82 to 0.98), respectively). Consumption of vegetables (0.85 (0.81 to 0.89) per portion) or salad (0.87 (0.82 to 0.92) per portion) were most protective, while frozen/canned fruit consumption was apparently associated with increased mortality (1.17 (1.07 to 1.28) per portion).

Conclusions

A robust inverse association exists between fruit and vegetable consumption and mortality, with benefits seen in up to 7+ portions daily. Further investigations into the effects of different types of fruit and vegetables are warranted.


Background

Studies have shown that immigrants residing in Spain have lower risks of delivering low birthweight (LBW) and preterm babies despite their socioeconomic disadvantages (the healthy migrant paradox). However, less is known about other important perinatal outcomes derived from birth weight and gestational age such as macrosomia and post-term birth. This paper aims to compare the main indicators related to birth weight and gestational age (LBW, macrosomia, preterm and post-term) for immigrants and Spaniards.

Methods

Cross-sectional study based on the Spanish vital statistics for years 2009–2011. Multinomial regression models were performed to obtain crude and adjusted ORs and their 95% CIs.

Results

After adjusting for known confounders, compared with Spaniards, most immigrant groups show lower or not significantly different risks of delivering LBW (OR between 0.65 and 0.87) or, more exceptionally, preterm babies (between 0.75 and 0.93). However, most of them also show higher risks of delivering macrosomic (OR between 1.21 and 2.58) and post-term babies (OR between 1.11 and 1.50). Mothers from sub-Saharan Africa show a higher risk in all perinatal outcomes studied.

Conclusions

The immigrant health paradox should be carefully assessed in comprehensive terms. Together with a predominantly lower risk of LBW, most immigrants have a higher risk of macrosomia, post-term and preterm births. These results have policy-making implications since studying the right tail of the birth weight and gestational age distributions implies considering a different set of risk factors.


Background

There is inconsistent evidence on population mortality, especially cardiovascular disease mortality, on match days of national soccer teams during particular international tournaments. This study examines the number of deaths in Germany on match days of the national soccer team during a long-term period including several tournaments.

Methods

We analysed all registered daily deaths in Germany from 1995 to 2009 (11 225 966 cases) using time series analysis methods. Following the Box/Jenkins approach, we applied a seasonal autoregressive integrated moving average model. To assess the effect of match days, we performed an intervention analysis by including a transfer function model representing match days of the national team in the statistical analyses. We conducted separate analyses for all matches and for matches during international tournaments (European and World Championships) only. Time series and results were stratified in terms of sex, age (<50 years, 50–70 years, >70 years) and cause of death (cardiovascular deaths, injuries, others). We performed a further independent analysis focusing only on the effect of match results (victory, loss, draw) and kind of tournament (international championships, qualifications, friendly matches).

Results

Most of the results did not indicate a distinct effect of matches of the national team on general mortality. Moreover, all null value deviations were small when compared with the average number of daily deaths (n=2270).

Conclusions

There is no relevant increase or decrease in mortality on match days of the German national soccer team.


Background

The objectives were to clarify the trend in the cause-specific mortality rate and changes in health and long-term-care use after the Great East Japan Earthquake in 2011.

Methods

We obtained the following data from national sources: the number of deaths by cause, age and month; the amount of healthcare insurance expenditures by type of services, age and month; the amount of long-term-care insurance expenditures by type of services, age, care need and month. We estimated increase in standardised mortality rate postearthquake compared with pre-earthquake, and change in the standardised amount of health and long-term-care insurance expenditures post-earthquake compared with pre-earthquake in three severely affected prefectures, Iwate, Miyagi and Fukushima, by the adjustment for trends in the other prefectures.

Results

The risk of indirect mortality increased in the month of the earthquake (relative risk (RR) with 95% CI 1.20 (1.13 to 1.28) for those 60–69 years of age, 1.25 (1.17 to 1.32) for 70–79 years, and 1.33 (1.27 to 1.38) for 80 years and older). The amount of health and long-term-care insurance expenditures decreased among elderly persons in the month of the earthquake, and recovered to 95% of usual level within 1–5 months. Among cities and towns hit by tsunami, higher percentage of households flooded was associated with higher risk of indirect mortality (p<0.001), lower expenditures for outpatient medical care (p<0.001), and lower expenditures for home-care services (p<0.001).

Conclusions

This study showed transient increase in indirect mortality and recovery of health and long-term-care system after the earthquake.


Background

Resting heart rate (RHR) is an independent risk factor for mortality. Nevertheless, it is unclear whether elevations in childhood and mid-adulthood RHR, including changes over time, are associated with mortality later in life. We sought to evaluate the association between RHR across the life course, along with its changes and all-cause mortality.

Methods

We studied 4638 men and women from the Medical Research Council (MRC) National Survey of Health and Development (NSHD) cohort born during 1 week in 1946. RHR was obtained during childhood at ages 6, 7 and 11, and in mid-adulthood at ages 36 and 43. Using multivariable Cox regression, we calculated the HR for incident mortality according to RHR measured at each time point, along with changes in mid-adulthood RHR.

Results

At age 11, those in the top fifth of the RHR distribution (≥97 bpm) had an increased adjusted hazard of 1.42 (95% CI 1.04 to 1.93) for all-cause mortality. A higher adjusted risk (HR, 95% CI 2.17, 1.40 to 3.36) of death was also observed for those in the highest fifth (≥81 bpm) at age 43. For a >25 bpm increased change in the RHR over the course of 7 years (age 36–43), the adjusted hazard was elevated more than threefold (HR, 95% CI 3.26, 1.54 to 6.90). After adjustment, RHR at ages 6, 7 and 36 were not associated with all-cause mortality.

Conclusions

Elevated RHR during childhood and midlife, along with greater changes in mid-adulthood RHR, are associated with an increased risk of all-cause mortality.


History confirms that while technological innovations can bring many benefits, they can also cause much human suffering, environmental degradation and economic costs. But are we repeating history with new and emerging chemical and technological products? In preparation for volume 2 of ‘Late Lessons from Early Warnings’ (European Environment Agency, 2013), two analyses were carried out to help answer this question. A bibliometric analysis of research articles in 78 environmental, health and safety (EHS) journals revealed that most focused on well-known rather than on newly emerging chemicals. We suggest that this ‘scientific inertia’ is due to the scientific requirement for high levels of proof via well replicated studies; the need to publish quickly; the use of existing intellectual and technological resources; and the conservative approach of many reviewers and research funders. The second analysis found that since 1996 the funding of EHS research represented just 0.6% of the overall funding of research and technological development (RTD). Compared with RTD funding, EHS research funding for information and communication technologies, nanotechnology and biotechnology was 0.09%, 2.3% and 4% of total research, respectively. The low EHS research ratio seems to be an unintended consequence of disparate funding decisions; technological optimism; a priori assertions of safety; collective hubris; and myopia. In light of the history of past technological risks, where EHS research was too little and too late, we suggest that it would be prudent to devote some 5–15% of RTD on EHS research to anticipate and minimise potential hazards while maximising the commercial longevity of emerging technologies.


A dangerous distortion of priorities seems to be currently apparent in the dominant approaches to major public health problems, including cardiovascular disease, diabetes, obesity, cancer and some infectious diseases. Relevant examples suggest an apparently inappropriate tendency to prioritise technocratic, partial solutions rather than confronting their true behavioural and structural determinants. Technically oriented preventive medicine often takes excessive precedence over simpler, more sensible approaches to modify lifestyles, the environment and the social structure. Structural factors (social, cultural, financial, familiar, educational, political or ideological factors) that act as determinants of individual behaviours should be effectively addressed to confront the essential causes of the most prevalent and important health problems. Some consumer-directed commercial forces seem to be increasingly driving many aspects of the current sociocultural environment, and may eventually compromise the main pursuits of public health. Population-wide strategies are needed to create a healthy sociocultural environment and to empower individuals and make themselves resistant to these adverse environmental and structural pressures. Otherwise most public health interventions will most likely end in failures.