Distinguishing independent and shared effects of material/structural conditions and psychosocial resources on educational inequalities in self-rated health: results from structural equation modelling.

OBJECTIVES: The aim of this study was to distinguish independent and shared effects of material/structural factors and psychosocial resources in explaining educational inequalities in self-rated health (SRH) by using structural equation modelling. STUDY DESIGN: Cross-sectional survey. METHODS: Data were derived from a questionnaire sent to a random sample of the population in five counties in Sweden in 2008. The study population (aged 25-75 years) included 15,099 men and 17,883 women. Exploratory structural equation modelling was used to analyse the pathways from educational level to SRH. RESULTS: The pathway including both material/structural factors (e.g. financial buffer and unemployment) and psychosocial resources (e.g. sense of coherence and social participation) explained about 40% of educational differences in SRH for both men and women. The pathways including only the independent effects of psychosocial resources (14% in men and 20% in women) or material/structural factors (9% and 18%, respectively) explained substantial but smaller proportions of the differences. CONCLUSIONS: The major pathway explaining educational inequalities in SRH included both material/structural factors and psychosocial resources. Therefore, to reduce educational inequalities in SRH, interventions need to address both material/structural conditions and psychosocial resources across educational groups.

Physical mobility, physical activity, and obesity among elderly: findings from a large population-based Swedish survey.

OBJECTIVE: To examine how physical activity and physical mobility are related to obesity in the elderly. STUDY DESIGN: A cross-sectional study of 2558 men and women aged 65 years and older who participated in a population survey in 2012 was conducted in mid-Sweden with an overall response rate of 67%. METHODS: Obesity (body mass index ≥30 kg/m2) was based on self-reported weight and height, and physical activity and physical mobility on questionnaire data. Chi-squared test and multiple logistic regressions were used as statistical analyses. RESULTS: The overall prevalence of obesity was 19% in women and 15% in men and decreased after the age of 75 years. A strong association between both physical activity and obesity, and physical mobility and obesity was found. The odds for obesity were higher for impaired physical mobility (odds ratio [OR] 2.83, 95% confidence interval [CI] 2.14-3.75) than for physical inactivity (OR 1.63, 95% CI 1.28-2.08) when adjusted for gender, age, socio-economic status and fruit and vegetable intake. However, physical activity was associated with obesity only among elderly with physical mobility but not among those with impaired physical mobility. CONCLUSION: It is important to focus on making it easier for elderly with physical mobility to become or stay physically active, whereas elderly with impaired physical mobility have a higher prevalence of obesity irrespective of physical activity.

A comparison of body mass index, waist-hip ratio and waist circumference as predictors of all-cause mortality among the elderly: the Rotterdam study.

OBJECTIVE: To compare body mass index (BMI), waist-hip ratio (WHR) and waist circumference as predictors of all-cause mortality among the elderly. DESIGN: Population-based cohort study; mean follow-up was 5.4 y. SETTING: The Rotterdam Study. PARTICIPANTS: A total of 6296 men and women; baseline age 55-102 y. MEASUREMENTS: Sex-specific all-cause mortality was compared between quintiles of BMI, WHR and waist circumference and between predefined categories of BMI and waist circumference, stratified for smoking category. RESULTS: High quintiles of waist circumference, but not high quintiles of BMI and WHR were related to increased mortality among never smoking men, without reaching statistical significance. Only the highest category of BMI (BMI>30 kg/m2) among never smoking men was related to increased mortality, compared to normal BMI (hazard ratio 2.6 (95% confidence interval: 1.3-5.3)). Waist circumference between 94 and 102 cm and waist circumference 102 cm and larger were related to increased mortality, compared to normal waist circumference (hazard ratios 1.7 (95% confidence interval 1.1-2.8) and 1.6 (95% confidence interval 1.0-2.8), respectively). The proportion of mortality attributable to large waist circumference among never smoking men was three-fold the proportion attributable to high BMI. Among never smoking women and ex- and current smokers, categories of large body fatness did not predict increased mortality. CONCLUSION: Among never smoking elderly men waist circumference may have more potential for detecting overweight than the BMI.

Trends in cigarette smoking in 36 populations from the early 1980s to the mid-1990s: findings from the WHO MONICA Project.

OBJECTIVES: This report analyzes cigarette smoking over 10 years in populations in the World Health Organization (WHO) MONICA Project (to monitor trends and determinants of cardiovascular disease). METHODS: Over 300,000 randomly selected subjects aged 25 to 64 years participated in surveys conducted in geographically defined populations. RESULTS: For men, smoking prevalence decreased by more than 5% in 16 of the 36 study populations, remained static in most others, but increased in Beijing. Where prevalence decreased, this was largely due to higher proportions of never smokers in the younger age groups rather than to smokers quitting. Among women, smoking prevalence increased by more than 5% in 6 populations and decreased by more than 5% in 9 populations. For women, smoking tended to increase in populations with low prevalence and decrease in populations with higher prevalence; for men, the reverse pattern was observed. CONCLUSIONS: These data illustrate the evolution of the smoking epidemic in populations and provide the basis for targeted public health interventions to support the WHO priority for tobacco control.

Misclassification of high-risk older subjects using waist action levels established for young and middle-aged adults--results from the Rotterdam Study.

OBJECTIVES: In the literature, cutoff points based on waist circumference (waist action levels) have been suggested to replace cutoff points based on body mass index (BMI) and waist-hip ratio (WHR) in identifying subjects who are overweight or obese and/or with central fat distribution. These cutoff points have been based on analysis in mainly middle-aged and younger adults. In this article, we examine the applicability of the suggested waist action levels in an older population. PARTICIPANTS: A total of 6,423 men and women aged 55 or over participating in the Rotterdam Study, a population-based cohort study. MEASUREMENTS: Sensitivities and specificities of the proposed waist action levels in relation to the cutoff points for BMI and WHR were calculated. Also, cardiovascular risk factor levels at baseline examination in the different categories defined by high/low waist circumference, BMI and WHR were investigated. RESULTS: At waist action level 1 (waist circumference > or =94 cm in men, > or =80 cm in women), sensitivity was 71% in men and 86% in women for detecting those with high BMI (> or =25 kg/m2) and/or WHR (> or =0.95 in men, > or =0.80 in women). At waist action level 2 (waist circumference > or =102 cm in men, > or =88 cm in women in comparison with BMI > or =30 kg/m2 and/or WHR > or =0.95 in men, > or =0.80 in women), sensitivity was considerably lower: 35% in men and 59% in women. This was mainly due to a large proportion of subjects with low waist and BMI but high WHR. Specificity was high (>90%) at both action levels. Cardiovascular disease risk factors, except smoking, tended to increase with increasing waist circumference, WHR, and BMI. CONCLUSIONS: The suggested cutoff points for waist circumference are only to a limited degree useful in identifying subjects with overweight and obesity and/or central fat distribution in an older population. This concerns especially the upper cutoff point (waist action level 2) and is mainly due to the increased central distribution of fat with advancing age.

Educational level, relative body weight, and changes in their association over 10 years: an international perspective from the WHO MONICA Project.

OBJECTIVES: This study assessed the consistency and magnitude of the association between educational level and relative body weight in populations with widely different prevalences of over-weight and investigated possible changes in the association over 10 years. METHODS: Differences in age-adjusted mean body mass index (BMI) between the highest and the lowest tertiles of years of schooling were calculated for 26 populations in the initial and final surveys of the World Health Organization (WHO) MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Project. The data are derived from random population samples, including more than 42,000 men and women aged 35 to 64 years in the initial survey (1979-1989) and almost 35,000 in the final survey (1989-1996). RESULTS: For women, almost all populations showed a statistically significant inverse association between educational level and BMI; the difference between the highest and the lowest educational tertiles ranged from -3.3 to 0.4 kg/m2. For men, the difference ranged from -1.5 to 2.2 kg/m2. In about two thirds of the populations, the differences in BMI between the educational levels increased over the 10-year period. CONCLUSION: Lower education was associated with higher BMI in about half of the male and in almost all of the female populations, and the differences in relative body weight between educational levels increased over the study period. Thus, socioeconomic inequality in health consequences of obesity may increase in many countries.

The feasibility of combining data from routine Hospital Discharge and Causes-of-Death Registers for epidemiological studies on stroke.

We assessed the validity of hospital discharge data on stroke in Finland and the feasibility of linked hospital discharge and causes-of-death data for epidemiological studies using the FINMONICA Stroke Register as the reference. The results showed that such data can, with some caution, be used for incidence studies and for identifying first stroke events. They cannot, however, be used for assessing secular trends in all stroke events.

Varying sensitivity of waist action levels to identify subjects with overweight or obesity in 19 populations of the WHO MONICA Project.

It has been suggested in the literature that cut-off points based on waist circumference (waist action levels) should replace cut-off points based on body mass index (BMI) and waist-to-hip ratio in identifying subjects with overweight or obesity. In this article, we examine the sensitivity and specificity of the cut-off points when applied to 19 populations with widely different prevalences of overweight. Our design was a cross-sectional study based on random population samples. A total of 32,978 subjects aged 25-64 years from 19 male and 18 female populations participating in the second MONICA survey from 1987 to 1992 were included in this study. We found that at waist action level 1 (waist circumference > or =94 cm in men and > or =80 cm in women), sensitivity varied between 40% and 80% in men and between 51% and 86% in women between populations when compared with the cut-off points based on BMI (> or =25 kg/m2) and waist-to-hip ratio (> or =0.95 for men, > or =0.80 for women). Specificity was high (> or =90%) in all populations. At waist action level 2 (waist circumference > or =102 cm and > or =88 cm in men and women, respectively, BMI > or =30 kg/m2), sensitivity varied from 22% to 64% in men and from 26% to 67% in women, whereas specificity was >95% in all populations. Sensitivity was in general lowest in populations in which overweight was relatively uncommon, whereas it was highest in populations with relatively high prevalence of overweight. We propose that cut-off points based on waist circumference as a replacement for cut-off points based on BMI and waist-to-hip ratio should be viewed with caution. Based on the proposed waist action levels, very few people would unnecessarily be advised to have weight management, but a varying proportion of those who would need it might be missed. The optimal screening cut-off points for waist circumference may be population specific.

Waist and hip circumferences, and waist-hip ratio in 19 populations of the WHO MONICA Project.

OBJECTIVE: To assess differences in waist and hip circumferences and waist-to-hip ratio (WHR) measured using a standard protocol among populations with different prevalences of overweight. In addition, to quantify the associations of these anthropometric measures with age and degree of overweight. DESIGN: Cross-sectional study of random population samples. SUBJECTS: More than 32000 men and women aged 25-64y from 19 (18 in women) populations participating in the second MONItoring trends and determinants in CArdiovascular disease (MONICA) survey from 1987-1992. RESULTS: Age standardized mean waist circumference range between populations from 83-98 cm in men and from 78-91cm in women. Mean hip circumference ranged from 94-105cm and from 97-108cm in men and women, respectively, and mean WHR from 0.87-0.99 and from 0.76-0.84, respectively. Together, height, body mass index (BMI), age group and population explained about 80% of the variance in waist circumference. BMI was the predominant determinant (77% in men, 75% women). Similar results were obtained for hip circumference. However, height, BMI, age group and population, accounted only for 49% (men) and 30% (women) the variation in WHR. CONCLUSION: Considerable variation in waist and hip circumferences and WHR were observed among the study populations. Waist circumference and WHR, both of which are used as indicators of abdominal obesity, seem to measure different aspects of the human body: waist circumference reflects mainly the degree of overweight whereas WHR does not.

Selection of anthropometric indicators for classification of abdominal fatness--a critical review.

In the literature, a variety of anthropometric indicators for abdominal obesity have been suggested. The criteria for their selection vary, and they have been justified mainly on the basis of being correlated with other risk factors, with morbidity and mortality, or to be predictors of the amount of visceral fat. Many of the studies, however, suffer from methodological limitations: they are based on a small number of subjects, often derived from cross-sectional data, based on indirect measurement of risk, or the indicators are complicated to interpret biologically or difficult to use in a public health context. The literature lacks a systematic evaluation of the proposed indicators taking into account possible differences between genders, age categories and ethnic groups and different diseases and mortality. Similar considerations relate to the cut-off points based on the indicators of abdominal obesity. The suggested cut-off points for waist-hip ratio have been based on rather arbitrary criteria, and the studies where cut-off points for waist circumference have been suggested have methodological shortcomings as well, such as being based on cross-sectional data and arbitrary cut-off points for other variables. It is also a reason for concern that so far all suggested cut-off points for abdominal obesity have been based on results obtained in Caucasian populations. Moreover, they are based on assessment of risk and their appropriateness in the use of intervention has not been evaluated. Therefore, no consensus about the appropriateness of the different cut-off points has been reached. We conclude that there is an apparent lack of consistency in the field and therefore a more scientifically and theoretically solid basis for the selection and use of anthropometric indicators of abdominal obesity and cut-off points based on them should be a high priority in this research field in the near future.

Incidence of cardiovascular disease in Type 1 (insulin-dependent) diabetic subjects with and without diabetic nephropathy in Finland.

This study evaluates the impact of diabetic nephropathy on the incidence of coronary heart disease, stroke and any cardiovascular disease in the Finnish population, which has a high risk of Type 1 (insulin-dependent) diabetes mellitus and cardiovascular disease. We performed a prospective analysis of the incidence of coronary heart disease, stroke and cardiovascular disease in all Type 1 subjects in the Finnish Type I diabetes mellitus register diagnosed before the age of 18 years between 1 January 1965 and 31 December 1979 nationwide. The effect of age at onset of diabetes, attained age at the end of follow-up, sex, diabetes duration and of the presence of diabetic nephropathy on the risk for cardiovascular disease was evaluated. Cases of nephropathy, coronary heart disease, stroke and all cardiovascular diseases were ascertained from the nationwide Finnish Hospital Discharge Register and National Death Register using computer linkage with the Type I diabetes mellitus register. Of the 5148 Type 1 diabetic patients followed up, 159 had a cardiovascular event of which 58 were coronary heart diseases, 57 stroke events and 44 other heart diseases. There were virtually no cases of cardiovascular disease before 12 years diabetes duration. The cumulative incidence of cardiovascular disease by the age of 40 years was 43% in Type 1 diabetic patients with diabetic nephropathy, compared with 7% in patients without diabetic nephropathy, similarly in men and women. The relative risk for Type 1 diabetic patients with diabetic nephropathy compared with patients without diabetic nephropathy was 10.3 for coronary heart disease, 10.9 for stroke and 10.0 for any cardiovascular disease, similarly in men and women. The presence of nephropathy in Type I diabetic subjects increases not only the risk of coronary heart disease, but also of stroke by tenfold.

The unchanging incidence of hospitalization for diabetic nephropathy in a population-based cohort of IDDM patients in Finland.

OBJECTIVE: Finland has the highest documented incidence of childhood IDDM in the world, but the incidence of diabetic nephropathy in Finland is unknown. The aim of the present study was to determine the incidence of hospitalization for diabetic nephropathy in a population-based cohort of Finnish IDDM patients and to analyze the prognostic effect of sex, age at diagnosis, and calendar year of diagnosis of IDDM. RESEARCH DESIGN AND METHODS: We included all Finnish patients who had onset of IDDM before age 18 years, were diagnosed between January 1965 and December 1979 (n = 5,149), and were traced for hospitalizations between January 1970 and the end of December 1989 in the Hospital Discharge Register, using the unique personal identification code given to all Finnish citizens. The development of diabetic nephropathy was defined as the first hospitalization with a diagnosis of nephropathy (International Classification of Diseases-8th Revision [ICD-8] 250.04, or 9th Revision [ICD-9] 2503B/2503X). RESULTS: Among the 5,149 patients included, we identified 446 cases of diabetic nephropathy. The incidence of hospitalization for diabetic nephropathy was very low during the first 8 years of diabetes duration, and after that increased to a maximum of 1.6-2.0% per year. Female subjects developed nephropathy slightly earlier than male subjects, but the cumulative risk was independent of sex. Patients diagnosed at ages 5-14 years had the highest risk of hospitalization for diabetic nephropathy. We observed no effect of calendar year of diagnosis. CONCLUSIONS: We found a 20% cumulative incidence of hospitalization for diabetic nephropathy during a total 24 years of IDDM duration. This finding is compatible with the cumulative incidence of hospitalization for diabetic nephropathy found in other European populations. The incidence of hospitalization for diabetic nephropathy did not decrease during the 20-year observation period.

Smoking and relative body weight: an international perspective from the WHO MONICA Project.

STUDY OBJECTIVE: To investigate the magnitude and consistency of the associations between smoking and body mass index (BMI) in different populations. DESIGN: A cross sectional study. SETTING AND PARTICIPANTS: About 69,000 men and women aged 35-64 years from 42 populations participating in the first WHO MONICA survey in the early and mid 1980s. MAIN RESULTS: Compared to never smokers, regular smokers had significantly (p < 0.05) lower median BMI in 20 (men) and 30 (women) out of 42 populations (range -2.9 to 0.5 kg/m2). There was no population in which smokers had a significantly higher BMI than never smokers. Among men, the association between leanness and smoking was less apparent in populations with relatively low proportions of regular smokers and high proportions of ex-smokers. Ex-smokers had significantly higher BMI than never smokers in 10 of the male populations but in women no consistent pattern was observed. Adjustment for socioeconomic status did not affect these results. CONCLUSIONS: Although in most populations the association between smoking and BMI is similar, the magnitude of this association may be affected by the proportions of smokers and ex-smokers in these populations.

The validity of hospital discharge register data on coronary heart disease in Finland.

We studied the validity of the Finnish hospital discharge register data on coronary heart disease (CHD) for the purposes of epidemiologic studies and health services research. The Finnish nationwide hospital discharge register (HDR) was linked with the FINMONICA acute myocardial infarction (AMI) register for the years 1983-1990. The frequency of errors in the HDR was assessed separately. Between 8% and 13% of hospitalized AMI events registered in the AMI Register were not found in the HDR with an ICD code for CHD. Problems with the register linkage and the use of some ICD code other than one of the codes for CHD explained these missing events. The frequency of errors in the personal identification number was about 5% in the early 1980s. After 1986 errors were found only occasionally. The diagnosis recorded in the HDR was the same as that in the discharge sheet in about 95% of hospitalizations. The positive predictive value of the ICD code 410 (AMI), compared with the FINMONICA definite+possible AMI category, was very high and stable, about 90% in all areas and all hospitals, but the sensitivity varied from 50% at local hospitals to 80% at central hospitals. In summary, data on CHD obtained from the Finnish hospital discharge register give, on average, a correct picture on changes in the occurrence of AMI in Finland and can, with necessary caution, be used in epidemiological studies and health services research. However, the classification of individual cases is not standardized in the HDR, but varies over time, between geographical areas and the levels of care. Therefore, these data should not be used without confirmation in studies where correct classification of individual outcomes is of crucial importance, such as follow-up studies and case-control studies.

Differences in the association between smoking and relative body weight by level of education.

OBJECTIVE: To investigate differences in the association between smoking and relative body weight by sex, age group and level of education. DESIGN: Cross-sectional study. SUBJECTS: About 36,000 men and women who participated in the Monitoring Project on Cardiovascular Disease Risk Factors in the Netherlands in 1987-1991. RESULTS: The association between smoking and relative body weight differed by level of education. This difference was more pronounced among men than among women. Male heavy smokers had statistically significantly (P < 0.05) higher mean body mass index (BMI) than never smokers at high educational level, whereas they had a significantly lower mean BMI than never smokers at low educational level. In addition, ex-smokers had significantly higher mean BMI than never smokers in men with high education but not in men with low education nor in women. The difference in the association between smoking and relative body weight by educational level could not be explained by physical activity, fat intake or alcohol consumption nor by factors related to smoking behaviour. CONCLUSION: The association between smoking and relative body weight may differ between subgroups within one population. Therefore adjustment for these subgroups, for example for educational level, may be inappropriate in studies of the BMI-smoking relationship. Also, stopping smoking may have difference effects on weight in these subgroups.

Blood pressure levels in the 41 populations of the WHO MONICA Project.

In the early to mid 1980s, the WHO MONICA Project conducted cardiovascular risk factor surveys in 41 study populations in 22 countries. Study populations aged 35-64 years comprised 32,422 men and 32,554 women. Blood pressures (BP) and body mass index (BMI) were measured according to a standard protocol. Participants were asked about antihypertensive medication. In men, the average age-standardized BPs ranged among the populations from 124 to 148 mm Hg for systolic (SBP) and from 75 to 93 mm Hg for diastolic (DBP). The corresponding values in women were 118-145 mm Hg for SBP and 74-90 mm Hg for DBP. In all populations, women had lower SBP than men in the age group 35-44. However, SBP in women rose more steeply with age so that in 34 of 41 populations women had higher SBP than men in the age group 55-64. The proportion of participants with untreated major elevation of BP ranged from 4.5% to 33.7% in men and from 1.9% to 22.3% in women. The proportions of participants receiving antihypertensive medication were 4.3-17.7% for men and 6.0-22.0% for women. These proportions were not correlated with the prevalence of untreated hypertensives. Age-adjusted BMI was associated with SBP and accounted for 14% of the SBP variance in men and 32% in women. We found a large difference in SBP among the MONICA study populations and conclude that the results represent a valid estimate of the public health problem posed by elevated BP. We also have shown that almost universally the problem of elevated BP is more prevalent in women than in men, especially in the older age groups.

Hospital discharge register data in the assessment of trends in acute myocardial infarction. FINMONICA AMI Register Study Team.

We evaluated the reliability hospital discharge register data in the assessment of acute myocardial infarction trends. In the FINMONICA study areas, trends in age standarized attack rates for the years 1983-90 were calculated independently from two sources: the nationwide Finnish hospital discharge register and the FINMONICA acute myocardial infarction register. The trends were compared by a statistical regression model. The trends obtained from the hospital discharge register were very similar to the trends obtained from the FINMONICA acute myocardial infarction register. The attack rates differed significantly, however, and the change in the International Classification of Diseases version from version 8 to version 9 brought on a change in the attack rates obtained from the hospital discharge register. Thus, hospital discharge register data can be used to assess acute myocardial infarction trends in the community. However, modifications of the International Classification of Diseases codes (new versions of the classification) and changes in the clinical use of the codes for coronary heart disease can have an impact on the attack rates obtained from the hospital discharge register, and the reliability of the hospital discharge register data should be regularly assessed.