Six-year mortality associated with living alone and loneliness in Swedish men and women born in 1930.

BACKGROUND: This study examined how living alone and loneliness associate with all-cause mortality in older men and women. METHODS: Baseline data from the Gothenburg H70 Birth Cohort Studies, including 70-year-olds interviewed in 2000 and 75-year-olds (new recruits) interviewed in 2005 were used for analyses (N = 778, 353 men, 425 women). Six-year mortality was based on national register data. RESULTS: At baseline, 36.6% lived alone and 31.9% reported feelings of loneliness. A total of 72 (9.3%) participants died during the 6-year follow-up period. Cumulative mortality rates per 1000 person-years were 23.9 for men and 9.6 for women. Mortality was increased more than twofold among men who lived alone compared to men living with someone (HR 2.40, 95% CI 1.34-4.30). Elevated risk remained after multivariable adjustment including loneliness and depression (HR 2.56, 95% CI 1.27-5.16). Stratification revealed that mortality risk in the group of men who lived alone and felt lonely was twice that of their peers who lived with someone and did not experience loneliness (HR 2.52, 95% CI 1.26-5.05). In women, a more than fourfold increased risk of mortality was observed in those who experienced loneliness despite living with others (HR 4.52, 95% CI 1.43-14.23). CONCLUSIONS: Living alone was an independent risk factor for death in men but not in women. Mortality was doubled in men who lived alone and felt lonely. In contrast, mortality was particularly elevated in women who felt lonely despite living with others. In the multivariable adjusted models these associations were attenuated and were no longer significant after adjusting for mainly depression in men and physical inactivity in women. Gender needs to be taken into account when considering the health consequences of living situation and loneliness.

Young patients with heart failure: clinical characteristics and outcomes. Data from the Swedish Heart Failure, National Patient, Population and Cause of Death Registers.

AIMS: The prevalence and hospitalizations of patients with heart failure (HF) aged <55 years have increased in Sweden during the last decades. We aimed to compare characteristics of younger and older patients with HF, and examine survival in patients <55 years compared with matched controls. METHODS AND RESULTS: All patients ≥18 years in the Swedish Heart Failure Register from 2003 to 2014 were included. Data were merged with National Patient and Cause of Death Registers. Among 60 962 patients, 3752 (6.2%) were <55 years, and were compared with 7425 controls from the Population Register. Compared with patients ≥55 years, patients <55 years more frequently had registered diagnoses of obesity, dilated cardiomyopathy, congenital heart disease, and an ejection fraction <40% (9.8% vs. 4.7%, 27.2% vs. 5.5%, 3.7% vs. 0.8%, 67.9% vs. 45.1%, respectively; all P < 0.001). One-year all-cause mortality was 21.2%, 4.2%, and 0.3% in patients ≥55 years, patients <55 years, and controls <55 years, respectively (all P < 0.001). Patients <55 years had a five times higher mortality risk compared with controls [hazard ratio (HR) 5.48, 95% confidence interval (CI) 4.45-6.74]; the highest HR was in patients 18-34 years (HR 38.3, 95% CI 8.70-169; both P < 0.001). At the age of 20, the estimated life-years lost was up to 36 years for 50% of patients, with declining estimates with increasing age. CONCLUSION: Patients with HF <55 years had different comorbidities than patients ≥55 years. The highest mortality risk relative to that of controls was among the youngest patients.

Cardiovascular and all-cause mortality attributable to loneliness in older Swedish men and women.

BACKGROUND: This study examined whether loneliness predicts cardiovascular- and all-cause mortality in older men and women. METHODS: Baseline data from the Gothenburg H70 Birth Cohort Studies, collected during 2000 on 70-year-olds born 1930 and living in Gothenburg were used for analysis (n = 524). Mortality data were analyzed until 2012 through Swedish national registers. RESULTS: Perceived loneliness was reported by 17.1% of the men and 30.9% of the women in a face-to-face interview with mental health professional. A total of 142 participants died during the 12-year follow-up period, with 5334 person-years at risk, corresponding to 26.6 deaths/1000 person-years. Cardiovascular disease accounted for 59.2% of all deaths. The cumulative rates/1000 person-years for cardiovascular mortality were 20.8 (men) and 11.5 (women), and for all-cause mortality 33.8 (men) and 20.5 (women), respectively. In Cox regression models, no significant increased risk of mortality was seen for men with loneliness compared to men without loneliness (cardiovascular mortality HR 1.52, 95% CI 0.78-2.96; all-cause HR 1.32, 95% CI 0.77-2.28). Increased risk of cardiovascular mortality was observed in women with loneliness compared to those without (HR 2.25 95% CI 1.14-4.45), and the risk remained significant in a multivariable-adjusted model (HR 2.42 95% CI 1.04-5.65). CONCLUSIONS: Loneliness was shown to be an independent predictor of cardiovascular mortality in women. We found no evidence to indicate that loneliness was associated with an increased risk of either cardiovascular- or all-cause mortality in men.

Body weight in midlife and long-term risk of developing heart failure-a 35-year follow-up of the primary prevention study in Gothenburg, Sweden.

BACKGROUND: This study aimed to determine whether midlife obesity predicts heart failure (HF) over an extended follow-up into old age. METHODS: We studied 7495 men (from a population sample of 9,998 men) without HF, who were 47-55 years old when investigated in 1970 to 1973. All participants were followed up for 35 years, or until death, using the Swedish National Inpatient Register (IPR) and the Cause of Death Register. Over follow-up, 1855 men (24.7%) were discharged from hospital or died with a diagnosis of HF. RESULTS: There was a strong relation between obesity and future risk of HF, which was accentuated over the last years of the long follow-up. After adjusting for age, the risk of HF increased stepwise with increasing body mass index (BMI), even in those with a normal BMI (22.5-24.9) The subdistribution hazard ratio (SHR) was 1.20 (95% CI: 1.02-1.39) in men with a normal BMI, 1.29 (95% CI: 1.11-1.50) for a BMI of 25-27.49, 1.50 (95% CI: 1.27-1.77) for a BMI of 27.5-29.99, and 1.62 (95% CI: 1.33-1.97) for a BMI >30. After adjusting for, age, smoking, occupational class, and physical activity, the results were unchanged. CONCLUSION: Obesity in midlife is strongly related to the long-term risk of developing HF extending into old age where the risk is highest. Even normal body weight (BMI <25) was related to an increased risk of developing HF during life. Because overweight and obesity are largely preventable, our findings further emphasize the importance of public health interventions against the development of obesity.

A longitudinal general population-based study of job strain and risk for coronary heart disease and stroke in Swedish men.

OBJECTIVES: The aim was to investigate whether psychosocial stress based on the job-demand-control (JDC) model increased the risk for coronary heart disease (CHD) and stroke. SETTING: Swedish men. PARTICIPANTS: The Primary Prevention Study (PPS) comprises 6070 men born between 1915 and 1925 free from previous history of CHD and stroke at baseline (1974-1977). Psychosocial workplace exposure was assessed using a job-exposure matrix (JEM) for the JDC model based on occupation at baseline. The participants were followed from baseline examination, until death, until hospital discharge or until 75 years of age, whichever occurred first, using the Swedish national register on cause of death and the Swedish hospital discharge register for non-fatal and fatal stroke and CHD events. Cox regression models were used with stroke or CHD as the outcome, using JDC model and age as explanatory variables, as well as stratified models with regard to smoking, self-reported stress, socioeconomic status, obesity, hypertension and diabetes. PRIMARY AND SECONDARY OUTCOME MEASURES: Risk for stroke and CHD. RESULTS: There was an increased risk (HR) for CHD in relation to high strain (HR 1.31, 95% CI 1.01 to 1.70). The risk was further increased among ever-smokers and among blue-collar workers. There was a relation between low control and increased risk for CHD (HR 1.19, 95% CI 1.06 to 1.35). There was no increased risk for stroke in any of the JDC categories. CONCLUSIONS: Exposure to occupational psychosocial stress defined as job strain or low control increased the risk for CHD, especially among smokers and blue-collar workers. There was no increased risk for stroke in any of the JDC categories.

Twenty-year trends in long-term mortality risk in 17,149 survivors of ischemic stroke less than 55 years of age.

BACKGROUND AND PURPOSE: The purpose of the present study was to investigate the 4-year mortality risk among patients<55 years with a first ischemic stroke during 1987-2006. METHODS: A total of 17,149 cases (37.4% women) aged 18 to 54 years who survived≥28 days after a first ischemic stroke were identified in the Swedish Inpatient Register from 1987 to 2006. All patients were followed for 4 years or until death. The standardized mortality ratio was calculated by comparing the mortality rates with those of the general population of equivalent age, sex, and calendar year. RESULTS: During the period, there were 1265 deaths. Long-term survival improved over time in both men and women. Among men, the mortality risk decreased by 32% (hazard ratio=0.68 [95% confidence interval, 0.56-0.82]) from the first 5-year period to the last 5-year period (1987-1991 versus 2002-2006), and among women, the mortality risk decreased by 45% (0.55 [0.41-0.75]). Despite an overall decrease in mortality, the standardized mortality ratios for the last 5-year period remained high: 5.88 (95% confidence interval, 5.10-6.71) for men and 5.91 (4.68-7.29) for women with an absolute excess risk of 1.60 and 0.97 per 100 person-years, respectively, with nearly half of all deaths related to cardiovascular disease. CONCLUSIONS: During the 20-year period, 4-year mortality decreased by one third but was still 6-fold higher than that of the general population in the most recent period, emphasizing the importance of secondary prevention in young persons who have had a stroke.

Occupational status and incidences of ischemic and hemorrhagic stroke in Swedish men: a population-based 35-year prospective follow-up study.

This study examined variations in stroke incidence across occupational classes over a 35-year follow-up period. We analyzed a random population-based sample of 6,994 men aged 47-56 years at baseline without prior history of stroke. Standardized incidence rates, subdistribution hazard ratios (SHRs) from competing risk regressions and cumulative incidence were calculated, after accounting for risk of death attributed to causes other than stroke. A total of 1,442 strokes were identified over the 35-year period with crude incidences of 5.50 (ischemic) and 1.16 (hemorrhagic) per 1,000 person-years. In the whole group, occupational class was not associated with either ischemic or hemorrhagic stroke. However, older men (≥51 years at baseline) with unskilled manual occupations had a significantly lower risk of ischemic stroke than those with high officials (referent). No association between occupation and stroke of either type was detected for men younger than 51 years. There was an inverse and graded risk of death from causes other than stroke; men in high official positions had the lowest cumulative risk and unskilled manual workers had the highest risk (P < 0.0001). The association between occupation and ischemic stroke in older men persisted after accounting for competing risks of death (SHR 0.62; 95 % CI 0.46-0.84). In conclusion, low socioeconomic status was not associated with an increased risk of incident hemorrhagic or ischemic stroke. Older men with the lowest occupational status i.e. unskilled manual had a significantly lower risk of ischemic stroke, even after controlling for other risk factors and competing risks of death.

Assessment of selection bias in a health survey of children and families - the IDEFICS Sweden-study.

BACKGROUND: A health survey was performed in 2007-2008 in the IDEFICS/Sweden study (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) in children aged 2-9 years. We hypothesized that families with disadvantageous socioeconomic and -demographic backgrounds and children with overweight and obesity were underrepresented. METHODS: In a cross-sectional study, we compared Swedish IDEFICS participants (N=1,825) with referent children (N=1,825) using data from Statistics Sweden population registers. IDEFICS participants were matched for age and gender with a referent child living in the same municipality. Longitudinal weight and height data from birth to 8 years was collected for both populations (n=3,650) from the children's local health services. Outcome measures included the family's socioeconomic and demographic characteristics, maternal body mass index (BMI) and smoking habits before pregnancy, the children's BMI standard deviation score (SDS) at the age of inclusion in the IDEFICS study (BMISDS-index), and the children's BMI-categories during the age-span. Comparisons between groups were done and a multiple logistic regression analysis for the study of determinants of participation in the IDEFICS study was performed. RESULTS: Compared with IDEFICS participants, referent families were more likely to have lower education and income, foreign backgrounds, be single parents, and have mothers who smoked before pregnancy. Maternal BMI before pregnancy and child's BMISDS-index did not differ between groups. Comparing the longitudinal data-set, the prevalence of obesity was significantly different at age 8 years n= 45 (4.5%) versus n= 31 (2.9%) in the referent and IDEFICS populations, respectively. In the multivariable adjusted model, the strongest significant association with IDEFICS study participation was parental Swedish background (odds ratio (OR) = 1.91, 95% confidence interval (CI) (1.48-2.47) followed by parents having high education OR 1.80, 95% CI (1.02-3.16) and being married or co-habiting OR 1.75 95% CI (1.38-2.23). CONCLUSION: Families with single parenthood, foreign background, low education and income were underrepresented in the IDEFICS Sweden study. BMI at inclusion had no selection effect, but developing obesity was significantly greater among referents.

Risk factors for Chlamydia trachomatis infection among users of an internet-based testing service in Sweden.

OBJECTIVE: This study aims to assess potential risk factors for Chlamydia trachomatis infection among users of an Internet-based testing service in Sweden. METHOD: Users of an Internet-based C. trachomatis testing service sent in home urine samples by post which were analysed for C. trachomatis and answered a questionnaire regarding their socio-demographic background, sexual risk behaviour, and sexual health. Potential risk factors for C. trachomatis were determined by logistic regression models. RESULTS: The questionnaire response rate was 86% (6025/6978) with a male and female response rate of 77% and 93%, respectively. 5763 subjects both answered questionnaire and supplied urine sample. Mean age was 24.4 years (range 15-67 years) and 62% were women. The participants'C. trachomatis prevalence in men was 8.0% (73/2163) and 5.6% in women (201/3600). Compared to non-infected individuals, the C. trachomatis infected men and women were younger, had a higher number of sexual partners, more intercourse without condom (only men). After adjusting for age, civil status, and geographical region, the risk factors significantly associated with C. trachomatis infection were multiple partners during the previous year, non-condom usage, and having symptoms (only men). A novel finding was that, in women, believing to be infected and having been requested to be tested by a sexual partner, was associated with an increased risk of having a C. trachomatis infection. CONCLUSION: The Internet-based C. trachomatis testing service reaches a risk group of men and women. The results emphasise the value of self-risk assessment for C. trachomatis infection and the importance of easy accessible and simple sexual transmitted infection testing services.

Stroke and coronary heart disease: predictive power of standard risk factors into old age--long-term cumulative risk study among men in Gothenburg, Sweden.

AIMS: The aim of this study was to examine the short-term and long-term cumulative risk of coronary heart disease (CHD) and stroke separately based on age, sex, smoking status, systolic blood pressure, and total serum cholesterol. METHODS AND RESULTS: The Primary Prevention Study comprising 7174 men aged between 47 and 55 free from a previous history of CHD, stroke, and diabetes at baseline examination (1970-73) was followed up for 35 years. To estimate the cumulative effect of CHD and stroke, all participants were stratified into one of five risk groups, defined by their number of risk factors. The estimated 10-year risk for high-risk individuals when adjusted for age and competing risk was 18.1% for CHD and 3.2% for stroke which increased to 47.8 and 19.6%, respectively, after 35 years. The estimates based on risk factors performed well throughout the period for CHD but less well for stroke. CONCLUSION: The prediction of traditional risk factors (systolic blood pressure, total serum cholesterol, and smoking status) on short-term risk (0-10 years) and long-term risk (0-35 years) of CHD of stroke differs substantially. This indicates that the cumulative risk in middle-aged men based on these traditional risk factors can effectively be used to predict CHD but not stroke to the same extent.

High-normal blood pressure and long-term risk of type 2 diabetes: 35-year prospective population based cohort study of men.

BACKGROUND: The link between type 2 diabetes and hypertension is well established and the conditions often coexist. High normal blood pressure, defined by WHO-ISH as systolic blood pressure (SBP) 130-139 mm Hg or diastolic blood pressure (DBP) 85-89 mm Hg, has been found to be an independent predictor for type 2 diabetes in studies, although with relatively limited follow-up periods of approximately 10 years. The aim of this study was to investigate whether hypertension, including mildly elevated blood pressure within the normal range, predicted subsequent development of type 2 diabetes in men over an extended follow-up of 35 years. METHODS: Data were derived from the Gothenburg Primary Prevention Study where a random sample of 7 494 men aged 47-55 years underwent a baseline screening investigation in the period 1970-1973. A total of 7 333 men were free from previous history of diabetes at baseline. During a 35-year follow-up diabetes was identified through the Swedish hospital discharge and death registries. The cumulative risk of diabetes adjusted for age and competing risk of death was calculated. Using Cox proportional hazard models we calculated the multiple adjusted hazard ratios (HR) (95% confidence interval (CI)) for diabetes at different blood pressure levels. RESULTS: During a 35-year follow-up, 956 men (13%) were identified with diabetes. The 35-year cumulative risk of diabetes after adjusting for age and competing risk of death in men with SBP levels <130 mm Hg, 130-139 mm Hg, 140-159 mm Hg and ≥160 mm Hg were 19%, 30%, 31% and 49%, respectively. The HR for diabetes adjusted for age, body mass index (BMI), cholesterol, antihypertensive treatment, smoking, physical activity and occupation were 1.43 (95% CI 1.12-1.84), 1.43 (95% CI 1.14-1.79) and 1.95 (95% CI 1.55-2.46) for men with SBP 130-139 mm Hg, 140-159 mm Hg, and ≥ 160 mm Hg, respectively (reference; SBP<130 mm Hg). CONCLUSION: In this population, at mid-life, even high-normal SBP levels were shown to be a significant predictor of type 2 diabetes, independently of BMI and other conventional type 2 diabetes risk factors over an extended follow-up.

Inequalities in smoking: influence of social chain of risks from adolescence to young adulthood: a prospective population-based cohort study.

BACKGROUND: The pathway between socioeconomic disadvantages and smoking is a process that requires an understanding of life-course influence. PURPOSE: This study investigated pathways of social risks at different life stages that are linked to adolescent smoking and maintenance of smoking through to young adulthood. METHOD: A cohort consisting of all pupils (n = 1083) from one Swedish city were followed from age 16 to age 30 (1981-1995), with a 96.4% response rate. RESULT: Odds ratios of being a smoker at age 30 among low educated were 2.54 for men and 2.53 for women. Using structural equation model analysis for men and women, a strong chain of risks was found from age 16 linking to smoking at age 30: adolescents with adverse socioeconomic status (SES) were more likely from a divorced family. Being from a divorced family and having poor contact with their parents influenced their smoking directly and through peers. Adolescents with adverse SES were also likely to be unpopular in school, which affected their smoking behavior directly and through peers. These socially disadvantaged participants, who were smokers at age 16, continued smoking until age 30 years. The risk pathways were similar for both men and women. CONCLUSIONS: Adult smoking reflects the cumulative influence of multiple socioeconomic and psychosocial chains of risks experienced during upbringing. The programs that are addressed to reduce smoking among socially disadvantaged adolescents would have an impact in reducing smoking inequalities in adults.

Food supplementation, nutritional intake of recipients and operational aspects: an integrated pilot nutrition initiative of BRAC.

OBJECTIVES: To explore the nutritional quality of supplementary foods and additional energy consumption by the recipients in a pilot nutrition initiative of BRAC. DESIGN: In-depth interviews, observations during feeding at feeding centres, and laboratory analyses of supplementary foods for nutrient contents performed at the Institute of Nutrition and Food Science, University of Dhaka, Bangladesh. SETTING: Muktagacha thana (sub-district) in Mymensingh district, a rural area of Bangladesh. SUBJECTS: Pregnant and lactating mothers and children below 2 years of age. RESULTS: Analysis revealed that supplementary food, if taken completely, could provide daily energy equivalent to 752 kcal to a mother and 212 kcal to a child below 2 years of age. Mothers consumed about 75% of the food provided (approximately 564 kcal day(-1)). The food was shared mostly with young children and husbands. In-depth interview with mothers also suggested that they usually skipped breakfast if the food was given in the morning. The children liked the taste of food, and unless the child was sick or had some food before coming to the centre, she/he ate all the food provided. Although the main purpose of the project was to provide nutrition education, it was observed that activities at feeding centres were limited to food distribution with little time devoted to the communication of nutritional messages. CONCLUSIONS: Training should be given to service providers to communicate nutritional messages effectively as part of understanding the goal of the initiative. It is important to explore whether the regular diets of the recipients are replaced by the food supplementation or not.