Income differences in mortality: a register-based follow-up study of three million men and women

OBJECTIVES: We analyse whether the relationship between net household income and mortality form a continuous linear gradient or is curvilinear, assess the attenuation of this association after adjusting for confounding and reverse causality, and assess the strength of the association by age and cause of death. DESIGN AND SETTING: Prospective study of mortality in Finland among all men and women over 30 years old. Information on household income and sociodemographic factors was from the records of the Finnish tax authorities and the 1990 census. Income data were available for more than 95% of the cohort. Follow-up was by record linkage to death certificates in 1991-1996; altogether about 261 000 deaths. RESULTS: The all-cause mortality ratio between the lowest and the highest household income decile is 2.37 (95% CI : 2.30-2.44) among men and 1.73 (95% CI : 1.67-1.80) among women. Adjusting for household structure, spouse's economic activity, social class, education and own economic activity attenuates the relationship by 61% among men and 52% among women. The association between income and mortality is mainly linear before and after adjusting for confounding, and the association is strong for all 5-year age groups below 60-64 years, after which it declines rapidly in strength. CONCLUSIONS: The mainly linear nature of the relationship and the strong attenuation after adjustment for other socioeconomic factors and economic activity status, and the age pattern of the relationship indicate that a large part of the relationship is unlikely to be due to direct causal effects of poverty and material hardship. Rather, income seems to be related to accumulation of factors that increase mortality over the whole range of incomes.     

Serum vitamin E and risk of cancer among Finnish men during a 10-year follow-up

The association between serum alpha-tocopherol levels and the subsequent incidence of cancer was investigated in a longitudinal study of 21,172 men initially aged 15-99 years in six geographic areas in Finland. The baseline examination was conducted in 1968-1972, and during the follow-up of 6-10 years, 453 cancers were diagnosed. The serum alpha-tocopherol levels were measured from stored serum samples from these men and from 841 male controls, matched for municipality and age, who did not develop cancer during the follow-up. The mean levels of serum alpha-tocopherol among the cancer cases and controls were 8.02 and 8.28 mg/liter, respectively. A high serum alpha-tocopherol level was associated with a reduced risk of cancer. The relative risk of cancer in persons in the two highest (threshold 8.70 mg/liter) quintiles of serum alpha-tocopherol was 0.64 (95 per cent confidence interval = 0.49-0.85) in comparison with those in the three lowest quintiles. The association was strongest for the combined group of cancers unrelated to smoking and varied between subgroups of the study population as well as between different cancers. The association persisted when adjusted for serum cholesterol, serum vitamin A, serum selenium, and various confounding factors. It also persisted when subjects with possible signs of cancer at the time when the blood samples were drawn or with cancers diagnosed during the first two years of follow-up were excluded. These findings agree with the hypothesis that high vitamin E intake protects against cancer.     

Inter-cohort differences in coronary heart disease mortality in the 25-year follow-up of the seven countries study

Sixteen cohorts of men aged 40–59 years at entry were examined with the measurement of some risk factors and then followed-up for mortality and causes of death for 25 years. These cohorts were located in the USA (1 cohort), Finland (2), the Netherlands (1), Italy (3), the former Yugoslavia (5), Greece (2), and Japan (2), and included a total of 12,763 subjects.Large differences in age-adjusted coronary heart disease (CHD) death rates were found, with extremes of 45 per 1000 in 25 years in Tanushimaru, Japan, to 288 per 1000 in 25 years in East Finland. In general, higher rates were found in the US and Northern European cohorts as compared to the Southern European and Japanese cohorts. However, during the last 10 years of follow-up large increases of CHD death rates were found in some Yugoslavian areas. Out of 5 measured entry characteristics treated as age-adjusted levels (serum cholesterol, systolic blood pressure, cigarette smoking, body mass index and physical activity at work), only serum cholesterol was significant in explaining cohort differences in CHD death rates.Over 50% of the variance in CHD death rates in 25 years was accounted for by the difference in mean serum cholesterol. This association tended to decline with increasing length of follow-up, but this was due to the great changes in mean serum cholesterol in the two Jugoslavian cohorts of Velika Krsna and Zrenjanin. When these two cohorts were excluded the association increased with time.Changes in mean serum cholesterol between year 0 and 10 helped in explaining differences in CHD death rates from year 10 onward.It can be concluded that this study suggests that mean serum cholesterol is the major risk factor in explaining cross-cultural differences in CHD.     

Coffee consumption and mortality in a 14-year follow-up of an elderly northern Finnish population

The present study assessed the relationship between coffee consumption and mortality in a home-dwelling elderly population. A population-based cohort of 817 men and women born in 1920 or earlier and living in northern Finland provided complete data on daily coffee consumption and other variables at the baseline examination in 1991-1992. Deaths were monitored through to the end of 2005 by national death certificates, resulting in 6960 person-years of follow-up. Hazard rate ratios for mortality by daily coffee intake were estimated by Poisson regression models adjusted for some known predictors of mortality. During 14.5 years of follow-up, 623 deaths occurred. The total mortality rate was inversely related to the number of cups (average volume, 125 ml) of coffee consumed daily. After adjustment for age, sub-period of follow-up, sex, marital status, basic educational level, previous occupational group, current smoking, BMI, history of myocardial infarction, self-rated health and presence of diabetes, cognitive impairment or physical disability, the estimated relative risk reduction of total mortality per an increment of one more cup of coffee per d reported at baseline was 4 (95% CI 0, 8) %. The observed associations between coffee consumption and mortality from CVD, cancer, and other or unknown causes, respectively, were qualitatively similar to that of total mortality but the estimates were less precise. The effect of coffee consumption at baseline appeared to attenuate after 10 years since the start of follow-up. The present study provides evidence for daily (caffeine-containing) coffee intake being inversely associated with mortality in the elderly.     

The effects of unemployment on mortality following workplace downsizing and workplace closure: a register-based follow-up study of Finnish men and women during economic boom and recession

Unemployment is strongly associated with mortality on the individual level. The reasons for this association are not fully established. The authors estimated the effects of unemployment and workplace downsizing on mortality during periods of low (1989) and high (1994) unemployment in Finland. They used prospective population registration data containing detailed socioeconomic and demographic information on two cohorts aged 35-64 years at the beginning of 1989 (N = 87,317) and 1994 (N = 72,419) followed up for mortality in 1990-1997 and 1995-2002, respectively. Unemployment was found to be associated with a 2.38-fold increase in the hazard of mortality after 1989 and with a 1.25-fold increase after 1994. No excess mortality was observed among those who, at baseline, were employed at workplaces that had experienced large reductions in employment. Furthermore, the association between unemployment and mortality was weaker among those working in establishments that had been strongly downsized. By showing that, in the context of either a high level of unemployment or rapid downsizing, the effects of unemployment on mortality are modest, this study provides strong evidence of unaccounted confounding. Individual-level studies may thus overestimate the causal effects of unemployment on mortality.     

Lung function predicts mortality: 10-year follow-up after lung cancer screening among asbestos-exposed workers

Purpose

To assess the predictive value of lung function impairment on mortality among asbestos-exposed workers.

Methods

A total of 590 workers originally screened for occupational lung disease including spirometry and pulmonary diffusing capacity measurements were followed up for mortality data (ICD-10 classification). The mean follow-up time was 10.5 years. Associations of different lung function parameters with mortality from all causes and from cardiovascular (I00-I99) and non-malignant respiratory diseases (J00-J99) were analysed. Factor analysis was used to create obstructive and restrictive factors.

Results

A total of 191 deaths were found altogether. Most measured lung function variables were associated with increased mortality when studied separately. Both decreased forced expiratory flow in one second (hazard ratio/measurement unit = 0.977, 95 % CI 0.969–0.988, p < 0.001) and impaired diffusing capacity (0.973, 0.965–0.981, p < 0.001) were independently associated with mortality from all causes, as well as from cardiovascular and non-malignant respiratory diseases. Both obstructive factor alone and the sum of obstructive and restrictive factors were associated with all studied mortality categories. The restrictive factor alone was associated with all-cause and respiratory mortality.

Conclusions

Deteriorated lung function predicts deaths. The reasons for impaired lung function should be medically explored to enable restoring measures aiming thus to prevent premature deaths.     

Occupational paraffin-induced pulmonary fibrosis: a 25-year follow-up

Abstract Exogenous lipid pneumonia can exceptionally be causedby occupational exposure to paraffin. The authors report a caseof severe interstitial pulmonary disease induced by occupationalexposure to paraffin, leading to delayed fibrosis over a 25-yearfollow-up, despite cessation of exposure.     

Weight and mortality in Finnish women

Mortality in relation to body mass index (BMI) was studied in 17,159 healthy Finnish women aged 25-79 followed up for a median of 12 years. Mortality from all cases was related to BMI only in non-smokers aged 25-64, among whom the mortality pattern was "U"-shaped, with a minimum in the second quintile of BMI (the reference range), and about 1.5 times higher in quintiles I and V. Most of the excess risk of mortality among overweight women was due to cardiovascular diseases. During the first 7 years of follow-up, and high risk (relative risk (RR) = 1.7, 95% confidence interval (CI) = 1.0-2.9 for quintile V compared to quintile II) depended on the association of BMI with the initial blood pressure level, but in the later years, the relative risk of cardiovascular death, ranging from 1.6 (95% CI = 1.0-2.5) for women in quintile III up to 2.6 (95% Ci = 1.7-4.0) for those in quintile V, was largely independent of the baseline levels of the main biological risk factors. The excess mortality among thin women under the age of 65 was mainly due to non-cardiovascular diseases (RR = 1.7, 95% CI = 1.2-2.3 for quintile I compared to quintile II) and was not attributable to antecedent disease, smoking or the biological risk factors studied. Among women aged 65 and over, overall mortality varied little with BMI, but thinness seemed to predict deaths from cancers (RR = 1.6, 95% CI = 0.9-3.0).(ABSTRACT TRUNCATED AT 250 WORDS)     

Mini nutritional assessment and 10-year mortality in free-living elderly women: a prospective cohort study with 10-year follow-up

Background/Objectives:Mini nutritional assessment (MNA) is the most frequently used screening test for malnutrition in elderly populations in continental Europe and Asia. Most studies on MNA's ability to predict mortality have only included persons admitted to hospital, living in nursing homes or at home with professional help with activities of daily living. The aim of this cohort study was to examine if MNA can predict 10-year mortality in the general elderly female population.Subjects/Methods:Of the 584 free-living elderly women invited, 351 agreed to participate and were tested with MNA between 1999 and 2000. A 10-year follow-up was conducted in 2010 with dates of death obtained from the Swedish death register.Results:Participants whose MNA score was 23.5 points at inclusion had a significantly higher age-adjusted 10-year mortality risk than participants with a MNA score of >23.5 points. The hazard ratio was 2.36 (95% confidence interval 1.25-4.46), P <0.01.Conclusions:Participants with a MNA score, indicating an increased risk for malnutrition, were more than twice as likely to die during the 10-year follow-up as participants whose MNA score indicated normal nutritional status. Hence, MNA can predict mortality in a general, free-living, elderly female population.     

Increased total mortality and cancer mortality in men with Dupuytren's disease: a 15-year follow-up study.

The aim of the present study was to evaluate the mortality rate and causes of death of individuals with Dupuytren's disease. In 1981/82, as part of The Reykjavík Study, a general health survey, 1297 males were examined for clinical signs of Dupuytren's disease. Based on the clinical evaluation the participants were classified into three groups: (1) those with no signs of Dupuytren's disease were referred to as the reference cohort; (2) those with palpable nodules in the palmar fascia were classified as having stage 1; and (3) those who had contracted fingers or had been operated on due to contractures were classified as having stage 2 of Dupuytren's disease. In 1997, after a 15- year follow-up period, the mortality rate and causes of death were investigated in relation to the clinical findings from 1981/82. Information about causes of death were obtained from the National Icelandic Death Registry and the Icelandic Cancer Registry. During the follow-up period, 21.5% (225/1048) of the reference cohort were deceased compared to 29.9% (55/184) of those with stage 1 and 47.7% (31/65) of those with stage 2 of Dupuytren's disease. When adjusted for age, smoking habits and other possible confounders, individuals with stage 2 of the disease showed increased total mortality [hazard ratio (HR) = 1.6; 95% CI 1.1-2.4]. Cancer deaths were increased (HR = 1.9; CI 1.0-3.6). In contrast, participants with stage 1 of Dupuytren's disease did not show increased mortality. A moderate but non-significant increase in cancer incidence was observed among individuals with stage 2 of Dupuytren's disease (HR = 1.5; 95% CI 0.9-2.4, P = 0.15). The study showed increased total mortality of individuals with Dupuytren's disease stage 2, where 42% of the excess in mortality could be attributed to cancer deaths.     

Differential trends in alcohol-related mortality: a register-based follow-up study in Finland in 1987-2003

AIMS: To assess to what extent alcohol-related mortality has changed by age, sex and education in Finland in 1987-2003, a period which saw two periods of economic growth, separated by a severe depression (1991-1995). METHODS: A register-based follow-up study of all over 15-year-old Finnish men and women. Age, sex and education of the participants were measured at the time of the 1985, 1990, 1995 and 2000 censuses. Follow-up for mortality was for 1987-2003. The outcome measure was alcohol-related mortality, which was defined using information on the underlying and contributory causes of death. RESULTS: Among men and women aged 45 years and over, the trends in alcohol-related mortality were associated with economic cycles. Among those aged less than 45 years, alcohol-related mortality decreased from the early 1990s, but intoxication-related accidents and violence still contributed largely to premature mortality. The unfavourable trend for older men resulted from an increase in mortality due to directly alcohol-attributable diseases, alcohol-related diseases of the circulatory system and accidents and violence, and for older women from an increase due to intoxication-related accidents and violence, and alcohol-attributable diseases. Alcohol-related mortality was higher in lower educational groups, and among women the educational gap widened towards the end of the study period. CONCLUSIONS: This study shows that trends in both economic conditions and per capita consumption of alcohol are not associated with trends in alcohol-related mortality in all population subgroups. In health policy more attention should be paid to divergent trends in gender, age and education specific alcohol-related mortality.     

Recent trends in breast cancer mortality among white and black US women.

OBJECTIVES: Time trends in breast cancer mortality were analyzed from 1970 to 1992 among White and Black US women aged 25 and over. METHODS: Mortality data from the National Center for Health Statistics were summarized within three periods 1970 to 1979, 1980 to 1988, and 1989 to 1992. The annual change was calculated as the average yearly percentage of change based on the logistic model. RESULTS: For White women of all ages, breast cancer mortality decreased by 1.6% (95% confidence interval = -2.0%, -1.1%) per year on average during 1989 to 1992, in contrast to the flat mortality rates observed during the 1970s and a 0.5% average annual increase during 1980 to 1988. The decline was observed for White women under age 60, among whom breast cancer mortality had been decreasing, and for White women aged 60 to 79, among whom breast cancer mortality had been increasing, but it was not observed among Black women. CONCLUSIONS: The long-awaited decline in US breast cancer mortality has finally appeared, although only among White women. The possible contributions are changes in inherent risk of disease, changes in treatment effectiveness, and increased use of screening mammography.     

Smoking-related costs among 25 to 59 year-old males in a 19-year individual follow-up

OBJECTIVE: To estimate the health care expenditure and productivity losses due to smoking. DESIGN: A retrospective cohort study of a random population sample of 5,247 men aged 25-59 years from the provinces of Kuopio and North Karelia in eastern Finland. Subjects initially surveyed in 1972 were linked to a set of national registers through their social security identification numbers and followed for 19 years. The difference in the number of life years and work years lost, the costs of drugs and hospitalization, and the value of productivity lost due to disability and premature mortality between smokers, former smokers and never-smokers was analysed. RESULTS: The difference in mean life expectancy between current smokers and never-smokers was 3.0 years, and the difference in mean lost work time was 2.6 years over the 19 years of follow-up. Between current smokers and former smokers, the difference in mean life expectancy was 1.8 years, and the difference in mean lost work time was 1.6 years. The mean difference between a current smoker and a never-smoker in health service costs was [symbol: see text] 2,900, and the difference in mean total costs was [symbol: see text] 69,300 (an increase of 86%). No difference in mean health care costs between current smokers and former-smokers was found, while the difference in mean total cost was [symbol: see text] 44,000. CONCLUSIONS: Smokers incurred excess costs in terms of both direct health care expenditure and indirect productivity losses in comparison to the never-smoking population. Most importantly, quitting smoking could save at least 60% of the losses related to excess mortality and disability of smokers.     

Late-life coronary heart disease mortality of Finnish war veterans in the TAMRISK study,a 28-year follow-up

Background  

Wartime stress has been associated with increased late-life mortality of all causes of death. We evaluated whether wounded Finnish World War II veterans who were alive at the age of 55 have increased long-term coronary heart disease (CHD) mortality.     

Age at natural menopause and all-cause mortality: a 37-year follow-up of 19,731 Norwegian women

In a cohort of 19,731 Norwegian postmenopausal women, the authors analyzed relations between the age at natural menopause and all-cause mortality. A total of 18,533 women died during the 37 years of follow-up from 1961 to 1997. An inverse relation was found between the age at menopause and the all-cause mortality rate (p = 0.003). The strength of the association was moderate, however, with 1.6% (95% confidence interval: 0.6, 2.7) reduced mortality per 3 years' increase in age at menopause. The impact appeared to be stronger in women with an attained age of less than 70 years (3.7% reduction in risk) than in women aged 80 years or more (1.0%). The inverse relation could not be explained by extreme mortality rates in women with very early (<40 years) or late (>55 years) menopause or by possible confounding variables like birth cohort, place of residence, occupational category (own or husband's occupation), body mass index, age at menarche, and first and last delivery or parity. The smoking prevalence was low in the underlying population, and the use of hormone replacement therapy was very rare. The authors conclude that age at natural menopause is inversely related to all-cause mortality.