Socioeconomic differences in fat intake in a middle-aged population: report from the Malmö Diet and Cancer Study

BACKGROUND: The objective was to investigate whether socioeconomic differences in fat intake may explain socioeconomic differences in cardiovascular diseases. METHODS: The Malm? Diet and Cancer Study is a prospective cohort study. The baseline examinations used in the present cross-sectional study were undertaken in 1992-1994. Dietary habits were assessed using a modified diet history method consisting of a 7-day menu book and a 168-item questionnaire. A subpopulation of 11 837 individuals born 1926-1945 was investigated. This study examined high fat intake, defined as >35.9% among men and >34.8% among women (25% quartile limit) of the proportion of the non-alcohol energy intake contributed by fat. The subfractions saturated, mono-unsaturated and poly-unsaturated fatty acids and the P:S ratio (polyunsaturated/saturated fatty acids) were analysed in the same way. The uppermost quartile (75%) of total and subgroup fat intake was also studied. Socioeconomic differences before and after adjustment for low energy reporting (LER), defined as energy intake below 1.2 x Basal Metabolic Rate, were examined. RESULTS: No socioeconomic differences in fat intake were seen between the SES groups, except for self-employed men, and male and female pensioners. Approximately 20% in most SES groups were LER. The LER and body mass index were strongly related. The SES pattern of fat intake remained unchanged after adjustment for age, country of origin and LER in a logistic regression model. The results for the subfractions of fat and the P:S ratio did not principally differ from the total fat results. CONCLUSIONS: This study provides no evidence that fat intake contributes to the inverse socioeconomic differences in cardiovascular diseases.     

Occupational status, educational level, and the prevalence of carotid atherosclerosis in a general population sample of middle-aged Swedish men and women: results from the Malmö Diet and Cancer Study

The associations among educational level, occupational status, and atherosclerosis were investigated during 1992-1994 in a general population sample of 4,176 Swedish men and women. Carotid artery intima-media thickness (IMT) and carotid stenosis were determined by B-mode ultrasound. Socioeconomic differences in mean carotid IMT and odds ratios for carotid stenosis prevalence were estimated. In women, the associations among educational level, occupational status, and IMT were weak. In men, there was no association between education and IMT, while low occupational status was associated with a thicker IMT. Women with low education had an increased odds of carotid stenosis compared with women with high education (odds ratio (OR) = 2.04, 95% confidence interval (CI): 1.53, 2.73), while this pattern was weaker among men. Women in manual occupations had an increased odds of carotid stenosis compared with women in high- or medium-level nonmanual occupations (OR = 1.75, 95% CI: 1.29, 2.36), which could not be seen among men. After adjustment for risk factors, the association between IMT and occupational status in men disappeared, while the associations among educational level, occupational status, and carotid stenosis in women persisted. The results imply that the atherosclerotic process is associated with socioeconomic status in both sexes, and they also indicate the possibility of sex differences in the mechanisms connecting socioeconomic status to atherosclerosis.     

Gender differences in physical activity and fitness—association with self-reported health and health-relevant attitudes in a middle-aged Swiss urban population

In Switzerland lack of exercise is common. To improve physical exercise in both women and men, campaigns should consider the motivation for physical activity with respect to gender. This study explores the patterns of self-reported sport activity, habitual physical activity and physical fitness, and associated indicators of self-reported health, health-relevant attitudes, and resources in an urban Swiss population. Using the Bern Lifestyle Panel questionnaire, 511 women and 413 men, aged 55–65 years, in the German-speaking capital of Switzerland were assessed. From the three surveys carried out from 1996 to 1998, this study used the data from the 1997 survey for a cross-sectional analysis. Women demonstrated a lower prevalence of sport activity than men but a higher prevalence of habitual physical activity. Forty-six percent of the women but 80% of the men reported a high level of fitness. In the logistic regression analysis, sport activity in the women was significantly associated with indicators of health, health-relevant attitudes such as internal and external health locus of control, and social class. Among the men, no association with health-relevant orientation could be found. The probability of habitual physical activity among the women was associated with perceived good health, health-relevant orientation and social class, while related factors among the men were indicators of health. In both women and men, perceived good health was strongly associated with self-reported physical fitness. Additionally, womens fitness was related to perceived disease-related limitation and indicators of health status. The findings indicate a gender-specific distribution of sport activity, habitual physical activity and fitness. Compared to men, physical activity in women is associated more with health-relevant orientation. Along with indicators of health, attention should be paid to both female and male perception of health and self-reported attitudes when there is an attempt to improve physical activity. Since self-reported health status, disease-related limitations, and habitual physical activity, among others, are strongly affected by sociocultural and structural influences, caution should be kept in drawing general conclusions from the findings.     

Early ageing in middle-aged men is associated with adverse social factors and increased mortality risk: the Malmö Preventive Project

AIMS: This study examined whether middle-aged men exhibiting markers of early ageing showed a different pattern of social factors, lifestyle, and biological variables compared with controls, and whether early ageing was associated with an increased mortality risk. SUBJECTS AND METHODS: We used a subgroup of 5,722 middle-aged men (mean age 47 years), investigated twice, from the Malm? Preventive Project (MPP), a screening programme attended by a total of 22,444 men between 1974 and 1992. Markers of biological ageing, such as decreased lung function, increased pulse pressure, and decreased height, were used to identify early aged subjects and a control group. These were followed up by use of local and national registers for a mean of 22 years. Cox's proportional regression was used to estimate multivariate relative risks (RR) for mortality with 95% confidence intervals (CI). RESULTS: Men with early ageing were more often smokers, living alone, or less likely to be non-manual workers than control subjects. These men also had an increased age-adjusted mortality relative risk, RR 1.29 (95% CI 1.10-1.52). After adjustment for social and lifestyle factor there was still a significant difference in mortality between the two groups, RR 1.19 (95% CI 1.00-1.42). CONCLUSION: Early biological ageing in middle-aged men is associated with an increased mortality risk during long-term follow-up that cannot be fully explained by social background characteristics or adverse lifestyle.     

Self-rated health in relation to age and gender: influence on mortality risk in the Malmö Preventive Project

AIMS: A study was undertaken to examine whether poor self-rated health (SRH) can independently predict all-cause mortality during 22-year follow-up in middle-aged men and women. SUBJECTS AND METHODS: Data are derived from a population-based study in Malm?, Sweden. This included baseline laboratory testing and a self-administered questionnaire. The question on global SRH was answered by 15,590 men (mean age 46.4 years) and 10,089 women (49.4 years). Social background characteristics (occupation, marital status) were based on data from national censuses. Mortality was retrieved from national registers. RESULTS: At screening 4,261 (27.3%) men and 3,085 (30.6%) women reported poor SRH. Among subjects rating their SRH as low, 1,022 (24.0%) men and 228 (7.4%) women died during follow-up. Corresponding figures for subjects rating their SRH as high were 1801 (15.9%) men and 376 (5.4%) women. An analysis of survival in subjects reporting poor SRH revealed an age-adjusted hazard risk ratio (HR, 95%CI) for men HR 1.5 (1.4-1.7), and for women HR 1.4 (1.2-1.6). The corresponding HR after adjusting for possible social confounders was for men HR 1.3 (1.1-1.4), and women HR 1.1 (0.9-1.4). When additional adjustment was made for biological risk factors the association for men was still significant, HR 1.2 (1.1-1.3). CONCLUSION: Poor SRH predicts increased long-term mortality in healthy, middle-aged subjects. For men the association is independent of both social background and selected biological variables. The adjustment for biological variables can be questioned as they might represent mediating mechanisms in a possible causal chain of events.     

SunSmart? Skin cancer knowledge and preventive behaviour in a British population representative sample

The incidence of skin cancer has risen rapidly in the UK over the last 20 years, prompting public health organizations to try and raise awareness of the dangers of sun exposure and the need to practice sun-safe behaviour. This study aimed to assess baseline levels of sun-safe knowledge and behaviour in a British population-representative sample, prior to the launch of Cancer Research UK's 'SunSmart' campaign. A face-to-face survey was conducted through the Office for National Statistics as part of their Omnibus survey. In total, 1848 men and women aged 18 and over were interviewed. Knowledge of what to do to reduce skin cancer risk was modest. Two-thirds mentioned avoiding the sun by seeking shade, 50% mentioned covering up and only 43% said to use high factor sunscreen. Practice of sun-safe behaviours was also poor, with only one-third saying they sought shade, covered up or used high factor sunscreen to protect themselves from the sun. Men and those from lower socioeconomic groups were least informed and least likely to report using sun-protective behaviours. Increases in both knowledge and use of appropriate sun-protective behaviours are needed if skin cancer incidence rates are to decrease.     

Intra-urban differences in breast cancer mortality: a study from the city of Malmö in Sweden

STUDY OBJECTIVE—To assess whether in an urban population stage at breast cancer diagnosis is related to area of living and to what extent intra-urban differences in breast cancer mortality are related to incidence respectively stage at diagnosis.DESIGN—National registries were used to identify cases. Mortality in 17 residential areas was studied in relation to incidence and stage distribution using linear regression analysis. Areas with high and low breast cancer mortality, incidence and proportion of stage II+ tumours at diagnosis were also compared in terms of their sociodemographic profile.SETTING—City of Malmö in southern Sweden.PATIENTS—The 1675 incident breast cancer cases and 448 deaths that occurred in women above 45 years of age in Malmö 1986-96.MAIN RESULTS—Average annual age standardised breast cancer mortality ranged between residential areas, from 35/10⁵ to 107/10⁵, p=0.04. Mortality of breast cancer was not correlated to incidence, r= 0.22, p=0.39. The ratio of stage II+/0-I cancer incidence varied between areas from 0.45 to 1.99 and was significantly correlated to breast cancer mortality, r= 0.53, p=0.03. Areas with high proportion of stage II+ cancers and high mortality/incidence ratio were characterised by a high proportion of residentials receiving income support, being foreigners and current smokers.CONCLUSIONS—Within this urban population there were marked differences in breast cancer mortality between residential areas. Stage at diagnosis, but not incidence, contributed to the pattern of mortality. Areas with high proportion of stage II+ tumours differed unfavourably in several sociodemographic aspects from the city average.     

Associations between estimated acrylamide intakes, and hemoglobin AA adducts in a sample from the Malmö Diet and Cancer cohort

OBJECTIVE: To examine the coherence of estimated intakes of acrylamide (AA) from foods, with hemoglobin (Hb) AA adduct levels, an objective marker of environmental AA exposure. DESIGN: A cross-sectional study. SETTING: The Malm? Diet and Cancer study, a large population-based prospective cohort (n=28 098) in the south of Sweden. SUBJECTS: A sample of non-smoking (n=70) and smoking (n=72) women and men selected to obtain large variation in Hb AA adducts. METHODS: Self-reported data on the usual consumption of foods were combined with published data on the AA content in Swedish foods. The Hb AA adduct levels were determined by a modified Edman degradation method. Linear regression and correlation analysis examined associations between estimated AA intakes, and Hb AA adducts. RESULTS: In randomly selected individuals (n=40), the estimated median AA intake was 28 mug per day. In linear regression models, adjusting for sex, significant associations were seen in non-smokers between Hb AA adducts and estimated AA from foods (P=0.006). In smokers both AA from foods (P=0.006) and the calculated amount of tobacco consumed (P=0.003) were significantly associated with Hb AA adducts. Positive partial correlations between dietary AA estimates and Hb AA adducts were seen in smoking men (r=0.37) and women (r=0.59), and in non-smoking men (r=0.60), but not in non-smoking women. CONCLUSIONS: This study suggests that both diet and tobacco are important sources of the environmental AA exposure, although the lack of correlations in non-smoking women cast doubt on the validity of dietary AA intake estimates used in cancer epidemiology, or suggest that unrecognized factors may influence the internal dose measure of AA exposure.     

Social mobility, marital status, and mortality risk in an adult life course perspective: the Malmö Preventive Project

AIMS: Adverse social factors predict increased mortality. This study aimed to assess the influence of social class and marital status on mortality, adding an adult life course perspective. METHODS: In total, 32,907 males and 20,204 females were evaluated based on census data in Malm?, Sweden. Of these subjects, 22,444 males and 10,902 females also took part in health screening. The main outcomes were all-cause and cause-specific mortality rates in subgroups based on social class and marital status, either measured once or repeatedly in adult life. Results were based on a total of 522,807 years of follow-up in men (5,761 deaths) and 239,815 in women (1,354 deaths). RESULTS: Total and cardiovascular mortality were significantly higher in manual male employees with age-adjusted risk ratios (RR) of 1.7 (95% CI 1.5-1.9) and 1.6 (1.3-2.0) in skilled manual workers, and 2.0 (1.7-2.2) and 1.9 (1.6-2.3) in unskilled manual workers, compared with high-level non-manual employees. The differences remained after adjustment for baseline risk factors and prevalent cardiovascular disease, and were similar for women. Increased mortality risk was also documented for subjects who were divorced or unmarried (adjusted for social class), as well as being downward socially mobile or in a permanent low social class (manual) position. CONCLUSIONS: Social class based on occupation, either measured once or repeatedly in adult life, is associated with marked differences in mortality risk in middle-aged subjects. People who remain married/cohabiting or remarry are at lower risk of early death than people who remain unmarried or divorced.     

Changes in government spending on healthcare and population mortality in the European union, 1995–2010: a cross-sectional ecological study

Objective

Economic measures such as unemployment and gross domestic product are correlated with changes in health outcomes. We aimed to examine the effects of changes in government healthcare spending, an increasingly important measure given constrained government budgets in several European Union countries.

Design

Multivariate regression analysis was used to assess the effect of changes in healthcare spending as a proportion of total government expenditure, government healthcare spending as a proportion of gross domestic product and government healthcare spending measured in purchasing power parity per capita, on five mortality indicators. Additional variables were controlled for to ensure robustness of data. One to five year lag analyses were conducted.

Setting and Participants

European Union countries 1995–2010.

Main outcome measures

Neonatal mortality, postneonatal mortality, one to five years of age mortality, under five years of age mortality, adult male mortality, adult female mortality.

Results

A 1% decrease in government healthcare spending was associated with significant increase in all mortality metrics: neonatal mortality (coefficient −0.1217, p = 0.0001), postneonatal mortality (coefficient −0.0499, p = 0.0018), one to five years of age mortality (coefficient −0.0185, p = 0.0002), under five years of age mortality (coefficient −0.1897, p = 0.0003), adult male mortality (coefficient −2.5398, p = 0.0000) and adult female mortality (coefficient −1.4492, p = 0.0000). One per cent decrease in healthcare spending, measured as a proportion of gross domestic product and in purchasing power parity, was both associated with significant increases (p < 0.05) in all metrics. Five years after the 1% decrease in healthcare spending, significant increases (p < 0.05) continued to be observed in all mortality metrics.

Conclusions

Decreased government healthcare spending is associated with increased population mortality in the short and long term. Policy interventions implemented in response to the financial crisis may be associated with worsening population health.     

A prospective study of adiposity and all-cause mortality: the Malmö Diet and Cancer Study

OBJECTIVE: This study aims to examine the association between various measures of adiposity and all-cause mortality in Swedish middle-aged and older men and women and, additionally, to describe the influences of age and sex on these associations. RESEARCH METHODS AND PROCEDURES: A prospective analysis was performed in a cohort of 10,902 men and 16,814 women ages 45 to 73 years who participated in the Malm? Diet and Cancer Study in Sweden. Baseline examinations took place between 1991 and 1996, and 982 deaths were documented during an average follow-up of 5.7 years. All-cause mortality was related to the following variables measured at baseline: body mass index (BMI), percentage of body fat, lean body mass (LBM), and waist-to-hip ratio (WHR), with adjustment for age and selected covariates. Body composition data were derived from bioelectrical impedance analysis. RESULTS: The association between percentage of body fat and mortality was modified by age, particularly in women. For instance, fatness was associated with excess mortality in the younger women but with reduced mortality in the older women. Weaker associations were seen for BMI than for percentage of body fat in both sexes. Placement in the top quintiles of waist-to-hip ratio, independent of overall body fat, was a stronger predictor of mortality in women than in men. The observed associations could not be explained by bias from early death or antecedent disease. DISCUSSION: The findings reveal sex and age differences for the effects of adiposity and WHR on mortality and indicate the importance of considering direct measures of adiposity, as opposed to BMI, when describing obesity-related mortality risks.     

Do you die from rheumatism? The five-year mortality in a middle-aged population sample with respect to reported joint symptoms.

With special reference to reported joint symptoms, the five-year mortality was studied of a population sample of 3394 persons, 56-60 years old in 1965. An age- and sex-matched comparison was made between the mortality of the total population of the same age-group, and the sample investigated. A significant excess mortality was found for males reporting previous hospital admission for "rheumatoid arthritis". In this group, however, only 28% really had rheumatoid arthritis according to generally used criteria. The other diseases were mainly previous rheumatic fever and degenerative joint disease. It is concluded that males are harder hit by degenerative joint disease than females. The sample investigated had a lower mortality than the population from which it was sampled. The comparability of a fixed sample and a mean population found in official statistics is discussed. The non-response group was estimated to have a considerable excess mortality.     

Dairy products and its association with incidence of cardiovascular disease: the Malmö diet and cancer cohort

It is unclear whether specific dairy products are associated with risk of cardiovascular disease (CVD). The aim of this project was therefore to examine the association between intake of milk, cheese, cream and butter, and incidence of CVD in the Swedish Malmö Diet and Cancer cohort. Milk was separated into fermented (yoghurt and cultured sour milk) versus non-fermented milk, and low-fat versus high-fat milk. Among 26,445 individuals without a history of myocardial infarction, stroke and diabetes (44–74 years; 62% females), 2,520 CVD cases (coronary and stroke events) were identified during a mean follow-up time of 12 years. Dietary data was collected using a modified diet history method. Overall consumption of dairy products was inversely associated with risk of CVD (P _trend = 0.05). Among the specific dairy products, a statistically significant inverse relationship was observed only for fermented milk. The highest versus lowest intake category of fermented milk was associated with 15% (95% CI: 5–24%; P _trend = 0.003) decreased incidence of CVD. We observed a statistically significant interaction between sex and cheese intake (P = 0.046). Cheese intake was significantly associated with decreased CVD risk in women (P _trend = 0.03), but not in men (P _trend = 0.98). The main finding was that a high intake of fermented milk may reduce the risk of CVD. This study suggests that it is important to examine dairy products separately when investigating their health effects.     

Socioeconomic inequalities in cancer incidence and mortality—a spatial analysis in Bremen, Germany

Aim

Several international studies have already investigated the influence of socioeconomic factors on the risk of cancer. For Germany, however, the data are still insufficient. We examined the effects of social differences on cancer incidence and mortality on the population of Bremen, a town in northwest Germany.

Subjects and methods

Data were obtained from the Bremen Cancer Registry, a population-based registry. The database comprised 27,430 incident cases, newly diagnosed between 2000 and 2006. The allocation of social class for each patient was based on the home address at the time of diagnosis, which led to the corresponding town district, which again could be linked to the “Bremen discrimination index.” Based on this index, cases were allocated to five categories, for which we compared standardized incidence ratios (SIR) and mortality ratios (SMR) for different cancers: prostate, breast, lung, colorectal, bladder, uterine, ovarian, cervical, malignant melanoma of the skin, non-melanoma skin cancer and all cancer sites summarized.

Results

The influence of social status was observed for different cancer sites. An inverse association was ascertained for all cancer sites (only men) and for tumors of the oral cavity and pharynx, and for lung, cervical and bladder cancers. A positive correlation was observed for female breast cancer, malignant melanoma, non-melanoma skin tumors and prostate cancer.

Conclusions

In spite of the methodical restrictions, our analyses suggest an association between social factors and cancer incidence and mortality. The results are in agreement with international studies. Many of the observed social class differences could probably be explained by known risk factors, such as smoking, alcohol consumption, diet and physical activity.     

Atrial fibrillation in the Malmö diet and cancer study: a study of occurrence,risk factors and diagnostic validity

The validity of atrial fibrillation (AF) diagnoses in national registers for use as endpoints in prospective studies has not been evaluated. We studied the validity of AF diagnoses in Swedish national hospital discharge and cause of death registers and the occurrence of and risk factors for AF in a middle-aged Swedish population using these registers. Our study included the 30,447 individuals (age 44–73) who attended baseline visits in 1991–1996 of the Malmö Diet and Cancer study. Individuals with a first AF diagnosis were identified by record linkage with national registers. A subset of cases was randomly selected for validation by examination of electrocardiograms and patient records. Electrocardiograms were available in 98% of the validation sample (95% definitive AF, 3% no AF). The 2% with ECGs unavailable had probable AF. Baseline AF prevalence was 1.3%, higher in men and increased with age. During 11.2 years of follow-up 1430 first AF diagnoses occurred. Risk factors were age, hypertension, BMI, diabetes, history of heart failure, history of myocardial infarction and, in men but not women, current smoking. The strongest risk factors were history of heart failure (hazard ratio men 4.5, women 8.7) and myocardial infarction (hazard ratio men 2.0, women 1.8). The largest population attributable risks were observed for hypertension (men 38%, women 34%) and obesity (men 11%, women 10%). In conclusion, case misclassification of AF in national registers is small, indicating feasibility of use in prospective studies. Hypertension and obesity account for large portions of population risk in middle-aged individuals with low prevalence of manifest cardiac disease.     

Increased mortality in the slim elderly: a 42 years follow-up study in a general population

The Bergen Clinical Blood Pressure Study in Norway was used to examine the relationship between body mass index (BMI (kg/m²)) and total mortality in different age segments. Of 6,811 invited subjects, 5,653 (84%) participated in the study (1965–1971) and 4,520 (66%) died during 182,798 person-years of follow-up (1965–2007). Mean age at baseline was 47.5 years; range 22–75 years. BMI (kg/m²) was calculated from standardized measurements of body height and weight and divided into four groups (<22.0, 22.0–24.9, 25.0–27.9, ≥28.0). The 20 years cumulative risk of death related to baseline BMI was U-shaped in the elderly (aged 65–75 years), whereas the pattern was more linear in the youngest age group (20–44 years). In contrast to the younger age groups, the highest mortality in the elderly was in the lower BMI range (<22.0 kg/m²) (adjusted Cox proportional Hazard Ratio 1.39, 95% Confidence Interval 1.10, 1.75) compared to the BMI reference group (22.0–24.9 kg/m²). This pattern persisted after 72 months of early follow-up exclusion and it was robust to adjustments for a wide range of possible confounders including gender, history of cardiovascular disease, respiratory disease or hypertension, smoking habits, physical activity, socioeconomic status, physical appearance and other anthropometric measures. The study shows that a low BMI is an appreciable independent risk factor of total mortality in the elderly, and not a result of subclinical disease or confounding factors such as current or previous smoking. Awareness of this issue ought to be emphasized in advice, care and treatment of elderly subjects.