Determinants of longevity and all-cause mortality among middle-aged men. Role of 48 personal characteristics in a 40-year follow-up of Italian Rural Areas in the Seven Countries Study

C. P, Kyrönlahti S, Goldberg M, Nygård CH, Neupane S. Associations of psychosocial and physical work demands with all-cause mortality: a pooled analysis of prospective cohort studies

BACKGROUND

The findings regarding mortality risk attributable to psychosocial and physical work demands are inconsistent. Pooled estimates using participant-level data from multiple cohort studies may provide more conclusive evidence.

METHODS

Four prospective cohort studies conducted in England, Finland, France, and the USA were used (age 36-62 years; n = 41 760). We studied 34 903 and 36 076 individuals who had baseline (1981-2005) information on self-reported psychosocial and physical work demands, respectively. All-cause mortality until the year 2018 was ascertained through linkage to national registers, National Death Index, and company databases. We investigated the associations of psychosocial and physical demands with all-cause mortality separately for females and males using Cox regression models that were adjusted for socio-demographic and lifestyle factors. Using random-effects meta-analysis, we calculated pooled estimates of all-cause mortality for moderate and high exposure levels.

RESULTS

During the mean follow-up of 25 years, 2105 deaths occurred among females and 5048 deaths occurred among males with information on psychosocial demands. The corresponding numbers for those with information on physical demands were 2176 and 5101. Fully adjusted models indicated that psychosocial demands were associated with both lower and higher all-cause mortality risks in both sexes. Physical demands increased the risk of all-cause mortality in both sexes and the association was strongest among males with moderate exposure levels (pooled hazard ratio 1.10, 95% confidence interval 1.02-1.19).

CONCLUSION

The relationship between psychosocial work demands and all-cause mortality remains inconclusive, whereas moderate physical work demands increase the mortality risk among males.

Men's baldness stigma: A mixed methods international survey

Men's baldness can be structurally stigmatized. For example, commercialized psychology research medicalizes it as a distressing "disease." A mixed-methods survey on baldness stigma among 357 balding men (49% from Central- and South- America, Africa, Asia) was conducted. Qualitative and quantitative responses were content analyzed into two approximate sets: those (1) impacted by baldness stigma versus (2) those resisting baldness stigma. (1) The former included about half who had internalized baldness stigma agreeing it was disadvantageous (44%) and reporting distress (39-45% e.g. "[I] dread the future"). Participants reported baldness was stigmatized structurally (68%; e.g. "[it's a] humiliating image") and were attempting to combat their baldness largely via "treatments" (57%). (2) The latter participant response set resisted baldness stigma by reporting minimal distress, and structural stigma whilst accepting baldness (33-61%). Psychosocial and evidence-based support is needed to help some men resist baldness stigmatization.

Occupational physical activity, mortality and CHD events in the Italian Longitudinal Study

Purpose

Several recent studies have suggested a ‘physical activity paradox’ whereby leisure-time physical activity benefits health, but occupational physical activity is harmful. However, other studies imply that occupational physical activity is beneficial. Using data from a nationally representative Italian sample, we investigate if the context, or domain, of physical activity matters for mortality and coronary heart disease (CHD) events.

Methods

Among 40,220 men and women aged 40–55 at baseline, we used Cox models to compare associations of occupational, domestic and leisure-time physical activity with risk of mortality and CHD events over a follow-up period of up to 14 years. We accounted for sociodemographic factors, smoking, body mass index (BMI), physical and mental health, and educational qualifications.

Results

Occupational physical activity was not significantly associated with risk of mortality or CHD events for women, or with CHD events for men. In crude models, risk of mortality was higher for men in the highest occupational activity group, compared to the lowest (HR 1.26, 95% CI 1.01, 1.57). This attenuated with adjustment for health-related behaviours, health, and education (HR 1.03, 95% CI 0.77, 1.38). In crude models, leisure-time physical activity was significantly associated with decreased mortality and CHD risk only for men. Domestic physical activity was not associated with either outcome for either gender.

Conclusion

In a large sample of middle-aged Italian workers, we found limited evidence of harmful or beneficial effects of occupational physical activity on mortality or CHD events. However, confidence intervals were wide, and results consistent with a range of effects in both directions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-021-01765-0.

How the Seven Countries Study contributed to the launch and development of cardiovascular epidemiology in Italy. A historical perspective

The Italian research group of the Seven Countries Study of Cardiovascular Diseases (SCS), through the independent use of the national cohorts and data, had the lucky opportunity, starting in the early 1960, to launch the Italian research in epidemiology of cardiovascular diseases (CVD). In this way, the Italian Section of that international study became the first investigation with baseline measurements in various cohorts, subsequent re-examinations, systematic search for morbid events, and follow-up for mortality up to 50 years. A large number of scientific aspects has been tackled including estimates of morbidity and mortality rates, the association of risk factors with cardiovascular events and total mortality, the role of risk factor changes, the use of multivariable models, the role of lifestyle behavior, the determinants of all-cause mortality including risk factors rarely measured in other studies, the identification of characteristics of a condition called Heart Disease of Uncertain Etiology (HDUE), the production of predictive tools for practical use and several other issues. All this has been enhanced by the availability of extremely long follow-up data rarely found in other studies. Field work organization, measurement techniques, diagnostic criteria, data handling and computing had the limitations and difficulties typical of those times, the mid of last century, when CVD epidemiology was at its beginning. All this represented anyhow the start of CVD epidemiology research in the country and was the stimulus to the start of other studies and a valuable collaboration with some of them.

Age at death in cohorts of middle-aged men followed-up until nearly extinction: the European areas of the Seven Countries Study

OBJECTIVES

To describe age at death (AD) in ten cohorts of middle-aged men followed-up until nearly extinction as a function of personal characteristics measured at baseline.

MATERIAL AND METHODS

Cohorts of men aged 40-59 years in five European countries (Finland, the Netherlands, Italy, Serbia, Greece) were examined and then followed-up for mortality during 45 (3 cohorts) or 50 years (7 cohorts). Multiple linear regression (MLR) models were computed with AD as dependent variable and 35 personal characteristics as independent variables.

RESULTS

Out of 7047 men, 6798 (96.5%) died in 45-50 years. Average AD was 74.4 (median 75) years. Only five variables were significant in all the five countries when tested by MLR. By pooling together all countries and selecting variables by a stepwise technique, 20 were significant (p < .05): age at entry examination, being married, being a never smoker or an ex-smoker (versus current smokers), forced expiratory volume, high socio-economic status, arm circumference, subscapular skinfold, having moderate or vigorous physical activity (all with a positive relationship with AD); father early mortality, laterality/linearity index, high systolic blood pressure, high serum cholesterol, having a major cardiovascular disease, diabetes or chronic bronchitis (these with a negative relationship), while body mass index, subdivided into four classes, showed a parabolic relationship (versus a reference class). Each factor was associated with a difference of months or a few years to AD, while their combinations were associated with several years of greater or smaller AD.

CONCLUSIONS

The availability of a relatively small number of risk factors measured in middle-aged men allows making rough estimates of AD as related to all-cause mortality during a follow-up of 50 years. AD is also a valuable metrics to describe past health in nearly extinct populations. Key messages We aimed at studying the age at death (AD) of middle-aged men of the European cohorts of the Seven Countries Study, followed-up 45-50 years until nearly extinction, as a function of personal characteristics measured at baseline. Multiple linear regression (MLR) models were computed with AD as dependent variable and 35 personal characteristics or risk factors as independent variables and only five were significant in all individual countries, whereas pooling together all countries, 20 variables were significant as selected by stepwise MLR. Each factor was associated with differences of months or a few years to AD, while their combinations were associated with several years of greater or smaller AD. AD is a valuable metrics to describe past health in nearly extinct populations: it might also be used to communicate years of life gained by preventive measures on modifiable variables.

Do highly physically active workers die early? A systematic review with meta-analysis of data from 193 696 participants

Objective

Recent evidence suggests the existence of a physical activity paradox, with beneficial health outcomes associated with leisure time physical activity, but detrimental health outcomes for those engaging in high level occupational physical activity. This is the first quantitative systematic review of evidence regarding the association between occupational physical activity and all-cause mortality.

Design

Systematic review with meta-analysis.

Data source

A literature search was performed in electronic databases PubMed, Embase, CINAHL, PsycINFO and Cochrane.

Eligibility criteria for selecting studies

We screened for peer reviewed articles from prospective studies assessing the association of occupational physical activity with all-cause mortality. A meta-analysis assessed the association of high (compared with low) level occupational physical activity with all-cause mortality, estimating pooled hazard ratios (HR) (with 95% CI).

Results

2490 unique articles were screened and 33 (from 26 studies) were included. Data from 17 studies (with 193 696 participants) were used in a meta-analysis, showing that men with high level occupational physical activity had an 18% increased risk of early mortality compared with those engaging in low level occupational physical activity (HR 1.18, 95% CI 1.05 to 1.34). No such association was observed among women, for whom instead a tendency for an inverse association was found (HR 0.90, 95% CI 0.80 to 1.01).

Conclusions

The results of this review indicate detrimental health consequences associated with high level occupational physical activity in men, even when adjusting for relevant factors (such as leisure time physical activity). These findings suggest that research and physical activity guidelines may differentiate between occupational and leisure time physical activity.

Behavioural Risk Factors in Mid-Life Associated with Successful Ageing, Disability, Dementia and Frailty in Later Life: A Rapid Systematic Review

BACKGROUND

Smoking, alcohol consumption, poor diet and low levels of physical activity significantly contribute to the burden of illness in developed countries. Whilst the links between specific and multiple risk behaviours and individual chronic conditions are well documented, the impact of these behaviours in mid-life across a range of later life outcomes has yet to be comprehensively assessed. This review aimed to provide an overview of behavioural risk factors in mid-life that are associated with successful ageing and the primary prevention or delay of disability, dementia, frailty and non-communicable chronic conditions.

METHODS

A literature search was conducted to identify cohort studies published in English since 2000 up to Dec 2014. Multivariate analyses and a minimum follow-up of five years were required for inclusion. Two reviewers screened titles, abstracts and papers independently. Studies were assessed for quality. Evidence was synthesised by mid-life behavioural risk for a range of late life outcomes.

FINDINGS

This search located 10,338 individual references, of which 164 are included in this review. Follow-up data ranged from five years to 36 years. Outcomes include dementia, frailty, disability and cardiovascular disease. There is consistent evidence of beneficial associations between mid-life physical activity, healthy ageing and disease outcomes. Across all populations studied there is consistent evidence that mid-life smoking has a detrimental effect on health. Evidence specific to alcohol consumption was mixed. Limited, but supportive, evidence was available relating specifically to mid-life diet, leisure and social activities or health inequalities.

CONCLUSIONS

There is consistent evidence of associations between mid-life behaviours and a range of late life outcomes. The promotion of physical activity, healthy diet and smoking cessation in all mid-life populations should be encouraged for successful ageing and the prevention of disability and chronic disease.

Lifestyle behaviour and lifetime incidence of heart diseases

OBJECTIVES

Investigate the relationship of some behavioural characteristics of a male population with lifetime incidence of heart diseases.

MATERIAL AND METHODS

In the Italian Rural Areas of the Seven Countries Study of Cardiovascular Diseases, 1677 heart disease-free men aged 40-59 years were followed up during 50 years for lifetime incidence of heart disease up to the age of 90 years. They were classified as coronary heart disease (CHD) and heart diseases of uncertain etiology (HDUE). Baseline cigarette smoking habits (non-smokers and ex-smokers, moderate smokers, heavy smokers), physical activity (sedentary, moderate, vigorous) and eating habits (non-Mediterranean Diet, Prudent Diet and Mediterranean Diet) were related to incidence of heart disease.

RESULTS

Incidence of CHD and HDUE up to the age of 90 years was 28.8 and 17.7%, respectively. Univariate and multivariate analyses showed strong association of behavioural characteristics with CHD incidence, but not with HDUE incidence. Cox proportional hazard rates for CHD were 1.45 (95% confidence intervals, CI: 1.11-1.90) for heavy smokers versus non-smokers; 0.67 (CI 0.50-0.89) for vigorous activity versus sedentary habits and 0.62 (CI 0.47-0.83) for Mediterranean Diet versus non-Mediterranean Diet. Combining CHD cases with HDUE cases made the predictive picture similar to that of CHD. When some basic risk factors were added to the model results remained substantially unaltered, despite the existence of some correlations of behaviours with risk factors.

CONCLUSIONS

Behavioural factors including cigarette smoking, physical activity and diet are strong predictors of lifetime incidence of common heart diseases even adding other traditional risk factors.

Is midlife occupational physical activity related to disability in old age? The SNAC-Kungsholmen study

Objectives

Leisure-time physical activity (PA) has been established to be related to more years lived without disability. However, less is known about the relationship between occupational PA and disability in old age. The aim of the study was 1) to investigate whether midlife occupational PA is related to late-life disability, and 2) to test the hypothesis that the association differs according to the occupational categories of blue and white collar work.

Methods

The study population was derived from the Swedish National Study on Aging and Care, and consisted of a random sample of 1804 subjects aged 72 and above. The association of occupational PA during the longest held occupation with disability in old age was determined using logistic regression.

Results

There was no significant relationship between occupational PA and disability in personal or instrumental activities of daily living (ADL) after controlling for demographic and health-related factors. However, in stratified analyses moderate levels of occupational PA was associated with a lower odds ratio of dependency in personal ADL amongst white collar workers, compared to low level of occupational PA (OR = 0.34 95% C1 0.12–0.98).

Conclusions

Moderate levels of midlife occupational PA were associated with a decreased risk of personal ADL disability in old age among white collar workers, but not among blue collar workers. Our results highlight the importance of encouraging white collar workers to engage in physical activity during or outside work hours.

Cardiovascular risk factors predict survival in middle-aged men during 50 years

OBJECTIVES

We aimed at studying the expectancy of life in middle-aged men as a function of several personal characteristics and risk factors.

MATERIAL AND METHODS

A sample of 1712 Italian men aged 40-59, first examined in 1960, was followed-up for mortality for 50 years. The length of survival was estimated as a function of 48 personal characteristics and risk factors using the multiple linear regression.

RESULTS

In 50 years 1672 men died (97.7%) and 40 survived (2.3%). Twenty risk factors, most of which were never measured in previous studies of such duration, proved to be significant, for the estimation of survival with an overall adjusted R(2) of 0.3236. They were: age, 4 anthropometric measurements (body mass index, and its squared term, laterality-linearity index, shoulder/pelvis shape), mean blood pressure, father and mother history of premature (<65-year) death, marital status, arm circumference, 2 respiratory measurements (vital capacity and forced expiratory volume), serum cholesterol, corneal arcus, xantelasma, cancer, cardiovascular diseases, diabetes and chronic bronchitis. Coefficients of 5 suitable risk factors became definitely larger after adjustment for regression dilution bias with 5 year data. All 40 cases of survival were located in the higher 5 deciles of estimated survival and 25 (62.5%) were in the upper decile.

CONCLUSION

A small number of risk factors and personal characteristics, mainly known as cardiovascular risk factors and measured once in middle-aged men, are strongly associated with the length of survival in a 50-year follow-up.

Artificial neural networks versus proportional hazards Cox models to predict 45-year all-cause mortality in the Italian Rural Areas of the Seven Countries Study

BACKGROUND

Projection pursuit regression, multilayer feed-forward networks, multivariate adaptive regression splines and trees (including survival trees) have challenged classic multivariable models such as the multiple logistic function, the proportional hazards life table Cox model (Cox), the Poisson's model, and the Weibull's life table model to perform multivariable predictions. However, only artificial neural networks (NN) have become popular in medical applications.

RESULTS

We compared several Cox versus NN models in predicting 45-year all-cause mortality (45-ACM) by 18 risk factors selected a priori: age; father life status; mother life status; family history of cardiovascular diseases; job-related physical activity; cigarette smoking; body mass index (linear and quadratic terms); arm circumference; mean blood pressure; heart rate; forced expiratory volume; serum cholesterol; corneal arcus; diagnoses of cardiovascular diseases, cancer and diabetes; minor ECG abnormalities at rest. Two Italian rural cohorts of the Seven Countries Study, made up of men aged 40 to 59 years, enrolled and first examined in 1960 in Italy. Cox models were estimated by: a) forcing all factors; b) a forward-; and c) a backward-stepwise procedure. Observed cases of deaths and of survivors were computed in decile classes of estimated risk. Forced and stepwise NN were run and compared by C-statistics (ROC analysis) with the Cox models. Out of 1591 men, 1447 died. Model global accuracies were extremely high by all methods (ROCs > 0.810) but there was no clear-cut superiority of any model to predict 45-ACM. The highest ROCs (> 0.838) were observed by NN. There were inter-model variations to select predictive covariates: whereas all models concurred to define the role of 10 covariates (mainly cardiovascular risk factors), family history, heart rate and minor ECG abnormalities were not contributors by Cox models but were so by forced NN. Forced expiratory volume and arm circumference (two protectors), were not selected by stepwise NN but were so by the Cox models.

CONCLUSIONS

There were similar global accuracies of NN versus Cox models to predict 45-ACM. NN detected specific predictive covariates having a common thread with physical fitness as related to job physical activity such as arm circumference and forced expiratory volume. Future attention should be concentrated on why NN versus Cox models detect different predictors.

Does physical activity increase life expectancy? A review of the literature

Physical activity reduces many major mortality risk factors including arterial hypertension, diabetes mellitus type 2, dyslipidemia, coronary heart disease, stroke, and cancer. All-cause mortality is decreased by about 30% to 35% in physically active as compared to inactive subjects. The purpose of this paper was to synthesize the literature on life expectancy in relation to physical activity. A systematic PubMed search on life expectancy in physically active and inactive individuals was performed. In addition, articles comparing life expectancy of athletes compared to that of nonathletes were reviewed. Results of 13 studies describing eight different cohorts suggest that regular physical activity is associated with an increase of life expectancy by 0.4 to 6.9 years. Eleven studies included confounding risk factors for mortality and revealed an increase in life expectancy by 0.4 to 4.2 years with regular physical activity. Eleven case control studies on life expectancy in former athletes revealed consistently greater life expectancy in aerobic endurance athletes but inconsistent results for other athletes. None of these studies considered confounding risk factors for mortality. In conclusion, while regular physical activity increases life expectancy, it remains unclear if high-intensity sports activities further increase life expectancy.

Determinants of 40-year all-cause mortality in the European cohorts of the Seven Countries Study

If a few risk factors had predictive power for all-cause mortality in different geographical-cultural areas, then preventive efforts might be concentrated on these. Thirteen potential risk factors were measured in 6,554 men aged 40-59 around 1960 in Northern, Southern and Eastern European areas of the Seven Countries Study. In 40 years 85.3% of men died in the pooled areas (87.9, 81.8 and 87.9% in Northern, Southern and Eastern Europe, respectively). Six risk factors were significant predictors of events in all three areas: directly for age, smoking habits, mean blood pressure, heart rate and ECG abnormalities; inversely for forced expiratory volume. In a pooled model also father and mother life status, socio-economic status, and arm circumference (the last one in an inverse way) had significant coefficients that were not heterogeneous across areas (except for socio-economic status). Serum cholesterol was around significance. ROC curves had values of 0.833, 0.806 and 0.819 respectively in Northern, Southern and Eastern Europe, and 0.827 in the pooled areas. Correlation coefficients between observed and expected cases in deciles of estimated risk were between 0.98 and 0.99. Survivors after 40 years in the lower half of the estimated risk were 10.7, 23.6 and 13.3% in Northern, Southern and Eastern Europe, respectively. Under- or over-estimate of cross-applying risk functions did not exceed 15%. All-cause mortality and survival in middle aged men during 40 years were strongly associated with a few, mainly cardiovascular, risk factors, whose predictive power was similar in different cultures across Europe.

Drosophila models of cardiac disease

The fruit fly Drosophila melanogaster has emerged as a useful model for cardiac diseases, both developmental abnormalities and adult functional impairment. Using the tools of both classical and molecular genetics, the study of the developing fly heart has been instrumental in identifying the major signaling events of cardiac field formation, cardiomyocyte specification, and the formation of the functioning heart tube. The larval stage of fly cardiac development has become an important model system for testing isolated preparations of living hearts for the effects of biological and pharmacological compounds on cardiac activity. Meanwhile, the recent development of effective techniques to study adult cardiac performance in the fly has opened new uses for the Drosophila model system. The fly system is now being used to study long-term alterations in adult performance caused by factors such as diet, exercise, and normal aging. The fly is a unique and valuable system for the study of such complex, long-term interactions, as it is the only invertebrate genetic model system with a working heart developmentally homologous to the vertebrate heart. Thus, the fly model combines the advantages of invertebrate genetics (such as large populations, facile molecular genetic techniques, and short lifespan) with physiological measurement techniques that allow meaningful comparisons with data from vertebrate model systems. As such, the fly model is well situated to make important contributions to the understanding of complicated interactions between environmental factors and genetics in the long-term regulation of cardiac performance.

Smoking offsets the metabolic benefits of parental longevity in women: the CoLaus study

OBJECTIVE

We evaluated whether subjects with long-lived parents show lower levels of cardiovascular risk factors, including the metabolic syndrome.

METHODS

We analyzed data from a Swiss population-based sample (1163 men and 1398 women) aged 55-75 years from Lausanne. Participants were stratified by number of parents (0, 1, 2) who survived to 85 years or more. The associations of parental longevity with cardiovascular risk factors and related metabolic variables were analyzed using multiple linear regressions.

RESULTS

Age-adjusted metabolic syndrome prevalence varied from 24.8%, 20.5% to 13.8% in women (P<0.05) and from 28.8%, 32.1% to 27.6% in men (not significant) with 0, 1 and 2 long-lived parents. The association between parental longevity and metabolic syndrome prevalence was particularly strong in women who had never smoked. In this group, women with 2 long-lived parents had lower Body Mass Index and smaller waist circumference. In never-smokers of both genders, mean (95% CI) adjusted High Density Lipoprotein-cholesterol levels were 1.64(1.61-1.67), 1.67(1.65-1.70) and 1.71(1.65-1.76) mmol/L for 0, 1 and 2 long-lived parents (P<0.01), respectively. The trend was not significant in former and current smokers.

CONCLUSIONS

In women, not in men, parental longevity is associated with a better metabolic profile. The metabolic benefits of having long-lived parents are offset by smoking.

Parental obesity and offspring serum alanine and aspartate aminotransferase levels: the Framingham heart study

BACKGROUND & AIMS

Obesity is an important correlate of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. We sought to examine the relations between parental obesity and the serum ALT and AST levels among offspring in a community-based sample.

METHODS

Participants (n = 1732) of the Framingham Offspring Study (50% women; mean age, 42 years) who had serum ALT and AST measurements and both parents in the original Framingham cohort were studied. Study participants were grouped into early-onset parental obesity (n = 193) (at least one parent obese), later-onset parental obesity (n = 460), and no parental obesity (n = 1079) subgroups. The association between elevated ALT or AST levels and parental obesity was tested using generalized estimating equations to account for familial correlations.

RESULTS

In multivariable analysis including adjustment for offspring obesity, significantly higher ALT levels were observed among individuals with paternal early-onset obesity as compared with those without paternal obesity (P = .02). Offspring with early-onset paternal obesity were more likely to have elevated ALT levels compared with those without paternal obesity (odds ratio, 1.75; 95% confidence interval, 1.06-2.89; P = .03). There was no association with elevated ALT levels among offspring with maternal early-onset obesity (odds ratio, 1.10; 95% confidence interval, 0.76-1.59; P = .61). There was no association between parental obesity and serum AST levels.

CONCLUSIONS

Early-onset paternal obesity, but not maternal obesity, increases the odds of elevated serum ALT levels in offspring, suggesting a predisposition to developing elevated serum ALT levels that may be mediated through familial early-onset obesity.