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Boersma GJ, Mijnster T, Vantyghem P, Kerkhof GA, Lancel M. Shift work is associated with extensively disordered sleep, especially when working nights. Front Psychiatry 2023; 14:1233640. [PMID: 38161719 PMCID: PMC10755475 DOI: 10.3389/fpsyt.2023.1233640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/17/2023] [Indexed: 01/03/2024] Open
Abstract
Background Shift work is generally associated with working and sleeping out of phase with the endogenous, circadian sleep-wake cycle. This exerts detrimental effects on sleep health. The present study aimed at evaluating the presence of short and long sleep as well as sleep disorders within a broad range of shift work schedules and elucidating the role of sociodemographic factors therein. Methods A large dataset containing information on sleep was collected through advertisement in a Belgium newspaper (De Standaard). Adult, working individuals were selected (n = 37,662) and categorized based on their work schedule (regular day, early morning, evening, night, and rotating shift). In this cross-sectional study, prevalence rates of short sleep (≤6 h), long sleep (≥9 h) and sleep disorders (screened with Holland Sleep Disorders Questionnaire), and associations between these sleep variables and sociodemographics (age, sex, education, living companion(s)) were analyzed using binominal logistic regression analyses. Results In the total sample all sociodemographic factors affected prevalences of short, long and disordered sleep, consistent with previous studies. Compared to day workers, shift workers more frequently reported short sleep, most prominently night workers (26 vs. 50%) (p < 0.001). Furthermore, all sleep disorders as well as sleep disorder comorbidity were more common in shift workers, again most pronounced in night workers (all p < 0.05). In night shift workers the level of education had the strongest associations with disturbed sleep with a two-fold higher prevalence of short and disordered sleep in low relative to academic educated groups (all p < 0.02). Conclusion Shift work is related not only to curtailed sleep and shift work disorder, but also to a plethora of sleep disorders, including insomnia, sleep-related breathing disorders and sleep-related movement disorders. Our findings imply that education on coping strategies may be especially important for young and/or lower educated shift workers.
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Affiliation(s)
- G. J. Boersma
- Forensic Psychiatric Hospital, GGZ Drenthe Mental Health Institute, Assen, Netherlands
| | - T. Mijnster
- Centre of Expertise on Sleep and Psychiatry, GGZ Drenthe Mental Health Institute, Assen, Netherlands
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands
| | - P. Vantyghem
- De Standaard (Daily Newspaper), Mediahuis, Brussels, Belgium
| | - G. A. Kerkhof
- Department of Psychology, University of Amsterdam, Amsterdam, Netherlands
- Sleep Disorders Center, Haaglanden Medical Center (HMC), The Hague, Netherlands
| | - Marike Lancel
- Forensic Psychiatric Hospital, GGZ Drenthe Mental Health Institute, Assen, Netherlands
- Centre of Expertise on Sleep and Psychiatry, GGZ Drenthe Mental Health Institute, Assen, Netherlands
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands
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Papantoniou K, Konrad P, Haghayegh S, Strohmaier S, Eliassen AH, Schernhammer E. Rotating Night Shift Work, Sleep, and Thyroid Cancer Risk in the Nurses' Health Study 2. Cancers (Basel) 2023; 15:5673. [PMID: 38067376 PMCID: PMC10705158 DOI: 10.3390/cancers15235673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 02/12/2024] Open
Abstract
Night shift work has been associated with breast, prostate, and colorectal cancer, but evidence on other types of cancer is limited. We prospectively evaluated the association of rotating night shift work, sleep duration, and sleep difficulty with thyroid cancer risk in the Nurses' Health Study 2 (NHS2). We assessed rotating night shift work duration (years) at baseline and throughout follow-up (1989-2015) and sleep characteristics in 2001. Cox proportional hazard models, adjusted for potential confounders, were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for (a) shift work duration, (b) sleep duration, and (c) difficulty falling or staying asleep. We stratified the analyses of night shift work by sleep duration and sleep difficulty. Over 26 years of follow-up, 588 incident cases were identified among 114,534 women in the NHS2 cohort. We observed no association between night shift work and the risk of thyroid cancer. Difficulty falling or staying asleep was suggestively associated with a higher incidence of thyroid cancer when reported sometimes (HR 1.26, 95% CI 0.95, 1.66) and all or most of the time (HR 1.35, 95% CI 1.00, 1.81). Night shift workers (10+ years) with sleep difficulty all or most of the time (HR 1.47; 0.58-3.73) or with >7 h of sleep duration (HR 2.17; 95% CI, 1.21-3.92) had a higher risk of thyroid cancer. We found modest evidence for an increased risk of thyroid cancer in relation to sleep difficulty, which was more pronounced among night shift workers.
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Affiliation(s)
- Kyriaki Papantoniou
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, 1090 Vienna, Austria; (P.K.); (S.S.); (E.S.)
| | - Peter Konrad
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, 1090 Vienna, Austria; (P.K.); (S.S.); (E.S.)
| | - Shahab Haghayegh
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA 02115, USA; (S.H.); (A.H.E.)
| | - Susanne Strohmaier
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, 1090 Vienna, Austria; (P.K.); (S.S.); (E.S.)
| | - A. Heather Eliassen
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA 02115, USA; (S.H.); (A.H.E.)
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Eva Schernhammer
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, 1090 Vienna, Austria; (P.K.); (S.S.); (E.S.)
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA 02115, USA; (S.H.); (A.H.E.)
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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Meal-timing patterns and chronic disease prevalence in two representative Austrian studies. Eur J Nutr 2023; 62:1879-1890. [PMID: 36864319 PMCID: PMC9980854 DOI: 10.1007/s00394-023-03113-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/07/2023] [Indexed: 03/04/2023]
Abstract
PURPOSE This study aimed at describing meal-timing patterns using cluster analysis and explore their association with sleep and chronic diseases, before and during COVID-19 mitigation measures in Austria. METHODS Information was collected in two surveys in 2017 (N = 1004) and 2020 (N = 1010) in representative samples of the Austrian population. Timing of main meals, nighttime fasting interval, last-meal-to-bed time, breakfast skipping and eating midpoint were calculated using self-reported information. Cluster analysis was applied to identify meal-timing clusters. Multivariable-adjusted logistic regression models were used to study the association of meal-timing clusters with prevalence of chronic insomnia, depression, diabetes, hypertension, obesity and self-rated bad health status. RESULTS In both surveys, median breakfast, lunch and dinner times on weekdays were 7:30, 12:30 and 18:30. One out of four participants skipped breakfast and the median number of eating occasions was 3 in both samples. We observed correlation between the different meal-timing variables. Cluster analysis resulted in the definition of two clusters in each sample (A17 and B17 in 2017, and A20 and B20 in 2020). Clusters A comprised most respondents, with fasting duration of 12-13 h and median eating midpoint between 13:00 and 13:30. Clusters B comprised participants reporting longer fasting intervals and later mealtimes, and a high proportion of breakfast skippers. Chronic insomnia, depression, obesity and self-rated bad health-status were more prevalent in clusters B. CONCLUSIONS Austrians reported long fasting intervals and low eating frequency. Meal-timing habits were similar before and during the COVID-19-pandemic. Besides individual characteristics of meal-timing, behavioural patterns need to be evaluated in chrono-nutrition epidemiological studies.
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Boivin DB, Boudreau P, Kosmadopoulos A. Disturbance of the Circadian System in Shift Work and Its Health Impact. J Biol Rhythms 2021; 37:3-28. [PMID: 34969316 PMCID: PMC8832572 DOI: 10.1177/07487304211064218] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The various non-standard schedules required of shift workers force abrupt changes in the timing of sleep and light-dark exposure. These changes result in disturbances of the endogenous circadian system and its misalignment with the environment. Simulated night-shift experiments and field-based studies with shift workers both indicate that the circadian system is resistant to adaptation from a day- to a night-oriented schedule, as determined by a lack of substantial phase shifts over multiple days in centrally controlled rhythms, such as those of melatonin and cortisol. There is evidence that disruption of the circadian system caused by night-shift work results not only in a misalignment between the circadian system and the external light-dark cycle, but also in a state of internal desynchronization between various levels of the circadian system. This is the case between rhythms controlled by the central circadian pacemaker and clock genes expression in tissues such as peripheral blood mononuclear cells, hair follicle cells, and oral mucosa cells. The disruptive effects of atypical work schedules extend beyond the expression profile of canonical circadian clock genes and affects other transcripts of the human genome. In general, after several days of living at night, most rhythmic transcripts in the human genome remain adjusted to a day-oriented schedule, with dampened group amplitudes. In contrast to circadian clock genes and rhythmic transcripts, metabolomics studies revealed that most metabolites shift by several hours when working nights, thus leading to their misalignment with the circadian system. Altogether, these circadian and sleep-wake disturbances emphasize the all-encompassing impact of night-shift work, and can contribute to the increased risk of various medical conditions. Here, we review the latest scientific evidence regarding the effects of atypical work schedules on the circadian system, sleep and alertness of shift-working populations, and discuss their potential clinical impacts.
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Affiliation(s)
- Diane B Boivin
- Centre for Study and Treatment of Circadian Rhythms, Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Philippe Boudreau
- Centre for Study and Treatment of Circadian Rhythms, Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Anastasi Kosmadopoulos
- Centre for Study and Treatment of Circadian Rhythms, Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, QC, Canada
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Jordakieva G, Markovic L, Rinner W, Santonja I, Lee S, Pilger A, Perkman T, Grabovac I, Schernhammer E, Crevenna R, Papantoniou K, Godnic-Cvar J. Workability, quality of life and cardiovascular risk markers in aging nightshift workers: a pilot study. Wien Klin Wochenschr 2021; 134:276-285. [PMID: 34487198 PMCID: PMC9023427 DOI: 10.1007/s00508-021-01928-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/21/2021] [Indexed: 12/27/2022]
Abstract
Background In aging healthcare professionals, multiple stressors such as night work may affect life and work satisfaction and risk for chronic diseases (e.g. cardiovascular disease [CVD]). In this pilot study we compared workability, quality of life (QoL), and CVD risk markers between night shift and day workers. Methods We included 70 hospital employees (mean age 52 ± 4 years, 91.4% female): 32 rotating night shift workers (> 3 nights/month) and 38 permanent day workers. In addition to sociodemographic, lifestyle, and sleep characteristics, we assessed i) workability index (WAI), ii) QoL (World Health Organization Quality of Life [WHOQOL-Bref]) and iii) CVD risk markers, i.e. carotid ultrasound measurements, and biomarkers (NTproBNP, CRP, IL‑6, LDL, ferritin, copper, zinc, and selenium). WAI, QoL, and CVD risk markers were compared between night and day workers. In a subgroup of participants (N = 38) with complete data, we used quantile regression analysis to estimate age and multivariate adjusted differences in biomarker levels. Results We found no differences in the domains of QoL (physical health, psychological, social relationships, and environment) and WAI scores between night and day workers. Night shift workers were less likely to report excellent workability than day workers, although differences were not statistically significant. Night shift workers reported more sleep problems (73.1% vs. 55.6%) and tended to have lower zinc levels and higher inflammatory markers (CRP, IL‑6, ferritin), but differences were not significant after adjusting for potential confounders. Conclusions Workability, QoL and CVD markers did not significantly differ between rotating night shift and day workers in this small pilot study. Sleep problems and inflammatory marker levels carry implications for occupational health. Supplementary Information The online version of this article (10.1007/s00508-021-01928-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Galateja Jordakieva
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Lovro Markovic
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Walter Rinner
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Isabel Santonja
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15, 1st floor, Vienna, Austria
- Center of Virology, Medical University Vienna, Vienna, Austria
| | - Seungjune Lee
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Alexander Pilger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Perkman
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Eva Schernhammer
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15, 1st floor, Vienna, Austria
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard, Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Richard Crevenna
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Kyriaki Papantoniou
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15, 1st floor, Vienna, Austria.
| | - Jasminka Godnic-Cvar
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria
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6
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Papantoniou K, Castaño-Vinyals G, Espinosa A, Turner MC, Martín-Sánchez V, Casabonne D, Aragonés N, Gómez-Acebo I, Ardanaz E, Jimenez-Moleon JJ, Amiano P, Molina-Barceló A, Alguacil J, Fernández-Tardón G, Huerta JM, Hernández-Segura N, Perez-Gomez B, Llorca J, Vidán-Alli J, Olmedo-Requena R, Gil L, Castañon-López C, Pollan M, Kogevinas M, Moreno V. Sleep duration and napping in relation to colorectal and gastric cancer in the MCC-Spain study. Sci Rep 2021; 11:11822. [PMID: 34083698 PMCID: PMC8175745 DOI: 10.1038/s41598-021-91275-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022] Open
Abstract
Sleep duration is a novel and potentially modifiable risk factor for cancer. We evaluated the association of self-reported sleep duration and daytime napping with odds of colorectal and gastric cancer. We included 2008 incident colorectal cancer cases, 542 gastric cancer cases and 3622 frequency-matched population controls, recruited in the MCC-Spain case-control study (2008-2013). Sleep information, socio-demographic and lifestyle characteristics were obtained through personal interviews. Multivariable adjusted logistic regression models were used to estimate odds ratios (OR) with 95% confidence intervals (CI) for cancer, across categories of sleep duration (≤ 5, 6, 7, 8, ≥ 9 hours/day), daytime napping frequency (naps/week) and duration (minutes/nap). Compared to 7 hours of sleep, long sleep was associated with increased odds of colorectal (OR≥9 hours: 1.59; 95%CI 1.30-1.94) and gastric cancer (OR≥9 hours: 1.95; 1.37-2.76); short sleep was associated with increased odds of gastric cancer (OR≤5 hours: 1.32; 0.93-1.88). Frequent and long daytime naps increased the odds of colorectal (OR6-7 naps/week, ≥30 min: 1.32; 1.14-1.54) and gastric cancer (OR6-7 naps/week, ≥30 min: 1.56; 1.21-2.02). Effects of short sleep and frequent long naps were stronger among participants with night shift-work history. Sleep and circadian disruption may jointly play a role in the etiology of colorectal and gastric cancer.
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Affiliation(s)
- Kyriaki Papantoniou
- Department of Epidemiology, Center of Public Health, Medical University of Vienna, Kinderspitalgasse 15, 1090, Vienna, Austria.
- ISGlobal, Barcelona, Spain.
| | - Gemma Castaño-Vinyals
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Ana Espinosa
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Michelle C Turner
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, ON, Canada
| | - Vicente Martín-Sánchez
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Biomedicine Institute (IBIOMED), University of León, Leon, Spain
| | - Delphine Casabonne
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Unit of Molecular and Genetic Epidemiology in Infections and Cancer (UNIC-Molecular), Cancer Epidemiology Research Programme, IDIBELL, Catalan Institute of Oncology, Hospitalet de Llobregat, Barcelona, Spain
| | - Nuria Aragonés
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Epidemiology Section, Public Health Division, Department of Health of Madrid, Madrid, Spain
| | - Inés Gómez-Acebo
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- University of Cantabria, Santander, Spain
- IDIVAL, Santander, Spain
| | - Eva Ardanaz
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Navarra Public Health Institute, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Jose-Juan Jimenez-Moleon
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
- Instituto de Investigacion Biosanitaria de Granada (Ibs.GRANADA), Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
| | - Pilar Amiano
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Public Health Division of Gipuzkoa, San Sebastian, Spain
- Biodonostia Research Institute, San Sebastian, Spain
| | | | - Juan Alguacil
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Centro de Investigación en Salud y Medio Ambiente (CYSMA), Universidad de Huelva, Campus Universitario de El Carmen, Huelva, Spain
| | - Guillermo Fernández-Tardón
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Health Research Institute of the Principality of Asturias, University of Oviedo, Oviedo, Spain
| | - José María Huerta
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain
| | | | - Beatriz Perez-Gomez
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Cancer Epidemiology Unit of the National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain
- Cancer Epidemiology Research Group, Oncology and Hematology Area, IIS Puerta de Hierro (IDIPHIM), Majadahonda, Madrid, Spain
| | - Javier Llorca
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- University of Cantabria, Santander, Spain
| | - Juana Vidán-Alli
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Navarra Public Health Institute, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Rocıo Olmedo-Requena
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
- Instituto de Investigacion Biosanitaria de Granada (Ibs.GRANADA), Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
| | - Leire Gil
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Public Health Division of Gipuzkoa, San Sebastian, Spain
- Biodonostia Research Institute, San Sebastian, Spain
| | | | - Marina Pollan
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Cancer Epidemiology Unit of the National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain
| | - Manolis Kogevinas
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Victor Moreno
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Unit of Biomarkers and Susceptibility, Oncology Data Analytics Program, Catalan Institute of Oncology (ICO), Hospitalet de Llobregat, Barcelona, Spain
- Colorectal Cancer Group, ONCOBELL Program, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, Faculty of Medicine, University of Barcelona, Barcelona, Spain
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