Cohort profile of the Young-HUNT Study, Norway: a population-based study of adolescents

Childhood trauma and the use of opioids and other prescription analgesics in adolescence and young adulthood: The HUNT Study

ABSTRACT

Opioid and nonopioid analgesics are commonly prescribed to young people to alleviate pain. Even short-term prescriptions increase the risk of persistent use and future misuse of potent analgesics, such as opioids. Childhood trauma exposure has been found to be related to pain conditions and to using more prescription analgesics. This large, prospective cohort study aimed to investigate the association of a broad range of childhood trauma exposures with prescription rates for opioid and nonopioid analgesics in adolescence and young adulthood. Self-reported data on childhood trauma exposures from adolescents (aged 13-19 years) who participated in the Young-HUNT3 Study (2006-2008, n = 8199) were linked to data from the Norwegian Prescription Database (NorPD, 2004-2021). We found that exposure to childhood trauma was consistently associated with higher prescription rates for opioids throughout adolescence and young adulthood. The highest incidence rate ratio (IRR) in adolescence was observed for sexual abuse (IRR 1.63, confidence interval [CI] 1.19-2.23). In young adulthood, the highest IRR was observed for physical violence (2.66, CI 2.27-3.12). The same overall pattern was observed for nonopioid analgesics. The more frequent prescriptions of opioid and nonopioid analgesics to participants exposed to childhood trauma suggests a higher symptom load of pain causing them to seek professional help with pain relief. Receiving potent analgesics is not without risk, and the likelihood of misuse may be elevated among trauma-exposed individuals. A trauma-informed approach to pain could be vital for guiding clinicians to the most effective and least harmful treatment for each patient.

Prevalence and risk factors of gastro-oesophageal reflux symptoms among adolescents, the HUNT study

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is recognized by symptoms of heartburn and acid regurgitation. These gastro-oesophageal reflux symptoms (GORS) are common in adults, but data from adolescents are sparse. This study aimed to assess the prevalence and risk factors of GORS among adolescents in a large and unselected population.

METHODS

This study was based on the Trøndelag Health Study (HUNT), a longitudinal series of population-based health surveys conducted in Nord-Trøndelag County, Norway. This study included data from Young-HUNT4 performed in 2017-2019, where all inhabitants aged 13-19 years were invited and 8066 (76.0%) participated. The presence of GORS (any or frequent) during the past 12 months and tobacco smoking status were reported through self-administrated questionnaires, whereas body mass index (BMI) was objectively measured.

RESULTS

Among 7620 participating adolescents reporting on the presence of GORS, the prevalence of any GORS and frequent GORS was 33.2% (95% confidence interval [CI] 32.2 - 34.3%) and 3.6% (95% CI 3.2 - 4.0%), respectively. The risk of frequent GORS was lower among boys compared to girls (OR 0.61; 95% CI 0.46 - 0.79), higher in current smokers compared to never smokers (OR 1.80; 95% CI 1.10 - 2.93) and higher among obese compared to underweight/normal weight adolescents (OR 2.50; 95% CI 1.70 - 3.66).

CONCLUSION

A considerable proportion of adolescents had GORS in this population-based study, particularly girls, tobacco smokers, and individuals with obesity, but frequent GORS was relatively uncommon. Measures to avoid tobacco smoking and obesity in adolescents may prevent GORS.

Prevalence of chronic and multisite pain in adolescents and young adults with ADHD: a comparative study between clinical and general population samples (the HUNT study)

Attention-deficit/hyperactivity disorder (ADHD) and chronic pain are prevalent and associated. We examined the prevalence and distribution of chronic pain in adolescents and young adults with ADHD using 9-years longitudinal data (from T1:2009-2011 to T3:2018-2019) with three time points from a clinical health survey compared to two age-matched reference population-based samples. Mixed-effect logistic regression and binary linear regression were used to estimate the probability for chronic and multisite pain at each time point and to compare the prevalence of chronic pain with the reference populations. The prevalence of chronic and multisite pain was high in those with ADHD, especially in female young adults, with highly prevalent chronic pain at 9 years of follow-up (75.9%) compared to 45.7% in females in the reference population. The probability of having pain was only statistically significant for chronic pain in males at 3 years of follow-up (41.9%, p = 0.021). Those with ADHD were at higher risk of reporting single-site and multisite pain compared to the general population at all measurement points. Longitudinal studies should be tailored to further understand the complex sex differences of comorbid chronic pain and ADHD in adolescents, exploring predictive factors of pain assessing long-term associations with bodyweight, psychiatric comorbidities, and possible mechanisms of stimulant use effects on pain.

Adolescent Social Anxiety, School Satisfaction, Family Emotional Support, and School Absenteeism: Findings from Young-HUNT3 and Norwegian National Education Data

Background: Adolescents grappling with social anxiety may experience poor school satisfaction, resorting to school-related avoidance behaviors, exemplified by absenteeism, as a coping mechanism. Understanding the role of family support in alleviating the adverse effects of social anxiety on school satisfaction is imperative for fostering supportive educational settings. Although there is literature regarding how school satisfaction promotes positive adolescent outcomes, empirical knowledge on the interrelation between social anxiety, school satisfaction, and family emotional support is limited. This study investigates the association between social anxiety, family emotional support, school satisfaction, and school absenteeism within the theoretical framework of the stage-environment fit theory to offer insight into how family emotional support can moderate the influence of social anxiety on school-related outcomes. Methods: Utilizing a population-based sample of 1861 upper secondary school pupils from the Trøndelag Young Health study "Young-HUNT3 study", we employed an index of moderated mediation to examine the role of family emotional support in moderating the association between social anxiety and school-related avoidance behavior related to school satisfaction. Results: Family emotional support had moderated mediation association for school absenteeism (β = 0.128, 95% CI 0.019, 0.278) and extracurricular activity (β = -0.003, 95% CI -0.008, -0.000). Conclusions: This urges further investigation into the specific mechanisms and individual differences influencing these relationships, aiming to deepen our understanding of adolescents' experiences and inform comprehensive strategies for promoting their well-being within school communities.

Secular trends in risk factors for adolescent anxiety and depression symptoms: the Young-HUNT studies 1995-2019, Norway

In recent decades, increases in mental health problems in adolescents have been reported from several large population-based surveys. This raises questions about changes in underlying risk and protective factors that can inform future intervention strategies. Population data were collected from 1995 to 2019 in three waves of the Young-HUNT studies in Norway to map decennial trends in the prevalence of established risk factors for, and their associations with, adolescent mental health problems. All adolescents (aged 13-19 years) attending lower and upper secondary school in the county of Trøndelag were invited, representing three historical cohorts of 25,245 unique adolescents. Mental health problems (HSCL-5) and established mental health risk factors were self-reported. Using a generalized linear model and linear regression, we calculated changes in relative and absolute differences between risk factors and mental health problems. Overall, the prevalence of established risk factors for mental health problems in adolescence increased markedly between 1995 and 2019, especially in girls. Prominent increases were observed for fatigue, bullying, musculoskeletal pain and migraine, loneliness, and overweight. Furthermore, with the exception of excess alcohol use and family economy, associations between each risk factor and adolescent mental health problems strengthened over the same time span in girls, but less among boys. Our findings suggest that several modifiable risk factors for poor mental health in adolescence are increasing, especially among girls, and should be targeted in community, school, and in clinical settings.

School completion and progression to higher education in adolescents with social anxiety: a linkage between Young-HUNT3 and national educational data (2008-2019), Norway

BACKGROUND

Social anxiety disorder (SAD) most commonly develops in adolescence-a period of life that includes a transition to upper secondary school. The aim of this study is to investigate the extent to which social anxiety in adolescence is associated with the completion of upper secondary school and progression to higher education.

METHODS

This longitudinal study includes 8,192 adolescents aged 13-19 years who participated in the Norwegian Young-HUNT 3 population-based study. Social anxiety is measured employing (1) diagnostic interview screening questions (interview) and (2) a self-reported symptom index (questionnaire). Notably, we define the cohorts based on these two methods. Using national educational data (2008-2019), we follow educational attainment among the cohorts until they turn 25 years of age.

RESULTS

We found that adolescents who screened positive (SP) for SAD had a predicted probability of upper secondary school completion at 21 years of age that was 14% points lower than those who screened negative (SN). Further, differences remained when looking at completion rates at age 25 years. Moreover, predicted probabilities for completion were inversely associated with increasing levels of self-reported social anxiety symptoms. Similarly, the proportion of the completers of an academic program in the SP group that were enrolled in higher education by 25 years of age, were lower than for the SN group (87 vs. 92%).

CONCLUSION

Social anxiety in adolescence, both self-reported symptoms and diagnostic screening, has long-term negative impact on upper secondary school completion and to some extent enrollment to higher education.

An online survey on clinical and healthy individuals with auditory verbal hallucinations: Abuse did not lead to more negative voice content

Despite the clinical and theoretical importance of the negative content in auditory verbal hallucinations (AVHs), little research has been conducted on the topic. A handful of studies suggest that trauma or adverse life events contribute to negative content. The findings are somewhat inconsistent, however, possibly due to methodological limitations. Moreover, only trauma occurring in childhood has been investigated so far. In the present study, we studied the effect of abuse, experienced in either child- or adulthood, and clinical status on negative content of AVHs in four groups of participants that were assessed as part of a large, previously published online survey: Individuals with a psychotic disorder and AVHs (total n = 33), who had experienced abuse (n = 21) or not (n = 12) as well as a group of healthy individuals with AVHs (total n = 53), who had experienced abuse (n = 31) or not (n = 22). We hypothesized that having experienced abuse was associated with a higher degree of negative content. The clinical group collectively reported significantly higher degrees of negative AVHs content compared to the healthy group, but there was no effect of abuse on the degree of negative AVHs content. The presence of AVHs was more common amongst individuals who reported a history of abuse compared to individuals with no history of abuse, both in clinical and healthy participants with AVHs. This implies that at group level, being subjected to traumatic events increases an individual's vulnerability to experiencing AVHs. However, it does not necessarily account for negative content in AVHs.

Adverse Childhood Experiences Are Associated With Personality Disorder: A Prospective, Longitudinal Study

There is a lack of studies that have prospectively examined adverse childhood experiences (ACEs) in association with a personality disorder (PD). Data from a sample of 8,199 adolescents first assessed for ACEs were linked with subsequent data from the Norwegian Patient Register in order to obtain diagnoses of a PD in adulthood (after a 14-year follow-up). We used logistic regression analysis. Any type of ACE gave a 3.8-fold higher risk of developing a PD. Abuse, more specifically emotional abuse, came out as one of the strongest predictors. Of the adolescents who developed a PD, approximately 90% had a history of ACE. The results of this study support the importance of assessing ACEs, such as abuse, neglect, and household dysfunction, in the diagnostic procedure and treatment for PD.

Loneliness in the Norwegian adolescent population: prevalence trends and relations to mental and self-rated health

BACKGROUND

Loneliness has become a significant public health problem and should be addressed with more research over a broader period. This study investigates the variations in the prevalence of loneliness among a nationally representative study population of Norwegian adolescents over the last three decades and whether age, gender, self-rated health, and mental distress are associated with these changes.

METHODS

Adolescents aged 13-19 years completed the structured and validated questionnaires from the three waves of the Young-HUNT Study: 1995-1997, 2006-2008, and 2017-2019. Loneliness was measured with one item asking, 'Are you lonely?'. Hopkins Symptom Checklist-5 was used to measure mental distress (cut-off ≥ 2). Self-rated health was assessed by a single question 'How is your health at the moment?' Measures were provided by self-report. Descriptive analyses were stratified by age, gender, self-rated health, and mental distress. Linear-by-Linear association test across survey years was performed to test time trends of loneliness. Logistic regression was used to analyze the cross-sectional associations of self-rated health and mental distress with loneliness, adjusting for sociodemographic factors in all three waves of Young-HUNT.

RESULTS

Loneliness prevalence doubled from 5.9% in 1995/97 to 10.2% in 2017/19 in the total population sample. The highest loneliness prevalence and an increase from 8.9% in 1995/97 to 16.7% in 2017/19 was observed in girls of 16-19 years. Among mentally distressed adolescents, loneliness increased from 22.3% in 1995/97 to 32.8% in 2006/08 and lowered to 27% in 2017/19. Increasing loneliness prevalence was seen in those with poor self-rated health, i.e., 14.6% in 1995-97 and 26.6% in 2017-19. Mental distress and poor self-rated health were associated with higher odds of loneliness in each wave (p < 0.001).

CONCLUSION

The results highlight the increasing burden of loneliness in the Norwegian adolescent population, especially girls. Those with mental distress and poor self-rated health have a higher risk of experiencing loneliness. Thus, health-promoting upbringing environments for children and adolescents that support mutual affinity, social support, integration, and belongingness in adolescents' daily arenas are essential.

Associations of adverse childhood experiences with caries and toothbrushing in adolescents. The Young-HUNT4 Survey

BACKGROUND

Adverse childhood experiences (ACEs) are associated with poor oral health. Using a life course theoretical framework, this study explored the associations of specific and cumulative ACEs with caries and toothbrushing frequency in a Norwegian adolescent population.

METHODS

Participants were adolescents (n = 6351) age 13-17 years from The Young-HUNT4 Survey. Clinical data were retrieved from dental health records. Oral health outcomes were toothbrushing frequency, dentine caries experience (Decayed, Missing, and Filled Teeth - DMFT), and enamel caries. ACE exposure variables were physical abuse, sexual abuse, witness to violence, parental separation/divorce, parental alcohol problems, and bully victimization. Negative binominal regression models (incident rate ratios, IRRs; 95% confidence intervals, CIs) were used to determine the associations of the various ACEs with caries; logistic regression analyses (odds ratios, ORs; 95% CIs) were used to estimate associations with toothbrushing frequency. Potential effect modification by age was assessed using likelihood ratio test.

RESULTS

Adolescents exposed to physical abuse by others, sexual abuse by peers, parental separation/divorce, bullying, or who had witnessed violence, were more likely to report non-daily toothbrushing compared with those with no exposure to the given ACEs. Each cumulative increase in ACE exposure was associated with a 30% higher likelihood of non-daily toothbrushing (OR 1.30, 95% CI 1.19-1.42). Similarly, increasing number of adversities were associated with both higher dentine caries experience (IRR 1.06, 95% CI 1.02-1.09) and higher enamel caries (IRR 1.07, 95% CI 1.03-1.11). This effect was modified by age (13-15 vs. 16-17 years) for dentine caries experience. Furthermore, there was evidence of effect modification by age with bully victimization for both toothbrushing frequency (Pinteraction = 0.014) and dentine caries experience (Pinteraction < 0.001). Specifically, bully victimization was associated with a higher likelihood of non-daily toothbrushing (OR 2.59, 95% CI 1.80-3.72) and higher dentine caries experience (IRR 1.30, 95% CI 1.14-1.50) among 16-17-year-olds.

CONCLUSIONS

Several specific ACEs were associated with non-daily toothbrushing and a higher caries experience among Norwegian adolescents in the Young-HUNT4 Survey.

Change Over 11-13 Year Periods in Quality of Life, Emotional Problems and Negative Stressful Life Events Among 13-17 Year Old Students

Studies investigating changes in the general population over time concerning adolescent self-reported Quality of life (QoL) are sparse. The aim of this study is to investigate stability and change over more than a decade in self-reported QoL, emotional problems, and negative stressful life-events among students. Three large cross-sectional samples (N = 1032, 4744 and 3826) of 13-17-year-old adolescents attending public school in the Norwegian County of Trøndelag provide data, one from 2017 to 2019 and two from 11 and 13 years earlier. We analyzed linear and binary linear regression adjusted for age. We found few indications of large changes in overall QoL. The exception was a 50% increase in reported emotional problems in both girls and boys. Girls also reported an increase of sexually uncomfortable/abusive acts from peers from 3.7 to 7.0%. The observed changes must be addressed through public health interventions targeting school as an important arena.

Problematic alcohol use in young adults exposed to childhood trauma: The Trøndelag Health (HUNT) Study

Problematic alcohol use (PAU) severely impacts the health, functioning, and long-term prospects of young people. Prior research indicates that childhood trauma exposure may be an important risk factor for PAU, but few longitudinal studies have looked at how specific trauma types influence this risk. The aim of this study was to investigate the association between childhood trauma exposure and PAU in a large, population-based cohort of young people. The study sample included 1,913 adolescents who participated in the Trøndelag Health Study (HUNT) between 2006 and 2008 (age range: 12-20) and completed follow-up 10 years later as young adults (age range: 22-32). The results revealed an increased risk of PAU in young adults exposed to childhood trauma, especially direct physical violence, OR = 2.38, [95% CI 1.56, 3.64]. Young adults who had witnessed violence, OR = 1.55, [95% CI 1.11, 2.17], or experienced an accident, disaster, or other traumatic event, OR = 1.60, [95% CI 1.19, 2.15], also had higher odds of PAU compared to those without such experiences. These associations remained consistent after adjusting for symptoms of headaches and pain as well as posttraumatic and general psychological distress as reported by the participants in adolescence. Future prevention efforts targeting PAU among adolescents and young adults should address violence and other trauma exposure as potential drivers of problematic drinking.

Trends in social inequality and how mental wellbeing vary and covary among Norwegian adolescents and their families: the Young-HUNT Study

BACKGROUND

The study had two aims: first, to investigate trends in socioeconomic inequalities in psychological distress and loneliness among Norwegian adolescents, and second, to study variation and covariation of psychological distress and loneliness within adolescents and between siblings within families.

METHODS

Multivariate mixed models were used to investigate trends in socioeconomic inequality in psychological distress and loneliness using three separate cohorts of Norwegian adolescents from the Young-HUNT study conducted in 1995-1997 (Young-HUNT1, n = 8980), 2006-2008 (Young-HUNT3, n = 8199) and 2017-2019 (Young-HUNT4, n = 8066). Register data on parental education level was used as a marker of socioeconomic position (SEP), and a unique family number was used to identify adolescents belonging to the same family. A three-level multivariate mixed model was created, consisting of the outcomes at level 1, adolescents at level 2 and families at level 3.

RESULTS

No statistically significant difference in scores on loneliness and psychological distress was observed between low and high parental education level in Young-HUNT1, whereas in Young-HUNT4, low parental education level was associated with a higher score on both psychological distress (β = 0.09; 95% confidence interval (CI), 0.03-0.14) and loneliness (β = 0.12; 95% CI 0.07-0.17). Analyses of covariation between psychological distress and loneliness showed that they were correlated within adolescents and strongly correlated within families across all timepoints.

CONCLUSIONS

Increasing socioeconomic inequalities in psychological distress and loneliness among Norwegian adolescents is worrisome. Further, the family seems to be an important arena for potential prevention of psychological distress and loneliness among adolescents, regardless of parental education level.

Killing pain? A prospective population-based study on trauma exposure in childhood as predictor for frequent use of over-the-counter analgesics in young adulthood. The HUNT study

Frequent and increasing use of over-the-counter analgesics (OTCA) is a public health concern. Pain conditions and psychological distress are related to frequent OTCA use, and as exposure to potentially traumatic events (PTE) in childhood appears to increase risk of experiencing such symptoms, we aimed to assess childhood PTEs and related symptoms in adolescence as predictors for frequent OTCA use in young adulthood. Prospective population survey data were used (n = 2947, 59.1% female, 10-13 years follow-up). Exposure to PTEs, symptoms of post-traumatic stress, anxiety and depression, musculoskeletal pain and headache were assessed in adolescence (13-19 years). Use of OTCA was assessed in young adulthood (22-32 years) and use of OTCA to treat musculoskeletal pain and headache served as separate outcomes in ordinal logistic regression analyses. Overall, exposure to childhood PTEs, particularly direct interpersonal violence, was significantly and consistently related to more frequent use of OTCA to treat musculoskeletal pain and headaches in young adulthood. Adjusting for psychological symptoms and pain attenuated associations, indicating that these symptoms are of importance for the relationship between traumatic events and OTCA use. These findings emphasize the need to address symptomatology and underlying causes at an early age.

Parental drinking, mental health and educational level, and offspring's subsequent prescription drugs treatment for sleep problems. A longitudinal HUNT survey and registry study

BACKGROUND

Parental drinking, mental health and family socioeconomic status are all associated with offspring sleep problems, but there is a paucity of research that considers the effect of risk factors, as they co-occur within and across families. Also, sleep problems are closely linked with mental health problems. Disentangling the effects on one or the other are important. We examined whether parental risk constellations are differently associated with offspring's subsequent prescription drug use for sleep problems during nine years with or without prescription drug use for anxiety and/or depression.

METHODS

The sample included 8773 adolescent offspring of 6696 two-parent families who participated in the Nord-Trøndelag Health Study in Norway. The exposures were five parental risk constellations, previously identified via Latent Profile Analysis, characterized by drinking frequencies and quantities, mental health, and years of education. The outcomes were dispensed prescription drugs in offspring during 2008-2016 for (a) only sleep problems (b) sleep problems and anxiety/depression or (c) only anxiety/depression. We used multinomial logistic regression to model the odds of the outcomes.

RESULTS

Compared to the overall low-risk parental constellation, none of the risky constellations were significantly associated with increased risk of being dispensed prescription drugs only for sleep problems. Offspring from two different risk profiles were at increased risk for being dispensed both sleep and anxiety/depression prescription drugs. These were parental profiles marked by (1) low education, symptoms of mental health problems and weekly binge drinking in both parents (OR 1.90, CI = 1.06;3.42); and (2) frequent heavy drinking in both parents and symptoms of mental health problems in fathers (OR 3.32, CI = 1.49;7.39). Offspring from the risk profile with lowest parental education had increased risk of only anxiety/depression prescription drugs (OR 1.25, CI = 1.05;1.49).

CONCLUSION

Our findings suggest that parental risk constellations are not associated with increased risk of offspring receiving sleep medications without also receiving anxiety/depression medications, as two risk constellations were associated with increased risk of dispensation of both sleep and anxiety/depression prescription drugs. Receiving both may be an indication of severity. The findings underscore the importance of including measures of mental health problems when investigating sleep problems to avoid misattribution of effects.

Rare variant analyses in large-scale cohorts identified SLC13A1 associated with chronic pain

ABSTRACT

Chronic pain is a prevalent disease with increasing clinical challenges. Genome-wide association studies in chronic pain patients have identified hundreds of common pathogenic variants, yet they only explained a portion of individual variance of chronic pain. With the advances in next-generation sequencing technologies, it is now feasible to conduct rarer variants studies in large-scale databases. Here, we performed gene-based rare variant analyses in 200,000 human subjects in the UK biobank whole-exome sequencing database for investigating 9 different chronic pain states and validated our findings in 3 other large-scale databases. Our analyses identified the SLC13A1 gene coding for sodium/sulfate symporter associated with chronic back pain and multisite pain at the genome-wide level and with chronic headache, knee, and neck and shoulder pain at the nominal level. Seven loss-of-function rare variants were identified within the gene locus potentially contributing to the development of chronic pain, with 2 of them individually associated with back pain and multisite pain. These 2 rare variants were then tested for replication in 3 other biobanks, and the strongest evidence was found for rs28364172 as an individual contributor. Transcriptional analyses of Slc13a1 in rodents showed substantial regulation of its expression in the dorsal root ganglia and the sciatic nerve in neuropathic pain assays. Our results stress the importance of the SLC13A1 gene in sulfate homeostasis in the nervous system and its critical role in preventing pain states, thus suggesting new therapeutic approaches for treating chronic pain in a personalized manner, especially in people with mutations in the SLC13A1 gene.

Adverse childhood experiences and their association with substance use disorders in adulthood: a general population study (Young-HUNT)

Aim

To investigate the association of adverse childhood experiences (ACEs) and substance use disorders (alcohol and illicit drug use disorders), specifically by gender, in a large longitudinal non-clinical population study.

Methods

Data from 8199 adolescents, first assessed for ACE (2006-2008), were linked with subsequent data from the Norwegian Patient Register to obtain diagnoses of a substance use disorder in adulthood (after 12-14 years' follow-up in March 2020). This study used logistic regression analysis to assess the associations between ACEs and substance use disorders with respect to gender.

Results

Adults with any history of ACEs have a 4.3-fold higher likelihood of developing a substance use disorder. Female adults had a 5.9-fold higher likelihood of developing an alcohol use disorder. Emotional neglect, sexual abuse and physical abuse were the strongest individual ACE predictors for this association. Male adults had a 5.0-fold higher likelihood of developing an illicit drug use disorder (for example stimulants such as cocaine, inhibiter such as opioids, cannabinoids and multiple drugs). Physical abuse, parental divorce and witnessed violence were the strongest individual ACE predictors for this association.

Conclusions

This study reinforces the association between ACEs and substance use disorders and exposes a gender-specific pattern. Increased attention should be paid to the meaning of individual ACEs as well as to the accumulation of ACEs in the development of a substance use disorder.

Using Genomic Structural Equation Modeling to Partition the Genetic Covariance Between Birthweight and Cardiometabolic Risk Factors into Maternal and Offspring Components in the Norwegian HUNT Study

The Barker Hypothesis posits that adverse intrauterine environments result in fetal growth restriction and increased risk of cardiometabolic disease through developmental compensations. Here we introduce a new statistical model using the genomic SEM software that is capable of simultaneously partitioning the genetic covariation between birthweight and cardiometabolic traits into maternally mediated and offspring mediated contributions. We model the covariance between birthweight and later life outcomes, such as blood pressure, non-fasting glucose, blood lipids and body mass index in the Norwegian HUNT study, consisting of 15,261 mother-eldest offspring pairs with genetic and phenotypic data. Application of this model showed some evidence for maternally mediated effects of systolic blood pressure on offspring birthweight, and pleiotropy between birthweight and non-fasting glucose mediated through the offspring genome. This underscores the importance of genetic links between birthweight and cardiometabolic phenotypes and offer alternative explanations to environmentally based hypotheses for the phenotypic correlation between these variables.

Musculoskeletal pain is not clearly associated with the risk of anterior cruciate ligament reconstruction in adolescents

Objectives

The purpose of this study was to investigate whether self-reported musculoskeletal pain (MSP) was associated with a future anterior cruciate ligament reconstruction (ACLR).

Methods

In this population-based prospective cohort study, we included 8087 participants from the adolescent part of the Trøndelag Health Study (Young-HUNT) in Norway. The exposure was self-reported MSP from the Young-HUNT3 study (2006-2008), which was categorised into two MSP load groups (high MSP and low MSP) based on frequency and number of pain sites. The outcome was ACLRs recorded in the Norwegian Knee Ligament Register between 2006 and 2019. Logistic regression was used to investigate association between MSP load and ACLR, given as ORs with 95% CIs. All tests were two-sided and p values of ≤0.05 were considered statistically significant.

Results

8087 adolescents were included. We identified a total of 99 ACLRs, with 6 ACLRs (0.9%) in adolescents who reported high MSP load and 93 ACLRs (1.3%) among those who reported low MSP load. Adolescents reporting high MSP load had 23% lower odds of an ACLR (OR 0.77, 95% CI 0.31 to 1.91) compared with adolescents with low MSP load. However, the CIs were very wide.

Conclusion

Self-reported high MSP load in adolescents was not associated with increased risk of future ACLR. Although the number of participants was high, the relatively few cases of ACLR mean that we cannot be conclusive about the presence or absence of an association.

The HUNT study: A population-based cohort for genetic research

The Trøndelag Health Study (HUNT) is a population-based cohort of ∼229,000 individuals recruited in four waves beginning in 1984 in Trøndelag County, Norway. Approximately 88,000 of these individuals have available genetic data from array genotyping. HUNT participants were recruited during four community-based recruitment waves and provided information on health-related behaviors, self-reported diagnoses, family history of disease, and underwent physical examinations. Linkage via the Norwegian personal identification number integrates digitized health care information from doctor visits and national health registries including death, cancer and prescription registries. Genome-wide association studies of HUNT participants have provided insights into the mechanism of cardiovascular, metabolic, osteoporotic, and liver-related diseases, among others. Unique features of this cohort that facilitate research include nearly 40 years of longitudinal follow-up in a motivated and well-educated population, family data, comprehensive phenotyping, and broad availability of DNA, RNA, urine, fecal, plasma, and serum samples.

HUNT for better public health

Aims:

The Trøndelag Health Study (HUNT) has collected population data through comprehensive decennial surveys over the last four decades and has so far collected data from 240,000 participants. The participants are identified with the unique Norwegian birth number, which enables them to be followed throughout different life stages, from survey to survey, and to endpoint measures in Norwegian national health registers without attrition bias.

Methods:

The study design of HUNT offers several advantages: it provides an overview of the public health development in the population over decades, the data can be used in health services research, clinical epidemiology, studies of causation, trajectories, and consequences of diseases, and to study gene × environment interactions.

Results:

HUNT data have shown major shifts in public health trends, such as decreasing mean blood pressure and resting heart rate among adults, increasing prevalence of obesity, geographical and socioeconomic inequalities in health, increasing mental health distress among adolescents and young adults with an opposite development among the elderly. Data from HUNT have been used in several major international research projects, where data harmonization with several other population cohorts internationally has been done. HUNT has placed great emphasis on safeguarding research ethics, privacy, and data security. The Norwegian authorities established national regulations for the surveys from the time General Data Protection Regulation was introduced in 2018.

Conclusions:

Researchers can apply for HUNT data access from HUNT Research Centre provided they have obtained project approval from the Regional Committee for Medical and Health Research Ethics. Researchers not affiliated to a Norwegian research institution must collaborate with and apply through a Norwegian principal investigator. Information on the application and conditions for data access is available at www.ntnu.edu/hunt/data.

Lifestyle behaviour in adolescence and musculoskeletal pain 11 years later: The Trøndelag Health Study

Background

There is limited knowledge on the association between lifestyle behaviour in adolescence and musculoskeletal pain in young adulthood. This study aimed to investigate whether an accumulation of adverse lifestyle behaviours in adolescents with and without musculoskeletal pain at baseline, was associated with persistent musculoskeletal pain (pain duration ≥3 consecutive months the last year) 11 years later.

Methods

Longitudinal data from the Trøndelag Health Study in Norway including 1824 adolescents (13–19 years old) was analysed. The outcome was persistent musculoskeletal pain (≥3 months). The number of adverse lifestyle behaviours (low physical activity level, sleep problems, insufficient fruit/vegetables consumption, smoking, frequent alcohol intoxication [drunkenness] and/or illicit drug use) were summed up to comprise an ordinal variable and analysed with 0 or 1 adverse behaviours as the reference. Multiple logistic regression analyses, stratified by individuals with and without baseline musculoskeletal pain, were conducted. The results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

In adolescents with musculoskeletal pain at baseline, reporting ≥ four adverse lifestyle behaviours increased the odds of persistent musculoskeletal pain (OR 2.23, 95% CI 1.36, 3.66) 11 years later. Two and three adverse behaviours were not associated with future persistent musculoskeletal pain. In adolescents without musculoskeletal pain at baseline, an accumulation of adverse lifestyle behaviours was not associated with future persistent musculoskeletal pain.

Conclusion

An accumulation of adverse lifestyle behaviours in adolescents with musculoskeletal pain at baseline was associated with persistent musculoskeletal pain 11 years later, but not in adolescents without musculoskeletal pain at baseline.

Significance

An accumulation of four or more adverse lifestyle behaviours in adolescents with musculoskeletal pain was associated with persistent musculoskeletal pain in young adulthood. In future health care of adolescents with musculoskeletal pain, lifestyle behaviours should be assessed, with emphasis on accumulation of multiple adverse lifestyle behaviours. Focusing on an accumulation of multiple adverse lifestyle behaviours, rather than each individual behaviour, might provide a potential area for future research and interventions targeting musculoskeletal pain in youth.

Divergent decennial trends in mental health according to age reveal poorer mental health for young people: repeated cross-sectional population-based surveys from the HUNT Study, Norway

OBJECTIVES

Public health trends are formed by political, economic, historical and cultural factors in society. The aim of this paper was to describe overall changes in mental health among adolescents and adults in a Norwegian population over the three last decades and discuss some potential explanations for these changes.

DESIGN

Repeated population-based health surveys to monitor decennial changes.

SETTING

Data from three cross-sectional surveys in 1995-1997, 2006-2008 and 2017-2019 in the population-based HUNT Study in Norway were used.

PARTICIPANTS

The general population in a Norwegian county covering participants aged 13-79 years, ranging from 48 000 to 62 000 000 in each survey.

MAIN OUTCOME MEASURES

Prevalence estimates of subjective anxiety and depression symptoms stratified by age and gender were assessed using the Hopkins Symptom Checklist-5 for adolescents and the Hospital Anxiety and Depression Scale for adults.

RESULTS

Adolescents' and young adults' mental distress increased sharply, especially between 2006-2008 and 2017-2019. However, depressive symptoms instead declined among adults aged 60 and over and anxiety symptoms remained largely unchanged in these groups.

CONCLUSIONS

Our trend data from the HUNT Study in Norway indicate poorer mental health among adolescents and young adults that we suggest are related to relevant changes in young people's living conditions and behaviour, including the increased influence of screen-based media.

Cross-sectional study of BMI, weight concern, body size perception, dieting and mental distress in adolescents: The HUNT Study

OBJECTIVE

We examined the associations between body mass index (BMI), weight concern, body size perception, dieting and mental distress in a population-based study of 7350 adolescents.

DESIGN

Cross-sectional.

SETTINGS

Data from a Norwegian population-based cohort, The Young-HUNT3 (2006-2008) from the county of Nord-Trøndelag, Norway.

PARTICIPANTS

A total of 7350 adolescents (13-19 years) who had both self-reported questionnaire data and anthropometric measures.

PRIMARY OUTCOME MEASURES

Odds for mental distress given sex, BMI, weight concern, body size perception and dieting. Analyses were performed in binomial logistic regression models.

RESULTS

Compared with being overweight/obese, having weight concern, irrespective of BMI, was associated with higher OR for mental distress (MD) among boys and girls. Body size overestimation was associated with an increase in the OR for MD, in participants who were overweight/obese, had weight concern or dieted. This effect was more pronounced in boys.

CONCLUSIONS

Weight concern and body-size estimation are strongly associated with mental health in adolescent boys and girls. Routine assessment of adolescents' attitudes towards their weight and body size is advised.

Social anxiety disorder in adolescents: Prevalence and subtypes in the Young-HUNT3 study

BACKGROUND

Few studies have examined the prevalence of social anxiety disorder (SAD) among adolescents and the associated sex-specific fears. No previous studies have reported variance in SAD prevalence among adolescents based on a stepwise diagnostic approach.

METHODS

Using various diagnostic thresholds from the Anxiety Disorders Interview Schedule child version, and the diagnostic criteria from both the 4th and 5th editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), we explored the point prevalence of SAD among a population-based sample of 8216 adolescents aged 13-19 years.

RESULTS

Overall, 2.6% of adolescents met the SAD diagnostic criteria. The prevalence varied from 2.0% to 5.7% depending on the criteria-set. Twice as many females met the overall SAD criteria. The DSM-IV generalized SAD subtype was assigned to 86.5% of the sample, while 3.5% met the DSM-5 performance-only subtype. Compared with males aged 16-19 years, significantly more of those aged 13-15 years met the SAD criteria; no significant age group differences were found among females.

CONCLUSIONS

This is the first study to demonstrate variance in SAD prevalence among adolescents based on the diagnostic threshold method. Depending on the threshold applied, SAD prevalence among adolescents varied from 2.0% to 5.7%. Age and sex differences in social fear experiences highlight the importance of considering developmental heterogeneity in SAD, especially for adapting prevention and treatment interventions.

Parental binge drinking and offspring's high school non-completion: A prospective HUNT survey and educational registry study

BACKGROUND

Alcohol-use disorders (AUD) in parents are associated with adverse outcomes in offspring. It is less known whether other forms of parental drinking such as binge drinking may also be a risk factor for offspring's outcomes -- specifically, high school non-completion.

METHODS

These questions were examined in a sample of 3101 offspring (M_age = 16.1 , SD = 1.68; 49.5% girls) from 2510 2-parent families who participated in the Nord-Trøndelag Health Study in Norway (HUNT3; Young-HUNT3) in 2006-08 and were followed-up through the National Education Database (NUDB) until 2014. Associations between maternal and paternal binge drinking patterns as reported in HUNT during offspring's adolescence and offspring's subsequent high school completion were examined using logistic regression models while accounting for a comprehensive set of socio-demographic, parental, and offspring characteristics as assessed at HUNT baseline. Effect modifications of these putative associations by offspring characteristics were also explored.

FINDINGS

Approximately 1 in 6 offspring (13.6% girls, 21.1% boys) failed to graduate high school within the officially designated time period, while roughly 1 in 5 mothers (20.4%) and 1 in 2 fathers (51.2%) reported any binge drinking. Weekly or more frequent binge drinking in fathers was prospectively associated with more than doubled odds of high school non-completion in offspring; OR = 2.23, 95% CI = 1.50-3.31. This effect remained substantively identical after adjustment for all covariates (aOR = 2.20, 95% CI = 1.38-3.50) and uniform across offspring characteristics such as gender, academic orientation and performance, anxiety and depression, typical alcohol consumption, and witnessing parental intoxication as assessed at HUNT baseline.

CONCLUSIONS

Weekly or more frequent binge drinking in fathers negatively affected high school graduation prospects in their offspring.

Prevalence of adverse childhood experiences and their co-occurrence in a large population of adolescents: a Young HUNT 3 study

PURPOSE

Studies of adverse childhood experiences (ACEs) undertaken at the time of adolescence in the general population are not common. The aim of this study was to determine the prevalence and co-occurrence of the individual ACEs and sub-types of ACEs in a large population of adolescents.

METHODS

Data were used from the Young Nord-Trøndelag Health (Young HUNT 3) study, a population-based study of young adolescents. ACEs were operational defined as sexual, physical and/or emotional abuse; physical and/or emotional neglect; and/or household dysfunction. Co-occurrence was measured as the accumulation of ACEs and as an overlap analysis.

RESULTS

Of the 8199 evaluable adolescents, 65.8% had experienced at least one ACE and 28% of those had experienced more than one ACE. Household dysfunction was the most prevalent ACE subtype. The biggest overlaps among the three ACE sub-types were seen in those reporting neglect or abuse.

CONCLUSION

There was a high degree of overlap between the three ACE sub-types and the individual ACEs, indicating that ACEs should be assessed together as a whole rather than separately. This study provides an opportunity to assess ACEs and their co-occurrences in relation to outcomes later in life.

Investigating a Potential Causal Relationship Between Maternal Blood Pressure During Pregnancy and Future Offspring Cardiometabolic Health

Observational epidemiological studies have reported that higher maternal blood pressure (BP) during pregnancy is associated with increased future risk of offspring cardiometabolic disease. However, it is unclear whether this association represents a causal relationship through intrauterine mechanisms. We used a Mendelian randomization (MR) framework to examine the relationship between unweighted maternal genetic scores for systolic BP and diastolic BP and a range of cardiometabolic risk factors in the offspring of up to 29 708 genotyped mother-offspring pairs from the UKB study (UK Biobank) and the HUNT study (Trøndelag Health). We conducted similar analyses in up to 21 423 father-offspring pairs from the same cohorts. We confirmed that the BP-associated genetic variants from the general population sample also had similar effects on maternal BP during pregnancy in independent cohorts. We did not detect any association between maternal (or paternal) unweighted genetic scores and cardiometabolic offspring outcomes in the meta-analysis of UKB and HUNT after adjusting for offspring genotypes at the same loci. We find little evidence to support the notion that maternal BP is a major causal risk factor for adverse offspring cardiometabolic outcomes in later life.

Genome-wide analysis identifies impaired axonogenesis in chronic overlapping pain conditions

Chronic pain is often present at more than one anatomical location, leading to chronic overlapping pain conditions (COPC). Whether COPC represents a distinct pathophysiology from the occurrence of pain at only one site is unknown. Using genome-wide approaches, we compared genetic determinants of chronic single-site vs. multisite pain in the UK Biobank. We found that different genetic signals underlie chronic single-site and multisite pain with much stronger genetic contributions for the latter. Among 23 loci associated with multisite pain, 9 loci replicated in the HUNT cohort, with the DCC netrin-1 receptor (DCC) as the top gene. Functional genomics identified axonogenesis in brain tissues as the major contributing pathway to chronic multisite pain. Finally, multimodal structural brain imaging analysis showed that DCC is most strongly expressed in subcortical limbic regions and is associated with alterations in the uncinate fasciculus microstructure, suggesting that DCC-dependent axonogenesis may contribute to COPC via cortico-limbic circuits.

Body mass index and physical activity in seven-year-old children whose mothers exercised during pregnancy: follow-up of a multicentre randomised controlled trial

BACKGROUND

There are limited data on long-term outcomes of children whose mothers have followed exercise interventions during pregnancy. The aim of this paper was to investigate whether regular moderate intensity exercise during pregnancy affected the children's body mass index (BMI) and physical activity (PA) at 7 years of age, and determine the relationship between children's and mothers' BMI and PA.

METHODS

This was a follow-up of a multicentre randomised controlled trial, carried out at St. Olavs Hospital, Trondheim University Hospital, and Stavanger University Hospital, Norway (2007-2009 and 2014-2016). Women were randomised to follow a 12-week structured exercise protocol or standard antenatal care during pregnancy. At the 7-year follow-up, parents reported their child's height, weight, and PA. The mothers also reported their own weight and PA. Main outcome variables were BMI, frequency and duration of moderate to vigorous PA (MVPA), and intensity of PA.

RESULTS

A total of 855 women were randomised to exercise (n = 429) or standard antenatal care (n = 426) during pregnancy. At follow-up, 164 (38.2%) children and mothers in the intervention group and 117 (27.5%) in the control group participated. We found no group differences in the children's iso-BMI or PA. Findings were similar when we performed stratified analyses by sex, except boys in the control group spent more time on electrical devices than boys in the intervention group. Subgroup analyses of children of mothers who adhered to the exercise protocol and sensitivity analyses excluding children born preterm, children admitted to the neonatal intensive care unit, and children with diseases or health problems at the 7-year follow-up, did not change the results. Children's BMI, weekly leisure time MVPA and intensity of PA correlated with mothers' BMI, daily exercise, and intensity of exercise.

CONCLUSIONS

Regular moderate intensity exercise during pregnancy did not affect BMI or PA of the children at 7 years. Good maternal health should be encouraged as it may influence the health of the next generation.

TRIAL REGISTRATION

The initial RCT study was registered in ClinicalTrials.gov NCT00476567 .

Multigenerational health research using population-based linked databases: an international review

Family health history is a well-established risk factor for many health conditions but the systematic collection of health histories, particularly for multiple generations and multiple family members, can be challenging. Routinely-collected electronic databases in a select number of sites worldwide offer a powerful tool to conduct multigenerational health research for entire populations. At these sites, administrative and healthcare records are used to construct familial relationships and objectively-measured health histories. We review and synthesize published literature to compare the attributes of routinely-collected, linked databases for three European sites (Denmark, Norway, Sweden) and three non-European sites (Canadian province of Manitoba, Taiwan, Australian state of Western Australia) with the capability to conduct population-based multigenerational health research. Our review found that European sites primarily identified family structures using population registries, whereas non-European sites used health insurance registries (Manitoba and Taiwan) or linked data from multiple sources (Western Australia). Information on familial status was reported to be available as early as 1947 (Sweden); Taiwan had the fewest years of data available (1995 onwards). All centres reported near complete coverage of familial relationships for their population catchment regions. Challenges in working with these data include differentiating biological and legal relationships, establishing accurate familial linkages over time, and accurately identifying health conditions. This review provides important insights about the benefits and challenges of using routinely-collected, population-based linked databases for conducting population-based multigenerational health research, and identifies opportunities for future research within and across the data-intensive environments at these six sites.

Intergenerational polygenic obesity risk throughout adolescence in a cross-sectional study design: The HUNT study, Norway

OBJECTIVE

This study examined the relationship between parental obesity polygenic risk and children's BMI throughout adolescence. Additionally, from a smaller subsample, the objective was to assess whether parental polygenic risk score (PRS) may act as a proxy for offspring PRS in studies lacking offspring genetic data.

METHODS

A total of 8,561 parent-offspring (age 13-19 years) trios from the Trøndelag Health Study (the HUNT Study) were included, of which, 1,286 adolescents had available genetic data. Weighted parental PRSs from 900 single-nucleotide polymorphisms robustly associated with adult BMI were constructed and applied in linear mixed-effects models.

RESULTS

A positive association between parental PRS and offspring sex- and age-adjusted BMI (iso-BMI) throughout adolescence was identified. The estimated marginal effects per standard deviation increase in parental PRS were 0.26 (95% CI: 0.18-0.33), 0.36 (95% CI: 0.29-0.43), and 0.62 kg/m² (95% CI: 0.51-0.72) for maternal, paternal, and combined parental PRS, respectively. In subsample analyses, the magnitude of association of the parental PRS versus offspring PRS with iso-BMI in adolescents was similar.

CONCLUSIONS

Parental PRS was consistently associated with offspring iso-BMI throughout adolescence. Results from subsample analyses support the use of parental PRS of obesity as a proxy for adolescent PRS in the absence of offspring genetic data.

School Functioning and Educational Aspirations in Adolescents With Social Anxiety-The Young-HUNT3 Study, Norway

Social anxiety disorder (SAD) typically emerges during childhood or early adolescence and often has long-term effects on several areas of an individual's life, including school and education. The purpose of this study is to examine whether social anxiety is associated with (1) school functioning in terms of behavioral difficulties (hyperactivity and/or attention problems), school dissatisfaction, social exclusion, truancy, and learning difficulties, and (2) educational aspirations (educational level). We use data from the population-based Young-HUNT3 study (2006-2008), where 8,199 Norwegian adolescents participated. Social anxiety is measured both as self-report [the Social Phobia and Anxiety Inventory for Children (SPAI-C)], and as screening information from diagnostic interviews [Anxiety Disorder Interview Schedule for DSM IV: child version (ADIS-C)]. ADIS-C screening positives (n = 388) reported higher rates of behavioral difficulties (RR = 1.06), school dissatisfaction (RR = 1.15), social exclusion (RR = 1.24), truancy (RR = 1.05), and learning difficulties (RR = 1.10) compared to screened negatives. Self-reported social anxiety symptoms showed similar patterns. Further, higher mean scores of self-reported social anxiety symptoms and being ADIS-C screening positive were negatively associated with aspirations of higher education (OR = 0.92 and OR = 0.74, respectively). However, as regards to having aspirations for the future (aspirations of higher education and/or aspirations of vocational training), no associations were found. The results indicate that social anxiety in adolescence is related to unfavorable/poorer school functioning and lower tendency of aspirations of higher education, which may have consequences for future educational pathways and later work life.

Risk factors and risk profiles for neck pain in young adults: Prospective analyses from adolescence to young adulthood-The North-Trøndelag Health Study

The objective was to investigate risk factors and risk profiles associated with neck pain in young adults using longitudinal data from the North-Trøndelag Health Study (HUNT). Risk factors were collected from adolescents (13-19 years of age), and neck pain was measured 11 years later. The sample was divided into two: Sample I included all participants (n = 1433), and Sample II (n = 832) included only participants who reported no neck/shoulder pain in adolescence. In multiple regression analyses in Sample I, female sex (OR = 1.9, 95% CI [1.3-2.9]), low physical activity level (OR = 1.6, 95% CI [1.0-2.5]), loneliness (OR = 2.0, 95% CI [1.2-3.5]), headache/migraine (OR = 1.7, 95% CI [1.2-2.6]), back pain (OR = 1.5, 95% CI [1.0-2.4]) and neck/shoulder pain (OR = 2.0, 95% [CI 1.3-3.0]) were associated with neck pain at the 11-year follow-up. Those with a risk profile including all these risk factors had the highest probability of neck pain of 67% in girls and 50% in boys. In Sample II, multiple regression analyses revealed that female sex (OR = 2.2, 95% CI [1.3-3.7]) and perceived low family income (OR = 2.4, 95% CI [1.1-5.1]) were associated with neck pain at the 11-year follow-up. Girls and boys with a perceived low family income had a 29% and 17% higher probability of neck pain than adolescents with a perceived high family income. The risk profiles in both samples showed that co-occurrence of risk factors, such as headache/migraine, neck/shoulder pain, back pain, low physical activity level, loneliness, and perceived low family income cumulatively increased the probability of neck pain in young adulthood. These results underline the importance of taking a broad perspective when studying, treating, and preventing neck pain in adolescents.

Underestimation of Overweight and Health Beneficial Outcomes in Two Adolescent Cohorts in Norway - The HUNT Study

PURPOSE

Underestimating overweight may prevent efforts toward reducing weight, but simultaneously benefit mental health and well-being. The magnitude of underestimation of overweight and obesity in adolescents is largely unknown, and so is to what extent this underestimation is associated with dieting behaviors, mental distress, and life satisfaction. As overweight has become more common during the past decades, associations between body size underestimation and mental health may have changed.

METHODS

Overweight (iso-body mass index, iso-BMI ≥25) adolescents (aged 13-19 years) who participated in The Young-HUNT1 (1995-97, n = 1,338) or The Young-HUNT3 (2006-08, n = 1,833) surveys were included. Being overweight, but perceiving oneself as average-weighted or underweighted was defined as underestimation. Results were based on clinical examinations and self-report questionnaires. Multivariable logistic regression models were used to examine associations between body size underestimation, dieting behaviors, and symptoms of anxiety, depression, and life satisfaction.

RESULTS

Among adolescents with overweight and obesity (iso-BMI ≥25), the prevalence of obesity (iso-BMI ≥30), body size underestimation, and having symptoms of anxiety and depression had increased from the first survey to the next. At both time points, body size underestimation was more common among boys than girls. In 2006-08, body size underestimation was negatively associated with symptoms of anxiety and depression in both sexes, and overall associated with higher life satisfaction equally over time. Dieting behavior was negatively associated with underestimation of body size.

CONCLUSIONS

Body size underestimation in adolescents with overweight/obesity has become more prevalent and a phenomenon associated with less dieting, better life satisfaction and mental health in both boys and girls.

Sociodemographic Correlates and Mental Health Comorbidities in Adolescents With Social Anxiety: The Young-HUNT3 Study, Norway

Social anxiety is highly prevalent in adolescents and is often associated with great individual suffering and functional impairment. Psychiatric comorbidity is common and further adds to this burden. The purposes of this study were: (1) to describe the occurrence of diagnosed and self-reported social anxiety among 8,199 Norwegian adolescents aged 13–19 years who participated in the population-based Young-HUNT3 study (2006–2008); (2) to examine associations between sociodemographic characteristics and different subgroups of social anxiety; and (3) to describe the psychiatric health comorbidities among adolescents diagnosed with social anxiety disorder (SAD). In total, 388 (5.9%) of the adolescents screened positive for SAD and were invited into a diagnostic interview, performed by professional nurses, using Anxiety Disorders Interview Schedule for DSM IV: child version (ADIS-C) (response rate = 54.6%). A SAD diagnosis was indicated in 106 individuals (50% of the interview subjects), and more than two-thirds of the adolescents diagnosed with SAD had one or more comorbid psychiatric disorders. Higher mean scores of self-reported social anxiety symptoms, poor self-rated health, sleep problems, poor family economic situation, low physical activity, and having sought professional help within the last year were associated with higher odds of being in the screening positive subgroup. Screening positive subjects who did not meet for a diagnostic interview did not differ notably from the rest of the screening positive group in terms of these sociodemographic characteristics. Based on our results and the fact that individuals with social anxiety often fear interview situations, the use of ADIS-C, screening questions and self-reports seem to be sufficient when aiming to identify epidemiologically representative cohorts of adolescents at risk of social anxiety.

Parental risk constellations and future alcohol use disorder (AUD) in offspring: A combined HUNT survey and health registries study

OBJECTIVE

We examined the risk of developing a future alcohol use disorder (AUD) among offspring of families with different constellations of parental risk factors.

METHOD

We analyzed a sample of 8,774 offspring (50.2% male) from 6,696 two-parent families who participated in the Nord-Trøndelag Health Study in Norway when offspring were 13-19 years old in 1995-1997 or 2006-2008. Based on population registry information and parental Nord-Trøndelag Health Study self-reports, families were classified via Latent Profile Analysis into fiver risk constellations reflecting parents' education, drinking quantities and frequencies, and mental health. Information about AUD-related diagnoses, treatments, and prescriptions for all offspring in the period between 2008 and 2016 was obtained from 3 national health registries and pooled to reflect any AUD. The likelihood of AUD in offspring was examined with a set of nested logistic regression models.

RESULTS

Registry records yielded 186 AUD cases (2.1%). Compared with the lowest-risk constellation, offspring from two constellations were more likely to present with AUD in unadjusted analyses. After adjusting for all covariates, including offspring's alcohol consumption and witnessing parental intoxication during adolescence, AUD risk remained elevated and statistically significant (adjusted odds ratio = 2.34, 95% confidence interval = 1.14, 4.85) for offspring from the constellation characterized by at least weekly binge drinking, low education, and poor mental health in both parents.

CONCLUSION

Weekly binge drinking by both parents was associated with future AUD risk among community offspring in Norway when clustered with additional parental risks such as poor mental health and low educational attainment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Danish National Youth Study 2019: study design and participant characteristics

AIM

To present the study design, study population and questionnaire content of the Danish National Youth Study 2019, and to describe the differences between participants and non-participants regarding demographic and socioeconomic characteristics.

METHOD

The Danish National Youth Study 2019 is a nationwide web-survey among high school students in Denmark. Data was collected from January to April 2019 through a self-administered questionnaire in the classroom. The questionnaire included 120 questions on, for example, physical and mental health, health behaviour and well-being. Data collection took place at 50 general high schools, 32 preparatory high schools, 15 commercial high school and 19 technical high schools.

RESULTS

A total of 29,086 students participated (20,287 general high school students, 2,113 preparatory higher school students, 4027 commercial high school students and 2659 technical high school students) corresponding to 66% of the students in the 88 participating schools (31% of invited schools). Among students, 55% were female and the mean age was 17.8 years. Participants were more likely to be female, to be younger, to be of Danish origin, and have family disposable income in the highest quartile compared to non-participants.

CONCLUSIONS

The Danish National Youth Study 2019 contributes to knowledge on high school students' health, health behaviour and well-being that can support health planning and prioritizing, through identification of specific risk groups at both local and national level. The study also offers great opportunities for future research as it provides possibility of linkage to various Danish national registers.

Mitigating adolescent social anxiety symptoms: the effects of social support and social self-efficacy in findings from the Young-HUNT 3 study

Adolescents' exposure to negative life events (NLEs) and potentially traumatic events is highly prevalent and increases their risk of developing psychological disorders considerably. NLE exposure has also been linked to the development of social anxiety disorder (SAD) among older children and young adolescents. Despite the relatively low treatment efficacy reported for children and adolescents suffering from SAD, few studies have addressed the extent to which resilience factors, such as social support and social self-efficacy, are associated with SAD symptoms. This study examined whether social support and social self-efficacy predict, and buffer against SAD symptoms using a large, population-based sample of adolescents, among whom a large proportion have experienced NLEs. The results reveal that NLEs are significantly associated with SAD symptoms, while social support and social self-efficacy are both negatively associated with SAD symptoms. Only the NLEs × social support interaction significantly predicted SAD symptoms, with social support attenuating the association between NLEs and SAD symptoms. Moreover, increases in both social self-efficacy and social support were associated with reduced SAD symptoms, over and above variance explained by social support alone. Our cumulative results suggest that interventions that can modify both social support and social self-efficacy may help reduce SAD symptoms in at-risk adolescents.

Developmental Course and Risk Factors of Physical Aggression in Late Adolescence

This study examined risk factors of physical aggression during transition from early to late adolescence using a two-wave longitudinal study. Specifically, we examined if risk factors in early adolescence predict physically aggressive behavior starting in late adolescence and why some adolescents desist physical aggressive behavior while others do not. The study sample consisted of 2289 Norwegian adolescents (1235 girls) who participated in the Young-HUNT1 study (mean age 14.5) and the follow-up study 4 years later, Young-HUNT2 study (mean age 18.4). One in six young adolescents reported engaging in physical fights. Moreover, physical aggression in early adolescence was significantly associated with male gender, attention problems, academic problems, being bullied, drinking alcohol, and smoking. Male gender and heavy drinking during early adolescence increased the risk for newly emerging aggressive behavior in late adolescence, whereas heavy drinking during early adolescence was a predictor for persistent versus desisting aggressive behavior in late adolescence.

The impact of diet during adolescence on the neonatal health of offspring: evidence on the importance of preconception diet. The HUNT study

Emerging evidence suggests that parents' nutritional status before and at the time of conception influences the lifelong physical and mental health of their child. Yet little is known about the relationship between diet in adolescence and the health of the next generation at birth. This study examined data from Norwegian cohorts to assess the relationship between dietary patterns in adolescence and neonatal outcomes. Data from adolescents who participated in the Nord-Trøndelag Health Study (Young-HUNT) were merged with birth data for their offspring through the Medical Birth Registry of Norway. Young-HUNT1 collected data from 8980 adolescents between 1995 and 1997. Linear regression was used to assess associations between adolescents' diet and later neonatal outcomes of their offspring adjusting for sociodemographic factors. Analyses were replicated with data from the Young-HUNT3 cohort (dietary data collected from 2006 to 2008) and combined with Young-HUNT1 for pooled analyses. In Young-HUNT1, there was evidence of associations between dietary choices, meal patterns, and neonatal outcomes, these were similar in the pooled analyses but were attenuated to the point of nonsignificance in the smaller Young-HUNT3 cohort. Overall, energy-dense food products were associated with a small detrimental impact on some neonatal outcomes, whereas healthier food choices appeared protective. Our study suggests that there are causal links between consumption of healthy and unhealthy food and meal patterns in adolescence with neonatal outcomes for offspring some years later. The effects seen are small and will require even larger studies with more state-of-the-art dietary assessment to estimate these robustly.

Parental alcohol intoxication and adverse health outcomes among offspring. A 4-year follow up HUNT study among 2399 Norwegian adolescents

This study aimed to investigate whether experience of parental alcohol intoxication was associated with adverse health outcomes among adolescents four years later. A population-based Norwegian cohort study of 2399 adolescents who participated in the Young-HUNT1 Survey 1995-97 (T1, 13-15 years old) was followed up four years later (T2) in 2000 (Young-HUNT2, 17-19 years old). Measures were based on adolescent self-report of exposure to parental alcohol intoxication, self-rated general health, mental distress (SCL-5) and lifetime hospital admission. Multivariable logistic regression analyses, adjusted for gender, age and parental education were applied. Results show that half of the adolescents (51%) had seen parents intoxicated at age 13-15 years. Four years later, those who had reported parental alcohol intoxication at T1 had increased odds of admission to hospital with odds ratios ranging from OR1.3; CI 1.0-1.7 to OR 2.2; CI 1.3-3.9, poorer self-rated health (odds ratio ranging from 1.8;1.2-2.6 to 2.0;1.1-3.7) and more mental distress (odds ratio ranging from 1.7;1.1-2.5 to 1.9;1.0-3.6). Furthermore, the increased frequency of experience of parental alcohol intoxication are associated with higher prevalence of admission to hospital and mental distress and lower levels of self-rated health. Findings from this large, representative population of Norwegian adolescents indicate that adverse health outcomes among adolescents in a general population are related to relatively common heavy drinking behaviours among parents.

Mendelian randomization study of maternal influences on birthweight and future cardiometabolic risk in the HUNT cohort

There is a robust observational relationship between lower birthweight and higher risk of cardiometabolic disease in later life. The Developmental Origins of Health and Disease (DOHaD) hypothesis posits that adverse environmental factors in utero increase future risk of cardiometabolic disease. Here, we explore if a genetic risk score (GRS) of maternal SNPs associated with offspring birthweight is also associated with offspring cardiometabolic risk factors, after controlling for offspring GRS, in up to 26,057 mother-offspring pairs (and 19,792 father-offspring pairs) from the Nord-Trøndelag Health (HUNT) Study. We find little evidence for a maternal (or paternal) genetic effect of birthweight associated variants on offspring cardiometabolic risk factors after adjusting for offspring GRS. In contrast, offspring GRS is strongly related to many cardiometabolic risk factors, even after conditioning on maternal GRS. Our results suggest that the maternal intrauterine environment, as proxied by maternal SNPs that influence offspring birthweight, is unlikely to be a major determinant of adverse cardiometabolic outcomes in population based samples of individuals.

Obesity in Young Adulthood: The Role of Physical Activity Level, Musculoskeletal Pain, and Psychological Distress in Adolescence (The HUNT-Study)

The global obesity epidemic raises long-term health concerns which underline the importance of preventive efforts. We aimed to investigate individual and combined effects of common health problems in adolescence on the probability of obesity in young adulthood. This prospective population-based study included data from participants in the Nord-Trøndelag Health Study in Norway (Young-HUNT1 (1995–1997), age 13–19, baseline) who participated in HUNT3 as young adults 11 years later (age 23–31). Exposure variables at baseline included self-reported physical activity, musculoskeletal pain, and psychological distress. We examined associations between exposure variables and the main outcome of obesity in young adulthood (BMI ≥ 30 kg/m²) using univariate and multiple logistic regression, stratified by sex. Probabilities of obesity for given combinations of the exposure variables were visualized in risk matrixes. The study sample consisted of 1859 participants (43.6% boys). Higher probabilities of obesity in young adulthood were found across combinations of lower physical activity levels and presence of musculoskeletal pain in adolescence. Additional adverse effects of psychological distress were low. Proactive intervention strategies to promote physical activity and facilitate sports participation for all adolescents, whilst addressing musculoskeletal pain and its potential individual causes, could prove helpful to prevent development of obesity in young adulthood.

Self-rated health in adolescence as a predictor of 'multi-illness' in early adulthood: A prospective registry-based Norwegian HUNT study

Self-rated health (SRH) is a marker of future health and a possible predictor of future multimorbidity, which is a major challenge for population health and health care. There is a lack of studies on adolescent SRH and patterns of health problems across the transitional period from adolescence to early adulthood. Therefore, this study aimed to identify groups of people with similar health problems in early adulthood and explore the predictive value of adolescent SRH on the group classification after a period of 10–19 years. Data from 8828 adolescents participating in the Young HUNT-1 survey (1995–1997) were linked to the Norwegian registry of general practitioner (GP) claims, which includes diagnoses recorded in GP consultations in 2006–2014. We used latent class analysis (LCA) to identify groups of patients with similar health problems in early adulthood and explored SRH as a predictor of class membership using latent class regression, adjusting for baseline chronic disease, frequency of health care attendance, sex and age. The mean age at baseline was 16 years, and 50% of the participants were female. SRH was reported as very good by 28%, good by 61% and not good by 11%. We identified five groups of patient classification (classes): Healthy (35%), Infections and general problems (26%), Musculoskeletal problems (21%), Psychological problems (6%) and Multi-illness (13%). We found a gradual increase in the probability of belonging to the Healthy class with better SRH, and an inverse pattern for the Psychological and Multi-illness classes. This pattern remained after adjusting for baseline variables. In conclusion, there is a clear association between adolescent SRH and the risk of having multi-illness in early adulthood, seen as a proxy for later multimorbidity. This finding warrants greater attention to SRH in adolescence as a possible indicator in targeted prevention of future health problems.

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Adolescent self-rated health (SRH) predicted health problems 10–19 years later.

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Patients were classified into five groups with similar patterns of health problems.

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Better SRH increased the probability of adults belonging to the healthiest group.

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Not good SRH tripled the risk for multi-illness compared to very good SRH.

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Low SRH in adolescence is a possible predictor of multimorbidity in adulthood.

Elucidating the role of maternal environmental exposures on offspring health and disease using two-sample Mendelian randomization

BACKGROUND

There is considerable interest in estimating the causal effect of a range of maternal environmental exposures on offspring health-related outcomes. Previous attempts to do this using Mendelian randomization methodologies have been hampered by the paucity of epidemiological cohorts with large numbers of genotyped mother-offspring pairs.

METHODS

We describe a new statistical model that we have created which can be used to estimate the effect of maternal genotypes on offspring outcomes conditional on offspring genotype, using both individual-level and summary-results data, even when the extent of sample overlap is unknown.

RESULTS

We describe how the estimates obtained from our method can subsequently be used in large-scale two-sample Mendelian randomization studies to investigate the causal effect of maternal environmental exposures on offspring outcomes. This includes studies that aim to assess the causal effect of in utero exposures related to fetal growth restriction on future risk of disease in offspring. We illustrate our framework using examples related to offspring birthweight and cardiometabolic disease, although the general principles we espouse are relevant for many other offspring phenotypes.

CONCLUSIONS

We advocate for the establishment of large-scale international genetics consortia that are focused on the identification of maternal genetic effects and committed to the public sharing of genome-wide summary-results data from such efforts. This information will facilitate the application of powerful two-sample Mendelian randomization studies of maternal exposures and offspring outcomes.

Questionnaire development for the Lolland-Falster Health Study, Denmark: an iterative and incremental process

In composing multi-thematic questionnaires for the Lolland-Falster Health Study (LOFUS), we faced a range of challenges, for which we found limited guidance in the literature. LOFUS is a household-based population study covering multiple medical and social research areas and targeting the mixed rural-provincial population of 103,000 persons on the Danish islands Lolland and Falster. Households were randomly selected for invitation. In this paper, we describe and discuss challenges in developing the questionnaires related to stakeholders, content of the questionnaire, and the process itself. The development process was characterised by loops of learning and can be described as an iterative and incremental process. We propose recommendations to researchers and administrators involved in similar development processes, including awareness of the non-linearity and complexity of the process, a need for negotiations and navigation among multiple stakeholders, and acknowledgement of pragmatism as an inherent part of decisions made in the process.