Lifetime and 10-year risks of cardiovascular mortality in relation to risk factors in middle and old age: 50-year follow-up of the Whitehall study of London Civil Servants

BACKGROUND

Cardiovascular disease (CVD)-related mortality has declined substantially in the United Kingdom (UK) in recent decades, but the continued relevance of conventional risk factors for prediction of CVD mortality throughout the life-course is uncertain. We compared the 10-year risks and lifetime risks of CVD mortality associated with conventional risk factors recorded in middle and old age.

METHODS

The Whitehall study was a prospective study of 19,019 male London civil servants (mean age 52 years) when enrolled in 1967-1970 and followed-up for 50 years for cause-specific mortality. In 1997, 7044 (83%) survivors (mean age 77 years) were re-surveyed. The 10-year and lifetime risks of CVD mortality were estimated by levels of CVD risk factors recorded in middle-age and old-age, respectively.

RESULTS

By July 2020, 97% had died (22%, 51% and 80% before age 70, 80 and 90 years, respectively) and 7944 of 17,673 deaths (45%) were from CVD. The 10-year and lifetime risks of CVD death increased linearly with higher levels of CVD risk factors recorded in middle-age and in old-age. Individuals in the top versus bottom 5% of CVD risk scores in middle age had a 10.3% (95% CI:7.2-13.4) vs 0.6% (0.1-1.2) 10-year risk of CVD mortality, a 61.4% (59.4-65.3) vs 31.3% (24.1-34.5) lifetime risk of CVD mortality and a 12-year difference in life expectancy from age 50 years. The corresponding differences using a CVD risk score in old-age were 11.0% (4.4-17.5) vs 0.8% (0.0-2.2) for 10-year risk and 42.1% (28.2-50.0) vs 30.3% (6.0-38.0) for lifetime risk of CVD mortality and a 6-year difference in life expectancy from age 70 years.

CONCLUSIONS

Conventional risk factors remained highly predictive of CVD mortality and life expectancy through the life-course. The findings highlight the relevance of estimation of both lifetime risks of CVD and 10-year risks of CVD for primary prevention of CVD.

Nurse understaffing and short work experience as predictors of healthcare-associated infections

Background

Healthcare-associated infections (HAIs) are a serious risk factor for hospital patients leading to more than 90 000 deaths each year in European countries. It has been evaluated that 7% of patients in European acute care hospitals acquire an HAI, and that a large part of cases could be prevented. Good hand hygiene is central in preventing HAIs, which may be compromised under high work pressure. The aim of this study was to analyse the associations between nurse understaffing and short work experience with the risk of HAIs at patient-level. Prior evidence on this topic remains inconclusive due to a reliance on imprecise measurement of these exposures.

Methods

We utilized administrative data on employees’ working hours and patient records from one hospital district in Finland from years 2013-2019. The data included in total 281,672 inpatient periods. We used mixed-effects survival analyses to predict the overall risk of HAIs, and four types of HAIs: bloodstream, Clostridium difficile, surgical-site and pneumonia. To consider the incubation time, exposure to nurse understaffing and short work experience were measured in preceding days in moving time windows when the patients were in the hospital.

Results

Preliminary results showed that exposure to nurse understaffing within two days, measured as low nursing hours relative to planned hours, was associated with increased risk of HAIs (hazard ratio was 1.23, 95% CI 1.05-1.45). Additional analyses showed that this risk was especially pronounced in surgical-site infections, which were also carefully monitored in the hospital district. We did not find associations between exposure to short work experience among nurses and HAI risk.

Conclusions

This study showed that nurse staffing below planned levels was associated with an increased overall risk of HAIs, particularly surgical-site infections, among patients. Adequate levels of nursing staff in hospitals may be important for preventing HAIs.

Key messages

Hospital nurse understaffing and short work experience: associations with mortality among patients

Background

Determining and maintaining optimal staffing level in hospitals is crucial, as understaffing may have serious consequences and even increase mortality risk among patients. There is no consensus, however, on the optimal way to determine staffing requirements in hospitals as patients’ care needs vary between wards and days. Nurse work experience may also affect quality of care and ultimately patients’ survival but research on this topic is scarce.

Methods

Administrative register data on patients (N = 254,308) and employees of 40 hospital units was used in one hospital district in Finland from years 2013-2019. Both nurse understaffing and nurse work experience were measured with two different indicators in each unit-day. Mixed-effects survival models were used to analyse the associations of these exposures with mortality at patient-level, when adjusted for patients’ characteristics, such as age, sex and comorbidities.

Results

Preliminary results showed that every one percent increase in the cumulative proportion of understaffed days - measured as low nursing hours relative to planned - was associated with 1.002-fold mortality risk among patients (95% CI, 1.000-1.004, p-value=0.044). Short work experience was not associated with increased risk of death.

Conclusions

This study supports previous findings on the associations between nurse understaffing and increased mortality risk among patients in Finland although no association with mortality was found for the other three staffing characteristics. However, the average daily shares of actualized nursing hours relative to planned hours were quite high in hospital units. An indicator based on actualized relative to planned working hours in routine administrative data could be useful in evaluating understaffing in hospitals.

Key messages

• Adequate level of nursing professional in hospitals is related to patient survival.

• It is also crucial of develop efficient ways to evaluate understaffing in hospitals.

Social network ties before and after retirement: a cohort study

Social networks are associated with individual's health and well-being. Working life offers opportunities to create and maintain social networks, while retirement may change these networks. This study examined how the number of ties in social network changes across the retirement transition. The study population consisted of 2319 participants (84% women, mean age 63.2 years) from the Finnish Retirement and Aging study. Information about social network ties, including the number of ties in the inner, middle and outer circles of the social convoy model, was gathered using annual postal surveys before and after retirement. Three repeat surveys per participant covered the retirement transition and the post-retirement periods. Mean number of network ties was 21.6 before retirement, of which 5.6 were situated in the inner, 6.9 in the middle and 9.1 in the outer circle. The number of ties in the outer circle decreased by 0.67 (95% CI - 0.92, - 0.42) during the retirement transition period, but not during the post-retirement period (0.11, 95% CI - 0.33, 0.12) (interaction period * time, p = 0.006). The pattern of change in these ties did not differ by gender, occupational status, marital status, number of chronic diseases and mental health during the retirement transition period. The number of ties in the inner and middle circles overall did not decrease during these periods. The number of peripheral relationships decreased during the retirement transition but not after that, suggesting that the observed reduction is more likely to be associated with retirement rather than aging.

Social relationships as predictors of extended employment beyond the pensionable age: a cohort study

The aim is to examine whether characteristics of social relationships predict extended employment beyond the pensionable age among Finnish public sector workers. The study population consisted of 4014 participants (83% women, age 62.56 ± 1.21) of the Finnish Retirement and Aging Study followed between 2014 and 2019. Extended employment was defined as the difference between actual retirement date and individual age-related pensionable date and classified into three groups: no extension (retired on pensionable age or extended by < 3 months), short extension (3 months–< 1 year), and long extension (≥ 1 year) beyond the pensionable date. Characteristics of social relationships and engagement were assessed 18 months prior to the pensionable date. Social engagement was classified into consumptive social participation, formal social participation, informal social participation, and other social participation. Data were analyzed using multinomial regression analysis. Of total study participants, 17.8% belonged to short- and 16.5% belonged to long-extension group. Adjusted for age, occupational status, self-rated health and depression, and having a working spouse (OR 2.34, 95% CI 1.39–3.95) were associated with long extension of employment beyond the pensionable age when compared to no extension among men. Likewise, among women, living alone (OR 1.60, 95% CI 1.28–2.00), having a working spouse (1.85, 1.39–2.45), and high consumptive (1.32, 1.07–1.65), high formal (1.47, 1.17–1.85), and other social participation (0.79, 0.63–0.98) were associated with long extension. Having a working spouse, living alone, and high consumptive social participation were associated with short extension. Several characteristics of social relationships, such as having a working spouse, living alone, and high frequency of social engagement, predicted an extension of employment beyond the pensionable age.

Association of nutritional components with falls in oldest-old men: The Helsinki Businessmen Study (HBS)

INTRODUCTION

Falls are associated with increased morbidity and mortality in older people. We examined how nutritional factors are associated with self-reported falls in the oldest-old community-dwelling men.

METHODS

Participants of the longitudinal and socioeconomically homogenous Helsinki Businessmen Study are men born in 1919-1934. A cross-sectional analysis from a random sample of 122 home-living oldest-old men who underwent medical examinations in 2017-2018 is reported here. Food and nutrient intakes were retrieved from 3-day food diaries, and the number of falls during past year was requested in the screening questionnaire. Nutritional status was assessed using Mini Nutritional Assessment Short Form (MNA-SF) and waist circumference was measured. Body composition was assessed with dual-energy X-ray absorptiometry (DXA)-scans, physical performance with short physical performance battery (SPPB), sarcopenia status using European Working Group on Sarcopenia in Older People's 2 (EWGSOP2) criteria, and frailty with phenotypic criteria.

RESULTS

Mean age of participants was 87 years (range 83-99 years) and 30% reported at least one fall during past year. Falls were associated with higher waist circumference (p = .031), frailty (p < .001) and sarcopenia (p = .002), and inversely associated with SPPB total score (p = .002). Of nutritional factors, intakes of fish (p = .016), fish protein (p = .039), berry (p = .027) and vitamin D (p = .041), and snacking more protein between breakfast and lunch (p = .017) were inversely associated with falls. Red meat intake was associated with higher frequency of falls (p = .044).

CONCLUSION

Higher waist circumference, but not body mass index, was associated with increased frequency of falls. Healthy dietary choices appeared protective from falls in these oldest-old men of similar socioeconomic status.

Psychosocial factors and hospitalisations for COVID-19: Prospective cohort study based on a community sample

BACKGROUND

While certain infectious diseases have been linked to socioeconomic disadvantage, mental health problems, and lower cognitive function, relationships with COVID-19 are either uncertain or untested. Our objective was to examine the association of a range of psychosocial factors with hospitalisation for COVID-19.

METHODS

UK Biobank, a prospective cohort study, comprises around half a million people who were aged 40-69 years at study induction between 2006 and 2010 when information on psychosocial factors and covariates were captured. Hospitalisations for COVID-19 were ascertained between 16th March and 26th April 2020.

RESULTS

There were 908 hospitalisations for COVID-19 in an analytical sample of 431,051 England-based study members. In age- and sex-adjusted analyses, an elevated risk of COVID-19 was related to disadvantaged levels of education (odds ratio; 95% confidence interval: 2.05; 1.70, 2.47), income (2.00; 1.63, 2,47), area deprivation (2.20; 1.86, 2.59), occupation (1.39; 1.14, 1.69), psychological distress (1.58; 1.32, 1.89), mental health (1.50; 1.25, 1.79), neuroticism (1.19; 1.00, 1.42), and performance on two tests of cognitive function - verbal and numerical reasoning (2.66; 2.06, 3.34) and reaction speed (1.27; 1.08, 1.51). These associations were graded (p-value for trend ≤ 0.038) such that effects were apparent across the full psychosocial continua. After mutual adjustment for these characteristics plus ethnicity, comorbidity, and lifestyle factors, only the relationship between lower cognitive function as measured using the reasoning test and risk of the infection remained (1.98; 1.38, 2.85).

CONCLUSIONS

A range of psychosocial factors revealed associations with hospitalisation for COVID-19 of which the relation with cognitive function, a marker of health literacy, was most robust.

Associations of protein source, distribution and healthy dietary pattern with appendicular lean mass in oldest-old men: the Helsinki Businessmen Study (HBS)

PURPOSE

We explored how food and dietary intakes, protein daily distribution and source are associated with appendicular lean mass (ALM)/m² of the oldest-old community-dwelling men.

METHODS

Cross-sectional analyses of Helsinki Businessmen Study (HBS, mean age 87 years) participants who came to clinic visit in 2017/2018. Nutritional status, physical performance and fasting blood samples were measured. Food and dietary intakes were retrieved from 3-day food diaries. Body composition was measured and appendicular lean mass (ALM) per m² was dichotomized as ALM/m² < 7 kg/m² and ≥ 7 kg/m². Differences between lower and higher ALM were analyzed using t test or Mann-Whitney U test. Analysis of covariance was used to investigate independent associations with ALM/m².

RESULTS

Random sample of 130 participants took part in the medical examinations, 126 returned food diaries, and 102 underwent DXA-scan. ALM/m² was associated with total protein (p = 0.033), animal protein (p = 0.043) and meat protein (p = 0.033) intakes. Protein distribution between daily meals differed at lunch; those with higher ALM/m² ate more protein (p = .047) at lunch. Consumption of fruits, vegetables (p = 0.022) and meat (p = 0.006) was associated with ALM/m².

CONCLUSION

Protein intake, source and distribution as well fruit and vegetable intakes were associated with higher ALM in oldest-old men.

STUDY REGISTRATION

The study is registered with ClinicalTrials.gov identifier: NCT02526082.

Macronutrient composition and sarcopenia in the oldest-old men: The Helsinki Businessmen Study (HBS)

BACKGROUND & AIM

Sarcopenia is associated with increased risk for several adverse health outcomes including frailty, disability, loss of independence, and mortality. We examined cross-sectional associations between sarcopenia and detailed dietary macronutrient composition in community-living oldest-old men (mean age 87).

METHODS

Participants were invited to a clinic visit in 2017/2018 including assessments of sarcopenia status using European Working Group on Sarcopenia in Older People's 2 (EWGSOP2) criteria and detailed macronutrient, vitamin D and food intakes retrieved from 3-day food diaries.

RESULTS

Of the 126 participants, 48 had probable sarcopenia and 27 sarcopenia. Sarcopenia was associated with lower energy (p = 0.020), total protein (p = 0.019), plant (p = 0.008) and fish proteins (p = 0.041), total fat (p = 0.015), monounsaturated fatty acids (MUFA) (p = 0.011), polyunsaturated fatty acids (p = 0.002), vitamin D intakes (p = 0.005) and, of fat quality indicators, MUFA: saturated fatty acid-ratio (p = 0.042).

CONCLUSION

These findings suggest that sufficient energy and protein intakes, but also fat quality may be important along with healthy dietary patterns for prevention of sarcopenia in the oldest-old.

Labor market outcomes before and after first episode of part-time sickness absence

Background

Previous research suggests that part-time sickness absence (PTSA) results in better work participation compared to full-time sickness absence (FTSA), but few studies have examined trends in FTSA and unemployment before and after PTSA.

Methods

This Finnish population-based cohort study included 3406 individuals with first episode (&gt;30 days) of PTSA in 2011 (=PTSA group), 42 510 individuals with FTSA (&gt;30 days) in 2011 (=FTSA group), and 25 167 individuals with no sickness absence (&gt;30 days) in 2011 from the general working-age population. Annual days of FTSA from 2007 to 2015 and unemployment from 2012 to 2015 were measured for the participants of each group. We modeled trends and relative risks for these labor market outcomes using negative binomial regression with generalized estimation equations.

Results

For the PTSA group, the adjusted mean annual number of FTSA days was 3 in the beginning of the follow-up, 15 a year before the index year, and 8-10 after the index year. The adjusted risk ratio (RR) of FTSA days after versus before PTSA was 1.95 (95% CI 1.75-2.17). For the FTSA group, mean of sickness absence days was 4 in the beginning, 13 a year before the index year and 9-19 after the index year. The mean of FTSA was 1-2 throughout the follow-up in the general population. An increasing slope in unemployment after the index year was observed in all groups, the absolute level of unemployment being highest among FTSA group and lowest among the general population group.

Conclusions

Long-term PTSA marks a decline in labour market participation. In absolute terms this decline is smaller than that in employees with long-term FTSA.

Key messages

Part-time sickness absence lasting &gt;30 days marked an increase in full-time sickness absence although the absence levels did not reach those observed after full-time sickness absence of &gt; 30 days. Our results show smaller impairment in labour market outcomes in employees granted a long-term part-time sickness absence than in those with long-term full-time sickness absence.

Prospective association between late evening food consumption and risk of prediabetes and diabetes: the Whitehall II cohort study

AIMS

We examined whether late evening food consumption was prospectively associated with the risk of developing prediabetes or diabetes in a large observational study of individuals with normoglycaemia.

METHODS

Participants were 2642 men and women with normoglycaemia (HbA_1c < 39 mmol/mol; < 5.7%) from the Whitehall II study. Time of last eating episode (TLEE) before the examination day was assessed at baseline. We studied the associations of TLEE with 5-year changes in HbA_1c and risk of developing prediabetes or diabetes (HbA_1c ≥ 39 mmol/mol; ≥ 5.7%). Potential heterogeneity in the association between TLEE and prediabetes or diabetes was examined using recursive partitioning modelling for time-to-event outcomes.

RESULTS

There was a tendency of an overall association of TLEE with change in HbA_1c but with little effect size [β per 1-h increase in TLEE = 0.2 mmol/mol, 95% CI -0.0 to 0.3 (0.01%, -0.00 to 0.03); P = 0.055] and no association with the risk of developing prediabetes/diabetes (risk ratio per 1-h increase in TLEE = 1.03, 95% CI 0.94 to 1.13; P = 0.511). According to the recursive partitioning modelling, women with HbA_1c ≤ 36 mmol/mol and TLEE after 21:00 had a 1.51 times (95% CI 1.16 to 1.93) higher 5-year risk of developing prediabetes or diabetes than those having their TLEE between 16:00 and 21:00 (35.4% vs. 23.5%; P = 0.003).

CONCLUSIONS

There was no overall association of TLEE with the development of prediabetes or diabetes in the Whitehall II population. However, explorative analyses suggested that eating late in the evening was associated with increased risk of developing prediabetes/diabetes among women with good glycaemic control. Whether restricting late evening food consumption is effective and feasible for the prevention of Type 2 diabetes needs testing in randomized controlled trials.

Antidepressant treatment among social workers, human service professionals, and non-human service professionals: A multi-cohort study in Finland, Sweden and Denmark

BACKGROUND

Social workers have an elevated risk for mental disorders, but little is known about their antidepressant treatment.

AIMS

To examine any and long-term antidepressant treatment among social workers in Finland, Sweden and Denmark.

METHODS

We linked records from drug prescription registers to three prospective cohorts: the Finnish Public Sector study, years 2006-2011, and nation-wide cohorts in Sweden and Denmark, years 2006-2014, including a total of 1.5 million employees in (1) social work, (2) other social and health care professions, (3) education and (4) office work. We used Cox proportional hazards models to estimate hazard ratios for any and long-term (>6 months) antidepressant treatment among social workers compared to the three reference occupational groups and carried out meta-analyses.

RESULTS

During follow-up, 25% of social workers had any prescriptions for antidepressants (19-24% reference occupations) and 20% for long-term treatment (14-19% reference occupations). The pooled effects for any and long-term treatment showed that probabilities were 10% higher in social workers compared to other health and social care professionals and 30% higher compared to education and non-human service professionals. Probabilities for any treatment in the three countries were relatively similar, but for long-term treatment social workers in Finland had a greater risk compared with other human service professions.

LIMITATIONS

There were differences between the cohorts in the availability of data. Specific diagnoses for the antidepressant treatment were not known neither adherence to treatment.

CONCLUSION

Social workers have a higher risk for any and long-term antidepressant treatment than other human and non-human service professionals.

Estimating sleep parameters using an accelerometer without sleep diary

Wrist worn raw-data accelerometers are used increasingly in large-scale population research. We examined whether sleep parameters can be estimated from these data in the absence of sleep diaries. Our heuristic algorithm uses the variance in estimated z-axis angle and makes basic assumptions about sleep interruptions. Detected sleep period time window (SPT-window) was compared against sleep diary in 3752 participants (range = 60-82 years) and polysomnography in sleep clinic patients (N = 28) and in healthy good sleepers (N = 22). The SPT-window derived from the algorithm was 10.9 and 2.9 minutes longer compared with sleep diary in men and women, respectively. Mean C-statistic to detect the SPT-window compared to polysomnography was 0.86 and 0.83 in clinic-based and healthy sleepers, respectively. We demonstrated the accuracy of our algorithm to detect the SPT-window. The value of this algorithm lies in studies such as UK Biobank where a sleep diary was not used.

Increased Mortality Despite Successful Multifactorial Cardiovascular Risk Reduction in Healthy Men: 40-Year Follow-Up of the Helsinki Businessmen Study Intervention Trial

OBJECTIVES

In a 5-year multifactorial risk reduction intervention for healthy men with at least one cardiovascular disease (CVD) risk factor, mortality was unexpectedly higher in the intervention than the control group during the first 15-year follow-up. In order to find explanations for the adverse outcome, we have extended mortality follow-up and examined in greater detail baseline characteristics that contributed to total mortality.

DESIGN

Long-term follow-up of a controlled intervention trial.

SETTING

The Helsinki Businessmen Study Intervention Trial.

PARTICIPANTS AND INTERVENTION

The prevention trial between 1974-1980 included 1,222 initially healthy men (born 1919-1934) at high CVD risk, who were randomly allocated into intervention (n=612) and control groups (n=610). The 5-year multifactorial intervention consisted of personal health education and contemporary drug treatments for dyslipidemia and hypertension. In the present analysis we used previously unpublished data on baseline risk factors and lifestyle characteristics.

MAIN OUTCOME MEASURES

40-year total and cause-specific mortality through linkage to nation-wide death registers.

RESULTS

The study groups were practically identical at baseline in 1974, and the 5-year intervention significantly improved risk factors (body mass index, blood pressure, serum lipids and glucose), and total CVD risk by 46% in the intervention group. Despite this, total mortality has been consistently higher up to 25 years post-trial in the intervention group than the control group, and converging thereafter. Increased mortality risk was driven by CVD and accidental deaths. Of the newly-analysed baseline factors, there was a significant interaction for mortality between intervention group and yearly vacation time (P=0.027): shorter vacation was associated with excess 30-year mortality in the intervention (hazard ratio 1.37, 95% CI 1.03-1.83, P=0.03), but not in the control group (P=0.5). This finding was robust to multivariable adjustments.

CONCLUSION

After a multifactorial intervention for healthy men with at least one CVD risk factor, there has been an unexpectedly increased mortality in the intervention group. This increase was especially observed in a subgroup characterised by shorter vacation time at baseline. Although this adverse response to personal preventive measures in vulnerable individuals may be characteristic to men of high social status with subclinical CVD, it clearly deserves further investigation.

Diabetes and risk of occupational injury: a cohort study

AIMS

To investigate if diabetes is associated with a higher risk of occupational (workplace or commuting) injury.

METHODS

Medication data from the Finnish Prescription Register were used to identify diabetes cases in 2004 in a large employee cohort (the Finnish Public Sector study). These data were linked to injury records obtained from the Federation of Accident Insurance Institutions. A total of 1020 diabetes cases (median age 52 years, range 20 to 65 years; 66% women) and their 5234 age- and sex-matched controls were followed up until 2011. Sex-stratified Cox proportional hazards models, adjusting for age, occupational status, obesity and health behaviours, were applied. Because of the small number of men in the cohort, injury types and locations were only examined among women.

RESULTS

During the median follow-up of 6.7 years, 25% of the participants with diabetes (n=252) and 20% of those without (n=1051) experienced an occupational injury. The association between diabetes and injury was stronger in women than men (P=0.048). Diabetes was associated with a higher risk of workplace (hazard ratio 1.37, 95% CI 1.11 to 1.69) and commuting (hazard ratio 1.36, 95% CI 1.03 to 1.79) injury in women. With regard to different injury types and locations, diabetes was associated with bone fractures, dislocations, sprains and strains, and injuries to upper and lower extremities. In men, there was an association between insulin-treated diabetes and commuting injury (hazard ratio 3.14, 95% CI 1.52 to 6.49).

CONCLUSIONS

Diabetes was associated with workplace and commuting injuries in women. Men with insulin-treated diabetes had a higher risk of commuting injuries.

Healthy obesity and risk of accelerated functional decline and disability

BACKGROUND/OBJECTIVES

Some obese adults have a normal metabolic profile and are considered 'healthy', but whether they experience faster ageing than healthy normal-weight adults is unknown. We compared decline in physical function, worsening of bodily pain and likelihood of future mobility limitation and disability between these groups.

SUBJECTS/METHODS

This was a population-based observational study using repeated measures over 2 decades (Whitehall II cohort data). Normal-weight (body mass index (BMI) 18.5-24.9 kg m-2), overweight (25.0-29.9 kg m-2) and obese (⩾30.0 kg m-2) adults were considered metabolically healthy if they had 0 or 1 of 5 risk factors (hypertension, low high-density lipoprotein cholesterol, high triacylglycerol, high blood glucose and insulin resistance) in 1991/1994. Decline in physical function and worsening of bodily pain based on change in Short Form Health Survey items using eight repeated measures over 18.8 years (1991/1994-2012/2013) were compared between metabolic-BMI groups using linear mixed models. Odds of mobility limitation based on objective walking speed (slowest tertile) and of disability based on limitations in ⩾1 of 6 basic activities of daily living, each using three repeated measures over 8.3 years (2002/2004-2012/2013), were compared using logistic mixed models.

RESULTS

In multivariable-adjusted mixed models on up to 6635 adults (initial mean age 50 years; 70% male), healthy normal-weight adults experienced a decline in physical function of -3.68 (95% CI=-4.19, -3.16) score units per decade; healthy obese adults showed an additional -3.48 (-4.88, -2.08) units decline. Healthy normal-weight adults experienced a -0.49 (-1.11, 0.12) score unit worsening of bodily pain per decade; healthy obese adults had an additional -2.23 (-3.78, -0.69) units worsening. Healthy obesity versus healthy normal-weight conferred 3.39 (2.29, 5.02) times higher odds of mobility limitation and 3.75 (1.94, 7.24) times higher odds of disability.

CONCLUSIONS

Our results suggest that obesity, even if metabolically healthy, accelerates age-related declines in functional ability and poses a threat to independence in older age.

Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data

BACKGROUND

Adverse psychosocial working environments characterized by job strain (the combination of high demands and low control at work) are associated with an increased risk of depressive symptoms among employees, but evidence on clinically diagnosed depression is scarce. We examined job strain as a risk factor for clinical depression.

METHOD

We identified published cohort studies from a systematic literature search in PubMed and PsycNET and obtained 14 cohort studies with unpublished individual-level data from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium. Summary estimates of the association were obtained using random-effects models. Individual-level data analyses were based on a pre-published study protocol.

RESULTS

We included six published studies with a total of 27 461 individuals and 914 incident cases of clinical depression. From unpublished datasets we included 120 221 individuals and 982 first episodes of hospital-treated clinical depression. Job strain was associated with an increased risk of clinical depression in both published [relative risk (RR) = 1.77, 95% confidence interval (CI) 1.47-2.13] and unpublished datasets (RR = 1.27, 95% CI 1.04-1.55). Further individual participant analyses showed a similar association across sociodemographic subgroups and after excluding individuals with baseline somatic disease. The association was unchanged when excluding individuals with baseline depressive symptoms (RR = 1.25, 95% CI 0.94-1.65), but attenuated on adjustment for a continuous depressive symptoms score (RR = 1.03, 95% CI 0.81-1.32).

CONCLUSIONS

Job strain may precipitate clinical depression among employees. Future intervention studies should test whether job strain is a modifiable risk factor for depression.

Informal caregiving as a risk factor for type 2 diabetes in individuals with favourable and unfavourable psychosocial work environments: A longitudinal multi-cohort study

AIM

To examine whether informal caregiving is associated with increased risk of type 2 diabetes (T2D), and whether job strain and social support at work modify the association.

METHODS

Individual participant's data were pooled from three cohort studies-the French GAZEL study, the Swedish Longitudinal Occupational Survey of Health (SLOSH) and the British Whitehall II study-a total of 21,243 study subjects. Informal caregiving was defined as unpaid care for a closely related person. Job strain was assessed using the demand-control model, and questions on co-worker and supervisor support were combined in a measure of social support at work. Incident T2D was ascertained using registry-based, clinically assessed and self-reported data.

RESULTS

A total of 1058 participants developed T2D during the up to 10 years of follow-up. Neither informal caregiving (OR: 1.09, 95% CI: 0.92-1.30) nor high job strain (OR: 1.04, 95% CI: 0.86-1.26) were associated with T2D risk, whereas low social support at work was a risk factor for T2D (OR: 1.18, 95% CI: 1.02-1.37). Also, informal caregivers who were also exposed to low social support at work were at higher risk of T2D (OR: 1.40, 95% CI: 1.08-1.82) compared with those who were not informal caregivers and had high social support at work (multiplicative test for interaction, P=0.04; additive test for interaction, synergy index=10).

CONCLUSION

Informal caregiving was not independently associated with T2D risk. However, low social support at work was a risk factor, and informal caregivers with low social support at work had even higher risks of T2D.

Organizational fairness and psychological distress in hospital physicians

Aims: Prior research has reported high levels of stress for physicians, but determinants of this stress are poorly understood. We explored whether problems in decision-making procedures and treatment of employees, as expressed in the theory of organizational fairness, may contribute to psychological distress in hospital physicians. Methods: Structural equation modelling (LISREL) was based on survey responses from 251 male and 196 female physicians working in 11 public hospitals in Finland. Results: Low organizational fairness increased the risk of psychological distress in male physicians but not in female physicians. In the former group, the association between organizational fairness and psychological distress was partially mediated by decreased job control and increased workload. Conclusions: These findings suggest that broadening the view from the traditional psychosocial work characteristics to justice in management may assist in efforts to promote physicians' health and well-being.

Antidepressant use and work-related injuries

BACKGROUND

Adverse effects of antidepressants are most common at the beginning of the treatment, but possible also later. We examined the association between antidepressant use and work-related injuries taking into account the duration of antidepressant use.

METHOD

Antidepressant use and work-related injuries between 2000 and 2011 were measured among 66 238 employees (mean age 43.8 years, 80% female) using linkage to national records (the Finnish Public Sector study). We analysed data using time-dependent modelling with individuals as their own controls (self-controlled case-series design).

RESULTS

In 2238 individuals who had used antidepressants and had a work-related injury during a mean follow-up of 7.8 years, no increase in the risk of injury was observed in the beginning of antidepressant treatment. However, an increased injury risk was seen after 3 months of treatment (rate ratio, compared with no recent antidepressant use, 1.27, 95% confidence interval 1.10-1.48). This was also the case among those who had used only selective serotonin reuptake inhibitors (n = 714; rate ratio 1.41, 95% confidence interval 1.08-1.83).

CONCLUSIONS

Antidepressant use was not associated with an increased risk of work-related injury at the beginning of treatment. Post-hoc analyses of antidepressant trials are needed to determine whether long-term use of antidepressants increases the risk of work-related injury.

Psychosocial factors associated with work disability in men and women with diabetes: a pooled analysis of three occupational cohort studies

AIMS

To examine the extent to which adverse psychosocial factors, such as living alone, psychological distress, job strain and low support from supervisor, increase the risk of work disability (sickness absence and disability pension) among employees with diabetes.

METHODS

In this pooled analysis of individual-participant data from three occupational cohort studies (the Finnish Public Sector Study, the British Whitehall II study, and the French GAZEL study), 1088 women and 949 men with diabetes were followed up to determine the duration (number of days) and frequency (number of spells) of work disability. The mean follow-up periods were 3.2 years in the GAZEL study, 4.6 years in the Whitehall II study and 4.7 years in the Finnish Public Sector Study. Psychosocial factors and potential confounding factors were assessed at baseline using standard questionnaires. Study-specific estimates were pooled using fixed-effects meta-analysis.

RESULTS

In analysis adjusted for sociodemographic factors, health behaviours and comorbidities, participants with psychological distress had longer (rate ratio 1.66; 95% CI 1.31-2.09) and more frequent absences (rate ratio 1.33; 95% CI 1.19-1.49) compared with those with no psychological distress. Job strain was associated with slightly increased absence frequency (rate ratio 1.19 95% CI 1.05-1.35), but not with absence duration. Living alone and low supervisor support were not associated with absence duration or frequency. We observed no sex differences in these associations.

CONCLUSIONS

Psychological distress was associated with increased duration and frequency of work disability among employees with diabetes. Job strain was associated with increased absence frequency but not with absence duration.

Effectiveness of legislative changes obligating notification of prolonged sickness absence and assessment of remaining work ability on return to work and work participation: a natural experiment in Finland

Objectives

Policies have been introduced to reduce sickness absence, but their effectiveness is largely unknown. In a natural experiment, we examined effects of legislative changes on return to work and work participation.

Methods

The source population consisted of up to 72 164 Finnish public sector employees with a permanent job contract in 2008–2011 (before) and in 2013–2014 (after). We used employees with a continuous sickness absence of at least 30 calendar-days (n=5708–6393), 60 compensated days (n=1481–1655) and 90 compensated days (n=766–932). We examined sustainable return to work (a minimum of 28 consecutive working days) with survival analysis as well as monthly work participation after a sickness absence, and annual gain in work participation after the intervention, using trajectory analyses.

Results

Sustainable return to work after 60 days of sickness absence occurred earlier after the legislative changes (p value 0.017), although the effect reduced towards the end of the follow-up. There were no differences in return to work after a 30 or 90 days of sickness absence. The largest annual gain, postintervention versus preintervention, in monthly work participation was observed among employees with 60 days of sickness absence and was 230.9 person-years/10 000 employees. The corresponding annual gains among those with 30 days and 90 days of sickness absence were 51.8 and 39.6, respectively.

Conclusions

Our findings suggest that the legislative changes, obligating early notification of prolonged sickness absences as well as assessment of remaining work ability and possibilities to continue working, may enhance sustainable return to work in the short term. Other measures will be needed to enhance work participation, especially in the long term.

Lifestyle-related risk factors and trajectories of work disability over 5 years in employees with diabetes: findings from two prospective cohort studies

AIMS

To examine work disability trajectories among employees with and without diabetes and identify lifestyle-related factors associated with these trajectories.

METHODS

We assessed work disability using records of sickness absence and disability pension among participants with diabetes and age- sex-, socio-economic status- and marital status-matched controls in the Finnish Public Sector Study (1102 cases; 2204 controls) and the French GAZEL study (500 cases; 1000 controls), followed up for 5 years. Obesity, physical activity, smoking and alcohol consumption were assessed at baseline and the data analysed using group-based trajectory modelling.

RESULTS

Five trajectories described work disability: 'no/very low disability' (41.1% among cases and 48.0% among controls); 'low-steady' (35.4 and 34.7%, respectively); 'high-steady' (13.6 and 12.1%, respectively); and two 'high-increasing' trajectories (10.0 and 5.2%, respectively). Diabetes was associated with a 'high-increasing' trajectory only (odds ratio 1.90, 95% CI 1.47-2.46). Obesity and low physical activity were similarly associated with high work disability in people with and without diabetes. Smoking was associated with 'high-increasing' trajectory in employees with diabetes (odds ratio 1.88, 95% CI 1.21-2.93) but not in those without diabetes (odds ratio 1.32, 95% CI 0.87-2.00). Diabetes was associated with having multiple ( ≥ 2) risk factors (21.1 vs. 11.4%) but the association between multiple risk factors and the 'high-increasing' trajectory was similar in both groups.

CONCLUSIONS

The majority of employees with diabetes have low disability rates, although 10% are on a high and increasing disability trajectory. Lifestyle-related risk factors have similar associations with disability among employees with and without diabetes, except smoking which was only associated with poorer prognosis in diabetes.

Severity of depressive symptoms as a predictor of mortality: the English longitudinal study of ageing

BACKGROUND

Major depressive disorder and subthreshold depression have been associated with premature mortality. We investigated the association between depressive symptoms and mortality across the full continuum of severity.

METHOD

We used Cox proportional hazards models to examine the association between depressive symptom severity, assessed using the eight-item Center for Epidemiological Studies Depression Scale (CES-D; range 0-8), and the risk of all-cause mortality over a 9-year follow-up, in 11 104 members of the English Longitudinal Study of Ageing.

RESULTS

During follow-up, one fifth of study members died (N = 2267). Depressive symptoms were associated with increased mortality across the full range of severity (p trend < 0.001). Relative to study members with no symptoms, an increased risk of mortality was found in people with depressive symptoms of a low [hazard ratio (HR) for a score of 2 was 1.59, 95% confidence interval (CI) 1.40-1.82], moderate (score of 4: HR 1.80, 95% CI 1.52-2.13) and high (score of 8: HR 2.27, 95% CI 1.69-3.04) severity, suggesting risk emerges at low levels but plateaus thereafter. A third of participants (36.4%, 95% CI 35.5-37.3) reported depressive symptoms associated with an increased mortality risk. Adjustment for physical activity, physical illnesses, and impairments in physical and cognitive functioning attenuated this association (p trend = 0.25).

CONCLUSIONS

Depressive symptoms are associated with an increased mortality risk even at low levels of symptom severity. This association is explained by physical activity, physical illnesses, and impairments in physical and cognitive functioning.

Interleukin-6 as a predictor of symptom resolution in psychological distress: a cohort study

BACKGROUND

Elevated levels of interleukin-6 (IL-6) have been associated with the development of common mental disorders, such as depression, but its role in symptom resolution is unclear.

METHOD

We examined the association between IL-6 and symptom resolution in a non-clinical sample of participants with psychological distress.

RESULTS

Relative to high IL-6 levels, low levels at baseline were associated with symptom resolution at follow-up [age- and sex-adjusted risk ratio (RR) = 1.15, 95% confidence interval (CI) 1.06-1.25]. Further adjustment for covariates had little effect on the association. Symptomatic participants with repeated low IL-6 were more likely to be symptom-free at follow-up compared with those with repeated high IL-6 (RR = 1.21, 95% CI 1.03-1.41). Among the symptomatic participants with elevated IL-6 at baseline, IL-6 decreased along with symptom resolution.

CONCLUSIONS

IL-6 is potentially related to the mechanisms underlying recovery from symptoms of mental ill health. Further studies are needed to examine these mechanisms and to confirm the findings in relation to clinical depression.

Job strain and risk of obesity: systematic review and meta-analysis of cohort studies

Job strain, the most widely used indicator of work stress, is a risk factor for obesity-related disorders such as cardiovascular disease and type 2 diabetes. However, the extent to which job strain is related to the development of obesity itself has not been systematically evaluated. We carried out a systematic review (PubMed and Embase until May 2014) and meta-analysis of cohort studies to address this issue. Eight studies that fulfilled inclusion criteria showed no overall association between job strain and the risk of weight gain (pooled odds ratio for job strain compared with no job strain 1.04, 95% confidence interval (CI) 0.99–1.09, N_Total=18 240) or becoming obese (1.00, 95% CI 0.89–1.13, N_Total=42 222). In addition, a reduction in job strain over time was not associated with lower obesity risk (1.13, 95% CI 0.90–1.41, N_Total=6507). These longitudinal findings do not support the hypothesis that job strain is an important risk factor for obesity or a promising target for obesity prevention.

Length of sick leave as a risk marker of hip fracture: a nationwide cohort study from Sweden

Sickness absence is a risk marker for future health outcomes, but no previous studies have examined its association with osteoporotic fractures in old age. The results of this prospective population-based cohort study based on Swedish registers suggest that sickness absence is associated with higher risk of hip fracture.

INTRODUCTION

Number of sick leave days is a risk marker for future health outcomes, but few studies have examined its association with major public health concerns in old age, such as osteoporotic fractures. The aim of this prospective, nationwide, population-based cohort study based on Swedish registers was to investigate the association between number of sick leave days and future risk of hip fracture.

METHODS

Participants included were all 983,244 individuals who were living in Sweden on 31 December 1995, aged 50 to 64 years, employed, and with no previous hip fracture. Those with sick leave days in 1995 were compared to those with no sickness absence. Incidence of hip fracture was followed from 1996 to 2010.

RESULTS

According to Cox regression models adjusted for sociodemographic factors and morbidity, being on sick leave more than 3 months, irrespective of cause, was associated with a 2.0-fold (hazard ratio (HR) 1.96, 95% confidence interval (CI) 1.74-2.20) and 1.4-fold (HR 1.40, 95% CI 1.27-1.56) increased risk of hip fracture in men and women, respectively. Analyses repeated among those with previous non-hip fractures replicated the significant associations.

CONCLUSION

This nationwide cohort study suggests that sickness absence in working-age women and men is a risk marker of hip fracture at old ages.

Personality change associated with chronic diseases: pooled analysis of four prospective cohort studies

BACKGROUND

Common chronic conditions, such as heart disease and cancer, are associated with increased psychological distress, functional limitations and shortened life expectancy, but whether these diseases alter aspects of personality remains unclear.

METHOD

To examine whether the onset of heart disease, stroke, diabetes, cancer, hypertension, arthritis and respiratory disease is associated with subsequent changes in personality traits of the five-factor model, we pooled data from the Health and Retirement Study, the Midlife in the United States Survey, and the graduate and sibling samples of the Wisconsin Longitudinal Study for an individual-participant meta-analysis (total n=17,493; mean age at baseline 55.8 years).

RESULTS

After adjustment for age, we observed consistent decreases in extraversion [-0.25 T-scores per one disease; 95% confidence interval (CI) -0.40 to -0.10], emotional stability (-0.40, 95% CI -0.61 to -0.19), conscientiousness (-0.44, 95% CI -0.57 to -0.30) and openness to experience (-0.25, 95% CI -0.37 to -0.13) but not in agreeableness (-0.05, 95% CI -0.19 to 0.08) after the onset of chronic diseases. The onset of each additional chronic disease accelerated the average age-related personality change by 2.5 years in decreasing extraversion, 5.5 years in decreasing conscientiousness, and 1.6 years in decreasing openness to experience, and attenuated the increasing levels of emotional stability by 1.9 years. Co-morbid conditions were associated with larger changes than single diseases, suggesting a dose-response association between morbidity and personality change.

CONCLUSIONS

These results support the hypothesis that chronic diseases influence personality development in adulthood.

Job strain and the risk of severe asthma exacerbations: a meta-analysis of individual-participant data from 100 000 European men and women

Background

Many patients and healthcare professionals believe that work‐related psychosocial stress, such as job strain, can make asthma worse, but this is not corroborated by empirical evidence. We investigated the associations between job strain and the incidence of severe asthma exacerbations in working‐age European men and women.

Methods

We analysed individual‐level data, collected between 1985 and 2010, from 102 175 working‐age men and women in 11 prospective European studies. Job strain (a combination of high demands and low control at work) was self‐reported at baseline. Incident severe asthma exacerbations were ascertained from national hospitalization and death registries. Associations between job strain and asthma exacerbations were modelled using Cox regression and the study‐specific findings combined using random‐effects meta‐analyses.

Results

During a median follow‐up of 10 years, 1 109 individuals experienced a severe asthma exacerbation (430 with asthma as the primary diagnostic code). In the age‐ and sex‐adjusted analyses, job strain was associated with an increased risk of severe asthma exacerbations defined using the primary diagnostic code (hazard ratio, HR: 1.27, 95% confidence interval, CI: 1.00, 1.61). This association attenuated towards the null after adjustment for potential confounders (HR: 1.22, 95% CI: 0.96, 1.55). No association was observed in the analyses with asthma defined using any diagnostic code (HR: 1.01, 95% CI: 0.86, 1.19).

Conclusions

Our findings suggest that job strain is probably not an important risk factor for severe asthma exacerbations leading to hospitalization or death.

Use of self-administered instruments to assess psychiatric disorders in older people: validity of the General Health Questionnaire, the Center for Epidemiologic Studies Depression Scale and the self-completion version of the revised Clinical Interview Schedule

BACKGROUND

Diagnosis of depressive disorder using interviewer-administered instruments is expensive and frequently impractical in large epidemiological surveys. The aim of this study was to assess the validity of three self-completion measures of depressive disorder and other psychiatric disorders in older people against an interviewer-administered instrument.

METHOD

A random sample stratified by sex, age and social position was selected from the Whitehall II study participants. This sample was supplemented by inclusion of depressed Whitehall II participants. Depressive disorder and other mental disorders were assessed by the interviewer-administered structured revised Clinical Interview Schedule (CIS-R) in 277 participants aged 58-80 years. Participants also completed a computerized self-completion version of the CIS-R in addition to the General Health Questionnaire (GHQ) and the Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

The mean total score was similar for the interviewer-administered (4.43) and self-completion (4.35) versions of the CIS-R [95% confidence interval (CI) for difference -0.31 to 0.16]. Differences were not related to sex, age, social position or presence of chronic physical illness. Sensitivity/specificity of self-completion CIS-R was 74%/98% for any mental disorder and 75%/98% for depressive episode. The corresponding figures were 86%/87% and 78%/83% for GHQ and 77%/89% and 89%/86% for CES-D.

CONCLUSIONS

The self-completion computerized version of the CIS-R is feasible and has good validity as a measure of any mental disorder and depression in people aged ≥ 60 years. GHQ and CES-D also have good criterion validity as measures of any mental disorder and depressive disorder respectively.

Ageing and the prevalence and treatment of mental health problems

BACKGROUND

Ageing is an important factor in the development of mental health problems and their treatment. We assessed age trajectories of common mental disorders (CMDs) and psychotherapy utilization from adolescence to old age, and examined whether these trajectories were modified by time period or birth cohort effects.

METHOD

British Household Panel Survey (BHPS) with an 18-year follow-up between 1991 and 2009 (n=30 224 participants, aged 15–100 years, with an average 7.3 person-observations per person). CMDs were assessed with the 12-item version of the General Health Questionnaire (GHQ). Psychotherapy treatment utilization during the past year was self-reported by the participants. The modifying influences of time period and cohort effects were assessed in a cohort-sequential longitudinal setting.

RESULTS

Following a moderate decrease after age 50, the prevalence of GHQ caseness increased steeply from age 75. This increase was more marked in the 2000s (GHQ prevalence increasing from 24% to 43%) than in the 1990s (from 22% to 34%). Psychotherapy utilization decreased after age 55, with no time period or cohort effects modifying the age trajectory. These ageing patterns were replicated in within-individual longitudinal analysis.

CONCLUSIONS

Old age is associated with higher risk of CMDs, and this association has become more marked during the past two decades. Ageing is also associated with an increasing discrepancy between prevalence of mental disorders and provision of treatment, as indicated by lower use of psychotherapy in older individuals.