Prostate Cancer Screening With PSA, Kallikrein Panel, and MRI: The ProScreen Randomized Trial

Importance

Prostate-specific antigen (PSA) screening has potential to reduce prostate cancer mortality but frequently detects prostate cancer that is not clinically important.

Objective

To describe rates of low-grade (grade group 1) and high-grade (grade groups 2-5) prostate cancer identified among men invited to participate in a prostate cancer screening protocol consisting of a PSA test, a 4-kallikrein panel, and a magnetic resonance imaging (MRI) scan.

Design, Setting, and Participants

The ProScreen trial is a clinical trial conducted in Helsinki and Tampere, Finland, that randomized 61 193 men aged 50 through 63 years who were free of prostate cancer in a 1:3 ratio to either be invited or not be invited to undergo screening for prostate cancer between February 2018 and July 2020.

Interventions

Participating men randomized to the intervention underwent PSA testing. Those with a PSA level of 3.0 ng/mL or higher underwent additional testing for high-grade prostate cancer with a 4-kallikrein panel risk score. Those with a kallikrein panel score of 7.5% or higher underwent an MRI of the prostate gland, followed by targeted biopsies for those with abnormal prostate gland MRI findings. Final data collection occurred through June 31, 2023.

Main Outcomes and Measures

In descriptive exploratory analyses, the cumulative incidence of low-grade and high-grade prostate cancer after the first screening round were compared between the group invited to undergo prostate cancer screening and the control group.

Results

Of 60 745 eligible men (mean [SD] age, 57.2 [4.0] years), 15 201 were randomized to be invited and 45 544 were randomized not to be invited to undergo prostate cancer screening. Of 15 201 eligible males invited to undergo screening, 7744 (51%) participated. Among them, 32 low-grade prostate cancers (cumulative incidence, 0.41%) and 128 high-grade prostate cancers (cumulative incidence, 1.65%) were detected, with 1 cancer grade group result missing. Among the 7457 invited men (49%) who refused participation, 7 low-grade prostate cancers (cumulative incidence, 0.1%) and 44 high-grade prostate cancers (cumulative incidence, 0.6%) were detected, with 7 cancer grade groups missing. For the entire invited screening group, 39 low-grade prostate cancers (cumulative incidence, 0.26%) and 172 high-grade prostate cancers (cumulative incidence, 1.13%) were detected. During a median follow-up of 3.2 years, in the group not invited to undergo screening, 65 low-grade prostate cancers (cumulative incidence, 0.14%) and 282 high-grade prostate cancers (cumulative incidence, 0.62%) were detected. The risk difference for the entire group randomized to the screening invitation vs the control group was 0.11% (95% CI, 0.03%-0.20%) for low-grade and 0.51% (95% CI, 0.33%-0.70%) for high-grade cancer.

Conclusions and Relevance

In this preliminary descriptive report from an ongoing randomized clinical trial, 1 additional high-grade cancer per 196 men and 1 low-grade cancer per 909 men were detected among those randomized to be invited to undergo a single prostate cancer screening intervention compared with those not invited to undergo screening. These preliminary findings from a single round of screening should be interpreted cautiously, pending results of the study's primary mortality outcome.

Trial Registration

ClinicalTrials.gov Identifier: NCT03423303.

Association between work-related factors and health behaviour clusters among Finnish private-sector service workers

PURPOSE

We examined how work-related factors associate with several health behaviours that appear together among the large, but less-studied, blue- and pink-collar worker group, which is characterized by low education and income levels.

METHODS

In 2019, we conducted a cross-sectional survey among private sector service workers (n = 5256) in Finland. We applied two-step cluster analysis to identify groups on the basis of leisure-time physical activity, sleep adequacy, frequency of heavy drinking, smoking status, and frequency of fruit, vegetable and berry consumption. We examined the associations with work-related factors, using multinomial regression analyses and adjusting for confounding factors.

RESULTS

We identified six clusters labelled as Moderately Healthy (28% of the participants), Healthy - Vigorous Exercise (19%), Sedentary Lifestyle (16%), Inadequate Sleep (15%), Mixed Health Behaviours (15%), and Multiple Risk Behaviours (8%). Those who perceived their work to be mentally or physically strenuous more commonly belonged to the Inadequate Sleep and Multiple Risk Behaviours clusters. Time pressure made belonging to the Inadequate Sleep, Mixed Health Behaviours, and Multiple Risk Behaviours clusters more likely. Those who were dissatisfied with their work more often belonged to the Healthy - Vigorous Exercise, Inadequate Sleep, and Multiple Risk Behaviours clusters.

CONCLUSION

In addition of finding several considerably differing health behaviour clusters, we also found that adverse working conditions were associated with clusters characterized by multiple risk behaviours, especially inadequate sleep. Private-sector service workers' working conditions should be improved so that they support sufficient recovery, and occupational health services should better identify co-occurring multiple risk behaviours.

The dynamics in food selection stemming from price awareness and perceived income adequacy: a cross-sectional study using 1-year loyalty card data

BACKGROUND

Higher cost of healthy foods may explain unhealthy dietary patterns in lower-income households. Unfortunately, combining food selection and nutrient intake data to price and expenditure is challenging. Food retailer's customer loyalty card data, linked to nutrient composition database, is a novel method for simultaneous exploration of food purchases, price, and nutrition.

OBJECTIVES

We studied the associations between perceived income adequacy (PIA) as a grouping variable with price (per kilogram or megajoule) and the volume of purchases (percentage of expenditure or energy) simultaneously as outcome variables for 17 most purchased food groups.

METHODS

We used 1-year (2018) loyalty card data from the largest grocery chain in Finland. Participants were 28,783 loyalty cardholders who made ≥41% of food purchases from the retailer and answered an online questionnaire at the midpoint of data collection. The 5-level PIA described the perceived financial situation in the household. Energy and nutrient content of foods purchased were from the Finnish Food Composition Database Fineli. We calculated the Nutrient Rich Food Index per 100 g food using 11 nutrients. Trends in prices and expenditures between PIA levels were analyzed using 2-sided Jonckheere-Terpstra tests, with false discovery rate control (Benjamini-Hochberg method) and confounder adjustments (inverse probability weighting).

RESULTS

Lower PIA participants selected cheaper foods per kilogram and megajoule within most food groups. They also favored unhealthy food groups cheap in energy [<1 € (USD 1.18)/MJ]. Despite lower purchase price, the expenditure (%) among lower PIA was higher on alcohol, snacks, sugar-sweetened beverages, and sweets and chocolates.

CONCLUSIONS

Participants with lower PIA showed stronger price awareness. It is crucial to consider the pricing of competing alternative food groups, when steering toward environmentally sustainable and healthier food purchases. Package labeling might also direct the selection of healthier choices among the less expensive items within a food group.

Building nutritionally meaningful classification for grocery product groups: the LoCard Food Classification process

Analysing customer loyalty card data is a novel method for assessing nutritional quality and changes in a population's food consumption. However, prior to its use, the thousands of grocery products available in stores must be reclassified from the retailer's original hierarchical structure into a structure that is suitable for the use of nutrition and health research. We created LoCard Food Classification (LCFC) and examined how it reflects the nutritional quality of the grocery product groups. Nutritional quality was considered the main criterion guiding the reclassification of the 3574 grocery product groups. Information on the main ingredient of the product group, purpose of use, and carbon footprint were also used at the more granular levels of LCFC. The main challenge in the reclassification was a lack of detailed information on the type of products included in each group, and that some of the groups included products that have opposite health effects. The final LCFC has four hierarchical levels and it is openly available online. After reclassification, the product groups were linked with the Finnish food composition database, and the nutrient profile was assessed by calculating the Nutrient Rich Food Index (NRFI) for each product group. Standard deviation in NRFI decreased from 0.21 of the least granular level to 0.08 of the most granular level of LCFC indicating that the most granular level of LCFC has more homogeneous nutritional quality. Studies that apply LCFC to examine loyalty card data with health and environmental outcomes are needed to further demonstrate its validity.

Do LUTS Predict Mortality? An Analysis Using Random Forest Algorithms

Purpose

To evaluate a random forest (RF) algorithm of lower urinary tract symptoms (LUTS) as a predictor of all-cause mortality in a population-based cohort.

Materials and Methods

A population-based cohort of 3143 men born in 1924, 1934, and 1944 was evaluated using a mailed questionnaire including the Danish Prostatic Symptom Score (DAN-PSS-1) to assess LUTS as well as questions on medical conditions and behavioral and sociodemographic factors. Surveys were repeated in 1994, 1999, 2004, 2009 and 2015. The cohort was followed-up for vital status until the end of 2018. RF uses an ensemble of classification trees for prediction with a good flexibility and without overfitting. RF algorithms were developed to predict the five-year mortality using LUTS, demographic, medical, and behavioral factors alone and in combinations.

Results

A total of 2663 men were included in the study, of whom 917 (34%) died during follow-up (median follow-up time 15.0 years). The LUTS-based RF algorithm showed an area under the curve (AUC) 0.60 (95% CI 0.52-0.69) for five-year mortality. An expanded RF algorithm, including LUTS, medical history, and behavioral and sociodemographic factors, yielded an AUC 0.73 (0.65-0.81), while an algorithm excluding LUTS yielded an AUC 0.71 (0.62-0.78).

Conclusion

An exploratory RF algorithm using LUTS can predict all-cause mortality with acceptable discrimination at the group level. In clinical practice, it is unlikely that LUTS will improve the accuracy to predict death if the patient's background is well known.

Early detection of clinically significant prostate cancer: protocol summary and statistical analysis plan for the ProScreen randomised trial

INTRODUCTION

Evidence on the effectiveness of prostate cancer screening based on prostate-specific antigen is inconclusive and suggests a questionable balance between benefits and harms due to overdiagnosis, and complications from biopsies and overtreatment. However, diagnostic accuracy studies have shown that detection of clinically insignificant prostate cancer can be reduced by MRI combined with targeted biopsies.The aim of the paper is to describe the analysis of the ProScreen randomised trial to assess the performance of the novel screening algorithm in terms of the primary outcome, prostate cancer mortality and secondary outcomes as intermediate indicators of screening benefits and harms of screening.

METHODS

The trial aims to recruit at least 111 000 men to achieve sufficient statistical power for the primary outcome. Men will be allocated in a 1:3 ratio to the screening and control arms. Interim analysis is planned at 10 years of follow-up, and the final analysis at 15 years. Difference between the trial arms in prostate cancer mortality will be assessed by Gray's test using intention-to-screen analysis of randomised men. Secondary outcomes will be the incidence of prostate cancer by disease aggressiveness, progression to advanced prostate cancer, death due to any cause and cost-effectiveness of screening.

ETHICS AND DISSEMINATION

The trial protocol was reviewed by the ethical committee of the Helsinki University Hospital (2910/2017). Results will be disseminated through publications in international peer-reviewed journals and at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03423303.

Geographical variation in treated psychotic and other mental disorders in Finland by region and urbanicity

PURPOSE

In Finland, prevalence of schizophrenia is higher in the eastern and northern regions and co-occurs with the distribution of schizophrenia polygenic risk scores. Both genetic and environmental factors have been hypothesized to contribute to this variation. We aimed to examine the prevalence of psychotic and other mental disorders by region and degree of urbanicity, and the impacts of socio-economic adjustments on these associations.

METHODS

Nationwide population registers from 2011 to 2017 and healthcare registers from 1975 to 2017. We used 19 administrative and three aggregate regions based on the distribution of schizophrenia polygenic risk scores, and a seven-level urban-rural classification. Prevalence ratios (PRs) were calculated by Poisson regression models and adjusted for gender, age, and calendar year (basic adjustments), and Finnish origin, residential history, urbanicity, household income, economic activity, and physical comorbidity (additional adjustments) on an individual level. Average marginal effects were used to visualize interaction effects between region and urbanicity.

RESULTS

A total of 5,898,180 individuals were observed. All mental disorders were slightly more prevalent (PR 1.03 [95% CI, 1.02-1.03]), and psychotic disorders (1.11 [1.10-1.12]) and schizophrenia (1.19 [1.17-1.21]) considerably more prevalent in eastern and northern than in western coastal regions. After the additional adjustments, however, the PRs were 0.95 (0.95-0.96), 1.00 (0.99-1.01), and 1.03 (1.02-1.04), respectively. Urban residence was associated with increased prevalence of psychotic disorders across all regions (adjusted PR 1.21 [1.20-1.22]).

CONCLUSION

After adjusting for socioeconomic and sociodemographic factors, the within-country distribution of mental disorders no longer followed the traditional east-west gradient. Urban-rural differences, on the other hand, persisted after the adjustments.

Tensorial Principal Component Analysis in Detecting Temporal Trajectories of Purchase Patterns in Loyalty Card Data: Retrospective Cohort Study

BACKGROUND

Loyalty card data automatically collected by retailers provide an excellent source for evaluating health-related purchase behavior of customers. The data comprise information on every grocery purchase, including expenditures on product groups and the time of purchase for each customer. Such data where customers have an expenditure value for every product group for each time can be formulated as 3D tensorial data.

OBJECTIVE

This study aimed to use the modern tensorial principal component analysis (PCA) method to uncover the characteristics of health-related purchase patterns from loyalty card data. Another aim was to identify card holders with distinct purchase patterns. We also considered the interpretation, advantages, and challenges of tensorial PCA compared with standard PCA.

METHODS

Loyalty card program members from the largest retailer in Finland were invited to participate in this study. Our LoCard data consist of the purchases of 7251 card holders who consented to the use of their data from the year 2016. The purchases were reclassified into 55 product groups and aggregated across 52 weeks. The data were then analyzed using tensorial PCA, allowing us to effectively reduce the time and product group-wise dimensions simultaneously. The augmentation method was used for selecting the suitable number of principal components for the analysis.

RESULTS

Using tensorial PCA, we were able to systematically search for typical food purchasing patterns across time and product groups as well as detect different purchasing behaviors across groups of card holders. For example, we identified customers who purchased large amounts of meat products and separated them further into groups based on time profiles, that is, customers whose purchases of meat remained stable, increased, or decreased throughout the year or varied between seasons of the year.

CONCLUSIONS

Using tensorial PCA, we can effectively examine customers' purchasing behavior in more detail than with traditional methods because it can handle time and product group dimensions simultaneously. When interpreting the results, both time and product dimensions must be considered. In further analyses, these time and product groups can be directly associated with additional consumer characteristics such as socioeconomic and demographic predictors of dietary patterns. In addition, they can be linked to external factors that impact grocery purchases such as inflation and unexpected pandemics. This enables us to identify what types of people have specific purchasing patterns, which can help in the development of ways in which consumers can be steered toward making healthier food choices.

Weekday and weekend physical activity patterns and their correlates among young adults

BACKGROUND

Accelerometers enable assessment of within and between day variation in physical activity. The main aim was to examine weekday and weekend physical activity patterns among young adults. Additionally, correlates of the physical activity patterns were examined.

METHODS

Overall 325 adults (mean age 26.0 years, standard deviation 0.03) from the Special Turku Coronary Risk Factor Intervention Project used a wrist-worn ActiGraph accelerometer continuously for 1 week. Physical activity patterns over weekdays and weekends were identified by using the group-based trajectory modeling. Adolescent leisure time physical activity (LTPA) and sociodemographic characteristics (sex, marital and family status, education, work status, occupation, and health consciousness) were examined as possible correlates of physical activity patterns using multinomial regression analysis.

RESULTS

Five patterns were identified: consistently low activity (45%), active on weekday evenings and weekends (32%), consistently moderate activity (11%), active on weekdays (7%), and consistently high activity (5%). Low adolescent LTPA was associated with consistently low activity pattern in young adulthood. Women were more likely than men to belong in the more physically active groups (all other groups except active on weekdays, odds ratios between 2.26 and 6.17). Those in the active on weekdays group had lower education, were more often in the working life and in manual occupations than those in the consistently low activity group.

CONCLUSIONS

Marked heterogeneity in physical activity patterns across the week was observed among young adults. Especially history of physical activity, sex, education, work status, and occupation were associated with different physical activity patterns.

Impact of timing of surgery and adjuvant treatment on survival of adult IDH-wildtype glioblastoma: a single-center study of 392 patients

BACKGROUND

The purpose of our study was to analyze the impact of time interval from referral to surgery and from surgery to adjuvant treatment on survival of adult IDH-wildtype glioblastomas.

METHODS

Data on 392 IDH-wildtype glioblastomas diagnosed at the Tampere University Hospital in 2004-2016 were obtained from the electronic patient record system. Piecewise Cox regression was used to calculate hazard ratios for different time intervals between referral and surgery, as well as between surgery and adjuvant treatments.

RESULTS

The median survival time from primary surgery was 9.5 months (interquartile range: 3.8-16.0). Survival among patients with an interval exceeding four weeks from referral to surgery was no worse compared to <2 weeks (hazard ratio: 0.78; 95% confidence interval: 0.54-1.14). We found indications of poorer outcome when the interval from surgery to radiotherapy exceeded 30 days (hazard ratio: 1.42; 95% confidence interval: 0.91-2.21 for 31-44 days and 1.59; 0.94-2.67 for over 45 days).

CONCLUSIONS

Interval from referral to surgery in the range of 4-10 weeks was not associated with decreased survivals in IDH-wildtype glioblastomas. In contrast, delay exceeding 30 days from surgery to adjuvant treatment may decrease long-term survival.

Infant Feeding, Gut Permeability, and Gut Inflammation Markers

OBJECTIVES

Increased gut permeability and gut inflammation have been linked to the development of type 1 diabetes. Little is known on whether and how intake of different foods is linked to these mechanisms in infancy. We investigated whether the amount of breast milk and intake of other foods are associated with gut inflammation marker concentrations and permeability.

METHODS

Seventy-three infants were followed from birth to 12 months of age. Their diet was assessed with structured questionnaires and 3-day weighed food records at the age of 3, 6, 9, and 12 months. Gut permeability was assessed with the lactulose/mannitol test and fecal calprotectin and human β-defensin-2 (HBD-2) concentrations were analyzed from stool samples at the age of 3, 6, 9, and 12 months. The associations between foods and gut inflammation marker concentrations and permeability were analyzed using generalized estimating equations.

RESULTS

Gut permeability and gut inflammation marker concentrations decreased during the first year of life. Intake of hydrolyzed infant formula ( P = 0.003) and intake of fruits and juices ( P = 0.001) were associated with lower intestinal permeability. Intake of fruits and juices ( P < 0.001), vegetables ( P < 0.001), and oats ( P = 0.003) were associated with lower concentrations of HBD-2. Higher intake of breast milk was associated with higher fecal calprotectin concentrations ( P < 0.001), while intake of fruits and juices ( P < 0.001), vegetables ( P < 0.001), and potatoes ( P = 0.007) were associated with lower calprotectin concentrations.

CONCLUSIONS

Higher intake of breast milk may contribute to higher calprotectin concentration, whereas several complementary foods may decrease gut permeability and concentrations of calprotectin and HBD-2 in infant gut.

What is the role of puberty in the development of islet autoimmunity and progression to type 1 diabetes?

In many populations, the peak period of incidence of type 1 diabetes (T1D) has been observed to be around 10-14 years of age, coinciding with puberty, but direct evidence of the role of puberty in the development of T1D is limited. We therefore aimed to investigate whether puberty and the timing of its onset are associated with the development of islet autoimmunity (IA) and subsequent progression to T1D. A Finnish population-based cohort of children with HLA-DQB1-conferred susceptibility to T1D was followed from 7 years of age until 15 years of age or until a diagnosis of T1D (n = 6920). T1D-associated autoantibodies and growth were measured at 3- to 12-month intervals, and pubertal onset timing was assessed based on growth. The analyses used a three-state survival model. IA was defined as being either positive for islet cell antibodies plus at least one biochemical autoantibody (ICA + 1) or as being repeatedly positive for at least one biochemical autoantibody (BC1). Depending on the IA definition, either 303 (4.4%, ICA + 1) or 435 (6.3%, BC1) children tested positive for IA by the age of 7 years, and 211 (3.2%, ICA + 1)) or 198 (5.3%, BC1) developed IA during follow-up. A total of 172 (2.5%) individuals developed T1D during follow-up, of whom 169 were positive for IA prior to the clinical diagnosis. Puberty was associated with an increase in the risk of progression to T1D, but only from ICA + 1-defined IA (hazard ratio 1.57; 95% confidence interval 1.14, 2.16), and the timing of pubertal onset did not affect the association. No association between puberty and the risk of IA was detected. In conclusion, puberty may affect the risk of progression but is not a risk factor for IA.

Childhood Dyslipidemia and Carotid Atherosclerotic Plaque in Adulthood: The Cardiovascular Risk in Young Finns Study

Background Childhood exposure to dyslipidemia is associated with adult atherosclerosis, but it is unclear whether the long-term risk associated with dyslipidemia is attenuated on its resolution by adulthood. We aimed to address this question by examining the links between childhood and adult dyslipidemia on carotid atherosclerotic plaques in adulthood. Methods and Results The Cardiovascular Risk in Young Finns Study is a prospective follow-up of children that began in 1980. Since then, follow-up studies have been conducted regularly. In 2001 and 2007, carotid ultrasounds were performed on 2643 participants at the mean age of 36 years to identify carotid plaques and plaque areas. For childhood lipids, we exploited several risk factor measurements to determine the individual cumulative burden for each lipid during childhood. Participants were categorized into the following 4 groups based on their childhood and adult dyslipidemia status: no dyslipidemia (reference), incident, resolved, and persistent. Among individuals with carotid plaque, linear regression models were used to study the association of serum lipids with plaque area. The prevalence of plaque was 3.3% (N=88). In models adjusted for age, sex, and nonlipid cardiovascular risk factors, the relative risk for carotid plaque was 2.34 (95% CI, 0.91-6.00) for incident adult dyslipidemia, 3.00 (95% CI, 1.42-6.34) for dyslipidemia resolved by adulthood, and 5.23 (95% CI, 2.57-10.66) for persistent dyslipidemia. Carotid plaque area correlated with childhood total, low-density lipoprotein, and non-high-density lipoprotein cholesterol levels. Conclusions Childhood dyslipidemia, even if resolved by adulthood, is a risk factor for adult carotid plaque. Furthermore, among individuals with carotid plaque, childhood lipids associate with plaque size. These findings highlight the importance of primordial prevention of dyslipidemia in childhood to reduce atherosclerosis development.

Lung cancer incidence attributable to residential radon exposure in Finland

This study aimed to estimate (1) the number of avoidable lung cancer cases attributable to residential radon in Finland in 2017, separately by age, sex, dwelling type and smoking status, (2) the impact of residential radon alone and the joint effect of residential radon and smoking on the number of lung cancers and (3) the potential decrease in the number of radon-attributable lung cancers if radon concentrations exceeding specified action levels (100, 200 and 300 Bq m^-3) would have been mitigated to those levels. Population-based surveys of radon concentrations and smoking patterns were used. Observed radon levels were contrasted with 25 Bq m^-3 representing a realistic minimum level of exposure. Lung cancer risk estimates for radon and smoking were derived from literature. Lastly, the uncertainty due to the estimation of exposure and risk was quantified using a computationally derived uncertainty interval. At least 3% and at most 8% of all lung cancers were estimated as being attributable to residential radon. For small cell carcinoma, the proportion of cases attributable to radon was 8-13%. Among smokers, the majority of the radon-related cases were attributable to the joint effect of radon and smoking. Reduction of radon exposure to 100 Bq m^-3 action level would eliminate approximately 30% of radon-attributable cases. Estimates were low compared with the literature, given the (relatively high) radon levels in Finland. This was mainly due to the lower radon levels and higher smoking prevalence in flats than in houses and a more realistic point of comparison, factors which have been ignored in previous studies. The results can guide actions in radon protection and in prevention of lung cancers.

Who buys non-alcoholic beer in Finland? Sociodemographic characteristics and associations with regular beer purchases

BACKGROUND

The consumption of non-alcoholic beer and other non-alcoholic and low-alcohol beverages has grown significantly in recent years. Due to a lack of suitable datasets, there have been few studies conducted on the forerunners of the non-alcoholic beer consumption trend. This study examined the associations of sociodemographic characteristics with non-alcoholic beer purchase, and of non-alcoholic beer purchases with regular beer purchases.

METHODS

The data consisted of longitudinal individual purchases of non-alcoholic and regular beer from grocery stores in 2017 and 2018. The study participants were loyalty cardholders from the largest food retailer in Finland (n = 47,066). The level of education, household income and occupational status were analyzed as determinants of non-alcoholic beer purchase using logistic regression models. The changes in the regular and non-alcoholic beer purchases from 2017 to 2018 and the distributions of non-alcoholic beer purchase by regular beer purchase, by gender and by age were described.

RESULTS

Between 2017 and 2018, the total volume of non-alcoholic beer purchases increased from 2.3% to 3.7% of the total volume of all beer purchases. Men and older people purchased non-alcoholic beer more often than women and younger people did. Non-alcoholic beer purchases were most common among the highly educated and high-income consumers. Non-alcoholic beer purchases were most prevalent in the groups with the highest volumes of regular beer purchase.

CONCLUSIONS

Educated and affluent consumers have been the forerunners of non-alcoholic beer consumption in Finland. In order to promote the substitution of regular beer with non-alcoholic beer the shift towards lower-strength beverages should be facilitated across social strata.

Dietary fatty acid intake in childhood and the risk of islet autoimmunity and type 1 diabetes: the DIPP birth cohort study

PURPOSE

The aim was to study the associations between dietary intake of fatty acids in childhood and the risk of islet autoimmunity and type 1 diabetes (T1D).

METHODS

The prospective Finnish Type 1 Diabetes Prediction and Prevention (DIPP) Study included children with genetic susceptibility to T1D born between 1996 and 2004. Participants were followed up every 3 to 12 months up to 6 years for diet, islet autoantibodies, and T1D. Dietary intake of several fatty acids at the age of 3 months to 6 years was assessed 1-8 times per participant with a 3-day food record. Joint models adjusted for energy intake, sex, HLA genotype and familial diabetes were used to investigate the associations of longitudinal intake of fatty acids and the development of islet autoimmunity and T1D.

RESULTS

During the 6-year follow-up, 247 (4.4%) children of 5626 developed islet autoimmunity and 94 (1.7%) children of 5674 developed T1D. Higher intake of monounsaturated fatty acids (HR 0.63; 95% CI 0.47, 0.82), arachidonic acid (0.69; 0.50, 0.94), total n-3 fatty acids (0.64; 0.48, 0.84), and long-chain n-3 fatty acids (0.14; 0.04, 0.43), was associated with a decreased risk of islet autoimmunity with and without energy adjustment. Higher intake of total fat (0.73; 0.53, 0.98), and saturated fatty acids (0.55; 0.33, 0.90) was associated with a decreased risk of T1D only when energy adjusted.

CONCLUSION

Intake of several fatty acids was associated with a decreased risk of islet autoimmunity or T1D among high-risk children. Our findings support the idea that dietary factors, including n-3 fatty acids, may play a role in the disease process of T1D.

Changes in alcohol purchases from grocery stores after authorising the sale of stronger beverages: The case of the Finnish alcohol legislation reform in 2018

Aims: The Finnish alcohol law was reformed in January 2018. The availability of alcoholic beverages in grocery stores increased as the legal limit for retail sales of alcoholic drinks was raised from 4.7% to 5.5% alcohol, and the requirement of production by fermentation was abolished. We analysed how the inclusion of strong beers, ciders, and ready-to-drink beverages in grocery stores was reflected in alcohol purchases, and how these changes differed by age, sex, level of education and household income. Design: The study sample included 47,066 loyalty card holders from the largest food retailer in Finland. The data consisted of longitudinal, individual-level information on alcohol purchases from grocery stores, covering the time period between 1 January 2017 and 31 December 2018. The volumes of absolute alcohol during a calendar year from beers, ciders, ready-to-drink beverages, and in total, were calculated. Alcohol purchases in 2017 and 2018 were compared. Results: There was no overall change in the total alcohol (0.04 [95% CI -0.03, 0.11] litres/year) or beer purchases (-0.05 [95% CI -0.11, 0.02] litres/year). Purchases of ready-to-drink beverages increased by 0.10 [95% CI 0.09, 0.11] litres/year (+ 84%). Total alcohol purchases increased in the three highest income groups, whereas they decreased in the two lowest groups (p for the interaction < 0.0001). Conclusions: The increased purchases of alcohol as ready-to-drink beverages were, on the average, compensated for by a decrease in purchases of other alcoholic beverages. Higher prices probably limited the purchases among lower income groups and younger consumers, while the increase was sharper in higher income groups.

Foot-related diabetes complications: care pathways, patient profiles and costs

BACKGROUND

Foot-related diabetes complications reduce individual well-being, increase mortality and results in increased healthcare costs. Despite their notable stress on health services, studies examining the foot complication care pathways, especially from the viewpoint of health services, are limited. We aimed to identify the most typical care pathways following an initial foot-related diabetes complication, to characterize the patients on each pathway and calculate the related healthcare costs.

METHODS

The identification of pathways was based on population-wide register-based data including all persons diagnosed with diabetes in Finland from 1964 to 2017. For each patient, initial foot-related complication from 2011-2016 was identified using the ICD-10 codes and related healthcare episodes were followed for two years until the end of 2017 or death. A sequence analysis was conducted on care episodes resulting in groups of typical care pathways, as well as their patient profiles. The costs of pathways resulting from the care episodes were calculated based on the data and the reported national unit costs and analyzed using linear models.

RESULTS

We identified six groups of typical pathways each comprising mainly single type of care episodes. Three of the groups comprised over 10 000 patients while the remaining groups ranged from a few hundred to a few thousand. Majority of pathways consisted only single care episode. However, among the rest of the care pathways variability in length of care pathways was observed between and within group of pathways. On average, the patients were over 65 years of age and were diagnosed with diabetes for over a decade. The pathways resulted in an annual cost of EUR 13 million. The mean costs were nearly 20-fold higher in the group with the highest costs (EUR 11 917) compared to the group with the lowest costs (EUR 609).

CONCLUSIONS

We identified groups of typical care pathways for diabetic foot and discovered notable heterogeneity in the resource use within the groups. This information is valuable in guiding the development of diabetes care to meet the growing need. Nevertheless, reasons underlying the observed heterogeneity requires further examination. Since foot complications are largely preventable, substantial savings could be achieved using cost-effective technologies and more efficient organization of care.

A Mobile App to Increase Fruit and Vegetable Acceptance Among Finnish and Polish Preschoolers: Randomized Trial

Background

Early childhood education and care (ECEC) centers are ideal venues for food education. As smartphones and tablets are becoming increasingly popular in ECEC centers, technology can be used to deliver such pedagogical content. Evidence suggests that video games can affect fruit and vegetable (FV) consumption among 9- to 12-year-old children, but studies among preschoolers are scarce.

Objective

This paper describes the development of the Mole’s Veggie Adventures app and its effectiveness in increasing FV acceptance among Finnish and Polish preschoolers aged 3 to 6 years.

Methods

A multiprofessional team created an app to be used in ECEC centers in groups of 3 to 10 children. The app aimed to increase vegetable acceptance, and it was built using elements that support the development of self-regulation and social skills. Altogether, 7 Finnish and 4 Polish ECEC centers participated in the study. Before randomization, parents reported background factors and their children’s willingness to taste different FVs. The ECEC professionals in the intervention arm were instructed to use the app at least once a week during the 3- to 4-week intervention period. The main outcomes in this unblinded, cluster-randomized study were FV acceptance and relative FV acceptance. The first was calculated as a sum variable describing the children’s willingness to taste 25 different FVs, the second as FV acceptance divided by the number of FVs served. We used analysis of covariance to compare the FV acceptance and relative FV acceptance scores between the intervention and control groups at follow-up.

Results

A total of 221 children were included in the analysis. At follow-up, the intervention group (115/221, 52%) had higher FV acceptance scores (baseline adjusted difference of mean 7.22; 95% CI 1.41-13.03) than the control group (106/221, 48%). The intervention effect was parallel for relative FV acceptance scores (baseline adjusted difference of mean 0.28; 95% CI 0.05-0.52).

Conclusions

The Mole’s Veggie Adventures app has the potential to increase FV acceptance among preschoolers and can be a valuable tool in supporting food education in ECEC centers. Furthermore, the app can be feasibly incorporated into preschool routines in countries with different educational environments.

Trial Registration

ClinicalTrials.gov NCT05173311; https://tinyurl.com/4vfbh283

Cancer screening simulation models: a state of the art review

Background

Nowadays, various simulation approaches for evaluation and decision making in cancer screening can be found in the literature. This paper presents an overview of approaches used to assess screening programs for breast, lung, colorectal, prostate, and cervical cancers. Our main objectives are to describe methodological approaches and trends for different cancer sites and study populations, and to evaluate quality of cancer screening simulation studies.

Methods

A systematic literature search was performed in Medline, Web of Science, and Scopus databases. The search time frame was limited to 1999–2018 and 7101 studies were found. Of them, 621 studies met inclusion criteria, and 587 full-texts were retrieved, with 300 of the studies chosen for analysis. Finally, 263 full texts were used in the analysis (37 were excluded during the analysis). A descriptive and trend analysis of models was performed using a checklist created for the study.

Results

Currently, the most common methodological approaches in modeling cancer screening were individual-level Markov models (34% of the publications) and cohort-level Markov models (41%). The most commonly evaluated cancer types were breast (25%) and colorectal (24%) cancer. Studies on cervical cancer evaluated screening and vaccination (18%) or screening only (13%). Most studies have been conducted for North American (42%) and European (39%) populations. The number of studies with high quality scores increased over time.

Conclusions

Our findings suggest that future directions for cancer screening modelling include individual-level Markov models complemented by screening trial data, and further effort in model validation and data openness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01713-5.

Influence of early-life body mass index and systolic blood pressure on left ventricle in adulthood - the Cardiovascular Risk in Young Finns Study

BACKGROUND

Increased left ventricular mass (LVM) predicts cardiovascular events and mortality. The objective of this study was to determine whether early-life exposures to body mass index (BMI) and systolic blood pressure (SPB) affects the left ventricular structure in adulthood.

METHODS

We used longitudinal data from a 31-year follow-up to examine the associations between early-life (between ages 6-18) BMI and SPB on LVM in an adult population (N = 1864, aged 34-49). The burden of early-life BMI and SBP was defined as area under the curve.

RESULTS

After accounting for contemporary adult determinants of LVM, early-life BMI burden associated significantly with LVM (3.61 g/SD increase in early-life BMI; [1.94 - 5.28], p < 0.001). Overweight in early-life (age- and sex-specific BMI values corresponding to adult BMI > 25 kg/m²) associated with 4.7% (2.5-6.9%, p < 0.0001) higher LVM regardless of BMI status in adulthood. Overweight in early-life combined with obesity in adulthood (BMI > 30kg/m²) resulted in a 21% (17.3-32.9%, p < 0.0001) increase in LVM. Higher early-life BMI was associated with a risk of developing eccentric hypertrophy. The burden of early-life SPB was not associated with adult LVM or left ventricular remodeling.

CONCLUSIONS

High BMI in early-life confers a sustained effect on LVM and the risk for eccentric hypertrophy independently of adulthood risk factors. KEY MESSAGES Excess in BMI in early-life has an independent effect on LVM and the risk of developing eccentric hypertrophy regardless of overweight status in adulthood. Systolic blood pressure levels in early-life did not have an independent effect on LVM or LV remodeling. The clinical implication of this study is that primary prevention of obesity in early-life may prevent the development of high LVM and eccentric hypertrophy.

Comparability and validity of cancer registry data in the northwest of Russia

BACKGROUND

Despite the elaborate history of statistical reporting in the USSR, Russia established modern population-based cancer registries (PBCR) only in the 1990s. The quality of PBCRs data has not been thoroughly analyzed. This study aims at assessing the comparability and validity of cancer statistics in regions of the Northwestern Federal District (NWFD) of Russia.

MATERIAL AND METHODS

Data from ten Russian regional PBCRs covering ∼13 million (∼5 million in St. Petersburg) were processed in line with IARC/IACR and ENCR recommendations. We extracted and analyzed all registered cases but focused on cases diagnosed between 2008 and 2017. For comparability and validity assessment, we applied established qualitative and quantitative methods.

RESULTS

Data collection in NWFD is in line with international standards. Distributions of diagnosis dates revealed higher variation in several regions, but overall, distributions are relatively uniform. The proportion of multiple primaries between 2008 and 2017 ranged from 6.7% in Vologda Oblast to 12.4% in Saint-Petersburg. We observed substantial regional heterogeneity for most indicators of validity. In 2013-2017, proportions of morphologically verified cases ranged between 61.7 and 89%. Death certificates only (DCO) cases proportion was in the range of 1-14% for all regions, except for Saint-Petersburg (up to 23%). The proportion of cases with a primary site unknown was between 1 and 3%. Certain cancer types (e.g., pancreas, liver, hematological malignancies, and CNS tumors) and cancers in older age groups showed lower validity.

CONCLUSION

While the overall level of comparability and validity of PBCRs data of four out of ten regions of NWFD of Russia meets the international standards, differences between the regions are substantial. The local instructions for cancer registration need to be updated and implemented. The data validity assessment also reflects pitfalls in the quality of diagnosis of certain cancer types and patient groups.

Frailty modeling under a selective sampling protocol: an application to type 1 diabetes related autoantibodies

In studies following selective sampling protocols for secondary outcomes, conventional analyses regarding their appearance could provide misguided information. In the large type 1 diabetes prevention and prediction (DIPP) cohort study monitoring type 1 diabetes-associated autoantibodies, we propose to model their appearance via a multivariate frailty model, which incorporates a correlation component that is important for unbiased estimation of the baseline hazards under the selective sampling mechanism. As further advantages, the frailty model allows for systematic evaluation of the association and the differences in regression parameters among the autoantibodies. We demonstrate the properties of the model by a simulation study and the analysis of the autoantibodies and their association with background factors in the DIPP study, in which we found that high genetic risk is associated with the appearance of all the autoantibodies, whereas the association with sex and urban municipality was evident for IA-2A and IAA autoantibodies.

Sociodemographic differences in motives for food selection: results from the LoCard cross-sectional survey

Background

Although sociodemographic differences in dietary intake have been widely studied, the up-to-date evidence on the corresponding variations in motives for food selection is limited. We investigated how sociodemographic characteristics and special diets in households are associated with the relative importance of various food motives.

Methods

Participants were members of the S Group loyalty card program across Finland who consented to release their grocery purchase data to be used for research purposes and responded to a web-based questionnaire in 2018 (LoCard study). Self-reported information on sociodemographic factors (age, gender, marital status, living situation, education, household income), special diets in household and food motives (Food Choice Questionnaire) were utilized in the present analyses (N = 10,795). Age- and gender-adjusted linear models were performed separately for each sociodemographic predictor and motive dimension (derived by factor analysis) outcome. The importance of each sociodemographic predictor was evaluated based on an increase in R² value after adding the predictor to the age- and gender-adjusted model.

Results

Age emerged as a central determinant of food motives with the following strongest associations: young adults emphasized convenience (∆R² = 0.09, P < 0.001) and mood control (∆R² = 0.05, P < 0.001) motives more than middle-aged and older adults. The relative importance of cheapness decreased with increasing socioeconomic position (SEP) (∆R² = 0.08, P < 0.001 for income and ∆R² = 0.04, P < 0.001 for education). However, the price item (“is good value for money”) depicting the concept of worth did not distinguish between SEP categories. Considerations related to familiarity of food were more salient to men (∆R² = 0.02, P < 0.001) and those with lower SEP (∆R² = 0.03, P < 0.001 for education and ∆R² = 0.01, P < 0.001 for income). Respondents living in households with a vegetarian, red-meat-free, gluten-free or other type of special diet rated ethical concern as relatively more important than households with no special diets (∆R² = 0.02, P < 0.001).

Conclusions

We observed sociodemographic differences in a range of food motives that might act as barriers or drivers for adopting diets that benefit human and planetary health. Interventions aiming to narrow SEP and gender disparities in dietary intake should employ strategies that take into account higher priority of familiarity and price in daily food selection in lower-SEP individuals and males.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01139-2.

Association of diabetes type and chronic diabetes complications with early exit from the labour force: register-based study of people with diabetes in Finland

AIMS/HYPOTHESIS

Diabetes and diabetes complications are a cause of substantial morbidity, resulting in early exits from the labour force and lost productivity. The aim of this study was to examine differences in early exits between people with type 1 and 2 diabetes and to assess the role of chronic diabetes complications on early exit. We also estimated the economic burden of lost productivity due to early exits.

METHODS

People of working age (age 17-64) with diabetes in 1998-2011 in Finland were detected using national registers (N_{type 1} = 45,756, N_{type 2} = 299,931). For the open cohort, data on pensions and deaths, healthcare usage, medications and basic demographics were collected from the registers. The outcome of the study was early exit from the labour force defined as pension other than old age pension beginning before age 65, or death before age 65. We analysed the early exit outcome and its risk factors using the Kaplan-Meier method and extended Cox regression models. We fitted linear regression models to investigate the risk factors of lost working years and productivity costs among people with early exit.

RESULTS

The difference in median age at early exit from the labour force between type 1 (54.0) and type 2 (58.3) diabetes groups was 4.3 years. The risk of early exit among people with type 1 diabetes increased faster after age 40 compared with people with type 2 diabetes. Each of the diabetes complications was associated with an increase in the hazard of early exit regardless of diabetes type compared with people without the complication, with eye-related complications as an exception. Diabetes complications partly but not completely explained the difference between diabetes types. The mean lost working years was 6.0 years greater in the type 1 diabetes group than in the type 2 diabetes group among people with early exit. Mean productivity costs of people with type 1 diabetes and early exit were found to be 1.4-fold greater compared with people with type 2 diabetes. The total productivity costs of incidences of early exits in the type 2 diabetes group were notably higher compared with the type 1 group during the time period (€14,400 million, €2800 million).

CONCLUSIONS/INTERPRETATION

We found a marked difference in the patterns of risk of early exit between people with type 1 and type 2 diabetes. The difference was largest close to statutory retirement age. On average, exits in the type 1 diabetes group occurred at an earlier age and resulted in higher mean lost working years and mean productivity costs. The potential of prevention, timely diagnosis and management of diabetes is substantial in terms of avoiding reductions in individual well-being and productivity.

Prognostic Index for Predicting Prostate Cancer Survival in a Randomized Screening Trial: Development and Validation

We developed and validated a prognostic index to predict survival from prostate cancer (PCa) based on the Finnish randomized screening trial (FinRSPC). Men diagnosed with localized PCa (N = 7042) were included. European Association of Urology risk groups were defined. The follow-up was divided into three periods (0-3, 3-9 and 9-20 years) for development and two corresponding validation periods (3-6 and 9-15 years). A multivariable complementary log-log regression model was used to calculate the full prognostic index. Predicted cause-specific survival at 10 years from diagnosis was calculated for the control arm using a simplified risk score at diagnosis. The full prognostic index discriminates well men with PCa with different survival. The area under the curve (AUC) was 0.83 for both the 3-6 year and 9-15 year validation periods. In the simplified risk score, patients with a low risk score at diagnosis had the most favorable survival, while the outcome was poorest for the patients with high risk scores. The prognostic index was able to distinguish well between men with higher and lower survival, and the simplified risk score can be used as a basis for decision making.

Vegan diet in young children remodels metabolism and challenges the statuses of essential nutrients

Vegan diets are gaining popularity, also in families with young children. However, the effects of strict plant-based diets on metabolism and micronutrient status of children are unknown. We recruited 40 Finnish children with a median age 3.5 years-vegans, vegetarians, or omnivores from same daycare centers-for a cross-sectional study. They enjoyed nutritionist-planned vegan or omnivore meals in daycare, and the full diets were analyzed with questionnaires and food records. Detailed analysis of serum metabolomics and biomarkers indicated vitamin A insufficiency and border-line sufficient vitamin D in all vegan participants. Their serum total, HDL and LDL cholesterol, essential amino acid, and docosahexaenoic n-3 fatty acid (DHA) levels were markedly low and primary bile acid biosynthesis, and phospholipid balance was distinct from omnivores. Possible combination of low vitamin A and DHA status raise concern for their visual health. Our evidence indicates that (i) vitamin A and D status of vegan children requires special attention; (ii) dietary recommendations for children cannot be extrapolated from adult vegan studies; and (iii) longitudinal studies on infant-onset vegan diets are warranted.

Number of screening rounds attended and incidence of high-risk prostate cancer in the Finnish Randomized Study of Screening for Prostate Cancer (FinRSPC)

BACKGROUND

The European Randomized Study of Screening for Prostate Cancer has shown a 20% reduction in prostate cancer (PC) mortality by prostate-specific antigen-based screening. In addition, screening has been shown to reduce the risk of advanced PC. The objective of the current study was to analyze the impact of screening participation on the incidence of PC by risk group.

METHODS

The participants in the screening arm of the Finnish trial (31,867 men) were classified according to screening attendance in a time-dependent fashion. Initially, all men in the screening arm were regarded as nonattenders until the first screening attendance; they then remained in the once-screened group until the second screen and similarly for the possible third round. The control arm formed the reference group. Follow-up started at randomization and ended at the time of diagnosis of PC, emigration, or the end of 2015. PC cases were divided into risk groups according to European Association of Urology definitions.

RESULTS

The incidence of low-risk PC increased with the number of screens, whereas no clear relation with participation was noted in the intermediate-risk and high-risk cases. For patients with advanced PC, attending screening at least twice was associated with a lower risk.

CONCLUSIONS

Screening reduces the risk of advanced PC after only 2 screening cycles. A single screen demonstrated no benefit in terms of PC incidence. Repeated screening is necessary to achieve screening advantages.

Food insecurity among Finnish private sector service workers and food pantry clients

Background

There is a paucity of comparable quantitative data on the prevalence and predictors of food insecurity in high-income countries. We applied the Household Food Insecurity Access Scale (HFIAS) to assess food insecurity among i) the Service Union United members; female-dominated, low-income employees of the Finnish private service sector, and ii) a convenience sample of Finnish food pantry clients.

Methods

The HFIAS classification was based on 9 validated questions capturing respondents' perceptions on food scarcity and behavioural responses to food insecurity due to lack of resources during the past month. The resulting indicator categorized respondents as food secure, and mildly, moderately and severely food insecure. We performed cross-tabulations and regression models to assess if education, housing, self-perceived health, income, and resource scarcity associated with levels of food insecurity. In addition, gender, age, and self-perceived disadvantage were assessed among the food pantry clients.

Results

Among the service workers (n = 6 573, 6% of those invited), 35% were food secure, 29% mildly or moderately food insecure, and 36% severely food insecure. The respective proportions were 28%, 26%, and 46% among the 129 food pantry clients. All assessed variables were associated to food insecurity status in the service workers (p &lt; 0.01 for all). Among the food pantry clients, men (OR 1.60; 95% CI 1.09 − 4.80) and homeless/tenants in community rental units (OR 7.12; 95% CI 2.42 − 20.95) were most likely to experience severe food insecurity.

Conclusions

Alongside the food pantry clients the majority of the service workers demonstrated some degree of food insecurity, with a considerable proportion being severely food-insecure. This predominantly low-income group is subject to rapid changes in the labour market and social security systems. The data demonstrated that well-known SES indicators and self-perceived health are linked to food insecurity.

Key messages

Severe food insecurity was common among predominantly low-income private sector service workers and food pantry clients. Food insecurity is linked to SES indicators and wellbeing.

Grocery purchase data in the study of alcohol use - A validity study

BACKGROUND

Alcohol use epidemiology is facing challenges as survey response rates decline. In addition, population surveys fail to capture a large proportion of alcohol consumed and are expensive to conduct. This study aims to aid in complementing traditional epidemiological methods by validate grocery purchase data in the research on population alcohol use.

METHODS

The LoCard study subjects were loyalty card holders of a grocery retail co-operative, which possessed more than 45 % market share in Finland. One third of those who consented to the analyses of their grocery purchases were presented a questionnaire including a Food Frequency Questionnaire on the web; N = 11,818 responded. The relationship between beer purchase frequency and self-reported beer drinking frequency was studied for association and agreement in different subgroups using crosstabulations and Poisson regression modeling.

RESULTS

The association between beer purchase frequency and self-reported beer drinking frequency was good (Gamma = .556). The agreement between beer purchase frequency and drinking frequency was only fair (Kappa = .189). Limiting the data to those single adult households that reported making at least 61 % of their grocery purchases from this grocery retailer and collapsing the frequency categories to three instead of six increased the agreement to good (Kappa = .463).

CONCLUSIONS

Information on beer purchase frequency from the loyalty card database can be used to rank people according to their drinking frequency and to estimate beer drinking frequency with fair to good accuracy, depending on what share of grocery purchases they make from the grocery retailer in question.

Alcohol purchases from a large Finnish retail chain before and after a change in alcohol legislation

Background

In January 2018, the legal limit for alcoholic beverages in grocery stores changed from 4.7 to 5.5 % alcohol. The increased availability of stronger beer, cider and ready-to-drink beverages was expected to increase the total amount of 100% alcohol bought. The study aimed to examine how the change in alcohol legislation affected the purchasing of 100% alcohol from grocery stores by comparing the years 2017 and 2018.

Methods

The study data consisted of 47,066 loyalty card holders of Finland's largest retail chain, who gave their consent and provided background information by an online questionnaire. The data contained the type, volume and alcoholic content of the purchases, from which we calculated the amount of 100% alcohol bought. The mean individual alcohol purchases in the years 2017 and 2018 were compared by age, gender, level of education and household income using repeated measurements ANOVA models.

Results

There was only a small, non-significant change in the total amount of 100% alcohol between 2017 and 2018 (mean 1.9 l and 2.0 l, respectively, p = 0.220). Lower income was associated with a decrease in total 100% alcohol purchased, whereas higher income groups showed an increase. Increase in 100% alcohol bought as ready-to-drink beverages was seen in all population groups.

Conclusions

The availability of stronger alcoholic beverages in grocery stores did not result in a notable overall increase in total purchases of 100% alcohol. The increased purchases of alcohol as ready-to-drink beverages were, on the average, compensated for by decreased purchases of alcohol as other beverages. The association of income with total alcohol purchases may indicate the effect of price in consumer behavior.

Key messages

The raise in the legal limit of alcohol content raised did not result in a significant increase in the total amount of 100% alcohol bought from grocery stores. Alcohol purchased as ready-to-drink beverages increased in all population groups.

Use of Antiasthmatic Drugs and the Risk of Type 1 Diabetes in Children: A Nationwide Case-Cohort Study

Asthma has been reported to be associated with an increased risk of type 1 diabetes mellitus in childhood, but the reasons are unclear. We examined whether the use of antiasthmatic drugs was associated with the development of type 1 diabetes in childhood in a nationwide, register-based case-cohort study. We identified all children who were born January 1, 1995, through December 31, 2008, in Finland and diagnosed with type 1 diabetes by 2010 (n = 3,342). A 10% random sample from each birth-year cohort was selected as a reference cohort (n = 80,909). Information on all dispensed antiasthmatic drugs (Anatomical Therapeutic Chemical classification system code R03) during 1995-2009 was obtained, and associations between the use of antiasthmatic drugs and the development of type 1 diabetes were investigated using time-dependent and time-sequential Cox regression models. Dispensed inhaled corticosteroids and inhaled β-agonists were associated with an increased risk of type 1 diabetes after adjusting for other antiasthmatic drugs, asthma, sex, and birth decade (hazard ratio = 1.29, 95% confidence interval: 1.09, 1.52, and hazard ratio = 1.22, 95% confidence interval: 1.07, 1.41, respectively). These findings suggest that children using inhaled corticosteroids or inhaled β-agonists might be at increased risk of type 1 diabetes.

Characterization and Correction of Bias Due to Nonparticipation and the Degree of Loyalty in Large-Scale Finnish Loyalty Card Data on Grocery Purchases: Cohort Study

Background

To date, the evaluation of diet has mostly been based on questionnaires and diaries that have their limitations in terms of being time and resource intensive, and a tendency toward social desirability. Loyalty card data obtained in retailing provides timely and objective information on diet-related behaviors. In Finland, the market is highly concentrated, which provides a unique opportunity to investigate diet through grocery purchases.

Objective

The aims of this study were as follows: (1) to investigate and quantify the selection bias in large-scale (n=47,066) loyalty card (LoCard) data and correct the bias by developing weighting schemes and (2) to investigate how the degree of loyalty relates to food purchases.

Methods

Members of a loyalty card program from a large retailer in Finland were contacted via email and invited to take part in the study, which involved consenting to the release of their grocery purchase data for research purposes. Participants’ sociodemographic background was obtained through a web-based questionnaire and was compared to that of the general Finnish adult population obtained via Statistics Finland. To match the distributions of sociodemographic variables, poststratification weights were constructed by using the raking method. The degree of loyalty was self-estimated on a 5-point rating scale.

Results

On comparing our study sample with the general Finnish adult population, in our sample, there were more women (65.25%, 30,696/47,045 vs 51.12%, 2,273,139/4,446,869), individuals with higher education (56.91%, 20,684/36,348 vs 32.21%, 1,432,276/4,446,869), and employed individuals (60.53%, 22,086/36,487 vs 52.35%, 2,327,730/4,446,869). Additionally, in our sample, there was underrepresentation of individuals aged under 30 years (14.44%, 6,791/47,045 vs 18.04%, 802,295/4,446,869) and over 70 years (7.94%, 3,735/47,045 vs 18.20%, 809,317/4,446,869), as well as retired individuals (23.51%, 8,578/36,487 vs 31.82%, 1,414,785/4,446,869). Food purchases differed by the degree of loyalty, with higher shares of vegetable, red meat & processed meat, and fat spread purchases in the higher loyalty groups.

Conclusions

Individuals who consented to the use of their loyalty card data for research purposes tended to diverge from the general Finnish adult population. However, the high volume of data enabled the inclusion of sociodemographically diverse subgroups and successful correction of the differences found in the distributions of sociodemographic variables. In addition, it seems that food purchases differ according to the degree of loyalty, which should be taken into account when researching loyalty card data. Despite the limitations, loyalty card data provide a cost-effective approach to reach large groups of people, including hard-to-reach population subgroups.

The importance of clinical and labour market histories in psychiatric disability retirement: analysis of the comprehensive Finnish national-level RETIRE data

OBJECTIVES

Despite the stable incidence of mental disorders in Finland and Europe, mental health-related occupational disability has been increasing. We unveiled the paths to permanent psychiatric disability, recovery, or death, by analysing sequences of labour market participation.

METHODS

The RETIRE register database includes information regarding all persons (n = 42,170) awarded an ICD-10 psychiatric disability pension between 2010 and 2015 in Finland. We identified clusters of typical paths of pre-retirement labour market history. Controlling for major mental disorders, age, and sex, we evaluated factors associated with returning to work (RTW), or death, over a 5-year follow-up period.

RESULTS

Only 10.5% of the disabled subjects returned to work within the follow-up. Half of them ended up with a permanent disability pension. Seven distinguishable paths to disability were identified. Subjects in the cluster characterized by steady employment were relatively often females, lost their work ability due to affective disorders, and had the highest rate of returning to work (16.3%). Mortality was highest (9%) among the cluster characterized by long-term unemployment. Distributions of major diagnostic groups, as well as age and sex, differed between clusters. After their adjustment in the analysis of RTW or death, the identified labour market history paths prior to losing work ability remained as important independent prognostic factors for both outcomes.

CONCLUSIONS

The complex retirement process involves identifiable clinical and contextual associating factors. Labour market history patterns associate with varying prognoses after psychiatric retirement. Prolonged unemployment appears as a predictor of relatively poor prognoses, whereas employment indicates the opposite.

Association of Cereal, Gluten, and Dietary Fiber Intake With Islet Autoimmunity and Type 1 Diabetes

IMPORTANCE

Dietary proteins, such as gluten, have been suggested as triggers of the disease process in type 1 diabetes (T1D).

OBJECTIVE

To study the associations of cereal, gluten, and dietary fiber intake with the development of islet autoimmunity (IA) and T1D.

DESIGN, SETTING, AND PARTICIPANTS

The prospective birth cohort Finnish Type 1 Diabetes Prediction and Prevention Study recruited children with genetic susceptibility to type 1 diabetes from September 1996 to September 2004 from 2 university hospitals in Finland and followed up every 3 to 12 months up to 6 years for diet, islet autoantibodies, and T1D. Altogether 6081 infants (78% of those invited) participated in the study. Dietary data were available for 5714 children (94.0%) and dietary and IA data were available for 5545 children (91.2%), of whom 3762 (68%) had data on islet autoantibodies up to age 6 years. Information on T1D was available for all children. Data were analyzed in 2018 and end point data were updated in 2015.

EXPOSURES

Each child's intake of cereals, gluten, and dietary fiber was calculated from repeated 3-day food records up to 6 years.

MAIN OUTCOMES AND MEASURES

Islet autoimmunity was defined as repeated positivity for islet cell antibodies and at least 1 biochemical autoantibody of 3 analyzed, or T1D. Data on the diagnosis of T1D were obtained from Finnish Pediatric Diabetes Register.

RESULTS

Of 5545 children (2950 boys [53.2%]), 246 (4.4%) developed IA and of 5714 children (3033 boys [53.1%]), 90 (1.6%) developed T1D during the 6-year follow-up. Based on joint models, the intake of oats (hazard ratio [HR], 1.08; 95% CI, 1.03-1.13), wheat (HR, 1.09; 95% CI, 1.03-1.15), rye (HR, 1.13; 95% CI, 1.03-1.23), gluten-containing cereals (HR, 1.07; 95% CI, 1.03-1.11), gluten without avenin from oats (HR, 2.23; 95% CI, 1.40-3.57), gluten with avenin (HR, 2.06; 95% CI, 1.45-2.92), and dietary fiber (HR, 1.41; 95% CI, 1.10-1.81) was associated with the risk of developing IA (HRs for 1 g/MJ increase in intake). The intake of oats (HR, 1.10; 95% CI, 1.00-1.21) and rye (HR, 1.20; 95% CI, 1.03-1.41) was associated with the risk of developing T1D. After multiple testing correction, the associations with IA remained statistically significant.

CONCLUSIONS AND RELEVANCE

A high intake of oats, gluten-containing cereals, gluten, and dietary fiber was associated with an increased risk of IA. Further studies are needed to confirm or rule out the findings and study potential mechanisms.

Examining retail purchases of cigarettes and nicotine replacement therapy in Finland

INTRODUCTION

Finland's success in achieving the goal of its tobacco endgame largely depends on rectifying deficiencies in the delivery of smoking cessation services. One such weakness, which has not been documented with empirical data, is misuse of nicotine replacement therapy (NRT). This study's objective was to examine purchase patterns of NRT for estimating improper use of the medication. The study was based on the assumption that duration of a purchase episode is indicative of either proper use or misuse of NRT.

METHODS

The participants (n=728), who purchased at least one NRT product in 2016 (mostly gum/lozenge), were selected through enrollment in a large customer loyalty program in Finland (LoCard). Participants were categorized into one of five groups according to their longest purchase episode of NRT, defined by purchases made in consecutive, 4-week intervals.

RESULTS

Most participants, who did not adhere to NRT guidelines, either purchased the medication for too short (≤4 weeks, 63.5%) or too long (>24 weeks, 13.2%) of a purchase episode. Median purchases of NRT in the first month of use were one and four in the former and latter, respectively. In contrast to other groups, persistent users (>24 weeks) did not curtail purchases of NRT across several 4-week intervals, suggesting potential for dependence on NRT.

CONCLUSIONS

The observation that most purchase episodes were terminated prematurely is consistent with surveys reporting widespread NRT misuse. Given uncertainty of greater regulation of NRT sales through legislation, it would be prudent for Finnish retailers to promote proper use of the therapy.

Alcohol expenditure in grocery stores and their associations with tobacco and food expenditures

Background

Alcohol consumption is a significant cause of disease, death and social harm, and it clusters with smoking tobacco and an unhealthy diet. Using automatically registered retail data for research purposes is a novel approach, which is not subject to underreporting bias. Based on loyalty card data (LoCard) obtained by a major Finnish retailer holding a market share of 47%, we examined alcohol expenditure and their associations with food and tobacco expenditures.

Methods

The data consisted of 1,527,217 shopping events in 2016 among 13,274 loyalty card holders from southern Finland. A K-means cluster analysis was applied to group the shopping baskets according to their content of alcoholic beverages. The differences in the absolute and relative means of food and tobacco between the clusters were tested by linear mixed models with the loyalty card holder as the random factor.

Results

By far, the most common basket type contained no alcoholic beverages, followed by baskets containing a small number of beers or ciders. The expenditure on food increased along with the expenditure on alcoholic beverages. The foods most consistently associated with alcohol purchases were sausages, soft drinks and snacks. The expenditure on cigarettes relative to total basket price peaked in the mid-price alcohol baskets.

Conclusion

Clustering of unhealthy choices occurred on the level of individual shopping events. People who bought many alcoholic beverages did not trim their food budget. Automatically registered purchase data provide valuable insight into the health behaviours of individuals and the population.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7096-3) contains supplementary material, which is available to authorized users.

Trends in occupational diseases in Finland, 1975-2013: a register study

OBJECTIVES

The objective was to investigate trends in the incidence of recognized and suspected cases of occupational diseases in Finland from 1975 to 2013, including variations by industry - and describe and recognize factors affecting variations in incidence.

DESIGN

A register study.

SETTING

The data consisted of recognized and suspected cases of occupational diseases recorded in the Finnish Registry of Occupational Diseases (FROD) in 1975-2013.

PARTICIPANTS

Altogether 240 000 cases of suspected and recognized ODs were analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

From the annual workforce statistics and FROD data, we calculated the incidence of ODs and suspected ODs per 10 000 employees. For time trends by industrial sector, we used a 5-year moving average and a Poisson regression analysis.

RESULTS

Annual average rates of ODs have varied from year to year. The total number was 25.0/10 000 employees in 1975 and 20.1/10 000 employees in 2013. Screening campaigns and legislative changes have caused temporary increases. When the financial sector was the reference (1.0), the highest incidence rates according to industrial sector were in mining and quarrying (9.87; 95% CI 8.65 to 11.30), construction (9.11; 95% CI 9.98 to 10.43), manufacturing (9.04; 95% CI 7.93 to 10.36) and agriculture (8.78; 95% CI 7.69 to 10.06). There is a distinct decreasing trend from 2005 onwards: the average annual change in incidence was, for example, -9.2% in agriculture, -10.3% in transportation and -4.7% in construction. The average annual decline was greatest in upper limb strain injuries (-11.1%).

CONCLUSION

This study provides a useful overview of the status of ODs in Finland over several decades. These data are a valuable resource for determining which occupations are at an increased risk and where preventive actions should be targeted. It is important to study long-term trends in the statistics of ODs to see beyond the year-to-year fluctuations.

The association between asthma and type 1 diabetes: a paediatric case-cohort study in Finland, years 1981-2009

Background

The association between asthma and type 1 diabetes, two chronic, immune-mediated diseases, has been of longstanding interest, but the evidence is still conflicting. We examined this association in a large, nationwide case-cohort study among Finnish children, using a novel statistical approach.

Methods

Among the initial cohort of all children born between 1 January 1981 and 31 December 2008, those who were diagnosed with asthma (n = 81 473) or type 1 diabetes (n = 9541) up to age 16 years by the end of 2009 were identified from the Central Drug Register maintained by the Social Insurance Institution of Finland. A 10% random sample from each initial birth year cohort was selected as a reference cohort (n = 171 138). The association between asthma and type 1 diabetes was studied using a multistate modelling approach to estimate transition rates between healthy and disease states since birth. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to represent the change in the transition rate between the disease states.

Results

After adjusting for sex and birth decade, previous diagnosis of asthma increased the risk of subsequent type 1 diabetes by 41% (95% CI: 1.28, 1.54), whereas previous diagnosis of type 1 diabetes decreased the risk of subsequent asthma by 18% (95% CI: 0.69, 0.98).

Conclusions

The findings of the present study imply that the association between the diseases is more complex than previously thought, and its direction depends on the sequential appearance of the diseases.

Large-scale loyalty card data in health research

Objective

To study the characteristics of large-scale loyalty card data obtained in Finland, and to evaluate their potential and challenges in health research.

Methods

We contacted the holders of a certain loyalty card living in a specific region in Finland via email, and requested their electronic informed consent to obtain their basic background characteristics and grocery expenditure data from 2016 for health research purposes. Non-participation and the characteristics and expenditure of the participants were mainly analysed using summary statistics and figures.

Results

The data on expenditure came from 14,595 (5.6% of those contacted) consenting loyalty card holders. A total of 68.5% of the participants were women, with an average age of 46 years. Women and residents of Helsinki were more likely to participate. Both young and old participants were underrepresented in the sample. We observed that annual expenditure represented roughly two-thirds of the nationally estimated annual averages. Customers and personnel differed in their characteristics and expenditure, but not so much in their most frequently bought items.

Conclusions

Loyalty card data from a major retailer enabled us to reach a large, heterogeneous sample with fewer resources than conventional surveys of the same magnitude. The potential of the data was great because of their size, coverage, objectivity, and long periods of dynamic data collection, which enables timely investigations. The challenges included bias due to non-participation, purchases in other stores, the level of detail in product grouping, and the knowledge gaps in what is being consumed and by whom. Loyalty card data are an underutilised resource in research, and could be used not only in retailers’ activities, but also for societal benefit.

Like parent, like child? Dietary resemblance in families

BACKGROUND

Studies investigating dietary resemblance between parents and their children have gained mixed results, and the resemblance seems to vary across nutrients, foods, dietary-assessment tools used, and parent-child pairs. We investigated parent-child dietary resemblance using a novel approach in applying statistical analysis, which allowed the comparison of 'whole-diet' between parents and their children. Additionally, we sought to establish whether sociodemographic factors or family meals were associated with dietary resemblance and whether parent-child dietary resemblance was dependent on the parent providing food consumption data on behalf of the child (father or mother, "the respondent").

METHODS

The DAGIS study investigated health behaviors among Finnish preschoolers using a cross-sectional design. One parent filled in a food frequency questionnaire (FFQ) measuring the child's food consumption outside preschool hours during the last week. In addition, we instructed both parents or legal guardians, should the child have two, to fill in a similar FFQ regarding their own food use. Parents also reported their educational level, the number of children living in the same household, and the number of family meals. As a measure of dietary resemblance between a parent and a child, we computed Spearman correlations ranging mostly from no resemblance (0) to complete resemblance (+ 1) between parent-child pairs over the 'whole-diet' (excluding preschool hours). These resemblance measures were further investigated using linear mixed models.

RESULTS

We obtained 665 father-child and 798 mother-child resemblance measures. Mother-child resemblance was on average 0.57 and stronger than father-child resemblance (0.50, p < 0.0001), which was explained by a parent-respondent interaction: the diet of the child resembled more the diet of the parent who provided food consumption data for the child. In univariate models, father- and mother-reported number of family meals were positively associated with father-child and mother-child resemblances. Mother-reported number of family meals was positively associated with mother-child resemblance in a full model.

CONCLUSIONS

The diet of the child seems to resemble more the diet of the parent responsible for the reporting of food consumption. Studies should report who provided the food consumption data for the child and take this into account in analyses, since reporter-bias can influence the results.

Incorporating interaction networks into the determination of functionally related hit genes in genomic experiments with Markov random fields

Motivation

Incorporating gene interaction data into the identification of ‘hit’ genes in genomic experiments is a well-established approach leveraging the ‘guilt by association’ assumption to obtain a network based hit list of functionally related genes. We aim to develop a method to allow for multivariate gene scores and multiple hit labels in order to extend the analysis of genomic screening data within such an approach.

Results

We propose a Markov random field-based method to achieve our aim and show that the particular advantages of our method compared with those currently used lead to new insights in previously analysed data as well as for our own motivating data. Our method additionally achieves the best performance in an independent simulation experiment. The real data applications we consider comprise of a survival analysis and differential expression experiment and a cell-based RNA interference functional screen.

Availability and implementation

We provide all of the data and code related to the results in the paper.

Supplementary information

Supplementary data are available at Bioinformatics online.

A Combined PLS and Negative Binomial Regression Model for Inferring Association Networks from Next-Generation Sequencing Count Data

A major challenge of genomics data is to detect interactions displaying functional associations from large-scale observations. In this study, a new cPLS-algorithm combining partial least squares approach with negative binomial regression is suggested to reconstruct a genomic association network for high-dimensional next-generation sequencing count data. The suggested approach is applicable to the raw counts data, without requiring any further pre-processing steps. In the settings investigated, the cPLS-algorithm outperformed the two widely used comparative methods, graphical lasso, and weighted correlation network analysis. In addition, cPLS is able to estimate the full network for thousands of genes without major computational load. Finally, we demonstrate that cPLS is capable of finding biologically meaningful associations by analyzing an example data set from a previously published study to examine the molecular anatomy of the craniofacial development.

Analysis of Proportions from Clustered Data with Missing Observations in a Matched-pair Design

Objectives: Typically, methods for the estimation of differences in proportions from clustered data are based on complete cases with no missing information [1, 2]. In this paper we propose an extension to the method of Rao and Scott [3] and Obuchowski [2] to allow for the explicit computation of the variance of the estimator for the difference in presence of incomplete cases.

Methods: We divided the full analysis set into a set of complete cases and a set of incomplete cases. The differences in proportions of correct diagnoses were estimated for each set by taking into consideration the clustering effect for both sets and the correlation between the procedures in the set with complete cases. Then the estimates of the two parts were combined by appropriate weights, which then allowed the explicit calculation of the variance. The performance of the extension as compared to the original method and generalized estimation equations model (GEEs) was examined by simulations.

Results: The results of the examples suggest that the extended approach is superior to the complete-case method and is therefore appropriate when all data are to be used. In comparison to GEEs, the extended method appears to be slightly inferior, when the number of observations per patient is high, but of similar efficiency with a low number of observations per patient.

Conclusions: With the extension of the method by Rao and Scott [3] and Obuchowski [2] we make use of all available data. Therefore, we follow the intent-to-treat principle as close as possible.

Infant Feeding in Relation to the Risk of Advanced Islet Autoimmunity and Type 1 Diabetes in Children With Increased Genetic Susceptibility: A Cohort Study

Breastfeeding, age at introduction of foods, and food diversity in infancy were studied for associations with advanced islet autoimmunity and type 1 diabetes. During 1996--2004, a total of 5,915 newborns with human leukocyte antigen-conferred susceptibility to type 1 diabetes were enrolled in the prospective Finnish Type 1 Diabetes Prediction and Prevention Nutrition Study. Children were assessed at intervals of 3-12 months for the appearance of 4 types of islet autoantibodies and type 1 diabetes up to the age of 15 years. Survival models indicated the 3 variables of interest were not associated with advanced islet autoimmunity or type 1 diabetes in the cohort. Early introduction of solid foods was associated with increased risk of advanced islet autoimmunity in children up to age 3 years (for <3 months vs. >4 months, hazard ratio = 2.33, 95% confidence interval: 1.39, 3.91; for 3-4 months vs. >4 months, hazard ratio = 2.18; 95% confidence interval: 1.38, 3.47) but not in longer follow-up (P for interaction = 0.046). Similar results were observed for age at introduction of roots, cereals, egg, and meat relative to risk of advanced islet autoimmunity. No consistent, long-term associations between infant feeding and advanced islet autoimmunity or type 1 diabetes were observed.