Psychometric properties and confirmatory factor analysis of the CASP-19, a measure of quality of life in early old age: the HAPIEE study

OBJECTIVES

The aim was to assess the reliability and validity of the quality of life (QoL) instrument CASP-19, and three shorter versions of CASP-12 in large population sample of older adults from the HAPIEE (Health, Alcohol, and Psychosocial factors In Eastern Europe) study.

METHODS

From the Czech Republic, Russia, and Poland, 13,210 HAPIEE participants aged 50 or older completed the retirement questionnaire including CASP-19 at baseline. Three shorter 12-item versions were also derived from original 19-item instrument. Psychometric validation used confirmatory factor analysis, Cronbach's alpha, Pearson's correlation, and construct validity.

RESULTS

The second-order four-factor model of CASP-19 did not provide a good fit to the data. Two-factor CASP-12v.3 including residual covariances for negative items to account for the method effect of negative items had the best fit to the data in all countries (CFI = 0.98, TLI = 0.97, RMSEA = 0.05, and WRMR = 1.65 in the Czech Republic; 0.96, 0.94, 0.07, and 2.70 in Poland; and 0.93, 0.90, 0.08, and 3.04 in Russia). Goodness-of-fit indices for the two-factor structure were substantially better than second-order models.

CONCLUSIONS

This large population-based study is the first validation study of CASP scale in Central and Eastern Europe (CEE), which includes a general population sample in Russia, Poland, and the Czech Republic. The results of this study have demonstrated that the CASP-12v.3 is a valid and reliable tool for assessing QoL among adults aged 50 years or older. This version of CASP is recommended for use in future studies investigating QoL in the CEE populations.

Fruit and vegetable consumption and mortality in Eastern Europe: Longitudinal results from the Health, Alcohol and Psychosocial Factors in Eastern Europe study

BACKGROUND

It is estimated that disease burden due to low fruit and vegetable consumption is higher in Central and Eastern Europe (CEE) and the former Soviet Union (FSU) than any other parts of the world. However, no large scale studies have investigated the association between fruit and vegetable (F&V) intake and mortality in these regions yet.

DESIGN

The Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) study is a prospective cohort study with participants recruited from the Czech Republic, Poland and Russia.

METHODS

Dietary data was collected using food frequency questionnaire. Mortality data was ascertained through linkage with death registers. Multivariable adjusted hazard ratios were calculated by Cox regression models.

RESULTS

Among 19,333 disease-free participants at baseline, 1314 died over the mean follow-up of 7.1 years. After multivariable adjustment, we found statistically significant inverse association between cohort-specific quartiles of F&V intake and stroke mortality: the highest vs lowest quartile hazard ratio (HR) was 0.52 (95% confidence interval (CI): 0.28-0.98). For total mortality, significant interaction (p = 0.008) between F&V intake and smoking was found. The associations were statistically significant in smokers, with HR 0.70 (0.53-0.91, p for trend: 0.011) for total mortality, and 0.62 (0.40-0.97, p for trend: 0.037) for cardiovascular disease (CVD) mortality. The association was appeared to be mediated by blood pressure, and F&V intake explained a considerable proportion of the mortality differences between the Czech and Russian cohorts.

CONCLUSIONS

Our results suggest that increasing F&V intake may reduce CVD mortality in CEE and FSU, particularly among smokers and hypertensive individuals.

Antioxidant vitamin intake and mortality in three Central and Eastern European urban populations: the HAPIEE study

PURPOSE

The aim of the study was to assess the relationships between individual-level dietary intakes of antioxidant vitamins C, E and beta-carotene with all-cause and cause-specific mortality in three Central and Eastern European (CEE) populations.

METHODS

Data from the Health, Alcohol and Psychosocial factors in Eastern Europe cohort study were used. At the baseline survey, between 2002 and 2005, 28,945 men and women aged 45-69 years were examined in Novosibirsk (Russia), Krakow (Poland) and seven Czech towns. Deaths in the cohorts were identified through mortality registers. Cox regression was used to estimate the association between vitamin consumption and all-cause, cardiovascular (CVD) disease and cancer mortality.

RESULTS

In multivariable-adjusted analyses, there were no clear inverse associations between antioxidant vitamin intakes and mortality, although in some groups, several hazard ratios (HRs) were significant. For example, in men, compared with the lowest quintile of vitamin C intake, all-cause mortality in the third and fourth quintiles was lower by 28 % (HR 0.72; 95 % CI 0.61-0.85) and by 20 % (HR 0.80; 95 % CI 0.68-0.95), respectively. CVD mortality was lower by 35 % (HR 0.65; 95 % CI 0.50-0.84) and by 23 % (HR 0.77; 95 % CI 0.59-0.99) in third and fourth quintile of vitamin C intake, respectively. In women, the third and fourth quintiles of dietary intake of vitamin E were associated with reduced risk of all-cause death by 33 % (HR 0.67; 95 % CI 0.53-0.84) and by 23 % (HR 0.77; 95 % CI 0.61-0.97), respectively. Consumption of vitamin C, vitamin E and beta-carotene was not related to CVD mortality in women and to cancer mortality in either gender.

CONCLUSION

This large prospective cohort study in CEE populations with low prevalence of vitamin supplementation did not find a strong, dose-response evidence for protective effects of antioxidant vitamin intake.

HMG-coenzyme A reductase inhibition, type 2 diabetes, and bodyweight: evidence from genetic analysis and randomised trials

BACKGROUND

Statins increase the risk of new-onset type 2 diabetes mellitus. We aimed to assess whether this increase in risk is a consequence of inhibition of 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR), the intended drug target.

METHODS

We used single nucleotide polymorphisms in the HMGCR gene, rs17238484 (for the main analysis) and rs12916 (for a subsidiary analysis) as proxies for HMGCR inhibition by statins. We examined associations of these variants with plasma lipid, glucose, and insulin concentrations; bodyweight; waist circumference; and prevalent and incident type 2 diabetes. Study-specific effect estimates per copy of each LDL-lowering allele were pooled by meta-analysis. These findings were compared with a meta-analysis of new-onset type 2 diabetes and bodyweight change data from randomised trials of statin drugs. The effects of statins in each randomised trial were assessed using meta-analysis.

FINDINGS

Data were available for up to 223 463 individuals from 43 genetic studies. Each additional rs17238484-G allele was associated with a mean 0·06 mmol/L (95% CI 0·05-0·07) lower LDL cholesterol and higher body weight (0·30 kg, 0·18-0·43), waist circumference (0·32 cm, 0·16-0·47), plasma insulin concentration (1·62%, 0·53-2·72), and plasma glucose concentration (0·23%, 0·02-0·44). The rs12916 SNP had similar effects on LDL cholesterol, bodyweight, and waist circumference. The rs17238484-G allele seemed to be associated with higher risk of type 2 diabetes (odds ratio [OR] per allele 1·02, 95% CI 1·00-1·05); the rs12916-T allele association was consistent (1·06, 1·03-1·09). In 129 170 individuals in randomised trials, statins lowered LDL cholesterol by 0·92 mmol/L (95% CI 0·18-1·67) at 1-year of follow-up, increased bodyweight by 0·24 kg (95% CI 0·10-0·38 in all trials; 0·33 kg, 95% CI 0·24-0·42 in placebo or standard care controlled trials and -0·15 kg, 95% CI -0·39 to 0·08 in intensive-dose vs moderate-dose trials) at a mean of 4·2 years (range 1·9-6·7) of follow-up, and increased the odds of new-onset type 2 diabetes (OR 1·12, 95% CI 1·06-1·18 in all trials; 1·11, 95% CI 1·03-1·20 in placebo or standard care controlled trials and 1·12, 95% CI 1·04-1·22 in intensive-dose vs moderate dose trials).

INTERPRETATION

The increased risk of type 2 diabetes noted with statins is at least partially explained by HMGCR inhibition.

FUNDING

The funding sources are cited at the end of the paper.

Alcohol consumption and physical functioning among middle-aged and older adults in Central and Eastern Europe: results from the HAPIEE study

Background: light-to-moderate drinking is apparently associated with a decreased risk of physical limitations in middle-aged and older adults.

Objective: to investigate the association between alcohol consumption and physical limitations in Eastern European populations.

Study design: a cross-sectional survey of 28,783 randomly selected residents (45–69 years) in Novosibirsk (Russia), Krakow (Poland) and seven towns of Czech Republic.

Methods: physical limitations were defined as <75% of optimal physical functioning using the Physical Functioning (PF-10) Subscale of the Short-Form-36 questionnaire. Alcohol consumption was assessed by a graduated frequency questionnaire, and problem drinking was defined as ≥2 positive responses on the CAGE questionnaire. In the Russian sample, past drinking was also assessed.

Results: the odds of physical limitations were highest among non-drinkers, decreased with increasing drinking frequency, annual consumption and average drinking quantity and were not associated with problem drinking. The adjusted odds ratio (OR) of physical limitations in non-drinkers versus regular moderate drinkers was 1.61 (95% confidence interval: 1.48–1.75). In the Russian sample with past drinking available, the adjusted OR in those who stopped drinking for health reasons versus continuing drinkers was 3.19 (2.58–3.95); ORs in lifetime abstainers, former drinkers for non-health reasons and reduced drinkers for health reasons were 1.27 (1.02–1.57), 1.48 (1.18–1.85) and 2.40 (2.05–2.81), respectively.

Conclusion: this study found an inverse association between alcohol consumption and physical limitations. The high odds of physical limitations in non-drinkers can be largely explained by poor health of former drinkers. The apparently protective effect of heavier drinking was partly due to less healthy former heavy drinkers who moved to lower drinking categories.

[Blood Lipid Parameters In Populations of Russia, Poland And Czech Republic: The Hapiee Study]

PURPOSE

to analyze population values of blood lipid parameters in general populations of Russia, Poland and Czech Republic.

MATERIALS AND METHODS

In the frame of international project HAPIEE representative samples of general population were examined in Novosibirsk (Russia), Krakow (Poland) and six centers in the Czech Republic. The analysis included data of 25,469 men and women aged 45-69 years old.

RESULTS

The average levels of total cholesterol (TC), non-high density lipoprotein cholesterol (non-HDL-C) and low density lipoprotein cholesterol (LDL-C) were found relatively high in all centers, though average levels of blood triglycerides (TG) and high-density lipoprotein (HDL) were within "normal" range. In Novosibirsk mean levels of blood TC and LDL-C in persons of both sexes were obtained the highest among the study participants: 6.3 mmol/ and 4.1 mmol/l, respectively (p < 0.001). But the level of blood triglycerides (1.5 mmol/l) in Novosibirsk was the lowest, and HDL-C (1.5 mmol/l) was the highest among three centres. There were clear trend of increasing concentration of blood TC, non-HDL-C,LDL-C and blood atherogenic indexes with increasing age in both sexes of all participating countries. In Czech Republic levels of blood TC, LDL-C, HDL-C in both sexes were relatively low: 5.7 mmol/l, 3.5 mmol/l, 1.4 mmol/l, respectively, but the level of blood TG were higher, than in other centers (1.9 mmol/l). Women of all centers had more demonstrative age changes of the blood lipid profile, than men.

CONCLUSIONS

The average levels of blood TC, non-HDL-C and LDL-C in men and women aged 45-69 years old in Russia (Novosibirsk) were higher and level of blood TG was lower than in Poland and the Czech Republic.

Alcohol consumption, drinking patterns, and cognitive function in older Eastern European adults

Objective:

To investigate associations of frequency, quantity, binge, and problem drinking with cognitive function in older Eastern European adults.

Methods:

The investigation included 14,575 participants, aged 47 to 78 years at cognitive assessment in 2006–2008 from Novosibirsk (Russia), Krakow (Poland), and 6 Czech towns participating in the HAPIEE (Health, Alcohol, and Psychosocial Factors in Eastern Europe) prospective cohort study. Average response rates were 59% at baseline (2002–2005) and 63% in 2006–2008. Alcohol consumption was assessed at baseline and in 2006–2008. Cognitive tests included immediate and delayed word recall, semantic fluency (animal naming), and letter cancellation. Associations between alcohol indices and cognitive scores were analyzed cross-sectionally (all measures from 2006 to 2008) and prospectively (alcohol and covariates from 2002 to 2005 and cognition from 2006 to 2008).

Results:

In cross-sectional analyses, nondrinkers had lower cognitive scores and female moderate drinkers had better cognitive performance than light drinkers. Heavy, binge, and problem drinking were not consistently associated with cognitive function. Few associations were replicated in prospective analyses. Participants who stopped drinking during follow-up had worse cognition than stable drinkers; in men, regression coefficients (95% confidence interval) ranged from −0.26 (−0.36, −0.16) for immediate recall to −0.14 (−0.24, −0.04) for fluency.

Conclusion:

Regular and episodic heavy drinking were not consistently associated with cognitive function. Worse cognition in participants who stopped drinking during follow-up suggests that inclusion of less healthy ex-drinkers may partly explain poorer cognition in nondrinkers.

Inclusion of hazardous drinking does not improve the SCORE performance in men from Central and Eastern Europe: the findings from the HAPIEE cohorts

Background

The SCORE (Systematic COronary Risk Evaluation) scale uses conventional risk factors for the prediction of the 10-year risk of fatal atherosclerotic cardiovascular disease (CVD). The high-risk version of SCORE is recommended by the European Society of Cardiology for use in the populations of Central and Eastern Europe and former Soviet Union (CEE/FSU). Given the role of hazardous alcohol consumption as an important determinant of CVD mortality in CEE/FSU men, this study investigated whether adding hazardous drinking characteristics to the high-risk SCORE improves its prognostic performance in contemporary population-based male CEE/FSU cohorts.

Methods

The HAPIEE (Health, Alcohol, and Psychosocial factors In Eastern Europe) study follows Czech (seven towns), Polish (Krakow), and Russian (Novosibirsk) cohorts from 2002–2005. In HAPIEE men (n = 8,927), 264 atherosclerotic cardiovascular deaths were registered over the median follow-up time of 6.2-8.1 years.

Results

In HAPIEE men, the baseline levels of the high-risk SCORE ≥5% significantly predicted fatal CVD. After controlling for the high-risk SCORE, binge drinking (drinking ≥100 g of ethanol at least once a month) and problem drinking (≥2 positive answers to CAGE questionnaire) were inconsistently associated with fatal CVD. No marked improvement in calibration and discrimination was observed for the high-risk SCORE extended by these hazardous drinking indicators, and all values of integrated discrimination improvement were <0.5%.

Conclusions

Extending the high-risk SCORE by hazardous drinking parameters failed to improve its prognostic performance across male CEE/FSU population samples. Our findings tentatively support the use of the original high-risk SCORE in male CEE/FSU populations. More research is needed on the potential use of hazardous drinking in cardiovascular risk prediction.

Alcohol consumption and cognitive performance: a Mendelian randomization study

AIMS

To use Mendelian randomization to assess whether alcohol intake was causally associated with cognitive function.

DESIGN

Mendelian randomization using a genetic variant related to alcohol intake (ADH1B rs1229984) was used to obtain unbiased estimates of the association between alcohol intake and cognitive performance.

SETTING

Europe.

PARTICIPANTS

More than 34 000 adults.

MEASUREMENTS

Any versus no alcohol intake and units of intake in the previous week was measured by questionnaire. Cognitive function was assessed in terms of immediate and delayed word recall, verbal fluency and processing speed.

FINDINGS

Having consumed any versus no alcohol was associated with higher scores by 0.17 standard deviations (SD) [95% confidence interval (CI) = 0.15, 0.20] for immediate recall, 0.17 SD (95% CI = 0.14, 0.19) for delayed recall, 0.17 SD (95% CI = 0.14, 0.19) for verbal fluency and 0.12 SD (95% CI = 0.09, 0.15) for processing speed. The minor allele of rs1229984 was associated with reduced odds of consuming any alcohol (odds ratio = 0.87; 95% CI = 0.80, 0.95; P = 0.001; R(2)  = 0.1%; F-statistic = 47). In Mendelian randomization analysis, the minor allele was not associated with any cognitive test score, and instrumental variable analysis suggested no causal association between alcohol consumption and cognition: -0.74 SD (95% CI = -1.88, 0.41) for immediate recall, -1.09 SD (95% CI = -2.38, 0.21) for delayed recall, -0.63 SD (95% CI = -1.78, 0.53) for verbal fluency and -0.16 SD (95% CI = -1.29, 0.97) for processing speed.

CONCLUSIONS

The Mendelian randomization analysis did not provide strong evidence of a causal association between alcohol consumption and cognitive ability.

A systematic review and meta-analysis of 130,000 individuals shows smoking does not modify the association of APOE genotype on risk of coronary heart disease

Background

Conflicting evidence exists on whether smoking acts as an effect modifier of the association between APOE genotype and risk of coronary heart disease (CHD).

Methods and results

We searched PubMed and EMBASE to June 11, 2013 for published studies reporting APOE genotype, smoking status and CHD events and added unpublished data from population cohorts. We tested for presence of effect modification by smoking status in the relationship between APOE genotype and risk of CHD using likelihood ratio test.

In total 13 studies (including unpublished data from eight cohorts) with 10,134 CHD events in 130,004 individuals of European descent were identified. The odds ratio (OR) for CHD risk from APOE genotype (ε4 carriers versus non-carriers) was 1.06 (95% confidence interval (CI): 1.01, 1.12) and for smoking (present vs. past/never smokers) was OR 2.05 (95%CI: 1.95, 2.14). When the association between APOE genotype and CHD was stratified by smoking status, compared to non-ε4 carriers, ε4 carriers had an OR of 1.11 (95%CI: 1.02, 1.21) in 28,789 present smokers and an OR of 1.04 (95%CI 0.98, 1.10) in 101,215 previous/never smokers, with no evidence of effect modification (P-value for heterogeneity = 0.19). Analysis of pack years in individual participant data of >60,000 with adjustment for cardiovascular traits also failed to identify evidence of effect modification.

Conclusions

In the largest analysis to date, we identified no evidence for effect modification by smoking status in the association between APOE genotype and risk of CHD.

•

We examined evidence for an interaction between APOE genotype, smoking and risk of coronary heart disease.

•

This was conducted in the largest meta-analysis of published and unpublished data sets to date (>130,000 individuals).

•

Our analysis did not identify evidence of interaction.

•

These findings bring into question presence of a clinically meaningful interaction between APOE genotype and smoking.

Healthy diet indicator and mortality in Eastern European populations: prospective evidence from the HAPIEE cohort

Background/Objectives

Unhealthy diet has been proposed as one of the main reasons for the high mortality in Central and Eastern Europe (CEE) and the former Soviet Union (FSU) but individual-level effects of dietary habits on health in the region are sparse. We examined the associations between the healthy diet indicator (HDI) and all-cause and cause-specific mortality in three CEE/FSU populations.

Subjects/Methods

Dietary intakes of foods and nutrients, assessed by food frequency questionnaire (FFQ) in the Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) cohort study, were used to construct the HDI which follows the WHO 2003 dietary recommendations. Among 18 559 eligible adult participants (age range: 45-69 years) without history of major chronic diseases at baseline, 1 209 deaths occurred over mean follow up of 7 years. The association between HDI and mortality was estimated by Cox regression.

Results

After adjusting for covariates, HDI was inversely and statistically significantly associated with cardiovascular disease (CVD) and coronary heart disease (CHD) mortality, but not with other cause-specific and all-cause mortality in the pooled sample. Hazard ratios per one standard deviation (SD) increase in HDI score were 0.95 (95%CI 0.89-1.00, p=0.068), 0.90 (0.81-0.99, p=0.030) and 0.85 (0.74-0.97, p=0.018) for all-cause, CVD and CHD mortality, respectively. Population attributable risk fractions for low HDI were 2.9% for all-cause, 14.2% for CVD and 10.7% for CHD mortality.

Conclusions

These findings support the hypothesis that unhealthy diet has played a role in the high CVD mortality in Eastern Europe.

Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data

OBJECTIVE

To use the rs1229984 variant in the alcohol dehydrogenase 1B gene (ADH1B) as an instrument to investigate the causal role of alcohol in cardiovascular disease.

DESIGN

Mendelian randomisation meta-analysis of 56 epidemiological studies.

PARTICIPANTS

261 991 individuals of European descent, including 20 259 coronary heart disease cases and 10 164 stroke events. Data were available on ADH1B rs1229984 variant, alcohol phenotypes, and cardiovascular biomarkers.

MAIN OUTCOME MEASURES

Odds ratio for coronary heart disease and stroke associated with the ADH1B variant in all individuals and by categories of alcohol consumption.

RESULTS

Carriers of the A-allele of ADH1B rs1229984 consumed 17.2% fewer units of alcohol per week (95% confidence interval 15.6% to 18.9%), had a lower prevalence of binge drinking (odds ratio 0.78 (95% CI 0.73 to 0.84)), and had higher abstention (odds ratio 1.27 (1.21 to 1.34)) than non-carriers. Rs1229984 A-allele carriers had lower systolic blood pressure (-0.88 (-1.19 to -0.56) mm Hg), interleukin-6 levels (-5.2% (-7.8 to -2.4%)), waist circumference (-0.3 (-0.6 to -0.1) cm), and body mass index (-0.17 (-0.24 to -0.10) kg/m(2)). Rs1229984 A-allele carriers had lower odds of coronary heart disease (odds ratio 0.90 (0.84 to 0.96)). The protective association of the ADH1B rs1229984 A-allele variant remained the same across all categories of alcohol consumption (P=0.83 for heterogeneity). Although no association of rs1229984 was identified with the combined subtypes of stroke, carriers of the A-allele had lower odds of ischaemic stroke (odds ratio 0.83 (0.72 to 0.95)).

CONCLUSIONS

Individuals with a genetic variant associated with non-drinking and lower alcohol consumption had a more favourable cardiovascular profile and a reduced risk of coronary heart disease than those without the genetic variant. This suggests that reduction of alcohol consumption, even for light to moderate drinkers, is beneficial for cardiovascular health.

Life course socioeconomic position and mid-late life cognitive function in Eastern Europe

OBJECTIVES

To investigate whether the positive relation between socioeconomic position (SEP) across the life course and later life cognitive function observed in Western populations exists in former communist countries with apparently smaller income inequalities.

METHOD

Structural equation modeling analysis of cross-sectional data on 30,846 participants aged 45-78 years in four Central and Eastern European centers: Novosibirsk (Russia), Krakow (Poland), Kaunas (Lithuania), and six Czech towns from the HAPIEE (Health, Alcohol, and Psychosocial factors In Eastern Europe) study. SEP was measured using self-reported childhood (maternal education, household amenities), adult (education), and older adult (current material circumstances) indicators. Latent variable for cognition was constructed from word recall, animal naming, and letter search.

RESULTS

Associations between SEP measures over the life course and cognition were similar across study centers. Education had the strongest direct association with cognition, followed by current material circumstances. Indirect path from education to cognition, mediated by current SEP, was small. Direct path from mother's education to cognition was significant but modest, and partially mediated by later SEP measures, particularly education.

DISCUSSION

In these Eastern European populations, late life cognition reflected life course socioeconomic trajectories similarly to findings in Western countries.

The association between APOA5 haplotypes and plasma lipids is not modified by energy or fat intake: the Czech HAPIEE study

BACKGROUND AND AIMS

Several smaller studies reported interactions between dietary factors and apolipoprotein A5 (APOA5) gene polymorphisms in determination of plasma lipids. We tested interactions between APOA5 haplotypes and dietary intake in determination of plasma triglycerides (TG) and other lipids.

METHODS AND RESULTS

Participants (5487 males and females aged 45-69) were classified according to the number (0, 1, 2+) of minor APOA5 alleles (using T-1131 > C; rs662799 and Ser19 > Trp; rs3135506 polymorphisms) and into three groups of low (bottom 25%), medium (26th-75th percentile) and high (top 25%) of intake of total energy and total, saturated and polyunsaturated fats, assessed by food frequency questionnaire. The age-sex adjusted geometric means of plasma TG increased with the number of minor alleles, from 1.57 (standard error 0.01), to 1.79 (0.02) to 2.29 (0.10) mmol/L (p < 0.00001) but TG did not differ between groups with low, medium and high total energy intake (p = 0.251). TG concentrations were highest in subjects with the combination of 2+ minor alleles and the highest energy intake (mean 2.59 [0.19], compared with 1.62 [0.03] in subjects with lowest energy intake and no minor allele) but the interaction between energy intake and APOA5 haplotypes was not statistically significant (p = 0.186). Analogous analyses with total, saturated and polyunsaturated fat intake yielded similar nonsignificant results. Effects of APOA5 and dietary intakes on total and HDL cholesterol were weaker and no interactions were significant.

CONCLUSION

In this Slavic Caucasian population sample, we did not detect the hypothesized interaction between common SNPs within the APOA5 gene and diet in determination of blood lipids.

Socioeconomic inequalities in all-cause mortality in the Czech Republic, Russia, Poland and Lithuania in the 2000s: findings from the HAPIEE Study

BACKGROUND

Relatively large socioeconomic inequalities in health and mortality have been observed in Central and Eastern Europe (CEE) and the former Soviet Union (FSU). Yet comparative data are sparse and virtually all studies include only education. The aim of this study is to quantify and compare socioeconomic inequalities in all-cause mortality during the 2000s in urban population samples from four CEE/FSU countries, by three different measures of socioeconomic position (SEP) (education, difficulty buying food and household amenities), reflecting different aspects of SEP.

METHODS

Data from the prospective population-based HAPIEE (Health, Alcohol, and Psychosocial factors in Eastern Europe) study were used. The baseline survey (2002-2005) included 16 812 men and 19 180 women aged 45-69 years in Novosibirsk (Russia), Krakow (Poland), Kaunas (Lithuania) and seven Czech towns. Deaths in the cohorts were identified through mortality registers. Data were analysed by direct standardisation and Cox regression, quantifying absolute and relative SEP differences.

RESULTS

Mortality inequalities by the three SEP indicators were observed in all samples. The magnitude of inequalities varied according to gender, country and SEP measure. As expected, given the high mortality rates in Russian men, largest absolute inequalities were found among Russian men (educational slope index of inequality was 19.4 per 1000 person-years). Largest relative inequalities were observed in Czech men and Lithuanian subjects. Disadvantage by all three SEP measures remained strongly associated with increased mortality after adjusting for the other SEP indicators.

CONCLUSIONS

The results emphasise the importance of all SEP measures for understanding mortality inequalities in CEE/FSU.

SCORE performance in Central and Eastern Europe and former Soviet Union: MONICA and HAPIEE results

Aims

The Systematic COronary Risk Evaluation (SCORE) scale assesses 10 year risk of fatal atherosclerotic cardiovascular disease (CVD), based on conventional risk factors. The high-risk SCORE version is recommended for Central and Eastern Europe and former Soviet Union (CEE/FSU), but its performance has never been systematically assessed in the region. We evaluated SCORE performance in two sets of population-based CEE/FSU cohorts.

Methods and results

The cohorts based on the World Health Organization MONitoring of trends and determinants in CArdiovascular disease (MONICA) surveys in the Czech Republic, Poland (Warsaw and Tarnobrzeg), Lithuania (Kaunas), and Russia (Novosibirsk) were followed from the mid-1980s. The Health, Alcohol, and Psychosocial factors in Eastern Europe (HAPIEE) study follows Czech, Polish (Krakow), and Russian (Novosibirsk) cohorts from 2002–05. In Cox regression analyses, the high-risk SCORE ≥5% at baseline significantly predicted CVD mortality in both MONICA [n = 15 027; hazard ratios (HR), 1.7–6.3] and HAPIEE (n = 20 517; HR, 2.6–10.5) samples. While SCORE calibration was good in most MONICA samples (predicted and observed mortality were close), the risk was underestimated in Russia. In HAPIEE, the high-risk SCORE overpredicted the estimated 10 year mortality for Czech and Polish samples and adequately predicted it for Russia. SCORE discrimination was satisfactory in both MONICA and HAPIEE.

Conclusion

The high-risk SCORE underestimated the fatal CVD risk in Russian MONICA but performed well in most MONICA samples and Russian HAPIEE. This SCORE version might overestimate the risk in contemporary Czech and Polish populations.

Binge drinking and blood pressure: cross-sectional results of the HAPIEE study

OBJECTIVES

To investigate whether binge drinking pattern influences blood pressure independently from drinking volume or whether it modifies the effect of volume of drinking.

METHODS

We used cross-sectional data from population samples of 7559 men and 7471 women aged 45-69 years in 2002-05, not on antihypertensive medication, from Russia, Poland and Czech Republic. Annual alcohol intake, drinking frequency and binge drinking (≥ 100 g in men and ≥ 60 g in women in one session at least once a month) were estimated from graduated frequency questionnaire. Blood pressure was analysed as continuous variables (systolic and diastolic pressure) and a binary outcome (≥ 140/90 mm Hg).

RESULTS

In men, annual alcohol intake and drinking frequency were strongly associated with blood pressure. The odds ratio of high blood pressure for binge drinking in men was 1.62 (95% CI 1.45-1.82) after controlling for age, country, body mass index, education and smoking; additional adjustment for annual alcohol intake reduced it to 1.20 (1.03-1.39). In women, the fully adjusted odds ratio of high blood pressure for binge drinking was 1.31 (1.05-1.63). Binge drinking did not modify the effect of annual alcohol intake. Consuming alcohol as wine, beer or spirits had similar effects.

CONCLUSIONS

The results suggest that the independent long-term effect of binge drinking was modest, that binge drinking did not modify the effect of alcohol intake, and that different alcoholic beverages had similar effects on blood pressure.

Age at natural menopause in three central and eastern European urban populations: the HAPIEE study

OBJECTIVES

To investigate the age at menopause in three urban populations in Central and Eastern Europe and to assess whether the (suspected) differences can be explained by a range of socioeconomic, reproductive and behavioural factors.

METHODS

The Health, Alcohol and Psychosocial factors in Eastern Europe (HAPIEE) Study examined random samples of populations aged 45-69 years in Novosibirsk (Russia), Krakow (Poland) and six Czech towns. Participants completed a questionnaire and attended an examination in clinic. A total of 12,676 of women were included in these analyses.

RESULTS

The median age at menopause was 50 years in Novosibirsk, 51 years in Czech towns and 52 years in Krakow; the Cox regression hazard ratios of menopause, compared with Krakow, were 1.47 (95% CI 1.40-1.55) for Novosibirsk and 1.10 (1.04-1.16) for Czech women. In multivariate analyses, higher education, using vitamin and mineral supplements and ever use of oral contraceptives were associated with later menopause, while smoking, abstaining from alcohol and low physical activity were associated with earlier menopause. These factors, however, did not explain the differences between populations; the multivariate hazard ratios of menopause, compared with Krakow, were 1.48 (1.40-1.57) for Novosibirsk and 1.11 (1.05-1.17) for Czech women.

CONCLUSIONS

In this large population based study, differences in age at menopause between Central and Eastern Europe populations were substantial and unexplained by a range of risk factors. Associations of age at menopause with risk factors were largely consistent with studies in other populations.

Socioeconomic circumstances, health behaviours and functional limitations in older persons in four Central and Eastern European populations

OBJECTIVES

to investigate functional limitations and their association with socioeconomic factors in four Central and Eastern European populations.

METHODS

a cross-sectional study of random population samples in Novosibirsk (Russia), Krakow (Poland), Kaunas (Lithuania) and six Czech towns participating in the HAPIEE study. Functional limitations (classified into tertiles of the SF-36 physical functioning subscale), socioeconomic circumstances and health behaviours were available for 34,431 subjects aged 45-69 years.

RESULTS

the proportion of subjects in the worst tertile of the functional limitations score (≤80% of the maximum score) ranged from 21% of the men in Kaunas to 48% in Krakow women. In multivariate ordered logistic regression, functional limitations were strongly inversely associated with education and positively with material deprivation and with being economically inactive. Functional limitations were more common in male smokers and less common in alcohol drinkers. Socioeconomic characteristics explained some of the differences in functional limitations between populations. Health behaviours explained some of the differences between social groups in both genders and between populations in women.

CONCLUSION

unexpectedly, functional limitations were not most common in the sample from Russia, the country with the highest mortality rates. All socioeconomic measures were strongly associated with functional limitations and made some contribution towards explaining differences in limitations between populations.

Lack of an association between left-handedness and APOE polymorphism in a large sample of adults: results of the Czech HAPIEE study

An association between APOE genotype and left-handedness has been previously reported. We examined whether such association exists in a population sample of 4438 unrelated Caucasian adults aged 45–69 years (2022 males and 2416 females). Left-handedness was based on self-reported left-hand dominance for writing (prevalence 4.9%) and on consistently higher left-hand grip strength in two repeated measurements (prevalence 12.2%). Individuals with higher left hand grip strength were seven times more likely to be self-reported left handers (p <.0001, χ² 159.7,2 df). There were no differences in the proportion of self-reported left-handedness (p =.828, χ² 2.1, 5df) or higher grip strength in left hand (p = .557, χ² 3.9, 5 df) between APOE genotypes. The lack of association was similar in both genders and did not differ by age group. The results suggest that left-handedness in adults is not related to APOE genotype.

An overview of the European Health Examination Survey Pilot Joint Action

Background

Health Examination Surveys (HESs) can provide essential information on the health and health determinants of a population, which is not available from other data sources. Nevertheless, only some European countries have systems of national HESs. A study conducted in 2006–2008 concluded that it is feasible to organize national HESs using standardized measurement procedures in nearly all EU countries. The feasibility study also outlined a structure for a European Health Examination Survey (EHES), which is a collaboration to organize standardized HESs in countries across Europe.

To facilitate setting up national surveys and to gain experience in applying the EHES methods in different cultures, EHES Joint Action (2010–2011) planned and piloted standardized HESs in the working age population in 12 countries. This included countries with earlier national HESs and countries which were planning their first national HES. The core measurements included in all surveys were weight, height, waist circumference and blood pressure, and blood samples were taken to measure lipid profiles and glucose or glycated haemoglobin (HbA_1c). These are modifiable determinants of major chronic diseases not identified in health interview surveys. There was a questionnaire to complement the data on the examination measurements.

Methods

Evaluation of the pilot surveys was based on review of national manuals and evaluation reports of survey organizers; observations and discussions of survey procedures during site visits and training seminars; and other communication with the survey organizers.

Results

Despite unavoidable differences in the ways HESs are organized in the various countries, high quality and comparability of the data seems achievable. The biggest challenge in each country was obtaining high participation rate. Most of the pilot countries are now ready to start their full-size national HES, and six of them have already started.

Conclusions

The EHES Pilot Project has set up the structure for obtaining comparable high quality health indicators on health and important modifiable risk factors of major non-communicable diseases from the European countries. The European Union is now in a key position to make this structure sustainable. The EHES core survey can be expanded to cover other measurements.

The interleukin-6 receptor as a target for prevention of coronary heart disease: a mendelian randomisation analysis

BACKGROUND

A high circulating concentration of interleukin 6 is associated with increased risk of coronary heart disease. Blockade of the interleukin-6 receptor (IL6R) with a monoclonal antibody (tocilizumab) licensed for treatment of rheumatoid arthritis reduces systemic and articular inflammation. However, whether IL6R blockade also reduces risk of coronary heart disease is unknown.

METHODS

Applying the mendelian randomisation principle, we used single nucleotide polymorphisms (SNPs) in the gene IL6R to evaluate the likely efficacy and safety of IL6R inhibition for primary prevention of coronary heart disease. We compared genetic findings with the effects of tocilizumab reported in randomised trials in patients with rheumatoid arthritis.

FINDINGS

In 40 studies including up to 133,449 individuals, an IL6R SNP (rs7529229) marking a non-synonymous IL6R variant (rs8192284; p.Asp358Ala) was associated with increased circulating log interleukin-6 concentration (increase per allele 9·45%, 95% CI 8·34-10·57) as well as reduced C-reactive protein (decrease per allele 8·35%, 95% CI 7·31-9·38) and fibrinogen concentrations (decrease per allele 0·85%, 95% CI 0·60-1·10). This pattern of effects was consistent with IL6R blockade from infusions of tocilizumab (4-8 mg/kg every 4 weeks) in patients with rheumatoid arthritis studied in randomised trials. In 25,458 coronary heart disease cases and 100,740 controls, the IL6R rs7529229 SNP was associated with a decreased odds of coronary heart disease events (per allele odds ratio 0·95, 95% CI 0·93-0·97, p=1·53×10(-5)).

INTERPRETATION

On the basis of genetic evidence in human beings, IL6R signalling seems to have a causal role in development of coronary heart disease. IL6R blockade could provide a novel therapeutic approach to prevention of coronary heart disease that warrants testing in suitably powered randomised trials. Genetic studies in populations could be used more widely to help to validate and prioritise novel drug targets or to repurpose existing agents and targets for new therapeutic uses.

FUNDING

UK Medical Research Council; British Heart Foundation; Rosetrees Trust; US National Heart, Lung, and Blood Institute; Du Pont Pharma; Chest, Heart and Stroke Scotland; Wellcome Trust; Coronary Thrombosis Trust; Northwick Park Institute for Medical Research; UCLH/UCL Comprehensive Medical Research Centre; US National Institute on Aging; Academy of Finland; Netherlands Organisation for Health Research and Development; SANCO; Dutch Ministry of Public Health, Welfare and Sports; World Cancer Research Fund; Agentschap NL; European Commission; Swedish Heart-Lung Foundation; Swedish Research Council; Strategic Cardiovascular Programme of the Karolinska Institutet; Stockholm County Council; US National Institute of Neurological Disorders and Stroke; MedStar Health Research Institute; GlaxoSmithKline; Dutch Kidney Foundation; US National Institutes of Health; Netherlands Interuniversity Cardiology Institute of the Netherlands; Diabetes UK; European Union Seventh Framework Programme; National Institute for Healthy Ageing; Cancer Research UK; MacArthur Foundation.

ADH1B polymorphism, alcohol consumption, and binge drinking in Slavic Caucasians: results from the Czech HAPIEE study

BACKGROUND

Several genetic polymorphisms influence the risk of heavy alcohol consumption but it is not well understood whether the genetic effects are similar in different populations and drinking cultures, nor whether the genetic influences on binge drinking are similar to those seen for alcoholism.

METHODS

We have analyzed the effect of the Arg47His (rs1229984) variant within the alcohol dehydrogenase (ADH1B) gene on a range of drinking related variables in a large Eastern European Slavic population (Czech HAPIEE study), which recruited random samples of men and women aged 45-69 years in 7 Czech towns (3,016 males and 3,481 females with complete data). Drinking frequency, annual alcohol intake, prevalence of binge drinking (≥100 g in men and ≥60 g in women at least once a month) and the mean dose of alcohol per occasion were measured by the graduated frequency questionnaire. Alcohol intake in a typical week was used to define heavy drinking (≥350 g/wk in men and ≥210 g in women). Problem drinking (≥2 positive answers on CAGE) and negative consequences of drinking on different aspects of life were also measured.

RESULTS

The frequency of the His47 allele carriers was 11%. Homozygotes in the common allele (Arg47Arg), among both males and females, had significantly higher drinking frequency, and annual and weekly intake of alcohol than His47 carriers. The odds ratio of heavy drinking in Arg47Arg homozygotes versus His47 carriers was 2.1 (95% confidence intervals 1.1-3.2) in men and 2.2 (1.0-4.7) in women. In females, but not in males, Arg47Arg homozygotes had marginally significantly higher prevalence of binge drinking and mean alcohol dose per drinking session. There was no consistent association with problem drinking and negative consequences of drinking.

CONCLUSIONS

The ADH1B genotype was associated with the frequency and volume of drinking but its associations with binge drinking and problem drinking were less consistent.

The FTO gene polymorphism is associated with end-stage renal disease: two large independent case-control studies in a general population

BACKGROUND

Genome-wide association studies identified the FTO (fat mass and obesity gene) gene as an important determinant of body weight. More recently, the FTO gene was reported to be associated with other outcomes, including major risk factors for chronic kidney disease (CKD). We investigated the role of this gene in the risk of end-stage renal disease (ESRD) caused by CKD.

METHODS

We conducted two large population-based case-control studies of ESRD. Study 1 compared 984 haemodialysed patients with ESRD with 2501 participants in the Czech post-MONICA study; Study 2 compared 1188 patients included in a kidney transplantation programme for ESRD with 6681 participants in the Czech HAPIEE study. The frequencies of the FTO rs17817449 single nucleotide polymorphism genotype were compared between cases and controls.

RESULTS

The FTO rs17817449 genotype was significantly associated with CKD in both studies (P-values 0.00004 and 0.006, respectively). In the pooled data, the odds ratios of CKD for GG and GT, versus TT genotype, were 1.37 (95% confidence interval 1.20-1.56) and 1.17 (1.05-1.31), respectively (P for trend <0.0001). Among haemodialysed and kidney transplant patients, the onset of ESRD in GG homozygotes was 3.3 (P = 0.012) and 2.5 (P = 0.032) years, respectively, earlier than in TT homozygotes.

CONCLUSIONS

These two large independent case-control studies in the general population found robust associations between the FTO rs17817449 polymorphism and the ESRD. The results suggest that the morbidities associated with the FTO gene include CKD.

Work stress and health in Western European and post-communist countries: an East-West comparison study

BACKGROUND

There is evidence that psychosocial factors at work influence the risk of poor health in Western societies, but little is known about the effect of work stress in the former communist countries. The aim of this paper is to compare the association of work stress with self-rated health in Western European and post-communist countries.

METHODS

Data from four epidemiological studies were used: the HAPIEE study (Poland, Russia and the Czech Republic), the Hungarian Epidemiological Panel (Hungary), the Heinz Nixdorf Recall study (Germany) and the Whitehall II study (UK). The overall sample consisted of 18 494 male and female workers aged 35-65 years.

RESULTS

High effort-reward imbalance at work was associated with poor self-rated health. The adjusted odds ratios for the highest versus lowest quartile of the effort-reward ratio were 3.8 (95% CI 1.9 to 7.7) in Hungary, 3.6 (95% CI 2.3 to 5.7) in the Czech Republic, 2.5 (95% CI 1.5 to 4.1) in the UK, 2.3 (95% CI 1.6 to 3.5) in Germany, 1.5 (95% CI 1.0 to 2.1) in Poland and 1.4 (95% CI 1.1 to 1.8) in Russia. The differences in odds ratios between countries were statistically significant (p<0.05). A similar pattern was observed for the effect of overcommitment on poor health.

CONCLUSION

The association of effort-reward imbalance at work and of a high degree of work-related overcommitment with poor self-rated health was seen in all countries, but the size of the effects differed considerably. It does not appear that the effects in Eastern Europe are systematically stronger than in the West.

APOE polymorphism and its effect on plasma C-reactive protein levels in a large general population sample

The published data remain inconsistent on association between apolipoprotein E (APOE) gene variations and plasma levels of C-reactive protein (CRP), mainly because of low statistical power of previous studies. To clarify this question, we analyzed data from large population sample of randomly selected individuals from seven Czech towns (2,886 males and 3,344 females, the HAPIEE [Health, Alcohol, and Psychosocial factors In Eastern Europe] study). In both males and females, the lowest levels of plasma hsCRP were observed in the carriers of the APOE epsilon 4 epsilon 4 and epsilon 4 epsilon 3 genotypes. The median (interquartile range, IQR) concentration of hsCRP in carriers of the most common APOE epsilon 3 epsilon 3 genotype (two-thirds of participants) was 1.13 mg/l (IQR, 0.56-2.33) in men and 1.23 mg/l (IQR, 0.61-2.65) in women, compared with 0.72 mg/l (IQR, 0.61-0.86) in male and 0.72 mg/l (IQR, 0.61-0.85) in female carriers of APOE epsilon 4 epsilon 3/epsilon 4 epsilon 4 genotypes; the differences were statistically significant (p < 0.001). The association between APOE and CRP was not materially affected by adjustment for age, sex, history of cardiovascular disease, or cardiovascular risk factors. This study, the largest to date, provides robust evidence of an association between plasma hsCRP and the APOE genotype, an association not explained by history of cardiovascular disease nor its risk factors.

Non-fatal injuries in three Central and Eastern European urban population samples: the HAPIEE study

Background: Despite high mortality from injuries and accidents, data on rates and distribution of non-fatal injuries in Central and Eastern European populations are scarce. Methods: Cross-sectional study of random population samples of 45–69-year-old men and women (n = 28 600) from Novosibirsk (Russia), Krakow (Poland) and six Czech towns, participating in the Health, Alcohol and Psychosocial factors In Eastern Europe (HAPIEE) study. Participants provided information on non-fatal injuries in the past 12 months, socio-economic characteristics, alcohol consumption and other covariates. Results: The period prevalence of non-fatal injuries in the last year among Czech, Russian and Polish men was 12.5, 9.4 and 5.3%, respectively; among women, the respective proportions were 9.9, 9.8 and 6.4%. Injury prevalence declined with age in men and increased with age in women. Higher injury prevalence was associated with being unmarried, material deprivation, higher drinking frequency and problem drinking. In the pooled data, the adjusted odds ratio (OR) for the highest versus lowest material deprivation category was 1.57 [95% confidence interval (CI) 1.38–1.79]; for problem drinking, the OR was 1.44 (95% CI 1.23–1.69). Alcohol did not mediate the link between socio-economic status and injury. Conclusion: Non-fatal injuries were associated with material deprivation, other socio-economic characteristics and with alcohol. These results not only underscore the universality of the inequality phenomenon, but also suggest that the mediating role of alcohol in social differentials in non-fatal injury remains an unresolved issue.

Dietary habits in three Central and Eastern European countries: the HAPIEE study

BACKGROUND

The high cardiovascular mortality in Eastern Europe has often been attributed to poor diet, but individual-level data on nutrition in the region are generally not available. This paper describes the methods of dietary assessment and presents preliminary findings on food and nutrient intakes in large general population samples in Russia, Poland and the Czech Republic.

METHODS

The HAPIEE (Health, Alcohol and Psychosocial factors In Eastern Europe) study examined random samples of men and women aged 45-69 years at baseline in Novosibirsk (Russia), Krakow (Poland) and six Czech urban centres in 2002-2005. Diet was assessed using a food frequency questionnaire (at least 136 items); complete dietary information was available for 26,870 persons.

RESULTS

Total energy intakes among men ranged between 8.7 MJ in the Czech sample and 11.7 MJ in the Russian sample, while among women, energy intakes ranged between 8.2 MJ in the Czech sample and 9.8 MJ in the Russian sample. A Healthy Diet Indicator (HDI), ranging from a score of 0 (lowest) to 7 (highest), was developed using the World Health Organisation's (WHO) guidelines for the prevention of chronic diseases. The mean HDI scores were low, ranging from 1.0 (SD = 0.7) among the Polish subjects to 1.7 (SD = 0.8) among the Czech females. Very few subjects met the WHO recommended intakes for complex carbohydrates, pulses or nuts; intakes of saturated fatty acids, sugar and protein were too high. Only 16% of Polish subjects met the WHO recommendation for polyunsaturated fat intake. Consumption of fruits and vegetables was lower than recommended, especially among those Russian subjects who were assessed during the low intake season. Fewer than 65% of subjects consumed adequate amounts of calcium, magnesium and potassium, when compared with the United Kingdom's Reference Nutrient Intake.

CONCLUSION

This first large scale study of individual-based dietary intakes in the general population in Eastern Europe implies that intakes of saturated fat, sugar and complex carbohydrates are a cause for concern. The development of country-specific nutritional tools must be encouraged and nutritional campaigns must undergo continuing development.

Association between year of birth and cognitive functions in Russia and the Czech Republic: cross-sectional results of the HAPIEE study

OBJECTIVES

To assess differences in cognitive functions by year of birth in Russia and the Czech Republic.

METHODS

A cross-sectional study in the general population of Novosibirsk (Russia) and 6 cities of the Czech Republic recruited random samples of men and women (3,874 Russians, 3,626 Czechs) aged 45-69 years in 2002 (i.e. born in 1933-1957). Word recall, verbal fluency (number of animals named in 1 min) and letter search were assessed in a clinic.

RESULTS

Except letter search in men, we found similar levels of cognitive functioning in Russians and Czechs in the youngest subjects and a steeper association of functioning with year of birth in Russia than in the Czech Republic. For example, the difference in the mean word recall, associated with 10 years difference in year of birth, was 0.9 (SE 0.06) words in Russian men, compared to 0.4 (0.06) words in Czech men; in women, these figures were 0.8 (0.05) and 0.3 (0.05), respectively. For all outcomes, except letter search in men, the interactions between year of birth and country were statistically highly significant, and the differences in the year of birth effects between countries were largely unexplained by socioeconomic indicators and risk factors.

CONCLUSION

The slope of association between lower cognitive functioning and earlier year of birth is much steeper in Russia than in the Czech Republic. Given that poor cognitive functioning is a risk factor for dementia, long-term follow-up of this cohort and other studies into population rates of cognitive impairment in Russia should be a priority.

Depressive symptoms and levels of C-reactive protein: a population-based study

BACKGROUND

Depression and depressive symptoms have been repeatedly linked to elevated levels of C-reactive protein (CRP) but questions remain as to the statistical robustness of the association and particularly whether the association between depression and CRP reflects the presence of a chronic disease.

METHODS

A random sample of 6,126 men and women aged 45-69 years was examined in a cross-sectional study in seven towns in the Czech Republic. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression (CESD) scale.

RESULTS

Center for Epidemiologic Studies Depression score was significantly related to increased levels of CRP in a linear fashion. After controlling for a range of potential confounders, subjects with depressive symptoms (CESD score >or= 16) had CRP concentrations 0.43 mg/l (95% CI 0.16-0.72) higher than those without symptoms. The association remained significant when study sample was restricted to healthy subjects; among individuals who did not report any chronic disease, the difference between those with and without depressive symptoms was 0.44 mg/l (95% CI 0.14-0.74), and among persons who did not visit a doctor in the last 12 months the difference was 1.20 mg/l (95% CI 0.52-1.87).

CONCLUSIONS

These results confirm that there is a statistically robust association between depressive symptoms and increased levels of CRP. We did not find evidence that the association is due presence of a chronic condition.

The FTO gene and obesity in a large Eastern European population sample: the HAPIEE study

Variants in the FTO (oxoglutarate-dependent nucleic acid demethylase) gene have been associated with the BMI determination in Western European and North American populations. To widen the geographical coverage of the FTO studies, we have analyzed the association between the FTO gene variant rs17817449 (G>C) and obesity in a Slavic Eastern European population. A total of 3,079 males and 3,602 females 45-69 years old were randomly selected from population registers of seven Czech cities. We examined three indices of obesity: BMI (kg/m(2)), waist circumference, and waist-to-hip ratio (WHR). The FTO rs17817449 variant was significantly associated with BMI both in males (GG 28.7 +/- 4.1; GT 28.3 +/- 3.9; TT 28.0 +/- 3.9; P = 0.003) and females (GG 28.7 +/- 5.2; GT 28.2 +/- 5.1; TT 27.2 +/- 4.9; P < 0.001); the associations were not affected by adjustment for age, smoking, socioeconomic status, and physical activity. The FTO variant was also associated with waist circumference (difference between GG and TT was 1.1 cm (P = 0.043) in men and 2.4 cm (P < 0.001) in women) but this relationship disappeared after adjustment for BMI. Similarly, BMI explained the weak association of FTO with WHR and C-reactive protein. FTO was not associated with plasma total and high-density lipoprotein cholesterol, triglycerides, blood glucose, and blood pressure. These results confirm that in a Slavic population the FTO variant is strongly associated with BMI but not with other risk factors.

MLXIPL variant in individuals with low and high triglyceridemia in white population in Central Europe

We tested the hypothesis that the MLXIPL rs3812316 variant predicts plasma triglyceride (TG) levels. We compared three groups of adult individuals: 162 persons with TG > 10 mmol/L, 266 persons with TG < 0.65 mmol/L, and 2,043 population-based controls (range of TG concentrations 0.7-8.7 mmol/L). We found a small difference in the frequency of the Gln allele carriers between population controls (20.4%) and persons with low TG (26.3%, P = 0.033). We found no difference between individuals with high TG and population controls, and there was no association between the MLXIPL variant and plasma TG levels among the population controls.

Childhood socioeconomic circumstances and adult height and leg length in central and eastern Europe

BACKGROUND

Adult height and leg length have been shown to be positively associated with childhood socioeconomic circumstances in several studies in western populations. This study will determine whether similar associations are observable in settings with different social histories, and will assess whether adult leg length is more strongly associated than adult height.

METHODS

Random samples of men and women aged 45-69 years were taken from population registers in Novosibirsk (Russia), Krakow (Poland) and six towns of the Czech Republic, recruiting nearly 29,000 people. Participants completed a questionnaire that included questions regarding their mother's and father's education (not available in the Czech Republic) and ownership of several household items when they were 10 years old. Participants' standing and sitting heights were measured and from these an estimate of leg length was derived. Associations between indicators of childhood socioeconomic circumstances and anthropometric measures were analysed using linear regression.

RESULTS

Russian individuals were shorter and reported fewer household assets at the age of 10 years than Czech and Polish individuals. Parental education and household assets were strongly associated with each other and both were independently associated with height, leg length and trunk length. Height was associated with childhood circumstances more strongly than leg length. The associations of childhood circumstances with the leg/trunk ratio were weak and inconsistent.

CONCLUSION

In these urban populations in eastern Europe, adult height is associated with childhood conditions at least as strongly as leg length.

Estimation of secular trends in adult height, and childhood socioeconomic circumstances in three Eastern European populations

The objective of these analyses was to estimate the strength and direction of secular trends in adult height and childhood socioeconomic circumstances in eight towns in three Eastern European countries in the mid-20th century, and to assess the extent to which childhood conditions might explain the height differences. We used cross-sectional data from the baseline survey of the Health, Alcohol and Psychosocial factors in Eastern Europe (HAPIEE) study, conducted in 2002-2005. The study examined 24,012 men and women born between 1933 and 1957, randomly selected from the general populations of Novosibirsk (Russia), Krakow (Poland) and six towns of the Czech Republic. To allow for age-related height loss we estimated maximum attained height. Parental education and household item ownership at age 10 were used as markers of childhood socioeconomic conditions. In all 5-year birth cohorts, Novosibirsk men and women were shortest. There were positive and statistically significant secular trends in childhood conditions and in maximum adult height. Adjustment for childhood conditions explained about one third of the trend in height. There appeared to be a small reduction in height of persons born during the Second World War which was, however, only significant in Novosibirsk. These results suggest that secular trends in height mirror, but are not wholly explained by, trends in socioeconomic circumstances in early life.

Socio-economic status over the life-course and depressive symptoms in men and women in Eastern Europe

OBJECTIVE

Research into social inequalities in depression has studied western populations but data from non-western countries are sparse. In this paper, we investigate the extent of social inequalities in depression in Eastern Europe, the relative importance of social position at different points of the life-course, and whether social patterning of depression differs between men and women.

METHOD

A cross-sectional study examined 12,053 men and 13,582 women in Russia, Poland and the Czech Republic. Depressive symptoms (16 or above on the CESD-20) were examined in relation to socio-economic circumstances at three phases of the life-course: childhood (household amenities and father's education); own education; current circumstances (financial difficulties and possession of household items).

RESULTS

Pronounced social differences in depression exist in men and women throughout Eastern Europe. Depression was largely influenced by current circumstances rather than by early life or education, with effects stronger in Poland and Russia. Odds ratios in men for current disadvantage were 3.16 [95% CI: 2.57-3.89], 3.16 [2.74-3.64] and 2.17 [1.80-2.63] in Russia, Poland and the Czech Republic respectively. Social variables did not explain the female excess in depression, which varied from 2.91 [2.58-3.27] in Russia to 1.90 [1.74-2.08] in Poland. Men were more affected by adult disadvantage than women, leading to narrower sex differentials in the presence of disadvantage.

LIMITATIONS

Cross-sectional data with recall of childhood conditions were used.

CONCLUSION

Current social circumstances are the strongest influence on increased depressive symptoms in countries which have recently experienced social changes.

Neighbourhood socioeconomic status and cardiovascular risk factors: a multilevel analysis of nine cities in the Czech Republic and Germany

Background

Previous studies have shown that deprived neighbourhoods have higher cardiovascular mortality and morbidity rates. Inequalities in the distribution of behaviour related risk factors are one possible explanation for this trend. In our study, we examined the association between cardiovascular risk factors and neighbourhood characteristics. To assess the consistency of associations the design is cross-national with data from nine industrial towns from the Czech Republic and Germany.

Methods

We combined datasets from two population based studies, one in Germany ('Heinz Nixdorf Recall (HNR) Study'), and one in the Czech Republic ('Health, Alcohol and Psychosocial Factors in Eastern Europe (HAPIEE) Study'). Participation rates were 56% in the HNR and 55% in the HAPIEE study. The subsample for this particular analysis consists of 11,554 men and women from nine German and Czech towns. Census based information on social characteristics of 326 neighbourhoods were collected from local administrative authorities. We used unemployment rate and overcrowding as area-level markers of socioeconomic status (SES). The cardiovascular risk factors obesity, hypertension, smoking and physical inactivity were used as response variables. Regression models were complemented by individual-level social status (education) and relevant covariates.

Results

Smoking, obesity and low physical activity were more common in deprived neighbourhoods in Germany, even when personal characteristics including individual education were controlled for. For hypertension associations were weak. In the Czech Republic associations were observed for smoking and physical inactivity, but not for obesity and hypertension when individual-level covariates were adjusted for. The strongest association was found for smoking in both countries: in the fully adjusted model the odds ratio for 'high unemployment rate' was 1.30 [95% CI 1.02–1.66] in the Czech Republic and 1.60 [95% CI 1.29–1.98] in Germany.

Conclusion

In this comparative study, the effects of neighbourhood deprivation varied by country and risk factor; the strongest and most consistent effects were found for smoking. Results indicate that area level SES is associated with health related lifestyles, which might be a possible pathway linking social status and cardiovascular disease. Individual-level education had a considerable influence on the association between neighbourhood characteristics and risk factors.

Determinants of cardiovascular disease and other non-communicable diseases in Central and Eastern Europe: rationale and design of the HAPIEE study

Background

Over the last five decades, a wide gap in mortality opened between western and eastern Europe; this gap increased further after the dramatic fluctuations in mortality in the former Soviet Union (FSU) in the 1990s. Recent rapid increases in mortality among lower socioeconomic groups in eastern Europe suggests that socioeconomic factors are powerful determinants of mortality in these populations but the more proximal factors linking the social conditions with health remain unclear. The HAPIEE (Health, Alcohol and Psychosocial factors In Eastern Europe) study is a prospective cohort study designed to investigate the effect of classical and non-conventional risk factors and social and psychosocial factors on cardiovascular and other non-communicable diseases in eastern Europe and the FSU. The main hypotheses of the HAPIEE study relate to the role of alcohol, nutrition and psychosocial factors.

Methods and design

The HAPIEE study comprises four cohorts in Russia, Poland, the Czech Republic and Lithuania; each consists of a random sample of men and women aged 45–69 years old at baseline, stratified by gender and 5 year age groups, and selected from population registers. The total planned sample size is 36,500 individuals. Baseline information from the Czech Republic, Russia and Poland was collected in 2002–2005 and includes data on health, lifestyle, diet (food frequency), socioeconomic circumstances and psychosocial factors. A short examination included measurement of anthropometric parameters, blood pressure, lung function and cognitive function, and a fasting venous blood sample. Re-examination of the cohorts in 2006–2008 focuses on healthy ageing and economic well-being using face-to-face computer assisted personal interviews. Recruitment of the Lithuanian cohort is ongoing, with baseline and re-examination data being collected simultaneously. All cohorts are being followed up for mortality and non-fatal cardiovascular events.

Discussion

The HAPIEE study will provide important new insights into social, behavioural and biological factors influencing mortality and cardiovascular risk in the region.

Depressive symptoms in urban population samples in Russia, Poland and the Czech Republic

BACKGROUND

Relatively little is known about depression in countries that were formerly part of the Soviet Union, especially Russia.

AIMS

To investigate the rates and distribution of depressive symptoms in urban population samples in Russia, Poland and the Czech Republic.

METHOD

A cross-sectional study was conducted in randomly selected men and women aged 45-64 years (n=2151 in total, response rate 69%) in Novosibirsk (Russia), Krakow (Poland) and Karvina (Czech Republic). The point prevalence of depressive symptoms in the past week was defined as a score of at least 16 on the Center for Epidemiological Studies Depression scale.

RESULTS

In men the prevalence of depressive symptoms was 23% in Russia, 21% in Poland and 19% in the Czech Republic; in women the rates were 44%, 40% and 34% respectively. Depressive symptoms were positively associated with material deprivation, being unmarried and binge drinking. The association between education and depression was inverse in Poland and the Czech Republic but positive in Russia.

CONCLUSIONS

The prevalence of depressive symptoms in these eastern European urban populations was relatively high; as in other countries, it was associated with alcohol and several sociodemographic factors.

The association between psychosocial characteristics at work and problem drinking: a cross-sectional study of men in three Eastern European urban populations

BACKGROUND

Psychosocial factors at work are thought to influence health partly through health behaviours.

AIMS

To examine the association between effort-reward imbalance and job control and several alcohol related measures in three eastern European populations.

METHODS

A cross-sectional study was conducted in Novosibirsk (Russia), Krakow (Poland), and Karvina (Czech Republic). The participants completed a questionnaire that included effort-reward at work, job control, and a number of sociodemographic variables. Annual alcohol intake, annual number of drinking sessions, the mean dose of alcohol per drinking session, and binge drinking (> or =80 g of ethanol in one session at least once a week) were based on graduated frequencies in the questionnaire. Data were also available on problem drinking (> or =2 positive answers on CAGE questionnaire) and negative social consequences of drinking. All male participants in full employment (n = 694) were included in the present analyses.

RESULTS

After controlling for age and centre, all indices of alcohol consumption and problem drinking were associated with the effort-reward ratio. Adjustment for material deprivation did not change the results but adjustment for depressive symptoms reduced the estimated effects. Job control was not associated with any of the alcohol related outcomes.

CONCLUSIONS

The imbalance of effort-reward at work is associated with increased alcohol intake and problem drinking. The association appears to be partly mediated by depressive symptoms, which might be either an antecedent or a consequence of men's drinking behaviour.

Do lipids contribute to the lack of cardio-protective effect of binge drinking: alcohol consumption and lipids in three eastern European countries

AIMS

The cardio-protective effect of moderate alcohol consumption is partly mediated by HDL cholesterol. However, epidemiological studies suggest that binge drinking may not be associated with reduced risk of heart disease; a possible explanation is that the relationship of blood lipids with binge drinking is different from that with moderate intake. We investigated this hypothesis in a population study in three eastern European countries.

METHODS

We conducted a cross-sectional study in random population samples in Novosibirsk (Russia), Krakow (Poland) and Karvina (Czech Republic). A sub-sample of 282 men aged 45-64 years who provided a fasting blood sample were analysed. Annual alcohol intake and the frequency of heavy binge drinking (> or =140 g of ethanol per session) were estimated from a graduated frequency questionnaire.

RESULTS

Annual intake of alcohol was positively associated with total and HDL cholesterol. After controlling for annual intake, the frequency of heavy binge drinking was associated with increased concentrations of total and HDL cholesterol. By combining annual intake and drinking pattern, we found that men consuming >8 l of alcohol per year who had a heavy binge at least once a month had the mean total, HDL and LDL cholesterol 1.69 (SE 0.35), 0.61 (0.11) and 0.97 (0.34) mmol/l, respectively, higher than non-drinkers; this resulted in more favourable ratios of total and LDL cholesterol relative to HDL cholesterol in frequent heavy bingers. Triglycerides were not related to alcohol intake or binge drinking.

CONCLUSIONS

Blood lipids do not seem to explain the apparent lack of the cardio-protective effect of binge drinking reported in epidemiological studies.

Psychosocial factors at work and depression in three countries of Central and Eastern Europe

Psychosocial factors at work have been found to predict a range of health outcomes but their effect on mental health outcomes has not been extensively studied. This paper explores the relationship between psychosocial factors at work and depression in three countries of Central and Eastern Europe. The data come from a cross-sectional study of working men (n = 645) and women (n = 523) aged 45-64 years, randomly selected from population registers in Novosibirsk (Russia), Krakow (Poland) and Karvina-Havirov (Czech Republic). The questionnaire included questions on the effort and reward at work, job control, the full CES-D scale of depression, and a range of other characteristics. Linear regression was used to estimate the association between depression score and work characteristics: the logarithm of the effort-reward ratio, and continuous job control score. The means of the depression score were 10.5 for men and 14.2 for women. After controlling for age, sex and country, effort-reward ratio (logarithmically transformed) was strongly related to depression score; a 1 SD increase in the log transformed effort-reward ratio was associated with an increase in the depression of 2.0 points (95% CI 1.5; 2.4), and further adjustment did not materially change the effect. Job control was inversely associated with depression score in Poland and the Czech Republic (not in Russia) but the association was largely eliminated by controlling for socioeconomic characteristics. This study suggests that the effort-reward imbalance at work is related to prevalence of depression in these central and eastern European populations.

Contribution of drinking patterns to differences in rates of alcohol related problems between three urban populations

OBJECTIVES

To examine, on empirical data, whether drinking patterns, in addition to overall alcohol consumption, contribute to differences in rates of alcohol related problems between populations.

DESIGN

Cross sectional survey.

SETTINGS

One Russian, one Polish, and one Czech city.

PARTICIPANTS

1118 men and 1125 women randomly selected from population registers.

MAIN OUTCOME MEASURES

Problem drinking; negative social consequences of drinking; alcohol consumption and drinking pattern.

RESULTS

Rates of problem drinking and of negative consequences of drinking were much higher in Russian men (35% and 18%, respectively) than in Czechs (19% and 10%) or Poles (14% and 8%). This contrasts with substantially lower mean annual intake of alcohol reported by Russian men (4.6 litres) than by Czech men (8.5 litres), and with low mean drinking frequency in Russia (67 drinking sessions per year, compared with 179 sessions among Czech men). However, Russians consumed the highest dose of alcohol per drinking session (means 71 g in Russians, 46 g in Czechs, and 45 g in Poles), and had the highest prevalence of binge drinking. In women, the levels of alcohol related problems and of drinking were low in all countries. In ecological and individual level analyses, indicators of binge drinking explained a substantial part of differences in rates of problem drinking and negative consequences of drinking between the three countries.

CONCLUSIONS

These empirical data confirm high levels of alcohol related problems in Russia despite low volume of drinking. The binge drinking pattern partly explains this paradoxical finding. Overall alcohol consumption does not suffice as an estimate of alcohol related problems at the population level.