Effects of education on adult mortality: a global systematic review and meta-analysis

Exercise intensity and mortality in overweight and obese patients with chronic kidney disease: longitudinal analysis (1999-2016)

BACKGROUND

Chronic kidney disease (CKD) and overweight/obesity are significant global public health issues. Appropriate free-time physical activity (PA) is essential for overweight/obese patients with chronic kidney disease, but specific guidelines are lacking. The present study was conducted to determine the association between PA and all-cause mortality in these patients.

METHODS

Data from 3,434 overweight/obese adults with CKD from the 1999-2016 National Health and Nutrition Examination Surveys were analyzed. Associations between clinical/laboratory findings and PA intensity (moderate and vigorous) were investigated. The all-cause mortality of patients in different PA categories were compared by Kaplan-Meier analysis. Factors associated with all-cause mortality were determined using a Cox proportional hazards model. A restricted cubic spline was employed to obtain a more flexible and detailed representation of the relationship between PA intensity and all-cause mortality, with better predictive capability.

RESULTS

The Kaplan-Meier analysis revealed that greater all-cause mortality was associated with < 10 min/week moderate/vigorous PA (log-rank p < 0.001). A greater survival probability was associated with ≥ 150 min/week vigorous PA or 10-149 min/week moderate PA (log-rank p < 0.001). Age, gender, vigorous PA, smoking status, alcohol consumption, diabetes status, eGFR, serum albumin level, uric acid level, and blood urea nitrogen level were identified as factors associated independently with mortality in the Cox proportional hazards analysis. The restricted cubic splines revealed that these relationships were non-linear (all p < 0.05). Kaplan-Meier analysis of data from patients who engaged in 10-450 min/week moderate/vigorous PA revealed significant differences between the 0-74-min/week and other vigorous PA groups (all log-rank p < 0.001).

CONCLUSIONS

Extended durations of vigorous PA are associated with reduced all-cause mortality in overweight/obese patients with CKD. Clinicians should recommend vigorous free-time PA to these patients, and public health interventions should target this goal to maximize patient health.

Environmental Risk Factors for Gallbladder Cancer: Field-Wide Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Cholelithiasis is the most well-recognized risk factor for gallbladder cancer (GBC), the predominant biliary-tract malignancy; however, credibility on other modifiable exposures remains uncertain. We performed a field-wide systematic review and meta-analysis on environmental factors associated with GBC.

METHODS

We systematically searched Medline/PubMed and Embase up to May 8, 2023, to identify randomized and nonrandomized studies examining environmental factors for GBC. We conducted random-effects meta-analyses focusing on longitudinal studies. Evidence from case-control studies was considered complementary. Evidence credibility was graded by prespecified criteria including the random-effects estimate, 95% confidence interval (CI), P value, statistical heterogeneity, small-study effects, and robustness to unmeasured confounding.

RESULTS

We identified 215 eligible primary studies and performed 350 meta-analyses across 7 domains: lifestyle, reproductive, metabolic, dietary, infections, interventions, and contaminants and occupational exposures. Based on longitudinal evidence, body mass index (relative risk [RR] per 5-unit increase, 1.27; 95% CI, 1.21‒1.33), hip circumference (RR per 5-cm increase, 1.16; 95% CI, 1.11‒1.22), infection of bile ducts (RR, 31.7; 95% CI, 24.8-40.6), high parity (RR, 1.48; 95% CI, 1.30‒1.68), obesity (RR, 1.70; 95% CI, 1.44‒2.01), overweight (RR, 1.28; 95% CI, 1.14‒1.43), waist circumference (RR per 5-cm increase, 1.14; 95% CI, 1.10‒1.18), and waist-to-height ratio (RR per 0.1 increase, 1.49; 95% CI, 1.36‒1.64) were robustly associated with increased GBC risk, whereas high education (RR, 0.63; 95% CI, 0.49‒0.82) was associated with reduced risk (moderate-to-high credibility). Another 39 significant associations showed lower credibility, including different exposure scenarios of tobacco smoking, alcohol consumption, and insufficient physical activity.

CONCLUSIONS

This study offers a detailed appraisal and mapping of the evidence on modifiable factors for GBC. Further high-quality prospective studies are essential to validate emerging associations and inform preventive strategies in high-incidence areas. (Systematic review registration: CRD42023434673.).

Systemic oxidative stress associates with the development of post-COVID-19 syndrome in non-hospitalized individuals

BACKGROUND

Post-COVID-19 syndrome (PCS) remains a major health issue worldwide, while its pathophysiology is still poorly understood. Systemic oxidative stress (OS) may be involved in PCS, which is reflected by lower circulating free thiols (R-SH, sulfhydryl groups), as they are receptive to rapid oxidation by reactive species. This study aimed to investigate the longitudinal dynamics of serum R-SH after SARS-CoV-2 infection and its association with the development of PCS in individuals with mild COVID-19.

METHODS

Baseline serum R-SH concentrations were measured and compared between 135 non-hospitalized COVID-19 subjects and 82 healthy controls (HC). In COVID-19 subjects, serum R-SH concentrations were longitudinally measured during the acute disease phase (up to 3 weeks) and at 3, 6, and 12 months of follow-up, and their associations with relevant clinical parameters were investigated, including the development of PCS.

RESULTS

Baseline albumin-adjusted serum R-SH were significantly reduced in non-hospitalized COVID-19 subjects as compared to HC (p = 0.041), reflecting systemic OS. In mild COVID-19 subjects, trajectories of albumin-adjusted serum R-SH levels over a course of 12 months were longitudinally associated with the future presence of PCS 18 months after initial infection (b = -9.48, p = 0.023).

CONCLUSION

Non-hospitalized individuals with COVID-19 show evidence of systemic oxidative stress, which is longitudinally associated with the development of PCS. Our results provide a rationale for future studies to further investigate the value of R-SH as a monitoring biomarker and a potential therapeutic target in the development of PCS.

Non-suicidal self-injury in the COVID-19 pandemic: results from cross-sectional surveys among Brazilian adults from 2020 to 2023

The multilevel psychosocial stressors associated with COVID-19 pandemic set the stage to investigate risk factors and groups susceptible for non-suicidal self-injury (NSSI). A national sample of 9,929 Brazilian adults aged 36.1 years on average participated in the study. Cross-sectional data were collected in 2020, 2021, 2022, and 2023. NSSI levels were considered high in the total sample (13.2%) when compared to other studies in this context. The variables with the highest explanatory power in the regression models were age, anxiety, and depression. The main risk factors were being younger, living in the South or Southeast regions of Brazil, having lower educational attainment, and having higher rates of anxiety and depression. Respondents had the highest probability of NSSI in 2022. The sustained higher rates of NSSI in 2023 compared to the beginning of the pandemic underscores the need for continuous monitoring and the development of preventive actions for self-injurious behaviors.

Prevalence and Determinants of Changes in Physical Activity and Sedentary Behavior during and after the COVID-19 Pandemic: A Swedish Repeated Cross-Sectional Study

Physical activity (PA) and sedentary behavior (SB) changed during the COVID-19 pandemic; hence, this study examined PA and SB at four time points between December 2019 and December 2022. The participants' PA decreased during the pandemic and did not recover afterwards. Among women, PA increased slightly in 2022 but not at all in men. From 2019 to 2020, SB increased and then decreased to near the pre-pandemic level in both sexes. Regarding age, PA decreased in the oldest age group (65-79 years) across all time points, while SB increased in all age groups during 2019-2020 and then returned close to pre-pandemic levels among the two middle age groups (30-64 years), but not among the youngest and oldest groups. Considering occupation, PA decreased from 2020 to December 2022 among retired and "other" participants, while SB decreased among nonmanual workers and retired participants. The regression models associated better self-reported health, male sex, and those born overseas with higher PA. Higher age, better self-reported health, poor education, and later survey time points were associated with lower SB. These findings highlight the need to return PA and SB to at least pre-pandemic levels and that subgroups may need different interventions.

Pro-vegetarian dietary patterns and mortality by all-cause and specific causes in an older Mediterranean population

PURPOSE

Pro-vegetarian (PVG) dietary patterns have shown health benefits, although the evidence concerning their association with mortality is scarce, particularly in older populations. We investigated the effect of three defined PVG patterns on all-cause, cardiovascular disease (CVD) and cancer mortality risk in an older Mediterranean population.

METHODS

We analysed baseline data from 597 adults aged 65 and older who participated in a population-based cross-sectional study, and mortality during a 12-year period. We used a validated food frequency questionnaire to estimate the adherence in tertiles to three evidence-based PVG dietary patterns: a general PVG pattern (gPVG) and two specific variations (healthful -hPVG, and unhealthful -uPVG). The gPVG pattern incorporated data from 12 food groups, consisting of 7 plant-based and 5 animal-based. The hPVG and uPVG versions included information from 18 food groups (4 food groups added and the splitting of 2 food groups). We used Cox regression to estimate hazard ratios (HR) and 95% confidence intervals (CI) adjusting for relevant covariates.

RESULTS

After the 12-years follow-up period, moderate adherence to hPVG pattern was associated with lower all-cause and CVD mortality whereas greater adherence to uPVG pattern was associated with higher all-cause and CVD mortality. Compared with those in the lowest tertile, participants in the second tertile of adherence to the hPVG pattern showed a significant lower risk of all-cause mortality (HR = 0.59; 95%CI: 0.43, 0.82) and CVD mortality (HR = 0.47; 0.28, 0.78). Participants in the highest tertile of adherence to the uPVG showed an increased mortality risk of all-cause (HR = 1.53; 1.07, 2.19) and CVD (HR = 2.10; 1.19, 3.70). No significant associations were found between adherence to any of the PVG dietary patterns and cancer mortality.

CONCLUSION

Moderate adherence to a healthy PVG pattern reduced the long-term mortality risk for all-cause and CVD in an older Mediterranean population, while higher adherence to an unhealthy PVG pattern increased the risk of all-cause and CVD mortality.

What Predicts a Longer Period of Pain in Patients Referred to an Interdisciplinary Center for Pain Care?

Chronic musculoskeletal pain (CMP) is a global health condition that affects thousands of people. CMP can substantially affect the functional capacity and quality of life of the people impacted, resulting in high costs for health care and social security systems. Sociodemographic factors may play a significant role in pain chronification prevention and control programs. Thus, current risk factors for CMP must be seriously considered as part of an interdisciplinary management strategy. The purpose of the study was to identify the primary sociodemographic characteristics of CMP patients at a multidisciplinary and specialized center for chronic pain. This is a retrospective investigation based on a review of medical records. Age, gender, income, and the time of onset of pain symptoms were among the variables included in the analyzed data. To analyze variables related to the duration of discomfort, a multiple regression model was utilized. Sociodemographic factors explained 37.94% of experiencing prolonged pain, according to the study's findings. Being female and having a family income above the minimum wage were variables that were directly proportional to discomfort duration. Age was not associated with a prolonged duration of pain perception.

Educational inequalities and self-reported health among men and women aged 18-49 years in Yangon Region, Myanmar: analysis of a population-based, cross-sectional study

OBJECTIVES

To estimate the prevalence of good self-reported health (SRH) in subpopulations based on the social determinants of health and to investigate the association between education (measured in years of schooling) and good SRH among men and women aged 18-49 years in Yangon Region, Myanmar.

DESIGN

Analysis of data from a population-based, cross-sectional study conducted in Yangon, Myanmar, from October to November 2016. A multistage sampling procedure was employed, and structured face-to-face interviews were conducted with standardised questions adapted from the Myanmar Demographic and Health Survey. Prevalence ratios (PRs) with 95% CIs were estimated using Poisson regression analyses by sex.

SETTING

Urban and rural areas of Yangon Region, Myanmar.

PARTICIPANTS

The sample included 2,506 participants (91.8% response rate) aged 18-49 years and excluded nuns, monks, soldiers, institutionalised people and individuals deemed too ill physically and/or mentally to participate.

RESULTS

The prevalence of good SRH was 61.2% (95% CI 59.3 to 63.1), with higher rates among men (72.0%, 95% CI 69.3 to 74.5), younger individuals (69.2%, 95% CI 66.2 to 72.1), urban residents (63.6%, 95% CI 60.8 to 66.3), extended family dwellers (66.6%, 95% CI 63.7 to 69.4) and those with a higher level of education (66.0%, 95% CI 61.3 to 70.5). After adjusting for confounders (age and area of residence), the association between years of schooling and SRH (PR) was 1.01 (95% CI 1.01 to 1.02, p=0.002) in men and 1.01 (95% CI 0.99 to 1.02, p=0.415) in women.

CONCLUSIONS

Good SRH was more prevalent among men than among women. Additionally, a 1-year increase in education was associated with a 1% increase in the prevalence of good SRH among men, whereas the association was not statistically significant among women. In order to enhance the educational benefits of health in Myanmar, we recommend a higher focus on the length of education and addressing gender inequalities in wage return from education.

Impact of Income-to-Poverty Ratio on Long-Term Mortality of Persons with Chronic Liver Disease in the USA, 1999-2018

INTRODUCTION

Chronic liver disease (CLD) is associated with increased morbidity and mortality. Understanding health disparities can inform appropriate interventions. We aimed to study mortality outcomes of those with CLD by the income level (income-to-poverty ratio <5 as lower income and ≥5 as higher income).

METHODS

In this retrospective cohort study, we analyzed data of adults from the National Health and Nutrition Examination Survey, 1999-2018. CLD included viral hepatitis, nonalcoholic fatty liver disease (NAFLD), and alcohol-associated liver disease (ALD).

RESULTS

We analyzed 59,204 adults: 47,224 without CLD and 11,980 with CLD. The CLD group was older, more likely male, racial/ethnic minority groups or foreign-born, and had lower educational and income levels (p < 0.001). Most (80.02%) CLD participants did not have college degrees and had lower income (79.18%). Among CLD participants, similar differences were observed between lower and higher income groups. Lower income participants with CLD had significantly higher 10-year cumulative mortality compared to higher income CLD participants (15.26 vs. 8.00%, p < 0.001), with consistent findings in viral hepatitis and NAFLD subgroups (p < 0.001) but not ALD (p = 0.71). Adjusting for age, sex, race, birthplace, lower income CLD participants were 2.01 (hazard ratio [HR]: 2.01; 95% CI: 1.79-2.26) times more likely to die overall and in viral hepatitis (HR: 2.05; 95% CI: 1.31-3.24) and NAFLD subgroups (HR: 2.32; 95% CI: 1.69-3.18) but not ALD (HR: 1.17; 95% CI: 0.55-2.51).

CONCLUSION

Lower income, foreign-born, and racial/ethnic minority groups were disproportionately represented among those with CLD, with lower income and CLD individuals having double the mortality risk compared to their higher income counterparts. Interventions should be culturally appropriate and address socioeconomic barriers.

Perceptions of Adulthood and Mental Health

BACKGROUND

In contrast to conventional definitions, the contemporary conceptualization of adulthood emphasizes psychological characteristics over sociodemographic milestones. At the same time, an increasing number of theorists propose that the way individuals view adulthood may have a significant impact on the mental health of both adolescents and adults. However, empirical examination of this hypothesis has been notably limited to date. The aim of this study is to explore the association between individuals' perceptions of adulthood and multiple dimensions of mental health.

METHOD

This study applied some adulthood markers and multiple mental health indexes (including well-being, optimism, Alexithymia, satisfaction with life, Goldberg's index of mental health, the dark triad, and dimensional personality disorders) to a community sample comprising 1772 individuals in Spain, spanning ages from 16 to 93 years.

RESULTS

The findings support the overarching hypothesis, as perceptions of adulthood display strong correlations with nearly every assessed index of mental health, particularly those that comprise a dimension of negative emotions. These associations persist even after accounting for age and socio-economic status, and in alignment with the psychological paradigm of adulthood, they show a notable consistency across various age groups.

CONCLUSIONS

This study establishes that such perceptions of adulthood represent a modifiable factor contributing to positive mental health. The implications of these findings for the formulation of public policies aimed at promoting mental health in the context of adulthood, as well as a number of future studies, are deliberated.

Polygenic Resilience Scores are Associated with Lower Penetrance of Schizophrenia Risk Genes, Protection Against Psychiatric and Medical Disorders, and Enhanced Mental Well-Being and Cognition

In the past decade, significant advances have been made in finding genomic risk loci for schizophrenia (SCZ). This, in turn, has enabled the search for SCZ resilience loci that mitigate the impact of SCZ risk genes. Recently, we discovered the first genomic resilience profile for SCZ, completely independent from the established risk loci for SCZ. We posited that these resilience loci protect against SCZ for those having a heighted genomic risk for SCZ. Nevertheless, our understanding of genetic resilience remains limited. It remains unclear whether resilience loci foster protection against adverse states associated with SCZ risk related to clinical, cognitive, and brain-structural phenotypes. To address this knowledge gap, we analyzed data from 487,409 participants from the UK Biobank, and found that resilience loci for SCZ afforded protection against lifetime psychiatric (schizophrenia, bipolar disorder, anxiety, and depression) and non-psychiatric medical disorders (such as asthma, cardiovascular disease, digestive disorders, metabolic disorders, and external causes of morbidity and mortality). Resilience loci also protected against self-harm behaviors, improved fluid intelligence, and larger whole-brain and brain-regional sizes. Overall, this study sheds light on the range of phenotypes that are significantly associated with resilience loci within the general population, revealing distinct patterns separate from those associated with SCZ risk loci. Our findings indicate that resilience loci may offer protection against serious psychiatric and medical outcomes, co-morbidities, and cognitive impairment. Therefore, it is conceivable that resilience loci facilitate adaptive processes linked to improved health and life expectancy.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

A causal relationship between educational attainment and risk of infectious diseases: A Mendelian randomisation study

Background

Previous observational studies have investigated the association between educational attainment and sepsis, pneumonia, and urinary tract infections (UTIs). However, their findings have been susceptible to reverse causality and confounding factors. Furthermore, no study has examined the effect of educational level on the risk of infections of the skin and subcutaneous tissue (SSTIs). Thus, we aimed to evaluate the causal relationships between educational level and the risk of four infectious diseases using Mendelian randomisation (MR) techniques.

Methods

We used univariable MR analysis to investigate the causal associations between educational attainment (years of schooling (n = 766 345) and holding college or university degree (n = 334 070)) and four infectious diseases (sepsis (n = 486 484), pneumonia (n = 486 484), UTIs (n = 463 010), and SSTIs (n = 218 792)). We included genetic instrumental variables with a genome-wide significance (P < 5 × 10-8) in the study. We used inverse variance-weighted estimation in the primary analysis and explored the stability of the results using multivariable MR analysis after adjusting for smoking, alcohol consumption, and body mass index.

Results

Genetically predicted years of schooling were associated with a reduced risk of sepsis (odds ratio (OR) = 0.763; 95% confidence interval (CI) = 0.668-0.870, P = 5.525 × 10-5), pneumonia (OR = 0.637; 95% CI = 0.577-0.702, P = 1.875 × 10-19), UTIs (OR = 0.995; 95% CI = 0.993-0.997, P = 1.229 × 10-5), and SSTIs (OR = 0.696; 95% CI = 0.605-0.801, P = 4.034 × 10-7). We observed consistent results for the correlation between qualifications and infectious diseases. These findings remained stable in the multivariable MR analyses.

Conclusions

Our findings suggest that increased educational attainment may be causally associated with a decreased risk of sepsis, pneumonia, UTIs, and SSTIs.