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Simkus A, Holtz KD, Twombly EC. An intersectionality framework for identifying relevant covariates in health equity research. Front Public Health 2024; 12:1286121. [PMID: 38560446 PMCID: PMC10979543 DOI: 10.3389/fpubh.2024.1286121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Health equity research uses impact evaluations to estimate the effectiveness of new interventions that aim to mitigate health inequities. Health inequities are influenced by many experiential factors and failure of research to account for such experiential factors and their potential interactions may jeopardize findings and lead to promoted methods that may unintentionally sustain or even worsen the targeted health inequity. Thus, it is imperative that health equity impact evaluations identify and include variables related to the circumstances, conditions, and experiences of the sample being studied in analyses. In this review, we promote intersectionality as a conceptual framework for brainstorming important yet often overlooked covariates in health equity related impact evaluations. Methods We briefly review and define concepts and terminology relevant to health equity, then detail four domains of experiential factors that often intersect in ways that may obscure findings: Biological, Social, Environmental, and Economic. Results We provide examples of the framework's application to lupus-related research and examples of covariates used in our own health equity impact evaluations with minority patients who have lupus. Discussion Applying an intersectionality framework during covariate selection is an important component to actualizing precision prevention. While we do not provide an exhaustive list, our aim is to provide a springboard for brainstorming meaningful covariates for health equity evaluation that may further help unveil sustainable solutions to persisting health inequities.
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Affiliation(s)
- Andrew Simkus
- KDH Research and Communication, Atlanta, GA, United States
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Garcia L, Pearce M, Abbas A, Mok A, Strain T, Ali S, Crippa A, Dempsey PC, Golubic R, Kelly P, Laird Y, McNamara E, Moore S, de Sa TH, Smith AD, Wijndaele K, Woodcock J, Brage S. Non-occupational physical activity and risk of cardiovascular disease, cancer and mortality outcomes: a dose-response meta-analysis of large prospective studies. Br J Sports Med 2023; 57:979-989. [PMID: 36854652 PMCID: PMC10423495 DOI: 10.1136/bjsports-2022-105669] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To estimate the dose-response associations between non-occupational physical activity and several chronic disease and mortality outcomes in the general adult population. DESIGN Systematic review and cohort-level dose-response meta-analysis. DATA SOURCES PubMed, Scopus, Web of Science and reference lists of published studies. ELIGIBILITY CRITERIA Prospective cohort studies with (1) general population samples >10 000 adults, (2) ≥3 physical activity categories, and (3) risk measures and CIs for all-cause mortality or incident total cardiovascular disease, coronary heart disease, stroke, heart failure, total cancer and site-specific cancers (head and neck, myeloid leukaemia, myeloma, gastric cardia, lung, liver, endometrium, colon, breast, bladder, rectum, oesophagus, prostate, kidney). RESULTS 196 articles were included, covering 94 cohorts with >30 million participants. The evidence base was largest for all-cause mortality (50 separate results; 163 415 543 person-years, 811 616 events), and incidence of cardiovascular disease (37 results; 28 884 209 person-years, 74 757 events) and cancer (31 results; 35 500 867 person-years, 185 870 events). In general, higher activity levels were associated with lower risk of all outcomes. Differences in risk were greater between 0 and 8.75 marginal metabolic equivalent of task-hours per week (mMET-hours/week) (equivalent to the recommended 150 min/week of moderate-to-vigorous aerobic physical activity), with smaller marginal differences in risk above this level to 17.5 mMET-hours/week, beyond which additional differences were small and uncertain. Associations were stronger for all-cause (relative risk (RR) at 8.75 mMET-hours/week: 0.69, 95% CI 0.65 to 0.73) and cardiovascular disease (RR at 8.75 mMET-hours/week: 0.71, 95% CI 0.66 to 0.77) mortality than for cancer mortality (RR at 8.75 mMET-hours/week: 0.85, 95% CI 0.81 to 0.89). If all insufficiently active individuals had achieved 8.75 mMET-hours/week, 15.7% (95% CI 13.1 to 18.2) of all premature deaths would have been averted. CONCLUSIONS Inverse non-linear dose-response associations suggest substantial protection against a range of chronic disease outcomes from small increases in non-occupational physical activity in inactive adults. PROSPERO registration number CRD42018095481.
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Affiliation(s)
- Leandro Garcia
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Matthew Pearce
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Ali Abbas
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Alexander Mok
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore
| | - Tessa Strain
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Sara Ali
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Alessio Crippa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Paddy C Dempsey
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Rajna Golubic
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul Kelly
- Physical Activity for Health Research Centre, University of Edinburgh Institute for Sport, Physical Education and Health Sciences, Edinburgh, UK
| | - Yvonne Laird
- Sydney School of Public Health, Prevention Research Collaboration, The University of Sydney, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Eoin McNamara
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Economic and Social Research Institute, Dublin, Ireland
| | - Samuel Moore
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Thiago Herick de Sa
- Center for Epidemiological Research in Nutrition and Health, University of Sao Paulo, Sao Paulo, Brazil
| | - Andrea D Smith
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
- Department of Behavioural Science and Health, University College London, London, UK
| | - Katrien Wijndaele
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - James Woodcock
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Soren Brage
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
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Kankaanpää A, Tolvanen A, Joensuu L, Waller K, Heikkinen A, Kaprio J, Ollikainen M, Sillanpää E. The associations of long-term physical activity in adulthood with later biological ageing and all-cause mortality - a prospective twin study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.02.23290916. [PMID: 37333101 PMCID: PMC10274991 DOI: 10.1101/2023.06.02.23290916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Objectives The association between leisure-time physical activity (LTPA) and a lower risk of mortality is susceptible to bias from multiple sources. We investigated the potential of biological ageing to mediate the association between long-term LTPA and mortality and whether the methods used to account for reverse causality affect the interpretation of this association. Methods Study participants were twins from the older Finnish Twin Cohort (n=22,750; 18-50 years at baseline). LTPA was assessed using questionnaires in 1975, 1981 and 1990. The mortality follow-up lasted until 2020 and biological ageing was assessed using epigenetic clocks in a subsample (n=1,153) with blood samples taken during the follow-up. Using latent profile analysis, we identified classes with distinct longitudinal LTPA patterns and studied differences in biological ageing between these classes. We employed survival models to examine differences in total, short-term and long-term all-cause mortality, and multilevel models for twin data to control for familial factors. Results We identified four classes of long-term LTPA: sedentary, moderately active, active and highly active. Although biological ageing was accelerated in sedentary and highly active classes, after adjusting for other lifestyle-related factors, the associations mainly attenuated. Physically active classes had a maximum 7% lower risk of total mortality over the sedentary class, but this association was consistent only in the short term and could largely be accounted for by familial factors. LTPA exhibited less favourable associations when prevalent diseases were exclusion criteria rather than covariate. Conclusion Being active may reflect a healthy phenotype instead of causally reducing mortality.
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Affiliation(s)
- Anna Kankaanpää
- Gerontology Research Center (GEREC), Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Asko Tolvanen
- Methodology Center for Human Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Laura Joensuu
- Gerontology Research Center (GEREC), Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Katja Waller
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Aino Heikkinen
- Institute for Molecular Medicine Finland (FIMM), HiLife, University of Helsinki, Helsinki, Finland
| | - Jaakko Kaprio
- Institute for Molecular Medicine Finland (FIMM), HiLife, University of Helsinki, Helsinki, Finland
| | - Miina Ollikainen
- Institute for Molecular Medicine Finland (FIMM), HiLife, University of Helsinki, Helsinki, Finland
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
| | - Elina Sillanpää
- Gerontology Research Center (GEREC), Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
- Wellbeing services county of Central Finland, Jyväskylä, Finland
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Ballin M, Nordström P. Does exercise prevent major non-communicable diseases and premature mortality? A critical review based on results from randomized controlled trials. J Intern Med 2021; 290:1112-1129. [PMID: 34242442 DOI: 10.1111/joim.13353] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Observational studies show that physical activity is strongly associated with a reduced risk of premature mortality and major non-communicable diseases. We reviewed to which extent these associations have been confirmed in randomized controlled trials (RCTs) for the outcomes of mortality, cardiovascular disease (CVD), type 2 diabetes (T2D), and fracture. The results show that exercise does not reduce all-cause mortality and incident CVD in older adults or in people with chronic conditions, based on RCTs comprising ∼50,000 participants. The results also indicate a lack of effect on cardiovascular mortality in people with chronic conditions, based on RCTs comprising ∼11,000 participants. Furthermore, there is inconsistent evidence regarding the effect of exercise on fractures in older adults, based on RCTs comprising ∼40,000 participants. Finally, based on RCTs comprising ∼17,000 participants, exercise reduces T2D incidence in people with prediabetes when combined with dietary modification, although evidence for the individual effect of exercise is lacking. Identified shortcomings of the current evidence include risks of publication bias, lack of high-quality studies in certain high-risk populations, and inconstant evidence with respect to some outcomes. Thus, additional large trials would be of value, especially with fracture as the primary outcome. In conclusion, according to current RCT evidence, exercise can prevent T2D assuming it is combined with dietary intervention. However, the current evidence shows that exercise does not prevent premature mortality or CVD, with inconsistent evidence for fractures.
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Affiliation(s)
- Marcel Ballin
- Department of Community Medicine and Rehabilitation, Unit of Geriatric Medicine, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, Umeå, Sweden
| | - Peter Nordström
- Department of Community Medicine and Rehabilitation, Unit of Geriatric Medicine, Umeå University, Umeå, Sweden
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Ballin M, Nordström A, Nordström P. Cardiovascular Disease and All-Cause Mortality in Male Twins With Discordant Cardiorespiratory Fitness: A Nationwide Cohort Study. Am J Epidemiol 2020; 189:1114-1123. [PMID: 32286630 PMCID: PMC7666408 DOI: 10.1093/aje/kwaa060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 04/10/2020] [Indexed: 12/15/2022] Open
Abstract
Whether genetic and familial factors influence the association between cardiorespiratory fitness (CRF) and cardiovascular disease (CVD) is unknown. Two cohorts were formed based on data from 1,212,295 men aged 18 years who were conscripted for military service in Sweden during 1972-1996. The first comprised 4,260 twin pairs in which the twins in each pair had different CRF (≥1 watt). The second comprised 90,331 nonsibling pairs with different CRF and matched on birth year and year of conscription. Incident CVD and all-cause mortality were identified using national registers. During follow-up (median 32 years), there was no difference in CVD and mortality between fitter twins and less fit twins (246 vs. 251 events; hazard ratio (HR) = 1.00, 95% confidence interval (CI): 0.83, 1.20). The risks were similar in twin pairs with ≥60-watt difference in CRF (HR = 0.96, 95% CI: 0.57, 1.64). In contrast, in the nonsibling cohort, fitter men had a lower risk of the outcomes than less fit men (4,444 vs. 5,298 events; HR = 0.83, 95% CI: 0.79, 0.86). The association was stronger in pairs with ≥60-watt difference in CRF (HR = 0.65, 95% CI: 0.59, 0.71). These findings indicate that genetic and familial factors influence the association of CRF with CVD and mortality.
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Affiliation(s)
| | | | - Peter Nordström
- Correspondence to Prof. Peter Nordström, Department of Community Medicine and Rehabilitation, Unit of Geriatric Medicine, Umeå University, 901 87 Umeå, Sweden (e-mail: )
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Affiliation(s)
- Ephraim Bernhard Winzer
- Department of Internal Medicine/Cardiology, Helios Stiftungsprofessur, Heart Center Leipzig-University Hospital, Leipzig, Germany
| | - Felix Woitek
- Department of Internal Medicine/Cardiology, Helios Stiftungsprofessur, Heart Center Leipzig-University Hospital, Leipzig, Germany
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Technische Universität Dresden Heart Center Dresden-University Hospital, Dresden, Germany
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Lundblad LC, Eskelin JJ, Karlsson T, Wallin BG, Elam M. Sympathetic Nerve Activity in Monozygotic Twins. Hypertension 2017; 69:964-969. [DOI: 10.1161/hypertensionaha.117.09079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 01/23/2017] [Accepted: 02/27/2017] [Indexed: 11/16/2022]
Abstract
Microneurographic recordings of human muscle sympathetic nerve activity responses to sudden sensory stimuli (ie, arousal) have revealed 2 intraindividually reproducible response profiles in healthy young males that predict different neural and blood pressure responses to more sustained stress. Approximately 50% of subjects inhibit muscle sympathetic nerve activity during arousal, whereas the remaining 50% do not, and the latter group displays a markedly greater blood pressure increase in response to arousal, as well as during and after 3 minutes of mental arithmetic. Studying a group of monozygotic twins (10 pairs, 2 excluded from analysis), the aim of the present study was to evaluate the degree of genetic determination of these sympathetic response profiles. Muscle sympathetic burst incidence at rest was similar in twins, with a within-pair burst incidence ratio of 0.87±0.02 (SEM) compared with 0.73±0.07 found in unrelated pairs (
P
=0.002), confirming a previous study from our laboratory. In contrast, the sympathetic responses to arousal showed large twin within-pair variance (arousal inhibition ratio 0.56±0.11), which did not significantly differ (
P
=0.939) from the variance in pairs of unrelated subjects (0.46±0.11). The finding that human muscle sympathetic nerve responses to arousal are less determined by genotype than the resting level of corresponding sympathetic nerve activity suggests that the arousal response pattern is more prone to be altered by environmental factors. This raises the possibility that these intraindividually reproducible sympathetic neural response profiles can be modified in a positive direction from a cardiovascular risk perspective.
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Affiliation(s)
- Linda C. Lundblad
- From the Department of Clinical Neurophysiology, Sahlgrenska University Hospital, Gothenburg, Sweden (L.C.L., M.E.); and Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sweden (L.C.L., J.J.E., T.K., B.G.W., M.E.)
| | - John J. Eskelin
- From the Department of Clinical Neurophysiology, Sahlgrenska University Hospital, Gothenburg, Sweden (L.C.L., M.E.); and Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sweden (L.C.L., J.J.E., T.K., B.G.W., M.E.)
| | - Tomas Karlsson
- From the Department of Clinical Neurophysiology, Sahlgrenska University Hospital, Gothenburg, Sweden (L.C.L., M.E.); and Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sweden (L.C.L., J.J.E., T.K., B.G.W., M.E.)
| | - B. Gunnar Wallin
- From the Department of Clinical Neurophysiology, Sahlgrenska University Hospital, Gothenburg, Sweden (L.C.L., M.E.); and Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sweden (L.C.L., J.J.E., T.K., B.G.W., M.E.)
| | - Mikael Elam
- From the Department of Clinical Neurophysiology, Sahlgrenska University Hospital, Gothenburg, Sweden (L.C.L., M.E.); and Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sweden (L.C.L., J.J.E., T.K., B.G.W., M.E.)
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Fernandez M, Boyle E, Hartvigsen J, Ferreira M, Refshauge K, Maher C, Christensen K, Hopper J, Ferreira P. Is this back pain killing me? All‐cause and cardiovascular‐specific mortality in older Danish twins with spinal pain. Eur J Pain 2017; 21:938-948. [DOI: 10.1002/ejp.996] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2016] [Indexed: 01/21/2023]
Affiliation(s)
- M. Fernandez
- Faculty of Health Sciences The University of Sydney NSW Australia
| | - E. Boyle
- Department of Sports Science and Clinical Biomechanics University of Southern Denmark Odense M Denmark
- Dalla Lana School of Public Health University of Toronto ON Canada
| | - J. Hartvigsen
- Department of Sports Science and Clinical Biomechanics University of Southern Denmark Odense M Denmark
- Nordic Institute of Chiropractic and Clinical Biomechanics University of Southern Denmark Odense M Denmark
| | - M.L. Ferreira
- The George Institute for Global Health Sydney Medical School The University of Sydney NSW Australia
- Institute of Bone and Joint Research The Kolling Institute Sydney Medical School The University of Sydney NSW Australia
| | - K.M. Refshauge
- Faculty of Health Sciences The University of Sydney NSW Australia
| | - C.G. Maher
- The George Institute for Global Health Sydney Medical School The University of Sydney NSW Australia
| | - K. Christensen
- Danish Aging Research Center Institute of Public Health, Epidemiology University of Southern Denmark Odense C Denmark
| | - J.L. Hopper
- Australian Twin Registry Centre for Molecular, Environmental, Genetic, and Analytic Epidemiology The University of Melbourne Vic. Australia
| | - P.H. Ferreira
- Faculty of Health Sciences The University of Sydney NSW Australia
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Blok IM, van Riel ACMJ, Schuuring MJ, Duffels MG, Vis JC, van Dijk APJ, Hoendermis ES, Mulder BJM, Bouma BJ. Decrease in quality of life predicts mortality in adult patients with pulmonary arterial hypertension due to congenital heart disease. Neth Heart J 2015; 23:278-84. [PMID: 25911012 PMCID: PMC4409603 DOI: 10.1007/s12471-015-0666-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Decrease in quality of life (QoL) in left-sided heart failure precedes poor survival, which can be reversed with exercise training. We investigated whether QoL is associated with mortality in pulmonary arterial hypertension due to congenital heart disease (PAH-CHD) patients. Methods In this observational study, PAH-CHD adults referred for PAH-specific therapy were included. QoL surveys (SF36) were recorded during 2 years of therapy. Based on shift in SF36 scores during this period, patients had either decreased or non-decreased QoL. Subsequently, the patients were followed for mortality. Results Thirty-nine PAH-CHD patients (mean age 42, 44 % male, 49 % Down’s syndrome) were analysed. Following PAH-specific therapy, SF36 physical component summary (PCS) decreased in 13 (35–31 points, p = 0.001) and showed no decrease in 26 patients (34–43 points, mean values, p < 0.001). Post-initiation phase, median follow-up was 4.5 years, during which 12 deaths occurred (31 %), 10 (56 %) in the decreased and 2 (10 %) in the non-decreased group (p = 0.002). Cox regression showed a decrease in SF36 PCS predicted mortality (HR 3.4, 95 % CI 1.03–11, p = 0.045). Conclusions In PAH-CHD patients, decrease in SF36 PCS following initiation of PAH-specific therapy is a determinant of mortality. Electronic supplementary material The online version of this article (doi:10.1007/s12471-015-0666-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- I M Blok
- Department of Cardiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Madsen M, Andersen PK, Gerster M, Andersen AMN, Christensen K, Osler M. Are the educational differences in incidence of cardiovascular disease explained by underlying familial factors? A twin study. Soc Sci Med 2014; 118:182-90. [PMID: 24768271 DOI: 10.1016/j.socscimed.2014.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/09/2014] [Accepted: 04/12/2014] [Indexed: 11/17/2022]
Abstract
To isolate the effect of education from the influence of potential underlying factors, we investigated the association of education with the risk of cardiovascular disease (CVD) and ischemic heart disease (IHD) using twin data to adjust for familial factors shared within twins, including genetic make-up and childhood environment. The study was based on data from the Danish Twin Registry linked to administrative and heath registers in Statistics Denmark. A total of 11,968 monozygotic and 20,464 dizygotic same sexed twins were followed from 1980 to 2009, including more than 8000 events of CVD. Unpaired and intra-pair analyses were compared. In the unpaired analyses, an inverse educational gradient in CVD- and IHD risk was observed. This association was not replicated in the intra-pair analyses that control for shared familial factors exploiting that twins share their intrauterine- and childhood environment and are matched partly or fully on genetic setup. The attenuation of association of education with CVD and IHD in the intra-pair analyses suggests that shared familial factors account for a substantial part of the observed association of education with CVD and IHD in Denmark.
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Affiliation(s)
- Mia Madsen
- Unit of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, J.B. Winsløwsvej 9B, 5000 Odense, Denmark; The Danish Twin Registry, University of Southern Denmark, J.B. Winsløwsvej 9B, Odense, Denmark; Danish Aging Research Center, University of Southern Denmark, J.B. Winsløwsvej 9B, Odense, Denmark.
| | - Per K Andersen
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark.
| | - Mette Gerster
- Unit of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, J.B. Winsløwsvej 9B, 5000 Odense, Denmark.
| | - Anne-Marie N Andersen
- Department of Public Health, Section of Social Medicine, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark.
| | - Kaare Christensen
- Unit of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, J.B. Winsløwsvej 9B, 5000 Odense, Denmark; The Danish Twin Registry, University of Southern Denmark, J.B. Winsløwsvej 9B, Odense, Denmark; Danish Aging Research Center, University of Southern Denmark, J.B. Winsløwsvej 9B, Odense, Denmark; Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Sdr. Boulevard 29, Odense, Denmark; Department of Clinical Genetics, Odense University Hospital, Sdr. Boulevard 29, Odense, Denmark.
| | - Merete Osler
- Danish Aging Research Center, University of Southern Denmark, J.B. Winsløwsvej 9B, Odense, Denmark; Department of Public Health, Section of Social Medicine, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark; Research Centre for Prevention and Health, Glostrup University Hospital, Nordre Ringvej 57, 84-85, Glostrup, Denmark.
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Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol 2013; 2:1143-211. [PMID: 23798298 DOI: 10.1002/cphy.c110025] [Citation(s) in RCA: 1205] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chronic diseases are major killers in the modern era. Physical inactivity is a primary cause of most chronic diseases. The initial third of the article considers: activity and prevention definitions; historical evidence showing physical inactivity is detrimental to health and normal organ functional capacities; cause versus treatment; physical activity and inactivity mechanisms differ; gene-environment interaction (including aerobic training adaptations, personalized medicine, and co-twin physical activity); and specificity of adaptations to type of training. Next, physical activity/exercise is examined as primary prevention against 35 chronic conditions [accelerated biological aging/premature death, low cardiorespiratory fitness (VO2max), sarcopenia, metabolic syndrome, obesity, insulin resistance, prediabetes, type 2 diabetes, nonalcoholic fatty liver disease, coronary heart disease, peripheral artery disease, hypertension, stroke, congestive heart failure, endothelial dysfunction, arterial dyslipidemia, hemostasis, deep vein thrombosis, cognitive dysfunction, depression and anxiety, osteoporosis, osteoarthritis, balance, bone fracture/falls, rheumatoid arthritis, colon cancer, breast cancer, endometrial cancer, gestational diabetes, pre-eclampsia, polycystic ovary syndrome, erectile dysfunction, pain, diverticulitis, constipation, and gallbladder diseases]. The article ends with consideration of deterioration of risk factors in longer-term sedentary groups; clinical consequences of inactive childhood/adolescence; and public policy. In summary, the body rapidly maladapts to insufficient physical activity, and if continued, results in substantial decreases in both total and quality years of life. Taken together, conclusive evidence exists that physical inactivity is one important cause of most chronic diseases. In addition, physical activity primarily prevents, or delays, chronic diseases, implying that chronic disease need not be an inevitable outcome during life.
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Affiliation(s)
- Frank W Booth
- Departments of Biomedical Sciences, Medical Pharmacology and Physiology, and Nutrition and Exercise Physiology, Dalton Cardiovascular Institute, University of Missouri, Columbia, Missouri, USA.
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Key issues of daily life in adults with congenital heart disease. Arch Cardiovasc Dis 2013; 106:404-12. [DOI: 10.1016/j.acvd.2013.02.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Revised: 02/07/2013] [Accepted: 02/14/2013] [Indexed: 12/31/2022]
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Abstract
Regular physical activity is now recognized as an important and very effective step to prevent many diseases, especially those of the cardiovascular system. Many studies within the last 20 years have also shown that exercise capacity or fitness is an important prognostic factor in healthy subjects and patients with cardiovascular diseases for both mortality and morbidity. Physical fitness, which is mainly determined by regular physical activity or training, can be analyzed by maximal exercise testing using the treadmill or cycle ergometry. In addition, fitness is also based on genetic factors. There are some methodological criticisms concerning self-reported questionnaires of physical activity, MET (metabolic equivalent) calculations and exhaustion during maximal voluntary stress testing. However, the results of both approaches are valid and reliable for daily use. Accordingly, every physician regardless of his or her discipline should encourage all patients at every visit to follow a healthy lifestyle, including regular exercise and physical activity. This also applies to older patients, who especially benefit from exercise and physical activity.
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Rantanen T, Masaki K, He Q, Ross GW, Willcox BJ, White L. Midlife muscle strength and human longevity up to age 100 years: a 44-year prospective study among a decedent cohort. AGE (DORDRECHT, NETHERLANDS) 2012; 34:563-70. [PMID: 21541735 PMCID: PMC3337929 DOI: 10.1007/s11357-011-9256-y] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 04/17/2011] [Indexed: 05/16/2023]
Abstract
We studied prospectively the midlife handgrip strength, living habits, and parents' longevity as predictors of length of life up to becoming a centenarian. The participants were 2,239 men from the Honolulu Heart Program/Honolulu-Asia Aging Study who were born before the end of June 1909 and who took part in baseline physical assessment in 1965-1968, when they were 56-68 years old. Deaths were followed until the end of June 2009 for 44 years with complete ascertainment. Longevity was categorized as centenarian (≥100 years, n = 47), nonagenarian (90-99 years, n = 545), octogenarian (80-89 years, n = 847), and ≤79 years (n = 801, reference). The average survival after baseline was 20.8 years (SD = 9.62). Compared with people who died at the age of ≤79 years, centenarians belonged 2.5 times (odds ratio (OR) = 2.52, 95% confidence interval (CI) = 1.23-5.10) more often to the highest third of grip strength in midlife, were never smokers (OR = 5.75 95% CI = 3.06-10.80), had participated in physical activity outside work (OR = 1.13 per daily hour, 95% CI = 1.02-1.25), and had a long-lived mother (≥80 vs. ≤60 years, OR = 2.3, 95% CI = 1.06-5.01). Associations for nonagenarians and octogenarians were parallel, but weaker. Multivariate modeling showed that mother's longevity and offspring's grip strength operated through the same or overlapping pathway to longevity. High midlife grip strength and long-lived mother may indicate resilience to aging, which, combined with healthy lifestyle, increases the probability of extreme longevity.
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Affiliation(s)
- Taina Rantanen
- Gerontology Research Center, Department of Health Sciences, University of Jyvaskylä, Finland.
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Sadler ME, Miller CJ, Christensen K, McGue M. Subjective wellbeing and longevity: a co-twin control study. Twin Res Hum Genet 2012; 14:249-56. [PMID: 21623655 DOI: 10.1375/twin.14.3.249] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mental health is increasingly defined not only by the absence of illness but by the presence of subjective well-being (SWB). Previous cohort studies have consistently shown that indicators of SWB predict favorable life outcomes, including better mental and somatic health, and longevity. The favorable effects associated with SWB have prompted new research aimed at raising happiness and wellbeing through individual interventions and public health initiatives. Standard observational studies of individual-level associations, however, are subject to potential confounding of exposure and outcome by shared genes and environment. The present study explored the association between SWB and increased longevity, using twin pair analyses to determine whether the association is consistent with causality or is due to genetic or environmental confounding. The study sample of 3,966 twins aged 70 or older, followed for a median time period of 9 years, was drawn from the population-based Longitudinal Study of Aging Danish Twins (LSADT). The association between SWB, operationalized as affect and life satisfaction, and all-cause mortality risk was examined using between-individual and within-pair survival analyses. As expected, at the individual level, SWB predicted increased longevity. Exposure effects were also present in unadjusted and adjusted within-pair analyses of 400 dizygotic (DZ) pairs and 274 monozygotic (MZ) pairs, indicating that SWB is associated with increased longevity independent of familial factors of genes and shared environment.
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Affiliation(s)
- Michael E Sadler
- Department of Psychology, Roosevelt University, United States of America.
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17
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Samitz G, Egger M, Zwahlen M. Domains of physical activity and all-cause mortality: systematic review and dose–response meta-analysis of cohort studies. Int J Epidemiol 2011; 40:1382-400. [PMID: 22039197 DOI: 10.1093/ije/dyr112] [Citation(s) in RCA: 518] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Guenther Samitz
- Centre of Sports Science and University Sports, University of Vienna, Wien, Austria
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Abstract
BACKGROUND Numerous studies have shown that higher body mass index (BMI) is associated with higher mortality. We investigated the extent to which this association might be explained by genetic factors. METHODS We used data from the Swedish Twin Registry on twins born 1886-1958 who answered a questionnaire in 1969/1970 or 1972 (n = 44,258). Information on mortality from all-causes (n = 14,217), cardiovascular disease (CVD; n = 9009), and coronary heart disease (CHD; n = 3564) was obtained by linkage to the national Causes of Death Registry for the years 1972-2004. The association between BMI and mortality was studied without control for genetic factors in cohort analyses and with control for genetic factors in co-twin control analyses. RESULTS In cohort analyses, there was a clear dose-response relationship between BMI and mortality. Hazard ratios per 1 unit increase in BMI in subjects with BMI ≥18.5 were 1.05 (95% confidence interval = 1.05-1.06) for all-cause mortality, 1.07 (1.07-1.09) for CVD mortality, and 1.09 (1.08-1.10) for CHD mortality. Similar results were seen in co-twin control analyses of dizygotic twins. However, within monozygotic twins, BMI was associated with death from CHD (OR = 1.06; 1.00-1.12), whereas the association with all-cause mortality (1.01, 0.98-1.04) and CVD mortality (1.02, 0.98-1.06) was weak. CONCLUSIONS Our findings indicate that there is an association between high BMI and mortality from CHD that is not explained by genetic confounding. However, a large part of the association between BMI and other causes of death may be explained by genes rather than by a causal link between these factors.
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Waller K, Kujala UM, Kaprio J, Koskenvuo M, Rantanen T. Effect of physical activity on health in twins: a 30-yr longitudinal study. Med Sci Sports Exerc 2011; 42:658-64. [PMID: 19952836 DOI: 10.1249/mss.0b013e3181bdeea3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The aim of this study was to investigate whether persistent leisure-time physical activity, adjusted for genetic liability and childhood experiences, protects against chronic diseases, early signs of disability, and loss of life satisfaction. METHODS From 5663 healthy adult twin pairs, we identified 146 pairs who were discordant for both intensity and volume of leisure physical activity in 1975 and 1981. Of them, both members of 95 pairs were alive and participated in our follow-up study in 2005 when chronic diseases (such as diabetes, cardiovascular disease, and osteoarthritis), life satisfaction, and disability were assessed by a structured telephone interview. The mean age of the participants was 58 yr (range = 47-79 yr) in 2005. Paired tests were used in the analyses. RESULTS At the end of follow-up, the active cotwins had a decreased risk of reporting at least one chronic diseases, whereas active monozygotic (MZ) twins had two or more chronic diseases significantly less often than their inactive cotwins (odds ratio [OR] = 0.14, P = 0.031). Overall, the risk for type 2 diabetes or glucose intolerance (OR = 0.09, P = 0.022) and elevated blood pressure (OR = 0.46, P = 0.039) was decreased among the active cotwins. These effects were seen clearly among dizygotic twins but not always among small number of monozygotic twins. The active cotwins reported greater life satisfaction (P = 0.047) and tended to be less likely to be hospitalized (P = 0.065), although active cotwins had somewhat more sports-related injuries (OR = 1.9, P = 0.051) than inactive cotwins. Studied disability variables did not differ between the active and the inactive cotwins. CONCLUSIONS Physical activity reduces the risk for chronic diseases and helps in maintaining life satisfaction. However, genetic factors may play a role in this association because some findings emerged more clearly among dizygotic than monozygotic twins discordant for physical activity.
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Affiliation(s)
- Katja Waller
- Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland.
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20
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Lindsay G, Macmillan A, Woodward A. Moving urban trips from cars to bicycles: impact on health and emissions. Aust N Z J Public Health 2010; 35:54-60. [PMID: 21299701 DOI: 10.1111/j.1753-6405.2010.00621.x] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To estimate the effects on health, air pollution and greenhouse gas emissions if short trips (≤7 km) were undertaken by bicycle rather than motor car. METHOD Existing data sources were used to model effects, in the urban setting in New Zealand, of varying the proportion of vehicle kilometres travelled by bicycle instead of light motor vehicle. RESULTS Shifting 5% of vehicle kilometres to cycling would reduce vehicle travel by approximately 223 million kilometres each year, save about 22 million litres of fuel and reduce transport-related greenhouse emissions by 0.4%. The health effects would include about 116 deaths avoided annually as a result of increased physical activity, six fewer deaths due to local air pollution from vehicle emissions, and an additional five cyclist fatalities from road crashes. In economic terms, including only fatalities and using the NZ Ministry of Transport Value of a Statistical Life, the health effects of a 5% shift represent net savings of about $200 million per year. CONCLUSION The health benefits of moving from cars to bikes heavily outweigh the costs of injury from road crashes. IMPLICATIONS Transport policies that encourage bicycle use will help to reduce air pollution and greenhouse emissions and improve public health.
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Affiliation(s)
- Graeme Lindsay
- School of Population Health, University of Auckland, New Zealand.
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McGue M, Osler M, Christensen K. Causal Inference and Observational Research: The Utility of Twins. PERSPECTIVES ON PSYCHOLOGICAL SCIENCE 2010; 5:546-56. [PMID: 21593989 PMCID: PMC3094752 DOI: 10.1177/1745691610383511] [Citation(s) in RCA: 341] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Valid causal inference is central to progress in theoretical and applied psychology. Although the randomized experiment is widely considered the gold standard for determining whether a given exposure increases the likelihood of some specified outcome, experiments are not always feasible and in some cases can result in biased estimates of causal effects. Alternatively, standard observational approaches are limited by the possibility of confounding, reverse causation, and the nonrandom distribution of exposure (i.e., selection). We describe the counterfactual model of causation and apply it to the challenges of causal inference in observational research, with a particular focus on aging. We argue that the study of twin pairs discordant on exposure, and in particular discordant monozygotic twins, provides a useful analog to the idealized counterfactual design. A review of discordant-twin studies in aging reveals that they are consistent with, but do not unambiguously establish, a causal effect of lifestyle factors on important late-life outcomes. Nonetheless, the existing studies are few in number and have clear limitations that have not always been considered in interpreting their results. It is concluded that twin researchers could make greater use of the discordant-twin design as one approach to strengthen causal inferences in observational research.
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Affiliation(s)
- Matt McGue
- Department of Psychology, University of Minnesota, Minneapolis Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Merete Osler
- Institute of Public Health, University of Southern Denmark, Odense, Denmark Research Center for Prevention and Health, Glostrup Hospital, Glostrup, Denmark
| | - Kaare Christensen
- The Danish Twin Registry and The Danish Aging Research Center Institute of Public Health, University of Southern Denmark, Odense, Denmark
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Waller K, Kujala UM, Rantanen T, Kauppinen M, Silventoinen K, Koskenvuo M, Kaprio J. Physical activity, morbidity and mortality in twins: a 24-year prospective follow-up. Eur J Epidemiol 2010; 25:731-9. [DOI: 10.1007/s10654-010-9493-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Accepted: 07/16/2010] [Indexed: 10/19/2022]
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Holmbäck I, Ericson U, Gullberg B, Wirfält E. Five meal patterns are differently associated with nutrient intakes, lifestyle factors and energy misreporting in a sub-sample of the Malmö Diet and Cancer cohort. Food Nutr Res 2009; 53:1970. [PMID: 19798420 PMCID: PMC2753298 DOI: 10.3402/fnr.v53i0.1970] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 06/25/2009] [Accepted: 08/18/2009] [Indexed: 12/03/2022] Open
Abstract
Objective Examine how meal patterns are associated with nutrient intakes, lifestyle and socioeconomic factors, and energy misreporting. Design A cross-sectional study within the Malmö Diet and Cancer (MDC) cohort. Participants reported on the overall types and frequency of meals consumed, and completed a modified dietary history, a lifestyle and socioeconomic questionnaire, and anthropometric measurements. Based on the reported intake of six different meal types, meal pattern groups were distinguished using Ward's cluster analysis. Associations between meal patterns and nutrient intakes, anthropometric, lifestyle and socioeconomic variables were examined using the χ2-method and analysis of variance. Subjects A sub-sample of the MDC study cohort (n=28,098), consisting of 1,355 men and 1,654 women. Results Cluster analysis identified five groups of subjects with different meal patterns in both men and women. These meal pattern groups differed regarding nutrient intakes, lifestyle and socioeconomic factors. Subjects reporting frequent coffee meals were more likely to report an ‘unhealthy’ lifestyle, e.g. smoking, high alcohol consumption and low physical activity, while those with a fruit pattern reported a more ‘healthy’ lifestyle. Women were more likely to underreport their energy intake than men, and the degree of underreporting varied between the meal pattern groups. Conclusions The meal pattern groups showed significant differences in dietary quality and socioeconomic and lifestyle variables. This supports previous research suggesting that diet is part of a multifaceted phenomenon. Incorporation of aspects on how foods are combined and eaten into public health advices might improve their efficiency.
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Affiliation(s)
- Isabel Holmbäck
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
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Farahmand B, Broman G, de Faire U, Vågerö D, Ahlbom A. Golf: a game of life and death--reduced mortality in Swedish golf players. Scand J Med Sci Sports 2009; 19:419-24. [PMID: 18510595 DOI: 10.1111/j.1600-0838.2008.00814.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The specific health benefits achieved from different forms and patterns of leisure-time physical activity are not established. We analyzed the mortality in a cohort of Swedish golf players. We used the Swedish Golf Federation's membership registry and the nationwide Mortality Registry. We calculated standardized mortality ratios (SMR) with stratification for age, sex, and socioeconomic status. The cohort included 300 818 golfers, and the total number of deaths was 1053. The overall SMR was 0.60 [95% confidence intervals (CIs): 0.57-0.64]. The mortality reduction was observed in men and women, in all age groups, and in all socioeconomic categories. Golfers with the lowest handicap (the most skilled players) had the lowest mortality; SMR=0.53 (95% CI: 0.41-0.67) compared with 0.68 (95% CI: 0.61-0.75) for those with the highest handicap. While we cannot conclude with certainty that all the 40% decreased mortality rates are explained by the physical activity associated with playing golf, we conclude that most likely this is part of the explanation. To put the observed mortality reduction in context, it may be noted that a 40% reduction of mortality rates corresponds to an increase in life expectancy of about 5 years.
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Affiliation(s)
- B Farahmand
- Department of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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25
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Byberg L, Melhus H, Gedeborg R, Sundström J, Ahlbom A, Zethelius B, Berglund LG, Wolk A, Michaëlsson K. Total mortality after changes in leisure time physical activity in 50 year old men: 35 year follow-up of population based cohort. BMJ 2009; 338:b688. [PMID: 19264819 PMCID: PMC2654773 DOI: 10.1136/bmj.b688] [Citation(s) in RCA: 182] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine how change in level of physical activity after middle age influences mortality and to compare it with the effect of smoking cessation. DESIGN Population based cohort study with follow-up over 35 years. SETTING Municipality of Uppsala, Sweden. PARTICIPANTS 2205 men aged 50 in 1970-3 who were re-examined at ages 60, 70, 77, and 82 years. MAIN OUTCOME MEASURE Total (all cause) mortality. RESULTS The absolute mortality rate was 27.1, 23.6, and 18.4 per 1000 person years in the groups with low, medium, and high physical activity, respectively. The relative rate reduction attributable to high physical activity was 32% for low and 22% for medium physical activity. Men who increased their physical activity level between the ages of 50 and 60 continued to have a higher mortality rate during the first five years of follow-up (adjusted hazard ratio 2.64, 95% confidence interval 1.32 to 5.27, compared with unchanged high physical activity). After 10 years of follow-up their increased physical activity was associated with reduced mortality to the level of men with unchanged high physical activity (1.10, 0.87 to 1.38). The reduction in mortality associated with increased physical activity (0.51, 0.26 to 0.97, compared with unchanged low physical activity) was similar to that associated with smoking cessation (0.64, 0.53 to 0.78, compared with continued smoking). CONCLUSIONS Increased physical activity in middle age is eventually followed by a reduction in mortality to the same level as seen among men with constantly high physical activity. This reduction is comparable with that associated with smoking cessation.
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Affiliation(s)
- Liisa Byberg
- Department of Surgical Sciences, Section of Orthopaedics, and Uppsala Clinical Research Centre, Uppsala University, SE-75185 Uppsala, Sweden.
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