The Roseto effect: a 50-year comparison of mortality rates

Community cohesion looseness in gene networks reveals individualized drug targets and resistance

Community cohesion plays a critical role in the determination of an individual's health in social science. Intriguingly, a community structure of gene networks indicates that the concept of community cohesion could be applied between the genes as well to overcome the limitations of single gene-based biomarkers for precision oncology. Here, we develop community cohesion scores which precisely quantify the community ability to retain the interactions between the genes and their cellular functions in each individualized gene network. Using breast cancer as a proof-of-concept study, we measure the community cohesion score profiles of 950 case samples and predict the individualized therapeutic targets in 2-fold. First, we prioritize them by finding druggable genes present in the community with the most and relatively decreased scores in each individual. Then, we pinpoint more individualized therapeutic targets by discovering the genes which greatly contribute to the community cohesion looseness in each individualized gene network. Compared with the previous approaches, the community cohesion scores show at least four times higher performance in predicting effective individualized chemotherapy targets based on drug sensitivity data. Furthermore, the community cohesion scores successfully discover the known breast cancer subtypes and we suggest new targeted therapy targets for triple negative breast cancer (e.g. KIT and GABRP). Lastly, we demonstrate that the community cohesion scores can predict tamoxifen responses in ER+ breast cancer and suggest potential combination therapies (e.g. NAMPT and RXRA inhibitors) to reduce endocrine therapy resistance based on individualized characteristics. Our method opens new perspectives for the biomarker development in precision oncology.

Implementation of Virtual Integrative Oncology Shared Medical Appointment Series (VIOSMAS) Within Mixed Diagnosis Population

BACKGROUND

Integrative oncology [IO] is sought-after by patients, endorsed by clinical guidelines, and valued within National Cancer Institute Centers. Shared Medical Appointments [SMA] leverage health education and social connection to deliver enhanced patient experience, population health, cost-reduction, and clinician well-being. Integrative Oncology Shared Medical Appointments increase access to integrative medicine but delivering these services via telehealth have not been evaluated.

OBJECTIVE

We created, and pilot tested a Virtual Integrative Oncology Shared Medical Appointment Series (VIOSMAS) to assess its feasibility, acceptability, and efficacy at an urban academic teaching hospital.

METHODS

The 7-session hour-long Living Well with and after Cancer series included didactics, multi-disciplinary experiential sessions, and group discussion. Topics included (1) Introduction, (2) Herbs/Botanicals/Fungi, (3) Mindful Movement, (4) Acupuncture, (5) Narratives and Nature, (6) Diet and Culinary Medicine, and (7) Vitamins/Supplements. Virtual visits via telehealth were offered to enhance patient participation during the pandemic. Outcome measures included recruitment, retention, pre/post-series patient survey and qualitative clinician feedback.

RESULTS

Between 9/2021 and 4/2023, 72 unique patients were recruited to 5 cohorts and had a total of 332 VIOSMAS visits. A total of 50 patients (69%) attended 4 or more of the 7-session series; 60 (83% were women); patients ranged in age from 28 to 93 years (median 66); 36 (50%) lived outside the city center; the most common cancer diagnoses were breast, lymphoma, and lung cancer. Patients were from diverse demographics. Pre-program, patients reported desiring assistance in addressing diverse symptoms including fatigue, insomnia, pain, gastrointestinal (GI) symptoms, anxiety, and depression. Post-series, patients reported that the VIOSMAS addressed their goals and symptoms; they also reported incorporating recommended lifestyle changes in diet, exercise, sleep, and stress management; they were satisfied with the number of sessions and telehealth format. The participating clinicians reported high levels of satisfaction with VIOSMAS. Revenue to the institution from VIOSMAS exceeded the revenue potential of equivalent time spent for individual visits while supporting extended physician-patient contact.

CONCLUSION

VIOSMAS is feasible for patients and clinicians, addresses patients' symptoms and questions about lifestyle and complementary therapies, and generates more revenue than individual visits. Larger implementation trials with appropriate comparison groups are recommended.

Social capital, food insecurity, and health outcomes in the US during the COVID-19 pandemic

AIMS

The purpose of this study was first, to investigate the harmful effects of food insufficiency on health outcomes - self-rated health (SRH) and self-assessed depressive symptoms - during the COVID-19 pandemic and, second, to test whether these effects fluctuated across the US in terms of state-level social capital.

METHODS

Data were drawn from the Census Household Pulse Survey (fielded between April 2020 and February 2021) consisting of community-dwelling American adults (N = 1.5M+). Social capital measures were taken from the 'Social Capital Project' sponsored by the US Congress. We estimated three-level mixed effects models to analyze multiple waves of repeated cross-sectional surveys.

RESULTS

Post-COVID-19 food insufficiency was significantly negatively associated with SRH and positively associated depression, adjusting for controls including food insufficiency prior to the onset of the pandemic. These relationships were also more pronounced in areas with higher aggregate social capital.

CONCLUSIONS

The health burdens of the new coronavirus disease have fallen disproportionately on the economically marginalized, as measured by food insufficiency. Contrary to the conventional literature, living in a state with a greater stock of social capital worsened its health effects.

Eviction as a community health exposure

Evidence suggests that being evicted harms health. Largely ignored in the existing literature is the possibility that evictions exert community-level health effects, affecting evicted individuals' social networks and shaping broader community conditions. In this narrative review, we summarize evidence and lay out a theoretical model for eviction as a community health exposure, mediated through four paths: 1) shifting ecologies of infectious disease and health behaviors, 2) disruption of neighborhood social cohesion, 3) strain on social networks, and 4) increasing salience of eviction risk. We describe methods for parsing eviction's individual and contextual effects and discuss implications for causal inference. We conclude by addressing eviction's potentially multilevel consequences for policy advocacy and cost-benefit analyses.

Multidisciplinary contributions towards an evolutive interpretation of bipolar disorders: Could it be the pathological drift of a potentially adaptive condition?

This paper tries to summarize the results of studies from different disciplines supporting the idea that temperamental traits, such as "reckless/hyper-exploratory" attitudes, commonly believed to be associated with psychopathology, surprisingly turn out as adaptive under specific stress conditions. In particular, this paper analyzes an ethologic line of research on primates suggesting models for a sociobiological interpretation of mood disorders in humans; a study that found high frequencies of a genetic variance associated with bipolar disorder in people without bipolar disorder but with hyperactivity/novelty-seeking traits; the outcomes of socio-anthropologicalhistorical surveys on the evolution of mood disorders in Western countries in the last centuries; surveys on changing societies in Africa and African migrants in Sardinia; and studies that found higher frequencies of mania and subthreshold mania among Sardinian immigrants in Latin American megacities. Although it is not unequivocally accepted that an increase in the prevalence of mood disorders has occurred, it would be logical to suppose that a nonadaptive condition should have disappeared over time; mood disorders, on the contrary, persist and their prevalence might have even increased. This new interpretation could lead to counter-discrimination and stigma towards people suffering from the disorder, and it would be a central point in psychosocial treatments in addition to drugs. The aim is to hypothesize that bipolar disorder, strongly characterized by these traits, may be the result of the interaction between genetic characteristics, not necessarily pathological, and specific environmental conditions, rather than a mere product of an aberrant genetic profile. If mood disorders were mere nonadaptive conditions, they would have disappeared over time, however, their prevalence, paradoxically, persists if not even increases over time. The hypothesis that bipolar disorder may result from the interaction between genetic characteristics, not necessarily pathological, and specific environmental factors, seem more credible than considering bipolar disorder as a mere product of an aberrant genetic profile.

Exploring Social Capital Level in Regions with Large and Increasing Wealth Inequality: Lesson from Seoul, South Korea

While wealth inequality is increasing worldwide, social interaction quality among communities is simultaneously decreasing. Although inequality is primarily correlated with the income gap, inequality is also significantly associated with the housing price gap, especially in South Korea. This study explores the correlation between housing price inequality and social interaction levels in Seoul. For this analysis, the housing price Gini coefficient was utilized through the housing transaction price, and social interaction was measured using the Korea Housing Survey. The results of this study indicate that the social interaction level was low in regions with large housing price inequality. Moreover, the social interaction level was low in regions where housing price inequality increased for 10 years. Furthermore, the negative correlation between housing price inequality and social interaction was significant only in the lower-asset class. The fact that inequality negatively influences social interactions only in the low-asset class is another aspect of inequality.

Determinants of longevity and age at death in a practically extinct cohort of middle-aged men followed-up for 61 years

OBJECTIVES

To explore possible determinants of longevity as a function of many personal characteristics in a cohort of middle-aged men followed-up until practical extinction.

MATERIALS AND METHODS

In the Italian Rural Area of the Seven Countries Study, 1712 men aged 40-59 were examined in 1960 and 35 personal characteristics were measured. The subsequent follow-up for life status was of 61 years when only 3 men survived. A Kaplan-Meier curve was computed. A Cox model was solved with all-cause mortality as end-point and 35 potential determinants as covariates. A Multiple Linear Regression (MLR) model was also solved with the same covariates and age at death (AD) as end-point.

RESULTS

After 61 years, 99.8% of men had died and median age at death was 75. Beneficial risk factors for both models (p < 0.05) were: never smoker, vigorous physical activity, prudent and Mediterranean diets, arm circumference, subscapular skinfold, and vital capacity. Adverse risk factors (p < 0.05) were: mother early death, laterality/linearity index, systolic blood pressure, serum cholesterol, corneal arcus, xanthelasma, cardiovascular diseases, cancer, diabetes, and chronic bronchitis. Some arbitrary combinations of selected risk factors were used to estimate AD as a function of coefficients of the MLR, showing large differences up to 10 years or more.

CONCLUSIONS

Several personal characteristics of anthropometric, behavioral, biophysical, biochemical, and clinical nature are strongly associated with longevity when measured in middle-aged men and then followed up until extinction.

Do Faith Friendly Workplaces Increase Well-Being?

Many will draw distinctions between finding your purpose and tapping into spirituality. And many more are quick to point out that they are spiritual but not religious. This predictable definitional dynamic makes me doubtful that adoption of purpose finding strategies will be the gateway to unlocking the ambivalence and stigma related to sharing one’s faith in company settings. Drawing from tenets that drive social epidemics, wellness professionals and faith leaders travel in ‘closed circles’ and it will take ‘connectors’ with ties in both circles to spread the idea that workplace wellness and faith traditions can have positive synergies. Healthy People 2030 defines health and well-being as “how people think, feel, and function—at a personal and social level—and how they evaluate their lives as a whole.” This editorial describes components of faith friendly organizations and argues that employee resource groups and trends in diversity, equity and inclusion initiatives could be a catalyst for greater openness to including people’s faith traditions as a part of bringing their whole selves to work.

Mortality Paradox of Older Italian-Born Men in Australia: The Concord Health and Ageing in Men Project

Italian migrants are one of the largest groups of older migrants in Australia. Past research has found lower mortality rates in Italian migrants but it is unclear if this persists into older age. Data came from 334 Italian-born and 849 Australian-born men aged 70 years and over participating in a longitudinal study of men's ageing. Male Italian migrants were more likely to smoke, be overweight, and have lower socio-economic status (SES). They also had higher morbidity from diabetes, chronic pain, dementia and depressive symptoms but lower morbidity from heart disease and cancer. There was no age-adjusted mortality difference. However, adjusting for SES, lifestyle and morbidity differences revealed a 25% lower mortality rate (adjusted HR = 0.75; 95% CI 0.57, 0.98) in Italian-born men. Compared to their Australian-born counterparts, older Italian-born men have a lower mortality than expected considering their lower SES, higher smoking and higher morbidity.

Twitter-Derived Social Neighborhood Characteristics and Individual-Level Cardiometabolic Outcomes: Cross-Sectional Study in a Nationally Representative Sample

BACKGROUND

Social media platforms such as Twitter can serve as a potential data source for public health research to characterize the social neighborhood environment. Few studies have linked Twitter-derived characteristics to individual-level health outcomes.

OBJECTIVE

This study aims to assess the association between Twitter-derived social neighborhood characteristics, including happiness, food, and physical activity mentions, with individual cardiometabolic outcomes using a nationally representative sample.

METHODS

We collected a random 1% of the geotagged tweets from April 2015 to March 2016 using Twitter's Streaming Application Interface (API). Twitter-derived zip code characteristics on happiness, food, and physical activity were merged to individual outcomes from restricted-use National Health and Nutrition Examination Survey (NHANES) with residential zip codes. Separate regression analyses were performed for each of the neighborhood characteristics using NHANES 2011-2016 and 2007-2016.

RESULTS

Individuals living in the zip codes with the two highest tertiles of happy tweets reported BMI of 0.65 (95% CI -1.10 to -0.20) and 0.85 kg/m2 (95% CI -1.48 to -0.21) lower than those living in zip codes with the lowest frequency of happy tweets. Happy tweets were also associated with a 6%-8% lower prevalence of hypertension. A higher prevalence of healthy food tweets was linked with an 11% (95% CI 2% to 21%) lower prevalence of obesity. Those living in areas with the highest and medium tertiles of physical activity tweets were associated with a lower prevalence of hypertension by 10% (95% CI 4% to 15%) and 8% (95% CI 2% to 14%), respectively.

CONCLUSIONS

Twitter-derived social neighborhood characteristics were associated with individual-level obesity and hypertension in a nationally representative sample of US adults. Twitter data could be used for capturing neighborhood sociocultural influences on chronic conditions and may be used as a platform for chronic outcomes prevention.

Precision Medicine in Lifestyle Medicine: The Way of the Future?

Precision medicine has captured the imagination of the medical community with visions of therapies precisely targeted to the specific individual's genetic, biological, social, and environmental profile. However, in practice it has become synonymous with genomic medicine. As such its successes have been limited, with poor predictive or clinical value for the majority of people. It adds little to lifestyle medicine, other than in establishing why a healthy lifestyle is effective in combatting chronic disease. The challenge of lifestyle medicine remains getting people to actually adopt, sustain, and naturalize a healthy lifestyle, and this will require an approach that treats the patient as a person with individual needs and providing them with suitable types of support. The future of lifestyle medicine is holistic and person-centered rather than technological.

The experience of social determinants of health within a Southern European Maltese culture

This study contributes to international research on geographies of health and wellbeing in Mediterranean cultures. The paper draws upon evidence from qualitative research in three localities in Malta, a country where previous research on this topic is quite limited. Through in-depth interviews with people from some of the most disadvantaged and socially marginalised groups in Maltese society, this research illustrates how psychosocial health and wellbeing of the inhabitants within this Mediterranean region are strongly influenced by wider social determinants, particularly the powerful dynamics of social norms involving roles of extended family, traditional attitudes towards marriage as an institution, family honour, gender roles and religious beliefs and practices. This research explores how these social determinants of health within a Maltese context are complex and contingent on personal and local socio-geographical conditions, so that while for some individuals they are beneficial for health and wellbeing, for others the effects are detrimental. The discussion considers how to interpret the 'Mediterranean model' of social determinants of health in light of the experiences of this group of inhabitants.

Comparative Analysis of Women With Notable Subjective Health Indicators Compared With Participants in the Australian Longitudinal Study on Women's Health: Cross-Sectional Survey

Background

At least six communities with unusually good health and longevity have been identified, but their lifestyles aren’t adopted widely. Informal evidence suggests that women associated with Universal Medicine (UM), a complementary medicine health care organization in Eastern Australia and the United Kingdom with normal lifestyles, also have several unusual health indicators.

Objective

Our objective was to determine how UM participants compared with women in the Australian population at large on a variety of health indicators.

Methods

In an Internet survey conducted July to September 2015, a total of 449 female UM participants from 15 countries responded to 43 health indicator questions taken from the Australian Longitudinal Study on Women’s Health (ALSWH).

Results

Survey responses revealed large positive differences in mental and physical health when compared with the ALSWH respondents, except for abnormal Pap test and low iron history. Differences and corresponding effect size estimates (Cohen d; ≥0.8 is a high difference, ≥0.5 a medium and ≥0.2 a small one with P<.001 except where indicated) included body mass index (BMI; 1.11), stress level (0.20, P=.006), depression (0.44), summary physical (0.31) and mental health (0.37), general mental health (0.39), emotional (0.15, P=.009) and social functioning (0.22), vitality (0.58), and general health (0.49), as well as lower incidences of diabetes, hypertension, and thrombosis (P<.001 each). Neither education levels nor country of residence had predictive value. Age did not predict BMI.

Conclusions

The women’s responses notably claim substantially lower levels of illness and disease than in the general Australian population.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12617000972325; https://www.anzctr. org.au/Trial/Registration/TrialReview.aspx?id=373120&isReview=true (Archived by WebCite at http://www.webcitation.org/ 6wEDDn45O)

International Registered Report Identifier (IRRID)

DERR2-10.2196/7993

A Group of 500 Women Whose Health May Depart Notably From the Norm: Protocol for a Cross-Sectional Survey

Background

Longitudinal studies of women’s health often seek to identify predictors of good health. Research has shown that following simple guidelines can halve women’s mortality. The ongoing Australian Longitudinal Study of Women’s Health (ALSWH) shows that Australian women are getting better at reducing their smoking and alcohol use, and are generally diligent about attending recommended health screenings, but are becoming less successful at dealing with obesity. There are communities of women who live unusually healthy lives (Rosetans, Seventh-Day Adventists, traditional Japanese women), but their lifestyles are unlikely to be adopted widely. Universal Medicine (UM) is a complementary-to-medicine approach that emphasizes personal empowerment and the importance of menstrual health symptoms.

Objective

This survey investigates whether the approximately 500 women associated with UM exhibit health status significantly above the norm. As part of this investigation, questions for a newly developed menstrual attitudes questionnaire will also be evaluated.

Methods

A quantitative cross-sectional survey of women in a UM cohort was designed with the help of three focus groups of women at three life stages: in menses, peri-menopausal, and menopausal. The menstrual attitudes portion of the survey incorporates the insights of these women regarding female health issues. The survey also includes 41 questions taken from the ALSWH. Focus groups generated additional questions about symptoms experienced and attitudes toward female health issues. ALSWH questions, including a range of health scales like the Short Form 36 (SF-36), Center for Epidemiologic Studies Depression Scale, Perceived Control Scale, Kessler Psychological Distress Scale, and the Multi-Item Summed Score for Perceived Stress, along with questions about experienced major health events, were investigated and incorporated if considered suitable. At the time of publication of this protocol, data collection has been completed.

Results

The validity of the menstrual attitudes questionnaire will be evaluated with Cohen’s kappa. ALSWH respondents and UM participants will be compared, using unweighted regression or regression weighted or normalized by age, education, and interest in alternative treatments (to increase comparability), as appropriate. Analyses will determine whether UM-related variables (being a UM participant, length of UM participation, number of UM events attended) are associated with: differences in the number of major health events and health symptoms experienced; SF-36 physical and mental health scores; body mass index; and consumption of alcohol, tobacco, sugar, salt, caffeine, and dairy.

Conclusions

If women in the UM cohort are truly in substantially better health than the norm, further investigations may be worthwhile to see whether UM plays a causal role, and whether the women’s practices are generalizable.

International Registered Report Identifier (IRRID)

DERR1-10.2196/7993

Neglected features of lifestyle: Their relevance in non-alcoholic fatty liver disease

AIM

To investigated in non-alcoholic-fatty-liver-disease (NAFLD), with ultrasound (US)-detected fatty liver, and in a group of non-alcoholic and otherwise healthy subjects, relationship of neglected features of lifestyle with NAFLD and obesity.

METHODS

Five hundred and thirty-two NAFLD and 667 non-NAFLD healthy subjects, age 21-60 years were studied. Severity of liver steatosis was assessed by US bright liver score. The adherence to mediterranean diet score (AMDS) was assessed on the basis of a 1-wk recall computerized questionnaire which included a detailed physical activity reports (Baecke questionnaire). The western dietary profile score, as a simplified paradigm of unhealthy diet, a questionnaire quantifying sun exposure score and a sleep habits questionnaires provided a further comprehensive lifestyle assessment.

RESULTS

Body mass index (BMI), insulin resistance (HOMA), and triglycerides, poorer adherence to a mediterranean diet profile, sedentary habits, minor sun exposure and use of “western diet” foods are greater in NAFLD. Multiple linear regression analysis, weighted by years of age, displays BMI, HOMA and AMDS as the most powerful independent predictors of fatty liver severity; however, also the physical activity score, the western diet habit and the sun exposure score are acting inside the model with significant independent effects.

CONCLUSION

Articulated clinical intervention, according to our results, are justified in NAFLD and can be pursued addressing by focused intervention nutritional profile, physical exercise mainly in open-air subsets for enhancing sun exposure and healthier sleep duration and rhythm.

Social Disorder in Adults with Type 2 Diabetes: Building on Race, Place, and Poverty

The recent resurgence of social and civic disquiet in the USA has contributed to increasing recognition that social conditions are meaningfully connected to disease and death. As a "lifestyle disease," control of diabetes requires modifications to daily activities, including healthy dietary practices, regular physical activity, and adherence to treatment regimens. One's ability to develop the healthy practices necessary to prevent or control type 2 diabetes may be influenced by a context of social disorder, the disruptive social and economic conditions that influence daily activity and, consequently, health status. In this paper, we report on our narrative review of the literature that explores the associations between social disorder and diabetes-related health outcomes within vulnerable communities. We also propose a multilevel ecosocial model for conceptualizing social disorder, specifically focusing on its role in racial disparities and its pathways to mediating diabetes outcomes.

Does evidence-based health care have room for the self?

Evidence-based health care (EBHC) has consistently been attacked by opponents for being perniciously reductive. Although these attacks are overwhelmingly framed as critiques of evidence-based medicine, they standardly target the research wing of EBHC upon which evidence-based medicine is dependent, and increasingly extend to adjacent health care disciplines, such as nursing. One of the most persistent forms this line of attack has taken is the allegation that EBHC, with its emphasis on the hierarchy of evidence, grounded in the use of randomized controlled trials, and the clinical guidelines developed on their basis, fails to recognize the patient as the complex self she is, treating her instead as merely a quantifiable, medical-scientific object. By reducing the patient to certain quantifiable dimensions, the patient as self is allegedly 'erased'. In short, the complaint is that an evidence-based approach to health care has no room for the self. Contrary to this persistently held view, it is argued here that EBHC does have room for the self. Review of these critiques suggests they can be categorized into two groups: soft critiques and strong critiques. Soft critiques tend to take a more measured tone grounded in empirical concerns about the dangers of an evidence-based approach to health care, whereas strong critiques tend to make sweeping claims grounded in theoretical commitments to anti-foundationalist philosophical frameworks. While both soft and strong critiques ultimately fail to make the case that EBHC has no room for the self, the empirical concerns of soft critiques nevertheless present a challenge EBHC advocates would do well to take seriously and address.

Exceptional patients and communication in cancer care-are we missing another survival factor?

OBJECTIVE

There is increased awareness of the issue of exceptional survival beyond expectations among cancer patients with poor prognosis, and researchers are starting to look closely at this phenomenon. In this study, we explored the perceptions of these "exceptional patients" as to their understanding and insight into their unusual experience.

METHODS

We used a qualitative approach consisting of in-depth, open-ended interviews with exceptional patients in two locations, Texas and Israel, from 2007 to 2014. The interviews were audio-recorded and qualitatively analyzed, and gave rise to illness narratives entailing detailed descriptions of patients experience over the course of their disease and treatment. A qualitative content analysis focusing on contextual meaning was utilized.

RESULTS

Twenty-nine patients participated in our study. The mean years since diagnosis was 9.55 years (range, 4-23 years). All patients had received conventional treatment, including surgery, chemotherapy, and radiation therapy. One of the prevailing themes in these interviews was related to the patient-doctor relationship. Most participants mentioned that the support they received from one or more physicians was a crucial factor for their exceptional survival.

CONCLUSION

The significance of patient-doctor relationship in cancer survival requires further research. This research is especially important as it adds to the current trend of patient centered care and points to the added value of relationship between health providers and patients. This relationship, as perceived by these exceptional patients, can be a factor that adds to improved survival in cancer care.

Iron metabolism in obesity: how interaction between homoeostatic mechanisms can interfere with their original purpose. Part II: epidemiological and historic aspects of the iron/obesity interaction

The change from a mainly vegetarian fare to meat consumption went along with brain growth and increased insulin resistance to improve brain's glucose supply. Meat consumption increased iron bioavailability and, thus, physical and mental fitness. The "predation-release-hypothesis" proposes that group coordination, arms and fire abolished the survival advantage of lean individuals from predation. The "thrifty gene-hypothesis", in contrast, proposes that surviving repeated episodes of starvation increased efficiency of food utilization in the offspring; they learned to utilize every available calorie. As a consequence of either mechanism, improved food security will increase prevalence of obesity along with that of its fatal consequences, such as diabetes, hypertension, heart diseases, and cancer. Thus, improved food security collides with the biologically evolved mechanisms to store excessive calories in preparation for a famine that never came. The crash between homoeostatic mechanisms and human intervention caused the presently observed pandemia of obesity and explains why it is so difficult to avoid, in spite of its well known and often fatal consequences.

Lessons from complex interventions to improve health

Complexity-resulting from interactions among many component parts-is a property of both the intervention and the context (or system) into which it is placed. Complexity increases the unpredictability of effects. Complexity invites new approaches to logic modeling, definitions of integrity and means of standardization, and evaluation. New metaphors and terminology are needed to capture the recognition that knowledge generation comes from the hands of practitioners/implementers as much as it comes from those usually playing the role of intervention researcher. Failure to acknowledge this may blind us to the very mechanisms we seek to understand. Researchers in clinical settings are documenting health improvement gains made as a consequence of complex systems thinking. Improvement science in clinical settings has much to offer researchers in population health.

Distressed personality without a partner enhances the risk of depression in patients with coronary heart disease

INTRODUCTION

Cultural differences in the combined effects of Type D personality and other mediating factors in the Asian population have not been reported. We examined the influence of the Type D personality in relation to the presence of a partner by measuring symptoms of anxiety and depression, quality of life, self-perception of health status in coronary heart disease (CHD) patients and normal controls.

METHODS

Normal controls (n = 541) and patients with CHD (n = 110) were included. All participants completed self-report measures on Type D personality, questionnaires on socio-demographic factors, the Spielberger State and Trait Anxiety Inventory-State (STAI-S), and the Center for Epidemiologic Studies Depression Scale (CES-D). By stratifying participant group, personality type, and partner status, eight groups were constructed.

RESULTS

The subjects with Type D personality showed higher mean scores on the STAI-S and CES-D as well as perception of their health. In cases of depression, CHD patients with Type D personality and without partner showed about a 50-fold increase in odds ratio when compared with non-Type D normal controls with partners. Odds ratio for depression changed from 31.44 to 48.72 in CHD patients with Type D personality based on the existence of a partner.

DISCUSSION

Having a partner significantly predicted the risk of depression. It is important to identify social support systems in CHD patients with Type D personality.

Processes linking cultural ingroup bonds and mental health: the roles of social connection and emotion regulation

Cultural and ethnic identities influence the relationships individuals seek out and how they feel and behave in these relationships, which can strongly affect mental and physical health through their impacts on emotions, physiology, and behavior. We proposed and tested a model in which ethnocultural identifications and ingroup affiliations were hypothesized explicitly to enhance social connectedness, which would in turn promote expectancy for effective regulation of negative emotions and reduce self-reported symptoms of depression and anxiety. Our sample comprised women aged 18-30 currently attending college in the Southwestern US, who self-identified as Hispanic of Mexican descent (MAs; n = 82) or as non-Hispanic White/European American (EAs; n = 234) and who completed an online survey. In the full sample and in each subgroup, stronger ethnocultural group identity and greater comfort with mainstream American culture were associated with higher social connectedness, which in turn was associated with expectancy for more effective regulation of negative emotions, fewer depressive symptoms, and less anxiety. Unexpectedly, preference for ingroup affiliation predicted lower social connectedness in both groups. In addition to indirect effects through social connection, direct paths from mainstream comfort and preference for ingroup affiliation to emotion regulation expectancy were found for EAs. Models of our data underscore that social connection is a central mechanism through which ethnocultural identities-including with one's own group and the mainstream cultural group-relate to mental health, and that emotion regulation may be a key aspect of this linkage. We use the term ethnocultural social connection to make explicit a process that, we believe, has been implied in the ethnic identity literature for many years, and that may have consequential implications for mental health and conceptualizations of processes underlying mental disorders.

Cardiovascular risk factors predict survival in middle-aged men during 50 years

OBJECTIVES

We aimed at studying the expectancy of life in middle-aged men as a function of several personal characteristics and risk factors.

MATERIAL AND METHODS

A sample of 1712 Italian men aged 40-59, first examined in 1960, was followed-up for mortality for 50 years. The length of survival was estimated as a function of 48 personal characteristics and risk factors using the multiple linear regression.

RESULTS

In 50 years 1672 men died (97.7%) and 40 survived (2.3%). Twenty risk factors, most of which were never measured in previous studies of such duration, proved to be significant, for the estimation of survival with an overall adjusted R(2) of 0.3236. They were: age, 4 anthropometric measurements (body mass index, and its squared term, laterality-linearity index, shoulder/pelvis shape), mean blood pressure, father and mother history of premature (<65-year) death, marital status, arm circumference, 2 respiratory measurements (vital capacity and forced expiratory volume), serum cholesterol, corneal arcus, xantelasma, cancer, cardiovascular diseases, diabetes and chronic bronchitis. Coefficients of 5 suitable risk factors became definitely larger after adjustment for regression dilution bias with 5 year data. All 40 cases of survival were located in the higher 5 deciles of estimated survival and 25 (62.5%) were in the upper decile.

CONCLUSION

A small number of risk factors and personal characteristics, mainly known as cardiovascular risk factors and measured once in middle-aged men, are strongly associated with the length of survival in a 50-year follow-up.

Impact of ethnic variation and residential segregation on long-term survival following myocardial perfusion SPECT

BACKGROUND

Ethnic characteristics of a neighborhood may impact upon all-cause mortality (ACM). It is not known whether this consideration remains a risk modifier among those being evaluated for CAD.

METHODS

6,477 pts (60 ± 13 years, male 38%) residing in NYC with normal or abnormal stress SPECT studies were assessed for ACM during a mean follow-up of 9 ± 3.8 years. Baseline CAD risk factors and ethnic characteristics of patient neighborhoods were considered. Zip-codes with >70% of one ethnicity was considered to be predominant of that ethnicity.

RESULTS

There were 573 (20%) Hispanics (HS), 765 (27%) African-Americans (AA), and 250 (30%) Caucasians (CC) residing in areas >70% of their own ethnicity. Compared to CC, the risk for ACM was lower in HS (hazard ratio (HR) 0.68, 95% CI 0.57-0.8, P < .0001) and similar among AA (HR 1.1, 95% CI 0.95-1.41, P = .2). Among HS, there was a lower ACM among those residing in HS areas compared to those residing in a non-HS areas (HR 0.7 95% CI 0.56-0.9, P = .03) despite a lower median household income ($27,838 ± 3,328 vs $37,751 ± 17,036; P < .0001). This survival difference was not seen in CC and AA.

CONCLUSION

Among patients referred for nuclear SPECT studies for suspected CAD, HS ethnicity was an independent predictor of a favorable prognosis. Among HS, the ethnic characteristic of patients' neighborhoods was an independent predictor of ACM. These results imply that ethnic social support is a potentially powerful modifier of patient outcomes among certain patient groups.

Social Capital and Human Mortality: Explaining the Rural Paradox with County-Level Mortality Data

The "rural paradox" refers to standardized mortality rates in rural areas that are unexpectedly low in view of well-known economic and infrastructural disadvantages there. We explore this paradox by incorporating social capital, a promising explanatory factor that has seldom been incorporated into residential mortality research. We do so while being attentive to spatial dependence, a statistical problem often ignored in mortality research. Analyzing data for counties in the contiguous United States, we find that: (1) the rural paradox is confirmed with both metro/non-metro and rural-urban continuum codes, (2) social capital significantly reduces the impacts of residence on mortality after controlling for race/ethnicity and socioeconomic covariates, (3) this attenuation is greater when a spatial perspective is imposed on the analysis, (4) social capital is negatively associated with mortality at the county level, and (5) spatial dependence is strongly in evidence. A spatial approach is necessary in county-level analyses such as ours to yield unbiased estimates and optimal model fit.

Migration at early age from a high to a lower coronary heart disease risk country lowers the risk of subclinical atherosclerosis in middle-aged men

BACKGROUND

Study of migrants offers a natural model to assess environmental risk of coronary heart disease (CHD) in countries differing in CHD occurrence. In Sweden, CHD risk has been markedly lower than in Finland from where a large migration occurred in the 1970s.

OBJECTIVES

To study the structural and functional markers of subclinical atherosclerosis in twin pairs discordant for migration with the main focus on age at migration, length of residence and integration into Swedish society after migration from a high to a lower CHD risk country.

METHODS

Carotid intima-media thickness (IMT) and brachial artery endothelial function (EF) were assessed with high-resolution ultrasound and a set of cardiovascular, socio-economic and psychosocial risk factors were estimated in 76 middle-aged male twin pairs discordant for migration from Finland to Sweden.

RESULTS

Men who had migrated in adolescence had lower IMT values compared with their co-twins living in Finland (0.665 +/- 0.114 vs. 0.802 +/- 0.167 mm, P = 0.009). Also men who integrated well to Swedish society had lower (0.720 +/- 0.154 vs. 0.799 +/- 0.207 mm, P = 0.013) IMT values than their twin brothers living in Finland. Associations between IMT and migration age and between IMT and integration remained significant in multivariate analyses of several CHD risk factors. The intrapair difference in IMT was significantly associated with immigration age and integration (ANOVA, P = 0.0082), the difference being greatest among pairs where the brother living in Sweden had migrated at early age and integrated well to Swedish society. EF was better in men who had migrated to Sweden before the age of 21 years, but not later, compared with their co-twins in Finland (6.4 +/- 4.6% vs. 3.8 +/- 3.6%, P = 0.025).

CONCLUSIONS

Migration at an early age and good integration are beneficial to vascular health associated with moving from a high to a lower CHD risk country, suggesting that an environment-sensitive period influences atherogenesis before adulthood.

BMI, income, and social capital in a native Amazonian society: interaction between relative and community variables

Researchers have shown interest in the relation between (a) social capital and individual income and (b) the individual health of people of industrial nations. The socioeconomic complexity of industrial nations makes it difficult to arrive at firm conclusions. We circumvent the obstacle by using data from a small-scale rural society of foragers-farmers in the Bolivian Amazon (Tsimane'). We examine the interactions between the outcome (BMI) and relative income, relative social capital, village income, and village social capital. We test three hypotheses: people in villages with more social capital should have higher BMI, the positive association between social capital and BMI will be more marked among the less well-off, and better-off people who display generosity will have higher BMI than better-off people who do not. On the methodological side we show the importance of: focusing on relative measures of income and social capital, estimating interaction between community and relative measures of income and social capital, and showing results through contour plots that summarize the relation between BMI and pairs of explanatory variables. On the substantive side we find evidence that village social capital and village income complement each other and are associated with higher BMI, the rich who are stingy have lower BMI than the rich who display generosity, and increase in village income might reduce individual incentives to invest in social capital. We explore interactions between explanatory variables and their influence on BMI, and end by recommending the use of an experimental research design to obtain unbiased estimates of causal effects.

U.S. State-Level Social Capital and Health-Related Quality of Life: Multilevel Evidence of Main, Mediating, and Modifying Effects

PURPOSE

The aim of this study was to investigate the relation between state-level social capital and adult health-related quality of life (HRQOL) in the United States.

METHODS

Using data from the 2001 Behavioral Risk Factor Surveillance System survey and other surveys and administrative sources, we conducted a two-level, multivariable analysis of 173,236 adults in 48 U.S. states to estimate the associations of state-level social capital (along two scales) with individual-level self-rated general health and the numbers of recent days of poor physical health, poor mental health, and activity limitation.

RESULTS

For each social capital scale, living in a state intermediate or high (vs. low) in social capital was each associated with 10% to 11% lower odds of fair/poor health. Higher state-level social capital also predicted fewer recent days of poor physical and mental health and activity limitation. Differential returns of social capital to HRQOL according to state-level mean income and individual-level age and race/ethnicity were observed. Furthermore, evidence was found compatible with mediation by social capital of income inequality effects on HRQOL.

CONCLUSIONS

This study yields new evidence consistent with protective effects of state-level social capital on individual HRQOL. Promoting social capital may provide a means of improving the health-related quality of life of Americans.

Does village inequality in modern income harm the psyche? Anger, fear, sadness, and alcohol consumption in a pre-industrial society

Researchers have found a positive association between income inequality and poor individual health. To explain the link, researchers have hypothesized that income inequality erodes community social capital, which unleashes negative emotions, stress, and stress behaviors that hurt health. Few studies have tested the hypothesized path. Here we estimate the association between (a) village income inequality and social capital, and (b) three distinct negative emotions (anger, fear, sadness) and one stress behavior (alcohol consumption). We use four quarters of panel data (2002-2003) from 655 adults in 13 villages of a foraging-farming society in the Bolivian Amazon (Tsimane'). We found that: (1) village income inequality was associated with more negative emotions but with less alcohol consumption, (2) social capital always bore a negative association with outcomes, and (3) results held up after introducing many changes to the main model. We conclude that village income inequality probably affects negative emotions and stress behaviors through other paths besides social capital because we conditioned for social capital. One such path is an innate dislike of inequality, which might have pre-human origins. Our prior research with the Tsimane' suggests that village income inequality bore an insignificant association with individual health. Therefore, village income inequality probably affects negative emotions and stress behaviors before undermining health.

Income inequality and adult nutritional status: Anthropometric evidence from a pre-industrial society in the Bolivian Amazon

Evidence has been accumulated about the adverse effects of income inequality on individual health in industrial nations, but we know less about its effect in small-scale, pre-industrial rural societies. Income inequality should have modest effects on individual health. First, norms of sharing and reciprocity should reduce the adverse effects of income inequality on individual health. Second, with sharing and reciprocity, personal income will spill over to the rest of the community, attenuating the protective role of individual income on individual health found in industrial nations. We test these ideas with data from Tsimane' Amerindians, a foraging and farming society in the Bolivian Amazon. Subjects included 479 household heads (13+ years of age) from 58 villages. Dependent variables included anthropometric indices of short-run nutritional status (body-mass index (BMI), and age- and sex-standardized z-scores of mid-arm muscle area and skinfolds). Proxies for income included area deforested per person the previous year and earnings per person in the last 2 weeks. Village income inequality was measured with the Gini coefficient. Income inequality did not correlate with anthropometric indices, most likely because of negative indirect effects from the omission of social-capital variables, which would lower the estimated impact of income inequality on health. The link between BMI and income and between skinfolds and income resembled a U and an inverted U; income did not correlate with mid-arm muscle area. The use of an experimental research design might allow for better estimates of how income inequality affects social capital and individual health.

Evolutionary, historical and political economic perspectives on health and disease

The origin and rise of social inequalities that are a feature of the post-Neolithic society play a major role in the pattern of disease in prehistoric and contemporary populations. We use the concept of epidemiological transition to understand changing ecological relationships between humans, pathogens and other disease insults. With the Paleolithic period as a baseline, we begin with ecological and social relationships that minimized the impact of infectious disease. Paleolithic populations would have retained many of the pathogens that they shared with their primate ancestors and would have been exposed to zoonoses that they picked up as they adapted to a foraging existence. The sparse mobile populations would have precluded the existence of endemic infectious disease. About 10,000 years ago, the shift to an agricultural subsistence economy created the first epidemiological transition, marked by the emergence of infections, a pattern that has continued to the present. Beginning about a century ago, some populations have undergone a second epidemiological transition in which public health measures, improved nutrition and medicine resulted in declines in infectious disease and a rise in non-infectious, chronic and degenerative diseases. Human populations are entering the third epidemiological transition in which there is a reemergence of infectious diseases previously thought to be under control, and the emergence of novel diseases. Many of the emerging and reemerging pathogens are antibiotic resistant and some are multi-antibiotic resistant. Inequality continues to widen within and between societies, accelerating the spread of emerging and reemerging diseases.

Individual and neighbourhood determinants of social participation and social capital: a multilevel analysis of the city of Malmö, Sweden

The aim of this study was to analyse the impact of neighbourhood on individual social capital (measured as social participation). The study population consisted of 14,390 individuals aged 45-73 that participated in the Malmö diet and cancer study in 1992-1994, residing in 90 neighbourhoods of Malmö, Sweden (population 250,000). A multilevel logistic regression model, with individuals at the first level and neighbourhoods at the second level, was performed. The study analysed the effect (intra-area correlation and cross-level modification) of the neighbourhood on individual social capital after adjustment for compositional factors (e.g. age, sex, educational level, occupational status, disability pension, living alone, sick leave, unemployment) and, finally, one contextual migration factor. The prevalence of low social participation varied from 23.0% to 39.7% in the first and third neighbourhood quartiles, respectively. Neighbourhood factors accounted for 6.3% of the total variance in social participation, and this effect was reduced but not eliminated when adjusting for all studied variables (-73%), especially the occupational composition of the neighbourhoods (-58%). The contextual migration variable further reduced the variance in social participation at the neighbourhood level to some extent. Our study supports Putnam's notion that social capital, which is suggested to be an important factor for population health and possibly for health equity, is an aspect that is partly contextual in its nature.

Population-based twin study of the effects of migration from Finland to Sweden on endothelial function and intima-media thickness

Finnish men have higher coronary heart disease (CHD) mortality than Swedish men do. To assess the impact of migration to a country with lower CHD mortality on subclinical atherosclerosis, we measured early functional and structural atherosclerotic vascular changes in twins discordant for migration from Finland to Sweden. Conventional CHD risk factors, flow-mediated dilatation (FMD) of the brachial artery, carotid intima-media thickness, and carotid artery compliance were measured in 74 male twin pairs (20 monozygous, 54 dizygous), aged 42 to 69 years, in which co-one twin had migrated more than 20 years ago permanently to Sweden. There were no significant differences in CHD risk factors except for diastolic blood pressure and body fat percentage, which were higher in Sweden. In all subjects, mean FMD was non-significantly higher in Sweden (5.7+/-4.3% vs 4.9+/-4.2%, P=0.22), but in monozygous twins the difference in FMD was highly significant (7.2+/-4.4 vs 3.7+/-2.9%, P=0.003). There was no significant difference in intima-media thickness or carotid artery compliance between Sweden and Finland. We conclude that in Finnish monozygous twins the endothelial function is better among the twins that have migrated to a country with lower CHD prevalence.

Income inequality and mortality in US counties: does minority racial concentration matter?

This study examined (1) the relationship between income inequality and mortality among all counties in the contiguous United States to ascertain whether the relationships found for states and metropolitan areas extend to smaller geographic units and (2) the influence of minority racial concentration on the inequality-mortality linkage.

METHODS

This county-level ecologic analysis used data from the Compressed Mortality Files and the US Census. Weighted least squares regression models of age-, sex-, and race-adjusted county mortality rates were estimated to examine the additive and interactive effects of income inequality and minority racial concentration.

RESULTS

Higher income inequality at the county level was significantly associated with higher total mortality. Higher minority racial concentration also was significantly related to higher mortality and interacted with income inequality.

CONCLUSIONS

The relationship between income inequality and mortality is robust for counties in the United States. Minority concentration interacts with income inequality, resulting in higher mortality in counties with low inequality and a high percentage of Blacks than in counties with high inequality and a high percentage of Blacks.

Ethnic differences in self reported health in Malmö in southern Sweden

STUDY OBJECTIVE

The aim of this study was to investigate ethnic differences in self reported health in the city of Malmö, Sweden, and whether these differences could be explained by psychosocial and economic conditions.

DESIGN/SETTING/PARTICIPANTS

The public health survey in Malmö 1994 was a cross sectional study. A total of 5600 people aged 20-80 years completed a postal questionnaire. The participation rate was 71%. The population was categorised according to country of origin: born in Sweden, other Western countries, Yugoslavia, Poland, Arabic speaking countries and all other countries. The multivariate analysis was performed using a logistic regression model in order to investigate the importance of possible confounders on the differences by country of origin in self reported health. Finally, variables measuring psychosocial and economic conditions were introduced into the model.

MAIN RESULTS

The odds ratios of having poor self reported health were significantly higher among men born in other Western countries, Yugoslavia, Arabic speaking countries and in the category all other countries, as well as among women born in Yugoslavia, Poland and all other countries, compared with men and women born in Sweden. The multivariate analysis including age and education did not change these results. A huge reduction of the odds ratios was observed for men and women born in Yugoslavia, Arabic speaking countries and all other countries, and for women born in Poland after the introduction of the social network, social support and economic factors into the multivariate model.

CONCLUSIONS

There were significant ethnic group differences in self reported health. These differences were greatly reduced by psychosocial and economic factors, which suggest that these factors may be important determinants of self rated health in certain minority groups.

Collective lifestyles as the target for health promotion

The last five years have witnessed intense debate among health researchers in Canada regarding the overlap of the health promotion and population health discourses. Meanwhile, strong currents within health promotion have attempted to move the field beyond a focus on individual behaviour towards the influence of social environments on health, although the tendency is often to fall back on individual behaviour modification as the primary lever for change. The Population Health research agenda bypasses behavioural determinants of health and explores instead social determinants. This body of knowledge provides useful insight for addressing some of the tensions in the health promotion discourse. This paper explores two of these tensions: whether individuals at risk or general populations should be targeted for change; and whether lifestyle is an individual or a collective attribute. We propose the notion of collective lifestyles as a heuristic for understanding the interaction between social conditions and behaviour in shaping health.

Toward a lexicon of population health

Despite its undeniable currency in research and policy circles, there remains considerable confusion about what 'population health' is. We propose a lexicon for population health in the hope of clarifying issues and advancing this important research emphasis and policy agenda. It distinguishes population health in its literal meaning from a population health perspective, population health research, a population health framework, and a population health approach to policy. Population health is more than just thinking in aggregate terms or about identifying vulnerable or at-risk subpopulations. A population health perspective is fundamentally concerned with the social nature of health influences. The social structures that shape health experiences transcend the characteristics or actions of any one individual, providing population health with analytic advantages over individualistic-oriented approaches to health and to health policy.

Collective lifestyles as the target for health promotion

The last five years have witnessed intense debate among health researchers in Canada regarding the overlap of the health promotion and population health discourses. Meanwhile, strong currents within health promotion have attempted to move the field beyond a focus on individual behaviour towards the influence of social environments on health, although the tendency is often to fall back on individual behaviour modification as the primary lever for change. The Population Health research agenda bypasses behavioural determinants of health and explores instead social determinants. This body of knowledge provides useful insight for addressing some of the tensions in the health promotion discourse. This paper explores two of these tensions: whether individuals at risk or general populations should be targeted for change; and whether lifestyle is an individual or a collective attribute. We propose the notion of collective lifestyles as a heuristic for understanding the interaction between social conditions and behaviour in shaping health.