Adapting an evidence-based, home cardiac rehabilitation programme for people with heart failure and their caregivers to the Danish context: DK:REACH-HF study

AIMS

Adapting interventions with an existing evidence base offers a more efficient approach than development of a new intervention. The aim of this study was to describe the process of adapting a home-based cardiac rehabilitation (CR) programme (REACH-HF) intervention originally developed in the United Kingdom for people with heart failure (HF) to the Danish health system - the 'DK:REACH-HF' programme.

METHODS AND RESULTS

We followed methodological framework for the conduct and reporting of studies adapting interventions, utilizing documentary analysis, qualitative interviews, stakeholder consultations, and mapping of the Danish policy context. Our study found broad support for the REACH-HF intervention as an alternative to existing centre-based CR. We also identified three key areas of adaptation for the Danish context. First, reduce the word-count of the intervention's resources by linking to existing publicly available CR materials. Second, whilst retaining REACH-HF core components, adapt its content and delivery to reflect differences between Denmark and United Kingdom. Thirdly, to develop a digital version of the intervention.

CONCLUSION

Using an evidence-based approach, we successfully adapted the REACH-HF intervention to the context of the Danish healthcare setting, maintaining core components of the original intervention, and developing both a paper based and digital version of the programme material. To inform scaled national implementation of the DK:REACH-HF programme, we seek to undertake a pilot study to test the adapted intervention materials feasibility and acceptability to healthcare practitioners, patients, and their caregivers and confirm the positive impact on the outcomes of HF patients and caregivers.

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

BACKGROUND

Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories.

METHODS

We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5-19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI <18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For school-aged children and adolescents, we report thinness (BMI <2 SD below the median of the WHO growth reference) and obesity (BMI >2 SD above the median).

FINDINGS

From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness.

INTERPRETATION

The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesity.

FUNDING

UK Medical Research Council, UK Research and Innovation (Research England), UK Research and Innovation (Innovate UK), and European Union.

Characteristics associated with non-initiation and non-completion of human papillomavirus vaccination among Danish girls: a nationwide register-based cohort study

AIM

The aim was to identify maternal and paternal socioeconomic and demographic characteristics for non-initiation and non-completion of the human papillomavirus (HPV) vaccination among Danish girls including time-trends.

METHODS

This nationwide register-based cohort study included all girls residing in Denmark who were offered free-of-charge HPV vaccination as a part of the childhood vaccination program between 2009 and 2018 (birth cohorts 1996-2005). The study samples included 296,461 daughter-mother dyads and 291,025 daughter-father dyads. Data from the Danish Vaccination Register were linked with socioeconomic and demographic data from Statistics Denmark. HPV vaccination status was classified as 'non-initiation' for girls who received no HPV vaccine and as 'non-completion' for girls who initiated the HPV vaccination program but did not receive all the scheduled HPV vaccines. Data were analyzed using logistic regression models.

RESULTS

Non-initiation of HPV vaccination was 13.7%, and non-completion was 24.2% among girls who initiated the HPV vaccination program. Girls of parents who were descendants of immigrants (adjusted odds ratio: 1.50; 95% confidence interval: 1.35-1.68), were at least 35-years old at time of birth, had basic or no education, had a low income, were not in the labor market, and were unmarried had the highest non-initiation and non-completion odds. The associations between socioeconomic and demographic characteristics and HPV vaccination uptake were similar for mothers and fathers.

CONCLUSIONS

Despite free-of-charge availability to HPV vaccination in Denmark, we found disparities in non-initiation and non-completion of HPV vaccination among Danish girls by both mothers' and fathers' socioeconomic and demographic characteristics.

Global variation in diabetes diagnosis and prevalence based on fasting glucose and hemoglobin A1c

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed and detected in survey screening ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the age-standardized proportion who had elevated levels of both FPG and HbA1c was 29-39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c was more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global shortfall in diabetes diagnosis and surveillance.

Associations between alcohol intake and hospital contacts due to alcohol and unintentional injuries in 71,025 Danish adolescents - a prospective cohort study

Background

Alcohol is a leading risk factor to adolescent health. However, it is unclear how associations between alcohol intake and injuries are shaped. We investigated the dose-response relationship between alcohol intake and risk of hospital contacts due to alcohol and unintentional injuries in adolescents.

Methods

We conducted a prospective cohort study including 71,025 Danish students aged 15-24 years, followed up for five years from 2014 to 2019. The main outcome measures were hospital contacts due to alcohol and unintentional injuries (all injuries and head injuries), obtained from hospital registers.

Findings

Approximately 90% of males and females reported drinking alcohol, and the median intake among those was 11 drinks/week in males and 8 drinks/week in females. During five years of follow-up, 1.3% had an alcohol-attributable hospital contact, the majority of which were due to acute intoxication (70%). Alcohol-attributable hospital contacts were equally frequent in males and females and between age groups (15-17-year-olds vs 18-24-year-olds). Compared with never drinking, the adjusted incidence rate ratios for weekly intake of <7, 7-13, 14-20, 21-27, and >27 drinks/week were 1.70 (95% confidence interval 1.23-2.34), 1.77 (1.27-2.46), 1.91 (1.35-2.70), 2.34 (1.59-3.46), and 3.25 (2.27-4.64) for having an alcohol-attributable hospital contact within five years of follow-up. Restricting follow-up to one year more than doubled risk estimates. During the five years of follow-up, 27% incurred an unintentional injury. The most frequent types of injury were to the wrist or hand (27.6%), ankle or foot (25.2%), or head (12.4%). Injuries were more frequent among males (first-time incidence rate 110 per 1000 person-years) compared to females (82 per 1000 person-years), with no differences between age groups. Compared with never drinking, the adjusted incidence rate ratios for weekly intake of <7, 7-13, 14-20, 21-27, and >27 drinks were 1.09 (1.03-1.15), 1.14 (1.07-1.20), 1.25 (1.17-1.33), 1.38 (1.28-1.49), and 1.58 (1.47-1.69) for having a hospital contact for any type of unintentional injury within five years of follow-up. Results for the one-year follow-up period were comparable. Separate analysis for head injuries showed similar results as the analysis on all injuries. Results were generally similar in males and females.

Interpretation

Adolescents' drinking is associated with a higher risk of acute harm in terms of hospital contacts due to alcohol and unintentional injuries in a dose-response relationship. Thus, increased risk was apparent in those with low alcohol intake, suggesting a need for awareness of and initiatives to prevent youth drinking. Furthermore, initiatives should include a strengthened focus on people younger than 18 years.

Funding

This study was funded by the Tryg Foundation (ID: 153539) and The Helse Foundation (21-B-0359).

Time trends in body mass index distribution in the general population in Denmark from 1987 to 2021

INTRODUCTION

The epidemic increase in obesity is well documented and of intensive public health interest. Attention has almost entirely focused on a dichotomous measure of obesity such as how the prevalence of BMI ≥ 30 kg/m2 has changed over time. Less consideration has been given to how the general distribution of BMI has evolved.

METHODS

We used data from the National Health and Morbidity Surveys, which are surveys of the adult Danish population (16 years or above) conducted in 1987, 2000, 2005, 2010, 2013, 2017 and 2021. Participants reported height and weight from which BMI was calculated following correction for systematic bias in self-reported data and non-response.

RESULTS

The prevalence of obesity in Denmark increased from 6.1% in 1987 to 18.4% in 2021. A right shift in BMI distribution was observed with positive linear slopes for high and low BMI percentiles and for all socioeconomic groups, although with steeper slopes for high BMI percentiles and for short education.

CONCLUSIONS

The right shift in the distribution curve of BMI from 1987 to 2021 with gradually higher values in all BMI percentiles and in all socioeconomic strata show that the increasing obesity prevalence may, to some extent, be attributed to a generally higher BMI in the entire Danish population.

FUNDING

None.

TRIAL REGISTRATION

Not relevant.

Trends in smoking-related diseases by socioeconomic position following a national smoking ban in 2007: a nationwide study in the Danish population

BACKGROUND

National comprehensive smoke-free legislation has been found to decrease the incidence of several smoking-related diseases. In 2007, Denmark introduced a national smoking ban, which banned smoking indoor in workplaces and public places, although only partial restrictions were applied in certain settings. We examined the impact of the smoking ban on smoking-related diseases and whether this differed across socioeconomic groups.

METHODS

Interrupted time series analyses of nationwide register data were performed using Poisson regression models to examine the differential impact of the smoking ban on monthly incidence rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers from 2002 to 2015. Immediate changes in incidence rates after the smoking ban and long-term changes in disease trends were estimated by comparing data from the pre- and post-ban period. Models were stratified by socioeconomic position.

RESULTS

Overall, we found neither immediate changes in rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers following the smoking ban nor long-term post-ban changes in disease trends as compared to before the ban. Results did not differ across socioeconomic groups. A pronounced socioeconomic gradient in incidence rates was observed for all outcomes both before and after the smoking ban.

CONCLUSION

The national smoking ban was not associated with a lower incidence of smoking-related diseases in the post-ban period compared to pre-ban levels and no differences between socioeconomic groups were observed. Future tobacco control in Denmark should consider which measures most effectively target the low socioeconomic groups to decrease the current strong socioeconomic inequality in health.

Socioeconomic inequalities in alcohol-related harm in adolescents: a prospective cohort study of 68,299 Danish 15-19-year-olds

Background

Evidence shows that similar levels of alcohol consumption lead to greater harm in adults with low socioeconomic position (SEP) compared to high SEP. We investigated if SEP is associated with alcohol-related hospital contacts in adolescents, and whether differences in risk can be explained by differences in levels of alcohol consumption, drinking pattern, and substance use.

Methods

This is a prospective cohort study of 68,299 participants aged 15-19 years old from the Danish National Youth Cohort 2014. SEP was operationalised as parent educational level, family income and perceived financial strain in the family. Data were linked to national registers and participants were followed up for five years from 2014 to 2019. Outcomes were hospital contacts due to alcohol. Multilevel Poisson regression was used to estimate incidence rates (IR) and incidence rate ratios (IRR).

Findings

During 280,010 person years of follow-up, 872 participants had an alcohol-attributable hospital contact; intoxications (n = 778, 89%) were the most common diagnosis. Low as compared to high SEP was associated with higher IRR of alcohol-attributable hospital contacts for all three SEP measures. The adjusted IRR of harm was 1.73 (95% CI: 1.29-2.33) for elementary school as the highest parent education compared to longer parent education and 1.57 (95% CI: 1.30-1.89) for family financial strain compared to those without financial strain. Adjustment for weekly alcohol intake, drinking pattern and substance use did not substantially change results. Cubic spline analysis of the association between family income and alcohol-attributable hospital contacts revealed a dose-response relationship with decreasing risk of alcohol-related harm with higher income.

Interpretation

Our findings suggested that alcohol-related harm is more common in socioeconomically disadvantaged adolescents despite similar levels of alcohol consumption, regardless of differences in drinking pattern or substance use. Future preventive strategies should prioritise young adolescents, including those who are most disadvantaged.

Funding

Tryg Foundation (ID: 153539).

Changes in loneliness prevalence in Denmark in the 21st century: Age-period-cohort analysis

AIM

The aim of this study was to investigate changes in the prevalence of loneliness in Denmark from 2000 to 2021 by conducting age-period-cohort analysis.

METHODS

Our study was based on a sample (N=83,437; age: ⩾16 years) of the Danish Health and Morbidity Surveys conducted in Denmark in 2000, 2005, 2010, 2013, 2017 and 2021. We used logistic regression models by gender to estimate the age-period-cohort effects, with loneliness as the dependent variable and age, survey year and birth cohort as independent variables, mutually adjusted.

RESULTS

The prevalence of adult loneliness increased by each survey year over the entire period (from 13.2% in 2000 to 27.4% in 2021 among men and from 18.8% to 33.7% among women). Overall, a U-shaped curve, for the prevalence of loneliness among different age groups, was observed, which was most pronounced among women. The greatest increase in the prevalence of loneliness from 2000 to 2021 was observed among the youngest age group (16-24 years), with 28.4 and 30.7 percentage points for men and women. No significant cohort effect was observed.

CONCLUSIONS

The observed increase in loneliness prevalence from 2000 to 2021 was driven by period and age effects rather than cohort effects. It should be noted that data from 2021 were collected during a national lockdown due to an outbreak of COVID-19, which could explain part of the large increase in loneliness from 2017 to 2021.

Alcohol-related mortality in 15–24-year-olds in Denmark (2010–2019): a nationwide exploratory study of circumstances and socioeconomic predictors

Background

Adolescents and young adults aged 15-24 years are disproportionately affected by unnatural deaths, including accidents, suicide and interpersonal violence for which alcohol is a leading risk factor. We aimed to explore the extent of and circumstances surrounding alcohol-related deaths in young people aged 15-24 years and whether socioeconomic background and ethnicity differ in those who died due to alcohol-related causes as compared to the background population.

Methods

All deaths of 15-24-year-olds occurring in Denmark from 2010 to 2019 were investigated. We manually reviewed death certificates containing information on circumstances, results from autopsies and blood tests, and statements from witnesses. Relevant information published in the media (most often newspaper articles) was included. Our main outcome measures were alcohol-related death and manner of death (accidents (transport accidents, drownings, falls, poisonings), suicide and violence). Further, we designed a population-based case-control study including 10 age- and sex-matched controls per case to test whether there was a socioeconomic gradient in alcohol-related deaths. We used parents' educational level and employment status to define socioeconomic position. Immigration status was used to assess ethnicity.

Findings

Over the 10-year period, 1783 deaths occurred among 15-24-year-olds. Of those, 1067 (60%) were due to unnatural causes, corresponding to a mortality rate of 14.8 (95% confidence interval: 13.9-15.7) per 100,000. Twelve percent of unnatural deaths (n = 125) were alcohol related, corresponding to a rate of 1.7 (1.4-2.0) per 100,000, and were higher in males (2.9 [2.3-3.4]) than in females (0.6 [0.3-0.8]); thus, males accounted for 105 (84%) of alcohol-related deaths. The majority of alcohol-related deaths occurred on Fridays, Saturdays and Sundays (n = 77, 62%). Accidents accounted for 82% (n = 102) of alcohol-related deaths, followed by suicide (n = 19, 15%) and interpersonal violence (n = 4, 3%). Of all fatal accidents, 102 of 636 (16%) were alcohol related. Of all deaths caused by drownings and falls, 14 of 26 (54%) and 10 of 25 (40%), respectively, were alcohol related. Alcohol-related drownings most often occurred while the deceased was alone, whereas alcohol-related falls most often occurred in relation to parties, involving falls from a window or balcony. Those who died from alcohol-related causes more often had parents with a short education or who were unemployed, as compared to the general population. For example, odds ratios were 3.9 (2.2-7.0) and 1.8 (1.2-2.9) for having parents with short and medium as compared to long educations. The odds ratio for being of Danish origin was 4.0 (1.7-9.5) compared to being first- or second-generation immigrants.

Interpretation

In 15-24-year-olds, alcohol-related deaths accounted for a substantial proportion of all unnatural deaths. There was substantial socioeconomic inequality in alcohol-related deaths, as has repeatedly been shown for chronic alcohol-related mortality in older adults.

Funding

Trygfonden.

Per- and Polyfluoroalkyl Substances and Breastfeeding as a Vulnerable Function: A Systematic Review of Epidemiological Studies

Milk formation in the breast during breastfeeding is a complex hormonally regulated process, potentially sensitive to the effects of endocrine-disrupting chemical exposures. The environmental chemicals, per- and polyfluoroalkyl substances (PFAS) are known endocrine disruptors. PFAS exposure have been associated with insufficient mammary gland development in mice and reduced breastfeeding duration in humans. The aim of this review was to gather the epidemiological evidence on the association between PFAS exposure and breastfeeding duration. Using PubMed and Embase, we performed a systematic literature search (on 23 January 2023) to identify epidemiological studies examining the association between maternal PFAS exposure and breastfeeding duration. Animal studies, reviews, and non-English studies were excluded. The risk of bias was assessed using the risk of bias in non-randomized studies of exposures tool. Estimates describing the association between PFAS exposure and the duration of breastfeeding were identified, and the data were synthesized separately for each type of PFAS and for the duration of exclusive and total breastfeeding. Six studies with between 336 and 2374 participants each were identified. PFAS exposure was assessed in serum samples (five studies) or based on residential address (one study). Five out of six studies found shorter total duration of breastfeeding with higher PFAS exposure. The most consistent associations were seen for perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), and perfluorononanoic acid (PFNA). The finding of a potential causal association between PFAS exposure and breastfeeding duration is in agreement with findings from experimental studies.

Diminishing benefits of urban living for children and adolescents' growth and development

Optimal growth and development in childhood and adolescence is crucial for lifelong health and well-being1-6. Here we used data from 2,325 population-based studies, with measurements of height and weight from 71 million participants, to report the height and body-mass index (BMI) of children and adolescents aged 5-19 years on the basis of rural and urban place of residence in 200 countries and territories from 1990 to 2020. In 1990, children and adolescents residing in cities were taller than their rural counterparts in all but a few high-income countries. By 2020, the urban height advantage became smaller in most countries, and in many high-income western countries it reversed into a small urban-based disadvantage. The exception was for boys in most countries in sub-Saharan Africa and in some countries in Oceania, south Asia and the region of central Asia, Middle East and north Africa. In these countries, successive cohorts of boys from rural places either did not gain height or possibly became shorter, and hence fell further behind their urban peers. The difference between the age-standardized mean BMI of children in urban and rural areas was <1.1 kg m-2 in the vast majority of countries. Within this small range, BMI increased slightly more in cities than in rural areas, except in south Asia, sub-Saharan Africa and some countries in central and eastern Europe. Our results show that in much of the world, the growth and developmental advantages of living in cities have diminished in the twenty-first century, whereas in much of sub-Saharan Africa they have amplified.

Changes in adult obesity prevalence in Denmark, 1987-2021: age-period-cohort analysis of nationally representative data

BACKGROUND

During the last decades, the prevalence of obesity [body mass index (BMI): weight/height2), ≥30.00 kg/m2] among adults has increased considerably. We examined whether this increase in a high-income, welfare state, like Denmark was driven by age, period or cohort effects, which would inform preventive strategies aiming at reducing the prevalence.

METHODS

We used data from the National Representative Health and Morbidity Studies, which are representative surveys of the Danish adult population (age 16 years and above), conducted in 1987, 1994, 2000, 2005, 2010, 2013, 2017 and 2021 (N = 91 684). Participants reported height and weight, from which BMI was calculated after correction for systematic bias in self-reported data and non-response. Age, survey year and birth cohorts were mutually adjusted and adjusted for sex in generalized linear models.

RESULTS

The obesity prevalence increased from 6.1% in 1987 to 18.4% in 2021, similarly in men (18.8%) and women (18.0%) and in all age groups. Age had an inverted u-shaped effect on the prevalence. Compared with individuals aged 16-24 years, the highest rate of obesity was seen for the age group 55-64 years [rate ratio 3.27, 95% confidence interval (CI): 2.58; 4.14]. The increasing rate for each recent survey year over time was compatible with a period effect without any birth cohort effects. The rate for obesity in 2021 was 4.16 in 1987 vs. 1987 (95% CI: 3.10; 5.59).

CONCLUSIONS

Obesity prevalence in Denmark increased steadily during the period 1987 through 2021, primarily driven by secular changes over time across all ages and birth cohorts.

Perceived parental alcohol problems and later dropout and grade point average in high school: A register-based follow-up study

INTRODUCTION

The aim of the study was to test the hypothesis that young people with perceived parental alcohol problems have higher dropout rates in high school and lower grade point average (GPA) at graduation compared to young people without perceived parental alcohol problems.

METHODS

Data come from Danish National Youth Study 2014 (n = 62,171), merged with register-data on later dropout of high school and GPA. Multilevel Poisson regression models of incidence rates of dropout and multilevel linear models of GPA were used to assess the association with perceived parental alcohol problems.

RESULTS

A total of 6.6% of the students perceived their parent(s) to have alcohol problems. Young people with perceived parental alcohol problems had higher dropout rate (girls incidence rate ratio 1.83; 95% confidence interval [1.62-2.06]); boys (incidence rate ratio 1.38; 95% confidence interval [1.17-1.64]) and lower grades (GPA: -0.24; 95% confidence interval [-0.32; -0.17]) compared to those without. There was no statistically significant difference between mother's and fathers' alcohol problems in the associations with dropout and GPA.

DISCUSSION AND CONCLUSIONS

Perceived parental alcohol problems were associated with higher incidence rate ratio of dropout and lower grades within all categories of the socioeconomic factors. Our results show that young people with perceived parental alcohol problems have higher high school dropout rates and lower grades compared to those without perceived parental alcohol problems across gender and socioeconomic position. The results call for evidence-based interventions to support young people with parental alcohol problems in the educational system.

Alcohol norms and alcohol intake among high school students

AIMS

To analyse whether parental alcohol norms were associated with the alcohol intake of high school students and whether this association persisted across different levels of alcohol intake in school and trustful communication with parents.

METHODS

This was a cross-sectional study among 70,544 high school students (mean age 18 years) participating in the Danish National Youth Study 2014. We examined the associations between parental alcohol norms and individual alcohol intake as the number of drinks at the most recent school party and the frequency of binge drinking in the last 30 days using negative binomial regression. We then performed joint analyses of parental alcohol norms and alcohol intake at school level, and parental alcohol norms and trustful communication with parents.

RESULTS

The mean intake of alcohol at the most recent school party was 9.9 units of alcohol for boys and 7.6 units of alcohol for girls. A total of 36.2% of boys and 24.7% of girls were binge drinking frequently (more than four occasions in the last month). Lenient parental alcohol norms and a low level of trustful communication with parents were associated with a higher intake at the most recent school party and with the frequency of binge drinking. Joint analyses showed that these associations persisted across different levels of school level alcohol intake and levels of trustful communication with parents.

CONCLUSIONS

Among high school students, parental alcohol norms were strongly associated with alcohol intake and consistently so across different levels of school level alcohol intake and level of trustful communication with parents. This indicates that the role of parents in preventing excessive drinking is important, even in older adolescents.

Are emotional symptoms and depression among young people with parental alcohol problems modified by socioeconomic position?

The aim was to test the hypothesis that parental alcohol problems and low socioeconomic position would be associated with higher odds ratio of emotional symptoms and depression as compared to high socioeconomic position and parental alcohol problems. Data came from Danish National Youth Study 2014, a web-based national survey with 75,853 high school and vocational school students participating, merged with register-data on family socioeconomic position. Multi-level logistic regression models (nesting participants within schools) were used to assess the association between perceived parental alcohol problems and frequent emotional symptoms and depression and effect modification by financial strains in the family, family income, or parental educational level. All analyses were adjusted for age, sex, education, immigration status, and cohabitation with parents. Young people with parental alcohol problems had higher odds ratio of experiencing frequent emotional symptoms (OR = 1.56 [1.46-1.66]) and depression (OR = 2.07 [1.88-2.28]), compared to young people without parental alcohol problems. There was no effect modification between severity of parental alcohol problems and the measures of socioeconomic position on the odds ratio of frequent emotional symptoms and depression. This study found that young people with parental alcohol problems in all social strata had higher odds ratios of frequent emotional symptoms and depression compared to young people without parental alcohol problems; the more severely they had been affected by parent's alcohol problems, the higher the odds ratios of frequent emotional symptoms and depression.

Smoking and labour market participation: a 5-year prospective cohort study of transitions between work, unemployment and sickness absence

AIM

To examine whether smokers are at higher risk of unemployment and sickness absence and have a lower chance of getting employed compared to never smokers.

METHODS

The study sample in this prospective register-based cohort study consisted of 87,830 men and women between 18 and 60 years of age from the Danish National Health Survey 2010. Assessment of smoking status was obtained at baseline and the participants were followed in the Danish register-based evaluation of marginalisation database from 2010 to 2015. Data were analysed by Cox proportional hazards.

RESULTS

The median age was 44.5 years and 47.3% were men. At baseline, 88.8% were categorised as working, 7.7% as unemployed and 3.5% as being on sickness absence. At the 5-year follow-up, hazard ratios for transitions from work to unemployment were 1.31 (95% confidence interval (CI) 1.22-1.40; P<0.001) for current smokers (<15/day) and 1.52 (95% CI 1.43-1.62; P<0.001) for current heavy smokers (⩾15/day), compared to never smokers. Hazard ratios for transitions from work to sickness absence were 1.31 (95% CI 1.24-1.38; P<0.001) for current smokers (<15/day) and 1.64 (95% CI 1.56-1.71; P<0.001) for current heavy smokers (⩾15/day). Current heavy smokers (⩾15/day) also had a lower chance of becoming re-employed with a hazard ratio of 0.81 (95% CI 0.75-0.88; P<0.001) compared to never smokers.

Smoking was associated with a higher risk of unemployment and sickness absence, and a lower chance of becoming employed. More focus on smoking prevention and smoking cessation could therefore be implemented in relation to job seeking and sickness absence.

Risk of somatic disease and mortality in individuals of parents with alcohol use disorder: a register-based cohort study

AIMS

To estimate the risks of 12 types of somatic disease-alcohol-related, blood, cancer, circulatory, digestive, endocrine and metabolic, genitourinary, infectious, musculoskeletal, nervous, respiratory and skin-in individuals with parental alcohol use disorder (AUD) versus a reference population, and to estimate the risks of all-cause mortality and of death from an alcohol-related cause.

DESIGN

Matched cohort study followed-up through nation-wide health registries. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

SETTING

Denmark.

PARTICIPANTS

A total of 14 008 individuals born 1962-2003 of parents with AUD and 139 087 reference offspring randomly selected from the Danish Civil Registration System were followed from their 15th birthday and onward during 1970-2018. Follow-up time ranged between 2 423 955 and 3 208 366 person-years for somatic diseases and was 3 214 411 person-years for all-cause and alcohol-related mortality.

MEASUREMENTS

Information on somatic disease was obtained from the Danish National Patient Registry. Causes of death were obtained from the Danish Cause of Death Registry.

FINDINGS

Individuals of parents with AUD had a higher risk of alcohol-related diseases (HR = 2.70, 95% CI = 2.24-3.24) compared with the reference individuals. Higher HRs among individuals with parental AUD compared with reference individuals were also observed in all other somatic diseases except for cancer. All-cause mortality (HR = 1.80, 95% CI = 1.63-2.00) and alcohol-related mortality (HR = 3.28, 95% CI = 2.11-5.08) were higher among individuals of parents with AUD compared with the reference individuals. No significant differences were found in relation to the gender of either parents or offspring.

CONCLUSIONS

In Denmark, parental alcohol use disorder appears to predict alcohol-related and non-alcohol-related somatic morbidity and mortality in offspring.

Long-Term Cardiovascular Health After Pregnancy in Danish Women With Congenital Heart Disease. A Register-Based Cohort Study Between 1993 and 2016

Background Little is known about the impact of pregnancy on long-term cardiovascular health in individuals with congenital heart disease (CHD). We aimed to determine if giving birth in patients with CHD is associated with higher risk of long-term cardiovascular morbidity. Methods and Results We studied a cohort of 1262 individuals with CHD giving birth (live or still) from 1993 to 2015 using Danish nationwide registers. We randomly sampled a comparison cohort matched on age of women with CHD who had not given birth at the time. We balanced the 2 cohorts on baseline demographic (eg, education) and clinical variables (eg, CHD severity) using inverse probability of treatment weighting. Individuals were followed for critical (eg, heart failure), other cardiovascular morbidity (eg, arrhythmia), and cardiac surgery/interventions after pregnancy. Individuals were followed for median 6.0 years (interquartile range 3.2-9.2). Among individuals giving birth the incidence rate per 1000 person-years was 1.6, 10.0, and 6.0 for critical and other cardiovascular morbidity and cardiac surgery, respectively. There was no overall difference in risk of neither critical and other cardiovascular morbidity nor cardiac surgery among individuals who gave birth and individuals who did not; adjusted hazard ratios (aHR) were 0.74 (95% CI, 0.37-1.48), 0.88 (95% CI, 0.65-1.19), and 0.78 (95% C,I 0.54-1.12), respectively. However, individuals with obstetric complications had a higher long-term risk of other cardiovascular morbidity (aHR, 1.85; 95% CI, 1.07-3.20). Conclusions Giving birth seemed not to be associated with a higher risk of long-term cardiovascular morbidity among women with CHD. However, individuals having obstetric complications had a higher risk of other cardiovascular morbidity in the long term.

Bariatric Surgery and Risk of Unemployment and Sickness Absence

BACKGROUND

Obesity is associated with adverse labor market outcomes. We examine whether undergoing bariatric surgery is associated with better labor market outcomes such as lower risks of unemployment and sickness absence.

METHODS

This is a register-based cohort study of 9126 patients undergoing bariatric surgery from 2005 to 2013 and a reference group of 10,328 individuals with obesity. Age: 18-60 years, body mass index (BMI): 32-60 kg/m². Participants were either working, unemployed, or on sickness absence at baseline. Inverse probability of treatment weighting was used to account for baseline differences between the two groups. Relative risk ratios of labor market participation were estimated at 1 year, 3 years, and 5 years of follow-up.

RESULTS

Women who had undergone bariatric surgery had a higher risk of unemployment 1 year (RRR = 1.20 (95% CI: 1.02-1.41)) and 5 years (RRR = 1.23 (95% CI: 1.05-1.44)) after surgery; however, men with bariatric surgery had a lower risk of unemployment after 5 years (RRR = 0.71 (95% CI: 0.55-0.92)). The risk of sickness absence was higher at all follow-up time points for both men and women who had undergone bariatric surgery compared with non-operated references with obesity.

CONCLUSIONS

Men undergoing bariatric surgery had a lower risk of unemployment 5 years after surgery compared with non-operated men with obesity; however, women presented a higher risk of unemployment after 5 years. The risk of sickness absence was higher for both men and women up to 5 years after undergoing bariatric surgery.

Length of hospital stay after delivery among Danish women with congenital heart disease: a register-based cohort study

Background

The literature about the impact of congenital heart disease (CHD) on the length of hospital stay after delivery is limited, and nonexisting in a country with free and equal access to healthcare. We aimed to examine the hypothesis that Danish women with CHD have a longer hospital stay after delivery compared to women without CHD. Secondarily, we aimed to examine the hypothesis that cesarean section modifies the association.

Methods

The study was a national cohort study using Danish nationwide registers in 1997–2014. Maternal CHD was categorized as simple, moderate, or complex CHD. The comparison group consisted of women without CHD. Outcome of interest was length of hospital stay after delivery registered in complete days. Mode of delivery was categorized as cesarean section or vaginal delivery. Data was analyzed using a generalized linear model with a Poisson distribution.

Results

We included 939,678 births among 551,119 women. Women without CHD were on average admitted to the hospital for 3.6 (SD 3.7) days, whereas women with simple, moderate, and complex CHD were admitted for 3.9 (SD 4.4), 4.0 (SD 3.8) and 5.1 (SD 6.7) days, respectively. The adjusted length of hospital stay after delivery was 12% (relative ratio (RR) = 1.12, 95% confidence interval (CI) 1.07–1.18), 14% (RR = 1.14, 95% CI: 1.07–1.21), and 45% (RR = 1.45, 95% CI: 1.24–1.70) longer among women with simple, moderate, and complex CHD, respectively, compared to women without CHD. The association between maternal CHD and length of hospital stay was not modified by mode of delivery (p-value of interaction = 0.62). Women who gave birth by cesarean section were on average admitted to the hospital for 2.7 days longer compared to women with vaginal delivery.

Conclusion

The hospital stay after delivery was significantly longer among women with CHD as compared to women without CHD. Further, higher complexity of CHD was associated with longer length of stay. Cesarean section did not modify the association.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04286-3.

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

BACKGROUND

Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories.

METHODS

We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age.

FINDINGS

The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran.

INTERPRETATION

Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings.

FUNDING

WHO.

Mental health groups in high school students and later school dropout: a latent class and register-based follow-up analysis of the Danish National Youth Study

Background

Mental health represents an important public health issue, and mental health problems have been linked to school dropout. This study aimed to identify mental health groups of high school students using both positive and negative aspects of mental health and to examine whether these mental health groups longitudinally predict school dropout.

Methods

We conducted latent class analysis using the Danish National Youth Study 2014 (n = 60,526; mean 17.9 years) to identify clustering of mental health (11 items covering positive and negative aspects of emotional wellbeing and functioning in daily life), separately by sex. The relationship with subsequent school dropout was examined using logistic regression models, adjusted for age, ethnicity and socioeconomic status. Information on dropout status was obtained through educational registers.

Results

School dropout rates was highest among first-year students. Four mental health groups were identified: Flourishing (females: 38%, males: 55%), moderate mental health (females: 15%, males: 20%), emotionally challenged (females: 28%, males: 15%) and languishing (females: 19%, males: 10%). Compared to the flourishing group, adjusted odds ratio (AOR) for dropout were 3.43 (95% CI: 2.98, 3.95), 1.73 (95% CI: 1.45, 2.06) and 1.76 (95% CI: 1.52, 2.04) in the languishing, moderate mentally healthy and emotional challenged females. Results in males were comparable.

Conclusions

Mental health in high school students cluster together in four categories among both males and females. Students who are languishing, emotionally challenged or moderate mentally healthy have about 1.5-fold to threefold higher risk of dropping out of high school compared with flourishing students. Universal mental health interventions may be a promising strategy, particularly in the first year of high school where most students drop out of school.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00621-7.

Cardiac rehabilitation for patients with heart failure: a national Danish register-based study of predictors of referral and outcomes

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

Background

 Heart failure (HF) places a large burden on patients and society as a major cause of morbidity, mortality and healthcare costs. Participation in exercise-based cardiac rehabilitation (CR) in people with HF is a clinically and cost-effective strategy and recommended in international clinical guidelines.

Purpose

The aims of this study were to: (1) examine the temporal trends and predictors of national CR referral, and (2) compare the risk of hospital readmission and mortality in those referred for CR compared to no referral.

Methods

All patients in Denmark with incident HF were identified by the Danish Heart Failure Register in the period 2010 to 2018 (n = 33,257) and CR referral assessed within 120 days of hospital admission. Multivariable logistic regression models were used to evaluate the association between CR referral and predictors and to compare risk of hospital readmission and mortality until 1 year between referred and not referred patients.

Results

Overall, 45.0% of HF patients were referred to exercise-based CR, increasing from 31.7% in 2010 to 52.2% in 2018. Factors independently associated with higher CR referral were: NYHA functional class II, LVEF &lt;50%, diagnosis of myocardial infarction and use of ACE inhibitor. Male gender, older age, region, unemployment, retirement, living alone, non-Danish ethnic origin, lower educational level, NYHA class IV, treatment for hypertension, existing chronic obstructive lung disease and stroke were associated with lower CR referral. CR referral was associated with lower risk of readmission (adjusted odds ratio: 0.90;95%CI: 0.85-0.95), HF-specific mortality (0.61; 0.39-0.95) and all-cause mortality (0.61; 0.55-0.69) as compared to no referral.

Conclusions

Although CR referral has increased over time, only some 1 in 2 diagnosed HF patients in Denmark are referred to exercise-based CR. CR referral is associated with lower risk in readmissions and mortality. Strategies to promote CR referral including healthcare professional education on the benefits of CR and alternative methods of CR delivery are urgently needed to improve access to CR, especially for high-risk groups.

Does Class Proportion of Students with Non-Western Origin in High Schools Affect Drinking Habits Among Ethnic Danish Students?

AIM

the objective was to test the hypothesis that a higher proportion of students with non-Western origin in high school classes is associated with lower and less frequent alcohol consumption among ethnic Danish students.

METHOD

data on country of origin was obtained from the Danish Civil Registration System, while information on drinking habits were derived from the Danish National Youth Study 2014. Multilevel zero-inflated binominal regression was used to assess the association between class proportion of students with non-Western origin and odds of non-drinking and mean weekly alcohol consumption, while multilevel logistic regression was used to assess the association with frequent binge drinking.

RESULTS

a higher proportion of students with non-Western origin in class was associated with higher odds of non-drinking among ethnic Danish student in the same class. For example, ethnic Danish boys in classes with more than 15% of the students of non-Western origin had 77% higher odds of being non-drinkers, compared to ethnic Danish boys in classes where 0-5% had non-Western origin (OR: 1.77, 95% CI; 1.42-2.20). Among ethnic Danish students that did consume alcohol, class proportion of students with non-Western origin was not associated with weekly alcohol consumption, while a higher proportion of students with non-Western origin in class was associated with lower odds of frequent binge drinking.

CONCLUSION

the downward drinking trend among adolescents in Western countries may be partly explained by the higher proportion of youth with non-Western origin, influencing the prevalence of drinking and frequency of binge drinking among adolescents in the ethnic majority population.

Bariatric surgery and risk of alcohol use disorder: a register-based cohort study

BACKGROUND

Bariatric surgery has been associated with altered alcohol metabolism. We examined whether patients undergoing bariatric surgery have a higher risk of developing alcohol use disorder (AUD) compared with individuals with obesity who have not received bariatric surgery.

METHODS

In this prospective cohort study, we followed 13 430 patients undergoing bariatric surgery (95% gastric bypass) between 2005 and 2013 and a reference group of 21 021 individuals with obesity for a median of 6.9 years (5th-95th percentile: 4.0-9.8). Four different approaches were used to account for baseline differences between the two groups: (i) adjustment; (ii) inverse probability of treatment weighting (IPTW); (iii) 1:1 matching based on propensity scores; and (iv) before-and-after analysis comparing the bariatric surgery group with itself 5 years before and after surgery. Cox proportional hazard modelling was used to estimate hazard ratios of AUD defined from national registers.

RESULTS

When applying the IPTW approach, the hazard ratio (HR) of AUD for bariatric surgery patients was 7.29 [95% confidence interval (CI): 5.06-9.48] compared with individuals without surgery. When employing different approaches (adjustment for baseline variables, matching on propensity scores, before-and-after analyses), results were of similar magnitude. Analysis stratified by time after surgery revealed a higher risk of AUD already within the first year following surgery [HR: 2.77 (95% CI: 1.39-5.53)].

CONCLUSIONS

Patients undergoing bariatric surgery have a higher risk of developing AUD compared with individuals without bariatric surgery. The higher risk observed in this group of patients cannot be explained by differences in baseline characteristics such as socioeconomic factors. Despite the higher risk of AUD, only few individuals developed AUD. Individuals with disabling obesity should therefore not rule out surgery based on these results but rather be aware of negative implications.

Changes in relationship status following bariatric surgery

BACKGROUND AND OBJECTIVE

Bariatric surgery is a major event associated with psychological changes such as improvements in self-esteem, increased autonomy, and better self-value. Such changes could affect the patient's interpersonal relationships; however, little is known about the impact of bariatric surgery on changes in relationship status. In this paper, we aim to test the hypothesis that bariatric surgery is associated with changes in interpersonal relationships such as becoming single for those who were in a relationship or entering a relationship among those who were single before surgery.

METHODS

This register-based cohort study consisted of 12,493 patients undergoing bariatric surgery (95% gastric bypass) from 2005 to 2013 and a reference group of 15,101 individuals with obesity between the age of 18-63 with a body mass index between 32 and 60 kg/m². Transitions between married, divorced, widowed, never-married single, and living with a partner without being married were analyzed by Poisson regression. Additionally, the outcome was dichotomized, and transitions between being single and being in a relationship were also analyzed. All analyses were weighted using inverse probability of treatment weighting based on propensity scores.

RESULTS

The overall incidence rate ratio (IRR) of changing status from being single to in a relationship was 2.03 (95% CI: 1.18-2.28), and the overall IRR of changing status from being in a relationship to single was 1.66 (95% CI: 1.50-1.83).

CONCLUSION

Bariatric surgery is associated with a higher chance of finding a partner among single individuals, and a higher risk of separating from a partner among individuals in a relationship.

Possible associations between callers' degree-of-worry and their socioeconomic status when contacting out-of-hours services: a prospective cohort study

Background

Telephone triage within out-of-hours (OOH) services aims to ascertain the urgency of a caller’s medical condition in order to determine the correct type of health care needed, ensuring patient safety. To improve the triage process by increasing patient-centred communication, a triage tool has been developed, whereby callers are asked to rate their degree-of-worry (DOW) as a measure of self-evaluated urgency. Studies show that low socioeconomic status (SES), being single and non-Western ethnicity are associated to low self-rated health and high morbidity and these factors may also be associated with high DOW. The aim of this paper was to examine if low SES, being single and non-Western ethnicity were associated to high DOW of callers contacting OOH services.

Methods

A prospective cohort study design, at the OOH services for the Capital Region of Denmark. Over 2 weeks, 6869 of 38,787 callers met the inclusion criteria: ≥18 years, patients themselves or close relative/friend, reported DOW, had a valid personal identification number and gave informed consent. Callers were asked to report their DOW (1 = minimal worry to 5 = maximal worry), which was dichotomized into low (1–3) and high (4, 5) DOW and linked to data from electronical medical records and Statistics Denmark. Socioeconomic factors (education and annual household income), marital status and ethnicity were assessed in relation to DOW by logistic regression.

Results

High DOW was reported by 38.2% of the participants. Low SES (low educational level; OR 1.5, 95% CI 1.3–1.7 and low annual household income; 1.5, 1.3–1.6) was associated with high DOW and so too was being single; 1.2, 1.1–1.3 and of non-Western ethnicity; 2.9, 2.5–3.4.

Conclusions

Knowledge of the association of low SES, marital status as single and non-Western ethnicity with high DOW among callers to OOH services may give call handlers a better understanding of callers’ DOW. If this does not correspond to the call handler’s perception of urgency, this knowledge may further encourage patient-centred communication, aid the triage process and increase patient safety. A better understanding of socioeconomic variables and their relation to callers’ DOW gives direction for future research to improve telephone triage of OOH services.

Plasma Concentrations of Magnesium and Risk of Dementia: A General Population Study of 102 648 Individuals

BACKGROUND

Low and high concentrations of plasma magnesium are associated with increased risk of future all-cause dementia; however, the underlying reasons remain elusive. The magnesium ion is an important electrolyte serving as a cofactor in many enzymatic processes in the human organism. Magnesium affects both neuronal and vascular functions. We investigated the associations of plasma concentrations of magnesium associate with common subtypes of dementia as Alzheimer dementia and non-Alzheimer dementia, and potential pathways by which magnesium may affect risk of dementia.

METHODS

Plasma concentrations of magnesium were measured in 102 648 individuals from the Copenhagen General Population Study. Cox regression and natural effects mediation analyses evaluated associations with either Alzheimer dementia or non-Alzheimer dementia.

RESULTS

Multifactorially adjusted hazard ratios for non-Alzheimer dementia were 1.50(95% confidence interval (CI):1.21-1.87) for the lowest and 1.34(1.07-1.69) for the highest vs the fourth quintile (reference) of plasma magnesium concentrations. Diabetes, cumulated smoking, stroke, and systolic blood pressure mediated 10.4%(3.1-22.8%), 6.8%(1.2-14.0%), 1.3%(0.1-3.6%), and 1.0%(0.2-2.6%), respectively, in the lowest quintile, whereas stroke mediated 3.2%(0.4-11.9%) in the highest quintile. No associations were observed for Alzheimer dementia.

CONCLUSIONS

Low and high plasma magnesium concentrations were associated with high risk of vascular-related non-Alzheimer dementia, with the lowest risk observed at a concentration of 2.07 mg/dL (0.85 mmol/L). No association was observed for Alzheimer dementia. Mediation analysis suggested that diabetes may be in the causal pathway between low plasma magnesium concentrations and high risk of non-Alzheimer dementia, while cumulated smoking, stroke, and systolic blood pressure played minor mediating roles.

Identifying and Characterizing Children of Parents with a Serious Illness Using Survey and Register Data

Purpose

To estimate the prevalence and characterize children and adolescents aged 0–21 years with a physically or mentally ill parent based on registers. Further, to explore the use of register and survey data to identify parental serious illness.

Methods

The study is based on: 1) a 20% register sample of children and adolescents aged 0–21 in 2014; and 2) survey data from the Danish Youth Profile 2014 including 63,437 youth education students linked to registers. In registers, parental physical illness comprised hospital diagnoses included in the Charlson Comorbidity Index, and parental mental illness encompassed all mental diagnosis in the registers. Information about socioeconomic and demographic characteristics and use of health care services was retrieved from national registers. In the survey, students were asked if they had experienced serious illness of a parent.

Results

In the register sample of 0–21-year-olds, 25.3% had a parent with a physical or mental diagnosis, the prevalence increasing with age of the child. Compared to children without parental illness, children with an ill parent more frequently had unemployed parents, lower parental educational level, and a chronic medical condition. Analyses of the discrepancies between register and survey data revealed that 9% of the adolescents were identified as having an ill parent in both data sources and 64.1% had no identified ill parents. Moreover, a higher frequency of parental primary health care service use was seen for adolescents with an ill parent, across identification method, indicating that both methods identify adolescents with an ill parent.

Conclusion

The social inequality and elevated frequency of health problems among children and adolescents with an ill parent, underline the vulnerability of this population. Parental illness can be identified from both parental hospital diagnoses as well as self-reported by adolescents, however the two methods detect different populations. Both methods have several limitations and would benefit from further refinement and validation.

Heterogeneous contributions of change in population distribution of body mass index to change in obesity and underweight

From 1985 to 2016, the prevalence of underweight decreased, and that of obesity and severe obesity increased, in most regions, with significant variation in the magnitude of these changes across regions. We investigated how much change in mean body mass index (BMI) explains changes in the prevalence of underweight, obesity, and severe obesity in different regions using data from 2896 population-based studies with 187 million participants. Changes in the prevalence of underweight and total obesity, and to a lesser extent severe obesity, are largely driven by shifts in the distribution of BMI, with smaller contributions from changes in the shape of the distribution. In East and Southeast Asia and sub-Saharan Africa, the underweight tail of the BMI distribution was left behind as the distribution shifted. There is a need for policies that address all forms of malnutrition by making healthy foods accessible and affordable, while restricting unhealthy foods through fiscal and regulatory restrictions.

Self-rated physical fitness and measured cardiorespiratory fitness, muscular strength, and body composition

The purpose was to examine the correlation and association between a single-item question of self-rated physical fitness and objective measures of fitness and cardiometabolic risk factors in a large population-based study. Participants were 3441 men and women aged 18-85 years who filled in a questionnaire and participated in a clinical health examination in the Danish Health Examination Survey 2007-2008. Cardiorespiratory fitness was estimated by an indirect maximal exercise test. Muscle strength was measured by (a) sit-to-stand test, (b) handgrip strength, and (c) bent arm strength. Body mass index and fat percentage were used as measures for body composition. Associations were derived from regression analyses, correlations were calculated using Spearman's correlation test, and agreement was tested by kappa statistics. Within categories of self-rated physical fitness moving from lowest to highest, objectively measured cardiorespiratory fitness increased. Self-rated physical fitness was strongly correlated to cardiorespiratory fitness (r_men  = 0.69 and r_women  = 0.65) and moderately correlated to the sit-to-stand test (r_men  = 0.49 and r_women  = 0.48), bent arm strength (r = 0.45) and fat percentage (r = 0.46) among men, and handgrip strength among women (r =0.41). Mutually adjusted analysis showed a significant association between self-reported physical fitness and cardiorespiratory fitness for men and women and bent arm strength for women. The single-item question of physical fitness was correlated to cardiorespiratory fitness, muscle strength, and body composition. However, this study suggests that it mainly captures cardiorespiratory fitness. At the population level, the single-item question could be a useful tool to identify and monitor variation in fitness levels.

Time trends in incidence and prevalence of chronic pancreatitis: A 25-year population-based nationwide study

BACKGROUND

Updated population-based estimates on incidence and prevalence of chronic pancreatitis are scarce.

METHODS

We used nationwide healthcare registries to identify all Danish patients diagnosed with chronic pancreatitis and computed crude and standardised incidence rates and prevalence estimates in 1994-2018. Incidence and prevalence were evaluated in relation to patients age and gender, aetiology (alcoholic vs. non-alcoholic) and smoking and alcohol consumption in the general Danish population.

RESULTS

The mean incidence rate of chronic pancreatitis during the study period was 12.6 per 100,000 person years for the total population, for women it was 8.6 per 100,000 person years and for men it was 16.7 per 100,000 person years. The standardised incidence rate was stable from 1994 to 2018, remaining at 12.5 per 100,000 person years in the last observation period (2014-2018). The point prevalence of chronic pancreatitis in 2016 was 153.9 per 100,000 persons. A gradual increase in standardised prevalence estimates was observed during the study period from 126.6 in 1996 to 153.9 in 2016. The mean age at chronic pancreatitis diagnosis increased from 52.1 to 60.0 years during the study period.

CONCLUSION

The prevalence of chronic pancreatitis is increasing in the Danish population despite a stable incidence level. Improved management strategies and changes in the underlying patient population may explain these observations.

Socioeconomic inequality in telephone triage on triage response, hospitalization and 30-day mortality

We investigated socioeconomic inequality (measured by the indicators highest attained education level and household income) in telephone triage on triage response (face-to-face contact), hospitalization and 30-day mortality among Danish citizens calling the medical helpline 1813 between 23 January and 9 February 2017. The analysis included 6869 adult callers from a larger prospective cohort study and showed that callers with low socioeconomic status (SES) were less often triaged to a face-to-face contact and had higher 30-day mortality than callers with high SES.

Height and body-mass index trajectories of school-aged children and adolescents from 1985 to 2019 in 200 countries and territories: a pooled analysis of 2181 population-based studies with 65 million participants

BACKGROUND

Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures weight gain beyond what is expected from height gain, for school-aged children and adolescents.

METHODS

For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in mean height and mean BMI in 1-year age groups for ages 5-19 years. The model allowed for non-linear changes over time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including periods of rapid growth during adolescence.

FINDINGS

We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia, and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and Chad for boys and girls; and in Japan and Romania for girls) was approximately 9-10 kg/m2. In some countries, children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as the best performing countries, but they became progressively less healthy compared with their comparators as they grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators (eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam, Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a much larger gain in height than they did in BMI. The unhealthiest changes-gaining too little height, too much weight for their height compared with children in other countries, or both-occurred in many countries in sub-Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys; and in Mexico for girls.

INTERPRETATION

The height and BMI trajectories over age and time of school-aged children and adolescents are highly variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and risks.

FUNDING

Wellcome Trust, AstraZeneca Young Health Programme, EU.

Advanced maternal age and risk of adverse perinatal outcome among women with congenital heart disease: A nationwide register-based cohort study

BACKGROUND

Women with maternal congenital heart disease have a higher risk of preterm birth (PTB) and giving birth to a small for gestational age (SGA) infant. Advanced maternal age (≥35 years) likewise increases the risk of PTB and SGA, probably explained by poorer cardiovascular status. It is likely that advanced maternal age is particularly detrimental in women with congenital heart disease.

OBJECTIVES

We aimed to determine whether the pattern of higher risk of PTB and SGA with higher maternal age varied among women with and without congenital heart disease. We hypothesised that the effect of age is higher among women with congenital heart disease.

METHODS

We did a cohort study using Danish nationwide registers. Births from 1997 to 2014 were included. Cox regressions were used to estimate hazard ratios (HRs) for PTB and SGA. Universal and congenital heart disease-specific references were used for comparison.

RESULTS

We included 932 772 births among 548 314 women. HRs of PTB and SGA were 1.55 (95% confidence interval [CI] 1.37, 1.77) and 1.43 (95% CI 1.29, 1.58) in women with congenital heart disease as compared to women without. For both PTB and SGA, HRs were higher for women ≥35 years as compared to women aged 25-29 years. HRs of PTB and SGA were higher among women with congenital heart disease within all strata of maternal age as compared to women without (eg 3.71, 95% CI 1.80, 7.63 vs 1.63, 95% CI 1.56, 1.70) for SGA for women aged 40-44 years). The pattern of higher risk of PTB and SGA with higher maternal age was, however, similar among women with and without congenital heart disease.

CONCLUSIONS

Women with congenital heart disease had a higher risk of PTB and giving birth to an SGA infant at all maternal ages. These two risk factors did not, however, seem to potentiate each other.

Alcohol in Greenland 1950-2018: consumption, drinking patterns, and consequences

Alcohol is the single most important public health challenge in Greenland. We provide an overview of alcohol consumption, drinking patterns, and consequences of excessive use of alcohol in Greenland since 1950 through a synthesis of published results and analyses of population-based interview surveys. The import of alcohol fluctuated over the last 70 years with a peak in the 1980s at 22 litres 100% alcohol per person per year. In 1950 and 2015, the import of alcohol was similar at 8 litres. Several explanations have been put forward to explain the changes including restrictions, increased tax, demographic changes, treatment of alcohol disorders, and public health interventions. The proportion of abstainers increased from 1993 to 2018 while the proportion of participants with regular consumption decreased. About half of the population reported binge drinking at least monthly. Compared with Denmark, there were more abstainers and binge drinkers in Greenland, and fewer had a regular consumption. Although genetics may play a role for drinking patterns, social and cultural conditions are more important. Exposure to domestic alcohol problems and sexual abuse in childhood parallel the recorded import of alcohol and is a likely cause of transgenerational consequences such as youth suicides and alcohol problems.

Alcohol and risk of non-traumatic bleeding events requiring hospital care in the general population: A prospective cohort study

Alcohol has a direct effect on blood coagulation and fibrinolysis. We studied how alcohol is related to common bleeding events (e.g., nose bleeding), as well as life-threatening bleeding events (e.g., hemorrhagic stroke) that required hospital care in the general population. We used data from The Copenhagen City Heart Study, 1991 to 1994 and 2001 to 2003. Baseline information on alcohol consumption and potential confounders was obtained by questionnaires, and participants were followed for incident bleeding events with nationwide registers until 2013. Among the 10,259 included participants, we observed 366 nose or other respiratory organ bleeding events, 149 hemorrhagic stroke events, 470 gastrointestinal bleeding events, 266 unspecified bleeding events, and 1088 any-bleeding events (composite endpoint) during follow-up. Compared to drinkers of 1-6 drinks per week, those drinking ≥35 drinks per week had a higher risk of hemorrhagic stroke [hazard ratio, 2.27 (1.14-4.55)] and non-variceal gastrointestinal bleeding [hazard ratio 2.04 (1.37-3.05)], whereas non-drinkers and drinkers of 7-13, 14-20, 21-27, and 28-34 drinks per week had not. Alcohol consumption was not associated with risk of nose or other respiratory organ bleeding or unspecified bleeding. For non-drinkers and drinkers of 7-13, 14-20, 21-27, 28-34, and 35 or more drinks per week, hazard ratios for the composite endpoint of any bleeding were 1.17 (95% CI: 0.99-1.37), 0.97 (95% CI: 0.81-1.15), 1.00 (95% CI: 0.80-1.26), 0.93 (95% CI: 0.69-1.25), 1.39 (95% CI: 1.00-1.94), and 1.83 (95% CI: 1.39-2.41) compared to drinkers of 1-6 drinks per week. In conclusion, drinking 35 or more drinks per week may be associated with a higher risk of hemorrhagic stroke and non-variceal gastrointestinal bleeding in the general population.

Patterns of multimorbidity and demographic profile of latent classes in a Danish population-A register-based study

Background

Multimorbidity is an increasing public health concern and is associated with a range of further adverse outcomes. Identification of disease patterns as well as characteristics of populations affected by multimorbidity is important for prevention strategies to identify those at risk.

Aim

The aim of the study was to identify and describe demographic characteristics of multimorbidity classes in three age groups (16–44 years, 45–64 years, and 65+ years).

Methods

Based on register information on 47 chronic diseases and conditions, we used latent class analysis to identify multimorbidity classes in a random sample of the Danish population (n = 470,794). Information on sociodemographic characteristics (age, sex, region of origin, educational level, employment status, and marital status) was obtained from registers and linked to the study population. Age- and sex-adjusted multinomial logistic regression models were used to examine associations between multimorbidity classes and sociodemographic characteristics.

Results

We identified seven classes among individuals in the age groups 45–64 years and 65+ years and five classes in the age group 16–44 years. Overall, the classes were similar in the three age groups, but varied in size, i.e. the class ‘No or few diseases’ was larger in the younger age group. The class ‘Many diseases’ (a class with both somatic diseases and mental illnesses) was only seen in individuals aged 45–64 years and 65+ years. There were social inequalities in odds of belonging to the multimorbidity classes compared to the healthier class. These social inequalities varied but were especially strong in the classes named ‘Many diseases’ and ‘Mental illness, epilepsy’.

Conclusion

The results of the study suggest that there are social inequalities in multimorbidity but that these inequalities are not universal to all types of multimorbidity. This supports that multimorbidity is diverse and should be prevented and treated accordingly.

"Oh-oh, the others are standing up... I better do the same". Mixed-method evaluation of the implementation process of 'Take a Stand!' - a cluster randomized controlled trial of a multicomponent intervention to reduce sitting time among office workers

Background

Multicomponent workplace-based interventions aimed at reducing sitting time among office workers are becoming increasingly popular. ‘Take a Stand!’ was such an intervention, reducing sitting time by 71 min after 1 month and 48 min after 3 months. However, it is unclear how the implementation process of ‘Take a Stand!’ affected these results. The present study explored how individual factors and organizational context influenced implementation and effect in ‘Take a Stand!’

Methods

This was a mixed-methods study, combining data from interviews, questionnaires and accelerometers. Directed content analysis was used for analysing interviews with participants, ambassadors and managers from the 10 intervention offices in the ‘Take a Stand!’ study. Categories for analysis were taken from Framework for Evaluating Organizational-level Interventions. Interview data were combined with questionnaire and activity data, and multilevel analysis was undertaken to assess how changes in sitting time varied depending on the assessed factors. In addition, interview data were used to underpin results from the multilevel analysis.

Results

Concurrent institutional changes were found to be a barrier for the intervention by ambassadors, while participants and managers did not find it to be an issue. Management support was consistently highlighted as very important. Participants evaluated ambassadors as being generally adequately active but also, that the role had a greater potential.

The motivational and social aspects of the intervention were considered important for the effect. This was supported by regression analyses, which showed that a strong desire to change sitting time habits, strong motivation towards the project, and a high sense of collective engagement were associated to less sitting time at 3 months of about 30 min/8 h working day compared to participants with low scores. Influence from other participants (e.g. seeing others raise their tables) and the use of humour were continuously highlighted by participants as positive for implementation. Finally, the intervention was found to influence the social climate at the workplace positively.

Conclusion

Individual motivation was related to the sitting time effect of ‘Take a Stand!’, but the organizational culture was relevant both to the implementation and effect within the office community. The organizational culture included among others to ensure general participation, to uphold management and peer-support, and maintain a positive environment during the intervention period.

Trial registration

ClinicalTrials.gov, NCT01996176. Prospectively registered 21 November 2013.

Family structure and alcohol use disorder: a register-based cohort study among offspring with and without parental alcohol use disorder

AIMS

To assess whether parental alcohol use disorder (AUD) is associated with higher risks of living in a non-intact family and assess whether non-intact family structure is associated with higher risks of AUD in the offspring.

DESIGN

Prospective cohort study.

SETTING

Danish nation-wide registries.

PARTICIPANTS

A total of 9948 parental AUD offspring and 98 136 reference offspring from the Danish population.

MEASUREMENTS

Family structure assessed at birth and at each birthday until age 15 as intact or non-intact (with mother only, father only or neither parent); years lived in an intact family defined as total number of years lived with both parents from birth until the 15th birthday; AUD defined as registration in medical, treatment and cause of death registries. Data were analyzed by Cox regression.

FINDINGS

At birth, 30.9% [95% confidence interval (CI) = 29.1-32.6] of parental AUD offspring and 10.7% (95% CI = 10.3-11.0) of reference offspring lived in a non-intact family. At age 15, the numbers were 84.6% (95% CI = 83.9-85.3) and 38.4% (95% CI = 38.1-38.7). Parental AUD was associated with a higher risk of offspring AUD [hazard ratio (HR) = 1.88, 95% CI = 1.74-2.02]. Offspring were at lower risk of AUD if they lived 15 years in an intact family compared with offspring who never lived in an intact family (HR = 0.67, 95% CI = 0.52-0.87 for those with parental AUD, and HR = 0.53, 95% CI = 0.48-0.59 for those whose parents did not have AUD). Findings were inconclusive as to whether or not an association was present between family structure and AUD among offspring with parental AUD and reference offspring.

CONCLUSIONS

The prevalence of non-intact family structure appears to be higher in offspring of parents with alcohol use disorder (AUD) than among offspring from the general population. Parental AUD appears to be associated with increased risk of offspring AUD, and non-intact family structure appears to be associated with increased risk of offspring AUD regardless of parental AUD.

Association between alcohol, socioeconomic position and labour market participation: A prospective cohort study of transitions between work and unemployment

Aims: This study aimed to test the hypothesis that heavy alcohol consumption and problem drinking is associated with a higher risk of becoming unemployed and a lower chance of entering the job market across socioeconomic positions. Methods: A sample of 84,474 men and women aged 18-60 years from the Danish National Health Survey 2010 participated in the study. Information on alcohol consumption and problem drinking was obtained by questionnaire. The primary outcomes were becoming unemployed and entering the job market. The follow-up period was five years. Information on labour market transitions and socioeconomic position (educational level) was obtained through nationwide registers. Multiplicative analyses were performed. Results: Heavy alcohol consumption and problem drinking were associated with a higher risk of unemployment among low-educated (hazard ratio (HR)=1.5; 95% confidence interval (CI) 1.3-1.9) and medium-educated (HR=1.3; 95% CI 1.1-1.5) individuals in comparison to individuals with a similar educational level drinking one to seven drinks per week. Excessive alcohol consumption and problem drinking were associated with a lower chance of entering the job market for individuals with a medium or high level of education: medium-educated individuals drinking >28 drinks per week had a HR of 0.82 (95% CI 0.69-0.98) when compared to medium-educated individuals drinking one to seven drinks per week. The corresponding HR among high-educated individuals was 0.71 (95% CI 0.49-1.0). Conclusions: Heavy alcohol consumption and problem drinking are associated with a higher risk of unemployment in some social strata, whereas excessive alcohol consumption and problem drinking are associated with a lower chance of entering the job market in other social strata.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Standing Meetings Are Feasible and Effective in Reducing Sitting Time among Office Workers-Walking Meetings Are Not: Mixed-Methods Results on the Feasibility and Effectiveness of Active Meetings Based on Data from the "Take a Stand!" Study

Active meetings (standing or walking) have the potential to reduce sitting time among office workers. The aim of the present study was to explore the feasibility and effectiveness of standing and walking meetings. The “Take a Stand!” study was a cluster-randomized trial, consisting of multiple components including the possibility of active meetings. Analyses were based on the 173 participants in the intervention group. Feasibility was evaluated by questionnaire and interview data from participants, ambassadors and leaders. Effectiveness was assessed as the change in objectively measured sitting time from baseline to 3 months follow-up. Regular standing meetings were implemented at all offices and were generally popular, as they were perceived as more effective and focused. In contrast, only a few walking meetings were completed, and these were generally associated with several barriers and perceived as ineffective. Participants who participated in standing meetings on a regular basis had 59 min less sitting per 8 h workday (95%CI −101;−17) compared to participants who did not participate in standing meetings at all. Walking meeting participation was not significantly associated with changes in sitting time, likely due to the low number of employees who used this option. This explorative study concludes that standing meetings in office workplaces were feasible and well-liked by the employees, and having frequent standing meetings was associated with reduced sitting time. In contrast, walking meetings were unfeasible and less liked, and thus had no effect on sitting time.

School factors and student drinking in high schools: a cross-sectional study of school policies and party regulation

BACKGROUND

The effectiveness of school alcohol polices may be affected by the degree of strictness of rules, how they are implemented and enforced, students' perception of the rules and the consequences of breaking them. The aim of the study was to test the hypothesis that more liberal school alcohol policies, lack of knowledge of the alcohol policy, lower prices of alcohol at school parties, and liberal party regulation were associated with more drinking among high school students.

METHODS

Participants were high school students (n = 68,898), participating in the Danish National Youth Study in 2014. Data came from questionnaires answered by high school students and school headmasters. Zero-inflated negative binominal regression with clustering of schools (n = 117) was used to assess the associations between alcohol policy reported by school headmaster and weekly alcohol intake reported by students. Multilevel negative binominal regression was used to assess the associations between alcohol price and liberal party regulations and units consumed at the last school party and units consumed at the school during the last school party.

RESULTS

In general, school alcohol policies were not associated with high school students' weekly alcohol intake. High school students who did not know the school alcohol policy had a higher weekly alcohol intake (0.16 drinks 95% CL [0.11;0.21] p = 0.000), compared to students who knew the policy. Lower beer prices were positively associated with the number of drinks consumed at the school (p = 0.004), but not with the total amount consumed at the last school party (p = 0.728). High school students who agreed that students who were drunk could buy alcohol had a higher alcohol intake at the last school party (OR = 0.20 drinks 95% CL [0.18;0.21], p < 0.001) and drank more at the school (0.17 drinks 95% CL [0.15;0.18], p < 0.001) compared to those who did not agree that students who were drunk could buy alcohol.

CONCLUSION

School alcohol policies were generally not associated with drinking among high school students, whereas students' lack of knowledge of the school policy was associated with a higher weekly alcohol intake. An addition, lower prices and liberal party regulation was associated with higher alcohol intake at school parties.

Hospital admissions and mortality in the 15 years after a first-time hospital contact with an alcohol problem: a prospective cohort study using the entire Danish population

BACKGROUND

Potential benefits of preventing continued alcohol intake in individuals presenting at the hospital with an alcohol problem can be highlighted by studying their excess risk of subsequent morbidity and mortality.

METHODS

All Danish residents with a first-time hospital contact with alcohol problems (intoxication, harmful use or dependence) in 1998-2002 were followed through 2012 using healthcare registries. We compared their cause-specific rates of hospital admission and mortality to the expected rates derived from the general population by calculating standardized incidence rate ratios.

RESULTS

The 26 716 men and 12 169 women who were hospitalized with alcohol problems (median age 44 years) had more than 10 times the rate of subsequent admission to psychiatric departments and three times the rate of subsequent admission to somatic departments compared with the general population. In particular, the hospital admission rates for gastroenterological disease and injuries were high. The cumulative all-cause 10-year mortality risk was 29% [95% confidence interval (CI), 28-30] in men and 26% (95% CI, 24-27) in women with alcohol problems. The ratios of observed to expected death rate for all-cause mortality were 4.0 (95% CI, 3.8-4.1) in men and 4.3 (95% CI, 4.0-4.7) in women and, for causes of death fully attributable to alcohol, 16 (95% CI, 15-17) in men and 33 (95% CI, 29-38) in women.

CONCLUSIONS

Individuals hospitalized with alcohol problems have much higher rates of subsequent alcohol-related hospital admission and mortality than the general population. Increased focus on preventing continued alcohol consumption in these individuals may reduce their subsequent morbidity and mortality.

Smoking, blood cells and myeloproliferative neoplasms: meta-analysis and Mendelian randomization of 2·3 million people

Meta-analyses and Mendelian randomization (MR) may clarify the associations of smoking, blood cells and myeloproliferative neoplasms (MPN). We investigated the association of smoking with blood cells in the Danish General Suburban Population Study (GESUS, n = 11 083), by meta-analyses (including GESUS) of 92 studies (n = 531 741) and MR of smoking variant CHRNA3 (rs1051730[A]) in UK Biobank, and with MPN in a meta-analysis of six studies (n (total/cases):1 425 529/2187), totalling 2 307 745 participants. In the meta-analysis the random-effects standardized mean difference (SMD) in current smokers versus non-smokers was 0·82 (0·75-0·89, P = 2·0 * 10^-108 ) for leukocytes, 0·09 (-0·02 to 0·21, P = 0·12) for erythrocytes, 0·53 (0·42-0·64, P = 8·0 * 10^-22 ) for haematocrit, 0·42 (0·34-0·51, P = 7·1 * 10^-21 ) for haemoglobin, 0·19 (0·08-0·31, P = 1·2 * 10^-3 ) for mean corpuscular haemoglobin (MCH), 0·29 (0·19-0·39, P = 1·6 * 10^-8 ) for mean corpuscular volume (MCV), and 0·04 (-0·04 to 0·13, P = 0·34) for platelets with trends for ever/ex-/current smokers, light/heavy smokers and female/male smokers. Analyses presented high heterogeneity but low publication bias. Per allele in CHRNA3, cigarettes per day in current smokers was associated with increased blood cell counts (leukocytes, neutrophils), MCH, red cell distribution width (RDW) and MCV. The pooled fixed-effects odds ratio for MPN was 1·44 [95% confidence interval (CI): 1·33-1·56; P = 1·8 * 10^-19 ; I²  = 0%] in current smokers, 1·29 (1·15-1·44; P = 8·0 * 10^-6 ; I²  = 0%) in ex-smokers, 1·49 (1·26-1·77; P = 4·4 * 10^-6 ; I²  = 0%) in light smokers and 2·04 (1·74-2·39, P = 2·3 * 10^-18 ; I²  = 51%) in heavy smokers compared with non-smokers. Smoking is observationally and genetically associated with increased leukocyte counts and red blood cell indices (MCH, MCV, RDW) and observationally with risk of MPN in current and ex-smokers versus non/never-smokers.

Neonatal Risk in Children of Women With Congenital Heart Disease: A Cohort Study With Focus on Socioeconomic Status

Background

We hypothesized that women with congenital heart disease (CHD) are at increased risk of giving birth preterm, including very and moderately preterm and giving birth to infants small for gestational age (SGA). We aimed to investigate this in a nation‐wide study with focus on the potential modifying effect of socioeconomic status.

Methods and Results

We performed a cohort study using Danish nation‐wide registers between 1997 and 2014. The exposure, maternal CHD, was subdivided into simple, moderate and complex based on severity of defects. Outcomes were preterm birth and SGA. Cox regression was used to estimate hazard ratios (HR). A total of 933 149 births including 3745 births among women with CHD were studied. The risk of giving birth preterm and SGA were higher among women with CHD as compared with women without CHD; for example, adjusted hazard ratios of preterm birth according to severity: simple 1.33 (95% CI, 1.11–1.59), moderate 1.45 (95% CI, 1.14–1.83) and complex 3.26 (95% CI, 2.41–4.40). Same pattern was seen for very and moderately preterm births and SGA. Education was a strong predictor of both preterm birth and SGA but did not modify the association between maternal congenital heart disease and preterm birth (P=0.38) or SGA (P=0.99).

Conclusions

Women with CHD were at increased risk of preterm birth both, moderately and very preterm, as well as giving birth to infants SGA. Education was a strong predictor of both preterm birth and SGA but the association between CHD and risk of preterm birth and SGA was independent of educational level.

BMI and Labor Market Participation: A Cohort Study of Transitions Between Work, Unemployment, and Sickness Absence

OBJECTIVE

This study aimed to test the hypotheses that individuals with obesity are at higher risk of unemployment and sickness absence and have a lower chance of getting employed compared with individuals with normal weight.

METHODS

Data on weight and height were collected at baseline from 87,796 participants in the Danish National Health Survey 2010. Participants were then followed in national registers for 5 years. Outcome measures were transitions from employment to unemployment and sickness absence and the transitions from unemployment or sickness absence to employment. Data were analyzed by Cox proportional hazards models adjusted for potential confounders.

RESULTS

Hazard ratios for unemployment were 1.18 (95% CI: 1.10-1.26) for individuals with obesity and 1.27 (95% CI: 1.14-1.41) for individuals with severe obesity compared with individuals with normal weight. Participants with obesity also had a higher risk of sickness absence. Additionally, participants with obesity who were unemployed at baseline had a lower chance of becoming employed compared with participants with normal weight.

CONCLUSIONS

Obesity was associated with a higher risk of unemployment and sickness absence compared with individuals with normal weight. Additionally, obesity was associated with a lower chance of employment.

Socioeconomic position and alcohol-related harm in Danish adolescents

BACKGROUND

In adults, it has consistently been observed that with equal alcohol consumption levels, alcohol harms individuals with low socioeconomic position (SEP) more than individuals with high SEP. It is unknown if this so-called alcohol harm paradox is also present in adolescents. We aim to test the hypothesis that low SEP is associated with more alcohol-related harm as compared with higher SEP in Danish adolescents.

METHODS

We used survey data from the Danish National Youth Study 2014 including 70 566 students from 119 high schools. Alcohol-related harm was measured by self-report as having been in a fight, involved in an accident, had problems with parents or friends, had sex that was regretted afterwards and done drugs that was regretted afterwards, because of alcohol. Further, a combined measure was constructed defined as having experienced any harm more than once within the last year. SEP was measured as parents' educational level, family income, parents' employment status and experiencing financial strain in the family. Analyses were adjusted by age, sex, perceived ethnicity, class type and binge drinking.

RESULTS

Lower SEP was associated with higher odds of experiencing alcohol-related harm more than once as compared with highest SEP, and lower SEP was associated with higher odds of having been in a fight, problems with parents or friends, sex and regretting afterwards or drugs and regretting afterwards, as compared with highest SEP. These associations were statistically significant. Adjustment for the frequency of binge drinking did not change results.

CONCLUSION

The alcohol harm paradox exists in Danish adolescents, and this should be addressed in future prevention strategies to reduce the risk of alcohol-related harm among adolescents.