Socioeconomic inequalities in adolescent mental health in the Nordic countries in the 2000s - A study using cross-sectional data from the Health Behaviour in School-aged Children study.

BACKGROUND: Adolescents in Sweden experience more mental health problems and lower mental well-being than adolescents in other Nordic countries. According to the literature, one possible explanation may be differences in income inequality. The at-risk-of-poverty rate varies significantly across the Nordic countries, and the highest rate is found in Sweden. The aims of the study were to examine socioeconomic inequalities in subjective health complaints and life satisfaction among adolescents in the Nordic countries during 2002 - 2018 and to explore whether subjective health complaints and life satisfaction were related to income inequality in terms of the at-risk-of-poverty rate at the country level. METHODS: Data regarding 15-year-olds from the Health Behaviour in School-aged Children study from five survey rounds (2002 - 2018) were used (n = 41,148). The HBSC Symptoms Checklist and Cantril's ladder were used as measures of subjective health complaints and life satisfaction, respectively. The Family Affluence Scale, the Perceived Family Wealth item and the at-risk-of-poverty rate in each country were used as measures of individual-level socioeconomic conditions and country-level income inequality. Statistical methods involved ANOVA, multiple linear regressions and multilevel regression analyses. RESULTS: Absolute and relative socioeconomic inequalities in both subjective health complaints and life satisfaction were found in all countries. Sweden showed average socioeconomic inequalities, Iceland the largest and Denmark the smallest. Country-level income inequality in terms of the at-risk-of-poverty rate was associated with a higher prevalence of subjective health complaints and lower levels of life satisfaction in all countries. CONCLUSION: Socioeconomic inequalities in adolescent mental health and well-being persisted in Nordic countries in the 2000s. Increasing income inequality may have contributed to higher levels of SHC and lower LS in Sweden compared to the other Nordic countries. Policies improving families' socioeconomic conditions and reducing income inequality at the country level are needed to improve and reduce inequalities in mental health and well-being among adolescents.

Childhood BMI trajectories predict cardiometabolic risk and perceived stress at age 13 years: the STARS cohort.

OBJECTIVE: The aim of this study was to examine BMI trajectories from birth throughout childhood, associations with health outcomes at age 13 years, and time frames during which early-life BMI influenced adolescent health. METHODS: Participants (1902, 44% male) reported perceived stress and psychosomatic symptoms and were examined for waist circumference (WC), systolic blood pressure (SBP), pulse wave velocity, and white blood cell counts (WBC). BMI trajectory was analyzed using group-based trajectory modeling of retrospective data of weight/height from birth throughout childhood. The authors performed linear regression to assess associations between BMI trajectories and health outcomes at age 13 years, presented as estimated mean differences with 95% CI among trajectories. RESULTS: Three BMI trajectories were identified: normal; moderate; and excessive gain. Adjusting for covariates, adolescents with excessive gain had higher WC (19.2 [95% CI: 18.4-20.0] cm), SBP (3.6 [95% CI: 2.4-4.4] mm Hg), WBC (0.7 [95% CI: 0.4-0.9] × 109 /L), and stress (1.1 [95% CI: 0.2-1.9]) than adolescents with normal gain. Higher WC (6.4 [95% CI: 5.8-6.9] cm), SBP (1.8 [95% CI: 1.0-2.5] mm Hg), and stress (0.7 [95% CI: 0.1-1.2]) were found in adolescents with moderate versus normal gain. The association of early-life BMI with SBP started around age 6 years with the excessive gain group, which was earlier than in the normal and moderate gain groups, in which it started at age 12 years. CONCLUSIONS: An excessive gain BMI trajectory from birth predicts cardiometabolic risk and stress in 13-year-old individuals.

Move for Your Heart, Break a Sweat for Your Mind: Providing Precision in Adolescent Health and Physical Activity Behaviour Pattern.

PURPOSE: Adolescent health benefits of different physical activity (PA) intensities, especially of lower intensities, are debated due to challenges in accelerometer data processing and analyses. Using a new accelerometer data processing method and multivariate pattern analysis, this study investigated the association of PA intensities with indicators of cardiovascular and mental health. METHODS: Adolescents (n = 1,235, mean age 13.6 years, 41% males) were examined for cardiovascular health: body mass index (BMI) z-score, waist circumference (WC), resting heart rate and blood pressure, white blood cell count (WBC), pulse wave velocity (PWV), and answered questionnaires assessing stress and psychosomatic symptoms. Sex, age, and socioeconomic status were confounders. Hip-worn accelerometer data were processed with 10 Hz frequency extended method and a spectrum of 22 PA intensity categories was analyzed for association with health using partial least squares regression. RESULTS: Total explained variances for BMI z-score, WC, resting heart rate, stress, and psychosomatic symptoms were higher (3.3%-8.7%) compared to diastolic blood pressure, WBC, and PWV (0.9%-1.4%). We found positive associations of high-end moderate PA and vigorous PA with cardiovascular and mental health indicators. More sedentary time and lower level of light PA were associated with higher BMI z-score, WC, resting heart rate, diastolic blood pressure, WBC, and PWV, but not with mental health indicators. Very vigorous PA was negatively associated with resting heart rate, stress, and psychosomatic symptoms. DISCUSSION: In adolescents, PA of varying intensities were generally found to be positively associated with better cardiovascular health, but only higher intensity PA was associated with better mental health.

Association between childhood BMI trajectories and cardiometabolic risk and mental health problems at the age of 13 years: the cohort STudy of Adolescence Resilience and Stress (STARS).

BACKGROUND: Research on BMI trajectories has been focused mainly on childhood and adolescence, missing birth and infancy, which are also relevant in the development of cardiometabolic disease in adulthood. We aimed to identify trajectories of BMI from birth throughout childhood, and to examine whether BMI trajectories predict health outcomes at the age of 13 years; and, if so, whether differences exist among trajectories regarding timeframes during which BMI in early life influences health outcomes. METHODS: Participants recruited from schools in the Västra Götaland region of Sweden completed questionnaires of perceived stress and psychosomatic symptoms and were examined for the following cardiometabolic risk factors: BMI, waist circumference, systolic blood pressure, pulse-wave velocity, and white blood cell counts. We collected ten retrospective measures of weight and height, from birth to the age of 12 years. Participants with at least five measures (at birth, one at age 6-18 months, two at age 2-8 years, and one at age 10-13 years) were included in the analyses. We used group-based trajectory modelling to identify BMI trajectories, ANOVA to compare different trajectories, and linear regression to assess associations. FINDINGS: We recruited 1902 participants (829 [44%] boys and 1073 [56%] girls, median age 13·6 years (IQR 13·3-13·8). We identified and named three BMI trajectories, and categorised participants accordingly: normal gain (847 [44%] participants), moderate gain (815 [43%] participants), and excessive gain (240 [13%] participants). Differences distinguishing these trajectories were established before the age of 2 years. After adjustments for sex, age, migrant background, and parental income, respondents with excessive gain had a higher waist circumference (mean difference 19·2 cm [95% CI 18·4-20·0]), higher systolic blood pressure (mean difference 3·6 mm Hg [95% CI 2·4-4·4]), more white blood cells (mean difference 0·7 × 109 cells per L [95% CI 0·4-0·9]), and higher stress scores (mean difference 1·1 [95% CI 0·2-1·9]), but similar pulse-wave velocity compared with adolescents with normal gain. Higher waist circumference (mean difference 6·4 cm [95% CI 5·8-6·9]), higher systolic blood pressure (mean difference 1·8 mm Hg [95% CI 1·0-2·5]), and a higher stress score (mean difference 0·7 [95% CI 0·1-1·2]) were also found in adolescents with moderate gain, compared with adolescents with normal gain. Regarding timeframes, we observed that a significant positive correlation of early life BMI with systolic blood pressure started approximately at the age 6 years for participants with excessive gain, much earlier than for participants with normal gain and moderate gain, for which it started at the age of 12 years. For waist circumference, white blood cell counts, stress, and psychosomatic symptoms, the timeframes were similar across the three BMI trajectories. INTERPRETATION: Excessive gain BMI trajectory from birth can predict both cardiometabolic risk and stress and psychosomatic symptoms in adolescents before the age of 13 years. FUNDING: Swedish Research Council (grant reference 2014-10086).

Hair glucocorticoid concentration, self-perceived stress and their associations with cardiometabolic risk markers in Swedish adolescents.

BACKGROUND: While hair cortisol is proposed as a biomarker for chronic stress and a possible mediator linking chronic stress and cardiovascular risk in adults, studies in adolescents are scarce. We explored the associations between self-perceived stress, hair cortisol (HairF) and cortisone (HairE), and cardiometabolic risk markers in adolescents. Further, we examined whether association between self-perceived stress and HairF may depend on the use of the coping strategies "shift-persist". METHODS: Participants were 7th grade pupils recruited to the STudy of Adolescence Resilience and Stress (STARS) and data from the baseline examinations were used. Adolescents (n = 1553, 26 % boys, Mage=13.6, SD = 0.4) completed questionnaires assessing perceived stress and coping strategies "shift-persist", provided hair sample, and examined for cardiometabolic risk factors including waist circumference (WC), body mass index (BMI) z-score, blood pressure, and white blood cell counts (WBC). HairF and HairE were analysed using liquid chromatography with tandem mass spectrometry. We conducted descriptive analyses (Student's t-test, Wilcoxon Signed Ranks test, Chi-square test) and linear regression analyses. RESULTS: Perceived stress was not associated with HairF, neither had the use of coping strategies "shift-persist" any influence on this association. Both HairF and HairE were positively associated with BMI z-score (beta coefficients (ß): 0.178 (p < 0.001) and 0.119 (p < 0.001) for boys; 0.123 (p < 0.001) and 0.089 (p < 0.01) for girls) and WC (ß: 0.089 (p > 0.05) and 0.098 (p < 0.05) for boys; 0.103 (p < 0.01) and 0.076 (p < 0.05) for girls). Perceived stress was also positively associated with BMI z-score and WC. Perceived stress, but not HairF, remained associated with WC in boys (ß = 0.200, p < 0.001) in the models with HairF and perceived stress presented simultaneously. Modest association between HairE and WBC was found in boys (ß = 0.149, p < 0.01). CONCLUSIONS: The study supports the association between chronic stress and overweight/obesity in adolescents. Hair cortisol and self-perceived stress capture different aspects of how chronic stress is related to overweight/obesity in adolescents.

The inclusion of health in major global reports on climate change and biodiversity.

This article argues that human health has become a key consideration in recent global reports on climate change and biodiversity produced by various international organisations; however, greater attention must be given to the unequal health impacts of climate change and biodiversity loss around the world and the different health adaptation measures that are urgently required.

Impact of COVID-19 pandemic on mental health and health behaviors in Swedish adolescents.

AIMS: There is an urgent need to explore the impact of the COVID-19 pandemic on adolescent mental health and health behaviours. To date, there are no such studies on Swedish adolescents. As COVID-19 emerged in the middle of our ongoing 2-year follow-up examination of the Study of Adolescence Resilience and Stress, we had the unique opportunity to use the corona outbreak as a 'natural experiment' to study the impact of COVID-19 on 15-year-old adolescents in Sweden. METHODS: Adolescents (baseline age 13.6±0.4 years) were recruited from schools in western Sweden (during the COVID-19 outbreak schools were kept open for those under 16 years of age). The COVID-19 pandemic reached Sweden on 31 January 2020. A total of 1316 adolescents answered the 2-year follow-up survey before (unexposed to COVID-19 pandemic, controls) and 584 after 1 February 2020 (COVID19-exposed). Data on stress, psychosomatic symptoms, happiness, relationships with parents and peers, school and health behaviours were collected. RESULTS: Adolescents reported higher levels of stress and psychosomatic symptoms and lower levels of happiness at follow-up compared to baseline. These changes occurred to a similar extent in both the control and COVID-19-exposed groups. Likewise, the COVID-19-exposed group showed no deterioration in peer relations or relations with parents versus controls. We did not find any significant differences between groups regarding sleep duration and physical activity. Conclusions: Swedish adolescents exposed to COVID-19 during most of 2020 showed no differences in longitudinal changes in mental health, relationships with parents and peers, and health behaviours compared to those not exposed to COVID-19.

Subjective health complaints in early adolescence reflect stress: A study among adolescents in Western Sweden.

Aims: Mental health problems are common among Swedish adolescents and are sometimes referred to as 'stress-related'. The overall aim of this study is to do an analysis of subjective health complaints (SHCs) and perceived general stress among adolescents in Sweden, both their prevalence and association, by gender, migration background, family structure and socioeconomic conditions. Methods: Data from the baseline (comprising 2283 adolescents aged 13) of the STudy of Adolescence Resilience and Stress (STARS) study in Västra Götaland in Sweden were used. SHCs were measured by the Psychosomatic Problems Scale (PSP-scale) and self-reported stress was measured by Cohen's Perceived Stress Scale (PSS-10). Socioeconomic conditions were measured with the Family Affluence Scale (FAS) and the MacArthur Scale of Subjective Social Status (SSS). Statistical analyses included Student's t-tests and ANOVAs of means, linear and logistic regression analyses and Pearson's correlations. Results: Social inequalities in both SHCs and self-reported stress were found; levels were higher among girls, adolescents living with one parent or in families with less favourable socioeconomic conditions. Self-reported stress and SHCs were found to be strongly correlated (r=0.70). Correlations with self-reported stress were stronger for psychological complaints (r=0.71) than for somatic complaints (r=0.52). Correlations did not vary with socioeconomic conditions of the family. Conclusions: SHCs do reflect general stress among adolescents, and it is appropriate to address the complaints as 'stress-related'. Measures to improve adolescents' mental health by reducing levels of SHCs should pay special attention to stressors in adolescents' daily lives and strengthening adolescent's coping resources and strategies.

Does the family affluence scale reflect actual parental earned income, level of education and occupational status? A validation study using register data in Sweden.

AIM: To examine the external validity of the Family Affluence Scale (FAS) among adolescents in Sweden by using register data for parental earned income, level of education and occupational status. METHODS: Data from the baseline (2015-2019) of the Study of Adolescence Resilience and Stress (STARS), comprising 2283 13-year-olds in the region of Västra Götaland, were used. The FAS III consists of six items: unshared bedroom, car ownership, computer/tablet ownership, dishwasher, number of bathrooms and number of holidays abroad. Register data regarding earned income, educational level and occupational status from Statistics Sweden (2014-2018) were linked to adolescents. In total, survey data were available for 2280 adolescents, and register data were available for 2258 mothers and 2204 fathers. RESULTS: Total parental earned income was moderately correlated with adolescents' scoring on FAS (0.31 < r < 0.48, p < 0.001), depending on examination year. The low FAS group mainly comprised low-income households, and the high FAS group mainly comprised high-income households. Correlations between mothers' and fathers' educational level and adolescents' scoring on FAS were low (r = 0.19 and r = 0.21, respectively, p < 0.001). FAS was higher among adolescents whose parents were working, but the correlation between parents' occupational status and FAS was low (r = 0.22, p < 0.001). CONCLUSIONS: The FAS can mainly identify low- and high-income households in Sweden. It may be used as an alternative measure of parental earned income in studies using self-reported socioeconomic status among adolescents.

The use of coping strategies "shift-persist" mediates associations between physical activity and mental health problems in adolescents: a cross-sectional study.

BACKGROUND: Self-perceived mental health problems among adolescents has had an upward trend. Concurrently, adolescents' physical activity (PA) has been falling whilst sedentary time (SED) has increased. There is a lack of research using accelerometer measured PA and SED to study their relationships to perceived stress and psychosomatic symptoms, both frequently observed mental health problems among adolescents. Whether coping strategies is one of the mechanisms underlying such relationship is less clear. METHODS: A total of 2283 13-year olds were enrolled in the baseline examination of the STARS (STudy of Adolescence Resilience and Stress) study in Western Sweden. Light-, moderate-, vigorous-intensity PA (LPA, MPA and VPA) and SED were measured using hip-worn ActiGraph GT3X+ accelerometer. A total of 1284 adolescents provided valid accelerometer data (at least 4 days with ≥10 h per day). PA and SED during school-time and leisure-time were analysed separately. Surveys were utilized to monitor perceived stress, psychosomatic symptoms and the use of coping strategies "shift-persist". Logistic regression and mediation analyses were performed adjusting for gender, ethnicity, socioeconomic status and puberty development. RESULTS: We observed that more time spent in PA was associated with less stress in adolescents. The associations were observed for LPA (Odds ratio for LPA per 60 min: 0.557 (95% CI 0.399-0.776), VPA (Odds ratio for VPA per 15 min: 0.688 (95% CI 0.588-0.806) and MVPA (Odds ratio for MVPA per 15 min: 0.795 (95%CI 0.718-0.879) during leisure time, but not during school time. Similar associations were observed between leisure time PA and psychosomatic symptoms. The associations remained statistically significant even after adjusting for the confounders. Further, our data showed that adolescents who engaged more time in PA during leisure time were more likely to adopt the coping strategies of "shift-persist". Mediation analysis showed that the use of "shift-persist" mediated the associations between leisure time PA and stress/psychosomatic symptoms. CONCLUSIONS: Leisure time physical activity, irrespective of intensity, may facilitate successful coping with stress and stress-related mental health problems in adolescents.

Climate change and child health: a scoping review and an expanded conceptual framework.

Climate change can have detrimental effects on child health and wellbeing. Despite the imperative for a fuller understanding of how climate change affects child health and wellbeing, a systematic approach and focus solely on children (aged <18 years) has been lacking. In this Scoping Review, we did a literature search on the impacts of climate change on child health from January, 2000, to June, 2019. The included studies explicitly linked an alteration of an exposure to a risk factor for child health to climate change or climate variability. In total, 2970 original articles, reviews, and other documents were identified, of which 371 were analysed. Employing an expanded framework, our analysis showed that the effects of climate change on child health act through direct and indirect pathways, with implications for determinants of child health as well as morbidity and mortality from a range of diseases. This understanding can be further enhanced by using a broader range of research methods, studying overlooked populations and geographical regions, investigating the costs and benefits of mitigation and adaptation for child health, and considering the position of climate change and child health within the UN Sustainable Development Goals. Present and future generations of children bear and will continue to bear an unacceptably high disease burden from climate change.

Global strategies and local implementation of health and health-related SDGs: lessons from consultation in countries across five regions.

Evidence on early achievements, challenges and opportunities would help low-income and middle-income countries (LMICs) accelerate implementation of health and health-related sustainable development goals (HHSDGs). A series of country-specific and multicountry consultative meetings were conducted during 2018-2019 that involved 15 countries across five regions to determine the status of implementation of HHSDGs. Almost 120 representatives from health and non-health sectors participated. The assessment relied on a multidomain analytical framework drawing on existing public health policy frameworks. During the first 5 years of the sustainable development goals (SDGs) era, participating LMICs from South and Central Asia, East Africa and Latin America demonstrated growing political commitment to HHSDGs, with augmentation of multisectoral institutional arrangements, strengthening of monitoring systems and engagement of development partners. On the other hand, there has been limited involvement of civic society representatives and academia, relatively few capacity development initiatives were in place, a well-crafted communication strategy was missing, and there is limited evidence of additional domestic financing for implementing HHSDGs. While the momentum towards universal health coverage is notable, explicit linkages with non-health SDGs and integrated multisectoral implementation strategies are lacking. The study offers messages to LMICs that would allow for a full decade of accelerated implementation of HHSDGs, and points to the need for more implementation research in each domain and for testing interventions that are likely to work before scale-up.