The evaluation of the 3-30-300 green space rule and mental health.

BACKGROUND AND AIMS: Urban green space has many health benefits, but it is still unclear how much actually is needed for better health. Recently a new 3-30-300 rule of thumb for urban forestry and urban greening has been proposed, but this rule has not been evaluated for benefits on health. The rule requires that every citizen should be able to see at least three trees from their home, have 30 percent tree canopy cover in their neighbourhood and not live more than 300 m away from the nearest park or green space. The aim of this study was to evaluate the relationship between the 3-30-300 green space rule and its components in relation to mental health. METHODS: We conducted a cross-sectional study based on a population-based sample of 3145 individuals aged 15-97 years from in Barcelona, Spain who participated in the Barcelona Health Survey (2016-2017). We created 3-30-300 green space indicators using questionnaire data, GIS, remote sensing and land cover maps. Mental health status was assessed with the 12-item General Health Questionnaire (GHQ-12) and also the use of tranquilizer/sedatives or antidepressants and psychiatrist or psychologist visits. Analyses were conducted using mixed effects logistic regression models with districts as the random effect, adjusted for relevant covariates. RESULTS: We found that people in Barcelona had relatively little exposure to green space, whether through window view, living in an area with sufficient greenness, or access to a major green space, and only 4.7% met a surrogate 3-30-300 green space rule. Residential surrounding greenness, but not tree window view or access to major green space, was significantly associated with better mental health, less medication use, and fewer psychologist or psychiatrist visits. Meeting the full surrogate 3-30-300 green space rule was associated with better mental health, less medication use, and fewer psychologist or psychiatrist visits, but only for the latter combined the association was statistically significant (Odds ratio = 0.31, 95% CI: 0.11, 0.91). CONCLUSION: Few people achieved the 3-30-300 green space in Barcelona and we used a surrogate measure. We observed health benefits when the full surrogate rule was met.

Does surrounding greenness moderate the relationship between apparent temperature and physical activity? Findings from the PHENOTYPE project.

BACKGROUND: Physical activity can be affected by both meteorological conditions and surrounding greenness, but few studies have evaluated the effects of these environmental factors on physical activity simultaneously. This multi-city comparative study aimed to assess the synergetic effects of apparent temperature and surrounding greenness on physical activity in four European cities. Specifically, we aimed to identify an interaction between surrounding greenness and apparent temperature in the effects on physical activity. METHODS: Data were collected from 352 adult residents of Barcelona (Spain), Stoke-on-Trent (United Kingdom), Doetinchem (The Netherlands), and Kaunas (Lithuania) as part of the PHENOTYPE study. Participants wore a smartphone for seven consecutive days between May-December 2013 and provided additional sociodemographic survey data. Hourly average physical activity (Metabolic Equivalent of Task (MET)) and surrounding greenness (NDVI) were derived from the Calfit mobile application collecting accelerometer and location data. Hourly apparent temperature was calculated from temperature and relative humidity, which were obtained from local meteorological stations along with other meteorological covariates (rainfall, windspeed, and sky darkness). We assessed the interaction effects of apparent temperature and surrounding greenness on hourly physical activity for each city using linear mixed models, while adjusting for meteorological, demographic, and time-related variables. RESULTS: We found significant interactions between apparent temperature and surrounding greenness on hourly physical activity in three of four cities, aside from the coastal city of Barcelona. Significant quadratic effects of apparent temperature were found in the highest level of surrounding greenness for Stoke-on-Trent and Doetinchem, with 4% decrease in median MET observed for a 10°C departure from optimal temperature (15.2°C and 14.6°C, respectively). Significant linear effects were found for higher levels of surrounding greenness in Kaunas, whereby an increase of 10°C was associated with ∼4% increase in median MET. CONCLUSION: Apparent temperature and surrounding greenness interacted in the effect on hourly physical activity across three of four European cities, with varying effect between cities. While quadratic effects of temperature suggest diminishing levels of physical activity in the highest greenness levels in cities of temperate climates, the variation in surrounding greenness between cities could be further explored, particularly by looking at indoor-outdoor locations. The study findings support the need for evidence-based physical activity promotion and urban design.

Residential urban greenspace and hypertension: A comparative study in two European cities.

BACKGROUND: Living in green areas has been associated with several health benefits; however, the available evidence on such benefits for hypertension is still limited. This study aimed to investigate and compare the association between residential exposure to greenspace and hypertension in Barcelona, Spain and Brussels, Belgium. METHODS: This cross-sectional study was based on data from the 2016 Barcelona Health Interview Survey (HIS) (n = 3400) and the 2013 Belgian HIS (n = 2335). Both surveys were harmonized in terms of outcomes, confounders and exposure assessment. Residential exposure to greenspace was characterized as 1) surrounding greenspace (normalized difference vegetation index (NDVI) and modified soil-adjusted vegetation index 2 (MSAVI2)) across buffers of 100 m, 300 m, and 500 m; 2) surrounding green space across 300 m and 500 m buffers; and 3) Euclidean distance to the nearest green space. Our outcome was self-reported hypertension. We developed logistic regression models to evaluate the city-specific association between each greenspace measure and hypertension, adjusting for relevant covariates. RESULTS: One interquartile range (IQR) increase in residential distance to the nearest green space was associated with higher risk of hypertension in Barcelona [odds ratio (OR): 1.15; 95%CI 1.03-1.29 (IQR: 262.2)], but not in Brussels [OR: 0.95; 95%CI 0.77-1.17 (IQR: 215.2)]. Stratified analyses suggested stronger associations in older participants (≥65 years) for both cities. Findings for residential surrounding green space and greenspace were not conclusive. However, in Brussels, we found protective associations in older participants for both residential surrounding greenspace metrics [NDVI 300 m buffer OR: 0.51; 95%CI 0.32-0.81 (IQR: 0.21) and MSAVI2 300 m buffer OR: 0.51; 95%CI 0.32-0.83 (IQR: 0.18)]. We did not find any indication for the modification of our evaluated associations by sex and education level. CONCLUSION: Our study suggests that living closer to greenspace could be associated with lower risk of hypertension, particularly in older age. Future research is needed to replicate our findings in other settings and shed light on potential underlying mechanism(s).

Impact of road traffic noise on obesity measures: Observational study of three European cohorts.

BACKGROUND: Environmental stressors such as transport noise may contribute to development of obesity through increased levels of stress hormones, sleep deprivation and endocrine disruption. Epidemiological evidence supporting an association of road traffic noise with obesity markers is still relatively scant and confined to certain geographical regions. We aimed to examine the cross-sectional associations between road traffic noise and obesity markers in three large European cohorts involving nearly 500,000 individuals. METHODS: Three population-based cohorts (UK Biobank, Lifelines, HUNT3) were established between 2006 and 2013 in the UK, the Netherlands and Norway respectively. For all three cohorts, residential 24-h road traffic noise (Lden) for 2009 was modelled from a standardised European noise assessment framework. Residential exposures to NO2 for 2007 and PM2.5 for 2010 were estimated from Europe-wide land use regression models. Obesity markers including body mass index and waist circumference were measured at recruitment. Obesity and central obesity status were subsequently derived. Regression models were fitted in each cohort, adjusting for a harmonised set of demographic and lifestyle covariates, with further adjustments for air pollution in the main model. RESULTS: The main analyses included 412,934 participants of UK Biobank, 61,032 of Lifelines and 30,305 of HUNT3, with a mean age of 43-56 years and Lden ranging 42-89 dB(A) across cohorts. In UK Biobank, per 10 dB(A) higher of Lden: BMI was higher by 0.14kg/m2 (95%CI: 0.11-0.18), waist circumference higher by 0.27 cm (95%CI: 0.19-0.35), odds of obesity was 1.06 (95%CI: 1.04-1.08) and of central obesity was 1.05 (95%CI: 1.04-1.07). These associations were robust to most other sensitivity analyses but attenuated by further adjustment of PM2.5 or area-level socioeconomic status. Associations were more pronounced among women, those with low physical activity, higher household income or hearing impairment. In HUNT3, associations were observed for obesity or central obesity status among those exposed to Lden greater than 55 dB(A). In contrast, no or negative associations were observed in the Lifelines cohort. CONCLUSIONS: This largest study to date providing mixed findings on impacts of long-term exposure to road traffic noise on obesity, which necessitates future analyses using longitudinal data to further investigate this potentially important epidemiological link.

Dog ownership, the natural outdoor environment and health: a cross-sectional study.

OBJECTIVES: Dog owners walking their dog in natural outdoor environments (NOE) may benefit from the physical activity facilitated by dog walking and from time spent in nature. However, it is unclear whether dog owners receive additional health benefits associated with having access to NOE above the physical activity benefit of walking with their dog. We investigated associations between dog ownership, walking, time spent in NOE and health and whether these associations differed among those with good and poor access to NOE and those living in green and less green areas. DESIGN: Cross-sectional study. SETTING: The Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe project. PARTICIPANTS: n=3586 adults from Barcelona (Spain), Doetinchem (the Netherlands), Kaunas (Lithuania) and Stoke-on-Trent (UK). DATA COLLECTION AND ANALYSIS: We calculated access to NOE with land maps and residential surrounding greenness with satellite data. Leisure time walking, time spent in NOE and general and mental health status were measured using validated questionnaires. Associations were estimated using multilevel analysis with a random intercept defined at the neighbourhood level. RESULTS: Dog ownership was associated with higher rates of leisure time walking and time spending in NOE (OR 2.17, 95% CI 1.86 to 2.54 and 2.37, 95% CI 2.02 to 2.79, respectively). These associations were stronger in those living within 300 m of a NOE and in greener areas. No consistent associations were found between dog ownership and perceived general or mental health status. CONCLUSIONS: Compared with non-dog owners, dog owners walked more and spent more time in NOE, especially those living within 300 m of a NOE and in greener areas. The health implications of these relationships should be further investigated. In a largely physically inactive society, dog walking in NOE may be a simple way of promoting physical activity and health.

The longitudinal association between natural outdoor environments and mortality in 9218 older men from Perth, Western Australia.

BACKGROUND/AIM: Natural outdoor environments may mitigate harmful environmental factors associated with city living. We studied the longitudinal relationship between natural ('green and blue') outdoor environments and mortality in a cohort of older men residing in Perth, Western Australia. METHODS: We studied a cohort of 9218 men aged 65 years and older from the Health In Men Study. Participants were recruited in 1996-99 and followed until 2014, during which 5889 deaths were observed. Time-varying residential surrounding greenness based on the Normalized Difference Vegetation Index, and the number and size of parks, natural space and waterbodies were defined to characterize the natural outdoor environment. All-cause non-accidental and cause-specific mortality was ascertained with the Western Australian Data Linkage System. The association of the natural outdoor environment with mortality was examined using Cox regression analysis. RESULTS: After adjusting for age, men living in the highest quartile of cumulative average surrounding greenness had a 9% lower rate of all-cause non-accidental mortality (95% confidence interval [CI] 0.84, 0.98; p = .013) compared with those in the lowest quartile. This association was no longer present after adjustment for other risk factors, especially level of education. Living within 500 m of one (vs. no) natural space was associated with decreased mortality risk (adjusted hazard ratio 0.93; 95% CI 0.86, 1.00; p = .046), but no association with mortality was found for two or more natural spaces compared to none and for parks. Associations between waterbodies and mortality were inconsistent, showing non-linear beneficial and harmful associations. CONCLUSIONS: In this longitudinal study of older men residing in Perth, we observed evidence suggestive of an association between access to natural spaces and decreased mortality. Associations between surrounding greenness and mortality seemed to be confounded by level of education, and associations with waterbodies were complex and need to be studied further.

Physical Activity and Sleep in Chronic Fatigue Syndrome and Fibromyalgia Syndrome: Associations with Symptom Severity in the General Population Cohort LifeLines.

Objective: The aim of the current study was to compare physical activity and sleep duration between patients with chronic fatigue syndrome (CFS), patients with fibromyalgia syndrome (FMS), and controls and to examine the association between physical activity level and sleep duration with symptom severity within these patient groups. Methods: This study used data of LifeLines, a general population cohort in which 1.0% (n=943, 63.7% female, age 44.9 (SD 11.6) years) reported CFS, 3.0% (n=2,714; 91.6% female; age 48.4 (SD 10.7) years) reported FMS, and 95.7% (n=87,532; 57.9% female; age 44.3 (SD 12.4) years) reported neither CFS nor FMS. Physical activity, sleep duration, and symptom severity were assessed by questionnaires and analysed using ANCOVA and regression analyses, adjusted for age, sex, body mass index, smoking, and educational level. Results: Patients with CFS and FMS had significantly lower physical activity scores (8834 ± 5967 and 8813 ± 5549 MET ∗ minutes) than controls (9541 ± 5533; p < 0.001). Patients with CFS had the longest sleep duration (466 ± 86 minutes) compared to patients with FMS and controls (450 ± 67 and 446 ± 56; p < 0.001). A linear association between physical activity, sleep duration, and symptom severity was only found in controls, in whom higher physical total activity scores and longer sleep duration were associated with a lower symptom severity. In contrast, quadratic associations were found in all groups: both relatively low and high physical activity scores and relatively short and long sleep duration were associated with higher symptom severity in CFS, FMS, and controls. Conclusion: This study indicates that patients with CFS or FMS sleep longer and are less physically active than controls on average. Both low and high levels of physical activity and short and long sleep duration are associated with higher symptom severity, suggesting the importance of patient-tailored treatment.

Active commuting through natural environments is associated with better mental health: Results from the PHENOTYPE project.

BACKGROUND: Commuting routes with natural features could promote walking or cycling for commuting. Commuting through natural environments (NE) could have mental health benefits as exposure to NE can reduce stress and improve mental health, but there is little evidence. This study evaluates the association between NE and commuting, whether active or not, and the association between commuting (through NE), whether active or not, and mental health. We also evaluate the moderating effect of NE quality on the association between NE commuting and mental health. METHODS: This cross-sectional study was based on adult respondents (n = 3599) of the Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe (PHENOTYPE) project. Data were collected in four European cities in Spain, the Netherlands, Lithuania and the United Kingdom. Data on commuting behavior (active commuting at least one day/week, daily NE commuting) and mental health were collected with questionnaires. Associations were estimated with multilevel analyses including random intercepts at city- and neighborhood level. RESULTS: Adjusted multilevel analyses showed that daily NE commuters were more often active commuters (OR 1.42; 95% CI 1.19, 1.70). There was no association between active commuting and mental health, but daily NE commuters had on average a 2.74 (95% CI 1.66, 3.82) point higher mental health score than those not commuting through NE. The association with mental health was stronger among active commuters (4.03, 95% CI 2.13, 5.94) compared to non-active commuters (2.21; 95% CI 0.90, 3.51) when daily commuting through NE, but NE quality did not have a moderating effect. CONCLUSIONS: Daily NE commuting was associated with better mental health, especially for active commuters. Daily NE commuters were likely to be active commuters. Active commuting itself was not associated with mental health. These findings suggest that cities should invest in commuting routes with nature for cycling and walking.

Long-term exposure to road traffic noise, ambient air pollution, and cardiovascular risk factors in the HUNT and lifelines cohorts.

AIMS: Blood biochemistry may provide information on associations between road traffic noise, air pollution, and cardiovascular disease risk. We evaluated this in two large European cohorts (HUNT3, Lifelines). METHODS AND RESULTS: Road traffic noise exposure was modelled for 2009 using a simplified version of the Common Noise Assessment Methods in Europe (CNOSSOS-EU). Annual ambient air pollution (PM10, NO2) at residence was estimated for 2007 using a Land Use Regression model. The statistical platform DataSHIELD was used to pool data from 144 082 participants aged ≥20 years to enable individual-level analysis. Generalized linear models were fitted to assess cross-sectional associations between pollutants and high-sensitivity C-reactive protein (hsCRP), blood lipids and for (Lifelines only) fasting blood glucose, for samples taken during recruitment in 2006-2013. Pooling both cohorts, an inter-quartile range (IQR) higher day-time noise (5.1 dB(A)) was associated with 1.1% [95% confidence interval (95% CI: 0.02-2.2%)] higher hsCRP, 0.7% (95% CI: 0.3-1.1%) higher triglycerides, and 0.5% (95% CI: 0.3-0.7%) higher high-density lipoprotein (HDL); only the association with HDL was robust to adjustment for air pollution. An IQR higher PM10 (2.0 µg/m3) or NO2 (7.4 µg/m3) was associated with higher triglycerides (1.9%, 95% CI: 1.5-2.4% and 2.2%, 95% CI: 1.6-2.7%), independent of adjustment for noise. Additionally for NO2, a significant association with hsCRP (1.9%, 95% CI: 0.5-3.3%) was seen. In Lifelines, an IQR higher noise (4.2 dB(A)) and PM10 (2.4 µg/m3) was associated with 0.2% (95% CI: 0.1-0.3%) and 0.6% (95% CI: 0.4-0.7%) higher fasting glucose respectively, with both remaining robust to adjustment for air/noise pollution. CONCLUSION: Long-term exposures to road traffic noise and ambient air pollution were associated with blood biochemistry, providing a possible link between road traffic noise/air pollution and cardio-metabolic disease risk.

The relationship between natural outdoor environments and cognitive functioning and its mediators.

BACKGROUND: Urban residents may experience cognitive fatigue and little opportunity for mental restoration due to a lack of access to nature. Natural outdoor environments (NOE) are thought to be beneficial for cognitive functioning, but underlying mechanisms are not clear. OBJECTIVES: To investigate the long-term association between NOE and cognitive function, and its potential mediators. METHODS: This cross-sectional study was based on adult participants of the Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe (PHENOTYPE) project. Data were collected in Barcelona, Spain; Doetinchem, the Netherlands; and Stoke-on-Trent, United Kingdom. We assessed residential distance to NOE, residential surrounding greenness, perceived amount of neighborhood NOE, and engagement with NOE. Cognitive function was assessed with the Color Trails Test (CTT). Mediation analysis was undertaken following Baron and Kenny. RESULTS: Each 100m increase in residential distance to NOE was associated with a longer CTT completion time of 1.50% (95% CI 0.13, 2.89). No associations were found for other NOE indicators and cognitive function. Neighborhood social cohesion was (marginally) significantly associated with both residential distance to NOE and CTT completion time, but no evidence for mediation was found. Nor were there indications for mediation by physical activity, social interaction with neighbors, loneliness, mental health, air pollution worries, or noise annoyance. CONCLUSIONS: Our findings provide some indication that proximity to nature may benefit cognitive function. We could not establish which mechanisms may explain this relationship.

Ambient air pollution, traffic noise and adult asthma prevalence: a BioSHaRE approach.

We investigated the effects of both ambient air pollution and traffic noise on adult asthma prevalence, using harmonised data from three European cohort studies established in 2006-2013 (HUNT3, Lifelines and UK Biobank).Residential exposures to ambient air pollution (particulate matter with aerodynamic diameter ≤10 µm (PM10) and nitrogen dioxide (NO2)) were estimated by a pan-European Land Use Regression model for 2007. Traffic noise for 2009 was modelled at home addresses by adapting a standardised noise assessment framework (CNOSSOS-EU). A cross-sectional analysis of 646 731 participants aged ≥20 years was undertaken using DataSHIELD to pool data for individual-level analysis via a "compute to the data" approach. Multivariate logistic regression models were fitted to assess the effects of each exposure on lifetime and current asthma prevalence.PM10 or NO2 higher by 10 µg·m-3 was associated with 12.8% (95% CI 9.5-16.3%) and 1.9% (95% CI 1.1-2.8%) higher lifetime asthma prevalence, respectively, independent of confounders. Effects were larger in those aged ≥50 years, ever-smokers and less educated. Noise exposure was not significantly associated with asthma prevalence.This study suggests that long-term ambient PM10 exposure is associated with asthma prevalence in western European adults. Traffic noise is not associated with asthma prevalence, but its potential to impact on asthma exacerbations needs further investigation.

The LifeLines Cohort Study: a resource providing new opportunities for environmental epidemiology.

BACKGROUND: Lifelines is a prospective population-based cohort study investigating the biological, behavioral and environmental determinants of healthy ageing among 167,729 participants from the North East region of the Netherlands. The collection and geocoding of (history of) home and work addresses allows linkage of individual-level health data to detailed exposure data. We describe the reasons for choosing particular assessments of environmental exposures in LifeLines and consider the implications for future investigations. METHODS: Exposure to ambient air pollution and road traffic noise was estimated using harmonized models. Data on noise annoyance, perceived exposure to electromagnetic fields, perceived living environment, and neighborhood characteristics were collected with questionnaires. A comprehensive medical assessment and questionnaires were completed in order to assess determinants of health and well-being. Blood and urine samples were collected from all participants and genome wide association data are available for a subsample of 15,638 participants. RESULTS: Mean age was 45 years (standard deviation (SD) 13 years), and 59 % were female. Median levels of NO2 and PM10 were 15.7 (interquartile range (IQR) 4.9) µg/m(3) and 24.0 (IQR 0.6) µg/m(3) respectively. Median levels of daytime road traffic noise were 54.0 (IQR 4.2) dB(A). CONCLUSIONS: The combination of harmonized environmental exposures and extensive assessment of health outcomes in LifeLines offers great opportunities for environmental epidemiology. LifeLines aims to be a resource for the international scientific community.

(Un)Healthy in the City: Respiratory, Cardiometabolic and Mental Health Associated with Urbanity.

BACKGROUND: Research has shown that health differences exist between urban and rural areas. Most studies conducted, however, have focused on single health outcomes and have not assessed to what extent the association of urbanity with health is explained by population composition or socioeconomic status of the area. Our aim is to investigate associations of urbanity with four different health outcomes (i.e. lung function, metabolic syndrome, depression and anxiety) and to assess whether these associations are independent of residents' characteristics and area socioeconomic status. METHODS: Our study population consisted of 74,733 individuals (42% males, mean age 43.8) who were part of the baseline sample of the LifeLines Cohort Study. Health outcomes were objectively measured with spirometry, a physical examination, laboratory blood analyses, and a psychiatric interview. Using multilevel linear and logistic regression models, associations of urbanity with lung function, and prevalence of metabolic syndrome, major depressive disorder and generalized anxiety disorder were assessed. All models were sequentially adjusted for age, sex, highest education, household equivalent income, smoking, physical activity, and mean neighborhood income. RESULTS: As compared with individuals living in rural areas, those in semi-urban or urban areas had a poorer lung function (ß -1.62, 95% CI -2.07;-1.16), and higher prevalence of major depressive disorder (OR 1.65, 95% CI 1.35;2.00), and generalized anxiety disorder (OR 1.58, 95% CI 1.35;1.84). Prevalence of metabolic syndrome, however, was lower in urban areas (OR 0.51, 95% CI 0.44;0.59). These associations were only partly explained by differences in residents' demographic, socioeconomic and lifestyle characteristics and socioeconomic status of the areas. CONCLUSIONS: Our results suggest a differential health impact of urbanity according to type of disease. Living in an urban environment appears to be beneficial for cardiometabolic health but to have a detrimental impact on respiratory function and mental health. Future research should investigate which underlying mechanisms explain the differential health impact of urbanity.

Mood and Anxiety Disorders in Chronic Fatigue Syndrome, Fibromyalgia, and Irritable Bowel Syndrome: Results From the LifeLines Cohort Study.

OBJECTIVE: Functional somatic syndromes (FSSs) have often been linked to psychopathology. The aim of the current study was to compare prevalence rates of psychiatric disorders among individuals with chronic fatigue syndrome (CFS), fibromyalgia (FM), and irritable bowel syndrome (IBS). METHODS: This study was conducted in 94,516 participants (mean [standard deviation] age = 44.6 [12.5] years, 58.7% women) of the general-population cohort LifeLines. FSSs were assessed by self-reports. Mood disorders (i.e., major depressive disorder and dysthymia) and anxiety disorders (i.e., generalized anxiety disorder, social phobia, panic disorder with/without agoraphobia, and agoraphobia) were assessed by means of the Mini International Neuropsychiatric Interview. Risks on psychiatric disorders were compared for individuals with CFS, FM, and IBS by using logistic regression analyses adjusted for age and sex. RESULTS: Prevalence rates of CFS, FM, and IBS were 1.3%, 3.0%, and 9.7%, respectively. Individuals with CFS, FM, and IBS had significantly more mood (odds ratios [ORs] = 1.72-5.42) and anxiety disorders (ORs = 1.52-3.96) than did individuals without FSSs, but prevalence rates were low (1.6%-28.6%). Individuals with CFS more often had mood (ORs = 2.00-4.08) and anxiety disorders (ORs = 1.63-2.32) than did individuals with FM and IBS. Major depressive disorder was more common in FM than in IBS (OR = 1.58, 95% confidence interval = 1.24-2.01), whereas these groups did not differ on dysthymia or anxiety disorders. CONCLUSIONS: Mood and anxiety disorders are more prevalent in individuals with FSSs, and particularly CFS, than in individuals without FSSs. However, most individuals with FSSs do not have mood or anxiety disorders.

How to assess common somatic symptoms in large-scale studies: a systematic review of questionnaires.

OBJECTIVE: Many questionnaires for assessment of common somatic symptoms or functional somatic symptoms are available and their use differs greatly among studies. The prevalence and incidence of symptoms are partially determined by the methods used to assess them. As a result, comparison across studies is difficult. This article describes a systematic review of self-report questionnaires for somatic symptoms for use in large-scale studies and recommends two questionnaires for use in such studies. METHODS: A literature search was performed in the databases Medline, PsycINFO and EMBASE. Articles that reported the development, evaluation, or review of a self-report somatic symptom measure were included. Instrument evaluation was based on validity and reliability, and their fitness for purpose in large scale studies, according to the PhenX criteria. RESULTS: The literature search identified 40 questionnaires. The number of items within the questionnaires ranged from 5 to 78 items. In 70% of the questionnaires, headaches were included, followed by nausea/upset stomach (65%), shortness of breath/breathing trouble (58%), dizziness (55%), and (low) back pain/backaches (55%). Data on validity and reliability were reported and used for evaluation. CONCLUSION: Questionnaires varied regarding usability and burden to participants, and relevance to a variety of populations and regions. Based on our criteria, the Patient Health Questionnaire-15 and the Symptom Checklist-90 somatization scale seem the most fit for purpose for use in large-scale studies. These two questionnaires have well-established psychometric properties, contain relevant symptoms, are relatively short, and are available in multiple languages.