Golf: a game of life and death--reduced mortality in Swedish golf players.

The specific health benefits achieved from different forms and patterns of leisure-time physical activity are not established. We analyzed the mortality in a cohort of Swedish golf players. We used the Swedish Golf Federation's membership registry and the nationwide Mortality Registry. We calculated standardized mortality ratios (SMR) with stratification for age, sex, and socioeconomic status. The cohort included 300 818 golfers, and the total number of deaths was 1053. The overall SMR was 0.60 [95% confidence intervals (CIs): 0.57-0.64]. The mortality reduction was observed in men and women, in all age groups, and in all socioeconomic categories. Golfers with the lowest handicap (the most skilled players) had the lowest mortality; SMR=0.53 (95% CI: 0.41-0.67) compared with 0.68 (95% CI: 0.61-0.75) for those with the highest handicap. While we cannot conclude with certainty that all the 40% decreased mortality rates are explained by the physical activity associated with playing golf, we conclude that most likely this is part of the explanation. To put the observed mortality reduction in context, it may be noted that a 40% reduction of mortality rates corresponds to an increase in life expectancy of about 5 years.

Cancer survival and social class in Sweden.

A study of 98,000 cases in the Swedish Cancer Registry from 1961 to 1979 was undertaken. The relative survival by social class was calculated. There was a higher survival probability for white collar workers than for blue collar workers or self-employed farmers for all cancer, as well as for particular cancers, such as, for instance, cancer of the breast and cervix among women and cancer of the rectum among men. For lung cancer, cancer of the stomach, and pancreatic cancer there were no detectable differences in survival probability. The findings can be considered in the light of various possible explanations, for instance, early detection, differential treatment, and host factors.

Mortality among children and young persons in Sweden in relation to childhood socioeconomic group.

More than 1.5 million children in Sweden were followed up for the period 1961-1979 with respect to mortality. Mortality differences by socioeconomic group were studied for the age groups 1-19 years. Children in families of non-manual workers, both boys and girls, had a significantly lower mortality than children of manual workers and children of self employed persons. The socioeconomic differences in risk of dying were greater among boys than among girls. For boys, the socioeconomic differences grew smaller as the boys grew older.

Adult body height and childhood socioeconomic group in the Swedish population.

Cross-sectional data from interviews of a sample of the Swedish population aged 16 to 74 years in 1980-81 were used to obtain information on the relation between father's socioeconomic status during the childhood of the participants and the adult body height of the latter. A difference in height between members of higher and lower socioeconomic groups was found. The difference diminished over falling age but was still noticeable among men born in the early and mid 1950s. The mean difference in height between sons of senior salaried employees and sons of unskilled workers was 2.9 cm. The difference was less for women.

Adult body height, self perceived health and mortality in the Swedish population.

STUDY OBJECTIVE: The purpose of the study was to examine adult body height as an indicator of general health. DESIGN: The study was a survey of a randomly selected sample of the adult Swedish population obtained by the Swedish National Central Bureau of Statistics. PARTICIPANTS: The sample studied was identified in 1980-81 and comprised 14,757 persons aged 16-74. Of these, 12,695 (86%) consented to interview. MEASUREMENTS AND MAIN RESULTS: Information was obtained on adult height, socioeconomic status in childhood and adult life, self perceived health, self reported longstanding illness, and mortality during a six year follow up. The numbers of people in three height groups who considered their general health as bad, who reported any longstanding illness or who died during the follow up were compared with the expected numbers in the same groups. The number of persons with reduced health and the number of deaths was larger than expected in the shortest height group. The excess risk of dying in the shortest group (about 20% higher compared to the tallest group) was reduced but not eliminated when present and childhood socioeconomic group was taken into account. Coronary heart disease mortality in particular was linked to height. The shortest group of men and women reported the largest proportion with bad general health and longstanding illness. For the latter the differences between height groups disappeared after controlling for present socioeconomic status. CONCLUSIONS: There is a detectable excess risk of morbidity and mortality from being short. Assuming that the childhood environment is an important determinant of adult stature it is also important for adult health.

Can confounding by sociodemographic and behavioural factors explain the association between size at birth and blood pressure at age 50 in Sweden?

STUDY OBJECTIVE: To evaluate whether socioeconomic confounding explains the relationship between size at birth and blood pressure at age 50. DESIGN: Cross sectional study with retrospectively collected data on size at birth. SETTING: Uppsala, Sweden. PARTICIPANTS: 1333 men born in 1920-24, and a subset of 615 men for analyses including early social circumstances. MAIN OUTCOME MEASURES: Blood pressure measured after 10 minutes rest in supine position. Crude and adjusted effect measures were compared. MAIN RESULTS: Controlling for sociodemographic characteristics at age 50, such as socioeconomic position, highest education achieved and marital status did not reduce the strength of the association between birth weight and systolic blood pressure at 50 years. In the total population, the slope of the body mass index adjusted relationship changed from -3.4 mmHg/kg to -3.5 mmHg/kg on additional adjustment for sociodemographic characteristics at age 50 (both p values < 0.01). Controlling for behavioural characteristics at age 50, such as smoking and recent alcohol drinking, did not affect the relationship between birth weight and blood pressure at 50. In the 615 men for whom information on sociodemographic circumstances in early life was available, adjustment for factors such as social class of the family, mother's marital status or area of residence, led to a slight reduction of the effect of birth weight on systolic blood pressure at age 50. The slope of the body mass index adjusted relationship changed from -2.8 mmHg/kg to -2.6 mmHg/kg after additional adjustment for early life circumstances in the sample as a whole (p values 0.09 and 0.12). Simultaneous adjustment for sociodemographic characteristics at birth together with sociodemographic and behavioural characteristics at age 50 led to only a slight reduction of the effect of birth weight on systolic blood pressure at 50 years. CONCLUSION: The strong inverse associations between birth weight and blood pressure among 50 year old Swedish men are highly unlikely to be explained by confounding with socioeconomic circumstances at birth or in adult life.

Equity and efficiency in health reform. A European view.

Health care reform in both eastern and western Europe is on the agenda, and in both parts of Europe the importance of equity targets has been questioned. In the East, the previously strongly held equity goals were largely a facade, covering all sorts of privilege systems, something which has brought equity as a concept into disrepute. However, present developments mean that it is quite likely to be back on the agenda again soon. In the West, equity has been seen as inevitably linked to non-market systems of health care. In moving towards market solutions equity has come to be seen as conflicting with efficiency goals. This contra-positioning of equity and efficiency does not stand up to critical examination. It is based on confusing strategic goals with the implementation of those goals. Equity could be seen as a strategic goal in its own right. We may ask what are the most efficient ways of financing, managing and delivering medical services to achieve that goal. Clearly this has not been the question on the agenda. Cost containment has been imperative, and the consequences for general health, equity in health or the health and care for those suffering most, has been relegated to second place. The reduction of inequalities in health can be seen as an overall strategy for the improvement of a population's health, and as helpful in the maintaining and improvement of its human capital.(ABSTRACT TRUNCATED AT 250 WORDS)

Inequality in health--some theoretical and empirical problems.

The present paper discusses the following problem; what is the best theoretical understanding of the social class distribution of health and mortality? The discussion identifies some theoretical problems. Some of these have to do with the importance of social causation of health on the one hand and health-related social mobility on the other. Each one of these two explanations has its own problems, but they are not mutually exclusive. The class distribution of early death can vary both between countries, between two periods in time and between causes of death. Such variability should be exploited for theoretical reasons. Empirical 'anomalies' should not be dismissed or ignored, but taken seriously. It seems clear that a theoretical over-simplification in analysing class and health will prove to be counter-productive.

Socio-economic differences in mortality among children. Do they persist into adulthood?

More than 1.2 million Swedish children born 1946-60 and enumerated in the 1960 population census were followed up with respect to mortality for the period of 1961-79. Thus the children were younger than 15 years at the start of the follow-up and their age of death varied between 1 and 33 years. More than 13,000 deaths were analysed. The purpose was to examine whether or not mortality differences by socio-economic group in childhood persist into adulthood. Mortality differences by childhood socio-economic group were studied for both children/adolescents (1-19 years old) and young adults (20-33 years old). Information about the adults' own occupational status was not available. Therefore, to allow a deeper analysis, another group of adults, whose mortality could be analysed by their own socio-economic group, was used as a comparison group. Among children and adolescents there was a clear socio-economic group difference in mortality. Children in families of non-manual workers had a significantly lower mortality than children in the families of manual workers. In particular this was the case for boys. Socio-economic differences in total mortality are evident also in the age between 20 and 33 years among men but it could not be demonstrated here that these are a result of childhood socio-economic group rather than achieved socio-economic group. However, the study indicates that some differences in childhood, to a certain degree and for some diagnoses, may persist into adulthood. Of particular interest may be a tendency for cardiovascular disease mortality to be elevated among sons and daughters of manual workers.(ABSTRACT TRUNCATED AT 250 WORDS)

Risks, survival and trends of malignant melanoma among white and blue collar workers in Sweden.

All persons in Sweden, classified as white or blue collar workers in the 1960 Population Census, were followed up for the period 1961-1973 with regard to the occurrence of cancer. The SMRs were calculated for 50 tumour sites and it was found that the crude classification of occupations into white or blue collar workers was particularly important for malignant melanoma risk. The number of malignant melanoma cases among blue collar workers was significantly lower than expected while it was significantly higher than expected among the white collar workers. This was true for men as well as for women. The SMRs were calculated to be 87 and 141 (men) and 79 and 117 (women), respectively. Comparing the relative survival probabilities it was found that white collar workers had a higher probability of survival than blue collar workers. This might indicate that the difference in occurrence could be dependent on early detection as well as differential risk. The incidence of malignant melanoma is increasing faster than any other kind of tumour in Sweden. For the period 1961-1970 the incidence rate increased two-fold for blue collar workers and more than two-fold for white collar workers (men). In absolute terms the white collar workers in the age group 45-64 had an appreciably faster increase in incidence over this period compared to all other groups studied.

Cost containment, solidarity and cautious experimentation: Swedish dilemmas.

This paper uses secondary data analysis and a literature review to explore a "Swedish Dilemma": Can Sweden continue to provide a high level of comprehensive health services for all regardless of ability to pay--a policy emphasizing "solidarity"--or must it decide to impose increasing constraints on health services spending and service delivery--a policy emphasizing "cost containment?" It examines recent policies and longer term trends including: changes in health personnel and facilities; integration of health and social services for older persons; introduction of competition among providers; cost sharing for patients; dismantling of dental insurance; decentralization of government responsibility; priority settings for treatment; and encouragement of the private sector. It is apparent that the Swedes have had considerable success in attaining cost containment--not primarily through "market mechanisms" but through government budget controls and service reduction. Further, it appears that equal access to care, or solidarity, may be adversely affected by some of the system changes.

Socio-economic inequalities in mortality. Methodological problems illustrated with three examples from Europe.

BACKGROUND: Studies from most European countries have been able to demonstrate that lower socioeconomic groups have higher risks of disease, disability and premature death. Uncertain is, however, whether these studies have also been able to estimate the precise magnitude of these inequalities, their patterns and their trends over time. The purpose of this paper is to illustrate the extent to which results of descriptive studies can be biased due to problems with the data that are commonly available to European countries. METHODS: Three illustrations are presented from a project on socio-economic inequalities in premature morbidity and mortality in Europe. These illustrations concern three problems often encountered in data on social class differences in mortality among middle aged men: the numerator/denominator bias in cross-sectional studies (illustrated for France), the exclusion of economically inactive men (illustrated for 4 countries), and the use of approximate social class schemes (illustrated for Sweden). RESULTS: In each illustration, inequalities in mortality among middle aged men could be demonstrated, but data problems appeared to bias estimates of the precise magnitude of inequalities in mortality, their patterns by social class and cause of death, and their trends over time. The bias was substantial in most cases. Usually, it was difficult to predict in which ways and to what extent inequality estimates would have been biased. CONCLUSIONS: When the aim of a study is to determine the precise magnitude, patterns or time trends of health inequalities, the results should be evaluated carefully against a number of potential data problems. Investments are needed, e.g. in data sources and in the measurement of socio-economic status, to secure that future studies can describe socio-economic inequalities in health in Europe in more detail and with more reliability.

Social class differences in infant mortality in Sweden: comparison with England and Wales.

OBJECTIVES: To investigate social class differences in infant mortality in Sweden in the mid-1980s and to compare their magnitude with that of those found in England and Wales. DESIGN: Analysis of risk of infant death by social class in aggregated routine data for the mid-1980s, which included the linkage of Swedish births to the 1985 census. SETTING: Sweden and England and Wales. SUBJECTS: All live births in Sweden (1985-6) and England and Wales (1983-5) and corresponding infant deaths were analysed. The Swedish data were coded to the British registrar general's social class schema. MAIN OUTCOME MEASURES: Risk of death in the neonatal and postneonatal period. RESULTS: Taking the non-manual classes as the reference group, in the neonatal period in Sweden the manual social classes had a relative risk for mortality of 1.20 (95% confidence interval 1.02 to 1.43) and those not classified into a social class a relative risk of 1.08 (0.88 to 1.33). In the postneonatal period the equivalent relative risks were 1.38 (1.08 to 1.77) for manual classes and 2.14 (1.65 to 2.79) for the residual; these are similar to those for England and Wales (1.43 (1.36 to 1.51) for manual classes, 2.62 (2.45 to 2.81) for the residual). CONCLUSIONS: The existence of an equitable health care system and a strong social welfare policy in Sweden has not eliminated inequalities in post-neonatal mortality. Furthermore, the very low risk of infant death in the Swedish non-manual group (4.8/1000 live births) represents a target towards which public health interventions should aim. If this rate prevailed in England and Wales, 63% of postneonatal deaths would be avoided.

Failure to realise growth potential in utero and adult obesity in relation to blood pressure in 50 year old Swedish men.

OBJECTIVES: To clarify the type of fetal growth impairment associated with increased blood pressure in adult life, and to establish whether this association is influenced by obesity and is mediated through impairment of insulin action. DESIGN: Cross sectional survey with retrospective ascertainment of size at birth from obstetric archives. SUBJECTS: 1333 men resident in Uppsala, Sweden, who took part in a 1970 study of coronary risk factors at age 50 and for whom birth weight was traced. MAIN OUTCOME MEASURES: Systolic and diastolic blood pressure at age 50. RESULTS: In the full study population for a 1000g increase in birth weight there was a small change in systolic blood pressure of -2.2mmHg (95% confidence interval -4.2 to - 0.3mmHg) and in diastolic blood pressure of -1.0mmHg (-2.2 to 0.1mmHg). Much stronger effects were observed among men who were born at term and were in the top third of body mass index at age 50, for whom a 1000g increase in birth weight was associated with a change of -9.1mmHg (-16.4 to-1.9mmHg) systolic and -4.2mmHg (-8.3 to -0.1mmHg) diastolic blood pressure. Men who were light at birth (<3250g) but were above median adult height had particularly high blood pressure. Adjustment for insulin concentrations reduced the associations of birth weight with systolic and diastolic blood pressure. CONCLUSIONS: A failure to realise growth potential in utero (as indicated by being light at birth but tall as an adult) is associated with raised adult blood pressure. Impaired fetal growth may lead to substantial increases in adult blood pressure among only those who become obese. Metabolic disturbances, possibly related to insulin resistance, may provide a pathway through which fetal growth affects blood pressure.

Reduced fetal growth rate and increased risk of death from ischaemic heart disease: cohort study of 15 000 Swedish men and women born 1915-29.

OBJECTIVE: To establish whether fetal growth rate (as distinct from size at birth) is associated with mortality from ischaemic heart disease. DESIGN: Cohort study based on uniquely detailed obstetric records with 97% follow up over the entire life course and linkage to census data in adult life. SUBJECTS: All 14 611 babies delivered at the Uppsala Academic Hospital, Sweden, during 1915-29 followed up to end of 1995. MAIN OUTCOME MEASURES: Mortality from ischaemic heart disease and other causes. RESULTS: Cardiovascular disease showed an inverse association with birth weight for both men and women, although this was significant only for men. In men a 1000 g increase in birth weight was associated with a proportional reduction in the rate of ischaemic heart disease of 0.77 (95% confidence interval 0.67 to 0.90). Adjustment for socioeconomic circumstances at birth and in adult life led to slight attenuation of this effect. Relative to the lowest fourth of birth weight for gestational age, mortality from ischaemic heart disease in men in the second, third, and fourth fourths was 0.81 (0.66 to 0.98), 0.63 (0.50 to 0.78), and 0.67 (0.54 to 0.82), respectively. The inclusion of birth weight per se and birth weight for gestational age in the same model strengthened the association with birth weight for gestational age but removed the association with birth weight. CONCLUSION: This study provides by far the most persuasive evidence of a real association between size at birth and mortality from ischaemic heart disease in men, which cannot be explained by methodological artefact or socioeconomic confounding. It strongly suggests that it is variation in fetal growth rate rather than size at birth that is aetiologically important.

[Not only the orienteers. A study of mortality from myocarditis among the younger Swedish population]. / Inte bara orienterare. En studie av dödligheten i myokardit hos den yngre svenska befolkningen.

All cases of death in the 11-45-year-old age group, occurring during the period 1981-1986, where myocarditis was given as the underlying or contributory cause, were analysed. Estimated per 100,000 person years, mortality was 0.5 for men and 0.2 for women. There was a tendency toward geographic clustering and, independently, a clustering in time. Some variation according to socio-economic class was also present. We conclude that the current focus of Swedish research on myocarditis among orienteers is too narrow, as more than 90 percent of cases occur outside this group.