The role of psychological distress in the relationship of financial strain with oral health and dental attendance in Dutch adults: A mediation analysis based on cross-sectional data.

OBJECTIVES: The study aimed to assess whether psychological distress mediates the association between financial strain and oral health and dental attendance in the Dutch adult population. METHODS: The study followed a cross-sectional design based on 2812 participants from the 2014 wave of the Dutch population-based GLOBE study. Financial strain was considered the exposure, while psychological distress measured with the Mental Health Inventory-5 (MHI-5) was the mediator. The outcomes included self-reported number of teeth, self-rated oral health, and self-reported dental attendance. Generalized regression analyses were used for the mediation analysis adjusted for several covariables. RESULTS: Greater financial strain was significantly associated with poorer self-rated oral health (total effect: 0.09, 95%CI: 0.05; 0.14) and restorative or no dental attendance (i.e. participants never visiting a dentist or only visiting a dentist for regular treatments or when they have complaints with their mouth, teeth, or prosthesis) (total effect: 0.05, 95%CI: 0.02; 0.09). Greater financial strain was not significantly associated with self-reported number of teeth (total effect: -0.14, 95%CI: -0.91; 0.64). Psychological distress significantly mediated the association of financial strain with self-rated oral health (average causal mediation effect [ACME]: 0.02, 95%CI: 0.01; 0.03) and self-reported dental attendance (ACME: 0.01, 95%CI: 0.00; 0.02), respectively. However, it did not significantly mediate the association of financial strain with self-reported number of teeth (ACME: -0.11, 95%CI: -0.25; 0.02). The estimated proportion of the total effect of financial strain on self-rated oral health and self-reported dental attendance that could be explained by psychological distress was respectively 24% (95%CI: 14%; 48%) and 19% (95%CI: 6%; 62%). CONCLUSIONS: Psychological distress partly explains the association of financial strain with self-rated oral health and dental attendance, but not with self-reported number of teeth. Future studies using longitudinal data are necessary to confirm the results.

Childhood obesity's influence on socioeconomic disparities in young adolescents' mental health.

PURPOSE: We investigated whether socioeconomic inequalities in young adolescents' mental health are partially due to the unequal distribution of childhood obesity across socioeconomic positions (SEP), i.e. differential exposure, or due to the effect of obesity on mental health being more detrimental among certain SEPs, i.e. differential impact. METHODS: We studied 4660 participants of the Generation R study, a population-based study in the Netherlands. SEP was estimated by mother's education and household income at age five of the child. We estimated the contribution of the mediating and moderating effects of high body fat percentage to the disparity in mental health. This was done through a four-way decomposition using marginal structural models with inverse probability of treatment weighting. RESULTS: Comparing children with the least to most educated mothers and the lowest to highest household income, the total disparity in emotional problems was 0.98 points (95%CI:0.35-1.63) and 1.68 points (95%CI:1.13-2.19), respectively. Of these total disparities in emotional problems, 0.50 points (95%CI:0.15-0.85) and 0.24 points (95%CI:0.09-0.46) were due to the differential exposure to obesity. Obesity did not contribute to disparities in behavioural problems. CONCLUSION: Addressing the heightened obesity prevalence among children in low SEP families may reduce inequalities in emotional problems in early adolescence.

Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences.

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

Explaining Outcome Differences between Men and Women following Mild Traumatic Brain Injury.

Men and women differ in outcomes following mild traumatic brain injury (TBI). In the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, we previously found that women had worse 6-month functional outcome (Glasgow Outcome Score Extended [GOSE]), health-related quality of life (HRQoL), and mental health following mild TBI. The aim of this study was to investigate whether those differences were mediated by psychiatric history, gender-related sociodemographic variables, or by care pathways. We analyzed sex/gender differences in 6-month GOSE, generic and TBI-specific HRQoL, and post-concussion and mental health symptoms using three sets of mediators: psychiatric history, sociodemographic variables (living alone, living with children, education and employment status/job category), and care-pathways (referral to study hospital and discharge destination after emergency department); while controlling for a substantial number of potential confounders (pre-injury health and injury-related characteristics). We included 1842 men and 1022 women (16+) with a Glasgow Coma Score 13-15, among whom 83% had GOSE available and about 60% other 6-month outcomes. We used natural effects models to decompose the total effect of sex/gender on the outcomes into indirect effects that passed through the specified mediators and the remaining direct effects. In our study population, women had worse outcomes and these were only partly explained by psychiatric history, and not considerably explained by sociodemographic variables nor by care pathways. Factors other than differences in specified variables seem to underlie observed differences between men and women in outcomes after mild TBI. Future studies should explore more aspects of gender roles and identity and biological factors underpinning sex and gender differences in TBI outcomes.

Differences between Men and Women in Treatment and Outcome after Traumatic Brain Injury.

Traumatic brain injury (TBI) is a significant cause of disability, but little is known about sex and gender differences after TBI. We aimed to analyze the association between sex/gender, and the broad range of care pathways, treatment characteristics, and outcomes following mild and moderate/severe TBI. We performed mixed-effects regression analyses in the prospective multi-center Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, stratified for injury severity and age, and adjusted for baseline characteristics. Outcomes were various care pathway and treatment variables, and 6-month measures of functional outcome, health-related quality of life (HRQoL), post-concussion symptoms (PCS), and mental health symptoms. The study included 2862 adults (36% women) with mild (mTBI; Glasgow Coma Scale [GCS] score 13-15), and 1333 adults (26% women) with moderate/severe TBI (GCS score 3-12). Women were less likely to be admitted to the intensive care unit (ICU; odds ratios [OR] 0.6, 95% confidence interval [CI]: 0.4-0.8) following mTBI. Following moderate/severe TBI, women had a shorter median hospital stay (OR 0.7, 95% CI: 0.5-1.0). Following mTBI, women had poorer outcomes; lower Glasgow Outcome Scale Extended (GOSE; OR 1.4, 95% CI: 1.2-1.6), lower generic and disease-specific HRQoL, and more severe PCS, depression, and anxiety. Among them, women under age 45 and above age 65 years showed worse 6-month outcomes compared with men of the same age. Following moderate/severe TBI, there was no difference in GOSE (OR 0.9, 95% CI: 0.7-1.2), but women reported more severe PCS (OR 1.7, 95% CI: 1.1-2.6). Men and women differ in care pathways and outcomes following TBI. Women generally report worse 6-month outcomes, but the size of differences depend on TBI severity and age. Future studies should examine factors that explain these differences.

Sleep characteristics across the lifespan in 1.1 million people from the Netherlands, United Kingdom and United States: a systematic review and meta-analysis.

We aimed to obtain reliable reference charts for sleep duration, estimate the prevalence of sleep complaints across the lifespan and identify risk indicators of poor sleep. Studies were identified through systematic literature search in Embase, Medline and Web of Science (9 August 2019) and through personal contacts. Eligible studies had to be published between 2000 and 2017 with data on sleep assessed with questionnaires including ≥100 participants from the general population. We assembled individual participant data from 200,358 people (aged 1-100 years, 55% female) from 36 studies from the Netherlands, 471,759 people (40-69 years, 55.5% female) from the United Kingdom and 409,617 people (≥18 years, 55.8% female) from the United States. One in four people slept less than age-specific recommendations, but only 5.8% slept outside of the 'acceptable' sleep duration. Among teenagers, 51.5% reported total sleep times (TST) of less than the recommended 8-10 h and 18% report daytime sleepiness. In adults (≥18 years), poor sleep quality (13.3%) and insomnia symptoms (9.6-19.4%) were more prevalent than short sleep duration (6.5% with TST < 6 h). Insomnia symptoms were most frequent in people spending ≥9 h in bed, whereas poor sleep quality was more frequent in those spending <6 h in bed. TST was similar across countries, but insomnia symptoms were 1.5-2.9 times higher in the United States. Women (≥41 years) reported sleeping shorter times or slightly less efficiently than men, whereas with actigraphy they were estimated to sleep longer and more efficiently than man. This study provides age- and sex-specific population reference charts for sleep duration and efficiency which can help guide personalized advice on sleep length and preventive practices.

The role of the built environment in explaining educational inequalities in walking and cycling among adults in the Netherlands.

BACKGROUND: This study examined whether characteristics of the residential built environment (i.e. population density, level of mixed land use, connectivity, accessibility of facilities, accessibility of green) contributed to educational inequalities in walking and cycling among adults. METHODS: Data from participants (32-82 years) of the 2011 survey of the Dutch population-based GLOBE study were used (N = 2375). Highest attained educational level (independent variable) and walking for transport, cycling for transport, walking in leisure time and cycling in leisure time (dependent variables) were self-reported in the survey. GIS-systems were used to obtain spatial data on residential built environment characteristics. A four-step mediation-based analysis with log-linear regression models was used to examine to contribution of the residential built environment to educational inequalities in walking and cycling. RESULTS: As compared to the lowest educational group, the highest educational group was more likely to cycle for transport (RR 1.13, 95% CI 1.04-1.23), walk in leisure time (RR 1.12, 95% CI 1.04-1.21), and cycle in leisure time (RR 1.12, 95% CI 1.03-1.22). Objective built environment characteristics were related to these outcomes, but contributed minimally to educational inequalities in walking and cycling. On the other hand, compared to the lowest educational group, the highest educational group was less likely to walk for transport (RR 0.91, 95% CI 0.82-1.01), which could partly be attributed to differences in the built environment. CONCLUSION: This study found that objective built environment characteristics contributed minimally to educational inequalities in walking and cycling in the Netherlands.