Narrative review of occupational exposures and noncommunicable diseases.

OBJECTIVE: Within the scope of the Exposome Project for Health and Occupational Research on applying the exposome concept to working life health, we aimed to provide a broad overview of the status of knowledge on occupational exposures and associated health effects across multiple noncommunicable diseases (NCDs) to help inform research priorities. METHODS: We conducted a narrative review of occupational risk factors that can be considered to have "consistent evidence for an association," or where there is "limited/inadequate evidence for an association" for 6 NCD groups: nonmalignant respiratory diseases; neurodegenerative diseases; cardiovascular/metabolic diseases; mental disorders; musculoskeletal diseases; and cancer. The assessment was done in expert sessions, primarily based on systematic reviews, supplemented with narrative reviews, reports, and original studies. Subsequently, knowledge gaps were identified, e.g. based on missing information on exposure-response relationships, gender differences, critical time-windows, interactions, and inadequate study quality. RESULTS: We identified over 200 occupational exposures with consistent or limited/inadequate evidence for associations with one or more of 60+ NCDs. Various exposures were identified as possible risk factors for multiple outcomes. Examples are diesel engine exhaust and cadmium, with consistent evidence for lung cancer, but limited/inadequate evidence for other cancer sites, respiratory, neurodegenerative, and cardiovascular diseases. Other examples are physically heavy work, shift work, and decision latitude/job control. For associations with limited/inadequate evidence, new studies are needed to confirm the association. For risk factors with consistent evidence, improvements in study design, exposure assessment, and case definition could lead to a better understanding of the association and help inform health-based threshold levels. CONCLUSIONS: By providing an overview of knowledge gaps in the associations between occupational exposures and their health effects, our narrative review will help setting priorities in occupational health research. Future epidemiological studies should prioritize to include large sample sizes, assess exposures prior to disease onset, and quantify exposures. Potential sources of biases and confounding need to be identified and accounted for in both original studies and systematic reviews.

A comparison of models with weight, height, and BMI as predictors of mortality.

INTRODUCTION: Body mass index (BMI) is a composite variable of weight and height, often used as a predictor of health outcomes, including mortality. The main purpose of combining weight and height in one variable is to obtain a measure of obesity independent of height. It is however unclear how accurate BMI is as a predictor of mortality compared with models including both weight and height or a weight × height interaction as predictors. METHODS: The current study used conscription data on weight, height, and BMI of Swedish men (N = 48,904) in 1969/70 as well as linked data on mortality (3442 deaths) between 1969 and 2008. Cox proportional hazard models including combinations of weight, height, and BMI at conscription as predictors of subsequent all-cause and cause-specific mortality were fitted to data. RESULTS: An increase by one standard deviation on weight and BMI were associated with an increase in hazard for all-cause mortality by 5.4% and 11.5%, respectively, while an increase by one standard deviation on height was associated with a decrease in hazard for all-cause mortality by 9.4%. The best-fitting model indicated lowest predicted all-cause mortality for those who weighed 60.5 kg at conscription, regardless of height. Further analyses of cause-specific mortality suggest that this weight seems to be a compromise between lower optimal weights to avoid cancer and CVD mortality and a higher optimal weight to not die by suicide. CONCLUSIONS: According to the present findings, there are several ways to make better use of measured weight and height than to calculate BMI when predicting mortality.

Fathers' Alcohol Consumption and Long-Term Risk for Mortality in Offspring.

AIM: This study examined associations between fathers' alcohol consumption and risk for total and cause-specific mortality in offspring. SHORT SUMMARY: We examined the associations between fathers' alcohol consumption and total and cause-specific mortality in adult offspring. Fathers' alcohol consumption was associated with increased risk of alcohol-related mortality in offspring. The association appeared to be weaker for causes of death in which alcohol plays a smaller, or less direct, role. METHODS: Data on fathers' alcohol consumption, and offspring's risky use of alcohol, smoking, mental health and contact with police/childcare authorities were collected among 46,284 men (sons) aged 18-20 years, during conscription for compulsory military training in 1969/70. Data on offspring mortality were obtained from the National Cause of Death register, 1971-2008. The mortality outcomes included total mortality, alcohol-related causes of death and violent causes of death (categorized into suicides vs violent/external causes excluding suicides). RESULTS: Compared to sons whose fathers never used alcohol, the risk for total and alcohol-related mortality among sons increased with the father's consumption level. The risk of violent death was significantly elevated among sons whose fathers drank alcohol occasionally or often, but the risk of suicide increased in the highest consumption category only. After adjustment for covariates, the results remained for alcohol-related mortality whereas they were significantly attenuated, or disappeared, for total mortality, violent death and suicide. CONCLUSIONS: Fathers' alcohol consumption is associated with increased risk of alcohol-related mortality in the offspring. Alcohol use among fathers also increases the offspring's risk of later total mortality, suicide and violent death, but these associations appear to be mediated or confounded by factors related to parental drinking and/or adverse childhood psychosocial circumstances.

Cannabis, Tobacco, Alcohol Use, and the Risk of Early Stroke: A Population-Based Cohort Study of 45 000 Swedish Men.

BACKGROUND AND PURPOSE: Current knowledge on cannabis use in relation to stroke is based almost exclusively on clinical reports. By using a population-based cohort, we aimed to find out whether there was an association between cannabis use and early-onset stroke, when accounting for the use of tobacco and alcohol. METHODS: The cohort comprises 49 321 Swedish men, born between 1949 and 1951, who were conscripted into compulsory military service between the ages of 18 and 20. All men answered 2 detailed questionnaires at conscription and were subject to examinations of physical aptitude, psychological functioning, and medical status. Information on stroke events up to ≈60 years of age was obtained from national databases; this includes strokes experienced before 45 years of age. RESULTS: No associations between cannabis use in young adulthood and strokes experienced ≤45 years of age or beyond were found in multivariable models: cannabis use >50 times, hazard ratios=0.93 (95% confidence interval [CI], 0.34-2.57) and 0.95 (95% CI, 0.59-1.53). Although an almost doubled risk of ischemic stroke was observed in those with cannabis use >50 times, this risk was attenuated when adjusted for tobacco usage: hazards ratio=1.47 (95% CI, 0.83-2.56). Smoking ≥20 cigarettes per day was clearly associated both with strokes before 45 years of age, hazards ratio=5.04 (95% CI, 2.80-9.06), and with strokes throughout the follow-up, hazards ratio=2.15 (95% CI, 1.61-2.88). CONCLUSIONS: We found no evident association between cannabis use in young adulthood and stroke, including strokes before 45 years of age. Tobacco smoking, however, showed a clear, dose-response shaped association with stroke.

Prevalence, co-occurrence, and clustering of health-risk behaviors among people with different socio-economic trajectories: A population-based study.

Only a few previously published studies have investigated the co-occurrence and clustering of health-risk behaviors in people with different socio-economic trajectories from childhood to adulthood. This study was based on data collected through the Stockholm County Council's public health surveys. We selected the 24,241 participants aged 30 to 65years, who responded to a postal questionnaire in 2010. Information on parents' and participants' educational levels was used for classification of four socio-economic trajectories, from childhood to adulthood: the 'stable high', the 'upwardly mobile', the 'downwardly mobile', and the 'stable low'. Information on daily smoking, risky drinking, physical inactivity, and poor diet was used for assessment of health-risk behaviors: their prevalence, co-occurrence, and clustering. We found all health-risk behaviors to be more prevalent among women and men with a downwardly mobile or stable low socio-economic trajectory. Accordingly, having three or four co-occurring health-risk behaviors were much more likely (up to 4 times, in terms of odds ratios) in these groups as compared to the women and men with an upwardly mobile or a stable high socio-economic trajectory. However, clustering of the health-risk behaviors was not found to be stronger in those with a downwardly mobile or stable low socio-economic trajectory. Thus, the fact that women and men with a disadvantageous socio-economic career were found to have co-occurring health-risk behaviors more often than people with an advantageous socio-economic career seemed to be generated by differences in prevalence of the health-risk behaviors, not by differences in clustering of the behaviors.

Risk of Coronary Heart Disease in Men With Poor Emotional Control: A Prospective Study.

OBJECTIVE: Many psychosocial factors have been associated with coronary heart disease (CHD), including hostility, anger, and depression. We tested the hypothesis that these factors may have their basis in emotion regulation abilities. Our aim was to determine whether poor emotional control predicted long-term risk of CHD. METHODS: This Swedish national study includes 46,393 men who were conscripted for military service in 1969 and 1970. The men were aged 18 to 20 years at the time of conscription. Psychologists used a brief semistructured interview to retrospectively assess the conscripts' level of emotional control in childhood and adolescence. The outcome measure was a first fatal or nonfatal event of CHD. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for poor and adequate versus good emotional control. RESULTS: After 38 years of follow-up (1971-2009), 2456 incident cases of CHD had occurred. Poor emotional control increased the risk of CHD (HR = 1.31, 95% CI = 1.18-1.45), adjusting for childhood socioeconomic position, anxiety, depression, and parental history of CHD. Further adjustment for life-style-related factors, for example, smoking and body mass index, attenuated the HR to 1.08 (95% CI = 0.97-1.21). In stratified analyses, the fully adjusted association between poor emotional control with CHD remained significantly elevated among men with a parental history of CHD (HR = 1.49, 95% CI = 1.11-2.01, p interaction = .037). CONCLUSIONS: In the overall study population, poor emotional control had no direct effect on CHD beyond life-style-related factors. However, in men with a parental history of CHD, poor emotional control in adolescence remained significantly predictive of long-term CHD risk even when adjusting for life-style-related factors.

Cannabis use among Swedish men in adolescence and the risk of adverse life course outcomes: results from a 20 year-follow-up study.

AIMS: To examine associations between cannabis use in adolescence (at age 18) and unemployment and social welfare assistance in adulthood (at age 40) among Swedish men. DESIGN: Longitudinal cohort study. SETTING AND PARTICIPANTS: A total of 49.321 Swedish men born in 1949-51, who were conscripted to compulsory military service at 18-20 years of age. MEASUREMENTS: All men answered two detailed questionnaires at conscription and were subject to examinations of physical aptitude psychological functioning and medical status. By follow-up in national databases, information on unemployment and social welfare assistance was obtained. FINDINGS: Individuals who used cannabis at high levels in adolescence had increased risk of future unemployment and of receiving social welfare assistance. Adjusted for all confounders (social background, psychological functioning, health behaviours, educational level, psychiatric diagnoses), an increased relative risk (RR) of unemployment remained in the group reporting cannabis use > 50 times [RR = 1.26, 95% confidence interval (CI) = 1.04-1.53] only. For social welfare assistance, RR in the group reporting cannabis use 1-10 times was 1.15 (95% CI = 1.06-1.26), RR for 11-50 times was 1.21 (95% CI = 1.04-1.42) and RR for > 50 times was 1.38 (95% CI = 1.19-1.62). CONCLUSIONS: Heavy cannabis use among Swedish men in late adolescence appears to be associated with unemployment and being in need of social welfare assistance in adulthood. These associations are not explained fully by other health-related, social or behavioural problems.

Low cardiorespiratory fitness in young adulthood and future risk of disability pension: a follow-up study until 59†years of age in Swedish men.

BACKGROUND: There is a strong belief in the potential of increased physical activity to improve the health of populations. The objective of the present study was to estimate the association between low cardiorespiratory fitness in young adulthood and subsequent health impairment until middle age, measured by disability pension. METHODS: The study utilised data on cardiorespiratory fitness and a number of covariates (social background, health behaviours and psychological characteristics) from the Swedish Conscription Cohort of 1969/1970 including 49,321 men born in 1949-1951, and data on disability pension from 1971 to 2008 (20-59 years of age) through record linkage with two national insurance databases. Cox proportional-hazards regressions yielded hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: Having low-level or mid-level cardiorespiratory fitness in late adolescence was associated with an increased HR of disability pension across the follow-up (HR for low fitness: 1.85, CI 1.71 to 2.00; HR for mid-level fitness: 1.40, CI 1.31 to 1.50). The association was stronger with earlier disability pensions than with later disability pensions, which was also seen after multiple confounding adjustments. At the same time, these adjustments revealed considerable confounding of the association by individual differences in psychological characteristics in particular. CONCLUSIONS: Lower levels of cardiorespiratory fitness in young adulthood were found to be associated with an increased HR of disability pension throughout the follow-up until 59 years of age, even after adjustment for important confounding factors measured in late adolescence. Increased physical fitness may thus have a lowering effect on the risk of disability pension.

Does high intelligence improve prognosis? The association of intelligence with recurrence and mortality among Swedish men with coronary heart disease.

BACKGROUND: Lower intelligence early in life is associated with increased risks for coronary heart disease (CHD) and mortality. Intelligence level might affect compliance to treatment but its prognostic importance in patients with CHD is unknown. METHODS: A cohort of 1923 Swedish men with a measure of intelligence from mandatory military conscription in 1969-1970 at age 18-20, who were diagnosed with CHD 1991-2007, were followed to the end of 2008. PRIMARY OUTCOME: recurrent CHD event. Secondary outcome: case fatality from the first event, cardiovascular and all-cause mortality. National registers provided information on CHD events, comorbidity, mortality and socioeconomic factors. RESULTS: The fully adjusted HRs for recurrent CHD for medium and low intelligence, compared with high intelligence, were 0.98, (95% CIs 0.83 to 1.16) and 1.09 (0.89 to 1.34), respectively. The risks were increased for cardiovascular and all-cause mortality with lower intelligence, but were attenuated in the fully adjusted models (fully adjusted HRs for cardiovascular mortality 1.92 (0.94 to 3.94) and 1.98 (0.89 to 4.37), respectively; for all-cause mortality 1.63 (1.00 to 2.65) and 1.62 (0.94 to 2.78), respectively). There was no increased risk for case-fatality at the first event (fully adjusted ORs 1.06 (0.73 to 1.55) and 0.97 (0.62 to 1.50), respectively). CONCLUSIONS: Although we found lower intelligence to be associated with increased mortality in middle-aged men with CHD, there was no evidence for its possible effect on recurrence in CHD.

Cannabis use in adolescence and risk of future disability pension: a 39-year longitudinal cohort study.

AIMS: This study aimed at examining a possible association between cannabis use in adolescence and future disability pension (DP). DP can be granted to any person in Sweden aged 16-65 years if working capacity is judged to be permanently reduced due to long-standing illness or injury. METHODS: Data were obtained from a longitudinal cohort study comprising 49,321 Swedish men born in 1949-1951 who were conscripted to compulsory military service aged 18-20 years. Data on DP was collected from national registers. RESULTS: Results showed that individuals who used cannabis in adolescence had considerably higher rates of disability pension throughout the follow-up until 59 years of age. In Cox proportional-hazards regression analyses, adjustment for covariates (social background, mental health, physical fitness, risky alcohol use, tobacco smoking and illicit drug use) attenuated the associations. However, when all covariates where entered simultaneously, about a 30% increased hazard ratio of DP from 40 to 59 years of age still remained in the group reporting cannabis use more than 50 times. CONCLUSIONS: This study shows that heavy cannabis use in late adolescence was associated with an increased relative risk of labor market exclusion through disability pension.

Psychosocial functioning and intelligence both partly explain socioeconomic inequalities in premature death. A population-based male cohort study.

OBJECTIVE: The possible contributions of psychosocial functioning and intelligence differences to socioeconomic status (SES)-related inequalities in premature death were investigated. None of the previous studies focusing on inequalities in mortality has included measures of both psychosocial functioning and intelligence. METHODS: The study was based on a cohort of 49 321 men born 1949-1951 from the general community in Sweden. Data on psychosocial functioning and intelligence from military conscription at ∼18 years of age were linked with register data on education, occupational class, and income at 35-39 years of age. Psychosocial functioning was rated by psychologists as a summary measure of differences in level of activity, power of initiative, independence, and emotional stability. Intelligence was measured through a multidimensional test. Causes of death between 40 and 57 years of age were followed in registers. RESULTS: The estimated inequalities in all-cause mortality by education and occupational class were attenuated with 32% (95% confidence interval: 20-45%) and 41% (29-52%) after adjustments for individual psychological differences; both psychosocial functioning and intelligence contributed to account for the inequalities. The inequalities in cardiovascular and injury mortality were attenuated by as much as 51% (24-76%) and 52% (35-68%) after the same adjustments, and the inequalities in alcohol-related mortality were attenuated by up to 33% (8-59%). Less of the inequalities were accounted for when those were measured by level of income, with which intelligence had a weaker correlation. The small SES-related inequalities in cancer mortality were not attenuated by adjustment for intelligence. CONCLUSIONS: Differences in psychosocial functioning and intelligence might both contribute to the explanation of observed SES-related inequalities in premature death, but the magnitude of their contributions likely varies with measure of socioeconomic status and cause of death. Both psychosocial functioning and intelligence should be considered in future studies.

Childhood socio-economic position and risk of coronary heart disease in middle age: a study of 49,321 male conscripts.

BACKGROUND: Poor social circumstances in childhood are associated with increased risk of coronary heart disease (CHD). In previous studies, social circumstances and risk factors in adulthood have been suggested to explain this association. In the present study, we included potential explanatory factors from childhood and adolescence. METHODS: We investigated the association between childhood socio-economic position (SEP) and CHD in middle age among 49,321 Swedish males, born during 1949-51, who were conscripted for military service at 18-20 years of age. Register-based data on childhood social circumstances, educational attainment and occupational class in adulthood were used in combination with information on cognitive ability, smoking, body mass index and body height in late adolescence obtained from a compulsory conscription examination. Incidence of CHD from 1991 to 2007 (between 40 and 58 years of age) was followed in national registers. RESULTS: We demonstrated an inverse association between childhood SEP and CHD in middle age: among men with the lowest childhood SEP the crude hazard ratio of CHD was 1.47 (95% CI = 1.30-1.67). Adjustment for crowded housing in childhood, body height, cognitive ability, smoking and BMI in late adolescence attenuated relative risks of CHD considerably. Additional adjustment for educational level had a further, although limited, attenuating effect on associations, but additional adjustment for occupational class had no such effect. CONCLUSIONS: Results showed that social, cognitive and behavioural factors evident prior to adulthood may be of greater importance in explaining the association between childhood SEP and CHD later in life than socio-economic indicators in adulthood.

Blood pressure in late adolescence and early incidence of coronary heart disease and stroke in the Swedish 1969 conscription cohort.

OBJECTIVES: The association between blood pressure measured in late adolescence and early incidence of coronary heart disease and stroke was investigated in Swedish men. We used measures of systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure. METHOD: Information on blood pressure at age 18-20 was obtained from a cohort of 49,321 men born in 1949-1951 examined at conscription in 1969/1970. Information on coronary heart disease, acute myocardial infarction, and stroke during 1971-2004 was obtained from national hospital discharge and cause of death registers. Associations between blood pressure and outcomes were estimated with Cox regression as hazard ratios per standard deviation in blood pressure increase in mmHg. RESULTS: Blood pressure at age 18-20 was found to be associated with coronary heart disease and stroke before 55 years of age. Adjustment for childhood socio-economic position and adolescent smoking, body mass index, and cognitive ability attenuated the associations. Systolic blood pressure was associated with coronary heart disease [hazard ratio (95% confidence interval) 1.09 (1.04, 1.15)] and acute myocardial infarction [1.09 (1.02, 1.17)]. Diastolic blood pressure was associated with coronary heart disease [1.06 (1.00, 1.11)], acute myocardial infarction [1.08 (1.01, 1.15)], and stroke [1.12 (1.04, 1.21)]. Blood pressure measured as mean arterial pressure was significantly associated with coronary heart disease and almost significantly associated with stroke. Pulse pressure had the weakest associations with all outcomes. CONCLUSION: Measures of blood pressure in late adolescence were found to be associated with early incidence of coronary heart disease and stroke. Prediction of outcomes differed between measures.