Joint effects of alcohol use, smoking and body mass index as an explanation for the alcohol harm paradox: causal mediation analysis of eight cohort studies.

BACKGROUND AND AIMS: Lower socio-economic status (SES) is associated with higher alcohol-related harm despite lower levels of alcohol use. Differential vulnerability due to joint effects of behavioural risk factors is one potential explanation for this 'alcohol harm paradox'. We analysed to what extent socio-economic inequalities in alcohol-mortality are mediated by alcohol, smoking and body mass index (BMI), and their joint effects with each other and with SES. DESIGN: Cohort study of eight health examination surveys (1978-2007) linked to mortality data. SETTING: Finland. PARTICIPANTS: A total of 53 632 Finnish residents aged 25+ years. MEASUREMENTS: The primary outcome was alcohol-attributable mortality. We used income as an indicator of SES. We assessed the joint effects between income and mediators (alcohol use, smoking and BMI) and between the mediators, adjusting for socio-demographic indicators. We used causal mediation analysis to calculate the total, direct, indirect and mediated interactive effects using Aalen's additive hazards models. FINDINGS: During 1 085 839 person-years of follow-up, we identified 865 alcohol-attributable deaths. We found joint effects for income and alcohol use and income and smoking, resulting in 46.8 and 11.4 extra deaths due to the interaction per 10 000 person-years. No interactions were observed for income and BMI or between alcohol and other mediators. The lowest compared with the highest income quintile was associated with 5.5 additional alcohol deaths per 10 000 person-years (95% confidence interval = 3.7, 7.3) after adjusting for confounders. The proportion mediated by alcohol use was negative (-69.3%), consistent with the alcohol harm paradox. The proportion mediated by smoking and BMI and their additive interactions with income explained 18.1% of the total effect of income on alcohol-attributable mortality. CONCLUSIONS: People of lower socio-economic status appear to be more vulnerable to the effects of alcohol use and smoking on alcohol-attributable mortality. Behavioural risk factors and their joint effects with income may explain part of the alcohol harm paradox.

Measurement error as an explanation for the alcohol harm paradox: analysis of eight cohort studies.

BACKGROUND: Despite reporting lower levels of alcohol consumption, people with lower socio-economic status (SES) experience greater alcohol-related harm. Whether differential biases in the measurement of alcohol use could explain this apparent paradox is unknown. Using alcohol biomarkers to account for measurement error, we examined whether differential exposure to alcohol could explain the socio-economic differences in alcohol mortality. METHODS: Participants from eight representative health surveys (n = 52 164, mean age 47.7 years) were linked to mortality data and followed up until December 2016. The primary outcome was alcohol-attributable mortality. We used income and education as proxies for SES. Exposures include self-reported alcohol use and four alcohol biomarkers [serum gamma-glutamyl transferase (available in all surveys), carbohydrate-deficient transferrin, alanine aminotransferase and aspartate aminotransferase (available in subsamples)]. We used shared frailty Cox proportional hazards to account for survey heterogeneity. RESULTS: During a mean follow-up of 20.3 years, totalling 1 056 844 person-years, there were 828 alcohol-attributable deaths. Lower SES was associated with higher alcohol mortality despite reporting lower alcohol use. Alcohol biomarkers were associated with alcohol mortality and improved the predictive ability when used in conjunction with self-reported alcohol use. Alcohol biomarkers explained a very small fraction of the socio-economic differences in alcohol mortality, since hazard ratios either slightly attenuated (percent attenuation range 1.0-12.1%) or increased. CONCLUSIONS: Using alcohol biomarkers in addition to self-reported alcohol use did not explain the socio-economic differences in alcohol mortality. Differential bias in the measurement of alcohol use is not a likely explanation for the alcohol-harm paradox.

Childhood socioeconomic status and lifetime health behaviors: The Young Finns Study.

BACKGROUND: Differences in health behaviors partly explain the socioeconomic gap in cardiovascular health. We prospectively examined the association between childhood socioeconomic status (SES) and lifestyle factors in adulthood, and the difference of lifestyle factors according to childhood SES in multiple time points from childhood to adulthood. METHODS AND RESULTS: The sample comprised 3453 participants aged 3-18 years at baseline (1980) from the longitudinal Young Finns Study. The participants were followed up for 31 years (N = 1675-1930). SES in childhood was characterized as reported annual family income and classified on an 8-point scale. Diet, smoking, alcohol intake and physical activity were used as adult and life course lifestyle factors. Higher childhood SES predicted a healthier diet in adulthood in terms of lower consumption of meat (ß ±â€¯SE -3.6 ±â€¯0.99,p < 0.001), higher consumption of fish (1.1 ±â€¯0.5, p = 0.04) and higher diet score (0.14 ±â€¯0.044, p = 0.01). Childhood SES was also directly associated with physical activity index (0.059 ±â€¯0.023, p = 0.009) and inversely with the risk of being a smoker (RR 0.90 95%CI 0.85-0.95, p < 0.001) and the amount of pack years (-0.47 ±â€¯0.18, p = 0.01). Life course level of smoking was significantly higher and physical activity index lower among those below the median childhood SES when compared with those above the median SES. CONCLUSIONS: These results show that childhood SES associates with several lifestyle factors 31 years later in adulthood. Therefore, attention could be paid to lifestyle behaviors of children of low SES families to promote cardiovascular health.

Participation rates by educational levels have diverged during 25 years in Finnish health examination surveys.

Background: Declining participation rates in health examination surveys may impair the representativeness of surveys and introduce bias into the comparison of results between population groups if participation rates differ between them. Changes in the characteristics of non-participants over time may also limit comparability with earlier surveys. Methods: We studied the association of socio-economic position with participation, and its changes over the past 25 years. Occupational class and educational level are used as indicators of socio-economic position. Data from six cross-sectional FINRISK surveys conducted between 1987 and 2012 in Finland were linked to national administrative registers, which allowed investigation of the differences between survey participants and non-participants. Results: Our results show that individuals with low occupational class or low level of education were less likely to participate than individuals with high occupational class or high level of education. Participation rates decreased in all subgroups of the population but the decline was fastest among those with low level of education. Conclusions: The differences in participation rates must be taken into account to avoid biased estimates because socio-economic position has also been shown to be strongly related to health, health behaviour and biological risk factors. Particular attention should be paid to the recruitment of the less-educated population groups.

Circulating sex hormones in relation to anthropometric, sociodemographic and behavioural factors in an international dataset of 12,300 men.

INTRODUCTION: Sex hormones have been implicated in the etiology of a number of diseases. To better understand disease etiology and the mechanisms of disease-risk factor associations, this analysis aimed to investigate the associations of anthropometric, sociodemographic and behavioural factors with a range of circulating sex hormones and sex hormone-binding globulin. METHODS: Statistical analyses of individual participant data from 12,330 male controls aged 25-85 years from 25 studies involved in the Endogenous Hormones Nutritional Biomarkers and Prostate Cancer Collaborative Group. Analysis of variance was used to estimate geometric means adjusted for study and relevant covariates. RESULTS: Older age was associated with higher concentrations of sex hormone-binding globulin and dihydrotestosterone and lower concentrations of dehydroepiandrosterone sulfate, free testosterone, androstenedione, androstanediol glucuronide and free estradiol. Higher body mass index was associated with higher concentrations of free estradiol, androstanediol glucuronide, estradiol and estrone and lower concentrations of dihydrotestosterone, testosterone, sex hormone-binding globulin, free testosterone, androstenedione and dehydroepiandrosterone sulfate. Taller height was associated with lower concentrations of androstenedione, testosterone, free testosterone and sex hormone-binding globulin and higher concentrations of androstanediol glucuronide. Current smoking was associated with higher concentrations of androstenedione, sex hormone-binding globulin and testosterone. Alcohol consumption was associated with higher concentrations of dehydroepiandrosterone sulfate, androstenedione and androstanediol glucuronide. East Asians had lower concentrations of androstanediol glucuronide and African Americans had higher concentrations of estrogens. Education and marital status were modestly associated with a small number of hormones. CONCLUSION: Circulating sex hormones in men are strongly associated with age and body mass index, and to a lesser extent with smoking status and alcohol consumption.

Early Protein Intake Is Associated with Body Composition and Resting Energy Expenditure in Young Adults Born with Very Low Birth Weight.

BACKGROUND: Suboptimal nutrition during fetal life and early childhood may be important in early programming of health and disease. Preterm infants born with very low birth weight (VLBW; <1500 g) frequently receive inadequate neonatal nutrition; the long-term consequences are poorly known. OBJECTIVE: We evaluated the association between early macronutrient intake and body composition in young adults born with VLBW. METHODS: We collected comprehensive information on daily nutritional intake during the initial hospital stay for 127 participants of the Helsinki Study of Very Low Birth Weight Adults. We calculated mean daily intakes of energy, protein, fat, and carbohydrate during the first 9 wk of life. At the mean age of 22.5 y, the subjects underwent measurements of weight, height, body composition by dual-energy X-ray absorptiometry, and resting energy expenditure. The associations were examined by linear regression. RESULTS: We found that energy, protein, and fat intakes during the first 3 wk of life, all below current recommendations, predicted adult body composition. When adjusted for sex, age, birth weight SD score, and gestational age, a 1 g · kg(-1) · d(-1) higher protein intake predicted 11.1% higher lean body mass (LBM) (95% CI: 3.7%, 18.9%) and 8.5% higher resting energy expenditure (REE) (95% CI: 0.2%, 17.0%). Among those born before 28 wk of gestation, the numbers were 22.5% (95% CI: 1.9%, 47.4%) for LBM and 22.1% (95% CI: 3.6%, 44.0%) for REE. Similar associations were seen with energy (P = 0.01, P = 0.05) and fat (P < 0.01, P = 0.03) but not with carbohydrate. Energy intake was also associated with BMI (P = 0.01) and fat intake with BMI (P < 0.01) and percentage body fat (P = 0.05). The results were little changed when adjusted for prenatal and postnatal characteristics. CONCLUSIONS: At relatively low neonatal protein intake levels, additional protein intake is reflected in a healthier body composition, accompanied by a higher metabolic rate, in young adults born with VLBW 20 y earlier.

Genetic variation in the hTAS2R38 taste receptor and food consumption among Finnish adults.

Genetic variation in bitter taste receptors, such as hTAS2R38, may affect food preferences and intake. The aim of the present study was to investigate the association between bitter taste receptor haplotypes and the consumption of vegetables, fruits, berries and sweet foods among an adult Finnish population. A cross-sectional design utilizing data from the Cardiovascular Risk in Young Finns cohort from 2007, which consisted of 1,903 men and women who were 30-45 years of age from five different regions in Finland, was employed. DNA was extracted from blood samples, and hTAS2R38 polymorphisms were determined based on three SNPs (rs713598, rs1726866 and rs10246939). Food consumption was assessed with a validated food frequency questionnaire. The prevalence of the bitter taste-sensitive (PAV/PAV) haplotype was 11.3 % and that of the insensitive (AVI/AVI) haplotype was 39.5 % among this Finnish population. PAV homozygotic women consumed fewer vegetables than did the AVI homozygotic women, 269 g/day (SD 131) versus 301 g/day (SD 187), respectively, p = 0.03 (multivariate ANOVA). Furthermore, the intake of sweet foods was higher among the PAV homozygotes of both genders. Fruit and berry consumption did not differ significantly between the haplotypes in either gender. Individuals perceive foods differently, and this may influence their patterns of food consumption. This study showed that the hTAS2R38 taste receptor gene variation was associated with vegetable and sweet food consumption among adults in a Finnish population.

European Health Examination Survey--towards a sustainable monitoring system.

BACKGROUND: Health examination surveys (HESs), including both questionnaire and physical measurements, and in most cases also collection of biological samples, can provide objective health indicators. This information complements data from health interview surveys and administrative registers, and is important for evidence-based planning of health policies and prevention activities. HESs are valuable data sources for research. The first national HESs in Europe were conducted in the late 1950s and early 1960s. They have recently been carried out in an increasing number of countries, but there has been no joint standardization between the countries. METHODS: The European Health Examination Survey Pilot Project was conducted in 2009-2012. The European Health Examination Survey Pilot Reference Centre was established and pilot surveys were conducted in 12 countries. RESULTS: European standardized protocols for key measurements on main chronic disease risk factors (height, weight, waist circumference, blood pressure, blood lipids and fasting glucose or HbA1c) were prepared. European-level training and external quality assessment were organized. Although the level of earlier experience, infrastructures, economic status and cultural settings varied between the pilot countries, it was possible to standardize measurements of HESs across the populations. Obtaining high participation rates was challenging. CONCLUSION: HESs provide high-quality and representative population data to support policy decisions and research. For future national HESs, centralized coordination, training and external quality assessment are needed to ensure comparability of the results. Further studies on effects of different survey methods on comparability of the results and on recruitment and motivation of survey participants are needed.

Vitamin D status is associated with sociodemographic factors, lifestyle and metabolic health.

PURPOSE: Low serum 25(OH)D concentration has been shown to predict the occurrence of several chronic diseases. It is, however, still unclear whether the associations are causal or due to confounding. The aim of this study was to investigate the associations between serum 25(OH)D concentration and sociodemographic, lifestyle and metabolic health-related factors. METHODS: The study population comprised 5,714 men and women, aged 30-79 years, from the Health 2000 Survey representing the Finnish population. Serum 25(OH)D concentration was determined by radioimmunoassay from serum samples frozen at -70 °C. Sociodemographic, lifestyle and metabolic factors were determined by questionnaires, interviews and measurements. Linear regression was used to assess the associations between serum 25(OH)D and the factors studied. RESULTS: The mean serum 25(OH)D concentration was 45.3 nmol/l and it varied between categories of sociodemographic, lifestyle and metabolic health variables. Older age, being married or cohabiting and higher education were related to higher serum 25(OH)D concentration. Those with the healthiest lifestyle estimated by a lifestyle index based on body mass index, physical activity, smoking, alcohol consumption and diet had 15.8 nmol/l higher serum 25(OH)D concentration compared to those with the unhealthiest lifestyle. Of the indicators of metabolic health, only waist circumference and HDL cholesterol were significantly associated with 25(OH)D after adjustment for sociodemographic, lifestyle and other metabolic health factors. CONCLUSION: This study suggests that serum 25(OH)D concentration is associated with a multitude of sociodemographic, lifestyle and metabolic health factors. Thus, it is possible that such factors confound associations observed between serum 25(OH)D concentration and chronic diseases.

Socio-economic disparities in the consumption of vegetables, fruit and energy-dense foods: the role of motive priorities.

OBJECTIVE: A low socio-economic status (SES) is related to less healthy dietary habits, but the reasons for this remain unclear. We examined whether the absolute or relative importance of various food choice motives contributed to SES disparities in vegetable/fruit and energy-dense food intake. DESIGN: We analysed cross-sectional data from the FINRISK Study 2007 by means of structural equation modelling and used a shortened version of the Food Choice Questionnaire to assess the absolute importance of health, pleasure, convenience, price, familiarity and ethicality motives. We calculated the relative importance of each motive by dividing the participant's rating of it by his/her mean score on all motives. Dietary intake was measured with an FFQ. SETTING: A population-based survey in Finland. SUBJECTS: Men (n 1691) and women (n 2059) aged 25-64 years. RESULTS: Higher education and income were related to a greater vegetable/fruit intake (ß = 0·12, P < 0·001), while education was associated negatively with the consumption of energy-dense foods (ß = -0·09, P < 0·001). Socio-economically disadvantaged individuals considered price and/or familiarity more important in their food choices in both absolute and relative terms. A higher income was related to a greater relative importance of health considerations. Relative motives were more strongly associated with vegetable/fruit and energy-dense food consumption than absolute motives and the relative importance of price, familiarity and health partly mediated the effects of the SES indicators on the consumption of these food items. CONCLUSIONS: Individual priorities in food choice motives, rather than the absolute importance of single motives, play a role in producing SES disparities in diet.

Nutrition policy in Finland.

The present study describes the main actions in Finnish nutrition policy during the past decades. The main actor is the National Nutrition Council, which provides nutritional recommendations and action programmes, and sets up expert groups to solve nutritional problems in the population. The main fortification programmes have been the iodization of table salt, supplementation of selenium to fertilizers and the vitamin D fortification programme. As an example of national legislation, labelling the salt content of foods is described. Finnish nutrition policy is based on a good monitoring system of nutrition and risk factors of chronic diseases, as well as active epidemiological research. However, the authorities have not often taken proposed fiscal measures seriously but have instead considered agricultural and economic policies more important than health policy.

Monitoring diet and diet-related chronic disease risk factors in Finland.

Health and dietary monitoring has a long history in Finland. The aim of this review is to summarise the main sources of Finnish dietary information including food balance sheets, household budget survey data, questionnaires related to dietary behaviour and risk factors of main chronic diseases as well as dietary surveys. According to these sources, dietary behaviour and food choices have changed considerably during the last decades. For example, the total fat intake (E %) has decreased remarkably from nearly 40 % in the late 1960s to close to 30 % in 2007. Furthermore, the type of fat consumed has changed noticeably due to the increased popularity of oil used in cooking and the large variety of softer spreads available. There has also been a notable decrease in intake of salt, and a multiple increase in the consumption of fruits and vegetables since the 1970s. The future challenges of dietary monitoring include keeping the participation rates in dietary surveys at acceptable levels, controlling under/over-reporting of diet, developing a national monitoring system for children and adapting to international changes and requirements to harmonise dietary monitoring in Europe.

Identifying vegetarians and their food consumption according to self-identification and operationalized definition in Finland.

OBJECTIVES: To determine the prevalence and sociodemographic factors related to vegetarians according to different definitions in Finland and to compare the consumption of selected foodstuffs and nutritional intakes among vegetarians and omnivores. DESIGN: Information about subjects' identification as vegetarians in a survey was used as a basis for self-defined vegetarianism. Foodstuffs consumed and their frequencies of consumption were obtained, and the reported consumption frequencies of meat, fish, milk and eggs or food portions containing these foodstuffs were used as a basis for an operationalized definition of different types of vegetarianism. Reported consumption was used to estimate foodstuff and nutritional intakes. SETTING: Three large nationwide surveys in Finland. SUBJECTS: In total, 24 393 participants aged between 18 and 79 years were included. RESULTS: The proportion of self-identified vegetarians was 3.3 % of the total population in Finland. According to responses to questions on consumption frequency, 1.4 % of the population were pesco-lacto-ovo-vegetarians, 0.43 % were vegans, lacto-vegetarians or lacto-ovo-vegetarians, and 0.18 % were vegans or lacto-vegetarians. Eighty per cent of the self-identified vegetarians did not follow a vegetarian diet according to the operationalized definition, but they consumed fewer meat products (P < 0.01).ConclusionSome self-defined vegetarians do consume red meat, poultry or fish, but they follow a healthier diet than self-defined omnivores. In the same sample self-identification indicated more than double the incidence of vegetarianism than the operationalized definition. Therefore self-identification is not a good method for observing the prevalence of vegetarianism.