Understanding the sex inequality in childlessness: an approach using Swedish register data.

In most countries, men are more likely to be childless than women. Understanding how this inequality arises is important given the significance of parenthood for individuals' lives. The objective of this study was to explore how three prominent explanations for sex inequalities in childlessness relate to the Sex Gap in Childlessness (SGC) in Sweden. The three explanations examined were sex ratio imbalance (more men than women), mismeasurement of fatherhood (inequalities in registration) and partnership differences (inequality in multi-partner fertility). Administrative register data for cohorts born in 1945-1974 were used. The population was restricted to men and women who were born in Sweden or arrived prior to the age of 15, and all registered childbearing partnerships were examined. To explore the possible significance of the three explanations, counter-factual standardization was used. Of the three explanations examined, the population sex ratio had the largest positive impact on the SGC, while multi-partner fertility had a negative impact. The results show that inequalities in the sex ratio can explain about 20-34% of the SGC depending on cohort. Inequalities in registration of fathers explain about 9-24% of the SGC depending on cohort. Finally, results show that women are slightly more likely to have multiple partners, and that this behaviour has a substantial minimizing effect on the SGC (minimizing it by 6-65%). To the authors' knowledge this was the first paper to estimate the scope of the impacts of these three mechanisms on the SGC. Differences in multi-partner fertility have in many instances been used as an explanation for men's higher childlessness. This study shows that women have slightly more childbearing partners than men, and that this actually leads to a smaller SGC in the studied population.

Lipid Lowering in "Very High Risk" Patients Undergoing Coronary Artery Bypass Surgery and Its Projected Reduction in Risk for Recurrent Vascular Events: A Monte Carlo Stepwise Simulation Approach.

ABSTRACT: 2018 AHA guidelines provide criteria to identify patients at very high risk (VHR) for adverse vascular events and recommend an low density lipoprotein-C (LDL-C) level <1.8 mmol/L. Data regarding the 10-year risk for adverse vascular events in coronary artery bypass grafting (CABG) patients at VHR and the need for nonstatin therapies in the VHR cohort are limited. We queried a national cohort of CABG patients to answer these questions. The projected reduction of LDL-C from stepwise escalation of lipid-lowering therapy (LLT) was simulated; Monte Carlo methods were used to account for patient-level heterogeneity in treatment effects. Data on preoperative statin therapy and LDL-C levels were obtained. In the first scenario, all eligible patients not at target LDL-C received high-intensity statins, followed by ezetimibe and then alirocumab; alternatively, bempedoic acid was also used. The 10-year risk for an adverse vascular event was estimated using a validated risk score. Potential risk reduction was estimated after simulating maximal LLT. Before CABG, 8948 of 27,443 patients (median LDL-C 85 mg/dL) were at VHR. In the whole cohort, 31% were receiving high-intensity statins. With stepwise LLT escalation, the proportion of patients at target were 60%, 78%, 86%, and 97% after high-intensity statins, ezetimibe, bempedoic acid, and alirocumab, respectively. The projected 10-year risk to suffer a vascular event reduced by 4.6%. A large proportion of CABG patients who are at VHR for vascular events fail to meet 2018 AHA LDL-C targets. A stepwise approach, particularly with the use of bempedoic acid, can significantly reduce the need for more expensive proprotein convertase subtilisin kexin 9 inhibitors.

Assessment of Traffic Accidents in Japan during the COVID-19 Pandemic vs. Previous Years: A Preliminary Report.

Beginning in April 2020, social distancing measures were implemented to mitigate the COVID-19 pandemic in Japan. We assessed whether traffic accident rates had decreased from April 2020 to December 2021 as compared with previous years. The analysis included 2,934,477 traffic accidents, and the trend of decreasing rates of traffic accidents in recent years and seasonal fluctuations in traffic accidents were considered. The yearly change in the traffic accident rate between 2015 and 2019 was estimated, and the traffic accident rate in 2020 and 2021 was predicted. This was followed by the comparison of observed vs. predicted traffic accident rate. In 2020, the observed vs. expected rates of traffic accidents were lower in April to December 2020, and the rate of traffic accidents in Japan was 30-40% lower in April-May 2020 than would be expected based on trends from previous years. In 2021, rates of traffic accidents remained lower than expected between January and November, but the magnitude of decrease was not as pronounced. These findings could be explained by social distancing policies, including the declaration of the state of emergency, and the relaxation of public health and social measures over time.

Salaries, degrees, and babies: Trends in fertility by income and education among Japanese men and women born 1943-1975-Analysis of national surveys.

BACKGROUND: While fertility rates have decreased during the second half of the 20th century in Japan, little is known regarding trends in the number of children that men and women have across birth cohorts and whether these differ by education and income. METHODS: We used data from four rounds of the National Fertility Survey (1992, 2005, 2010 and 2015) and included men and women aged 40-49 years (16728 men and 17628 women). By 5-year birth cohorts, we assessed the distribution of number of children (0, 1, 2 and 3 or more) and total fertility (the mean number of children) at completed fertility (age 45-49 or 40-44 years depending on birth cohort). We assessed trends in these fertility outcomes in men and women separately, and by education (no university education; university education) for men and women and by reported annual income (0 to <3 000 000 JPY; 3 000 000 to <6 000 000 JPY; ≥6 000 000 JPY) for men. RESULTS: When comparing those born in 1943-1948 with those born in 1971-1975, the proportion with no children had increased from 14.3 to 39.9% for men and from 11.6 to 27.6% for women. This increase coincided with a decrease in the proportions of individuals with 2 or more children. Total fertility had decreased from 1.92 to 1.17 among men and from 1.96 to 1.42 among women. For men, those with a university degree were more likely to have children than those without a university degree in all birth cohorts except 1943-1947. Men with higher income were more likely to have children across birth cohorts. While the proportion who had children had decreased in all income groups, the decrease was steeper among those in the lowest income group. Among women born 1956-1970, those with a university degree were less likely to have children than those without a university degree; this difference was no longer seen among those born 1971-1975. For both men and women, trends in having children and total fertility across birth cohorts did not differ by educational status. CONCLUSIONS: The decline in the total fertility rate in Japan can be attributed to both an increasing proportion of the population who have no children and a lower number of children among those who have children. Men with lower education and income were less likely to have children and the disparity in the number of children that men have by income had increased in more recent birth cohorts. Among women, higher education was associated with lower fertility, although this pattern was no longer observed among those born in 1971-1975.

Fish in the sea: Number, characteristics, and partner preferences of unmarried Japanese adults - analysis of a national survey.

BACKGROUND: A large proportion of adults in Japan remain unmarried even though they intend to marry during their lifetime. To provide data for policy makers and those searching for partners in the Japanese marriage market, we estimated the number and characteristics of unmarried women and men with marriage intention and assessed their partner preferences. Based on the findings, we hypothesized regarding potential mismatches between the individuals available in the marriage market and the type of partners they are looking for. METHODS: We used data from the National Fertility Survey (2015), a nationally representative survey in Japan, and included 20,344 participants aged 18-49 years, of which 6,568 were unmarried with marriage intention. We estimated the total number of unmarried women and men who intend to marry, extrapolated their characteristics to the Japanese population, and assessed their partner preferences, as well as their ideal age of marriage and the ideal age of their partner. RESULTS: In 2015, there were 8.48 million unmarried women and 9.83 million unmarried men aged 18-49 years with marriage intention in Japan. Surpluses of around 600,000 men were observed in non-densely inhabited areas (men-to-women ratio: 1.31) and in the Kanto region (1.23). Most of the women and men in the marriage market had annual incomes lower than 3,000,000 JPY (28,000 USD) and only 263,000 women (3%) and 883,000 men (9%) had an income of 5,000,000 JPY (47,000 USD) or more; 167,000 men (2%) had an income of 7,000,000 JPY (66,000 USD) or more, with roughly three-quarters of them having a university degree. When asked about eight items that one may consider in a potential partner, the proportion of women listing an item as "important" tended to be larger than those of men across all items (education, occupation, finances, personality, mutual hobbies, cooperation/understanding regarding one's work, and attitude towards/skills in housework and childrearing) except appearance. The largest differences were observed for finances (proportion of women vs. men listing the item as "important" or "would consider:" 94.0% vs. 40.5%, p<0.001), occupation (84.9% vs. 43.9%, p<0.001), and education (53.9% vs. 28.7%, p<0.001). While women, on average, preferred men who were around 1-3 years older than themselves, men preferred women around their own age until the age of 26 years, at which point men preferred women who were younger than themselves, with the preferred age difference increasing substantially with age. As such, the number of men preferring a younger partner was larger than the number of women who preferred an older partner. CONCLUSIONS: By providing data on the number, characteristics and partner preferences of individuals in the marriage market, our study could inform decisions for those searching for marriage partners in Japan. Moreover, we hypothesize that mismatches in geographical location, the supply-demand disparity for partners with higher income, and age preferences could partly explain the large number of Japanese women and men who remain unmarried despite intending to get married. Further studies are needed to assess if, and to what extent, the identified mismatches may affect marriage rates.

How do Japanese rate the severity of different diseases and injuries?-an assessment of disability weights for 231 health states by 37,318 Japanese respondents.

BACKGROUND: Disability weights (DWs) are weight factors that reflect the severity of health states for estimates of disability-adjusted life years. A new set of global DWs was published for the Global Burden of Diseases and Injuries (GBD) 2013 study, which relied on sampling from various world regions, but included little data for countries in East Asia. This study aimed to measure DWs in Japan using comparable methods, and compare the results with previous estimates from the GBD 2013 DW study. METHODS: We conducted a web-based survey in 2019 to estimate DWs for 231 health states for the Japanese population. The survey included five new health states but otherwise followed the method of the GBD DW measurement study. The survey consisted of 15 paired comparison (PC) questions and 3 population health equivalence questions (PHE) per respondent. We analyzed PC data using probit regression and rescaled results to DW units between 0 (equivalent to full health) and 1 (equivalent to death). FINDINGS: We considered 37,318 nationally representative respondents. The values of the resulting DWs ranged from 0.707 (95% uncertainty interval (UI) 0.527-0.842) for spinal cord injury at neck level (untreated) to 0.004 (UI 0.001-0.009) for mild anemia. High correlation between Japanese DW and GBD 2013 DW was observed, but there was considerable disagreement. Out of 226 comparable health states, 55 (24.3%) showed more than a factor-of-two difference, of which 41 (74.6%) had a higher value in Japanese DW. Many of the health states with higher DW in the Japan study were injuries, including amputation and fracture, and hearing and vision loss, while mental, behavioral, and substance use disorders generally tended to be lower. CONCLUSIONS: This study has created an empirical basis for assessment of Japanese DWs of health status. The findings from this study based on the Japanese population suggest that there might be contextual differences in rating the severity of health states compared to previous surveys conducted elsewhere.

Projections of disability-adjusted life years for major diseases due to a change in vegetable intake in 2017-2040 in Japan.

BACKGROUND: Low vegetable intake is one of the key dietary risk factors known to be associated with a range of health problems, including cardiovascular diseases (CVDs), cancer, and diabetes and kidney diseases (DKDs). Using data from Japan's National Health and Nutrition Surveys and the Global Burden of Diseases study in 2017, this study aimed to forecast the impact of change in vegetable intake on disability-adjusted life years (DALYs) between 2017 and 2040 for three diseases. METHODS: We generated a three-component model of cause-specific DALYs, including changes in major behavioural and metabolic risk predictors, the socio-demographic index and an autoregressive integrated moving average model to project future DALY rates for 2017-2040 using the data between 1990 and 2016. Data on Vegetable consumption and risk predictors, and DALY rate were obtained from Japan's National Health and Nutrition Surveys and the Global Burden of Diseases Study in 2017. We also modelled three scenarios of better, moderate and worse cases to evaluate the impact of change in vegetable consumption on the DALY rates for three diseases (CVDs, cancer, and DKDs). RESULTS: Projected mean vegetable intake in the total population showed a decreasing trend through 2040 to 237.7 g/day. A significant difference between the reference scenario and the better case scenario was observed with un-overlapped 95% prediction intervals of DALY rates in females aged 20-49 years (- 8.0%) for CVDs, the total population for cancer (- 5.6%), and in males (- 8.2%) and females (- 13.7%) for DKDs. CONCLUSIONS: Our analysis indicates that increased vegetable consumption would have a significant reduction in the burdens of CVDs, cancer and DKDs in Japan. By estimating the disease burden attributable to low vegetable intake under different scenarios of future vegetable consumption, our study can inform the design of targeted interventions for public health challenges.

Assessment of Suicide in Japan During the COVID-19 Pandemic vs Previous Years.

Importance: There are concerns that suicide rates may have increased during the coronavirus disease 2019 (COVID-19) pandemic. Objective: To assess whether suicide rates in Japan increased in April through November 2020 compared with previous years. Design, Setting, and Participants: This cross-sectional study used national data obtained from the Ministry of Health, Labor and Welfare from 2016 to 2020 on the monthly number of individuals who died of suicide in Japan from January to November of 2016 to 2020. Exposure: 2020 vs previous years. Main Outcomes and Measures: The main outcome was monthly suicide rates, calculated as the number of individuals who died of suicide divided by the total population. A difference-in-difference regression model was used to estimate the change in monthly suicide rates in April to November 2020 vs these months in 2016 to 2019. Results: Analyses included 90 048 individuals (61 366 [68.1%] men) who died of suicide from 2016 to 2020. The difference-in-difference analysis of men showed that there was no increase in suicide rates from April through September 2020 compared with these months in 2016 to 2019, but that suicide rates were increased in October (difference-in-difference, 0.40 [95% CI, 0.14 to 0.67] suicide deaths per 100 000 population) and November (difference-in-difference, 0.34 [95% CI, 0.07 to 0.60] suicide deaths per 100 000 population). Among women, suicide rates in 2020 compared with 2016 to 2019 increased in July (difference-in-difference, 0.24 [95% CI, 0.09 to 0.38] suicide deaths per 100 000 population), August (difference-in-difference, 0.30 [95% CI, 0.16 to 0.45] suicide deaths per 100 000 population), September (difference-in-difference, 0.29 [95% CI, 0.15 to 0.44] suicide deaths per 100 000 population), October (difference-in-difference, 0.62 [95% CI, 0.48 to 0.77] suicide deaths per 100 000 population), and November (difference-in-difference, 0.29 [95% CI, 0.15 to 0.44] suicide deaths per 100 000 population). In secondary analyses in which the suicide rates of 2020 were compared with the expected rates based on trends from 2011 to 2019, the increases in suicide rates were most pronounced among men aged younger than 30 years (eg, November: observed vs expected rate ratio [RR], 1.48 [95% CI, 1.26-1.71]) and women aged younger than 30 years (eg, October: observed vs expected RR, 2.14 [95% CI, 1.76 to 2.52]) and 30 to 49 years (eg, October: observed vs expected RR, 2.30 [95% CI, 2.01 to 2.58]). Conclusions and Relevance: These findings suggest that compared with previous years, suicide rates in Japan in 2020 increased in October and November for men and in July through November for women.

Associations between parental socioeconomic position and health-seeking behaviour for diarrhoea and acute respiratory infection among under-5 children in Myanmar: a cross-sectional study.

OBJECTIVES: To examine the associations of parental social and economic position with health-seeking behaviour for diarrhoea and acute respiratory infection (ARI) among under-5 children in Myanmar and explore potential underlying mechanisms. DESIGN: A cross-sectional study. SETTING: A secondary dataset from the nationwide 2015-2016 Myanmar Demographic and Health Survey (MDHS). PARTICIPANTS: All under-5 children in the sampled households with reported symptoms of diarrhoea and ARI during the 2-week period preceding the MDHS survey interview. PRIMARY AND SECONDARY OUTCOME MEASURES: Four parental health-seeking behaviours: 'seeking treatment', 'formal health provider', 'public provider' and 'private provider' were considered. Social and economic positions were determined by confirmatory factor analysis. Multilevel logistic regressions were employed to examine the associations of social and economic positions with health-seeking behaviours for diarrhoea and ARI. Mediation analyses were conducted to explore potential underlying mechanisms in these associations. RESULTS: Of the 4099 under-5 children from the sampled households in MDHS, 427 (10.4%) with diarrhoea and 131 (3.2%) with ARI were considered for the analyses. For diarrhoea, social position was positively associated with seeking treatment and private provider use (adjusted OR: 1.60 (95% CIs: 1.07 to 2.38) and 1.83 (1.00 to 3.34), respectively). Economic position was positively associated with private provider use for diarrhoea (1.57 (1.07 to 2.30)). Negative associations were observed between social and economic positions with public provider use for diarrhoea (0.55 (0.30 to 0.99) and 0.64 (0.43 to 0.94), respectively). Social position had more influence than economic position on parental health-seeking behaviour for children with diarrhoea. No evidence for a significant association of social and economic position with health-seeking for ARI was observed. CONCLUSIONS: Social and economic positions were possible determinants of health-seeking behaviour for diarrhoea among children; and social position had more influence than economic position. The results of this study may contribute to improve relevant interventions for diarrhoea and ARI among children in Myanmar.

Prevalence and types of sexual inactivity in Britain: analyses of national cross-sectional probability survey data.

OBJECTIVES: To examine how prevalence and context of sexual inactivity varies across the life-course, assess dissatisfaction with sex life among those who are sexually inactive and identify associations with factors that may represent reasons for sexual inactivity. DESIGN: Analysis of cross-sectional probability sample survey data. SETTING: British general population. PARTICIPANTS: 14 623 participants (n men: 6045 unweighted, 7245 weighted), aged 16-74 years, of the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), undertaken in 2010-2012. MAIN OUTCOME MEASURES: Sexual inactivity, defined as not reporting oral, vaginal or anal intercourse in the past year and further categorised into those who were sexually inexperienced (had never had sex), single or in a relationship. RESULTS: Overall, 15.9% (weighted n 1155/7245) of men and 22.2% (1646/7410) of women were sexually inactive (p<0.001). The proportion of sexually inactive individuals who were sexually inexperienced was larger among men than women (26.3% (304/1155) vs 16.3% (268/1646)), while the proportion who were singles was larger among women (49.8% (820/1646) vs 40.4% (467/1155)). Sexual inexperience was the most common type of sexual inactivity in early adulthood, with this declining with age. A minority of those who had sexual experience but were sexually inactive-34.8% (293/842) of men and 23.6% (319/1349) of women-reported being dissatisfied with their sex lives. Associations with sexual inactivity was observed for a range of sociodemographics and sexual behaviours/attitudes, for example, religion, ethnicity, Body mass index, height, employment status and index of multiple deprivation; these associations varied by type of sexual inactivity and gender. CONCLUSIONS: While sex is important for well-being, a non-negligible proportion of the population at all ages are sexually inactive, yet many are not dissatisfied with their situation, with implications for sex and relationship counselling.

Gotta catch'em all! Pokémon GO and physical activity among young adults: difference in differences study.

OBJECTIVE:  To estimate the effect of playing Pokémon GO on the number of steps taken daily up to six weeks after installation of the game. DESIGN:  Cohort study using online survey data. PARTICIPANTS:  Survey participants of Amazon Mechanical Turk (n=1182) residing in the United States, aged 18 to 35 years and using iPhone 6 series smartphones. MAIN OUTCOME MEASURES:  Number of daily steps taken each of the four weeks before and six weeks after installation of Pokémon GO, automatically recorded in the "Health" application of the iPhone 6 series smartphones and reported by the participants. A difference in difference regression model was used to estimate the change in daily steps in players of Pokémon GO compared with non-players. RESULTS:  560 (47.4%) of the survey participants reported playing Pokémon GO and walked on average 4256 steps (SD 2697) each day in the four weeks before installation of the game. The difference in difference analysis showed that the daily average steps for Pokémon GO players during the first week of installation increased by 955 additional steps (95% confidence interval 697 to 1213), and then this increase gradually attenuated over the subsequent five weeks. By the sixth week after installation, the number of daily steps had gone back to pre-installation levels. No significant effect modification of Pokémon GO was found by sex, age, race group, bodyweight status, urbanity, or walkability of the area of residence. CONCLUSIONS:  Pokémon GO was associated with an increase in the daily number of steps after installation of the game. The association was, however, moderate and no longer observed after six weeks.

Month of birth and cause-specific mortality between 50 and 80 years: a population-based longitudinal cohort study in Sweden.

Month of birth-a proxy for a variety of prenatal and early postnatal exposures including nutritional status, ambient temperature and infections-has been linked to mortality risk in adult life. We assessed the relation between month of birth and cause-specific mortality risk from cardiovascular diseases, infections, tumors and external causes-in ages of more than 50-80 years. In this nation-wide Swedish study, 4,240,338 subjects were followed from 1991 to 2010, using data from population-based health and administrative registries. The relation between month of birth and cause-specific mortality risk was assessed by fitting Cox proportional hazard regression models with attained age as the underlying time scale. In models adjusted for sex and education, month of birth was associated with cardiovascular and infectious mortality, but not with deaths from tumors or external causes. Compared with subjects born in November, a higher cardiovascular mortality was seen in subjects born from January through August, peaking in March/April [hazard ratio (HR) 1.066 compared to November, 95 % CI 1.045-1.086]. The mortality from infections was lowest for the birth months November and December and a distinct peak was observed for September-born (HR 1.108 compared to November, 95 % CI 1.046-1.175). Month of birth is associated with mortality from cardiovascular diseases and infections in ages of more than 50-80 years in Sweden. The mechanisms behind these associations remain to be elucidated.

Food marketing towards children: brand logo recognition, food-related behavior and BMI among 3-13-year-olds in a south Indian town.

OBJECTIVES: To assess exposure to marketing of unhealthy food products and its relation to food related behavior and BMI in children aged 3-13, from different socioeconomic backgrounds in a south Indian town. METHODS: Child-parent pairs (n=306) were recruited at pediatric clinics. Exposure to food marketing was assessed by a digital logo recognition test. Children matched 18 logos of unhealthy food (high in fat/sugar/salt) featured in promotion material from the food industry to pictures of corresponding products. Children's nutritional knowledge, food preferences, purchase requests, eating behavior and socioeconomic characteristics were assessed by a digital game and parental questionnaires. Anthropometric measurements were recorded. RESULTS: Recognition rates for the brand logos ranged from 30% to 80%. Logo recognition ability increased with age (p<0.001) and socioeconomic level (p<0.001 comparing children in the highest and lowest of three socioeconomic groups). Adjusted for gender, age and socioeconomic group, logo recognition was associated with higher BMI (p=0.022) and nutritional knowledge (p<0.001) but not to unhealthy food preferences or purchase requests. CONCLUSIONS: Children from higher socioeconomic groups in the region had higher brand logo recognition ability and are possibly exposed to more food marketing. The study did not lend support to a link between exposure to marketing and poor eating behavior, distorted nutritional knowledge or increased purchase requests. The correlation between logo recognition and BMI warrants further investigation on food marketing towards children and its potential role in the increasing burden of non-communicable diseases in this part of India.