Development of an action programme tackling obesity-related behaviours in adolescents: a participatory system dynamics approach.

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10-14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

Socioeconomic inequalities in self-rated health in Japan, 32 European countries and the United States: an international comparative study.

AIMS: Japan is known as a country with low self-rated health despite high life expectancy. We compared socioeconomic inequalities in self-rated health in Japan with those in 32 European countries and the US using nationally representative samples. METHODS: We analysed individual data from the Comprehensive Survey of Living Conditions (Japan), the European Union Statistics on Income and Living Conditions, and the Behavioral Risk Factor Surveillance System (US) in 2016. We used ordered logistic regression models with four ordinal categories of self-rated health as an outcome, and educational level or occupational class as independent variables, controlling for age. RESULTS: In Japan, about half the population perceived their health as 'fair', which was much higher than in Europe (≈20-40%). The odds ratios of lower self-rated health among less educated men compared with more educated were 1.72 (95% confidence interval (CI) 1.61-1.85) in Japan, and ranged from 1.67 to 4.74 in Europe (pooled; 2.10 (95% CI 2.01-2.20)), and 6.65 (95% CI 6.22-7.12) in the US. The odds ratios of lower self-rated health among less educated women were 1.79 (95% CI 1.65-1.95) in Japan, and ranged from 1.89 to 5.30 in Europe (pooled; 2.43 (95% CI 2.33-2.54)), and 8.82 (95% CI 8.29-9.38) in the US. Socioeconomic inequalities were large when self-rated health was low for European countries, but Japan and the US did not follow the pattern. CONCLUSIONS: Japan has similar socioeconomic gradient patterns to European countries for self-rated health, and our findings revealed smaller socioeconomic inequalities in self-rated health in Japan compared with those in western countries.

Future trends of life expectancy by education in the Netherlands.

BACKGROUND: National projections of life expectancy are made periodically by statistical offices or actuarial societies in Europe and are widely used, amongst others for reforms of pension systems. However, these projections may not provide a good estimate of the future trends in life expectancy of different social-economic groups. The objective of this study is to provide insight in future trends in life expectancies for low, mid and high educated men and women living in the Netherlands. METHODS: We used a three-layer Li and Lee model with data from neighboring countries to complement Dutch time series. RESULTS: Our results point at further increases of life expectancy between age 35 and 85 and of remaining life expectancy at age 35 and age 65, for all education groups in the Netherlands. The projected increase in life expectancy is slightly larger among the high educated than among the low educated. Life expectancy of low educated women, particularly between age 35 and 85, shows the smallest projected increase. Our results also suggest that inequalities in life expectancies between high and low educated will be similar or slightly increasing between 2018 and 2048. We see no indication of a decline in inequality between the life expectancy of the low and high educated. CONCLUSIONS: The educational inequalities in life expectancy are expected to persist or slightly increase for both men and women. The persistence and possible increase of inequalities in life expectancy between the educational groups may cause equity concerns of increases in pension age that are equal among all socio-economic groups.

Projecting years in good health between age 50-69 by education in the Netherlands until 2030 using several health indicators - an application in the context of a changing pension age.

OBJECTIVE: We investigate whether there are changes over time in years in good health people can expect to live above (surplus) or below (deficit) the pension age, by level of attained education, for the past (2006), present (2018) and future (2030) in the Netherlands. METHODS: We used regression analysis to estimate linear trends in prevalence of four health indicators: self-assessed health (SAH), the Organization for Economic Co-operation and Development (OECD) functional limitation indicator, the OECD indicator without hearing and seeing, and the activities-of-daily-living (ADL) disability indicator, for individuals between 50 and 69 years of age, by age category, gender and education using the Dutch National Health Survey (1989-2018). We combined these prevalence estimates with past and projected mortality data to obtain estimates of years lived in good health. We calculated how many years individuals are expected to live in good health above (surplus) or below (deficit) the pension age for the three points in time. The pension ages used were 65 years for 2006, 66 years for 2018 and 67.25 years for 2030. RESULTS: Both for low educated men and women, our analyses show an increasing deficit of years in good health relative to the pension age for most outcomes, particularly for the SAH and OECD indicator. For high educated we find a decreasing surplus of years lived in good health for all indicators with the exception of SAH. For women, absolute inequalities in the deficit or surplus of years in good health between low and high educated appear to be increasing over time. CONCLUSIONS: Socio-economic inequalities in trends of mortality and the prevalence of ill-health, combined with increasing statutory pension age, impact the low educated more adversely than the high educated. Policies are needed to mitigate the increasing deficit of years in good health relative to the pension age, particularly among the low educated.

Smoking and inequalities in mortality in 11 European countries: a birth cohort analysis.

PURPOSE: To study the trends of smoking-attributable mortality among the low and high educated in consecutive birth cohorts in 11 European countries. METHODS: Register-based mortality data were collected among adults aged 30 to 79 years in 11 European countries between 1971 and 2012. Smoking-attributable deaths were estimated indirectly from lung cancer mortality rates using the Preston-Glei-Wilmoth method. Rate ratios and rate differences among the low and high-educated were estimated and used to estimate the contribution of inequality in smoking-attributable mortality to inequality in total mortality. RESULTS: In most countries, smoking-attributable mortality decreased in consecutive birth cohorts born between 1906 and 1961 among low- and high-educated men and high-educated women, but not among low-educated women among whom it increased. Relative educational inequalities in smoking-attributable mortality increased among both men and women with no signs of turning points. Absolute inequalities were stable among men but slightly increased among women. The contribution of inequality in smoking-attributable mortality to inequality in total mortality decreased in consecutive generations among men but increased among women. CONCLUSIONS: Smoking might become less important as a driver of inequalities in total mortality among men in the future. However, among women, smoking threatens to further widen inequalities in total mortality.

Are we really all in this together? The social patterning of mortality during the first wave of the COVID-19 pandemic in Belgium.

BACKGROUND: Belgium was one of the countries that was struck hard by COVID-19. Initially, the belief was that we were 'all in it together'. Emerging evidence showed however that deprived socioeconomic groups suffered disproportionally. Yet, few studies are available for Belgium. The main question addressed in this paper is whether excess mortality during the first COVID-19 wave followed a social gradient and whether the classic mortality gradient was reproduced. METHODS: We used nationwide individually linked data from the Belgian National Register and the Census 2011. Age-standardized all-cause mortality rates were calculated during the first COVID-19 wave in weeks 11-20 in 2020 and compared with the rates during weeks 11-20 in 2015-2019 to calculate absolute and relative excess mortality by socioeconomic and -demographic characteristics. For both periods, relative inequalities in total mortality between socioeconomic and -demographic groups were calculated using Poisson regression. Analyses were stratified by age, gender and care home residence. RESULTS: Excess mortality during the first COVID-19 wave was high in collective households, with care homes hit extremely hard by the pandemic. The social patterning of excess mortality was rather inconsistent and deviated from the usual gradient, mainly through higher mortality excesses among higher socioeconomic groups classes in specific age-sex groups. Overall, the first COVID-19 wave did not change the social patterning of mortality, however. Differences in relative inequalities between both periods were generally small and insignificant, except by household living arrangement. CONCLUSION: The social patterning during the first COVID-19 wave was exceptional as excess mortality did not follow the classic lines of higher mortality in lower classes and patterns were not always consistent. Relative mortality inequalities did not change substantially during the first COVID-19 wave compared to the reference period.

Mixed evidence for the compression of morbidity hypothesis for smoking elimination-a systematic literature review.

BACKGROUND: There is debate around the composition of life years gained from smoking elimination. The aim of this study was to conduct a systematic review of the literature to synthesize existing evidence on the effect of smoking status on health expectancy and to examine whether smoking elimination leads to compression of morbidity. METHODS: Five databases were systematically searched for peer-reviewed articles. Studies that presented quantitative estimates of health expectancy for smokers and non-/never-smokers were eligible for inclusion. Studies were searched, selected and reviewed by two reviewers who extracted the relevant data and assessed the risk of bias of the included articles independently. RESULTS: The search identified 2491 unique records, whereof 20 articles were eligible for inclusion (including 26 cohorts). The indicators used to measure health included disability/activity limitations (n=9), health-related quality of life (EQ-5D) (n=2), weighted disabilities (n=1), self-rated health (n=9), chronic diseases (n=6), cardiovascular diseases (n=4) and cognitive impairment (n=1). Available evidence showed consistently that non-/never-smokers experience more healthy life years throughout their lives than smokers. Findings were inconsistent on the effect of smoking on the absolute number of unhealthy life years. Findings concerning the time proportionally spent unhealthy were less heterogeneous: nearly all included articles reported that non-/never-smokers experience relatively less unhealthy life years (e.g. relative compression of morbidity). CONCLUSIONS: Support for the relative compression of morbidity due to smoking elimination was evident. Further research is needed into the absolute compression of morbidity hypothesis since current evidence is mixed, and methodology of studies needs to be harmonized.

Determinants of inequalities in years with disability: an international-comparative study.

BACKGROUND: Persons with a lower socioeconomic position spend more years with disability, despite their shorter life expectancy, but it is unknown what the important determinants are. This study aimed to quantify the contribution to educational inequalities in years with disability of eight risk factors: father's manual occupation, low income, few social contacts, smoking, high alcohol consumption, high body-weight, low physical exercise and low fruit and vegetable consumption. METHODS: We collected register-based mortality and survey-based disability and risk factor data from 15 European countries covering the period 2010-14 for most countries. We calculated years with disability between the ages of 35 and 80 by education and gender using the Sullivan method, and determined the hypothetical effect of changing the prevalence of each risk factor to the prevalence observed among high educated ('upward levelling scenario'), using Population Attributable Fractions. RESULTS: Years with disability among low educated were higher than among high educated, with a difference of 4.9 years among men and 5.5 years among women for all countries combined. Most risk factors were more prevalent among low educated. We found the largest contributions to inequalities in years with disability for low income (men: 1.0 year; women: 1.4 year), high body-weight (men: 0.6 year; women: 1.2 year) and father's manual occupation (men: 0.7 year; women: 0.9 year), but contributions differed by country. The contribution of smoking was relatively small. CONCLUSIONS: Disadvantages in material circumstances (low income), circumstances during childhood (father's manual occupation) and high body-weight contribute to inequalities in years with disability.

Trends in health inequalities in 27 European countries.

Unfavorable health trends among the lowly educated have recently been reported from the United States. We analyzed health trends by education in European countries, paying particular attention to the possibility of recent trend interruptions, including interruptions related to the impact of the 2008 financial crisis. We collected and harmonized data on mortality from ca 1980 to ca 2014 for 17 countries covering 9.8 million deaths and data on self-reported morbidity from ca 2002 to ca 2014 for 27 countries covering 350,000 survey respondents. We used interrupted time-series analyses to study changes over time and country-fixed effects analyses to study the impact of crisis-related economic conditions on health outcomes. Recent trends were more favorable than in previous decades, particularly in Eastern Europe, where mortality started to decline among lowly educated men and where the decline in less-than-good self-assessed health accelerated, resulting in some narrowing of health inequalities. In Western Europe, mortality has continued to decline among the lowly and highly educated, and although the decline of less-than-good self-assessed health slowed in countries severely hit by the financial crisis, this affected lowly and highly educated equally. Crisis-related economic conditions were not associated with widening health inequalities. Our results show that the unfavorable trends observed in the United States are not found in Europe. There has also been no discernible short-term impact of the crisis on health inequalities at the population level. Both findings suggest that European countries have been successful in avoiding an aggravation of health inequalities.

Potential gains in health expectancy by improving lifestyle: an application for European regions.

BACKGROUND: Prevention aiming at smoking, alcohol consumption, and BMI could potentially bring large gains in life expectancy (LE) and health expectancy measures such as Healthy Life Years (HLY) and Life Expectancy in Good Perceived Health (LEGPH) in the European Union. However, the potential gains might differ by region. METHODS: A Sullivan life table model was applied for 27 European countries to calculate the impact of alternative scenarios of lifestyle behavior on life and health expectancy. Results were then pooled over countries to present the potential gains in HLY and LEGPH for four European regions. RESULTS: Simulations show that up to 4 years of extra health expectancy can be gained by getting all countries to the healthiest levels of lifestyle observed in EU countries. This is more than the 2 years to be gained in life expectancy. Generally, Eastern Europe has the lowest LE, HLY, and LEGPH. Even though the largest gains in LEPGH and HLY can also be made in Eastern Europe, the gap in LE, HLY, and LEGPH can only in a small part be closed by changing smoking, alcohol consumption, and BMI. CONCLUSION: Based on the current data, up to 4 years of good health could be gained by adopting lifestyle as seen in the best-performing countries. Only a part of the lagging health expectancy of Eastern Europe can potentially be solved by improvements in lifestyle involving smoking and BMI. Before it is definitely concluded that lifestyle policy for alcohol use is of relatively little importance compared to smoking or BMI, as our findings suggest, better data should be gathered in all European countries concerning alcohol use and the odds ratios of overconsumption of alcohol.

Progress against inequalities in mortality: register-based study of 15 European countries between 1990 and 2015.

Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., 'relative' and 'absolute' inequalities, inequalities in 'attainment' and 'shortfall'). We determined which causes of death contributed to narrowing of inequalities, and conducted country- and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.

Socioeconomic inequalities in disability in Europe: contribution of behavioral, work-related and living conditions.

BACKGROUND: Previous studies have shown the existence of social inequalities in disability in many European countries. However, it is not clear what factors are associated with these inequalities. The aim of this study was to assess the contribution of behavioral factors, work-related factors and living conditions to educational inequalities in disability. METHODS: We pooled data from the seventh wave of the European Social Survey (2014) which included self-reported disability measured with the Global Activity Limitations Indicator for 19 European countries. We used multivariate logistic regression to determine the contributions of behavioral factors, work-related and living conditions to educational inequalities in disability among respondents aged 30-79. RESULTS: We found that adjusting simultaneously for three groups of determinants (behavioral, work-related and living conditions) reduces the greatest proportion of inequalities in disability in both men and women, in a range >70%. Each group of determinants contributes substantially to explain inequalities in disability. CONCLUSIONS: Inequalities in disability are a major challenge for public health in most European countries. Our findings suggest that these inequalities can be reduced by diminishing inequalities in exposure to well-known health determinants.

Women's excess unhealthy life years: disentangling the unhealthy life years gap.

BACKGROUND: Compared to men, women live longer but have more years with disability. We assessed the contribution of gender differences in mortality and disability, total and by cause, to women's excess unhealthy life years (ULYs). METHODS: We used mortality data for France 2008 from Eurostat, causes of death from the CépiDc-INSERM-database; and disability and chronic conditions data from the French Disability Health Survey 2008-09. ULYs were calculated by the Sullivan method. The contributions of mortality and disability differences to gender differences in ULY were based on decomposition analyses. RESULTS: Life expectancy of French women aged 50 was 36.3 years of which 19.0 were ULYs; life expectancy of men was 30.4 years of which 14.2 were ULYs. Of the 4.8 excess ULYs in women, 4.0 years were due to lower mortality. Of these 4.0 ULYs, 1.8 ULY originated from women's lower mortality from cancer, 0.8 ULY from heart disease and 0.3 ULY from accidents. The remaining 0.8 excess ULY in women were from higher disability prevalence, including higher disability from musculoskeletal diseases (+1.8 ULY) and anxiety-depression (+0.6 ULY) partly offset by lower disability from heart diseases (-0.8 ULY) and accidents (-0.3 ULY). CONCLUSION: Lower mortality and higher disability prevalence contributed to women's longer life expectancy with disability. Women's higher disability prevalence due to non-fatal disabling conditions was partly offset by lower disability from heart disease and accidents. Conditions differentially impact gender differences in ULY, depending on whether they are mainly life-threatening or disabling. The conclusions confirm the health-survival paradox.

Contribution of chronic conditions to disability in men and women in France.

Background: Women report more disability than men perhaps due to gender differences in the prevalence of diseases and/or in their disabling impact. We compare the contribution of chronic diseases to disability in men and women in France, using a disability survey conducted in both private households and institutions, and we also examine the effect of excluding the institutionalized population. Methods: Data comprised 17 549 individuals age 50+, who participated in the 2008-09 French Disability Health Survey including people living in institutions. Disability was defined by limitations in activities people usually do due to health problems (global activity limitation indicator). Additive regression models were fitted separately by gender to estimate the contribution of conditions to disability taking into account multi-morbidity. Results: Musculoskeletal diseases caused most disability for both men (10.1%, CI: 8.1-12.0) and women (16.0%, CI 13.6-18.2). The second contributor for men was heart diseases (5.7%, CI: 4.5-6.9%), and for women anxiety-depression (4.0, CI 3.1-5.0%) closely followed by heart diseases (3.8%, CI 2.9-4.7%). Women's higher contribution of musculoskeletal diseases reflected their higher prevalence and disabling impact; women's higher contribution of anxiety-depression and lower contributions of heart diseases reflected gender differences in prevalence. Excluding the institutionalized population did not change the overall conclusions. Conclusions: The largest contributors to the higher disability of women than men are moderately disabling conditions with a high prevalence. Whereas traditional disabling conditions such as musculoskeletal diseases are more prevalent and disabling in women, fatal diseases such as cardiovascular disease are also important contributors in women and men.

Unnatural death: a major but largely preventable cause-of-death among homeless people?

Background: We aimed to assess the contribution of specific causes-of-death to excess mortality of homeless persons and to identify differences in cause-specific mortality rates after vs. before implementing social policy measures. Methods: We conducted a register based 10-year follow-up study of homeless adults in Rotterdam and calculated the proportion of deaths by cause-of-death in this cohort in the period 2001-2010. We estimated cause-specific mortality among the homeless compared to the general population with Standardized Mortality Ratios. We calculated Hazard Ratios adjusted for age and sex to compare mortality rates by cause-of-death among the homeless in the period after (2006-2010) vs. before (2001-2005) implementing social policy measures. Results: Our cohort consisted of 2130 homeless persons with a mean age of 40, 3 years. Unnatural death, cardiovascular disease and cancer were the main causes of death. Compared to the general population of Rotterdam, the homeless had an excess risk of death for all causes. The largest mortality differences with Rotterdam citizens were observed for unnatural death (SMR 14.8, CI 11.5-18.7), infectious diseases (SMR 10.0, CI 5.2-17.5) and psychiatric disorders (SMR 7.7, CI 4.0-13.5). Mortality due to intentional injuries (suicide and homicide) differed significantly between the two study periods (HR 0.45, CI 0.20-0.97). Conclusions: Reducing unnatural death should be a target in social policies aimed at improving the health of the homeless. We generated the hypothesis that social policies aimed at housing, work and improved contact with health care could be accompanied by less suicides and homicides within this vulnerable group.

Physical activity types and life expectancy with and without cardiovascular disease: the Rotterdam Study.

Background: We aimed to determine the contribution of specific physical activity (PA) types (i.e. walking, cycling, domestic work, sports and gardening) on total life expectancy (LE) and LE with and without cardiovascular disease (CVD). Methods: We constructed multistate life tables to calculate the effects of total PA and PA types on LE, among individuals older than 55 years from the Rotterdam Study. For the life table calculations, we used sex-specific prevalences, incident rates and hazard ratios for three transitions (healthy-to-CVD, healthy-to-death and CVD-to-death) by levels of PA and adjusted for confounders. Results: High total PA was associated with gains in total and CVD-free LE. High cycling contributed to higher total LE in men (3.7 years) and women (2.1 years) and higher LE without CVD in men (3.1 years) and women (2.4 years). Total and CVD-free LE were increased by high domestic work in women (2.6 and 2.4 years, respectively) and high gardening in men (2.7 and 2.0 years, respectively). Conclusions: Higher PA levels are associated with increased LE and more years lived without CVD. Of the different PA types, cycling provided high effects in both men and women. Cycling could be more strongly encouraged in activity guidelines to maximize the population benefits of PA.

Taking multi-morbidity into account when attributing DALYs to risk factors: comparing dynamic modeling with the GBD2010 calculation method.

BACKGROUND: Disability Adjusted Life Years (DALYs) quantify the loss of healthy years of life due to dying prematurely and due to living with diseases and injuries. Current methods of attributing DALYs to underlying risk factors fall short on two main points. First, risk factor attribution methods often unjustly apply incidence-based population attributable fractions (PAFs) to prevalence-based data. Second, it mixes two conceptually distinct approaches targeting different goals, namely an attribution method aiming to attribute uniquely to a single cause, and an elimination method aiming to describe a counterfactual situation without exposure. In this paper we describe dynamic modeling as an alternative, completely counterfactual approach and compare this to the approach used in the Global Burden of Disease 2010 study (GBD2010). METHODS: Using data on smoking in the Netherlands in 2011, we demonstrate how an alternative method of risk factor attribution using a pure counterfactual approach results in different estimates for DALYs. This alternative method is carried out using the dynamic multistate disease table model DYNAMO-HIA. We investigate the differences between our alternative method and the method used by the GBD2010 by doing additional analyses using data from a synthetic population in steady state. RESULTS: We observed important differences between the outcomes of the two methods: in an artificial situation where dynamics play a limited role, DALYs are a third lower as compared to those calculated with the GBD2010 method (398,000 versus 607,000 DALYs). The most important factor is newly occurring morbidity in life years gained that is ignored in the GBD2010 approach. Age-dependent relative risks and exposures lead to additional differences between methods as they distort the results of prevalence-based DALY calculations, but the direction and magnitude of the distortions depend on the particular situation. CONCLUSIONS: We argue that the GBD2010 approach is a hybrid of an attributional and counterfactual approach, making the end result hard to understand, while dynamic modelling uses a purely counterfactual approach and thus yields better interpretable results.

Multinomial additive hazard model to assess the disability burden using cross-sectional data.

Population aging is accompanied by the burden of chronic diseases and disability. Chronic diseases are among the main causes of disability, which is associated with poor quality of life and high health care costs in the elderly. The identification of which chronic diseases contribute most to the disability prevalence is important to reduce the burden. Although longitudinal studies can be considered the gold standard to assess the causes of disability, they are costly and often with restricted sample size. Thus, the use of cross-sectional data under certain assumptions has become a popular alternative. Among the existing methods based on cross-sectional data, the attribution method, which was originally developed for binary disability outcomes, is an attractive option, as it enables the partition of disability into the additive contribution of chronic diseases, taking into account multimorbidity and that disability can be present even in the absence of disease. In this paper, we propose an extension of the attribution method to multinomial responses, since disability is often measured as a multicategory variable in most surveys, representing different severity levels. The R function constrOptim is used to maximize the multinomial log-likelihood function subject to a linear inequality constraint. Our simulation study indicates overall good performance of the model, without convergence problems. However, the model must be used with care for populations with low marginal disability probabilities and with high sum of conditional probabilities, especially with small sample size. For illustration, we apply the model to the data of the Belgian Health Interview Surveys.

Obesity and Life Expectancy with and without Diabetes in Adults Aged 55 Years and Older in the Netherlands: A Prospective Cohort Study.

BACKGROUND: Overweight and obesity are associated with increased risk of type 2 diabetes. Limited evidence exists regarding the effect of excess weight on years lived with and without diabetes. We aimed to determine the association of overweight and obesity with the number of years lived with and without diabetes in a middle-aged and elderly population. METHODS AND FINDINGS: The study included 6,499 individuals (3,656 women) aged 55 y and older from the population-based Rotterdam Study. We developed a multistate life table to calculate life expectancy for individuals who were normal weight, overweight, and obese and the difference in years lived with and without diabetes. For life table calculations, we used prevalence, incidence rate, and hazard ratios (HRs) for three transitions (healthy to diabetes, healthy to death, and diabetes to death), stratifying by body mass index (BMI) at baseline and adjusting for confounders. During a median follow-up of 11.1 y, we observed 697 incident diabetes events and 2,192 overall deaths. Obesity was associated with an increased risk of developing diabetes (HR: 2.13 [p < 0.001] for men and 3.54 [p < 0.001] for women). Overweight and obesity were not associated with mortality in men and women with or without diabetes. Total life expectancy remained unaffected by overweight and obesity. Nevertheless, men with obesity aged 55 y and older lived 2.8 (95% CI -6.1 to -0.1) fewer y without diabetes than normal weight individuals, whereas, for women, the difference between obese and normal weight counterparts was 4.7 (95% CI -9.0 to -0.6) y. Men and women with obesity lived 2.8 (95% CI 0.6 to 6.2) and 5.3 (95% CI 1.6 to 9.3) y longer with diabetes, respectively, compared to their normal weight counterparts. Since the implications of these findings could be limited to middle-aged and older white European populations, our results need confirmation in other populations. CONCLUSIONS: Obesity in the middle aged and elderly is associated with a reduction in the number of years lived free of diabetes and an increase in the number of years lived with diabetes. Those extra years lived with morbidity might place a high toll on individuals and health care systems.