Socioeconomic Inequalities in Type 2 Diabetes: Mediation Through Status Anxiety?

Objectives: While status anxiety has received attention as a potential mechanism generating health inequalities, empirical evidence is still limited. Studies have been ecological and have largely focused on mental and not physical health outcomes. Methods: We conducted individual-level analyses to assess status anxiety (feelings of inferiority resulting from social comparisons) and resources (financial difficulties) as mediators of the relationship between socioeconomic status (SES) (education/occupation/employment status) and type 2 diabetes (T2D). We used cross-sectional data of 21,150 participants (aged 18-70 years) from the Amsterdam-based HELIUS study. We estimated associations using logistic regression models and estimated mediated proportions using natural effect modelling. Results: Odds of status anxiety were higher among participants with a low SES [e.g., OR = 2.66 (95% CI: 2.06-3.45) for elementary versus academic occupation]. Odds of T2D were 1.49 (95% CI: 1.12-1.97) times higher among participants experiencing status anxiety. Proportion of the SES-T2D relationship mediated was 3.2% (95% CI: 1.5%-7.0%) through status anxiety and 10.9% (95% CI: 6.6%-18.0%) through financial difficulties. Conclusion: Status anxiety and financial difficulties played small but consistent mediating roles. These individual-level analyses underline status anxiety's importance and imply that status anxiety requires attention in efforts to reduce health inequalities.

The effect on women's health of extending parental leave: a quasi-experimental registry-based cohort study.

BACKGROUND: Parental leave policies have been hypothesized to benefit mothers' mental health. We assessed the impact of a 6-week extension of parental leave in Denmark on maternal mental health. METHODS: We linked individual-level data from Danish national registries on maternal sociodemographic characteristics and psychiatric diagnoses. A regression discontinuity design was applied to study the increase in parental leave duration after 26 March 1984. We included women who had given birth between 1 January 1981 and 31 December 1987. Our outcome was a first psychiatric diagnosis following the child's birth, ascertained as the first day of inpatient hospital admission for any psychiatric disorder. We presented cumulative incidences for the 30-year follow-up period and reported absolute risk differences between women eligible for the reform vs not, in 5-year intervals. RESULTS: In all, 291 152 women were followed up until 2017, death, emigration or date of first psychiatric diagnosis. The median follow-up time was 29.99 years, corresponding to 10 277 547 person-years at risk. The cumulative incidence of psychiatric diagnoses at 30 years of follow-up was 59.5 (95% CI: 57.4 to 61.6) per 1000 women in the ineligible group and 57.5 (95% CI: 55.6 to 59.4) in the eligible group. Eligible women took on average 32.85 additional days of parental leave (95% CI: 29.20 to 36.49) and had a lower probability of having a psychiatric diagnosis within 5 years [risk difference (RD): 2.4 fewer diagnoses per 1000 women, 95% CI: 1.5 to 3.2] and up to 20 years after the birth (RD: 2.3, 95% CI: 0.4 to 4.2). In subgroup analyses, the risk reduction was concentrated among low-educated, low-income and single women. CONCLUSIONS: Longer parental leave may confer mental health benefits to women, in particular to those from disadvantaged backgrounds.

Chronic disorders, work-unit leadership quality and long-term sickness absence among 33 025 public hospital employees.

OBJECTIVE: This study aimed to examine the association between work-unit level leadership quality and individual-level long-term sickness absence (LTSA) in the hospital sector and effect modification by chronic disorders. METHODS: This longitudinal analysis included 33 025 Danish public hospital employees who were followed-up for one year after baseline in March 2014. Leadership quality was assessed by questionnaire with mean responses aggregated by work-unit and characterized in tertiles. LTSA during follow-up was determined from employer records. Chronic disorders at baseline was assessed from the Danish hospital and prescription registers. We performed multilevel logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) adjusting for potential confounders. We evaluated interaction between chronic illness and low leadership quality on multiplicative and additive scales. RESULTS: We identified employees as healthy (60.8%) or with somatic (31.6%), mental (3.3%), or both somatic and mental (4.3%) disorders. During follow-up, 6% of employees registered a LTSA. Medium and high leadership quality were associated with lower risk of LTSA with OR of 0.84 (95% CI 0.76-0.94) and 0.73 (95% CI 0.65-0.82) respectively, compared to low leadership quality. Associations were similar for healthy employees and employees with only somatic disorders, whereas no association was observed for employees with mental disorders (in presence or absence of somatic disorders). No statistically significant (α=0.05) interactions between leadership quality and chronic disorders on LTSA were observed. CONCLUSION: The findings suggest that the quality of leadership in work units is associated with risk of long-term sick leave in the Danish public hospital sector and that strong leadership protects employees against LTSA.

Predicting stress and depressive symptoms using high-resolution smartphone data and sleep behavior in Danish adults.

STUDY OBJECTIVES: The early detection of mental disorders is crucial. Patterns of smartphone behavior have been suggested to predict mental disorders. The aim of this study was to develop and compare prediction models using a novel combination of smartphone and sleep behavior to predict early indicators of mental health problems, specifically high perceived stress and depressive symptoms. METHODS: The data material included two separate population samples nested within the SmartSleep Study. Prediction models were trained using information from 4522 Danish adults and tested in an independent test set comprising of 1885 adults. The prediction models utilized comprehensive information on subjective smartphone behavior, objective night-time smartphone behavior, and self-reported sleep behavior. Receiver operating characteristics area-under-the-curve (ROC AUC) values obtained in the test set were recorded as the performance metrics for each prediction model. RESULTS: Neither subjective nor objective smartphone behavior was found to add additional predictive information compared to basic sociodemographic factors when forecasting perceived stress or depressive symptoms. Instead, the best performance for predicting poor mental health was found in the sleep prediction model (AUC = 0.75, 95% CI: 0.72-0.78) for perceived stress and (AUC = 0.83, 95%CI: 0.80-0.85) for depressive symptoms, which included self-reported information on sleep quantity, sleep quality and the use of sleep medication. CONCLUSIONS: Sleep behavior is an important predictor when forecasting mental health symptoms and it outperforms novel approaches using objective and subjective smartphone behavior.

Proposing network analysis for early life adversity: An application on life event data.

Commonly used methods for modelling early life adversity (e.g., sum-scores, latent class or trajectory approaches, single-adversity approaches, and factor-analytical approaches) have not been able to capture the complex nature of early life adversity. We propose network analysis as an alternative way of modelling early life adversity (ELA). Our aim was to construct a network of fourteen adverse events (AEs) that occurred before the age of 16 in the TRacking Adolescents Individual Lives Survey (TRAILS, N = 1029). To show how network analysis can provide insight into why AEs are associated, we compared findings from the resulting network model to findings from tetrachoric correlation analyses. The resulting network of ELA comprised direct relationships between AEs and more complex, indirect relationships. A total of fifteen edges emerged in the network of AEs (out of 91 possible edges). The correlation coefficients suggested that many AEs were associated. The network model of ELA indicated, however, that several associations were attributable to interactions with other AEs. For example, the zero-order correlation between parental addiction and familial conflicts (0.24) could be explained by interactions with parental divorce. Our application of network analysis shows that using network analysis for modelling the ELA construct allows capturing the constructs' complex nature. Future studies should focus on gaining more insight into the most optimal model estimation and selection procedures, as well as sample size requirements. Network analysis provides researchers with a valuable tool that allows them as well as policy-makers and professionals to gain insight into potential mechanisms through which adversities are associated with each other, and conjunctively, with life course outcomes of interest.

Workplace discrimination as risk factor for long-term sickness absence: Longitudinal analyses of onset and changes in workplace adversity.

Workplace discrimination may affect the health of the exposed employees, but it is not known whether workplace discrimination is also associated with an increased risk of long-term sickness absence. The aim of this study was to examine the longitudinal associations of changes in and onset of workplace discrimination with the risk of long-term sickness absence. Data on workplace discrimination were obtained from 29,597 employees participating in survey waves 2004, 2006, 2008 and/or 2010 of the Finnish Public Sector Study. Four-year changes in long-term sickness absence (≥10 days of medically certified absence with a mental or non-mental diagnosis) were assessed. This covered successive study waves in analyses of onset of workplace discrimination as well as fixed effect analyses of change in workplace discrimination (concurrent i.e. during the exposure year and 1-year lagged i.e. within one year following exposure), by using each employee as his/her own control. The risk of long-term sickness absence due to mental disorders was greater for employees with vs. without onset of workplace discrimination throughout the 4-year period, reaching a peak at the year when the onset of discrimination was reported (adjusted risk ratio 2.13; 95% confidence interval (CI) 1.80-2.52). The fixed effects analyses showed that workplace discrimination was associated with higher odds of concurrent, but not 1-year lagged, long-term sickness absence due to mental disorders (adjusted odds ratio 1.61; 95% CI 1.33-1.96 and adjusted odds ratio 1.02; 95% CI 0.83-1.25, respectively). Long-term sickness absence due to non-mental conditions was not associated with workplace discrimination. In conclusion, these findings suggest that workplace discrimination is associated with an elevated risk of long-term sickness absence due to mental disorders. Supporting an acute effect, the excess risk was confined to the year when workplace discrimination occurred.

'Standing together - at a distance': Documenting changes in mental-health indicators in Denmark during the COVID-19 pandemic.

Aims: There is a need to document the mental-health effects of the COVID-19 pandemic and its associated societal lockdowns. We initiated a large mixed-methods data collection, focusing on crisis-specific worries and mental-health indicators during the lockdown in Denmark. Methods: The study incorporated five data sources, including quantitative surveys and qualitative interviews. The surveys included a time series of cross-sectional online questionnaires starting on 20 March 2020, in which 300 (3×100) Danish residents were drawn every three days from three population groups: the general population (N=1046), families with children (N=1032) and older people (N=1059). These data were analysed by trend analysis. Semi-structured interviews were conducted with 32 people aged 24-83 throughout Denmark to provide context to the survey results and to gain insight into people's experiences of the lockdown. Results: Absolute level of worries, quality of life and social isolation were relatively stable across all population groups during the lockdown, although there was a slight deterioration in older people's overall mental health. Many respondents were worried about their loved ones' health (74-76%) and the potential long-term economic consequences of the pandemic (61-66%). The qualitative interviews documented significant variation in people's experiences, suggesting that the lockdown's effect on everyday life had not been altogether negative. Conclusions: People in Denmark seem to have managed the lockdown without alarming changes in their mental health. However, it is important to continue investigating the effects of the pandemic and various public-health measures on mental health over time and across national contexts.

Smartphone interactions and mental well-being in young adults: A longitudinal study based on objective high-resolution smartphone data.

Aims: To investigate the effects of objectively measured smartphone interactions on indicators of mental well-being among men and women in a population of young adults. Methods: A total of 816 young adults (mean±SD age 21.6±2.6 years; 77% men) from the Copenhagen Network Study were followed with objective recordings of smartphone interactions from calls, texts and social media. Participants self-reported on loneliness, depressive symptoms and disturbed sleep at baseline and in a four-month (interquartile range 75-163 days) follow-up survey. Multiple linear regression was used to analyse the association between smartphone interactions and mental well-being separately for men and women. Results: A higher number of smartphone interactions was associated with lower levels of loneliness at baseline and the same pattern appeared for depressive symptoms, although this was less pronounced. A high level of smartphone interaction was associated with lower levels of disturbed sleep for men, but not for women. In follow-up analyses, a high versus low level of smartphone interaction was associated with an increase in loneliness and depressive symptoms over time for women, but not for men. Conclusions: Smartphone interactions are related to better mental well-being, which may be attributed to the beneficial effects of an underlying social network. Over time, accommodating a large network via smartphone communication might, however, have negative effects on mental well-being for women.

Cohort profile: the DANish LIFE course (DANLIFE) cohort, a prospective register-based cohort of all children born in Denmark since 1980.

PURPOSE: The DANish LIFE course (DANLIFE) cohort is a prospective register-based study set up to investigate the complex life course mechanisms linking childhood adversities to health and well-being in childhood, adolescence and young adulthood including cumulative and synergistic actions and potentially sensitive periods in relation to health outcomes. PARTICIPANTS: All children born in Denmark in 1980 or thereafter have successively been included in the cohort totalling more than 2.2 million children. To date, the study population has been followed annually in the nationwide Danish registers for an average of 16.8 years with full data coverage in the entire follow-up period. The information is currently updated until 2015. FINDINGS TO DATE: DANLIFE provides information on a wide range of family-related childhood adversities (eg, parental separation, death of a parent or sibling, economic disadvantage) with important psychosocial implications for health and well-being in childhood, adolescence and young adulthood. Measurement of covariates indicating demographic (eg, age, sex), social (eg, parental education) and health-related factors (eg, birth weight) has also been included from the nationwide registers. In this cohort profile, we provide an overview of the childhood adversities and covariates included in DANLIFE. We also demonstrate that there is a clear social gradient in the exposure to childhood adversities confirming clustering of adverse experiences within individuals. FUTURE PLANS: DANLIFE provides a valuable platform for research into early life adversity and opens unique possibilities for testing new research ideas on how childhood adversities affect health across the life course.

Trajectories of family poverty and children's mental health: Results from the Danish National Birth Cohort.

Children exposed to socioeconomic adversity have elevated levels of psychological difficulties immediately and long-term. However, few studies have examined the consequences of long-term patterns of dynamic trajectories of family income. The Danish National Birth Cohort (DNBC) is a longitudinal, population-based birth cohort study (1996-2002). Data on household poverty from the year before birth until the child was 10 years of age (n = 12 measures) were obtained from the National Danish Registries and modeled using semiparametric group-based modeling. Child mental health symptoms were measured at 11 years using mother and child-reported Strengths and Difficulties Questionnaires (n = 40 192), and the child-reported Stress in Childhood (SiC) scale (n = 46 284). Four categories of family socioeconomic position were identified: 1) No poverty (83.5%); 2) Intermittent poverty, representing families who alternate between being above and below the poverty cut-off (8.6%); 3) Poverty during the perinatal period (4.9%); and 4) Chronic poverty (3.0%). Controlling for several early life characteristics of the family, mother and child, intermittent poverty vs. no poverty was consistently associated with child psychological difficulties (any problem: RR = 1.38, 95% CI: 1.16-1.64; conduct problems: RR = 1.38, 95% CI: 1.16-1.64; and stress: RR = 1.07, 95% CI: 1.02-1.12). An association was also found between perinatal poverty and children's symptoms of hyperactivity/inattention (RR = 1.28, 95% CI = 1.03; 1.59). We found no associations between chronic poverty and any of the outcome measures when adjusting for early life risk factors. Children growing up in households characterized by financial instability have elevated levels of psychosocial symptoms, especially externalizing behaviors, as well as stress in early adolescence.

Weekly hours of informal caregiving and paid work, and the risk of cardiovascular disease.

Background: Little is known on the association between weekly hours of informal caregiving and risk of cardiovascular disease (CVD). The objective was to investigate the individual and joint effects of weekly hours of informal caregiving and paid work on the risk of CVD. Methods: Pooled analysis with 1396 informal caregivers in gainful employment, from the Swedish Longitudinal Occupational Survey of Health and the Whitehall II study. Informal caregiving was defined as care for an aged or disabled relative. The outcome was CVD during 10 years follow-up. Analyzes were adjusted for age, sex, children, marital status and occupational grade. Results: There were 59 cases of CVD. Providing care >20 h weekly were associated with a higher risk of CVD compared to those providing care 1-8 h weekly (hazard ratio = 2.63, 95%CI: 1.20; 5.76), irrespectively of weekly work hours. In sensitivity analyzes, we found this risk to be markedly higher among long-term caregivers (6.17, 95%CI: 1.73; 22.1) compared to short-term caregivers (0.89, 95%CI: 0.10; 8.08). Caregivers working ≥55 h weekly were at higher risk of CVD (2.23, 95%CI: 1.14; 4.35) compared to those working 35-40 h weekly. Those providing care >8 h and working ≤40 h weekly had a higher risk of CVD compared to those providing care 1-8 h and working ≤40 h (3.23, 95%CI: 1.25; 8.37). Conclusion: A high number of weekly hours of informal caregiving as opposed to few weekly hours is associated with a higher risk of CVD, irrespectively of weekly work hours. The excess risk seemed to be driven by those providing care over long periods of time.

Work stress, anthropometry, lung function, blood pressure, and blood-based biomarkers: a cross-sectional study of 43,593 French men and women.

Work stress is a risk factor for cardio-metabolic diseases, but few large-scale studies have examined the clinical profile of individuals with work stress. To address this limitation, we conducted a cross-sectional study including 43,593 working adults from a French population-based sample aged 18-72 years (the CONSTANCES cohort). According to the Effort-Reward Imbalance model, work stress was defined as an imbalance between perceived high efforts and low rewards at work. A standardized health examination included measures of anthropometry, lung function, blood pressure and standard blood-based biomarkers. Linear regression analyses before and after multivariable adjustment for age, socioeconomic status, depressive symptoms, health-related behaviours, and chronic conditions showed that work stress was associated with higher BMI, waist circumference, waist-hip ratio, alanine transaminase, white blood cell count and lower high-density lipoprotein cholesterol in men, and with higher BMI and white blood cell count in women (differences 0.03-0.06 standard deviations, P < 0.05 between individuals with and without work stress). No robust associations were observed with lung function, haemoglobin, creatinine, glucose levels or resting blood pressure measures. This indicates that work stress is associated altered metabolic profile, increased systemic inflammation, and, in men, poorer liver function, which is a marker of high alcohol consumption.

Role of psychosocial work factors in the relation between becoming a caregiver and changes in health behaviour: results from the Whitehall II cohort study.

BACKGROUND: The present study tested the effects of becoming a caregiver combined with adverse working conditions on changes in health behaviours. METHODS: Participants were 5419 British civil servants from the Whitehall II cohort study who were not caregivers at baseline (phase 3, 1991-1994). Psychosocial work factors were assessed at baseline. Phase 4 questionnaire (1995-1996) was used to identify participants who became caregivers to an aged or disabled relative. Smoking, alcohol consumption and exercise were assessed at baseline and follow-up (phase 5, 1997-1999). RESULTS: Those who became caregivers were more likely to increase frequency of alcohol consumption, but only if they also reported low decision latitude at work (OR= 1.65, 95% CI 1.15 to 2.37 compared with non-caregivers with average decision latitude), or belonged to low occupational social class (OR=2.38, 95% CI 1.17 to 4.78 compared with non-caregivers of high occupational social class). Caregivers were more likely to quit smoking if job demands were low (OR=2.92; 95% CI 1.07 to 7.92 compared with non-caregivers with low job demands), or if social support at work was high (OR=2.99, 95% CI 1.01 to 8.86 compared with caregivers with average social support). There was no effect of caregiving on reducing exercise below recommended number of hours per week, or on drinking above recommended number of units per week, regardless of working conditions. CONCLUSIONS: The findings underscore the importance of a well-balanced work environment as a resource for people exposed to increased family demands.

Accumulation of Major Life Events in Childhood and Adult Life and Risk of Type 2 Diabetes Mellitus.

BACKGROUND: The aim of the study was to estimate the effect of the accumulation of major life events (MLE) in childhood and adulthood, in both the private and working domains, on risk of type 2 diabetes mellitus (T2DM). Furthermore, we aimed to test the possible interaction between childhood and adult MLE and to investigate modification of these associations by educational attainment. METHODS: The study was based on 4,761 participants from the Copenhagen City Heart Study free of diabetes at baseline and followed for 10 years. MLE were categorized as 0, 1, 2, 3 or more events. Multivariate logistic regression models adjusted for age, sex, education and family history of diabetes were used to estimate the association between MLE and T2DM. RESULTS: In childhood, experiencing 3 or more MLE was associated with a 69% higher risk of developing T2DM (Odds Ratio (OR) 1.69; 95% Confidence Interval (CI) 1.60, 3.27). The accumulation of MLE in adult private (p-trend = 0.016) and work life (p-trend = 0.049) was associated with risk of T2DM in a dose response manner. There was no evidence that experiencing MLE in both childhood and adult life was more strongly associated with T2DM than experiencing events at only one time point. There was some evidence that being simultaneously exposed to childhood MLE and short education (OR 2.28; 95% C.I. 1.45, 3.59) and work MLE and short education (OR 2.86; 95% C.I. 1.62, 5.03) was associated with higher risk of T2DM, as the joint effects were greater than the sum of their individual effects. CONCLUSIONS: Findings from this study suggest that the accumulation of MLE in childhood, private adult life and work life, respectively, are risk factors for developing T2DM.

Stressful social relations and mortality: a prospective cohort study.

BACKGROUND: Few studies have examined the relationship between stressful social relations in private life and all-cause mortality. OBJECTIVE: To evaluate the association between stressful social relations (with partner, children, other family, friends and neighbours, respectively) and all-cause mortality in a large population-based study of middle-aged men and women. Further, to investigate the possible modification of this association by labour force participation and gender. METHODS: We used baseline data (2000) from The Danish Longitudinal Study on Work, Unemployment and Health, including 9875 men and women aged 36-52 years, linked to the Danish Cause of Death Registry for information on all-cause mortality until 31 December 2011. Associations between stressful social relations with partner, children, other family, friends and neighbours, respectively, and all-cause mortality were examined using Cox proportional hazards models adjusted for age, gender, cohabitation status, occupational social class, hospitalisation with chronic disorder 1980-baseline, depressive symptoms and perceived emotional support. Modification by gender and labour force participation was investigated by an additive hazards model. RESULTS: Frequent worries/demands from partner or children were associated with 50-100% increased mortality risk. Frequent conflicts with any type of social relation were associated with 2-3 times increased mortality risk. Interaction between labour force participation and worries/demands (462 additional cases per 100,000 person-years, p=0.05) and conflicts with partner (830 additional cases per 100,000 person-years, p<0.01) was suggested. Being male and experiencing frequent worries/demands from partner produced 135 extra cases per 100,000 person-years, p=0.05 due to interaction. CONCLUSIONS: Stressful social relations are associated with increased mortality risk among middle-aged men and women for a variety of different social roles. Those outside the labour force and men seem especially vulnerable to exposure.