Association of Cardiometabolic Multimorbidity With Mortality.

IMPORTANCE: The prevalence of cardiometabolic multimorbidity is increasing. OBJECTIVE: To estimate reductions in life expectancy associated with cardiometabolic multimorbidity. DESIGN, SETTING, AND PARTICIPANTS: Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates. EXPOSURES: A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI). MAIN OUTCOMES AND MEASURES: All-cause mortality and estimated reductions in life expectancy. RESULTS: In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy. CONCLUSIONS AND RELEVANCE: Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

Occupational class differences in later life hospital use by women who survived to age 80: the Renfrew and Paisley prospective cohort study.

BACKGROUND: population ageing challenges the sustainability of healthcare provision. OBJECTIVE: to investigate occupational class differences in hospital use in women aged 80+ years. METHODS: a total of 8,353 female residents, aged 45-64, took part in the Renfrew and Paisley prospective cohort study in 1972-76. Information on general and mental health hospital discharges was provided from computerised linkage with the Scottish Morbidity Records data to 31 December 2012. Numbers of admissions and bed-days after the 80th birthday were calculated for all and specific causes. Rate ratios by occupational class were calculated using negative binomial regression analysis, adjusting for age and a range of risk factors. RESULTS: four thousand and four hundred and seven (56%) women survived to age 80 and had 17,563 general admissions thereafter, with a mean stay of 19.4 days. There were no apparent relationships with occupational class for all general admissions, but lower occupational class was associated with higher rate ratios for coronary heart disease and stroke and lower rate ratios for cancer. Adjustment for risk factors could not fully explain the raised rate ratios. Bed-day use was higher in lower occupational classes, especially for stroke. There were strong associations with mental health admissions, especially dementia. Compared with the highest occupational class, admission rate ratios for dementia were higher for the lowest occupational class (adjusted rate ratio = 2.60, 95% confidence interval 1.79-3.77). CONCLUSION: in this population, there were no socio-economic gradients seen in hospital utilisation for general admissions in old age. However, occupational class was associated with mental health admissions, coronary heart disease, stroke and cancer.

Parental height in relation to offspring coronary heart disease: examining transgenerational influences on health using the west of Scotland Midspan Family Study.

BACKGROUND: Adult height is known to be inversely related to coronary heart disease (CHD) risk. We sought to investigate transgenerational influence of parental height on offspring's CHD risk. METHODS: Parents took part in a cardiorespiratory disease survey in two Scottish towns during the 1970s, in which their physical stature was measured. In 1996, their offspring were invited to participate in a similar survey, which included an electrocardiogram recording and risk factor assessment. RESULTS: A total of 2306 natural offspring aged 30-59 years from 1456 couples were subsequently flagged for notification of mortality and followed for CHD-related hospitalizations. Taller paternal and/or maternal height was associated with socio-economic advantage, heavier birthweight and increased high-density lipoprotein cholesterol in offspring. Increased height in fathers, but more strongly in mothers (risk ratio for 1 SD change in maternal height = 0.85; 95% confidence interval: 0.76 to 0.95), was associated with a lower risk of offspring CHD, adjusting for age, sex, other parental height and CHD risk factors. CONCLUSION: There is evidence of an association between taller parental, particularly maternal, height and lower offspring CHD risk. This may reflect an influence of early maternal growth on the intrauterine environment provided for her offspring.

Association between long-term exposure to air pollution and specific causes of mortality in Scotland.

OBJECTIVE: This study investigated the association between long-term exposure to black smoke (BS) air pollution and mortality in two related Scottish cohorts with 25 years of follow-up. METHODS: Risk factors were collected during 1970-1976 for 15331 and 6680 participants in the Renfrew/Paisley and Collaborative cohorts respectively. Exposure to BS during 1970-1979 was estimated by inverse-distance weighted averages of observed concentrations at monitoring sites and by two alternative spatial modelling approaches which included local air quality predictors (LAQP). RESULTS: Consistent BS-mortality associations (per 10 µg m(-3) increment in 10-year average BS) were observed in the Renfrew/Paisley cohort using LAQP-based exposure models (all-cause mortality HR 1.10 (95% CI 1.04 to 1.17); cardiovascular HR 1.11 (1.01 to 1.22); ischaemic heart disease HR 1.13 (1.02 to 1.25); respiratory HR 1.26 (1.02 to 1.28)). The associations were largely unaffected by additional adjustment for area-level deprivation category. A less consistent and generally implausible pattern of cause-specific BS-mortality associations was found for inverse-distance averaging of BS concentrations at nearby monitoring sites. BS-mortality associations in the Collaborative cohort were weaker and not statistically significant. CONCLUSIONS: The association between mortality and long-term exposure to BS observed in the Renfrew/Paisley cohort is consistent with hypotheses of how air pollution may affect human health. The dissimilarity in pollution-mortality associations for different exposure models highlights the critical importance of reliable estimation of exposures on intraurban spatial scales to avoid potential misclassification bias.

A comparison of short-term and long-term air pollution exposure associations with mortality in two cohorts in Scotland.

BACKGROUND: Air pollution-mortality risk estimates are generally larger at longer-term, compared with short-term, exposure time scales. OBJECTIVE: We compared associations between short-term exposure to black smoke (BS) and mortality with long-term exposure-mortality associations in cohort participants and with short-term exposure-mortality associations in the general population from which the cohorts were selected. METHODS: We assessed short-to-medium-term exposure-mortality associations in the Renfrew-Paisley and Collaborative cohorts (using nested case-control data sets), and compared them with long-term exposure-mortality associations (using a multilevel spatiotemporal exposure model and survival analyses) and short-to-medium-term exposure-mortality associations in the general population (using time-series analyses). RESULTS: For the Renfrew-Paisley cohort (15,331 participants), BS exposure-mortality associations were observed in nested case-control analyses that accounted for spatial variations in pollution exposure and individual-level risk factors. These cohort-based associations were consistently greater than associations estimated in time-series analyses using a single monitoring site to represent general population exposure {e.g., 1.8% [95% confidence interval (CI): 0.1, 3.4%] vs. 0.2% (95% CI: 0.0, 0.4%) increases in mortality associated with 10-µg/m³ increases in 3-day lag BS, respectively}. Exposure-mortality associations were of larger magnitude for longer exposure periods [e.g., 3.4% (95% CI: -0.7, 7.7%) and 0.9% (95% CI: 0.3, 1.5%) increases in all-cause mortality associated with 10-µg/m³ increases in 31-day BS in case-control and time-series analyses, respectively; and 10% (95% CI: 4, 17%) increase in all-cause mortality associated with a 10-µg/m³ increase in geometic mean BS for 1970-1979, in survival analysis]. CONCLUSIONS: After adjusting for individual-level exposure and potential confounders, short-term exposure-mortality associations in cohort participants were of greater magnitude than in comparable general population time-series study analyses. However, short-term exposure-mortality associations were substantially lower than equivalent long-term associations, which is consistent with the possibility of larger, more persistent cumulative effects from long-term exposures.

Cause specific mortality, social position, and obesity among women who had never smoked: 28 year cohort study.

OBJECTIVE: To investigate the relations between causes of death, social position, and obesity in women who had never smoked. DESIGN: Prospective cohort study. SETTING: Renfrew and Paisley, Scotland. PARTICIPANTS: 8353 women and 7049 men aged 45-64 were recruited to the Renfrew and Paisley Study in 1972-6. Of these, 3613 women had never smoked and were the focus of this study. They were categorised by occupational class (I and II, III non-manual, III manual, and IV and V) and body mass index groups (normal weight, overweight, moderately obese, and severely obese). MAIN OUTCOME MEASURES: All cause and cause specific mortality during 28 years of follow-up by occupational class and body mass index, using Cox proportional hazards models adjusted for age and other confounders. RESULTS: The women in lower occupational classes who had never smoked were on average shorter and had poorer lung function and higher systolic blood pressure than women in the higher occupational classes. Overall, 43% (n = 1555) were overweight, 14% (n = 515) moderately obese, and 5% (n = 194) severely obese. Obesity rates were higher in lower occupational classes and much higher in all occupational classes than in current smokers in the full cohort. Half the women died, 51% (n = 916) from cardiovascular disease and 27% (n = 487) from cancer. Relative to occupational class I and II, all cause mortality rates were more than a third higher in occupational classes III manual (relative rate 1.35, 95% confidence interval 1.16 to 1.57) and IV and V (1.34, 1.17 to 1.55) and largely explained by differences in obesity, systolic blood pressure, and lung function. Similar upward gradients were seen for cardiovascular disease and respiratory disease but not for cancer. Mortality rates were highest in severely obese women in the lowest occupational classes. CONCLUSIONS: Women who had never smoked and were not obese had the lowest mortality rates, regardless of their social position. Where obesity is socially patterned as in this cohort, it may contribute to health inequalities and increase pressure on health and social services serving more disadvantaged populations.

The combined effect of smoking tobacco and drinking alcohol on cause-specific mortality: a 30 year cohort study.

BACKGROUND: Smoking and consuming alcohol are both related to increased mortality risk. Their combined effects on cause-specific mortality were investigated in a prospective cohort study. METHODS: Participants were 5771 men aged 35-64, recruited during 1970-73 from various workplaces in Scotland. Data were obtained from a questionnaire and a screening examination. Causes of death were all cause, coronary heart disease (CHD), stroke, alcohol-related, respiratory and smoking-related cancer. Participants were divided into nine groups according to their smoking status (never, ex or current) and reported weekly drinking (none, 1-14 units and 15 or more). Cox proportional hazards models were used to obtain relative rates of mortality, adjusted for age and other risk factors. RESULTS: In 30 years of follow-up, 3083 men (53.4%) died. Compared with never smokers who did not drink, men who both smoked and drank 15+ units/week had the highest all-cause mortality (relative rate = 2.71 (95% confidence interval 2.31-3.19)). Relative rates for CHD mortality were high for current smokers, with a possible protective effect of some alcohol consumption in never smokers. Stroke mortality increased with both smoking and alcohol consumption. Smoking affected respiratory mortality with little effect of alcohol. Adjusting for a wide range of confounders attenuated the relative rates but the effects of alcohol and smoking still remained. Premature mortality was particularly high in smokers who drank 15 or more units, with a quarter of the men not surviving to age 65. 30% of men with manual occupations both smoked and drank 15+ units/week compared with only 13% with non-manual ones. CONCLUSIONS: Smoking and drinking 15+ units/week was the riskiest behaviour for all causes of death.

Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies.

OBJECTIVE: To investigate whether alcohol consumption and raised body mass index (BMI) act together to increase risk of liver disease. DESIGN: Analysis of data from prospective cohort studies. SETTING: Scotland. PARTICIPANTS: Data were from two of the Midspan prospective cohort studies (9559 men): "Main" study 1965-8, participants from workplaces across central belt of Scotland, population of island of Tiree, and mainland relatives, and "Collaborative" study, 1970-3, participants from 27 workplaces in Glasgow, Clydebank, and Grangemouth. Follow-up was to 31 December 2007 (median 29 years, range 0.13-42). We divided participants into nine groups based on measures of body mass index (BMI) (underweight/normal weight <25, overweight 25 to <30, and obese >or=30) and alcohol consumption (none, 1-14, and >or=15 units per week). MAIN OUTCOME MEASURES: Liver disease morbidity and mortality. RESULTS: 80 (0.8%) men died with liver disease as the main cause and 146 (1.5%) with liver disease as any cause. In the Collaborative study, 196 men (3.3%) had liver disease defined by a death, admission, or cancer registration. BMI and alcohol consumption were strongly associated with liver disease mortality in analyses adjusted for other confounders (P=0.001 and P<0.0001 respectively). Drinkers of 15 or more units per week in any BMI category and obese drinkers had raised relative rates for all definitions of liver disease, compared with underweight/normal weight non-drinkers. Drinkers of 15 or more units per week had adjusted relative rates for liver disease mortality of 3.16 (95% confidence interval 1.28 to 7.8) for underweight/normal weight men, 7.01 (3.02 to 16.3) for overweight, and 18.9 (6.84 to 52.4) for obese men. The relative rate for obese men who consumed 1-14 units per week was 5.3 (1.36 to 20.7). The relative excess risk due to interaction between BMI and alcohol consumption was 5.58 (1.09 to 10.1); synergy index=2.89 (1.29 to 6.47). CONCLUSIONS: Raised BMI and alcohol consumption are both related to liver disease, with evidence of a supra-additive interaction between the two. The occurrence of both factors in the same populations should inform health promotion and public health policies.

What is the predictive value of established risk factors for total and cardiovascular disease mortality when measured before middle age? Pooled analyses of two prospective cohort studies from Scotland.

AIMS: To examine the association of physiological, behavioural and social characteristics in pre-middle age with future total and cardiovascular disease (CVD) mortality. METHODS AND RESULTS: Risk factor data on 1503 individuals aged 16-35 years at baseline were collected in two prospective cohort studies using standard protocols. Their association with total and CVD mortality ascertained during 40 years of follow-up was summarized using Cox proportional hazards regression. A median follow-up of 39.6 years gave rise to 255 deaths (103 from CVD). In age-adjusted and sex-adjusted analyses, impaired lung function [one standard deviation increases in forced expiratory volume in 1 s: hazards ratio 0.69; 95% confidence interval 0.55, 0.86; and in forced vital capacity: 0.76; 0.59, 0.98], current cigarette smoking (4.16; 2.22, 7.80) and higher alcohol consumption (one standard deviation increase in standard units consumed: 1.20; 1.02, 1.41) were associated with CVD. In fully adjusted analyses associations generally held. For total mortality, these factors and obesity and socioeconomic disadvantage were predictive. CONCLUSION: A range of risk factors measured before middle age were related to risk of total and CVD mortality up to four decades later, indicating that public health interventions should be implemented earlier in the life course than is currently the case.

Effect of tobacco smoking on survival of men and women by social position: a 28 year cohort study.

OBJECTIVE: To assess the impact of tobacco smoking on the survival of men and women in different social positions. DESIGN: A cohort observational study. SETTING: Renfrew and Paisley, two towns in west central Scotland. PARTICIPANTS: 8353 women and 7049 men aged 45-64 years recruited in 1972-6 (almost 80% of the population in this age group). The cohort was divided into 24 groups by sex (male, female), smoking status (current, former, or never smokers), and social class (classes I + II, III non-manual, III manual, and IV + V) or deprivation category of place of residence. MAIN OUTCOME MEASURE: Relative mortality (adjusted for age and other risk factors) in the different groups; Kaplan-Meier survival curves and survival rates at 28 years. RESULTS: Of those with complete data, 4387/7988 women and 4891/6967 men died over the 28 years. Compared with women in social classes I + II who had never smoked (the group with lowest mortality), the adjusted relative mortality of smoking groups ranged from 1.7 (95% confidence interval 1.3 to 2.3) to 4.2 (3.3 to 5.5). Former smokers' mortalities were closer to those of never smokers than those of smokers. By social class (highest first), age adjusted survival rates after 28 years were 65%, 57%, 53%, and 56% for female never smokers; 41%, 42%, 33%, and 35% for female current smokers; 53%, 47%, 38%, and 36% for male never smokers; and 24%, 24%, 19%, and 18% for male current smokers. Analysis by deprivation category gave similar results. CONCLUSIONS: Among both women and men, never smokers had much better survival rates than smokers in all social positions. Smoking itself was a greater source of health inequality than social position and nullified women's survival advantage over men. This suggests the scope for reducing health inequalities related to social position in this and similar populations is limited unless many smokers in lower social positions stop smoking.

Alcohol consumption behaviours and social mobility in men and women of the Midspan Family study.

AIMS: The aim of this study was to investigate relationships between alcohol consumption and social mobility in a cohort study in Scotland. METHODS: 1040 sons and 1298 daughters aged 30-59 from 1477 families reported their alcohol consumption from which was derived: weekly units (1 UK unit being 8 g ethanol), exceeding daily or weekly limits, binge drinking and consuming alcohol on 5+ days per week. Own and father's social class were available enabling social mobility to be investigated. RESULTS: More downwardly mobile men exceeded the weekly limit, the daily limit, were defined as binge drinkers and drank the most units per week of the four social mobility groups. Stable non-manual women were more likely to consume alcohol on 5+ days a week but very few were binge drinkers. Stable non-manual and upwardly mobile men and women were more likely to drink wine, and downwardly mobile men to drink beer. CONCLUSIONS: Downward mobility was associated with less favourable alcohol behaviours, especially in men. Wine consumption was more closely related to the social mobility groups than beer and spirits consumption. Drinking patterns could both influence and be influenced by social mobility.

The scope for biased recall of risk-factor exposure in case-control studies: evidence from a cohort study of Scottish men.

AIMS: Case-control studies are prone to recall bias, a participant's case-control status influencing their recall of exposure to risk factors. We aimed to demonstrate empirically the scope for this bias. METHODS: Two thousand five hundred and fifty men without coronary heart disease at enrollment to a prospective cohort study underwent two health assessments, about 5 years apart. The association between the development of coronary heart disease in the intervening period and changes in reported stress and cigarette smoking were investigated. RESULTS: Men admitted to hospital with coronary heart disease reported a greater increase in psychological stress (p=0.032) and greater cessation of smoking (22% vs. 10%; p=0.007) than men not admitted. Consequently, when exposure data are collected at the end rather than at the start of the follow-up period, coronary heart disease is observed to be more strongly associated with psychological stress, and more weakly associated with smoking. CONCLUSIONS: At the time when a case-control study is conducted, levels of exposure to risk factors will have been influenced by disease development. When participants are asked about their level of exposure for a previous time period, recall is likely to be influenced by present outcome and exposure status, especially when psychological states are being investigated.

Contribution of Midparental BMI and other determinants of obesity in adult offspring.

The aim of this study was to evaluate midparental BMI among intergenerational factors associated with obesity in adult offspring. The data was from an unusual two-generational observational design of 1,477 married couples from Renfrew and Paisley in Scotland who were aged 45-64 years when screened in 1972-1976, and 1,040 sons and 1,298 daughters aged 30-59 years when screened in 1996. BMI was categorized as normal (< 25 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (> or = 30 kg/m(2)) in offspring and parents. Midparental BMI was defined as the mean of the mother's and father's BMI. Low physical activity, nonsmoking status, higher cholesterol level, and manual social class were all associated with increased BMI in offspring. The effect of reported dietary intake was less clear. Offspring of obese parents (defined by midparental BMI) were over four times more likely to be obese than offspring of normal weight parents. Midparental BMI had a strong effect on offspring BMI, independent of social class, smoking habit, physical activity, and reported dietary intake. Adding midparental BMI to the regression model more than doubled the explained variation of offspring BMI from 7.7 to 17%. Every 1 kg/m(2) increment in midparental BMI was associated with a BMI greater by 0.51 kg/m(2) in offspring. We conclude that midparental BMI is a useful simple tool to predict offspring BMI. Whether it represents genetic or environmental family effects, it is easily ascertained by the individual and could be used in health promotion and clinical settings to target individuals who are at increased risk of becoming obese.

Alcohol consumption and mortality and hospital admissions in men from the Midspan collaborative cohort study.

AIMS: To investigate the relationships between alcohol consumption and mortality and morbidity risk by specific causes. DESIGN: Prospective cohort study. SETTING: Twenty-seven work-places in West and Central Scotland. PARTICIPANTS: A total of 6000 men aged 21-64 years at screening in 1970-1973, median follow-up 29 years. MEASUREMENTS: Relative rates, using Cox's proportional hazard models, by weekly reported units of alcohol consumption for all cause, coronary heart disease (CHD), stroke, respiratory, digestive, liver disease and alcohol-related causes of mortality and for specific causes of acute hospital admissions. FINDINGS: Mortality risk was increased for men drinking 15-21 or more units per week for all causes, stroke, liver disease and alcohol-related causes. For respiratory mortality, drinkers of 35 or more units had double the risk compared to non-drinkers. CHD mortality showed increasing trends with consumption when adjusted for age and after full adjustment showed no clear patterns, although the 8-14 units group had a lower risk than non-drinkers [relative rate 0.81 (0.68-0.97)]. Hospital admissions had similar patterns to mortality for stroke and liver disease. Increased risk began at 8-14 units for alcohol-related admissions, and at 15-21 units for respiratory admissions. Non-drinkers had higher risks of having a CHD admission than drinkers and there were decreasing trends with increasing consumption (P = 0.019). CONCLUSIONS: Consumption of 15-21 units per week and over was associated with increased mortality from most causes and increased risk of hospital admissions from stroke, liver disease and respiratory diseases. Alcohol-related admissions were raised from 8 to 14 units. Alcohol use may have been under-reported in our study, but it was similar to other studies of the time. The apparent protective effect of alcohol with CHD admissions could be due partly to detrimental effects of heavy drinking causing sudden deaths. The associations, including that with respiratory disease, may arise from inadequate adjustment for confounding by other factors such as smoking.

Body mass index in middle life and future risk of hospital admission for psychoses or depression: findings from the Renfrew/Paisley study.

BACKGROUND: There is evidence that greater body mass index (BMI) protects against depression, schizophrenia and suicide. However, there is a need for prospective studies. METHOD: We examined the association of BMI with future hospital admissions for psychoses or depression/anxiety disorders in a large prospective study of 7036 men and 8327 women. Weight and height were measured at baseline (1972-76) when participants were aged 45-64. Follow-up was for a median of 29 years. RESULTS: Greater BMI and obesity were associated with a reduced risk of hospital admission for psychoses and depression/anxiety in both genders, with the magnitude of these associations being the same for males and females. With adjustment for age, sex, smoking and social class, a 1 standard deviation (s.d.) greater BMI at baseline was associated with a rate ratio of 0.91 [95% confidence interval (CI) 0.82-1.01] for psychoses and 0.87 (95% CI 0.77-0.98) for depression/anxiety. Further adjustment for baseline psychological distress and total cholesterol did not alter these associations. CONCLUSIONS: Our findings add to the growing body of evidence that suggests that greater BMI is associated with a reduced risk of major psychiatric outcomes. Long-term follow-up of participants in randomized controlled trials of interventions that effectively result in weight loss and the use of genetic variants that are functionally related to obesity as instrumental variables could help to elucidate whether these associations are causal.

Effect of conjugal bereavement on mortality of the bereaved spouse in participants of the Renfrew/Paisley Study.

OBJECTIVES: To investigate how loss of a spouse affects mortality risk in the bereaved partner. DESIGN AND SETTING: Prospective cohort study in Renfrew and Paisley in Scotland. PARTICIPANTS: 4395 married couples aged 45-64 years when the study was carried out between 1972 and 1976. METHODS: The date of bereavement for the bereaved spouse was the date of death of his or her spouse. Bereavement could occur at any time during the follow-up period, so it was considered as a time-dependent exposure variable and the Cox proportional hazards model for time-dependent variables was used. The relative rate (RR) of mortality was calculated for bereaved versus non-bereaved spouses and adjusted for confounding variables. MAIN OUTCOME MEASURES: Causes of death to 31 March 2004. RESULTS: Bereaved participants were at higher risk than non-bereaved participants of dying from any cause (RR 1.27; 95% CI 1.2 to 1.35). These risks remained but were attenuated after adjustment for confounding variables. There were raised RRs for bereaved participants dying of cardiovascular disease, coronary heart disease, stroke, all cancer, lung cancer, smoking-related cancer, and accidents or violence. After adjustment for confounding variables, RRs remained higher for bereaved participants for all these causes except for mortality from lung cancer. There was no strong statistical evidence that the increased risks of death associated with bereavement changed with time after bereavement. CONCLUSIONS: Conjugal bereavement, in addition to existing risk factors, is related to mortality risk for major causes of death.

Reverse causality and confounding and the associations of overweight and obesity with mortality.

OBJECTIVE: To examine the effect of reverse causality and confounding on the association of BMI with all-cause and cause-specific mortality. RESEARCH METHODS AND PROCEDURES: Data from two large prospective studies were used. One (a community-based cohort) included 8327 women and 7017 men who resided in two Scottish towns at the time of the baseline assessment in 1972-1976; the other (an occupational cohort) included 4016 men working in the central belt of Scotland at the time of the baseline assessment in 1970-1973. Participants in both cohorts were ages 45 to 64 years at baseline; the follow-up period was 28 to 34 years. RESULTS: In age-adjusted analyses that did not take account of reverse causality or smoking, there was no association between being overweight (BMI 25 to <30 kg/m(2)) and mortality, and weak to modest associations between obesity (BMI > or =30 kg/m(2)) and mortality. There was a strong association between smoking and lower BMI in women and men in both cohorts (all p < 0.0001). Among never-smokers and with the first 5 years of deaths removed, overweight was associated with an increase in all-cause mortality (relative risk ranging from 1.12 to 1.38), and obesity was associated with a doubling of risk in men in both cohorts (relative risk, 2.10 and 1.96, respectively) and a 60% increase in women (relative risk, 1.56). In both never-smokers and current smokers, being overweight or obese was associated with important increases in the risk of cardiovascular disease. DISCUSSION: These findings demonstrate that with appropriate control for smoking and reverse causality, both overweight and obesity are associated with important increases in all-cause and cause-specific mortality, and in particular with cardiovascular disease mortality.

Psychological distress and chronic obstructive pulmonary disease in the Renfrew and Paisley (MIDSPAN) study.

BACKGROUND: This study examined whether psychological distress might be a predictor of chronic obstructive pulmonary disease (COPD). METHOD: The relation between psychological distress at baseline, measured by the general health questionnaire (GHQ), and chronic bronchitis three years later, as measured by the Medical Research Council (MRC) bronchitis questionnaire and forced expiratory flow in one second (FEV(1)), was examined in 1682 men and 2203 women from the Renfrew and Paisley (MIDSPAN) study. The analyses were run on men and women separately and adjustments were made for age, socioeconomic position, and lung function at baseline (FEV(1)). People with chronic diseases at baseline were then excluded to give a "healthy" baseline cohort. The effect of psychological distress on individual components of the MRC bronchitis questionnaire and FEV(1) was also assessed. RESULTS: In multivariate analyses of the whole cohort baseline psychological distress in women was associated with reduced FEV(1) at follow up (OR 1.31 95% CI 1.0 to 1.73) after adjustment. In women, in the healthy cohort, psychological distress was associated with chronic bronchitis (OR 2.00, 95% CI 1.16 to 3.46), symptoms of bronchial infection (OR 2.14, 95% CI 1.44 to 3.19), symptoms of breathlessness (OR 3.02, 95% CI 1.99 to 4.59), and reduced FEV(1) (OR 1.62, 95% CI 1.13 to 2.32). In men psychological distress predicted symptoms of bronchial infection (OR 2.09, 95% CI 1.28 to 3.42). CONCLUSION: This study supports research suggesting that psychological distress is associated with COPD and shows that psychological distress predicts COPD in women. The robustness of the association and the exact mechanism requires further investigation.

The accuracy of the Framingham risk-score in different socioeconomic groups: a prospective study.

BACKGROUND: The primary prevention of cardiovascular disease involves using the Framingham risk score to identify high risk patients and then prescribe preventive treatments. AIM: To examine the performance of the Framingham risk score in different socioeconomic groups in a population with high rates of cardiovascular disease. DESIGN OF STUDY: A prospective study. SETTING: West of Scotland. METHOD: The observed 10-year cardiovascular disease and coronary heart disease mortality rates in 5626 men and 6678 women free from cardiovascular disease from the Renfrew/Paisley Study were compared with predicted rates, stratified by socioeconomic class and by area deprivation score. RESULTS: The ratio of predicted to observed cardiovascular mortality rate in the 12 304 men and women with complete risk factor information was 0.56 (95% confidence interval [CI] = 0.52 to 0.60), a relative underestimation of 44%. Cardiovascular disease mortality was underestimated by 48% in manual participants (predicted over observed = 0.52, 95% CI = 0.48 to 0.56) compared to 31% in the non-manual participants (predicted over observed = 0.69, 95% CI = 0.60 to 0.81, P = 0.0005). Underestimation was also worse in participants from deprived areas (P = 0.0017). Only 4.8% of individuals had a 10-year cardiovascular risk of >40% (equivalent to >30% 10-year coronary risk), and 81% of deaths occurred in the rest. If the Framingham score had been recalibrated for manual and non-manual members of this population, an additional 3611 individuals mainly from manual social classes would have reached the treatment threshold. CONCLUSION: Currently recommended risk scoring methods underestimate risk in socioeconomically deprived individuals. The likely consequence is that preventive treatments are less available to the most needy.

Childhood IQ and social factors on smoking behaviour, lung function and smoking-related outcomes in adulthood: linking the Scottish Mental Survey 1932 and the Midspan studies.

OBJECTIVE: To investigate the associations of childhood IQ and adult social factors, and smoking behaviour, lung function (forced expiratory volume in one second; FEV(1)), and smoking-related outcomes in adulthood. DESIGN: Retrospective cohort study. METHOD: Participants were from the Midspan prospective studies conducted on Scottish adults in the 1970s. The sample consisted of 938 Midspan participants born in 1921 who were successfully matched with their cognitive ability test results on the Scottish Mental Survey 1932. RESULTS: Structural equation modelling showed that age 11 IQ was not directly associated with smoking consumption, but that IQ and adult social class had indirect effects on smoking consumption via deprivation category. The influence of IQ on FEV(1) was partly indirect via social class. Gender influenced smoking consumption and also IQ and social class. There was a 21% higher risk of having a smoking-related hospital admission, cancer, or death during 25 years of follow-up for each standard deviation disadvantage in IQ. Adjustment for adult social class, deprivation category, and smoking reduced the association to 10%. CONCLUSION: Childhood IQ was associated with social factors which influenced lung function in adulthood, but was not associated directly with smoking consumption. In future studies, it is important to consider other pathways which may account for variance in the link between childhood IQ and health in later life.