Emilie Elisabet Agardh

Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis

BACKGROUND We conducted a systematic review and meta-analysis, the first to our knowledge, summarizing and quantifying the published evidence on associations between type 2 diabetes incidence and socio-economic position (SEP) (measured by educational level, occupation and income) worldwide and when sub-divided into high-, middle- and low-income countries. METHODS Relevant case-control and cohort studies published between 1966 and January 2010 were searched in PubMed and EMBASE using the keywords: diabetes vs educational level, occupation or income. All identified citations were screened by one author, and two authors independently evaluated and extracted data from relevant publications. Risk estimates from individual studies were pooled using random-effects models quantifying the associations. RESULTS Out of 5120 citations, 23 studies, including 41 measures of association, were found to be relevant. Compared with high educational level, occupation and income, low levels of these determinants were associated with an overall increased risk of type 2 diabetes; [relative risk (RR) = 1.41, 95% confidence interval (CI): 1.28-1.51], (RR = 1.31, 95% CI: 1.09-1.57) and (RR = 1.40, 95% CI: 1.04-1.88), respectively. The increased risks were independent of the income levels of countries, although based on limited data in middle- and low-income countries. CONCLUSIONS The risk of getting type 2 diabetes was associated with low SEP in high-, middle- and low-income countries and overall. The strength of the associations was consistent in high-income countries, whereas there is a strong need for further investigation in middle- and low-income countries.

Coffee consumption, type 2 diabetes and impaired glucose tolerance in Swedish men and women.

Objectives.  The association between coffee consumption, type 2 diabetes and impaired glucose tolerance was examined. In addition, indicators of insulin sensitivity and β‐cell function according to homeostasis model assessment were studied in relation to coffee consumption.

Socioeconomic differences in lung cancer incidence: a systematic review and meta-analysis

ObjectiveTo investigate the associations between various socioeconomic indicators and lung cancer incidence.MethodsWe searched PubMed and EMBASE databases for studies on socioeconomic position (SEP) and lung cancer incidence published through October 2007. Random-effect model was used to pool the risk estimates from the individual studies. We stratified the analysis by adjustment strategy to investigate the influence of smoking on socioeconomic gradient in lung cancer incidence.ResultsOut of 3,288 citations, we identified 64 studies eligible for inclusion. Compared to the highest SEP level, we observed an overall increased risk in lung cancer incidence among people with low educational SEP (61%), low occupational SEP (48%), and low income-based SEP (37%). The negative social gradient for lung cancer incidence remained for most of the possible sets of pooled estimates obtained in subgroup analyses for occupational and educational SEP with less consistency for SEP based on income in studies adjusted and unadjusted for smoking. No evidence of publication bias was apparent.ConclusionLung cancer incidence was associated with low educational, occupational, and income-based SEP. The association, adjusted or unadjusted for smoking, points out the importance of social position to be addressed in all discussions on cancer preventive measures.

Burden of type 2 diabetes attributed to lower educational levels in Sweden

BackgroundType 2 diabetes is associated with low socioeconomic position (SEP) in high-income countries. Despite the important role of SEP in the development of many diseases, no socioeconomic indicator was included in the Comparative Risk Assessment (CRA) module of the Global Burden of Disease study. We therefore aimed to illustrate an example by estimating the burden of type 2 diabetes in Sweden attributed to lower educational levels as a measure of SEP using the methods applied in the CRA.MethodsTo include lower educational levels as a risk factor for type 2 diabetes, we pooled relevant international data from a recent systematic review to measure the association between type 2 diabetes incidence and lower educational levels. We also collected data on the distribution of educational levels in the Swedish population using comparable criteria for educational levels as identified in the international literature. Population attributable fractions (PAF) were estimated and applied to the burden of diabetes estimates from the Swedish burden of disease database for men and women in the separate age groups (30-44, 45-59, 60-69, 70-79, and 80+ years).ResultsThe PAF estimates showed that 17.2% of the diabetes burden in men and 20.1% of the burden in women were attributed to lower educational levels in Sweden when combining all age groups. The burden was, however, most pronounced in the older age groups (70-79 and 80+), where lower educational levels contributed to 22.5% to 24.5% of the diabetes burden in men and 27.8% to 32.6% in women.ConclusionsThere is a considerable burden of type 2 diabetes attributed to lower educational levels in Sweden, and socioeconomic indicators should be considered to be incorporated in the CRA.

Cannabis use, depression and anxiety: A 3-year prospective population-based study.

BACKGROUND Whether or not cannabis use may increase the risk for depression and/or anxiety is not clear. For one thing, it has not been possible to draw a definitive conclusion regarding the direction of causality, i.e. whether cannabis use increases the risk for depression/anxiety or vice versa. This study aimed at examining possible associations between cannabis use, depression and anxiety, using all three measures as both exposure and outcome. METHODS Data were obtained from a longitudinal cohort study comprising 8598 Swedish men and women, aged 20-64, with a three-year-follow-up. RESULTS Adjusted for sex and age, cannabis use at baseline was associated with an increased relative risk (RR) for depression and anxiety at follow-up, with RR=1.22 [1.06-1.42 Cl 95%] for depression and RR=1.38 [1.26-1.50 Cl 95%] for anxiety. Adjusted for all confounders (alcohol and illicit drug use, education, family tension, place of upbringing), the associations were no longer statistically significant; RR=0.99 [0.82-1.17 Cl 95%] for depression and RR=1.09 [0.98-1.20 Cl 95%] for anxiety. Age-adjusted, reporting depression or anxiety at baseline increased the risk of cannabis onset at follow-up three years later; RR=1.62 [1.28-2.03 CI 95%] and RR=1.63 [1.28-2.08 CI 95%] respectively. However, adjusted for other illicit drug use the associations were no longer statistically significant. LIMITATIONS Lack of information on frequency of cannabis use and of age of initiation of use. CONCLUSIONS We found no longitudinal associations between cannabis use and incidence of depression/anxiety, or between depression/anxiety and later cannabis use onset.

Cannabis use among Swedish men in adolescence and the risk of adverse life course outcomes: results from a 20 year-follow-up study.

Abstract Aims To examine associations between cannabis use in adolescence (at age 18) and unemployment and social welfare assistance in adulthood (at age 40) among Swedish men. Design Longitudinal cohort study. Setting and Participants A total of 49 321 Swedish men born in 1949–51, who were conscripted to compulsory military service at 18–20 years of age. Measurements All men answered two detailed questionnaires at conscription and were subject to examinations of physical aptitude psychological functioning and medical status. By follow‐up in national databases, information on unemployment and social welfare assistance was obtained. Findings Individuals who used cannabis at high levels in adolescence had increased risk of future unemployment and of receiving social welfare assistance. Adjusted for all confounders (social background, psychological functioning, health behaviours, educational level, psychiatric diagnoses), an increased relative risk (RR) of unemployment remained in the group reporting cannabis use > 50 times [RR = 1.26, 95% confidence interval (CI) = 1.04–1.53] only. For social welfare assistance, RR in the group reporting cannabis use 1–10 times was 1.15 (95% CI = 1.06–1.26), RR for 11–50 times was 1.21 (95% CI = 1.04–1.42) and RR for > 50 times was 1.38 (95% CI = 1.19–1.62). Conclusions Heavy cannabis use among Swedish men in late adolescence appears to be associated with unemployment and being in need of social welfare assistance in adulthood. These associations are not explained fully by other health‐related, social or behavioural problems.

Alcohol‐attributed disease burden in four Nordic countries: A comparison using the Global Burden of Disease, Injuries and Risk Factors 2013 study

Abstract Aims (1) To compare alcohol‐attributed disease burden in four Nordic countries 1990–2013, by overall disability‐adjusted life years (DALYs) and separated by premature mortality [years of life lost (YLL)] and health loss to non‐fatal conditions [years lived with disability (YLD)]; (2) to examine whether changes in alcohol consumption informs alcohol‐attributed disease burden; and (3) to compare the distribution of disease burden separated by causes. Design A comparative risk assessment approach. Setting Sweden, Norway, Denmark and Finland. Participants Male and female populations of each country. Measurements Age‐standardized DALYs, YLLs and YLDs per 100 000 with 95% uncertainty intervals (UIs). Findings In Finland, with the highest burden over the study period, overall alcohol‐attributed DALYs were 1616 per 100 000 in 2013, while in Norway, with the lowest burden, corresponding estimates were 634. DALYs in Denmark were 1246 and in Sweden 788. In Denmark and Finland, changes in consumption generally corresponded to changes in disease burden, but not to the same extent in Sweden and Norway. All countries had a similar disease pattern and the majority of DALYs were due to YLLs (62–76%), mainly from alcohol use disorder, cirrhosis, transport injuries, self‐harm and violence. YLDs from alcohol use disorder accounted for 41% and 49% of DALYs in Denmark and Finland compared to 63 and 64% in Norway and Sweden 2013, respectively. Conclusions Finland and Denmark has a higher alcohol‐attributed disease burden than Sweden and Norway in the period 1990–2013. Changes in consumption levels in general corresponded to changes in harm in Finland and Denmark, but not in Sweden and Norway for some years. All countries followed a similar pattern. The majority of disability‐adjusted life years were due to premature mortality. Alcohol use disorder by non‐fatal conditions accounted for a higher proportion of disability‐adjusted life years in Norway and Sweden, compared with Finland and Denmark.

Alcohol–attributed disease burden and alcohol policies in the BRICS–countries during the years 1990–2013

Background We aimed to assess alcohol consumption and alcohol–attributed disease burden by DALYs (disability adjusted life years) in the BRICS countries (Brazil, Russia, India, China and South Africa) between 1990 and 2013, and explore to what extent these countries have implemented evidence–based alcohol policies during the same time period. Methods A comparative risk assessment approach and literature review, within a setting of the BRICS countries. Participants were the total populations (males and females combined) of each country. Levels of alcohol consumption, age–standardized alcohol–attributable DALYs per 100 000 and alcohol policy documents were measured. Results The alcohol–attributed disease burden mirrors level of consumption in Brazil, Russia and India, to some extent in China, but not in South Africa. Between the years 1990–2013 DALYs per 100 000 decreased in Brazil (from 2124 to 1902), China (from 1719 to 1250) and South Africa (from 2926 to 2662). An increase was observed in Russia (from 4015 to 4719) and India (from 1574 to 1722). Policies were implemented in all of the BRICS countries and the most common were tax increases, drink–driving measures and restrictions on advertisement. Conclusions There was an overall decrease in alcohol–related DALYs in Brazil, China and South Africa, while an overall increase was observed in Russia and India. Most notably is the change in DALYs in Russia, where a distinct increase from 1990–2005 was followed by a steady decrease from 2005–2013. Even if assessment of causality cannot be done, policy changes were generally followed by changes in alcohol–attributed disease burden. This highlights the importance of more detailed research on this topic.

Cannabis use in adolescence and risk of future disability pension: A 39-year longitudinal cohort study

AIMS This study aimed at examining a possible association between cannabis use in adolescence and future disability pension (DP). DP can be granted to any person in Sweden aged 16-65 years if working capacity is judged to be permanently reduced due to long-standing illness or injury. METHODS Data were obtained from a longitudinal cohort study comprising 49,321 Swedish men born in 1949-1951 who were conscripted to compulsory military service aged 18-20 years. Data on DP was collected from national registers. RESULTS Results showed that individuals who used cannabis in adolescence had considerably higher rates of disability pension throughout the follow-up until 59 years of age. In Cox proportional-hazards regression analyses, adjustment for covariates (social background, mental health, physical fitness, risky alcohol use, tobacco smoking and illicit drug use) attenuated the associations. However, when all covariates where entered simultaneously, about a 30% increased hazard ratio of DP from 40 to 59 years of age still remained in the group reporting cannabis use more than 50 times. CONCLUSIONS This study shows that heavy cannabis use in late adolescence was associated with an increased relative risk of labor market exclusion through disability pension.

Low cardiorespiratory fitness in young adulthood and future risk of disability pension: a follow-up study until 59 years of age in Swedish men

Background There is a strong belief in the potential of increased physical activity to improve the health of populations. The objective of the present study was to estimate the association between low cardiorespiratory fitness in young adulthood and subsequent health impairment until middle age, measured by disability pension. Methods The study utilised data on cardiorespiratory fitness and a number of covariates (social background, health behaviours and psychological characteristics) from the Swedish Conscription Cohort of 1969/1970 including 49 321 men born in 1949–1951, and data on disability pension from 1971 to 2008 (20–59 years of age) through record linkage with two national insurance databases. Cox proportional-hazards regressions yielded hazard ratios (HR) with 95% confidence intervals (CI). Results Having low-level or mid-level cardiorespiratory fitness in late adolescence was associated with an increased HR of disability pension across the follow-up (HR for low fitness: 1.85, CI 1.71 to 2.00; HR for mid-level fitness: 1.40, CI 1.31 to 1.50). The association was stronger with earlier disability pensions than with later disability pensions, which was also seen after multiple confounding adjustments. At the same time, these adjustments revealed considerable confounding of the association by individual differences in psychological characteristics in particular. Conclusions Lower levels of cardiorespiratory fitness in young adulthood were found to be associated with an increased HR of disability pension throughout the follow-up until 59 years of age, even after adjustment for important confounding factors measured in late adolescence. Increased physical fitness may thus have a lowering effect on the risk of disability pension.