Juhani Mäki

Individual-level measures of social capital as predictors of all-cause and cardiovascular mortality: a population-based prospective study of men and women in Finland

Individual-level social capital was assessed for prediction of mortality in a nationally representative study population aged 30–99xa0years at the baseline. A total of 90% of the original sample had participated in a comprehensive health examination (Mini-Finland Health Survey) in 1978–1980. After the first 5xa0years of the 24-year follow-up period, 1,196 of 3,014 men and 1,280 of 3,689 women died. Individual-level social capital was determined by factor analysis that revealed three factors: residential stability, leisure participation and interpersonal trust. Factor analysis showed a gender difference in leisure social participation. All-cause mortality and cardiovascular mortality were analyzed using Cox proportional hazard models. Adjusted for demographic, life style and biological risk factors, and for health and socio-economic status, leisure participation was associated with reduced all-cause mortality in men (hazard ratio, HR: 0.94; 95% confidence interval, CI: 0.89–1.00). This association seems to be related to economic status in men. Age modifies the effect of interpersonal trust on all-cause mortality in men. In women, leisure participation (HR: 0.96; 95% CI: 0.91–1.00) and interpersonal trust (HR: 0.69; 95% CI: 0.51–0.93) predicted all-cause mortality, and the latter also cardiovascular mortality (HR: 0.93; 95% CI: 0.86–1.00). The associations between individual-level social capital and mortality are gender- and age-related. Understanding the gender and age perspectives appears to be essential for better insight into the interrelations between social capital and health.

Office, Home, and Ambulatory Blood Pressures as Predictors of Cardiovascular Risk

Ambulatory blood pressure (BP) is considered as the gold standard of BP measurement although it has not been shown to be more strongly associated with cardiovascular risk than is home BP. Our objective was to compare the prognostic value of office, home, and ambulatory BP for cardiovascular risk in 502 participants examined in 1992 to 1996. The end point was a composite of cardiovascular mortality, myocardial infarction, stroke, heart failure hospitalization, and coronary intervention. We assessed the prognostic value of each BP in multivariable-adjusted Cox models. The likelihood &khgr;2 ratio value was used to test whether the addition of a BP variable improved the model’s goodness of fit. After a follow-up of 16.1±3.9 years, 70 participants (13.9%) had experienced ≥1 cardiovascular event. Office (systolic/diastolic hazard ratio per 1/1 mm Hg increase in BP, 1.024/1.018; systolic/diastolic 95% confidence interval, 1.009–1.040/0.994–1.043), home (hazard ratio, 1.029/1.028; 95% confidence interval, 1.013–1.045/1.005–1.052), and 24-hour ambulatory BP (hazard ratio, 1.033/1.049; 95% confidence interval, 1.019–1.047/1.023–1.077) were predictive of cardiovascular events. When all 3 BP variables were included in the model simultaneously, only systolic/diastolic ambulatory BP was a significant predictor of cardiovascular events (P=0.002/<0.001). Home systolic/diastolic BP improved the fit of the model only marginally when added to a model including office BP (&khgr;2=3.0/4.0, P=0.09/0.047). Ambulatory BP, however, improved the fit of model more clearly when added to office and home BP (&khgr;2=9.0/12.3, P=0.001/<0.001). Our findings suggest that ambulatory BP is prognostically superior to office and home BP.

Vitamin D status and common risk factors for bone fragility as determinants of quantitative ultrasound variables in a nationally representative population sample.

Calcaneal quantitative ultrasound (QUS) can predict bone strength and fracture risk. Bone fragility has no single cause but results from a complex interplay of several etiologic or contributing factors. Vitamin D is essential for bone health even though it is still unclear how much of this vitamin is required to maintain bone strength and prevent fractures. Measurements of serum 25-hydroxyvitamin D [S-25(OH)D] have indicated a high prevalence of inadequate vitamin D status in a number of studies mostly based on selected study populations. The objective of this study was to examine the associations between S-25(OH)D, common risk factors for bone fragility, and QUS variables in a large unselected population sample. The study population consisted of 2736 men and 3299 women from a nationally representative population sample, aged 30 years or over. Information on lifestyle was elicited by means of interviews and questionnaires. Body fat mass was estimated using an impedance-meter. S-25(OH)D was measured by radioimmunoassay. Calcaneal QUS was performed on the Hologic Sahara apparatus recording broadband ultrasound attenuation (BUA) and speed of sound (SOS). The potential determinants of BUA and SOS were analysed using separate multiple linear regression models for men and women. S-25(OH)D proved to be an independent determinant of BUA (P<0.0001 for men, P<0.001 for women) and SOS (P<0.0001 for men, P<0.05 for women). BUA was also independently associated with age, height, weight, alcohol consumption, and postmenopausal status in women, and with weight, alcohol consumption, smoking and physical activity in men. All of the above variables, except for weight in women, were also found to be independent determinants of SOS in both men and women. A reverse association was found between S-25(OH)D and adiposity in spite of higher intakes of vitamin D in those with higher fat mass. In this unselected sample of men and women, vitamin D status, several lifestyle factors and physical characteristics proved to be significant determinants of BUA and SOS. Inadequate vitamin D status was common, and measures ensuring adequate intakes of vitamin D in the population thus deserve continued attention. Obesity should be taken into account in future assessments of vitamin D status in Finland as in other countries.

High and increasing prevalence of inflammatory bowel disease in Finland with a clear North–South difference

BACKGROUND AND AIMnInflammatory bowel disease (IBD) prevalence has increased and a North-South gradient has been reported. We estimated the nationwide prevalence of IBD, ulcerative colitis (UC) and Crohns disease (CD) in 1993, and prevalence of IBD in 2008, and assessed the geographical distribution of IBD in Finland. In addition, we investigated the vitamin D levels in a study population from a large, nationally representative health examination survey, the Health 2000 Survey.nnnMETHODSnThe register study for prevalences included all patients who had special reimbursement of medications for IBD in the years 1993 (n=10,958) and 2008 (31,703). The study for D-vitamin measurement consisted of 6134 persons who had participated in the Health 2000 Survey.nnnRESULTSnThe nationwide point prevalence of IBD in 1993 was 216 per 100,000 inhabitants, and 595 in 2008. In 1993, the prevalence of UC (177) was fourfold higher than the prevalence of CD (38). The prevalence of IBD and UC in Finland increased from South to North. For CD, no geographical variation could be demonstrated. In the Health 2000 survey, vitamin D levels were lower in Northern than in Southern Finland.nnnCONCLUSIONSnFinland belongs to high prevalence area of IBD and this prevalence has increased nearly threefold during the past 15 years. A clear North-South gradient has been shown for IBD and UC, but not for CD. Slightly lower vitamin D levels in Northern Finland may be associated with the observed higher prevalence of IBD there.

Hip fractures and femoral bone mineral density in male former elite athletes.

INTRODUCTIONnWe studied whether vigorous physical activity in young adulthood is associated with higher femoral bone density and lower risk of hip fracture at older age in men.nnnMATERIALSnA cohort of former male elite athletes (n=2147) and matched control subjects (n=1467) were studied for their leisure physical activity, and for fragility fractures at the hip (proximal femur) by Cox regression. Areal bone mineral densities (aBMD) at femoral neck and trochanter region were measured using dual-energy X-ray absorptiometry in a subgroup of the former athletes (n=87; median age 59 years) and in a population-based control group (n=194) and compared by general linear models.nnnRESULTSnAfter their active sporting careers, the former athletes participated in leisure physical activity more than the matched control subjects (p<0.0001). The hazard ratio (HR) of osteoporotic hip fracture adjusted for the occupational group was 0.77 (95% CI 0.45 to 1.32, p=0.34) in the athletes compared with the control subjects. The mean age at the time of the fracture event was 76.9 years (95% CI 73.2 to 78.8) for the athletes and 70.6 years (95% CI 67.1 to 72.9) for the matched control subjects (p=0.005). Adjusted for age and body mass index, aBMD at the proximal femur was significantly higher in the former athletes compared with the population-based control group (p<0.0001 for both measurement sites).nnnCONCLUSIONSnOsteoporotic hip fractures were sustained at a significantly older age among former athletes compared with control subjects. Clear skeletal benefits of long-term physical loading were also observed in comparative DXA measurements of aBMD.

Thyroid-stimulating hormone reference range and factors affecting it in a nationwide random sample.

Abstract Background: Previous studies with mainly selected populations have proposed contradicting reference ranges for thyroid-stimulating hormone (TSH) and have disagreed on how screening, age and gender affect them. This study aimed to determine a TSH reference range on the Abbott Architect ci8200 integrated system in a large, nationwide, stratified random sample. To our knowledge this is the only study apart from the NHANES III that has addressed this issue in a similar nationwide setting. The effects of age, gender, thyroid peroxidase antibody (TPOAb)-positivity and medications on TSH reference range were also assessed. Methods: TSH was measured from 6247 participants randomly drawn from the population register to represent the Finnish adult population. TSH reference ranges were established of a thyroid-healthy population and its subpopulations with increasing and cumulative rigour of screening: screening for overt thyroid disease (thyroid-healthy population, n=5709); screening for TPOAb-positivity (risk factor-free subpopulation, n=4586); and screening for use of any medications (reference subpopulation, n=1849). Results: The TSH reference ranges of the thyroid-healthy population, and the risk factor-free and reference subpopulations were 0.4–4.4, 0.4–3.7 and 0.4–3.4 mU/L (2.5th–97.5th percentiles), respectively. Although the differences in TSH between subgroups for age (p=0.002) and gender (p=0.005) reached statistical significance, the TSH distribution curves of the subgroups were practically superimposed. Conclusions: We propose 0.4–3.4 mU/L as a TSH reference range for adults for this platform, which is lower than those presently used in most laboratories. Our findings suggest that intensive screening for thyroid risk factors, especially for TPOAb-positivity, decreases the TSH upper reference limit.

Fall-related risk factors and heel quantitative ultrasound in the assessment of hip fracture risk: a 10-year follow-up of a nationally representative adult population sample.

SummaryMaximal walking speed and quantitative ultrasound index (QUI) were significant and independent predictors of hip fracture among subjects aged ≥55xa0years. A model including readily available variables along with simple fall-related factors may be clinically useful in the assessment of hip fracture risk even without a QUI measurement.IntroductionThis study assessed fall-related risk factors along with heel bone quantitative ultrasound (QUS) measurements for the prediction of hip fracture during a mean follow-up of 9.8xa0years in a nationally representative population sample.MethodsThe study population consisted of 2,300 subjects (1,331 women and 969 men) aged 55xa0years or over, who had participated in a comprehensive health survey in 2000–2001. Information on the subjects’ health and fall-related risk factors was obtained with interviews, questionnaires and tests carried out by specially trained professionals. QUS measurements were made by means of the Hologic Sahara device. First emerging cases of hip fracture were identified from the National Hospital Discharge Register.ResultsDuring the follow-up, 96 subjects sustained a hip fracture. Slow maximal walking speed, low quantitative ultrasound index (QUI), high age, tallness, short waist circumference, Parkinson’s disease and the number of central nervous system active medication were significant and independent predictors of hip fracture. The model including all of these risk factors explained 68xa0% of the variation in hip fracture risk. Excluding QUI from this model reduced the percentage to 66xa0%.ConclusionsMaximal walking speed and QUI were significant and independent predictors of hip fracture. A model including readily available variables such as age, gender, height and waist circumference along with simple fall-related factors may be of clinical use in the assessment of hip fracture risk even without a QUS measurement.

Quantitative ultrasound measurements and vitamin D status in the assessment of hip fracture risk in a nationally representative population sample

SummaryAdjusted for age, gender, height and weight, calcaneal quantitative ultrasound (QUS) and serum 25-hydroxyvitamin D (S-25(OH)D) proved to be significant predictors of hip fracture among subjects aged ≥50xa0years. Even if their contribution to the predictive power was modest, they may be useful in the assessment of hip fracture risk in the elderly.IntroductionThis study assessed calcaneal QUS measurements, S-25(OH)D and several other factors for the prediction of hip fracture risk in a nationally representative population sample.MethodsThe study population consisted of 3,305 subjects (1,872 women), aged 50xa0years or over, who had participated in a comprehensive health survey. QUS measurements were made by means of the Hologic Sahara device. S-25(OH)D was measured by radioimmunoassay. Emerging cases of hip fracture were identified from the National Hospital Discharge Register.ResultsDuring a mean follow-up of 8.4xa0years, 95 subjects sustained a hip fracture. After adjusting for age, gender, height, weight and each other, a 1 standard deviation increment in the quantitative ultrasound index (QUI) (21.7) and in S-25(OH)D (17.5xa0nmol/L) reduced the risk of hip fracture by 40xa0% (hazard ratio [HR]u2009=u20090.60, 95xa0% confidence interval [CI]u2009=u20090.42–0.86) and by 31xa0% (HRu2009=u20090.69, 95xa0% CIu2009=u20090.55–0.87), respectively. The predictive power of a model including age, gender, height and weight was improved by about 8xa0% after the addition of QUI and S-25(OH)D. Among subjects aged 75xa0years or over, the corresponding improvement was about 130xa0%.ConclusionsQUI and S-25(OH)D were significant and independent predictors of hip fracture. However, their ability to increase the predictive power of a statistical model including readily available simple variables such as age, gender, height and weight was rather modest. Still, our findings suggest that QUI and S-25(OH)D may be of clinical use in the assessment of hip fracture risk particularly in the elderly.

Positive change in the utilization of antihypertensive and lipid-lowering drugs among adult diabetics in Finland. Results from large national database between 2000 and 2006.

Objectives To assess changes in the utilization of antihypertensive and lipid-lowering drugs among all adult Finnish diabetics between 2000 and 2006, and to evaluate the treatment and control of hypertension and dyslipidemia in a population-based sample of diabetic patients. Methods From the databases of the Social Insurance Institution of Finland, 143 366 diabetic patients aged 30 years or over in 2000–2001 and 187 099 in 2006–2007, respectively, were identified, and changes in the prevalence of antihypertensive and lipid-lowering drugs were determined. In addition, from the Health 2000 Survey representing the whole Finnish population aged 30 years or over, 388 diabetic patients were identified, to assess their characteristics and control of hypertension and dyslipidemia. Results Between the fall of 2000 and spring of 2001, 83% of the diabetics were classified as hypertensives. Sixty-nine percent of them used antihypertensive medication. From 2000 to 2006, utilization of lipid-lowering drugs increased by 111%, and combination antihypertensive medication, by 31%, for patients with diabetes. Among those using antihypertensive drugs, the use of angiotensin receptor blockers increased by 196%, and the use of either an angiotensin receptor blocker or an angiotensin-converting enzyme inhibitor, by 31%, respectively. Of the treated hypertensive diabetic patients in 2000–2001, only 14% had the blood pressure below 130/80 mmHg, and only 17% of the diabetics using lipid-lowering drugs had the serum low-density lipoprotein-cholesterol value less than 2.5 mmol/l. Conclusion Our findings indicate that the control of hypertension and dyslipidemia among adult diabetics in the beginning of the decade was poor. On the contrary, utilization of antihypertensive agents (especially angiotensin receptor blockers) and lipid-lowering drugs has increased remarkably by the end of 2006. Still, the treatments are far from optimal.

Adding a low-dose antihypertensive regimen would substantially improve the control of hypertension and reduce cardiovascular morbidity among uncomplicated hypertensive patients

Aims: To assess the utilization of antihypertensive drugs among uncomplicated hypertensive patients in Finland between 2000 and 2006 and to calculate the achievable reduction in cardiovascular morbidity, with intensified antihypertensive treatment. Methods: From the databases of the Social Insurance Institution of Finland, 428,986 treated hypertensives without diabetes or cardiac disease (further named uncomplicated hypertensives) in 2000 and 591,206 in 2006, respectively, were identified. In addition, from the Health 2000 survey representing the whole Finnish adult population, 729 uncomplicated hypertensives were determined to assess their characteristics and control of hypertension. Applying Law′s meta-analyses we calculated the reduction of blood pressure (BP) by intensifying the treatment with low-dose antihypertensive regimens for those with a BP ≥140/90u2009mmHg. Results: The nationwide data suggests a relative overuse of beta-blockers. Combination antihypertensive treatment increased relatively 8%, while at least three drug combinations increased from 19.8% to 21.6% between 2000 and 2006. However, calculated prevalence of controlled BP (<140/90u2009mmHg) increased only from 30.3% to 33.9%. Addition of one half standard dose or one to two half standard doses for the treatment of the patients with a BP ≥140/90u2009mmHg would improve the control of hypertension from 33.9% to 47.8% and 67.3%, respectively. The intensified treatment would reduce strokes by 18% and 28%, and ischaemic heart disease events by 13% and 21%, respectively. Conclusions: Underutilization of preferred drugs and poor control of BP continues. Surprisingly small addition of the number of low-dose antihypertensive regimen is needed in order to substantially improve the control of hypertension and to decrease cardiovascular morbidity among uncomplicated hypertensive patients.