Many countries, including Brazil, are facing growing social inequalities in diabetes prevalence. The different states in Brazil represent different levels of development and by comparing diabetes ...inequalities across states we aim to get a better understanding of how educational inequalities in diabetes are linked to social development. We use the latest cross-sectional national health survey of Brazil - PNS-2013 (N = 60,202) and analyse the disparities in diabetes as well as the differential exposure and susceptibility to the effect of obesity across states for men and women. Among women in high-HDI states the prevalence of diabetes is 11.7 percentage units (CI: 9.3; 14.0) higher among the lowest compared to the highest educated. In less-developed states the disparity is smaller. Among men, there is no social gradient found for diabetes, but obesity is positively associated with education. The association between obesity and diabetes is stronger among the low educated particularly for men in high-HDI states. Here the interaction effect between low education and obesity is 11.7 (CI 8.1; 15.4) percentage units. The fact that economic development is associated with increasingly unequal levels of diabetes and with unequal levels of exposure and susceptibility to obesity indicates that other interacting determinants are important for the development of the diabetes epidemic in Brazil.
The aim of this study was to examine the associations between social inequalities and daily smoking among 13 and 15 year olds, and to determine the role of students' academic achievement and school ...satisfaction in these associations.
HBSC is an international study including adolescents from 32 countries in Europe, Israel, and North America. The present study was based on information from 20,399 adolescents from Denmark, Sweden, Norway, Finland and the United Kingdom. Data were analysed by regression models.
The initial analyses showed significant inequality in daily smoking in all countries except for Sweden. When adjusted for the mediating role of academic achievement, estimates were attenuated, but remained significant in three countries.
The study found social inequality in daily smoking in Denmark, Sweden, Norway, Finland and United Kingdom, as well as inequalities in students' academic achievement and school satisfaction. The analyses also showed that above average academic achievement was associated with lower OR of smoking. Teachers and politicians may find this information useful, and allocate resources to give higher priority to a supportive environment in schools especially for children and adolescents in lower social groups. Subsequently this prioritisation might contribute to reducing smoking in this group.
It has been suggested that it would be more appropriate to term the COVID-19 pandemic a syndemic, as the infection interacts synergistically with pre-existing chronic conditions such as obesity. Both ...conditions occur with steep socio-economic inequalities, and Brazil is suffering a heavy burden from both. What and who drives the clustering and interaction of these disorders? In this commentary, we examine the pathways leading to the COVID-19 syndemic. Deforestation, declining biodiversity and factory farming are promoting the emergence of new pathogens. Widespread use of pesticides influences immune, endocrine and metabolic systems. The ingestion of ultra-processed food promotes malnutrition and obesity in a country where at the same time poverty and food insecurity is rising. Brazilian agribusiness is focused on the production and global export of agricultural commodities, mainly for animal food and meat production. It is made possible through a combination of expanded land use, with deforestation in Amazonas and other Brazilian biomes, and the intensification of land use and cultivation of genetically modified crops with fertilizers and pesticides. This development is not sustainable for either population health or the environment.
Background Forced expiratory volume in 1 s as a percentage of predicted (%FEV1) is a key outcome in cystic fibrosis (CF) and other lung diseases. As people with CF survive for longer periods, new ...methods are required to understand the way %FEV1 changes over time. An up to date approach for longitudinal modelling of %FEV1 is presented and applied to a unique CF dataset to demonstrate its utility at the clinical and population level. Methods and findings The Danish CF register contains 70 448 %FEV1 measures on 479 patients seen monthly between 1969 and 2010. The variability in the data is partitioned into three components (between patient, within patient and measurement error) using the empirical variogram. Then a linear mixed effects model is developed to explore factors influencing %FEV1 in this population. Lung function measures are correlated for over 15 years. A baseline %FEV1 value explains 63% of the variability in %FEV1 at 1 year, 40% at 3 years, and about 30% at 5 years. The model output smooths out the short-term variability in %FEV1 (SD 6.3%), aiding clinical interpretation of changes in %FEV1. At the population level significant effects of birth cohort, pancreatic status and Pseudomonas aeruginosa infection status on %FEV1 are shown over time. Conclusions This approach provides a more realistic estimate of the %FEV1 trajectory of people with chronic lung disease by acknowledging the imprecision in individual measurements and the correlation structure of repeated measurements on the same individual over time. This method has applications for clinicians in assessing prognosis and the need for treatment intensification, and for use in clinical trials.
The objectives are to examine if the excess risk of myocardial infarction from exposure to job strain is due to interaction between high demands and low control and to analyse what role such an ...interaction has regarding socioeconomic differences in risk of myocardial infarction. The material is a population-based case-referent study having incident first events of myocardial infarction as outcome (SHEEP: Stockholm Heart Epidemiology Program). The analysis is restricted to males 45–64
yr of age with a more detailed analysis confined to those still working at inclusion. In total, 1047 cases and 1450 referents were included in the analysis. Exposure categories of job strain were formed from self reported questionnaire information. The results show that high demands and low decision latitude interact with a synergy index of 7.5 (95% C.I.: 1.8–30.6) providing empirical support for the core mechanism of the job strain model. Manual workers are more susceptible when exposed to job strain and its components and this increased susceptibility explains about 25–50% of the relative excess risk among manual workers. Low decision latitude may also, as a causal link, explain about 30% of the socioeconomic difference in risk of myocardial infarction. The distinction between the interaction and the causal link mechanisms identifies new etiologic questions and intervention alternatives. The specific causes of the increased susceptibility among manual workers to job strain and its components seem to be an interesting and important research question.
It is a widely held belief in public health and clinical decision-making that interventions or preventive strategies should be aimed at patients or population subgroups where most cases could ...potentially be prevented. To identify such subgroups, deviation from additivity of absolute effects is the relevant measure of interest. Multiplicative survival models, such as the Cox proportional hazards model, are often used to estimate the association between exposure and risk of disease in prospective studies. In Cox models, deviations from additivity have usually been assessed by surrogate measures of additive interaction derived from multiplicative models—an approach that is both counter-intuitive and sometimes invalid. This paper presents a straightforward and intuitive way of assessing deviation from additivity of effects in survival analysis by use of the additive hazards model. The model directly estimates the absolute size of the deviation from additivity and provides confidence intervals. In addition, the model can accommodate both continuous and categorical exposures and models both exposures and potential confounders on the same underlying scale. To illustrate the approach, we present an empirical example of interaction between education and smoking on risk of lung cancer. We argue that deviations from additivity of effects are important for public health interventions and clinical decision-making, and such estimations should be encouraged in prospective studies on health. A detailed implementation guide of the additive hazards model is provided in the appendix.
Use of invasive revascularization percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) after acute myocardial infarction (AMI) in Denmark increased between 1996 and ...2004. We investigated how this affected socioeconomic differences in their use.
All patients aged 30-74 years in hospital for a first AMI in Denmark between 1996 and 2004 were included. Cox proportional hazard models were used to estimate the association between individual income (tertiles) and education (>12, 10-12 and <10 years) and time to revascularization within 6 months. Revascularization was stratified into CABG, acute PCI (within 2 days of admission) and non-acute PCI (after the third day).
A total of 38,803 patients were included. In 1996-1998, 6.8% received CABG, 9.3% non-acute PCI and 2.4% acute PCI; in 2002-2004, these numbers were 11.8, 36.1 and 29.1%. CABG was more likely to be performed for patients with a high income hazard ratio (HR), 1.18; 95% confidence interval (CI), 1.08-1.28 or a medium income (HR, 1.16; 95% CI, 1.07-1.25) than for those with a low income throughout the period. A similar income gradient was seen for non-acute PCI, but not for acute PCI, for which no gradient was seen. No educational gradient was found for CABG, and that for non-acute and acute PCI decreased during the period; by the end of the period, more patients with low than high education received acute PCI.
In the universal health care system of Denmark, income differences in CABG and non-acute PCI persisted, whereas no such differences were seen for acute PCI.
Aim
To explore whether long-term adherence to preventive statin therapy depends on socioeconomic position (SEP).
Methods
A cohort of individuals without established cardiovascular disease (CVD) or ...diabetes initiating preventive statin therapy during 2002–2005 was followed in the individual-level Danish registries for 4 years or until censoring events (death, emigration, CVD or diabetes). Only individuals aged 40–84 years for whom information was available on the SEP indicators, education and income were included (
N
= 76,038). Two different aspects of poor adherence were applied as outcome measures: (1) Proportion of days covered (PDC) with medication below 80 %, assuming a daily dose of one tablet (continuity); (2) Discontinuation defined as a gap between two consecutive prescriptions exceeding 365 days (persistence). Stratum-specific logistic regression analyses were applied to estimate the odds ratio (OR) for PDC <80 % across SEP, adjusting for age and hypertension. Hazard ratio (HR) for discontinuation was estimated by Cox regression analyses.
Results
Adjusting mutually for income and education, the OR for PDC <80 % decreased with increasing income. Comparing the highest income quintile with the lowest, the OR were 0.64 (95 % Confidence Interval 0.64–0.65) and 0.73 (0.73–0.74) in men aged 40–64 and 65–84 years, respectively; in women, the figures were 0.79 (0.79–0.79) and 0.95 (0.94–0.95), respectively. While observed increases in adherence with longer education in unadjusted analyses were attenuated after adjustment for income among men, the potential inverse relationship between length of education and adherence was enhanced among women. Applying discontinuation as outcome, analogous differences were demonstrated.
Conclusion
Adherence to preventive statin therapy in Denmark decreases with decreasing income—especially in men aged 40–64 years.
BACKGROUND AND PURPOSE—Combined effects of socioeconomic position and well-established risk factors on stroke incidence have not been formally investigated.
METHODS—In a pooled cohort study of 68 643 ...men and women aged 30 to 70 years in Denmark, we examined the combined effect and interaction between socioeconomic position (ie, education), smoking, and hypertension on ischemic and hemorrhagic stroke incidence by the use of the additive hazards model.
RESULTS—During 14 years of follow-up, 3613 ischemic strokes and 776 hemorrhagic strokes were observed. Current smoking and hypertension were more prevalent among those with low education. Low versus high education was associated with greater ischemic, but not hemorrhagic, stroke incidence. The combined effect of low education and current smoking was more than expected by the sum of their separate effects on ischemic stroke incidence, particularly among men134 (95% confidence interval, 49–219) extra cases per 100 000 person-years because of interaction, adjusted for age, cohort study, and birth cohort. There was no clear evidence of interaction between low education and hypertension. The combined effect of current smoking and hypertension was more than expected by the sum of their separate effects on ischemic and hemorrhagic stroke incidence. This effect was most pronounced for ischemic stroke among women178 (95% confidence interval, 103–253) extra cases per 100 000 person-years because of interaction, adjusted for age, cohort study, and birth cohort.
CONCLUSIONS—Reducing smoking in those with low socioeconomic position and in those with hypertension could potentially reduce social inequality stroke incidence.
BackgroundThe social inequality in mortality is due to differential incidence of several disorders and injury types, as well as differential survival. The resulting clustering and possible ...interaction in disadvantaged groups of several disorders make multimorbidity a potentially important component in the health divide. This study decomposes the effect of education on mortality into a direct effect, a pure indirect effect mediated by multimorbidity and a mediated interaction between education and multimorbidity.MethodsThe study uses the Danish population registers on the total Danish population aged 45–69 years. A multimorbidity index based on all somatic and psychiatric hospital contacts as well as prescribed medicines includes 22 diagnostic groups weighted together by their 5 years mortality risk as weight. The Aalen additive hazard model is used to estimate and decompose the 5 years risk difference in absolute numbers of deaths according to educational status.ResultsMost (69%–79%) of the effect is direct not involving multimorbidity, and the mediated effect is for low educated women 155 per 100 000 of which 87 is an effect of mediated interaction. For low educated men, the mediated effect is 250 per 100 000 of which 93 is mediated interaction.ConclusionMultimorbidity plays an important role in the social inequality in mortality among middle aged in Denmark and mediated interaction represents 5%–17%. As multimorbidity is a growing challenge in specialised health systems, the mediated interaction might be a relevant indicator of inequities in care of multimorbid patients.
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