161 results on '"Winkleby MA"'
Search Results
2. Predictors of physicians' smoking cessation advice
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Frank, E, primary, Winkleby, MA, additional, Altman, DG, additional, Rockhill, B, additional, and Fortmann, SP, additional
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- 1992
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3. Genetic and familial environmental influences on the risk for drug abuse: a national Swedish adoption study.
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Kendler KS, Sundquist K, Ohlsson H, Palmér K, Maes H, Winkleby MA, and Sundquist J
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- 2012
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4. Preterm birth and risk of epilepsy in Swedish adults.
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Crump C, Sundquist K, Winkleby MA, Sundquist J, Crump, Casey, Sundquist, Kristina, Winkleby, Marilyn A, and Sundquist, Jan
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- 2011
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5. Changes in neighbourhood food store environment, food behaviour and body mass index, 1981--1990.
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Wang MC, Cubbin C, Ahn D, Winkleby MA, Wang, May C, Cubbin, Catherine, Ahn, Dave, and Winkleby, Marilyn A
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Objective: This paper examines trends in the neighbourhood food store environment (defined by the number and geographic density of food stores of each type in a neighbourhood), and in food consumption behaviour and overweight risk of 5779 men and women.Design: The study used data gathered by the Stanford Heart Disease Prevention Program in four cross-sectional surveys conducted from 1981 to 1990.Setting: Four mid-sized cities in agricultural regions of California.Subjects: In total, 3154 women and 2625 men, aged 25-74 years.Results: From 1981 to 1990, there were large increases in the number and density of neighbourhood stores selling sweets, pizza stores, small grocery stores and fast-food restaurants. During this period, the percentage of women and men who adopted healthy food behaviours increased but so did the percentage who adopted less healthy food behaviours. The percentage who were obese increased by 28% in women and 24% in men.Conclusion: Findings point to increases in neighbourhood food stores that generally offer mostly unhealthy foods, and also to the importance of examining other food pattern changes that may have a substantial impact on obesity, such as large increases in portion sizes during the 1980s. [ABSTRACT FROM AUTHOR]- Published
- 2008
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6. Changing patterns in health behaviors and risk factors related to chronic diseases, 1990-2000.
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Winkleby MA, Cubbin C, Winkleby, Marilyn A, and Cubbin, Catherine
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Purpose: Assess changes in chronic disease-related health behaviors and risk factors from 1990 to 2000, by race/ethnicity, age, and gender.Design: Stratified cross-sectional design.Setting: United States.Subjects: 16,948 black, 11,956 Hispanic, and 158,707 white women and men, ages 18 to 74.Measures: Cigarette smoking, obesity, sedentary behavior, low vegetable or fruit intake. From the Behavioral Risk Factor Surveillance System.Results: Young women and men, ages 18 to 24, had poor health profiles and experienced adverse changes from 1990 to 2000. After the variables were adjusted for education and income, these young people had the highest prevalence of smoking (34%-36% current smokers among white women and men), the largest increases in smoking (10%-12% increase among white women and men; 9% increase among Hispanic women), and large increases in obesity (4%-9% increase, all gender and racial/ethnic groups). Young women and men from each racial/ethnic group also had high levels of sedentary behavior (approximately 20%-30%) and low vegetable or fruit intake (approximately 35%-50%). In contrast, older Hispanic women and men and older black men, ages 65 to 74, showed some of the most positive changes. They had the largest decreases in smoking (Hispanic women), largest decreases in sedentary behavior (Hispanic women and black men), and largest increases in vegetable or fruit intake (Hispanic women and men, and black men).Conclusion: The poor and worsening health profile of young women and men is a particular concern, as they will soon enter the ages of high chronic disease burden. [ABSTRACT FROM AUTHOR]- Published
- 2004
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7. Using focus groups to develop a heart disease prevention program for ethnically diverse, low-income women.
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Gettleman L and Winkleby MA
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Although low-income women have higher rates of cardiovascular disease (CVD) than higher-income women, health promotion and disease prevention are often low priorities due to financial, family, and health care constraints. In addition, most low-income women live in environments that tend to support and even promote high risk CVD behaviors. Low-income African-American, Hispanic, and White women constitute one of the largest groups at high risk for CVD but few heart disease prevention programs have effectively reached them. The purpose of this project was to use feedback from focus groups to generate ideas about how to best structure and implement future CVD intervention programs tailored to low-income populations. Seven focus groups were conducted with 51 low-income African-American, Hispanic, and White women from two urban and two agricultural communities in California. The women in the study shared many common experiences and barriers to healthy lifestyles, despite their ethnic diversity. Results of the focus groups showed that women preferred heart disease prevention programs that would address multiple CVD risk factors, emphasize staying healthy for themselves, teach specific skills about how to adopt heart-healthy behaviors, and offer them choices in effecting behavioral change. For health information, they preferred visual formats to written formats. They also expressed a desire to develop knowledge to help them separate health 'myths' from health 'facts' in order to reduce their misconceptions about CVD. Finally, they stressed that health care policies and programs need to address social and financial barriers that impede the adoption of heart-healthy behaviors. [ABSTRACT FROM AUTHOR]
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- 2000
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8. Population frequency distribution of non-high-density lipoprotein cholesterol (Third National Health and Nutrition Examination Survey [NHANES III], 1988-1994).
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Gardner CD, Winkleby MA, Fortmann SP, Gardner, C D, Winkleby, M A, and Fortmann, S P
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The objective of this study was to provide population frequency distribution data for non-high-density lipoprotein (HDL) cholesterol (total cholesterol minus HDL cholesterol) concentrations and to evaluate whether differences exist by gender, ethnicity, or level of education. Serum levels of non-HDL cholesterol and sociodemographic characteristics were determined for 3,618 black, 3,528 Mexican-American, and 6,043 white women and men, aged >/=25 years, from a national cross-sectional survey of the US population (National Health And Nutrition Examination Survey III, 1988-1994). Age-adjusted non-HDL cholesterol concentrations were lower in women than men (154.1 vs 160.4 mg/dL, p <0.001). In women and men, age was positively associated with non-HDL cholesterol in the 25 to 64-year age range, and the slope of the association was steeper for women. For women and men >/=65 years, age was negatively associated with non-HDL cholesterol, and the slope of the association was steeper for men. Black women and men had lower non-HDL cholesterol levels than either Mexican-American or white women and men (women, p <0.02; men, p <0.001, for both ethnic contrasts). Women with less education had higher levels of non-HDL cholesterol than women with more education (p <0.01). These nationally representative population frequency distribution data provide non-HDL cholesterol reference levels for clinicians and investigators and indicate that there are significant variations in non-HDL cholesterol by gender, age, ethnicity, and level of education. [ABSTRACT FROM AUTHOR]
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- 2000
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9. Ethnic variation in cardiovascular disease risk factors among children and young adults: findings from the Third National Health and Nutrition Examination Survey, 1988-1994.
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Winkleby MA, Robinson TN, Sundquist J, Kraemer HC, Winkleby, M A, Robinson, T N, Sundquist, J, and Kraemer, H C
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Context: Knowledge about ethnic differences in cardiovascular disease (CVD) risk factors among children and young adults from national samples is limited.Objective: To evaluate ethnic differences in CVD risk factors, the age at which differences were first apparent, and whether differences remained after accounting for socioeconomic status (SES).Design: Third National Health and Nutrition Examination Survey, 1988-1994.Setting: Eighty-nine mobile examination centers.Participants: A total of 2769 black, 2854 Mexican American, and 2063 white (non-Hispanic) children and young adults aged 6 to 24 years.Main Outcome Measures: Ethnicity and household level of education (SES) in relation to body mass index (BMI), percentage of energy from dietary fat, cigarette smoking, systolic blood pressure, glycosylated hemoglobin (HbA1c), and non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]).Results: The BMI levels were significantly higher for black and Mexican American girls than for white girls, with ethnic differences evident by the age of 6 to 9 years (a difference of approximately 0.5 BMI units) and widening thereafter (a difference of >2 BMI units among 18- to 24-year-olds). Percentages of energy from dietary fat paralleled these findings and were also significantly higher for black than for white boys. Blood pressure levels were higher for black girls than for white girls in every age group, and glycosylated hemoglobin levels were highest for black and Mexican American girls and boys in every age group. In contrast, smoking prevalence was highest for white girls and boys, especially for those from low-SES homes (77% of young men and 61% of young women, aged 18-24 years, from low-SES homes were current smokers). All ethnic differences remained significant after accounting for SES and age.Conclusion: These findings show strong ethnic differences in CVD risk factors among youths of comparable age and SES from a large national sample. The differences highlight the need for heart disease prevention programs to begin early in childhood and continue throughout young adulthood to reduce the risk of atherosclerosis. [ABSTRACT FROM AUTHOR]- Published
- 1999
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10. The long-term effects of a cardiovascular disease prevention trial: the Stanford Five-City Project.
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Winkleby MA, Taylor CB, Jatulis D, and Fortmann SP
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OBJECTIVES: This study examined long-term effects of a health-education intervention trial to reduce the risk of cardiovascular disease. METHODS: Surveys were conducted in California in two treatment and two control cities at baseline (1979/1980), after the 6-year intervention (1985/1986), and 3 years later at follow-up (1989/1990). Net treatment/control differences in risk-factor change were assessed for women and men 25 to 74 years of age. RESULTS: Blood pressure improvements observed in all cities from baseline to the end of the intervention were maintained during the follow-up in treatment but not control cities. Cholesterol levels continued to decline in all cities during follow-up. Smoking rates leveled out or increased slightly in treatment cities and continued to decline in control cities but did not yield significant net differences. Both coronary heart disease and all-cause mortality risk scores were maintained or continued to improve in treatment cities while leveling out or rebounding in control cities. CONCLUSIONS: These findings suggest that community-based cardiovascular disease prevention trials can have sustained effects. However, the modest net differences in risk factors suggest the need for new designs and interventions that will accelerate positive risk-factor change. [ABSTRACT FROM AUTHOR]
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- 1996
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11. Physical, addictive, and psychiatric disorders among homeless veterans and nonveterans.
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Winkleby MA and Fleshin D
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A cross-sectional survey of 1,431 homeless adults was conducted during the winter of 1989-90 at three shelters in Santa Clara County, CA, with a 98 percent response rate. Of the 1,008 U.S.-born men, 423, or 42 percent, were veterans, including 173 combat-exposed veterans and 250 noncombat-exposed veterans. There were 585 nonveterans. Both combat and noncombat-exposed veterans were significantly more likely to report excessive alcohol consumption before their initial loss of shelter than were nonveterans. Combat-exposed veterans had the highest prevalences of psychiatric hospitalizations and physical injuries before homelessness, 1.5 to 2 times higher than nonveterans and noncombat-exposed veterans. The length of time between military discharge and initial loss of shelter was longer than a decade for 76 percent of combat-exposed veterans and 50 percent of noncombat-exposed veterans. The extended time from discharge to homelessness suggests that higher prevalences of alcohol consumption, psychiatric hospitalization, and physical injury among veterans, especially those exposed to combat, may not have arisen from military service. It is possible, however, that such disorders may be considerably delayed before becoming serious enough to impact one's family, work, and the availability of shelter. [ABSTRACT FROM AUTHOR]
- Published
- 1993
12. Health-related risk factors of homeless families and single adults.
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Winkleby MA and Boyce WT
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Using data from two cross-sectional surveys, we examine how homeless adults living with children differ in sociodemographic characteristics, adverse childhood experiences, and addictive and psychiatric disorders from homeless adults who are not living with children. The surveys were conducted in late 1989 and early 1990 in Santa Clara County, California. Women (n= 100) and men (n=41) with children were sampled from the two largest family shelters in the County (94% response rate); women (n= 169) and men (n= 1268) without children were sampled from the three main adult shelters in the County (98% response rate). Adults with children (especially women) were significantly younger, less educated, less likely to have experienced full-time employment, and more likely to have been supported by public assistance before first becoming homeless than adults without children. In addition, adults with children became homeless at younger ages, had been homeless for less time, and were less likely to experience multiple episodes of homelessness. Further differences were found for addictive and psychiatric disorders -- adults with children were significantly less likely to enter homelessness with histories of excessive alcohol intake (both men and women) and psychiatric hospitalizations (women only) than adults without children. The distinct risk factor profile of homeless adults living with children renders them a critically important demographic group on which to focus new public health programs and social strategies. [ABSTRACT FROM AUTHOR]
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- 1994
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13. The interplay of socioeconomic status and ethnicity on Hispanic and White men's cardiovascular disease risk and health communication patterns.
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Ribisl, KM, Winkleby, MA, Fortmann, SP, and Flora, JA
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CARDIOVASCULAR diseases ,ETHNICITY ,EDUCATION ,MEDICAL communication ,HEALTH - Abstract
In this article, we seek to confirm past studies that document increased levels of cardiovascular disease (CVD) risk factors among White men with lower educational attainment. Second, we include a population of Hispanic men (89% Mexican American) to examine the separate and interactive effects of ethnicity and education (our measure of socioeconomic status) on CVD risk factors. Third, we examine how education and ethnicity are related to receiving health messages from print media and interpersonal channels, with the hypothesis that less educated, higher CVD risk Hispanic and White men receive fewer messages than more educated men. Finally, we examine other psychosocial variables (e.g. knowledge, self-efficacy and motivation) that may help explain observed differences in CVD risk and health communication. The study sample included 2029 men, 25-64 years of age, from three population-based, cross-sectional surveys conducted from 1979 to 1990 as part of the Stanford Five-City Project. Hispanic and White men with lower educational attainment had higher levels of CVD risk factors, and received less health information from print media and interpersonal channels than Hispanic and White men with higher educational attainment. Furthermore, less educated men from both ethnic groups reported less CVD knowledge, lower self-efficacy and lower motivation to reduce CVD risk factors than higher educated men. These results highlight the need for effective intervention programs that target low educated Hispanic and White men to decrease the disproportionate risk of CVD. [ABSTRACT FROM AUTHOR]
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- 1998
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14. Changes in coronary heart disease risk factors in the 1980s: evidence of a male-female crossover effect with age.
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Williams EL, Winkleby MA, and Fortmann SP
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- 1993
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15. Effect of community health education on plasma cholesterol levels and diet: the Stanford Five-City Project.
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Fortmann SP, Taylor CB, Flora JA, and Winkleby MA
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- 1993
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16. The neighborhood food environment: sources of historical data on retail food stores
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Gonzalez Alma A, Wang May C, Ritchie Lorrene D, and Winkleby Marilyn A
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Nutritional diseases. Deficiency diseases ,RC620-627 ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract With the rapidly increasing prevalence of obesity in the United States, and the minimal success of education-based interventions, there is growing interest in understanding the role of the neighborhood food environment in determining dietary behavior. This study, as part of a larger study, identifies historical data on retail food stores, evaluates strengths and limitations of the data for research, and assesses the comparability of historical retail food store data from a government and a commercial source. Five government and commercial listings of retail food stores were identified. The California State Board of Equalization (SBOE) database was selected and then compared to telephone business directory listings. The Spearman's correlation coefficient was used to assess the congruency of food store counts per census tract between the SBOE and telephone business directory databases. The setting was four cities in Northern California, 1979–1990. The SBOE and telephone business directory databases listed 127 and 351 retail food stores, respectively. The SBOE listed 36 stores not listed by the telephone business directories, while the telephone business directories listed 260 stores not listed by the SBOE. Spearman's correlation coefficients between estimates of stores per census tract made from the SBOE listings and those made from the telephone business directory listings were approximately 0.5 (p < .0001) for the types of stores studied (chain supermarkets, small grocery stores, and chain convenience markets). We conclude that, depending on the specific aims of the study, caution and considerable effort must be exercised in using and applying historical data on retail food stores.
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- 2006
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17. Identifying patients for weight-loss treatment: an empirical evaluation of the NHLBI Obesity Education Initiative Expert Panel treatment recommendations.
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Kiernan M and Winkleby MA
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- 2000
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18. Development of a curriculum to lower dietary fat intake in a multiethnic population with low literacy skills.
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Albright CL, Bruce B, Howard-Pitney B, Winkleby MA, and Fortmann SP
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- 1997
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19. Cardiorespiratory fitness and long-term risk of sleep apnea: A national cohort study.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Cohort Studies, Humans, Male, Middle Aged, Prevalence, Risk Factors, Young Adult, Cardiorespiratory Fitness physiology, Sleep Apnea Syndromes complications
- Abstract
Sleep apnea is increasing in prevalence, and is an important cause of cardiometabolic diseases and mortality worldwide. Its only established modifiable risk factor is obesity; however, up to half of all sleep apnea cases may occur in non-obese persons, and hence there is a pressing need to identify other modifiable risk factors to facilitate more effective prevention. We sought to examine, for the first time, cardiorespiratory fitness in relation to the risk of sleep apnea, independent of obesity. A national cohort study was conducted to examine cardiorespiratory fitness in all 1,547,478 Swedish military conscripts during 1969-1997 (97%-98% of all 18-year-old men) in relation to risk of sleep apnea through 2012 (maximum age 62 years). Cardiorespiratory fitness was measured as maximal aerobic workload in Watts, and sleep apnea was identified from nationwide outpatient and inpatient diagnoses. A total of 44,612 (2.9%) men were diagnosed with sleep apnea in 43.7 million person-years of follow-up. Adjusting for age, height, weight, socioeconomic factors and family history of sleep apnea, low cardiorespiratory fitness at age 18 years was associated with a significantly increased risk of sleep apnea in adulthood (lowest versus highest cardiorespiratory fitness tertile: incidence rate ratio, 1.44; 95% confidence interval, 1.40-1.49; p < 0.001; continuous cardiorespiratory fitness per 100 Watts: incidence rate ratio, 0.71; 95% confidence interval, 0.70-0.73; p < 0.001). An increased risk was observed even among men with normal body mass index (lowest versus highest cardiorespiratory fitness tertile: incidence rate ratio, 1.30; 95% confidence interval, 1.26-1.35; p < 0.001). These findings identify low cardiorespiratory fitness early in life as a new modifiable risk factor for development of sleep apnea in adulthood., (© 2019 European Sleep Research Society.)
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- 2019
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20. Prevalence of Survival Without Major Comorbidities Among Adults Born Prematurely.
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Crump C, Winkleby MA, Sundquist J, and Sundquist K
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- Adolescent, Adult, Cohort Studies, Epidemiology, Female, Gestational Age, Humans, Infant, Extremely Premature, Male, Poisson Distribution, Prevalence, Registries, Sweden epidemiology, Young Adult, Comorbidity, Infant, Premature
- Abstract
Importance: Preterm birth has been associated with cardiometabolic, respiratory, and neuropsychiatric disorders in adulthood. However, the prevalence of survival without any major comorbidities is unknown., Objective: To determine the prevalence of survival without major comorbidities in adulthood among persons born preterm vs full-term., Design, Setting, and Participants: National cohort study of all 2 566 699 persons born in Sweden from January 1, 1973, through December 31, 1997, who had gestational age data and who were followed up for survival and comorbidities through December 31, 2015 (ages 18-43 years)., Exposures: Gestational age at birth., Main Outcomes and Measures: Survival without major comorbidities among persons born extremely preterm (22-27 weeks), very preterm (28-33 weeks), late preterm (34-36 weeks), or early term (37-38 weeks), compared with full-term (39-41 weeks). Comorbidities were defined using the Adolescent and Young Adult Health Outcomes and Patient Experience (AYA HOPE) Comorbidity Index, which includes conditions that commonly manifest in adolescence or young adulthood, including neuropsychiatric disorders; and the Charlson Comorbidity Index (CCI), which includes major chronic disorders predictive of mortality in adulthood. Poisson regression was used to determine prevalence ratios and differences, adjusted for potential confounders., Results: In this study population, 48.6% were female, 5.8% were born preterm, and the median age at end of follow-up was 29.8 years (interquartile range, 12.6 years). Of all persons born preterm, 54.6% were alive with no AYA HOPE comorbidities at the end of follow-up. Further stratified, this prevalence was 22.3% for those born extremely preterm, 48.5% for very preterm, 58.0% for late preterm, 61.2% for early term, and 63.0% for full-term. These prevalences were significantly lower for earlier gestational ages vs full-term (eg, adjusted prevalence ratios: extremely preterm, 0.35 [95% CI, 0.33 to 0.36; P < .001]; all preterm, 0.86 [95% CI, 0.85 to 0.86; P < .001]; adjusted prevalence differences: extremely preterm, -0.41 [95% CI, -0.42 to -0.40; P < .001]; all preterm, -0.09 [95% CI, -0.09 to -0.09; P < .001]). Using the CCI, the corresponding prevalences were 73.1% (all preterm), 32.5% (extremely preterm), 66.4% (very preterm), 77.1% (late preterm), 80.4% (early term), and 81.8% (full-term) (adjusted prevalence ratios: extremely preterm, 0.39 [95% CI, 0.38 to 0.41; P < .001]; all preterm, 0.89 [95% CI, 0.89 to 0.89; P < .001]; adjusted prevalence differences: extremely preterm, -0.50 [95% CI, -0.51 to -0.49; P < .001]; all preterm, -0.09 [95% CI, -0.09 to -0.09; P < .001])., Conclusions and Relevance: Among persons born preterm in Sweden between 1973 and 1997, the majority survived to early to mid-adulthood without major comorbidities. However, outcomes were worse for those born extremely preterm.
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- 2019
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21. Gestational age at birth and mortality from infancy into mid-adulthood: a national cohort study.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Child, Child, Preschool, Cohort Studies, Female, Humans, Infant, Newborn, Male, Premature Birth epidemiology, Regression Analysis, Risk Factors, Sweden epidemiology, Young Adult, Gestational Age, Mortality trends, Premature Birth mortality, Survivors statistics & numerical data, Term Birth
- Abstract
Background: Breakthroughs in the treatment of preterm birth approximately 40 years ago have enabled a generation of preterm survivors to now reach mid-adulthood. Understanding their health sequelae is essential for guiding their long-term care. We did a study to examine preterm birth in relation to mortality into mid-adulthood., Methods: A national cohort study was done of all 4 296 814 singleton livebirths in Sweden between 1973 and 2015, who were followed up for mortality through Dec 31, 2017 (maximum age 45 years). Cox regression was used to examine gestational age at birth in relation to all-cause and cause-specific mortality, and cosibling analyses assessed for potential confounding by shared familial (genetic or environmental) factors., Findings: In 103·5 million person-years of follow-up, 43 916 (1·0%) deaths were reported. Gestational age at birth was inversely associated with mortality from infancy to mid-adulthood. Relative to full-term birth (39-41 weeks), the adjusted hazard ratios for mortality associated with gestational age at birth were: 66·14 (95% CI 63·09-69·34) for extremely preterm (22-27 weeks), 8·67 (8·32-9·03) for very preterm (28-33 weeks), 2·61 (2·52-2·71) for late preterm (34-36 weeks), and 1·34 (1·30-1·37) for early term (37-38 weeks), from birth to age 45 years; and 2·04 (0·92-4·55) for extremely preterm, 1·48 (1·17-1·87) for very preterm, 1·22 (1·07-1·39) for late preterm, and 1·16 (1·08-1·25) for early term, at ages 30-45 years. Preterm birth accounted for more deaths among males than females (additive interaction p<0·001). Multiple underlying causes were identified, including congenital anomalies; respiratory, endocrine, cardiovascular, and neurological diseases; cancer; and external causes. Cosibling analyses suggested that the observed associations were not due to shared genetic or environmental factors in families., Interpretation: Preterm and early term birth should be recognised as chronic conditions that require long-term follow-up for adverse health sequelae in adulthood., Funding: National Heart, Lung, and Blood Institute at the National Institutes of Health., (Copyright © 2019 Elsevier Ltd. All rights reserved.)
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- 2019
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22. Exercise Is Medicine: Primary Care Counseling on Aerobic Fitness and Muscle Strengthening.
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Crump C, Sundquist K, Sundquist J, and Winkleby MA
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- Health Promotion statistics & numerical data, Humans, Physical Fitness physiology, Primary Health Care statistics & numerical data, Sedentary Behavior, Counseling statistics & numerical data, Health Promotion methods, Physical Conditioning, Human physiology, Primary Health Care methods
- Abstract
Patient counseling on physical fitness remains underutilized in primary care, despite its clinical and cost effectiveness. Most counseling interventions have focused on aerobic activity and neglected another vital component of physical fitness, muscle strengthening, which has recently been shown to be independently protective against cardiometabolic diseases and premature mortality. This article reviews the latest scientific evidence and makes recommendations toward a more comprehensive approach for promoting physical fitness in primary care. Given the high prevalence and wide-ranging health impacts of physical inactivity, counseling on physical fitness should be a standard part of wellness promotion and disease prevention and treatment for all patients. Interventions that include muscle strengthening will have a significantly greater impact on health outcomes than those focused on aerobic fitness alone. Counseling to promote both aerobic fitness and muscle strengthening is indicated for all patients, irrespective of body weight, and should begin early in life and continue across the life course., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)
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- 2019
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23. Height, Weight, and Aerobic Fitness Level in Relation to the Risk of Atrial Fibrillation.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Atrial Fibrillation epidemiology, Exercise, Humans, Inpatients statistics & numerical data, Male, Middle Aged, Military Personnel statistics & numerical data, Outpatients statistics & numerical data, Proportional Hazards Models, Risk Factors, Sweden epidemiology, Young Adult, Atrial Fibrillation etiology, Body Height, Body Weight, Physical Fitness
- Abstract
Tall stature and obesity have been associated with a higher risk of atrial fibrillation (AF), but there have been conflicting reports of the effects of aerobic fitness. We conducted a national cohort study to examine interactions between height or weight and level of aerobic fitness among 1,547,478 Swedish military conscripts during 1969-1997 (97%-98% of all 18-year-old men) in relation to AF identified from nationwide inpatient and outpatient diagnoses through 2012 (maximal age, 62 years). Increased height, weight, and aerobic fitness level (but not muscular strength) at age 18 years were all associated with a higher AF risk in adulthood. Positive additive and multiplicative interactions were found between height or weight and aerobic fitness level (for the highest tertiles of height and aerobic fitness level vs. the lowest, relative excess risk = 0.51, 95% confidence interval (CI): 0.40, 0.62; ratio of hazard ratios = 1.50, 95% CI: 1.34, 1.65). High aerobic fitness levels were associated with higher risk among men who were at least 186 cm (6 feet, 1 inch) tall but were protective among shorter men. Men with the combination of tall stature and high aerobic fitness level had the highest risk (for the highest tertiles vs. the lowest, adjusted hazard ratio = 1.70, 95% CI: 1.61, 1.80). These findings suggest important interactions between body size and aerobic fitness level in relation to AF and may help identify high-risk subgroups.
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- 2018
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24. Aerobic fitness, muscular strength and obesity in relation to risk of heart failure.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Age Factors, Body Mass Index, Health Status, Heart Failure diagnosis, Humans, Incidence, Male, Middle Aged, Military Personnel, Obesity diagnosis, Prognosis, Prospective Studies, Risk Assessment, Risk Factors, Sweden epidemiology, Time Factors, Heart Failure epidemiology, Muscle Strength, Obesity epidemiology, Physical Fitness
- Abstract
Objective: Low physical fitness and obesity have been associated with higher risk of developing heart failure (HF), but their interactive effects are unknown. Elucidation of interactions among these common modifiable factors may help facilitate more effective primary prevention., Methods: We conducted a national cohort study to examine the interactive effects of aerobic fitness, muscular strength and body mass index (BMI) among 1 330 610 military conscripts in Sweden during 1969-1997 (97%-98% of all 18-year-old men) on risk of HF identified from inpatient and outpatient diagnoses through 2012 (maximum age 62 years)., Results: There were 11 711 men diagnosed with HF in 37.8 million person-years of follow-up. Low aerobic fitness, low muscular strength and obesity were independently associated with higher risk of HF, after adjusting for each other, socioeconomic factors, other chronic diseases and family history of HF. The combination of low aerobic fitness and low muscular strength (lowest vs highest tertiles) was associated with a 1.7-fold risk of HF (95% CI 1.6 to 1.9; p<0.001; incidence rates per 100 000 person-years, 43.2 vs 10.8). These factors had positive additive and multiplicative interactions (p<0.001) and were associated with increased risk of HF even among men with normal BMI., Conclusions: Low aerobic fitness, low muscular strength and obesity at the age of 18 years were independently associated with higher risk of HF in adulthood, with interactive effects between aerobic fitness and muscular strength. These findings suggest that early-life interventions may help reduce the long-term risk of HF and should include both aerobic fitness and muscular strength, even among persons with normal BMI., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)
- Published
- 2017
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25. Interactive Effects of Aerobic Fitness, Strength, and Obesity on Mortality in Men.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Age Factors, Body Mass Index, Cohort Studies, Humans, Male, Middle Aged, Mortality, Premature, Obesity mortality, Sweden epidemiology, Young Adult, Military Personnel, Muscle Strength physiology, Obesity epidemiology, Physical Fitness physiology
- Abstract
Introduction: Low aerobic fitness, low muscular strength, and obesity have been associated with premature mortality, but their interactive effects are unknown. This study examined interactions among these common, modifiable factors, to help inform more-effective preventive interventions., Methods: This national cohort study included all 1,547,478 military conscripts in Sweden during 1969-1997 (97%-98% of all men aged 18 years each year). Aerobic fitness, muscular strength, and BMI measurements were examined in relation to all-cause and cardiovascular mortality through 2012 (maximum age, 62 years). Data were collected/analyzed in 2015-2016., Results: Low aerobic fitness, low muscular strength, and obesity at age 18 years were independently associated with higher all-cause and cardiovascular mortality in adulthood. The combination of low aerobic fitness and muscular strength (lowest versus highest tertiles) was associated with twofold all-cause mortality (adjusted hazard ratio=2.01; 95% CI=1.93, 2.08; p<0.001; mortality rates per 100,000 person years, 247.2 vs 73.8), and 2.6-fold cardiovascular mortality (2.63; 95% CI=2.38, 2.91; p<0.001; 43.9 vs 8.3). These factors also had positive additive and multiplicative interactions in relation to all-cause mortality (their combined effect exceeded the sum or product of their separate effects; p<0.001), and were associated with higher mortality even among men with normal BMI., Conclusions: Low aerobic fitness, low muscular strength, and obesity at age 18 years were associated with increased mortality in adulthood, with interactive effects between aerobic fitness and muscular strength. Preventive interventions should begin early in life and include both aerobic fitness and muscular strength, even among those with normal BMI., (Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)
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- 2017
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26. Interactive effects of obesity and physical fitness on risk of ischemic heart disease.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Body Mass Index, Disease Susceptibility, Follow-Up Studies, Humans, Male, Middle Aged, Muscle Strength physiology, Risk Assessment, Risk Factors, Socioeconomic Factors, Sweden epidemiology, Time Factors, Young Adult, Military Personnel, Myocardial Ischemia epidemiology, Myocardial Ischemia physiopathology, Obesity epidemiology, Obesity physiopathology, Physical Fitness physiology
- Abstract
Background/objectives: Obesity and low physical fitness are known risk factors for ischemic heart disease (IHD), but their interactive effects are unclear. Elucidation of interactions between these common, modifiable risk factors may help inform more effective preventive strategies. We examined interactive effects of obesity, aerobic fitness and muscular strength in late adolescence on risk of IHD in adulthood in a large national cohort., Subjects/methods: We conducted a national cohort study of all 1 547 407 military conscripts in Sweden during 1969-1997 (97-98% of all 18-year-old males each year). Aerobic fitness, muscular strength and body mass index (BMI) measurements were examined in relation to IHD identified from outpatient and inpatient diagnoses through 2012 (maximum age 62 years)., Results: There were 38 142 men diagnosed with IHD in 39.7 million person years of follow-up. High BMI or low aerobic fitness (but not muscular strength) was associated with higher risk of IHD, adjusting for family history and socioeconomic factors. The combination of high BMI (overweight/obese vs normal) and low aerobic fitness (lowest vs highest tertile) was associated with highest IHD risk (incidence rate ratio, 3.11; 95% confidence interval (CI), 2.91-3.31; P<0.001). These exposures had no additive and a negative multiplicative interaction (that is, their combined effect was less than the product of their separate effects). Low aerobic fitness was a strong risk factor even among those with normal BMI., Conclusions: In this large cohort study, low aerobic fitness or high BMI at age 18 was associated with higher risk of IHD in adulthood, with a negative multiplicative interaction. Low aerobic fitness appeared to account for a similar number of IHD cases among those with normal vs high BMI (that is, no additive interaction). These findings suggest that interventions to prevent IHD should begin early in life and include not only weight control but aerobic fitness, even among persons of normal weight., Competing Interests: None.
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- 2017
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27. Interactive effects of physical fitness and body mass index on risk of stroke: A national cohort study.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Brain Ischemia epidemiology, Cerebral Hemorrhage epidemiology, Follow-Up Studies, Humans, Incidence, Male, Middle Aged, Military Personnel, Muscle Strength, Risk Factors, Stroke pathology, Stroke physiopathology, Sweden epidemiology, Young Adult, Body Mass Index, Physical Fitness, Stroke epidemiology
- Abstract
Background: High body mass index (BMI) and low physical fitness are risk factors for stroke, but their interactive effects are unknown. Elucidation of interactions between these modifiable risk factors can help inform preventive interventions in susceptible subgroups., Methods: National cohort study of all 1,547,294 military conscripts in Sweden during 1969-1997 (97-98% of all 18-year-old males). Standardized aerobic capacity, muscular strength, and body mass index measurements were examined in relation to stroke identified from inpatient and outpatient diagnoses through 2012 (maximum age 62 years)., Results: Sixteen thousand nine hundred seventy-nine men were diagnosed with stroke in 39.7 million person-years of follow-up. High body mass index, low aerobic fitness, and (less strongly) low muscular fitness were associated with higher risk of any stroke, ischemic stroke, and intracerebral hemorrhage, independently of family history and sociodemographic factors. High body mass index (overweight/obese vs. normal) and low aerobic capacity (lowest vs. highest tertile) had similar effect magnitudes, and their combination was associated with highest stroke risk (incidence rate ratio, 2.36; 95% CI, 2.14-2.60; P < 0.001). Aerobic capacity and muscular strength had a positive additive and multiplicative interaction (P < 0.001), indicating that low aerobic capacity accounted for more strokes among men with low compared with high muscular strength., Conclusions: High body mass index and low aerobic capacity in late adolescence are associated with increased risk of stroke in adulthood. Low aerobic capacity and low muscular strength also have a synergistic effect on stroke risk. These findings suggest that preventive interventions should include weight control and aerobic fitness early in life, and muscular fitness especially among those with low aerobic capacity., (© 2016 World Stroke Organization.)
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- 2016
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28. Physical Fitness Among Swedish Military Conscripts and Long-Term Risk for Type 2 Diabetes Mellitus: A Cohort Study.
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Crump C, Sundquist J, Winkleby MA, Sieh W, and Sundquist K
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- Adolescent, Adult, Body Mass Index, Diabetes Mellitus, Type 2 physiopathology, Exercise Test, Follow-Up Studies, Humans, Incidence, Male, Middle Aged, Muscle Strength physiology, Oxygen Consumption, Risk Factors, Socioeconomic Factors, Sweden epidemiology, Diabetes Mellitus, Type 2 epidemiology, Military Personnel statistics & numerical data, Physical Fitness
- Abstract
Background: Early-life physical fitness has rarely been examined in relation to type 2 diabetes mellitus (DM) in adulthood because of the lengthy follow-up required. Elucidation of modifiable risk factors at young ages may help facilitate earlier and more effective interventions., Objective: To examine aerobic capacity and muscle strength at age 18 years in relation to risk for type 2 DM in adulthood., Design: National cohort study., Setting: Sweden., Participants: 1 534 425 military conscripts from 1969 to 1997 (97% to 98% of all men aged 18 years nationwide) without prior type 2 DM., Measurements: Aerobic capacity and muscle strength (measured in watts and newtons per kilogram of body weight, respectively) were examined in relation to type 2 DM identified from outpatient and inpatient diagnoses from 1987 to 2012 (maximum age, 62 years)., Results: 34 008 men were diagnosed with type 2 DM in 39.4 million person-years of follow-up. Low aerobic capacity and muscle strength were independently associated with increased risk for type 2 DM. The absolute difference in cumulative incidence of type 2 DM between the lowest and highest tertiles of both aerobic capacity and strength was 0.22% at 20 years of follow-up (95% CI, 0.20% to 0.25%), 0.76% at 30 years (CI, 0.71% to 0.81%), and 3.97% at 40 years (CI, 3.87% to 4.06%). Overall, the combination of low aerobic capacity and muscle strength was associated with a 3-fold risk for type 2 DM (adjusted hazard ratio, 3.07 [CI, 2.88 to 3.27]; P < 0.001), with a positive additive interaction (P < 0.001). These associations were seen even among men with normal body mass index., Limitation: This cohort did not include women and did not measure physical fitness at older ages., Conclusion: In this large cohort of Swedish male military conscripts, low aerobic capacity and muscle strength at age 18 years were associated with increased long-term risk for type 2 DM, even among those with normal body mass index., Primary Funding Source: National Institutes of Health.
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- 2016
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29. Stress resilience and subsequent risk of type 2 diabetes in 1.5 million young men.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Body Mass Index, Cohort Studies, Diabetes Mellitus, Type 2 etiology, Humans, Male, Risk Factors, Sweden epidemiology, Diabetes Mellitus, Type 2 epidemiology, Stress, Psychological complications, Stress, Psychological epidemiology
- Abstract
Aims/hypothesis: Psychosocial stress in adulthood is associated with a higher risk of type 2 diabetes, possibly mediated by behavioural and physiological factors. However, it is unknown whether low stress resilience earlier in life is related to subsequent development of type 2 diabetes. We examined whether low stress resilience in late adolescence is associated with an increased risk of type 2 diabetes in adulthood., Methods: We conducted a national cohort study of all 1,534,425 military conscripts in Sweden during 1969-1997 (97-98% of all 18-year-old men nationwide each year) without prior diagnosis of diabetes, who underwent standardised psychological assessment for stress resilience (on a scale of 1-9) and were followed up for type 2 diabetes identified from outpatient and inpatient diagnoses during 1987-2012 (maximum attained age 62 years)., Results: There were 34,008 men diagnosed with type 2 diabetes in 39.4 million person-years of follow-up. Low stress resilience was associated with an increased risk of developing type 2 diabetes after adjusting for BMI, family history of diabetes, and individual and neighbourhood socioeconomic factors (HR for lowest vs highest quintile: 1.51; 95% CI 1.46, 1.57; p < 0.0001), including a strong linear trend across the full range of stress resilience (p trend < 0.0001). This association did not vary by BMI level, family history of diabetes or socioeconomic factors., Conclusions/interpretation: These findings suggest that low stress resilience may play an important long-term role in aetiological pathways for type 2 diabetes. Further elucidation of the underlying causal factors may help inform more effective preventive interventions across the lifespan.
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- 2016
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30. Low stress resilience in late adolescence and risk of hypertension in adulthood.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Age of Onset, Body Mass Index, Cohort Studies, Humans, Longitudinal Studies, Male, Middle Aged, Psychological Techniques, Risk Factors, Sweden epidemiology, Adaptation, Psychological physiology, Hypertension diagnosis, Hypertension epidemiology, Hypertension psychology, Resilience, Psychological, Stress, Psychological diagnosis, Stress, Psychological epidemiology, Stress, Psychological physiopathology, Stress, Psychological psychology
- Abstract
Objective: Greater blood pressure reactivity to psychological stress has been associated with higher risk of developing hypertension. We hypothesised that low stress resilience based on psychological assessment early in life is associated with hypertension in adulthood., Methods: National cohort study of 1,547,182 military conscripts in Sweden during 1969-1997 (97-98% of all 18-year-old males) without prior history of hypertension, who underwent standardised psychological assessment by trained psychologists for stress resilience (1-9 scale), and were followed up for hypertension identified from outpatient and inpatient diagnoses during 1969-2012 (maximum age 62)., Results: 93,028 men were diagnosed with hypertension in 39.4 million person-years of follow-up. Adjusting for body mass index (BMI), family history and socioeconomic factors, low stress resilience at age 18 was associated with increased risk of hypertension in adulthood (lowest vs highest quintile: HR 1.43; 95% CI 1.40 to 1.46; p < 0.001; incidence rates, 278.7 vs 180.0 per 100,000 person-years), including a strong linear trend across the full range of stress resilience (p(trend) < 0.0001). We also found a positive additive interaction between stress resilience and BMI (p < 0.001), indicating that low stress resilience accounted for more hypertension cases among those with high BMI. Men with a combination of low stress resilience and high BMI had a more than threefold risk of hypertension., Conclusions: These findings suggest that low stress resilience may contribute to etiological pathways for hypertension and accounts for more cases among those with high BMI. If confirmed, this knowledge may help inform better preventive interventions by addressing psychosocial risk factors and stress management across the lifespan., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)
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- 2016
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31. Fetal growth and subsequent maternal risk of thyroid cancer.
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Crump C, Sundquist J, Sieh W, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Aged, Birth Weight, Cohort Studies, Female, Humans, Middle Aged, Pregnancy, Risk, Fetal Development, Thyroid Neoplasms etiology
- Abstract
Thyroid cancer has peak incidence among women of reproductive age, and growth factors, which have procarcinogenic properties, may play an important etiologic role. However, the association between fetal growth rate during a woman's pregnancy and her subsequent risk of thyroid cancer has not been previously examined. We conducted a national cohort study of 1,837,634 mothers who had a total of 3,588,497 live-births in Sweden in 1973-2008, followed up for thyroid cancer incidence through 2009. There were 2,202 mothers subsequently diagnosed with thyroid cancer in 36.8 million person-years of follow-up. After adjusting for maternal age, height, weight, smoking, and sociodemographic factors, high fetal growth (birth weight standardized for gestational age and sex) was associated with a subsequent increased risk of thyroid cancer in the mother (incidence rate ratio [IRR] per additional 1 standard deviation, 1.05; 95% CI, 1.01-1.09; p = 0.02). Each 1,000 g increase in the infant's birth weight was associated with a 13% increase in the mother's subsequent risk of thyroid cancer (IRR, 1.13; 95% CI, 1.05-1.22; p = 0.001). These findings appeared to involve both papillary and follicular subtypes, and did not vary significantly by the mother's height, weight or smoking status. In this large national cohort study, high fetal growth during a woman's pregnancy was independently associated with a subsequent increased risk of her developing thyroid cancer. If confirmed, these findings suggest an important role of maternal growth factors in the development of thyroid cancer, and potentially may help facilitate the identification of high-risk subgroups of women., (© 2015 UICC.)
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- 2016
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32. Interactive Effects of Physical Fitness and Body Mass Index on the Risk of Hypertension.
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Crump C, Sundquist J, Winkleby MA, and Sundquist K
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- Adolescent, Follow-Up Studies, Humans, Male, Middle Aged, Risk, Sweden epidemiology, Body Mass Index, Exercise Tolerance, Hypertension epidemiology, Muscle Strength, Physical Fitness
- Abstract
Importance: High body mass index (BMI) and low physical fitness are risk factors for hypertension, but their interactive effects are unknown. Elucidation of interactions between these modifiable risk factors may help inform more effective interventions in susceptible subgroups., Objective: To determine the interactive effects of BMI and physical fitness on the risk of hypertension in a large national cohort., Design, Setting, and Participants: This cohort study included all 1,547,189 military conscripts in Sweden from January 1, 1969, through December 31, 1997 (97%-98% of all 18-year-old men nationwide each year), who were followed up through December 31, 2012 (maximum age, 62 years). Data analysis was conducted August 1 through August 15, 2015., Exposures: Standardized aerobic capacity, muscular strength, and BMI measurements obtained at a military conscription examination., Main Outcomes and Measures: Hypertension identified from outpatient and inpatient diagnoses., Results: A total of 93,035 men (6.0%) were diagnosed with hypertension in 39.7 million person-years of follow-up. High BMI and low aerobic capacity (but not muscular strength) were associated with increased risk of hypertension, independent of family history and socioeconomic factors (BMI, overweight or obese vs normal: incidence rate ratio, 2.51; 95% CI, 2.46-2.55; P < .001; aerobic capacity, lowest vs highest tertile: incidence rate ratio, 1.50; 95% CI, 1.47-1.54; P < .001). Aerobic capacity was inversely associated with hypertension across its full distribution (incidence rate ratio per 100 W, 0.70; 95% CI, 0.69-0.71; P < .001). A combination of high BMI (overweight or obese vs normal) and low aerobic capacity (lowest vs highest tertile) was associated with the highest risk of hypertension (incidence rate ratio, 3.53; 95% CI, 3.41-3.66; P < .001) and had a negative additive and multiplicative interaction (P < .001). Although high BMI was a significant risk factor for hypertension, low aerobic capacity also was a significant risk factor among those with normal BMI., Conclusions and Relevance: In this large national cohort study, high BMI and low aerobic capacity in late adolescence were associated with higher risk of hypertension in adulthood. If confirmed, our findings suggest that interventions to prevent hypertension should begin early in life and include not only weight control but aerobic fitness, even among persons with normal BMI.
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- 2016
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33. School Achievement and Risk of Eating Disorders in a Swedish National Cohort.
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Sundquist J, Ohlsson H, Winkleby MA, Sundquist K, and Crump C
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- Adolescent, Adult, Cohort Studies, Female, Humans, Male, Proportional Hazards Models, Registries, Risk Factors, Schools, Sweden epidemiology, Young Adult, Anorexia Nervosa epidemiology, Bulimia Nervosa epidemiology, Educational Status, Family psychology, Siblings psychology
- Abstract
Objective: High achievement in school has been associated with increased risk of eating disorders, including anorexia nervosa (AN) and bulimia nervosa (BN), but causality of these relationships is unclear. We sought to examine the association between school achievement and AN or BN in a national cohort and to determine the possible contribution of familial confounding using a co-relative design., Method: This national cohort study involved 1,800,643 persons born in Sweden during 1972 to 1990 who were still living in Sweden at age 16 years and were followed up for AN and BN identified from inpatient and outpatient diagnoses through 2012. We used Cox regression to examine the association between school achievement and subsequent risk of AN or BN, and stratified Cox models to examine the gradient in this association across different strata of co-relative pairs (first cousins, half siblings, full siblings)., Results: School achievement was positively associated with risk of AN among females and males (hazard ratio [HR] per additional 1 standard deviation, females: HR = 1.29; 95% CI = 1.25-1.33; males: HR = 1.29; 95% CI = 1.10-1.52), and risk of BN among females but not males (females: HR = 1.16; 95% CI = 1.11-1.20; males: HR = 1.05; 95% CI = 0.84-1.31). In co-relative analyses, as the degree of shared genetic and environmental factors increased (e.g., from first-cousin to full-sibling pairs), the association between school achievement and AN or BN substantially decreased., Conclusion: In this large national cohort study, high achievement in school was associated with increased risk of AN and BN, but this appeared to be explained by unmeasured familial (genetic and environmental) factors., (Copyright © 2016 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)
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- 2016
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34. Perinatal risk factors for acute myeloid leukemia.
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Crump C, Sundquist J, Sieh W, Winkleby MA, and Sundquist K
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- Adult, Birth Order, Child, Child, Preschool, Cohort Studies, Female, Fetal Development, Follow-Up Studies, Genetic Predisposition to Disease, Gestational Age, Humans, Incidence, Infant, Infant, Newborn, Male, Maternal Age, Perinatal Care, Population Surveillance, Pregnancy, Registries, Risk Factors, Socioeconomic Factors, Sweden epidemiology, Young Adult, Leukemia, Myeloid, Acute epidemiology, Leukemia, Myeloid, Acute etiology
- Abstract
Infectious etiologies have been hypothesized for acute leukemias because of their high incidence in early childhood, but have seldom been examined for acute myeloid leukemia (AML). We conducted the first large cohort study to examine perinatal factors including season of birth, a proxy for perinatal infectious exposures, and risk of AML in childhood through young adulthood. A national cohort of 3,569,333 persons without Down syndrome who were born in Sweden in 1973-2008 were followed up for AML incidence through 2010 (maximum age 38 years). There were 315 AML cases in 69.7 million person-years of follow-up. We found a sinusoidal pattern in AML risk by season of birth (P < 0.001), with peak risk among persons born in winter. Relative to persons born in summer (June-August), incidence rate ratios for AML were 1.72 (95 % CI 1.25-2.38; P = 0.001) for winter (December-February), 1.37 (95 % CI 0.99-1.90; P = 0.06) for spring (March-May), and 1.27 (95 % CI 0.90-1.80; P = 0.17) for fall (September-November). Other risk factors for AML included high fetal growth, high gestational age at birth, and low maternal education level. These findings did not vary by sex or age at diagnosis. Sex, birth order, parental age, and parental country of birth were not associated with AML. In this large cohort study, birth in winter was associated with increased risk of AML in childhood through young adulthood, possibly related to immunologic effects of early infectious exposures compared with summer birth. These findings warrant further investigation of the role of seasonally varying perinatal exposures in the etiology of AML.
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- 2015
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35. Transnational research partnerships: leveraging big data to enhance US health.
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Crump C, Sundquist K, and Winkleby MA
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- Biomedical Research economics, Biomedical Research organization & administration, Cooperative Behavior, Cost Control methods, Data Collection economics, Data Collection methods, Electronic Health Records economics, Electronic Health Records statistics & numerical data, Health Information Management economics, Health Information Management organization & administration, Humans, Medical Record Linkage, State Medicine economics, State Medicine organization & administration, United States, Biomedical Research statistics & numerical data, Health Information Management statistics & numerical data, International Cooperation, State Medicine statistics & numerical data
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- 2015
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36. Fetal growth and subsequent maternal risk of colorectal cancer.
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Crump C, Sundquist J, Sieh W, Winkleby MA, and Sundquist K
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- Cohort Studies, Female, Humans, Male, Middle Aged, Mothers, Pregnancy, Risk Factors, Fetal Development physiology
- Abstract
Background: High birth weight has been associated with subsequent increased risk of breast cancer in the infant's mother, possibly related to maternal estrogen and growth factor pathways. However, its association with maternal risk of colorectal cancer, the third most common cancer among women, is unknown., Methods: We conducted a national cohort study of 1,838,509 mothers who delivered 3,590,523 babies in Sweden in 1973-2008, followed up for colorectal cancer incidence through 2009., Results: There were 7,318 mothers diagnosed with colorectal cancer in 36.8 million person-years of follow-up. After adjusting for maternal age, body mass index, diabetes, and other potential confounders, high fetal growth was associated with a subsequent increased risk of colorectal cancer in the mother [incidence rate ratio (IRR) per additional 1 SD relative to mean birth weight for gestational age and sex, 1.05; 95% confidence intervals (CI), 1.03-1.07; P < 0.0001]. Each 1,000 g increase in the infant's birth weight was associated with a 12% increase in the mother's subsequent risk of colorectal cancer (IRR, 1.12; 95% CI, 1.07-1.17; P < 0.0001). Multiple gestation was also independently associated with increased maternal risk of colorectal cancer (IRR for twin or higher order vs. singleton, 1.22; 95% CI, 1.04-1.44; P = 0.02)., Conclusion: In this large cohort study, high fetal growth and multiple gestation were independently associated with subsequent higher maternal risk of colorectal cancer. These findings warrant further investigation of maternal growth factor and estrogen pathways in the etiology of colorectal cancer., Impact: If confirmed, our findings may help identify subgroups of women at high risk of colorectal cancer., (©2015 American Association for Cancer Research.)
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- 2015
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37. The Stanford Medical Youth Science Program: educational and science-related outcomes.
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Crump C, Ned J, and Winkleby MA
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- Adolescent, California, Cohort Studies, Education, Premedical, Educational Measurement, Female, Humans, Male, Program Evaluation, Socioeconomic Factors, Minority Groups statistics & numerical data, Science education, Universities organization & administration, Universities statistics & numerical data
- Abstract
Biomedical preparatory programs (pipeline programs) have been developed at colleges and universities to better prepare youth for entering science- and health-related careers, but outcomes of such programs have seldom been rigorously evaluated. We conducted a matched cohort study to evaluate the Stanford Medical Youth Science Program's Summer Residential Program (SRP), a 25-year-old university-based biomedical pipeline program that reaches out to low-income and underrepresented ethnic minority high school students. Five annual surveys were used to assess educational outcomes and science-related experience among 96 SRP participants and a comparison group of 192 youth who applied but were not selected to participate in the SRP, using ~2:1 matching on sociodemographic and academic background to control for potential confounders. SRP participants were more likely than the comparison group to enter college (100.0 vs. 84.4 %, p = 0.002), and both of these matriculation rates were more than double the statewide average (40.8 %). In most areas of science-related experience, SRP participants reported significantly more experience (>twofold odds) than the comparison group at 1 year of follow-up, but these differences did not persist after 2-4 years. The comparison group reported substantially more participation in science or college preparatory programs, more academic role models, and less personal adversity than SRP participants, which likely influenced these findings toward the null hypothesis. SRP applicants, irrespective of whether selected for participation, had significantly better educational outcomes than population averages. Short-term science-related experience was better among SRP participants, although longer-term outcomes were similar, most likely due to college and science-related opportunities among the comparison group. We discuss implications for future evaluations of other biomedical pipeline programs.
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- 2015
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38. Perinatal and familial risk factors for acute lymphoblastic leukemia in a Swedish national cohort.
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Crump C, Sundquist J, Sieh W, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Birth Order, Birth Weight, Child, Child, Preschool, Cohort Studies, Female, Follow-Up Studies, Humans, Incidence, Infant, Infant, Newborn, Male, Perinatal Care, Prognosis, Risk Factors, Sweden epidemiology, Young Adult, Fetal Development, Gestational Age, Maternal Age, Precursor Cell Lymphoblastic Leukemia-Lymphoma epidemiology, Precursor Cell Lymphoblastic Leukemia-Lymphoma etiology
- Abstract
Background: Perinatal factors including high birth weight have been found to be associated with acute lymphoblastic leukemia (ALL) in case-control studies. However, to the best of our knowledge, these findings have seldom been examined in large population-based cohort studies, and the specific contributions of gestational age and fetal growth remain unknown., Methods: The authors conducted a national cohort study of 3,569,333 individuals without Down syndrome who were born in Sweden between 1973 and 2008 and followed for the incidence of ALL through 2010 (maximum age, 38 years) to examine perinatal and familial risk factors., Results: There were 1960 ALL cases with 69.7 million person-years of follow-up. After adjusting for potential confounders, risk factors for ALL included high fetal growth (incidence rate ratio [IRR] per additional 1 standard deviation, 1.07; 95% confidence interval [95% CI], 1.02-1.11 [P =.002]; and IRR for large vs appropriate for gestational age, 1.22; 95% CI, 1.06-1.40 [P =.005]), first-degree family history of ALL (IRR, 7.41; 95% CI, 4.60-11.95 [P<.001]), male sex (IRR, 1.20; 95% CI, 1.10-1.31 [P<.001]), and parental country of birth (IRR for both parents born in Sweden vs other countries, 1.13; 95% CI, 1.00-1.27 [P =.045]). These risk factors did not appear to vary by patient age at the time of diagnosis of ALL. Gestational age at birth, season of birth, birth order, multiple birth, parental age, and parental education level were not found to be associated with ALL., Conclusions: In this large cohort study, high fetal growth was found to be associated with an increased risk of ALL in childhood through young adulthood, independent of gestational age at birth, suggesting that growth factor pathways may play an important long-term role in the etiology of ALL., (© 2014 American Cancer Society.)
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- 2015
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39. Tapping Underserved Students to Reshape the Biomedical Workforce.
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Winkleby MA, Ned J, and Crump C
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Low-income and underrepresented minority students remain a largely untapped source of new professionals that are increasingly needed to diversify and strengthen the biomedical workforce. Precollege enrichment programs offer a promising strategy to stop the "leak" in the biomedical pipeline. However, in the era of highly competitive science education funding, there is a lack of consensus about the elements that predict the long-term viability of such programs. In this commentary, the authors review the critical elements that contribute to the long-term viability of university-based precollege biomedical pipeline programs. Successful programs are built on a foundation of responding to local community workforce needs, have access to local universities that provide an organizational home, and offer a direct pipeline to strong undergraduate science training and support for graduate or professional training. Such programs have shown that there are substantial pools of diverse students who can thrive academically when given enrichment opportunities. Replication of pipeline programs with long-term viability will be instrumental in reaching the large numbers of talented underserved students who are needed to diversify and strengthen the biomedical workforce over the coming decades.
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- 2015
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40. Perinatal and familial risk factors for brain tumors in childhood through young adulthood.
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Crump C, Sundquist J, Sieh W, Winkleby MA, and Sundquist K
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- Adolescent, Adult, Astrocytoma diagnosis, Birth Weight, Child, Child, Preschool, Cohort Studies, Female, Humans, Incidence, Infant, Infant, Newborn, Male, Registries, Risk Factors, Sweden epidemiology, Young Adult, Brain Neoplasms epidemiology, Gene Expression Regulation, Neoplastic
- Abstract
Perinatal factors, including high birth weight, have been associated with childhood brain tumors in case-control studies. However, the specific contributions of gestational age and fetal growth remain unknown, and these issues have never been examined in large cohort studies with follow-up into adulthood. We conducted a national cohort study of 3,571,574 persons born in Sweden in 1973-2008, followed up for brain tumor incidence through 2010 (maximum age 38 years) to examine perinatal and familial risk factors. There were 2,809 brain tumors in 69.7 million person-years of follow-up. After adjusting for potential confounders, significant risk factors for brain tumors included high fetal growth [incidence rate ratio (IRR) per additional 1 SD, 1.04; 95% confidence interval (CI), 1.01-1.08, P = 0.02], first-degree family history of a brain tumor (IRR, 2.43; 95% CI, 1.86-3.18, P < 0.001), parental country of birth (IRR for both parents born in Sweden vs. other countries, 1.21; 95% CI, 1.09-1.35, P < 0.001), and high maternal education level (Ptrend = 0.01). These risk factors did not vary by age at diagnosis. The association with high fetal growth appeared to involve pilocytic astrocytomas, but not other astrocytomas, medulloblastomas, or ependymomas. Gestational age at birth, birth order, multiple birth, and parental age were not associated with brain tumors. In this large cohort study, high fetal growth was associated with an increased risk of brain tumors (particularly pilocytic astrocytomas) independently of gestational age, not only in childhood but also into young adulthood, suggesting that growth factor pathways may play an important long-term role in the etiology of certain brain tumor subtypes., (©2014 American Association for Cancer Research.)
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- 2015
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41. Season of birth and risk of Hodgkin and non-Hodgkin lymphoma.
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Crump C, Sundquist J, Sieh W, Winkleby MA, and Sundquist K
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- Adolescent, Birth Order, Child, Child, Preschool, Cohort Studies, Female, Follow-Up Studies, Hodgkin Disease etiology, Humans, Incidence, Infant, Infant, Newborn, Lymphoma, Non-Hodgkin etiology, Male, Prognosis, Registries, Risk Factors, Sweden epidemiology, Hodgkin Disease epidemiology, Lymphoma, Non-Hodgkin epidemiology, Seasons
- Abstract
Infectious etiologies have been hypothesized for Hodgkin and non-Hodgkin lymphoma (HL and NHL) in early life, but findings to date for specific lymphomas and periods of susceptibility are conflicting. We conducted the first national cohort study to examine whether season of birth, a proxy for infectious exposures in the first few months of life, is associated with HL or NHL in childhood through young adulthood. A total of 3,571,574 persons born in Sweden in 1973-2008 were followed up through 2009 to examine the association between season of birth and incidence of HL (943 cases) or NHL (936 cases). We found a sinusoidal pattern in NHL risk by season of birth (p = 0.04), with peak risk occurring among birthdates in April. Relative to persons born in fall (September-November), odds ratios for NHL by season of birth were 1.25 [95% confidence interval (CI), 1.04-1.50; p = 0.02] for spring (March-May), 1.22 (95% CI, 1.01-1.48; p = 0.04) for summer (June-August) and 1.11 (95% CI, 0.91-1.35; p = 0.29) for winter (December-February). These findings did not vary by sex, age at diagnosis or major subtypes. In contrast, there was no seasonal association between birthdate and risk of HL (p = 0.78). In this large cohort study, birth in spring or summer was associated with increased risk of NHL (but not HL) in childhood through young adulthood, possibly related to immunologic effects of delayed infectious exposures compared with fall or winter birth. These findings suggest that immunologic responses in early infancy may play an important role in the development of NHL., (© 2014 UICC.)
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- 2014
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42. Season of birth and other perinatal risk factors for melanoma.
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Crump C, Sundquist K, Sieh W, Winkleby MA, and Sundquist J
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- Adolescent, Adult, Child, Child, Preschool, Cohort Studies, Female, Genetic Predisposition to Disease, Humans, Male, Risk Factors, Sex Factors, Socioeconomic Factors, Sunlight, Sweden epidemiology, Ultraviolet Rays adverse effects, Melanoma, Cutaneous Malignant, Melanoma epidemiology, Seasons, Skin Neoplasms epidemiology
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Background: Ultraviolet radiation (UVR) exposure is the main risk factor for cutaneous malignant melanoma (CMM), but its specific effect in infancy is unknown. We examined whether season of birth, a proxy for solar UVR exposure in the first few months of life, is associated with CMM in childhood through young adulthood., Methods: National cohort study of 3,571,574 persons born in Sweden in 1973-2008, followed up for CMM incidence through 2009 (maximum age 37 years) to examine season of birth and other perinatal factors., Results: There were 1595 CMM cases in 63.9 million person-years of follow-up. We found a sinusoidal pattern in CMM risk by season of birth (P=0.006), with peak risk corresponding to birthdates in spring (March-May). Adjusted odds ratios for CMM by season of birth were 1.21 [95% confidence interval (CI), 1.05-1.39; P=0.008] for spring, 1.07 (95% CI, 0.92-1.24; P=0.40) for summer and 1.12 (95% CI, 0.96-1.29; P=0.14) for winter, relative to fall. Spring birth was associated with superficial spreading subtype of CMM (P=0.02), whereas there was no seasonal association with nodular subtype (P=0.26). Other CMM risk factors included family history of CMM in a sibling (>6-fold) or parent (>3-fold), female gender, high fetal growth and high paternal education level., Conclusions: In this large cohort study, persons born in spring had increased risk of CMM in childhood through young adulthood, suggesting that the first few months of life may be a critical period of UVR susceptibility. Sun avoidance in early infancy may play an important role in the prevention of CMM in high-risk populations., (© The Author 2014; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.)
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- 2014
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43. Intrauterine factors and risk of nonepithelial ovarian cancers.
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Sieh W, Sundquist K, Sundquist J, Winkleby MA, and Crump C
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- Adolescent, Adult, Child, Child, Preschool, Cohort Studies, Female, Humans, Infant, Newborn, Infant, Premature, Pregnancy, Proportional Hazards Models, Risk Factors, Sweden epidemiology, Young Adult, Gestational Age, Neoplasms, Germ Cell and Embryonal epidemiology, Ovarian Neoplasms epidemiology, Prenatal Exposure Delayed Effects epidemiology, Sex Cord-Gonadal Stromal Tumors epidemiology
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Objective: The majority of ovarian tumors in girls and young women are nonepithelial in origin. The etiology of nonepithelial ovarian tumors remains largely unknown, and intrauterine exposures may play an important role. We examined the association of perinatal factors with risk of nonepithelial ovarian tumors in girls and young women., Methods: National cohort study of 1,536,057 women born in Sweden during 1973-2004 and followed for diagnoses of nonepithelial ovarian tumors through 2009 (attained ages 5-37 years). Perinatal and maternal characteristics and cancer diagnoses were ascertained using nationwide health registry data., Results: 147 women were diagnosed with nonepithelial ovarian tumors in 31.6 million person-years of follow-up, including 94 with germ cell tumors and 53 with sex-cord stromal tumors. Women born preterm (<37 weeks of gestation) had a significantly increased risk of developing nonepithelial ovarian tumors (adjusted hazard ratio 1.86, 95% CI 1.03-3.37; p=0.04). Histological subgroup analyses showed that preterm birth was associated with increased risk of sex-cord stromal tumors (4.39, 2.12-9.10; p<0.001), but not germ cell tumors (0.68, 0.21-2.15; p=0.51). No significant associations were found with fetal growth, birth order, and maternal age at birth., Conclusions: This large cohort study provides the first evidence that preterm birth is a risk factor for developing sex cord-stromal tumors. Ovarian hyperstimulation in response to high gonadotropin levels in preterm girls could mediate disease risk through the proliferative and steroidogenic effects of FSH and LH on granulosa and theca cells, from which most sex-cord stromal tumors are derived., (Copyright © 2014 Elsevier Inc. All rights reserved.)
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- 2014
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44. Perinatal risk factors for Wilms tumor in a Swedish national cohort.
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Crump C, Sundquist J, Sieh W, Winkleby MA, and Sundquist K
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- Age Factors, Birth Order, Birth Weight, Female, Follow-Up Studies, Gestational Age, Humans, Incidence, Infant, Infant, Newborn, Male, Maternal Age, Population Surveillance, Proportional Hazards Models, Registries, Regression Analysis, Risk Factors, Sex Factors, Socioeconomic Factors, Sweden epidemiology, Wilms Tumor diagnosis, Wilms Tumor etiology, Fetal Development, Wilms Tumor epidemiology
- Abstract
Perinatal risk factors including high birth weight have been associated with Wilms tumor in case-control studies. However, these findings have seldom been examined in large cohort studies, and the specific contributions of gestational age at birth and fetal growth remain unknown. We conducted the largest population-based cohort study to date consisting of 3,571,574 persons born in Sweden in 1973-2008, followed up for Wilms tumor incidence through 2009 to examine perinatal risk factors. There were 443 Wilms tumor cases identified in 66.3 million person-years of follow-up. After adjusting for gestational age and other perinatal factors, high fetal growth was associated with increased risk of Wilms tumor among girls (hazard ratio per 1 standard deviation (SD), 1.36; 95% CI 1.20-1.54; P < 0.001), but not boys (1.10; 95% CI 0.97-1.25; P = 0.14) (P interaction = 0.02). Among girls, high fetal growth was associated with disease onset before age 5 years (odds ratio per 1 SD, 1.47; 95% CI 1.28-1.69; P < 0.001), but not beyond (1.00; 95% CI 0.76-1.31; P = 0.99). No clear associations were found for gestational age at birth or other perinatal factors. In this large cohort study, high fetal growth was associated with Wilms tumor before age 5 years among girls. These findings suggest that early-life growth factor pathways for Wilms tumor may be more common among girls than boys. Further elucidation of these mechanisms may reveal better targets for prevention or treatment of specific subtypes of Wilms tumor.
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- 2014
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45. A CONTROLLED EVALUATION OF A HIGH SCHOOL BIOMEDICAL PIPELINE PROGRAM: DESIGN AND METHODS.
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Winkleby MA, Ned J, Ahn D, Koehler A, Fagliano K, and Crump C
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Given limited funding for school-based science education, non-school-based programs have been developed at colleges and universities to increase the number of students entering science- and health-related careers and address critical workforce needs. However, few evaluations of such programs have been conducted. We report the design and methods of a controlled trial to evaluate the Stanford Medical Youth Science Program's Summer Residential Program (SRP), a 25-year-old university-based biomedical pipeline program. This 5-year matched cohort study uses an annual survey to assess educational and career outcomes among four cohorts of students who participate in the SRP and a matched comparison group of applicants who were not chosen to participate in the SRP. Matching on sociodemographic and academic background allows control for potential confounding. This design enables the testing of whether the SRP has an independent effect on educational- and career-related outcomes above and beyond the effects of other factors such as gender, ethnicity, socioeconomic background, and pre-intervention academic preparation. The results will help determine which curriculum components contribute most to successful outcomes and which students benefit most. After 4 years of follow-up, the results demonstrate high response rates from SRP participants and the comparison group with completion rates near 90%, similar response rates by gender and ethnicity, and little attrition with each additional year of follow-up. This design and methods can potentially be replicated to evaluate and improve other biomedical pipeline programs, which are increasingly important for equipping more students for science- and health-related careers.
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- 2014
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46. Age, period and cohort trends in drug abuse hospitalizations within the total Swedish population (1975-2010).
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Giordano GN, Ohlsson H, Kendler KS, Winkleby MA, Sundquist K, and Sundquist J
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- Adult, Age Factors, Cohort Studies, Female, Humans, Male, Middle Aged, Substance-Related Disorders diagnosis, Sweden epidemiology, Time Factors, Young Adult, Hospitalization trends, Population Surveillance methods, Substance-Related Disorders epidemiology, Substance-Related Disorders therapy
- Abstract
Background: The societal consequences of drug abuse (DA) are severe and well documented, the World Health Organization recommending tracking of population trends for effective policy responses in treatment of DA and delivery of health care services. However, to correctly identify possible sources of DA change, one must first disentangle three different time-related influences on the need for treatment due to DA: age effects, period effects and cohort effects., Methods: We constructed our main Swedish national DA database (spanning four decades) by linking healthcare data from the Swedish Hospital Discharge Register to individuals, which included hospitalisations in Sweden for 1975-2010. All hospitalized DA cases were identified by ICD codes. Our Swedish national sample consisted of 3078,129 men and 2921,816 women. We employed a cross-classified multilevel logistic regression model to disentangle any net age, period and cohort effects on DA hospitalization rates., Results: We found distinct net age, period and cohort effects, each influencing the predicted probability of hospitalisation for DA in men and women. Peak age for DA in both sexes was 33-35 years; net period effects showed an increase in hospitalisation for DA from 1996 to 2001; and in birth cohorts 1968-1974, we saw a considerable reduction (around 75%) in predicted probability of hospitalisation for DA., Conclusions: The use of hospital admissions could be regarded as a proxy of the population's health service use for DA. Our results may thus constitute a basis for effective prevention planning, treatment and other appropriate policy responses., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)
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- 2014
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47. Sociodemographic, psychiatric and somatic risk factors for suicide: a Swedish national cohort study.
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Crump C, Sundquist K, Sundquist J, and Winkleby MA
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- Adolescent, Adult, Aged, Chronic Disease mortality, Cohort Studies, Depressive Disorder epidemiology, Depressive Disorder mortality, Female, Humans, Male, Mental Disorders mortality, Middle Aged, Registries statistics & numerical data, Risk Factors, Sex Factors, Socioeconomic Factors, Sweden epidemiology, Young Adult, Chronic Disease epidemiology, Mental Disorders epidemiology, Suicide statistics & numerical data
- Abstract
Background: More effective prevention of suicide requires a comprehensive understanding of sociodemographic, psychiatric and somatic risk factors. Previous studies have been limited by incomplete ascertainment of these factors. We conducted the first study of this issue using sociodemographic and out-patient and in-patient health data for a national population., Method: We used data from a national cohort study of 7,140,589 Swedish adults followed for 8 years for suicide mortality (2001-2008). Sociodemographic factors were identified from national census data, and psychiatric and somatic disorders were identified from all out-patient and in-patient diagnoses nationwide., Results: There were 8721 (0.12%) deaths from suicide during 2001-2008. All psychiatric disorders were strong risk factors for suicide among both women and men. Depression was the strongest risk factor, with a greater than 15-fold risk among women or men and even higher risks (up to 32-fold) within the first 3 months of diagnosis. Chronic obstructive pulmonary disease (COPD), cancer, spine disorders, asthma and stroke were significant risk factors among both women and men (1.4-2.1-fold risks) whereas diabetes and ischemic heart disease were modest risk factors only among men (1.2-1.4-fold risks). Sociodemographic risk factors included male sex, unmarried status or non-employment; and low education or income among men., Conclusions: All psychiatric disorders, COPD, cancer, spine disorders, asthma, stroke, diabetes, ischemic heart disease and specific sociodemographic factors were independent risk factors for suicide during 8 years of follow-up. Effective prevention of suicide requires a multifaceted approach in both psychiatric and primary care settings, targeting mental disorders (especially depression), specific somatic disorders and indicators of social support.
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- 2014
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48. Mortality in persons with mental disorders is substantially overestimated using inpatient psychiatric diagnoses.
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Crump C, Ioannidis JP, Sundquist K, Winkleby MA, and Sundquist J
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- Adolescent, Adult, Aged, Aged, 80 and over, Cause of Death, Female, Humans, Male, Mental Disorders diagnosis, Middle Aged, Proportional Hazards Models, Psychiatric Status Rating Scales, Retrospective Studies, Suicide statistics & numerical data, Sweden epidemiology, Young Adult, Inpatients, Mental Disorders epidemiology, Mental Disorders mortality
- Abstract
Mental disorders are associated with premature mortality, and the magnitudes of risk have commonly been estimated using hospital data. However, psychiatric patients who are hospitalized have more severe illness and do not adequately represent mental disorders in the general population. We conducted a national cohort study using outpatient and inpatient diagnoses for the entire Swedish adult population (N = 7,253,516) to examine the extent to which mortality risks are overestimated using inpatient diagnoses only. Outcomes were all-cause and suicide mortality during 8 years of follow-up (2001-2008). There were 377,339 (5.2%) persons with any inpatient psychiatric diagnosis, vs. 680,596 (9.4%) with any inpatient or outpatient diagnosis, hence 44.6% of diagnoses were missed using inpatient data only. When including and accounting for prevalent psychiatric cases, all-cause mortality risk among persons with any mental disorder was overestimated by 15.3% using only inpatient diagnoses (adjusted hazard ratio [aHR], 5.89; 95% CI, 5.85-5.92) vs. both inpatient and outpatient diagnoses (aHR, 5.11; 95% CI, 5.08-5.14). Suicide risk was overestimated by 18.5% (aHRs, 23.91 vs. 20.18), but this varied widely by specific disorders, from 4.4% for substance use to 49.1% for anxiety disorders. The sole use of inpatient diagnoses resulted in even greater overestimation of all-cause or suicide mortality risks when prevalent cases were unidentified (~20-30%) or excluded (~25-40%). However, different methods for handling prevalent cases resulted in only modest variation in risk estimates when using both inpatient and outpatient diagnoses. These findings have important implications for the interpretation of hospital-based studies and the design of future studies., (Copyright © 2013 Elsevier Ltd. All rights reserved.)
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- 2013
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49. Comorbidities and mortality in bipolar disorder: a Swedish national cohort study.
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Crump C, Sundquist K, Winkleby MA, and Sundquist J
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- Adult, Aged, Aged, 80 and over, Bipolar Disorder diagnosis, Bipolar Disorder drug therapy, Cohort Studies, Comorbidity, Female, Humans, Male, Middle Aged, Mortality, Premature, Registries, Sweden epidemiology, Young Adult, Bipolar Disorder epidemiology, Bipolar Disorder mortality
- Abstract
Importance: Bipolar disorder is associated with premature mortality, but the specific causes and underlying pathways are unclear., Objective: To examine the physical health effects of bipolar disorder using outpatient and inpatient data for a national population., Design, Setting, and Participants: National cohort study of 6,587,036 Swedish adults, including 6618 with bipolar disorder., Main Outcomes and Measures: Physical comorbidities diagnosed in any outpatient or inpatient setting nationwide and mortality (January 1, 2003, through December 31, 2009)., Results: Women and men with bipolar disorder died 9.0 and 8.5 years earlier on average than the rest of the population, respectively. All-cause mortality was increased 2-fold among women (adjusted hazard ratio [aHR], 2.34; 95% CI, 2.16-2.53) and men (aHR, 2.03; 95% CI, 1.85-2.23) with bipolar disorder, compared with the rest of the population. Patients with bipolar disorder had increased mortality from cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), influenza or pneumonia, unintentional injuries, and suicide for both women and men and cancer for women only. Suicide risk was 10-fold among women (aHR, 10.37; 95% CI, 7.36-14.60) and 8-fold among men (aHR, 8.09; 95% CI, 5.98-10.95) with bipolar disorder, compared with the rest of the population. Substance use disorders contributed only modestly to these findings. The association between bipolar disorder and mortality from chronic diseases (ischemic heart disease, diabetes, COPD, or cancer) was weaker among persons with a prior diagnosis of these conditions (aHR, 1.40; 95% CI, 1.26-1.56) than among those without a prior diagnosis (aHR, 2.38; 95% CI, 1.95-2.90; P(interaction) = .01)., Conclusions and Relevance: In this large national cohort study, patients with bipolar disorder died prematurely from multiple causes, including cardiovascular disease, diabetes, COPD, influenza or pneumonia, unintentional injuries, and suicide. However, chronic disease mortality among those with more timely medical diagnosis approached that of the general population, suggesting that better provision of primary medical care may effectively reduce premature mortality among persons with bipolar disorder.
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- 2013
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50. Mental disorders and risk of accidental death.
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Crump C, Sundquist K, Winkleby MA, and Sundquist J
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- Accidents psychology, Adult, Aged, Epidemiologic Methods, Female, Humans, Male, Middle Aged, Socioeconomic Factors, Suicide statistics & numerical data, Sweden epidemiology, Young Adult, Accidents mortality, Mental Disorders mortality
- Abstract
Background: Little is known about accidental death risks among psychiatric patients., Aims: To examine this issue in the most comprehensive study to date., Method: National cohort study of all Swedish adults (n = 6 908 922) in 2001-2008., Results: There were 22 419 (0.3%) accidental deaths in the total population, including 5933 (0.9%) accidental deaths v. 3731 (0.6%) suicides among psychiatric patients (n = 649 051). Of persons who died from accidents, 26.0% had any psychiatric diagnosis v. 9.4% in the general population. Accidental death risk was four- to sevenfold among personality disorders, six- to sevenfold among dementia, and two- to fourfold among schizophrenia, bipolar disorder, depression or anxiety disorders, and was not fully explained by comorbid substance use. Strong associations were found irrespective of sociodemographic characteristics, and for different types of accidental death (especially poisoning or falls)., Conclusions: All mental disorders were strong independent risk factors for accidental death, which was substantially more common than suicide.
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- 2013
- Full Text
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