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Introduction: Given the absence of curative interventions and the rising global incidence of dementia, research is increasingly focusing on lifestyle factors for prevention. However, identifying shared environmental risk for dementia, next to individual factors, is crucial for optimal risk reduction strategies. Therefore, in the present study we investigated the association between air pollution, cognitive functioning, and markers of structural brain damage., Methods: We used cross-sectional data from 4,002 participants of The Maastricht Study on volumetric markers of brain integrity (white and grey matter volume, cerebrospinal fluid volume, white matter hyperintensities volume, presence of cerebral small vessel disease) and cognitive functioning (memory, executive functioning and attention, processing speed, overall cognition). Individuals were matched by postal code of residence to nationwide data on air pollution exposure (particulate matter < 2.5 μm (PM 2.5 ), particulate matter <10 μm (PM 10 ), nitrogen dioxide (NO 2 ), soot). Potentia linear and non-linear associations were investigated with linear, logistic, and restricted cubic splines regression. All analyses were adjusted for demographic characteristics and a compound score of modifiable dementia risk and protective factors., Results: Exposure to air pollutants was not related to cognitive functioning and most brain markers. We found curvilinear relationships between high PM 2.5 exposures and grey matter and cerebrospinal fluid volume. Participants in the low and high range of exposure had lower grey matter volume. Higher cerebrospinal fluid volumes were only associated with high range of exposure, independent of demographic and individual modifiable dementia risk factors. After additional post hoc analyses, controlling for urbanicity, the associations for grey matter volume became non-significant. In men only, higher exposure to all air pollutants was associated with lower white matter volumes. No significant associations with white matter hyperintensities volume or cerebral small vessel disease were observed., Discussion: Our findings suggest that higher PM 2.5 exposure is associated with more brain atrophy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

The role of the social environment can facilitate positive health outcomes through active community engagement, normalization of healthy behaviors, and stress buffering. We aim to examine the associations of neighborhood social cohesion with changes in BMI over time. A total of 7641 participants from The Maastricht Study between the ages of 40 and 75 years were analyzed. Weight and height were measured at baseline, and weight was self-reported annually up to 10 years of follow-up (median = 4.7 years). Perceived social cohesion was obtained by questionnaire. Home addresses for each participant were linked to geographic information system data from the Geoscience and Health Cohort Consortium to create neighborhood exposure variables including area level social cohesion, neighborhood walkability, and food environment within a 1000 m Euclidian buffer. Linear regression analyses were performed with BMI adjusted for socioeconomic variables. A mixed model analysis was carried out to examine changes in BMI. Living in the highest quartile area of individually perceived social cohesion was associated with lower BMI (Q4 B: -.53; 95% CI = -.79, -.28) compared to the lowest quartile. Similar findings were discovered using the area level measure (Q4 B: -.97; 95% CI = -1.29, -.65). There was no longitudinal association between social cohesion and BMI. Neighborhood social cohesion was associated with lower BMI classifying it as an obesogenic area characteristic that influences weight, independent of conventional built environment features., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Public Health Association.)

Aim: Type 2 diabetes (T2D) is a common chronic disease that disproportionally affects groups with a low socioeconomic position (SEP). This study aimed to examine associations between childhood SEP and incident T2D, independent of adult SEP., Methods: Longitudinal data from The Maastricht Study were used (N=6,727, 55.2 % female, mean (SD) age 58.7(8.7) years). Childhood SEP was determined by asking for the highest completed educational level for the father and mother and childhood income inadequacy. Adult SEP was determined by highest completed educational level, equivalent household income, and occupational position. Incident T2D was self-reported yearly (up to 12 years of follow-up). Associations were studied with Cox regression analyses., Results: In participants without T2D at baseline, 3.7% reported incident T2D over 8.2 (median) years of follow-up. Incident T2D was most common in people with low childhood and adult SEP and lowest in those with high childhood and adult SEP (1.7 vs. 7.5 per 1,000 person years). The association between childhood SEP and incident T2D was mainly explained by adult SEP, except for childhood income inadequacy which was independently associated with incident T2D., Conclusion: Socioeconomic inequalities in childhood and adulthood are risk factors for incident T2D. More attention is needed to reduce childhood poverty and improve adult SEP to reduce the T2D risk., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Low socioeconomic position (SEP) has been identified as a risk factor for type 2 diabetes mellitus (T2DM), and psychosocial resources might be on the pathway in this association. We examined two poor psychosocial resources, low control beliefs and inferiority beliefs, that might link low SEP with T2DM. 8292 participants aged 40-75 living in Southern Netherlands participated in The Maastricht Study starting from September 2010 to October 2020 and were followed up to 10 years with annual questionnaires. SEP (education, income, occupation), low control beliefs, inferiority beliefs, and (pre)diabetes by oral glucose tolerance test were measured at baseline. Incident T2DM was self-reported per annum. We analysed the mediating roles of poor psychosocial resources by using counterfactual mediation analysis. People with low SEP had more often prevalent and incident T2DM (e.g. low education: HR = 2.13, 95%CI: 1.53-2.97). Low control beliefs and high inferiority beliefs were more common among people with low SEP. Moreover, low control beliefs and high inferiority beliefs were risk factors for T2DM (e.g. low control beliefs: HR = 1.50, 95%CI: 1.08-2.09). The relationship between SEP and T2DM was partially mediated by control beliefs (8.0-13.6%) and inferiority beliefs (2.2-4.5%). We conclude that poor psychosocial resources are important in socioeconomic inequalities in diabetes. Researchers and practitioners should consider the psychosocial profile of people with lower SEP, as such a profile might interfere with the development, treatment, and prevention of T2DM. Further research should explore how poor psychosocial resources interact with chronic stress in relation to socioeconomic health inequalities., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Public Health Association.)

Objective: We aim to study the "golden youth" hypothesis, which suggests that risky behaviors might be prevalent among affluent adolescents in post-Communist countries of Europe (PCCE) with high income inequality., Methods: We included 71,119 adolescents aged 11-15 from 14 PCCE participating in the Health Behavior in School-aged Children survey 2017/18. A K-means cluster analysis was conducted to group adolescents based on risky behavior. Generalized linear mixed models were fitted., Results: The proportion of high-SEP adolescents in Cluster 2, characterized by frequent alcohol consumption but moderate frequency of drunkenness, was greater than that of low-SEP adolescents (14.3 % vs. 10.7 %). The prevalence of risky behaviors was similar for high and low-SEP adolescents in Cluster 3 (high smoking, frequent alcohol use, drunkenness, and moderate bullying) (8.0 % vs. 8.2 %) and Cluster 4 (high bullying perpetration) (6.7 % vs. 7.2 %). Countries with higher Gini index were at greater risk of reporting risky behaviors. High-SEP adolescents were more likely to engage in risky behaviors in countries with high income inequality. The odds ratios comparing high- vs. low-SEP adolescents ranged from 0.89 in the least unequal to 1.67 in the most unequal countries for multiple risky behaviors (Cluster 3: P -interaction = 0.042) and from 0.61 to 1.19 for bullying perpetration (Cluster 4: P -interaction = 0.030)., Conclusions: High-SEP adolescents in PCCE might be at increased risk for unhealthy and vicious behaviors, especially in countries with high income inequality. Redistributive policies decreasing the gap between rich and poor are needed to ensure the health and well-being of adolescents in PCCE., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Background: Despite evidence on socioeconomic inequalities in psychosocial well-being of adolescents under the COVID-19 pandemic, the explanatory factors and their potential variations across contexts remained understudied. Hence, this cross-regional study compared the extent of inequalities and the mediating pathways across Hong Kong, Mainland China, and the Netherlands., Methods: Between July 2021 and January 2022, 25 secondary schools from diverse socioeconomic background were purposively sampled from Hong Kong, Zhejiang (Mainland China), and Limburg (the Netherlands). 3595 junior students completed an online survey during class about their socioeconomic position, psychosocial factors, and well-being. Socioeconomic inequalities were assessed by multiple linear regressions using the Slope Index of Inequality (SII), whereas the mediating pathways through learning difficulty, overall worry about COVID-19, impact on family' financial status, resilience, trust in government regarding pandemic management, and adaptation to social distancing were examined by mediation analyses moderated by regions., Results: The adverse psychosocial impact of COVID-19 was stronger in the Netherlands and Hong Kong compared with Mainland China. The greatest extent of socioeconomic inequalities in the change in psychosocial well-being was observed among students in the Netherlands (SII = 0.59 [95% CI = 0.38-0.80]), followed by Hong Kong (SII = 0.37 [0.21-0.52]) and Mainland China (SII = 0.12 [0.00-0.23]). Learning difficulty and resilience were the major mediators in Mainland China and Hong Kong, but to a lesser extent in the Netherlands., Conclusion: Socioeconomic inequalities in psychosocial well-being were evident among adolescents under the pandemic, with learning difficulty and resilience of students as the key mediators. Differences in the social contexts should be considered to better understand the variations in inequalities and mediating pathways across regions., (© 2024. The Author(s).)

Background: Socioeconomic inequalities in cognitive impairment may partly act through structural brain damage and reduced connectivity. This study investigated the extent to which the association of early-life socioeconomic position (SEP) with later-life cognitive functioning is mediated by later-life SEP, and whether the associations of SEP with later-life cognitive functioning can be explained by structural brain damage and connectivity., Methods: We used cross-sectional data from the Dutch population-based Maastricht Study (n = 4,839; mean age 59.2 ± 8.7 years, 49.8% women). Early-life SEP was assessed by self-reported poverty during childhood and parental education. Later-life SEP included education, occupation, and current household income. Participants underwent cognitive testing and 3-T magnetic resonance imaging to measure volumes of white matter hyperintensities, grey matter, white matter, cerebrospinal fluid, and structural connectivity. Multiple linear regression analyses tested the associations between SEP, markers of structural brain damage and connectivity, and cognitive functioning. Mediation was tested using structural equation modeling., Results: Although there were direct associations between both indicators of SEP and later-life cognitive functioning, a large part of the association between early-life SEP and later-life cognitive functioning was explained by later-life SEP (72.2%). The extent to which structural brain damage or connectivity acted as mediators between SEP and cognitive functioning was small (up to 5.9%)., Conclusions: We observed substantial SEP differences in later-life cognitive functioning. Associations of structural brain damage and connectivity with cognitive functioning were relatively small, and only marginally explained the SEP gradients in cognitive functioning., Competing Interests: Declaration of competing interest The authors have no relevant financial or nonfinancial interests to disclose., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aims/hypothesis: The associations of sitting, standing, physical activity and sleep with cardiometabolic health and glycaemic control markers are interrelated. We aimed to identify 24 h time-use compositions associated with optimal metabolic and glycaemic control and determine whether these varied by diabetes status., Methods: Thigh-worn activPAL data from 2388 participants aged 40-75 years (48.7% female; mean age 60.1 [SD = 8.1] years; n=684 with type 2 diabetes) in The Maastricht Study were examined. Compositional isometric log ratios were generated from mean 24 h time use (sitting, standing, light-intensity physical activity [LPA], moderate-to-vigorous physical activity [MVPA] and sleeping) and regressed with outcomes of waist circumference, fasting plasma glucose (FPG), 2 h plasma glucose, HbA 1c , the Matsuda index expressed as z scores, and with a clustered cardiometabolic risk score. Overall analyses were adjusted for demographics, smoking, dietary intake and diabetes status, and interaction by diabetes status was examined separately. The estimated difference when substituting 30 min of one behaviour with another was determined with isotemporal substitution. To identify optimal time use, all combinations of 24 h compositions possible within the study footprint (1st-99th percentile of each behaviour) were investigated to determine those cross-sectionally associated with the most-optimal outcome (top 5%) for each outcome measure., Results: Compositions lower in sitting time and with greater standing time, physical activity and sleeping had the most beneficial associations with outcomes. Associations were stronger in participants with type 2 diabetes (p<0.05 for interactions), with larger estimated benefits for waist circumference, FPG and HbA 1c when sitting was replaced by LPA or MVPA in those with type 2 diabetes vs the overall sample. The mean (range) optimal compositions of 24 h time use, considering all outcomes, were 6 h (range 5 h 40 min-7 h 10 min) for sitting, 5 h 10 min (4 h 10 min-6 h 10 min) for standing, 2 h 10 min (2 h-2 h 20 min) for LPA, 2 h 10 min (1 h 40 min-2 h 20 min) for MVPA and 8 h 20 min (7 h 30 min-9 h) for sleeping., Conclusions/interpretation: Shorter sitting time and more time spent standing, undergoing physical activity and sleeping are associated with preferable cardiometabolic health. The substitutions of behavioural time use were significantly stronger in their associations with glycaemic control in those with type 2 diabetes compared with those with normoglycaemic metabolism, especially when sitting time was balanced with greater physical activity., (© 2024. The Author(s).)

Intro: We aim to investigate the relationship between social cohesion and sedentary behavior (SB), total physical activity (PA), moderate-to-vigorous PA (MVPA), and dietary quality. Additionally, we assess whether these associations are independent of neighborhood walkability and the food environment., Methods: A total of 7641 participants from The Maastricht Study in the Netherlands between the ages of 40 and 75 years were analyzed. Neighborhood social cohesion was obtained by participant questionnaire completed at baseline and measured by the Dutch Livability meter. Home addresses were linked to geographic information system (GIS) data from the Geoscience and Health Cohort Consortium (GECCO) to create neighborhood exposures of walkability and food environment. A thigh worn accelerometer collected data to measure sedentary time, total daily PA, and MVPA. Dietary quality was measured with a food frequency questionnaire. Multivariate linear regression analyses were adjusted for age, sex, socioeconomic position, neighborhood walkability, and food environment., Results: Those living in the highest quartile area of perceived social cohesion had statistically significant lower levels of SB (Q4 B: -13.04; 95% CI = -20.23, -5.85), higher total PA (Q4 B: 4.39; 95% CI = 1.69, 7.10), and higher MVPA (Q4 B: 2.57; 95% CI = 0.83, 4.31) and better diet quality (Q4 B: 1.12; 95% CI = 0.24, 2.01) compared to the lowest quartile independent of walkability and food environment. Similar results were found using the Livability meter., Conclusion: We discovered neighborhood social cohesion as an important obesogenic determinant that should be considered in policymaking to encourage higher levels of PA and higher diet quality., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Age-related declines in physical functioning have significant implications for health in later life. Physical activity (PA) volume is associated with physical function, but the importance of the pattern in which PA is accumulated is unclear. This study investigates associations between accelerometer-determined daily PA patterns, including composition and temporal distribution (burstiness) of upright and stepping events, with physical function., Methods: Data was from participants who wore an activPAL3 accelerometer as part of The Maastricht Study. Exposures included a suite of metrics describing the composition and the temporal distribution (burstiness) of upright and sedentary behaviour. Physical function outcomes included the six-minute walk test (6MWT), timed chair-stand test (TCST), grip strength (GS), and SF-36 physical functioning sub-scale (SF-36pf). Multivariable linear regression models were used to assess associations, adjusting for covariates including overall PA volume (daily step count)., Results: Participants(n = 6085) had 6 or 7 days of valid data. Upright and stepping event metrics were associated with physical function outcomes, even after adjusting PA volume. Higher sedentary burstiness was associated with better function (6MWT, TCST, and SF-36pf), as was duration and step volume of stepping events (6MWT, TCST, GS, and SF-36pf), step-weighted cadence (6MWT, TCST, and SF-36pf). Number of stepping events was associated with poorer function (6MWT, GS, and SF-36pf), as was upright event burstiness (SF-36pf). Associations varied according to sex., Conclusion: Our study reveals that diverse patterns of physical activity accumulation exhibit distinct associations with various measures of physical function, irrespective of the overall volume. Subsequent investigations should employ longitudinal and experimental studies to examine how changing patterns of physical activity may affect physical function, and other health outcomes., (© 2024. The Author(s).)

While physical activity (PA) is understood to promote vascular health, little is known about whether the daily and weekly patterns of PA accumulation associate with vascular health. Accelerometer-derived (activPAL3) 6- or 7-day stepping was analyzed for 6430 participants in The Maastricht Study (50.4% women; 22.4% Type 2 diabetes mellitus (T2DM)). Multivariable regression models examined associations between stepping metrics (average step count, and time spent slower and faster paced stepping) with arterial stiffness (measured as carotid-femoral pulse wave velocity (cfPWV)), and several indices of microvascular health (heat-induced skin hyperemia, retinal vessel reactivity and diameter), adjusting for confounders and moderators. PA pattern metrics were added to the regression models to identify associations with vascular health beyond that of stepping metrics. Analyses were stratified by T2DM status if an interaction effect was present. Average step count and time spent faster paced stepping was associated with better vascular health, and the association was stronger in those with compared to those without T2DM. In fully adjusted models a higher step count inter-daily stability was associated with a higher (worse) cfPWV in those without T2DM (std β = 0.04, p = 0.007) and retinal venular diameter in the whole cohort (std β = 0.07, p = 0.002). A higher within-day variability in faster paced stepping was associated with a lower (worse) heat-induced skin hyperemia in those with T2DM (std β = -0.31, p = 0.008). Above and beyond PA volume, the daily and weekly patterns in which PA was accumulated were additionally associated with improved macro- and microvascular health, which may have implications for the prevention of vascular disease., (© 2024 The Authors. Scandinavian Journal of Medicine & Science In Sports published by John Wiley & Sons Ltd.)

Background: Type 2 diabetes mellitus (T2DM) is a common chronic disease that disproportionally affects disadvantaged groups. People with a low socioeconomic position (SEP) have increased risk of T2DM and people with a low SEP and T2DM have higher HbA 1c -levels compared to people with T2DM and high SEP. The aim of this study is to analyze longitudinal socioeconomic differences in health-related functioning in people with T2DM., Methods: Longitudinal data from 1,537 participants of The Maastricht Study with T2DM were used (32.6% female, mean (SD) age 62.9 (7.7) years). SEP was determined by baseline measures of education, occupation and income. Health-related functioning (physical, mental and social) was measured with the Short-Form Health Survey and the Impact on Participation and Autonomy survey (all scored from 0 to 100). Associations of SEP and health-related functioning were studied annually over a 10-year period (median (IQR) 7.0 (5.0) years, baseline 2010-2018) using linear mixed methods adjusting for demographics, HbA 1c -levels and lifestyle factors., Results: Participants with a low SEP had significantly worse health-related functioning compared to those with a high SEP. For example, participants with low income had lower scores for physical (-4.49[CI -5.77;-3.21]), mental (-2.61[-3.78,-1.44]) and social functioning (-9.76[-12.30;-7.23]) compared to participants with high income on a scale from 0 to 100. In addition, participants with a low education significantly declined more over time in mental (score for interaction education with time - 0.23[-0.37;-0.09]) and social functioning (-0.44[-0.77;-0.11]) compared to participants with high education. Participants with low and intermediate incomes significantly declined more over time in physical functioning (-0.17 [-0.34, -0.01 and - 0.18 [-0.36, 0.00]) compared to participants with high income., Conclusions: Among people with T2DM, those with a lower SEP had worse health-related functioning in general than people with a higher SEP. Additionally, people with T2DM and low education developed poorer mental and social functioning over time compared to people with T2DM and high education. People with T2DM and low or intermediate income declined more in physical functioning over time than those with high incomes. In addition to HbA 1c -levels and lifestyle patterns, more attention is needed for socioeconomic differences in health-related functioning for people living with T2DM., (© 2024. The Author(s).)

Background: Adolescent bullying is a major public health concern in post-Communist countries of Europe (PCCE). We studied the impact of income inequality on the prevalence of and socioeconomic differences in bullying perpetration., Methods: Nationally representative samples of adolescents aged 11-15 years from 14 PCCE participating in the Health Behavior in School-aged Children survey during 2017-18 years were included. Multilevel logistic regression models were fitted., Results: Overall, 71,119 adolescents participated in the survey. About 27.7 % of country differences in bullying perpetration were attributable to high income inequality. Adolescents with low and high family socioeconomic status (SES) had a 10-15 % greater risk ( P  < 0.05) of bullying perpetration compared to middle-SES adolescents. In cross-level interaction, the risk of bullying perpetration was the highest among high-SES adolescents from countries with wider income inequality ( P -interaction = 0.003). The odds ratios of bullying perpetration comparing high- vs. low-SES adolescents ranged from 0.67 in the least unequal to 1.59 in the most unequal countries., Conclusions: Our findings suggest that high income inequality might contribute to school bullying among adolescents in PCCE, particularly those from high-SES families. The necessary political and economic interventions should focus on improving the country socioeconomic environment in PCCE. Moving towards less neoliberal policies and creating a strong welfare state that promotes the population's economic and social well-being and reduces income inequality might be a necessary component of macro-level strategies aimed at preventing bullying among adolescents. Targeted public health interventions might be required for high-SES adolescents in countries with wide income inequality., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Background: We investigated the association of neighborhood walkability with accelerometer-measured physical activity (PA) and sedentary behavior (SB) and examined whether objective and subjective measures of walkability resulted in similar findings., Methods: PA and SB from the first 7689 Maastricht Study participants ages 40-75 from 2010 to 2017 were measured using accelerometers for 7 days. Mean daily step count, light-intensity PA, moderate- to vigorous- intensity PA (MVPA), and SB were calculated. Objective walkability was measured by the 7-component Dutch Walkability Index within 500 m Euclidean buffers around residential addresses of participants. Subjective walkability was obtained from the Abbreviated Neighborhood Environment Walkability Scale. Linear regression models analyzed the associations of walkability with PA and SB, controlling for potential confounders., Results: Objective walkability was negatively associated with light intensity PA in the most walkable quartile (b = -14.58, 95% CI = -20.94, -8.23). Compared to participants living in the least walkable neighborhoods, those in the most walkable quartile had statistically significantly higher SB levels (b = 11.64, 95% CI = 4.95, 18.32). For subjective walkability, mean daily step count was significantly higher in the most walkable quartile (b = 509.60, 95% CI = 243.38, 775.81). Higher subjective walkability was positively associated with MVPA (b = 4.40, 95% CI = 2.56, 6.23)., Conclusion: Living in a neighborhood with higher objective walkability was associated with lower levels of PA and higher SB levels while higher subjective walkability was associated with higher levels of PA. These results show discordant findings and thus, the effect of walkability on participant PA and SB within our sample is to be determined., (© 2023 The Authors. Scandinavian Journal of Medicine & Science In Sports published by John Wiley & Sons Ltd.)

Objectives: This study investigated whether the association between modifiable dementia risk and rate of cognitive decline differs across socioeconomic status (SES) strata., Design, Setting and Participants: Data were used from Maastricht Aging Study, a prospective cohort study with a 12-year follow-up. The baseline sample consisted of 1023 adults over 40 years old., Measurements: The "LIfestyle for BRAin health" (LIBRA) index was used to assess modifiable dementia risk. Cognitive performance was assessed at baseline, 6 and 12 years, and measured in the domains of information processing speed, executive functioning and verbal memory function. An SES score was calculated from equivalent income and educational level (tertiles). Linear mixed models were used to study the association between LIBRA, SES and their interaction on the rate of cognitive decline., Results: Participants in the lowest SES tertile displayed more decline in information processing speed (vs. middle SES: X 2 = 7.08, P = 0.029; vs. high SES: X 2 = 9.49, P = 0.009) and verbal memory (vs. middle SES: X 2 = 9.28, P < 0.001; vs. high SES: X 2 = 16.68, P < 0.001) over 6 years compared to their middle- and high-SES counterparts. Higher (unhealthier) LIBRA scores were associated with more decline in information processing speed (X 2 = 12.66, P = 0.002) over 12 years and verbal memory (X 2 = 4.63, P = 0.032) over 6 years. No consistent effect modification by SES on the association between LIBRA and cognition was found., Conclusions: Results suggest that lifestyle is an important determinant of cognitive decline across SES groups. Yet, people with low SES had a more unfavorable modifiable risk score suggesting more potential for lifestyle-based interventions.

Objectives: This study examined the cross-sectional association between sleep duration, prediabetes, and type 2 diabetes, and its independence from the traditional lifestyle risk factors diet, physical activity, smoking behavior, and alcohol consumption., Methods: Cross-sectional data from 5561 people aged 40-75 years recruited into The Maastricht Study between 2010 and 2018 were used (1:1 female:male and mean age: 60.1 years [standard deviation: 8.6]). Sleep duration was operationalized as in-bed time, algorithmically derived from activPAL3 accelerometer data (median 7 nights, IQR 1). Glucose metabolism status was determined with an oral glucose tolerance test. Multinomial logistic regression was used to assess the association of sleep duration as restricted cubic spline with prediabetes and type 2 diabetes. We adjusted for sex, age, educational level, the use of sleep medication or antidepressants, and the following lifestyle risk factors: diet quality, physical activity, smoking behavior, and alcohol consumption., Results: A U-shaped association between sleep duration and type 2 diabetes was found. Compared to those with a sleep duration of 8 hours, participants with a sleep duration of 5 and 12 hours had higher odds of type 2 diabetes (OR: 2.9 [95% CI 1.9 to 4.4] and OR 3.2 [2.0 to 5.2], respectively). This association remained after further adjustment for the lifestyle risk factors (OR: 2.6 [1.7 to 4.1] and OR 1.8 [1.1 to 3.1]). No such association was observed between sleep duration and prediabetes., Conclusions: Both short and long sleep durations are associated positively and independently of lifestyle and cardiovascular risk factors with type 2 diabetes, but not with prediabetes., (Copyright © 2023 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: We examined the association between low socioeconomic position (SEP) and Type 2 Diabetes Mellitus (T2DM), and the mediating role of psychosocial work environment by using counterfactual mediation analysis. Methods: Data from 8,090 participants of The Maastricht Study were analysed. SEP indicators (education, income, occupation), self-reported psychosocial work stressors, (pre)diabetes by oral glucose tolerance test were measured at baseline. Incident T2DM was self-reported per annum up to 9 years. Cox regression and causal mediation analyses were performed. Results: 2.8% ( N = 172) of the participants without T2DM at baseline reported incident T2DM. People with lower SEP more often had prevalent T2DM (e.g., education OR = 2.49, 95% CI: 2.16-2.87) and incident T2DM (e.g., education HR = 2.21, 95% CI: 1.53-3.20) than higher SEP. Low job control was associated with prevalent T2DM (OR = 1.44 95% CI: 1.25-1.67). Job control partially explained the association between income and prevalent T2DM (7.23%). Job demand suppressed the associations of education and occupation with prevalent T2DM. The mediation models with incident T2DM and social support were not significant. Conclusion: Socioeconomic inequalities in T2DM were present, but only a small part of it was explained by the psychosocial work environment., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2023 Sezer, Koster, Albers, Meisters, Schram, Eussen, Dukers, de Rijk, Stehouwer and Bosma.)

Objective: The purpose of this study is to determine if healthier neighbourhood food environments are associated with healthier diet quality., Design: This was a cross-sectional study using linear regression models to analyse data from the Maastricht Study. Diet quality was assessed using data collected with a FFQ to calculate the Dutch Healthy Diet (DHD). A buffer zone encompassing a 1000 m radius was created around each participant home address. The Food Environment Healthiness Index (FEHI) was calculated using a Kernel density analysis within the buffers of available food outlets. The association between the FEHI and the DHD score was analysed and adjusted for socio-economic variables., Setting: The region of Maastricht including the surrounding food retailers in the Netherlands., Participants: 7367 subjects aged 40-75 years in the south of the Netherlands., Results: No relationship was identified between either the FEHI (B = 0·62; 95 % CI = -2·54, 3·78) or individual food outlets, such as fast food (B = -0·07; 95 % CI = -0·20, 0·07) and diet quality. Similar null findings using the FEHI were identified at the 500 m (B = 0·95; 95 % CI = -0·85, 2·75) and 1500 m (B = 1·57; 95 % CI = -3·30, 6·44) buffer. There was also no association between the food environment and individual items of the DHD including fruits, vegetables and sugar-sweetened beverages., Conclusion: The food environment in the Maastricht area appeared marginally unhealthy, but the differences in the food environment were not related to the quality of food that participants reported as intake.

Purpose: In this study, we tested the "golden youth" hypothesis, which suggests that in Eastern Europe, affluent adolescents are at an increased risk of alcohol use. Also, we hypothesized that the relationship between high socioeconomic position (SEP) and more alcohol use is stronger in countries with wider income inequality., Methods: In total, 50,421 adolescents aged 13-15 years were included from 16 Eastern European countries participating in the 2013-2014 Health Behaviour in School-aged Children survey. Multilevel logistic regression analyses were performed., Results: Affluent adolescents had greater odds of weekly alcohol use (OR = 1.32, 95% CI = 1.23-1.41) and binge drinking (OR = 1.24, 95% CI = 1.16-1.32) than their peers from low-SEP families. However, no significant difference was observed between middle- and low-SEP adolescents. In countries with wider income inequality, the relationship between high family-SEP and weekly alcohol use (p interaction = .006), as well as high family-SEP and binge drinking (p interaction = .007), was stronger compared to countries with lower income inequality., Discussion: Possibly, influenced by the lifestyle choices of their parents, and using alcohol as a status symbol to establish and maintain friendly relationships with peers, Eastern European adolescents from affluent families, particularly in the most unequal settings, are at increased risk of alcohol use, confirming the golden youth hypothesis. Insecure self-image and perceived threat to their high status might be explanatory factors. More research is needed to identify the precise individual and family characteristics responsible for increased alcohol use among wealthy adolescents, especially in Eastern European countries with high income inequality., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Recent studies have unveiled an association between socioeconomic position (SEP) and intrahepatic lipid (IHL) content. The aim of this study was to examine to what extent traditional lifestyle factors mediate the relationship between SEP and IHL content, independent of aetiology, and non-alcoholic fatty liver disease (NAFLD)., Methods: We used cross-sectional data derived from The Maastricht Study (N = 4,001; mean age: 60 years, 49% women, 32% low education level, 21% diabetes, 21% NAFLD). Education, income, and occupation were used as indicators of SEP. Physical activity (accelerometer), intake of total energy, alcohol, saturated fat, protein, vitamin E, dietary fibre, and fructose from sugar-sweetened beverages (SSBs) and fruit juice (food frequency questionnaires) were potential mediators. IHL content was quantified by magnetic resonance imaging. Age, sex, and type 2 diabetes were covariates. Multiple parallel mediation analyses (bootstraps = 10,000) were performed., Results: Individuals with a low education level had a 1.056-fold higher IHL content (95% CI: 1.03-1.08) and a 44% greater NAFLD risk (OR:1.44; 95% CI:1.18-1.77) compared with those with higher education levels. Approximately 8.9% of educational disparity in risk of IHL content was attributable to moderate-to-vigorous physical activity; 6.3% to fructose intake from SSBs; 5.5% to dietary fibre; and -23% to alcohol. Approximately 8.7% of educational disparity in risk of NAFLD was attributable to moderate-to-vigorous physical activity; and 7.7% to fructose intake from SSBs. However, the indirect effect of these mediators was small (0.998 for IHL content and 1.045 for NAFLD) in comparison to the total effect. Similar results were found when income and occupation were used as SEP indicators., Conclusions: Societal measures may alleviate the burden of NAFLD and further studies that identify mediators other than traditional lifestyle factors are warranted to define the relationship underlying SEP and IHL content., Impact and Implications: Individuals with a low or medium level of education, income, or occupational status had more fat accumulation in their livers than individuals with a higher education, income, or occupational status. This difference may be attributed to the influence of unhealthy lifestyle factors, such as reduced physical activity and a higher intake of sugar-sweetened beverages among individuals with lower socioeconomic position. Nevertheless, other yet unknown factors may also play a role., Competing Interests: All authors declare no conflicts of interest related to this manuscript. Please refer to the accompanying ICMJE disclosure forms for further details., (© 2023 The Author(s).)

Background: Absolute income is commonly used in studies of health inequalities, however it does not reflect spending patterns, debts, or expectations. These aspects are reflected in measures concerning perceived income inadequacy. While health inequities by absolute income or perceived income inadequacy are well established, few studies have explored the interplay of absolute income and perceived income inadequacy in relation to health., Methods: Multiple data sources were linked into a nationally representative dataset (n = 445,748) of Dutch adults (18 +). The association between absolute income, perceived income inadequacy and health (self-reported health, chronic disease and psychological distress) was tested using logistic and Poisson regressions, controlling for various potential confounders (demographics, education) and mastery. Interactions were tested to check the association between perceived income inadequacy and health for different absolute income groups., Results: Perceived income inadequacy was reported at every absolute income group (with 42% of individuals in the lowest income group and 5% of individuals in the highest income group). Both absolute income and perceived income inadequacy were independently associated with health. The adjusted relative risk (RR) for lowest absolute income group is 1.11 (1.08-1.1.14) and 1.28 (1.24-1.32) for chronic disease and self-reported health respectively, and the Odds Ratio (OR) for psychological distress is 1.28 (1.16-1.42). For perceived income inadequacy the RR's were 1.41 (1.37-1.46) and 1.49 (1.44-1.54) and the OR for psychological distress is 3.14 (2.81-3.51). Mastery appeared to be an important mediator for the relationship between perceived income inadequacy, poor self-rated health and psychological distress., Conclusions: Absolute income and perceived income inadequacy reflect conceptually different aspects of income and are independently associated with health outcomes. Perceived income inadequacy may be accounted for in health inequality studies, alongside measures of absolute income. In policy-making, targeting perceived income inadequacy might have potential to reduce health inequalities., (© 2023. The Author(s).)

Background: Detrimental associations of sedentary behaviour (time spent sitting) with musculoskeletal pain (MSP) conditions have been observed. However, findings on those with, or at risk of, type 2 diabetes (T2D) have not been reported. We examined the linear and non-linear associations of device-measured daily sitting time with MSP outcomes according to glucose metabolism status (GMS)., Methods: Cross-sectional data from 2827 participants aged 40-75 years in the Maastricht Study (1728 with normal glucose metabolism (NGM); 441 with prediabetes; 658 with T2D), for whom valid data were available on activPAL-derived daily sitting time, MSP [neck, shoulder, low back, and knee pain], and GMS. Associations were examined by logistic regression analyses, adjusted serially for relevant confounders, including moderate-to-vigorous intensity physical activity (MVPA) and body mass index (BMI). Restricted cubic splines were used to further examine non-linear relationships., Results: The fully adjusted model (including BMI, MVPA, and history of cardiovascular disease) showed daily sitting time to be significantly associated with knee pain in the overall sample (OR = 1.07, 95%CI: 1.01-1.12) and in those with T2D (OR = 1.11, 95%CI: 1.00-1.22); this was not statistically significant in those with prediabetes (OR = 1.04, 95%CI: 0.91-1.18) or NGM (OR = 1.05, 95%CI: 0.98-1.13). There were no statistically significant associations between daily sitting time and neck, shoulder, or low back pain in any of the models. Furthermore, the non-linear relationships were statistically non-significant., Conclusion: Among middle-aged and older adults with T2D, daily sitting time was significantly associated with higher odds of knee pain, but not with neck, shoulder, or low back pain. No significant association was observed in those without T2D for neck, shoulder, low back, or knee pain. Future studies, preferably those utilising prospective designs, could examine additional attributes of daily sitting (e.g., sitting bouts and domain-specific sitting time) and the potential relationships of knee pain with mobility limitations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Dzakpasu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Adoption and implementation are prerequisites for the effectiveness of organisational interventions, but successful implementation is not self-evident. This article provides insights into the implementation of the organisational intervention 'Healthy Human Resources' (HHR). HHR is developed with Intervention Mapping and aims at improving sustainable employability (SE) of employees in low-skilled jobs., Methods: Qualitative data on adoption and implementation were collected by interviews with three employees and seven middle managers in five Dutch organisations and by extensive notes of observations and conversations in a logbook. Data triangulation was applied and all data were transcribed and analysed thematically using the qualitative analysis guide of Leuven (QUAGOL)., Results: All organisations adopted HHR, but three failed during the transition from adoption to implementation, and two implemented HHR only partially. The steepness of the organisational hierarchy emerged as an overarching barrier: steeper hierarchical organisations faced more difficulties with implementing HHR than flatter ones. This was reflected in middle managers' lack of decision-making authority and being overruled by senior management. Middle managers felt incapable of remedying the lack of employees' voice. Subsequently, 'us-versus-them' thinking patterns emerged. These power imbalances and 'us-versus-them' thinking reinforced each other, further strengthening the hierarchical steepness. Both processes could be the result of wider socio-political forces., Conclusions: This study improved the understanding of the difficulties to adopt and implement such organisational intervention to contribute to the sustainable employability of employees in low-skilled jobs. Practical implications are given for future implementation of organisational interventions., (© 2022. The Author(s).)

In recent years, early retirement decisions have become more frequent in the European Union despite political efforts to prevent early retirement. This is a growing problem for the social security system. The study focuses on a life course approach using employment biographies and investigates the influence of work stress and health on early retirement intentions. Data of employees who were born in either 1959 or 1965 of the German cohort study on work, age, health and work participation are analysed ( n  = 3338). By linking survey and register data from 1993 to 2011, a sequence analysis is conducted to identify employment biographies. To analyse the relationship between the employment biographies and intended early retirement, a longitudinal path analysis is computed and includes work stress, measured through effort-reward imbalance, and self-rated health. The statistical analyses identify three adverse employment biographies, i.e. part-time work, episodes of unemployment or marginal employment. In addition, two favourable employment biographies are determined, characterised by full-time work and few episodes of unemployment. The results of the path analysis show that employment biographies with high work-related stress have early retirement intentions. Among adverse employment biographies, indirect effects of poor health on the association between work stress and early retirement intentions are found. Unexpectedly, among full-time workers, work stress is also associated with early retirement intentions with an additional mediation through health. The findings of this study highlight the importance of the life course perspective when analysing retirement decisions. In addition to health-promoting interventions in the labour market, effects of psychosocial factors should be focussed on in order to reduce early exits from the labour market., Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00731-0., Competing Interests: Conflict of interestAll authors declare that they have no conflict of interest., (© The Author(s) 2022.)

Context: The timing of sleep, physical activity, and dietary intake show variation over the week, with different timings in the weekend compared to the weekdays, which may potentially lead to impaired glucose and lipid regulation on Mondays compared to other weekdays., Objective: The aim of the study was to investigate differences in glucose metabolism and fasting triglyceride concentrations on Mondays compared to the rest of the week., Design, Setting and Participants: This cross-sectional study is based on data from the Maastricht Study, including 6067 participants without known diabetes and 1568 previously diagnosed with type 2 diabetes., Main Outcome Measures: Confounder-adjusted linear regression analysis was applied to study the associations of day of the week of examination with glucose and insulin responses to an oral glucose tolerance test and fasting triglyceride concentrations., Results: In fully confounder-adjusted models, mean (95% CI) concentrations of fasting glucose, insulin, and triglycerides were slightly higher on Mondays compared with the other weekdays [glucose: 1% (0-2); insulin: 9% (1-18); triglycerides: 5% (2-8)]. Interaction analyses revealed that the association of weekday with insulin was only pronounced in men [18% (3-35)], but not in women [1% (-8-10)], whereas the associations with glucose and triglycerides were only apparent for individuals with known type 2 diabetes [glucose: 4% (0-7); triglycerides: 14% (6-23)] compared to the background population [glucose: 0% (0-1); triglycerides: 3% (0-6)]., Discussion: Being examined on a Monday was associated with higher fasting insulin concentrations among men but not women., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background : Sustainable employability (SE) is important for work organizations. Recently, the MAastricht Instrument for Sustainable Employability (MAISE-NL) was developed and validated. This study describes the development and validation of an adapted version of the MAISE-NL, the MAISE-Easy, which can be used for employees in low-skilled jobs. Methods : The adaptation of the MAISE-NL was based on six focus groups with employees in low-skilled jobs in various sectors. The MAISE-Easy was distributed among employees in five organizations. The response rate ( n = 1033) was 53%. Construct validity, reliability and criterion validity were analyzed by means of principal component analysis (PCA), confirmatory factor analysis (CFA), Cronbach's alpha and correlational analyses. Results : The MAISE-Easy included 17 scales divided over four main areas: (1) level of SE; (2) factors affecting SE; (3) overall responsibility for SE; (4) responsibility for factors affecting SE. Construct validity, reliability and criterion validity were adequate to good. Conclusions : The MAISE-Easy is a well-validated instrument for measuring SE among employees in low-skilled jobs in terms of the level of SE, factors affecting SE, responsibility for SE and responsibility for factors affecting SE. MAISE-Easy is recommended for both needs assessments and evaluation research in as yet underserved groups of low-skilled workers.

Bullying perpetration might be an alternative way of hierarchy formation among adolescents. It can potentially compensate for the negative health influences of low socioeconomic status (SES), rewarding this unwanted behavior. This study aimed to investigate the role of bullying perpetration in the relationship between SES and health among Armenian adolescents. A nationally representative sample of 3679 adolescents aged 11-15 years (mean = 13.1, standard deviation = 1.6) participated in the Health Behavior in School-aged Children 2013/14 survey in Armenia. Complex samples multiple logistic regression were used to estimate the associations between two SES measures (family socioeconomic position [SEP] and material well-being) and three health outcomes (perceived health status, psychosocial well-being, and psychosomatic symptoms). Bullying perpetration was not associated with less than good health or low psychosocial well-being (P > 0.05) but increased the odds of reporting high psychosomatic symptoms (P < 0.05). Perpetration did not change the SES-health gradient substantially. However, in stratified analyses, socioeconomic inequalities in health were consistently weaker among perpetrators. The largest observed difference was in the relationship between low family SEP and less than good health (OR = 3.60, 95% CI = 2.77-4.67 vs. OR = 1.80, 95% CI = 1.06-3.04), whereas the smallest difference was in the relationship between low family SEP and high psychosomatic symptoms (OR = 1.27, 95% CI = 1.03-1.56 vs. OR = 1.04, 95% CI = 0.61-1.77). Our findings suggest that bullying perpetration, as an alternative hierarchy, may be looked at as a compensatory but vicious strategy in the face of the negative health influences of low SES in Armenian adolescents. For high-SES adolescents, on the other hand, social, emotional, or psychological problems might contribute to bullying perpetration. Consequently, bullying prevention activities in Armenia should focus on both low and high-SES adolescents, considering SES-specific pathways and mechanisms., Competing Interests: The authors have declared that no competing interests exist.

Vaccine uptake is one of the indicators that has been used to guide immunization programs. This study aimed to evaluate whether measles vaccine uptake is predicted by measles vaccine hesitancy. A community-based cross-sectional study was conducted in urban districts in Khartoum state in February 2019. Measles vaccine uptake among children was measured as either fully vaccinated or partially/not vaccinated. The Parent Attitudes about Childhood Vaccines (PACV) scale was used to measure measles vaccine hesitancy. Multivariate logistic regression was run to identify the predictors of measles vaccination uptake, controlling for sociodemographic variables, and the adjusted odds ratios (aORs) with 95% CI were calculated. The receiver operator characteristic (ROC) curve was created, and the area under the curve (AUC) for the PACV was computed. Data were collected from 495 participants. We found that measles vaccine hesitancy (PACV scores) predicts the uptake of measles vaccine after controlling for other potential social confounders, such as the mother's age and the number of children (aOR 1.055; 95% CI 1.028-1.028). Additionally, the ROC for the PACV yielded an area under the curve (AUC 0.686 (95% CI 0.620-0.751; p < 0.001)). Our findings show that measles vaccine hesitancy in Sudan directly influences the uptake of the measles vaccine. Addressing the determinants of vaccine hesitancy through communication strategies will improve vaccine uptake.

Healthcare costs in the Netherlands are rising and vary considerably among regions. Explaining regional differences in healthcare costs can help policymakers in targeting appropriate interventions in order to restrain costs. Factors usually taken into account when analyzing regional differences in healthcare costs are demographic structure and socioeconomic status (SES). However, health, lifestyle, loneliness and mastery have also been linked to healthcare costs. Therefore, this study analyzes the contribution of health, lifestyle factors (BMI, alcohol consumption, smoking and physical activity), loneliness, and mastery to regional differences in healthcare costs. Analyses are performed in a linked dataset ( n  = 334,721) from the Dutch Public Health Services, Statistics Netherlands, the National Institute for Public Health and the Environment (year 2016), and the healthcare claims database Vektis (year 2017) with Poisson and zero-inflated binomial regressions. Regional differences in general practitioner consult costs remain significant even after taking into account health, lifestyle, loneliness, and mastery. Regional differences in costs for mental, pharmaceutical, and specialized care are less pronounced and can be explained to a large extent. For total healthcare costs, regional differences are mostly explained through the factors included in this study. Hence, addressing lifestyle factors, loneliness and mastery can help policymakers in restraining healthcare costs. In this study, the region of Zuid-Limburg represents the reference region. Use compare regions for health and healthcare costs (Regiovergelijker gezondheid en zorgkosten) in order to select all other Dutch regions as reference region., Supplementary Information: The online version of this article (10.1007/s12508-022-00369-4) contains supplementary material, which is available to authorized users., (© The Author(s) 2022.)

The gender pay gap has been observed for decades, and still exists. Due to a life course perspective, gender differences in income are analyzed over a period of 24 years. Therefore, this study aims to investigate income trajectories and the differences regarding men and women. Moreover, the study examines how human capital determinants, occupational positions and factors that accumulate disadvantages over time contribute to the explanation of the GPG in Germany. Therefore, this study aims to contribute to a better understanding of the GPG over the life course. The data are based on the German cohort study lidA (living at work), which links survey data individually with employment register data. Based on social security data, the income of men and women over time are analyzed using a multilevel analysis. The results show that the GPG exists in Germany over the life course: men have a higher daily average income per year than women. In addition, the income developments of men rise more sharply than those of women over time. Moreover, even after controlling for factors potentially explaining the GPG like education, work experience, occupational status or unemployment episodes the GPG persists. Concluding, further research is required that covers additional factors like individual behavior or information about the labor market structure for a better understanding of the GPG., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Toczek, Bosma and Peter.)

Determinants of vaccine hesitancy are not yet well understood. This study aims to assess measles vaccine hesitancy and characterize its determinants among Sudanese parents in Omdurman in Khartoum State. A community-based cross-sectional quantitative study was conducted in Khartoum State in February 2019. The Parent Attitudes about Childhood Vaccination (PACV) was used to measure measles vaccine hesitancy. Questions about the sociodemographic characteristics of the family, the perception of the parents about the measles vaccine, and the parental exposure to information were asked. Proportions of vaccine hesitancy and coefficients of linear regression were computed. Five hundred parents were recruited for the study. We found that a significant proportion of participants (about 1 in 5 parents) had hesitations regarding the measles vaccine. Significant predictors of measles vaccine hesitancy were parental exposure to anti-vaccination information or materials (β = -0.478, p -value < 0.001), the parents' perception of the effectiveness of measles vaccines (β = 0.093, p -value = 0.020), the age of the mother (β = 0.112, p -value = 0.017), the birth rank of the child (β = -0.116, p -value = 0.015), and the total number of the children in the family (β = 0.098, p -value = 0.013). Vaccination access issues were the common justification for parental vaccination hesitancy. Our findings indicate that investment in vaccine communication as well as addressing access issues might be an effective intervention for improving measles vaccine acceptance and, ultimately, measles vaccine coverage.

Aims: Social network characteristics may provide a novel non-pharmaceutical target for the prevention of depression. We investigated the temporal association of a broad range of structural and functional social network characteristics with incident depressive symptoms over 5 years of follow-up., Methods: We used data from The Maastricht Study, a population-based prospective cohort study (n=2,465, mean age 59.8±8.1 years, 49.1% women, 11,585 person-years of follow-up). Social network characteristics were assessed through a name generator questionnaire. Clinically relevant depressive symptoms (9-item Patient Health Questionnaire score≥10) were assessed at baseline and annually. We used multivariable logistic and Cox regression analyses, adjusted for sociodemographic, lifestyle and cardiovascular risk factors., Results: In cross-sectional analyses less emotional support for discomfort and with important decisions, and less informational support were associated with prevalent depressive symptoms (OR[95%CI] 1.19 [1.01-1.40]; 1.22 [1.05-1.43], and 1.20 [1.04-1.39], respectively). Every fewer 10% of family members was associated with prevalent depressive symptoms (1.11 [1.01-1.23]). In longitudinal analyses, less emotional support on important decisions was also associated with higher risk of incident depressive symptoms (HR[95%CI] 1.13 [1.03-1.25]). In addition, every fewer 10% of the network that was a family member was associated with a higher hazard of incident depressive symptoms (1.07 [1.01-1.13])., Conclusions: This study shows that less emotional support and fewer family members in the network were associated with higher risk of both prevalent and incident depression. The importance of emotional support and the role that family plays should be considered in treatment and prevention of depression., (Copyright © 2021. Published by Elsevier B.V.)