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Purpose To investigate the association between fruit and vegetable intake (FVI) and the risk of developing prediabetes and type 2 diabetes (T2D) in a Swedish prospective cohort study. Methods Subjects were 6961 men and women aged 35–56 years old at baseline, participating in the Stockholm Diabetes Prevention Program cohort. By design, the cohort was enriched by 50% with subjects that had family history of diabetes. Anthropometric measurements, oral glucose tolerance tests and questionnaires on lifestyle and dietary factors were carried out at baseline and two follow-up occasions. Cox proportional hazard models were used to estimate hazard ratios with 95% CIs. Results During a mean follow-up time of 20 ± 4 years, 1024 subjects developed T2D and 870 prediabetes. After adjustments for confounders, the highest tertile of total FVI was associated with a lower risk of developing T2D in men (HR 0.76, 95% CI 0.60–0.96). There was also an inverse association between total fruit intake and prediabetes risk in men, with the HR for the highest tertile being 0.76 (95% CI 0.58–1.00). As for subtypes, higher intake of apples/pears was inversely associated with T2D risk in both sexes, whereas higher intakes of banana, cabbage and tomato were positively associated with T2D or prediabetes risk in either men or women. Conclusion We found an inverse association between higher total FVI and T2D risk and between higher fruit intake and prediabetes risk, in men but not in women. Certain fruit and vegetable subtypes showed varying results and require further investigation.

Background The coronavirus disease 2019 (COVID-19) disproportionately affects minority populations in the USA. Sweden — like other Nordic countries — have less income and wealth inequality but lacks data on the socioeconomic impact on the risk of adverse outcomes due to COVID-19. Methods This population-wide study from March 2020 to March 2022 included all adults in Stockholm, except those in nursing homes or receiving in-home care. Data sources include hospitals, primary care (individual diagnoses), the Swedish National Tax Agency (death dates), the Total Population Register “RTB” (sex, age, birth country), the Household Register (size of household), the Integrated Database For Labor Market Research “LISA” (educational level, income, and occupation), and SmiNet (COVID data). Individual exposures include education, income, type of work and ability to work from home, living area and living conditions as well as the individual country of origin and co-morbidities. Additionally, we have data on the risks associated with living areas. We used a Cox proportional hazards model and logistic regression to estimate associations. Area-level covariates were used in a principal component analysis to generate a measurement of neighborhood deprivation. As outcomes, we used hospitalization and death due to COVID-19. Results Among the 1,782,125 persons, male sex, comorbidities, higher age, and not being born in Sweden increase the risk of hospitalization and death. So does lower education and lower income, the lowest incomes doubled the risk of death from COVID-19. Area estimates, where the model includes individual risks, show that high population density and a high percentage of foreign-born inhabitants increased the risk of hospitalization. Conclusions Segregation and deprivation are public health issues elucidated by COVID-19. Neighborhood deprivation, prevalent in Stockholm, adds to individual risks and is associated with hospitalization and death. This finding is paramount for governments, agencies, and healthcare institutions interested in targeted interventions.

Rationale: Ambient air pollution exposure has been linked to mortality from chronic cardiorespiratory diseases, while evidence on respiratory infections remains more limited. Objectives: We examined the association between long-term exposure to air pollution and pneumonia-related mortality in adults in a pool of eight European cohorts. Methods: Within the multicenter project ELAPSE (Effects of Low-Level Air Pollution: A Study in Europe), we pooled data from eight cohorts among six European countries. Annual mean residential concentrations in 2010 for fine particulate matter, nitrogen dioxide (NO2), black carbon (BC), and ozone were estimated using Europe-wide hybrid land-use regression models. We applied stratified Cox proportional hazard models to investigate the associations between air pollution and pneumonia, influenza, and acute lower respiratory infections (ALRI) mortality. Measurements and Main Results: Of 325,367 participants, 712 died from pneumonia and influenza combined, 682 from pneumonia, and 695 from ALRI during a mean follow-up of 19.5 years. NO2 and BC were associated with 10–12% increases in pneumonia and influenza combined mortality, but 95% confidence intervals included unity (hazard ratios, 1.12 [0.99–1.26] per 10 μg/m3 for NO2; 1.10 [0.97–1.24] per 0.5 1025m21 for BC). Associations with pneumonia and ALRI mortality were almost identical. We detected effect modification suggesting stronger associations with NO2 or BC in overweight, employed, or currently smoking participants compared with normal weight, unemployed, or nonsmoking participants. Conclusions: Long-term exposure to combustion-related air pollutants NO2 and BC may be associated with mortality from lower respiratory infections, but larger studies are needed to estimate these associations more precisely.

Background The health consequences of the use of Swedish snus, including its relationship with mortality, have not been fully established. We investigated the relationship between snus use and all-cause and cause-specific mortality (death due to cardiovascular diseases, cancer diseases and all other reasons, respectively) in a nationwide collaborative pooling project. Methods We followed 169 103 never-smoking men from eight Swedish cohort studies, recruited in 1978–2010. Shared frailty models with random effects at the study level were used in order to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of mortality associated with snus use. Results Exclusive current snus users had an increased risk of all-cause mortality (aHR 1.28, 95% CI 1.20–1.35), cardiovascular mortality (aHR 1.27, 95% CI 1.15–1.41) and other cause mortality (aHR 1.37, 95% CI 1.24–1.52) compared with never-users of tobacco. The risk of cancer mortality was also increased (aHR 1.12, 95% CI 1.00–1.26). These mortality risks increased with duration of snus use, but not with weekly amount. Conclusions Snus use among men is associated with increased all-cause mortality, cardiovascular mortality, with death from other causes and possibly with increased cancer mortality.

This study used the Stockholm Youth Cohort, a total population cohort ( N = 364,957), to describe patterns and predictors of qualification for upper secondary education, defined by passing graduation grades in core compulsory school subjects in contemporary young individuals diagnosed with autism spectrum disorders without intellectual disability ( n = 6138). At the expected age for graduation, 16 years, 29% (adjusted rate difference 95% confidence interval (28.0–30.0)) fewer autistic than non-autistic individuals were qualified for upper secondary education (57% and 86%, respectively). Comorbid attention-deficit hyperactivity disorder further increased this difference. Within the group of autistic students without intellectual disability, female sex and lower family income were associated with non-qualification for upper secondary education. The proportion of students with autism without intellectual disability who qualified for upper secondary education increased at age 20. These findings underline the need for improved support for students with a diagnosis of autism without intellectual disability in mainstream education. Lay abstract Obtaining a quality education is important for any individual’s chances of leading a healthy and thriving life. Currently, educational policies in many countries underscore the rights of students with autism to be educated in mainstream schools. While there is some knowledge on school outcomes among students with autism from older studies, little is known about rates of qualification for upper secondary education among children with autism in mainstream schools today. This lack of knowledge is problematic since autism is diagnosed more widely, and prior evidence may not be relevant for individuals with autism and their families today. Using Swedish registers, we therefore examined this in a study including all children and young people in Stockholm County in 2001 through 2011. We found that about two thirds of children with autism without intellectual disability qualified for upper secondary education at the expected age, in comparison with about nine in ten among typically developing peers. We also found that girls with autism had further difficulties obtaining such qualification than boys and that those who were additionally diagnosed with attention-deficit hyperactivity disorder were particularly at risk of non-qualification. Finally, students with autism without intellectual disability had a greater chance of completing compulsory education if given an extended period to graduate. These findings underline the need for supportive interventions for children with autism during compulsory school. They may also challenge the inclusive education policy adopted by majority of western countries, at least in the wake of addressing special needs in mainstream schooling.

Background: The evidence linking ambient air pollution to bladder cancer is limited and mixed. Methods: We assessed the associations of bladder cancer incidence with residential exposure to fine particles (PM2.5), nitrogen dioxide (NO2), black carbon (BC), warm season ozone (O3) and eight PM2.5 elemental components (copper, iron, potassium, nickel, sulfur, silicon, vanadium, and zinc) in a pooled cohort (N = 302,493). Exposures were primarily assessed based on 2010 measurements and back-extrapolated to the baseline years. We applied Cox proportional hazard models adjusting for individual- and area-level potential confounders. Results: During an average of 18.2 years follow-up, 967 bladder cancer cases occurred. We observed a positive though statistically non-significant association between PM2.5 and bladder cancer incidence. Hazard Ratios (HR) were 1.09 (95% confidence interval (CI): 0.93–1.27) per 5 µg/m3 for 2010 exposure and 1.06 (95% CI: 0.99–1.14) for baseline exposure. Effect estimates for NO2, BC and O3 were close to unity. A positive association was observed with PM2.5 zinc (HR 1.08; 95% CI: 1.00–1.16 per 10 ng/m3). Conclusions: We found suggestive evidence of an association between long-term PM2.5 mass exposure and bladder cancer, strengthening the evidence from the few previous studies. The association with zinc in PM2.5 suggests the importance of industrial emissions.

Particulate matter air pollution and diesel engine exhaust have been classified as carcinogenic for lung cancer, yet few studies have explored associations with liver cancer. We used six European adult cohorts which were recruited between 1985 and 2005, pooled within the “Effects of low-level air pollution: A study in Europe” (ELAPSE) project, and followed for the incidence of liver cancer until 2011 to 2015. The annual average exposure to nitrogen dioxide (NO 2), particulate matter with diameter 2.5), black carbon (BC), warm-season ozone (O 3), and eight elemental components of PM 2.5 (copper, iron, zinc, sulfur, nickel, vanadium, silicon, and potassium) were estimated by European-wide hybrid land-use regression models at participants' residential addresses. We analyzed the association between air pollution and liver cancer incidence by Cox proportional hazards models adjusting for potential confounders. Of 330 064 cancer-free adults at baseline, 512 developed liver cancer during a mean follow-up of 18.1 years. We observed positive linear associations between NO 2 (hazard ratio, 95% confidence interval: 1.17, 1.02-1.35 per 10 μg/m 3), PM 2.5 (1.12, 0.92-1.36 per 5 μg/m 3), and BC (1.15, 1.00-1.33 per 0.5 10 −5/m) and liver cancer incidence. Associations with NO 2 and BC persisted in two-pollutant models with PM 2.5. Most components of PM 2.5 were associated with the risk of liver cancer, with the strongest associations for sulfur and vanadium, which were robust to adjustment for PM 2.5 or NO 2. Our study suggests that ambient air pollution may increase the risk of liver cancer, even at concentrations below current EU standards.

Although exposure to overweight and obesity at different ages is associated to a higher risk of type 2 diabetes, the effect of different patterns of exposure through life remains unclear. We aimed to characterize life-course trajectories of weight categories and estimate their impact on the incidence of type 2 diabetes. We categorized the weight of 7203 participants as lean, normal or overweight at five time-points from ages 7–55 using retrospective data. Participants were followed for an average of 19 years for the development of type 2 diabetes. We used latent class analysis to describe distinctive trajectories and estimated the risk ratio, absolute risk difference and population attributable fraction (PAF) associated to different trajectories using Poisson regression. We found five distinctive life-course trajectories. Using the stable-normal weight trajectory as reference, the stable overweight, lean increasing weight, overweight from early adulthood and overweight from late adulthood trajectories were associated to higher risk of type 2 diabetes. The estimated risk ratios and absolute risk differences were statistically significant for all trajectories, except for the risk ratio of the lean increasing trajectory group among men. Of the 981 incident cases of type 2 diabetes, 47.4% among women and 42.9% among men were attributable to exposure to any life-course trajectory different from stable normal weight. Most of the risk was attributable to trajectories including overweight or obesity at any point of life (36.8% of the cases among women and 36.7% among men). The overweight from early adulthood trajectory had the highest impact (PAF: 23.2% for woman and 28.5% for men). We described five distinctive life-course trajectories of weight that were associated to increased risk of type 2 diabetes over 19 years of follow-up. The variability of the effect of exposure to overweight and obesity on the risk of developing type 2 diabetes was largely explained by exposure to the different life-course trajectories of weight.

BACKGROUND: Inconsistent associations between long-term exposure to particles with an aerodynamic diameter ≤ 2.5 μ m [fine particulate matter ( PM 2.5 )] components and mortality have been reported, partly related to challenges in exposure assessment. OBJECTIVES: We investigated the associations between long-term exposure to PM 2.5 elemental components and mortality in a large pooled European cohort; to compare health effects of PM 2.5 components estimated with two exposure modeling approaches, namely, supervised linear regression (SLR) and random forest (RF) algorithms. METHODS: We pooled data from eight European cohorts with 323,782 participants, average age 49 y at baseline (1985-2005). Residential exposure to 2010 annual average concentration of eight PM 2.5 components [copper (Cu), iron (Fe), potassium (K), nickel (Ni), sulfur (S), silicon (Si), vanadium (V), and zinc (Zn)] was estimated with Europe-wide SLR and RF models at a 100 × 100 m scale. We applied Cox proportional hazards models to investigate the associations between components and natural and cause-specific mortality. In addition, two-pollutant analyses were conducted by adjusting each component for PM 2.5 mass and nitrogen dioxide ( NO 2 ) separately. RESULTS: We observed 46,640 natural-cause deaths with 6,317,235 person-years and an average follow-up of 19.5 y. All SLR-modeled components were statistically significantly associated with natural-cause mortality in single-pollutant models with hazard ratios (HRs) from 1.05 to 1.27. Similar HRs were observed for RF-modeled Cu, Fe, K, S, V, and Zn with wider confidence intervals (CIs). HRs for SLR-modeled Ni, S, Si, V, and Zn remained above unity and (almost) significant after adjustment for both PM 2.5 and NO 2 . HRs only remained (almost) significant for RF-modeled K and V in two-pollutant models. The HRs for V were 1.03 (95% CI: 1.02, 1.05) and 1.06 (95% CI: 1.02, 1.10) for SLR- and RF-modeled exposures, respectively, per 2 ng / m 3 , adjusting for PM 2.5 mass. Associations with cause-specific mortality were less consistent in two-pollutant models. CONCLUSION: Long-term exposure to V in PM 2.5 was most consistently associated with increased mortality. Associations for the other components were weaker for exposure modeled with RF than SLR in two-pollutant models. https://doi.org/10.1289/EHP8368.

Background Throughout the industrialized world, demand for low skilled labour is falling. The length of schooling is increasing in response, but so is the proportion of individuals not finishing upper secondary school. The objective of this study was to evaluate the associations between labour market positions at age 18 and all-cause and suicide- and accident-specific mortality in later adulthood. Methods Labour market positions at age 18 were categorized for all Swedes born 1972-77 (n=630 959) into four main groups: employed, successful students, students not about to qualify (SNAQs), and individuals not in employment, education or training (NEETs). Cox proportional hazard models were fitted to assess all-cause, suicide and accident mortality up to 2016 (ages 39-44), adjusting for high school grades, parental and own prior psychiatric diagnoses, and childhood socioeconomic status. Findings SNAQs had substantially increased all-cause (men: HR=2.10; 95% CI 1.92-2.28, women: HR=1.64; 95% CI: 1.44-1.86), suicide (men: HR=2.16; CI: 1.86-2.51, women: HR=2.10; 95% CI 1.64-2.69), and accident specific (men: HR=2.08; 95% CI 1.77-2.44, women: 1.87; 95% CI 1.33;2.62) mortality risks compared to successful students. The risks were similar for NEETs. There was no increased risk among full-time employed compared to successful students. Interpretation Expanding the educational system may be a natural response to falling demand for low skilled labour but not by far one that corrects the major societal challenge of it. Unless educational systems adequately respond to this challenge, only more inequality is to be expected ahead. Funding This work was supported by a grant to FR and AL from the Swedish Research Council for Health, Working Life, and Welfare with contract number (2014-2009).

ObjectivesTo estimate concentration–response relationships for particulate matter (PM) and black carbon (BC) in relation to mortality in cohorts from three Swedish cities with comparatively low pollutant levels.SettingCohorts from Gothenburg, Stockholm and Umeå, Sweden.DesignHigh-resolution dispersion models were used to estimate annual mean concentrations of PM with aerodynamic diameter ≤10 µm (PM10) and ≤2.5 µm (PM2.5), and BC, at individual addresses during each year of follow-up, 1990–2011. Moving averages were calculated for the time windows 1–5 years (lag1–5) and 6–10 years (lag6–10) preceding the outcome. Cause-specific mortality data were obtained from the national cause of death registry. Cohort-specific HRs were estimated using Cox regression models and then meta-analysed including a random effect of cohort.ParticipantsDuring the study period, 7 340 cases of natural mortality, 2 755 cases of cardiovascular disease (CVD) mortality and 817 cases of respiratory and lung cancer mortality were observed among in total 68 679 individuals and 689 813 person-years of follow-up.ResultsBoth PM10 (range: 6.3–41.9 µg/m3) and BC (range: 0.2–6.8 µg/m3) were associated with natural mortality showing 17% (95% CI 6% to 31%) and 9% (95% CI 0% to 18%) increased risks per 10 µg/m3 and 1 µg/m3 of lag1-5 exposure, respectively. For PM2.5 (range: 4.0–22.4 µg/m3), the estimated increase was 13% per 5 µg/m3, but less precise (95% CI −9% to 40%). Estimates for CVD mortality appeared higher for both PM10 and PM2.5. No association was observed with respiratory mortality.ConclusionThe results support an effect of long-term air pollution on natural mortality and mortality in CVD with high relative risks also at low exposure levels. These findings are relevant for future decisions concerning air quality policies.

Objective To investigate the associations between air pollution and mortality, focusing on associations below current European Union, United States, and World Health Organization standards and guidelines. Design Pooled analysis of eight cohorts. Setting Multicentre project Effects of Low-Level Air Pollution: A Study in Europe (ELAPSE) in six European countries. Participants 325 367 adults from the general population recruited mostly in the 1990s or 2000s with detailed lifestyle data. Stratified Cox proportional hazard models were used to analyse the associations between air pollution and mortality. Western Europe-wide land use regression models were used to characterise residential air pollution concentrations of ambient fine particulate matter (PM 2.5 ), nitrogen dioxide, ozone, and black carbon. Main outcome measures Deaths due to natural causes and cause specific mortality. Results Of 325 367 adults followed-up for an average of 19.5 years, 47 131 deaths were observed. Higher exposure to PM 2.5 , nitrogen dioxide, and black carbon was associated with significantly increased risk of almost all outcomes. An increase of 5 µg/m 3 in PM 2.5 was associated with 13% (95% confidence interval 10.6% to 15.5%) increase in natural deaths; the corresponding figure for a 10 µg/m 3 increase in nitrogen dioxide was 8.6% (7% to 10.2%). Associations with PM 2.5 , nitrogen dioxide, and black carbon remained significant at low concentrations. For participants with exposures below the US standard of 12 µg/m 3 an increase of 5 µg/m 3 in PM 2.5 was associated with 29.6% (14% to 47.4%) increase in natural deaths. Conclusions Our study contributes to the evidence that outdoor air pollution is associated with mortality even at low pollution levels below the current European and North American standards and WHO guideline values. These findings are therefore an important contribution to the debate about revision of air quality limits, guidelines, and standards, and future assessments by the Global Burden of Disease.

Background Transportation noise is increasingly acknowledged as a cardiovascular risk factor, but the evidence base for an association with stroke is sparse. Objective We aimed to investigate the association between transportation noise and stroke incidence in a large Scandinavian population. Methods We harmonized and pooled data from nine Scandinavian cohorts (seven Swedish, two Danish), totaling 135,951 participants. We identified residential address history and estimated road, railway, and aircraft noise for all addresses. Information on stroke incidence was acquired through linkage to national patient and mortality registries. We analyzed data using Cox proportional hazards models, including socioeconomic and lifestyle confounders, and air pollution. Results During follow-up ( median = 19.5 y ), 11,056 stroke cases were identified. Road traffic noise ( L den ) was associated with risk of stroke, with a hazard ratio (HR) of 1.06 [95% confidence interval (CI): 1.03, 1.08] per 10-dB higher 5-y mean time-weighted exposure in analyses adjusted for individual- and area-level socioeconomic covariates. The association was approximately linear and persisted after adjustment for air pollution [particulate matter (PM) with an aerodynamic diameter of ≤ 2.5 μ m ( PM 2.5 ) and NO 2 ]. Stroke was associated with moderate levels of 5-y aircraft noise exposure (40-50 vs. ≤ 40 dB ) ( HR = 1.12 ; 95% CI: 0.99, 1.27), but not with higher exposure ( ≥ 50 dB , HR = 0.94 ; 95% CI: 0.79, 1.11). Railway noise was not associated with stroke. Discussion In this pooled study, road traffic noise was associated with a higher risk of stroke. This finding supports road traffic noise as an important cardiovascular risk factor that should be included when estimating the burden of disease due to traffic noise. https://doi.org/10.1289/EHP8949.

IntroductionReadmissions are very costly, in monetary terms but also for the individual patient’s safety and health. Only by understanding the reasons and drivers of readmissions, it is possible to ensure quality of care and improve the situation. The aim of this study was to assess inpatient readmissions during the first three months after discharge from geriatric inpatient care regarding main diagnosis and frequency of readmission. Furthermore, the aim was to analyze association between readmission and patient characteristics including demography and socioeconomics, morbidity, physical function, risk screening and care process respectively.MethodsThe study includes all individuals admitted for inpatient care at three geriatric departments operated by the Stockholm region during 2016. Readmission after discharge was studied within three different time intervals; readmission within 10 days after discharge, within 11–30 days and within 31–90 days, respectively. Main diagnosis at readmission was assessed.ResultsOne fourth of the individuals discharged from inpatient geriatric care was readmitted during the first three months after discharge. The most common main diagnoses for readmission were heart failure, chronic obstructive pulmonary disease and pneumonia. Statistically significant risk factors for readmission included age, sex, number of diagnoses at discharge, and to some extent polypharmacy and destination of discharge.ConclusionsSeveral clinical risk factors relating to physical performance and vulnerability were associated with risk of readmission. Socioeconomic information did not add to the predictability. To enable reductions in readmission rates, proactive monitoring of frail individuals afflicted with chronic conditions is necessary, and an integrated perspective including all stakeholders involved is crucial.

Background Body image concerns may give rise to a multitude of risk behaviors, such as unhealthy weight control practices, disordered eating behaviors (e.g., compensatory purging or preoccupation with food), smoking, excessive alcohol intake, or sunbed use. However, the distribution of these risk behaviors across adulthood has rarely been studied. Methods The aim of this study was to explore health risk behaviors as correlates of body image perception in a randomly selected study population of 30,245 individuals aged 30–66 in Stockholm, Sweden, utilizing data from the Stockholm Public Health Cohort. Bivariate correlations were explored and a hierarchic binary logistic regression analysis was performed. Results The prevalence of body image discrepancy was higher among smokers and respondents displaying disordered eating behaviors. In contrast, alcohol and sunbed use were inversely correlated to body image discrepancy. Body mass index was the substantially strongest explanatory factor behind the observed variance in body image discrepancy, followed by loss-of-control eating. Notably, no major gender differences in body image perception were detected. Some unexpected patterns of association between variables other than body image perception, such as those between smoking, alcohol use, and sunbed use, were seen. Conclusions Overall, the patterns differ substantially from what has previously been found in adolescent and young adult samples, indicating that the synergy and aggregation of risk behaviors observed among younger individuals may not apply to adults aged 30–66.

Background Overweight and obesity are risk factors for type 2 diabetes (T2D) with a cumulative effect. However, individuals experience important variation throughout life. We aimed to identify life-course trajectories of changes in weight categories among men and women and their association with T2D. Methods 4,820 women and 3,128 men participants of the Stockholm Diabetes Preventive Program (1992-2017) provided self-reported weight status at age 7 and 18, BMI 10 and 5 years before the study and measured BMI at baseline. Exposure was categorized as low weight, normal weight and high weight. Diagnosis of T2D was assessed with an oral glucose tolerance tests (OGTT) or taken from inpatient and outpatient registries. The life course trajectories were estimated using latent group mixture models, risk of T2D and population attributable fractions with Poisson regression. Results We found five trajectories in women and men: stable normal (44.8%, 34.2%), low increasing (17.4%, 18.7%), high in early adulthood (18.6%, 27.8%), high in late adulthood (14.7%, 14.5%), and stable high (4.5%, 4.5%). Compared to stable normal, the risk of T2D was higher in the low increasing (RR: 1.4 (95%CI: 1.0-2.0), RR:1.54(95%CI: 1.0-2.2)), high in early adulthood ((RR: 2.79 (95%CI: 2.1-3.7), RR: 2.8 (95%CI: 2.0-3.6)), high in late adulthood ((RR: 1.6 (95%CI: 1.1-2.2), RR: 1.6 (95%CI: 1.1-2.3)) and stable high groups ((RR: 2.9 (95%CI: 1.9-4.3), RR: 2.7 (95%CI 1.8-4.0)), and 48.2% (95% CI: 36.3% - 57.8%) of the cases of T2D in women and 41.2% (95%CI: 27.4% - 52.3%) in men could have been avoided if participants had been in the stable normal group. PAF was higher for the high in early adulthood group -25.5% (19%-31%) and (27.2% (19%-35%)-. Conclusions We identified five life course trajectories of changes in weight status. Risk of T2D was greater in the stable high and high in early adulthood groups but the proportion of T2D cases that can be attributed to the high in early adulthood group was greater. Key messages Different life-course trajectories of high body weight are associated to the risk of diabetes in late adulthood. The largest proportion of cases of T2D can be attributed to weight gain in early adulthood.

Issue Public health problems and interventions are often addressed in sub-optimal ways by not prioritizing them based on the best available evidence. Description of the Problem The public health report 2019 for the Stockholm region aims to inform decision makers, politicians, and public health workers about the risk factors and diseases that account for the biggest part of the burden of disease with a clear focus on high quality evidence and communication of main messages. How did the public health report 2019 affect public health policy in the Stockholm region? Results The public health report 2019 influenced agenda setting, resource allocation and priority setting in the Stockholm region. Lessons We identified the following facilitating factors in the process, of which most also are supported in scientific literature, in chronological order: 1) understanding the policymaking context to be aware of windows of opportunity, 2) establishing relationships with relevant policymakers, engage with them routinely in the decision-making process, and being accessible for questions, 3) doing high-quality research by considering the latest scientific literature, multiple data sources and involving academic experts in the field, 4) communicating clear and relevant messages for generalists by translating research into easy-understandable texts and attractive figures, and 5) active dissemination of the report through multiple channels. In addition, the following barriers were identified: 1) the timeframe of the policymaking process was not in line with the research process, and 2) involving politicians in an early stage can potentially harm the objectivity of research in media messages. Key messages By focussing on major problems, high quality evidence and clear messages a public health report can contribute to more evidence-informed policy making. Engaging decision makers in the process of public health reporting is critical for the impact on agenda setting, resource allocation, and priority setting.

Background Type 2 diabetes (T2D) is an important cause of mortality, disability and health care expenditures. Prevention is crucial to counter global trends, but individual variability of different risk factors leading to T2D has made prevention difficult to achieve. We aimed to identify clusters of individuals based on individual level characteristics of different risk factors using a data driven approach. Methods We used data from the Stockholm Diabetes Prevention Program. A population-based, prospective study. Healthy participants who were born in Sweden and aged 35 to 55 years old were recruited between 1992 and 1998 and followed up after 10 and 20 years. At each visit, participants answered extensive questionnaires, anthropometric measures, laboratory examinations and an oral glucose tolerance test. We used age, sex, family history of diabetes, fasting and two hours glucose and insulin, body mass index (BMI), systolic and diastolic blood pressure, and level of education were at baseline to group participants using the k-prototype algorithm. We then examined the risk of diabetes between clusters using survival analysis. Results A total of 7,173 participants representing 138,942 person years of follow-up were included in this study. Among them, 998 (14%) developed T2D. We identified six stable clusters: the group with the lowest cumulative incidence of T2D (2.3%) was used as reference (n = 1,265). In the group with the highest risk, 47% developed T2D (n = 772, HR 26.3, 95%CI 17.9-38.5) followed by 17.1% (n = 1,146, HR 7.6, 95%CI 5.1-11.22), 15.2% (n = 1,453, HR 6.7, 95%CI 4.5-9.8), 9.5% (n = 1,384, HR 4.1, 95%CI 2.8-6.2) and 5.2% (n = 1,157, HR 2.0, 95%CI 1.3-3.1) in the remaining groups. Conclusions There is important variability between individuals regarding the effect of different risk factors on the incidence of T2D. Data driven categorization strategies can be useful epidemiological tools to pave the way for more precise T2D intervention programs. Key messages Prevention strategies for T2D usually follow a one-size fits all approach, ignoring the important variability of risk factors and their consequences among individuals. It is possible to identify subgroups of people with different risk of T2D based on simple clinical and phenotypical characteristics, and could help to improve prevention and treatment of T2D.

Aims: Worldwide, smokeless-tobacco use is a major risk factor for oral cancer. Evidence regarding the particular association between Swedish snus use and oral cancer is, however, less clear. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess the association between snus use and oral cancer. Methods: A total of 418,369 male participants from nine cohort studies were followed up for oral cancer incidence through linkage to health registers. We used shared frailty models with random effects at the study level, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for confounding factors. Results: During 9,201,647 person-years of observation, 628 men developed oral cancer. Compared to never-snus use, ever-snus use was not associated with oral cancer (adjusted HR 0.90, 95% CI: 0.74, 1.09). There were no clear trends in risk with duration or intensity of snus use, although lower intensity use (⩽ 4 cans/week) was associated with a reduced risk (HR 0.65, 95% CI: 0.45, 0.94). Snus use was not associated with oral cancer among never smokers (HR 0.87, 95% CI: 0.57, 1.32). Conclusions: Swedish snus use does not appear to be implicated in the development of oral cancer in men.

Poor academic performance in childhood is associated with suicide attempt in adulthood, but the mechanisms are not known. We investigated educational attainment as a possible pathway.We followed two sets of cohorts, born around 1950/1970, respectively, in the Swedish population-representative 'Evaluation Through Follow-up' study for a first suicide attempt in national records up to 2013. Data on grade point average (GPA) at age 13/16 and educational attainment (years of schooling) in adulthood were used. The path models included linear and Cox proportional hazards regressions. A model with matched age range during follow-up was used to compare the cohorts.In the 1970 cohort, the association between GPA and suicide attempt between age 26 and 46 was partly mediated by attained education (total association, β=-0.82; via education: -0.29, per SD increase in GPA), but GPA also had a direct path to suicide attempt (β=-0.53). There was no evidence of such a pathway in the 1950 cohort between age 41 and 65. In the age-matched analysis, at age 26-46, the association between GPA and suicide attempt was stronger in the 1970 cohort compared to the 1950 cohort (β=-0.72 and -0.24, respectively).Differences in attained education seem to partly explain the associations of academic performance with suicide attempt up to middle age. Furthermore, there is some indication that academic performance may have become more important for young people's mental health than it was in previous generations.

Dominika Seblova,1,2 Maria Lopez Quiroga,3 Stefan Fors,1 Kristina Johnell,1 Martin Lövdén,1 Antonio Ponce de Leon,2,4 Anna Christina Svensson,2 Susanne Wicks,2,4 Anton Lager1,2,4 1Aging Research Center, Karolinska Institutet, Stockholm, Sweden; 2Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; 3Complutense University of Madrid, Madrid, Spain; 4Center for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden Background: The continuous growth of the current dementia epidemic is contingent on the stability of age- and sex-specific trends over time. However, recent evidence suggests declining or stable trends. The aim of this study was to evaluate the real-world changes in the burden of dementia in older adults in Sweden from 1987 to 2016 by estimating age- and sex-specific incidence of dementia diagnosis in hospital inpatient records (dementia incidence). Differences in trends by sex, age, and educational levels were also examined.Methods: The entire Swedish population aged 65 years and older was followed up from 1987 to 2016. Age-, sex-, and education-stratified dementia incidence rates for every follow-up year were estimated using the National Patient Register. Hazard ratio of receiving a dementia diagnosis in the inpatient records per 1 calendar year increase was estimated with discrete time logistic models with a complementary log–log link.Results: After increase, especially in those >85 years of age, dementia incidence started to decrease in the last 5 years of the study period. After 2011, 1 calendar year increase was associated with lower hazard ratio of receiving a hospital diagnosis of dementia. The decrease had the highest magnitude in 70–74-year-olds (–5.5%), followed by 75–79-year-olds (–4.5%) and 80–84-year-olds (–4.0%). The decrease was present in both sexes and at all educational levels up to 90 years of age. Age was associated with the level of dementia incidence, and the trends differed by age group. Educational gradient was observed. University-educated older adults had the lowest rates of dementia. However, the trend over time did not substantially differ by sex or educational level.Conclusion: Our results provide more evidence that dementia incidence may be declining. They also suggest that at least in hospitals, the number of new patients with dementia may decrease in the future. Keywords: incidence, Alzheimer’s, hospitalization, population study, heterogeneous association, education

Objective There is a paucity of data on disordered eating among adoptees. The aim of the present study was to explore the prevalence of symptoms of disordered eating and body image concerns among international adoptees in a large representative community survey on health-related behaviours. Method Combining survey data from the Stockholm Public Health Cohort and Swedish population data, adult international adoptees were compared with total participant data to assess differences in disordered eating and body dissatisfaction. Results International adoptee women displayed significantly higher levels of self-induced vomiting, loss-of-control eating, food preoccupation, underweight, and wish for thinness compared with nonadoptee women, albeit with small or very small effect sizes. No significant differences were found in terms of mean body mass index, cognitive restraint, or emotional eating. Conclusion International adoptee women were disproportionally affected on several measures of disordered eating, although the magnitude of these differences were generally small in absolute terms.

While smoking is a well-established risk factor for pancreatic cancer, the effect of smokeless tobacco is less well understood. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess the association between Swedish snus use and the risk of pancreatic cancer. A total of 424,152 male participants from nine cohort studies were followed up for risk of pancreatic cancer through linkage to health registers. We used shared frailty models with random effects at the study level, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for confounding factors. During 9,276,054 person-years of observation, 1,447 men developed pancreatic cancer. Compared to never-snus use, current snus use was not associated with risk of pancreatic cancer (HR 0.96, 95% CI 0.83-1.11) after adjustment for smoking. Swedish snus use does not appear to be implicated in the development of pancreatic cancer in men. Tobacco smoke constituents other than nicotine or its metabolites may account for the relationship between smoking and pancreatic cancer.

Background and aims Frequent back, neck and/or shoulder pain (BNSP) are common conditions which pose high burden for the society. Results from previous studies suggest that diabetes and hyperlipidaemia may be associated with a higher risk of getting such conditions, but there is in general, few studies based on longitudinal designs. The aim of this study was therefore to compare the risk of developing frequent BNSP in men and women with and without diabetes and/or hyperlipidaemia. Methods A longitudinal study based on the Stockholm Public Health Cohort was conducted based on subjects aged 45–84, who were free from pain at the mentioned sites in 2006 and followed up until 2010. The data in the current study is based on questionnaires, except socioeconomic status which was derived from Statistics Sweden. The exposure diabetes and hyperlipidaemia was self-reported and, a categorical variable was created; without any of the conditions, with hyperlipidaemia only, with diabetes only and with both conditions. The outcome frequent BNSP was defined using the following questions in the questionnaire in 2010: “During the past 6 months, have you had pain in the neck or upper part of the back?”, “During the past 6 months, have you had pain in the lower back?”, and “During the past 6 months, have you had pain in the shoulders/arms?”. All questions had three possible response options: no; yes, a couple of days per month or less often and; yes, a couple of days per week or more often. Those who reported weekly pain to at least one of these questions were considered to having frequent BNSP. Binomial regressions were run to calculate the crude and adjusted risk ratio (RR) in men and women separately. Additional analysis was performed in order to control for potential bias derived from individuals lost to follow-up. Results A total of 10,044 subjects fulfilled the criteria to be included in the study. The mean age of the sample was 60 years and evenly distributed by sex. After adjusting for age, body mass index, physical activity, high blood pressure and socioeconomic status, the RR for frequent BNSP among men with diabetes was 1.64 (95% CI: 1.23–2.18) and 1.19 (95% CI: 0.98–1.44) for hyperlipidaemia compared to men with neither diabetes nor hyperlipidaemia. Among women the corresponding RRs were 0.92 (95% CI: 0.60–1.14) and 1.23 (95% CI: 1.03–1.46). Having both diabetes and hyperlipidaemia at baseline was not associated with increased risk of frequent BNSP. Diabetes and hyperlipidaemia seems to be associated with an increased risk for frequent BNSP and the risk may differ between men and women. Behaviours and/or biological underlying mechanisms may explain the results. Conclusions This study suggests that metabolic diseases such as diabetes and hyperlipidaemia may have an impact on the pathophysiology of frequent BNSP and thus, contributes to the knowledge in musculoskeletal health. Furthermore, it confirms that men and women may differ in terms of risk factors for BNSP. Implications Health professionals should contemplate the results from this study when planning primary prevention strategies.

Intervening on modifiable risk factors to prevent dementia is of key importance, since progress-modifying treatments are not currently available. Education is inversely associated with dementia risk, but causality and mechanistic pathways remain unclear. We aimed to examine the causality of this relationship in Sweden using, as a natural experiment, data on a compulsory schooling reform that extended primary education by 1 year for 70% of the population between 1936 and 1949. The reform introduced substantial exogenous variation in education that was unrelated to pupils’ characteristics. We followed 18 birth cohorts (n = 1,341,842) from 1985 to 2016 (up to ages 79–96 years) for a dementia diagnosis in the National Inpatient and Cause of Death registers and fitted Cox survival models with stratified baseline hazards at the school-district level, chronological age as the time scale, and cohort indicators. Analyses indicated very small or negligible causal effects of education on dementia risk (main hazard ratio = 1.01, 95% confidence interval: 0.98, 1.04). Multiple sensitivity checks considering only compliers, the pre-/post- design, differences in health-care-seeking behavior, and the impact of exposure misclassification left the results essentially unaltered. The reform had limited effects on further adult socioeconomic outcomes, such as income. Our findings suggest that without mediation through adult socioeconomic position, education cannot be uncritically considered a modifiable risk factor for dementia.

Background: Long-term exposure to particulate matter (PM) in ambient air has been associated with cardiovascular mortality, but few studies have considered incident disease in relation to PM from different sources. Objectives: We aimed to study associations between long-term exposure to different types of PM and sources, and incident ischemic heart disease (IHD) and stroke in three Swedish cities. Methods: Based on detailed emission databases, monitoring data, and high-resolution dispersion models, we calculated source contributions to PM with aerodynamic diameter ≤10μm (PM10), PM with aerodynamic diameter ≤2.5μm (PM2.5), and black carbon (BC) from road wear, traffic exhaust, residential heating, and other sources in Gothenburg, Stockholm, and Umeå. Registry data for participants from four cohorts were used to obtain incidence of IHD and stroke for first hospitalization or death. We constructed time windows of exposure for same-year, 1- to 5-y, and 6- to 10-y averages preceding incidence from annual averages at residential addresses. Risk estimates were based on random effects meta-analyses of cohort-specific Cox proportional hazard models. Results: We observed 5,166 and 3,119 incident IHD and stroke cases, respectively, in 114,758 participants. Overall, few consistent associations were observed between the different air pollution measures and IHD or stroke incidence. However, same-year levels of ambient locally emitted BC (range: 0.01−4.6 μg/m3) were associated with a 4.0% higher risk of incident stroke per interquartile range (IQR), 0.30 μg/m3 [95% confidence interval (CI): 0.04, 7.8]. This association was primarily related to BC from traffic exhaust. PM10 (range: 4.4−52 μg/m3) and PM2.5 (range: 2.9−22 μg/m3) were not associated with stroke. Associations with incident IHD were observed only for PM2.5 exposure from residential heating. Discussion: Few consistent associations were observed between different particulate components and IHD or stroke. However, long-term residential exposure to locally emitted BC from traffic exhaust was associated with stroke incidence. The comparatively low exposure levels may have contributed to the paucity of associations. https://doi.org/10.1289/EHP4757

Background: Education is related to dementia risk. Researchers in public health often treat education as a modifiable risk factor, implying that prolonging education may reduce dementia incidence. This reasoning rests on the largely untested assumption that education has causal effects on dementia risk. Methods: We used variance in education induced by a compulsory schooling reform, which extended Swedish primary school (Folkskola) from 6 to 7 years as a tool for studying direct causal effects of education on dementia risk. The reform was implemented gradually in school districts and had minor spillover effects. We studied 18 birth cohorts (1920-1937), excluding individuals with unknown reform status, those who died, emigrated, or received dementia diagnosis prior to 65 years of age. The outcome was dementia diagnosis in the National Inpatient and Cause of Death Registers. The reform allowed us to study direct effects of prolonged education with high validity and statistical precision. In the main analyses, we employed sex-stratified Cox survival models with stratified baseline hazards at the school-district level, used chronological age as the time scale, and dummy-coded cohort effects. Findings: 1,341,842 individuals were included. The reform did not affect the risk of dementia diagnosis in a statistically significant way. The estimates and associated confidence intervals (women: HR = 1.01; 95% CI = 0.97-1.04; men: HR = 1.02; 95% CI = 0.99-1.06; all: HR = 1.01; 95% CI = 0.98-1.04) indicate that any direct effect is likely of a negligible or very small magnitude. Sensitivity analyses targeting pre-post changes, differences in healthcare-seeking behavior, and impact of exposure misclassification left results essentially unaltered. Interpretation: Longer education, at least in the absence of sizable spillover effects to adult socio-economic factors, cannot be uncritically assumed to substantially reduce the risk of moderate to severe dementia. Funding Statement: FORTE (2013-2277) and Swedish Research Council (446-2013-7189) to ML. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study was approved by the Regional Ethical Review Board in Stockholm (Case number: 2010/1185-31/5).

Aims: We investigate (a) alcohol consumption in association with type 2 diabetes, taking heavy episodic drinking (HED), socioeconomic, health and lifestyle, and psychosocial factors into account, and (b) whether a seemingly protective effect of moderate alcohol consumption on type 2 diabetes persists when stratified by occupational position. Methods: This population-based longitudinal cohort study comprises 16,223 Swedes aged 18–84 years who answered questionnaires about lifestyle, including alcohol consumption in 2002, and who were followed-up for self-reported or register-based diabetes in 2003–2011. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated in a multivariable-adjusted logistic regression model for all participants and stratified by high and low occupational position. We adjusted for HED, socioeconomic (occupational position, cohabiting status and unemployment), health and lifestyle (body mass index (BMI), blood pressure, smoking, physical inactivity, poor general health, anxiety/depression and psychosocial (low job control and poor social support) characteristics one by one, and the sets of these factors. Results: Moderate consumption was inversely associated with type 2 diabetes after controlling for health and lifestyle (OR=0.47; 95% CI: 0.29–0.79) and psychosocial factors (OR=0.40; 95% CI: 0.22–0.79) when compared to non-drinkers. When adjusting for socioeconomic factors, there was still an inverse but non-significant association (OR=0.59; 95% CI: 0.35–1.00). In those with high occupational position, there was no significant association between moderate consumption and type 2 diabetes after adjusting for socioeconomic (OR=0.67; 95% CI: 0.3–1.52), health and lifestyle (OR=0.70; 95% CI: 0.32–1.5), and psychosocial factors (OR=0.75; 95% CI: 0.23–2.46). On the contrary, in those with low occupational position, ORs decreased from 0.55 (95% CI: 0.28-1.1) to 0.35 (95% CI: 0.15–0.82) when adjusting for psychosocial factors, a decrease that was solely due to low job control. HED did not influence any of these associations. Conclusions: Moderate alcohol consumption is associated with a lower risk of type 2 diabetes, after adjusting for HED, health and lifestyle, and psychosocial characteristics. The association was inverse but non-significant after adjusting for socioeconomic factors. When stratified by occupational position, there was an inverse association only in those with low occupational position and after adjusting for low job control.

Aims: Although smoking is considered to be an established risk factor for colorectal cancer, the current evidence on the association between smokeless tobacco and colorectal cancer is scant and inconclusive. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess this association. Methods: A total of 417,872 male participants from nine cohort studies across Sweden were followed up for incidence of colorectal cancer and death. Outcomes were ascertained through linkage to health registers. We used shared frailty models with random effects at the study level to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results: During 7,135,504 person-years of observation, 4170 men developed colorectal cancer. There was no clear association between snus use and colorectal cancer overall. Exclusive current snus users, however, had an increased risk of rectal cancer (HR 1.40: 95% CI 1.09, 1.79). There were no statistically significant associations between snus use and either all-cause or colorectal cancer-specific mortality after colorectal cancer diagnosis. Conclusions: Our findings, from a large sample, do not support any strong relationships between snus use and colorectal cancer risk and survival among men. However, the observed increased risk of rectal cancer is noteworthy, and in merit of further attention.

Objective: Academic performance in youth, measured by grade point average (GPA), predicts suicide attempt, but the mechanisms are not known. It has been suggested that general intelligence might underlie the association. Methods: We followed 26 315 Swedish girls and boys in population-representative cohorts, up to maximum 46 years of age, for the first suicide attempt in hospital records. Associations between GPA at age 16, IQ measured in school at age 13 and suicide attempt were investigated in Cox regressions and mediation analyses. Results: There was a clear graded association between lower GPA and subsequent suicide attempt. With control for potential confounders, those in the lowest GPA quartile had a near five-fold risk (HR 4.9, 95% CI 3.7-6.7) compared to those in the highest quartile. In a mediation analysis, the association between GPA and suicide attempt was robust, while the association between IQ and suicide attempt was fully mediated by GPA. Conclusions: Poor academic performance in compulsory school, at age 16, was a robust predictor of suicide attempt past young adulthood and seemed to account for the association between lower childhood IQ and suicide attempt.