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BACKGROUND: Major depressive disorder (MDD) onset varies by socioeconomic position (SEP), this could be explained by lifestyle factors, but little is known about this pathway. Our study aims to disentangle the interplay between SEP measures (i.e., education, income and occupational prestige) and MDD onset and to examine to what extent these associations are mediated by lifestyle (i.e., occupational- and leisure time physical activity, smoking, alcohol intake, diet quality, sleep and central adiposity).METHODS: A subsample (n = 76,045) of the Lifelines Cohort Study without MDD at baseline was included. MDD onset was measured after a median follow-up time of 3.8 years with the Mini International Neuropsychiatric Interview (MINI). Direct associations between SEP, lifestyle and MDD onset were estimated using logistic regression analyses. Mediating percentages were estimated using the Karlson-Holm-Breen method.RESULTS: 1864 participants (2.5 %) showed MDD at follow-up. SEP was inversely associated with MDD onset, with education showing the strongest association. Educational- and income differences in MDD onset were for 18.7 % and 5.9 % explained by lifestyle factors (mainly smoking, alcohol intake and central adiposity). Occupational prestige differences in MDD onset were not explained by lifestyle factors.LIMITATIONS: SEP and lifestyle factors were measured simultaneously at baseline. MDD status (only based on a screening tool) was only measured at baseline and 3.8 years later.CONCLUSIONS: Compared to their lower SEP counterparts, higher SEP individuals had a lower risk of MDD onset. This was partially explained by a healthier lifestyle (mainly less smoking, alcohol intake and central adiposity) of the higher SEP individuals.

Purpose Evidence suggests an increase of depression and anxiety symptoms during the Covid-19 pandemic but most studies relied on cross-sectional designs and/or small samples, and they often overlooked subgroup effects in the impact of the lockdown. We investigated the effect of the pandemic on depression and anxiety symptoms, and whether it differed by employment situation and alcohol consumption. Methods This longitudinal study used 23 waves of the Covid-Questionnaire (April 2020—July 2021), within the Lifelines cohort from the Netherlands (n = 76,254). Depression and anxiety symptoms were combined in a “mental health score”. Linear fixed-effects models were fitted to analyse trends in mental health throughout the observation period. The moderating role of pre-existing mental health, employment situation, and alcohol consumption was tested. Results Depression and anxiety symptoms fluctuated considerably during the observation period, with clear peaks in winter 2021, during the strictest lockdown period. Moreover, temporal patterns differed by employment situation and alcohol consumption patterns, suggesting that various subgroups reacted to the pandemic and the lockdown in different ways. Conclusion Lockdowns increased depression and anxiety symptoms in the Netherlands. The effect was particularly strong for unemployed individuals, those with risky alcohol consumption patterns and those with pre-existing mental health disorders.

Background The aim of this study was to identify the main trends in terms of changes in body mass index (BMI) during the Covid-19 pandemic in the Netherlands. Moreover, we aimed to investigate whether work- and health-related disruptive events triggered by the pandemic, such as job insecurity or mental health issues, were associated with such changes in BMI. Methods Longitudinal data from the Lifelines Covid Questionnaire was used (21 waves between April 2020 and July 2021; n=64,630). Overall BMI trends were analysed using growth curve modelling. Different trajectories were identified using group-based trajectory models. Multinomial regression models were fitted to analyse the main determinants of experiencing changes in BMI during the pandemic. Results Experiencing disruptive work-related events (e.g. being laid-off or having a temporary contract) and health-related events (e.g. anxiety or depression) during the pandemic were associated with changes in BMI, particularly weight gain. Conclusions Work- and health-related events were strongly associated with changes in BMI during the Covid-19 pandemic. Although such changes may be partly explained by lifestyle factors, such as diet or physical activity, this study aligns with the existing evidence on the embodiment of stress, suggesting a strong association between disruptive events and changes in body weight.

Objective: The goal of this study was to investigate the association between neighborhood socioeconomic status (NSES) and BMI and to what extent this association is moderated by availability of fast-food (FF) outlets and pay-for-use physical activity (PA) facilities.Methods: Baseline data of adults in Lifelines (N = 146,629) were linked to Statistics Netherlands and a register using geocoding to compute, respectively, NSES (i.e., low, middle, high) and the number of FF outlets and PA facilities within 1 km of the residential address. Multivariable multilevel linear regression analyses were performed to examine the association between NSES and BMI. Two-way and three-way interaction terms were tested to examine moderation by FF outlets and PA facilities.Results: Participants living in low NSES areas had a higher BMI than participants living in high (B [95% CI]: 0.76 [0.65 to 0.87]) or middle NSES areas (B [95% CI]: 0.40 [0.28 to 0.51]), independent of individual socioeconomic status. Although two- and three-way interactions between NSES, FF outlets, and PA facilities were significant, stratified analyses did not show consistent moderation patterns.Conclusions: People living in lower NSES areas had a higher BMI, independent of their individual socioeconomic status. The study found no clear moderation of FF outlets and PA facilities. Environmental factors that may mitigate NSES differences in BMI should be the subject of future research.

The aim of the current study is to investigate which major life events are associated with transitions into and out of volunteering over the life course and, especially, why these associations exist. Social Production Function theory is used to derive hypotheses, which are tested using longitudinal data (adult subsample) from Lifelines. Associations between major life events and (a) volunteer take-up, nonvolunteer sample ( N = 59,773) and (b) volunteer cessation, volunteer sample ( N = 32,143) are studied by applying Linear Probability Modeling. Results show clear associations between specific major life events and starting and quitting volunteering. The influence on the latter is stronger than on the former. Most findings are in line with our theory-based expectations indicating that (a) voluntary work contributes especially to the fulfillment of the needs for status, stimulation, and behavioral confirmation and (2) life events causing losses (gains) in these needs are associated with a higher likelihood to take-up (quit) volunteering.

Background Alcohol use constitutes a major health risk and is related to unemployment. However, the direction of this relationship is unclear: unemployment may change drinking patterns (causation), but heavy drinkers may also be more prone to lose their job (selection). We simultaneously examined selection and causation, and assessed the role of residual confounding. Moreover, we paid attention to the subgroup of abstainers and occupationally disabled, often disregarded in the literature. Methods Longitudinal data (three waves collected between 2006 and 2018) of the Lifelines Cohort study from the Netherlands were used (138 875 observations of 55 415 individuals, aged 18–60 at baseline). Alcohol use was categorized as ‘abstaining’, ‘moderate drinking’ and ‘binge drinking’ (≥5 drinks/occasion for male; ≥4 for women). Employment status included occupational disability, short ( Results Long unemployment spells increase the risk for both binge drinking (β = 0.23; 95% CI 0.04–0.42) and abstinence (β = 0.27; 95% CI 0.11–0.44), and the effects hold after accounting for reciprocal causality and time-constant confounding. Contrarily, the effect of binge drinking on unemployment is weak (β = 0.14; 95% CI −0.03 to 0.31). Abstinence is strongly associated with occupational disability (β = 0.40; 95% CI 0.24–0.57). Conclusions We find evidence supporting the causation hypothesis (unemployment altering drinking patterns), whereas evidence for the selection hypothesis is weak and mostly confounded by unobserved variables, such as poor health prior to baseline.

We examined whether childhood abuse is related to body mass index (BMI) in young adults and whether this relationship is mediated by depression and anxiety. Data are from the Dutch longitudinal cohort study TRAILS (nfemales = 836, nmales = 719). At wave 4, childhood sexual, physical and verbal abuse, and lifetime major depressive disorder (MDD) and generalized anxiety disorder (GAD) were assessed. BMI was measured at wave 4 and 5 (mean age = 19.2/22.4 years). Sex-stratified structural equation models were estimated. Females who had experienced sexual abuse had a higher BMI at wave 4 (B = 0.97, 95%CI = [−0.01,1.96]) and a higher increase in BMI between wave 4 and 5 (B = 0.52, 95%CI = [0.04,1.01]) than females who had not experienced sexual abuse. Additionally, MDD and BMI at wave 4 were related in females (B = 1.35, 95%CI = [0.52,2.18]). MDD mediated the relationship between sexual abuse and BMI at wave 4 in females. In addition, sexual abuse moderated the relationship between MDD and BMI at wave 4. The relationship was stronger among females who had experienced sexual abuse than among females who had not. Prevention of BMI changes among females who experienced sexual abuse may thus be warranted, particularly when they developed MDD. MDD treatment, such as abuse-focused psychotherapy, may aid this prevention.

Background cognitive impairment is highly prevalent among older patients attending the Emergency Department (ED) and is associated with adverse outcomes. Methods we conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of cognitive screening instruments to rule out cognitive impairment in older patients in the ED. A comprehensive literature search was performed in MEDLINE, EMBASE, CINAHL and CENTRAL. A risk of bias assessment using QUADAS-2 was performed. Results 23 articles, examining 18 different index tests were included. Only seven index tests could be included in the meta-analysis. For ruling out cognitive impairment irrespective of aetiology, Ottawa 3 Day Year (O3DY) (pooled sensitivity 0.90; (95% CI) 0.71–0.97) had the highest sensitivity. Fourteen articles focused on screening for cognitive impairment specifically caused by delirium. For ruling out delirium, the 4 A’s Test (4AT) showed highest sensitivity (pooled sensitivity 0.87, 95% confidence interval (95% CI) 0.74–0.94). Conclusions high clinical and methodological heterogeneity was found between included studies. Therefore, it is a challenge to recommend one diagnostic test for use as a screening instrument for cognitive impairment in the ED. The 4AT and O3DY seem most promising for ruling out cognitive impairment in older patients attending the ED. The review protocol was registered in PROSPERO (CRD42018082509).

BACKGROUND: The effectiveness of surgical interventions for cervical degenerative disorders has been investigated in multiple systematic reviews. Differences in study population (e.g., patients with myelopathy and/or radiculopathy) were often neglected. Therefore, the objective of this study was to investigate the effectiveness of surgical interventions for patients with symptoms of cervical radiculopathy without myelopathy by conducting a systematic review and meta-analysis based on randomized controlled trials (RCTs). METHODS: A comprehensive systematic search was conducted in MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) to identify RCTs that investigated the effectiveness of surgical interventions using an anterior or posterior approach compared with other interventions for patients with pure cervical radiculopathy. Outcomes were success rates (Odom criteria, similar rating scales, or percentage of patients who improved), complication and reoperation rates, work status, disability (Neck Disability Index), and pain (arm and neck). The Cochrane risk-of-bias tool was used to assess the likelihood of the risk of bias. A random-effects model was used. Heterogeneity among study results (I ≥ 50% or p < 0.05) was explored by conducting subgroup analyses. Funnel plots were used to assess the likelihood of publication bias. RESULTS: A total of 21 RCTs were included, comprising 1,567 patients. For all outcomes, among all surgical techniques, only 1 pooled estimate showed a significant effect on success rate, which was in favor of anterior cervical discectomy with fusion compared with anterior cervical discectomy without an intervertebral spacer (p = 0.02; risk ratio [RR] = 0.87; 95% confidence interval [CI] = 0.77 to 0.98). Complication rates were higher when autologous bone graft from the iliac crest was used as an intervertebral spacer (p < 0.01; RR = 3.40; 95% CI = 1.56 to 7.43), related to donor-site morbidity. CONCLUSIONS: This meta-analysis demonstrated consistent results regarding clinical outcome for pure cervical radiculopathy among all studied interventions. Complication and reoperation rates were also similar, with the exception of higher complication rates in patients in whom autologous bone grafts were used. On the basis of clinical outcome and safety, there is no superior surgical intervention for pure cervical radiculopathy. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background The original Pittsburgh Fatigability Scale (PFS) was developed to assess perceived fatigability in older adults. The objective of this study was to translate the PFS into Dutch and investigate its validity and reliability among hospitalized older adults aged ≥70 years. Methods The PFS was translated into Dutch and pretested for comprehensibility by the Three-Step Test Interview method. The factor structure underlying the final version was evaluated by confirmatory factor analysis (CFA) and exploratory factor analyses (EFA). Internal consistency of the identified subscales was evaluated by Cronbach’s alpha. Construct validity was evaluated by hypothesis testing. Test-retest reliability was evaluated using intraclass correlation coefficients (ICC) and Bland Altman plots. Results The validation sample included 233 patients. CFA of the original factor structure resulted in poor model fit in our Dutch sample. EFA of PFS physical and mental subscales resulted in a two-factor solution underlying the data with good internal consistency of the identified subscales (Cronbach’s alpha: 0.80–0.92). Five out of six hypotheses were confirmed, indicating good construct validity. Retest assessments were performed among 50 patients and showed good reliability for both the physical (ICC: 0.80, 95%CI: 0.68; 0.88) and mental subscale (ICC: 0.81, 95%CI: 0.68; 0.89). Conclusion The Dutch PFS is a valid and reliable instrument to assess fatigability in older hospitalized patients.

OBJECTIVES: To examine the association of social network size and loneliness with cognitive performance and -decline in depressed older adults.METHOD: A sample of 378 older adults [70.7 (7.4) years] with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of current depressive disorder were recruited from primary care and specialized mental health care. Cognitive performance was assessed at baseline and 2 years follow-up with the Stroop colored-word test, a modified version of the Auditory Verbal Learning Task and the Digit Span subtest from the Wechsler Adult Intelligence Scale, encompassing four cognitive domains; processing speed, interference control, memory, and working memory. Social network size was assessed with the Close Person Inventory and loneliness with the de Jong Gierveld Loneliness Scale at baseline.RESULTS: After adjusting for baseline working memory performance, loneliness was associated with impaired working memory after 2 years [B = -0.08 (-0.17 to 0.00)]. This association was no longer significant after adjusting for age, sex, education level, physical activity, alcohol use and depressive symptom severity [B = -0.07 (-0.16 to 0.03)]. A backward elimination procedure revealed education level to be the only covariable to explain this association. Loneliness was not associated with impairments or decline in other cognitive domains. Social network size was not associated with cognitive impairments or decline.CONCLUSION: Social network size and loneliness do not predict cognitive decline in depressed older adults.

Evidence on the association between physical activity (PA) and adiposity in young children is inconclusive. A systematic review and meta-analyses were conducted to examine associations between accelerometer-derived PA and varying adiposity outcomes in preschool children. Searches were conducted in Embase, MEDLINE and Web of Science to identify studies on the association between total PA, sedentary behaviour or different PA intensities and adiposity in children aged 2 to 7 years. Separate random effects meta-analyses were performed for varying PA intensities and adiposity outcomes. Fifty-six articles were included in the review and 48 in the meta-analyses. There was substantial evidence of an inverse association between moderate-to-vigorous- or vigorous PA and body fat percentage (stdβ [SE] = −0.162[0.041]; 5 studies), weight status (r = −0.120, P

BACKGROUND: Our aim was to investigate sex differences in the associations between socioeconomic position (SEP) and metabolic syndrome (MetS) development, and to what extent these associations are mediated by health literacy and self-management skills.METHODS: A subsample (n = 88,384, 59.5% female) of the adult Lifelines Cohort Study was used. MetS development according to NCEP-ATPIII criteria was assessed on average 3.8 years after baseline. SEP-MetS associations were assessed for moderation by sex, and sex-stratified accordingly. Associations between SEP measures (education, income and occupational prestige), health literacy and self-management skills, and MetS development were investigated using logistic regression analyses. The mediating effects of health literacy and self-management skills on the SEP-MetS associations were investigated using the Karlson-Holm-Breen method.RESULTS: Among males and females, respectively 9.4% and 7.1% developed MetS. For males, education was inversely associated with MetS development; health literacy (7.1%) and self-management skills (1.9%) mediated a proportion of these educational differences. For females, education, income and occupational prestige were inversely associated with MetS development; health literacy (respectively 5.9% and 6.4%) and self-management skills (respectively 4.1% and 3.7%) mediated a proportion of the educational and occupational differences in MetS development. Neither health literacy nor self-management skills mediated female income differences in MetS development.CONCLUSIONS: Socioeconomic differences in MetS development differ between males and females. Both for males and females, health literacy and self-management skills mediated a small proportion of socioeconomic differences in MetS development.

ObjectiveIndividuals with a parental family history (PFH) of dementia have an increased risk to develop dementia, regardless of genetic risks. The aim of this study is to investigate the association between a PFH of dementia and currently known modifiable risk factors for dementia among middle-aged individuals using propensity score matching (PSM).DesignA cross-sectional study.Setting and participantsA subsample of Lifelines (35–65 years), a prospective population-based cohort study in the Netherlands was used.Outcome measuresFourteen modifiable risk factors for dementia and the overall Lifestyle for Brain Health (LIBRA) score, indicating someone’s potential for dementia risk reduction (DRR).ResultsThe study population included 89 869 participants of which 10 940 (12.2%) had a PFH of dementia (mean (SD) age=52.95 (7.2)) and 36 389 (40.5%) without a PFH of dementia (mean (SD) age=43.19 (5.5)). Of 42 540 participants (47.3%), PFH of dementia was imputed. After PSM, potential confounding variables were balanced between individuals with and without PFH of dementia. Individuals with a PFH of dementia had more often hypertension (OR=1.19; 95% CI 1.14 to 1.24), high cholesterol (OR=1.24; 95% CI 1.18 to 1.30), diabetes (OR=1.26; 95% CI 1.11 to 1.42), cardiovascular diseases (OR=1.49; 95% CI 1.18 to 1.88), depression (OR=1.23; 95% CI 1.08 to 1.41), obesity (OR=1.14; 95% CI 1.08 to 1.20) and overweight (OR=1.10; 95% CI 1.05 to 1.17), and were more often current smokers (OR=1.20; 95% CI 1.14 to 1.27) and ex-smokers (OR=1.21; 95% CI 1.16 to 1.27). However, they were less often low/moderate alcohol consumers (OR=0.87; 95% CI 0.83 to 0.91), excessive alcohol consumers (OR=0.93; 95% CI 0.89 to 0.98), socially inactive (OR=0.84; 95% CI 0.78 to 0.90) and physically inactive (OR=0.93; 95% CI 0.91 to 0.97). Having a PFH of dementia resulted in a higher LIBRA score (RC=0.15; 95% CI 0.11 to 0.19).ConclusionWe found that having a PFH of dementia was associated with several modifiable risk factors. This suggests that middle-aged individuals with a PFH of dementia are a group at risk and could benefit from DRR. Further research should explore their knowledge, beliefs and attitudes towards DRR, and whether they are willing to assess their risk and change their lifestyle to reduce dementia risk.

Unemployment is expected to influence alcohol consumption, but studies show mixed results, partly because most studies concentrate on current employment status.However, unemployment could be particularly consequential if it is part of a trajectory of employment precariousness. Moreover, the association between unemployment and alcohol consumption may not be homogeneous across the population, but differ by subgroups (e.g. socioeconomic status). This study longitudinally analyses the association between different employment trajectories and alcohol consumption, and examines if the association is moderated by socioeconomic status (SES), partner status, age and gender. Four waves of data of the Lifelines Cohort study are used.Sample consists of individuals from 18-50 years old, active in the labor market (n = 104,766) from the northern provinces of the Netherlands. Employment trajectories are defined by employment status in each wave, duration of unemployment, and number of exposures to unemployment. Drinking patterns are divided into "abstainers", "moderate drinking" (1.5 drinks/day) and "binge drinking" (>5 drinks/occasion; 4 for women). The associations are estimated with multinomial logistic regression models. Results show that recent, long-term unemployment (> 6 months) is associated with higher rates of heavy drinking (RRR = 1.26 [95 % CI 1.03-1.54]), whereas short-term unemployment does not show any association with the outcome. Being continuously unemployed throughout the observation period shows a strong association with binge drinking (RRR = 1.43 [95 % CI 1.06-1.93]), as well as reporting 2 or more long unemployment spells (RRR = 1.49 [95 % CI 1.21-1.83]). The group of abstainers (77.95 % women) have significantly lower SES, and poorer health than their peers. For some individuals, recent unemployment increases the likelihood for abstinence (RRR = 1.23 [95 % CI 1.00-1.51]). Evidence suggests that length of unemployment is key in order to grasp its effects in terms of changing drinking patterns.

Background Although the incidence of metabolic syndrome (MetS) strongly varies based on individuals’ socioeconomic position (SEP), as yet no studies have examined the SEP-MetS remission relationship. Our aim is to longitudinally assess the associations between SEP measures education, income and occupational prestige, and MetS remission, and whether these associations are mediated by health behaviors, including physical activity, smoking, alcohol intake and diet quality. Methods A subsample (n = 16,818) of the adult Lifelines Cohort Study with MetS at baseline was used. MetS remission was measured upon second assessment (median follow-up time 3.8 years), defined according to NCEP-ATPIII criteria. To estimate direct associations between SEP, health behaviors and MetS remission multivariable logistic regression analyses were used. To estimate the mediating percentages of health behaviors that explain the SEP-MetS remission relationship the Karlson-Holm-Breen method was used. Analyses were adjusted for age, sex, the other SEP measures and follow-up time. Results At the second assessment, 42.7% of the participants experienced MetS remission. Education and income were positively associated with MetS remission, but occupational prestige was not. The association between education and MetS remission could partly (11.9%) be explained by health behaviors, but not the association between income and MetS remission. Conclusions Individuals with higher education more often experienced remission from MetS, mainly because individuals with higher education were more likely to have healthier behaviors. However, individuals with higher income more often experienced MetS remissions, regardless of their health behaviors. The occupational prestige of individuals was not associated with MetS remission.

Background Major depressive disorder (MDD) onset strongly varies by socioeconomic position (SEP). One of the pathways that could explain the SEP-MDD onset relationship is via lifestyle factors, but little is known about this pathway. This study aims to disentangle the complex interplay between SEP measures, education, income and occupational prestige, and MDD development and to what extent the associations are mediated by lifestyle (related) factors, occupational and leisure time physical activity, smoking, alcohol intake, diet quality, sleep and central adiposity. Methods An adult subsample (n = 76,045) of the Lifelines Cohort Study without MDD at baseline was used. MDD onset was measured after a median follow-up time of 3.8 years with the Mini International Neuropsychiatric Interview (MINI). Direct associations between the SEP measures, the lifestyle factors and MDD onset were estimated, independent of age, sex, depression history and time between baseline and second assessment, using logistic regression analyses. Mediating percentages were estimated using the Karlson-Holm-Breen method. Results A total of 1,864 participants (2.5%) developed MDD during follow-up. Education, income and occupational prestige were inversely associated with MDD onset. Educational differences in MDD onset were for 18.7% explained by lifestyle factors, with smoking (9.1%) and central adiposity (6.7%) being the strongest mediating factors. Income differences in MDD onset were for 5.9% explained by lifestyle factors, with alcohol intake (4.0%) and central adiposity (2.6%) being the strongest mediating factors. Occupational prestige differences in MDD onset were not explained by lifestyle factors. Conclusions Individuals with a higher education, income or occupational prestige had a lower risk of MDD onset compared to their lower SEP counterparts. This was mainly due to a healthier lifestyle, with smoking, alcohol intake and central adiposity being the most important factors. Key messages Education, income and occupational prestige were inversely associated with MDD onset. Educational and income differences were mainly explained by smoking, alcohol intake and central adiposity.

Background Metabolic syndrome (MetS) incidence strongly varies by socioeconomic position (SEP), but to date, no studies have assessed the mediating role of perceived stress from long-term difficulties (chronic stress) in this association. This study examines the mediating role of chronic stress in the associations between SEP measures education, occupational prestige and income, and incident MetS and whether the associations between chronic stress and MetS are moderated by sex. Methods An adult subsample (n = 53,216) of the Lifelines Cohort Study without MetS at baseline was used. MetS incidence was measured at follow-up (median follow-up time 3.9 years) defined according to the NCEP-ATPIII criteria. Chronic stress was measured with the Long-term Difficulties Inventory (LDI) and consists of 12 items evaluating (on a 3-point Likert scale) to what extent various domains of life had been perceived as stressful during the last year. Direct associations between SEP, chronic stress and incident MetS were estimated using multivariable logistic and linear regression analyses, adjusted for age, sex, the other SEP measures and follow-up time. The mediating percentages of chronic stress explaining the associations between SEP and incident MetS were estimated using the Karlson-Holm-Breen method. Results At follow-up 7.4% of the participants developed MetS. Years of education and occupational prestige were inversely associated with MetS incidence. Chronic stress suppressed the association between education and MetS incidence (5.4%) as well as the association between occupational prestige and MetS incidence (6.0%). No effect modification of sex in the chronic stress-MetS pathway was observed. Conclusions Chronic stress does not explain educational and occupational differences in developing MetS. In fact, individuals with more years of education or a higher occupational prestige perceive more chronic stress, compared to their lower SEP counterparts. Key messages Education and occupational prestige are inversely associated with metabolic syndrome incidence. Chronic stress does not explain SEP differences in developing metabolic syndrome.

Background There is growing interest for interventions aiming at preventing frailty progression or even to reverse frailty in older people, yet it is still unclear which frailty instrument is most appropriate for measuring change scores over time to determine the effectiveness of interventions. The aim of this prospective cohort study was to determine reproducibility and responsiveness properties of the Frailty Index (FI) and Frailty Phenotype (FP) in acutely hospitalized medical patients aged 70 years and older. Methods Reproducibility was assessed by Intra-Class Correlation Coefficients (ICC), standard error of measurement (SEM) and smallest detectable change (SDC); Responsiveness was assessed by the standardized response mean (SRM), and area under the receiver operating characteristic curve (AUC). Results At baseline, 243 patients were included with a median age of 76 years (range 70–98). The analytic samples included 192 and 187 patients in the three and twelve months follow-up analyses, respectively. ICC of the FI were 0.85 (95 % confidence interval [CI]: 0.76; 0.91) and 0.84 (95% CI: 0.77; 0.90), and 0.65 (95% CI: 0.49; 0.77) and 0.77 (95% CI: 0.65; 0.84) for the FP. SEM ranged from 5 to 13 %; SDC from 13 to 37 %. SRMs were good in patients with unchanged frailty status ( Conclusions The Frailty Index showed better reproducibility and responsiveness properties compared to the Frailty Phenotype among acutely hospitalized older patients.

Background Individuals with a parental family history of dementia have an increased risk of developing dementia because they share their genes as well as their psychosocial behaviour. Due to this increased risk and their experience with dementia, they may be particularly eager to receive information regarding dementia risk reduction (DRR). This study evaluated the knowledge, beliefs and attitudes towards dementia and DRR among descendants of people with dementia. Method Using a semi-structured topic guide, three focus group discussions were conducted consisting of 12 female (80%) and 3 male (20%) descendants of people with dementia with a mean (± SD) age of 48.8 (± 12) years. Focus group discussions were audio recorded and transcribed. Each transcript was analysed thoroughly, and where appropriate, a code was generated and assigned by two researchers independently. Then, similar codes were grouped together and categorized into themes. Results The items in the topic guide could only be addressed after participants had been given the opportunity to share their experiences of having a parent with dementia. Participants were unaware or uncertain about the possibility of reducing the risk of developing dementia and therefore hesitant to assess their dementia risk without treatment options in sight. Moreover, participants indicated that their general practitioner only gave some information on heritability, not on DRR. Although participants identified a large number of modifiable risk factors as a group during the group discussions, they were eager to receive more information on dementia and DRR. In the end, participants adopted a more positive attitude towards a DRR programme and provided suggestions for the development of future DRR programmes. Conclusions Although the research aim was to evaluate the knowledge, beliefs and attitudes towards dementia and DRR, sharing experiences of having a parent with dementia seemed a prerequisite for considering participants’ own risk of developing dementia and participating in a DRR programme. Knowledge of dementia and DRR was limited. Due to unawareness of the possibility of reducing dementia risk, participants were hesitant about assessing their dementia risk. Group discussions positively changed the perception of dementia risk assessment and participants’ willingness to participate in a DRR programme.

Background: The incidence of metabolic syndrome (MetS) strongly varies by socioeconomic position (SEP), but little is known about the mediating role of health behaviours in this association. This study examines the associations between the SEP measures, education, income and occupational prestige, and incident MetS and whether the associations are mediated by health behaviours, including physical activity, smoking, alcohol intake and diet quality.Methods: A subsample (n = 85,910) of the adult Lifelines Cohort Study without MetS at baseline was used. MetS was measured at the second assessment (median follow-up time 3.8 years) defined according to the NCEP-ATPIII criteria. Direct associations between SEP, health behaviours and incident MetS were estimated using multivariable logistic regression analyses. The mediating percentages of health behaviours explaining the associations between SEP and incident MetS were estimated using the Karlson-Holm-Breen method. Analyses were independent of age, sex, the other SEP measures and follow-up time.Results: Education and occupational prestige were inversely associated with MetS. Income was not associated with MetS. Health behaviours explained only partly (13.8%) the association between education and MetS, with smoking as the strongest mediating factor (8.8%). Health behaviours played also a minor role (2.7%) in explaining occupational MetS differences, with physical activity as the strongest suppressing factor (-9.4%).Conclusion: Individuals with more years of education or a higher occupational prestige had a lower risk to develop MetS. This was mainly because of non-smoking, less excessive alcohol intake and a higher diet quality. However, individuals with a higher SEP were more often physically inactive.

Large multigenerational cohort studies offer powerful ways to study the hereditary effects on various health outcomes. However, accounting for complex kinship relations in big data structures can be methodologically challenging. The traditional kinship model is computationally infeasible when considering thousands of individuals. In this article, we propose a computationally efficient alternative that employs fractional relatedness of family members through a series of founding members. The primary goal of this study is to investigate whether the effect of determinants on health outcome variables differs with and without accounting for family structure. We compare a fixed-effects model without familial effects with several variance components models that account for heritability and shared environment structure. Our secondary goal is to apply the fractional relatedness model in a realistic setting. Lifelines is a three-generation cohort study investigating the biological, behavioral, and environmental determinants of healthy aging. We analyzed a sample of 89,353 participants from 32,452 reconstructed families. Our primary conclusion is that the effect of determinants on health outcome variables does not differ with and without accounting for family structure. However, accounting for family structure through fractional relatedness allows for estimating heritability in a computationally efficient way, showing some interesting differences between physical and mental quality of life heritability. We have shown through simulations that the proposed fractional relatedness model performs better than the standard kinship model, not only in terms of computational time and convenience of fitting using standard functions in R, but also in terms of bias of heritability estimates and coverage.

Background Positive health beliefs and attitudes towards dementia and dementia risk reduction may encourage adopting a healthy behaviour. Therefore, we aimed to investigate the knowledge, health beliefs and attitudes towards dementia and dementia risk reduction among the Dutch general population and its association with the intention to change health behaviours. Methods A random sample of Dutch residents (30 to 80 years) was invited to complete an online survey. We collected data on knowledge, health beliefs and attitudes towards dementia (risk reduction) and the intention to change health behaviours. Multivariable logistic regression analyses were used to obtain effect estimates. Results Six hundred fifty-five participants completed the survey. In general, participants had insufficient knowledge about dementia and dementia risk reduction. Participants had relatively high scores on general health motivation and perceived benefits, but low scores on perceived susceptibility, perceived severity, perceived barriers, cues to action and self-efficacy. Individuals with higher scores on perceived benefits and cues to action had more often the intention to change their behaviour with regard to physical activity (OR = 1.33, 95%-CI:1.11–1.58; OR = 1.13, 95%-CI:1.03–1.24, respectively) and alcohol consumption (OR = 1.30, 95%-CI:1.00–1.69; OR = 1.17, 95%-CI:1.02–1.35, respectively). Younger excessive alcohol consumers with higher perceived severity scores had more often the intention to change their alcohol consumption behaviour (OR = 2.70, 95%-CI:1.04–6.97) compared to older excessive alcohol consumers. Opposite results were found for middle-aged excessive alcohol consumers (OR = 0.81, 95%-CI:0.67–0.99). Individuals who perceived more barriers had more often the intention to change their diet (OR = 1.10, 95%-CI:1.01–1.21), but less often the intention to change their smoking behaviour (OR = 0.78, 95%-CI:0.63–0.98). Moreover, less educated individuals with higher perceived benefits scores had less often the intention to change their diet (OR = 0.78, 95%-CI:0.60–0.99), while highly educated individuals with higher perceived benefits scores had more often the intention to change their diet (OR = 1.41, 95%-CI:1.12–1.78). Conclusions The knowledge, beliefs and attitudes towards dementia and dementia risk reduction among the Dutch general population is insufficient to support dementia risk reduction. More education about dementia and dementia risk reduction is needed to improve health beliefs and attitudes towards dementia and dementia risk reduction in order to change health behaviour.

Background The Ruff Figural Fluency Test (RFFT) is a valid but time-consuming and labour-intensive cognitive paper-and-pencil test. A digital RFFT was developed that can be conducted independently using an iPad and Apple Pencil and RFFT scores are computed automatically. We investigated the validity and reliability of this digital RFFT. Methods We randomly allocated participants to the digital or paper-and-pencil RFFT. After the first test, the other test was performed immediately (cross-over). Participants were invited for a second digital RFFT 1 week later. For the digital RFFT, an (automatic) algorithm and two independent raters (criterion standard) assessed the number of unique designs (UD) and perseverative errors (PE). These raters also assessed the paper-and-pencil RFFT. We used Intraclass correlation coefficients (ICC), sensitivity, specificity, %-agreement, Kappa, and Bland–Altman plots. Results We included 94 participants (mean (SD) age 39.9 (14.8), 73.4% follow-up). Mean (SD) UD and median (IQR) PE of the digital RFFT were 84.2 (26.0) and 4 (2–7.3), respectively. Agreement between manual and automatic scoring of the digital RFFT was high for UD (ICC = 0.99, 95% CI 0.98, 0.99, sensitivity = 0.98; specificity = 0.96) and PE (ICC = 0.99, 95% CI 0.98, 0.99; sensitivity = 0.90, specificity = 1.00), indicating excellent criterion validity. Small but significant differences in UD were found between the automatic and manual scoring (mean difference: − 1.12, 95% CI − 1.92, − 0.33). Digital and paper-and-pencil RFFT had moderate agreement for UD (ICC = 0.73, 95% CI 0.34, 0.87) and poor agreement for PE (ICC = 0.47, 95% CI 0.30, 0.62). Participants had fewer UD on the digital than paper-and-pencil RFFT (mean difference: − 7.09, 95% CI − 11.80, − 2.38). The number of UD on the digital RFFT was associated with higher education (Spearman’s r = 0.43, p r = − 0.36, p Conclusions The automatic scoring of the digital RFFT has good criterion and convergent validity. There was low agreement between the digital RFFT and paper-and-pencil RFFT and moderate test–retest reliability, which can be explained by learning effects. The digital RFFT is a valid and reliable instrument to measure executive cognitive function among the general population and is a feasible alternative to the paper-and-pencil RFFT in large-scale studies. However, its scores cannot be used interchangeably with the paper-and-pencil RFFT scores.

Unhealthy food environments may contribute to an elevated Body Mass Index (BMI), which is a chronic disease risk factor. We examined the association between residential fast-food outlet exposure, in terms of proximity and density, and BMI in the Dutch adult general population. Additionally, we investigated to what extent this association was modified by urbanisation level. In this cross-sectional study, we linked residential addresses of baseline adult Lifelines cohort participants (N = 147,027) to fast-food outlet locations using geo-coding. We computed residential fast-food outlet proximity, and density within 500 m(m), 1, 3, and 5 km(km). We used stratified (urban versus rural areas) multilevel linear regression models, adjusting for age, sex, partner status, education, employment, neighbourhood deprivation, and address density. The mean BMI of participants was 26.1 (SD 4.3) kg/m2. Participants had a mean (SD) age of 44.9 (13.0), 57.3% was female, and 67.0% lived in a rural area. Having two or more (urban areas) or five or more (rural areas) fast-food outlets within 1 km was associated with a higher BMI (B = 0.32, 95% confidence interval (CI):0.03,0.62; B = 0.23, 95% CI:0.10,0.36, respectively). Participants in urban and rural areas with a fast-food outlet within

Background Individuals with a parental family history of dementia have an increased risk of developing dementia because they share their genes as well as their psychosocial behaviour. Due to this increased risk and their experience with dementia, they may be particularly eager to receive information regarding dementia risk reduction (DRR). This study evaluated the knowledge, beliefs and attitudes towards dementia and DRR among descendants of people with dementia.Method Using a semi-structured topic guide, three focus group discussions were conducted consisting of 12 female (80%) and 3 male (20%) descendants of people with dementia with a mean age of 48.8 ± 12.0 years. Focus group discussions were audio recorded and transcribed. Each transcript was analysed thoroughly, and where appropriate, a code was generated and assigned by two researchers independently. Then, similar codes were grouped together and categorized into themes.Results The items in the topic guide could only be addressed after participants had been given the opportunity to share their experiences of having a parent with dementia. Participants were unaware or uncertain about the possibility of reducing the risk of developing dementia and therefore hesitant to assess their dementia risk without treatment options in sight. Moreover, participants indicated that their general practitioner only gave some information on heritability, not on DRR. Although participants identified a large number of modifiable risk factors as a group during the group discussions, they were eager to receive more information on dementia and DRR. In the end, participants adopted a more positive attitude towards a DRR program and provided suggestions for the development of future DRR programs.Conclusions Although the research aim was to evaluate the knowledge, beliefs and attitudes towards dementia and DRR, sharing experiences of having a parent with dementia seemed a prerequisite for considering participants’ own risk of developing dementia and participating in a DRR program. Knowledge of dementia and DRR was limited. Due to unawareness of the possibility of reducing dementia risk, participants were hesitant about assessing their dementia risk. Group discussions positively changed the perception of dementia risk assessment and participants’ willingness to participate in a DRR program.

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