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1.  Personality and the risk of cancer: a 16-year follow-up study of the GAZEL cohort 
Psychosomatic Medicine  2013;75(3):262-271.
Objective
Large-scale prospective studies do not support an association between neuroticism and extroversion with cancer incidence. However, research on other personality constructs is inconclusive. This longitudinal study examined the associations between four personality measures, Type 1 “suppressed emotional expression,” Type 5 “rational/anti-emotional,” hostility and Type A with cancer incidence.
Methods
Personality measures were available for 13,768 members in the GAZEL cohort study (baseline assessment in 1993). Follow-up for diagnoses of primary cancers was obtained from January 1, 1994 to December 31, 2009. Associations between personality and cancer incidence were evaluated using Cox proportional hazards analyses and adjusted for potential confounders.
Results
During a median follow-up of 16.0 years [range: 9 days-16 years], 1,139 participants received at least one diagnosis of primary cancer. The mean duration between baseline and cancer diagnosis was 9.3 years. Type 1 personality was associated with a decreased risk of breast cancer [hazard ratio (HR) per standard deviation: 0.81, 95% confidence interval (CI) = 0.68–0.97, p=.02]. Type 5 personality was not associated with prostate, breast, colorectal or smoking-related cancers, but was associated with other cancers (HR per standard deviation: 1.17, 95% CI = 1.04–1.31, p=.01). Hostility was associated with an increased risk of smoking-related cancers, which was explained by smoking habits, and Type A was not associated with any of the cancer end-points.
Conclusions
Several personality measures were prospectively associated with the incidence of selected cancers. These links may warrant further epidemiological studies and investigations about potential biobehavioral mechanisms.
doi:10.1097/PSY.0b013e31828b5366
PMCID: PMC3977138  PMID: 23513238
Adult; Cohort Studies; Female; Follow-Up Studies; France; epidemiology; Hostility; Humans; Incidence; Longitudinal Studies; Male; Middle Aged; Neoplasms; epidemiology; psychology; Personality; Personality Inventory; statistics & numerical data; Proportional Hazards Models; Prospective Studies; Registries; statistics & numerical data; Risk; Risk Factors; Emotion; Epidemiology; Incidence; Personality; Risk; Cancer
2.  Trajectories of the Framingham general cardiovascular risk profile in midlife and poor motor function later in life: The Whitehall II study☆☆☆ 
Background
Vascular risk factors are associated with increased risk of cognitive impairment and dementia, but their association with motor function, another key feature of aging, has received little research attention. We examined the association between trajectories of the Framingham general cardiovascular disease risk score (FRS) over midlife and motor function later in life.
Methods
A total of 5376 participants of the Whitehall II cohort study (29% women) who had up to four repeat measures of FRS between 1991–1993 (mean age = 48.6 years) and 2007–2009 (mean age = 65.4 years) and without history of stroke or coronary heart disease in 2007–2009 were included. Motor function was assessed in 2007–2009 through objective tests (walking speed, chair rises, balance, finger tapping, grip strength). We used age- and sex-adjusted linear mixed models.
Results
Participants with poorer performances for walking speed, chair rises, and balance in 2007–2009 had higher FRS concurrently and also in 1991–1993, on average 16 years earlier. These associations were robust to adjustment for cognition, socio-economic status, height, and BMI, and not explained by incident mobility limitation prior to motor assessment. No association was found with finger tapping and grip strength.
Conclusions
Cardiovascular risk early in midlife is associated with poor motor performances later in life. Vascular risk factors play an important and under-recognized role in motor function, independently of their impact on cognition, and suggest that better control of vascular risk factors in midlife may prevent physical impairment and disability in the elderly.
doi:10.1016/j.ijcard.2013.12.051
PMCID: PMC3991855  PMID: 24461963
CVD, cardiovascular disease; FRS, Framingham general cardiovascular disease risk score; SES, socioeconomic status; BMI, body mass index; SD, standard deviation; Cardiovascular risk score; Motor function; Aging; Stroke; Cohort study
3.  Low Conscientiousness and Risk of All-Cause, Cardiovascular and Cancer Mortality over 17 Years: Whitehall II Cohort Study 
Objective
To examine the personality trait conscientiousness as a risk factor for mortality and to identify candidate explanatory mechanisms.
Methods
Participants in the Whitehall II cohort study (N = 6800, aged 34 to 55 at recruitment in 1985) completed two self-reported items measuring conscientiousness in 1991–1993 (‘I am overly conscientious’ and ‘I am overly perfectionistic’, Cronbach's α = .72), the baseline for this study. Age, socio-economic status (SES), social support, health behaviours, physiological variables and minor psychiatric morbidity were also recorded at baseline. The vital status of participants was then monitored for a mean of 17 years. All-cause and cause-specific mortality was ascertained through linkage to a national mortality register until January 2010.
Results
Each 1 standard deviation decrease in conscientiousness was associated with a 10% increase in all-cause (hazard ratio [HR] = 1.10, 95% CI 1.003, 1.20) mortality. Patterns were similar for cardiovascular (HR = 1.17, 95% CI 0.98, 1.39) and cancer mortality (HR = 1.10, 95% CI 0.96, 1.25), not reaching statistical significance. The association with all-cause mortality was attenuated by 5% after adjustment for SES, 13% for health behaviours, 14% for cardiovascular risk factors, 5% for minor psychiatric morbidity, 29% for all variables. Repeating analyses with each item separately and excluding participants who died within five years of personality assessment did not change the results materially.
Conclusion
Low conscientiousness in midlife is a risk factor for all-cause mortality. This association is only partly explained by health behaviours, SES, cardiovascular disease risk factors and minor psychiatric morbidity in midlife.
doi:10.1016/j.jpsychores.2012.05.007
PMCID: PMC3936113  PMID: 22789411
cohort study; conscientiousness; mortality; perfectionism; personality traits; socio-economic status
4.  Influence of retirement on nonadherence to medication for hypertension and diabetes 
Background:
The extent to which common life transitions influence medication adherence among patients remains unknown. We examined whether retirement is associated with a change in adherence to medication in patients with hypertension or type 2 diabetes.
Methods:
Participants in the Finnish Public Sector study were linked to national registers. We included data for the years 1994–2011. We identified and followed 3468 adult patients with hypertension and 412 adult patients with type 2 diabetes for medication adherence for the 3 years before their retirement and the 4 years after their retirement (mean follow-up 6.8 yr). Our primary outcome was proportion of patients with poor adherence to medication, which we defined as less than 40% of days covered by treatment. We determined these proportions before and after retirement using data from filled prescriptions.
Results:
The preretirement prevalence of poor adherence to medication was 6% in men and women with hypertension, 2% in men with diabetes and 4% in women with diabetes. Among men, retirement was associated with an increased risk of poor adherence to both antihypertensive agents (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.03–1.68) and antidiabetic drugs (OR 2.40, 95% CI 1.37–4.20). Among women, an increased risk of poor adherence was seen only for antihypertensive agents (OR 1.25, 95% CI 1.07–1.46). Similar results were apparent for alternative definitions of poor adherence. Our results did not differ across strata of age, socioeconomic status or comorbidity.
Interpretation:
We found a decline in adherence to medication after retirement among men and women with hypertension and men with type 2 diabetes. If these findings can be confirmed, we need randomized controlled trials to determine whether interventions to reduce poor adherence after retirement could improve clinical outcomes of treatments for hypertension and diabetes.
doi:10.1503/cmaj.122010
PMCID: PMC3832579  PMID: 24082018
5.  Usefulness of a single-item measure of depression to predict mortality: the GAZEL prospective cohort study 
Background: It remains unknown whether short measures of depression perform as well as long measures in predicting adverse outcomes such as mortality. The present study aims to examine the predictive value of a single-item measure of depression for mortality. Methods: A total of 14 185 participants of the GAZEL cohort completed the 20-item Center-for-Epidemiologic-Studies-Depression (CES-D) scale in 1996. One of these items (I felt depressed) was used as a single-item measure of depression. All-cause mortality data were available until 30 September 2009, a mean follow-up period of 12.7 years with a total of 650 deaths. Results: In Cox regression model adjusted for baseline socio-demographic characteristics, a one-unit increase in the single-item score (range 0–3) was associated with a 25% higher risk of all-cause mortality (95% CI: 13–37%, P < 0.001). Further adjustment for health-related behaviours and physical chronic diseases reduced this risk by 36% and 8%, respectively. After adjustment for all these variables, every one-unit increase in the single-item score predicted a 15% increased risk of death (95% CI: 5–27%, P < 0.01). There is also an evidence of a dose–reponse relationship between reponse scores on the single-item measure of depression and mortality. Conclusion: This study shows that a single-item measure of depression is associated with an increased risk of death. Given its simplicity and ease of administration, a very simple single-item measure of depression might be useful for identifying middle-aged adults at risk for elevated depressive symptoms in large epidemiological studies and clinical settings.
doi:10.1093/eurpub/ckr103
PMCID: PMC3457003  PMID: 21840893
6.  Obesity phenotypes in midlife and cognition in early old age 
Neurology  2012;79(8):755-762.
Objective:
To examine the association of body mass index (BMI) and metabolic status with cognitive function and decline.
Methods:
A total of 6,401 adults (71.2% men), aged 39–63 years in 1991–1993, provided data on BMI (normal weight 18.5–24.9 kg/m2, overweight 25–29.9 kg/m2; and obese ≥30 kg/m2) and metabolic status (abnormality defined as 2 or more of 1) triglycerides ≥1.69 mmol/L or lipid-lowering drugs, 2) systolic blood pressure ≥130 mm Hg, diastolic blood pressure ≥85 mm Hg, or antihypertensive drugs, 3) glucose ≥5.6 mmol/L or medications for diabetes, and 4) high-density lipoprotein cholesterol <1.04 mmol/L for men and <1.29 mmol/L for women). Four cognitive tests (memory, reasoning, semantic, and phonemic fluency) were administered in 1997–1999, 2002–2004, and 2007–2009, standardized to z scores, and averaged to yield a global score.
Results:
Of the participants, 31.0% had metabolic abnormalities, 52.7% were normal weight, 38.2% were overweight, and 9.1% were obese. Among the obese, the global cognitive score at baseline (p = 0.82) and decline (p = 0.19) over 10 years was similar in the metabolically normal and abnormal groups. In the metabolically normal group, the 10-year decline in the global cognitive score was similar (p for trend = 0.36) in the normal weight (−0.40; 95% confidence interval [CI] −0.42 to −0.38), overweight (−0.42; 95% CI −0.45 to −0.39), and obese (−0.42; 95% CI −0.50 to −0.34) groups. However, in the metabolically abnormal group, the decline on the global score was faster among obese (−0.49; 95% CI −0.55 to −0.42) than among normal weight individuals (−0.42; 95% CI −0.50 to −0.34), (p = 0.03).
Conclusions:
In these analyses the fastest cognitive decline was observed in those with both obesity and metabolic abnormality.
doi:10.1212/WNL.0b013e3182661f63
PMCID: PMC3421151  PMID: 22915175
7.  Association between Dietary Patterns and Depressive Symptoms Over Time: A 10-Year Follow-Up Study of the GAZEL Cohort 
PLoS ONE  2012;7(12):e51593.
Background
Data on the association between dietary patterns and depression are scarce. The objective of this study was to examine the longitudinal association between dietary patterns and depressive symptoms assessed repeatedly over 10 years in the French occupational GAZEL cohort.
Methods
A total of 9,272 men and 3,132 women, aged 45–60 years in 1998, completed a 35-item Food Frequency Questionnaire (FFQ) at baseline. Dietary patterns were derived by Principal Component Analysis. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression scale (CES-D) in 1999, 2002, 2005 and 2008. The main outcome measure was the repeated measures of CES-D. Longitudinal analyses were performed with logistic regression based on generalized estimating equations.
Principal Findings
The highest quartile of low-fat, western, high snack and high fat-sweet diets in men and low-fat and high snack diets in women were associated with higher likelihood of depressive symptoms at the start of the follow-up compared to the lowest quartile (OR between 1.16 and 1.50). Conversely, the highest quartile of traditional diet (characterized by fish and fruit consumption) was associated with a lower likelihood of depressive symptoms in women compared to the lowest quartile, with OR = 0.63 [95%CI, 0.50 to 0.80], as the healthy pattern (characterized by vegetables consumption) with OR = 0.72 [95%CI, 0.63 to 0.83] and OR = 0.75 [95%CI, 0.61 to 0.93] in men and women, respectively. However, there was probably a reverse causality effect for the healthy pattern.
Conclusion
This longitudinal study shows that several dietary patterns are associated with depressive symptoms and these associations track over time.
doi:10.1371/journal.pone.0051593
PMCID: PMC3520961  PMID: 23251585
8.  Association of lung function with physical, mental and cognitive function in early old age 
Age  2010;33(3):385-392.
Lung function predicts mortality; whether it is associated with functional status in the general population remains unclear. This study examined the association of lung function with multiple measures of functioning in early old age. Data are drawn from the Whitehall II study; data on lung function (forced expiratory volume in 1 s, height FEV1), walking speed (2.44 m), cognitive function (memory and reasoning) and self-reported physical and mental functioning (SF-36) were available on 4,443 individuals, aged 50–74 years. In models adjusted for age, 1 standard deviation (SD) higher height-adjusted FEV1 was associated with greater walking speed (beta = 0.16, 95% CI: 0.13, 0.19), memory (beta = 0.09, 95% CI: 0.06, 0.12), reasoning (beta = 0.16, 95% CI: 0.13, 0.19) and self-reported physical functioning (beta = 0.13, 95% CI: 0.10, 0.16). Socio-demographic measures, health behaviours (smoking, alcohol, physical activity, fruit/vegetable consumption), body mass index (BMI) and chronic conditions explained two-thirds of the association with walking speed and self-assessed physical functioning and over 80% of the association with cognitive function. Our results suggest that lung function is a good ‘summary’ measure of overall functioning in early old age.
doi:10.1007/s11357-010-9189-x
PMCID: PMC3168608  PMID: 20878489
Ageing; Lung function; Cognitive function; Physical function
9.  Combined Effects of Depressive Symptoms and Resting Heart Rate on Mortality: The Whitehall II Prospective Cohort Study 
The Journal of clinical psychiatry  2010;72(9):1199-1206.
Objective
To examine the combined effects of depressive symptoms and resting heart rate (RHR) on mortality.
Methods
Data come from 5936 participants, aged 61 ± 6 years, from the Whitehall II study. Depressive symptoms were assessed in 2002–2004 using the center-for-epidemiologic-studies-depression-scale (score ≥ 16). RHR was measured at the same study phase via electrocardiogram. Participants were assigned to 1 of 6 risk-factor-groups based on depression status (yes/no) and RHR categories (<60, 60 – 80, >80 bpm). Mean follow-up for mortality was 5.6 years.
Results
In mutually adjusted Cox regression models, depression (hazard ratio = 1.93 p<0.001) and RHR>80 bpm (hazard ratio = 1.67, p<0.001) were independent predictors of mortality. After adjustment for potential confounding and mediating variables, participants with both depression and high RHR had a 3.0-fold higher (p<0.001) risk of death compared to depression-free participants with RHR ranging from 60 to 80 bpm. This risk is particularly marked in participants with prevalent CHD.
Conclusions
This study provides evidence that the coexistence of depressive symptoms and elevated RHR is associated with substantially increased risk of death compared to those without these two factors. This finding raises the possibility that treatments that improve both depression and RHR might improve survival.
doi:10.4088/JCP.09m05901blu
PMCID: PMC3226937  PMID: 21208592
depression; resting heart rate and mortality
10.  Association of lung function with physical, mental and cognitive function in early old age 
Age  2010;33(3):385-392.
Lung function predicts mortality, whether it is associated with functional status in the general population remains unclear. This study examined the association of lung function with multiple measures of functioning in early old age. Data are drawn from the Whitehall II study; data on lung function (forced expiratory volume in one second, height FEV1), walking speed (over 2.44 m), cognitive function (memory and reasoning), and self-reported physical and mental functioning (SF-36) were available on 4443 individuals, aged 50–74 years. In models adjusted for age, one standard deviation (SD) higher height-adjusted FEV1 was associated with greater walking speed (beta=0.16, 95% CI: 0.13, 0.19), memory (beta=0.09, 95% CI: 0.06, 0.12), reasoning (beta=0.16, 95% CI: 0.13, 0.19), and self-reported physical functioning (beta=0.13, 95% CI: 0.10, 0.16). Socio-demographic measures, health behaviours (smoking, alcohol, physical activity, fruit/vegetable consumption), BMI and chronic conditions explained two-thirds of the association with walking speed and self-assessed physical functioning and over 80% of the association with cognitive function. Our results suggest that lung function is a good “summary” measure of overall functioning in early old age.
doi:10.1007/s11357-010-9189-x
PMCID: PMC3168608  PMID: 20878489
Aged; Aging; physiology; psychology; Cognition; physiology; Female; Health Status; Humans; Lung; physiology; Male; Middle Aged; Spirometry; Walking; physiology; ageing; lung function; cognitive function; physical function
11.  Letter by Nabi regarding article, "attained educational level and incident atherothrombotic events in low- and middle-income compared with high-income countries" 
Circulation  2011;123(20):e605; author reply e606.
doi:10.1161/CIRCULATIONAHA.110.000133
PMCID: PMC3348122  PMID: 21606403
Coronary Artery Disease; epidemiology; Developing Countries; statistics & numerical data; Educational Status; Humans; Incidence; Income; statistics & numerical data; Peripheral Vascular Diseases; epidemiology; Risk Factors; Socioeconomic Factors
12.  Influence of retirement and work stress on headache prevalence: a longitudinal modelling study from the GAZEL Cohort Study 
Cephalalgia  2011;31(6):696-705.
Aims
To examine trajectories of headache in relation to retirement and to clarify the role of work stress and stress-prone personality.
Methods
Headache prevalence during seven years before and after retirement was measured by annual questionnaires from GAZEL cohort comprising French national gas and electricity company employees (N=12,913). Odds ratios and 95% confidence intervals for headache during pre- peri- and post-retirement were calculated. The role of effect modifiers (work stress, type A or hostile personality) was tested by multiplicative interactions and synergy indices.
Results
11%–13% reduction in headache prevalence was found during pre- and post-retirement, whereas decline was much steeper (46%) during the retirement transition. In absolute terms, the decline was greater among persons with high work stress or stress-prone personality than among other participants.
Conclusions
Retirement is associated with a decrease in headache prevalence, particularly among persons with high amount of work stress or proneness to overreact to stress.
doi:10.1177/0333102410394677
PMCID: PMC3317892  PMID: 21220374
headache; retirement; work stress; stress-prone personality
13.  INFLUENCE OF RETIREMENT AND WORK STRESS ON HEADACHE PREVALENCE: A LONGITUDINAL MODELLING STUDY FROM THE GAZEL COHORT 
Cephalalgia  2011;31(6):696-705.
Aims
To examine trajectories of headache in relation to retirement and to clarify the role of work stress and stress-prone personality.
Methods
Headache prevalence during seven years before and after retirement was measured by annual questionnaires from GAZEL cohort comprising French national gas and electricity company employees (N=12,913). Odds ratios and 95% confidence intervals for headache during pre- peri- and post-retirement were calculated. The role of effect modifiers (work stress, type A or hostile personality) was tested by multiplicative interactions and synergy indices.
Results
11%-13% reduction in headache prevalence was found during pre- and post-retirement, whereas decline was much steeper (46%) during the retirement transition. In absolute terms, the decline was greater among persons with high work stress or stress-prone personality than among other participants.
Conclusions
Retirement is associated with a decrease in headache prevalence, particularly among persons with high amount of work stress or proneness to overreact to stress.
doi:10.1177/0333102410394677
PMCID: PMC3317892  PMID: 21220374
headache; retirement; work stress; stress-prone personality
14.  TRAJECTORIES OF DEPRESSIVE EPISODES AND HYPERTENSION OVER 24 YEARS: THE WHITEHALL II PROSPECTIVE COHORT STUDY 
Hypertension  2011;57(4):710-716.
Prospective data on depressive symptoms and blood pressure (BP) are scarce, and the impact of age on this association is poorly understood. The present study examines longitudinal trajectories of depressive episodes and the probability of hypertension associated with these trajectories over time. Participants were 6,889 men and 3,413 women London based civil servants, aged 35–55 years at baseline, followed for 24 years between 1985 and 2009. Depressive episode (defined as scoring 4 or more on the General Health Questionnaire-Depression subscale or using prescribed antidepressant medication) and hypertension (systolic/diastolic blood pressure ≥ 140/90 mm Hg or use of antihypertensive medication) were assessed concurrently at five medical examinations. In the fully adjusted longitudinal logistic regression analyses based on Generalized-Estimating-Equations using age as the time scale, participants in the “increasing depression” group had a 24% (p<0.05) lower risk of hypertension at ages 35–39, compared to those in the “low/transient depression” group. However, there was a faster age-related increase in hypertension in the “increasing depression” group, corresponding to a 7% (p<0.01) greater increase in the odds of hypertension for every each five-year increase in age. A higher risk of hypertension in the first group of participants was not evident before age 55. A similar pattern of association was observed in men and women although it was stronger in men. This study suggests that the risk of hypertension increases with repeated experience of depressive episodes over time and becomes evident in later adulthood.
doi:10.1161/HYPERTENSIONAHA.110.164061
PMCID: PMC3065997  PMID: 21339474
Depression; hypertension; longitudinal analysis; repeated measures
15.  Combined effects of depressive symptoms and resting heart rate on mortality: the Whitehall II prospective cohort study 
The Journal of Clinical Psychiatry  2010;72(9):1199-1206.
Objective
To examine the combined effects of depressive symptoms and resting heart rate (RHR) on mortality.
Methods
Data come from 5936 participants, aged 61 ±6 years, from the Whitehall II study. Depressive symptoms were assessed in 2002–2004 using the center-for-epidemiologic-studies-depression-scale (score ≥16). RHR was measured at the same study phase via electrocardiogram. Participants were assigned to 1 of 6 risk-factor-groups based on depression status (yes/no) and RHR categories (<60, 60–80, >80 bpm). Mean follow-up for mortality was 5.6 years.
Results
In mutually adjusted Cox regression models, depression (hazard ratio = 1.93 p<0.001) and RHR>80 bpm (hazard ratio = 1.67, p<0.001) were independent predictors of mortality. After adjustment for potential confounding and mediating variables, participants with both depression and high RHR had a 3.0-fold higher (p<0.001) risk of death compared to depression-free participants with RHR ranging from 60 to 80 bpm. This risk is particularly marked in participants with prevalent CHD.
Conclusions
This study provides evidence that the coexistence of depressive symptoms and elevated RHR is associated with substantially increased risk of death compared to those without these two factors. This finding raises the possibility that treatments that improve both depression and RHR might improve survival.
doi:10.4088/JCP.09m05901blu
PMCID: PMC3226937  PMID: 21208592
depression; resting heart rate and mortality
16.  Lost work days in the 6 years leading to premature death from cardiovascular disease in men and women 
Atherosclerosis  2010;211(2):689-693.
Background
It is unclear whether individuals experience specific patterns of morbidity prior to premature death from cardiovascular disease (CVD).
Methods
We examined morbidity levels in the 6 years leading up to death from CVD in 37,397 men and 113,198 women under 65 years of age from the Finnish Public Sector study, with a particular focus on gender differences. Morbidity was assessed using lost days from work, extracted from register data on sickness leave and disability pension. Data on cause-specific mortality were obtained from national health registers.
Results
During a median follow-up of 8.5 years, there were 361 CVD deaths (174 from ischemic heart disease (ICD9 410-414, 427.5; ICD10 I21-I25, I46), 91 from stroke (ICD9 430, 431, 434; ICD10 I60-I60, I61, I63), and 96 from other diseases of circulatory system (ICD9 390-459; ICD10 I00-I99). Women had lower morbidity than men over the 6 years preceding stroke deaths (RR for mean annual days=0.33 (95% CI 0.14-0.78). For other causes of CVD mortality, there were no gender differences in morbidity rates prior to death. In men, those who died from CVD had substantially greater morbidity levels than matched controls through the entire 6-year period preceding death (rate ratio=3.59; 95% confidence interval 2.62-4.93). Among women, morbidity days were greater particularly in the year preceding death from stroke.
Conclusion
Our results on working age men and women suggest no gender differences in morbidity prior to death from heart disease and lower morbidity in women prior to death from stroke. These findings challenge the widespread belief that women experience more morbidity symptoms than men.
doi:10.1016/j.atherosclerosis.2010.04.013
PMCID: PMC3249378  PMID: 20444450
cardiovascular disease; stroke; mortality; gender
17.  Trends in the association between height and socioeconomic indicators in France, 1970–2003 
Economics and human biology  2010;8(3):396-404.
Average physical stature has increased dramatically during the 20th century in many populations across the world with few exceptions. It remains unclear if social inequalities in height persist despite improvements in living standards in the welfare economies of Western Europe. We examined trends in the association between height and socioeconomic indicators in adults over three decades in France. The data were drawn from the French Decennial Health Surveys: a multistage, stratified, random survey of households, representative of the population, conducted in 1970, 1980, 1991, and 2003. We categorised age into 10-year bands, 25–34, 35–44, 45–54 and 55–64 years. Education and income were the two socioeconomic measures used. The slope index of inequality (SII) was used as a summary index of absolute social inequalities in height. The results show that average height increased over this period; men and women aged 25–34 years were 171.9 and 161.2 cm tall in 1970 and 177.0 and 164.0 cm in 2003. However, education-related inequalities in height remained unchanged over this period and in men were 4.48 cm (1970), 4.71 cm (1980), 5.58 cm (1991) and 4.69 cm (2003), the corresponding figures in women were 2.41, 2.37, 3.14 and 2.96 cm. Income-related inequalities in height were smaller and much attenuated after adjustment for education. These results suggest that in France, social inequalities in adult height in absolute terms have remained unchanged across the three decades under examination.
doi:10.1016/j.ehb.2010.03.002
PMCID: PMC2914812  PMID: 20400383
height; trends; social inequalities
18.  Effects of depressive symptoms and coronary heart disease and their interactive associations on mortality in middle-aged adults: the Whitehall II cohort study 
Heart  2010;96(20):1645-1650.
BACKGROUND
Depression and mortality have been studied separately in patients with coronary heart disease (CHD) and in populations healthy at study inception. This does not allow comparisons across risk-factor groups based on the cross-classification of depression and CHD status.
OBJECTIVE
To examine effects of depressive symptoms and coronary heart disease and their interactive associations on mortality in middle-aged adults followed over 5.6 years.
DESIGN AND SETTING
A prospective population-based cohort study of 5936 middle-aged men and women from the British Whitehall II study. We created 4 risk-factor-groups based on the cross classification of depressive symptoms and CHD status.
RESULTS
The age- and sex-adjusted hazard ratios for death from all causes were 1.67 (p<0.05) for participants with only CHD, 2.10 (p<0.001) for those with only depressive symptoms and 4.99 (p<0.001) for those with both CHD and depressive symptoms when compared to participants without either condition. The two latter risk-factor groups remained at increased risk after adjustments for relevant confounders. The relative excess risk due to the interaction between depressive symptoms and CHD for all-cause mortality was 3.58 (95% CI, −0.09–7.26), showing some evidence of an additive interaction. A similar pattern was also observed for cardiovascular death.
CONCLUSIONS
This study provides evidence that depressive symptoms are associated with an increased risk of all-cause and cardiovascular death and that this risk is particularly marked in depressive participants with co-morbid CHD.
doi:10.1136/hrt.2010.198507
PMCID: PMC3151258  PMID: 20844294
Coronary heart disease; depressive symptoms; survival
19.  Does depression predict coronary heart disease and cerebrovascular disease equally well? The Health and Social Support Prospective Cohort Study 
Background The relationship between depression and cerebrovascular disease (CBVD) continues to be debated although little research has compared the predictive power of depression for coronary heart disease (CHD) with that for CBVD within the same population. This study aimed to compare the importance of depression for CHD and CBVD within the same population of adults free of apparent cardiovascular disease.
Methods A random sample of 23 282 adults (9507 men, 13 775 women) aged 20–54 years were followed up for 7 years. Fatal and first non-fatal CHD and CBVD events were documented by linkage to the National-hospital-discharge and mortality registers.
Results Sex–age–education-adjusted hazard ratio (HR) for CHD was 1.66 [95% confidence interval (CI) 1.24–2.24] for participants with mild to severe depressive symptoms, i.e. those scoring ≥10 on the 21-item Beck Depression Inventory, and 2.04 (1.27–3.27) for those who filled antidepressant prescriptions compared with those without depression markers in 1998, i.e. at study baseline. For CBVD, the corresponding HRs were 1.01 (0.67–1.53) and 1.77 (0.95–3.29). After adjustment for behavioural and biological risk factors these associations were reduced but remained evident for CHD, the adjusted HRs being 1.47 (1.08–1.99) and 1.72 (1.06–2.77). For CBVD, the corresponding multivariable adjusted HRs were 0.87 (0.57–1.32) and 1.52 (0.81–2.84).
Conclusions Self-reported depression using a standardized questionnaire and clinical markers of mild to severe depression were associated with an increased risk for CHD. There was no clear evidence that depression is a risk factor for CBVD, but this needs further confirmation.
doi:10.1093/ije/dyq050
PMCID: PMC2950797  PMID: 20360321
Depression; coronary heart disease; cerebrovascular disease
20.  Does depression predict coronary heart disease and cerebrovascular disease equally well? The Health and Social Support Prospective Cohort Study 
Background
The relationship between depression and cerebrovascular disease (CBVD) continues to be debated although little research has compared the predictive power of depression for coronary heart disease (CHD) to that for CBVD within the same population. This study aimed to compare the importance of depression for CHD and CBVD within the same population of adults free of apparent cardiovascular disease.
Methods
A random sample of 23282 adults (9507 men, 13775 women) aged 20–54 years were followed-up for 7 years. Fatal and first non-fatal CHD and CBVD events were documented by linkage to the National-hospital-discharge and mortality registers.
Results
Sex-age-education-adjusted Hazard Ratio (HR) for CHD was 1.66 (95% confidence interval (CI) 1.24–2.24) for participants with mild to severe depressive symptoms, i.e. those scoring 10 or more on the 21-item Beck-Depression-Inventory, and 2.04 (1.27–3.27) for those who filled antidepressant prescriptions compared to those without depression markers in 1998, i.e., at study baseline. For CBVD, the corresponding HRs were 1.01 (0.67–1.53) and 1.77 (0.95–3.29). After adjustment for behavioural and biological risk factors these associations were reduced but remained evident for CHD, the adjusted HRs being 1.47 (1.08–1.99) and 1.72 (1.06–2.77). For CBVD, the corresponding multivariable adjusted HRs were 0.87 (0.57–1.32) and 1.52 (0.81–2.84).
Conclusions
Self-reported depression using a standardized questionnaire and clinical markers of mild to severe depression were associated with an increased risk for CHD. There was no clear evidence that depression is a risk factor for CBVD, but this needs further confirmation.
doi:10.1093/ije/dyq050
PMCID: PMC2950797  PMID: 20360321
Adult; Coronary Disease; epidemiology; psychology; Depression; complications; Female; Finland; epidemiology; Humans; Incidence; Male; Middle Aged; Proportional Hazards Models; Prospective Studies; Risk Factors; Stroke; epidemiology; psychology; Young Adult; depression; coronary heart disease; cerebrovascular disease
21.  Predictive utility of the Framingham general cardiovascular disease risk profile for cognitive function: evidence from the Whitehall II study 
European Heart Journal  2011;32(18):2326-2332.
Aims
Vascular risk factors are associated with cognitive impairment and dementia, although most of the research in this domain focuses on cerebrovascular factors. We examined the relationship between the recently developed Framingham general cardiovascular risk profile and cognitive function and 10-year decline in late midlife.
Methods and results
Study sample comprised of 3486 men and 1341 women, mean age 55 years [standard deviation (SD)=6], from the Whitehall II study, a longitudinal British cohort study. The Framingham General Cardiovascular Risk profile, assessed between 1997 and 1999, included age, sex, HDL cholesterol, total cholesterol, systolic blood pressure, smoking status, and diabetes status. Measures of cognitive function consisted of tests of reasoning (Alice Heim 4-I), memory, phonemic and semantic fluency, and vocabulary (Mill-Hill), assessed three times (1997–1999, 2002–2004, 2007–2009) over 10 years. In cross-sectional age-adjusted models, 10% point increments in cardiovascular risk were associated with poor performance in all cognitive domains in both men and women (all P-values <0.001). In models adjusted for age, ethnicity, marital status, and education, 10% higher cardiovascular risk was associated with greater overall 10-year cognitive decline in men, reasoning in particular (−0.47; 95% CI: −0.81, −0.11).
Conclusion
In middle-aged individuals free of cardiovascular disease, an adverse cardiovascular risk profile is associated with poor cognitive function, and decline in at least one cognitive domain in men.
doi:10.1093/eurheartj/ehr133
PMCID: PMC3172575  PMID: 21606085
Framingham General Cardiovascular Profile; Cognitive function; Cardiovascular risk scores; Cognitive decline
22.  Incremental Predictive Value of Adding Past Blood Pressure Measurements to the Framingham Hypertension Risk Equation: the Whitehall II Study 
Hypertension  2010;55(4):1058-1062.
Records of repeated examinations of blood pressure are increasingly available for primary care patients, but the utility of this information in predicting incident hypertension remains unclear because cohort studies with repeat blood pressure monitoring are rare. We compared the incremental value of using data on blood pressure history to a single measure as in the Framingham hypertension risk score, a validated hypertension risk prediction algorithm. Participants were 4314 London-based civil servants (1297 women) aged 35 to 68 who were free from prevalent hypertension, diabetes and coronary heart disease at baseline examination (the Whitehall II study). Standard clinical examinations of blood pressure, weight and height, current cigarette smoking and parental history of hypertension were undertaken on a 5-yearly basis. A total of 1052 incident (new-onset) cases of hypertension were observed in two 5-year baseline-follow-up data cycles. Comparison of the Framingham risk score with a score additionally incorporating 5-year blood pressure history showed, at best, modest improvements in indicators of predictive performance: C-statistics (0.796 vs 0.799), predicted-to-observed ratios (1.04, 95%CI: 0.95-1.15 vs 0.98, 95%CI: 0.89-1.08) or Hosmer-Lemeshow chi-square values (11.5 vs 6.5). The net reclassification improvement with the modified score was 9.3% (95%CI: 4.2%-14.4%) resulting from a net 17.1% increase in non-hypertensives correctly identified as being at lower risk, but a net 7.8% increase in hypertensives incorrectly identified as at lower risk. These data suggest that despite the net reclassification improvement, the clinical utility of adding repeat measures of blood pressure to the Framingham hypertension risk score may be limited.
doi:10.1161/HYPERTENSIONAHA.109.144220
PMCID: PMC2862166  PMID: 20157053
Hypertension; prevention; primary prevention; public health; risk assessment; risk factors
23.  Psychological and Somatic Symptoms of Anxiety and Risk of Coronary Heart Disease: The Health and Social Support Prospective Cohort Study 
Biological psychiatry  2009;67(4):378-385.
Background
Despite evidence showing anxiety to be a negative emotion that can be accompanied by various psychological and somatic complaints, previous studies have rarely considered these two components of anxiety separately in relation to coronary heart disease (CHD) events. This study aims to examine the extent to which the psychological and somatic components of anxiety are predictive of CHD.
Methods
This is a prospective population-based cohort study of 24,128 participants (9830 men, 14,298 women) aged 20 to 54 years. Psychological and somatic symptoms were assessed at study baseline in 1998. Fatal and nonfatal CHD events during the following 7 years were documented from data on hospitalizations from the National Hospital Discharge Register and mortality records from the Statistics Finland Register.
Results
In men, unadjusted hazard ratios for CHD per one unit increase in mean score were 1.50 (95% confidence interval [CI], 1.21–1.87) for somatic symptoms and 1.04 (95% CI, .85–1.29) for psychological symptoms. After serial adjustment for sociodemographic characteristics, biobehavioral risk factors, and clinically significant symptoms of depression, these associations were completely attenuated. In women, the corresponding unadjusted hazard ratios were 2.25 (95% CI, 1.66–3.06) and 1.55 (95% CI, 1.12–2.13), respectively. The corresponding fully adjusted hazard ratios were 1.47 (95% CI, 1.04–2.06) and 1.24 (95% CI, .91–1.70).
Conclusions
Somatic symptoms of anxiety were robustly associated with an increased risk of CHD in women. This finding lends support to the physiological pathway for the association between psychological factors, anxiety in particular, and CHD.
doi:10.1016/j.biopsych.2009.07.040
PMCID: PMC2963017  PMID: 19819425
Coronary heart disease; dimensions of anxiety; epidemiology
24.  Association of socioeconomic position with health behaviors and mortality. The Whitehall II study 
Context
Previous studies may have underestimated the contribution of health behaviors to social inequalities in mortality because health behaviors were assessed only at the baseline of the study.
Objective
To examine the role of health behaviors in the association between socioeconomic position and mortality and compare whether their contribution differs when assessed at only one point in time to that assessed longitudinally through the follow-up.
Main outcome measures
All-cause and cause-specific mortality.
Design, Setting, and Participants
Participants are drawn from the British Whitehall II longitudinal cohort study, established in 1985 on 10,308 London based civil servants, aged 35–55 years. Analyses are based on 9,590 men and women followed for mortality until 2009. Socioeconomic position was derived from civil service employment grade (high, intermediate and low) at baseline. Smoking, alcohol consumption, diet and physical activity were assessed four times over the follow-up.
Results
654 participants died during the follow-up. In analysis adjusted for sex and year of birth, those in the low socioeconomic position had 1.60 times higher risk of death from all causes than those in the high position (a rate difference of 1.94 per 1000 person-years). This association was attenuated by 42% (95% CI, 21%–94%) when health behaviors assessed at baseline were entered into the model and by 72% (95% CI, 42%–154%) when they were entered as time dependent covariates. The corresponding attenuations were 29% (95% CI, 11%–54%) and 45% (95% CI, 24%–79%) for cardiovascular mortality and 61% (95% CI, 16%–425%) and 94% (95% CI, 35%–595%) for non-cancer non-cardiovascular mortality. The difference between the baseline only and repeated assessments of health behaviors was mostly due to an increased explanatory power of diet (from 7% to 17% for all-cause mortality), physical activity (from 5% to 21% for all-cause mortality) and alcohol consumption (from 3% to 12% for all-cause mortality). The role of smoking, the strongest mediator in these analyses, did not change when using baseline or repeat assessments (from 32% to 35% for all-cause mortality).
Conclusions
In a civil service population in London, there was an association between socioeconomic position and mortality that was substantially accounted for by adjustment for health behaviors, particularly when the behaviors were assessed repeatedly.
doi:10.1001/jama.2010.297
PMCID: PMC2918905  PMID: 20332401
25.  Health behaviors from early to late midlife as predictors of cognitive function: The Whitehall II study 
American Journal of Epidemiology  2009;170(4):428-437.
The authors examined associations of health behaviors over a 17-year period, separately and in combination, with cognition in late midlife in 5123 men and women from the Whitehall II study (United Kingdom). Health behaviors were assessed in early midlife (mean age=44 years, Phase 1, 1985–1988), in midlife (mean age=56 years, Phase 5, 1997–1999) and in late midlife (mean age=61 years, Phase 7, 2002–2004). A score of the number of unhealthy behaviors (smoking, alcohol abstinence, low physical activity, and low fruit and vegetable consumption) was defined as ranging from 0 to 4. Poor (defined as scores in the worst sex-specific quintile) executive function and memory in late midlife (Phase 7) were analyzed as outcomes. Compared to those with no unhealthy behaviors, those with 3–4 unhealthy behaviors at Phase 1 (Odds Ratio (OR)=1.84; 95% Confidence Interval: 1.27,2.65), Phase 5 (OR=2.38; 1.76, 3.22) and Phase 7 (OR=2.76;2.04,3.73) were more likely to have poor executive function. A similar association was observed for memory. Odds of poor executive function and memory were the greater the more times the participant reported unhealthy behaviors over the three phases. This study suggests that both the number of unhealthy behaviors and their duration is associated with subsequent cognitive function in later life.
doi:10.1093/aje/kwp161
PMCID: PMC2727179  PMID: 19574344
Adult; Alcohol Drinking; epidemiology; Cognition Disorders; epidemiology; Exercise; Female; Food Habits; Great Britain; epidemiology; Health Behavior; Humans; Life Style; Longitudinal Studies; Male; Memory Disorders; epidemiology; Middle Aged; Risk; Smoking; epidemiology; cognition, health behaviors, longitudinal studies, middle aged.

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