Patients with a history of myocardial infarction (MI) are often at risk for complications, including subsequent MI and death. Use of prognostic markers may aid in preventing these poor outcomes. Hyperuricemia is associated with increased risk for coronary heart disease (CHD) and/or mortality; however, it is unknown if serum urate (sUA) levels predict outcomes in patients with previous MI. The purpose of this study was to assess hyperuricemia as a biomarker of CHD outcomes in such patients.These were post hoc analyses of datasets from the Aspirin Myocardial Infarction Study, a 1:1 randomized, double-blind clinical trial, conducted from 1975 to 1979, that examined mortality rates following daily aspirin administration over three years in individuals with documented MI. The primary outcome measures were all-cause death, CHD mortality, coronary incidence, and stroke by quartile of baseline sUA. A sub-analysis of all outcome measures in the presence or absence of gouty arthritis was also performed.P < 0.01) for these outcomes. Participants with gout who were receiving treatment did not exhibit this additional risk.Of 4,524 enrolled participants, data on 4,352 were analyzed here. All outcomes were greatest for patients in the fourth sUA quartile. In multivariate regression models, the hazard ratios (HR) for patients in the highest quartile were 1.88 for all-cause mortality , 1.45 to 2.46), 1.99 for CHD mortality , and 1.36 for coronary incidence . Participants with untreated gout had an adjusted hazard ratio ranging from 1.5 to 2.0 (all sUA and untreated gout may be independent prognostic markers for poor all-cause and CHD mortality in patients with recent acute MI. In 2010, the estimated annual incidence of myocardial infarction (MI) in the US was 610,000 new attacks and 325,000 recurrent attacks ,5.Hyperuricemia is known to be correlated with a greater risk for coronary artery calcification, a surrogate measure of coronary atherosclerosis . Both asThis study was performed as a post hoc analysis using datasets from the Aspirin Myocardial Infarction Study (AMIS) , a National Heart, Lung and Blood Institute (NHLBI)-sponsored 1:1 randomized, double-blind clinical trial. It examined the hypothesis that daily administration of 1 g of aspirin orally in 2 divided doses to individuals with documented CHD would result in significantly reduced mortality over a three-year period [n = 2,267) or placebo  over a 13-month period at 30 clinical centers starting in 1974. Main inclusion criterion was presence of documented MI. The main exclusion criteria included history of aspirin intolerance, severe peptic ulcer disease, previous cardiovascular (CV) surgery, uncontrolled hypertension, and use of anticoagulants, aspirin, dipyridamole, or sulfinpyrazone. The study also followed participants for a minimum of three years for mortality outcomes and non-fatal CHD events. Subcommittees of investigators adjudicated CV and mortality outcome assessments in a standardized manner. Enrollees reported to clinical centers every four months except the first post-randomization visit that occurred at the end of month one. Participants were educated about avoiding aspirin and aspirin-containing over-the-counter medications; acetaminophen was suggested for analgesic use. The last study visit in the trial was August 6, 1979, when all study medications were discontinued and treatment assignment was revealed.The design of the AMIS has been described previously . In brien = 2,169 in the aspirin group; n = 2,183 in the placebo group; n = 4,352 overall). The analysis also utilized annual follow-up data from all participants. The outcome definitions were similar to those of AMIS: 1) all-cause mortality; 2) CHD mortality, defined as death from definite MI documented by electrocardiogram and enzyme changes or autopsy, deaths suspected to be due to MI, and sudden unexpected deaths ; 3) coronary incidence, defined as CHD mortality or non-fatal MI; and 4) fatal or non-fatal stroke [The present analysis included data from all participants with information on sUA at baseline  can be calculated by multiplying by 59.48. The covariates used in the present analyses were age, gender, African American ethnicity, body mass index, blood pressure/hypertension, smoking, diabetes status, physical activity measure, hyperlipidemia, hypertriglyceridemia, renal function, and other non-steroidal anti-inflammatory drug use. Participants who were actively treated for diabetes, hypertension, and hyperlipidemia were considered to have those conditions.Chi-square tests were used to assess statistical significance between cumulative incidences of outcomes by study group. For primary analyses, we used multivariable Cox regression models to generate hazard ratios (HR) after ensuring the condition of proportionality was met. In these regressions, time to the event was modeled as a function of baseline sUA concentration. Since the lifetime duration of hyperuricemia was unknown, we recognized that the Cox models may be subject to left censoring and the data were reanalyzed using logistic regression models. The results of logistic regression models did not differ from Cox models--the latter are presented here.Baseline characteristics of the study group stratified by quartile of sUA concentration are presented in Table P < 0.05).Quartiles of sUA concentrations were defined following baseline measurements at randomization Table . The meaP < 0.001), CHD mortality with a hazard ratio of 1.24 , and coronary incidence with a hazard ratio of 1.12 ; this trend was not statistically significant for stroke .Cox regression models were used to calculate HRs per quartile of sUA for each outcome. Since there was no difference between the aspirin and placebo groups in terms of risk by sUA quartile, these data were subsequently pooled. Table P < 0.001 for all gout groups compared with patients without gout; Table Records of all study participants were utilized for subgroup analysis of study outcomes by gouty arthritis. Mean baseline sUA was 6.06 ± 1.33 mg/dL in participants without gout, 7.18 ± 1.80 mg/dL in participants with gout and on gout medications, and 7.00 ± 1.66 mg/dL in participants with gout not receiving gout medication . Notably, risk for all study outcomes in patients treated with gout medications was indistinguishable from that of patients without gout. However, those with gout not receiving gout medications had significantly higher risk for all-cause death , P < 0.05), CHD mortality , P < 0.01), and coronary incidence , P < 0.05), compared with patients without evidence of gout.Table The novelty of this study lies in the selection of the previously unstudied, yet high-risk, population of patients with existing coronary artery disease, and in the observed disparities in the outcomes with respect to gout treatments. Our observations that the patients with untreated gout have a significantly increased risk for all-cause death, CHD mortality, and coronary incidence and that participants with gout on treatment had risk comparable to those of participants without gout are important, yet must not be over-interpreted, given the modest sample size. As previously mentioned, the association between gout and the risk for CV outcomes is well recognized. The results reported here provide yet another reason for improving the treatment of gout ,14.P = 0.0009) [et al. in which post-MI risk for poor outcomes was predicted by sUA [Findings from this present study support the potential use of sUA as a biomarker for mortality outcomes in adult patients with pre-existing MI. Among participants of the AMIS Study, there is an association between sUA and risk of all-cause death, CHD mortality, and coronary incidence in individuals with a history of MI. Similar results were reported in a recent Israeli study, where, among 2,966 patients with documented CHD followed for 6.2 years, including those with a history of MI in the 6 months to 5 years prior to enrollment, there was a significant and positive correlation between the occurrence of fatal MI, nonfatal MI, or sudden cardiac death and increasing baseline sUA ( 0.0009) . These rd by sUA .Among patients with a history of heart failure (HF), a history of gout increased the risk of readmission due to HF or death by 63%, and recent acute gout (within 60 days) doubled the risk for HF readmission or death and increased the risk for all-cause mortality by 76%, after adjusting for confounders . Of inteAt low doses (less than 1 g per day), aspirin reduces urate excretion in the kidney . At the In vitro studies have demonstrated that soluble uric acid promotes inflammation [The causal relationship between uric acid, gout, and the pathogenesis of CHD is under investigation. A growing body of literature, comprehensively reviewed elsewhere , points ammation , generatammation  and leadammation . The preammation  providesammation . Uric acammation .While the above evidence suggests a direct role for uric acid in the progression of CVD, other data suggest that the oxidative stress may be due to the activity of xanthine oxidase (XO), of which sUA is a marker. Urate lowering therapy (ULT) with allopurinol reduced the level of oxidized LDL in gout patients, while treatment with benzbromarone did not . In patiImportant caveats are due. First, the results on gout treatment and improved cardiovascular outcomes should be treated as hypothesis generating and not causative, since channeling bias  can make it impossible to assess the true impact of ULT. Another piece of evidence suggesting a non-random 'allocation' of therapy might be the serum urate concentrations. The fact that serum urate concentration is not lower in the treated group suggests that these individuals had higher serum urate/more severe gout to begin with. With such a bias, the mortality benefit associated with urate lowering might be an underestimate. Another data-related issue is our inability to exclude colchicine from urate lowering therapies. Our study examined risk factors for coronary events among those who survived such an event in the past. The influence of survivor effect and the importance of lifestyle modification following a diagnosis of coronary artery disease is difficulty to model in our study. Another important facet of this study is that it was performed in the 1970s, before the advent of current sophisticated diagnostic tools to detect subtle coronary syndromes. The patients with MI included in the trial are likely to be survivors from a more definitive, more severe, acute myocardial infarction. In that context there is a survival bias in that these individuals are likely to be hardier than those who survive a non-ST-elevation acute myocardial infarction. Nevertheless, the outcome we studied, mortality, was applied uniformly across all strata of urate levels as well as gout status, and arguably there were no differential biases.Other factors can be expected to attenuate the relationship between hyperuricemia and gout and coronary events. When multiple risk factors contribute to the risk of an outcome, the risk factors for the recurrence of the event tend to be correlated with each other leading to index event bias. This bias could have resulted in the underestimation of the true relationship between hyperuricemia and gout and coronary events in our study. Our study data did not have the granularity or statistical power to discern any differences by the type of gout medication used. Finally, the effect of residual confounding by unobserved and unadjusted risk factors could not be estimated in our study.The data presented here suggest that hyperuricemia is an independent predictor of all-cause and CHD mortality, as well as coronary incidence, in individuals with confirmed CHD. Analysis of sUA levels in patients following MI may be a reliable and inexpensive method for distinguishing patients at risk for mortality. Measurement of sUA levels may contribute to existing strategies that stratify risk for secondary CHD events, including mortality, in patients with previous MI.ACS: acute coronary syndrome; AMIS: Aspirin Myocardial Infarction Study; CHD: coronary heart disease; CI: confidence interval; CRP: C-reactive protein; CVD: cardiovascular disease; HR: hazard ratio; LDL: low density lipoprotein; MI: myocardial infarction; NHLBI: National Heart Lung Blood Institute; sUA: serum urate; ULT: urate lowering therapy; XO: xanthine oxidase.Eswar Krishnan has received honoraria, research grants, ad-board fees or consulting fees from the following entities: Ardea Biosciences, URL Pharma, Metabolex, Takeda Pharmaceuticals and Savient Pharmaceuticals. Dr Krishnan has held common stocks for Savient Pharmaceuticals in the recent past. Drs Hariri and Dabbous are employees of Takeda, Inc. Dr Pandya was an employee of Takeda at the time of performance of this work.Dr Lingala has no conflicts of interest to declare.Proprietary products manufactured by these companies are not discussed in this manuscript.The data used for these analyses were obtained from the NHLBI Limited Access program. EK conceived the manuscript idea, designed the analysis plan, performed statistical analysis, interpreted the results, and wrote the first draft of the manuscript with assistance from other authors. He has possession of raw data sets and takes responsibility for the integrity of the data and the accuracy of the data analysis. Takeda Pharmaceuticals International, Inc. did not have access to the raw data and Takeda authors contributed primarily to refinement of study design, interpretation of data, editing, and revisions to the initial drafts. Editing and bibliography assistance on earlier versions of this manuscript was provided by Kristen Wieghaus Quinn, PhD, and Meryl Gersh, PhD, of AlphaBioCom, LLC, in Radnor, PA, and was funded by Takeda Pharmaceuticals, Inc. The authors had complete authority over the content and received no financial remuneration for the article. All authors have read and approved the manuscript for publication.


Viral hemorrhagic fevers (VHF) are acute diseases associated with bleeding, organ failure, and shock. VHF may hardly be distinguished clinically from other diseases in the African hospital, including viral hepatitis. This study was conducted to determine if VHF and viral hepatitis contribute to hospital morbidity in the Central and Northern parts of Ghana.From 2009 to 2011, blood samples of 258 patients with VHF symptoms were collected at 18 hospitals in Ashanti, Brong-Ahafo, Northern, Upper West, and Upper East regions. Patients were tested by PCR for Lassa, Rift Valley, Crimean-Congo, Ebola/Marburg, and yellow fever viruses; hepatitis A (HAV), B (HBV), C (HCV), and E (HEV) viruses; and by ELISA for serological hepatitis markers. None of the patients tested positive for VHF. However, 21 (8.1%) showed anti-HBc IgM plus HBV DNA and/or HBsAg; 37 (14%) showed HBsAg and HBV DNA without anti-HBc IgM; 26 (10%) showed anti-HAV IgM and/or HAV RNA; and 20 (7.8%) were HCV RNA-positive. None was positive for HEV RNA or anti-HEV IgM plus IgG. Viral genotypes were determined as HAV-IB, HBV-A and E, and HCV-1, 2, and 4.VHFs do not cause significant hospital morbidity in the study area. However, the incidence of acute hepatitis A and B, and hepatitis B and C with active virus replication is high. These infections may mimic VHF and need to be considered if VHF is suspected. The data may help decision makers to allocate resources and focus surveillance systems on the diseases of relevance in Ghana. Ghana is endemic for yellow fever and lies between two Lassa fever endemic areas — Guinea, Liberia, Sierra Leone, and Mali in the West, and Nigeria in the East. Ebola hemorrhagic fever has been documented in the neighboring Cote d'Ivoire. Thus, it is plausible that the latter VHFs also occur in Ghana, and there have been rumors of cases, which present like VHF in the north of the country. Our study aimed at verifying or disproving this suspicion. At 18 hospital-based study sites in the Central and Northern part of the country, samples from 258 patients with VHF symptoms were collected and tested for various VHF by PCR. As viral hepatitis is an important differential diagnosis of yellow fever, we also tested for several serological and molecular hepatitis markers. Rather surprisingly, VHFs were not detected, indicating that, even if they are endemic in the North of Ghana, they do not significantly contribute to hospital morbidity. However, a large fraction of patients showed markers of acute hepatitis A, and active hepatitis B and C. Children were mainly affected by hepatitis A, while adults were affected by hepatitis B and C. Hepatitis A and B are vaccine-preventable, and chronic hepatitis B and C are treatable diseases. Further efforts are needed to reduce the burden of these diseases in Ghana. Filoviridae (Ebola and Marburg virus), Arenaviridae (Lassa virus), Bunyaviridae , and Flaviviridae (yellow fever [YF] virus). The case fatality rate depends on the causative virus and may be as high as 90% Viral hemorrhagic fevers (VHF) are acute viral diseases associated with bleeding, organ failure, and shock. The syndrome is caused by RNA viruses belonging to the families Several VHFs are endemic in West Africa, such as Lassa fever For several years, there have been anecdotic reports of cases presenting with VHF symptoms in the north of the country. The scarcity of reliable data on suspect cases is in part due to the lack of diagnostic tools and active surveillance systems. Therefore, we established PCR diagnostics for VHF at Noguchi Institute and conducted a hospital-based surveillance study to determine the etiology of illnesses presenting with VHF symptoms in the north of Ghana. In addition, viral hepatitis being an important differential diagnosis of hemorrhagic fevers was included in the study.The study was approved by the Institutional Review Board of the Noguchi Memorial Institute of Medical Research (NMIMR-IRB 003/07-08). All subjects provided written informed consent.The study was carried out from 2008 through 2011 at 18 hospitals in the Ashanti, Brong-Ahafo, Northern, Upper West, and Upper East regions in the Central and Northern sectors of Ghana . In totaA blood specimen was taken and basic clinical and demographic data were recorded on the case investigation form. Serum was separated by centrifugation. If a centrifuge was not available, blood was kept in the refrigerator until there was complete retraction of the clot and serum could be removed. Serum was stored in the refrigerator for a maximum of one week at the study site and transported in a cool box with ice packs to the laboratory at Noguchi Memorial Institute. In the laboratory, sera were stored at −20°C.Viral nucleic acid was extracted from 140 µl serum using the QIAamp viral RNA kit (Qiagen). All PCR assays were performed in a volume of 25 µl with 2.5 µl or 5 µl nucleic acid extract as a template. Nested PCRs contained 1 µl PCR product of the first round RT-PCR as a template. Reagents, cycle numbers, primer sequences, target region, and amplicon length are shown in Serological tests for HAV, HBV, and HEV were performed in 96-well ELISA format using commercially available kits according to the manufacturer's instructions: HAV IgM ELISA , HBsAg one Version Ultra , HBc IgM , and RecomWell HEV IgG and IgM .Serum levels of total protein, albumin, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), amylase, creatinine, and urea nitrogen were determined with a Spotchem EZ SP-4430 analyzer  at room temperature. Samples had been stored for ≥3 years at −20°C before analysis. Reference values were defined according to Kratz et al. 7 steps with sampling every 104th step; and 3 independent runs combined .PCR products generated in the conventional PCRs were sequenced on both stands using the PCR primers. The sequences were assembled using Lasergene software (DNASTAR) and automated base calling was proofread by visual inspection of the electropherograms. Phylogenetic analysis included the novel sequences of HAV , HBV , and HCV  as well as sequences available from GenBank by December 2012. Three categories of GenBank entries were retrieved: (i) sequences with close relationship to the novel sequences as determined by BLAST search, (ii) sequences from Ghana, and (iii) representative sequences of genotypes and sub-genotypes Quantitative variables were analyzed using non-parametric descriptive statistics and statistical tests. Statistical comparison of unpaired groups was performed for continuous parameters with the Mann–Whitney U test and for frequencies with two-tailed Fisher's Exact test. A critical p value of 0.01 was considered appropriate, given that several tests were performed on the data set. If a study participant had missing data for a specific variable, he/she was excluded from the analysis of this variable, but not of the other variables. Relative frequencies (e.g. in %) for a variable were calculated with the denominator: group size minus number of participants with missing data for this variable.A representative set of 6 HAV, 28 HBV, and 10 HCV sequences has been sent to GenBank and assigned the accession nos. KC632110–KC632153.The project started in 2008 with a pilot study involving 27 patients. VHF was not detected, but 7 (26%) patients had acute hepatitis B or an exacerbation of chronic hepatitis B as evidenced by presence of HBV DNA, HBsAg, and anti-HBc IgM or seroconversion to HBsAg/HBV DNA-positive. Therefore, the design of the main study was adjusted to incorporate a wider range of tests for viral hepatitis.The main study was conducted from 2009 to 2011 and included 258 patients from 18 study sites. The number of patients per site ranged from 1 to 72  with a diagnosis of viral hepatitis . AlthougTo determine the genotype of HAV, HBV, and HCV circulating in the study area, the PCR products were sequenced and subjected to phylogenetic analysis . The GhaThis study was conducted to determine if VHF or other infectious diseases presenting with similar symptoms are of medical importance in Central and Northern areas of Ghana. The main conclusion from our data is that VHF hardly contributes to hospital morbidity in the study area indicating a low incidence of severe VHF. This does not prove that VHF is absent and in fact, YF is endemic in the country and cases may be seen at any time. In addition, mild VHF cases may not attend the hospital. Instead of VHF, a high incidence of viral hepatitis was found.conditio sine qua non, as patients presenting in the terminal stage of Lassa fever — and probably other VHFs as well — are often normo- or hypothermic The case definition to screen for potential VHF patients was intentionally broad. On the one hand, clinical complications of VHF can mimic other diseases Whether the diagnosed HAV, HBV, or HCV infections actually caused the clinical symptoms is difficult to prove. As the study was focused on diagnostic aspects, only minimal clinical information was collected and additional invasive or non-invasive diagnostic procedures were not performed. However, the retrospective analysis of clinical chemistry parameters provides some clues. For patients positive for anti-HAV IgM and/or HAV RNA or anti-HBc IgM plus HBV DNA, there is little doubt that the clinical symptoms are due to HAV or HBV infection, respectively. Anti-HBc IgM is a classical marker of acute or fulminant hepatitis B, but may also indicate an acute exacerbation of chronic hepatitis A large fraction of study patients showed HBsAg and HBV DNA without being anti-HBc IgM positive, suggesting chronic hepatitis B with active virus replication. The clinical chemistry data show that about 60% of these patients had liver damage . Similarly, about 85% of patients with active HCV infection, as evidenced by virus detection, had biochemical evidence of liver damage . In particular, AST and LDH levels were elevated and albumin levels were decreased in both groups. Thus, it is plausible that a large fraction of anti-HBc IgM-negative hepatitis B patients and hepatitis C patients attended the hospital due to the related liver disease. However, superinfection by another pathogen may not be excluded as cause of the disease.http://www.afro.who.int/en/ghana/country-programmes/3215-expanded-program-of-immunisation-epi.html). An immunization coverage survey conducted in 2008 showed a national coverage for the third dose (Penta 3) of 72% (range 40 to 89% at district level) Acute hepatitis A and B may lead to fulminant liver failure in a small fraction of patients The vast majority of hepatitis A patients were young children. This is consistent with the known epidemiology of this infection. HAV is transmitted by the fecal-oral route, e.g. via contaminated food or water. In the developing world, infections are most frequently acquired during early childhood, resulting in a high proportion of adults that are immune to HAV The prevalence of HBsAg carriers among blood donors in the Northern and Ashanti regions is 11% The incidence of hepatitis B in the study hospitals of the Northern region and the Upper West & East regions was higher and lower, respectively, relative to the control group of patients without diagnosis. We have no good explanation for this finding. The three regions are the poorest of the country and comparable with respect to many indicators A few patients showed serological markers of HEV infection. However, all PCR assays were negative, HEV immunoassays are prone to false reactivity Though a minor aspect of our study, the phylogenetic analysis revealed some peculiarities of HAV, HBV, and HCV strains circulating in Ghana. All HAV strains are closely related to each other and belong to genotype IB, though the patients originate from Ashanti, Brong-Ahafo, Northern, or Upper West region. This suggests that a predominant HAV strain circulates in large parts of Ghana. In agreement with previous reports from Ghana and other West African countries Checklist S1STROBE checklist.(PDF)Click here for additional data file.


The Day Reconstruction Method (DRM) was developed to assess affective states as measures of experienced well-being. The present study aimed to validate an abbreviated version of the DRM in a representative sample of the population in seven countries , and to examine whether there are country differences in affect and in the relationships among the activities based on the similarity of the affect associated with each of them.Interviews were conducted with 47,222 non-institutionalized adults from seven countries, using an abbreviated version of the DRM. A cluster analysis was carried out to classify activities on the basis of the similarity of the associated affect. In each country, the factorial structure of the affect adjectives was tested through Confirmatory Factor Analysis. Internal consistency and construct validity were also assessed. Moreover, the differences in affect across countries and the diurnal cycles of affect were evaluated.The DRM showed adequate psychometric properties regarding reliability and construct validity in all countries. Respondents from Ghana and South Africa reported more positive net affect whereas Indian respondents reported less positive net affect. Most of the countries showed a similar diurnal variation of affect, which tended to improve throughout the day.The results show that this abbreviated version of the DRM is a useful tool for multi-country evaluation of experienced well-being. The Day Reconstruction Method (DRM) et al.Kahneman This original self-administered paper-and-pencil version of the DRM takes 45–75 minutes to complete Due to time and economic constraints, most national comparisons of well-being assess evaluative well-being based on global life satisfaction or general happiness questions Experienced well-being is perhaps a more challenging construct to measure. In recent years, some attempts have been made to evaluate experienced well-being in larger samples. Krueger and Stone A brief measure of experienced well-being that could be used in large national representative survey samples could overcome the logistical barriers needed to generate comparable data on well-being across countries worldwide. One example of an abbreviated version of the DRM that can be used in large population surveys, irrespective of literacy levels and the ubiquity of telephones, has been recently validated in Jodhpur, India as part of the World Health Organization's Study on Global Ageing and Adult Health (SAGE) The present study aimed to validate this abbreviated version of the DRM in a representative sample of the population of seven countries, and to examine whether country differences exist in affect and in the activity-affect relationships.The data were obtained from SAGE and the Collaborative Research on Ageing in Europe (COURAGE in Europe), which are two multi-country projects compiling comprehensive data on the health and well-being of adult populations and the ageing process. Both studies collected data on respondents aged 18+ years, with an emphasis on populations aged 50+ years, from nationally representative samples. The data from Spain presented in the present paper come from COURAGE in Europe, whereas the data from the other six countries come from SAGE. The details of the design and methods for SAGE are published elsewhere The sample consists of 47,222 non-institutionalized adults aged 18-plus years from China , Ghana (5108), India , Mexico (2742), Russia (4355), South Africa (4223), and Spain (4753). Face-to-face interviews were conducted at the respondents' homes by trained interviewers. The individual response rate ranged from 53% in Mexico to 93% in China.http://www.who.int/healthinfo/systems/sage/en/index.html) used to obtain information about participants' daily activities and their subjective well-being, was limited to a maximum of 15 minutes of interview time. Respondents were asked to reconstruct a portion  of their previous day's activities, and reported the positive and negative emotions associated with each activity. The data provided a picture of the participants' daily lives, including what they did, for how long, and who they were with, as well as a way of calculating how much of their time was spent feeling pleasant or unpleasant emotions.Respondents were also asked to provide demographic information  at the beginning of the interview. The abbreviated version of the Day Reconstruction Method Respondents were randomly assigned to complete one of the four different versions of the abbreviated DRM . In sets A, B and C, respondents reconstructed only a portion of their previous day's activities  and responded to questions about each episode, including the nature of the activity , any people who were present , and the extent to which they experienced various feelings–worried, rushed, irritated or angry, depressed, tense or stressed, calm or relaxed, and enjoying on a 3-point response scale . In the sample from Spain, the scale ranged from 0  to 6 (very much) with the remaining points unlabeled. In set D, participants reported the activities, people present, and feelings for each part of the day  altogether, instead of activity by activity along with the respective accompanying emotion. In sets A, B and C, the day was recorded in an event-by-event manner, and the participants reported the time at which the first activity registered started and the duration of each activity. This information was used to estimate the affective state at each hour of the day. Set D recorded broadly what was done in the morning, afternoon, and evening, and therefore the duration of each activity was not reported. Set D was not used in Spain.Two measures were calculated based on the scores obtained with the seven affect items: net affect and U-index The questions were translated from English into the local languages, following the WHO translation guidelines for assessment instruments. This included a forward translation, a targeted back-translation, review by a bilingual expert group and the elaboration of a detailed translation report. Ethical approvals from the following institutions were obtained: Ethics Review Committee, World Health Organization; Ethics Review Committee, Parc Sanitari Sant Joan de Déu, Barcelona, Spain; Ethics Review Committee, La Princesa University Hospital, Madrid, Spain; Ethical Committee, Ghana Medical School, Accra, Ghana; Ethics Committee, OPM , Russian Academy of Medical Sciences, Moscow, Russia; Ethics Committee, Shanghai Municipal Centre for Disease Control and Prevention, Shanghai, China; Institutional Review Board, International Institute of Population Sciences, Mumbai, India; Research Ethics Committee, Human Sciences Research Council, Pretoria, South Africa; and Ethics Committee, National Institute of Public Health (INSP), Cuernavaca, Mexico. Written informed consent from each participant was also obtained.t-tests (continuous variables) and χ2 tests .The sociodemographic characteristics of respondents were recorded for each country. Differences in sociodemographic characteristics between the final and the excluded sample were assessed by means of unpaired p-values were calculated. The p-value of a cluster is a value between 0 and 1, which indicates how strong the cluster is supported by the data. The pvclust package provides two types of p-values: Approximately Unbiased (AU) p-value and Bootstrap Probability (BP) value before statistical adjustments were reported. AU p-value, which is computed by multiscale bootstrap resampling, is a better approximation to unbiased p-value than the BP value computed by normal bootstrap resampling. Clusters strongly supported by the data (with AU higher than 95%) were highlighted by rectangles.Descriptive analyses generated mean scores of positive and negative adjectives  for the different activities. Based on these means, a cluster analysis was carried out in order to identify the relationships among the activities coded in the DRM in each country, according to the similarity of the activity-affect relationship. Variables were standardized, and the Euclidean distance was employed as a dissimilarity measure. Divisive hierarchical clustering method was used. The average linkage method was chosen because it maximizes the cophenetic correlation coefficient (CCC) 2; b) comparative fit index (CFI)>0.95; c) Tucker-Lewis index (TLI)>0.95; d) root mean square error of approximation (RMSEA)<0.08; and e) weighted root mean square residual (WRMR)<1.0. Since the χ2 statistic is sensitive to sample size 2 values might be inflated  due to the large size of the sample, which might erroneously imply a poor data-to-model fit In each country, the factorial structure (negative versus positive items) of the seven adjectives was tested through Confirmatory Factor Analysis (CFA) for categorical outcomes, with the robust weighted least square estimator , and using polychoric correlations In sets A, B and C, the affective state associated with each activity was coded. Because the affective state was not reported for each activity in set D, cluster analysis and CFA were carried out only with the activities reported in sets A, B and C, pooling the data corresponding to these sets.Reliability was assessed in terms of internal consistency using the Raykov & Marcoulides V for contingency table chi-square tests, Hedges' g for unpaired t-tests and pairwise comparisons, and Cohen's f for ANOVA tests) are reported. Cohen's guidelines were used as a reference g values of 0.20, 0.50, and 0.80 constitute small, medium, and large effect sizes, respectively; these values are, respectively, 0.10, 0.25, and 0.40, in case of Cohen's f; and 0.10, 0.30, and 0.50, in case of Cramer's V for chi-square test for 2×2 contingency tables. Cluster analyses were carried out using R version 2.10.1 Diurnal variation of affect was assessed in each country, using the affective state reported by respondents in each hour of the day. This information was calculated for each participant assigned to sets A, B, and C based on the time at which the first activity reported began and the duration of each activity. Cross-country differences in net affect and U-index were tested by an ANOVA test. Bonferroni tests for post-hoc pairwise comparisons were used. 95% confidence levels were considered in hypothesis tests. Since statistical significance of differences could be due to the large sample size, effect size measures , mean age (58.06 (s.d. = 14.84) vs. 59.43 (s.d. = 17.74), p<0.001, Hedges' g = 0.09), percentage of people married or in partnership , or percentage of people currently working .A total of 47,222 people from China, Ghana, India, Mexico, the Russian Federation, South Africa, and Spain were interviewed. However, 1564  were removed from these analyses because they did not answer the subjective well-being section analyzed in the present article. The respondents excluded from the survey did not differ  by sex  were collected from participants who answered sets A, B, and C. The activity “went to sleep for the night” was excluded from the cluster analyses because the affective state was not coded for this activity.The average linkage method presented a good value for CCC in each country. CCC values ranged from 0.73 in Russia to 0.98 in South Africa. The clusters edges in  with higConsidering the activities reported in sets A, B and C, a CFA was carried out by country to examine the construct validity and to test whether the factorial structure of affect was comprised of two factors: negative items loading on one factor and positive items loading on the other. Adequate fit indices, indicating satisfactory model fit, were found for all the countries, pooling sets A, B and C in each of them. In all cases, CFI and TLI values were higher than 0.98. RMSEA values ranged from 0.026 to 0.074. Moreover, in each group and subgroup, the upper boundaries of 90% confidence intervals were always lower than 0.080. These findings suggest that a two-factor model (negative affect and positive affect) can be considered a plausible hypothesis for the initial seven-item instrument in each country.p-values of the null hypothesis that in the studied population the pertinent factor loading was zero. Factor correlation was negative and significant in all cases, with values ranging from −0.374 in Mexico to −0.753 in South Africa. The values associated with composite reliability in the two factors suggested an adequate reliability for the DRM in all the countries considered. Composite reliability values for negative affect ranged from 0.770 in India to 0.911 in Spain, whereas values ranging from 0.700 in Russia to 0.893 in China were found for positive affect.The results of the model shown in In set D, the affect was coded for each part of the day, not separated by activity, so CFA and reliability analyses were carried out separately for each country, pooling the responses in the morning, afternoon and evening. The results in g = 1.00), Mexico (Hedges' g = 0.92), and Russia (Hedges' g = 0.91). Similar results were found for the U-index, with lower values for South Africa, Spain, China, and Ghana, and higher values for India, Mexico, and Russia , ranging from 2.5 in Mexico to 6.0 in Spain; average episode duration was 85.7 minutes (s.d. = 68.9), ranging from 60.5 in India to 146.4 in Mexico.As shown in Positive affect showed a similar pattern as net affect . In someNegative affect was most pronounced in the morning and tended to decrease as the day passed, although in most countries (except China) it rose in the evening. Mexico showed a different pattern, with negative affect increasing as the day passed.The present study's results show that this abbreviated version of the DRM is a useful tool for multi-country studies evaluating experienced well-being. This study confirms that the abbreviated version of the DRM tested showed adequate psychometric properties regarding reliability and construct validity in the seven countries. The cluster of activities varied in each country, although the results showed a tendency to form two groups of activities: one group comprising work and household activities and therefore with a lower net affect, and another one mainly comprising leisure activities, with a higher associated net affect.et al.The results obtained from the fitted CFA model support the two-factor hypothesis regarding the seven affective state items of the DRM, with worried, rushed, irritated/angry, depressed, and tense/stressed loading on the negative affect factor, and calm/relaxed and enjoying loading on the positive affect factor. Lucas Ghana and South Africa presented the highest net affect, whereas India showed the lowest net affect. Regarding the diurnal variation of affect, all countries showed a similar pattern, with the exception of Mexico. In general terms affect improved as the day passed (positive affect increased and negative affect declined), and in the evening it worsened (positive affect declined and negative affect increased). Previous studies in the United States with the Experience Sampling Method and the DRM have also found similar patterns regarding the diurnal rhythms of affect, with negative affect falling for most of the day et al.Regarding the feasibility of use, this is a much shorter version of the DRM, since it is designed to last a maximum of 15 minutes of interview time, whereas completion times for the self-administered original DRM instrument This instrument can therefore be used to measure everyday experiences and activities and can be useful in social and health research to analyze the associations between affective states in everyday life and behavior, such as time use, or underlying biological processes One of the strengths of the present study is its large sample size and the fact that the recruited sample included geographically and socio-economically diverse participants who are representative of each country's population. Nevertheless, large sample sizes can mean that small differences are detected as statistically significant. For this reason, in the present study effect sizes were calculated to describe the magnitude of the differences.The results of this study should be interpreted taking into account some limitations. Convergent validity and test-retest reliability were not assessed. However, the convergent validity of the DRM has been previously shown to be appropriate when compared with the Ecological Momentary Assessment Figure S1Cluster dendrograms of activities in the DRM with AU/BP values. Analyses separated for each country.(TIFF)Click here for additional data file.


Retrovirology has moved to the forefront of virology journals in Impact Factor.Nine years after its founding,  Retrovirology employing the then “new way” of publishing [Retrovirology was not the first journal that I helped found. Ten years earlier, in 1994, I was one of nine editors, led by Dr. Chuan C. Chang, who started the Journal of Biomedical Science[Journal of Biomedical Science originated as a subscription-based journal; thus, when Retrovirology began I understood the difference between a publishing model based on subscription (readers/subscribing libraries and institutions pay) versus Open Access .In 2004, during the early days of Open Access, I had the opportunity to start blishing . RetroviRetrovirology’s success. The first was whether Open Access would be a sustainable business model. In those days, this was an unknown. Today, the increasing popularity of journals like PLoS ONENature’s Scientific Reports (http://www.nature.com/srep/index.html)Cell Reports (http://www.cellreports.cell.com)Cell and Bioscience[Journal of the International AIDS Society (http://www.jiasociety.org/index.php/jias), and the recent migration of journals such as EMBO Molecular Medicine from a subscription to an Open Access format indicate that the latter business model has achieved financial traction, if not overt profitability.At the outset, there were two challenges to ioscience, JournalRetrovirology will never reach the Impact Factors of the Journal of Virology, Virology, and the Journal of General Virology!” In retrospect, they were wrong; Retrovirology achieved and surpassed those metrics. Indeed, in the 2011 tabulation of Impact Factor and Immediacy Index, Retrovirology placed ahead of the Journal of Infectious Diseases, AIDS, JAIDS, J Virol., Virology, J Gen Virology; and two established standards of molecular biology and biochemistry, the Journal of Molecular Biology and the Journal of Biological Chemistry  [Retrovirology’s Open Access format was particularly instrumental in permitting interested individuals, who were not career scientists, to freely, rapidly, and fully access those paradigm-changing peer-reviewed publications.Impact Factor and Immediacy Index are two of several proxies of a journal’s quality, and one should interpret cautiously their meaning . Arguablme (CFS) -10. In tRetrovirology’s strong progress forward is owed to the efforts of its board members (http://www.retrovirology.com/about/edboard).Increasing data support the absence of inherent reasons for qualitative difference between papers published in subscription versus Open Access journals . In my v


To elucidate whether repeated exposures to iodinated contrast media increase the risk of adverse reaction.We retrospectively reviewed 1,861 patients with hepatocellular carcinoma who visited authors’ institution, a tertiary referral center, between 2004 and 2008. We analyzed cumulative probability of adverse reactions and risk factors. We categorized all symptoms into hypersensitivity reactions, physiologic reactions, and other reactions, according to the American College of Radiology guidelines, and evaluated each category as an event. We estimated the association between hazard for adverse reactions and the number of cumulative exposures to contrast media. We also evaluated subsequent contrast media injections and adverse reactions.th, 20th, and 30th examination was 7.9%, 15.2%, and 24.1%, respectively. Presence of renal impairment was found to be one of risk factors for adverse reactions. The estimated hazard of overall adverse reaction gradually decreased until around 10th exposure and rose with subsequent exposures. The estimated hazard of hypersensitivity showed V-shaped change with cumulative number of exposures. The estimated hazard of physiologic reaction had a tendency toward decreasing and that of other reaction had a tendency toward increasing. Second adverse reaction was more severe than the initial in only one among 130 patients receiving subsequent injections.There were 23,684 contrast media injections in 1,729 patients. One hundred and thirty-two patients were excluded because they were given no contrast media during the study period. Adverse reactions occurred in 196 (0.83%) patients. The cumulative incidence at 10Repeated exposures to iodinated contrast media increase the risk of adverse reaction. Hepatocellular carcinoma (HCC) is the sixth most prevalent cancer and the third most frequent cause of cancer-related death  and the The non-ionic CM have lower osmolality and tend to have fewer side effects, while retaining satisfactory radiographic opacification ,7, and aAlthough the etiology of many or most hypersensitivity reactions is unknown, an allergic-like mechanism appears to be engaged in some patients because allergic individuals or patients with asthma are considered to be at an increased risk for developing AR . TherefoThe aim of this study was to evaluate the risk factors for AR to non-ionic iodinated CM, among a large number of contrast-enhanced computed tomography (CT) examinations and, and to elucidate whether repeated exposures to CM increase the risk of AR upon subsequent exposure in patients with HCC.http://gastro.m.u-tokyo.ac.jp/med/0602A.htm) and participants who do not agree to the use of their clinical data can claim deletion of them.This retrospective study was conducted according to the ethical guidelines for epidemiological research designed by the Japanese Ministry of Education, Culture, Sports, Science and Technology and Ministry of Health, Labour, and Welfare. The study design was included in a comprehensive protocol of retrospective study at the Department of Gastroenterology, The University of Tokyo Hospital approved by The University of Tokyo Medical Research Center Ethics Committee . The following statements were posted at a website  and long-term  outcomes. Obtained data were stored in an encrypted hard disk separated from outside of the hospital. When reporting analyzed data, we protect the anonymity of participants for the sake of privacy protection. If you do not wish the utilization of your data for the clinical study or have any question on the research content, please do not hesitate to make contact with us.The medical records of 1,861 consecutive patients with HCC who visited the authors’ institution between January 1, 2004 and December 31, 2008 were reviewed retrospectively. Most of these patients received contrast-enhanced CT examinations on a regular basis for the assessment of disease status, including HCC recurrence. We counted the number of cumulative contrast-enhanced CT examinations and transarterial chemoembolization (TACE) treatments with intra-arterial infusion of iodinated CM, until death, drop-out, or December 31, 2011, whichever came first.We collected the following data recorded on the application form for contrast-enhanced CT or TACE: sex, age, past history of ARs to iodinated CM, past history of asthma, history of other allergies, corticosteroid use and the presence of renal impairment, defined as an estimated glomerular filtration rate (eGFR) < 60 ml min−1, as an indicator of chronic renal insufficiency . We alsoPregnant women, patients with previous severe AR to CM and patient with severe thyroid disease are contraindicated to administration of CM at our institution. Patients with asthma, renal impairment, severe heart disease, macroglobulinemia, multiple myeloma and pheochromocytoma are also in principle excluded from an indication for CM administration. However, in clinical practice, patients with these impairments or diseases sometimes receive CM when the clinical advantages outweigh the potential toxicity.Corticosteroid is sometimes given prophylactically to patients with previous mild AR to CM and patients with mild asthma when they are exposed to iodinated CM. In this study, the decision whether or not to utilize corticosteroid prophylaxis was made by individual clinicians, based on the available information –18.All contrast-enhanced CT examinations and TACE, performed on HCC patients at the authors’ hospital from January 1, 2004 through December 31, 2011, were identified by means of an electronic query to the institutional database system. The following non-ionic low osmolality CM had been in use: iopamidol 300-mg iodine per mL , iopamidol 370-mg iodine per mL , or iohexol 350-mg iodine per mL . The choice of iodinated CM depended on the protocol and the attending physician. When a patient with a previous immediate AR to iopamidol required further examination, we switched to iohexol and vice versa in accordance with the guidelines set forth by the European Society of Urogenital Radiology .CT scanning was performed according to standard clinical protocols. The standard volume of 2 mL kg−1, to a maximum of 100 mL, was injected at a rate of 2.3–3.3 mL s−1 with a power injector. All patients were monitored closely during injection. If any symptom was observed during or immediately after CM injection, the clinician or radiologist checked the patient’s vital signs and performed a physical examination.TACE was performed under local anesthesia. A catheter was inserted into the hepatic artery via the femoral artery. When hypervascular tumors were identified during the hepatic angiography procedure, the feeding arteries were selectively embolized with gelatin sponge particles after an emulsion of epirubicin hydrochloride , and iodized oil  was injected under X-ray monitoring.Contrast-enhanced magnetic resonance imaging (MRI) and contrast-enhanced ultrasonography (CEUS) are efficient tools for detecting HCC ,21. HoweThis study was focused on ARs related to iodinated CM. However, it is difficult to discriminate between ARs to CM and accidental events. Therefore, after considerable preliminary evaluation of the data, we concluded that the following view of ARs was useful and statistically sound. First, we evaluated any symptom as an AR, regardless of whether the symptom was attributable to CM, to the procedure, or an accidental event. Second, we categorized all symptoms into hypersensitivity reactions, physiologic reactions, and ‛other’ reactions, according to the American College of Radiology (ACR) guidelines, and evaluated each category as an event . HyperseThe radiologists and physicians attending the CT examination and TACE reported on the manifestation and severity of the AR, and whether the patient received medical treatment. These data were fed immediately into the electronic medical record system shared by hospital staff. If more than one manifestation of the AR to a single CM injection was identified, we chose the most severe reaction as the manifestation.Some patients who exhibited an AR subsequently received another CM injection and experienced subsequent ARs. Thus, we investigated the association between the initial ARs and the reactions to subsequent injections. We also elucidated manifestations and the severity of subsequent reactions and, if present, incremented its severity.We retrospectively collected the demographic and laboratory data that were available 2 weeks before the initial CM examination. The difference was assessed using the Mann–Whitney U-test for continuous data; the chi-squared test or Fisher’s exact test was used for categorical data. The cumulative probability curves were constructed using the method of Kaplan–Meier, which were compared with the log-rank test. We also analyzed the cumulative incidence of ARs with respect to each AR category described above  and compared this using the log-rank test. We did not treat these categories as competing risks, because these reactions may have occurred at a single administration.To investigate whether the risk of AR increased with accumulated exposure to CM, we analyzed the relationship between the hazard function for AR to CM and the number of cumulative exposures to CM. The hazard function, defined as h(t) = −S′(t)/S(t), where S(t) is the survival function, and S′(t) its derivative, is a measure of the tendency for the event to occur. By calculating the hazard function for the occurrence of AR, with respect to the number of previous exposures as a function of time, we can evaluate whether or not the number of previous exposures affected the immediate risk of AR. In this analysis, the cumulative number of exposures to CM had a major influence on the results. Thus, we calculated the hazard functions for only the ‛exposure-naïve’ patients, defined as those who had their initial injection of iodinated CM during the study period. Additionally, we used restricted quadratic splines in the Poisson-rate regression model, with three knots at the 10th, 50th, and 90th percentiles of the number of cumulative exposures to CM, to investigate the possible nonlinear relationship between the number of cumulative exposures to CM and the hazard function ,27.Risk factors for AR were analyzed by univariate and multivariate Cox proportional hazard-regression models. A stepwise variable selection was performed with Akaike Information Criteria in a multivariate analysis. The results of the multivariate analyses were presented as hazard ratios (HR), with their corresponding 95% confidence intervals (CI) and P values from the Wald test.In clinical practice, we often do not know the cumulative number of iodinated CM injections a patient has been administered; but instead, are aware of the presence or absence of past injection. Hence, we included past exposure to iodinated CM before the study period as a covariate, in addition to the following variables: age (as a continuous number), sex, presence of a previous AR to iodinated CM, presence of allergy, presence of asthma, presence of renal impairment, defined as an estimated glomerular filtration rate (eGFR) < 60 ml min−1, as an indicator of chronic renal insufficiency , presencStatistical analyses were performed using R 2.13.0 (http://www.R-project.org) and SAS . All tests were two-sided, with P < 0.05 denoting statistical significance.Overall, 1,861 patients with HCC were reviewed, of which 132 were excluded because they were given no CM during the study period. The baseline characteristics of the remaining 1,729 (92.9%) patients are summarized in A total of 23,684 iodinated CM examinations were performed in the 1,729 patients during the study period; the total number of ARs were recorded for 196 (0.83% on an injection basis and 11.3% on a patient basis) examinations.P = 0.0017). This difference was attributed to the number of physiologic reactions, in particular, vasovagal reflux .The manifestations and severity of the recorded ARs are summarized in Additionally, we analyzed the cumulative probability of AR by drawing a cumulative probability curve over the number of cumulative exposures. The cumulative probabilities of overall immediate reaction at the 10th, 20th, and 30th contrast-enhanced CT examinations were 7.9%, 15.2%, and 24.1%, respectively . CumulatWe analyzed the hazard of ARs to CM in 973 exposure-naïve patients. The estimated hazard of overall AR gradually decreased until around the 10th exposure, and then increased thereafter . The hazIn multivariate analysis with stepwise variable selection, the presence of previous iodinated CM exposure , presence of renal impairment , previous AR to iodinated CM , past history of asthma , and past history of allergies other than iodinated contrast media  were found to be significant risk factors .Subsequent injections after the initial AR and ARs to subsequent injections are summarized in Although there are many reports of CM for CT, the current study is, to our knowledge, the first to report the cumulative effect of repeated iodinated CM injections on immediate ARs.According to the hazard functions of AR analyzed in this study, the risk of ARs seemed to change biphasically ; the decBy separate analyses for each AR category, we showed that the increasing phase consisted of hypersensitivity reaction and other reaction. Therefore, the risk of hypersensitivity reaction to iodinated contrast media accumulates with increasing number of exposures to CM. From the viewpoint of the cumulative effects of repeated exposures to CM, other reactions had similar properties to the hypersensitivity reactions. In this study, sneezing was classified as an ‛other’ reaction. However, given that paroxysmal sneezing is classified as a hypersensitivity reaction according to the ACR guidelines, a portion of the sneezing reactions may be caused by an allergic-like mechanism. Therefore, it was plausible that other reactions had similar properties to the hypersensitivity reactions.In accordance with previous reports ,18, the This present study also showed that the cumulative probability of ARs were significantly higher in patients with renal impairment than in patients with normal renal function . We coulWhen patients with AR to iodinated CM were repeatedly re-injected with CM, subsequent ARs occurred at high rates (36.7%) . PreviouThis study has some limitations. First, the data set was obtained from a single institution and reviewed retrospectively, leading to an underestimation of the true incidence of ARs, due to the tendencies of retrospective investigations. Second, we admit that several patients may have received intravenous CM at other institutions, and developed an AR without our knowledge. Third, we did not evaluate other risk factors, such as the use of beta-adrenergic blockers ,32. FourIn conclusion, the risk of immediate AR to iodinated CM increases with repeated exposures, and the incidence is strongly associated with renal function in patients with HCC. Not only renal toxicity but also AR to CM should be monitored carefully when iodinated CM are injected into HCC patients with mild renal impairment. However, even if patients with previous AR for iodinated CM were re-injected with iodinated CM, the patients with HCC had subsequent reactions at levels similar to the initial reaction.


Objectives. To systematically review articles investigating the relationship between religion and spirituality (R/S) and fruit, vegetable, and fat intake. Methods. PubMed, CINAHL, and PsycInfo were searched for studies published in English prior to March 2013. The studies were divided into two categories: denominational studies and degree of R/S studies. The degree of R/S studies was further analyzed to (1) determine the categories of R/S measures and their relationship with fruit, vegetable, and fat intake, (2) evaluate the quality of the R/S measures and the research design, and (3) determine the categories of reported relationship. Results. Thirty-nine studies were identified. There were 14 denominational studies and 21 degree of R/S studies, and 4 studies were a combination of both. Only 20% of the studies reported validity and 52% reported reliability of the R/S measures used. All studies were cross-sectional, and only one attempted mediation analysis. Most studies showed a positive association with fruit and vegetable intake and a mixed association with fat intake. Conclusion. The positive association between R/S and fruit and vegetable intake may be one possible link between R/S and positive health outcome. However, the association with fat intake was mixed, and recommendations for future research are made. Unhealthy diet is a major risk factor in the development of noncommunicable diseases (NCD), which are responsible for about 63% of deaths globally . One of The World Health Organization recommends a daily intake of at least 400 g (5 servings) of fruit and nonstarchy vegetable, and fat that is less than 30% of total dietary energy, of which less than 10% is from saturated fat and less than 1% from transfat . HoweverResearch has shown that religion and spirituality (R/S) has a positive association with health . About 8The study of the relationship between R/S and health remains relatively novel. Initially it was not well accepted because it was thought that it is impossible (within a positivist framework) to study R/S scientifically. However, starting in the early 1990s, with the improvement of methodology, the study of religion and health has been increasingly recognized as a legitimate domain of scientific inquiry and is becoming more established . BetweenIn the research of R/S and health, one of the major issues is defining religion and spirituality in a way that supports their measurement. Historically the notions of religion and spirituality have often been used interchangeably; however, recently there has been a trend towards distinguishing the two concepts . BroadlyThe most commonly used R/S measure has been the single-item measuring religious attendance because of its “ease of use” . In mostReligion is considered important to many people around the world. One recent survey estimated that 51% of the population in the world believe in god(s) . Anothermay also result in poorer health outcomes, such as extreme asceticism. Notwithstanding that, numerous studies have shown that R/S is negatively associated with many harmful behaviors such as smoking [One of the proposed mechanisms by which R/S benefits health is through the adoption of religious practices that are also health-promoting . Many re smoking , 44, alc smoking , 46, sub smoking , 48, and smoking , 50 and  smoking , 52, phy smoking , and sea smoking . Certain health practices are endorsed and encouraged by most religions, such as healthy eating. In fact, most religions have specific dietary guidelines regarding what food to eat or avoid. These guidelines fall into two categories. The first category involves “a temporal abstinence from all or certain foods (fasting)”—the majority of religions have fasting guidelines, for example, Muslims fasting during Ramadan and oriental orthodox Christians fasting before Holy Communion. The second category relates to “stable and distinctive dietary habits that differ from the general population”; for example, Muslims consume halal meat and Jews consume kosher meat . The maiR/S might encourage the consumption of fruit and vegetable and discourage fat intake  because of specific doctrines of a particular religion. For example, the teaching of Ahimsa (do no harm) in Mahayana Buddhism and Hinduism encourages their adherents to be vegetarians in order to cultivate compassion, since eating animals requires slaughtering. Nonvegetarian food is considered impure and could hinder one's spiritual development . The SevThe long term dietary practices required by certain religions could be a protective factor in preventing diet-related diseases. For example, the Seventh-day Adventist Church and the Church of Jesus Christ of the Latter-day Saints both encourage their believers to consume more fruit and vegetable and less fat. There is evidence from observational studies that Adventists, Mormons, and adherents of religions with strict dietary guidelines have healthier diets, better physical health, and longer lifespans than the general population , 58. Notwithstanding the importance of food in many religions, there is a surprising scarcity of research on the relationship between R/S and diet. According to the first edition of the Handbook of Religion and Health , the mosA few other reviews also identified generally positive associations between R/S and a healthier diet. Groen and van der Heide , for insHowever, to date, there has been no review that examined the relationship between R/S and specific dietary intake. The past reviews have only examined R/S and diet in general. Thus, the purpose our review was to address this gap and systematically review the relationship between R/S and fruit, vegetable and fat intake. We hypothesized that R/S was positively associated with fruit and vegetable intake, and negatively associated with fat intake. PubMed, CINAHL, and PsycInfo were searched by using two categories of key terms: religious key terms  and dietary key terms . The Boolean operator “OR” was used to combine key terms within each category, and “AND” to combine both categories. In PubMed database, the “NOT” operator was also used to eliminate studies related to clinical trials, fasting, reviews, systematic reviews, case reports, editorial, and comment. The full search strategy can be obtained from the authors. The research analyzed the direct association between at least one quantified R/S measure and at least one quantified measure of fruit and vegetable or fat intake. Thus, qualitative studies and case studies were excluded.The paper was published in English and in a peer-reviewed journal before 1 March 2013.To be eligible for inclusion, a paper had to fulfill the following criteria.R/S and fruit, vegetable, and/or fat intake were included but their relationship was not examined directly only overall health/dietary behavior was assessed but not fruit, vegetable, and/or fat intake specificallyR/S was included as part of the measure of another variable  but the direct relationship between R/S and fruit, vegetable, and/or fat intake was not assessed;the focus of the paper was fasting and/or eating disorders;only serum levels of nutrients and not direct intake. Serum level or biomarkers of nutrients might not be an accurate indicator of fruit, vegetable, and fat intake since the nutrients could be obtained from supplements;the paper examined did not specify its dietary source as fruit and vegetable. Fiber could be obtained from supplements and nonfruit or vegetable food source such as grains.the paper examined fiber intake but A paper was excluded ifThe references and bibliographies of the papers were also examined to identify other relevant articles. Previous reviews of the relationship between diet  and R/S were also examined , 61, 62,The frequency and types of fruit, vegetable, and fat intake measures used were first examined. The measures were categorized into dietary records, 24-hour dietary recall, food frequency, brief dietary assessment methods, and dietary history. A dietary record is a detailed record of all food and drinks consumed over a period of time by a respondent; in 24-hour dietary recall, a respondent is asked about the food and drinks he/she consumed during the past 24 hours; a food frequency questionnaire is a list of commonly consumed food that could be selected by respondents; brief dietary assessments are used to estimate the intake of a nutrient or a type of food but do not assess overall diet; dietary history assesses dietary patterns over time . The studies were divided into two categories: (1) denominational studies that compared fruit, vegetable, and/or fat intake between members of different religions, or denominations within the same religion, or between a religion with the general population and (2) degree of R/S studies that examined the degree of R/S and its association with fruit and vegetable and/or fat intake. The two categories were analyzed separately. The analyses of degree of R/S studies were guided by Rew and Wong  and WongThe quality of R/S measures was assessed by examining whether their validity and reliability were reported. The number of studies that used single-item measure was also examined. Many R/S and health studies relied solely on the use of single-item measure of religious attendance, which has its limitations in health research . The quaOut of the 3298 potentially relevant papers identified by the database search strategy, 32 papers fulfilled the inclusion criteria. An additional seven papers were obtained through cross reference of included papers and previous reviews. The majority (77%) of the studies were conducted in the United States. Five were conducted in other Western countries , and one each (2.6%) in Scotland, Slovakia, and Canada), two in Israel (5.1%) one in Japan (2.6%), and one in South Korea (2.6%). Four studies included only female samples. Eleven studies were race-specific; seven examined African Americans, two examined non-Hispanic Whites, one examined Koreans, and one examined Japanese. Thirty-two of the studies (79.4%) included samples that were predominantly Christians. Four studies examined Jews and three examined Buddhists.Out of the 39 studies, 12 examined fruit, vegetable, and fat intake, 14 examined only fruit and vegetable intake, and the other 13 only examined fat intake. A total of 18 studies were analyzed. Eight (44%) of them compared Seventh-Day Adventists with the other denominations  or non-Adventists, three compared fruit, vegetable, and fat intake, three compared only fruit and vegetable intake, and two compared only fat intake. Among the six studies that compared fruit and vegetable intake, three (50%) showed that Adventists consumed significantly more fruit and vegetable than members of other denominations and non-Adventists, one (16.7%) had positive but nonsignificant association, one was nonsignificant in vegetable intake but significant in higher fruit intake, and one showed that Adventists consumed less deep fried vegetable.Five studies compared total fat intake between Adventists and non-Adventists. Two (40%) showed that Adventists consumed less fat. One showed that Adventists consumed less fat when comparing total fat in grams, but similar amount of fat as non-Adventists when comparing the percentage of energy from fat. Another study showed that Adventist females consumed more fat. One showed no significant relationship. These five studies also examined the intake of saturated fat, and all found that Adventists consumed less saturated fat, even though their total fat intake was similar to those of non-Adventists. Three of the studies also compared the intake of unsaturated fat. Two found no significant relationship, and one found that among Adventists, the vegetarians consumed more unsaturated fat than Mormons, but Adventist omnivores consumed less saturated fat than the Mormons. Among the studies that compared unsaturated fat intake, two also looked at the polyunsaturated fat and saturated fat (P : S) ratio and found that Adventists had a higher P : S ratio.Two of the denominational studies examined Jews. One compared the Jews with the general population in Italy and found that there was no difference in fat intake between the two groups. However, Jews consumed more animal fat than the general population. Another study compared two Jewish Hassidic sects and found that Lubavitcher Hassidim consumed more cooked fruit. There are two denominational studies that examined fat intake in Buddhists. The study that compared Japanese Zen Buddhist monks with the general population in Japan found that Zen Monks consumed less total fat and saturated fat, more unsaturated fat, and had a higher P : S ratio. However, another study that compared Buddhist nuns with Catholic nuns found no significant difference in total fat and unsaturated fat intake, but Catholic nuns consumed more animal fat.One study compared Mennonites with the general US population and found that the Mennonites have higher total fat, saturated fat, and unsaturated fat intake. Another one study compared Catholics with non-Catholics in Scotland and found that Catholics consumed less pure fruit juice and Catholic males consumed less fruit and vegetable.Four studies were multidenominational. One examined fruit, vegetable, and fat intake and found no significant relationship. Three studies examined fat intake only. One found no significant association. One study found that religious denomination mediates fat intake. One showed that among females, conservative protestant and those who have no religious preferences consumed more fat than Catholics.A total of 25 studies were analyzed. The R/S measures were categorized into the six categories described in the previous section. In addition to total fat intake, three studies also examined saturated fat intake. Two studies showed no significant association. One examined the degree of orthodoxy among Jews and found that more Orthodox Jews consumed less total fat and saturated fat, more unsaturated fat, and have a higher P : S ratio. Only 20% (5 out of 25) of the papers reported the validity of R/S measures, and 52% (13 out of 25) reported reliability of at least one of the R/S measures. Of the 12 studies that do not report reliability, three of them utilized a single-item measure of attendance. The majority of the studies (88%) controlled for covariates such as age, gender and years of education. All the studies were cross-sectional. Only one study investigated the mediator between R/S measures and healthy behaviors. However, since the mediator (self-assurance) was not associated with the intake of fruit and vegetable in the study, no further mediation test was carried out.About half of the denominational studies compared Adventists and non-Adventists. Healthy eating is one of the major teachings in the Adventist Church; other Christian denominations (except the Church of Jesus Christ of the Latter-day Saints) do not emphasize healthy eating as much as the Adventist Church. Thus, it is not surprising to find that Adventists generally consumed more fruit and vegetable and less total fat and saturated fat than non-Adventists. Similarly in studies that compared Buddhist monks and nuns with non-Buddhists, because of the teaching of Ahimsa (do no harm), Buddhists monks and nuns are vegans, and again it is not surprising to find that they consumed less saturated fat or animal fat. A weakness of denominational studies is the assumption of homogeneity of dietary practices among the members within a denomination. Denominational studies only compared denominational differences as a whole and omitted the individual variation of R/S of members within a denomination. It is unknown whether this variation is associated with dietary intake. In addition, denominational studies are “likely to be confounded with region and the effects of socioeconomic status” , and almFour of the denominational studies included samples from various Christian denominations. Three of the studies found no significant relationship between religious denomination and dietary intake. The nonsignificant findings were probably due to the fact that respondents from various denominations interpreted questionnaire items related to R/S differently. Although a meta-analysis was not conducted due to heterogeneity of R/S measures and dietary measures, the present review on the relationship between degree of R/S and fruit and vegetable intake points towards a positive association; that is, a higher score of R/S is associated with higher fruit and vegetable intake. About half of the Christian studies showed a significant positive relationship with fruit and vegetable. This is consistent with the previous review that R/S is associated with a better diet . The resSix of the 17 studies reported no association between degree of R/S and fruit and vegetable intake. All three studies that included only Jewish samples showed no association. This may arise because the dietary restrictions of Judaism only revolve around meat and animal products and not on fruit and vegetable. The consumption of fruit and vegetable is neither restricted nor encouraged. The findings for fat intake contradicted the previous review. Almost half of the studies reported no association, and an equal number reported positive and negative findings. The contradiction might be due to the fact that the previous review examined diet as a whole and not particularly fat intake. There are other studies which showed that R/S was positively associated with greater body weight  and obesMost of the studies in this systematic review included samples that were from the USA and Western countries where Christianity is the predominant religion; only two studies were conducted in Asia and one in Africa, even though religion is considered important by most people on these two continents . None ofThe most frequently used dietary assessment methods were brief dietary assessments. However, they are crude estimates of dietary intake. For example, the Fat- and Fiber-Related Behavior Questionnaire does not report dietary intake per se but only an overall score of fruit and vegetable and fat intake. Dietary records are considered the “gold standard” of dietary assessment methods . HoweverThe present review also showed a diversity of R/S measures used. Even within a category see , there wBecause of the diversity of R/S measures and that different R/S measures show different effects in different populations, it was proposed that R/S should be treated as a multidimensional construct . HoweverVery little information was provided with regard to the psychometric properties of the R/S measures. In this review, only 20% of the papers reported validity and 52% reported reliability of at least one R/S measure. However, only three studies (out of 25) used single-item measures of religious attendance. The overall quality of the degree of R/S studies was mixed, most of the studies control for covariates, but none of them used longitudinal data and only one attempted mediation analysis. All the studies were cross-sectional; thus the inference of causal relationship between R/S and fruit, vegetable, and fat intake could not be established. In R/S and health research, there are very few experimental studies, and the wide use of cross-sectional data is another major drawback, in addition to lack of clear definition of R/S . There are several limitations in this review. Only peer-reviewed studies that are published in English were included. This could be the reason why most studies in this review were from Western countries and included mostly Christian samples. Second, unpublished studies were excluded and this might lead to publication bias, since studies with significant results are more likely to be published. Nonetheless, the present review was the first that examined the relationship of R/S with specific dietary intake. The contradictory findings among the studies of degree of R/S point to the need for more studies that control for health behaviors, for example, smoking, and use more rigorous dietary assessment method. In addition, more studies are needed that include participants of other religions, especially those of Eastern traditions and from non-Western countries. There is also a need to use more rigorous R/S measures that are validated, reliable, and multidimensional. Overall, the denominational studies showed that religious denomination is significantly related to fruit, vegetable, and fat intake. Specifically, the Adventists consumed more fruit and vegetable and less fat than non-Adventists. However, the relationship between the degree of R/S and dietary intake is mixed. The results of this review suggest that future research on R/S and diet may help explain the possible mechanism between religion and health. Methodology more sophisticated than observational studies is required. Longitudinal study methodologies  may enhance our understanding of underlying mechanisms. As religion is important for many people and affects their diet, improved methodological quality of R/S and diet research will surely shed more light on this area.


Previous studies have found associations between various health factors and behaviors and mental disorders. However, knowledge of such associations with disability pension (DP) due to mental diagnoses is scarce. Moreover, the influence of familial factors (genetics and family background) on the associations are mainly unknown. The aim of the study was to investigate associations between health factors and behaviors and future DP due to mental diagnoses in a twin cohort, accounting for familial confounding.A prospective cohort study of Swedish twins (N=28 613), including survey data and national register data on DP and other background factors was conducted. Cox proportional hazards regression models were used to calculate hazard ratios (HR) with 95% confidence intervals (CI) for the whole twin cohort, and for discordant twin pairs.During follow-up 1998–2008 (median 10 years), 2.2% of the cohort was granted a DP with a mental diagnosis. In the fully adjusted analyses of the whole cohort, the associations of poor or moderate self-rated health (SRH), under- or overweight, former or current tobacco use, or being an abstainer from alcohol were significantly associated with risk of DP due to mental diagnoses. Analyses of discordant twin pairs confirmed all these associations, except for current tobacco use, being independent from familial confounding. Exclusion of individuals with current or previous depression or anxiety at baseline did not influence the associations found.Poor or moderate SRH, under- or overweight, former tobacco use or being an abstainer from alcohol seem to be strong direct predictors of DP due to mental diagnoses, independently of several confounders of this study, including familial factors. Mental disorders, alongside musculoskeletal disorders, are today the major disability pension (DP) diagnostic groups in OECD countries . Even thStudies of DP in general, and of DP due to mental diagnoses, have shown that poor/moderate SRH, in comparison with excellent/good SRH, is associated with a higher risk of DP, even after accounting for various confounders -22. HoweStudies of the association between leisure-time physical activity and DP in general have found a protective effect of high physical activity on DP ,21-27. AUnderweight or overweight/obesity has been shown to be associated with increased risk of DP in general, in comparison with normal weight -31. SimiStudies of smoking in relation to DP in general have shown that former or current regular smoking ,26,36-38For alcohol consumption and the risk of DP in general or DP due to mental diagnoses a U-shaped relationship has been suggested; that is, both being an abstainer or infrequent consumer and being a heavy or frequent consumer seem to be associated with higher risk of DP ,25,39-45SRH ,47, leisThe aims of this prospective cohort study were to investigate the associations of health factors and behaviors with DP due to mental diagnoses among women and men in a Swedish twin cohort, and to establish whether familial factors influenced the associations found. The hypotheses were that poor or moderate SRH, either underweight or overweight/obesity, low leisure-time physical activity, current or former tobacco use, and either being an abstainer from alcohol/infrequent consumer or high/frequent consumer of alcohol are independent predictors of DP due to mental diagnoses.A prospective twin cohort study was performed, using data from the Swedish Twin Study of Disability Pension and Sickness Absence (STODS) .STODS includes all twins born 1925–1958 in Sweden (29 799 complete twin pairs) and identified in the Swedish Twin Registry (STR) . The STRTo include information on DP, censoring, and background factors, data from national registries were linked to all the twins, using the unique personal identification number assigned to all people living in Sweden. Information on DP (date and diagnosis) was obtained from Sweden’s National Social Insurance Agency. DP due to mental diagnoses were coded according to the International Classification of Diseases (ICD), F-chapter (F00-F99) . Informast of December 2008).To be eligible for this study, the twins needed to have participated in the SALT study . Other inclusion criteria were that the individuals, at the time of the SALT study, were living in Sweden, below the age of 65, and neither on DP nor old-age pension. The final sample consisted of 28 613 individuals (52% women), of which there were 10 531 complete twin pairs (2811 monozygotic (MZ), 3783 dizygotic (DZ), 3835 opposite-sexed DZ, 102 unknown zygosity) and 7551 single individuals without information on the co-twin due to non-participation in the SALT-interview, death, emigration, DP, or early old age pension. The twins were between 41 and 64 years of age  at inclusion. During follow-up, information was obtained about the individuals on person time in days until death, emigration, reaching 65 years of age, or the granting of DP or old-age pension (whichever came first) up to the end of follow-up , moderate , and low . The moderate group was used as the reference category [BMI, which has been shown to be a reliable measure of underweight/overweight, was calculated by dividing weight in kilograms by height in meters squared [Tobacco use, including the use of both cigarettes and moist snuff, was measured in four categories: ‘never tried’ , ‘current user’ , and ‘former user’. Never tried was used as the reference category [Alcohol consumption was measured in two ways. Those who either responded yes to 'ever been drinking alcohol' or no to 'drinking alcohol the last two months' were asked probing questions about the total alcohol  they consumed on a typical occasion (infrequent consumption). Those who, on the other hand, responded yes to 'drinking alcohol the last two months' were asked probing questions about the total alcohol  they consumed on weekdays (Monday to Thursday) and at weekends (Friday to Sunday) (frequent consumption). Beer was measured in glasses/bottles (ranging from one glass to 6 bottles or more), wine in glasses/bottles (ranging from one glass to one bottle or more), and liquor in centiliters (ranging from 4 to 37 centiliters or more). The different units were then converted into grams, using the Alcohol Use Disorders Identification (AUDIT) guidelines [category . BMI, wh squared ,66. As a squared : underwecategory . Alcoholidelines , as adapidelines ,68. For idelines .sex was used as the reference group. Age at interview was measured as a continuous (birth year) variable. Education was measured as a continuous variable (years of study). Marital status was dichotomized into married (reference group) and unmarried . Both education and marital status were measured in the year 2000. Severity of diseases was measured by applying the rating schema devised by Gold and colleagues [very life threatening’, ‘somewhat life threatening’, or ‘not at all life threatening’. If an individual had several diseases with varying degrees of severity, the most severe disease was used. ‘No disease reported’ was used as the reference group. Current or previous history of MD was measured using WHO’s Composite International Diagnostic Interview procedure [In your lifetime, have you ever had two weeks or more when you nearly every day felt sad, blue, depressed?”, and on at least four out of eight additional symptoms: ‘lost interest ’, ‘changed weight (gained or lost)’, ‘trouble falling asleep’, ‘feeling tired, trouble concentrating’, and/or ‘thoughts about death’. Current or previous history of GAD was measured according to DSM-IV [Have you had an episode lasting at least a month in which you felt worried and anxious most of the time?", and on least one out of five additional symptoms: ‘feeling tense’, ‘irritable’, tired, ‘trouble sleeping’, and the combination of ‘being restless’ and ‘on the edge’.Male lleagues , slightllleagues   were calculated. The correlation coefficients between the health factors and behaviors were all below 0.30 (range 0.05-0.30), so all the factors were considered to be acceptable included in the models. Then, Cox proportional hazard regression models were applied to the whole cohort, and hazard ratios (HR) with 95% confidence intervals (CI) were computed. The underlying time scale was time since interview in the study, and the time units were days. All the self-reported variables had internal missing (1-6%) due to non-participation in a single item or a non-response to a question as a whole (don’t know or don’t want to answer). In order to include the maximum number of individuals in the statistical analyses, the missing information for each variable was coded in a separate category. Hence, the missing category contributed to variation in the analyses, but was not interpreted in the results. However, for the continuous covariates, years of education and BMI, missing observations  were not included in the analyses. The proportional hazards assumption was tested by graphically plotting all the categorical variables; all the curves were found to be parallel. In order to investigate potential sex differences, interaction terms between sex and the studied exposures were added in the models and evaluated with likelihood ratio test. However none of these tests turned out to be significant why we decided to combine men and women in the further analyses, although adjusting for sex. Hence, the first (base) model was adjusted for age and sex, the second model additionally for education, marital status, and severity of diseases, and the third model additionally for health behaviors, including leisure-time physical activity, BMI, tobacco, and alcohol, depending on the factor under study. Finally, SRH was added to complete the full model. All analyses were corrected for within-pair dependency, by clustering on pair identification, to avoid underestimation of the variance. In an attempt to account for the potential confounding effects of current or previous history of MD and/or GAD at baseline, we performed additional analyses from which these individuals were excluded (n=4615) (data not shown). The estimates were in the same direction and of the same magnitude as those for the whole cohort.Second, conditional Cox proportional hazard analyses were applied to complete MZ and same-sexed DZ twin pairs who were discordant with regard to DP. By stratifying the analyses by pair identification, the follow-up time to DP of a twin was analyzed in relation to the follow-up time of the co-twin. The purpose of this discordant twin pair analysis was to control for age, sex, genetics (100% for MZ and≈50% for DZ), and shared environmental factors, such as intrauterine and rearing environment (100% for both MZ and DZ) . First, In total, the twin individuals contributed 246 101 person-years at risk of DP during follow up 1998–2008. The median follow-up time was 10 years (inter quartile range 8–10 years), and 3073 individuals (10.7%) were granted a DP during follow-up. Among all DPs, 20.2% (n=621) were due to mental diagnoses. Depression (F30-F39) and anxiety (F40-F48) diagnoses constituted the largest sub-groups of the mental diagnoses, 48% and 37%, respectively. Among those granted DP due to mental diagnoses, 72% were women. Mean age at the time of being granted DP due to a mental diagnosis was 53 years (SD 4.6) , which made it possible to account for familial confounding in the analyses; the study’s prospective design; the relatively long follow-up (median 10 years); and the use of high quality registry data on DP and other background factors, with no loss to follow-up. An additional strength was access to information on current and/or previous history of MD and/or GAD, which made it possible to study the influence of these disorders at the baseline of this study. MD and GAD are two examples of mental disorders (WHO 2007), which account for the majority of newly granted DPs due to mental diagnoses today 3, which -66,73A limitation of the study was the relatively low statistical power of the analyses of the discordant twin pairs, especially when stratified for zygosity. Hence, the interpretation of these analyses merit caution. However, although the point estimates decreased in the discordant twin pair analyses, the magnitudes and directions of effects remained largely unchanged. This tends to confirm the results for the whole cohort, rather than indicating the presence of familial confounding. Another limitation of the study is that the health factors and behaviors were only measured at one point in time; hence they could have been different both before and after the SALT interview. However, adjustment for several important and known confounders was done and is a strength of this study. Finally, given that the sample only included middle-aged twins born and living in Sweden, the results of this study is not valid for younger adults , nor to To conclude, rating one’s general health as either poor or moderate, being under- or overweight, being a former user of tobacco products, or an abstainer from alcohol seem all to be factors independently associated with the risk of DP due to a mental diagnosis, even after accounting for several confounders of this study, including familial factors.The authors declare that there are no competing interests.PS was the PI of the study and main responsible for data acquisition and ethical approvals. The study was jointly designed by all authors. ÅS was responsible for the data analyses. Findings were jointly interpreted by all authors. ÅS drafted the initial paper outline and all co-authors contributed to successive drafts. The final manuscript was approved by all authors.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/621/prepub