Previous behavioral and neural studies have shown the effects of malicious envy on schadenfreude. However, it is unclear whether these effects are modulated by contextual frames . Thus, the present study aimed to investigate whether behavioral and event-related potential (ERP) effects of malicious envy on schadenfreude were different in gain and loss frames. To address this issue, the participants in the present study believed they were playing a monetary game with several other players. In the malicious envy condition, the participants won less money than the player in the gain frame and lost more money in the loss frame; in the control condition, both participants and the player gained little money in the gain frame and lost much in the loss frame. Subsequently, the participants were informed that the player encountered a misfortune, i.e., gained little in the gain frame and lost much in the loss frame. Results showed that malicious envy increased feelings of schadenfreude and ERP responses when the player encountered a misfortune. Moreover, increased ERP responses by malicious envy occurred at the feedback-related negativity (FRN), and early late positive potential (LPP) time ranges in the gain frame but at the late LPP time range in the loss frame. The findings might suggest that malicious envy affects schadenfreude and corresponding neural activity, whereas the neural effects occur at comparatively early time ranges in the gain frame but at a later time range in the loss frame. Envy is a social-comparison-based emotion that arises when we compare ourselves unfavorably with superior quality, achievement, or possessions of another . Envy isPrevious empirical studies have utilized a scenario task to investigate the effect of envy on schadenfreude e.g., . In thisUsing the abovementioned task, several behavioral studies have shown that envy increases feelings of schadenfreude e.g., . HoweverRegarding neural studies, functional magnetic resonance imaging (fMRI) study of In general, previous studies have suggested that  envy influences feelings of schadenfreude and neural responses associated with reward processing when enviable persons encounter a misfortune. It is notable that some studies, in particular neural studies, used a virtual social comparison scenario to elicit envy  or a loss frame . Similarly, schadenfreude could also occur in both gain and loss frames . It has been suggested that individuals in the gain frame focus on not only their own outcome but also the outcome of other individuals, whereas those in the loss frame are more likely to focus on their own outcome . As the Taken together, the present study aimed to investigate whether a contextual frame influenced the behavioral and neural effects of malicious envy on schadenfreude by using a real social comparison task. To address this issue, the participants were asked to play a monetary game with several other players. The participants and the players gained some money in the gain frame and lost money in the loss frame. In the experimental  condition, the outcome was better for the players than for the participants ; in the control condition, both the players and the participants obtained a bad outcome . Subsequently, the players obtained a bad outcome. The participants were required to assess the feeling of schadenfreude for this bad outcome.As mentioned above, different attentional allocations to outcomes of others in gain and loss frames might influence the effect of malicious envy on schadenfreude. This influence might take place in two ways: first, the effects of malicious envy on schadenfreude might be stronger in the gain frame than in the loss frame; and second, the effects might occur earlier in the gain frame than in the loss frame. Due to low temporal resolutions, however, the second hypothesis could not be understood by behavioral, fMRI, or brain injury techniques. To investigate both of these two ways simultaneously, techniques with high temporal resolutions  should be used. Two ERP components  might reflect the effect of malicious envy on schadenfreude. The FRN, which starts at approximately 200 ms with a stimulus onset and is distributed over anterior scalp sites, is thought to reflect expectancy violation. The response is more negative for unexpected outcomes than for expected outcomes e.g., . In a laBased on previous studies, we predict that, in the present study, malicious envy would generally increase feelings of schadenfreude and ERP responses  when enviable persons encounter misfortune. Moreover, as mentioned above, previous studies have suggested that individuals are more sensitive to outcomes of others in the gain frame than in the loss frame . This prM = 20.32, SD = 1.04; 20 females). All the participants were right-handed, as is determined by the Edinburgh Handedness Inventory , and the results showed a significant effect of malicious envy on feelings of schadenfreude. Thus, the sample size in the present study was sufficient. The participants reported normal or corrected-to-normal vision and no history of neurological illness. All the participants gave written informed consent in accordance with standard ethical guidelines as defined in the Declaration of Helsinki. The study was approved by the local ethics committee.Thirty-six undergraduate students were recruited from Guangdong University of Education. Two were excluded due to being given wrong instructions, and another two were excluded due to EEG artifacts. Therefore, the reported data were from 32 participants . All stimuli were presented against a dark background.Prior to the actual experiment, each participant was told that he/she would play a monetary game with three anonymous players. As the effect of malicious envy on schadenfreude is more evident when enviable persons are competitive out-group members  and servM = 1,000 ms). The participants were told that the blank screen would appear when their response was faster than the response of the player. This manipulation allowed the participants to believe they were playing with real persons. Then, the outcomes of the participant and the player were presented on the left and right sides, respectively, of the center for 1,500 ms. The number presented signified the amount of money gained or lost. On the left side of the number, there was a symbol “+” in the gain frame to indicate a monetary gain and a symbol “−” in the loss frame to indicate a monetary loss. The participants were then asked to rate how much malicious envy they felt toward the player on a nine-point scale  by pressing the number on the number keypad of the keyboard, using the right hand. Given that previous studies showed that the effect of envy on schadenfreude was evident when envy was malicious rather than benign . Therefore, the actual experiment consisted of 380 trials . In each frame, there were five breaks. The duration of the break was controlled by the participants. Prior to the actual experiment for each frame, there were eight practice trials so the participants could familiarize themselves with the experimental procedure. The experiment (including practices) lasted approximately 2.5 h.Malicious envy and schadenfreude ratings were recorded for each trial. The ratings were averaged for all trials separately for each level of combination of emotion and frame.Electroencephalograms (EEGs) were recorded, using two 32 BrainAmp amplifiers . Ag/AgCl electrodes were placed on the scalp by means of an EasyCap electrode system  in the accordance with the 10–20 system. The electrode AFz was used as the ground electrode. The other channels were referenced to the electrode FCz online. The horizontal electrooculogram (EOG) was recorded from two electrodes at the outer canthi of both eyes, and the vertical EOG was recorded bipolarly from two electrodes above and below the right eye to monitor eye blinks and movements. The EEG was amplified, using a 0.016–100 Hz bandpass filter and a 50 Hz notch filter, and sampled at 1,000 Hz/channel. Electrode impedances were maintained below 10 kΩ.Offline, EEG data were further processed, using BrainVision Analyzer 2.0 software . Raw data were re-referenced to the average of the left and right mastoids. Ocular movements were inspected and removed from the EEG signal, using the algorithm by Event-related potentials were qualified, using the mean amplitudes for FRN 264–364 ms), early LPP (364–800 ms), and late LPP . The FRN was measured at frontal and frontocentral electrodes . The early and late LPPs were measured at parietal electrodes . The time window for the FRN was chosen on the basis of peaks identified in the grand waveforms across conditions, electrodes of interest, and participants (314 ms); and the time windows for early and late LPP were selected based on the visual inspection of the grand waveforms. Electrodes of interest were selected based on previous studies e.g., . Grand-a–364 ms, means and SEs of the ratings are shown in SE of the amplitudes of FRN and early and late LPPs for each condition are shown in p values when appropriate. Statistical analyses were performed, using IBM SPSS Statistics software .For the behavioral data, ratings on malicious envy and schadenfreude were separately performed by 2 × 2 analyses of variance (ANOVA) with frame (gain versus loss) and emotion  as the within-subject factors. The F = 171.38, p < 0.001, η2p = 0.85] and frame . In general, the ratings were higher in the experimental condition than in the control condition and in the loss frame than in the gain frame. The interaction between emotion and frame was not significant .This analysis aimed to understand whether malicious envy was elicited successfully. The results showed the main effects of emotion . The main effect of frame  or the interaction between frame and emotion was not significant .The results showed that feelings of pleasure (schadenfreude) were stronger in the experimental condition than in the control condition  or emotion  but rather an interaction between those two factors . Further analysis showed that, for the gain frame, the FRN was shifted to a more negative direction in the experimental condition than in the control condition , whereas the emotional effect was not significant in the loss frame .The results on FRN responses showed that there was no main effect of frame . Further analysis showed that, for the gain frame, the response of early LPP was more positive in the control condition than in the experimental condition , whereas the emotional effect was not significant in the loss frame . There was no significant effect of frame  or emotion .There was a two-way interaction between emotion and frame  or frame , whereas the interaction between these two factors was significant . Further analysis showed that, in the loss frame, the response of late LPP was more positive in the experimental condition than in the neutral condition , whereas the emotional effect was not significant in the gain frame .ANOVA showed that there were no main effects of emotion [post hoc power analysis by using G∗Power 3.1.9.2 software (2p in SPSS = 0.12–0.14) to perform a post hoc power analysis. Results showed that the power for the interaction was higher than 0.85, suggesting the actual sample size  and the acquired effect size in the present study were sufficient.In order to understand whether the actual sample and effect sizes can achieve adequate power, we conducted a software . The maiThe present study investigated the modulation of the contextual frame on the behavioral and ERP effects of malicious envy on schadenfreude when malicious envy was elicited in the context of real social comparisons. Behavioral results showed that malicious envy increased feelings of schadenfreude irrespective of the frame. Moreover, ERP results showed that, in the gain frame, ERP responses from FRN to early LPP time ranges were shifted to a more negative direction in the experimental condition than in the control condition when a misfortune occurred to enviable persons, whereas the experimental condition resulted in a larger late LPP response than did the control condition in the loss frame. The findings might suggest that the contextual frame influences the neural effects of malicious envy on schadenfreude.The effect of malicious envy on feelings of schadenfreude in the present study might be associated with the achievement of the motivation goal of malicious envy. Malicious envy is elicited when others are superior to individuals themselves. Under the influence of malicious envy, individuals have a strong motivation to damage the superior position of others . A misfoHowever, behavioral results did not show a modulation of the contextual frame on the effect of malicious envy on schadenfreude. As mentioned in the section “Introduction,” the modulation of the contextual frame might be reflected in two different ways: first, the effect of malicious envy on schadenfreude might be stronger in the gain frame than in the loss frame; and second, the ERP effect in the gain frame might occur at earlier time ranges than the effect in the loss frame. Thus, the absence of the behavioral modulation of the contextual frame in the present study might be because the modulation of the contextual frame is reflected only by the second way. This interpretation can be further validated by ERP results.The ERP results clearly suggested that the modulation of the contextual frame was reflected by the abovementioned second way, i.e., the ERP effects of malicious envy on schadenfreude occurred at earlier time ranges  in the gain frame and later time ranges  in the loss frame. Moreover, previous studies have repeatedly suggested that FRN is an indicator of expectancy violation e.g., . At lateWhen the player in the experimental condition obtained a superior position during Phase 1 of the game, the participants might expect that the superior position would be sustained in later Phase 2. However, this expectation is not met when the superior position of the player was damaged by his/her misfortune. In contrast, the participants in the control condition might not expect that the player obtained a superior position in Phase 2 due to his/her misfortune during Phase 1. Thus, the participants did not feel surprised when the player encountered a misfortune once again during Phase 2. The stronger degree of expectancy violation in the experimental condition might thus result in larger neural responses from FRN to early LPP time ranges (in the gain frame).In addition, the misfortune of the player was beneficial to damaging his or her superior position in the experimental condition. In the control condition, however, the misfortune did not help much to damage the position of the player, as his or her original position had been not superior. Therefore, the misfortune might be evaluated as more positive in the experimental condition than in the control condition and thus elicit stronger responses in the late LPP time range (in the loss frame).Furthermore, the FRN and (early and late) LPP effects of malicious envy on schadenfreude were distinctive between gain and loss frames. It has been suggested that individuals are more sensitive and pay more attention to outcomes of others in the gain frame than in the loss frame . AccordiIn addition, due to attentional focuses on outcomes of others, the participants in the gain frame of the present study might expect what the outcome of the player would be before Phase 2  and subsequently, compare the expected outcome with the actual outcome after Phase 2. Such expectation and comparison processing might result in the effect of malicious envy on schadenfreude, occurring at expectancy (-violation)-related time ranges in the gain frame. In the loss frame, however, self-focus might allow the participants to concentrate on evaluating how the outcome of the player has an impact on participants themselves after Phase 2 . Such evaluations might result in the effect of malicious envy on schadenfreude, occurring at outcome-evaluation-related time ranges in the loss frame.In general, the findings obtained in this study appear to be in line with the theories on envy [e.g., the malicious envy theory , the duaMore importantly, the current findings might reveal new insights, demonstrating that the effects – at least the ERP effects – of malicious envy on schadenfreude are influenced by the contextual frame. In the gain frame, the effect of malicious envy on schadenfreude takes place at expectancy-violation-related  time ranges; the effect occurs at outcome-evaluation-related  time ranges in the loss frame. The findings might extend the theories on envy e.g., , in whicFinally, we would like to mention several limitations to the present study and suggest outlines of research in the future studies. First, in addition to envy, schadenfreude is also thought to be a social-comparison-based emotion . Little The findings in the present study suggested that malicious envy increased feelings of schadenfreude and ERP responses when a misfortune occurred to enviable persons. More importantly, the contextual frame influenced the processing stages of the effect of malicious envy on schadenfreude. These findings might expand our understanding of the influence of envy on other emotions.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Academic Committee of School of Public Administration, Guangdong University of Finance. The patients/participants provided their written informed consent to participate in this study.HL contributed to the conception and design of the study and wrote the first draft of the manuscript. HL and JL performed the data collection and statistical analysis. Both authors contributed to manuscript revision and read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The use of anabolic androgenic steroids (AAS) and associated image and performance enhancing drugs (IPEDs) is now a global phenomenon. There is a need to develop evidence to support the development of interventions to prevent the commencement of use, to minimise the potential harms or to support those in their cessation of use. While the United Kingdom (UK) is no exception to this issue, its public health and legislative response to the phenomenon differs to other countries and requires the examination of research specific to the UK. Therefore, a scoping review has been conducted to examine the recent relevant literature to help inform the development and evaluation of effective interventions to reduce the harmful use of IPEDs.A comprehensive search strategy was developed for multiple bibliographic databases, supported by and iterative citation searching process and complimented by expert input from the Anabolic Steroid UK Network. Research conducted by or UK academics or within the UK were eligible, if published in the previous five years.In total 87 eligible outputs were identified, including 26 review articles, 25 qualitative papers and 24 quantitative papers. together with small numbers of clinical studies/case reports (6) and commentaries/correspondence (6). The most common topics of research were public health, treatment and harm reduction (41), followed by studies focusing on epidemiology, sub-groups of people using IPEDs and motivations for use (34). The studies illustrated the diverse populations of people who use a range of enhancement drugs including concomitant psychoactive drug use. A number of papers focused on blood borne viruses and associated issues, while others reported on the uptake of needle and syringe programmes. No effectiveness evaluations related to any aspect of treatment, harm reduction or other intervention were published during study period.There is a need for the development of effectiveness evaluations of current interventions and any future service provision for people using image and performance enhancing drugs. While there have been no studies of this nature to date, this review illustrates the rich data that has been gathered through diverse methodologies, that will assist in the development of future effectiveness evaluations.The online version contains supplementary material available at 10.1186/s12954-021-00550-z. Image and performance and enhancing drugs (IPEDs) include a wide range of drugs across various pharmacological categories. Their common features are the function of their use: the alteration of physical performance, or appearance. IPEDs  form a sThe UK is unique in its response to the use of IPEDs. In the 1990s, on the recommendation of the Advisory Council for the Misuse of Drugs, a decision was made not to criminalise the personal possession of these drugs, but to focus legislation on manufacture, distribution, and possession with intent to supply . SubsequUnlike the evidence that is specific to the AAS environment in the UK, much of our knowledge in relation to the pharmacological effects of IPEDs is generalisable from research around the world and includes an increasing body of evidence highlighting physical and psychological harms stemming from AAS use. While harms to major organs and systems, in particular the heart and cardiovascular, have long been associated with the use of AAS , it is oWhile the majority of people who use AAS and associated IPEDs inject at least some of these drugs , 28,a reWhile AAS are the most used IPEDs, polypharmacy is the norm , 40. AddPeople who use AAS and associated IPEDs are by no means a homogenous group. Recent work has highlighted various typologies of user comprised of multiple subgroups with varied characteristics, risk behaviours and levels of engagement with support services –45. WhilThe need for evidence to support our understanding of interventions that can reduce the harmful use of IPEDs is increasingly recognised e.g. , 48). As. As48]).“a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps”. This independent research methodology addresses broader research questions than systematic reviews can answer [A scoping review design was chosen to map and describe what is known about the current status and focus of research in relation to IPEDs in the UK. Scoping reviews were first proposed by Arksey and O'Malley  and haven answer –52. Scopn answer , 55.Arksey and O'Malley  five-stan = 1279) followed by title and abstract screening of the remainder (n = 3461), where inclusion and exclusion criteria were applied to all citations. Studies included were: all published empirical research including articles in peer-reviewed journals and book chapters; and grey literature such as national policy reports and documents, needs assessments, service evaluations, and locally commissioned research. Date range was restricted to between January 1st 2016 and December 31st 2020 to capture current, relevant literature to inform the development and evaluation of effective interventions to reduce harmful IPED use, and studies conducted by UK academics or those with a UK focus due to the unique situation in the UK relating to legislation and NSP provision. Academic theses, animal models, and in-vitro studies were excluded. A total of 77 records were identified at this stage of the search .


Natural disasters are believed to be associated with cardiovascular disease. This study aimed to explore the changes in mortality due to ischemic heart disease (IHD) and their associations with natural disasters at the global level.Country-specific data on the impact of natural disasters, rates of mortality due to IHD and years of life lost (YLL) and socioeconomic variables were obtained for 193 countries for the period from 1990 to 2017. An ecological trend study was conducted to estimate the changes in the IHD mortality and YLL rates and their associations with natural disasters . Correlation analyses and multivariate linear regression were used.Significant changes were found in the IHD mortality and YLL rates and the occurrence of disasters between the two equal periods (1990 to 2003 and 2004 to 2017) (p<0.001). The bivariate Pearson correlation test revealed that the trend in the occurrence of natural disasters was positively correlated with trends in the IHD mortality and YLL rates among females and all individuals (p<0.05) and was marginally correlated among males. Multiple linear regression revealed an independent association between the occurrence of natural disasters and the IHD mortality rate among males, females and all individuals , and similar associations were found for the YLL rate .Our study demonstrated significant changes in the IHD mortality and YLL rates at the global level and their independent associations with natural disasters. Both males and females were vulnerable to natural disasters. These results provide evidence that can be used to support policy making and resource allocation when responding to disasters and developing strategies to reduce the burden of IHD. Ischemic heart disease (IHD), characterized by insufficient blood flow to the muscle tissue of the heart, is the world’s biggest killer, responsible for 16% of global deaths in 2019 according to the World Health Organization (WHO) ,4. A natIn the past two decades, an accumulation of epidemiological and clinical evidence ,4 has suRecently, the Global Burden of Disease (GBD) Study by the Institute for Health Metrics and Evaluation (IHME)  publisheThis study was an ecological analysis designed to explore the association between trends in the annual mean natural disaster impact and the IHD mortality and YLL rates from 1990 to 2017 in 193 countries, including all populations. The annual mean was calculated for each variable with original data from the two equal periods (1990–2003 and 2004–2017). The trends in the variables in the two periods were calculated with the following formula:Trends were replaced by 0 for variable with unavailable data. All the original data for each variable were collected from the same 193 countries. A list of the countries included is provided as supplemental information. Countries missing any data were excluded. The data that support the findings of this study are available from the corresponding author upon reasonable request.Since our study was a population-based ecological trend study using data accessible from open sources and no identification of individuals was involved in the recruitment or conduct of the study, the need to obtain informed consent from participants and approval were waived by the research ethics committees of the People’s Hospital of Deyang City.The analysis of trends in variables relied on original data from two periods, namely, 1990–2003 and 2004–2017, which were obtained from open sources, including the CRED, the GBD Study, the World Bank and the Food and Agriculture Organization of the United Nations (FAO).The impacts of natural disasters were quantified as the occurrence, casualties and total damage; this information was obtained from the Emergency Events Database  (EM-DAT)Occurrence (per year): The average annual number of natural disasters in each country.Casualties : The average annual number of deaths, injuries, people left homeless, and affected people requiring immediate assistance due to the natural disaster, i.e., requiring basic survival resources such as food, water, shelter, sanitation and immediate medical assistance.Total damage (US$1000 per year): The value of all damage and economic losses directly or indirectly related to the disaster. The information may include a breakdown of the figures by sector: social, infrastructure, production, environment and other (when available).2 emissions (metric tons per capita), urban population (%), and trade (% of GDP). Additionally, the population of each country was obtained from the World Bank as a weighting factor for multivariate regression. The following three variables came from the FAO [Another 10 variables were collected as confounding factors from two sources: the World Bank and the FAO. The following seven variables came from the World Bank : life ex the FAO : tobaccoIHD has been consistently defined as an underlying cause of death across ICD revisions  . The GBDDeath : annual IHD deaths per 100,000 population of interest  in that year.YLL : the total product of multiplying IHD deaths by the standard life expectancy at the age of death in years per 100,000 population of interest  in that year.Statistical analyses were conducted for 193 countries using IBM SPSS version 22 , and a p value <0.05 was considered to be statistically significant. Nonnormally distributed continuous variables are presented as medians and quartiles.The Wilcoxon signed-rank test, a nonparametric test, was used to assess the distributions of the two groups of variables representing the impacts of natural disasters and the IHD mortality and YLL rates. The bivariate Pearson correlation test was used to quantify associations between trends in natural disaster impacts and IHD mortality and YLL rates. The correlations were visualized as a world map of trends with Quantum Geographic Information Systems (QGIS) .Multivariate linear regression was used to investigate the associations between the trends in the dependent variables  and independent variables  with the criteria for entry and removal of F = 0.05 and 0.1, respectively. Multivariate linear regression was conducted with stepwise methodology  and weighting by the average population size from 1990–2017. Coefficients with 95% confidence intervals (95% CIs) and p values are reported for the variables included in the multivariate linear regression. Additionally, standardized coefficients were calculated to evaluate the size of the effect for all variables. All analyses were performed separately for males, females and both sexes. To confirm the robustness of the findings, different analyses (bivariate Pearson correlation test and multivariate linear regression) were conducted by subgroup  or with different analytical methods with or without confounding variables.The funders of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.The descriptive statistics for natural disaster and IHD rates are summarized separately for two equal periods(1990–2003 and 2004–2017), and the trends in both periods are presented . The WilThe correlations between natural disasters and the rate of mortality and YLL due to IHD are summarized in The results of multivariate linear regression among males are shown in The results of multivariate linear regression among females are shown in The results of multivariate linear regression for both sexes are shown in To the best of our knowledge, this is the first study to demonstrate the associations between trends in natural disasters and IHD mortality and YLL rates at the global level. Both males and females were vulnerable to IHD following natural disasters. This strong and unambiguous association indicates that natural disasters have a significant impact on IHD on a worldwide scale.IHD is is the world’s biggest killer, responsible for 16% of global deaths in 2019 according to the WHO ,7, are sThe findings of our research are consistent with observations in previous studies. The association between IHD and geophysical disasters  has been well studied. Takiguchi et al.  reportedAfter geophysical disasters, climate-related natural disasters  , or other harmful substances after natural disasters ,9,29. SeIn addition to direct physical and mental effects on the population, catastrophic natural disasters have also been found to be related to increased exposure to well-established risk factors for IHD, such as hypertension, increased BMI, smoking, alcohol abuse, high blood glucose, high-sodium diets and a lower socioeconomic level (as represented by the GDP per capita) ,31–33. MSome advantages of our study merit mention. First, our study provides the first evidence at the global level from 193 countries using two indicators: the mortality rate and the YLL rate. Second, unlike previous observational studies, a series of relevant socioeconomic variables were included in the same set of multivariate linear regression analyses, ensuring the statistical reliability of the results. Third, we studied ecological trends in natural disasters and the burden of IHD in the entire population, thus avoiding the disadvantages of previous studies in which disaster-affected and control populations could not be convincingly identified, especially from a psychosocial perspective. Fourth, the effects of other factors, such as genetics, geography and climate, on IHD could be eliminated with this design, if we assume that the genetics, geography, climate and other population -level factors in a given country remain unchanged. Finally, the the similarity of the results of subgroup analyses and different analytical methods confirms the robustness of our findings.Our study has several limitations. The main limitation lies in the intrinsic limitation of the ecological study design , which means that the results obtained from populations cannot be extrapolated to individuals. Another limitation to be considered is that, as shown in the inclusion criteria, the natural disasters included in our study are extremely destructive. Whether natural disasters of lesser severity have similar impacts on IHD is not clear. In addition, most of the confounding factors included in our study were protective or risk factors at the population level. Individual intermediate factors  should be included if data are available. Meanwhile, the data we used in this study came from a secondary source, and there might be discrepancies between these data and the actual situation. Finally, our study reflects the associations among trends in variables in the long term, and short-term associations were not investigated.The multivariate linear regression analysis in our study suggested that each single-incident increase in the annual natural disaster occurrence was associated with an increase in IHD mortality of approximately 1.679 deaths per 100,000 for men, 3.24 deaths per 100,000 for women and 2.295 deaths per 100,000 for both sexes. Each single-incident increase in the annual natural disaster occurrence was also associated with an increase in the YLL of approximately 40.027 years per 100,000 for males, 30.111 years per 100,000 for females and 31.141 years per 100,000 for both sexes. Furthermore, the trends in total damage caused by natural disasters showed similar associations with IHD. However, considering the inaccuracy of economic loss statistics and the difficulty in calculating them, the occurrence of natural disasters seems to be a better predictor of the burden of IHD. Our study showed that other measures of the severity of natural disasters, including deaths and total number of people affected, were not significantly associated with IHD mortality. This finding suggests that the impact of natural disasters on IHD spreads beyond the directly affected population.In our study, GDP per capita, which is a measure of a country’s economic output and standard of living, was significantly and negatively associated with IHD mortality and YLL. This finding was consistent with a previous study . In addiWith regard to the response to public health impacts following natural disasters, emerging guidelines or studies have emphasized the development of specialized interventions for noncommunicable diseases in addition to physical trauma therapy, nursing care and infection control . On DeceOur ecological study confirmed and quantified the associations between the occurrence of natural disasters and the IHD mortality and YLL rates in 193 countries. Both males and females were vulnerable to IHD following natural disasters. It is imperative to increase awareness of the association between the occurrence of natural disasters and IHD. Our study provides evidence that can be used to support policy making and resource allocation regarding the response to disasters, with the aim of reducing the IHD burden.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(SAV)Click here for additional data file.


Demographic changes can be observed all over the world. The number of seniors located in the societies of well-developed countries continues to rise. Both enterprises and governments need to be prepared for such changes. Consequently, public spaces need to evolve to reduce problems related to ageism and be friendly to all. Much attention is currently being paid to finding solutions for redesigning public spaces and adjusting them to the needs and requirements of senior citizens. To identify the preferences of seniors in relation to the characteristics of furniture in indoor public spaces, a survey study with 1539 respondents aged 60+ was conducted in Denmark, Finland, Latvia, Poland, Russia and Sweden. The gathered data were coded and implemented to the unified database. The statistical grouping method was used to recognize the characteristics of the needs and attitudes of seniors related to the use of public space furniture. The main variables taken into consideration in the analysis were the age and gender of respondents and their country of living. Among the most important findings are those indicating the necessity to provide the increased number of furniture for sitting in the public spaces and making sure they are not located too far away from each other. As the main disadvantages of public space furniture respondents indicated the lack of armrests or other solutions to facilitate getting up and/or sitting down, as well as profiled backrests that constitute solid support for the spine. The implementation of these data in the process of rethinking and redesigning public spaces may support the adaptation of indoor public furniture according to the requirements of a very large group of customers, namely, seniors. Due to demographic changes, the structure of modern societies in highly developed countries is characterized by a growing number of senior citizens. Both public and private institutions need to be prepared for this social and economic challenge in order to provide best possible opportunities for health, participation and security to enhance quality of life as people age. This entails a great business opportunity exists for furniture manufacturing companies as there is a gap observed in the market. It is due to the fact that the senior population has never before been so numerous. Plouffe and Kalache  point ouThe World Health Organization (WHO) has developed an age-friendly city guide. The document highlights several domains that cities and communities can focus on to better adapt their structures and services to the needs of seniors. These domains include, among others, factors related to buildings . The guiet al. [Public spaces are of crucial importance for sustaining the public realm. This is currently especially important, as modern societies no longer depend on town squares or piazzas for basic needs; therefore, designed for diversity public spaces are required for the social and psychological health of modern communities . Consequet al. , 40 highThe concept of indoor public spaces covers a wide range of public places that are often visited by senior citizens, including city halls, museums, libraries, restaurants, healthcare facilities, accommodation facilities such as hotels and culture or sport institutions, and many more. A significant part of the public space constitute waiting rooms. They are often considered as travel stops. Therefore, their important function is to provide the user with a place where he/she can comfortably gather energy for further activities. It is important to investigate design requirements of such public spaces especially in the context of their use by seniors, the vulnerable groups in late life who often experience increased tiredness . This isBased on the information collected during the literature review, it was noticed that there are only fragmentary recommendations that are useful in designing waiting rooms also for the senior population. Epprecht  recommenUndoubtedly an important aspect of the indoor public space constitutes the furniture equipment. One must not forget that furniture pieces, especially e.g. the ones for sitting are among the pieces of furniture that are used directly–meaning the user’s body has a direct contact with the furniture. Therefore, they are of crucial importance to assure comfort, safety, and quality of living . Thus, tThe survey was performed within realization of international project BaltSe@nioR 2.0 aiming to provide new knowledge supporting creation of senior-friendly public spaces. The overall aim of the wide, international study performed within this project is also to indicate paths for potential areas of interest when solving problems that seniors face while functioning in public spaces. The results presented below refer to the part of the study concerning the preferences of seniors when using the public space furniture and their evaluation of disadvantages of furniture located in indoor public spaces.To acquire the study data for the project realization the survey format was developed by experts representing various fields such as wood technology, design, geriatrics, and robotics from nine countries located in the Baltic Sea region. The survey format consisted of open- and closed-ended questions regarding the needs and problems seniors face while using public space furniture. The study was performed from April until September 2020. The closed-ended questions were followed by an open answer possibility which together with open-ended questions constituted a significant part of the study, enabling the respondents to describe in more detail their personal observations or provide comments about their doubts, worries or possible solutions that could be incorporated in the design and construction of furniture located in indoor public spaces.4P, Warsaw) in Poland, Survey Monkey platform in Denmark, Finland, and Anketolog service in Russia (https://anketolog.ru/). Paper versions of surveys were conducted in Sweden and Latvia with the support of university network and volunteer students. Project partners distributed the questionnaires using their own professional networks and personal contacts via e-mails, newsletters, websites, social media . Also various senior organizations have been contacted in order to facilitate reaching the target audience. They have redistributed the survey forms among their members. Participants were asked to fill in the questionnaires if they were 60+ and forward it further to whom it might concern. Such distribution of surveys did not allow for personal identification of individual respondents. The method used in the case of electronic surveys was a Computer-Assisted Web Interview (CAWI). All surveys were anonymous.A survey was conducted among people aged 60+. The study population comprised seniors living in Denmark, Finland, Latvia, Poland, Russia and Sweden. The research was conducted in the form of an electronic and paper survey distributed among seniors. The study was conducted in a written format with the help of a professional online survey platform What activities would you like to be able to perform while using indoor seating furniture for example in the waiting room?Do you read newspapers / leaflets / books, etc. while waiting in the waiting room? If not, why?What weaknesses does furniture in the indoor public spaces have?The gathered data were coded, implemented to the unified database and subjected to statistical analysis. The coding was done by transferring each item of the questionnaire into a variable reflecting the answer of the respondent. The answers provided under the open-answer option were analyzed separately. If various respondents indicated similar answers, the new codes were assigned to those responses, and that allowed for further comparative analysis of these data. Using the statistical grouping method, the characteristics of the needs and attitudes of seniors related to the analyzed subject were developed. The analysis was conducted using STATISTICA 13 PL software . Three main variables were taken into consideration–the age and gender of respondents, and their country of living.The research question concerned the identification of the similarities regarding preferable senior-friendly features of indoor public space furniture in the 6 analyzed countries and age groups. The results may constitute inspirational source of knowledge for designers and furniture manufacturers to support them in creation of age-friendly products and through this facilitate senior daily functioning in indoor public spaces.Taking into account the percentage of completed surveys, a statistical analysis was conducted on the data obtained from 1539 seniors. Women constituted 49.6% of the sample population while men 50.4% .The first issue investigated was whether senior citizens prefer to spend their time in indoor public spaces, such as shopping malls, bus and train stations, museums, theaters, etc., or in outdoor public spaces, such as estates, parks, and promenades. In general, seniors preferred to spend the time in outdoor public spaces. In all analyzed countries, the majority of the responding seniors chose the outdoor public space as a more preferable one. The biggest number of seniors preferring indoor public space is seen in Latvia (43.6%), Denmark (38.6%) and Finland (29.1%) . As far The next issue investigated related to the preferences of seniors concerning the design and construction of public space furniture, was their opinion on the adaptation of such furniture to the needs and requirements of senior users. When the whole study sample was considered, it turned out that only 35.7% of the respondents reported that public space furniture is adapted to seniors’ needs. This result sheds light on how important the subject of the properly recognized needs of senior citizens is and how essential it is to incorporate those insights into the process of designing public spaces. This recognition is of crucial importance, as the wellbeing of senior citizens is also influenced by their participation in society and their ability to take an active part in public activities. Furthermore, public spaces, in addition to having functional value, foster a sense of identity with a city and have a wide influence on citizens’ activity patterns . WysockiA more comprehensive analysis was performed to recognize whether there are any similarities between the analyzed countries or aged group Figs  and 4. TWhen investigating the age factor we can observe that various generations are represented in the sample population, as there are representatives of the Silent generation (born 1928–1945) and the Baby boomer generation. Furthermore, there is a need to acknowledge that Baby boomer generation is also divided into Early Boomer (born 1946–1954) and Generation Jones (born 1955–1964) .In the next step, the analyze was focused on the types of furniture seniors use most often while being in the indoor public space Figs  and 6. ITo recognize the preferences of seniors concerning indoor public spaces such as waiting rooms, we decided to investigate the obtained results in more detail. Thus, we asked the senior respondents what additional activities they would like to engage in while using indoor public space furniture for sitting, for example, in waiting rooms. We discovered that over half of the respondents (51.2%) would like to feel relaxed in waiting rooms thanks to the elements of interior design . This isThe possibility of relaxation during the waiting was the most important for the respondents in Sweden (63.3%), Denmark (59.6%) and Poland (54.5%) . SeniorsSome interesting findings can be drawn from the data presented in et al. [Furthermore, among those who declared that they do not read newspapers, flyers, or books while using furniture in waiting rooms, we examined the reasons behind such decisions and wondered if those decisions were connected with the furniture and the interior elements of those indoor public spaces Figs  and 11. et al.  investigTo provide recommendations for the design of furniture used in indoor public spaces, a decision was taken to investigate in more detail the disadvantages of furniture located in such spaces. Most frequently, seniors reported that the amount of furniture provided within a given space is too small and thus they are not able to use furniture in the indoor public spaces every time they would like to (26.1% of the respondents) . The resOver 60% of respondents in Latvia and Sweden admitted that the furniture located in indoor public space have inappropriate dimensions–the seats are located too low or too high or they are too narrow and thus they are difficult to use for example get up or sit down .As understanding the attitudes of seniors towards the furniture they come in contact with in indoor public spaces is crucial in regard to making further improvements to senior-friendly public spaces, it was decided to investigate how those opinions change according to age. Thus, a statistical analysis was conducted of this issue with regard to the age of the respondents using the statistical grouping method .As mentioned earlier various generations were observed in the investigated sample. The generations differ between each other and this is also reflected in the results obtained. Even though the oldest groups of users were supposed to feel the greatest discomfort while using public space furniture, the representatives of the Silent generation did almost not complain at all. Among the 80+ age group, the largest percentage paid attention to the fact that there is not enough furniture, so they are not able to use it every time they need it. They also noticed that the furniture in indoor public spaces usually does not have backrests, armrests and other supports to increase the comfort of using the furniture. When the answers of Baby boomer generation are analyzed, it can be noticed that seniors in this generation complained the most about the number of pieces of furniture in indoor public spaces. Among respondents in the Baby boomer generation, the low number of people who considered the lack of backrests, armrests and other supports as one of the biggest disadvantages of indoor public space furniture increased with an increase of the age of respondents.When the gender factor was considered, it turned out that more men than women among the weaknesses of pieces of furniture in the indoor public spaces list the insufficient number of them (28%) and the lack of backrests, armrests, supports etc. (26%). Whereas more women than men pointed out the furniture is not adapted to seniors’ needs (16%), it has inappropriate dimensions (19%) and it is difficult to use, e.g. get up or sit down (21%). It is worth to notice that all 3 above mentioned weaknesses of the furniture are among others connected with the anthropometrics of a human body that is significantly different for men and women especially in later stages of life –65.As far as the limitations of the study are concerned, it needs to be stated that, due to the realization of the study also in the form of face-to-face interviews that might have been more suggestive with how the questions were asked than the electronic versions, some subjectivity could have influenced the participants’ answers. Furthermore health-related and other socio-demographic issues such as income, education, ethnicity or sexuality were not taken into consideration. Limitations also include the large variety in the number of respondents from the 6 countries as well as the possibility for various interpretations of questions when the survey questions are translated into many different languages. Nevertheless a big number of participants of this study allows for receiving a valuable insights into the analyzed subjects. Additional research must be conducted to further investigate the cultural aspects’ effects on the detailed preferences of seniors in different countries. Additional factors connected with the space such as type of the public space, it’s size, availability of staff, length of the stay in the space will be investigated in further studies. Thus, it can clearly be stated that the manuscript, although being a valuable inspiration source about the preferences of seniors should not discourage for including seniors into the design process. Inclusive design brings in enormous possibilities for finding the solutions that meet the needs of wider group of people and is always a beneficial approach , 67.et al. [The obtained results provide valuable insights for designing more senior-friendly furniture for indoor public spaces. This is especially crucial in the context of the results of Avlud et al.  who indiet al. , 70. ResProviding senior-friendly public spaces that promotes seniors’ wellbeing and quality in life constitutes a large design challenge; however, with a detailed analysis of users’ needs and a deep understanding of seniors’ attitudes and requirements, it is possible to redesign indoor public spaces in such a way that senior citizens are able to fully participate in their communities and maintain an active social life. Senior-friendly furniture located in various types of indoor public spaces can encourage senior citizens to use public spaces more frequently and seize the opportunity to function more independently, which is beneficial for the both the individual and society as a whole.


While many social scientists view heart disease as the outcome of current conditions, this cannot fully explain the significant geographic disparities in cardiovascular disease (CVD) mortality rates in the USA. The developmental origins hypothesis proposes that CVD vulnerability is created by poor conditions in utero that underbuilds major organs relative to those needed to process lush nutrition later in life. The American South underwent an economic transformation from persistent poverty to rapid economic growth in the post-World War II era. We use state-level data on income growth and current conditions to explain variation in CVD mortality rates in 2010–2011. Our proxy for unbalanced physical growth, the ratio of median household income in 1980 to that in 1950, has a large systematic influence on CVD mortality, an impact that increases dramatically with age. The income ratio combined with smoking, obesity, healthcare access, and education explain more than 70% of the variance in CVD mortality rates. Cardiovascular disease, also known as CVD, is a costly health problem that absorbs nearly $450 billion annually in health care expenditures . Nearly Some argue the American South’s poor showing follows from concurrent conditions, such as low levels of education, lack of exercise, a poor diet, and lack of healthcare access. While this idea has merit, past research on diabetes and hypertension indicates that the developmental origins hypothesis can contribute to understanding the current CVD mortality disparity. The developmental origins hypothesis is rooted in the fact that intergenerational transitions from persistent poverty to prosperity promotes chronic non-infectious diseases in adults. Poor nutrition and stress in utero compromise the construction of vital organs and degrade processes that regulate physiological systems in later life, making these individuals vulnerable to chronic diseases as adults ,7,8,9.Rapidly improving socioeconomic conditions that follow persistent poverty creates non-harmonious growth, whereby vital organs are prepared in utero for the individual to live a lean life but face a lush one as an adult, which elevates the risk of CVD complications. For example, a representative study of Puerto Ricans aged 60–74 found that after controlling for standard risk factors the probability of heart disease was 65% higher among individuals who were born during seasons in which the incidence of disease and poor nutrition were higher . ResearcWe evaluate the hypothesis that rapidly improving socioeconomic conditions preceded by intergenerational poverty causes a higher likelihood of CVD. The basis for the hypothesis is found in earlier epidemiological studies . FamilieIn this paper, we argue that the geographic disparity in CVD can be partial explained by the rapid and uneven economic growth that began in the 1950s. Finding a suitable socioeconomic proxy for non-harmonious growth is a challenge for this line of research. The economic history of the South, however, creates a fortunate opportunity for study. The American South was poor for decades relative to the national average following the Civil War but grew faster than the national average beginning in the 1960s . Our appThe data in What distinctive features of the South might have translated rapid income growth into adolescent weight gain, and eventually elevated CVD mortality rates? Higher incomes alone enabled families to purchase more food, an item that would have been high on the list of priorities for southern families, which were especially poor. This relationship is enshrined in Engle’s Law, the poorer the family the greater the outlay of income on food. The proportion of income spent on food is a good measure of the standard of living of a population, and numerous modern studies substantiate this conclusion .Economic historians know that rapid economic change creates many new opportunities but also disrupts family life, as studies of industrialization make clear ,18. As sSouthern mothers were overwhelmingly responsible for domestic chores, like preparing meals, which did not change when they started to enter the labor force. However, they now had less time for home production and less opportunity to supervise the eating habits of their children. They may have used their earnings to purchase more of the newly available processed food, which often has lower nutritional quality . AnotherThe possible role of southern culture and the interaction of diet and traditional attitudes towards physical exercise is another factor. Unlike other regions, agriculture was the dominant employer in the South prior to the beginning of industrialization after the middle of the 20th century. Relative to other regions, southern farmers were slow to adopt the tractor, and mules lingered on small farms until well into the 1950s . MechaniSouthern customs were fashioned by a long history of physical labor in the fields that welcomed rest at the end of the day. The South was not a region where habits of recreational exercise and health club memberships readily replaced a decline in caloric expenditure associated with a reduction in physical labor. In 2007, the share of the population belonging to health clubs ranged from a low of 6.3% in West Virginia to a high of 21.8% in Colorado . There iRising incomes enabled families to replace walking with a less taxing form of transportation and hauling, the automobile. According to the Federal Highway Administration’s National Household Travel Survey, from 1950 to 1980, the number of miles traveled in a personal vehicle per capita increased by more than 2.3 times while the number of vehicle registration per capita increased by about 2.5 times for the South. That was by far the biggest increase of any region in the country.The Southern food ways had deep roots in the 19th century when pioneer farmers planted corn and created swine herds . For moshttp://www.cdc.gov/nutrition/downloads/State-Indicator-Report-Fruits-Vegetables-2013.pdf accessed on 12 June 2019). By the 20th century the price of wheat began to decline, and new methods of milling and distribution enabled even poor southern farmers to buy flour in bulk. Biscuits became a staple of the diet. In the environment of income growth, the declining food prices, the reduction of work, and changing roles within the family created the perfect storm to make a generation of Southerners especially vulnerable to chronic adult diseases.When available, vegetables were usually fried or boiled with a piece of lard or pork. Sweet potatoes were also common fare in the diet because they required minimal cultivation and they could be stored for months in underground cellars. According to USDA Nationwide Food Surveys from 1955 and 1977, southerners consumed about 12% fewer fresh fruits by weight than the national average. This lower consumption pattern still holds today, where southern states have the highest proportions of adults who self-report consuming one or less fruit and one or less vegetable in any form per day (We use detailed data of the underlying cause of death from the CDC’s Wide-ranging Online Data for Epidemiologic Research (WONDER) to examine the impact median household income changes have on the white CVD mortality rate in 2010–2011. The mortality rate is measured at the state-level and includes deaths which had a recorded underlying cause within the ICD I00I99 categories; diseases of the circulatory system which includes disorders like hypertensive diseases, cerebrovascular diseases, and pulmonary heart disease. The CDC collects this data from official death certification published by the county governments. We examine crude death rates per 100,000 people in 2010 and 2011 for individuals in the age groups of 55–64, 65–74, 75–84, and 55–84. The individuals in these age cohorts were born between 1926 and 1955.Researchers have identified numerous factors associated with CVD, including lifestyle, family history, and genetics. Genetic and family-history research in the area has mushroomed in the past decade, and while researchers can point to progress, the information acquired explains relatively little of the variation in deaths across individuals and populations ,30,31,32As such, we use state level data on average levels of obesity, smoking, and educational attainment from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS) in 2010. The BRFSS is a cross-sectional telephone survey conducted by state health departments with technical assistance from the CDC. The respondents are asked to self-report basic demographics  as well other health related conditions. Smoking was indicated by a dummy  variable indicating whether the individual smoked more than 10 cigarettes per day. The BRFSS staff then calculate each respondent’s body mass index, which is coded as obese if the BMI is greater than or equal to 30. Respondents also report their highest grade or year of school completed. An indicator variable was created to for individuals whose highest level education was high school.Median household income is taken directly from the U.S. Census of Population for 1950 and 1980. The nominal income was adjusted using the Federal Reserve Bank of Minneapolis’ Chained-weighted CPI with 1982–1984 as the base years. The growth rate is found by dividing median household income in 1980 by median household income in 1950. We also use information on the number of active physicians per capita in 2011 from State Physician Workforce Data Report put out by the Association of American Medical Colleges. We recognize that interstate migration can distort the empirical analysis, for which we do not have a fully satisfactory solution. We contend with the problem by using weighted regressions employing different measures of population turnover within the state. The turnover measure is based on domestic in- and out-migration data coming from the U.S. Census. We define turnover as the sum of immigration and out-migration for a state, which is used to measure chronological change in the state population. A larger turnover value implies the actual composition of individuals residing in the state have changed dramatically over time, which could potentially be masked by simply using net migration numbers. For example, if the entire state population departed, but was replaced by the exact same number of people arriving, the net migration for the state would be zero. We use a state’s average turnover from 1950 to 1980 as regression weight, thereby giving less weight to states that had high turn-over.The average turnover from 1950 to 1980 does not recognize the origins of the new residents which is does not account for the fact intra-region migration is less problematic for our analysis than inter-region. Therefore, we also collect data from the U.S. Census on the proportion of each state’s adult residents in 2010 who were born in the South. While this measure does not capture more general migration, it better represents the mixture of individuals with high probabilities of arriving from high growth income areas  who were vulnerable to CVD. As a robustness check, we also estimate our model using the share of the population born in the South as a weight.i in 2010–2011, X is a set of covariates that control for other conditions. Risk factors for CVD mortality include low levels of education, active physicians per capita, smoking, and obesity [β1 should be positive, large, and statistically significant.The OLS model we estimate is: obesity ,38. Thes2 and coefficients that were statistically insignificant, or worse, a statistical outcome that contradicted well-founded results, such as smoking or obesity being beneficial for CVD. Plausible outcomes for well-researched variables would lend credence to the measured impact of past income change on mortality rates. We use a weighting scheme that reduces the importance of high-turnover states in the analysis by weighting states by their inverse of turn-over rates.Population turnover is relevant because current mortality rates are hypothesized to be a function of conditions that existed from 1950 to 1980. It would be ideal if there was no population turnover from 1950 to 2010, such that the population under study was constant, or at least undisturbed by people moving in or out of the state. Of course, that is not true, and the amount of turnover varies across states and must be considered in using state-level data. The issues at hand are how to incorporate turnover into the analysis, and whether there was enough stability in state populations to yield a systematic relationship between past conditions and current outcomes. If migration heavily contaminated the relationship and the error term was large, one would expect to find a low RThe four positive outliers have above average values of smoking, obesity, and years of education at high school or less, while all those below the line have below average values of these variables. Notably, Arkansas is third lowest and West Virginia is the lowest among all states on the scale of education . Oklahoma, Louisiana, Arkansas, Alabama, and Mississippi have the second through sixth highest levels of smoking. It emerges that much of the scatter around the regression line may be explained by current conditions adversely linked to CVD.To further account for the effects of southern birth, One might think that the initial level of income would affect the relationship. However, including median household income in 1950 does not qualitatively change the results, with the variable being statistically insignificant. We also test whether the relationship of the income ratio to mortality is nonlinear. We find that the coefficient of the squared term is insignificant, the other coefficients are less significant, and the adjusted R2 is lower. This suggests that the variable is irrelevant to the equation. Further, the results are essentially unaffected by using a log functional form.The coefficient on the education control also has the expected sign. More people with less education implies that the average resident of the state is less informed about the importance of regular health maintenance, less knowledge of resources to assist in obtaining healthcare, and potentially less able to understand the medical advice received. This lack of information will generally be associated with an increase in the mortality rate ,40. StudIt turns out that smoking and obesity are substantially correlated (r = 0.64), and so it is difficult to obtain precise estimates of their independent effects on mortality. When entered separately each variable is statistically significant, but standard errors of the coefficients are somewhat higher when entered together. Goodness of fit tests suggest that are jointly significant and should be included together.In this section, we perform some sensitivity analysis by exploring the inclusion of other explanatory variables. The inequality within states might affect the measured income–mortality relationship to the extent that income growth generated rising inequality. This pattern called the Kuznets curve is found within many countries during industrialization . The exp2 are about the same.One of the factors behind the rapid household income growth from 1950 to 1980 is the increase in female participation in the labor force. The state with the smallest increase in the female labor force participation rate still had over 44% more women in the force labor, while the average growth is 75%. It is possible that the income growth variable is also capturing some of the effect from mothers spending more time working outside the home. To explore this factor, we add the ratio of female labor force participation rate 1980 to 1950 to the main specification. The coefficient is positive but insignificant for all age cohorts. The inclusion of this variable only slightly reduces the coefficient on the ratio of median income and the adjusted R2 are about the same.Another factor to consider is the compositional shift that occurred in the sectors of employment from the 1950 to 1980. Individuals were moving away from employment in the agricultural sector to the manufacturing and service sectors. We rerun the main regression including the ratio of the share of non-agriculture employment 1980 to 1950. The coefficients are positive but insignificant. The inclusion of this variable only slightly reduces the coefficient on the ratio of median income and the adjusted RIt is important to recognize limitations of this statistical analysis, first in linking cohorts born near the middle of the century with economic change at the state level from 1950 to 1980. An improvement would be to link the income growth of annual birth cohorts with CVD deaths in the same birth cohorts; however, this option is unavailable with the data at hand. The approximation employed here adds some noise to the relationship, which might diminish the precision of the estimates. Nevertheless, the coefficients of interest are both statistically and economically significant, as predicted by the developmental origins hypothesis. These results add to the theoretically underpinnings of the hypothesis and provide strong credibility to the developmental origins hypothesis and its continued investigation.Next, states are heterogeneous in all the variables employed, and so it might be desirable to use smaller geographic units of analysis such as counties that are more homogeneous. Units such as small as counties, however, often have very high rates of population turnover (above those of states) that complicate the links between income in the past with that of heart disease mortality in the present. States are not free of these problems, but they have fewer issues in this regard. Despite the shortcomings noted here, a state-level analysis explains over 70% of the variance in CVD mortality.The coefficients on the ratio of median household income in 1980 to that in 1950 are all positive, and economically and statistically significant. Considering the three mutually exclusive groups , the magnitude of the effect of a rise in household income increases as the groups climb in age. The 55–64-year-old cohort would have been under 4 years old in 1950 and between 25 and 34 years old in 1980. The 75–84-year-old cohort would have been between 15 and 24 years old in 1950 and between 45 and 54 years old in 1980. This result suggests that if the income growth occurs early enough in life, while the individual is still developing, the body is better able to adjust to the changing nutritional state. The individuals who were older when the income growth occurred were less able to physiologically adapt and are the most adversely affected by the income growth ,45.Our analysis agrees with many studies that show smoking, obesity, lack of healthcare access, and low levels of education are all risk factors for CVD mortality. This is the case despite known problems of inference about individual behavior from regressions based on aggregate data. The ecological fallacy does not distort the interpretation of relationships measured in our results. First, we are not trying to infer individual behavior from aggregate data on smoking, obesity, and education. These relationships are already well-established at the individual level. We include these variables in the regressions to control for distortions they may impose on the income-mortality relationship. Second, examples of the fallacy contemplate distortions created by contemporaneous feed-back loops, such as immigrants who often have low levels of education, deciding where to settle based on the quality of educational opportunities. In our case, there is no such feed-back loop, or if there was it would operate with an implausibly very long lag.We argue that income change from 1950 to 1980 affected mortality rates a half a century or more later, and it is hard to imagine how mortality rates could affect past income change. Individual death from CVD is not subject to decision in the same way as immigrants choosing a destination. A devil’s advocate might argue that older individuals with CVD chose to live in states that had high levels of past income change, but the mechanism is unclear. This might mean that CVD sufferers who lived in low-mortality states migrated to the South, perhaps for the availability of good medical care boosted by past income growth; we find that implausible and inconsistent with known migration patterns.The coefficients on the obesity rate are positive and statistically significant for all age group cohorts. Other research has shown that carrying elevated amounts of body fat is associated with higher levels of mortality ,42. FurtThe coefficients on smoking are positive and statistically significant for all age cohorts except for 65–74-year-olds. The overall mortality among smokers in the United States is about three times higher than that among similar people who never smoked . Our resOur paper makes two important contributions and contributes several suggestions for additional research. First, the analysis confirms or is at least consistent with the developmental origins hypothesis as applied to CVD in explaining regional differences in mortality within the United States. These differences are large and contribute importantly to understanding sources of health inequality. Second, the impact on mortality of rapidly improving intergenerational conditions during the middle of the twentieth century increases with age across the groups 55–64 to 75–84. This suggests that the penalties of unbalanced physical growth increase when the body has less ability to adapt to a new environment.The traditional southern diet was a disaster for heart disease when accompanied by a decline in physical labor and habits that eschewed recreational exercise. The southern diet is gradually changing but fried foods, such as chicken, catfish, and hushpuppies, remain popular to this day. Pockets of strong dietary tradition linger in many rural regions, a pattern that offers an opportunity to study CVD at the county level.A topic untouched by the evidence analyzed here is the consequence of duration of relative poverty and affluence on CVD mortality. One might reasonably hypothesize that for a given increase in income, children of those women having had longer intergenerational experiences of poverty may have had greater susceptibility. Similarly, for a given duration of poverty, children of women having had greater increases in income would also be more susceptible. Individual-level intergenerational evidence is needed to investigate these interesting questions.Lastly, the developmental origins hypothesis has especially relevant implications for the developing world, where vast amounts of poor families are on the verge of experiencing significant increases in relative income. Chronic adult illness, like heart disease, are projected to increase dramatically in these locations in the future ,50.


Osteoarthritis (OA) is one of the most prevalent degenerative joint diseases, which results in the inevitable destruction of joints leading to pain and joint immobility. Some studies have reported a potential link between diabetes mellitus (DM) and the worsening symptoms and severity of OA. Based on our literature review, the microcellular environment of patients with DM showed accelerated joint destruction and increased inflammation in every anatomical aspect of the joint including the bones, tendons, ligaments, cartilage, and synovium. Additionally, the biomechanical and biochemical properties of these tissues were more severely impacted in patients with DM and OA compared to those without DM, suggesting that DM plays an important role in the pathogenesis of OA. Specifically, we found that advanced glycation end products (AGEs) are the key to inducing the acceleration of joint destruction; however, their role in the pathogenesis has yet to be fully mapped out. In this narrative review, we aim to explore the role that DM plays in the acceleration of OA leading to increased reports of joint pain in those with both diseases. We believe this topic of discussion to be important due to the increased prevalence of both diseases over the last several decades, potentially leading to an increased medical burden on both patients and the community at large. Osteoarthritis (OA) is one of the most prevalent joint disorders, and it leads to diarthrodial articular cartilage deterioration with eventual disability in adults ,2. The pOA is a degenerative disease leading to the inevitable destruction and disfigurement of joints in adults. This condition occurs with the common symptoms of pain and joint immobility, which can be the initial motivation for patients to consult a physician for relief. Pain in OA is one of the most reported symptoms and ranges drastically in severity on a multifactorial basis, with one of the etiologies appearing to branch from DM. In a study where patients were assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC), those with coexisting DM and OA more frequently reported more severe symptoms compared to those without ,7. ThoseIn this narrative review, we aim to explore the relationship between DM and the progression of OA in terms of patient-reported pain severity. We intend to review the related literature and report how elevated glucose levels in DM play a role in the pathogenesis of OA from the anatomical level to the metabolic level. Based on the literature review, we report on DM influencing the musculoskeletal system, specifically the bones, tendons, ligaments, and cartilage of joints most frequently affected in OA. We will further discuss how DM interferes with the mechanism and mediators involved with joint destruction. The goal of this review is to shed light on the relationship between these two incredibly common diseases to help reduce the severity of pain experienced by patients with OA.MethodologyData collection was performed, without any language restriction, using the databases PubMed/Medline, BIREME, and Cochrane, as well as the references found within these articles. Three reviewers performed independent data extractions of the articles chosen for this narrative review. Subsequently, these reviewers further scrutinized the articles to ensure their methodological quality Figure .Impact of diabetes on the musculoskeletal system, bone, and articular cartilageMetabolism of bone and articular cartilage can be greatly affected by a hyperglycemic condition, which could prove to be detrimental . The intImpact of diabetes on tendons and ligamentsHyperglycemia can lead to biomechanical and biochemical tendon abnormalities, which contribute to debilitating tendinopathies, further exacerbating OA. Several studies have consistently shown that hyperglycemic states lead to increased AGE levels that have detrimental effects on the integrity of the chemical structure of collagen resulting in increased microtears ,10. AddiIt is very well known that collagen has a triple helix structure, which contributes to collagen’s inherent strength, stability, and linear organization within the tissues of tendons ligaments and cartilage ,12. AGEsAlong with interfering with the mechanical structure of tendons, AGEs also seem to play a role in increasing TSPC apoptosis, decreasing their ability to maintain tendon homeostasis and repair of extracellular matrix ,10. WhilMechanism and mediators involved in joint destructionEffects of DM on joints are complex; King et al. have clearly explained the effects of diabetes and hyperglycemia on bone, articular cartilage, synovium, tendons, and ligaments . In T1DMA hyperglycemic environment increases the production of reactive oxygen species and oxidants and promotes matrix catabolism. In these environments, cellular transport of glucose becomes critical, which, if altered as in DM, contributes to excess oxidative stress and tissue damage and accelerates OA; this was extensively explained by Rosa et al. in two different studies Figure  18,19].,19.18,19High tissue levels of glucose also accelerate the formation of AGEs. The AGEs signal through RAGE (receptor for AGEs) and other receptors and produce various deleterious effects on chondrocytes such as inflammation and cytokine-mediated catabolism. Also, cross-linking of collagen by AGEs alters tissue biomechanical properties  and may Since the prevalence of both OA and DM is increasing, the relationship between these two diseases needs to be investigated to help reduce the health burden on both the individual and the community of those affected. It can be concluded that DM has a crucial role in the acceleration of OA pathogenesis even in its early onset; however, the definitive causal pathway still needs to be established. Based on the available literature, chronic hyperglycemic states can increase inflammation in the microcellular environments of joints. Although the complete pathogenesis is not mapped out, AGEs have a central role in perpetuating inflammatory processes in every anatomical part of the joint. This increased inflammation can then exponentiate the breakdown of cells and tissues, potentiating the progression of OA. Therefore, an individual with poor glycemic control is more prone to have osteoarthritic pain with more severity in contrast to one with OA only. Choosing appropriate anti-diabetic agents to decelerate the rate of subchondral bone changes in OA could be an excellent topic for further studies. Specifically, further investigation on how AGEs exactly affect chondrocytes through the RAGE receptor should be pursued as decreased chondrocyte function correlates to increased pathological fractures and increased need for joint arthroplasty. Furthermore, early lifestyle changes, dietary modification, and intensive glycemic control should be practiced and encouraged to delay the onset and severity of the pain in OA.


Based on data collected from a sample of 91 senior leaders in one US financial services organization over a 3-year period prior to Covid-19, the results showed a negative relationship between directing others behaviors and leadership potential ratings for females and a positive relationship between these variables for males. A negative relationship between engaging others behaviors and performance assessments was also found for females. This study highlights the continuing bias in leadership assessments of women and explores the contradictions between the perception and the reality of women's leadership.The impact of gender on assessments of leadership performance and leadership potential was examined through two clusters of leadership behaviors, one set related to traditional constructions of leadership labeled  Organizations face a persistent gender gap in leadership. In the United States, women comprise nearly half of the labor force, yet only 6.2% of S&P 500 company's CEOs are women  Gender will moderate the relationship between leadership behaviors associated with directing others and performance evaluations. The relationship for males will be positive and for females will be negative.Leadership behaviors related to engaging others effectively, e.g., teamwork, adaptability, and empathy, are behaviors distinctly characteristic of women. Arguments have been made that there is a female advantage, and that women may in fact benefit from demonstrating collaborative behaviors Vecchio, . Women aH2) Gender will not moderate the relationship between leadership behaviors associated with engaging others and performance evaluations. Both males and females will show a positive relationship.Distinct from performance appraisals, evaluations of leadership potential assess the future capabilities of individuals for promotion into senior organizational positions. Evaluation bias against women occurs not only in the assessment of women's actual and perceived behaviors, illustrating descriptive and prescriptive gender stereotypes, but also in the ratings of the potential of women for higher-level leadership roles  Gender will moderate the relationship between leadership behaviors associated with directing others and high potential ratings. The relationship for males will be positive and for females will be negative.H4) Gender will moderate the relationship between leadership behaviors associated with engaging others and high potential ratings. The relationship for males will be positive and for females will be negative.The sample consisted of 91 senior leaders, 26 females (29%) and 65 males (71%), in one financial services institution with offices throughout the United States. This institution is one of the Top 100 US Best Banks named by Forbes magazine. The respondents mirrored the gender proportions of the senior leadership population in this organization, which comprised 130 individuals, 40 females and 90 males. The sample group identified as either male or female, and no participant responded to the category option of “Other.” Over a 2-year period, five groups of the organization's top leaders participated in a custom-designed executive development program conducted by a local university focused on developing leadership capabilities linked to organizational business priorities. Their selection was based solely on their leadership level, and all senior leaders attended the program. Our sample was drawn from this population. One organization as the research site controlled for possible contextual differences in the criterion variables of performance and potential for male and female leaders. A comparison of males and females in one organization ensured that any observed gender differences were not due to factors such as differences in industries or management hierarchies across organizations.The mean age of the participants was 46 for the males and 44 for the females. On average, the males had been in managerial roles for 17 years and the females for 14 years, and had held their current positions an average of 2.6 and 3.0 years, respectively. Both the men and women had been with the organization an average of 14 years.An introductory email was sent from the Executive Vice President of Human Resources to the sample population, explaining the study and inviting participation. The researchers then emailed the population to describe the study and the method of participation in greater detail. The data were collected prior to the Covid-19 pandemic.The leadership behaviors were assessed through a multi-rater assessment instrument composed of behavioral indicators designed to measure leadership competencies  and annual potential ratings on a three-item scale  were conducted for every leader in the organization by the leader's immediate manager. These assessments were standard annual evaluations used in the organization. All of the assessing managers to whom the participants reported were male. The scores were averaged over 3 years to compute two outcome numbers representing the participant's measure of performance and leadership potential.Gender was coded as zero for males and one for females.performance (for H1 & H2) and a second analysis for the dependent variable potential (for H3 & H4). We included age and years within a management role at the first step in both moderated regression analyses to control for possible confounds in the relationships. In the second step the main effects, which included the variables gender, engaging others, and directing others, were entered into the regression equation. Finally, in the third step, the interaction terms were added; specifically, the interaction between gender and engaging others and the interaction between gender and directing others. All variables were centered to help control for multicollinearity and to aid in the interpretation of results , and inter-correlations for the study's variables are included in The results from the two hierarchical moderated regression analyses can be found in performance as the dependent variable, only the results from the third step can be examined because only at this step is the model significant . Nineteen percent of the variation in performance scores is accounted for by the variables in the third step, which includes the interaction terms. Looking within this step, the interaction between gender and the competency cluster engaging others is significant . To further understand this interaction, we did a post-hoc moderator analysis as outlined in Aiken and West  = 9.723, p = 0.000], the control variable age is significantly and negatively related to potential . This finding makes sense as a younger employee would have more time for growth and the potential to be successful in the future, whereas an older employee is less likely to be perceived as having as much potential for future improvement. Eighteen percent of the variation in potential scores is accounted for by age and years in a managerial role. The second step, adding the main effects, was also significant ; however, none of the main effects were significantly related to the dependent variable, potential. Twenty one percent of the variation in potential scores is accounted for by the variables in the second step. Finally, the third step, which includes the interaction terms, was significant . Twenty eight percent of the variation in potential scores is accounted for by the variables in the third step, which includes the interaction terms. Within this third step, the interaction between the competency cluster directing others and gender was significant . To further understand this interaction, we did a post-hoc moderator analysis as outlined in Aiken and West  in our study were found to be negatively related to leadership potential assessments for women and positively related to leadership potential assessments for men. It would appear in this case that the prescriptive gender role behaviors for women trump the leader role behaviors for women, and consequently women pay a price. Women demonstrating out-of-gender role behaviors such as achievement orientation or driving change conflict with the stereotype fit model for women. As Schein  can provide a deeper understanding of the importance of demonstrating specific behaviors to each of these distinct groups.Examinations of the impact of leadership behaviors on assessments of performance and leadership potential with larger samples of male and female leaders from multiple organizations will extend this research and the generalizability of the results. It will be important to address the question of whether the practice of relying on perceptions and assessing female leaders with prescriptive bias is a universal practice in organizations or was it unique to the organization in this research study.First and foremost, it is imperative that organizational decision-makers recognize the overt and covert, as well as the individual and structural biases that prevent women from assuming leadership roles and reaching their full leadership potential. Empirical evidence of these biases abounds (Morrison et al., Beyond continuing to discover the unrecognized and unacknowledged potential of female leaders, organizations need to examine their practices, procedures, and policies on a regular basis to determine whether they are reinforcing gender stereotypes and stereotypical behavior. For example, hiring procedures, training and development opportunities, benefits packages, leave policies, and performance, salary and promotional evaluations can all play a part in contributing to gender stereotypes. One recommendation for performance evaluations would be to include 360-degree assessment tools in the formal assessment process for leaders, to include data from a variety of perspectives and individuals. Leaders in policy-making positions should periodically reflect on their own behaviors, not only for their own learning and development but also to see whether they are behaving in ways that contribute to gender stereotypical practices. Perhaps they are sending subtle messages throughout the organization that sustain and support such behaviors.The repertoire of leadership behaviors used in organizational assessments for hiring, training and development, and promotions must be expanded to reflect best practices and include the broadest possible range. Leaders who have the capacity to demonstrate a large repertoire of behaviors are able to effectively respond to a variety of situations. Organizational systems that have a limited framework for essential leadership behaviors will restrict their ability to recruit and develop outstanding leaders.Leadership behaviors focused on relationship management, teamwork, collaboration, and empathy must be acknowledged as important for organizational viability, growth and change when demonstrated by both males and females. These behaviors provide the necessary bond for an organization's continued development. It is not enough to rely solely on leadership behaviors that are germane to one's gender, particularly if they might be discredited, or to behaviors that strictly match one's organizational position and are incongruent with gender. What is needed is the recognition of a broad array of leadership behaviors demonstrated by both women and men.Special attention needs to be paid to the opportunities for, and pace of, career advancement for women. Career paths for women in particular must be reconsidered to reflect boundaryless Arthur,  or kaleiThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Case Western Reserve University. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.