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Abs Ac
Pu pose The coho was se up o s udy he impac o
li es yle ac o s in ea ly adul hood on disease ou comes,
wi h a ocus on assessing he in luence o body
composi ion and physical pe o mance in ea ly adul hood
on subsequen cance isk.
Pa icipan s Men bo n in 1958 who pe o med hei
mili a y se ice be ween he ages o 17 and 30 yea s
we e included in his s udy (n=31 158). They we e
eligible o mili a y se ice i hey we e heal hy o had
only mino heal h p oblems diagnosed a he beginning
o hei se ice. Men wi h ch onic illnesses equi ing
egula medica ion o ea men we e no eligible o
se ice. Comp ehensi e heal h da a including diagnosed
illnesses, an h opome ic measu es and heal h beha iou
we e collec ed a he beginning and a he end o mili a y
se ice, including da a om medical check-ups.
Findings o da e Du ing he ollow-up, 1124 new cance
cases we e diagnosed be ween baseline (ie, end o he
mili a y se ice o each indi idual) and end o he yea
2014. In he end o he ollow-up, 91% o he s udy
pa icipan s we e s ill ali e. O e weigh (body mass index
(BMI) ≥25 kg/m2) and obesi y (BMI ≥30 kg/m2) we e
associa ed wi h an o e all inc eased isk o cance . A good
o excellen physical condi ion signi ican ly educed cance
isk.
Fu u e plans The da ase o e s he possibili y o linkage
wi h o he da abases, such as he Finnish Cance Regis y
(eg, p ima y si e o he umou , mo phology, ime o
de ec ion, sp eading and p ima y ea men ), i al s a is ics
(da e o emig a ion o dea hs), censuses (socioeconomic
indica o s), hospi al discha ge da a (como bidi y) and
popula ion su eys (li e habi s).
In oduc Ion
The Finnish Mili a y Rec ui s Coho was
se up o s udy he impac o se e al li e-
s yle ac o s in ea ly adul hood on disease
ou comes. Mili a y se ice in Finland is
manda o y o men a he age o 17–30 yea s
o a pe iod o 8–11 mon hs, meaning ha
i ually e e y Finnish man can be aced
back in mili a y eco ds. In 2012, we s a ed
elec onic ansc ip ion o he pape -based
medical examina ion eco ds a en y and
exi o he manda o y mili a y se ice o all
men bo n in 1958, which was he oldes ull
da ase a ailable o us. These eco ds con ain
demog aphic in o ma ion, da a on common
heal h isk ac o s such as obacco smoking o
heigh and weigh , measu emen s o gene al
physical pe o mance, a s anda d medical
examina ion such as blood p essu e, esul s
o basic u ine examina ions (suga , p o eins,
leucocy es, ni i es and bac e ia) and eyesigh
sc eening es s as well as sel - epo ed heal h
s a us.
One o he ini ial aims o his s udy was o
documen and assess he in luence o ea ly
adul hood body composi ion and physical
pe o mance on adul cance isk. This was
mo i a ed by he inc easing bu den o disease
pa icula ly in high-income coun ies such as
Finland ha has been linked o he g owing
p opo ion o he popula ion wi h insu i-
cien physical ac i i y and high body weigh .
Regula physical ac i i y (PA) and a heal hy
Coho p o ile: a na ionwide coho o
Finnish mili a y ec ui s bo n in 1958 o
s udy he impac o li es yle ac o s in
ea ly adul hood on disease ou comes
Jo ma So munen,1,2 Melina A nold,3 Isabelle Soe joma a am,3 Ee o Pukkala1,4
To ci e: So munenJ, A noldM,
Soe joma a amI, e al. Coho
p o ile: a na ionwide coho
o Finnish mili a y ec ui s
bo n in 1958 o s udy he
impac o li es yle ac o s in
ea ly adul hood on disease
ou comes. BMJ Open
2017;7:e016905. doi:10.1136/
bmjopen-2017-016905
► P epublica ion his o y o
his pape is a ailable online.
To iew hese iles, please isi
he jou nal online (h p:// dx. doi.
o g/ 10. 1136/ bmjopen- 2017-
016905).
Recei ed 30 Ma ch 2017
Re ised 13 July 2017
Accep ed 10 Augus 2017
1Facul y o Social Sciences,
Uni e si y o Tampe e, Tampe e,
Finland
2Depa men o Oncology,
Tampe e Uni e si y Hospi al,
Tampe e, Finland
3Sec ion o Cance Su eillance,
In e na ional Agency o
Resea ch on Cance , Lyon,
F ance
4Finnish Cance Regis y,
Ins i u e o S a is ical and
Epidemiological Cance
Resea ch, Helsinki, Finland
co espondence o
D Jo ma So munen;
jo ma. so munen@ gmail. com
Coho p o ile
s eng hs and limi a ions o his s udy
►The la ge numbe o a p opo ion- ep esen a i e
sample o men bo n in 1958 in Finland included in
his s udy.
►A ho ough e alua ion pe o med by medical
pe sonnel and measu emen o di e en heal h
a iables in a uni o m manne .
►Possibili y o a wide ange o linkages wi h di e en
egis ies.
►The coho is no ully ep esen a i e o he male
popula ion bo n in 1958, which means ha he
esul s canno be ully gene alised o he en i e
popula ion. Those su e ing om ch onically bad
heal h be o e mili a y se ice and hose who chose
o pu sue hei na ional se ice in ci il se ice o
any eason (e hicalo eligious) we e no included
in he coho .
►We only ha e da a om he mili a y consc ip s
collec ed du ing hei mili a y se ice, when hei
a e age age was 20 yea s.
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box Lis o he a iables collec ed a s udy en y o each
membe o he coho
►Pe sonal iden i y code o he indi idual
►P o essional g oup
►Ma i al s a us
►Beginning o mili a y se ice (da e)
►End o mili a y se ice (da e)
►Reason o p elimina y discon inua ion o mili a y se ice (diagnosis)
►Du a ion o mili a y se ice
►Mili a y se ice classi ica ions a di e en s ages o he se ice
►Classi ica ion diagnoses a di e en s ages o he mili a y se ice
►Sel -pe cei ed heal h s a us a he beginning and a he end o he
se ice
►Heigh and weigh a di e en s ages o he se ice
►Blood p essu e a di e en s ages o he se ice
►Physical condi ion es esul s a di e en s ages o he se ice
–Twel e-minu e unning es esul s
–Muscle s eng h es esul s
►Smoking s a us and amoun smoked a di e en s ages o he
se ice
►Use o alcohol and he amoun d unken a di e en s ages o he
se ice
body weigh ha e been epo ed o posi i ely impac
gene al heal h and ha e been associa ed wi h lowe isks
o se e al non-communicable diseases including ca dio-
ascula diseases,1 diabe es2 and cance .3 4
In men, egula PA shows su icien e idence o p o ec
om colo ec al cance .5 6 Simila associa ions ha e also
been sugges ed o p os a e7–9 and bladde cance , ye
e idence is s ill inconsis en .10 11 P e ious esea ch om
Finland has shown ha he incidence o cance among
wo ld-class male a hle es is educed when compa ed wi h
he gene al popula ion, wi h he la ges isk educ ion seen
in lung cance (s anda dised incidence a io (SIR) 0.40,
95% CI: 0.27 o 0.55) and kidney cance (SIR 0.23, 95%
CI: 0.06 o 0.57).12 13 As o high body weigh , ce ain
cance si es ha e been causally linked o body weigh ,
including cance s o he oesophagus (adenoca cinoma),
gas ic ca dia, colo ec um, gallbladde , panc eas, li e ,
b eas (pos menopausal), endome ium, o a y, kidney
and p os a e (non-localised).14
Two ained cle ks pe o med he da a ex ac ion om
pape -based mili a y eco ds (ha d copy) in o elec onic
o ma . The quali y o he collec ed da a was con inuously
moni o ed bo h by check-up ools buil in he da a inpu
p og amme and by ollowing he summa y inpu s a is ics.
coho desc ip ion
The coho consis s o men bo n in 1958, who se ed in
he Finnish De ence Fo ces (FDF). The e is a uni e sal
male consc ip ion in Finland o ei he mili a y se ice
o ci il se ice, which is usually comple ed a he age o
20 yea s. A he ime o he se ice o he coho in ques-
ion (en y be ween 1975 and 1989), men we e liable o
se e be ween 240 and 330 days depending on he le el
o aining hey we e o ecei e. O he men bo n in 1958,
almos 90% s a ed hei mili a y se ice, whe eas he es
ei he se ed in ci il se ice o we e comple ely libe a ed
om he se ice.
In o al, he coho comp ises 31 158 men bo n in
1958, who we e andomly selec ed om he o al popula-
ion and ep esen 74% o all Finnish men bo n in 1958.
The a e age age a s udy en y was 20 yea s ( ange 17–31
yea s). In he end o 2014, 91% o all s udy pa icipan s
we e s ill ali e.
Du ing hei mili a y se ice, he consc ip s we e
ollowed-up by heal hca e p o essionals a leas wice (a
he beginning and a he end o hei mili a y se ice).
Thei physical condi ion (PC) was eco ded a leas once
du ing hei mili a y se ice. Owing o unique pe son
iden i ie s, eco d linkage wi h heal h and adminis a-
i e da abases allows o a wide ange o epidemiological
s udies on di e en ou comes in his coho . Follow-up
o inciden cance s is cu en ly a ailable un il he end o
2014, wi h annual upda es en isaged depending on ele-
an esea ch ques ions.
WhA hAs been meAsu ed?
A he s a o mili a y se ice (baseline)
All baseline measu emen s we e pe o med by heal h-
ca e p o essionals (nu ses, physicians and den is s) a
he beginning o he mili a y se ice (be ween 1975 and
1989). A e an ini ial heal h check, a i ness classi ica ion
(A–E) was assigned o each consc ip , based on his heal h.
Class A indica es good physical and men al heal h and
capabili y o ield se ice. Men wi h B-classi ica ion we e
i o ligh e se ice oops, wi h heal h condi ions no
needing egula ea men o medica ion, o example,
la oo . C-classi ied men we e libe a ed om peace ime
se ice, and D-classi ied men we e exemp ed om mili-
a y se ice comple ely. Men classi ied as C ypically need
egula ea men o hei condi ion (eg, diabe es) bu
a e o he wise heal hy and can hus be d a ed a wa ime.
D-classi ied men ha e a condi ion ha a ec s hei daily
li e so se iously ha hey canno be d a ed e en du ing
wa ime. E-classi ica ion means de e men o medical
easons up o 3 yea s. Diagnoses leading o E-classi ica-
ion a e ypically young men’s adjus men diso de s.15
A e he baseline medical check-up, he basic PC o he
consc ip s was measu ed by a 12 min unning es and a
es measu ing muscle s eng h. Da a on heal h beha iou
(eg, smoking habi s and alcohol consump ion) we e
collec ed du ing he medical check-ups. A de ailed lis
o all demog aphic, beha iou al and heal h da a i ems
collec ed a baseline is p esen ed in box. A ec ui men ,
91.5% o he men we e heal hy (classi ied o se ice
class A), and 7.1% had mino heal h p oblems (se ice
class B) ( able 1). In addi ion, 411 men we e classi ied
o se ice classes C, D o E be o e he end o he mili-
a y se ice (beginning o he ollow-up). The majo i y
o all men had a no mal weigh a ec ui men (body
mass index, BMI 18.5–25 kg/m2), 10.6% we e o e weigh
(BMI 25–30 kg/m2) and 1.4% we e obese (BMI >30 kg/
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Table 1 Coho cha ac e is ics a s udy en y (n=31 158)
n %
Se ice classi ica ion
A (heal hy) 28 520 91.5
B (mino heal h p oblems) 2227 7.1
C o D 192 0.6
Missing 219 0.7
Smoking s a us
Yes 10 707 34.4
No 16 066 51.6
Missing 4385 14.1
Ciga e es/day among smoke s
<10 ciga e es/day 2010 18.8
10–19 ciga e es/day 5657 52.8
≥20 ciga e es/day 2862 26.7
Missing 178 1.7
Alcohol consump ion
Yes 19 052 61.1
No 8097 26.0
Missing 4009 12.9
BMI
Unde weigh (BMI<18.5) 1489 4.8
No mal weigh (18.5≤BMI<25) 25 939 83.2
O e weigh (25≤BMI<30) 3294 10.6
Obesi y (BMI≥30) 421 1.4
Missing 15 0.0
Body su ace a ea
<2 m226 729 85.8
≥2 m24415 14.2
Missing 14 0.0
O e all PC
Bad 1326 4.3
Sa is ying 6294 20.2
Good 12 707 40.8
Excellen 5503 17.7
Missing 5328 17.1
BMI and PC c oss-ca ego y
BMI<25 and good/excellen PC 16 930 54.3
BMI≥25 and good/excellen PC 1277 4.1
BMI<25 and bad/sa is ying PC 6001 19.3
BMI≥25 and bad/sa is ying PC 1618 5.2
Missing 5332 17.1
BMI, body mass index; PC, physical condi ion.
m2). O e all PC was excellen in 17.7%, good in 40.8%
and sa is ac o y o bad in 24.5%. Mos men wi h BMI <25
we e also in a good o excellen PC, whe eas he o e -
weigh and obese men (BMI ≥25) we e mo e likely o be
in a sa is ac o y o bad PC. O e all, 51.6% o he men
we e non-smoke s, and 26.0% s a ed a he beginning
o hei mili a y se ice ha hey did no consume any
alcohol. The numbe o men in se ice classes C and D
was small so hese da a a e no sepa a ely epo ed.
A he end o mili a y se ice
Typically, assessmen s o PC ake place a leas wice
du ing he mili a y se ice o each consc ip , including
medical check-ups a he beginning and a he end o
mili a y se ice. The medical check-up a he end o mili-
a y se ice has he same elemen s as he check-up a
he beginning e en hough i is usually no as igo ously
ollowed as he medical check-up a he beginning. This
is because sel -pe cei ed heal h is conside ed he mos
impo an heal h indica o a he end o he se ice, only
signi ican changes in his indica o lead o a igo ous
medical check-up.
Follow-up ia eco d linkage
A e a comple e ansc ip ion o he mili a y eco ds,
he coho da a we e linked wi h he Finnish Cance
Regis y (FCR); Na ional Popula ion Regis y (da e o
emig a ion o dea h) and censuses (socioeconomic
indica o s), hospi al discha ge da a (mo bidi y) and he
cause o dea h egis e a S a is ics Finland. The linkage
equi ed app o als by he FDF and he Na ional Ins i u e
o Heal h and Wel a e in Finland. The high-quali y FCR
da a con ains in o ma ion on cance diagnosis da e, ype
and loca ion o he cance ( opog aphy), mo phology,
sp eading o he cance and he p ima y ea men
me hod.16
All eco d linkages we e pe o med using he unique
pe sonal iden i y code (PIC) gi en o e e y esiden o
Finland and used as he key in all egis ies in Finland.
PICs o he men in he coho collec ed om he pape -
based iles we e i s linked o he Popula ion Regis y
and checked ha e e y pe son exis ed in he popula ion
ei he ali e o wi h da e o emig a ion o dea h.
In ou aw da a collec ion sys em, we had a buil -in
mechanism o checking he co ec o ma o he PICs.
Only 26 PICs we e no ound in he popula ion egis y.
In addi ion, we had one PIC o w ong gende . These indi-
iduals we e excluded om he coho .
s a is ical me hods
Cox p opo ional haza d models wi h age as unde lying
ime me ic we e i ed o es ima e HRs and 95% CIs)
o he ela ion be ween each s udy a iable and he isk
o de eloping malignan cance by si e. Subjec s we e
censo ed as hey emig a ed om Finland o died be o e
he end o ollow-up (31 Decembe 2014), whiche e
occu ed i s . All analyses we e ca ied ou using S a a
13.
esul s: indings o da e
In his i s p esen a ion o his coho , we demons a e
he linkage ha was done wi h he FCR o ob ain da a
on cance incidence. We u he mo e assessed he
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associa ion be ween obacco smoking, alcohol use and
an h opome ic measu es as epo ed in young adul -
hood (a s udy baseline) and cance isk. All men, excep
hose wi h a missing se ice classi ica ion (n=219), hose
wi h se ice classi ica ion C o D (n=192) and hose wi h
a cance diagnosis be o e he end o he mili a y se ice
(n=5) we e included in he ollow-up. The inal s udy
sample comp ised 30 742 men.
Du ing he ollow-up, 1124 new cance cases we e diag-
nosed be ween baseline (ie, end o he mili a y se ice
o each indi idual) and end o he yea 2014. S udy a i-
ables we e BMI (weigh in kilog am di ided by heigh in
squa e me e), o e all PC (excellen /good/sa is ying/
bad), se ice classi ica ion (A/B), smoking s a us (yes/
no) and amoun (ciga e es/day) and alcohol use (yes/
no).
Mo e han h ee decades a e he end o hei mili-
a y se ice, his is he i s epidemiological assessmen
o he impac o PC, body composi ion and ce ain li e-
s yle ac o s (eg, smoking and alcohol consump ion),
measu ed in young adul hood, on cance isk la e in li e.
O e weigh (BMI ≥25 kg/m2) and obesi y (BMI ≥30
kgm2) we e associa ed wi h an o e all inc eased, bu
s a is ically no signi ican , isk o cance (age-adjus ed
HR: 1.08, 95% CI: 0.89 o 1.30), a good o excellen PC
signi ican ly educed cance isk (HR: 0.82, 95% CI: 0.71
o 0.95). When compa ed wi h hose wi h no mal weigh
and good PC, hose wi h no mal weigh bu bad PC had
an inc eased isk o all cance s combined (HR: 1.18,
95% CI: 1.01 o 1.38). Men who we e in poo PC and also
we e o e weigh had an HR o 1.30 (95% CI: 1.01 o 1.69)
when compa ed wi h hose wi h no mal weigh and good
PC. These associa ions howe e dec eased and became
s a is ically insigni ican ( espec i e HRs: 1.05 (95% CI:
0.88 o 1.26) and 1.13 (95% CI: 0.85 o 1.50)) when
adjus ed o smoking, alcohol consump ion and se ice
class. Men in se ice class B we e a a mo e han h ee old
highe isk o ad anced p os a e cance as compa ed wi h
hose in se ice class A (HR adjus ed o age, PC, BMI,
smoking and alcohol use: 3.35, 95% CI: 1.14 o 9.90).
To u he alida e heal h indica o s a ailable o his
coho , we also obse ed a dose– esponse ela ionship
be ween he numbe o ciga e es smoked daily and o al
cance incidence. The HR among hose who smoked
20 ciga e es o mo e pe day was 1.54 (95% CI: 1.25 o
1.89). Inc eased isk was mos p onounced o incidence
o lung cance (HR: 9.65, 95% CI: 4.83 o 19.27).
main s eng hs and weaknesses
The main s eng h o his s udy is he la ge numbe o
a p opo ion- ep esen a i e sample o men bo n in 1958
in Finland included in his s udy. A ho ough e alua ion
pe o med by medical pe sonnel and measu emen o
di e en heal h a iables including gene al heal h and
PC we e measu ed in a uni o m manne . The FDF ha e
a ho ough aining p o ocol o all mili a y and medical
pe sonnel especially o classi ying se ice class and o
measu e PC. O e he 14-yea pe iod (1975–1989) du ing
which he men in he coho comple ed hei se ice,
he e we e nei he new se ice class classi ica ions no
PC measu emen me hods in oduced in he FDF. We
belie e ha he da a we collec ed om he mili a y
eco ds a e o high quali y.
Si ua ed in Finland, his coho p o ides he possibili y
o a wide ange o linkages wi h di e en egis ies. In
his i s s udy, we linked he coho da a o he FCR and
alida ed associa ions wi h BMI, PC and smoking.
Usually, ill-heal h seems o be associa ed wi h poo PC
o high BMI, which in u n a e ela ed o some o he
ac o s ypical wi h low socioeconomic s a us (SES).
Finland has ied o ake s eps in o de o dec ease
hese isks. Owing o cheap uni e sal heal h co e age
in Finland, all Finns ha e simila access o heal hca e
independen o hei inancial o SES. In addi ion o
his, mos Finnish municipali ies encou age people o
imp o e hei heal h by physical exe cise and by o e ing
planned ac i i ies o people o all ages, e en people
wi h disabili ies.
Some weaknesses should be no ed in ela ion o hese
da a. Fi s , he coho is no ully ep esen a i e o he
male popula ion bo n in 1958, which means ha he
esul s canno be ully gene alised o he en i e popula-
ion. Those su e ing om ch onically bad heal h (eg,
de elopmen diso de s o men al diso de s) be o e
mili a y se ice and hose who chose o pu sue hei
na ional se ice in ci il se ice o eligious, e hical o
o he easons we e no included in he coho , bu hei
p opo ion is small.
Second, we only ha e da a om he mili a y consc ip s
collec ed du ing hei mili a y se ice, las ing be ween
8 and 11 mon hs. The consc ip s we e be ween he ages
o 17 and 30 yea s a he beginning o hei mili a y
se ice. We do no ha e da a on he possible changes
in hei heal h habi s a e he comple ion o hei
se ice. Conside ing he ela i ely s able li e habi s in
he majo i y o he popula ion and he long lag ela ed o
cance de elopmen , we belie e ha he changes in he
heal h habi s do no ma kedly con ound ou esul s. In
he u u e, linkage wi h na ional popula ion su ey da a,
such as he FINRISK s udy (ex ensi e popula ion s udy
on isk ac o s behind ch onic diseases, whici is ca ied
ou by he Na ional Ins i u e o Heal h and Wel a e
THL), which is conduc ed e e y 5 yea s since 1972,17
will allow o be e unde s anding o he magni ude o
changes in he isk ac o s measu ed du ing he mili a y
se ice, as well as o he isk ac o s. A ma ked p opo ion
o he young-age cance s de ec ed up- o-da e may ha e
a gene ic backg ound which was no aken in o accoun
in he p esen analyses. I is, howe e , possible o iden-
i y i s -deg ee amily membe s o he men in ou coho
om he Finnish Popula ion Regis y and hen link hei
PICs o he FCR o ge in o ma ion on cance cases in
he amily.
A p esen , he coho is s ill ela i ely young, wi h
mode a e numbe o cance cases o dea hs. Howe e ,
p elimina y esul s o his coho show ha i can al eady
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be used o epidemiological pu poses and will become
e en mo e in e es ing as he coho g ows olde .
Acknowledgemen s We hank he impo an wo k done by Päi i Haapakangas
and Anna Kaisa Pasanen, who collec ed and digi alised he da a. Wi hou hei wo k,
his s udy would no be possible.
con ibu o s JS, EP, MA and IS we e esponsible o he planning, da a collec ion,
da a analysis and p epa ing o he manusc ip . All au ho s ha e con ibu ed equally.
The p ojec has been managed by JS.
Funding This wo k was suppo ed by a g an o €50 000 om he Finnish Cance
Founda ion.
compe ing in e es s None decla ed.
Pa ien consen De ail has been emo ed om his case desc ip ion/ hese case
desc ip ions o ensu e anonymi y. The edi o s and e iewe s ha e seen he de ailed
in o ma ion a ailable and a e sa is ied ha he in o ma ion backs up he case he
au ho s a e making.
P o enance and pee e iew No commissioned; ex e nally pee e iewed.
da a sha ing s a emen The s udy da a a e no eely a ailable due o
con iden iali y easons, bu he esea ch eam welcomes po en ial collabo a ion
wi h o he esea che s. Fo u he in o ma ion, con ac he au ho EP a he Finnish
Cance Regis y ( ee o. pukkala@ cance . i) o JS ( jo ma. so munen@ imne . i).
open Access This is an Open Access a icle dis ibu ed in acco dance wi h he
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pe mi s o he s o dis ibu e, emix, adap , build upon his wo k non-comme cially,
and license hei de i a i e wo ks on di e en e ms, p o ided he o iginal wo k is
p ope ly ci ed and he use is non-comme cial. See: h p:// c ea i ecommons. o g/
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© A icle au ho (s) (o hei employe (s) unless o he wise s a ed in he ex o he
a icle) 2017. All igh s ese ed. No comme cial use is pe mi ed unless o he wise
exp essly g an ed.
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on disease ou comes
impac o li es yle ac o s in ea ly adul hood
mili a y ec ui s bo n in 1958 o s udy he
Coho p o ile: a na ionwide coho o Finnish
Pukkala
Jo ma So munen, Melina A nold, Isabelle Soe joma a am and Ee o
doi: 10.1136/bmjopen-2017-016905
2017 7: BMJ Open
h p://bmjopen.bmj.com/con en /7/10/e016905
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