Cohort profile: a nationwide cohort of Finnish military recruits born in 1958 to study the impact of lifestyle factors in early adulthood on disease outcomes

1 So munenJ, e al. BMJ Open 2017;7:e016905. doi:10.1136/bmjopen-2017-016905 Open Access 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. g oup.bmj.com on Oc obe 30, 2017 - Published by h p://bmjopen.bmj.com/Downloaded om 2So munenJ, e al. BMJ Open 2017;7:e016905. doi:10.1136/bmjopen-2017-016905 Open Access 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/ g oup.bmj.com on Oc obe 30, 2017 - Published by h p://bmjopen.bmj.com/Downloaded om 3 So munenJ, e al. BMJ Open 2017;7:e016905. doi:10.1136/bmjopen-2017-016905 Open Access 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 g oup.bmj.com on Oc obe 30, 2017 - Published by h p://bmjopen.bmj.com/Downloaded om 4So munenJ, e al. BMJ Open 2017;7:e016905. doi:10.1136/bmjopen-2017-016905 Open Access 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 g oup.bmj.com on Oc obe 30, 2017 - Published by h p://bmjopen.bmj.com/Downloaded om 5 So munenJ, e al. BMJ Open 2017;7:e016905. doi:10.1136/bmjopen-2017-016905 Open Access 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 C ea i e Commons A ibu ion Non Comme cial (CC BY-NC 4.0) license, which 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/ licenses/ by- nc/ 4. 0/ © 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. eFe ences 1. Vanhees L, De Su e J, GeladaS N, e al. Impo ance o cha ac e is ics and modali ies o physical ac i i y and exe cise in de ining he bene i s o ca dio ascula heal h wi hin he gene al popula ion: ecommenda ions om he EACPR (Pa I). Eu J P e Ca diol 2012;19:670–86. 2. Lamb MJ, Wes ga e K, B age S, e al. P ospec i e associa ions be ween seden a y ime, physical ac i i y, i ness and ca diome abolic isk ac o s in people wi h ype 2 diabe es. Diabe ologia 2016;59:110–20. 3. B enne DR. Cance incidence due o excess body weigh and leisu e- ime physical inac i i y in Canada: implica ions o p e en ion. P e Med 2014;66:131–9. 4. de V ies E, Soe joma a am I, Lemmens VE, e al. Li es yle changes and educ ion o colon cance incidence in Eu ope: a scena io s udy o physical ac i i y p omo ion and weigh educ ion. Eu J Cance 2010;46:2605–16. 5. Boyle T, Keegel T, Bull F, e al. Physical ac i i y and isks o p oximal and dis al colon cance s: a sys ema ic e iew and me a-analysis. J Na l Cance Ins 2012;104:1548–61. 6. F ieden eich CM, Neilson HK, Lynch BM. S a e o he epidemiological e idence on physical ac i i y and cance p e en ion. Eu J Cance 2010;46:2593–604. 7. De Nunzio C, P esicce F, Lomba do R, e al. Physical ac i i y as a isk ac o o p os a e cance diagnosis: a p ospec i e biopsy coho analysis. BJU In 2016;117. 8. Johnsen NF, Tjønneland A, Thomsen BL, e al. Physical ac i i y and isk o p os a e cance in he Eu opean P ospec i e In es iga ion in o Cance and Nu i ion (EPIC) coho . In J Cance 2009;125:902–8. 9. Da ling on GA, K eige N, Ligh oo N, e al. P os a e cance isk and die , ec ea ional physical ac i i y and ciga e e smoking. Ch onic Dis Can 2007;27:145–53. 10. Liu Y, Hu F, Li D, e al. Does physical ac i i y educe he isk o p os a e cance ? A sys ema ic e iew and me a-analysis. Eu U ol 2011;60:1029–44. 11. Keimling M, Beh ens G, Schmid D, e al. The associa ion be ween physical ac i i y and bladde cance : sys ema ic e iew and me a- analysis. B J Cance 2014;110:1862–70. 12. So munen J, Bäckmand HM, Sa na S, e al. Li e ime physical ac i i y and cance incidence—a coho s udy o male o me eli e a hle es in Finland. J Sci Med Spo 2014;17:479–84. 13. Pukkala E, Kap io J, Kosken uo M, e al. 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Eu J Public Heal h 2015;25:539–46. g oup.bmj.com on Oc obe 30, 2017 - Published by h p://bmjopen.bmj.com/Downloaded om 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 Upda ed in o ma ion and se ices can be ound a : These include: Re e ences #BIBLh p://bmjopen.bmj.com/con en /7/10/e016905 This a icle ci es 16 a icles, 0 o which you can access o ee a : Open Access h p://c ea i ecommons.o g/licenses/by-nc/4.0/non-comme cial. See: p o ided he o iginal wo k is p ope ly ci ed and he use is non-comme cially, and license hei de i a i e wo ks on di e en e ms, pe mi s o he s o dis ibu e, emix, adap , build upon his wo k Commons A ibu ion Non Comme cial (CC BY-NC 4.0) license, which This is an Open Access a icle dis ibu ed in acco dance wi h he C ea i e se ice Email ale ing box a he op igh co ne o he online a icle. Recei e ee email ale s when new a icles ci e his a icle. Sign up in he Collec ions Topic A icles on simila opics can be ound in he ollowing collec ions (2182)Epidemiology No es h p://g oup.bmj.com/g oup/ igh s-licensing/pe missions To eques pe missions go o: h p://jou nals.bmj.com/cgi/ ep in o m To o de ep in s go o: h p://g oup.bmj.com/subsc ibe/ To subsc ibe o BMJ go o: g oup.bmj.com on Oc obe 30, 2017 - Published by h p://bmjopen.bmj.com/Downloaded om