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Re: The Spillover Influence of Partner’s Education on Myocardial Infarction Incidence and Survival

Oude Groeniger, Joost; van Lenthe, Frank, J.

doi: 10.1097/EDE.0000000000000830
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Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands, j.oudegroeniger@erasmusmc.nl

Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands

The authors report no conflicts of interest.

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To the Editor:

Marriage rates have steadily decreased since the mid-20th century, and approximately half of all marriages end in a divorce.1 Against this background, some results of Kilpi et al2 are particularly noteworthy: whereas the focus was on the role of partner’s education, the study showed that individuals without a partner had the highest risks of myocardial infarction (MI) incidence and fatality. Given that 60% of the participants without a partner were also in the lowest educational group, this is (as acknowledged by the authors) an important target group for public health interventions. However, it remains unclear which individuals in the “no-partner” group are actually most at risk. Further differentiation is critical for at least 3 reasons.

First, health risks of singles, divorced, and widowed may differ substantially, due to different underlying factors.

Second, although Kilpi et al2 allowed for changes in partnership status by updating information for each year of follow-up in the MI incidence analysis, this may also introduce time-varying confounding. Changes in partnership status occur for different reasons, which—particularly in the case of divorce—may also affect MI incidence. For example, excessive alcohol consumption, financial difficulties, or stress may contribute to a divorce and also increase risk of MI. If no control is made for these risk factors, MI incidence may be wrongfully attributed to “having no partner.”3 Because lower educated individuals are more likely to experience these risk factors and also have a higher rate of marital dissolution,1 further differentiation by educational groups seems warranted.

Third, the health consequences of marital separation seem to depend on who initiated the separation (self-initiated, partner initiated, or jointly initiated), which subsequently varies by sex and health outcome.4 Especially for women, separation may be associated with some physical health benefits,4 which cannot be observed from aggregated estimates.

In conclusion, Kilpi et al2 have convincingly shown the importance of partner’s educational resources for MI risks but perhaps even more drawn attention to the need to better understand the health risks of those without a partner. In contemporary societies, where an increasing percentage of the population lives without a partner, identification of those most at risk becomes even more prudent.

Joost Oude Groeniger

Department of Public Health

Erasmus University Medical Center

Rotterdam, The Netherlands

j.oudegroeniger@erasmusmc.nl

Frank J. van Lenthe

Department of Public Health

Erasmus University Medical Center

Rotterdam, The Netherlands

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REFERENCES

1. Amato PRResearch on divorce: continuing trends and new developments. J Marriage Fam. 2010;72:650–666.
2. Kilpi F, Martikainen P, Konttinen H, Silventoinen K, Torssander J, Kawachi IThe spillover influence of partner’s education on myocardial infarction incidence and survival. Epidemiology 2017;28:237–245.
3. Oude Groeniger J, van Lenthe FJContribution of time-varying measures of health behaviours to socioeconomic inequalities in mortality: how to understand the underlying mechanisms? J Epidemiol Community Health. 2016;70:1045–1048.
4. Hewitt B, Turrell GShort-term functional health and well-being after marital separation: does initiator status make a difference? Am J Epidemiol. 2011;173:1308–1318.
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