C H A P T E R
29
Boiled Coffee: An Arctic Example of Potential
Residual and Unmeasured Confounding in
Coffee Epidemiology
Lena Maria Nilsson
Public Health and Clinical Medicine, Nutritional Research, and Arctic Research Centre,
Ume University, Ume, Sweden
List of Abbreviations
BMI Body mass index
CI Confidence interval; i.e., in exactum
MI Myocardial infarction
PProbability
The VIP cohort The Vsterbotten Intervention Programme cohort
29.1INTRODUCTION
For decades, the impact of coffee consumption on
health has been a constant epidemiological matter, typi-
cally focusing on habitual intake of the general beverage
in grams/day, cups/day, or occasions/day. As a result,
a large number of meta-analyses are continuously being
performed to explore general doseresponse associa-
tions between coffee and common diseases (e.g., see Refs
15). Coffee-specific components such as caffeine, diter-
penes, and chlorogenic acids also have been thoroughly
explored,6 and it has been pointed out that coffee may
contain up to 1000 different co-occurring phytochemi-
cal substances with the potential of providing a complex
pattern of synergistic, additive, or antagonistic health
effects.7
Coffee culture, including brewing technique, varies
worldwide and may affect the chemical quality of cof-
fee8,9 as well as reflect altered lifestyle factors related
to coffee drinking. For example, it has been shown
that coffee consumption is correlated with hazardous
lifestyle factors such as smoking, as well as hazard-
ous eating and drinking,10 and that deliberate changes
in coffee intake may induce spontaneous changes in
lifestyle, at least regarding diet.11 Among the Sami
Coffee in Health and Disease Prevention
http://dx.doi.org/10.1016/B978-0-12-409517-5.00029-2 2015 Elsevier Inc. All rights reserved.
people, the indigenous population of Arctic Scandi-
navia, boiled coffee is strongly connected to the tradi-
tional lifestyle1214; this is true as well in the common,
non-Sami population.15 Thus, from an epidemiological
point of view, residual or unmeasured confounding in
populations with heterogeneous coffee cultures may
hide or distort true causal risk associations related to
lifestyle. Despite this obvious risk of erroneous con-
clusions, to date surprisingly little attention has been
given to more detailed descriptions of potential con-
founding factors connected to different coffee cultures.
What are the characteristics of the women and men
who regularly drink espresso, cappuccino, or instant or
decaffeinated coffee?
The aim of this chapter is to present the coffee culture
of the Arctic parts of Scandinavia with focus on boiled
coffee culture and to discuss the impact of this coffee cul-
ture on potential residual and unmeasured confounding
in coffee epidemiology.
29.2 RESIDUAL AND UNMEASURED
CONFOUNDING IN COFFEE
EPIDEMIOLOGY
Ideally, covariance between coffee intake and exam-
ined risk factors would reflect a causal pathway between
chemical components ingested through coffee consump-
tion and the risk factor. Unfortunately, this is rarely the
case. Often, at least theoretically, other factors outside of
the exposure considered cannot be excluded as alterna-
tive explanationsthat is, residual or unmeasured con-
founding may have occurred.
265
266 29. ARCTIC BOILED COFFEE CULTURE AS A CONFOUNDER
A good example of this is lung cancer. Smoking is
universally accepted as a modifiable risk factor for lung
cancer, explaining a great majority of all cases.16 Still,
15% of the cases in men and 53% of the cases in women
are explained by other factors,16 of which coffee is one
possible candidate. A recent meta-analysis showed that
an increase in coffee consumption of 2cups/day was
associated with a 14% increased risk of developing lung
cancer after adjusting for smoking.17 Surprisingly, how-
ever, when merging the results for nonsmokers (three
studies), there was a tendency of an inverse association:
increased coffee consumption was associated with a
decreased risk for lung cancer. Supposing that the lat-
ter tendency reflects the true risk association, the deviant
main result could be explained by residual confounding
as follows: It is, as already mentioned, well known that
there is a covariance between consumption of coffee and
many lifestyle factors that are hazardous to ones health,
such as smoking.10 The increased risk of developing lung
cancer among heavy consumers of coffee could then be
explained by not adjusting for smoking and other haz-
ardous lifestyle factors to a sufficient extent or not at all.
Consequently, the authors of this meta-analysis conclude
that their results should be interpreted with caution.17
In a cohort study in Vsterbotten County, a part of
Arctic Sweden, lung cancer was not associated with cof-
fee consumption in general.18 When coffee consumption
was stratified according to different brewing methods,
however, an interesting and significant heterogeneity
appeared: boiled coffee was positively associated with
lung cancer, in line with the previously described meta-
analysis, whereas filtered coffee was not. To be more
exact, men who drank boiled coffee four or more times
every day had a significant 122% increased risk of being
diagnosed with a carcinoma in the respiratory tract com-
pared with nondaily consumers. For women, the cor-
responding risk increase was 29%. For filtered coffee,
the tendency was opposite: all risk associations were
inverse, but none of them were statistically significant.18
The authors concluded that residual confounding due
to insufficient estimates of smoking and lifestyle factors
associated with boiled coffee likely played a role in these
results.18 Thus, to understand these results and others, a
deeper knowledge of Arctic Scandinavian boiled coffee
culture, and lifestyle factors associated with boiled cof-
fee, is essential.
29.3 COFFEE: A PART OF THE
SCANDINAVIAN CULTURE SINCE THE
1700s
Coffee was introduced to Scandinavia in the late 1600s
and accounted for the largest import increase over the
1700 and 1800s.19,20 Unlike tea drinking, which mainly
I. INTRODUCTORY AND GENERAL TEXT
became a habit of the upper class, coffee culture spread
quickly among the broad masses all over Norway, Sweden,
and Finland.1921 A Scottish chemist, Thomas Thomson,
visiting Sweden in 1812, described the contemporary
coffee culture like this: It is but doing the Swedes jus-
tice to say that their coffee is excellent, greatly preferable
to what is drunk in England You can get coffee in the
meanest peasants house, and it is always excellent22
One explanation for the rapidly growing demand for
coffee was decreasing coffee prices because of increased
transatlantic coffee trade, which made this colonial
beverage economically attractive to common people in
comparison with locally produced beers and spirits.19,20
When coffee consumption was banned by authorities
during five different episodes, the latest from 1817 to
1822, large-scale smuggling supplied the consumers with
the coveted item.20 An extensive use of coffee, even from
a Scandinavian perspective, has been noted among Sami
people from the mid-1800s into modern times,1214,23
with an exception for Russian Skolt Sami, who instead
have developed a tea culture in accordance with Russian
traditions.24 One could speculate whether the Northern
Scandinavian Sami coffee culture may have its roots in
involvement in the profitable legal and illegal coffee
trade of the 1700 and 1800s. Spmi, the traditional area
of the Sami peoples, extends namely over the entirety
of Northern Scandinavia (Figure 29.1), and for centuries
Sami peoples have been naturally involved in extensive
cross-border trade. Besides the smuggling episodes,
there are more examples of Arctic people defying bans
and intense moralistic anticoffee propaganda. During
the severe food crisis of northern Sweden (18611867),
authorities recommended that no poor relief should be
offered to anyone seen drinking coffee. But coffee still
continued to be treated as staple food.23 More specifi-
cally, coffee consumption went into a temporary stagna-
tion during this period, but after the crisis it continued
FIGURE 29.1 Arctic Scandinavia. Spmi is the customary area of
the Sami people, the indigenous people of the northernmost Arctic,
Scandinavia, and the Kola Peninsula of Russia. Sami people histori-
cally drink large amounts of boiled coffee. Only in the Russian part of
Spmi is tea preferred over coffee.
 29.4 Chemical Implications of the Preparation of Boiled Coffee
to increase.23 Actually, it has been proposed that sticking
to coffee drinking may have been one of the few ways
common people of the North could oppose authorities
and manifest autonomy in the 1700 and 1800s.23
In the 1930s, Swedish national health care authorities
were seriously concerned with the widespread coffee
abuse in the north; 94% of the schoolchildren got at
least one cup of coffee in the morning before breakfast,
and adults drank on average 58cups/day, which was
more than twice as much as in southern Sweden.25 Con-
sidering the difficult social and economic situation of
the north, coffee was seen as an unjustified luxury con-
sumption as well as a health threat.25 Today, Finland and
Norway are counted as the two highest consumers of
coffee worldwide, and Sweden is counted as number 6,
following closely after Iceland, Denmark, and the Neth-
erlands.26 During the years 19711991, a reduction in car-
diovascular mortality in Norway was partly explained
by a reduced consumption of boiled coffee.27 Despite a
general health claim to avoid it, however, the tradition
of consuming boiled unfiltered coffee is still maintained
in the north to a larger extent than in the south.28,29 In
numbers, about 40% of the Arctic Scandinavian popula-
tion still prefer traditionally boiled coffee,15,29,30 whereas
the proportion in the south is much lower.31,32 Among
Norwegian Sami with a strong cultural connection, as
many as 48% reported a preference for boiled coffee.29
29.4 CHEMICAL IMPLICATIONS OF THE
PREPARATION OF BOILED COFFEE
Boiled coffee is prepared on the stove top or over an
open fire both in modern and traditional settings, as
shown in Figure 29.2. According to a standard cookbook,
FIGURE 29.2 Scandinavian boiled coffee. Preparation of boiled coffee in traditional and modern settings.
I. INTRODUCTORY AND GENERAL TEXT
267
1l of water should be mixed with 11.5dl coffee grounds,
independent of brewing technique, and will result in 68
cups of either boiled or filtered coffee.33 Personal pref-
erences may, of course, also affect these proportions. In
historical sources, boiled coffee of the north has been
described as strong,23 and there is a saying that for the
best result, boiled coffee should not be prepared too
weak, and filtered coffee should not be prepared too
strong.
To prepare boiled coffee, coffee grounds are mixed
with fresh water and heated to a boil. Coffee beans, in
the old days coarsely crushed with stones, axes, or coffee
mills,23 are today mostly industrially coarsely ground.
After the coffee has been boiling for a short while, there
are varying procedures to let it settle, that is, to let the
grounds sink to the bottom of the pot. One of the most
simple is just to remove the coffee pot from the heat, add
a little dash of cold water to it, and wait.33 In the old
days, another way of getting it clear was adding dried
fish skin to the coffee.34 There also is a traditionamong
both Sami and non-Samiof adding sugar, cheese, ani-
mal (reindeer) fat, and/or dried meat into the coffee,
making it somewhat resemble a quick meal.23,35 Today,
coffee cheese (Figure 29.3) and other accessories are
rarely used, though all items are available at least to a
certain extent in the commodity markets all over north-
ern Scandinavia.
When preparing filtered coffee, sub-boiling water
(9296C) is poured through a paper filter containing finely
ground coffee. Diterpenes, the cholesterol-increasing lip-
ids in coffee, are extracted by the hot water, but retained
by the paper filter. Lower water temperature in combina-
tion with the filtering process drastically limits the lipid
levels. Thus, the lipid content of boiled coffee may be as
much as 60 times higher than the lipid content of filtered
268 29. ARCTIC BOILED COFFEE CULTURE AS A CONFOUNDER
FIGURE 29.3 Coffee cheese. Coffee cheese is
a fresh cheese traditionally made from reindeer
or goat milk. It somewhat resembles that of Greek
Halloumi with no added salt.
coffee.28 From a cancer perspective, diterpenes are sup-
posed to have a protective effect,36 and from a cardiovas-
cular perspective they have a detrimental effect because
of the effect of increasing cholesterol levels.3739 An effect
of increasing blood pressure also has been connected to
consumption of boiled coffee.40 Regarding other chemi-
cal components, for example, caffeine, brewing method
has little effect. However, culture and individual pref-
erences may still be of some importance. For example,
the grade of roasting affects the availability of many
coffee-specific components. The darker roasted coffee
beans, the more components available,33 which means
that filtered coffee, sold as medium or dark roasted, still
may contain more different coffee-specific phytochemi-
cal substances, such as flavonoids and polyphenols, than
boiled coffee, sold as light or medium roasted.33
29.5 RISK ASSOCIATIONS IN BOILED
AND FILTERED COFFEE
Results from studies distinguishing between boiled
and filtered coffee are summarized in Tables 29.1 and
29.2. Table 29.1 exemplifies the first research question
where such a distinction was at issue, namely the cho-
lesterol-increasing effect of coffee in four cross-sectional
studies from Finland, Sweden, and Norway. All of these
studies confirm that a high intake of boiled coffee is
associated with increased cholesterol levels in humans
and that this effect is much weaker or absent in those
who consume high amounts of filtered coffee.15,29,41,42
Four studies of associations between boiled and filtered
coffee and some lifestyle-related diseases, namely myo-
cardial infarction, diabetes, and cancer, are summarized
in Table 29.2. In two of these studies, associations are
similar in filtered and boiled coffee31,43; more precisely,
there is an increased risk of myocardial infarction in a
cohort of non-Arctic Swedes31 and a decreased risk of
type 2 diabetes43 in a nationwide study in Norway. In
the other two, some of the associations were found in
people who drank either boiled or filtered coffee. For
example, both in pancreas and lung cancer (the latter
was described earlier in Section 29.2), risk associations
in different coffee types opposed each other, with an
I. INTRODUCTORY AND GENERAL TEXT
increased risk among people preferring boiled coffee.
Women with a frequent intake of boiled coffee, in other
words, four or more times per day, had a decreased risk
of breast cancer, whereas no significant association was
confirmed among women with a corresponding intake
of filtered coffee. However, it is worth pointing out that
the number of cases among women having this frequent
intake of boiled coffee was low. Moreover, some results
deserve extra attention. For example, an increased risk
for myocardial infarction was found only in men who
drank filtered coffee more than four times per day. Men
who consumed an equal amount of boiled coffee had
a similar tendency but no statistically significant asso-
ciation.30 Considering the proven cholesterol- and blood
pressure-increasing effects of boiled coffee compared to
filtered coffee, this result should rather have been the
opposite.3740 Residual or unmeasured confounding
due to lifestyle factors cannot be excluded. The obvious
question is, what are the characteristics of the women
and men who drink boiled coffee at least four times a
day? What are the characteristics of the women and men
who have a correspondingly high consumption of fil-
tered coffee?
29.6 LIFESTYLE FACTORS ASSOCIATED
WITH CONSUMPTION OF BOILED AND
FILTERED COFFEE
Coffee consumption is an integral part of daily life all
over Scandinavia. It is considered impolite not to offer
a visitor a cup of coffee, no meal is complete without a
final cup of coffee, and in workplaces there is a general
pattern of two regular coffee breaks per day (in Swedish
fikaraster), when everybody gathers and chats.23 In larger
indoor workplaces, filtered coffee is most likely enjoyed
this way three times per day. Among people with out-
door occupations such as forestry, hunting, fishing,
and reindeer herding, boiled coffee is a more common
choice.35 Positive connotations to this kind of tradi-
tional lifestyle have recently been used in advertising of
a new coffee brand, an advertising campaign criticized
by indigenous organizations for its stigmatizing under-
tones (Figure 29.4).
 29.6Lifestyle Factors Associated with Consumption of Boiled and Filtered Coffee
TABLE 29.1 The Cholesterol-Increasing Effect of Boiled and Filtered Coffee
Research Number of Confounders Included in Association with Boiled Association with Filtered
Question Design Subjects the Model Exposure Coffee Coffee Sources
I. INTRODUCTORY AND GENERAL TEXT

Coffee and serum Cross-sectional 5647 men, 6347 Age, BMI, physical activity, 9cups/day vs 0cups/ Positive association Yes, but weaker 29
total cholesterol women smoking day

Cross-sectional 5704 men, women Age, BMI, smoking, serum Boiled coffee Higher Lower 41
study total -glutamyltransferase, index consumers vs filtered
of saturated fat intake, physical coffee consumers
activity

Coffee and blood Population-based 1625 men, women Age, diastolic blood pressure, 4cups/day vs Positive in boiled coffee None 15
cholesterol cross-sectional BMI, fiber intake, fat intake, >5cups/day
total coffee intake

Coffee and Cross-sectional 14,168 men, 14,859 BMI, number of cigarettes, salt 4cups/day Increased cholesterol Lower cholesterol 42
cholesterol, study women and fat intake, time since last increase, only significant
triglycerides, and meal, physical activity in women
blood pressure

This table summarizes results from epidemiological studies in Scandinavia comparing the cholesterol-increasing effect of boiled and filtered coffee. BMI, body mass index.

269
 270
TABLE 29.2 Coffee Type as a Determinant of Health
Number of Confounders Included Association with Boiled Association with Filtered

29. ARCTIC BOILED COFFEE CULTURE AS A CONFOUNDER

Outcome Design Subjects in the Model Exposure Coffee Coffee Source
I. INTRODUCTORY AND GENERAL TEXT

Myocardial Population-based 1171 men, 472 Age, hospital catchment >9cups/day vs Increased risk of MI in Increased risk of MI in men 31
infarction case-control study women area, smoking <3cups/day men No associations in women
Similar tendency in
women

Nested case/referent 1353 men, 315 Smoking, education, 1time/day vs No associations in men Increased risk of MI in men 30
study women apolipoprotein B-to- 23times/day and Unstable results in No associations in women
apolipoprotein A ratio, 4times/day women
BMI, hypertension,
sedentary lifestyle

Type 2 diabetes Cross-sectional 171,414 men, Year of birth, sex, BMI, >9cups/day vs Decreased risk Decreased risk 43
190,631 women smoking, education, <1cup/day
physical activity

Incident cancer Cohort study 32,425 men, 32,178 Age, sex, BMI, smoking, <1time/day vs Increased risk for (a) and (b) not confirmed 30
women education, recreational 13times/day and respiratory tract (a) and Decreased risk for breast cancer
physical activity 4times/day pancreas (b) cancers, (c) only in postmenopausal
decreased risk for breast women
cancer (c) in women

The table shows results from Scandinavian epidemiological studies distinguishing between consumption of boiled and filtered coffee. BMI, body mass index; MI, myocardial infarction.
 29.6Lifestyle Factors Associated with Consumption of Boiled and Filtered Coffee
FIGURE 29.4 Coffee culture as a purchase incentive. This adver-
tising image, whose brand and identity have been masked by the
author with the Swedish word for brand, varumrke, shows how
Sami coffee culture has been used as a quality guarantee for a new
coffee brand. The advertising text above the man dressed in traditional
Sami clothes reads: New varumrkeacceptable but queer, if you ask
me! At the bottom the text reads Good taste from Stockholm.
271
In a previously published partial least squares analy-
sis focusing on known risk factors for cancer, consump-
tion of boiled coffee was associated with male sex,
increased intake of fat, decreased intake of vegetables,
and low education.35 Increased consumption of filtered
coffee was associated with smoking, higher education
levels, households of only a single person, increased age,
and high intake of alcohol, vitamin D, and selenium.35
This study was performed in a Northern Swedish pop-
ulation, and it was based on lifestyle and dietary data
from the Vsterbotten Intervention Programme (VIP)
cohort.44 The VIP is a huge population-based survey of
the inhabitants of the county of Vsterbotten in Arctic
Sweden, and it has been ongoing since 1985.44
Table 29.3 shows previously unpublished Spearman
correlations for 62,582 daily consumers and nondaily
consumers of different kinds of coffee from the VIP
cohort. Boiled and filtered coffees are correlated mutu-
ally and in relation to age, height, and intake of macronu-
trients. Before studying these results, it is worth noting
that in data sets of this large magnitude, even minor
correlations may become statistically significant. First,
consumption of boiled coffee is significantly negatively
correlated with consumption of filtered coffee. That is,
there is an obvious collinearitythe more boiled coffee
consumed, the less filtered coffee people drinkand the
correlation coefficient is relatively large: 0.288 (P0.001).
Further, daily consumers of boiled coffee are somewhat
older and somewhat shorter compared with nondaily
consumers. They have a higher intake of fat and lower
intakes of carbohydrates, protein, and alcohol (corre-
lation coefficients=0.112, 0.086, 0.056, and 0.042,
respectively). In contrast, daily consumers of filtered cof-
fee drink more alcohol, have a higher intake of protein,
and have close to zero (but somewhat lower) intakes of

TABLE 29.3 Coffee Type and Lifestyle I

Boiled Coffee Filtered Coffee

Mean (SD) Correlation Coefficient P (2-Tailed) Correlation Coefficient P (2-Tailed)

Age (years) 47.4 (9.6) 0.034 0.001 0.082 0.001

Height (cm) 171.6 (9.3) 0.021 0.001 0.028 0.001

Consumption

Boiled coffee (g/day) 111 (183) 0.288 0.001

Filtered coffee (g/day) 299 (209) 0.288 0.001

Fat (% energy) 34.6 (6.5) 0.112 0.001 0.008 0.042

Carbohydrates (% energy) 49.9 (6.3) 0.086 0.001 0.015 0.001

Proteins (% energy) 14.6 (2.1) 0.056 0.001 0.063 0.001

Alcohol (g/day) 4.2 (4.8) 0.042 0.001 0.167 0.001

The table shows Spearman correlations for boiled and filtered coffee mutually and in relation to age, height, and dietary Factors in the population-based Vsterbot-
ten cohort of Northern Sweden, sorted according to the magnitude of the correlation with boiled coffee.
N=62,582 men and women from the Vsterbotten Intervention Programme in Northern Sweden.

I. INTRODUCTORY AND GENERAL TEXT

272 29. ARCTIC BOILED COFFEE CULTURE AS A CONFOUNDER

carbohydrates and fat (correlation coefficients=0.167,
0.063, 0.015, and 0.008, respectively; see Table 29.3).
Table 29.4 shows previously unpublished logistic
regressions of lifestyle-related events among daily con-
sumers of boiled and filtered coffee compared with non-
daily consumers. Daily consumption of coffee is more
common among men than among women but does not
differ significantly between consumers of boiled and fil-
tered coffee (P for heterogeneity=0.591). All other life-
style-related events differ significantly between boiled
and filtered coffee (P for heterogeneity0.001). Smoking
is the only event that has an equal direction of the associa-
tion in both types of coffee. A daily consumer of boiled
coffee is 49% more likely to be a smoker compared with
a nondaily consumer. The corresponding number for fil-
tered coffee is 28%. All other lifestyle factors differ dia-
metrically from each other in terms of the direction of
the associations. People who drink boiled coffee daily
are 46% more likely to occupy themselves with regular
leisure-time hunting and fishing, 24% more likely to lack
a postsecondary education, 14% more likely to come from
a rural area, 13% more likely to never perform physical
activity in exercise clothes, 8% more likely to have a work-
ing situation without time-related stress, and, among
women are 34% more likely to have had a first full-term
pregnancy at the age of 20 or earlier than people who do
not consume boiled coffee daily. Daily consumers of fil-
tered coffee reflect an opposite pattern: they are 13% more
likely to come from an urban area and have time-related
stress at work, 10% less likely to hunt or fish, 7% more
likely to have a postsecondary education, 2% more likely
to sometimes perform physical activity in exercise clothes,
and, among women, are 8% less likely to have had a first
full-term pregnancy at the age 20 or earlier than nondaily
consumers of filtered coffee (Table 29.4).
29.7DISCUSSION
This is the first interdisciplinary description of the
boiled coffee culture of the Scandinavian Arctic. It eluci-
dates the complexity of interpreting coffee epidemiology,
especially in a setting where individual coffee choice may
affect the nature of the exposure in focus as well as the pat-
tern of residual or unmeasured confounding related to it.
In addition to the lifestyle factors described by data
from the VIP cohort, there are many more lifestyle-
related differences that could be captured if the data set
had been specially designed to depict the boiled coffee
culture. A desirable question would, for example, ask
about the frequency of occasions (e.g., times per week)
when boiled coffee is prepared over an open fire. If the
increased risk of lung and pancreas cancer (only found
in consumers of boiled coffee) could be statistically
adjusted for confounding by exposure to wood smoke,
risk associations may have been different.
Similarly, it is well known that reproductive factors
have a significant influence on the risk of breast cancer and

TABLE 29.4 Coffee Type and Lifestyle II

Likelihood of Event (CI)

(N=62,582 persons) Number of Events (%) Boiled Coffee Filtered Coffee Heterogeneitye (P)

Male sex 31,397 (50.2) 1.05 (1.021.08) 1.04 (1.021.07) 0.591

Events

Current smoker 11,607 (18.5) 1.49 (1.431.55) 1.28 (1.231.33) 0.001

Regular leisure-time hunting/ 17,830 (28.0) 1.46 (1.411.50) 0.90 (0.870.92) 0.001
fishinga

First full-term birth at an early 4039 (13.9) 1.34 (1.251.43) 0.92 (0.860.98) 0.001
ageb (only women)

No postsecondary education 45,983 (73.5) 1.24 (0.221.27) 0.93 (0.910.95) 0.001

Living in a rural areac 26,596 (42.5) 1.14 (1.121.17) 0.87 (0.850.89) 0.001

No regular physical activity in 41,648 (66.5) 1.13 (1.101.15) 0.98 (0.961.00) 0.001
exercise clothes

No stress at workd 15,388 (24.6) 1.08 (1.041.12) 0.87 (0.840.89) 0.001

Logistic regressions of lifestyle-related events among daily consumers of boiled and filtered coffee compared with nondaily consumers in the population-based
Vsterbotten cohort of Northern Sweden, sorted according to the magnitude of the association with boiled coffee.
aDefined as leisure-time fishing or hunting at least every month.
bDefined as first full-term birth at the age of 20 or earlier.
cDefined as not living in the communities of Ume and Skellefte.
dDefined as never or rarely having time-related stress at work.
eHeterogeneity between boiled and filtered coffee calculated by a chi-square test. P<0.05 indicates heterogenic results.

I. INTRODUCTORY AND GENERAL TEXT

 References
that first full-term birth at an early age is protective against
the most common types of breast cancer.45 Since women
who drink boiled coffee every day had a 34% increased
likelihood of first full-term birth at an early age, this may
have confounded the risk association and reinforced the
results showing a decreased risk of breast cancer among
women drinking boiled coffee four or more times per day.
As already pointed out, however, the number of cases
among women frequently drinking boiled coffee was low;
therefore, the results should be interpreted with caution.
Regarding the lack of significant positive risk associa-
tion between consumption of lipid-rich boiled coffee and
myocardial infarction, lifestyle-related confounding also is
likely involved. We recapitulate that men who drink boiled
coffee on a daily basis are more likely to live in a rural area
and less likely to have a stressful working situation (Table
29.4). Having time to perform the procedure of preparing
boiled coffee four times per day or more often is perhaps a
part of a lifestyle favorable for cardiac health, independent
of the chemical composition of the beverage ingested.
In contrast to boiled coffee, filtered coffee is more
often mechanically prepared and requires less time to
reach the consumer. Thus, it is better adapted to a stress-
ful working situation. Physical and emotional stress
are known triggers of myocardial infarction.46 Frequent
male coffee consumers with a preference for lipid-poor
filtered coffee may suffer from this kind of stress more
than from poisoning by coffee. If so, lifestyle-related
stress confounds the true risk relationship and may, at
least to some extent, explain the increased risk for myo-
cardial infarction found in these men.30
Observational studies distinguishing between con-
sumption of boiled and filtered coffee are rare.15,18,29
31,41,43 International observational studies distinguishing
between different brewing methods may be even rarer
(e.g., Ref. 9). Even if considering only chemical differ-
ences due to different brewing techniques, there is an
apparent need to further elucidate risk associations
related to different types of coffee. When adding to this
the cultural and lifestyle-related differences between
consumers of different coffee types, as demonstrated by
this chapter, the risk of ignoring residual or unmeasured
confounding is alarming. In conclusion, when interpret-
ing chemical differences between different coffee brews,
lifestyle factors related to coffee culture should always be
taken into consideration or at least discussed as apparent
candidates of residual or unmeasured confounding.
29.8 SUMMARY POINTS
C
 offee culture differs all over the world and affects
the chemical composition of coffee, as well as
quantities consumed and lifestyle factors associated
with coffee drinking.
I. INTRODUCTORY AND GENERAL TEXT
273
B oiled coffee is a good example of residual or
unmeasured confounding in an Arctic population
with two heterogeneous coffee cultures.
Although filtered coffee is the most common caffeine
brew in this area today, for cultural reasons boiled
coffeetraditionally prepared on a stove top or over
an open firestill plays an important role in the
population.
There are chemical differences between boiled coffee
and drip-filtered coffee that might have an impact on
public health regarding lifestyle-related diseases.
There are certain lifestyle factors, such as leisure-time
hunting and fishing, first full-term pregnancy at an
early age, and low education level, that are positively
associated with the consumption of boiled coffee and
inversely associated with the consumption of filtered
coffee.
The Scandinavian Arctic boiled coffee example
illustrates that, when interpreting chemical
differences between different coffee brews, lifestyle
factors related to coffee culture should always be
taken into consideration or at least discussed as
apparent candidates of residual or unmeasured
confounding.
References
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