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  • 1.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    What about healthy participants?: the improvement and deterioration of self-reported health at a 10-year follow-up of the Västerbotten Intervention Programme2011In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, p. 5435-Article in journal (Refereed)
    Abstract [en]

    AIM: The Västerbotten Intervention Programme (VIP) addresses cardiovascular disease and diabetes in the middle-aged population of Västerbotten County, Sweden. Self-reported health (SRH) is one of the risk factors for both conditions. The aim of this study was to analyse the development patterns of SRH among the VIP participants.

    METHODS: Cross-sectional data from 1990 to 2007 were used to analyse the prevalence of poor SRH among 101,396 VIP participants aged 40-60 years. Panel data were used to study the change in SRH among 25,695 persons aged 30-60 years, who participated in the VIP twice within a 10-year interval.

    RESULTS: Prevalence of poor SRH fluctuated between 1990 and 2007 in Västerbotten County. There was a temporary decline around 2000, with SRH continuously improving thereafter. The majority of panel participants remained in good SRH; over half of those with poor or fair SRH at baseline reported better SRH at follow-up. SRH declined in 19% of the panel participants, mostly among those who had good SRH at the baseline. The decline was common among both women and men, in all educational, age and marital status groups.

    CONCLUSIONS: The SRH improvement among those with poor and fair SRH at baseline suggests that VIP has been successful in addressing its target population. However, the deterioration of SRH among 21% of the individuals with good SRH at baseline is of concern. From a public health perspective, it is important for health interventions to address not only the risk group but also those with a healthy profile to prevent the negative development among the seemingly healthy participants.

  • 2.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lönnberg, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Impact of a combined community and primary care prevention strategy on all-cause and cardiovascular mortality: a cohort analysis based on 1 million person-years of follow-up in Västerbotten County, Sweden, during 1990-20062015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 12, article id e009651Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate the impact of the Västerbotten Intervention Programme (VIP) by comparing all eligible individuals (target group impact) according to the intention-to-treat principle and VIP participants with the general Swedish population.

    DESIGN: Dynamic cohort study.

    SETTING/PARTICIPANTS: All individuals aged 40, 50 or 60 years, residing in Västerbotten County, Sweden, between 1990 and 2006 (N=101 918) were followed from their first opportunity to participate in the VIP until age 75, study end point or prior death.

    INTERVENTION: The VIP is a systematic, long-term, county-wide cardiovascular disease (CVD) intervention that is performed within the primary healthcare setting and combines individual and population approaches. The core component is a health dialogue based on a physical examination and a comprehensive questionnaire at the ages of 40, 50 and 60 years.

    PRIMARY OUTCOMES: All-cause and CVD mortality.

    RESULTS: For the target group, there were 5646 deaths observed over 1 054 607 person-years. Compared to Sweden at large, the standardised all-cause mortality ratio was 90.6% (95% CI 88.2% to 93.0%): for women 87.9% (95% CI 84.1% to 91.7%) and for men 92.2% (95% CI 89.2% to 95.3%). For CVD, the ratio was 95.0% (95% CI 90.7% to 99.4%): for women 90.4% (95% CI 82.6% to 98.7%) and for men 96.8% (95% CI 91.7 to 102.0). For participants, subject to further impact as well as selection, when compared to Sweden at large, the standardised all-cause mortality ratio was 66.3% (95% CI 63.7% to 69.0%), whereas the CVD ratio was 68.9% (95% CI 64.2% to 73.9%). For the target group as well as for the participants, standardised mortality ratios for all-cause mortality were reduced within all educational strata.

    CONCLUSIONS: The study suggests that the VIP model of CVD prevention is able to impact on all-cause and cardiovascular mortality when evaluated according to the intention-to-treat principle.

  • 3.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Souares, Aurelia
    Niamba, Louis
    Sie, Ali
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sauerborn, Rainer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Measuring self-reported health in low-income countries: piloting three instruments in semi-rural Burkina Faso2012In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 5, p. 8488-Article in journal (Refereed)
    Abstract [en]

    Background: National surveys in low-income countries increasingly rely on self-reported measures of health. The ease, speed, and economy of collecting self-reports of health make such collection attractive for rapid appraisals. However, the interpretation of these measures is complicated since different cultures understand and respond to the same question in different ways. Objective: The aim of this pilot study was to develop a culturally sensitive tool to study the self-reported health (SRH) of the local adult population in Burkina Faso. Design: The study was carried out in the 2009 rainy season. The sample included 27 men and 25 women aged 18 or older who live in semi-urban Nouna, Burkina Faso. Three culturally adapted instruments were tested: a SRH question, a wooden visual analogue scale (VAS), and a drawn VAS. Respondents were asked to explain their answers to each instrument. The narratives were analyzed with the content analysis technique, and the prevalence of poor SRH was estimated from the quantitative data by stratification for respondent background variables (sex, age, literacy, education, marital status, ethnicity, chronic diseases). The correlation between the instruments was tested with Spearman's correlation test. Results: The SRH question showed a 38.5% prevalence of poor SRH and 44.2% prevalence with both VAS. The correlation between the VAS was 0.89, whereas the correlation between the VAS and the SRH question was 0.60-0.64. Nevertheless, the question used as the basis of each instrument was culturally sensitive and clear to all respondents. Analysis of the narratives shows that respondents clearly differentiated between the various health statuses. Conclusion: In this pilot, we developed and tested a new version of the SRH question that may be more culturally sensitive than its non-adapted equivalents. Additional insight into this population's understanding and reporting of health was also obtained. A larger sample is needed to further study the validity and reliability of the SRH question and the VAS and understand which instrument is best suited to study SRH in the low-income setting of semi-rural Burkina Faso.

  • 4. Boeing, H
    et al.
    Dietrich, T
    Hoffmann, K
    Pischon, T
    Ferrari, P
    Lahmann, PH
    Boutron-Ruault, MC
    Clavel-Chapelon, F
    Allen, N
    Key, T
    Skeie, G
    Lund, E
    Olsen, A
    Tjonneland, A
    Overvad, K
    Jensen, MK
    Rohrmann, S
    Linseisen, J
    Trichopoulou, A
    Bamia, C
    Psalttopoulou, T
    Weinehall, L
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Sanchez, MJ
    Jakszyn, P
    Ardanaz, E
    Amiano, P
    Chirlaque, MD
    Quiros, JR
    Wirfalt, E
    Berglund, G
    Peeters, PH
    van Gils, CH
    Bueno-de-Mesquita, HB
    Buchner, FL
    Berrino, F
    Palli, D
    Sacerdote, C
    Tumino, R
    Panico, S
    Bingham, S
    Khaw, KT
    Slimani, N
    Norat, T
    Jenab, M
    Riboli, E
    Intake of fruits and vegetables and risk of cancer of the upper aero-digestive tract: the prospective EPIC-study.2006In: Cancer Causes and Control, ISSN 0957-5243, E-ISSN 1573-7225, Vol. 17, no 7, p. 957-969Article in journal (Refereed)
    Abstract [en]

    Epidemiologic studies suggest that a high intake of fruits and vegetables is associated with decreased risk of cancers of the upper aero-digestive tract. We studied data from 345,904 subjects of the prospective European Investigation into Cancer and Nutrition (EPIC) recruited in seven European countries, who had completed a dietary questionnaire in 1992-1998. During 2,182,560 person years of observation 352 histologically verified incident squamous cell cancer (SCC) cases (255 males; 97 females) of the oral cavity, pharynx, larynx, and esophagus were identified. Linear and restricted cubic spline Cox regressions were fitted on variables of intake of fruits and vegetables and adjusted for potential confounders. We observed a significant inverse association with combined total fruits and vegetables intake (estimated relative risk (RR) = 0.91; 95% confidence interval (95% CI) 0.83-1.00 per 80 g/d of consumption), and nearly significant inverse associations in separate analyses with total fruits and total vegetables intake (RR: 0.97 (95% CI: 0.92-1.02) and RR = 0.89 (95% CI: 0.78-1.02) per 40 g/d of consumption). Overall, vegetable subgroups were not related to risk with the exception of intake of root vegetables in men. Restricted cubic spline regression did not improve the linear model fits except for total fruits and vegetables and total fruits with a significant decrease in risk at low intake levels (<120 g/d) for fruits. Dietary recommendations should consider the potential benefit of increasing fruits and vegetables consumption for reducing the risk of cancers of the upper aero-digestive tract, particularly at low intake.

  • 5.
    Brännström, Inger
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Rosén, M
    SPRI, Stockholm, Sweden.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Local health planning and intervention: the case of a Swedish municipality1988In: Scandinavian journal of primary health care. Supplement, ISSN 0284-6020, Vol. 1, p. 57-64Article in journal (Refereed)
    Abstract [en]

    This article attempts to illustrate the process from community diagnosis to community involvement by a case study from the north of Sweden. The case of Norsjö is one of few documented Swedish examples of a preventive program with a broad participation from the community. The results up to now are promising and further illustrate the importance of decentralized health planning and local data.

  • 6.
    Brännström, Inger
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Persson, Lars Åke
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wester, P O
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Changing social patterns of risk factors for cardiovascular disease in a Swedish community intervention programme1993In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 22, no 6, p. 1026-1037Article in journal (Refereed)
    Abstract [en]

    Since 1985 a small-scale community-based cardiovascular disease (CVD) preventive programme has been in operation in an inland municipality, Norsjö, in Northern Sweden. The aim of this study was to assess the development of the relationship between social position and CVD risk factors in repeated cross-sectional surveys (1985-1990) among all men and women aged 30, 40, 50 and 60 years in the study area, using an age-stratified random sample from the Northern Sweden MONICA Study of 1986 and 1990 as reference population. These multiple cross-sectional surveys comprised a self-administered questionnaire and a health examination. Of the study population 95% (n = 1499) and 80% of those in the reference area (n = 3208) participated. Subjects were classified with regard to demographic, structural and social characteristics in relation to CVD risk factors and self-reported health status. Time trends in classical risk factor occurrence were assessed in terms of age- and sex- adjusted odds ratios using Mantel-Haenszel procedures. When simultaneously adjusting for several potential confounders we used a logistic regression analysis. Initially, more than half of the study population, both males and females, had and elevated (> or = 6.5 mmol/l) serum cholesterol level. After adjustments had been made for age and social factors it was found that the relative risk of hypercholesterolaemia dropped substantially and significantly among both sexes during the 6 years of CVD intervention in the study area. However, the probability of being a smoker was significantly reduced only in highly educated groups. Among other risk factors no single statistically significant change over time could be found. In the reference area there were no changes over time for the selected CVD risk factors. People in the study area had a less favourable perception of their health than those in the reference area. Social differences were found when perceived good health was measured, especially in variables indicating emotional and social support. When sex, age and social factors had been accounted for there was not clear change over the years in perceived good health.

  • 7. Cvetkovic, Jasmina Trifunovic
    et al.
    Wiklund, Per Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Medicin.
    Ahmed, Ejaz
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Biobank Research. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Lefvert, Ann Kari
    Polymorphisms of IL-1beta, IL-1Ra, and TNF-alpha genes: A nested case-control study of their association with risk for stroke2005In: Journal of Stroke & Cerebrovascular Diseases, ISSN 1052-3057, E-ISSN 1532-8511, Vol. 14, no 1, p. 29-35Article in journal (Refereed)
    Abstract [en]

    Certain alleles of cytokine genes interleukin-1 beta (IL-1β), interleukin-1 receptor antagonist (IL-1Ra), and tumor necrosis factor alpha (TNF-α) are correlated with increased production of the proteins. The aim of this study was to investigate polymorphisms of these genes and their possible correlation with the development of stroke. This matched case-control study was nested within the population-based Västerbotten Intervention Program (VIP) cohort and the Northern Sweden World Health Organization MONICA (Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases) cohort, based on individuals who were free from cardiovascular events when the cohorts were established. After an average period of 34.1 months, 113 individuals developed stroke and to each case 2 individuals not suffering from cardiovascular events were matched to serve as controls. Polymerase chain reaction amplification was used to analyze genetic polymorphisms. There was no association between polymorphic sites of the IL-1β and IL-1Ra genes and stroke. Carriage of haplotype A2+IL-1β/A2+IL-1Ra was significantly increased in normotensive cases (23.1%) compared with normotensive controls (8.9%) (odds ratio [OR] = 3.07; P = .045). In hypertensive male cases, there was an association between the A1A1 genotype of TNF-α and risk of stroke (OR = 2.46; P = .034). Our findings indicate an association between allele A1 of the TNF-α NcoI polymorphism and stroke in hypertensive male cases, as well as an association between haplotype A2+IL-1β/A2+IL-1Ra and stroke in normotensive cases.

  • 8.
    Dewi, Fatwa Sari Tetra
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Public Health Division, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hakimi, Mohammad
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    An increase in risk factors for cardiovascular disease in Yogyakarta, Indonesia: a comparison of two cross-sectional surveys2015In: Southeast Asian Journal of Tropical Medicine and Public Health, ISSN 0125-1562, Vol. 46, no 4, p. 775-785Article in journal (Refereed)
    Abstract [en]

    This paper aims to describe changes in risk factors for cardiovascular disease (CVD) over a five year period in urban Indonesia. In 2004 (n=3,205) and 2009 (n=2,467) we conducted cross-sectional surveys of residents in Yogjakarta City, Indonesia evaluating risk factors for CVD. Smoking habits, fruit and vegetable intake, physical activity, blood pressure, weight, and height were recorded. The results of these 2 surveys conducted 5 years apart were then compared. The risk for having a CVD event was also calculated. Behavioral CVD risk factors were more common among men. The predicted risk of having a CVD event increased from 8.4% to 11.3% among men between 2004 and 2009. Effective measures need to be taken to change these behaviors among men in Yogyakarta, Indonesia.

  • 9.
    Dewi, Fatwa Sari Tetra
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Marlinawati, V Utari
    Öhman, Ann
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Community intervention for behaviour modification: an experience to control cardiovascular diseases in Yogyakarta, IndonesiaIn: Article in journal (Refereed)
  • 10.
    Dewi, Fatwa Sari Tetra
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Öhman, Ann
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hakimi, Mohammad
    Center for Health and Nutrition Research Laboratory, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mobilising a disadvantaged community for a cardiovascular intervention: designing PRORIVA in Yogyakarta, Indonesia2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. 4661-Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Cardiovascular disease (CVD) is a burden for developing countries, yet few CVD intervention studies have been conducted in developing countries such as Indonesia. This paper outlines the process of designing a community intervention programme to reduce CVD risk factors, and discusses experiences with regard to design issues for a small-scale intervention.

    DESIGN PROCESS: THE DESIGN PROCESS FOR THE PRESENT COMMUNITY INTERVENTION CONSISTED OF SIX STAGES: (1) a baseline risk factor survey, (2) design of a small-scale intervention by using both baseline survey and qualitative data, (3) implementation of the small-scale intervention, (4) evaluation of the small-scale intervention and design of a broader CVD intervention in the Yogyakarta municipality, (5) implementation of the broader intervention and (6) evaluation of the broader CVD intervention. According to the baseline survey, 60% of the men were smokers, more than 30% of the population had insufficient fruit and vegetable intake and more than 30% of the population were physically inactive, this is why a small-scale population intervention approach was chosen, guided both by the findings in the quantitative and the qualitative study.

    EXPERIENCES: A quasi-experimental study was designed with a control group and pre- and post-testing. In the small-scale intervention, two sub-districts were selected and randomly assigned as intervention and control areas. Within them, six intervention settings (two sub-villages, two schools and two workplaces) and three control settings (a sub-village, a school and a workplace) were selected. Health promotion activities targeting the whole community were implemented in the intervention area. During the evaluation, more activities were performed in the low socioeconomic status sub-village and at the civil workplace.

  • 11.
    Dewi, Fatwa Sari Tetra
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Öhman, Ann
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    'Maintaining balance and harmony': Javanese perceptions of health and cardiovascular disease2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3Article in journal (Refereed)
    Abstract [en]

    Community intervention programmes to reduce cardiovascular disease (CVD) risk factors within urban communities in developing countries are rare. One possible explanation is the difficulty of designing an intervention that corresponds to the local context and culture.

    Objectives: To understand people’s perceptions of health and CVD, and how people prevent CVD in an urban setting in Yogyakarta, Indonesia.

    Methods: A qualitative study was performed through focus group discussions and individual research interviews. Participants were selected purposively in terms of socio-economic status (SES), lay people, community leaders and government officers. Data were analysed by using content analysis.

    Results: Seven categories were identified: (1) heart disease is dangerous, (2) the cause of heart disease, (3) men have no time for health, (4) women are caretakers for health, (5) different information-seeking patterns, (6) the role of community leaders and (7) patterns of lay people’s action. Each category consists of sub-categories according to the SES of participants. The main theme that emerged was one of balance and harmony, indicating the necessity of assuring a balance between ‘good’ and ‘bad’ habits.

    Conclusions: The basic concepts of balance and harmony, which differ between low and high SES groups, must be understood when tailoring community interventions to reduce CVD risk factors. The basic concepts of balance and harmony, which differ between low and high SES groups, must be understood when tailoring community interventions to reduce CVD risk factors.

  • 12.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Van Guelpen, Bethany
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Johansson, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wiklund, Per-Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Marklund, Stefan L
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Iron stores and HFE genotypes are not related to increased risk of ischemic stroke.: a prospective nested case-referent study2007In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 24, no 5, p. 405-411Article in journal (Refereed)
    Abstract [en]

    Background: High iron levels can increase the formation of noxious oxygen radicals, which are thought to contribute to cerebrovascular disease. The aim of this prospective study was to determine if iron status and HFE genotypes constitute risk factors for stroke.

    Methods: First-ever stroke cases (231 ischemic and 42 hemorrhagic) and matched double referents from the population-based Northern Sweden cohorts were studied in a nested case-referent setting.

    Results: For total iron binding capacity, an increased risk of ischemic stroke was seen in the highest quartile (OR 1.80; 95% CI 1.14-2.83; p for trend 0.012). The highest quartile of transferrin iron saturation showed a decreased risk of ischemic stroke in men (OR 0.44; 95% CI 0.22-0.87; p for trend 0.028), but not in women. There was an increased risk of hemorrhagic stroke in the second (OR 4.07; 95% CI 1.09-15.20) and third quartile (OR 4.22; 95% CI 1.08-16.42) of ferritin. Neither quartiles of plasma iron concentrations nor the HFE C282Y and H63D genotypes were associated with ischemic or hemorrhagic stroke.

    Conclusions: Iron stores were not positively related to increased risk of ischemic stroke. Furthermore, HFE genotypes did not influence the risk of ischemic or hemorrhagic stroke. Copyright (c) 2007 S. Karger AG, Basel.

  • 13.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Marklund, Stefan L
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Jansson, Jan-Håkan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Iron stores and HFE genotypes are not related to increased risk of first-time myocardial infarction: a prospective nested case-referent study2011In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 150, no 2, p. 169-172Article in journal (Refereed)
    Abstract [en]

    Objectives: Our objectives were to study the relationship between iron stores, HFE genotypes and the risk for first-ever myocardial infarction.

    Methods: First-ever myocardial infarction cases (n=618) and double matched referents from the Northern Sweden Health and Disease Cohort Study were studied in a prospective nested case-referent setting. Plasma iron, total iron binding capacity, transferrin iron saturation and ferritin were analyzed, as well as several confounders. HFE C282Y and H63D genotypes were determined.

    Results: There was an inverse risk association for myocardial infarction in the highest quartiles of iron (OR 0.68; 95% CI 0.48-0.96) and transferrin iron saturation (OR 0.62; 95% CI 0.42-0.89) in men. This association, however, was lost after adjusting for C-reactive protein. Women homozygous for H63D had a higher risk for myocardial infarction.

    Conclusions: No risk association between high iron stores and first-ever myocardial infarction was found. The higher risk in female H63D homozygotes is probably not related to iron metabolism.

  • 14.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Marklund, Stefan L
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Jansson, Jan-Håkan
    Medicinkliniken, Skellefteå lasarett.
    Osterman, Pia
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Plasma Bilirubin and UGT1A1*28 Are Not Protective Factors Against First-Time Myocardial Infarction in a Prospective, Nested Case–Referent Setting2010In: Circulation: Cardiovascular Genetics, ISSN 1942-325X, E-ISSN 1942-3268, no 3, p. 340-347Article in journal (Refereed)
    Abstract [en]

    Background: Bilirubin, an effective antioxidant, shows a large variation in levels between individuals and has been positively associated with reduced cardiovascular disease risk. A major reason for the variability is a common promoter polymorphism, UGT1A1*28, which reduces the transcription of the enzyme that conjugates bilirubin, UDP-glucuronosyltransferase 1A1. The aim of the study was to evaluate a possible protective effect of plasma bilirubin and the UGT1A1*28 polymorphism against myocardial infarction in a prospective case-referent setting.

    Methods and Results: 618 subjects with a first-ever myocardial infarction (median event age 60.5 years, median lag time 3.5 years) and 1184 matched referents were studied. Plasma bilirubin was lower in cases vs. referents. Despite a strong gene-dosage effect on bilirubin levels in both cases and referents, the UGT1A1*28 polymorphism did not influence the risk of myocardial infarction. Among multiple other variables, serum iron showed one of the strongest associations with bilirubin levels.

    Conclusion: We found no evidence for a protective effect of the UGT1A1*28 polymorphism against myocardial infarction and consequently neither for bilirubin. The lower bilirubin levels in cases might be caused by decreased production, increased degradation or increased elimination.

  • 15.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Marklund, Stefan L
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Jansson, Jan-Håkan
    Osterman, Pia
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Response to letter regarding article "Plasma bilirubin and UGT1A1*28 are not protective factors against first-time myocardial infarction in a prospective nested case-referent setting"2011In: Circulation: Cardiovascular Genetics, ISSN 1942-325X, E-ISSN 1942-3268, Vol. 4, no 1, p. e2-Article in journal (Refereed)
  • 16.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Marklund, Stefan L
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Johansson, Lars
    Osterman, Pia
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wiklund, Per-Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Bilirubin and UGT1A1*28 are not associated with lower risk for ischemic stroke in a prospective nested case-referent setting.2010In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 30, no 6, p. 590-596Article in journal (Refereed)
    Abstract [en]

    Background: Bilirubin, an antioxidant, has been associated with reduced cardiovascular disease risk. A major cause of elevated plasma bilirubin is the common UGT1A1*28 promoter polymorphism in the gene of the bilirubin-conjugating enzyme UDP-glucuronosyltransferase 1A1, which reduces transcription by 70%. Earlier studies reporting a protective effect of bilirubin on stroke have not included analysis of UGT1A1*28. The purpose of this study is to investigate if bilirubin and UGT1A1*28 are protective against ischemic stroke in a prospective case-referent setting. Methods: Cases with first-ever ischemic stroke (n = 231; median lag time 4.9 years) and 462 matched referents from the Northern Sweden Health and Disease Study Cohort were included. Plasma bilirubin was measured and UGT1A1*28 was analyzed by fragment analysis. Results: Plasma bilirubin was lower in cases than in referents, but the difference reached significance only for women. The UGT1A1*28 polymorphism (allele frequency 30%) showed a strong gene-dose relationship with bilirubin levels both among cases and referents, but was not associated with risk for stroke. Among multiple other variables analyzed, the strongest correlation with bilirubin was found for plasma iron. Conclusions: There was no evidence for a protective effect of the UGT1A1*28 polymorphism against stroke and consequently neither for bilirubin. The findings suggest that other factors influencing the risk for stroke might also affect bilirubin levels.

  • 17.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Marklund, Stefan L
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Johansson, Lars
    Medicinkliniken, Skellefteå lasarett.
    Osterman, Pia
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wiklund, Per-Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Bilirubin and UGT1A1*28, are not associated with lower risk for ischemic stroke in a prospective nested case-referent settingArticle in journal (Refereed)
    Abstract [en]

    Background: Bilirubin, an antioxidant, has been associated with reduced cardiovascular disease risk. A major cause of elevated plasma bilirubin is the common UGT1A1*28 promoter polymorphism in the gene of the bilirubin-conjugating enzyme UDP-glucuronosyltransferase-1A1, which reduces transcription by 70%. Earlier studies reporting a protective effect of bilirubin on stroke, have not included analysis of UGT1A1*28. The purpose of this study is to investigate if bilirubin and UGT1A1*28 are protective against ischemic stroke in a prospective case-referent setting.

    Methods: Cases with first-ever ischemic stroke (n=231; median lag time 4.9 years), and 462 matched referents from the The Northern Sweden Health and Disease Study Cohort were included. Plasma bilirubin was measured and UGT1A1*28 was analyzed by fragment analysis.

    Results: Plasma bilirubin was lower in cases than in referents, but the difference reached significance only for women. The UGT1A1*28 polymorphism (allele frequency 30%), showed a strong gene-dose relationship with bilirubin levels both among cases and referents, but was not associated with risk for stroke. Among multiple other variables analysed the strongest correlation with bilirubin was found for plasma iron.

    Conclusions: There was no evidence for a protective effect of the UGT1A1*28 polymorphism against stroke and consequently neither for bilirubin. The findings suggest that other factors influencing the risk for stroke also might affect bilirubin levels.

  • 18.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Marklund, Stefan L.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Palmqvist, Richard
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Van Guelpen, Bethany
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Iron Biomarkers in Plasma, HFE Genotypes, and the Risk for Colorectal Cancer in a Prospective Setting2012In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 55, no 3, p. 337-344Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: High iron levels can increase the formation of noxious oxygen radicals, which are thought to promote carcinogenesis. OBJECTIVE: The aim of this prospective study was to determine whether iron biomarkers and HFE genotypes, which influence iron regulation, constitute risk factors for colorectal cancer. DESIGN: This is a prospective nested case-referent study. SETTINGS: The study was performed within the population-based Northern Sweden Health and Disease Study. PATIENTS: The study included 226 cases of colorectal cancer and 437 matched referents. MAIN OUTCOME MEASURES: Conditional regression analysis was performed. Adjustments for smoking, smoking and BMI, and HFE C282Y and H63D were performed. RESULTS: The highest quintile of total iron-binding capacity showed significantly higher risk for colorectal cancer, unadjusted OR 2.35 (95% CI 1.38-4.02). When stratified by sex, the findings were only present in women (OR 3.34 (95% CI 1.59-7.02)). Ferritin was associated with reduced risk throughout quintiles 2 to 5 both in univariate and multivariate models. LIMITATIONS: Colorectal cancer may influence iron markers because of occult bleeding. Homozygotes for HFE C282Y were too few to make conclusions for this group. The relatively short follow-up time might be insufficient to detect risk of iron biomarkers. CONCLUSIONS: High iron levels do not increase the risk of colorectal cancer. HFE genotypes influencing iron uptake had no effect on colorectal cancer risk.

  • 19.
    Emmelin, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Nafziger, Anne N
    Clinical Pharmacology Research Center and Department of Adult and Pediatric Medicine, Bassett Healthcare,.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Cardiovascular risk factor burden has a stronger association with self-rated poor health in adults in the US than in Sweden, especially for the lower educated.2006In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 34, no 2, p. 140-149Article in journal (Refereed)
    Abstract [en]

    Background: There is an ongoing debate about the importance of biomedical and sociodemographic risk factors in the prediction of self-rated health. Objectives: To compare the association of sociodemographic and cardiovascular risk factors and self-rated health in Sweden and the US. Design: Data from two population-based cross-sectional health surveys, one in Sweden and one in the US. Subjects: The surveys included questionnaire and measured data from 5,461 adults in Sweden and 7,643 in the US. Participants were between 35 and 65 years of age. Results: The odds ratios for poor self-rated health for the included cardiovascular risk factors were greater in the US. Low education was significantly more prevalent among those with self-rated poor health in the US, but not in Sweden. Using Swedes with high education as reference group (OR51), adults in the US with low education and 2+ risk factors had a greater than threefold risk (OR56.3) of self-rated poor health compared with Swedish low-educated adults with the same risk factor burden (OR51.9). The better-educated US adults with 2+ risk factors were significantly more likely to report poor health (OR53.4) compared with their Swedish counterparts (OR52.4). Conclusions: The interaction between risk factors, education, and self-rated health suggests a frightening picture, especially for the US. Public health interventions for reducing cardiovascular risk factors need to include both population and individual measures. Taking people’s overall evaluation of their health into account when assessing total health risk is important.

  • 20.
    Emmelin, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Dahlgren, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Self-rated ill-health strengthens the effect of biomedical risk factors in predicting stroke especially for men: An incident case referent study2003In: Journal of Hypertension, ISSN 0263-6352, E-ISSN 1473-5598, Vol. 21, no 5, p. 887-896Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To examine how self-rated ill-health interacts with biomedical stroke risk factors in predicting stroke and to explore differences between men and women and educational groups. DESIGN: An incident case-referent study where the study subjects had participated in a prior health survey. SETTING: Nested within the Västerbotten Intervention Program (VIP) and the Northern Sweden MONICA cohorts. SUBJECTS: The 473 stroke cases had two referents per case, matched for age, sex and residence, from the same study cohorts. RESULTS: Self-rated ill-health independently increased the risk of stroke, specifically for men. The interaction effect between self-rated health and biomedical risk factor load was greater for men than for women. The attributable proportion due to interaction between having a risk factor load of 2+ and self-rated ill-health was 42% for men and 15% for women. Better-educated individuals with self-rated ill-health and two or more of the biomedical risk factors had a higher risk of stroke than the less educated. Calculations of the respective contribution to the stroke cases of self-rated health, hypertension and smoking showed that self-rated ill-health had a role in 20% of the cases and could alone explain more than one-third of the cases among those who rated their health as bad, more so for men than for women. CONCLUSIONS: The results underscore the importance of including both a gender and a social perspective in discussing the role of self-rated health as a predictor of disease outcome. Physicians must be more gender sensitive when discussing their patient's own evaluation of health in relation to biomedical risk factors.

  • 21.
    Emmelin, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Dahlgren, Lars
    Umeå University, Faculty of Social Sciences, Department of Sociology. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    To be seen, confirmed and involved - a ten year follow-up of perceived health and cardiovascular risk factors in a Swedish community intervention programme2007In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 7, p. 190-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Public health interventions are directed towards social systems and it is difficult to foresee all consequences. While targeted outcomes may be positively influenced, interventions may at worst be counterproductive. To include self-reported health in an evaluation is one way of addressing possible side-effects. This study is based on a 10 year follow-up of a cardiovascular community intervention programme in northern Sweden. METHODS: Both quantitative and qualitative approaches were used to address the interaction between changes in self-rated health and risk factor load. Qualitative interviews contributed to an analysis of how the outcome was influenced by health related norms and attitudes. RESULTS: Most people maintained a low risk factor load and a positive perception of health. However, more people improved than deteriorated their situation regarding both perceived health and risk factor load. "Ideal types" of attitude sets towards the programme, generated from the interviews, helped to interpret an observed polarisation for men and the lower educated. CONCLUSION: Our observation of a socially and gender differentiated intervention effect suggests a need to test new intervention strategies. Future community interventions may benefit from targeting more directly those who in combination with high risk factor load perceive their health as bad and to make all participants feel seen, confirmed and involved.

  • 22.
    Eriksson, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ahlm, Kristin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine.
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bygren, Lars Olov
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Johansson, Lars Age
    Swedish National Board of Health and Welfare.
    Olofsson, Bert-Ove
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Accuracy of death certificates of cardiovascular disease in a community intervention in Sweden.2013In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 41, no 8, p. 883-889Article in journal (Refereed)
    Abstract [en]

    Aim: The aim was to investigate the possibility to evaluate the mortality pattern in a community intervention programme against cardiovascular disease by official death certificates.

    Methods: For all deceased in the intervention area (Norsjö), the accuracy of the official death certificates were compared with matched controls in the rest of Västerbotten. The official causes of death were compared with new certificates, based on the last clinical record, issued by three of the authors, and coded by one of the authors, all four accordingly blinded.

    Results: The degree of agreement between the official underlying causes of death in "cardiovascular disease" (CVD) and the re-evaluated certificates was not found to differ between Norsjö and the rest of Västerbotten. The agreement was 87% and 88% at chapter level, respectively, but only 55% and 55% at 4-digit level, respectively. The reclassification resulted in a 1% decrease of "cardiovascular deaths" in both Norsjö and the rest of Västerbotten.

    Conclusions: The disagreements in the reclassification of cause of death were equal but large in both directions. The official death certificates should be used with caution to evaluate CVD in small community intervention programmes, and restricted to the chapter level and total populations.

  • 23.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dahlgren, Lars
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Social capital, gender and educational level: impact on self-rated health2010In: The Open Public Health Journal, ISSN 1874-9445, Vol. 3, p. 1-12Article in journal (Refereed)
    Abstract [en]

    Objectives: Social capital has been recognized as one important social determinant for health, but we still have limited knowledge about how it can be used to explain inequality in health. This study investigated the links between individual social capital and self-rated health by gender and educational level, and analyzed if access to social capital might explain the observed disparities in self-rated health between men and women and different educational groups. Study design: A cross-sectional survey in Northern Sweden. Methods: A social capital questionnaire was constructed and mailed to 15 000 randomly selected individuals. Different forms of structural and cognitive social capital were measured. Self-rated health was used as the outcome measure. Crude and adjusted OR and 95% CI were calculated for good selfrated health and access to each form of social capital. Multivariate regression was used to analyze how sociodemographic factors and access to social capital might influence differences in self-rated health by gender and educational level. Results: Access to almost each form of social capital significantly increased the odds for good self-rated health for all groups. A higher education significantly increased the odds for access to each form of social capital, and being a man significantly increased the odds for having access to some forms of social capital. The health advantage for higher educated and men partly decreased when controlling for access to social capital. Conclusions: Access to social capital can partly explain the observed health inequality between men and women and different educational groups. Strengthening social capital might be one way of tackling health inequality. It is important to consider the structural conditions that create unequal opportunities for different groups to access social capital.

  • 24.
    Eriksson, Malin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    The importance of gender and conceptualization for understanding the association between collective social capital and health: a multilevel analysis from northern Sweden2011In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 73, no 2, p. 264-273Article in journal (Refereed)
    Abstract [en]

    Growing research on social capital and health has fuelled the debate on whether there is a place effect on health. A central question is whether health inequality between places is due to differences in the composition of people living in these places (compositional effect) or differences in the local social and physical environments (contextual effects). Despite extensive use of multilevel approaches that allows controlling for whether the effects of collective social capital are confounded by access to social capital at the individual level, the picture remains unclear. Recent studies indicate that contextual effects on health may vary for different population subgroups and measuring "average" contextual effects on health for a whole population might therefore be inappropriate. In this study from northern Sweden, we investigated the associations between collective social capital and self-rated health for men and women separately, to understand if health effects of collective social capital are gendered. Two measures of collective social capital were used: one conventional measure (aggregated measures of trust, participation and voting) and one specific place-related (neighbourhood) measure. The results show a positive association between collective social capital and self-rated health for women but not for men. Regardless of the measure used, women who live in very high social capital neighbourhoods are more likely to rate their health as good-fair, compared to women who live in very low social capital neighbourhoods. The health effects of collective social capital might thus be gendered in favour for women. However, a more equal involvement of men and women in the domestic sphere would potentially benefit men in this matter. When controlling for socioeconomic, sociodemographic and social capital attributes at the individual level, the relationship between women's health and collective social capital remained statistically significant when using the neighbourhood-related measure but not when using the conventional measure. Our results support the view that a neighbourhood-related measure provides a clearer picture of the health effects of collective social capital, at least for women.

  • 25.
    Eriksson, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Jansson, Jan-Håkan
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Olsson, Tommy
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Leptin and adiponectin predict independently a first-ever myocardial infarction with a sex difference: data from a large prospective Swedish nested case-referent studyManuscript (preprint) (Other academic)
  • 26. Feldman, Adina L
    et al.
    Griffin, Simon J
    Ahern, Amy L
    Long, Grainne H
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Impact of weight maintenance and loss on diabetes risk and burden: a population-based study in 33,184 participants2017In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 17, article id 170Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Weight loss in individuals at high risk of diabetes is an effective prevention method and a major component of the currently prevailing diabetes prevention strategies. The aim of the present study was to investigate the public health potential for diabetes prevention of weight maintenance or moderate weight loss on a population level in an observational cohort with repeated measurements of weight and diabetes status.

    METHODS: Height, weight and diabetes status were objectively measured at baseline and 10 year follow-up in a population-based cohort of 33,184 participants aged 30-60 years between 1990 and 2013 in Västerbotten County, Sweden. The association between risk of incident diabetes and change in BMI or relative weight was modelled using multivariate logistic regression. Population attributable fractions (PAF) were used to assess population impact of shift in weight.

    RESULTS: Mean (SD) BMI at baseline was 25.0 (3.6) kg/m(2). Increase in relative weight between baseline and follow-up was linearly associated with incident diabetes risk, odds ratio (OR) 1.05 (95% confidence interval (CI) 1.04-1.06) per 1% change in weight. Compared to weight maintenance (±1.0 kg/m(2)), weight gain of > +1.0 kg/m(2) was associated with an increased risk of incident diabetes, OR 1.52 (95% CI 1.32, 1.74), representing a PAF of 21.9% (95% CI 15.8, 27.6%). For moderate weight loss (-1.0 to -2.0 kg/m(2)) the OR was 0.72 (95% CI 0.52, 0.99).

    CONCLUSIONS: Weight maintenance in adulthood is strongly associated with reduced incident diabetes risk and there is considerable potential for diabetes prevention in promoting this as a whole population strategy.

  • 27. Feldman, Adina L.
    et al.
    Griffin, Simon J.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Screening for type 2 diabetes: do screen-detected cases fare better?2017In: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 60, no 11, p. 2200-2209Article in journal (Refereed)
    Abstract [en]

    AIMS/HYPOTHESIS: We aimed to investigate whether diabetes cases detected through screening have better health outcomes than clinically detected cases in a population-based cohort of adults who were eligible to be screened for diabetes at 10 year intervals.

    METHODS: The Västerbotten Intervention Programme is a community- and individual-based public health programme in Västerbotten County, Sweden. Residents are invited to clinical examinations that include screening for diabetes by OGTTs at age 30, 40, 50 and 60 years (individuals eligible for screening, n = 142,037). Between 1992 and 2013, we identified 1024 screen-detected cases and 8642 clinically detected cases of diabetes using registry data. Clinically detected individuals were either prior screening participants (n = 4506) or people who did not participate in screening (non-participants, n = 4136). Study individuals with diabetes were followed from date of detection until end of follow-up, emigration, death or incident cardiovascular disease (CVD), renal disease or retinopathy event, and compared using Cox proportional hazard regression adjusted for calendar time, age at detection, year of detection, sex and socioeconomic status.

    RESULTS: The average age at diabetes diagnosis was 4.6 years lower for screen-detected individuals compared with clinically detected individuals. Overall, those who were clinically detected had worse health outcomes than those who were screen-detected (HR for all-cause mortality 2.07 [95% CI 1.63, 2.62]). Compared with screen-detected study individuals, all-cause mortality was higher for clinically detected individuals who were screening non-participants (HR 2.31 [95% CI 1.82, 2.94]) than for those clinically detected who were prior screening participants (HR 1.70 [95% CI 1.32, 2.18]). Estimates followed a similar pattern for CVD, renal disease and retinopathy.

    CONCLUSIONS/INTERPRETATION: Individuals with screen-detected diabetes were diagnosed earlier and appeared to fare better than those who were clinically detected with regard to all-cause mortality, CVD, renal disease and retinopathy. How much of these associations can be explained by earlier treatment because of screening rather than healthy user bias, lead time bias and length time bias warrants further investigation.

  • 28.
    Feldman, Adina L
    et al.
    MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge.
    Long, Gráinne H
    MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Griffin, Simon J
    MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Change in lifestyle behaviors and diabetes risk: evidence from a population-based cohort study with 10 year follow-up2017In: International Journal of Behavioral Nutrition and Physical Activity, ISSN 1479-5868, E-ISSN 1479-5868, Vol. 14, article id 39Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Promoting positive changes in lifestyle behavior in the whole population may be a feasible and effective approach to reducing type 2 diabetes burden, but the impact of population shifts of modifiable risk factors remains unclear. Currently most of the evidence on modifiable lifestyle behavior and type 2 diabetes risk on a population level comes from studies of between-individual differences. The objective of the study was to investigate the association and potential impact on disease burden for within-individual change in lifestyle behavior and diabetes risk.

    METHODS: Population-based prospective cohort study of 35,680 participants aged 30-50 at baseline in 1990-2003 in Västerbotten County, Sweden (follow-up until 2013). Five self-reported modifiable lifestyle behaviors (tobacco use, physical activity, alcohol intake, dietary fiber intake and dietary fat intake) were measured at baseline and 10 year follow-up. Lifestyle behaviors were studied separately, and combined in a score. Incident diabetes was detected by oral glucose tolerance tests. Multivariate logistic regression models and population attributable fractions (PAF) were used to analyze the association between change in lifestyle behavior between baseline and 10 year follow-up, and risk of incident diabetes.

    RESULTS: Incident diabetes was detected in 1,184 (3.3%) participants at 10 year follow-up. There was a reduced diabetes risk associated with increase in dietary fiber intake, odds ratio (OR) 0.79 (95% confidence interval (CI) 0.66, 0.96) for increase of at least one unit standard deviation (3.0 g/1,000 kcal) of the baseline distribution, PAF 16.0% (95% CI 4.2, 26.4%). Increase in the lifestyle behavior score was associated with reduced diabetes risk, OR 0.92 (95% CI 0.85, 0.99) per unit increase of the score.

    CONCLUSIONS: These results support a causal link between lifestyle behavior and type 2 diabetes incidence. A small shift in lifestyle behaviors, in particular intake of dietary fiber, has the potential to reduce diabetes burden in the population and might be a suitable target for public health intervention.

  • 29.
    Fhärm, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Guidelines improve general trend of lowered cholesterol levels in type 2 diabetes patients in spite of low adherence2008In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 36, no 1, p. 69-75Article in journal (Refereed)
  • 30.
    Fhärm, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Lower cholesterol levels among diabetes subjects increase in body mass index.2003In: 18th International Diabetes Federation Congress August 24-29 2003: Epidemiology - Type 2 Diabetes Mellitus, 2003Conference paper (Other academic)
  • 31. Fiskesund, Roland
    et al.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Vikström, Max
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    de Faire, Ulf
    Frostegård, Johan
    Low levels of antibodies against phosphorylcholine predict development of stroke in a population-based study from northern Sweden2010In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 41, no 4, p. 607-612Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Natural immunoglobulin M antibodies specific for phosphorylcholine (anti-PC) have been implicated in atherosclerosis. We have shown previously that high levels of anti-PC predict a slower progression of atherosclerosis in humans and that low levels of anti-PC are associated with higher risk for cardiovascular disease. Here we determine the association between anti-PC and the incidence of stroke. METHODS: Using a nested case control study design, we examined 227 incident cases (125 men and 102 women) of first-time stroke and 455 age- and sex-matched controls identified during a 13-year time period (1985 to 1999) within the population-based cohorts of the Västerbotten Intervention Project (VIP) and the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) project in Northern Sweden. Odds ratios of stroke with 95% CIs with adjustments for age, gender, smoking, serum cholesterol, diabetes, body mass index, and blood pressure were determined. Anti-PC levels were measured using ELISA. RESULTS: A significant association between low levels of anti-PC at baseline and incident stroke was seen for the whole group of anti-PC levels below the 30th percentile (multivariately adjusted odds ratio, 1.62; CI, 1.11 to 2.35). Analyses of gender-specific associations indicated fairly strong associations for females, especially at the lowest 30th percentile (multivariately adjusted odds ratio, 2.65; CI, 1.41 to 4.95). No associations were noted for men. CONCLUSION: Low anti-PC is a novel independent risk marker for development of stroke. Measurements of anti-PC could be used to identify immunodeficient subjects at an increased risk for stroke. The possibility that such subjects might be targets for novel modes of treatment such as immunotherapies deserves further investigation.

  • 32. Färnkvist, Lisbeth
    et al.
    Olofsson, Niclas
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Did a health dialogue matter? Self-reported cardiovascular disease and diabetes 11 years after health screening.2008In: Scandinavian journal of primary health care, ISSN 1502-7724, Vol. 26, no 3, p. 135-9Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To study the potential impact of health screening, with or without a motivational health dialogue, on the risk and morbidity of cardiovascular diseases (CVD) and diabetes (DM). DESIGN: Two cross-sectional studies with an interval of 11 years. SETTING: The community of Härnösand, Sweden. SUBJECTS: In the first study, 402 men born in 1934, 1944, or 1954 underwent health screening for CVD prevention in 1989. In the second study, 415 men (of the same ages) completed a questionnaire in 2000 (11 years later). MAIN OUTCOME MEASURES: Odds ratio (OR) for self-reported CVD and DM. RESULTS: The odds ratio of self-reported CVD and DM was more than doubled among participants in the health screening without a health dialogue (OR 2.5; 95% CI 0.8-7.4) and threefold for those not participating (OR 3.0; 95% CI 1.0-8.8) compared with those who reported participation in health screening that included a structured health dialogue. CONCLUSIONS: Health screening for the prevention of CVD and DM benefits from inclusion of a structured, motivational health dialogue.

  • 33. Färnkvist, Lisbeth
    et al.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Assessment of intervention intensity: experiences from a small-scale Swedish cardiovascular disease prevention programme.2006In: Scand J Public Health, ISSN 1403-4948, Vol. 34, no 3, p. 279-86Article in journal (Refereed)
  • 34.
    Hallmans, Göran
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Agren, A
    Johansson, G
    Johansson, Anders
    Umeå University, Faculty of Medicine, Department of Odontology, Periodontology.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jansson, JH
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindahl, B
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Nilsson, M
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Cardiovascular disease and diabetes in the Northern Sweden Health and Disease Study Cohort: evaluation of risk factors and their interactions.2003In: Scandinavian Journal of Public Health. Supplement Links, ISSN 1403-4956, Vol. 61, p. 18-24Article in journal (Refereed)
    Abstract [en]

    The purpose of this paper is, first, to describe the organization, sampling procedures, availability of samples/database, ethical considerations, and quality control program of the Northern Sweden Health and Disease Study Cohort. Secondly, some examples are given of studies on cardiovascular disease and diabetes with a focus on the biomarker programme. The cohort has been positioned as a national and international resource for scientific research.

  • 35.
    Hultdin, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Thøgersen, Ann Margreth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jansson, Jan-Håkan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nilsson, T K
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Elevated plasma homocysteine: cause or consequence of myocardial infarction?2004In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 256, no 6, p. 491-498Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To determine whether a first myocardial infarction leads to increased plasma homocysteine concentrations and whether the association between homocysteine and myocardial infarction was greater at follow-up compared with baseline. DESIGN: A population-based, prospective, nested case-referent study. SETTING: Screening took place at the nearest health survey centre in northern Sweden. SUBJECTS: Of more than 36,000 persons screened, 78 developed a first myocardial infarction (average 18 months after sampling). Fifty of these had participated in a follow-up health survey (average 8(1/2) years between surveys) and were sex- and age-matched with 56 referents. MAIN OUTCOME MEASURES: Comparison of plasma homocysteine levels in case and referent subjects before and after development of a first myocardial infarction. RESULTS: No statistically significant difference was found between cases and referents regarding homocysteine at baseline or follow-up. Plasma homocysteine and plasma creatinine increased significantly, and plasma albumin decreased significantly over time. Conditional univariate logistic regression indicated that high homocysteine at follow-up but not baseline was associated with first myocardial infarction (OR 2.49; 95% CI: 1.03-6.02), but the relation disappeared in multivariate analyses including plasma creatinine and plasma albumin. High plasma creatinine remained associated with first myocardial infarction at both baseline (OR 2.94; 95% CI: 1.05-8.21) and follow-up (OR 3.38; 95% CI: 1.21-9.48). CONCLUSION: In this study, first myocardial infarction did not cause increased plasma homocysteine concentration.

  • 36.
    Hultdin, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Van Guelpen, Bethany
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Winkvist, Anna
    Department of Clinical Nutrition, Göteborg University, Gothenburg, Sweden.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nilsson, Torbjörn K.
    Department of Laboratory Medicine, Örebro University Hospital, Örebro, Sweden.
    Prospective study of first stroke in relation to plasma homocysteine and MTHFR 677C > T and 1298A > C genotypes and haplotypes: evidence for an association with hemorrhagic stroke2011In: Clinical Chemistry and Laboratory Medicine, ISSN 1434-6621, E-ISSN 1437-4331, Vol. 49, no 9, p. 1555-1562Article in journal (Refereed)
    Abstract [en]

    Background: Abnormalities in homocysteine metabolism have been suggested as risk factors for stroke. The aim of this prospective study was to examine whether total plasma homocysteine concentration (tHcy) and its main genetic determinant, methylene tetrahydrofolate reductase (MTHFR) polymorphisms, were associated with first ischemic or hemorrhagic stroke.

    Methods: This was a nested case-referent study of 321 ischemic and 60 hemorrhagic stroke cases, defined by WHO MONICA criteria and each matched with two event-free referents for sex, age, cohort, recruitment date and geographical area. All subjects were from the population-based Northern Sweden Health and Disease Study cohorts. Odds ratios were determined by conditional logistic regression.

    Results: The mean follow-up time was 4.2 years. Both tHcy and MTHFR were independent predictors of hemorrhagic stroke in multivariate models including body mass index, hypertension and, for MTHFR, tHcy [OR for the highest vs. lowest tHcy quartile 8.13 (95% CI 1.83-36.1), p(trend)=0.002; OR for MTHFR 677TT vs. 677CC genotype 3.62 (95% CI 0.77-17.0), p(trend)=0.040]. Haplotype analyses confirmed that the MTHFR 677T-1298A haplotype was positively associated with hemorrhagic stroke [OR 1.81 (95% CI 1.09-3.00), p=0.022], whereas the MTHFR 677C-1298C haplotype was not significantly related to either hemorrhagic or ischemic stroke. Neither tHcy nor the MTHFR polymorphisms were significant predictors of ischemic stroke.

    Conclusion: Both elevated plasma homocysteine levels and the MTHFR 677T allele are indicators of increased risk of hemorrhagic stroke in the northern Swedish population.

  • 37.
    Hörnell, Agneta
    et al.
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Winkvist, Anna
    Department of Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg .
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Mis-reporting, previous health status and health status of family may seriously bias the association between food patterns and disease2010In: Nutrition Journal, ISSN 1475-2891, E-ISSN 1475-2891, Vol. 9, no 48Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Food pattern analyses are popular tools in the study of associations between diet and health. However, there is a need for further evaluation of this methodology. The aim of the present cross-sectional study was to evaluate the relationship between food pattern groups (FPG) and existing health, and to identify factors influencing this relationship.

    METHODS: The inhabitants of Västerbotten County in northern Sweden are invited to health check-ups when they turn 30, 40, 50, and 60 years of age. The present study includes data collected from almost 60,000 individuals between 1992 and 2005. Associations between FPG (established using K-means cluster analyses) and health were analyzed separately in men and women.

    RESULTS: The health status of the participants and their close family and reporting accuracy differed significantly between men and women and among FPG. Crude regression analyses, with the high fat FPG as reference, showed increased risks for several health outcomes for all other FPGs in both sexes. However, when limiting analysis to individuals without previous ill-health and with adequate energy intake reports, most of the risks instead showed a trend towards protective effects.

    CONCLUSIONS: Food pattern classifications reflect both eating habits and other own and family health related factors, a finding important to remember and to adjust for before singling out the diet as a primary cause for present and future health problems. Appropriate exclusions are suggested to avoid biases and attenuated associations in nutrition epidemiology.

  • 38.
    Höög, Elisabet
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm.
    Garvare, Rickard
    Division of Quality Management, Luleå University of Technology, Luleå.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Monica
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm.
    Challenges in managing a multi-sectoral health promotion program2013In: Leadership in Health Services, ISSN 1751-1879, E-ISSN 1751-1887, Vol. 26, no 4, p. 368-386Article in journal (Refereed)
    Abstract [en]

    Purpose: The purpose of this paper is to investigate program management teams’ views on issuesand challenges in managing a large, multi-sectoral child health promotion program in Sweden.

    Design/methodology/approach: In total, 17 participants representing two autonomous programmanagement teams, one strategic and one operational, were interviewed. Analysis of interview datawas complemented with reviews of program documents.

    Findings: Program management teams identified important issues concerning the program’sformal structure, goals, role distribution, and change and dissemination processes, but lacked a sharedmental model of the situation. Inter and intra group communication, long- and short-term strategicplanning were further areas in need of improvement. While issues and challenges might seem to beagreed upon by the program’s change agents, closer inspection reveals variation in key characteristicsas well as in perspectives on solutions.

    Originality/value: Health promotion programs are challenging. Researchers trying tounderstand program success have focused on particular interventions, contextual factors andprogram recipients. Less research has focused on the internal processes of teams tasked withwide-ranging change mandates and the effects such processes can have on program outcomes. Thisstudy contributes to a deeper understanding on internal processes and mental models of changeagent teams.

  • 39.
    Höög, Elisabet
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm.
    Lysholm, Jack
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Garvare, Rickard
    Division of Business Administration and Industrial Engineering, Luleå University of Technology, Luleå.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Monica Elisabeth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm.
    Quality improvement in large health care organizations: searching for system-wide and coherent monitoring and follow-up strategiesIn: Article in journal (Other academic)
  • 40.
    Jerdén, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Bildt-Ström, Pia
    Burell, Gunilla
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Bergström, Erik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Personal health documents in school health education: a feasibility study2007In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 35, no 6, p. 662-665Article in journal (Refereed)
    Abstract [en]

    Aims: To examine the feasibility of a school intervention using a personal health document adapted for adolescents. Methods: The health document was developed in close cooperation with groups of adolescents and tested among seventh-grade students at two junior high schools (n=339). The document was presented to the students by their regular teachers. For evaluation, an adolescent questionnaire was used at baseline and after one year. Results: After one year, 87% of adolescents reported having written in the health document, and 77% reported having had classes with discussions on subjects in the document. The health document was perceived as useful by 35% of the adolescents. Factors significantly related to personal usefulness were being born outside Sweden, experiencing fair treatment by teachers, being a non-smoker, and having a positive school experience. Conclusions: Implementation of a personal health document in junior high-school health education was feasible and well accepted.

  • 41.
    Jerdén, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Burell, Gunilla
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Bergström, Erik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Empowerment: a key to a better understanding of adolescent health?2008In: International journal of child and adolescent health, ISSN 1939-5930, Vol. 1, no 1, p. 61-68Article in journal (Refereed)
  • 42.
    Jerdén, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Burell, Gunilla
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergström, Erik
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Gender differences and predictors of self-rated health development among Swedish adolescents2011In: Journal of Adolescent Health, ISSN 1054-139X, E-ISSN 1879-1972, Vol. 48, no 2, p. 143-150Article in journal (Refereed)
    Abstract [en]

    During adolescence, girls reported lower self-rated health than boys and this gender difference increased over the years. High empowerment is related to high self-rated health, and positive school experiences and a good mood in the family seem to be important predictors of a positive development of self-rated health.

  • 43.
    Jerdén, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Center for Clinical Research Dalarna, Falun, Sweden; School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Dalton, James
    Johansson, Helene
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sorensen, Julie
    Jenkins, Paul
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lifestyle counseling in primary care in the United States and Sweden: a comparison of patients' expectations and experiences2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1438238Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite various guidelines, shortcomings in lifestyle counseling in primary care have been demonstrated. Comparisons between countries may provide insight on how to improve such counseling. To the best of our knowledge, studies comparing patients' views of lifestyle counseling beween the United States (US) and European countries have not been reported.

    OBJECTIVES: To quantify and compare patients' perspectives in the US and Sweden on primary care providers' counseling on weight, eating habits, physical activity, smoking, and alcohol consumption.

    METHODS: In a cross-sectional study, 629 patients from Sweden and the US completed a telephone interview about their experiences after a visit to a physician in primary care. The survey focused on patients' perception of the importance of healthy lifestyle habits, their need to change, their desire to receive support from primary care, and the support they had actually received. Data were analyzed using chi-square or Fisher's exact test.

    RESULTS: For three of the four lifestyle habits, the proportion saying they needed to change was higher in the US. The exception was for alcohol, where Swedish subjects indicated a greater need to change. Among those stating a need to change, the proportion saying that they would like to have support from primary care was generally above 80% in both countries. The proportion of US patients reporting that their primary care provider had initiated a discussion of lifestyle modification was, with the exception of alcohol, roughly double the level reported by the Swedish patients.

    CONCLUSIONS: This study demonstrates high and quite similar patient expectations concerning lifestyle counseling in both countries, but more frequent initiation of discussions of most lifestyle issues in US primary care. Further studies, e.g. qualitative interviews with physicians, and medical record reviews, are required to better understand what can explain the differences between countries indicated by the study.

  • 44.
    Jerdén, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hillervik, Charlotte
    Hansson, Ann-Christin
    Flacking, Renée
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Experiences of Swedish community health nurses working with health promotion and a patient-held record2006In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 20, no 4, p. 448-454Article in journal (Refereed)
  • 45.
    Jerdén, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Cost-effectiveness of a personal health document in different distribution settings2008In: Health promotion journal of Australia, ISSN 1036-1073, Vol. 19, no 2, p. 125-131Article in journal (Refereed)
    Abstract [en]

    The aim was to compare the cost-effectiveness of different ways to distribute a personal health document that was primarily aimed at supporting behaviour change. Personal health documents have been widely used in health-promoting efforts but their effective use is rather sparsely studied. METHODS: Four types of distribution were tested in Sweden: primary health care centres (n=418); work site meetings (n=164); at an occupational health examination (n=279); by mail (n=445). Participant behaviour changes were measured by a questionnaire. Cost calculations were made based on the results of the study. RESULTS: Between 10% and 26% of participants reported behaviour changes as a result of reading the booklet. A change in health situation was less likely using postal distribution. There were no significant differences between the other types of distribution. Cost-effective distribution at work sites and in occupational health was superior to distribution in primary health care when direct costs were used. Distribution at work sites was the least cost-effective when indirect costs, i.e. productivity losses of participants, were included. CONCLUSIONS: Cost-effectiveness analyses support distribution of personal health documents in occupational health. In primary health care, high training costs in combination with low distribution rates might be problematic. Providing information during distribution at work sites is time-consuming and might therefore be a problem if productivity losses are taken into account.

  • 46.
    Jerdén, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Epidemiologi och folkhälsovetenskap.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Epidemiologi och folkhälsovetenskap.
    Does a patient-held health record give rise to lifestyle changes? A study in clinical practice.2004In: Family Practice, ISSN 0263-2136, E-ISSN 1460-2229, Vol. 21, no 6, p. 651-653Article in journal (Refereed)
  • 47.
    Johansson, Helene
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lundström, Lena
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Infectious Diseases.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Is it within the system? A study comparing how health care professionals define health themselves and their perception of the health service view of healthIn: Article in journal (Refereed)
  • 48.
    Johansson, Helene
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lundström, Lena
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Reorientation to more health promotion in health services: a study of barriers and possibilities from the perspective of health professionals2010In: Journal of Multidisciplinary Healthcare, ISSN 1178-2390, E-ISSN 1178-2390, Vol. 3, p. 213-224Article in journal (Refereed)
    Abstract [en]

    This study found strong support for reorientation of health services in the incorporation of a greater health promotion. A number of professions that are not usually associated with health promotion practices are knowledgeable and wish to focus more on health promotion and disease prevention. Management has a major role in creating opportunities for these professionals to participate in health promotion practices. Men and physicians reported less positive attitudes to a more health-promoting health service and often possess high positions of power. Therefore, they may play an important role in the process of change toward more health promotion in health services.

  • 49.
    Johansson, Helene
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lundström, Lena
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Infectious Diseases.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Re-orientation to more health promotion in health services:  a study of barriers and possibilities from the perspective of health professionalsIn: Article in journal (Other academic)
  • 50.
    Johansson, Helene
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    “If we only got a chance.” Barriers to and possibilities for a more health-promoting health service2010In: Journal of multidisciplinary healthcare, ISSN 1178-2390, Vol. 3, p. 1-9Article in journal (Refereed)
    Abstract [en]

    Aim: With the overall objective to develop future strategies for a more health-promoting health service in Sweden, the aim of this paper was to describe how health personnel view barriers and possibilities for having a health-promoting role in practice.

    Materials and methods: Seven focus group discussions were carried out with a total of 34 informants from both hospital and primary health care settings in Sweden. The informants represented seven professional groups; counselors, occupational therapists, assistant nurses, midwives, nurses, physicians, and physiotherapists. The data were analyzed using qualitative content analysis.

    Results:

    The analysis resulted in one major theme “If we only got a chance”. The theme captures the health professionals’ positive view about, and their willingness to,  evelop a healthpromoting and/or preventive role, while at the same time feeling limited by existing values, structures, and resources. The four categories,  organizational commitment to a paradigm shift”, “recognition of staff as health-promoting instruments”, “a balance between resources and tasks”, and “freedom of action” capture what is needed for implementing and increasing health promotion and preventive efforts in the health services.

    Conclusions:

    The study indicates that an organizational setting that support health promotion is still to be developed. There is a need for a more explicit leadership with a clear direction towards the goal of “a more health–promoting health service” and with enough resources for achieving this goal.

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